Qass Book COPYRIGHT DEPOSIT SPECIAL PATHOLOGY AND DIAGNOSTICS WITH THERAPEUTIC HINTS BY C. G. RAUE, M. D., Formerly Professor of Special Pathology and Therapeutics in the Hahnemann Medical College of Philadelphia. FOURTH EDITION REVISED AND AUGMENTED. JIM ^\*ns-B-i PHILADELPHIA: BOERICKE & TAFEL 1896. Copyrighted, 1896, By Boericke & Tafel. T. B. & H. B. COCHRAN, PRINTERS, LANCASTER, PA. fll>£ Stubents, near anfc far in wbose bebalf the ffirst BMtion was Elaborated ant) to tbe memory ot our mutual frienfc anfc teacber, Constantine Ibering, tbis tourtb edition is fcefcicatefc. PREFACE TO FOURTH EDITION. IN this, the fourth edition, there will be found a number of changes and revisions induced by the progress of medical science since the appearance of the last edition. A new chapter on Mental Diseases has been added, my object being to bring to the attention of the general practitioner and student in a concise manner the present state of this branch of medicine as developed in the last years by practical experience, experimental work in large hospitals, and the progress of psychology itself. Some changes have also been made in the classification of the acute diseases treated of, those of infectious origin being grouped into the chapter, "Acute Infectious Diseases." Hoping that with these additions and changes the entire work may have gained a new starting point in its practical worth to the student and busy practitioner, I again send it forth on its mission. C. G. RAUE. Philadelphia, 121 N. 10th Street, May ist, 1896. PREFACE TO THIRD EDITION. ATOW that I have finished this revision and can look over the task performed — I at last begin to realize a sense of satisfaction and com- fort. Not that I have made great changes in the text of the second edition — the pathology of to-day remains nearly the same as it was a few years ago, with the exception of increased efforts bestowed upon the cultivation of disease-germs, things already alluded to in many places of the second edition, but of little use as to curing disease — neither have I changed the therapeutic hints, although new experiences have been added; the main work done in this revision is the addition of a digest to all such chapters which present a list of therapeutic hints of three pages and over. These formidable lists appeared to me always as pretty hard lumps, that needed some aid for digestion — indeed required means which would make it easier for the practitioner to find out of the many the one remedy for a given case. A similar plan had been conceived and executed by Hering in his ' ' Analytical Therapeutics of Typhoid Fevers, ' ' and in his first volume of ' ' Analytical Therapeutics. ' ' Bell has given us a repertory on diarrhoea and dysentery, Gushing on leucorrhoea, Hggert on uterine and vaginal dis- charges, King on headaches, Wm. A. Allen on intermittent fevers, Minton on uterine therapeutics, Iyee on cough and expectoration, H. C. Allen on intermittent fevers and P. P. Wells on cholera — all very valuable contribu- tions to our therapeutics. My "digests," however, are not alphabetical repertories; each single one has been arranged according to the requirements of each single chapter. What belongs naturally together, or what is nearly related to each other, has been put together in order to facilitate comparison and choice between the different remedies. These digests further contain only what the preced- ing therapeutic hints contain, and are not made up artificially from the Materia Medica or existing repertories; they are not meant to present any- thing more or less than the preceding hints worked over and arranged meth- odically for ready use. This laborious task I have undertaken because I wished to accomplish two very important objects. First, to assist the accurate prescribe! 1 , as far XVI PREFACE. as it lies in the scope of this work, in his arduous task of finding the required remedy quickly and safely; and, secondly, to induce my young friends to study closely their cases, in order to keep out of the ruts, so easily trodden, of prescribing for a name. For in these digests they surely will find inducements for individualizing their cases, and although I do not promise that they will find in every instance what they are hunting for, I am sure they will be greatly aided in many cases. C. G. Raue. Philadelphia, August, 1885. PREFACE TO SECOND EDITION. OTVHE first edition had become old; it needed renovation. The pathologi- cal views had changed so grievously since its appearance, that a re-statement of the same throughout the work became a necessity. Not so, however, the therapeutic hints. They are as true to-day as they were when written years ago, and, I am happy to say, have been reliable guides at the bedside to many physicians, and also a fruitful source, acknowledged or not, to many writers in journals and of books. What I had to do with these hints was this: To express their meaning still more accurately, to enlarge their spheres, and to add such new facts as the exper- ience of others and my own would admit. This has augmented to a considerable extent even the therapeutic part of the work, and thus I may state in truth, that this second edition is re-written for the most part, that it is greatly enlarged, and, I hope, also greatly improved. Although I have given credit in the text to the several authors from whom I have drawn, it may be well to mention the principal sources for the pathological part: von Ziemssen's Cyclopaedia, French's Diseases of the Liver, Walton's work on the Eye, and von Trcelsch's work on the Ear. Compare also the introductory remarks to the first edition. The therapeutic hints I have selected from the entire homoeopathic literature, using all such indications as I deemed reliable and characteristic. The chapter on the eye has been kindly and carefully overhauled in the manuscript by Dr. G. S. Norton, and that on the ear by Drs. G. S. Norton and Henry C. Houghton; their valuable notes will be found credited to them in the text. The arrangement is the same as that of the first edition. Although great pains have been taken to avoid clerical errors, neverthe- less some have crept in, for instance, salycilic for salicylic and others. Wherever you find them, please correct them. C. G. RAUE. Philadelphia, September, 1881. INTRODUCTORY REMARKS TO FIRST EDITION. TTTHEN I was called upon to lecture on Special Pathology and Diag- * nostics, about four years ago, I looked around for a work which would furnish the essential points of these branches of medical education, together with Homoeopathic Therapeutics, in a concise manner and up to the latest researches; but I looked in vain. I was obliged to prepare my own materials. The result of these labors seemed, in the estimation of my pupils and indulgent friends, worthy of a more permanent form and a wider diffu- sion than oral teaching affords. In its preparation I have consulted the best recent as well as older works on the different subjects contained herein: Virchow, Rokitansky, Vogel, Griesinger, Hasse, Wintrich, Bamberger, Simon, Niemeyer, Bock, Bednar, Hiibner, Kuttner, Wagner, Skoda, Hebra, Wilson, DaCosta, Hughes, Barclay, Bryan. Hammond, Hahnemann, Hering, v. Boenning- hausen, Riickert, Oehme, Hartmann, Jahr, v. Grauvogl, Miiller, Meyer, Baehr, Kafka, Ludlam, Hale, Wells, Dunham, and others; New York Homoeopathic Transactions and various journals. I have made free use of all of them as far as they suited my purpose, but have not followed any one exclusively. The arrangement, selection and elaboration of the whole are my own. The composition, however, would have unavoidably contained many Germanisms had they not been expurgated. I am indebted to Dr. G. R. Starkey, formerly Professor of Surgery in the Homoeopathic College of Pennsylvania, for his kind offices in correcting the manuscript so as to render it more agreeable to the English ear. This book does not pretend to be a special Therapia, because as v. Grauvogl already remarks: " It is i77ipossible to prepare a complete, special Therapia for any so-called disease; just as impossible as to describe all human beings of all times, because the conditions of getting sick change constantly in the course of time." What the genius epidemicus requires, for example, in an epidemic of whooping-cough at this season may not answer at all for a like epidemic of the next year. Hence, my intention has been to give only therapeutic hints. These hints I have carefully selected out of the rich treasury of our Homoeopathic literature, and I have added the results of my own experience. But all this does not make it perfect. Many a colleague. on opening the book and glancing over this or that chapter, will miss one or XX INTRODUCTORY REMARKS TO FIRST EDITION. another remedy which he has been applying successfully in a certain form of disease. It lies in the nature of such a work that this must be so. On being informed, however, of such remedies and their characteristic indica- tions, the author would be happy to receive and apply them. This book does not give any prescriptions in regard to the dose, because that is still an open question, and must be left entirely to the free judgment of the practitioner. My hints are collected from all sorts of observations, with low, middle, high and highest potencies. I, myself, prefer the higher potencies; and it is possible that the more accurately we individualize the more we may become inclined to choose the highest. Others may think differently. So much is certain, that there are undoubted facts which seem to favor both sides of the question. Cases are recorded in which low poten- cies were given in vain, and a higher one of the same remedy at once effected a cure, and vice versa. Judge then for thyself. THE AUTHOR. ERRATA. Page 42 . ( ' Convulsions, ' ' read ' ' Convolutions. ' Page 137. " Hordeoleum," read "Hordeolum." Page 358. "Grabbet's," read " Gabbed s." Page 547. " Kchinococcus-cryst," read "cyst." Page 769. " Panaritum , " read "Panaritium." CONTENTS. MIND. MENTAL DISEASES. Introduction = 33 I. The Sphere of the Intellect. Paranoia, Insanity, Verriicktheit 34 Paranoia Inventoria seu Reformatoria 36 Paranoia Religiosa 36 Dementia Paralytica 40 Senile Dementia ■ 41 Checked Evolution of the Psychical Development 49 Weak-Mindedness 50 II. The Sphere oe Conation and Activity. Exultatio Furiosa, Frenzy, Tobsucht 52 III. The Sphere of Feelings or Emotions. Melancholia 56 Delirium Tremens 60 Chronic Alcoholism, Dipsomania 62 Opium Poisoning and Morphinismus 65 HEAD. DISEASES OF THE BRAIN AND ITS MEMBRANES. Anaemia 67 Hyperemia , 69 Vertigo 74 Sleep, Stupor, Insomnia ' 86 Meningitis Tuberculosa, Hydrocephalus Acutus, Basilar Meningitis 91 Leptomeningitis Infantum, Hydrocephalus Acutus Sine Tuberculis 93 Simple Meningitis, Meningitis of the Convexity, Leptomeningitis ..... 93 Hydrocephalus Acquisitus 101 Hydrocephalus Congenitus 101 Hydrocephalus Senilis 103 Pachymeningitis, Inflammation of the Dura Mater 104 Encephalitis; Abscess of the Brain; Red and Yellow Softening of the Brain . . 105 Insolatio, Sunstroke, Thermic Fever 106 Apoplexia Sanguinea 109 Occlusion of the Cerebral Arteries; Embolism and Thrombosis; Softening of the Brain 113 Aphasia 115 Thrombosis of the Cerebral Sinuses 117 Hypertrophy of the Brain 119 Atrophy of the Brain 120 Tumors of the Brain and Its Membranes 120 XX11 CONTENTS. DISEASES OF THE CRANIUM AND ITS INTEGUMENTS. a. Abnormal Largeness of the Head. Dropsy of the Scalp 123 Hypertrophy of the Skull 123 The Bruised Head of a Child after Birth 123 b. Abnormal Smallncss. c. Affections of the Skull without Enlargement. Atrophy of the skull 125 d. Diseases of the Integuments. Eczema Capitis, Humid Tetter or Scald f . . 125 Impetigo 126 Dandruff 128 Seborrhcea Capillittii 128 Favus, Honey-comb Ringworm, Tinea Favosa or Maligna 129 Tinea, Herpes Tonsurans, or Ringworm of the Scalp 130 The Wen 130 The Teleangiectasia, or Vascular Naevus, Mother's Mark 130 The Hair 131 EYES. General Observations 133 Lids and Lachrymal Apparatus. Inflammation of the Eyelids 133 Hordeoleum, Stye 137 Tumors of the Lid , 138 Dacryocystitis 139 Blenorrhcea of the Lachrymal Sac 139 Conjunctiva. Catarrhal Ophthalmia 140 Purulent Ophthalmia 142 Granular Ophthalmia 144 Phlyctenular Ophthalmia 146 Diphtheritic Conjunctivitis 150 Croupous Conjunctivitis • 151 Pterygium 152 Cornea. Corneitis, Keratitis 152 Abscess of the Cornea 153 Onyx 153 Hypopion 153 Staphyloma 154 Sclerotica. Scleritis, Sclerotitis 157 Iris. Iritis 158 Choroidea. Choroiditis 160 Glaucoma 162 Optic Nerve and Retina. Neuro-Retinitis Jk 164 CONTENTS. XX111 Hemiopia 166 Hemeralopia, Night-Blindness 166 Hyperaesthesia Retinae 167 Lens. Cataract 167 Sight Refraction and Accommodation 169 Presbyopia, or Old Sight 170 Hypermetropia 17 1 Myopia, or Short Sightedness 17 1 Astigmatism 17 2 Asthenopia 173 Muscles and Nerves. Mydriasis 175 Myosis 175 Ptosis 175 Strabismus, or Squint 176 Nystagmus, Trembling of the Eyeballs 177 Luscitas, or Fixed State of the Eyeball 179 Morbid Winking 177 Twitching of the Eyelids 177 Blepharospasm 177 Neuralgia of the Eye 178 Orbit. Orbital Cellulitis 179 Basedow's, or Grave's Disease; Exophthalmic Goitre 179 EARS. Analogy Between the P'ar and the Eye 182 General Observation on the Ear 183 Auricle. Eczema 184 Auditory Canal and Drumhead, or Membrana Tympani. Examination of the parts .... 184 Earwax, Diminished or Increased 186 Furuncles of the External Canal 188 Otitis Externa, or Diffuse Inflammation of the Auditory Canal 188 The Middle Ear. Examination of the Middle Ear 190 Otitis Media 193 Chronic Forms of Otitis Media 197 Polypi 206 Nervous Deafness 207 Meniere's Disease ■ 207 Tinitus Aurium • 209 Otalgia Nervosa. . . ' 209 NOSE. General Observations 210 Examination of the Cavity of the Nose 211 Catarrh, Coryza, Cold in the Head 213 Chronic Catarrh, Ozaena 217 XXIV CONTENTS. Yearly Cold, Rose Cold, Hay Fever, Hay Asthma 224 Epistaxis, Nosebleed 225 Polypi in the Nose 227 Inflammation of the Nose 227 FACE. "General Observations 229 Crusta Lactea, Milk Crust, Eczema 231 Comedo, Acne Punctata et Rosacea 233 Lupus 233 Ulcus Rodens and Epithelioma • 234 MOUTH. General Observations 233 The Gums. Parulis, Gumboil, Inflammatory Swelling of the Gums 236 Epulis 236 Fistula of the Teeth 236 The Teeth. Odontalgia, Toothache 238 Swelled Face 252 The Tongue. Its Color 253 Its Humectation 253 Its Temperature 253 Its Covering, or Coating 254 Its Form and Size 254 Its Consistency 255 Cracks and Fissures 255 Paralysis 255 Glossitis, Inflammation of the Tougue 257 Cancer of the Tongue , 258 The Salivary Glands and their Ducts. Saliva 259 Ranula, Frog 260 The Tonsils. Inflammation of the Tonsils; Amygdalitis; Tonsilitis; Angina Tonsillaris . . . 261 The Uvula and Soft Palate. Angina Faucium, Angina Catarrhalis, Sore Throat 263 Chronic Sore Throat, Angina Granulosa or Follicularis 265 Ulcers in the Fauces; Ulcerated Sore Throat 270 Retro-Pharyngeal Abscess 270 Deep Inflammation of the Connective Tissue of the Throat; Angina Uudovici . 271 The Mucous Membra?ie of the Mouth In General. Stomatitis 272 Catarrhal Stomatitis 272 Parasitic Stomatitis, Thrush 272 Stomatitis Ulcerosa; Formation of Ulcers in the Cavity of the Mouth 274 Noma, Gangrene of the cheeks 276 NEOK. General Observations . ' ' 278 Bronchocele, Struma or Goitre 279 CONTENTS. XXV Oesophagus. Oesophagitis, Dysphagia Inflammatoria # 280 Stenosis Oesophagi, Narrowing of the Oesophagus 281 Dilatation of the Oesophagus 281 Larynx and Trachea. Auscultation 284 Laryngoscopy . 284 Acute Catarrhal Laryngitis 286 Laryngitis Catarrhalis Chronica 288 Croup 292 oedema Glottidis, Oedema Laryngis 296 Perichondritis Laryngea 298 Phthisis Laryngis, Tubercular Ulceration 298 Syphilis Laryngis 300 Neoplasms of the Larynx 300 Neuroses of the Larynx 302 Spasm of the Glottis 303 THORAX. Inspection. General Observations ... 306 Local Abnormalities 308 Palpation. Temperature 308 Form , . 309 Resistance 309 Fremitus 309 Friction 310 Pulsation of the Heart f : . 311 Percussion. General Observations 311 Tympanitic Sound 412 Non-Tympanitic Sound of Skoda, the Resonant Sound of the Lungs 314 Hyper-resonance 315 Amphoric Resonance 125 Cracked-pot Sound 315 Auscultation. The Normal Sounds of Respiration 316 Pathological Deviations from the Normal Vesicular Respiration 318 Auscultation of Voice 323 Auscultation of Cough 326 Special Diseases of the Respiratory Orgrans 326 Affections of the Bronchial Tubes. Bronchitis, Bronchial Catarrh 327 Bronchial Asthma 340 Affections of the Pulmonary Parenchyma. Lobular Pneumonia, Catarrhal Pneumonia 344 Lobar Pneumonia, Croupous, Pueumonia, Lung Fever 345 Pulmonary Tuberculosis, Phthisis Pulmonum, Pulmonary Consumption .... 354 Emphysema Pulmonum 366 Hyperemia and oedema of the Lungs 370 Gangrsena Pulmonum 571 xxvi CONTENTS. Haemorrhages of the Lungs, Haemoptoe, Haemoptysis 372 Affections of the Pleura. Pleuritis, Pleurisy, Inflammation of the Pleura 374 Pneumothorax 381 Hydrothorax, Dropsy of the Chest 383 Haematothorax 385 THE HEART. Auscultation 387 Diseases of the Pericardium. Pericarditis, Inflammation of the Pericardium 394 Hydropericardium, Dropsy of the Pericardium 397 Diseases of the Endocardium . Endocarditis 39S Insufficiency of the Mitral or Bicuspid Valve 401 Constriction or Stenosis of the Left Auriculo- Ventricular Opening 402 Insufficiency of the Aortic Valves 402 Constriction or Stenosis of the Aortic Opening 403 Insufficiency of the Tricuspid Valves 404 Stenosis of the Right Auriculo- Ventricular Opening 404 Insufficiency of the Pulmonary Valves 404 Stenosis of the Pulmonary Opening 404 Heart Clots 406 Diseases of the Heart Muscle. Myocarditis, Carditis 407 Hypertroph}- and Dilatation of the Heart 407 Fatty Heart and Fatty Degeneration of the Heart 409 Nervous Affections of the Heart. Nervous Palpitation of the Heart 410 Angina Pectoris, Stenocardia 412 Diseases of the Aorta. Aneurism of the Thoracic Aorta 415 Diaphragm. Diaphragmitis 416 Singultus, Hiccough 418 Neuralgia of the Diaphragm 418 Rupture and Perforation of the Diaphragm 418 ABDOMEN. General Observations 420 Stomach. Dyspepsia, Indigestion 423 Vomiting 424 Acute Catarrh of the Stomach, Gastritis 425 Chronic Catarrh of the Stomach 428 Gastritis Toxica seu Caustica 429 Gastralgia, Cardialgia Nervosa, Cramp of the Stomach • ■ 430 Ulcus Ventriculi Perforans, Round Perforating Ulcer of the Stomach 435 Carcinoma or Scirrhus Ventriculi, Cancer of the Stomach 439 Hemorrhage from the Stomach, Haematemesis 443 CONTENTS. XXVll Gastromalacia, Softening of the Stomach 445 Intestinal Canal. Catarrhus Intestinalis, Enteritis Catarrhalis, Intestinal Catarrh 447 Chronic Intestinal Catarrh 449 Typhilitis, Perityphlitis and Appendicitis 455 Proctitis, Catarrhal Inflammation of the Rectum 458 Periproctitis 459 Dysentery 460 Cholera Morbus, or Nostras 468 Summer Complaint 469 Hydrocephaloid . . 469 Constipation 478 Hernia 484 Torsion or Twisting of the Bowels 487 Intussusception, Invagination 487 Ileus, Miserere 488 Hsemorrhagia Intestinalis, Intestinal Hemorrhage, Malsena 490 Haemorrhoids.. Piles 490 Flatulency, Meteorism of the Abdomen 498 Colica, Enteralgia • ■ 500 Tuberculosis Intestinalis, Consumption of the Bowels , 509 Cancer of the Intestines . -. 509 Poh r pus of Rectum 510 Fissura Ani 511 Fistula Recti ..••• 512 Prolapsus Recti 513 Proctalgia 514 Intestinal Worms, Bntozoa, Helminthes 514 Tape Worms 516 Trichocephalus Dispar 519 Anchylostomum Duodenale, Dochmius s. Strongylus Duodenalis 519 Trichina Spiralis 520 Trichinosis 522 Peritoneum. Peritonitis 526 Ascites, Dropsy of the Peritoneum . 529 Tympanites Abdominalis 532 Liver. Physical Examination 533 Pigment Liver, Melansemic Liver Resulting from Malaria Fevers 533 Hypersemia, Congestion of the Liver 533 Peri-Hepatitis, Inflammation of the Capsule of the Liver and of Glisson's Capsule 536 Hepatitis vera circumscripta, seu Suppurativa 536 Cirrhosis, Hob-Nail Liver, Interstitial Inflammation of the Liver 539 Syphilitic Inflammation of the Liver 541 Acute Yellow Atrophy 541 Hepar Adiposum, Fatty Liver 543 Colloid Liver, Lardaceous Liver, Waxy Liver, Amyloid Degeneration 544 Carcinoma Hepatis, Cancer of the Liver 545 Hydatids of the Liver, Echinococcus-cysts 547 Catarrhal Inflammation of the Biliary Passages 548 Cholelithiasis, Gall-Stones 549 xxviii - CONTEXTS. Thrombosis and Occlusion of the Portal Vein; Pylethrombosis, Pylephlebitis Adhsesiva Chronica 552 Pylephlebitis Suppurativa, Purulent Inflammation of the Portal Vein 553 Icterus, Cholaemia, Jaundice 554 Spleen. Physical Examination > . . 563 Anatomical Peculiarities of the Spleen 564 Hemorrhagic Infraction; Splenitis, Lienitis, or Inflammation of the Spleen . . 564 Acute Tumor, or Hyperaemia of the Spleen 566 Chronic Tumor, or Hypertrophy of the Spleen 566 Cancer of the Spleen 567 Echinococcus-cysts 567 Rupture of the Spleen 567 Pancreas. General Observations 568 Pancreatitis, Inflammation of the Pancreas 569 Fatty Diseases of the Pancreas 569 Cancer of the Pancreas 569 Kidneys. Examination of the Urine 569 Diabetes, Mellituria, Glycosuria '. 576 Diabetes Insipidus 583 Hematuria, Passing Blood with the Urine 585 Albuminuria 587 Uraemia 588 Bright's Disease 589 Acute Parenchymatous Nephritis 589 Chronic Parenchymatous Nephritis 593 Interstitial Inflammation or Induration of the Connective Tissue of the Kidneys, 597 Amyloid Degeneration of the Kidneys, Lardaceous or Waxy Kidney 600 Suppurative Nephritis, Renal Abscess 601 Nephrolithasis, Renal Gravel or Calculi; Nephralgia, Colica Renalis 601 Pyelitis, Inflammation of the Renal Pelvis 604 Perinephritis, Paranephritis, Inflammation of the Renal Capsule 605 Morbus Addisonii 605 Bladder. Cystitis, Inflammation of the Bladder 607 Calculi Vesicae, Stones in the Bladder 612 Hyperaethesia or Irritability of the Bladder; Spasms of the Bladder 613 Atony, Paresis, Paralysis of Bladder , 614 Eneuresis Nocturna 616 Retention of Urine, Ischuria Vesicalis 617 ORGANS OF GENERATION. MALE GENITALS. Venereal Diseases. Gonorrhoea 619 Complications Sequelae 624 Epididymitis; Orchitis 624 Prostatitis Gonorrhoica, Inflammation of the Prostate 624 Gonorrhoea Vesicae 625 CONTENTS. XXIX Buboes 625 Ophthalmia Gonorrhoica . . 625 Gonorrhoea of Rectum 625 Strictures of Urethra 625 Gonorrhoeal Rheumatism 625 General Contamination of the System in Consequence of Gonorrhoea 626 Chancre 626 Constitutional Syphilis 629 Condylomata, Sycosis, Fig-Warts 637 Inguinal Bubo . . . . • 638 Syphilitic Skin Diseases • 540 Syphilitic Affections of the Mucous Membranes 643 Syphilitic Affections of the Periosteum 643 Syphilitic Contractions of Muscles and Tendons 644 Gummata in the Subcutaneous and Submucous Cellular Tissue 644 Syphilitic Affections of Inner Organs 644 Syphilis Congenita sive Hereditaria 645 Testes. Hydrocele 646 Orchitis, Inflammation of the Testicles 647 Carcinoma Testis 648 Varicocele 648 Spermatocele 648 Prostata. Prostatitis, Inflammation of the Prostata Gland 649 Enlargement and Tumors of the Prostata . . . . 649 Vesiculce Seminales. Pollutiones Noctunse et Diurnse; Spermatorrhoea 652 Impotence; Sterility in the Male • • 655 FEMALE GENITAL ORGANS. Examination of the Parts. . . • . • . . ■ 657 Ovaries. Hydrops Ovarii, Ovarian Dropsy; Formation of Cysts in the Ovaries 661 Uterus. * Endometritis, Catarrh of the Uterus, Leucorrhcea 663 Parenchymatous Metritis 672 Hydrometra, Hsemometra 675 Displacements of the Womb, 676 Anteversion and Anteflexion • 676 Retroversion and Retroflexion 677 Prolapsus and Procidentia 677 Inversion of the Womb 67S Morbid Growths of the Womb 686 Cancer of the Womb 687 Hysteralgia 690 Metrorrhagia, Haemorrhage from the Womb 691 Menstrual Anomalies. Menorrhagia 694 Amenorrhcea 700 Dysmenorrhcea - ^ Vagina. Catarrh of the Vagina: Vaginitis y XI XXX CONTENTS. Vaginismus. 711 Pruritus Vulvae 712 Mai inner. Mastitis, Inflammation of the Breasts 713 Scirrhus seu Carcinoma Mammae; Scirrhus, or Cancer of the Breast 715 SPINE. Anaemia 718 Hyperaernia 718 Apoplexy 719 Spinal Irritation 721 Hydrorrhachis Congenita; Spina Bifida 723 Leptomeningitis Spinalis 724 Myelitis, Inflammation of the Spinal Marrow 726 Myelomalacia, Non-Inflammatory Softening of the Spinal Marrow 728 Multiple Sclerosis 728 Tabes Dorsalis, Locomotor Ataxia 730 Spasmodic Spinal Paralysis 734 Polyomyelitis Anterior Acuta 735 Polyomyelitis Anterior Subacuta, et Chronica 436 Paralysis Ascendens Acuta 736 Coccyodynia 737 MOTORY APPARATUS. Rheumatism 739 Rheumatismus Articulorum Acutus, Rheumatic Fever 739 Rheumatismus Muscularis, Muscular Rheumatism 741 Gout, Podagra, Arthritis 753 Arthritis Deformans. . 755 Rachitis, Rickets 756 Malacosteon, Osteomalacia 758 Progressive Muscular Atrophy 758 9 Osteites, Caries, Necrosis 760 Tuberculosis of the Joints. White Swelling 762 Coxarthrocace, Coxalgia, Hip Disease * 763 Gonarchrocace, Tumor Albus Genu, White Swelling of the Knee 765 Bursitis 767 Podarthrocace, Abscess of the Ankle Joint 767 Malum Potii, Kyphosis, Angular Curvature of the Spine 768 Panaritium, Paronychia, Whitlow, Felon • 769 Bunion ■ ■ 771 Ingrowing Toe-Nails 771 NERVES. Anatomical Diseases of the Peripheral Nerves. Neuritis, Inflammation of the Nerves • 772 Atrophy of the Nerves 772 Hypertrophy and Neoplastic Formations of the Nerves 772 Functional Diseases. Hyperaesthesia, Anaesthesia 773 Neuralgia 774 CONTENTS . XXXI Cephalalgia; Heinicrania or Migrsena 775 Neuralgia of the Trigeminus or Fifth Nerve, Prosopalgia, Tic Douleuoreux. . . 784 Cervico-Occipital Neuralgia 790 Cervico-Brachial Neuralgia , 791 Intercostal Neuralgia 791 Lumbo- Abdominal Neuralgia 792 Mastodynia, Neuralgia of the Mammae 792 Sciatica 793 Anaesthesia 798 Anaesthesia of the Trigeminus 799 Spasm, Convulsion, Cramp, Hyperkinesis 800 Spasmus Facialis, Mimic Spasm 801 Mogigraphia, Graphospasmus, Writers' Cramp 802 Chorea, St. Vitus' Dance ' 802 Hysteria 806 Neurasthenia 810 Catalepsy • 812 Epilepsy 813 Eclampsia Acuta 823 Eclampsia Gravidarum, Puerperal Convulsions 823 Eclampsia Infantum 825 Tremor, Trembling 827 Paralysis Agitans 828 Paralysis, Akinesis 829 THE BLOOD. Cyanosis 836 Dissolution of the Red Blood-Corpuscles 837 L,eucocythaemia, Leukaemia 837 Hydraemia 838 Plethora 839 Symptomatic Anaemia, Oligaemia 839 Progressive Pernicious Anaemia, Idiopathic Anaemia 840 Chlorosis, Green Sickness 841 Scurvy, Scorbutus 848 Purpura Haemorrhagica, Morbus Maculosus Werlhofii 850 Haemophilia, Haemorrhophilia 851 ACUTE INFECTIOUS DISEASES. Fever 855 Clinical Thermometry 855 Crisis and Critical Days 857 Intermittent Fever, Fever and Ague S5S Pernicious Intermittent; Remittent and Continuous Malarial Fevers; Congestive Fevers S75 Yellow Fever 877 Dengue, or Break- Bone Fever SS8 Typhus S89 Typhus Exanthematicus, Petechial Typhus SS9 Typhoid Fever, Typhus Abdominalis, Enteric Fever S92 Relapsing Fever, Typhus Recurrens 919 XXX11 CONTENTS. Influenza, La Grippe 922 Parotitis, Mumps 923 Diphtheria, Diphtheritis 925 Tussis Convulsiva, Pertussis, Whooping-cough 939 Meningitis Cerebro-Spinalis Epidemica, Spotted Fever 943 Acute Miliary Tuberculosis 948 Anthrax, Malignant Pustule 950 Hydrophobia, Lyssa, Rabies 951 Tetanus 956 Cholera Asiatica 959 Erysipelas 969 The Plague 972 EXANTHEMATA. Measles 974 Scarlatina 978 Rubella, Rcetheln 994 Variola, Small-pox; Variolois, Varioloid 995 Varicella, Chicken-pox 1001 SKIN. Hypertrophy of the Skin. Ichthyosis, Fish-Skin 1003 Atrophy of the Skin. Rupia or Rhypia, Isolated Blisters 1013 Hyperemia and Anczmia of the Skin. Dermatitis, Inflammation of the Skin. Erythema 1004 Herpes 1005 Urticaria, Nettle-Rash IOO y Eczema 1008 Ulcus Varicosum ion Impetigo, Pustular Eruption ion Ecthyma; Isolated, Large Pustule 1012 Pemphigus, Pompholyx, Isolated Large Bullae or Blisters 1012 Furunculus, Boil 1014 Carbunculus, Carbuncle , 1014 Psoriasis 1015 Lichen 1016 Prurigo, Pruritus * 1017 Scabies, Itch 10 18 Prairie Itch, Prurigo Contagiosa 1020 Burns and Scalds 1020 Chilblains, Frostbites 1022 Anomalies in the Secretions of the Skin. Sudamina 1024 Foot-Sweats 1024 Anidrosis 1026 Comedo, Milium, Molluscum 1026 INDEX ....• 1027 RAUE'S SPECIAL PATHOLOGY. MIND, MENTAL DISEASES. We find very little agreement in the classification of mental diseases among the different authors on the subject. The difficulty to agree lies un- doubtedly in the varied combinations of psychical and physical symptoms which constitute these various and constantly changing affections. Are they purely mental, or are they merely the effects of somatic (cerebral or systemic) disorders ? In many cases it is certainly difficult to decide where the origin of the trouble lies. For instance, mania may be the effect of purely psychic causes, such as anger, chagrin or sorrow, especially if associated with emotions par- tially depressing and partially exciting like fear and love, sorrow and am- bition, great joy after great depression, enthusiasm even fanaticism after desperation and despondency. As regards somatic origin it may be caused by excessive heat or cold, fever, suppressed eruptions of all kinds, periods of evolution, excessive loss of vital fluids, of sleep, starvation, etc. And in some cases it may be the effect of both mental and bodily causes working together at the same time, for instance, when excessive intellectual or emotional excitations undermine the system upon the basis of which the continued nervous strain produces an outbreak of maniacal fits. All this proves merely that soul and body are very intimately connected and that in mental diseases the cause may rest on psychical as well as bodily ground and that, therefore, in treating such disorders we will have to look most carefully on both sides of the question. On the reciprocal relation between soul and body, I have treated in my " Psychology as a Natural Science," to which I here refer, especially to chapters 109 and no, and for the reason that this reciprocity establishes such great uncertainty between what might be a clear psychical or a clear somatic foundation, I shall dismiss the idea of classifying mental diseases into purely psychical and purely somatic affections. This cannot be done, because both are continually intermixed and the bodily cause is in most instances unknown. We will fare better if we establish our classification on a basis which the natural spheres of mental manifestations suggest, instead of attempting an 3 34 MENTAL DISEASES. artificial grouping of the subject. These spheres are the intellectual, the conative and the emotional spheres of psychic modifications. Even in this way we should not expect to escape all complications arising from the mixing of the different classes, but we at least build upon a ground which by its pre- dominant symptoms will clearly characterize the class to which these symp- toms belong. We must also take into consideration that all mental diseases, even the most violent and strangest, grow out of natural psychical developments, so that even in these disordered conditions there lies nothing of a foreign nature to the natural development of the soul. All are either exaggerations, or de- pressions or perversions of natural psychic developments, and there is no defi- nite line between a sound and a morbid mental development. The one may so gradually deepen or rise into the other that no one can say, here lies the boundary between the two. Insanity is therefore a term indefinable, and designates merely an abnormal or unsound state of the mind, either as an exaggeration or a depression of the mind in one or the other or several spheres of mental development. I. The sphere of the intellect or understanding may become deranged, first, by the excessive growth in strength of one or a group of mental modifi- cations, so that fixed ideas of various kinds grow to dominant or leading modifications of the mind and constitute all sorts of insane notions, as we find in Pa?'anoia (insanity, Verriicktheit) in its different forms, or secondly, by the great weakness of many or all mental modifications, which constitutes imbe- cility, dementia, stupidity, idiocy, cretinism either by an inborn weakness of the primary forces (idiocy, cretinism); or by a disturbed psychic development in consequence of bodily causes, such as epilepsy, apoplex}^, acute fevers of all sorts, excessive sexual indulgencies, or excesses in drinking spirituous liquors, excessive heat or cold, starvation, etc., or in consequence of psychical causes, such as fright, grief, anger, excessive joy, etc., or by a natural de- velopment during old age — dementia senilis. Paranoia, Insanity, Verrucktheit. This form of mental derangement is either acquired or inherited. In either case it grows to be of a chronic nature and its course goes often in leaps or jumps. Such aggravations are frequently attended by cerebral or psychical s}~mptoms. In both cases we have as main mental disorder delu- sive ideas which develop upon a prenatal tendency towards constitutional neuroses, such as neurasthenia, hysteria, hypochondria and abnormal or per- verse sexual desires and habits — commencing in the inherited form early in life, of which in one thousand cases Dr. Kraft-Ebing observed not a solitary cure, although frequently lucid intervals of varying duration and also long continued remissions with total latency of the delusive ideas of sensory de- ceptions have been observed. The acquired form is much more frequent than the inherited, and commences usually not before the 5th decennium, usually in females during the climacteric changes, although it may develop also at an earlier time of life. PARANOIA, INSANITY, VERRUCKTHEIT. PARANOIA SEXUAEIS. 35 The main contents of the delirium of such patients are fixed ideas of being persecuted or of being grand or rich personalities. Dr. Kraft-Ebing gives in his Lehrbuch der Psychiatrie , a work from which most of the newer writers have drawn much of their information without giv- ing the source where the}- found it — a description of a typical form of acquired Paranoia: The victims are queer from childhood; they are quiet, irritable, sus- picious subjects. Their main trouble is the fixed idea of persecution, con- stantly imagining that they are wronged either by a particular enemy or a general conspiracy against their life, welfare or prosperity. Exciting somatic causes are catarrhal affections of the stomach, uterine troubles, climaxis, neurasthenia, in consequence of masturbation, constitu- tional hypochondriacal or hysterical neuroses. By degrees their surround- ings appear to change in their imagination against them, and they appear to themselves as the victims of all kinds of intrigues about them. By degrees also their own behavior toward the outer world changes to greater irritability until at last the height of the disease may slowly or more suddenly transform the patient into a most dangerous and aggressive maniac, who kills not secretly, but openly, that which excites his suspicion, in the fullest belief of necessary self-defence. This condition of the patient terminates either directly in imbecility or is transformed into a different kind of delirium, into the opposite of what the patient has thus far imagined to be. From a poor persecuted victim the patient rises in his own imagination to the dignity of a prince, emperor, prophet, God, Messias, ruler of the whole world; mother of Christ, etc., etc. ' ' This interesting change of the personality is found at least in one- third of the cases, and, as far as my experience reaches, without exception in hereditary cases." Kraft-Ebing. The paranoia sexualis, a sub-division of the paranoia persecutoria, is found in the male almost exclusively in consequence of masturbation, which causes neurasthenia of the genitals or neurasthenia in general; in the female it may be brought about by the same causes or by diseases of the female organs, such as mal-positions of the uterus, etc. Its main features in both sexes are jealousy, with delusive ideas of being wronged and persecuted by their partners as well as by acquaintances and strangers. These delusive ideas are nurtured in both sexes by the slightest signs, or accidental incidents, which the jealous victim at once accepts in confirmation of his belief that his partner is false to him. By degrees it may be exaggerated to violent deeds toward the partner or the person who is supposed to be the rival. But just as the paranoia persecutoria frequentl} T turns into delusions of grandeur and riches, so does the sexual paranoia frequently change into the expansive form of erotomania, which consists of the fixed idea of being the favorite and the beloved of a person of the opposite sex of high rank. It 36 PARANOIA IXVENTORIA SEU REFORMATORIA. culminates in the exposure of the foolishly imagined love affair, excites ridi- cule from all sides, ends in necessary confinement in an asylum and with intermissions goes on for life. "A cure," Dr. Kraft- Ebing says, " I have never seen." Besides the erotic form of expansive paranoia can be mentioned the Paranoia Inventoria Seu Reformatoria. Such patients are always persons burdened by inheritance with con- stitutional tendencies towards neuroses, and are cranky and one-sidedly gifted, with a great deal of self-esteem. According to the character of their tendencies and education they dream a phantastical future of grandeur and power, or are brooding over new inventions or new discoveries, live in delusive ideas of being great poets, artists, social reformers, disdain in their excessive self-esteem to associate with all commoner people below their dignity, have mostly sill}', absurd ideas, though occasionally they may show some originality, which on first sight may deceive the unsuspecting observer- It is quite remarkable how such a crank in stirring, excited times may turn a large number of people to partisans in a particular cause. Only subsequent observations will gradually detect the uselessness and foolishness of such fanatically eccentric ideas, and undeceive those who were caught unawares by the seeming originality and brilliancy of these paranoias. The termination of such disorders is the mad-house, where the poor insane creatures continue in their delusive ideas, hoping the future will make it all right, or gradually grow distracted and completely crazed, and at last imbecile, though not fully idiotic. Another variety of the expansive paranoia is the Paranoia Religiosa. "The representatives of this group," says Kraft-Ebing, "are almost always persons of weak minds, whose narrow understanding is not capable of grasping the ethic contents of religion, but who take the exterior, glitter- ing forms of a cultus for the essence of religion." Such constant exercises from childhood in misunderstood formalities must eventually color the whole mind in its wa}' of thinking and feeling, and we need not wonder when by the influence of eloquent missionaries and zelotic priests, who paint heaven and hell in the liveliest colors, these poor and weak minds are lost in religious entanglements. At times this result may be brought about by hard blows of fate, which entirely estrange the mind from material interests and throw it into the arms of blind faith and religious formalities. The mental excitation reaches by degrees a state of extasis which soon combines with hallucinations, in men with glorification and communion with the holy ghost, in women, often in consequence of sexual excitement, with fixed ideas of becoming mothers of God through the influence of the holy ghost. Frequently these sublime extases are interspersed with paroxysms of precordial anxiety and a sense of deepest contrition, or feelings of sinful un- PARANOIA RKLIGIOSA. 37 worthiness, with a desire of clearing away the sins by self-punishment and to oppose the temptations of the devil by all means. Although in asylums for the insane, by isolating these poor creatures from religious exercises, their exaltations may be lessened, their morbid tendency still remains; long-continued confinement, however, may gradually change them into useful, industrious inmates of the institution. The main danger with these patients is, that in paroxysms of depression they may be driven to self-mutilation, or in paroxysms of fanaticism to attacks upon others. The termination of religious paranoia is imbecility, but not total apathic idiocy. Therapeutic Hints. The old school knows only of palliatives, to force sleep by subcutaneous injections of Morphium or other hypnotics, such as -Sulphonal, Chloral, etc., •which are all supposed to be means to induce sleep, whilst, in fact, they merely produce stupefaction. Bromides in large doses against sexual irritation and hallucinatoric deliria do certainly quiet these irritations, but they also gradually depress plrysical and psychical life to a degree that nothing but a wreck is left, unable to get up any kind of excitement at all. The best of all is the asylum for the insane, in which they may find, we hope, shelter and protection against the outside world and their own self. In this way, by well-directed methods, their mental confusion may be greatly lessened. As homoeopathic remedies I shall give only briefly the most important indications for their use and refer for closer study to Jahr's "Mental Diseases. ' ' . Aconite. Fixed ideas, worse at night, with restlessness and anxiety, fear of death; prediction of hour of death. Agaricus. Makes verses, sings; laughs, thinks himself immensely wealthy; appears very happy. Amm. carb. Anguish as if he had committed a crime; loathing of life. Aiiacardium. General insane notions; hallucinations of sight and hear- ing; sees a bier in next room, upon which he himself or a friend is lying as a •corpse; hears his name called by deceased relatives; timid and apprehensive; great loss of memory; swearing and cursing. Ant. crudum. Ecstatic love; sentimental, distrustful; gastricism. Apis mell. Paranoia senualis; jealous; nymphomania; pain, tenderness and dropsy of ovaries, especially the right. Argent. ?iit. Believes he is despised by his family; fixes da} T of death; always hurried, must walk very fast; suicidal sadness, but lacks courage. Arsen. Sees an absent person lying dead before him; sees ghosts; believes thieves to be in the house, for whom he searches; sees worms on his bed; jumps out of bed from fear and conceals himself; "perspiration from fear; kneeling and holding of the hands in an entreating manner ;" great 38 THERAPEUTIC HINTS TO PARANOIA. anxiousness; ringing as of bells in the ears and vision of a person hanging by the neck, with inclination to hang himself. Aurum. Religious insanity with praying and weeping. Mercurial poisoning. Baptisia. Imagines he " cannot get himself together;" as if the pieces of his body were scattered about. Bell. Illusions of all the senses: beautiful images, or frightful visions of ghosts, insects, bats, black dogs that will bite, devils, soldiers and execu- tioners, who want to take away the patient; fixed ideas of journeying home, where he believes everything is destroyed by fire; buffoonish insanity , with ridiculous and foolish actions; conceals herself; tries to escape; walks about with busy, important looks; loquacious, lascivious; growling and barking like a dog; singing, whistling, trilling, hopping, dancing. Berberis. Urinar} T and menstrual, arthritic and hepatic derangements. Bry. Thinks himself in a strange place; wants to go home; dreams full of business. Calc. c. Fears to lose his reason; hallucinations of sight and hearing. Camphora. Puerperal rage; indecent language; strips himself naked; tries to jump out of window; lochia suppressed; erethism of sexual system. Cannab. Bid. Roaming hallucinations in grand style; happy or terribly horrifying; conception of time and space exceedingly exaggerated; dreamy, as if things were not real. Canth. Frenzied with sexual excitement; masturbation; inflammation of bladder with strangury. Cicuta. Everything about him appears strange and frightful; staring look; insane dancing, laughing, clapping of hands with hot and red face; childish, happy feeling about little things. Cimicifuga . ' ' Suspicious of everything; would not take medicine if she knew it; indifference, taciturn, takes no interest in household matters; fre- quent sighs and ejaculations." (Dunham.) Confused and wild; intense anxiety and pain about the heart; functional disorder, from mental depres- sion; puerperal melancholy and mania, with sleeplessness. Cocculus. Weakened, miserable subjects from onanism and other debili- tating causes, such as sickness, disappointment in ambition, from anger or grief. Changing with lively humor, etc. Conium mac. Consequences from not satisfied sexual desires. Crocus sat. Great cheerfulness, mirthful and witty; quarrelsome mood, followed by repentance and timidity; wants to kiss everybody; very affec- tionate; uterine haemorrhages. Cuprum. Foolish gestures of imitation and mimicry; full of insane, spiteful tricks; again, anxiety and despair, shrinks away from everybody. Cyclamen. Mental derangement at climaxis. Hyosc. n. Erotic hallucinations and jealousy are its main features. Ign. Sexual paranoia; thinks she is married and pregnant; suffers terribly from imaginary sins, and tries to escape and drown herself; is more THERAPEUTIC HINTS TO PARANOIA. 39 quiet when left alone, but if interfered with her ideas becomes wild and crazy. (Gross. ) Lack. "Jealous insanity; ecstatic insanity; loquacious insanity after over-study, with long speeches, rapidly passing from one idea to another, and pride and mistrust toward those about him; religious insanity, believes himself to be predestinated by God to be everlastingly damned." ( Jahr.) Lilium tig. Religious paranoia; doubtful of her salvation, worse by consolation; sexual paranoia; strong sexual desire, obscene talking. Uter- ine disturbances. Merc. sol. BufFoonish insanity; does all kinds of absurd things and sees frightful visions at night when in bed; uncovers himself at night, throws bedclothes around and uses abusive language. (Jahr.) Suicidal inclina- tion, after suppression of foot-sweat; syphilitic taints. Nux vom. After allopathic drugging; abuse of coffee, mental exertion, loss of sleep; fixed ideas of wounded pride; domestic worries; constantly talking about one thing. Opium. Fantastical and sexual insanity, both with audacity or great fear; indifference to joy or suffering; effects of being stunned psychically by hard blows of fate. Phosphor. Imagination of grandeur; satyriasis and nymphomania in old people, with insane shamelessness; want to expose themselves and go naked; excitement of sexual desires and destructive tendencies; somnambu- listic states. Platina. Pride, arrogance; thinks himself above everybody; and again low-spirited; fearful; precordial anguish with violent weeping and fear of death; sexual excitement; bodily symptoms alternate with mind symptoms. Plumbum. Fixed ideas of being persecuted; hears voices and sees frightful things; maniacal rage with cries, brawling and convulsions. Pulsat. Anxious and tearful; terrible visions which throw her into great fear; think they will not be saved; feel tired of life; think of drowning themselves. The psychic derangement is mostly in connection with bodily irregularities during pregnancy, child-bed or monthly troubles. Sabad. She considers herself pregnant; he fears that his sexual parts are shrinking; maniacal rage better from the application of cold water to the head. Secale. Insanity with senseless actions and inclination to treat his rela- tions contemptuously and sarcastically; inclination to drown himself. Strammonium. Excited state; sometimes abusing others; more fre- quently constant talking, foolish laughing and acting, restlessness and desire to go away; visions of ghosts and fighting with them; visions of animals; sexual irritation; wants to be kissed, and indecent, lewd talk; great agility in muscular motions. Depressed states are changes sometimes with the excitement, thinking that he is not worthy of salvation, etc.; proud, lascivi- ous, enthusiastic, religious, buffoonish insanities. Sulphur. Fearful; unconsolable about all she does as bad and wicked; 40 DEMENTIA PARALYTICA. religious insanity about his soul's salvation; indifferent about the lot of others; foolish, happiness and pride; everything, even rags, appear beauti- ful; inclined to decorate himself with gaudily colored rags, believing to have everything in abundance, though emaciated to a skeleton. Everything has a disgusting smell to him, as if coming from his own body, without having soiled himself. Tarantula hisp. Paranoia sexualis; sudden insane paroxysms with fox-like and destructive efforts. J r iratr. alb. " The excited state of mind showed itself in raving, laugh- ing, singing, whistling, and constant indecent talking, with sexual excite- ment . \ ' — Riikerf s Klin . Erf ah rn?ige?i . DEMENTIA PARALYTICA Is understood as " a diffused disease of the brain and often also of the spinal cord, which is characterized by a peculiar combination of physical changes with motor disturbances in the muscles of different parts of the body, which has a chronic course and ends in death." (Hitzig.) In the protracted cases post-mortem always shows atrophy of the brain, which can be recognized by inspection and frequently by weight. The dura lies in folds over the frontal lobes; the pia is either locally or universally cedematous; the ventricles are enlarged; the dura often adheres so firmly to the skull that it cannot be removed without injuring the brain; it may pre- sent all varieties of dulness, thickening and deposits upon its surface, also innumerable larger or smaller flattened extravasations, which have all shades of color between yellow, red and black; even large haematomas have been found; yet there are numerous other cases in which the dura appeared intact. The brain tissue by microscopical examination reveals a chronic or sometimes a subacute interstitial (peri) encephalitis, which in course of time leads to destruction of the ganglion cells and to atrophy of the brain. The spinal cord presents gray degeneration of the posterior columns or granular cell myelitis; the membranes of the spinal cord undergo, though more rarefy, changes similar to those of the brain. As predisposing causes heredity has been mentioned. Probably the combination of excessive labor with excesses in Baccho and Venere is the most common cause, although injuries of the head, constitutional syphilis and the influence of acute febrile diseases may also give rise to the develop- ment of this disease. It scarcely occurs under the age of twenty; is most frequent between thirty and forty-five or, according to some authors, between fifty and sixty years of age. Its Prodromal Symptoms, which sometimes for years precede the final outbreak, are the most important for the physician, because then and there lies his only chance of preventing greater mischief. Spells of dizziness, which pass over quickly ; of headache, more or less severe and worse in the morning; of rheumatic pains, especially in the lower extremities, changing SENILE DEMENTIA. 4 1 location and coming and going suddenly, worse at night. With these chance symptoms appear an unusual irritability of character entirely foreign to the patient's former behavior, and a weakness of memory, especially for recent events, while past ones are well remembered; he often forgets his hat, his cane, or pocket handkerchief, etc., the muscles around his mouth occasionally are seen to tremble either spontaneously or when other facial muscles are in action. The patient is unconscious of it, and recognizes the fact only when he sees it in the mirror; his speech becomes nasal, or difficult and imperfect, especially in regard to the labials and sibilants; a kind of lisping as if slightly intoxicated; the tongue trembles, and the voice changes. Apoplectic attacks are often the commencement of the disease. In its furthei progress the patient shows peculiar exaggerated ideas of his own importance or greatness, he possesses a thousand or a million horses, a thousand million dollars, etc., and although now it may be proved to him that he is wrong, he immediately forgets all about it, and gradually falls into an idiotic silliness from the weakness of memory, which was one of the very first symptoms of the disease. He also gradually loses his affection for his family, and before his friends may have become aware of his unaccountable- ness he may have squandered away the very subsistence of his family. Sometimes there are outbursts of anger amounting to blind rage, making him dangerous to those around him, and in other cases we meet with depress- ing, hypochondriacal, melancholic states of mind, which again may inter- change with conditions of excitation. So also is kleptomania of frequent occurrence; the patients pocket things without in fact knowing it, or carry them away openly, because they believe they are making use of their own property. The motor changes consist either of disturbances of co-ordination — staggering when the eyes are shut; jerking, uncertain gait, difficulty of turning round, peculiar trembling, jerking handwriting — when there is gray degeneration of the posterior columns — or shuffling, awkward, helpless gait, unsteadiness on attempting to turn quickly, but no increased swaying of the body when the eyes are shut — when there is granular cell myelitis. More or less complete, persistent, unilateral facial paralysis is often noticed, and if apoplectic attacks repeat, they leave behind hemiplegia which may dis- appear again, while the intelligence degenerates so much more quickly; or the attack is often combined with unilateral or general epileptiform spasms, ending occasionally in death. Ansethesia, persistent and extreme, is found in all cases, when far enough advanced. SENILE DEMENTIA. "To be perfectly candid, we must confess that there is not a single symptom which is so pathognomonic of general paralysis that it may not be found also in senile dementia, and excepting the peculiar weakness of mem- ory, in alcoholism also; and even the grouping of the sj'mptoms as a whole may, in the two latter diseases, be such as to afford an entire analogv with 42 SENILE DEMENTIA. undoubted cases of general paralysis. In senile dementia the course of the affection itself often enough furnishes no definite conclusion, while alcoholism certainly affords a much more favorable prognosis. ' ' ' ' Only those cases can with certainty be considered as senile dementia in which advanced age, want of motor disturbances, or the presence of very marked hemiplegia, and, finally, absence of the extravagant delirium of grandeur, are all found associated. The delirium of old age is, as a rule, almost invariably of a more childish nature, while it is concerned with the most diverse subjects. Besides, epileptiform attacks almost never occur in the dementia of age, and the apopletic attacks of these old people are accom- panied with serious permanent paralysis, if the}' do not end in death. Finally, the course of senile dementia is regular, less broken by remissions and inter- missions. Nevertheless, that is an uncertain criterion, and the same may be said to a still higher degree of all the other diagnostic points mentioned above." (Hitzig. ) The anatomical changes in dementia senilis are atrophy of the hemis- pheres of the brain and at the same time an atherosis of the arteries. The atrophy is most clearly seen in the cerebral convulsions. Microscopically there are found changes in the ganglion cells of the cortical portions of the brain. Corresponding to these alterations we find thickening of the skull, collec- tion of serum in the arachnoideal space and in the ventricles, pachymenin- gitis externa and interna, oedema of the pia. The course is always chronic, taking years to end the same, which usually ensues in consequence of cerebral complications, pneumonia, bladder affections, decubitus, colliquative diarrrhoeas. Therapeutic Hints. — Of great benefit in the course of this disease, as well as'of dementia paralitica, may be the following remedies: Amm. card., gloomy and uneasy mood, aggravated by cloudy weather; low spirits, with considerable excitement; verj^ forgetful, and headache when reflecting; absence of mind, with anxiety; speaks and writes incorrectly; women lose all taste for dress and nearly their intelligence; weight and con- fusion of the head; vertigo, as from intoxication; great lassitude, and disin- clination to all work; most severe muscular contractions, spasms; violent rheumatic drawing pains through all the limbs, hands, feet, nape of the neck, head, etc. (Lilienthal.) Aurum. — We here find hypochondriasis, but not melancholia so much; the epilepsy rests upon a very material basis; the exhaustion is a natural consequence of premature senility, hence the disgust of life, and we mention it only as having many symptoms in common with the prodromal stage, but the causes being so often different, it will be only in rare cases of real benefit. It maj 7 alleviate, but will not stay the ravages of this disease. Bcllad., after excessive fatigues, bad nourishment, loss of sleep, pros- trated, enfeebled, imbecile; dilatation of pupils. (Gallavardin.) Caustic, great melancholy, looking on the dark side of everything; facial neuralgia and facial paralysis; weakness of voice, and other paralytic THERAPEUTIC HINTS TO DEMENTIA. 43 affections. Hypochondriac depression of spirits; peevishness; dull, gloomy; pressure on the brain making the head feel obtuse; vertigo; incipient amau- rosis; roaring and buzzing in the ears; rheumatic and arthritic affections of all kinds; tremulous weakness; epileptic convulsions; prosopalgia; para- lytic affections, especially of one side. Tearing, lancinating pains of the extremities; muscular twitchings, and excessive weariness in both limbs, especially in the morning in bed; attacks of spasms, in the morning in bed, sometimes with consciousness, at other times with unconsciousness; peevish, irritable mood, fretfulness, indolence; slow succession of thoughts, absence of mind with loss of ideas; weakness of memory; vertigo, forward and sideways, at night in bed; vertigo, almost like a loss of consciousness, while sitting he nearly fell; constrictive pressure in the forehead; tensive headache arising from the nape of the neck; indistinct vision, it seems as though a thick cloud hovered before the eyes; spasmodic sensation in the lips, etc. (Lilienthal. ) Cuprufn — What Zincum is for later stages Cuprum might be for the prodroma. According to Schmid, of Vienna, all the cerebral disorders cured by Cuprum are of the reflex order, which would limit the applicability of Cuprum in dementia paralytica to very rare cases; still, Rademacher's in- dication, when there is premature exhaustion of strength in illness, may point towards its use in patients of neurotic temperament, especially where heredity can be shown. Laches. , for persons with a melancholic or choleric temperament, with a phlegmatic, spong\ T constitution; with dark eyes and disposition to lowness of spirits and indolence; for acute and chronic rheumatism, recurring every year; for emaciation and exhaustion; for hemiplegia; for convulsions and epilepsy. Among its symptoms we read: Indolent, taciturn, brooding and melancholic; he considers himself too feeble to do anything, with aggrava- tion of the symptoms every other day; great absence of mind; great weak- ness of memory, he forgets entirely what he had been hearing a moment be- fore; frequent mistakes in writing; vertigo, with staggering to the left side, early in the morning after rising; deep stinging through the whole head deep-seated headache; sensitiveness of the eyes to light; dim and weak eyes very sensitive to noise; prosopalgia; distortion of mouth and lips; difficulty of speech, as if the tongue were too heavy; rheumatic pains extending from the back to the limbs; difficulty of falling asleep for weeks; no sleep in spite of great lassitude; constant exhausting sleeplessness; aggravation of all com- plaints after sleeping; painful wandering of the pains from one part to another; awkward, stumbling gait ; hemiplegia; t} T pical recurrence of the aggravations. (Lilienthal.) Natr. mur., "brain fag from overwork; difficulty in thinking; sad; angry at' trifles; called up all the past grievances and loved to dwell upon them; headache as though the head would burst, worse in morning 011 awak- ing, from thinking and reading; sweating at times; neuralgic pains occasion- ally running up back of neck, like stitches; frequent attacks of uncontrol- able weeping, during which any attempt at consolation is met by a violent 44 THERAPEUTIC HINTS TO DEMENTIA. outburst of anger; flares up at the merest nothing, followed by weeping; forgetful; omits words in writing; tells the same story over and over again. Eyes sensitive to light; blur as soon as he attempts to read; eyeballs feel stiff when moving them; humming in the ears; speech drawling, with numb- ness and stiffness of tongue, especially in the morning; appetite good, often ravenous; sometimes cramp in stomach, better from tightening clothes; tongue slightly coated white, in morning feels dry and sticky (but is not so), and burns, especially at tip; more or less loss of taste; posterial nasal catarrh with loss of smell and hawking of clear mucus in the morning; when first awaking mouth is dry, burns a little and feels sore; lips dry; very thirsty, especially towards night; wants all his food very salt; empty eructations, especially after eating; bowels constipated; stools light brown or yellow, crumbling, very difficult owing to actual contraction of anus, as well as in- activity of rectum, followed by burning and smarting at anus; urine clear, light-colored and passed too frequently; any excitement causes immediate desire to urinate; bruised, lame pain in small of back, as though he could not stand straight, relieved by pressing something hard against it; hands tend to go to sleep; unrefreshed and dizzy in the morning; itching and pricking in various parts, skin unhealthy; sweats very easily with great relief; skin of face has greasy look. Attacks intermittent; painful sensations in various localities; better in open air." (F. F. Laird, Hah?ie?nan?iia?i Monthly , April, 1882.) " Haggard eyes, dull features, just intelligence enough to ask me to cure him, in senile dementia; formerly subject to haemorrhoids." " Begin- ning general paralysis; unjustifiable antipathy against certain persons, with increasing awkwardness . " ( Galla vardin . ) Nux vom. exactly suits such cases which owe their origin to sexual excesses and immoderate intellectual exertion, and also to persons of middle age, especially when they have changed their former busy life for a quiet one. Among its symptions we find: Periodical affections of the nervous system; tearing, drawing-tensive rheumatic pains, with weakness and feeling of numb- ness in the affected parts; hyperesthesia of the nerves of the senses; tonic spasms and convulsions; emotional epilepsy; central softening of the spinal cord (here also the gray matter); paralysis of the upper and lower extremi- ties; periodical headache, gradually increasing, and after reaching its acme, gradually decreasing; dulness of mental powers; obscuration of sight; pa- ralysis of the tongue, with difficult and indistinct speech, in consequence of cerebral apoplexy. The irritable temper of Nux is well known, and even for the second stage of the disease we find corresponding symptoms, as awk- wardness, he easily stumbles against something; makes mistakes in speaking and writing (certainly cerebral functions); compression of the head as from nightly revelling; chronic vertigo, with obscuration of sight and buzzing in the ears; twitching of the facial muscles; distortion of the mouth to one side, etc. (Lilienthal.) Phosphor, is the grand remedy for a weak, exhausted brain. Here we have to deal with a disease whose whole tendency is to degeneration of the DIGEST TO DEMENTIA PARALYTICA. 45 nerve-mass, to atrophy of the brain, and we might with certainty expect some benefit from a remedy which causes fatty degeneration throughout the bod}\ Among its symptoms we find: Great lowness of spirits; great irrita- bility; forgetful and dizzy; vertigo; dull, stupefying headache; constrictive headache every other day; frequent attacks of sudden blindness in the day- time, and sensation as if a gray cover were hanging over the eyes; constant buzzing in the ears; pale, sickly complexion; great weariness in the extremi ties; sleeplessness and restlessness; heaviness of mind and body; exaggerated ideas of his own importance; monomania le grandeur et de la richesse; for- gets names and what has happened recently; unconnectedness of ideas when writing or talking; lastly silliness; idiocy. Silic. Carroll Dunham, in his usual masterly manner (N. A.J. of H. y xx, 361), thus describes the action of Silicea on the nervous system: " With evidence of exhaustion, furnished by sensation of weakness, paralysis, etc., there is an exalted condition of susceptibility to nervous stimuli; the special senses are morbidly keen, the brain cannot bear even moderate concussion, and the whole surface is unnaturally tender and sensitive; cold aggravates and warmth relieves. There is an erethism, conjoined with exhaustion, which is not evanescent, but endures for some time." Certainly such a remedy promises much in the prodromal stage of our disease, and carefully studied and applied in the right case may fulfill this promise and lead to a cure . ( Lilienthal . ) In addition I may recommend to compare corresponding chapters, pre- viously treated of, and also chronic alcoholism. Digest to Dementia Paralytica. STAGES. For prodromal stage: Cuprum, Nux vom., Silic. For the second stage with symptoms like: awkwardness, he easily stumbles against something; makes mistakes in speaking and writing; compression of the head as from nightly revelling; chronic vertigo, with obscuration of sight and buzzing in the ears; twitching of the facial muscles; distortion of the mouth to one side: JSfux vom. For later stage: Zincum. Loss of memory: Arg. nitr. Weak memory: Carb. veg., Caustic. for what has happened: Graphit., Natr. mur., Phosphor., Sulphur. for words and names: Baryta, Lycop. , Phosphor., Sulphur. on awaking: Stannum. with debility: Nitr. ac. with headache: Kalmia, Moschus. Forgets entirely what he had been hear- ing a moment before: Laches. Forgetfulness : Amm. carb., Capsic, Caustic, Mezer., Moschus, Natr. mur., Viol. od. Forgetfulness, and dizzy: Phosphor. Unconnectedness of ideas when writing or talking: Phosphor. Speaks and writes incorrectly: Amm. carb. Frequent mistakes in writing: Laches. Omits words in writing: Natr. mur. Incapable for doing business: Arg. nitr. Awkwardness : Natr. mur. Great absence of mind: Laches. Loses the train of ideas: Amm. carb., Caustic. Absence of mind, with anxiety: Amm. carb. Tells the same thing over and over again : Natr. mur. Calls up all past grievances to dwell upon them: Natr. mur. 46 DIEGST TO DEMENTIA PARALYTICA. Heaviness of mind and body: Phosphor., Phosph. ac. Slow succession of thoughts: Caustic. Obtuseness of intellect with obscuration of eyes: Carb. veg. Dlllness of mental powers: Xux. vom. with prostration: Alum, Anac, A u rum.. Digit. Difficulty of thinking: Xatr. mur. Mental listlessness and nervous affection: Xux mosch. and physical prostration in the morn- ing: Laches., Phosph oi'. Nearly loses intelligence: Alum, carb., Xatr. mur. ,^ Bodily and mental infirmity: Xatr. carb. Silliness, idiocy: Phosphor. Prostrated, enfeebled, imbecile after ex- cessive fatigues, bad nourishment and loss of sleep : Bel I ad. Idiotic condition before the attacks: Caust. exaggerated ideas of his own impor- tance, monomania le grandeur et de la richesse: Phosphor. Doxoniania, conceited mania: Platina, Cuprum, Hyosc, Laches., Lycop., Stra. mon., Veratr., Alum., Arnica, China, Conium, Ferrum, Lpec, Paris, Phos- phor., Secale. Mania de grandeur: Cuprum, Platina, Lycop., Laches., Stramon., Veratr. Periodical mania: Arg. nitr. Weeping" spells, during which any at- tempt at consolation is met by a violent outburst of anger: Xatr. mur. Kleptomania: Sulphur, Pulsat., Arsen., Bryon., Kali, Lycop., Xu.v vom., Sepia. Extravagance: Amnion., Bel I ad., Caus- tic, Chin in., Iodine, Petrol., Phosph. ac, Platina, Stramon., Sulphur, Veratr. Indisposed to work or walk: Ziiicum. Great lassitude and disinclination to work: A mm. carb. Lassitude with irritability: Ambra,Calc carb., Carb. veg., Caustic. No ambition, soon tires: Xux vom. Loses all interest in work and business: 4 Irg. nitr. Indolence : Caustic taciturn and brooding: Laches. Sad: Xatr. mur. Great lowness of spirits: Phosphor. and indolence; with dark eyes: Laches. with considerable excitement: A mm. carb. Women lose all taste for dress: Amm. carb. Melancholy: Arg. nitr., Laches. looks on the dark side of everything: Caustic. with a phlegmatic spongy constitu- tion: Laches. Gloomy and uneasy mood, aggravated by cloudy weather: Amm. carb. Hypochondriasis: Aurum. Fear, by noise in the street: Caustic. Disgust of life: Aurum. Great irritability : Xux vom., Phosphor. and discontented: Xux vom. Peevish, irritable mood, fretfulness: Caustic. Fretful, discontented, complaining: Arsen. Angry at trifles: Xatr. mur. Flares up at the merest nothing, followed by weeping: Xatr. mur. Antipathy against certain persons: Xatr. mur. Vertigo: Arg. nitr. Vertigo on walking with shut eyes: Arg. nitr. on seeing high houses; it makes him stagger: Arg. nitr. as from intoxication: Amm. carb. almost like a loss of consciousness, while sitting he nearly fell: Caustic. dull, stupefying headache: Phosphor. forward and sideways, at night in bed: Caustic. with staggering to the left side, early in the morning after rising: Laches. and unre freshed in the morning: Xair. mur. Congestions to the head: Arg. nitr. Headache with diminished intellectual power: Phosphor., Nux mosch., Sarsap. with ill-humor, and especially in the forenoon: Amm. carb., A'reos., Platina, Petrol., Stannum (gradual increase and gradual decrease), Calc. phosph., Phos- phor. from reflecting: Amm. carb. DIGEST TO DEMENTIA PARALYTICA. 47 as though head would burst: Natr. mur. worse in morning on awaking: Natr. mur. worse from thinking or reading: Natr. mur. worse from reflecting: Amm. carb. Periodical headache, gradually increas- ing, and after reaching its acme gradu- ally decreasing: Nux vom., Stannum. Deep-seated headache: Laches. Pressing pain all over the head, some- times only on the left frontal bone, bet- ter by external pressure: Arg. nitr. Pressure on the brain making the head feel obtuse: Caustic. Constrictive pressure in the forehead: Caustic. headache every other day: Phosphor. Tensive headache arising from the nape of the neck: Caustic. Weight and confusion of the head: Amm. carb. Deep stinging through the whole head: Laches. Sensation in forehead as if the skin were too tight, with anxiousness: Phosphor. The brain cannot bear even moderate concussion: Si lie. Eyeballs feel stiff when moving them: Natr. mur. Dilatation of pupils: Bellad., Calcar., Crocus., Hyosc, Nux vom., Opium. The special senses are morbidly keen: Silic. Sensitive to light: Arsen. , Laches., Natr. mur. Dim and weak eyes: Laches. Indistinct vision, it seems as though a thick cloud hovered before the eyes: Caustic. Blurr as soon as he attempts to read: Natr. mur. Sees objects cloudy, sometimes double: Arg. nitr. Obscuration of sight: Nux vom. Frequent attacks of sudden blindness in the daytime, and sensation as if a gray cover were hanging over the eyes: Phosphor. Capsic, Caustic, Petrol., Pulsat. Very sensitive to noise: Laches. with ill-humor: Bellad., Phosphor. Humming' in ears: Natr. mur. Roaring and buzzing in ears: Caustic. Posterior nasal catarrh with loss of smell: Natr. mur. Face looks old, and of earthy color: Arg. nitr. emaciated, colorless: Arg. nitr, Haggard eyes and dull features: Natr. mur. Pale, sickly: Phosphor. Greasy look: Natr. mtir. Prosopalgia: Caustic, Laches. Distortion of the mouth: Bellad., Graphit., Laches., Lycop., Nux vom., Opium, Phosph. ac, Secale., Stramon. Spasmodic sensation in the lips: Caustic Lips dry: Natr. mur. Oversensitiveness of hearing: Carb. veg. Noise unbearable, with anxiety: Aurmn, Mouth dry; burning and sore in morn- ing: Nat?, mur. Tongue feels dry and sticky; but is not so: Natr. mur. burns at tip: Natr. mur. slightly coated white: Natr. mur. Loss of taste: Natr. mur. Speech drawling, with numbness and stiffness of tongue, especially in morn- ing: Natr. mur. Difficult speech: Bellad., Caustic, Laches., Nux vom., Opium, Sulphur, Stramon., Verat. Paralysis of the tongue, with difficult and indistinct speech, in consequence of cerebral apoplexy: Nux vom. Cannot move the tongue right, with anx- iety: Caustic. As if tongue were too heavy: Laches. Cannot talk: Arg. nitr. Hawking of clear mucus in morning: Natr. mur. Hoarse voice: Arg. nitr. Appetite good, often ravenous: Natr. mur. Craves all food very salt: Nat/ . mur. Very thirsty, especially toward night: Natr. mur. Empty eructations after eating: Natr. 48 DIGEST TO DEMENTIA PARALYTICA. Cramp in stomach, better from tighten- ing clothes: Natr mur. Constipation: Natr. mur. Stools light brown or yellow, crumbling, very difficult owing to actual contrac- tion of anus, as well as inactivity of rectum, followed by burning and smart- ing at anus: Natr. mur. Haemorrhoids formerly: Natr. mur. Desire to urinate from any excitement: Natr. mur. Urine clear, light colored and frequent: Natr. mur. Rheumatic pains extending from the back to the limbs: Laches. Violent rheumatic drawing pains through all the limbs, hands, feet, nape of the neck, head, etc.: Amm. card. Rheumatic and arthritic affections of all kinds: Caustic. Acute and chronic rheumatism, recur- ring every year: Ladies. Tearing, drawing tensive rheumatic pains, with weakness and feeling of numbness in the affected parts: Nux vom. Tearing, lancinating pains of the ex- tremities: Caustic. Painful wandering of the pains from one part to another: Laches. Great weariness in the extremities: Phos- phor. Bruised, lame in small of back, as though he could not stand straight, better from pressing something hard against it: Natr. mur. Periodical affections of nerves: Nux. vom. Creeping as of ants in arms and legs: Arg. nitr. Hands tend to go to sleep: Arg. nit. Entire insensibility of the body, except against cold air: Arg. nitr. The whole surface is naturally tender and sensitive: Silic. Hyper aesthesia of the nerves of senses: Nux vom. Neuralgic pains like stitches up back of neck: Natr. mur. Intercostal neuralgia: Arg. nitr. Muscular twitchings and excessive weari- ness in both limbs, especially in the morning in bed: Caustic. Most severe muscular contractions, spasms: Amm. card. Attacks of spasms, in the morning in bed, sometimes with consciousness, at other times with unconsciousness: Caustic. Tonic spasms and convulsions: Nux vom. Convulsions with or without conscious- ness: Kati card., Lycop., Nux vom., Platiua, Plumbum. and epilepsy: Laches. Epileptic convulsions, paralytic affec- tions, especially of one side: Caustic. fits as complication: Arsen. , Bet lad. , Calcar., Cuprum., Hyos., Lgnat., Laches., Mercur., Opium, Nux vom., Plumbum, Pulsat., Sulphur. Emotional epilepsy: Nux vom. Weakness of the whole left side: Arg. nitr. Beginning general paralysis: Natr. mur. Constant trembling of the hands: Arg. nitr. Trembling of limbs: Arg. nitr. Tremulous weakness: Caustic. Awkward, stumbling gait: Laches. Cannot walk with shut eyes: Arg. nitr. Exhaustion, sensation of weakness, pa- ralysis, etc., with an exalted condition of susceptibility to nervous stimuli: Silic. Hemiplegia: Laches. Paralysis of the upper and lower ex- tremities: Nux vom. Paralytic affections: Caustic. Sleepy in daytime, sleepless at night: Arg. nitr. Sleep disturbed by restless dreams: Arse?i. No sleep in spite of great lassitude: Laches. Difficulty of falling asleep for weeks: Laches. Sleeplessness before midnight: A rsen., Kali carb., Pulsat., Verat. Constant exhausting sleeplessness: Laches. Sleeplessness and restlessness: Phosphor. Aggravation of all complaints after sleeping: Laches. Sweating at times: Natr. mur. Sweats easily with great relief: Natr CHECKED EVOLUTION OF THE PSYCHICAL DEVELOPMENT. 49 Itching" and pricking in various parts: Natr. mur. Skin unhealthy: Natr. mur. Tired: Arg. nitr. Lassitude in the limbs, with indisposition to work: Amm. carb. He considers himself too feeble to do any- thing, with aggravation of the symp- toms every other day. Laches. Emaciation: Arg. nitr., Laches. AMELIORATION, AGGRAVATION AND CAUSES. Wants fresh air, windows open, yet to be covered: Arg. nitr. Feels worse in open air: Natr. mur. Cold aggravates and warmth relieves: Silic. Intermittent attacks: Natr. mur. Typical recurrence of the aggravations: Laches. Brain-fag" from overwork: Natr. mur. From immoderate intellectual exertion: Nux vom. Persons of middle age, especially when they have changed their former busy life for a quiet one: Nux vom. After excessive fatigues, bad nourish- ment, loss of sleep : Bet lad. Exhaustion: Laches. Premature exhaustion of strength in ill- ness: Cuprum. Exhaustion is a natural consequence of premature senility: Aurum. From sexual excesses: Nux vom. CHECKED EVOLUTION OF THE PSYCHICAL DEVELOP- MENT. During the whole period of development any detrimental influence which checks the natural growth of the brain, or single parts of it, does last- ing injury to the working of the psychical organ, and may produce Intellectual Idiocy. The causes for such insufficiencies may lie in the germ cells of the new product, when the parents, one or the other or both, are burdened with epi- leptic tendencies or cerebral maladies; also by continued intermarrriages between consanguineously related persons, or by drunkards, or even by cohabitation when drunk. During pregnancy the foetus may be checked in its natural brain-growth by inanition and high degrees of anaemia, or deep emotions and mental troubles of the mother, or violent concussions of the mother by a fall or kick upon her abdomen; also syphilis of one or both parents. It is not always the case that the child shows signs of idiocy immedi- ately after birth; the development of it may be delayed until the third or seventh year of age. Besides these prenatal causes idiocy may be brought about also by trau- matic injuries during birth from instrumental injuries of the head, or a fall upon the head from the mother during a precipitated birth. Most cases, however, are contracted in early age by a great number of various noxious and pernicious influences, such as falls upon the head, miasma in the surroundings, uncleanliness, insufficient and unsuitable nour- ishment, acute exanthematous diseases with cerebral complications, etc., which may make the brain unfit for sound psychical actions. Cretinism is the consequence of certain telluric influences which are not 4 50 CRETINISMUS. yet fully known. The disease is endemic, and found especially in Europe in the Alps, in Asia in the Himilayas, and in America in the Cordilleries. As cretinism can be propagated by inheritance, it proves that it must be already an infection of the germ-cells, and the inhabitants of such infected regions show by a less degree of psychical as well as corporeal strength and endurance and a shorter duration of life that the entire population of such districts is more or less affected by this detrimental telluric influence. The check of growth may anatomically be characterized as an abnormal smallness of the whole brain, although proportioned in its single parts (microcephalus) ; or as a smallness only of certain parts, either of the front or posterior lobes, or of one hemisphere, or of the medulla oblongata. If there is a deficiency in the development of the convolusions and of the centrem semi-ovale, causing a chasm to the ventricle, which fills with serum (a so-called porencephaly), the wall bulges out like a bladder on that place. This is mostly accompanied with paralysis and contracture of the opposite side. In some cases there is an actual absence of certain parts of the brain, such as the cerebellum, the pineal gland, or the corpus callosum. There is also frequently found a chronic hydrocephalus, either inherited or acquired, with fontanelles remaining open, and enlargement of the skull (makrocephalus) . Kncephalitic processes, especially with consecutive sclerosis of the brain and atrophy of the parts affected, are mostly attended with half-sided paresis, contracture, and frequently also with epilepsy. The deepest grade of idiocy is characterized by a complete absence of mental processes, nothing but the lowest requisites to sustain life, hunger and thirst, which to assuade is the only activity of the poor soul; it is apathic idiocy, which not even is capable of forming sensory psychic modifi- cations and to select the proper food, as any animal is able to do by instinct. He puts everything of which he can get hold of into his mouth, and is as helpless as a new-born child. Idiocy in a milder degree is Weak-mindedness. The primitive forces are not produced in a normal strength, conse- quently the formation of psychical modifications is much less in quantity and quality, and correspondingly the associations and reproductions of the mental modifications for judgment are much poorer than in normal minds. The language of such persons is poor, and wanting naturally in expressions for transcendental ideas which they do not possess. Some of these persons are singularly gifted by talents to mechanical working, music, drawing, and sometimes by remarkable memory for num- bers and words. These psychical insufficiencies are in many cases attended w T ith somatic disturbances, such as spasms of different forms, chorea, epilepsy, con- THE SPHERE OF CONATION AND ACTIVITY. 5 1 tractures, paralysis, impotence, respectively sterility; in lighter grades masturbation. Trophic anomalies such as a dwarfish growth, a thick, fleshy tongue, puffy lips, bad, easily decaying teeth are not unfrequently found. The prognosis of idiocy depends entirely upon the various anatomical processes which are the cause of it. Where prenatal insufficiencies which do not progress any further are the cause, the trouble is usually a stationary idiocy-. If caused by epilepsy or hydrocephalus the disease goes on progressively to the final destruction of all mental activities. In general, idiots do not attain old age. Kndemic cretinism shows perhaps most favorably amongst this class of cases, although an age of sixty years is even here of rare occurrence. In rare cases lasting improvement has been observed. Therapeutic Hints. It is self-evident that a part of the brain which is wanting cannot be produced by any mode of treatment, and it is only that the newest develop- ment of mechanical ingenuity has imagined to also entice the growth of a brain, by opening the skull, entirely forgetting that the small and narrow skull is not the cause of the small brain, but that the small brain is the cause of the narrow skull-box. Medicine in idiocy will often be indicated by the accompanying somatic symptoms, but the main help which can be given to these unfortunate beings is careful nursing and untiring efforts to educate them and to remove all telluric, atmospheric and hygienic conditions unfavorable to a healthy growth as far as possible. H. THE SPHERE OF CONATION AND ACTIVITY. The disturbances of this sphere consist of an exaltation of natural im- pulses or emotions, resting upon a base of pleasurable psychical modifications. These exaltations are known under the name of mania. They cover a wide field of mental life, but as long as they keep in the boundary of innocent exaltations of natural desires, inclinations, propensi- ties, it is scarcely worth the while to describe them as separate mental dis- orders. All hobby-horse riders all cranks, dudes, etc., belong to this class; worse are the immoral traits if aggravated to passion and obscuration of sound judgment. The highest development of mania, however, is that raging, fury-like exaltation of psychical processes, where the regulating Ego-perception has lost all control in the process of mental excitations, where, like a cyclone, the natural and perpetual alternation and resuscitation of mental modifica- tions run wild without aim or end in heated explosions. This is the case mostly in the terrible form of acute "furious mania." In chronic forms there exist occasionally some relaxations in which conscious and rational acts 52 MANIA. are interspersed between the forced movements of excited psycho-motoric centres. Mania. — Mania is an exaltation of the entire psychical life, characterized especially by a heightened activity of the conative sphere. It is the psycho- motoric life of the soul which is exalted, showing itself as a stronger will and more lively impulse to action. The motives for such actions are still clearly conscious perceptions and mental modifications corresponding to a normal mental development, only more conspicuous in this way, that they show a character of too great a hurry, indiscretion, unsuitableness, mischievousness, offensiveness and even im- morality, without a sign of real insanity. There are, however, actions in the psycho-pathological sphere which do not exhibit clear conscious motives, but appear as abrupt, impulsive acts, as if they sprang forward from the deep unconscious life of the soul like a con- vulsive motion. Such impulsive acts, among which we find perverse sexual actions, rape, suicide, murder, incendiary, with some forms of melancholic affections and maniacal incentives to actions, which cannot be checked in consequence of the absence of the rational Ego-consciousness — all these various and numerous maniacal utterances of psychical life have given rise to that great class of so-called monomanias. Besides these many shades of psychical morbid impulses with or with- out the presence of clear conscious motives, there is a still higher degree of maniacal exaltation, and that is EXULTATIO FURIOSA, FRENZY, TOBSUCHT. In this affection the psychical processes are in such a degree accelerated that the entire psychical life appears convulsed. The normal consciousness of the Ego has so lost all power of control that it cannot check or direct the process of psychical activity as in normal life, and with this utter confusion of impulsiveness there is connected an accelerated process in the becoming conscious of mental modifications with a rapidity which does not allow a single one time enough to combine with any other to a logical judgment; the entire psychical fabric seems convulsed. The apperception is during this giddy chase of mental modifications imperfect and illusive. Hallucinations may occur in any of the senses, and delusive ideas crop out r mostly of an expansive nature, e. g., the ideas of being rich, great, etc.; in women when attended with sexual excitement or religious feelings, of being the mother of God, etc. But the most characteristic of this mental disorder is the uncontrollable haste and acceleration with which all psychical acts roll off, combined with constant muscular activity in which no set of the voluntary muscles is ex- cepted. Only during pauses of complete exhaustion this agitation ceases for a while. It is a forced motion from cerebral irritations which , during the height of EXUI/TATIO FURIOSA. 53 the disease does not show any similarity to rational actions; it is a continued urgency from stimulated psycho-motoric centres for all kinds of movements induced by pleasurable or painful sensations, but without sufficient conscious- ness for a rational control. During an attack of exultatio furiosa there is frequently a great excite- ment of the sexual instinct which, when occurring in the male, has been named "Satyriasis," when in the female " Nymphomania." Somatic Symptoms. — The inability to sleep, sometimes for weeks with frequent congestions to the brain, is of frequent occurrence. The pulse is not materially hastened, but in violent cases even slower and smaller than normal. The bodily warmth is normal, sometimes even below the normal point, because the greater amount of heat caused by the greater amount of muscular movements is spent again by a greater loss of heat from insufficient covering of the body. If there should be a rising of normal heat without a sufficient other bodily cause for it, it is likely that the cause is not mania but the con- sequence of some other organic brain lesion. During an attack of furious mania the patient usually appears at the com- mencement younger and fresher; soon, however, digestion and assimilation fail and the patient loses in flesh and strength. Frequently the urine be- comes saturated with phosphates and at times salivation sets in with exacer- bation of the disease. During the remissions of the attacks the patient occasionally complains of headache. Insensibility against external cold temperature is a peculiar symptom which probably has its origin in central lesions. Sensorial hyperaethesia is occasionally present and partial cramps, jacti- tation of muscles and grimaces of the face occur at times. Frenzy, if not an independent form of mental disorder, is occasionally attending dementia paralytica and different brain diseases, hysteria and other forms of insanity. Mania exists either in an acute or chronic form. The acute form sets in suddenly as a maniacal exaltation which soon mounts up to frenzy. The more acute the attack the greater is the disturb- ance of consciousness. Its acute outbreak is often characterized by irascibil- ity or irritability when its duration is usually short, but liable to aggravations with angry explosions and remissions of exhaustion and irritableness. The chronic form lasts longer, for months and over a year; has usually as a forerunner melancholia of varying duration. Its turn into frenzy is usually sudden, sometimes, however, the melancholy and frantic spells fight, so to say, for supremacy, when after a shorter or longer duration the melan- cholic exaltation reaches the degree of Tobsucht with its flight of mental modifications, expansive ideas, unceasing, uncontrollable movements of all the voluntary muscles, increasing disturbance of consciousness, deliria and hallucinations. Its course is remitting, alternating with spells of milder maniacal exaltations, with occasional angry explosions; also with regular 54 MANIA PERIODICA. interpositions of melancholia, and then again with nearly normal states of the mind, on account of which this form of maniacal excitement has been termed mania periodica, and by some French physicians folie circulaire. The dura- tion of these alternating attacks is very variable, it may be short or long; but the cycle returns and returns, so that the prognosis of periodical mania is very unfavorable. The termination of mania in general is either gradual recovery, or a gradual sinking into lasting imbecility, or idiocy, or death by exhaustion or intercurring diseases, such as fat-emboly of the lung vessels or brain lesions. Therapeutic Hints. No matter how kindly we may feel towards the unfortunate, and how much we may dislike the idea of separation and putting the patient into an asylum, the nature of the disease imperatively demands his removal to such an institution, because there alone he can find the necessary protection against the outer world and against himself. Most families are not capable of taking care of such unfortunates who have become uncontrolable. Yet here we meet with a great desideratum which only by the indomit- able energy of our successors will at last be called into fulfillment — the foundation of homoeopathic asylums for the insane. Although we have a few of them already, they are by far not sufficient for the need. We must have many more. The existing allopathic institutions do not come up to the standard where experiment and experience in the treatment of such dis- eases has placed Homoeopathy. Although palliative Allopathy has abandoned the former cruelties of treating the insane with ropes, jackets, revolving tables and the like obsolete cruel machinery, and although it is a fact that the violence of frenzy has decidedly decreased since the ' ' no restraint ' ' method has more and more been employed, yet it is equally a fact that the old custom of forcing methods is still lingering in the minds of a new set of scientifics in a disguised form. Instead of tying with ropes and holding quiet by the jacket, they use injec- tions of Morphium ; instead of frightening by the revolving table, they nauseate by continued doses of Tartarus emeticus ; instead of reducing the excitement of the nerves and circulatory system by repeated blood-letting, they induce torpidity and physical inertness by large doses of Bromide of potassium. We might well ask here what is preferable: The old cruel treatment ot applying brutal force, or that sly, insidious demolishment of vital structure and force ? If the former shows unblushingly the naked beast, is not the latter, so to speak, a disguised fiend in the attire of a good Samaritan? Who has not seen the agonizing consequences of such palliation, making recovery in most cases impossible ? We need institutions from which all this open and sly inhumane treat- ment is absolutely banished, and I hope that in the second century of THERAPEUTIC HINTS TO MANIA. 55 Homoeopathy we will be blessed with abundant means to demonstrate con- clusively to those then living the grand blessing which Homoeopathy has bestowed upon the unfortunate insane. The following homoeopathic therapeutic hints include only a few of the main remedies frequently indicated in the different forms of mania, and I refer again for further particulars to Jahr's excellent work on mental diseases: Aeon. Furious, stubborn, quarrelsome; bold, lively; running away; fitful mood, now full of mirth, soon followed by weeping and great mental anxiety. Agaricus. Fur} 7 , as if intoxicated; daring, revengeful, threatening against others and himself; fancies, extases, prophesying, versification. A?iacard. Wrathful, violent in quarrel; cruel, wicked, cursing, swear- ing; laughing at serious, serious on ridiculous matters. Bell. All senses very acute; irritable, with howling, sobbing; quarrel- some, insulting others; cursing, with staring looks; raving, with barking, growling, grinding of teeth, convulsions, burning heat; violent, cunning; inclined to bite, to spit, to strike, tear everything to pieces, to get hold of others by the hair; singing, whistling, silly mad laughing; loquacious, las- civious; visions of all kinds of beautiful and terrible images. Aggravation by kind words. Camphora. Senseless talking and acting, fury with foaming at the mouth, frenzy; fits like epilepsy. After having used many days. Canth. Paroxysmus with convulsions, and recurrence of fits by touch- ing the throat and at sight of water, as in hydrophobia; loss of reason, illu- sions of feeling and hearing; satyriasis. Coldness of body. Hyosc. Feels well and strong; nothing the matter with him; loquacity; senseless laughter, quarrelsome; jealousy; would like to murder those who approach him, with open eyes and wild look; strips himself naked, runs away; stumbles against everything, with open eyes; lascivious, sings amor- ous and obscene songs; furious shouts, ungovernable fury, for days and nights; shameless, violent, jealous with rage; sees persons who are not present. Laches. Loquacious, constantly jumping from subject to subject; sings, whistles, makes odd motions; proud and jealous, suspicious; cannot bear pressure of neck-cloths; all worse after sleep; after mental emotions, or abuse of alcohol, at climaxis. Nux vom. Blames and reproaches others, jealous abuse, shouting, bursts of passion; looks maliciously, quarrelsome; full of malice and mischief. Opium. Exaltation of mind; thinks she is not at home; imbecility of will as though annihilated; nervous and irritable; from excessive joy, or fright, anger or shame, violent emotions, like a blow upon the entire mental frame; frightful visions; alternate fury and dread. Platina. Everything seems strange and horrible; thinks all persons are demons; everything around her is very small and even'bod}^ inferior in 56 THE SPHKRE OF FEELINGS OR EMOTIONS. mind and body; over-estimation of self; haughtiness, voluptuousness and cruelty; great pride; fault-finding; unchaste talk; physical symptoms disap- pear and mental symptoms set in, and vice versa; mental disturbance after fright, grief and vexation. Stramonium. Terrifying hallucinations; sees ghosts, hears voices back of his ears; sees strangers, or imagines animals jumping sideways out of ground, or running at him; thinks herself tall, double, lying crosswise, one half of body cut off, etc.; prays, sermonizes; ecstatic; wants light and com- pany, cannot bear to be alone; runs about; rage; proud, haughty or merry. Veratr. alb. Thinks himself distinguished, squanders his money; rage with desire to cut and tear, especially clothes; with lewdness and lascivious talk; praying, religious talk; longevity; disposed to talk about faults of others; irritated, scolding, calling names; impudent; cursing; despair of salvation, with suppressed catamenia; consequences of injured pride or honor. Veratr. vir. Excessive physical unrest; depressed, but comparatively careless of the future; cerebral congestion, purplish redness of face, or if cold it has a pale bluish cast; muscles relaxed and restless, nausea, retching and vomiting. m. THE SPHERE OF FEELINGS OR EMOTIONS. The disturbances of this sphere are characterized by excessive depres- sion. Instead of pleasurable elation as in mania, we meet here with unpleas- ant feelings of all descriptions, which in fully developed cases may be associated with difficulty or even impossibile intellectual activity, and all this without sufficient apparent causes. This mental state is known under the name of "Melancholia," and may have a great variety of origin and charac- ter. In consequence of the weakened state of psychic life any little irritation may act like an over-excitation, and cause wild, extravagant, angry spells, even insane hallucinations as interspersed manifestations, and thus frequently all three spheres of mental activities may be greatly disturbed and disordered. Melancholia. Such excessive mental depression may be caused in consequence of somatic disturbances from material influences, or from suppressions of bodily evolutions in consequence of psychical influences; the most frequent causes are unhappy love, disappointed ambition, fear of disgrace, sudden impoverish- ment, fright, nostalgia, debauchery , and excess in sexual indulgences; also climaxis, haemorrhages, etc. The characteristic depressed states of the mind amount often to attacks of desperation and despondency; it is often such an unbearable state of psychical pain and discomfort which is caused by mixt- ures of psychical anaesthesia, hyperesthesia, want of thinking power, forced and fixed ideas and complicating bodily bad feelings, precordial anxiety, frightful sensorial delusions and delusive ideas, that suicidal or even mur- MELANCHOLIA. 57 derotis tendencies against the surrounding people seem almost natural prod- ucts. In such aggravated states the patient's agitation is maniacal. How- ever, this is not found in all cases. Some of them wind up without any delirious excitement; there is only a state of gloominess, irritability and ill- temper, which may appear as mere consequence of .a chronic catarrh of the stomach or of neurasthenia. In other cases there is an aggravated precordial anxiety which is really one of the most essential elements in melancholia. In still other cases there are delusive ideas and sensory delusions the most prominent features. These delusive ideas may be of a religious nature or may assume the character of hypochondriasis. Still other cases are of a heavier type and are characterized by a dis- turbance of consciousness; the patients appear to be entirely absorbed in themselves, seemingly disconnected with the outer world, and deprived of spontaneous action, appearing almost like idiots. This state of mental dis- order is usually the consequence of a vulnerable brain (after typhus, puer- perium), or a suddenly appearing cause (shock, fright, etc.). F,ven during such helpless stupor the patient may be liable to sudden acts of self-destruc- tion or dangerous insults upon others. The course of melancholia may be continual, sub-acute, or chronic. In all cases there are remissions and exacerbations. The remissions are usually in the afternoon and evening; the aggravations are most prominent in the early morning hours. The entire sickness may last months, and even years. The prognosis in mild cases is favorable; the heavier cases may end in mental weakness. The therapeutic hints consist, according to Kraft-Ebing: i. In perfect bodily rest. 2. In guarding the patient against hurting himself or others. 3. In watching closely the patient's strength and his partaking of nourishment. 4. In fighting against insomnia, for which he recommends lukewarm baths and Opium, or Sulfonal and Trional, and in anaemic cases spirituous liquors, wine and beer. Therapeutic Hints. Aconite. Fear of approaching death, telling the hour of its occurrence; fear of darkness and of being alone; starting, dread of ghosts; great restless- ness and irritability; acute cases. Act: Helleb. heavy, slow and deep: Digit. Low respiration : Gratiola. Occasional sighing: Gratioa, Helleb. Heart beats strong and laborious: Glonoin. Pnlse full and bounding or thready: Aeon. mostly suddenly Glonoin. Pulse depressed at first, later frequent and soft: Gelsetn. very quick and weak: Apis. sometimes intermittent and small: Digit. slow and irregular: Apis, Gratiola. very slow, often hard, with a corre- sponding powerful stroke of the heart: Digit. Temporal arteries pulsate violently, throbbing of the carotid arteries: Bel lad. Neck, stiffness of : Lyeop. , muscles tense: Apis. Coldness of the hands, and a bluish appearance of the fingers: Cuprum. Hands and feet cool: Gelsetn. Feet are cold in the morning and hot in the evening: Sulphur. One foot cold, the other hot: Lyeop. Feet damp and cool: Cale. earl). , fetid sweat: Si lie. Run about, but do not like to stand: Sulphur. Will not stand any more, and do not learn to walk: Cale. phosph. Sit hunched and walk stooping: Sulphur. Uncertain, tottering gait, fall often and strike against things: Bryon. Tired: Bryon. Trembling of the limbs: Apis. and convulsive movements of the limbs: Stramon. Eyes, ears and skin lose their sensitive- ness: . I pis. Twitching of the muscles with the fever: Spongia. Jerking of limbs: Cieuta. Convulsive movements of muscles and jerking: Helleb. Frequent torsions of the trunk: Stramon. Sudden spasms: Glonoin. Convulsions: Apis, Digit. with screaming afterwards: Cieuta. Bright light and glistening things cause spasms: Stramon. Spasms affecting eyes and face: Bellad. One-half of face convulsed: Digit. Twitching or moving of the limbs of one side and paralysis of the other: Apis. Convulsions of right and paralysis of left side: Art. vulg. Spasms of one side and paralysis of the other: Bellad. Constant involuntary motion of one leg and arm: Apoc. eanu., Helled. Stupid slumber: Spongia. Sopor: Digit. , interrupted by piercing shrieks: Apis. , with half open eyes: Opium. , and yet drinking and swallowing water eagerly: Art. vulg. , with screaming and starting: Helleb. , with twitching and jerking of limbs: Cuprum. Comato.e state: Lyeop. Stupor: Apoc. eann. Drowsy sleep: Bryon. , restless sleep, with frequent start- ings: Bellad. , sleepiness with restless throwing about and occasional waking with a shrill cry, which is followed again by dozing off: JLerc. sol. Drowsiness: Lyeop. , yet inability to sleep: Bellad. Sleepy and drowsy, sometimes comatose: Gelsem. Sleep restless: Sulphur. Restless sleep before midnight, after midnight more quiet, and in the morn- ing awakes brightly: Zincum. Starts when falling asleep: Sulphur. During sleep loud screams: Lyeop. Children sleep apparently soundly, but scream out suddenly in sleep, stare about and cannot easily be pacified: Lyeop. HYDROCEPHALUS . IOI Cry out, or murmur, moan and whine: Sulphur. Snoring: Opium, Sulphur. Frequent startings: Digit., Spongia. and dreams of falling: Digit. Head sweats profusely, especially on the occiput: Calc. card. Half open eyes, throwing the head from side to side with moaning: Lycop. Chewing" and swallowing: Bryon. Convulsive motions: Gelsem. Cold all over: Art. vulg. Creeps and flushes run up the back: Gelsem. Fever-heat and dryness of skin: Aeon. Dry heat all over and especially the head: Bryon. Heat and fever morning, evening and part of night: Zincum. Profuse, sticky sweat on the head, of a musk-like odor: Apis, Sulphur. Sweat much about the head, especially forehead and face: Silic. Uncovered parts sweat, while the covered parts are dry and hot: Thuja. Fetid foot-sweats: Silic, Thuja. More or less moisture of the skin, espe- cially on palms of hands and in the axillae: Gelsem. Better when lying in a horizontal posi- tion: Spongia. Tossing* about: Spongia. Cannot keep the feet still: Zincum. Glandular swellings and abscesses : Silic. HYDROCEPHALUS ACQUISITUS Develops itself secondary to acute attacks of the different forms of men- ingitis, external injuries, the abuse of intoxicating drinks, or too great mental exertion. In children, even if it originates after birth, it is never- theless similar to the affection called HYDROCEPHALUS CONGENITUS, that form with which children are born. It is probably the consequence of an inflammatory process of the lining of the ventricles during foetal life; perhaps it is a deficiency in the proper assimilation of calcareous substances which form the bones. Why this is we do not know in either case. Some women have given birth to hydrocephalitic children several times in succes- sion, without any apparent cause. As the water collects in the ventricles while the sutures of the bones have not yet united, its constantly increasing bulk drives the bones asunder and enlarges the head to an enormous size. Or, if we take the other view, which is perhaps the more plausible of the two, we might explain it in this manner: The insufficiently developed bones are not capable of restricting the growing brain within its proper limits; they give way here and there, and the brain gains entirely too much space within the skull. As, however, a vacuum can never exist, it is at once filled up with the general equalizing medium, water or serum. In this way the inner pressure becomes still stronger, and the still deficient bony structure becomes still less capable of restraining the increased internal pressure; it gives way again and again; and for the same reason the effusion of water must increase still more, until at length the whole cranium attains to an enormous size. 102 THERAPEUTIC HINTS TO HYDROCEPHALUS. The disease can be recognized at once, although it may not have come to its full development. There is a disproportion between the size of the skull and that of the face; the fontanelles are much wider than usual, and the frontal opening may be traced down into the frontal bone; and laterally, down between the parietal and frontal bones. The bones themselves feel thin under pressure of the fingers; and externally the veins appear greatly enlarged, shining through the skin. All these external changes appear only when the collection of w T ater is very considerable. There have been found from six to ten pounds of serum within the ventricles, which then appear enormously distended and thickened, while the substance of the brain in the neighborhood is wasting away. A small amount of serum does, of course, not change the external form of the cranium, neither is it changed should the effusion take place at a later period, when the sutures of the skull bones have closed; to this there are a very few recorded exceptions. Children born with hydrocephalus fully developed, die frequently dur- ing birth or soon afterwards. Others show no signs of this malady in the first weeks; even during the whole of the first year it may be overlooked, until the inability of the child to hold up its head calls attention to it. But even then there may be no enlargement of the head visible, yet the child is slow in all its mental developments; it does not make any attempt to talk or walk; it remains uncleanly, and its actions look strangely; when in joy or fear it makes antics and straggles with its extremities. Its eyes do not look knowingly at any object; it shows no interest for things; it appears imbecile and foolish. Saliva is constantly oozing out of the half opened mouth; it eats greedily, and often is seized with spasms. The progress of the disease is either a steady one, going on from bad to worse, until at last general paralysis ends the scene; or it is interrupted by stationary periods, or it remains for years seemingly unaltered. It is rare, however, for such patients to live beyond the age of puberty; a few only have been observed to live to the age of twenty. Therapeutic Hints. As a general rule the pregnant woman ought to be under the watchful eye of her physician during that whole period. She may be relieved just during that time of many chronic troubles, better than at any other time and her offspring saved of as many serious afflictions. But where a mother has lost already one or more children from hydrocephalus, Grauvogl's advice to administer to such a mother during her next pregnancy Sulphur and Calc. phosph. at suitable intervals, ought never to be forgotten. Even after the birth of a child with suspicious hereditary proclivities, we may be able to ward off an acute "outbreak of meningeal inflammation by one or the other of the following remedies: Bar. curb. Children who do not grow, but pine away, with swelling of glandular structures. HYDROCEPHALUS SENILIS. 103 Calc. card. Fat babies with large heads, wide open fontanelles, which are often covered with dirty or scurfy skin; fair complexion; they are lively, precocious; their head sweats profusely during sleep, especially on the occi- put; stomach and bowels are large, sensitive to pressure; bowels inclined to be loose; feet damp and cool; dentition slow and troublesome. Calr. phosph. Flabby, shrunken, emaciated children; skull thin and soft, with fontanelles wide open; will not stand any more; do not learn to walk; want to nurse all the time; great desire for salt meats and potatoes; after eating and drinking, bellyache; retarded dentition with cold tumors, emaciation and loose green, at times slimy stools. Lycop. Children sleep apparently soundly, but scream out suddenly in sleep, stare about and cannot easily be pacified. Silk. Rickety children; sweat much about the head, especially fore- head and face; claw their mouth during dentition; are prone to abscesses, glandular swellings and a fetid sweat of the feet. Sulphur. Children who do not like to be washed; have pimples, boils and other eruptions on head, face and everywhere; pick at nose; have red lips; crave sour things; feel faint in the forenoon; may have diarrhoea early in the morning; sleep restless; start when falling asleep; cry out during sleep; or murmur, moan and whine, or snore; their feet are cold in the morn- ing and hot in the evening; they run about, but do not like to stand; sit hunched and walk stooping. Thuja. Children of sycotic and syphilitic taint; they are rather thin than fat, are prone to eruptions which, on healing, leave purple spots; their teeth soon turn black and decay at the gums; the salivary glands swell; there is sometimes thrush or ranula; offensive discharge from the ears; sore- ness of penis or vulva and about the buttocks; frequently recurring morning diarrhoea; pain in the left iliac region ; fetid foot-sweats; often the uncovered parts sweat, while the covered parts are dry and hot. Their parents, one or both, have a greasy skin, and warts and moles, and crave salt, and the little one will by and by show these hereditary symptoms. — (T. B. Scales). HYDROCEPHALUS SENILIS Is that form of hydrocephalus which is found in old age, the second child- hood of man. It seems to be developed from the following condition of things: The brain in old age is apt to shrink, which necessarily would cause an empty space within the skull. As no vacuum can exist, the would-be empty space is at once filled up with serum. The same takes place when, from some cause or other, only a portion of the brain becomes atrophied. The space which hereby is vacated is at once taken up hy an exudation of fluid. Hence this sort of hydrocephalus is termed Hydrocephalus ex vacuo. It sometimes happens that the exudation of serum takes place so suddenly and so profusely as to cause all the symptoms of an apoplectic stroke, when it is called Apoplexia serosa. In most cases it is impossible to make a differential diagnosis between it 104 PACHYMENINGITIS. and Apoplexia sanguinea ; neither have we any distinct signs by which to diagnose Hydrocephalus senilis. PACHYMENINGITIS, INFLAMMATION OF THE DURA MATER. The dura consisting of a periosteal (external) and an inner lamella, pathology recognizes: r. Pachymeningitis externa, which may be caused by external injuries, separating the membrane from the inner surface of the skull, or bruising and tearing it; or by transmission of inflammation from neighboring tissues (otitis media). It always is confined to circumscribed spots, and seldom recognizable as a separate affection, because of the ease with which the inflammatory process may spread to the inner lamella and pia. Pachymen- ingitis of old age is frequently detected post-mortem, without any marked symptoms during life. 2. Pachymeningitis interna may be a mere continuation of inflammatory and suppurative processes of the outer layer. As such it is as little recog- nizable during life as the former. It may occur secondarily to the acute infectious diseases. 3. Pachymeningitis interna Haemorrhagica or Haematoma durae matris is in fact not an inflammation, but an extravasation of blood, which under- goes the usual changes of a coagulum, and developing from itself a new formation. It is found either on the surface of both hemispheres or only on one, and principally attacks persons after thirty years of age and upwards, although cases under that age are likewise recorded. The Symptoms must naturally vary according to the quantity of extrava- sation, its location on one or both hemispheres or its spreading from one to the other, and its repetition. A sudden and increasing compression is indi- cated by headache, drowsiness, loss of consciousness, fever, slow, sometimes irregular, and towards the end mostly very frequent pulse. The contraction of the pupils, the absence of strabismus and ptosis indicate that the convexity is the seat of the lesion; the simple rigidity, paresis or actual paralysis of the muscles, the disturbances of sensation, numbness, formication, when present on one side only or on both, or progressing from one side to the other, indicate its location on the opposite hemisphere or over both, or its spreading from one to the other. Coma, disturbances of respiration, slow- ness of pulse, inability to swallow, cessation of reflex movements of the pupils, indicate a compression of the whole brain, while convulsions of one side and then on the other, afterwards paresis of one side with paresis of the facial or hypoglossus of the same side, then paresis of the other side show irritation of the motor centres of the surface of the brain. The intervals between different attacks of extravasation are characterized by headache, diminution of intelligence, loss of memory, drowsiness, partial paralysis, dis- turbance of speech, sudden mental excitement without cause and frequently mixed symptoms of dementia paralytica. Its predisposing influences are old age, atrophy of the brain from alco- ENCEPHALITIS. . 105 holism, atheroma, affections of the lungs, heart and kidneys, chronic psy- choses, anaemia perniciosa, haemophilia, scorbutus. Its duration ma}^ extend from one day to one year and longer. For therapeutic hints see under meningitis and apoplexy. ENCEPHALITIS; ABSCESS OF THE BRAIN; RED AND YELLOW SOFTENING OF THE BRAIN. It is a true inflammatory lesion of the cerebral substance, a red softening and consequent abscess of the brain. The yellow softening is the consequence of a hsemorrhagic infraction, through the plugging up of a cerebral vessel, which may lead, however, by irritation, to a true encephalitis, and so may, vice versa, after its inflammatory stage has passed away, the true encepha- litis assume the appearance of yellow softening and even be accompanied on the surrounding cerebral tissue by a partial necrosis, so that indeed we may find spots of softening in the brain, of which we cannot ascertain the nature of the preceding process. True encephalitis is found always only in small spots (foci). These foci are red from extravasated blood and swollen; its boundaries imperfectly defined. By and by, if they are not absorbed almost completely, which small ones of a traumatic nature certainly do in many cases, they undergo the well-known destructive and reabsorbing changes; we see before us a focus of yellow softening, which gradually becomes more colorless, is transformed into a cavity with a thin, emulsive fluid, and may, at last, lead to the formation of firm sclerotic cicatrices; or the transformation results in a collection of pus — an abscess. Recent abscesses have usually no enveloping capsule, while old ones have. As they grow they increase the intercranial pressure and retard the circulation in the brain, or compress the neighboring vessels in such a degree as to cause yellow softening of the sur- rounding brain-tissue to a large extent. The abscess may perforate the surface of the brain into the ventricles, or open upon the base and give rise to diffuse acute meningitis of the base. It causes widespread acute oedema and also anaemia of the brain, and when located in the cerebellum in such a poistion that it lessens the cavity of the fourth ventricle, or of the aquaeductus Sylvii, hydrocephalus internus chronicus. It ma} 7 discharge through the skull into the subcutaneous tissue, or into the frontal sinuses and nasal fossae, or through the temporal bone in the neighborhood of the processus zygomaticus, under the temporal muscle, or into the cavity of the tympanum. Abscess of the brain is either single or multiple and varies in size. The most frequent Cause of acute inflammation and recent abscess is traumatic injury ; but there are also mentioned: Affections of the skull bones, tumors in the brain, acute diseases, such as typhoid, scarlatina, affections of the heart, suppurating and sloughing processes in different portions of the body. These same causes apply to the capsulated and chronic abscess. 106 IXSOLATIO. Its Symptoms are not at all well defined. An acute encephalitis, say from a non-perforating- injury of the head, may run its course without our having a suspicion of its existence. Still, symptoms like the following should not be unheeded: Dizziness; headache; vomiting; loss of consciousness; sopor; pupils wide and fixed; pulse slow; rolling of the eyeballs; transitory divergence; paralysis of the face or even hemiparesis or hemiplegia ; twitching of both hands and feet; convulsions of the extremities. Its extent cannot be determined. If not cured, it may result in calcification of ganglion-cells, situated under the injured part; in chronic irritable melancholy; in chronic headache, dizziness, anxiety and hallucinations; in inability to think, with intercurrent periods of excitement and illusions of the senses; in complete im- becility, in a state resembling dementia paralytica; in epilepsy and tumors. The Diagnosis must principally be based on the knowledge of its etiology. Therapeutic Hints may be looked after under the preceding chapters on the different forms of meningitis. INSOLATIO, SUNSTROKE, THERMIC FEVER. Whether it be, according to von Grauvogl, a want of water in the blood; or according to H. C. Wood, a paralysis of the vasomotor nerves or some controlling centre in the brain, which influences the production of heat in the body; or according to Hill in Braithzcaitc s Retrospect, 1867, an imperfect decarbonization of the blood; or according to Huguen, a hyperaemia of the pia and brain; or according to Arndt, a diffuse encephalitis; or according to Xothnagel, a venous hyperaemia, dependent upon a diminished power of activity of the heart — we shall leave undecided; all physicians, however, agree that it is caused by the influence of excessive heat, and not merely by an exposure to the direct rays of the sun. The results of post-mortems are meagre; the most important may be gleaned from Dr. H. C. Wood's Thermic J 7 ci'ci\ 1S72, in which he states: " Right heart and pulmonary arteries, with their branches, gorged with dark fluid blood; venous congestion of the lungs and entire body. The heart, especially left ventricle, rigidly contracted in every case, caused by a coagulation of the myosin, is pathognomic of sun- stroke. It most cases, however, it is a post-mortem rather than an ante- mortem phenomenon. The muscles after death from each stroke soon become rigid, sometimes instantaneously so." As Predisposing Causes are enu- merated: "Want of acclimatization, lengthened exertions, deprivation of water, the free and habitual use of vile drinks, debility, a febrile state, fatigue, bad ventilation, improper head covering and clothing, depressing influences. Symptoms. — The final " stroke " does not at all set in without warnings. At first the wonted work becomes a burden; the muscles lose their elasticity; there is great debility, loss of appetite, but great thirst. The head grows dizzy, achy; the chest feels oppressed, with frequent and short breathing THERAPEUTIC HINTS TO INSOLATIO. 107 and sighing; the throat gets dry, and swallowing painful; the voice becomes weak and hoarse; there is a general anxiety and irritableness of the mind; numb feeling in the extremities; restless sleep, or great drowsiness; increased vertigo, perhaps nosebleed, redness of the conjunctiva, pale face, tottering gait, or giving away of the knees. Many complain of a dreadful goneness at the pit of the stomach, nausea, vomiting; pain in the bowels, perhaps sudden diarrhoea, with profuse cold perspiration. Oftener the bowels remain consti- pated. The mind becomes clouded, he answers confusedly. If for such and similar indications nothing is done in the vain hope that it be a mere tran- sient indisposition, the "stroke" will surely and speedily follow, unless a change in the temperature should head it off by a still more rapid turn. This last link of a whole chain of more or less pronounced symptoms is very appropriate^ called ' ' stroke. " As if felled down by a blow, the patient sinks suddenly to the ground, with entire loss of consciousness, and complete insen- sibility of longer or shorter duration; subsultus tendinum; partial spasms, or violent general convulsions; or paralysis of the spinal cord, so that he cannot move a limb. The face at first is very pale, gradually growing flushed, suffused, often deeply cyanosed, and finally assuming a leaden hue. The breathing is slow and sighing, or rapid; or deep and labored, often ster- torous, with rattling in the trachea. The pulse grows feeble and exceedingly rapid; later irregular, intermittent and thready. Such a " stroke " might be mistaken for apoplexy, if it were not for the heat of the season and the premonitory symptoms. Apoplexy ma3^ occur at any season and is often preceded by apparent good health. In some cases the temperature rises to 106 to no° Fahr., this form is called Thermic Fever. Sunstroke is not necessarily fatal and least under homoeopathic treat- ment; however, it occasionally leaves very unpleasant after-effects, which " consist principally in symptoms of deranged innervation, inability to endure heat and sunshine, insomnia, vertigo and weakness, headache which returns after exposing oneself to the rays of the sun, or comes at regular times and in various parts of the v head; chronic encephalitis; insanity; constipation; dyspepsia and derangement of the liver. ' ' Therapeutic Hints. Man will never be satisfied. Cold water he improves by ice. Now-a-da3 T s it would be very old-fashioned not to keep ice- water summer and winter, and to gulp it down during, after and between meals. So dictates fashion, and it is good for the doctors and ice-companies. So in the treatment of sunstroke. Plain water, as river or well provide it, is entirely out of date. Being a "stroke," it must be dealt with "strikingly." Ice-water and ice-bags are the order of the day. Do we cure a frozen limb by boiling it ? Will you cure a man, nearly boiling, by freezing him ? Where is the sense ? But fashion has none. When you are called to treat a man struck down by the sweltering heat, take water as river or well present it, and bathe his face. IOS THERAPEUTIC HINTS TO IXSOLATIO. head, chest and spine, arms and limbs well with it. If you can have it luke- warm, it is better, because it is nearer to his temperature, and by evaporation will withdraw sufficient heat to cool the body down to a natural temperature in a very short time, without shock or malice. This alone may restore con- sciousness in a short time. But we have also remedial agents which may prevent the stroke or shorten its attacks and prevent bad consequences. Among the remedies of prevention Gelsem. is the most important. It covers all the symptoms of a man who feels "play'd out," as Lilienthal so characteristically designates it. It is especially indicated in hot, damp, stifling weather, the exact meteorological condition of sunstroke and it has, at least in my practice, proved itself ade- quate to the occasion. Aeon, and Arsen. are characterized by great thirst, hot and dry skin. Ant. crud. by a white tongue, loss of appetite. Bryon. by great thirst, gastric derangements and aversion to motion. Carb.veg. Vertigo; heaviness of head ; pulsative pain above eyes; gen- eral debility; obtuseness of sensibility. Laches, by great dryness of throat, hoarseness; tightness and oppression of chest, and drowsiness. Ver. vir. by prostration, febrile motion and accelerated pulse. Among the remedies during the attack Glonoin is the most important. Violent headache; vertigo; does not know the street nor his own house; losing senses and sinking down uncon- scious. Conjunctiva reddened; mist, black spots or visions of light before the eyes; pale and agitated countenance. White tongue as if painted. Thirst, pain and throbbing in the pit of stomach with a sense of sinking. Oppressed breathing, sighing, constriction and anxiety. Laborious and violent action of the heart. Numbness of limbs; muscular tremor; great prostration; sopor; convulsions. Amy! nitr. Anxiety; longing for fresh air; dull confusion of head; giddy, intoxicated feeling; head feels full to bursting; eyes protruded, star- ing; conjunctiva bloodshot; intense surging of blood to the face; crampy, epigastric pain; burning and pressure in stomach; dyspnoea and constriction of chest and heart; tumultuous beating of heart; tremulousness of hands and tired feeling in legs; tottering gait; weak, relaxed feeling. Bellad. Similar to Glonoin. Drowsiness; dulness of mind; congestions towards head; loss of consciousness; headache; vertigo; anguish; flashes before the eyes; whizzing in ears; constriction of chest; worse in summer heat. Campoora. Sinking of the forces; oppression of breathing; embarrassed action of the heart; coldness of body, tremors and cramps. Opium. Unconsciousness; deep coma; eyes glass}' and half closed. SEQUELS may be met with by . igar. Vertigo from sunlight. A)iac. Loss of memory. Bar. carl?., Laches., Natr. card., Stramon. Headache from being ex- posed to the sun. APOPLEXIA SANGUINE A. IO9 APOPLEXIA SANGUINEA. It consists of an intracerebral haemorrhage, forming clots of various dimensions, usually from the size of a hazel-nut to that of a small apple, but they may be much larger or much smaller; their shape is either round or they are spread out in layers to a greater or less extent; they may occur singly, which is the rule, or in numbers of two, four or more. Their favorite seats are the corpus striatum and the nucleus lenticularis, with the neighbor- ing parts of the hemisphere, and the thalami optici; in other parts they occur only exceptionally, and in the cornu Ammonis, the corpus callosum or the fornix scarcely ever. Unless fatal after a few hours, these clots and the surrounding tissue soon undergo structural changes. By absorptions of the fluid parts the whole mass thickens, turns at first dark red and later yellowish, and the surrounding tissue becomes soft partly from the inhibition of serum and partly from fatty degeneration, or inflames to a greater or less extent. If the patient survives the attack for some time, the clot forms into a cyst which may persist without change; or is converted into so-called apoplectic cicatricial tissue. Capillary haemorrhages, showing blood-points of the size of a pin's head and smaller, are met with in places of softening, or in the cortex cerebri in consequence of thrombosis of the venous sinuses; they are secondary processes and should not be considered under this head. The Cause of these intracerebral haemorrhages is now in general at- tributed to a diseased condition of the cerebral vessels, especially the arteries, which consists, according to Charcot and Bouchard, in the formation of numerous miliary aneurisms, in consequence of chronic periarteritis. They may burst spontaneously under an ordinary amount of blood-pressure within the cranium, as in cases where the apoplectic attack occurs during sleep or in perfect rest, or they may be ruptured by an increased amount of blood- pressure during spells of hard coughing, vomiting, laughing, straining at stool, or during parturition; in consequence of mental excitement, or bodily exertions; after a full meal and the use of alcohol and coffee, and other car- diac stimulants. The most frequent occurrence of apoplectic attacks is after forty years of age, although childhood is not exempt. Symptoms. — In some cases, not in all, the first attack is preceded by premonitions for weeks, months, even }^ears. These are: frequentty recurring dizziness, headache, ringing in the ears, muscae volitantes, alterations in the disposition, sudden but transient loss of power to speak without paralysis of the tongue; sudden transient paresis in one arm, or leg, or both; or a sense of stiffness, a feeling of " pins and needles," numb feelings, or sensation of heat and cold, or of pain of an indescribable character in the extremities; disturbances of vision, diplopia and even amaurosis; sometimes nosebleed. The attack itself is ushered in by a sudden loss of consciousness, in many but not in all cases. It may develop itself gradually with symptoms above described, and unconsciousness following only after a lapse of several II,, APOPLEXIA SANGUINEA. hours or days, especially after venesection; or it may commence with pa- ralysis of one side: or with chronic or tonic spasms of certain muscles which later become paralyzed, when hours afterwards sopor follows; or conscious- ness may not be lost for a moment, although the symptoms which precede the attack and those which usually follow and remain permanently after the return of consciousness in the usual cases, leave no doubt of an actual intra- cranial haemorrhage. In case of complete sopor and relaxation of all the muscles in a degree that hemiplegia cannot be recognized in order to distin- guish the attack from opium poison, asphyxia, etc., we shall find the eyeballs turned toward the non-paralyzed side of the body; this symptom usually lasts a few days. The color of the face is not uniformly the same in all cases; sometimes it is deep *ed, even cyanotic; sometimes natural, or again quite pale; the pupils may be dilated, of normal size or contracted; one pupil larger than the other points to a unilateral affection of the brain ; the pulse varies likewise in different cases; in most cases it is slow and some- times irregular; in others very rapid and regular; the respiration may be quiet and regular as in healthy sleep; it may be labored, stertorous; it may, during deep sopor, be a kind of blowing, drawing the cheeks in during in- spiration and puffing them out during expiration — the so-called tobacco- smoker's respiration; towards the end respiration becomes intermittent and irregular. The temperature is at first usuahV lowered to 96. 3 F., and re- mains so in the fulminating form until death. If life endures for from ten to twenty-four hours the temperature rises rapidly. If life is prolonged to a still longer period the temperature rises only to 99. 8° or 100. 4 F., where it remains; another sudden rise is a very unfavorable symptom, as it usually precedes death. Urine and feces pass off involuntary during sopor. Ful- minating cases terminate in from five minutes (rare cases) to three or four days. Recovery rarely takes place after the coma has lasted forty-eight hours. But even if the coma ceases health is by far not restored; now in- flammatory reaction sets in; the temperature rises from a few tenths of a degree to two degrees; there is occasional cloudiness of mind, even delirium; loss of appetite; convulsive movements, even tonic contractions with pain in these parts. This may last for several days and then subside for a time, when the same symptoms, although in a milder form, reappear again at in- tervals of two, four or eight days. But there remain permanent symptoms for a long time, often through life, which depend on the extent and seat of the destruction caused by the haemorrhage. These are, with a few excep- tions, hemiplegia of that side of the body which is opposite to that in which the lesion of the brain occurred; paraplegia if the haemorrhage occurred simultaneously in both hemispheres; partial paralysis, for example, of the facial nerve, in connection with extravasation in the optic thalmus, and in the corpus striatum; contracture (in the later stages) of the paralyzed limbs; anaesthesia of the affected parts, which may or may not diminish or com- pletely disappear; hyperalgesia, by which a light touch is felt as pain, and THERAPEUTIC HINTS TO APOPLEXIA SANGUINEA. Ill which may alternate with anaesthesia or even exist side by side with it for years; spontaneous attacks of pain in the partially or totally paralyzed limbs. There are also disburbances of the trophic and vasomotor nerves. The affected limbs are often hotter and redder for some time than those of the unaffected side; they are swollen, oedematous; they sweat profusely; after some time, however, they become cold; or the skin is tending to be dry and scaly from the first; the pulse is diminished in its amplitude; bedsores ap- pear; the nails become yellowish, ridgy, brittle and curved in both direc- tions; the hair grows thicker and longer and the skin becomes hypertophied — all on the paralyzed side. Of the special senses taste is limited to the forepart of the tongue on one side in consequence of an affection of the chorda tympani; this symptom usually disappears soon, but may last for a long time. Hearing is sometimes slightly affected, and sight in the form of hemiopia frequently. Among the mental disturbances deficiency of memory is the most promi- nent, especially in regard to recent impressions, while old ones can be re- called with unimpaired distinctness. The power of judging may gradually weaken until the patient is reduced to childishness or dementia; the disposi- tion often changes to peevishness and irritableness. The Prognosis is grave; even if recovery from the shock takes place the consequences of the reactive inflammation are always to be dreaded, and there is no safety for a renewed attack at any time thereafter. Therapeutic Hints. Remedies to prevent the attack ought to be studied under hyperemia, to which may be added: Sepia. After previous attacks; in men who have been addicted to drinking and sexual excesses, with a disposition to gout and haemorrhoids. Forerunners: dizziness in walking, with staggering; things fall out of their hands; forgetfulness; use wrong words when writing; cold feet; intermitting pulse. Remedies during the attack and its inflammatory stage : Aeon. Head hot; carotids throbbing; skin hot; pulse full and hard, but not intermittent; after fright or vexation, or suppressed habitual bleedings. Arnica. Head hot and rest of body cool; paralysis of left side; pulse intermittent and irregular. Bellad. Red face; dilated pupils; loss of sight, smell and speech; pul- sation of carotids; spasms in the face; thick tongue, protruding; difficult deglutition; involuntary emission of urine; reaching with the hands to the genitals; moaning; paratysis of limbs, right or left; coma, sopor. Cocad. Face red and hot; eyes closed, with the balls constantly roll- ing about; pupils dilated; breathing without noise; stupor; left or right ex- tremities paralyzed; after night- watching and exhaustion. Conium. " Eighty years of age; one side completely paralyzed: sweat as soon as he falls asleep and even with the closing of the eyes.' 1 (Nash.) Gelsem. and Glonoin. See under Hyperaeniia. 112 THERAPEUTIC HINTS TO APOPLEXIA SANGUINEA. Hyosc. Sudden falling down with a shriek; soporous condition; face red; inability to swallow; involuntary discharge of feces; blood-vessels swollen; pulse quick and full; numbness of hands after consciousness returns. Laches. Left side mostly affected; blowing expiration; cannot bear anything to touch his neck; when conscious talks and jumps abruptly from one idea to another; after the use of liquors or mental emotions. Lauroc. Vertigo; bloated face; jerking of the facial muscles; speech- less by full consciousness; palpitation of the heart; scarcely perceptible pulse; cold, moist skin, Xux vom. Snoring; paralysis of lower jaw and (mostly) of the lower extremities, which are cold and without sensation; after a heart}' dinner, or abuse of liquor or coffee. Opium. Open eyes; dilated pupils; red face; jerking of the muscles of the face; sinking of the lower jaw; foam before the mouth; slow, irregular or stertorous breathing; convulsive motions of the extremities, or tetanic stiffness of the whole body; cold, paralyzed limbs; hot sweat on the head. After consciousness is restored, the patient cannot retain what he reads and forgets the connection of consecutive thoughts. Old drunkards; is followed well by Xux vom. Remedies for subsequent chronic changes : ^iiiac. Loss of memory; general paralysis. Caustic. Inability to select proper words; paralysis of face or extremi- ties, which latter is complicated with muscular contractions. Cuprum. Paralysis of tongue, stuttering, deficient speech; the para- lyzed limbs grow thinner, but preserve sensation; frequently complicated with unyielding contractions or chorea-like paroxysms. Plumbum. Consciousness blunted; mem or}' deficient; speech impeded, single syllables are omitted or the syllables cannot be combined into words; mimic spasms of face when speaking; trembling of tongue when it is put out; semi-paralysis of the buccinator muscles and of the velum palatinum, which manifests itself by violent snoring; sleeplessness, fear of death; the organs of the senses are torpid and insensible, the eyes are principally affected; the eyelids droop as if paralyzed; the pupils most constantly dilated; all objects seem smaller and further removed from the focus of vision, they may be seen as through a gauze; diplopia; pulse always slow, 50 to 60 in the minute; sometimes hard and tense like a wire; all the muscles may be paralyzed, especially of left side; the paralysis affects equally the motor and sentient nerves, is often attended with violent pains in the paralyzed parts, and con- siderable contractions, especially of the extensor muscles, which feel as hard as wood; in other cases the spasms are tonic, which, if they reach their full development, run into complete epileptic convulsions; the muscles of the affected parts become atrophied. If the paralysis is not complete, the patient's gait is unsteady, with particular tendency to fall forward. The paralyzed respirator}- muscles often occasion a high degree of dyspnoea. The' sphincters are scarcely ever paralyzed. (Baehr. ) Ziucum. Senses remain disturbed after the attack. Besides, compare what has been said under Meningitis. OCCLUSION OF THE CEREBRAL ARTERIES. 113 OCCLUSION OF THE CEREBRAL ARTERIES; EMBOLISM AND THROMBOSIS ; SOFTENING OF THE BRAIN. An occlusion of the cerebral arteries takes place either by embolism, when the occluding mass is carried by the stream of blood from some other parts of the vascular system to a place where, on account of the smallness of the vessel, it cannot go any further; or by thrombosis, when the occluding mass is produced on the very spot of the occlusion. The emboli consist either of blood clots, masses of fibrine, connective tissue growths, or chalky concretions, the principal source of which is endo- carditis ; and next aneurism of the aorta; seldom thrombotic masses from within the lungs. Thrombosis takes its origin through structural changes in the vascular walls, such as fatty degeneration, or inflammation of the coats of the arteries, leading to sclerosis, ossification, or calcification, by which a gradual slack- ening in the speed of the blood current takes place, until an entire stoppage ensues. The emboli are carried much oftener into the left carotid than into the right, and they only exceptionally become lodged below the circle of Willis, but are swept into the arteria fossae Sylvii, which is the chief direct prolonga- tion of the carotid. Sometimes several arteries become the seat of occlusion at the same time. If the seat of occlusion is below or on the cardiac side of the circle of Willis, or if the embolus is swept onward into the arterial system of the cortex, no anatomical changes follow in the cerebral substance, because the circulatory disturbances are readily compensated for by collateral circu- lation. When, however, the embolus is lodged in a terminal artery of the basal system, or is carried beyond the circle of Willis, it causes first " red softening" of the neighboring brain-tissue, that is, the brain substance appears swollen and discolored in different shades of red and is dispersed with numerous dots of blood ( ' ' capillary apoplexies " ) . By and by the red color fades into yellow, partly from the absorption of the coloring matter of the blood, and partly from the ensuing fatty degeneration of the nerve elements; this state of things is called "yellow softening." After a lapse of several months, if the patient lives that long, the affected tissue is converted into a semi-fluid milky substance, which is termed "white softening." At length even this may partially be absorbed, leaving a sort of cyst filled with quite thin fluid. The Predisposing Cause of embolism is preeminently acute rheuma- tism, and it is therefore found oftener in relative^ youthful persons, while thrombosis has its predisposing cause in a morbid change of the vascular system, and is therefore oftenest met with in advanced years. Symptoms. — Embolism always sets in suddenly, and very often with a condition, which] resembles precisely that of an apoplectic stroke, without any premonitory symptoms. In some cases, however, there is no loss of con- 114 THERAPEUTIC HINTS TO OCCLUSION OF THE CEREBRI, ARTERIES. sciousness or coma; there ma}' be delirium, aphasia, vomiting, paralysis — all disappearing in a few hours. Thrombosis comes on slowly with headache, dizziness and a sense of general confusion, loss of memory, numbness, coldness, and creepings either in only one extremity, or throughout the distribution of one nerve, or in one entire half of the body; paretic and paralytic symptoms, perhaps w r ith pre- ceding slight convulsive movements, likewise confined to certain regions of the body and determined by the size and importance of the occlued vessel. Finally the total occlusion ma}- manifest itself with all the symptoms of an apoplectic fit, or may occur without any loss of consciousness. In the further course of development embolism or thrombosis may be described conjointly. Either of them may terminate in death or in com- plete recovery, or be followed by a repetition, or by a chronic development of symptoms as consequences of the structural changes within the brain above described. Only these latter symptoms concern us here. The tem- perature begins to rise on the second or third day and may quickly reach 104 F. , when after two or three days it rapidly sinks again and finally becomes stationary. Indeed the complex of symptoms now developing may be regarded as identical with that of cerebral haemorrhage, and need not, therefore, be repeated. Aphasia is of very frequent occurrence in this affec- tion, because the left Sylvian artery is the most common seat for embolic occlusion, inducing functional disturbances in that district of the cortex cerebri with which disorders of speech are regularly associated. The Diagnosis between embolism and haemorrhage is very difficult, unless we can take the predisposing causes (valvular diseases of heart and affection of the lungs) as a starting point. A distinction between throm- bosis and haemorrhage is not possible, only that the first occurs much less frequently than the latter. Therapeutic Hints. Compare Apoplexy and the various forms of meningeal affections spoken of before, to which I add the following remarks of Dr. H. R. Stiles: "When the disease shows evidence of inflammatory action, or is recent, Bellad., Nux vom., Mercur.; where it is evidently due to atheromatous conditions of arteries, Phosphor., Phosph. ac, Anac, Zincum; for hemiplegia, Nux vom., Coccul., Bar. carb., Arnica; for vertigo, Iodine (congestive), Sulphur, Digit., (cardiac); for sleeplessness, Coffea, Hyosc, or Nux vom., and Chamom., if the patient has been addicted to the use of coffee; China, if he has been a great tea drinker; for paralysis (general), Phosphor., Conium, Coccul. (local), Caustic, Aeon., Ignat., Bellad.; for convulsions (simulating epilyeps), Bellad.. Cole, carb., Cuprum, Strychnine; for emotional disturbances, Ignat. ; headache (active), Aeon., Bellad., Bryon., A T ux vom., Glonoin. (passive), Gelsem.j Opium,- for imbecility, Arnica, Ambra, Selen., Sepia; or sensation of formication, Secale. ' ' Compare nlso therapeutic hints under dementia paralytica. APHASIA. 115 APHASIA. Under this term clinical observers have arranged a variety of deficien- cies of speech. When there is an incapacity for the motor co-ordination, so that the pa- tient, although he understands all that is said to him, and is able to express his wishes by writing, is yet unable to express them by words, although his organs of speech — tongue, etc. — are in perfect order, it is called ataxic aphasia. Here the connection between the idea and the organs of speech is interrupted. In some of these cases this does not amount to entire speech- lessness, some words of one syllable may possibly be in his reach, and he uses them as best he can, making up by writing and gestures what he cannot con- vey bywords; others utter only a few senseless syllables and words; but none can repeat words even if dictated to them. At times ataxic aphasia is com- plicated with agraphia, an inability to write either a single letter or a com- bination of letters into intelligible words and sentences, although otherwise the hands are fit to perform all sorts of other mechanical uses. The speech of gestures is seldom implicated in this affection. When there is an incapacity for the recollection of words, although the idea is present and the articulation is at the service of the word, it is called amnesic aphasia. Here the association between the idea and the word (its verbal expression) is interrupted. This occurs even during health. Some- times, with our best endeavors, we cannot recollect a name; in the diseased state especially nouns, which cannot be roused into consciousness; therefore the patient tries to describe what he means by other words, for instance, call- ing a pair of scissors ' ' that which cuts. " Or it is only the initial letters which are wanting, and he omits them in speaking and writing; or in more profound derangements, although the patient may be able, by paying strict attention, to repeat what another speaks aloud before him several times, of his own accord he cannot utter it at all, or only badly articulated, mutilated and distorted. So also the letter-signs are either totally forgotten, or ap- plied in unintelligible connections, while on the other hand the reading of written or printed matter may not meet any obstacles. When there is an inability to understand the words wnich they hear, or to read the words which they see, although sight or hearing and the ability to express their thoughs by speech and writing are unimpaired, it is called word deafness and word-blindness (Kussmaul). Here the association be- tween the word (spoken or written) and the idea is impeded, or in other words the external stimulus does not reach the idea, while in the amnesic form of aphasia the idea is not capable of exciting its corresponding verbal expression. This affection, however, is generally combined with amnesic aphasia or agraphia, and patients of this kind have been taken for deaf and demented, because their answers did not correspond to the sense of the ques- tions and they used distorted or wrong words. When there is an inability to connect the ideas with their appropriate Il6 THERAPEUTIC HINTS TO APHASIA. word-expressions, so that instead of the appropriate term another word of a different meaning or altogether strange and unintelligible expressions are used, it is called paraphasia. Here the connection between the ideas and their proper expressions is loosened, in a way that other words or names of ideas similar perhaps in meaning or sound interpose themselves and repress the proper ones. This disorder occurs at times without any pronounced morbid condition of the brain, when for instance from want of proper atten- tion we use a word which belongs perhaps to another train of thoughts, but which at that time preoccupies the mind; or in the hurry of excitement, dis- place the consonants of certain words and form strange, irregular combina- tions, say, for instance, " mood goring " instead of " good morning," or in- stead of "Liebig and Mitscherlich," as an absent-minded professor did, '' Mitschich and Liederlich." But in marked states of the brain this para- phasic confusion may amount to such total perversion and corruption of words and sentences that it is completely impossible for the hearer to under- stand what the patient means. And the same is true of paragraphia. "Royal naval medical office, etc.," one wrote in the following manner: 11 Roydudendd navendendd oforendendd, etc." By numerous post-mortems it is proved that lesions of the left frontal lobe, and especially its third frontal convolution, are the most frequent Causes of aphasia ; the island with the neighboring frontal, parietal and temporal districts comes next in frequency. Aphasias, from lesions in other regions, are exceptions to the rule, as for instance the lesions of the right frontal lobe. These latter cause aphasia only in left-handed people, for the reason that such persons have exercised for speech and action the right frontal lobe; a lesion of the left frontal lobe does not affect their speech, since that of the right, which alone has been exercised, remains intact. Left-handed people, therefore, become aphasic only when the lesions include the right hemisphere; while lesions of the left lobe always cause aphasia in right-handed persons. These lesions for the most part consist of necrotic softenings from embolism and thrombosis of the artery of the fissure of Sylvius; then follow in frequency in the order named haemorrhages, abscesses and tumors of this region. Aphasia is, therefore, merely a symptom of pathological conditions, most of which we have already described separately. Its Prognosis depends entirely on the severity of these conditions, and they ought to be studied thoroughly in any case of aphasia. Therapeutic Hints. Here we must naturally refer to those already given under the corre- sponding chapters. Cases reported have been cured by: Bellad. Compare symptoms under apoplexy. ' ' After excessive fatigue, bad nourishment, loss of sleep, prostrated and enfeebled, that he cannot answer the simplest question. ' ' (Gallavardin. ) THROMBOSIS OF THE CEREBRAL SINUSES. 117 Conium. Parenchymatous nephritis after scarlet fever. Glonoin. Loss of memory for words and of the power to articulate. Kali brom., 3d trit. Without symptoms mentioned. Lycop. Confusion of thoughts; forgetful; mixed up letters and sylla- bles of words in writing, or left out part of them. Stramon. In several cases used empirically with success. For additional hints compare the following collection of symptoms: Senseless after waking from a sleep at noon: Conium. Forgetful and absent-minded, with headache: Amm. carb. Cannot remember things which he wants to remember: Hyosc. ?iig. Forgets names: Anac, Oleand., Sulphur. Remembers having seen a person, but cannot remember her name. Crocus. All things appear new to him, after waking, even his friends: Stramon. Makes mistakes about time and objects, although they are quite clear and visible: Crocus. Unable to express himself properly while talking: Conium. Cannot talk connectedly: Canthar. nor express himself properly, with rush of blood to the head: Arg. nitr. Distracted, does not know what to say: Natr. mur. Slow remembrance, talks slow, hunts for the words when talking: Thuja. Absent-minded and forgetful: Alum., Bellad., Bovista, Coccul., Phosph. ac, Platin. with awkwardness in talking: Amm. carb., Natr. mur., Sepia, Sulph. ac. and awkwardness in writing: Bovista. Inability to find the right words: Anac, Arg. nitr., Mercur., Pulsat. with stammering: Chamom., Opium. with making mistakes in writing: Chamom., China, Graphit., Hepar, Ignat., Nux vom. With headache uses wrong words: Caustic, Nux mosch., or has difficulty in talking: Thuja. Absent-minded, says what she does not intend: Natr. mur., and makes mistakes in writing: Natr. mur. Leaves words out when writing: Rhodod. When he wants to write something down, he loses the ideas: Crocus. Forgetful, so that he cannot recall what he was about to write: Natr. mur. He can express himself on abstract subjects very well; when talking about common things, he gets confused: Lycop. He cannot read what he wrote himself: Lycop. Difficulty in understanding what he is reading: Conium. THROMBOSIS OF THE CEREBRAL SINUSES. The sinuses being ot a rigid nature and incapable of collapsing, they being also traversed by bands of connective tissue, and having no muscular walls to promote the flow of blood, it is easily comprehensible that in them a I i S THROMBOSIS OF THE CEREBRAL SINUSES. coagulation of blood may readily occur, if either the propelling power of the heart, the vis a tergo, should become weakened, or there should form obstacles to the flow of blood in the sinuses themselves by inflammation of their walls I phlebitis). The first usually occurs under conditions as are known by the name of marasmus, particularly common among children during their first year of life, when they are prone to sudden collapse induced by severe diarrhoeas; also in adults through the influence of various conditions which induce enfeeblement of the propelling force of the heart, such as profuse sup- puration, cancer, marasmus, senilis, etc. This form of thrombosis is especially found in the longitudinal sinus and in the transverse sinuses, and is called marantic thrombosis. The second or phlebitic form originates most commonly from disease of the cranial bones, especially of the petrous portion of the temporal bones which accompanies otitis media; then its seat is in the neighboring sinuses — the sinus transversus and petrosus; if phlebitis arises from caries of other cranial bones, or large furuncles in the face, especially on the upper lip, or erysipelas of the head and face, its seat is determined by the location of these lesions. The Symptoms of marantic thrombosis when accompanying conditions of marasmus in children, resemble greatly those of hydrencephaloid, both giving rise to cerebral anaemia; collapse, followed by somnolence and coma, is common to both. As a general rule of distinction between the two, the following may be laid down: If diarrhoeas, occurring in children a few months old, are followed by cerebral disorders of the active motor kind, such as rigidity of the muscles of the neck and sometimes of the back, and even of the limbs, sometimes nystagmus, the probability speaks for thrombosis of the superior longitudinal sinus; whereas the clinical history of hydrencephaloid usually closes with collapse, somnolence and coma, terminating either in death or recovery; convulsions or paralysis are only exceptionally met with. Marantic thrombosis in adults is in its manifestations still more indefinite. It may show nothing but a slight degree of apathy and general depression, a varying complex of symptoms of diffused, undefined cerebral diseases, such as headache, delirium, loss of consciousness, disturbance of the motor func- tions either of the spasmodic or paralytic kind. In some cases, however, symptoms occur in children as well as in adults, which are diagnostic, namely: swelling of those veins outside of the skull, which communicate with the af- fected sinuses; epistaxis ; tensely filled vessels, running from the anterior fontanelle to the neighborhood of the temples and ears on both sides; cyanosis of the face, all this in case of thrombosis of the superior longitudinal sinus. When the transverse sinuses are affected, there may be oedema limited to the parts behind the ears; or the internal jugular vein may be found less filled on the side of the lesion, than on the other side, but this symptom is not often so prominent that it could be turned to account. When the sinus cavernosus is the seat of the disease, there usually exists hyperaemia of the fundus oculi, oedema of the eyelids and. conjunctiva, and HYPERTROPHY OF THE BRAIN. 1 19 prominence of the eyeball ; sometimes on account of the pressure upon the first division of the trigeminus, the trochlearis, the abducens, and the oculo- motorius, paratysis of the motor nerves, or neuralgia or trophic disturbance of the eye may arise. Sometimes particles from the thrombi are carried off by the blood-cur- rent and become lodged in the lungs. If such pulmonary embolism are found under conditions above described, it would be another sign in favor of the conclusion, that thrombosis of the cerebral sinuses actually exists. The Prognosis of this affection is decidedly unfavorable, and in regard to therapeutic hints, I must refer to hydrencephaloid, anaemia, summer-com- plaint, inflammation of the inner ear and other affections which are more or less related to this affection. HYPERTROPHY OF THE BRAIN Means an overgrowth of the brain. However, we ought to know, that it is not the cerebral substance itself, which develops more largely than naturally, but that "it consists of an undue growth of the interstitial tissue which binds the nervous elements together. It is confined mostly to the cerebrum; yet there are a few cases in which the cerebellum has also been said to be affected. Partial hypertrophy is still more rare, and in part, of very doubtful nature. On post-mortem examination the brain is observed to swell out from under the removed bone above the skull bones. The adjustment of the re- moved bones to their original position is quite difficult. The membranes are thin and bloodless, and between the arachnoidal spaces there is no cerebro- spinal fluid. The convolutions on the surface of the cerebral hemispheres are flattened and compressed, and the sulci between them scarcely noticeable. The ventricles are narrow and the substance of the brain itself is anaemic, but its consistence and elasticity is greater than in a normal brain. This abnormal growth is either congenital (and then is frequently com- bined with an imperfect growth of the body), or it develops itself after birth, mostly during early childhood, rarely afterwards. In the latter case we find it frequently associated with rhachitis and enlarged lymphatic glands. Its Causks are unknown. Its external Symptoms are: a considerable enlarge- ment of the head, if it takes place before the sutures of the skull are perfectly closed; a condition entirely similar to that in the enlargement of the head in consequence of hydrocephalus. When it takes place after the closure of the sutures, such extension is impossible, but the skull bones grow thinner and their inner layer becomes roughened by absorption. In the first place it can be distinguished from hydrocephalus by this fact: that children having this affection are rather forward in their mental development, while in hydro- cephalus the reverse always obtains. A hypertrophy after the closure of the sutures is never recognizable with certaint}'. One of its most important symptoms, however, are frequent attacks of fits, which resemble epilepsy. 120 atrophy of the brain. Therapeutic Hints Cannot be given a priori. Each individual case must be studied by itself. Compare Hyperemia. ATROPHY OF THE BRAIN Is the opposite of hypertrophy, a shrinking, wasting away of the brain. Deficiencies of growth have been found congenital, being confined either — i, to both hemispheres of the cerebrum; or 2, to both hemispheres of the cerebellum ; or 3 , to certain parts of the brain which are not developed at all. In such cases the children are idiots. In some other cases the defi- ciency has been found confined; 4, to one-half of the cerebrum and to the opposite half of the cerebellum (the usual condition), or to the corresponding half of the cerebellum; then the children are not idiots, but mostly affected with hemiplegia of the opposite side and in a great many cases with epileptic fits. This deficiency, in the proper development of the brain, the causes of which we do not know, is called agenesia. Ileal atrophy is a shrinking — wasting away — of the cerebral substance. It occurs, occasionlly, in old age, in consequence of marasmus senilis, where a want of general nutrition causes a waste of the brain; the lost substance being at once replaced by an exudation of serum, constituting hydrocephalus senilis. It also occurs as a result of exhausting diseases and chonic alco- holism, almost always leading to general paralysis and imbecility of mind. But it may develop itself in portions of the brain only — partial atrophy — when in consequence of apoplexy, inflammation or exudation, as we have, already seen, by destruction or pressure upon the capillaries or arteries, such portions become deprived of the necessary nutrition. Its consequences are, in almost all cases, aberrations of the intellect, imbecility of mind, and para- lytic affections. Therapeutic Hints. A deficient development of a portion of the brain can not be remedied; congenital deficiencies are therefore clearly out of the reach of any medicine. Where we suspect an atrophy in consequence of exhausting disease, we must select our remedies according to these circumstances. Destroyed portions will ever remain destroyed in spite of medicine. TUMORS OF THE BRAIN AND ITS MEMBRANES Consist of morbid growths in the connective and epithelial tissues of the blood-vessels and their sheaths, which either retain the character of the affected tissue, or become altered by modification of the newly-formed ele- ments and by changes in their relations to the connective tissue and vascular distribution. Their Causes seem to be a hereditary predisposition, abuses of spiritu- ous drinks, blows and falls of all kinds, syphilis and tuberculosis. They occur much more frequently in men than in women. TUMORS OF THE BRAIN AND ITS MEMBRANES. 121 Tumors which retain the character of the affected tissue, are: Glioma, formed by proliferation of the neuroglia, greatly resembles normal brain tissue, and is therefore not easily distinguishable; when it assumes a more mucous character, it is soft and closely resembles myxoma ; when its structure is harder, it resembles and is allied to sarcoma. It grows slowly, may finally undergo fatty degeneration, and is found usually in the white substance of the cerebral hemispheres and especially their posterior lobes. Hyperplasia of the pineal gland presents a solid, grayish-red, slightly lobulated or else smooth, round tumor, which may grow as large as a walnut or even larger; its histological elements are somewhat larger and firmer than in the normal. Psammona or sand tumor is an inflammatory proliferation of the cellular tissue in which a calcareous deposit takes place; it usually grows from the dura mater commonly at the base of the skull, is a hard, hemispherical tumor, white and smooth and of the size of a cherry-stone. Melanoma takes its origin in the pigment cells of the pia, is small in size, but may be multiple; is of rare occurrence. Neuroma, a genuine hyperplasia of the gray substance, occurs in sizes from a millet-seed to that of a pea and is found on the ventricular surface, in the white substance, or on the outer surface of the brain. Hyperplasia of the anterior half of the pituitary gland. Cysts may be the result from apoplectic effusions, abscesses and softening. Aneurisms are of frequent occurrence, especially upon the large vessels at the base of the brain, and usually in consequence of atheroma; when bursting they cause fatal apoplexy. Cholesteatomata consist partly of hardened epithelial cells and partly of epithelial cells which have undergone fatty degeneration; they unite, as Rindfleish says, ' ' the structure of an epithelial carcinoma with the harmless- ness of a wart or weal. ' ' They are generally found in some hollow at the base of the skull or in some recess of the brain. Tumors by which the affected tissue is changed in its character, are: Tubercles, gray, yellow, or yellowish- white, hard tumors, which fre- quently grow larger than a hazel-nut; their favorite position is the gray sub- stance, especially of the cerebellum; they occur most frequently in child- hood. Miliary tubercles are a frequent concomitant or source of meningeal inflammation. Carcinoma appears usually as primary fungus hsematodes on the outer or inner surface of the dura. When starting from the outer surface it rapidly softens and pierces the skull bones and then spreads on the external surface of the skull (fungus durse matris); when originating on the inner surface its growth is entirely directed towards the brain; it never penetrates the dura, except at the natural openings for the nerves, such as the olfactory, optic, etc. , hence the growing in and out of cancers in the orbits on the perforated plate of the ethmoid bone, in the spheno-maxillary fossa and so on. 122 THERAPEUTIC HINTS TO TUMORS OF THE BRAIX. Sarcoma is either a hard, dense, homogeneous mass, which can easily be detached from the surrounding tissue, or is of a soft, medullary consistence, which constitutes a transition to a myxoma or glioma. Myxoma forms a very soft gelatinous mass, which frequently breaks down into cysts containing a mucous fluid; they may attain the size of a man's fist, and are met with only occasionally in the cerebral hemispheres. Syphilitic tumors are not common; they generally resemble the gum- mata of other parts, being composed chief!)* of grayish, semi-translucent matter, which is liable to become opaque and crumbling on undergoing a caseous transformation. Symptoms. — One should suppose that the pressure of any of these tumors should manifest itself more or less by various outward symptoms. But this is not always the case. Large tumors have been found post- mortem, and not a single symptom did betray them during life. It is remarkable how the system, even the brain, ma}* become accustomed to an abnormal growth, when it is invaded slowly. Yet there are symptoms in many cases which should rouse our suspicion in this direction. They are: Depression of spirits, melancholy, rarely maniacal attacks, mental derange- ment, aphasia, sleepiness; amblyopia and amaurosis, with the appearance of choked disk and neuroretinitis; inequality of the pupils; strabismus; violent headache, often accurately localized; monolateral anaesthesia, usually in the form of anaesthesia dolorosa; neuralgia; monolateral paralysis of varying degree, gradually increasing; jerking; quivering; cramps of the affected groups of muscles, developing sometimes into epileptoid attacks." Further on: "imbecility; total want of energy; sopor; comatose condition; wide- spread anaesthesia; very hesitating speech; paraplegia; incontinentia urinae et alvi, or else retention; increased temperature of the body; symptoms of meningitis: apoplexy." Glioma is to be thought of when there is: "preceding considerable injur}* of the skull; slow progress of the symptoms and hence relatively long duration of the illness; intercurrent apoplexies; good state of nutrition." Tubercular tumors, when there is " a hereditary predisposition to tuber- culosis; occurrence in childhood; tuberculosis of other organs; commence- ment of the symptoms after acute febrile diseases, for instance measles; complication with meningitis. ' ' Carcinoma, when there is " a rapid progress of the symptoms; perfora- tion of the bones of the skull; carcinoma in other organs." Notwithstanding all this, the Diagnosis of brain tumors will in many cases remain problematic and is often impossible. Therapeutic Hints. Little can be said. In all cases we must be governed by the totality of the symptoms, even if we should suspect a tumor. When a considerable injury of the skull has preceded, we will have to choose a remedy accordingly. DISEASES OF THE CRANIUM AND ITS INTEGUMENTS. 1 23 When tubercles are suspected, compare what has been given under meningitis tuberculosa. In case of carcinoma, compare: Calc. carb. or phosph., Arsen., Carb. an., Bellad., Laches., Phosphor., Silic, and many others. DISEASES OF THE CRANIUM AND ITS INTEGUMENTS. a. ABNORMAL LARGENESS OF THE HEAD May be caused \yy hydrocephalus, hypertrophy of the brain and by pseudo- formations within the cavity of the skull, when they perforate the skull. To this are to be added morbid conditions of a more external nature. Dropsy of the Scalp. This is a collection of serum either in the cellular tissue (cellular dropsy) or between the aponeurosis and the pericranium (aponeurotic dropsy). When the watery fluid collects in the cellular tissue, it is apt to spread down to the face, and on pressure with the finger it leaves a pit, as is seen on all parts of the body, where dropsical effusions exist within its cellular tissue. When it is underneath the aponeurosis or the galea capitis, the swelling is tight, elastic, fluctuating, and leaves no pit on pressure, and never spreads over the ears or eyelids, and this for obvious anatomical reasons. Both forms exist without cerebral symptoms, and may be the conse- quence of either a general dropsical condition, or of erysipelas, external in- juries, stings of insects, eruptions, and so on. Hypertrophy of the Skull. This may either involve a part only of the cranium, in which case it forms exostosis or bony protuberances ; or the whole skull, whereby the bony walls may attain a thickness of one inch and a half. Both forms cause an enlargement of the head, and are mostly found as a concomitant to rhachitis or syphilis. When they grow from the inner plate of the skull, the}' do not cause an external enlargement of it, and are therefore not recognizable with any degree of certainty. The Bruised Head of a Child after Birth, Caused by the pressure during birth, is either an extravasation of lymph or blood into the cellular tissue, in which case it is called caput succedaneum ; or it is an extravasation of blood between the bones and the pericranium, causing the affection called thrombus neonatorum. The Caput succedaneum may extend over the fontanelles or sutures of the bones; it may even be formed on any part of the head sufficiently ex- 124 AFFECTIONS OF THE SKULL WITHOUT ENLARGEMENT. posed to a great pressure of the pelvis, or the forceps, during labor. It has a soft, doughy feel, and the outer skin looks bruised. The Thrombus, however, is confined generally to the parietal bones, and never extends over the sutures of the bones, because there the peri- cranium adheres firmly to the skull. It feels elastic and fluctuates, and shows no discoloration of the external skin. Both forms are bruises in their nature, and ought to be treated, should treatment be necessary at all, like bruises. Aniica will usually do what is required; in some cases, however, Bar. mur. and Mercur. have been success- fully applied. b. ABNORMAL SMALLNESS Of the head is found in idiots. It may be partial or general, congenital, or caused after birth, before ossification is completed. Always, however, it will be found in connection with an imperfect development or derangement of the brain. c. AFFECTIONS OF THE SKULL WITHOUT ENLARGE- MENT. The cranium consists of two tables, which run parallel with each other, and are separated by an intermediate cellular structure, which is called diploe. The whole, however, consists of eight different bones, which are connected to each other by sutures. Before these sutures consolidate, there are, of course, on those places where different bones are to meet, larger or smaller openings, which are called fontanelles. At the time of birth, how- ever, as a general thing, only one of these fontanelles exist, and that is the anterior opening, whilst the posterior and parietal openings have already closed. The anterior fontanelle closes normally in the second year of life. If it stays open much longer than two } T ears, it shows a want of proper nutritive action in the system; if it grows larger, dividing the frontal bone and parting the parietal bones, it is a sign of chronic hydrocephalus, or of hypertrophy of the brain. If you lay your hand softly upon it, or watch it closely, you will observe a constant motion up and down, a kind of breathing of the brain. Screaming or coughing causes momentary distention and protrusion of the integument over it. If, however, as in cases of meningitis, this opening swells out permanently, it is a sign of exudation of serum in the brain. Its suddenly sinking in denotes a collapse of the brain, which is soon followed by death. In like manner, the posterior fontanelle, by a morbid process of ab- sorption of the already formed bony substances, ma}* reopen; or several holes may form near by — the bony structure withering away gradually, leaving only the integuments. This is called the Soft occiput or Craniotabes. It has been observed mostly towards the end of the first year, especially in children of rhachitic or scrofulous parents. It is doubtless a deep-seated, constitutional disorder, and can be successfully treated only by a careful DISEASES OF THE INTEGUMENTS. 1 25 stud)' of all the symptoms. Nevertheless, Sulphur, Calc. carb., Calc. phosph. and Silic. might often be indicated. If not checked, it frequently becomes complicated with meningitis, or pneumonia, or tuberculosis and diarrhoea, which soon end the scene. To this I ma)' add — Atrophy of the Skull. This may be a consequence of internal pressure from carcinoma within the cavity of the skull, which may even perforate the cranium; or from hy- pertrophy of the brain; all of which have already been mentioned. We also meet with inflammation of the skull or ostitis, with all its sequelae — caries and necrosis — which is mostly of a syphilitic or tuberculous origin, or is caused by external wounds badly treated. Therapeutic Hints. Caries call for Asa/., Calc. carb., Calc. phosph., Fluor, ac, Pulsat., Silic, Sulphur, and other remedies. d. DISEASES OF THE INTEGUMENTS. The integuments of the cranium consist of the following five different layers: 1 . The external skin or derma is covered thickly with hair, and contains innumerable sebaceous and sudoriparous glands, of which the former secrete an oily, fatty substance, and the latter are the organs of perspiration. 2. The subcutaneous cellular tissue, in which the net- work of the larger blood-vessels and nerves lies imbedded, and which conjoins the derma to 3. The aponeurosis; which is expanded tightly over the cranium. Under it is found — 4. The second cellular tissue, which consists of loose meshes and con- nects the aponeurosis only loosely with 5. The pericranium, which is the immediate covering of the bones, and which, although very thin, is nevertheless of great strength. It transmits numerous blood-vessels into the bones. In diseases of the scalp all or single of these different layers may be affected. Eczema Capitis, Humid Tetter or Scald. " A non-contagious affection, characterized by the eruption of minute vesicles of great numbers, and frequently confluent, upon a surface of ir- regular form and usually of considerable extent. The vesicles are so closely aggregated in some situations as to give rise to one continuous vesicle of great breadth . " ( Wilson . ) They dry and form thin scales, or else break and discharge a watery or milky fluid of different consistencies, which, by concreting, give rise to 126 THERAPEUTIC HINTS TO DISEASES OF THE INTEGUMENTS. thinner or thicker crusts. It is acute and chronic in its nature, and may appear on any part of the body. According to its appearance, location, or severity and obstinacy, it has received a variety of names, which gives a nomenclature most remarkably confused and confounding. It is called ekthenia, porrigo, tinea with various adjectives, and, if chronic, psoriasis. In order to simplify the whole we will just remember that eczema exhibits the following characteristics: It is a vesicular eruption, in clusters, often con- fluent, discharging limpid or turbid and milky fluid, which forms crusts of different thicknesses, is acute or chronic, mild or severe, situated here or there. It may be confounded with Impetigo, Because its appearance so closely resembles this latter as to force upon the mind the impression that they are the same disease. And, indeed, impetigo, derived from ab impetu — a bursting forth with violence — is nothing but a pus- tular eczema; so that, in order to distinguish between the two, we must know what is a vesicle and what is a pustule. A vesicle is understood to be a very small blister, containing a transparent, limpid fluid; a pustule means a pimple containing pus. The difference between eczema and impetigo lies then in the pyogenetic (that is, pus-forming) character of the latter. If both are found together, covering large patches on the scalp, their distinction is quite difficult, unless w T e say: the hardened coverings of the excoriations of eczema are thin scabs, because growing out of a limpid, thin fluid — lymph; while those of impetigo are tense and thick, greenish-yellow, or brownish crusts, on account of their being formed from pus. Therapeutic Hints. Calcar., Lycop. When the eruption yields a thick and mild secretion. Arsen., Natr. mur., Rhus tox. When it looks angry, excoriated. Bar. card., Graphit., Natr. mur., Rhus tox. When it causes falling out ot the hair. Lycop., Psori)i. \\ nen it smells very badly and causes lice. Natr. mur. When situated on the boundaries of the hair on the nape of the neck. Clemat., Petrol. When on the neck and occiput. Hepar sulph. When the eruption itches worse in the morning, when rising, with burning and smarting after scratching — likewise after external application of salves. Clemat., Graphil., Hepar sulph., Lycop., Natr. vnir., Rhus tox., St aphis., Thuja. For moist eruptions. Arsen. > Calcar., Mcrcur., Sepia, Silic, Sulphur. For dry crusts. Mercur. When the lymphatic glands are inflamed. Bar. card. When the lymphatic glands are swollen and painless. THERAPEUTIC HINTS .OF DISEASES OF THE INTEGUMENTS. 1 27 Arsen. Nightly burning and itching, relieved from external warmth. Bar. card. Falling off of the hair; glandular swelling on the neck and under the lower jaw. Bromium. Eruption covering the scalp like a cap; oozing profusely and smelling badly; cervical glands swollen. Calc. card. During teething; scrofulous habit, swollen glands of the neck; burning worse after washing; small wounds suppurate easily; sweat after eating or drinking anything warm; worse about new moon. Cicuta. Thick yellow crusts. Clem at. The eruption looks angry and inflamed during the increasing, and is dry during the decreasing moon. Crol. tig. Vesicles and erysipelatous inflammation around the crusts; itching, and burning after scratching. Graphit. Eruption with sticky secretion; causing falling out of the hair; commencing behind the ears and spreading over the scalp and face, especially on chin; chronic lachrymation ; fluor albus; worse after washing. Hepar. Especially back part of head; itching; worse in the morning; falling out of hair and leaving bald spots; crusts dry on some and moist on other places with inflamed surface and pus underneath; hard, knotty pimples like small furuncles in the face and other parts of the body; scrofulous ophthalmia; enlarged glands on nape of neck; frequent urging to stool and difficult discharge; sour smelling sweat at nights. Hydrast. Especially on margin of hair in front; oozing after washing; all secretions tenacious, ropy and profuse. Lycop. Crusts with lice between the crevices; underneath oozing of bloody or purulent fluid; badly smelling; sore and moist behind the ears; often eruptions on other parts of the body. Skin dry, raw, chapped and cracked; disturbed sleep with sudden loud screams; emaciation. Mercur. Stinging and burning; surroundings inflame after scratching; salivation and sore gums. Mezer. Eruption dry and scaly, extending over forehead, ears and neck, or thick leathery crusts with pus underneath, matting the hair, and breeding vermin; violent itching, worse in bed and from touch. Natr. mur. Raw surface; the discharge is corroding, eating away the hair, without forming thick crusts. Especially on the boundary of the hair on the nape of the neck. Petrol. Crusts on scalp; soreness behind the ears; tetter on nape of neck, breast and knees; chapped skin; hands and fingers full of bloody rha- gades during winter. Psorin. Badly smelling, yellowish, moist crust with lice; terrible itch- ing; sadness; don't want the head uncovered; the whole body has a filthy smell, even after bathing. Rhus tox. Often indicated; the crusts are thick with greenish, fetid pus underneath and fresh pimples on the surroundings; stiffness of neck and swollen glands on nape of neck and axillae; itching worse at night. 128 DANDRUFF. Staph is. Crusts are moist, offensive, and itch violently; on scratching the itching is relieved, but appears immediately at some other place. Sulphur. Dry or moist crusts; eruptions, pimples on different places of the body; eyes inflamed with photophobia; face bloated, pale; cervical glands swollen; stool undigested, diarrhoea early in the morning; belly bloated; sleepless nights on account of itching; easily bleeding after scratching. Viol. trie. (Jacea). Thick crusts and oozing of profuse yellow fluid, matting the hair together; frequent involuntary urination; the urine smells like cat's urine. Dandruff Is an eczema with but scanty exudation, not sufficient to raise the epidermis into vesicles; it merely loosens it, when it dries and peels off in scales. The scalp underneath remains congested, and thus new scales are constantly reproduced. It may extend over the whole scalp even down to the eyebrows, the whiskers and the beard, or be confined to patches only of irregular form and variable dimensions. The most effective remedies against small, brany scales are according to Jahr: Bryon., Sulphur, Calc. carb., Kali card., Arsen., Alum. For the peeling off of large scales, the same author recom- mends: Phosphor., Lycop., Sulphur, Calc. carb., Nitr. ac. Seborrhoea Oapillittii. ' ' The secretion of the sebaceous glands in the foetus is greater during intra- uterine life than subsequently, and we meet it at birth on the body generally, where it constitutes the vernix caseosa. This abundant secretion continues on the scalp during the first year of extra-uterine life, and if the sebum is allowed to collect there and gather dirt and dust from without, we may have finally crusts several lines in thickness, and the whole hairy scalp may be enveloped in a thick layer of sebum. When the crusts remain for a long time, the seborrhoea is generally complicated with eczema, for the col- lected mass of sebum decomposes, macerates and irritates the skin, and pro- duces redness and moisture on it. The same disease appears also as thick scales, which cause the hair to adhere to one another in little bundles (psori- asis amianthacea). In adults it forms one of the commonest varieties of scurf, or dry scales, which are formed in large quantities, and in old people it is seen in connection with senile decay. The scalp is for the most part devoid of hair, and covered with a dirty, 3 T ellow T ish-brown, easily removable crust. It may also be a part of syphilis. ' ' (Xilienthars Ski?i Diseases, p. 1 18. ) Therapeutic Hints. These crusts are best dissolved by the application of oil or grease, and afterwards removed by washing with castile soap. The internal use of Sul- phur ', a dose of a high potency occasionally, corrects the disposition for this abundant secretion. For adults Phosphor., Calc. carb., Natr. mur., Graphit., Vine, min., Mercur.. have been recommended. FAVOUS, HONEY-COMB RINGWORM, &C. I2Q Favus, Honey-comb Ringworm, Tinea Favosa or Maligna, Porrigo Favosa or Lupinosa, Is a vegetable parasite, the achorion Schoenleinii. "It used to be classed among the pustular eruptions, because it first appears as a small yellow spot, the sheath of the hair being filled with the fungous growth; but it has no tendency to suppurate. It grows with great rapidity, and forms large, hard, dry crusts, which have a peculiar mouse-like odor. It is most liable to be confounded with impetigo, but it requires only moderate care to determine whether the crust be hardened pus or an independent growth. The distinc- tion is based upon the presence or absence of secretion; be the crust of im- petigo ever so dry, some trace of purulent secretion is sure to be met with; and if removed by a poultice, the moist, exuding surface cannot be mistaken. Knowing this fact we have no need to particularize the rounded form, the cracked, broken-looking surface, and all the other characters resembling honey-comb, which the older writers were obliged to enumerate." (Bar- cley.) The scalp is its most usual place of development, but it is sometimes found upon the nape of the neck, or in front of the ear, and even upon the arms. 1 ' The pathology of favus is best understood by considering it essentially to be a form of abnormal nutrition, with exudation of a matter analogous to, if not identical with, that of tubercle, which constitutes a soil for the germi- nation of cryptogamic plants, the presence of which is the pathognomic of the disease. Hence is explained the frequency of its occurrence in scrofulous persons, among cachectic or ill-fed children, and the impossibility of incubat- ing the disease in healthy tissues, or the necessity of there* being scaly, pustular and vesicular eruptions on the integuments previous to contagion. ' ' (Bennet, Lilienthal's Skin Diseases.^) This view is borne out by actual clinical experience. Jahr says: "Notwithstanding its parasitic nature it has been cured by the sole internal administration of Sulp/ncr, Calc. card., Rhus fox., and Arsen.," and Teste considers the treatment of this affection the triumph of Homoeopathy, recommending: Sulphur and Dulcam. for the humid form in children of blonde and fresh complexion. Viol, trie, in alternation with either of the above when the itching is very violent. Oleand. , when there is intense itching and an insupportable nocturnal burning after scratching; affection of the mesenteric glands with swelling, hardness and tension of the abdomen, and frequently loose and undigested stools. Hepar sulph., when extending to the nape of the neck or the face: ophthalmia with or without ulceration of the cornea, etc. Besides compare Arsen., Bar. carb., Bromine, Calc. carb. } Dulcam., 130 TINEA, HERPES TONSURANS. Graphit., Hepar, Mercur., Jfczcr., Rhus fox., Petrol, Staphis., Sulphur, I 'iol. trie. , under Tinea capitis. Crysophanic acid has been recommended by C. E. Fisher. Lapp, maj., grayish-white crust over head, face and neck; swelling and suppuration of the axillary gland. Phosphor., the skin of the denuded scalp is clear, white and smooth. Vine, min., spots on head, oozing, matting the hair together; the hair falls out in single spots, while hair grows on it. Tinea, Herpes Tonsurans, or Ringworm of the Scalp. The hair falls out in a patch of a circular form, leaving the skin of the head perfectly smooth. It is a microscopic fungus, known as trichophytum tonsurans, that invests the roots of the hair and destroys them. Cases are reported as having been cured by Graphit., Phosphor., Arsen. y Tcllur., Sepia, and others. Alcohol is said to destroy the parasite. The Wen Is an encysted tumor of varying size; from that of a small pea to the size of a walnut, and even a small orange. ' ' The sebaceous or fatty substance in these sacs or cysts is variously altered in its qualities and appearance. Sometimes it is a limpid fluid-like serum, and contains crystals of stearine; at other times it is soft and white, of a pappy consistency; again, it is 3-ellowish and resembles beeswax. Some- times it contains epidermal scales and hairs. Sometimes the contents of the cysts are exceedingly fetid ; and the fetor is increased when the tumor in- flames." (Wilson). Under the pressure of the finger they feel elastic and are movable under the skin. Therapeutic Hints. Thus far have been successfully applied: Bar. carb., Bellad., Calc. carb., Caustic., Clemat., Phytol., Sepia, Silic, Sidphur, Thuja. The Teleangiectasia, or Vascular Naevus, Mother's Mark, Is a dilatation of a portion of that fine net-work of capilllary vessels which everywhere pervade the derma and cellular tissue. Such dilatations may occur in either of them. They form red, easily compressible, flat tumors, of different sizes. They are sometimes stationary, but more frequently increase slowly in size; and we often find enlarged blood-vessels in their vicinity. They generally appear on the scalp and still oftener on forehead, but also on other parts of the body. Therapeutic Hints. Carbo veg., Condur., Fluor, ac, Strontian, Sulphur, Silic, Thuja. Phos- phor., when they bleed easily. Sepia in broad, flat, dark venous nsevi, par- ticular! v when on the face, head or nose. THE HAIR. 131 The Hair. Alopecia — its falling off — may originate in various conditions. If it consists in a total atrophy of the hair- follicles the hair, of course, will never grow again; if it is only a partial atrophy, the hair grows thin. A transient deficiency in the nutrition of the hair-follicles, as it occurs in several ill- nesses, such as typhoid fever, pneumonia, puerperal fever, chronic head- aches, syphilis, does not hinder the hair from growing again as soon as these disturbances have passed away. The Alopecia circumscripta or Porrigo devalcans has its cause in a parasite, microsporon audonini, which attacks the hair in isolated patches, and the denuded spots are left clean and polished and of a marble whiteness; it is not considered as contagious. Alopecia in consequence of erysipelas, seborrhcea and different eruptions of the scalp, disappears after these disturbances are healed. Cosmetic means also may bring on alopecia. Baldness is more or less an attribute of old age; it is found oftener in men than in women ; it also is seen in younger individuals in consequence of hereditary disposition. Therapeutic Hints. Kali carb. , Natr. mur. , with great dryness of the hair. Carb. veg. after Kali carb. Hepar sulph., Phosphor., Sepia, Silic. After chronic headaches. Kali carb. , Nitr. ac. After nervous fevers. Phosph. ac. After great anxiety and grief. Besides these compare Ambra, Amm. carb., Bar. carb., Calc. carb., Conium, Fluor, ac, Graphit., Lycop., Natr. mur., Sulphur, Zincum. For bald patches: Aloes, Arsen., Phosphor., Vi?ica min. The cutting of the hair is often attended with great effect upon the general system. Colds in the head are a very frequent consequence, and in children even spasms may result therefrom. But there are also cases on record where it proved beneficial to patients, relieving them of headache, and in one case even from a sort of mania. The changing of color into gray and white is usually a process of age; but grief, sorrow and worriment may bring it on much before its time, and sometimes in a very short time. There are a number of cases related where this change took place during one night in consequence of terror, or other violent emotions of the mind, so that the poet says: " O nox ! quam longa es, quae facis una senem !" But of late these instances have been doubted, because they are not well authenticated. However that may be, so much is certain, that strong mental emotions have great effect upon the discoloration of the hair. 132 THERAPEUTIC HINTS. Therapeutic Hints. Bad consequences of cutting the hair are mostly removed by Bellad. or Dry on. The process of growing gray and white we best leave undisturbed, unless we choose remedies for its next causes. All of the so-called cosmetic means are hurtful, sometimes dangerous; and the vain will be punished for his vanity. The Plica polonica — matted hair — as is here and there found in Poland, is, according to Hebra, an eczema of the scalp, forming crusts and matting the hair together in a most hideous manner. EYES. Considering the eye as a whole, we find its general appearance frequently altered by disease. Without dwelling upon the language which the mental emotions — fright, terror, joy or sorrow, love or hatred — speak through them, we observe: An unnatural lustre of the eyes in fevers; and A brilliancy in consumptives. Glassy eyes are characteristic, in children, of inflammation of the mesen- teric glands; and, if accompanied with dark, dry lips and tongue, dry skin, and great restlessness, of an acute inflammation of the stomach. In fevers the}' indicate great danger, or critical changes. Dull eyes are frequently observed in febrile conditions of the system; during catamenia, in catarrhal and other affections. Sunken eyes are the consequence of an absorption of 'the fat cushions, whereupon the eyeballs rest and turn in their sockets. This takes place in all diseases which are accompanied with great loss of blood or other vital fluids. Exophthalmus or protruding eyes, when not congenital, is a characteristic sign of Basedow's disease. In treating the particular diseases of the eye, I shall condense in a small space what is important for the general practitioner in his daily practice; the specialist will necessarily have to consult special works on this subject. LIDS AND LACHRYMAL APPARATUS. Inflammation of the Eyelids. It may be of various character. A simple inflammation may be the con- sequence of a cold. It usually commences on the edge and thence spreads over the whole lid to the margo orbitalis, where it abruptly ceases. By this it is distinguished from erysipelas, which is apt to diffuse itself further and further. The lid is hard, swollen and red, sometimes covered with little blisters. A graver form is the Phlegmonous inflammation, or Abscess of lid. Commencing as a little, firm nodule, it often extends over the eyebrow and cheek, and the lid may attain the size of a pigeon's egg. If not checked in the onset, it terminates in the formation of an abscess which breaks either outside or, in rarer instances, perforates the conjunctiva. If this abscess forms at the inner angle of the eye, near the lachrymal sac, it has been 134 THENAPBUTIC HINTS TO INFLAMMATION OF THE EYELIDS. termed Anchylops. The Causes are: injuries (wounds or blows upon the eve); severe conjunctivitis, or erysipelas; spontaneous development has also been observed. A third form is the Tinea tarsi, Ophthalmia tarsi, or Blepharitis margin- alis, etc., which consists of an inflammation of the edges of the eyelids. In its simplest form it shows merely a slight redness of the edges and some gluing together of the lids in the morning. This may increase, however, to ulceration, thickening and hardening of the whole margin of the lids, when it is termed Tylosis. The conjunctiva and the Meibomian glands usually participate more or less in this inflammation, and if the ulceration extends to the hair-follicles the lashes loosen and fall out. In places where the destruc- tion is not too extensive, the lashes grow again, but thinner, crooked and often inverted, which state is called Trichiasis; or there forms a double row of cilia either along the greater portion of the lid, or chiefly at one point; this is called Distichiasis. This faulty position of the cilia is generally ac- companied, or soon followed, by a certain degree of inversion of the eyelid, and perhaps by a shortening and incurvation of the tarsal cartilage, which state is termed Entropium, though in simple trichiasis or distichiasis it is not always present. ' ' Entropium may also result from spasmodic contrac- tion of the orbicularis muscle, especially in elderly persons, where the skin of the eyelids is abundant and lax." (G. S. Norton.) When, however, by extensive ulceration of the edges and consequent cicatrization the appertures of the Meibomian follicles become closed and obliterated, the lid's margin thickens, and shows a tendency to become everted. This grows the more apparent, when the conjunctiva also is involved in the inflammatory process. And, if to all this a certain degree of atrophy and relaxation of the orbicu- laris associates, the somewhat everted lid no longer covers the eyeball, but sinks away from it and the punctum lachrymale becomes exposed. This state of things is termed Ectropium. ''Ectropium ma}' also result from paralysis of the facial nerves, tumors, caries of the orbit, etc., but the most frequent cause is from cicatrices in the vicinity of the lids. " (G. S. Norton. ) Blepharitis marginalis occurs often as a consequence of hypermetropia or myopia, but very frequently it is associated either with, or caused by, conjunctivitis or corneitis, affections of the lachrymal canal, as stricture, blenorrhoea, etc. Its intensity is much aggravated by dirt and want, by exposure to wind, cold, bright glare, or an impure, smoky atmosphere. Therapeutic Hints. Simple inflammation of the lids is easily arrested by: A<-on. After exposure to cold winds. Apis. With cedematous swelling and stinging pain. Bellad. Bright, shining redness; right side; photophobia. Chamom. Red swelling after a cold. Pul sat. With catarrh in the head. Rhus tox. From left to right; dull redness; watery vesicles. THERAPEUTIC HINTS TO EYELIDS. 1 35 Phlegmonous inflammation L "ires besides one or the other of the above : Hepar. Pricking and throbbing pa worse from cold and contact; anchylops. Laches. Purplish hue. Merc, sol. Pain worse at night. Pul sat. Anchylops. Silic. After Hepar, when suppuration has taken place, and the patient wants to have his head wrapped up. Blepharitis marginalis is often very obstinate and difficult to treat. When caused hy h}-permetropia or myopia, suitable eyeglasses are the remedy; when caused by dirt and want, their removal ought to be attended to; washing and cleaning the lids with lukewarm water is a daily require- ment. Remedial agents are quite as necessary. Alum. Dryness of lids, worse in the morning; absence of lachrymation. Arsen. Burning, acrid lachrymation, excoriating the lids and cheek. Calc. carb. and jod. Lids swollen and hard, indurated, also after styes; tonsils enlarged. Carb. ac. When caused by parasitic fungi, embedded around the hair follicles. Cinfiab. Discharge in the morning; dull pain from the inner canthus over the eye, or around it. Caustic. Better in the open air; warts on the eyebrows, upper lid or nose. Digit. Lid-margin slightly swollen and pale red; inside of lids yellowish- red; burning of the lid-margin; photophobia; lachrymation and mucous discharge. Euphras. Suppurating lid-margins; constant winking of lids; profuse, acrid, burning lachrymation, or very acrid, thick or yellow discharge, excoriating lid and cheek; fluent coryza, which is mild. Graphit. Dry crusts on the cilise, and scales on the margins; the outer canthi are often the most affected part; they crack and bleed easily; moist eczema on the head and behind the ears, cracking and bleeding. " It is the most frequently indicated remedy for chronic ciliary blepharitis, and a more rapid cure can usually be effected by its local application at the same time of its internal administration. I use it locally in some unguent, as cosmoline, about eight grains to the ounce." (G. S. Norton.) Hepar. Upper lid-margins unevenly rounded, swollen and red; tough mucus in lashes and canthi; scleral conjunctiva injected with red vessels running towards the cornea, where they form little vesicles with turbid secre- tion, lachrymation; pain in the evening, agglutination in the morning; right eye worse; small pimples or little furuncles on the face, or elsewhere, in com- plication with tinea. Kali carb. Swelling of lids; edges, canthi and caruncula red and swol- len; lachrymation and pain from bright light; pressing pain in front of head 136 therapeutic hints to inflammation of the eyelids. and temples into the eyes, with heat in face and head; after eating, pressure in stomach, belching; nausea and emptiness in stomach; gagging and vomit- ing of slime; pressure and anxious feeling in chest; face pale, dirty gray. Magn. mur. When accompanied with pimply eruption on the face, which comes and goes, but is worse after supper, in a warm room, and before the menses. Merc. sol. Lids smart, are sore and red, especially upper lids; worse at night in bed, from warmth and cold, and from the glare of a fire. Merc. corr. Indurated lids; secretion thin and excoriating; nocturnal aggravation. Mezer. Accompanied by tinea capitis of thick, hard crusts, from which pus exudes upon pressure. Natr. mm. After the application of nitrate of silver; after measles; acrid lachrymation, excoriating the lids and cheeks and making the skin glossy and shining; eczema. Nux vom. After previous drugging and when worse in the morning. Petrol. Pain in the back of the head, rough skin; diarrhoea only dur- ing the day. Phosph. ac. Lid-margins swollen, red and rounded; lashes partially falling out; pus particles on lashes and in canthi; itching and burning; sen- sitiveness to candle-light; difficult opening of the eyes in the morning. Psorin. From right to left; worse mornings and during the day; old chronic cases; offensive discharges from the eyes; photophobia; strumous diathesis. Pidsat. Worse in the evening and in a warm room, better in the open air; lachrymal apparatus affected; styes and acne in the face. Rhus fox. Lids cedematously swollen; copious, acrid and serous dis- charge, corroding the adjacent parts of the cheeks. Sepia. " Small pustules, like acne, on the edge of the lids; tight feel- ing in lids; aggravation morn and eve." (G. S. Norton.) Silic. Objects appear as if seen through a fog, ameliorated by wiping the eyes; fluent coryza, corners of mouth cracked; offensive sweat of feet. Stop his. Lid-margins dry, with hard lumps and destruction of the ciliary roots; small tarsal tumors. Sulphur. Lid-margins thick, granulated and rounded; dry crusts in lashes; sharp, sticking pains, as if pins or a splinter of glass was sticking in the eye; morning agglutination; glandular swellings on the head and neck; eruption on the face; pale and puffed face; abdomen hard; disturbed diges- tion; worse in the evening and gaslight; cannot bear to have the eyes washed. Tellur. Eczema impetiginoides on the lids, with pustular conjunctivitis; much purulent discharge from the eyes; offensive otorrhcea. Thuja. Dry, branny eruption upon the lids, chiefly about the ciliae; lashes irregular and imperfectly grown; eyes weak and watery. HORDEOLEUM, STYE. 137 Anchylops will best be met in the beginning by Apis, Bellad. , Hepar, Pulsate or Rhus tox. Trichiasis may require operative measures; but cases have been cured without them. Aeon. Has been successfully applied in a case of trichiasis and en- tropium. Borax. Has the symptom, but no verification to my knowledge. Graph it. May soften the scars. Natr. vuu . After abuse of nitrate of silver. Sepia. Eyelashes gone; edges raw and sore; eversion of puncta; eyes full of matter. Thuja. Dry, bramry eruption upon the lids, chiefly about the ciliae; lashes irregular and imperfectly grown; eyes weak and watery. Entropium is surety amenable to internal treatment, if recent. Aeon. Acute inflammation with dryness and burning. Calc. card. Has cured cases of senile entropium. Merc, corr., Rhus tox. and Sulphur are oftene'r indicated than Lycop. Natr. viur. After abuse of nitrate of silver. Sepia. Acute belpharitis. Ectr opium has been cured by: Apis. Stinging pains and great ©edematous swelling of lids and con- junctiva. Ai'g. nitr. Tear-points greatly inflamed and prominent. Hamam. During the course of a severe conjunctivitis — by external application of ' ' Pond's Extract. ' ' Merc, corr., Nitr. ac. and Sulphur have been successfully employed. Rhus tox. Sac-like swelling of the conjunctiva; oedematous swelling of the lids; cilise fall out; acrid lachrymation in the morning and in the open air. Lids are spasmodically closed; on opening them, protrusion of a thick red swelling and yellow, purulent discharge. Hordeoleum, Stye. It is in its nature a small furuncle, forming in the connective tissue near the edge of the lid, and has its name from its fancied resemblance to a grain of barley. It appears as a red, hard swelling, which rapidly increases until it suppurates and breaks, either outside or inside of the lid-margin. In some cases it is attended with considerable pain and swelling of the whole lid. Some persons are subject to repeated outbreaks of this furuncular inflammation. • We find it most frequently in youthful individuals of rather delicate health with a tendency to acne, or in persons addicted to free living or dissipation. If by frequent relapses it induces inflammatory changes in the Meibomian glands, and is followed by fatty or chalky degeneration of their contents, it is called Chalazion. I 28 TUMORS OF THE LID. Therapeutic Hints. Pulsat. Most frequently used and indicated; it often arrests its growth. Hepar. If Palsat. has not been sufficient to prevent suppuration. Staph is. Often found useful and especially when the stye does not sup- purate and break, but remains a hard nodule. Upper lid: Alum., Caustic, Ferrum, Mercur., Phosph. ac, Sulphur. Lower lid: Phosphor., Rhus tox., Senega, Staphis. Right side: Cale. card., Canthar., Natr. mur. Left side: Colehic., Lycop., Pulsat., Staphis. For removing the disposition : Amm. cark. , Cale. carb. , Ferrum. , GrapJiit. , Su iphur, Th uja . Chalazion : Cale. carb., Conium, Graph it., Pulsat., Sepia, Silic, Staphis., Th uja . Tumors of the Lid. Chalazion has been mentioned under styes. "It is mostly situated at some distance from the free margin of the lid and generally most manifest on its inner surface, lying close beneath the conjunctiva. In rarer cases the tumor points outwards and lies close beneath the skin, which is frequently somewhat reddened and thinned over and around it. It occurs far more frequently in the upper than in the lower lid." (Walton.) Sebaceous tumors occur most frequently at the outer and upper mar- gin of the orbit, close to the eyebrow. Their contents are suet-like and seba- ceous, consisting of broken-down epithelial cells, fat molecules and hairs; sometimes they are softer and more oily. The whole is encased in a cyst wall, the posterior portion of which is somewhat thickened and hyper- trophied. Warts occur occasionaly on the edges of eyelids. Fatty tumors (wens) are of rare occurrence. ' ' They may be recognized by their smooth, circumscribed, somewhat lobulated form, and are firm and elastic to the touch." Epithelioma ' ' is the most frequent in occurrence of all malignant tumors of the lids; arises as a small nodule near the edge of lid, and is painless, slow in its progress and at last ulcerates. The skin around the ulcer is not swollen and discolored as in lupus. The slowness of its growth and the his- tory of the case distinguish from syphilitic ulcer." (G. S. Norton.) Therapeutic Hints. Encysted tumors have been cured by: Cale. carb., Graphit., Silic,, Staphis., Thuja; warts by: Caustic, Thuja; wens by: Bar. carb., Graphit.; epithelioma by: Apis, Hydr. ac, Laches. (G. S. Norton.) Dacryocystitis Is an acute inflammation of the lachrymal sac, which frequently reaches its acme in a few days and is very painful. Its swelling may extend to the BLENNORRHEA OF TAE LACHRYMAL SAC. 139 cheek, eyelids and even conjunctiva. In less severe cases, or after the acute inflammatory symptoms have passed away, pus may be squeezed out of the puncta ; but when the swelling and thickening of the lining membrane closes the passage, or the opening into the sac becomes somewhat displaced by it, the pus cannot escape, and if left alone, will finally force its way through the skin. After the discharge of pus, the inflammation subsides either entirely, and the opening heals, or there remains a chronic inflammation of the sac, with subsequent renewals of acute attacks, or the aperture in the skin does not firmly cicatrize, but merely scabs over, while fresh pus is collecting, which again forces its w T ay out at the same place, thus finally leaving a fistu- lous opening, through which a thin, muco-purulent discharge and the tears constantly ooze — Fistula lachrymalis. Or again the sac may undergo ulcera- tion at one point and the matter escape into the neighboring cellular tissue, thus giving rise to a secondary sac or pouch, which may break, whereby another more or less extensive fistulous opening is established, often very obstinate and intractable, especially if the bony structure is likewise diseased. Of chronic cases there are instances where several such pouches burrow beneath the skin in different directions. The Causes. — This inflammation is often merely an extension of con- junctivitis, especially the granular form, or of nasal catarrh; it may be pro- duced by periostitis and caries of the nasal bones in scrofulous or syphilitic persons, or may occur as a primary affection, being then generally due to exposure to cold and wet. " Its most frequent cause is a previous stricture of the nasal duct or blennorrhoea of the lachrymal sac." (G. S. Norton.) Therapeutic Hints. Instrumental aid may be required, but often bad cases have been cured by internal treatment alone. For dacryocystitis, at the beginning, Pulsat. , or Apis, when there is cedematous swelling and stinging pains, but Bellad. , Hepar and Silic. may also be indicated. We will, no doubt, have to consider its causes (conjunctivitis, nasal catarrh, etc.), and then compare the corre- sponding remedies. Fistula lachrymalis : Bellad., inflammation of the lachrymal duct; intol- erance of light; profuse lachrymation; lid edges inflamed and agglutinated; morning and evening a gritting sensation in the lids; aggravation in the evening. Bromine, Calc. carb., Caustic., Fluor, ac., Hepar, Laches., Natr. mur., Petrol., Pulsat., Sulphur, Silic, disorganization of the walls of the sac; denu- dation of the internal horny wall and closure of the nasal canal. Blennorrhoea of the Lachrymal Sac Is another consequence which may follow acute inflammation of the lach- rymal sac, in fact it is a chronic inflammation of that organ by which its w r alls become either thickened and hypertrophied, or thinned and greatly distended, secreting constantly a thin, glairy, viscid fluid, which flows down 140 CONJUNCTIVA. the nasal duct, or oozes up through the puncta. When the sac gets filled with this secretion, we observe it as a swelling of varying size and hardness. On pressure its contents discharge through the puncta, and the finger sinks in as the sac is being emptied. During warm and dry weather the patient usually experiences very little inconvenience, while on exposure to cold and damp winds the trouble increases, inducing fresh inflammatory action. In this way it comes to pass that strictures are formed either in some part of the nasal duct, or of the canaliculus near its opening into the sac. Its Causes are like those of dacryocystitis — conjunctivitis, nasal catarrh, periostitis or caries of the nasal bones; also obstructions in the lachrymal passages either above or below the sac by a narrowing obliteration, or ever- sion of the puncta; or by contraction or stricture of the canaliculus or of the nasal duct; or by polypi or other growths which compress and obstruct the duct. Therapeutic Hints. Compare the previous article and also those which treat of its causes. Stannum. "Is one of the most important remedies, especially if the discharge is profuse, thick and of a yellow white color." (Geo. S. Norton.) Firm strictures require instrumental aid. CONJUNCTIVA. Catarrhal Ophthalmia Is an inflammation of the conj unctiva which may extend into the Meibomian ducts, the canaliculi, and the ducts of the lachrymal gland. In its mild form it shows merely a slight hyperaemia with a sensation of grit in the eye, itch- ing, stiffness and heaviness of the eyelids with or without sticking together in the morning; there is only exceptionally some mucus excreted and found collected at the inner canthus either fresh or dried into little yellowish or brownish crusts. It is aggravated by exposure to cold winds, when lachry- mation is produced. Usually of a chronic nature, it is found especially in persons of ill health, and is often difficult to cure. In its acute form the blood-vessels are much enlarged and appear as a vascular net-work of brick-dust, or of bluish or lilac hue, especially on the ocular portion of the conjunctiva, while on the palpebral portion it is less marked. Often it is accompanied by spots of extra vasated blood within the meshes of the membrane, which swells, and has, especially on its palpebral portion, a villous appearance, being due to the engorged state of the villi, an appearance which must not be confounded with granular conjunctivitis. At first there is an increased flow of tears which after a while is replaced by a secretion of mucus, which by degrees gets thicker and is either whitish or yellowish. If it assume a purulent character, the mere catarrhal ophthalmia passes into the purulent form. Chemosis is very rare; photophobia, pain and impairment of vision do not occur in the catarrhal form. In severe THERAPEUTIC HINTS TO CATARRHAL OPHTHALMIA. 141 cases the eyelids participate in the inflammation; usually both ej^es are affected, not, however, always simultaneously; the second often becomes involved when the first is getting well; it always shows an evening aggrava- tion; and is apt to recur. Its Causes are: mechanical and chemical irrita- tion; getting cold and wet; excessive strain of the eyes by artificial light; extension from inflammatory processes of neighboring parts; measles, scarlet fever, small-pox; sometimes it appears epidemic. It is infectious. Therapeutic Hints. If caused by some foreign body this ought to be removed. Aeon. Reduces the inflammation caused by a piece of steel or cinder and facilitates its removal, if that could not be effected before the inflamma- tion had full}' developed. If there remains still some inflammation after Aeon., Sulphur will cure it. Aeon, is also indicated at the beginning of any ordinary catarrhal conjunctivitis, where there is great dryness, burning and heat in the eye and where it has been brought on by exposure to sharp, cold winds. Apis. CEdematous swelling of lids and skin over orbits with redness, heat and sensitiveness to external covering; stinging pains. Arg. nitr. Profuse discharge approaching a purulent character; feels better in the open air, worse in warm room. Arsen. Lids spasmodically closed; conjunctiva of a dark, violet color; secretion thin and acrid with burning pain, worse at night. Bellad. Right eye; throbbing pain, hot tears or dryness of the eyes; light is painful; nose sore from coryza; headache and similar Belladonna symptoms. Chamom. Often for infants after exposure to cold while bathing and washing. The children cry much; have colic and green stools; also during dentition. Extravasation of blood sometimes. Conium. Right eye bloodshot; aches on lying down to sleep; thirsty; sweat on head, face and neck. Crocus. Feeling in the eyes as after weeping with a corresponding appearance, extending from left to right eye; feeling of something alive and moving in the abdomen. Digit. Chronic; a yellowish redness of the palpebral conjunctiva. Eiphras. Acrid tears and profuse, acrid, thick and yellow discharge; blurring of vision relieved hy winking; coryza with burning and pain in the frontal sinuses; after exposure to cold and during the first stage of measles. Graphit. Chronic; thin, acrid discharge; external canthi crack and bleed easily; nose sore and excoriated, with crust on the nostrils. Merc. sol. Blenorrhcea, thin and acrid; great swelling of lids; sensitive to touch; worse in warm room or in the cold air, and in damp weather; also from evening till midnight; no relief from sweat; frequent relapses. Nux vom. The inner canthi are more inflamed than other parts: bloody exudation; smarting like salt; all worse in the morning. 142 PURULENT OPHTHALMIA. Pulsat. Bland, moderately profuse, white discharge; worse in the warm room: in the evening; from reading; better in the open air. Rhus fox. (Edematous swelling of the lids; chemosis of conjunctiva; great restlessness; after getting wet. Sepia. Muco-purulent discharge in the morning and dryness in the evening; the conjunctiva is of a dull red color with some photophobia and swelling of the lids, especially in the morning. Sulphur. Acute and chronic; sharp, darting pains, like pins piercing the eye; severe pain darting through the eye back into the head, from i to 3 a. m., waking the patient from sleep; feverish and restless at night. Zincum. The inner half of the eye is the most affected part, with much discharge; worse in the evening and in the cool air. Digest follows at the end of the ophthalmias. Purulent Ophthalmia. Commencing with mere congestion, itching and dryness, particularly at the inner corner, it gradually augments to intense inflammation of the whole conjunctiva with considerable mucous secretion, which soon is changed into a purulent discharge, dissolved in the tears. The lids swell and become slightly everted, the conjunctiva is dark red and the single blood-vessels are no longer to be seen. The parts affected feel hot and scalding with neuralgic pains which may extend to the temple and forehead. As the disease pro- gresses, Chemosis sets in, that is an infiltration of the conjunctival and subconjunctival tissue, and in addition we observe spots of extravasated blood. In this way the conjunctiva swells often to a degree that it overlaps the cornea, but shows itself most prominently at the lateral sides of the eyeball, where it receives the least pressure from the eyelids. The inflammation generally spreads to the areolar tissue of the orbits together with the tunica vaginalis oculi, causing a slight protrusion of the eyeball; the eyelids swell still more and the upper overlaps the lower, while the protruding conjunctiva always averts the lower and sometimes both. The protruding part of the conjunctiva is very marked in its villous appearance. If cured in this stage, the eye may escape serious injury. But if it goes on the palpebral papillae may undergo a change which is called granulation, of which later; the cornea may be rendered opaque by interstitial changes, or it may be destroyed by softening and ulceration; the iris ma}- inflame and adhere to the cornea; the vibrous body, the retina, and the choroid may be partially or quite spoiled; the sclerotica may become softened; the crystalline lens, when not discharged through the perforated cornea, becomes quite yellow; and all this destructive process may run its course in a space of time from a few days to three weeks. This dreadful disease is most common and severe in hot climates; in temperate latitudes it is found more especially in the army, navy, in work- houses, prisons, and among the poor; it is chief!}* endemic and spreads b}~ infection. Gonorrhoeal ophthalmia, which has been developed by infection from THERAPEUTIC HINTS TO PURULENT OPTHALMIA. 1 43 urethral pus, cannot be distinguished from the purulent form, except by the history. It is one and the same kind of inflammation, only intensified, destroying the eye with great rapidity. Ophthalmia neonatorum ' ' is essentially the same disease as purulent ophthalmia in the adult, merely modified by the undeveloped tissues of the babe, and the activity of the growing processes, the infant organism, but it is generally more severe." (Walton.) Usually about three or four days after birth it commences with some slight redness of the lids and slight discharge; the e}-es are kept closed; light is distressing; then gradually the lids swell, and the purulent discharge becomes profuse, when the whole train of symp- toms, above described, may be considered as fairly set in motion. But for- tunately not all cases are of this virulent nature; simple catarrhal inflamma- tion, caused by chilling the child when bathing or washing it, or using strong soap, which irritates the eyes — may as well commence at that time; the purulent form originates from leucorrhceal or gonorrhoeal discharges of the mother transmitted to the eyes of the child during parturition. Therapeutic Hints. As in all three forms of purulent ophthalmia the discharge is poisonous, great care should be taken as to cleanliness in nursing such cases. Apis. CEdematous swelling of the lids and adjacent cellular tissue; con- junctiva congested, puffy, chemosed; lids everted, villous; cornea grayish, smoky, opaque; burning, stinging pain, photophobia and hot lachrymation. Arg. met. Purulent; infant; any effort to separate the lids caused a drawing-in of their edges. (After Sulphur and Calc. curb, had been without effect. ) Arg. nitr. Allen and Norton have witnessed the most intense chemo- sis with strangulated vessels, most profuse purulent discharge and commenc- ing haziness of cornea with a 'tendency to slough, subside rapidly under this remedy in its 30th potency internally, and at the same time a solution of five or ten grains to two drachms of water of the 1st, 3d or 30th dilution as an external application. The very absence of subjective symptoms, with the profuse purulent discharge and the bulging lids from a collection of pus underneath or from swelling of the subconjunctival tissues, and not from in- filtration of the connective tissue of the lids themselves (as in Rhus or Apis), indicate this drug. Arsen. Is characterized by a thin and corroding discharge with great burning pain and restlessness; after abuse of Nitrate of silver. Calc. carb. Profuse, yellowish-white discharge; ulceration of cornea; oedema of lids; later opacities of cornea; well-known Calcarea symptoms; after working in the water. Chamom. Ophth. neonatorum; lids much swollen; conjunctiva bleed- ing w T hen separating the lids; child cries much; wants to be carried about; has colicky pains and green discharges. Euphras. Compare catarrhal ophthalmia. 144 GRANULAR OPHTHALMIA. Hepar. Purulent secretion in scrofulous subjects; lids swollen, spas- modically closed, bleeding easily on attempting to open them and sensitive to touch: intense photophobia; throbbing pain, better from external warmth, worse from any draught of cold air. Ulceration of cornea and hypopion; affection of Meibomian glands. Lycop. Ophth. neonatorum; copious discharge of pus; the lids are puffed out by pus beneath; the conjunctiva looks like a piece of raw flesh. Merc. sol. Ophth. neonatorum; thin, excoriating secretion from the eves; green, diarrhceic stools with straining; soreness of anus; jaundice; syphilitic and gonorrhoeal infection. The other mercurial preparations have also been successfully used. Natr. mur. Especially as an antidote to Nitrate of Silver, so frequently abused. Nitr. ac. Especially as an antidote to mercurial and syphilitic poison. Pulsat. Ophth. neonatorum; profuse and bland discharge; from gonor- rhoeal poison; all worse in the evening and better in the open air. Allen and Norton found it of great benefit as an intercurrent remedy when Arg. nitr. seemed to give out. Rhus tox. (Edematous swelling of lids, and of conjunctiva; great rest- iessness; after getting wet; commences on the left eye. The discharge is profuse, or tears are gushing out of the eye. Sulphur. Often in chronic cases with an outspoken psoric cachexia. The gonorrhoeal and syphilitic form may require besides the remedies mentioned: Cannab., Cin?iab., Card, veg., Kali biehr., Phytol., Tart. emet.> Thuja. Granular Ophthalmia. y a deposit of lymph on the posterior surface of the cornea, which takes a pyramidal shape with apex toward the centre of the cornea, cloudiness and hypersecretion of the aqueous humor, dilated pupil, deep anterior chamber and slight photophobia, lachrymation, ciliary injection. (Geo. S. Norton.) Therapeutic Hints. " In the treatment of iritis Atropine is, I believe, of the greatest impor- tance. The pupil must be kept dilated, or you are always certain, in the great majority of cases, to have serious results, as posterior S3mochia remain- ing after the inflammation has been subdued. Dry warmth and rest are also very important aids in the treatment." (Geo. S. Norton.) Aeon. Rheumatic form, after exposure to cold winds, with great dry- ness and heat in the eye; traumatic origin, even more important than Arnica. Rheumatic and traumatic form. Arsen. Burning pains worse after midnight, better from warm appli- cations. THERAPEUTIC HINTS TO IRITIS. 159 Asa/. Syphilitic form and after overdosing with Mercury ; severe throbbing, or burning, or sticking pain from within outward, better from rest and pressure. Aurum. Syphilitic form and after the abuse of Mercury and Potash; pain in the orbital bones, pressing from above downwards, or from without inwards, worse on touch; great mental depression. Bellad. Rheumatic form, pressing pain around the eye, or stitching pain above or beside the eye, as if it were torn out or pressed in; pains come and go, with flashes of light or dark spots with light margins, or dark fog before the eyes; severe vertigo and headache even to loss of consciousness. Bryon. Rheumatic form; the pain is worse from moving the eyes and also in the evening and at night; there is shooting pain in the head, and pain as if the head should burst on stooping. Catena 1 . Traumatic iritis. Cedron. Supraorbital neuralgia, periodical. China. Periodical pains; after loss of vital fluids and of malarial in- fection. Cinnab. Syphilitic form; pain commences at inner canthus, extending across the brow, or passing around the eye; nocturnal aggravation; inter- mitting pain. Clemat. Pressing pain in the eyes, photophobia and lachrymation, worse in the open air; heat in the eyes. Coloc. Rheumatic form; around the cornea a bluish- white ring; photo- phobia; no lachrymation; tearing pain in eye and surroundings; worse in the evening and at night. Conium. Excessive photophobia without corresponding redness of eye. Euphras. Rheumatic form; aching and occasional darting pain in eye, worse at night; iris adhering. Gelsem. Serous form with choroidal exudation. Hamam. Traumatic form with haemorrhage into the anterior chamber. Hepar. With corneitis or hypopion. Characteristics see in former chapters. Kalijod. Syphilitic form. After abuse of Mercury. Mercur. and its various preparations, syphilitic and other forms; tearing, boring pains in the bones around the eyes; worse at night; sclerotitis; and conjunctivitis; sweat without relief; bad smell from mouth; frequent spitting of saliva; tenesmus. Merc. corr. , is commonly indicated by the symptoms of iritis more than any other drug. (Norton.) Natr. mur. Pupil contracted; iris discolored; violent stitches in the temples on looking into the light or when the light is changed; on reading or writing the letters run together; sight much impaired. Nitr. ac. Chronic syphilitic form with very little pain (Norton"); also after abuse of mercury; pain worse on any change of temperature, at night and on touching the parts. l6o CHOROIDITIS. Nux vom. Rheumatic and syphilitic form; after drugging; pain worse in the morning. Petrol. Syphilitic form with occipital headache. Pulsat. Rheumatic form; pain worse in the afternoon and evening; cries easily and is worse after crying. Rhus fox. Rheumatic and traumatic form; lids swollen and spasmodi- cally closed; lachrymation; conjunctiva chemosed; pain worse at night; after getting wet; rainy weather; after Bryon. Si lie. With hypopion and corneitis. Spigcl. Rheumatic form; excessive pain in and around the eye, espe- cially on moving; sometimes periodically from morning till noon, and then abruptly ceasing. Sulphur. Rheumatic and other forms; with hypopion; relapsing cases; psoric tendency; pain worse in the evening and at night; ears often affected. Tereb. Rheumatic form; after suppression of perspiration of the feet; urinary symptoms. Thuja. Syphilitic form; condylomata on the iris; wart-like excrescences on the iris; pain better by warmth. Besides have been successfully employed: A?g. nitr., Crot. tigl., JPyos., Iodum y Lyeop., Plumbum, Stilling., Zincuvi. CHOROIDEA. The choroid is a dark brown vascular coat, which lies within and in contact with the sclera, and between it and the retina; its proper structure terminates anteriorly where the ciliary body commences, which forms the connecting link between it and the iris. Choroiditis Is usually found uncomplicated with inflammation of other portions of the uveal tract. In Choroiditis disseminata the eyes feel weak and vision is blurred. The ophthalmoscope shows a yello wish- red nodule in the choroid in the first stage which soon atrophies, leaving a white spot surrounded by a rim of pro- liferated pigment. Other spots follow, and as they have a tendency to coalesce the}' form large atrophic plaques. The haziness of the vitreous is not marked unless the choroiditis is of the syphilitic variety, when the hazi- ness of the vitreous is a very prominent symptom, as is the non-tendeiKry of the spots to run together. Choroiditis suppurativa ( panophthalmitis) is usually the result of foreign bodies or injuries and its course is generally rapid, destroying the eye. Characteristic symptoms are: cedematous swelling of the lids, chemosis, pro- trusion of the eye, hypopion, synochia posteriora, white reflex from the fundus, tension increased, eye sensitive to touch, loss of vision, very severe pain, fever and vomiting. THERAPEUTIC HINTS TO CHOROIDITIS. l6l Sclerotico-choroiditis posteriora or Posterior staphlyoma is found in myopia, especially high degrees, and is characterized by a white crescent around the optic nerve entrance, especially outer side, which corresponds to the bulging of the sclera at that point. It may, however, be irregular and extend around the optic disc. When it is progressing the myopia increases, vision becomes more impaired, black, floating spots appear before the sight and the edges of the crescent are not as well defined. It is a congenital trouble and is increased by overuse of the eyes. Cyclitis usually passes over into irido-cyclitis or irido- choroiditis. A prominent symptom of irido-choroiditis is the increased tension in its early, and diminished tension in its late stage. (G. S. Norton.) Therapeutic Hints. Aurum. Serous exudation between the choroid and retina; haziness of the vitreous; sensitiveness to light and touch; pressive pain in eye from above downward or from without inward; pain in the bones around the eye. After abuse of Mercury or Potash. Bellad. Often indicated by congestion towards the head; eyes sensitive to light; halo around the light; various flashes of light, sparks, etc., before the eyes. Bryon. Serous exudation; following rheumatic iritis; eyeball sore to touch and motion; darting pains through the eye into the head. Gelsem. Serous choroiditis; iritic complications; vision varies from day to day or from hour to hour; sometimes fever, with thirstlessness. Kalihydroj. Syphilitic origin; disseminate variety. Meir. corr. or sol. disseminate form; iritic complications; syphilitic dyscrasia; tendency to adhesion; nocturnal aggravation of the pains, both in and around the eye. Nux vom. After use of stimulants; aggravation in the morning. Phosphor. Luminous appearance before the eyes, especially red; after sexual excesses; bright light, natural or artificial, hurts the eyes; they feel better in the twilight. Prun. spin. With or without iritic or retinal complication; severe pain in the eyeball, as if it were being pressed asunder, or else shooting and cut- ting pain through the eye and corresponding side of head, or crushing pain. Palsat. When corresponding to the general disposition of the patient. Sulphur. Chronic state; sharp, darting pains; after suppression of eruptions; psoric taint. Besides, the following remedies have been useful: Aeon., Arsen., Coloc, Hepar, Ipec., Psorin., Pufa, Silic, Sol. nig. In Sclerotico-choroiditis posteriora has been found useful: Bellad. Flushed face and throbbing congested headaches; photophobia. Crocus. Pain from the e}^e to the top of the head; also pain from left eye darting to the right; sensation of cold wind blowing across the eyes. Mercur. Usual indication. ii 1 62 GLAUCOMA. Phosphor. Muscae volitantes, flashes of light before the eyes. Prun. spin. Pains in eye as if pressed asunder, or sharp and darting in and around the eye. Spigel, Sharp, stabbing pains through the eye and around it, often commencing at one point and then seeming to radiate in every direction. Thuja. Often called for in strumous and sycotic persons. Besides compare: Carb. veg., Kali jod., Lycop., Physost., Rata and Sulphur. In Choroiditis suppurativa compare: Aeon., Apis., Arsen., Hepar, Phxtol. (traumatic origin, lids very hard, red and swollen; conjunctiva chemosed and pus in the interior of the eye; severe pain). Rhus tox. is the most important remedy. Lids (Edematous, much chemosis, photophobia and profuse gush of tears on opening the spasmodically closed lids, hypopion, pains at night, etc. (Norton.) Also: Asa/., Bellad., Mercur., Sulphur. In Haemorrhage compare: Arnica, Bellad., Cinchona, Crotal., Hamam., Laches., Phosphor., etc. Glaucoma. i. Acute Form. — Its onset ma}' for hours, days, weeks, months, even years, be premonitioned by one or the other, or several of the following symptoms: a halo, gray or colored, or a circle or several in the same or dif- ferent colors around candle-light or luminous objects; flashes or wheels of light in the dark, as well as in the light, with or without intercurrent obscura- tions of sight; periodic dimness of sight, or dimness of a part of the visual field; rapid increase of presbyopia, ciliary neuralgia, headaches. The attack itself often commences suddenly with severe throbbing pain in the eyeball and the corresponding side of the head ; the eyeball is very sensitive to touch ; flashes of a vivid red or deep orange color appear before the eyes with great photophobia, increased by exertion, or anything that quickens the heart's action, even the taking of food. The eyeball shows signs of inflammation in different degrees of intensity, such as: lachrymation and intolerance to light; swelling and redness of the eyelids; conjunctivitis with serous chemosis; but scarcely an}- purulent discharge; hyperemia of the sclerotica and congestion of the anterior ciliary veins; the cornea is hazy and a little roughened, or even vesicular in spots, or sometimes opaque interstitially ; its sensibility is more or less lost in parts or in its entire structure. The iris loses its color, acquiring a slate-like aspect and is pushed against the cornea; the pupil becomes dilated, irregular and fixed; its color is less black than usual, but more of a drab color, showing sometimes even a shade of green. The eye- ball, on palpation, feels harder than natural. The vision gradually grows duller, a thick fog appears before the eye in daylight and at night prismatic colors surround the candle-light. The visual field usually commences to con- tract on the inner side and after a while all vision is lost. Ophthalmoscopic inspection reveals: haziness of the vitreous body; in hemorrhagic glaucoma, which is rare, there is haemorrhage either from the disc, the retina or the THERAPEUTIC HINTS TO GEAUCOMA. 1 63 choroidea, singly or combined; excavation of the optic disc, called glauco- matous cupping, with dilatation of the retinal veins and pulsation of the central retinal arteries. 2. The subacute form, or chronic glaucoma, shows all the symptoms above enumerated, only not so sharp and definitely marked, although lead- ing in an insidious and slow manner to the same results. Glaucoma always begins in one eye, and is very apt to develop in the other, in the course of months or years. Its causes have not been sufficiently explained, and the nature of the glaucomatous tension of the eyeball is also not fully established. Post-mortem examinations have revealed: obliteration of Schlemm's canal (Kniess); closure of the drainage channels (Weber); atrophy of "the ciliary body, and atrophy or adhesion of the iris (Brailey), all of which are supposed to be more or less concerned in producing the increased tension of the globe. Therapeutic Hints. Iridectomy, first recommended by Dr. von Graefe, is by some considered as the only remedy worth speaking of, while other eye-surgeons recommend frequent tapping of the cornea, and the newest of all is sclerotomy. Which- ever may be preferred or deemed necessary, in this I agree entirely with Walton, when he says: ' ' Treatment by practical surgery alone is not enough; it should be but a part, an auxiliary of a therapeutic system, embracing those details which help so much in subduing the abnormal conditions which are common to other affections and to glaucoma. I allude, of course, to the abnormal conditions of inflammation of the uveal tract, particularly choroid- itis, to neuro-retinitis and hyalitis." (Page 1172.) Arg. nitr. See Advance, October, 1879. Aurum. Pressure from within outward, and from above downward in eyeball; heavy; dull aching of the globes; upper half of an object invisible; showers of bright, star-like bodies appear in the upper dark section; bright, floating streaks and dots in gaslight before the eyes. Bellad. Pain in and around the eye, of a pressing nature, as if the eye were being pressed into the head, or sometimes as if the eye were being torn out; the eyes feel hot, dry and stiff, as if they might protrude. Bryon. The eyes feel as if pressed out, often attended with sharp shoot- ing pains through the e}^es and head; the}'' feel sore to touch and on moving them. Cedron. Severe shooting pain along the course of the supra-orbital nerve. Coloc. Severe burning, aching, sticking, cutting pain in the eye and around, always relieved by firm pressure, and by walking in a warm room, worse by rest at night and upon stooping. Eserine. Is much used at present and in some cases seems to act well. (Norton.) 1 64 OPTIC NERVE AND RETINA. Phosphor. Halo around the light, and various lights and colors flashing before the eyes. Prun. spin. Severe crushing pain in the eye as if pressed asunder, or sharp shooting through the eye and corresponding side of the head. Rhodod. Periodic pain in and around the eye, worse before a storm and better after the storm commences. Spigcl. Sharp and stabbing pains through the eye and head, worse on motion and at night. Besides should be compared: Arnica, Arsen., Chamom., Coccul, Collin., Conium, Crot. tigl., Gel son., Hamam., Kali carb., and Jod., Mercur., Nux vom., Phytol., Sulphur and Val. of Zinc. OPTIC NERVE AND RETINA. The optic nerve and the retina may, each of them, be the isolated seat of morbid derangement, the first usualh' from some cerebral disturbance, the latter from intraocular disorder; but either of them, if extensively affected, will also affect the other. We speak therefore of Neuro-Retinitis As an inflammation of the optic nerve, the optic disk and the retina, a separation of which into different forms would be of little practical use. Its Subjective Symptoms are: haziness or fogginess in various degrees; reduction of acuteness of direct and indirect vision ; contraction of the visual field; blind spots in the visual field; distortion of objects looked at; sub- jective appearance of light, so-called sparks, or flashes, or photopsia ; sub- jective play of colors, colored spectra, or chromotopsy ; the latter two may occur even when the case has proceeded to absolute blindness. Still all these symptoms may occur also in various other intraocular diseases, and the only certain way of making a diagnosis is with the ophthalmoscope. The Ophthalmoscopic Symptoms are: optic disc swollen and outlines ill-defined, retina hazy and vessels veiled here and there; tortuous appear- ance of the veins, which are dark and full; usually haemorrhage, most fre- quently observed in the retina, seldom in the disc; occasionally whitish dots scattered in groups or dull, glistening patches in the semi- opaque retina. There are no external objective symptoms, unless other ocular tissues are involved in the morbid process. It may lead to partial or complete atrophy of the retina. Its Causes are: Albuminuria, and then it is called Retinitis albumi- nurica ; haemorrhage into the retina and white spots here and there, espe- cially of a stellate arrangement in the maculae lutea are characteristic and early symptoms of this form. Syphilis, and then it is called Retinitis syphi- litica ; it can be diagnosed only by the precedence or presence of some other mark of constitutional syphilis. Diabetes, and then it is called Retinitis diabetica, with similar appearance as retinitis albuminurica ; Leucaemia (Retinitis leucaeniica ) ; great pallor of the retinal vessels; haemorrhages in THERAPEUTIC HINTS TO OPTIC NERVE AND RETINA. 1 65 retina (Retinitis apoplectica) ; deposits of pigment in the retina (Retinitis pigmentosa) ; contraction of field of vision, night-blindness and deposits of pigment in retina, extending from periphery to centre of fundus. Direct and reflected rays of artificial light or of the sun, and overstraining the eyes under imperfect or unsteady light, also traumatic injuries. There are other affections of the optic nerve and of the retina which, too, inay cause impairment of sight or even total blindness, without showing externally any objective symptoms. Such affections were, before the oph- thalmoscope was known, classed under the terms Amblyopia (impaired sight) or Amaurosis (what renders obscure, dark). These terms have of late been stricken out of the books, because where there is impaired sight or loss of vision there can now, by the use of the ophthalmoscope, be found also a cor- responding change in the optic nerve or retina, a pathological cause of amblyopia or amaurosis, from which the affection receives its proper name. Therapeutic Hints. Aeon. Total blindness produced suddenly by taking cold. Ammoniacum. After severe blows upon the head, sight impaired; smoke before the eyes, shaping different circles, most distinctly on white ground; the margins of the circles are gray and become black upon sudden motions of the eye; better in clear, worse in cloudy weather; persons at a distance he cannot recognize; by candle-light their faces appear dark. Apis. Albuminuria, after scarlet fever. Arnica. After a violent blow, loss of sight. Arsen. After abuse of liquor and tobacco; urine scanty and albuminous. Aur. mnr. After scarlet fever and during childbed (albuminuria); sudden loss of vision, with cold perspiration, small pulse, quick and irregular breathing. Bellad. Optic disc swollen and outlines ill-defined, retinal vessels large and tortuous, blue and bluish-gray film seems to cover fundus. (Norton.) Haemorrhage of retina, with suppression of menses; cerebral congestion; sudden heat of head; vertigo, burning and throbbing pain; noises in ears and illusions of vision, while the rest of the body is cold and shivering; pulsation of carotids. After suppressed scarlet eruption. Bryon. Byes feel full and sore on motion or to touch. Cactus. With heart troubles. Cinchona. Sudden blindness with violent pain in occiput, extending into the eyes; irritability of entire spine; spleen swollen and painful to pres- sure; rumbling in the abdomen; sour vomiting; constipation. Crotal. Haemorrhages in retina. (Norton.) Gelsem. Thirst for light; after apoplexy, congestion to the head; albu- minuria during pregnancy, after diphtheritis. Kali hydr. Syphilitic form. Laches. Haemorrhage of retina; albuminuria. Merc. corr. Albuminuric form, especially during pregnancy. 1 66 HEMIOPIA. Merc. sol. Sensitiveness of the eye to the glare of a fire. Nux votn. Abuse of stimulants and tobacco. Phosphor. Photopsies and chromotopsies, as halo around the light; dry- ness of the nose; after sexual excesses. Pulsat. "Choked disc," great swelling of optic papillae and enlarge- ment of vessels; vision nearly lost, with severe headache, only relieved in the open air. (Norton) Menstrual difficulties. Secale. Photophobia; suppressed secretion of tears; stitching pain in the eyes; dilated pupils; blue and fiery dots flying before the eyes. Sulphur. Suppressed itch. For impaired sight (amblyopia) and blindness (amaurosis) the following remedies also have been found useful: Alum., Bar. carb., Bovista, Calc. card., Chclid., Crotal., Cyclani., Elaps, Hepar, Ignat., Kali acet., Lycop., Natr. mur.y Ruta, Santon., Sepia, Thuja, Zincum. Hemiopia, Or half vision, is a contraction of the visual field, either on the two right or on the two left sides of the eyes, in consequence of an affection of either the right or the left optic nerve tract before the crossing at chiasm; blindness of the opposite sides of each retina, occurs when the optic nerve fibres are dis- turbed at the chiasma, that is at the point where the nerve fasciculi cross each other. Upper half blindness denotes an insensibility of the lower por- tion of the retinal nerve fibres, and is usually dependent upon a detachment of retina or embolism of a branch of the central retinal artery. Scotomata, or blind spots, are insensibility of certain corresponding parts of the retina. Therapeutic Hixts. Upper half blindness: Aurum, Digit., Phosphor.; right half blindness: Cyclam,, Lith. carb., Lycop.; half vision either side: Bovista, Calc. carb., Caustic, Chin, sulph.. Lob. infl., Lycop., Mur. ac, Natr. mur., Sepia, Viol, od. Hemeralopia, Night-Blindness. The patient sees well enough, as long as there is enough stimulus of bright light, but he cannot discern objects any more, as soon as the amount of light required by him is withdrawn, be it daylight or candle-light. It is most common among seafaring men. The glare from the sea seems to be the exciting cause added to some constitutional weakness; but is also found occasionally with harvesters and soldiers, where fatigue and exposure to the glaring sunlight seem the elements in its production. Therapeutic Hints. Cases. have been cured by: Arg. nitr., Bcllad., China, Hyosc, Lycop., Pulsat., Ran. bulb., Stramon., Sulphur, Veratr. HYPERESTHESIA RETINA. 1 67 Hyperaesthesia Retinae. We understand by it an oversensitiveness of the optic nerve and retina; even a small amount of light cannot be borne, and sometimes its impression lasts too long. This may be caused by irritation of the optic nerve and retina, with or without ciliary irritation. Ciliary irritation is usually accom- panied by lachr3 T mation and pain in the eyeball, and associated with many affections of the cornea and conjunctiva; this affection is usually spoken of as Photophobia. When the overexcitement of the optic nerve and retina does not depend on external conditions, we have, with or without intolerance to light, subjective appearances before the eyes, such as sparks, bright white, or colored patches, flames, colored rings, chromatic clouds, so-called phos- phenes, also known under the name of Photopsia and Chromotopsy; and in some instances a too long duration of the impressions, especially from bright objects, which continue to affect the optic nerve even after the eyes have been turned to some other object, whereby confusion arises and the objects seem to dance. Therapeutic Hints. For this affection a great number of remedies may present themselves for consideration. We shall have to weigh carefully all the symptoms of the case. Perhaps one or the other of the following maybe indicated: Aeon., Be/lad., Cinchona, Conium, Ge/sem., Hepar., Hyosc., Ignat., Lad. ac, Merc. sol+ Natr. mur., Nux vom., Phosphor., Pulsat., Sulphur, Tart. emet. LENS. Cataract, Is loss of transparency of a part or of the whole, either of the crystalline lens (lenticular cataract), or of the capsule (capsular cataract), or of both (cap- sulo-lenticular cataract). In the course of physiological development the lens commences to change after the age of about thirty-five years to greater density, more coloration and loss of convexity, and in the senile eye the pupil has lost its blackness, appears cloudy or of a light amber tint, or brownish-yellow, yet without loss of transparency. This ought to be borne in mind. The cataractous changes are different. Consisting in atrophy from loss of nutrition, the lens fibres are converted into different solid and fluid materials; the nucleus becomes hard and dry, while the cortex may be softening to the state of a semi-fluid pulp, which remains of opaque fibres, molecular substance and fatty tissue, especially in its hypermature state. This is the nature of the so-called Hard cataract. The Soft cataract consists of the conversion of the lens tissue into a paste-like material, or a degeneration of it into a soft substance of a thin milk-like color with granular flocculi, corpuscles and fatty material. The former is the cataract of adults, elderly and old people; the latter is met with from birth to puberty. 1 68 THERAPEUTIC HINTS TO CATARACT. The cataractous changes of the capsule are probably the result of inflam- matory action; they are mostly attended by a secondary degeneration of the lens, or vice versa, accompany a fluid degeneration of the lens. In Trau- matic cataract, which originates in consequence of a blow or other external injury to the eye, the capsule is nearly always opaque, and the cataract is of the soft kind; in the uncomplicated cataract of the aged, however, the capsule is seldom altered. The Objective Symptoms of these different affections can clearly be elucidated only by the ophthalmoscope. They are important to the e3 r e- surgeon, who will consult special works thereon, but even the naked eye is capable of detecting opacities of the lens. The following are the Subjective Symptoms: As soon as the opacity upon either the lens or the capsule is dense enough to interfere w T ith the rays of light, the first symptom is indis- tinctness of sight or mistiness; at first distant objects are seen as if through a mist or fog, or a bit of glass that has been breathed on; after awhile this mistiness envelopes near objects also. The adjusting power is lessened, because of the lens losing its elasticity. The patient now sees better in twi- light; then the pupil expands and more rays are allowed to pass through the lens. For this reason the patient shades his eyes in bright light and derives benefit from wearing goggles. In some cases there is even intolerance to bright light. In other cases the objects appear doubled or even farther multiplied, and are seen in fantastic forms. This arises when portions of the lens still remain transparent, but vary in the degree of their destiny, whereby an irregular astigmatism is produced. Muscae, of all shapes and sizes, and sometimes in showers, are of frequent occurrence; but flashes, stars, fiery circles, bright metallic light, bright spectra like silver must be attributed to other diseases of the eye; they have nothing to do with the cataractous affec- tion of the lens. Causes. — " Defective nutrition," merely expresses, in other words, what cataract consists of, but does not tell the cause, which in fact w 7 e know not. We can merely state, that cataract has been observed to develop: after ex- ternal injuries of the eye; in consequence of diabetes; after fever; in con- sequence of other diseases of the eyes, either active or of a low type; in consequence of hereditary influences. After one eye has been attacked the other is likely to follow. Therapeutic Hints. Under certain circumstances the quickest relief may be afforded by an operation, but there is no doubt that homoeopathic treatment has succeeded not only in checking further development, but also in clearing up existing opacities of lens and capsule. Dr. J. C. Burnett bases the curability of cata- ract on the homologus nature of the lens with the mucous membrane of the common integument, and gives a number of cases cured by him and by others in his most interesting monograph on: Curabilility of Cataract with Medicines. Boericke & Tafel, 1880. REFRACTION AND ACCOMMODATION. 1 69 The following are the most important remedies: Amm. carb. (right eye); Bar. carb.) Bellad. (after acute inflammation of the eye); Calc. carb. (scrofulous individuals); Ca?inab., Caustic, (constant inclination to touch and rub the eye, which seems to relieve a pressure in it) ; Conium (old persons); Euphras. after Sulphur (congenital cataract); Lycop. (after typus; suppressed menses) ; Mag?i. carb. (from left to right; previous disposition to headache and furuncles); Natr. mur. (Burnett) Phosphor.; Saccharum Sacchari (in several cases of old age); Sepia, Silic (after inflam- mation of the eye; preceding ringworms; suppressed sweat of feet); Sulphur (from right to left; after cutaneous eruptions, especially suppressed itch. According to Jahr main remedy.) According to Goullon, Jr., the main remedies are: Sulphur, high potency (30th and higher), or Spiritus sulph.; Silic, or Aq. silic; Calc. fluor., or Lapis albus ; Calc. carb., Phosphor., Caustic, Sepia, Bar. carb. Intercurring remedies: Bellad., Ferr. phosph., Euphras., Pulsat., Chelid., Cannab., Colchic, Sec. cor?i. — Allgem. Horn. Zeit., Vol. 107, page 125.) "Dislocation of the lens often results from injury and may be spontane- ous. It is most commonly dislocated backward into the vitreous, though it may lie in the anterior chamber or even under the conjunctiva. The lens may be seen in any case lying in its unnatural position. When in the vitre- ous, the tremulous condition of the iris will call attention to the trouble." — (Geo. S. Norton.) SIGHT. Refraction and Accommodation. A luminous body sends off rays of light in all directions, and in whatever direction they go they always move in straight lines, unless interfered with by a medium of different density. When entering a lens they are bent towards its thicker portion; a biconvex lens converges them to a focus; a biconcave lens scatters them for the same reason. Now when parallel or even slightly divergent rays of light from an object enter the pupil, and pass through the crystalline lens of the eye, they are bent by this body towards its thicker part and are thus focussed upon the retina. In this bending and gathering of the rays of light to a focus upon the retina consists what is technically called the Refraction of light. It is a purely mechanical process conditioned by the transparency and biconvexity of the lens, which like any other biconvex lens focusses the parallel and divergent rays of light at a certain distance, according to the amount of its convexity, that is according to its refractive power. When an object is sufficiently near the eye to emit divergent rays it is said to be at a finite distance; when, however, it is sufficiently far away to emit parallel rays of light to the eye, it is spoken of as being at an indefinite or indeterminate distance. In either case the rays are not entirely and equally parallel, and consequently the focus must vary in its distance behind the lens, either fall in front of or behind the retina. I JO PRESBYOPIA, OR OLD SIGHT. Only if an object were brought in the exact position from which its rays could be focussed upon the retina, could it be seen distinctly. We know, however, from experience, that for a normal eye such exact position of objects as to distance, in order to be seen, is not required. The healthy eye possesses a faculty by which it brings both parallel rays and rays in various degrees of divergency, to an accurate focus upon the retina; it sees clearly and distinctly at different distances, adapting itself for the position of the object looked at; and this is called its power of Accommodation or Adaptation. The nearest distance to the eye at which a small object can be seen distinctly by the maximum of accommodation, or by its greatest effort to see, is termed "the near point of vision;" the farthest distance at which anything can be clearly discerned, is ' ' the far point of vision. ' ' These points vary in different eyes; the interval between the near and the far point is termed the range or territory of accommodation. Xow the question arises, how is this accommodation of the eye to the various distances of objects effected? As the lens is only a passive agent of refraction, and as upon its form depends the distance where the transient rays are focussed, we must look for the means b} r which this change in the form of the lens is effected. And here all the latest researches agree in this, that the constant variations in the curvings of the lens, as accommodation for near and far objects requires, are brought about by the ciliary muscle of the eye. Associated with this ever-changing form of the lens by means of the cili- ary muscle are also pupillary movements — contraction for near objects to cut off the lateral rays of light, and dilatation for distant objects, the sphincter pupillse and the ciliary muscle being in a functional connection by nerve- fibres; and to this may be added the action of the recti muscles, which in accommodating for near binocular vision, turn the eyeballs inwards, while for perceiving distant objects, they place them parallel. Presbyopia, or Old Sight. The constant change in the curvings of the lens, as accommodation requires, can readily be affected only so long as the lens is sufficiently soft and yielding. As, however, the lens in the course of years grows denser and therefore less capable of being acted on by the ciliary muscle in the process of accommodation, and as also its shape becomes flatter and in consequence its refractive power reduced — the near point of vision gradually recedes, that is to say* If we were formerly able to see an object distinctly at a distance of four or five inches, etc. , because of the greater convexity to which the lens could be shaped by the ciliary muscle for such purpose, we now have to hold the same object further off, in order to receive a distinct visual impres- sion, showing that the lens is not capable any more of being shaped convex enough to gather the divergent rays of the near point to a focus upon the retina. The near point of vision has receded to eight, twelve or sixteen inches. With all this, distinct objects are discerned as accurately as before. HYPERMETROPIA. 171 This is Presbyopia — a diminution of accommodation for near objects, with diminution of refraction , consequent on age. This natural change in the crystalline lens commences in early life and gradually increases with advancing years. Generally about the age of forty, the near point is eight inches from the cornea, and at about forty-five years it recedes to twelve or sixteen inches. In some instances the change sets in suddenly, so that a month or even a week will make all the difference in the condition of the eye. In such cases we should bear in mind that a rapid increase of presbyopia is also a prominent symptom of glaucoma. Still later the far point for distinct vision, too, declines, and the focal range is thereby lessened. With the loss of range, there ma3 T be loss of the acuteness of vision, arising from retinal obtuseness. Presbyopia requires convex glasses, which ought to be changed as often as the progress in the change of the crystalline lens demands it. Lenses will not afford any help to distant vision, unless there be hypermetropia combined with it. Hypermetropia. This affection is caused by a congenital, often hereditary malformation of the eyeball, which is smaller than the emmetropic eye; its antero-posterior diameter is shorter than that of a normal eye, consequently the parallel rays of light entering the pupil do not unite and form a focus on the retina, but fall behind it, and were the sclerotica removed posteriorly, they would con- verge to a point behind its boundary. Therefore, it is still further impossible for divergent rays to be properly refracted for the function of sight. Only rays that have been artificially rendered convergent by a convex lens, are properly focussed upon the retina. Slight degress of this affection are often masked by the great accommodat- ing power of the lens during youth; an abnormally distant position of the near point, however, in young persons may be taken as., a very conclusive evidence of the presence of hypermetropia; after manhood the marked removal of the near point, the loss of acuteness of vision, the very decided assistance afforded to far vision by a convex lens, and the strong glasses needed for seeing small type confirm its presence. "In hypermetropia, asthenopic symptoms, as: eyes tire easily, blurring of vision, aching in and over the eyes, etc., after using for near work, occur early and require immediate selection of the proper convex glass. ' ' (Norton. ) Myopia, or Short-sightedness, Is the opposite condition to hypermetropia. The antero-posterior diameter of the eyeball is longer than in the emmetropic or normal eye, hence distant or parallel rays of light are brought to a focus before they reach the retina and the image which is formed on the retina is blurred and indistinct. Only divergent rays, that is, rays coming from near objects, are accurately focussed on the retina. While, therefore, the myopic eye can see near objects, it can- not see distant ones well without optical aid. The myopic far-point is always 1 72 ASTIGMATISM. at a definite distance; in bad cases it ma)' be within a few inches of the cor- nea; there is in such cases little difference between it and the near point. The two are in proportion to each other, the further the far-point, the further also the near-point, and vice versa. " Myopia may be produced by a spasm of the ciliary muscle, and must not be confounded with an elongation of the antero-posterior axis. ' ' ( Norton . ) The disposition to myopia is almost invariably congenital and heredi- tary; it is, therefore, a most uncommon occurrence for myopia to appear after the fifteenth year of age, and it is never acquired after the twentieth in eyes that are normal Its development is favored by the tension of the eye, which is insepara- bly connected with looking at near objects, where, by the constant and strong action of the internal recti muscles to produce the necessary convergence of the optic axis for the requisite position of the corresponding portions of the retinae, the eyeball gradually is drawn into a more or less oval shape, which finally may amount to the formation of a posterior staphyloma by atrophy of the choroid and sclerotica. Myopia is, therefore, essentially an accompani- ment of civilization, where it prevails chiefly among those classes who, from childhood on, have had to use their eyes continuously in reading and writing or other close work. In old age, when the lens grows flatter (see Presbyopia) the near-point recedes and consequently the myopic can often read again without the aid of glasses. This gain in sight is not an actual improvement of the eye; its myopic defect remains the same, but the flattening of the lens by age lengthens the focal distance which now reaches the retina. The myopic eye can be relieved by concave lenses, which ought to be used carefully and not too strong. Astigmatism. ' ' The term astigmatism is used to express a state of sight resulting from want of symmetry in the anterior portion of the eyeballs. The rays of light do not unite by convergence and form in a regular manner in one point or focus on the retina, but reach it partially or irregularly, some of them coming to a focus in front of it, or not forming any focus, whereby circles of disper- sion or diffuse images fall on the retina, and indistinctness of vision is produced." (Walton.) This irregularity in focussing the rays of light is mainly due to assymetry of the cornea, and in some cases also to that of the lens. The patient usually holds objects close to his eyes, as a myopic; the lines of adjoining letters seem to cover each other; parallel lines in different directions, one set for instance being vertical and another horizontal, do not appear equally distinct, but blurred; things at a distance are sometimes seen double, and a square figure will have the appearance of an oblong; in high degrees of astigmatism there is chromatic aberration, so that luminous objects sometimes appear surrounded by variously colored borders. Astigmatism may be combined with myopia or hypermetropia. It is often hereditary or ASTHENOPIA. 173 may be caused by the removal of the pupil from its central position either from accident, disease or in consequence of an operation; by the slightly irregular manner in which the corneal flap may heal after an operation for the extraction of cataract ; by the irregularity in the corneal curves produced by inflammation of the cornea; by the dislocation of the crystalline lens from accident or disease. Its remedies are carefully selected cylindrical glasses, and in case of inflammatory diseases of the cornea or traumatical causes, carefully selected medicines. Compare Corneitis, etc. Asthenopia. " This may be defined to be inability to maintain the adjustment of the eye for short distances, for a sufficient period without fatigue." (Walton.) The asthenopic eye gets tired when employed any length of time in reading, writing or other close work, especially by insufficient or artificial light; the ciliary muscle, which is the muscle of accommodation, cannot stand the strain required by the smallness of the objects and the close approximation of the eyes to them; it relaxes and the crystalline lens flattens, whereby the focus from the objects is changed and the objects become indistinct and blurred. A little rest relieves it all; the ciliary muscle is ready again for shaping the lens to the necessary convexity — but soon gives out again. At last a pressure and fullness is felt in the eyes and a tension and pain in the forehead; sometimes the pupils become contracted and the conjunctiva red- dened. The cause of all this is an imperfection in the refraction in the eye- ball, which is principally found in a hypermetropic formation of the eye, and therefore there is a close relationship between the two affections; in pure forms of asthenopia, according to Walton, hypermetropia is never absent. This form is called Accommodative Asthenopia. Asthenopic symptoms will also occur when the ciliary muscle, in consequence of illness or exhaustive diseases, becomes paretic, or when the internal recti muscles, from relative or absolute deficiency of power, cannot maintain the proper convergence of the eyes for near sight; then this is called Muscular Asthenopia. The accomodative form depends chiefly on the degree of the existing hyperme- tropia; it may develop itself at the early age of ten. The muscular form depends more on general conditions of the system, and as exciting causes may therefore be mentioned for the first: long-continued application of the eyes to close work, especially by insufficient light; and for the second: gen- eral debility; mental troubles; dissipation, etc. Therapeutic Hints. The accommodative form requires convex glasses for the relief of the existing hypermetropia; the muscular form also needs correction of the usually existing anomaly of refraction by suitable glasses. A stud}' of the general state of the debilitated system will be required for the selection of the corresponding remedy. IJ4 THERAPEUTIC HINTS TO ASTHENOPIA. Aeon. Eyes hot and dry from overuse; relieved temporarily by cold water. Apis. Stinging pain and lachrymation. Arg. nit. Blepharitis; hypermetrophia and weakness of the ciliary muscle. Calc. card. Fatigue and pain from using the eyes; on looking at near objects they become indistinct and blurred; general Calcarca symptoms. Chelid. " Letters run together while reading; left eye agglutinated in morning; lachrymation in the wind; pain from reading in the eye; worse from candle-light; lachrymation from reading." (E. Rushmore.) China. Debility after exhausting sickness. Cina. Spasmodic twitchings of the orbicular muscle; twitchings in the muscles of the face; from intestinal irritation by worms or otherwise; after masturbation. Cinnab. Pain from inner canthus, extending above and around the eye. Conium. Cannot bear bright light or heat. Euphras. Blurring of vision relieved by winking. Gelsem. Especially in the muscular form from weakness of the external rectus. Ignat. Nervous, hysterical females; onanism. Jabor. Asthenopic symptoms, especially dependent upon an irritable condition of the ciliary muscle. (Norton.) Lilium. Pain in forehead; photophobia; blepharitis; astigmatism. Natr. viur. Stiff and drawing sensation in the muscles upon moving the eyes; the eyes smart, itch and burn; feel best on being kept shut and pressed upon; muscular form. Nux vom. After dissipations. Onosmodium. Headache in occipital region, dull, aching pain, extend- ing down the back of neck, or over one side of the head, generally the left; is accompanied more or less with dizziness and sometimes nausea; is either preceded or followed by pain over or in the corresponding eye, with a stiff, strained sensation in the eye, aggravated from reading or use at near vision. (Geo. L. Norton, N. A. Journal, December, 1886, p. 794.) Phosphor. Dull pain deep in the eyes; black spots before the eyes, especially when looking at bright objects and by artificial light; better in twilight. Rhodod. Weakness of internal recti; darting pains through head and eyes, w r orse before a storm. Rhus tox. After great strain of the eyes; muscular form. Rufa. Aching in and over the eyes after straining the eyes at fine work; heat in the eyes and lachrymation after close work; accommodative form. MYDRIASIS. 175 MUSCLES AND NERVES. Mydriasis. This is a dilatation of the pupils. The iris is chiefly composed of non- striated muscular fibres, arranged in a circular and in a radiating direction. The circular fibres are supplied by the third nerve, and act as a sphincter pupillae, while the radiating fibres are supplied by the sympathetic nerve, and increase the aperture when stimulated to contract. Mydriasis may there- fore be caused either by a paralysis of the third nerve or by stimulation of the sympathetic. One of the differences between the two is, that with the paralysis of the third nerve there almost alwa} r s is associated a paralysis of the ciliary muscle, which more or less destroys the power of accommodation. Its exciting Causes maj^ be either peripheral, from exposure to cold winds, blows, etc., or cerebral, in consequence of effusion into the ventricles of the brain, concussion of the brain, basilar meningitis, diseases of the cerebellum, apoplectic effusions at the base of the brain, glaucoma and certain narcotics. Myosis ' ' Is a persistent regular contraction of the pupil below its medium size, with immobility and without change of structure in the iris or in the eye." (Walton.) It is caused either by a paralysis of the sympathetic nerve or by an irritation of the third. In the first case there probably are diseases of the neck, or in the spinal cord, which involve the cervical sympathetic, at the bottom of the trouble; in the latter case the cause lies in morbid conditions of the brain, which irritate the third nerve. Special Therapeutic Hints cannot be given. Mydriasis, as well as m3 T osis, are mere symptoms of other more deeply seated disorders, which must be studied accordingly. Our repertories show a number of remedies for both of these symptoms. Ptosis, or Falling of the Upper Eyelid. This affection may be due: 1st, to a paralysis of the levator palpebrse muscle, which is under the control of the third cerebral nerve; 2d, to a loss of muscular power in the levator, consequent on age; 3d, to a falling of the eyebrow, in consequence of paralysis of the occipito-frontalis muscle; 4th, to a congenital deficiency of the levator palpebral; 5th, to a hypertrophy of the palpebral integument; or, 6th, to chronic ophthalmia with granular eyelid. Therapeutic Hints. The most frequently indicated remedies are: Caustic, Gel son., Hvosc, Nux vom., Plumbitm, Rhus lox., Sepia and Zincum. A congenital deficiency of the levator palpebrse cannot be reached by any medicine. For granular eyelid compare the corresponding chapter. 176 STRABISMUS, OR SQUINT. Strabismus, or Squint. " Strabismus is deviation of the visual axes. The axis of the one eye being directed to the object desired to be seen, while that of the other is turned too much inwards (internal squint), or outwards (external squint)." 1 Walton.) Internal squint is the most frequent of the two. It may arise from greater or less paralysis of the external rectus, generally of the one eye, ex- ceptionally of the two; or from some functional change, some shortening, at first dynamically, afterwards at a varying period, organic shortening, with or without hypertrophy of the internal rectus; from lesion of the brain or of the ocular nerves in cases of inflammation, softening, apoplexy, hydroce- phalus, scrofulous tubercles, epilepsy; from intestinal irritation by worms; durning teething; from visual defects, in consequence of inflammation w T ithin the eye or the cornea ; from diseases which damage the function of the ex- ternal rectus, such as tumors, traumatic or specific inflammations, abscesses, neuralgia. Its most frequent cause is hypermetropia. The External or Divergent suqint seldom appears before puberty, except in connection with a diseased brain. It mostly arises from some form of impairment of vision affecting either on or both eyes, or from a difference in the refraction of the two eyes, or some disparity between them in the func- tion of sight, all of which is commonly associated with myopia. Its direct cause in most cases is paralysis of the motor oculi nerve. The external rectus muscle is influenced in the same way b\ r effusion in the orbit, tumors and all mechanical lesions of its muscles, and by cerebral disorders like the internal muscle in inward squint. Therapeutic Hints. Cerebral irritation with corresponding symptoms require: Agar., Bcllad., Cicuta, Gelsem., Hyosc, Nux vom., Stramon., Sulphur. Alum. Recommended h\ Jahr if Bellad. and Hyosc. have failed. Cicuta. After convulsions. Calc. card. After ophthalmia, or overstrain by close work; strumous subjects. Cyclavi. After unsuccessful operation; after convulsions, or measles. Intestinal irritation from worms or other causes requires: Cina. Picking of nose; restless sleep; grating of teeth; short, hacking cough through the night. Cyclam. See above. Sepia. Nocturnal enuresis during first sleep. Spigel. Itching at the anus. Sulphur. Nightly itching of the skin; cutaneous eruption; constipation. Suitable glasses may be of great help. Surgical operation is required where there is an organic shortening of the internal or external rectus; paralytic squint is least benefited by it, and in mere nervous disturbances it is not called for at all. NYSTAGMUS, TREMBLING OF THE EYEBAIJ^S. 1 77 Nystagmus, Trembling of the Eyeballs. It is an involuntary, rhythmical motion of the eyeball, mostly from side to side, sometimes in an oblique direction, without impairment of the mus- cular movements. These oscillatory motions are nearly always permanent during the waking hours, but do not interfere with the simultaneous action of the two eyes; sometimes they are associated with internal squint. The disease nearly always arises in infancy, and is frequently seen in connection with congenital cataract, or other states of the eye which impair sight. It is common to the Albinos, when there is an absence of the pigmentum nigrum. Although ascribed to a morbid condition of innervation, its true nature is unknown. Luscitas, or Fixed State of the Eyeball, Is limited or lost power of movement of the eyeball, which remains in a fixed position either with or without deviation from the orbital axis, and cannot in any degree follow the movements of the other eye. Luscitas is a symptom either of paral} T sis of the third nerve, when the eyeball is turned outward by the abductor muscle, or of paralysis of the abductor, when the eyeball is turned inside— all consequences of brain-disease, chronic hydro- cephalus especially. But external causes, such as injuries to the muscles of the orbit or to their nerves, tumors, staphylomatous enlargements of the sclerotica, may also fix the eyeball in any direction. Morbid Winking Is a clonic spasm of the orbicularis palpebrarum muscle, and frequently found in connection with severe conjunctival irritation; sometimes it is of constitutional origin. Twitching of the Eyelids, or Quivering, Nearly related to the above, may affect one lid or both. It sometimes is so slight that it cannot be seen, but may plainly be felt; although annoying it seldom is attended with pain, and is usually the consequence of deranged digestion or feebleness from overwork. Blepharospasm. The eyelids are violently and persistently closed. It is nearly alwa}^s associated with intolerance of light and discharge of tears. Its sources are various. They may arise in the eye itself, or in other organs, and transmit their influence to the brain at the origin of the portio dura, through the fifth nerve, the optic, the vagus, the sympathetic, or directly from cerebral disturbance. Thus we see it produced by trichiasis, strumous conjunctivitis, corneitis, retinitis; carious teeth, supraorbital neu- 12 178 NEURALGIA OF THE EYE. ralgia, a blow on the head or other injury; hysterical irritation. It may affect one or both eyes, it may last a long time uninterruptedly or in spells; it may be associated with spasm of the facial muscles. Therapeutic Hints. N ystagmus — Hyosc. f Morbid winking has been relieved by Agar and Ignat. Twitching by Cina, Physost. Blepharospasm by Bel/ad., Viola trie, Symphitum (after a blow), and other remedies, which must be selected according to the individual state of the patient. Compare the chapters which treat of its sources. Neuralgia of the Eye. It is usually an affection of the ophthalmic and superior maxillary divi- sion of the fifth cranial nerve, which supply the eyeball, the ocular append- ages, and the circumorbital region. One or the other of the branches of these nerve-trunks may be affected. Most frequently we find it located in the upper eyelid, the middle of the eyebrow, the nasal extremity of the super- ciliary arch, the inner canthus, or the temple; or it follows in the direction of the supra and infraorbital nerves; or it is entirely intraocular without any affection of the nerves radiating from the orbit. The first of these varieties is often intermittent or remittent, and may become chronic; it may alternate with nervous pains in other parts of the body. The Causes are frequently obscure, often, however, traceable to malarial influences or exposure to cold. The second variety may arise out of the effects of the fangs of carious upper back teeth. When the pains are deep-seated, its origin is intraorbital or even intracranial and may arise from thickening of the dura mater, orbital or cranial exostoses, aneurisms or tumors. Therapeutic Hints. These different forms and causes show that not a few remedies ma}' pre- sent themselves for our consideration. However, to avoid repetition, I refer to the chapter on neuralgia of the face. ORBIT. Orbital Cellulitis. 11 Inflammation of the orbit is usually severe and acute in character; is marked by great swelling of the lids, extensive chemosis, protrusion of the eyeball and intense pain in and around the eye, aggravated on any movement of the eye. Movements of the eyeball are impaired. Pus soon forms, when we have an abscess in orbit, which may perforate through lids or conjunctiva. The inflammation may extend to the eyeball, producing a panophthalmitis, or to the brain, or may cause caries of orbit, etc. General febrile disturb- EXOPHTHALMIC GOITRE. 1 79 ances usually accompany the above local inflammation . Trauma is the most frequent cause. It may result from extension of inflammation in neighboring parts or from constitutional diseases. Therapeutic Hints. Aeon., Apis, Hepar, Laches., Mercur. and Silic. may be indicated, but Rhus fox. is most frequently indicated." (George S. Norton.) Basedow's or Graves's Disease; Exophthalmic Goitre, Is characterized by palpitation with accelerated pulse, swelling of the thyroid gland, and exophthalmus or protrusion of the eyeballs. In its nature it has been considered by some as a morbid crasis, by others as a heart disease, and by still others as a neurosis of either the cervical sympathetic or the cervical medulla spinalis and medulla oblongata. I feel, therefore, at liberty to treat of it here as an3^where else. Autopsies have shown a considerable development of fat behind the eye- balls, which causes their protrusion; also at times fatty degeneration of the eye-muscles, probably caused by disease and stretching; and atheromatous changes of the ophthalmic artery. Changes in the sympathetic and its ganglia have not at all been of a uniform nature, and in some cases have been wanting altogether. Symptoms. — Usually this disease develops itself very slowly, though some few cases of sudden origin have also been observed. Its first symptoms in a majority of cases is palpitation conjoined with acceleration of the pulse, without any abnormal symptoms of the heart on physical examination* occasionally there are epigastric pulsation, increased force of the pulse in the carotids and their larger branches, especially in the thyroids, and a whirring and blowing that may be heard by auscultation before the struma is developed; pulsation of the retina and in rare cases pulsation of the liver. Some weeks or months later, slowly or rapidly, struma is developed, a soft, elastic swelling of the entire thyroid gland, which, however, does not attain to a very great size and is moreover subject to frequent changes. The surface of the tumor is often marked by veins, greatly dilated and crowded with blood, and auscultation reveals loud blowing sounds, often increased durino- systole. Struma seldom appears before palpitation and still more rarely is it wholly absent. Exophthalmus, the third prominent symptom, makes its appearance soon after the struma — in a few cases before it — and still more rarely as the initial symptom, preceding the struma and the palpitations. It always attacks both eyes, but sometimes appears on the one eye earlier, or remains at least more prominent than on the other. It seldom is wholly wanting, while in other cases it forms the only cardinal symptom, when it is associated with other kinds of general disturbances. In degree it varies greatly, from a slight prominence of the eyeballs to an excessive protrusion of the same, that no part of the globe is covered by the eyelids and even may amount to a luxation of the globe. The eyes protrude; the eyeballs I So THERAPEUTIC HINTS TO EXOPHTHALMIC GOITRE. have an unusual lustre; appear stiff and gradually lose their mobility in part or wholly. But this protrusion is not at all times the same, it increases and decreases proportionate!}' to the force of the pulsations of the heart, and sometimes may be diminished by light pressure upon the eyeball. Von Graefe has observed, that " the upper lid loses its power to move in harmony with the eyeball in the act of looking up or down," and he considers it a path- ognomonic sign of exophthalmus, which, however, others do not admit, as its occurrence, although frequent, is not constant. As a secondary group of symptoms in some cases may be mentioned; dryness of the conjunctival sac, distention of the conjunctival veins, and conjunctivitis; the lachrymal secre- tion is often increased. In bad cases: insensibility, diffuse desiccation or even perforation of the cornea. Ophthalmoscopic examination usually shows dilatation and increased tortuosity of the retinal veins, and in some cases spontaneous pulsation of the retina. The temperature of the body has been found increased to 101.8 F. in some cases, while in others it remained entirely normal. x\lso nervous disturbances have been observed, but the} 7 are so varied and so little characteristic, that they may be omitted without injur}' to the diagnosis of this malady. Its duration is protracted; months and years may pass with alternate improvement and relapse; some cases get well, others hasten to a fatal issue by the consecutive changes of the heart, the permanent increased labor of which leads to dilatation of both ventricles and compensating hypertrophy. In other cases marasmus and other inter- curring diseases or complications may end the scene. Women are more subject to it than men; in chilhood it is rare, it occurs mostly during the time of puberty and climacteric years, seldom later. As predisposing Causes have been mentioned: chlorosis, anaemia and neurotic tendencies; as exciting causes have been found: injuries, traumatic or other- otherwise, and mental excitement, violent fright. Therapeutic Hints. As this affection is not poor in symptoms and mostly of long standing, by a careful examination will be able to detect leading symptoms for one or another remedy, even not mentioned below. Amy I nitr. Frequent flushes of face and head; oppression of chest; tumultuous palpitation. (Olfaction.) Ba diaga . ( Norton . ) Bellad. Has cured cases in allopathic hands, although the doses applied were certainly too massive, as they produced headache, nosebleed and angina. Calc. card. In combination with a diet of nitrogenous substances, re- lieved greatly in a case of pronounced lymphatic constitution. Ferrum. In cases with disturbances in the sexual sphere, scanty or suppressed menses and great nervousness. Ly copies. Has relieved the protrusion of the eyes and the cyanosis, but had no effect upon the glandular enlargement, which yielded to Iodine. THERAPEUTIC HINTS TO EXOPHTHALMIC GOITRE. l8l Nair. mur. Depressed vegetative vitality; despairing, hopless feeling about the future; dryness of the mouth; sore tongue; map tongue; chronic constipation with hard stool; chlorotic symptoms, with dirty, flaccid, torpid skin; fluttering of the heart; intermitting and irregular pulse. Secale. Has been successfully used by the old school. Spongia. Easily frightened, especially at night, as if suffocating. It appears from this that the most efficient remedies used thus far were such which are capable of acting especially upon the heart and the thyroid gland; under certain circumstances, therefore, Bar. carb., Bromium, Cad. grand., Phosphor., Silic. and Sulphur may likewise be indicated. EARS. Analogy Between the Ear and the Eye. At first sight, these organs appear so entirely unlike each other, that it would seem scarcely possible to discover any analogy between them; yet on closer inspection, the similarity between the two is quite striking. As I consider this similarity in the structure of the eye and ear of great importance in clearing up the rather occult affections of the ear (the treat- ment of which is often very difficult), I shall point out, with some detail, the following remarkable features of similarity between the organ of sight and the organ of hearing. The pinna corresponds to the upper and the tragus to the lower eyelid. In animals the auricle is even movable, to collect or reject sounds, as the eyelids are to take in or to keep out the light. The eyelashes are represented by the bristly hairs at the mouth of the meatus extemus; to keep out dust and insects. The meatus externus is lined by a semi-mucous membrane, secreting ear-wax, corresponding to the conjunctiva of the eye, which secretes eye- butter; both are subject to similar inflammations and mucous or purulent discharges. The membrana tympani corresponds, not only in function, but also most strikingly in structure, with the cornea. It collects sounds, while the cornea collects light; and it is, at least, of a half-transparent texture. The diseases to which it is liable correspond with those of the cornea: inflammation, thickening, ulceration and perforation. Immediately back of this membrane, in the middle ear or tympanum, we find the ossicula auris, by which sound is broken and communicated to the auditory nerve, in the labyrinth, just as light, by means of the crystal- line lens, is refracted upon the optic nerve. The middle ear or tympanum, with its ossicula, corresponds, therefore, precisely to the anterior and posterior chamber of the eye with the lens. Still further back we come into the labyrinth of the ear, which is filled, in its membranous portion, with a limpid fluid, first well-described by Scarpa, and which corresponds to the vitreous humor of the eye; while the numerous filaments of the two branches of the auditor)* nerve, the vestibular and cochlear nerves, spread out into a nervous membrane, closely resembling that of the retina, so that the labyrinth of the ear corresponds to the posterior part of the eye with its vitreous humor and its retina. The nerve-mem- GENERAL OBSERVATIONS ON THE EAR. 183 brane of the ear terminates in fine fibrils or ciliae (Corti's mechanism), and the retina in a layer of rods and cones. There is one appendix to the ear — the Eustachian tube — which starts at the tympanum and opens into the lateral wall of the throat, and there is also one appendix to the eye — the lachrymal duct — which starts at the inner canthus of the eye and opens into the nose; while lastly both organs are situated in close proximity to porous bones: the ear on the mastoid portion of the temporal bone, and the eyes below the frontal sinuses of the frontal bone. This striking similarity in the structures of the ear and eye at once brings the diseases of the ear (by comparing them with those of the eye) nearer to our comprehension, and may even influence the choice of a remedy in a given case. General Observations on the Ear. The auricles grow pale from fright, chills, spasms, loss of vital fluids, exhaustion and frost. A marked paleness of the left auricle denotes inflam- mation of the spleen. Redness of the auricles is found in congestive and inflammatory condi- tions of the head and ears. Flushes are caused by mental emotion; or occur before bleeding of the nose, delirium, apolexy. An habitual or frequently-occurring redness of the auricles denotes dis- turbed actions in the abdominal organs; or else menstrual and hemorrhoidal affections. Hyperaemia of the auricle, and sometimes of the middle ear, is often associated with the climacteric period. A striking redness of the auricles in new-born children is a sign of pre- mature birth. Small, inflammatory, purplish, suppurating spots on the auricles are a sign of chronic syphilis. A slight inflammatory, painful redness of the upper part of the auricle is often the forerunner of an attack of gout. Swollen auricles, if inflammatory, are caused by erysipelas, injuries, eruptions; if habitual, not inflammatory, it is a sign of scrofulous conditions; if oedematous, a consequence of abscesses or Bright' s disease. The auricles are: Hot, in inflammatory and congestive conditions of the head and ears, also in consequence of great exertion of the voice, and in diseases of the larynx. Cold, in chills, spasms, and from exhaustion. Auricles habitually cold are found in weak and chlorotic individuals. In hysteric persons, cold auricles are the forerunners of a hysterical spasm; while in delirium and mania they denote a cessation of the paroxysm. Discharges from the ears may originate either in the meatus auditorius 184 ECZEMA. externus, in the middle ears (the tympanum), or in the cavity of the skull. They are of various characters. If, after a fall or external injury of the head, there be a discharge of blood, it denotes a fracture of the skull. The ears bleed also in scorbutic affections; from too great a pressure, or from insufficient pressure of the at- mospheric air (cannon-shot; on high mountains;), from too great exertions in screaming, coughing, vomiting, straining, blowing musical instruments. Pus or ichorous matter is the product of a previous inflammation, either in the meatus auditorius or in the middle ear. In rare cases the pus comes from an abscess in the brain, which has broken through the petrous portion of the temporal bone. Thin earwax is, in most cases, the consequence of a chronic inflamma- tory state of the meatus auditorius externus. THE AURICLE. Eczema. Various kinds of eruptions may befall the auricle, either spreading to it from adjacent parts or originating there. From among them eczema is the most common, differing in no way from its kind on other parts of the body. We meet it in its acute as well as in its chronic form, and very often asso- ciated with similar eruptions on the scalp, or face or other parts of the body. It may affect the entire lobe, or select only certain portions of it ; the sharp crevice behind the ear, where the auricle joins the mastoid process, is fre- quently its favorite seat. Therapeutic Hints. Bar. carb., Calc. card., Graphit., Hepar, Lycop., Merc, sol., Nitr. ac, Oleand. , Petrol. , Rhus tox. , Sulphur, are the main remedies. For particulars compare Eczema of the Scalp. By their position the auricles are naturally exposed to various external injuries, from blows, cuts, heat or cold, and the} 7 also are not unfreqnently the seat of depositions of urate of soda in arthritic patients. Their lower lobe is often disfigured by hypertrophy or little, round, hard tumors in con- sequence of previous piercing. THE AUDITORY CANAL AND THE DRUMHEAD, OR MEM- BRANA TYMPANI. Examination of these Parts. The canal is not straight but curved on its anterior and lower wall, and often obstructed by hair growing from its cartilaginous walls. The drum- head is placed obliquely across the canal at its furthest extremity, which it shuts off from the middle ear. In consequence of the crooked structure a simple look into the ear does not give us a full view of its walls nor of the drumhead. We have to straighten its curved course and push aside obstruct- THE AUDITORY CANAL AND THE DRUMHEAD. 1 85 ing hair or other impediments, as far as possible. This can best be done by an ear-speculum, which consists of a simple funnel-shaped tube, made of polished metal. There are usually three of different diameters fitted to- gether, for the purpose of giving choice to select that which best corresponds to the dimensions of the canal under examination. Its application is the following: Draw the article upwards and backwards, and insert the tube by gentle turning and twisting into the meatus as far as it can be done without using force or causing pain. Keep it then in its position and illuminate through it the parts to be examined. The best light is clear daylight or lamplight; the direct rays of the sun may be too dazzling. In order to pre- vent the intervention of the head of the observer with the rays of light, an ordinary laryngoscopy mirror or reflector fixed upon the forehead of the ob- server, or one of shorter focus made for the purpose of aural requirements, or, for preliminary examination, even a common hand-looking-glass can so be held as to reflect the rays of light into the tube, that by a little manage- ment and turning of the ear-speculum we are enabled to inspect readily the drumhead and the walls of the external canal in all their parts. The membrana tympani, or drumhead, is a thin, semi-transparent, parchment-like membrane, spread obliquely across the external auditory canal at its farthest extremity. In its normal state its surface, as seen through the ear-speculum, appears concave. Its shape is that of an irregu- lar oval disc, the long axis of which is directed from above downwards; it is attached to a well-marked bony groove upon an elevated ridge upon the bony canal — the Annulus tympanicus, being fixed to it by a cartilaginous ring — the Annulus cartilaginus , just as is the crystal of a watch to its bezel. It is composed of " three distinct structures, the external layer being a prolongation of the skin of the meatus externus, the internal being derived from the mucous membrane of the middle ear, while between these two comes the fibrous layer, and which is itself composed of two distinct layers, the one external, the fibres of which radiate, the other internal, the fibres of which take a circular course." "When we look at the healthy membrane, we may observe at its upper- most edge a whitish prominent part, the short process of the malleolus, and extending from this downwards and backwards nearly to the centre of the membrane, we see a whitish or pale yellow stripe, and which is the malleus handle, widening out at its lower end into the form of a spatula. In front of and below the manubrium we see a triangular reflection, the cone of light, its apex being at the umbo, or deepest point of the convexity of the mem- brane, its base forwards and downwards towards and slightly short of the periphery; and then we may, on looking closely, sometimes see shining through the membrane the promontory of the middle ear, and the long pro- cess of the incus. ' ' ( Cooper. ) The color of the membrane is a peculiar gray of different shades, con- ditioned by its transparent nature, by the bodies which lie behind it and the 1 86 EARWAX DIMINISHED OR INCREASED. light which strikes upon it. If the mucous membrane which lines its inter- nal surface, or that of the entire middle ear is congested, we find the natural gray mixed with a faint or deep red; or with a yellowish tint when the mid- dle ear is filled with yellowish secretion. Indeed pathological changes have a marked influence upon the color of the membrane. So also is the natural soft gloss of the membrane greatly altered, or even extinguished by patho- logical processes. The brightest reflection from the health}- membrane is the " cone of light," a triangular reflex of light in the anterior and inferior quarter of the membrane, which has its apex in the umbo and its base near along the periphery of the membrane ; it is analogous to the reflex of light of the cornea. Its locality and brightness too changes from .various patho- logical conditions. The external auditory canal is lined by a continuation of the external skin, which grows thinner as it approaches the drumhead, but is not changed to a mucous membrane. It is studded by numerous sebaceous and ceruminous glands from which the earwax is derived. Earwax Diminished or Increased. The lining of the auditory canal being a continuation of the external skin, great dryness of the same is usually found in persons whose skin in general is of a dry nature. It seldom has anything to do with nervous hard- ness of hearing. It may, however, be in connection with torpid processes within the middle ear, especially the drying up and hardening process of its mucous membrane. An increase of earwax may be caused by frequent picking and boring with hard instruments* in the ear, whereby a congested state of its lining membrane is induced; we find it in persons whose scalp produces much sebaceous secretion and who are inclined to sweat easily about the head; it is sometimes connected with a chronic eczema of the canal. Its accumula- tion usually goes on slowly and the forming of hard plugs of cerumen takes frequently a long time, the patient being not at all aware of their formation, until a gradually increasing deafness reminds him of something wrong in his ears. In other cases indurated earwax causes quite annoying symptoms. Besides hardness of hearing, amounting sometimes to deafness, there is great itchiness of the meatus, or a feeling of fullness and heaviness in the head, or there are spells of pain deep in the ear, and in some cases even serious attacks of vertigo. These attacks of vertigo in consequence of hardened earwax are caused by its pressure upon the drumhead, which is propagated by the chain of the ossicula to the fluid of the labyrinth. Vertigo, however, is a symptom also of other affections of the labyrinth. The hardened plugs of cerumen consist either of an amorphous, dark brown-red mass, principally made up from the secretion of the sebaceous and ceruminous glands, or they are strongly mixed with scales of the epidermis and in old persons with hair; some old plugs, w T hich shine like mother-of pearl, are mixed with cholesterin; and in still others we find an admixture THERAPEUTIC HINTS TO THE AUDITORY CANAL. 1 87 of cotton, seeds, dirt and other substances from the surrounding atmosphere. There are, however, cases where the hardened masses which obstruct the auditory canal have originated in the middle ear, and consist of dried pus mixed with blood, in consequence of catarrh of the middle ear and perfora- tion of the drumhead; in still other cases the plugging up material consists of accumulated masses of fungi or the formation of polypi. All this must be borne in mind. Deafness from hardened plugs of cerumen will certainly be cured by the removal of this obstruction, while in complications with affections of the middle ear this is by far not so certain. Here the tuning fork will give us the best instruction. When deafness is caused by mere obstruction of the external meatus, the tuning fork vibrating on the vertex is heard better in the obstructed ear, contrary to the patient's expectation. When, however, we find that it sounds louder in the ear which is not affected, or is heard, at least, no better in the obstructed ear, we may assume that there is some complication in the inner ear, and need not expect a full return of hearing after the removal of the obstruction. Therapeutic Hints. Plugs of hardened earwax must be removed, and to do this there is nothing so expedient and harmless as injections of hike- warm water, by a suitable ear- syringe. It is not necessary to do it forcibly and if, as in some cases, the plug is very hard, and adheres very tightly to the walls of the canal, it is better to take for its accomplishment two or three sittings and in the meantime have the hardened substances softened by occasional application of warm water, than to try to force it in one sitting. "Carbonate of soda added to the warm water hastens the removal of ceru- men." (Houghton.) Often the hearing maybe worse and a feeling of fullness come on after the first sitting, in consequence of swelling of the hardened mass, and the entire closing up of the canal. The patient ought to be advised of this possible seeming aggravation. After the earwax is removed it will always be advisable to put some cotton or wool into the ear in order to protect the drumhead from shrill sounds and cold. But why does the earwax accumulate and harden in some persons, and not in others? There surely must be some constitutional reason for it, which we must try to mend, otherwise the same process will go on again. The following remedies must be considered: Carb. veg. ' ' Has served me well in malsecretion of cerumen with ex- foliation of dermoid layer of meatus. " (Houghton.) Discharge of flesh- colored, offensive moisture from right ear; deficient or badly-smelling cerumen. Conium. Accumulation of earwax, looking like decayed paper (scales of epidermis) mixed with pus or mucus, or blood-red; hardness of hearing ceasing when the wax is removed and returning with the wax. Graphit. In young persons with habitual herpetic eruptions in the meatus; or meatus dry and scabby. Laches. Want of wax; ears very dry. 188 FURUNCLES OF THE EXTERNAL CANAL. Mur. ac. Accumulation of wax which is dry and hard, and of a brown- red color, with hardness of hearing. Petrol. Large quantities of thick or thin wax; sensation of rushing of water in the ear; old, aged persons. Furuncles of the External Canal. The}- correspond entirely to boils on an}- other part of the body. Start- ing at first as an inflammation of a hair-follicle or of a glandular follicle, by spreading, the surrounding subcutaneous connective tissue is drawn in the same process and a limited abscess is formed. In the auditory canal their size is naturally still more limited; they may, however, for a time completely close the canal, until they break and discharge the core. They are quite painful and sometimes we find several together or following each other. They correspond to styes on the eyelids. As a diagnostic sign from abscesses, Cooper states that when they discharge the pillow-case in the morning will be studded over with stains so closely resembling small sized buttons, as to deceive the most clear-sighted at a distance. Therapeutic Hints. Hepar., Merc, sol., Pulsat., Sulphur. ' ' Picric ac. Is as near a specific for small furuncles in any part of the body as any remedy can be. In the meatus externus it aborts the furuncle if seen early and mitigates, if advanced, as well as corrects the habit." (Houghton. ) ' ' Furuncles in external auditory canal dependent upon mental overwork." (Geo. S. Norton.) Otitis Externa, or Diffuse Inflammation of the Auditory Canal. In its Acute form it commences frequently with itching, heat and a sensation of dryness in the ear, which gradually changes to a dull pain or a boring and tearing deep in the ear, and being generally worse in the night, deprives of sleep and causes feverish restlessness. In severe cases the pain may extend all around the ear and to the corresponding side of the head. A jar from sneezing or coughing, or the motion of chewing or gaping make it worse. The hearing grows duller in the degree in which the outer lining of the drumhead becomes involved. On inspection we find it congested and swollen and also the lining of the canal; gradually exudation ensues, which at first is watery, but finally becomes yellowish and purulent. With the establishment of otorrhcea the pain decreases, the epidermis loosens and the canal fills up with the products of desquamation. This state of things may gradually wear off and heal, or it may become chronic; the otorrhoea may continue for years. Usually Chronic otitis externa takes its origin in an acute attack as described above; but there are cases where such acute and painful outbreaks are not remembered; very often the commencement dates back to infant life. Sometimes the otorrhcea ceases for a time, especially during summer, but comes back again with damp and cold weather or from THE MIDDLE EAR. 1 89 aii} T other exciting cause. This form is often characterized by the presence of fungi. Chronic otitis may lead to ulceration, deep opacity and extensive thickening of the drumhead, to narrowing of the external canal by hyperos- tosis, to polypous growths within the canal, or to an extension of the inflam- matory process to the middle ear or the neighboring diploetic bony struct- ures, or even to the dura mater and brain. Deafness of various degrees is a usual concomitant. The Causes of external otitis are various. Acute and chronic exanthe- mata; eczematous eruptions; pemphigus; irritating substances; fungi of the aspergillus kind; exposure to cold draughts. Most liable to its attacks are children. The Prognosis of an acute attack may be called favorable, the chronic form is mostly difficult to manage. Therapeutic Hints. As soon as otorrhoea has commenced, great care should be taken to keep the ear clean. Occasional injections of luke-warm water, administered care- fully, are of great benefit. "Aurists are now beginning to advise dry appli- cations, avoiding warm water except in acute troubles." (Houghton.) As regards the remedies, compare Otitis Media. THE MIDDLE EAR. The ca vitas tympani is bounded exteriorly by the drumhead; interiorly by the wall of the labyrinth; its roof divides it from the brain; under its floor, which is very irregular in shape and greatly varying in thickness and compactness in different persons, even sometimes in the two ears of one and the same person, lies the vena jugularis interna; on its posterior wall we find the inlet to the antrum mastoideum, and on its anterior wall, nearer to the roof than the floor, just opposite to the antrum mastoideum, is the mouth of the Eustachian tube. The entire cavity is lined by a mucus membrane, which is smooth, whitish, very thin and tender. It does the service of the periosteum, as it contains the vessels which nourish the bony structure underneath. The antrum mastoideum and the numerous air-containing cells of the mastoid process are a kind of air-reservoir and resonator, a very important appendix to the middle ear, as by it the sonorous vibrations are more or less controlled. The Eustachian tube on the other hand is the draining canal for the secretions of the middle ear, and also its ventilation tube. For its outlet, which in grown persons resembles the mouth-piece of a trumpet, opens into the naso-pharyngeal cavity, where it is constantly exposed to the stream of atmospheric air during respiration, by which communication the air in the middle ear is kept in the nearest possible equal tension with that of the atmosphere. I90 EXAMINATION OF THE MIDDLE EAR. Examination of the Middle Ear. 2. By Means of the Ear Speculum. — We can ascertain by its application the color and condition of the drumhead. When it is of a reddish tinge, there is inflammation of its inner lining, in consequence of catarrh of the middle ear; when it bulges there is an accumulation of mucus or pus behind it; when it is perforated we ma)* be able to view the condition of the ossicula behind it. By Means of Vasalva's Method. — This consists of a forced expiration by the patient himself, by keeping mouth and nose tightly shut. The effort of blowing without allowing the air to pass out either of the mouth or the nose forces it into the Eustachian tubes, through which it enters into the ears, where it causes a sense of fulness and a crackling in the drumheads, which from the internal pressure are made to bulge, provided the Eustachian tubes be pervious. If this sense is not produced, or only in one ear, we know that then and there the Eustachian tube or tubes are closed. This method re- quires intelligent patients. ' ' In many cases the testimony of the patient is negative as regards the passage of air, when test with the watch shows that it did pass into the tympanum. ' ' (Houghton. ) 3. By means of Politzer's Method. — This consists of blowing, by means of an india-rubber bag with a tube, a current of air into one or both nostrils of the patient in the moment when he is made to swallow a sip of water. The nostrils of course must be held shut so that the current of air cannot return through them, while the act of swallowing closes the upper portion of the pharynx, preventing the air from escaping through the mouth. Thus it has to pass through the Eustachian tubes into the ears of the patient, of which he will be cognizant by a certain fulness and pressure in the ear, or in- case of perforation of the drumhead, by a whistling sound and a simulta- neous ejection of collected mucus into the external meatus. This method, too, requires intelligent patients, but it excels over Valsalva's method in this, that it acts more energetically. " Politzer's method of inflation can be made available without the use of water in most cases, by directing the patient to close the mouth and blow steadily as in the act of whistling, or blowing out a candle. In children the tympanum can usually be inflated without either expedient; a forcible emp- tying of the air-bag will dilate the Eustachian tube and fill the cavity." (Houghton.) 4. By Means of Catheterism. — It consists of blowing air into the middle ear by means of an Eustachian catheter. Here are Kramer's directions for the introduction of this instrument: "As a rule, the catheterism of the Eustachian tube should be accomplished with one of the catheters of size 1 to 4, introduced through the corresponding nasal meatus of the ear that is to be examined. For this purpose the patient is to be placed upon a chair with a common back, or with one somewhat higher than usual, in order that the head may be supported." "After the patient has blown his nose (partly for EXAMINATION OF THE MIDDLE EAR. 191 the purpose of clearing away a too abundant secretion, partly, in case the nose is too dry, to moisten it, and thus enable the instrument to slide alcng it with greater facility) , we dip the catheter into pure olive oil, and blow through it to assure ourselves of its permeability. The head of the patient is then fixed with the left hand; the catheter is held with the thumb and finger of the right hand close to the funnel-shaped extremity, in such a manner that the ring attached is downward; the beak is placed in the nasal meatus, resting upon its floor, close to the septum, with the convexity upwards. From this point it is pushed backwards with 2, very light hand, sweeping as much as possible along the floor of the nostril, with continual elevation of the handle, till the instrument becomes horizontal and its ex- tremity rests against the posterior wall of the pharynx. The thicker the catheter, the more easily are these movements executed." "Irregularities in the form of the inferior turbinate bone and strong lateral displacement of the septum may render the first introduction of the catheter very difficult, and test severely the delicacy of the sense of touch in the hand of the operator. As the point of the beak arrives at the posterior wall of the pharynx, the funnel-shaped end of the catheter is to be raised a little above the horizontal line, and at the same time to be lightly withdrawn. The beak then sinks and rests upon the posterior wall of the soft palate, which at that instant contracts, performs a swallowing movement, raises itself, and when assisted by a quarter turn upon its axis from within out- wards, lifts the beak of the instrument into the tube." 1 ' If this rapid movement is not successful in the hands of an inexpe- rienced person, the beak of the catheter must be conducted back to the upper part of the pharynx, in order that it may be slowly drawn forwards and turned at the same time laterally a quarter turn upon its axis towards the outside, by which means the ring of the funnel-shaped end is directed hori- zontally. It now slides over and into the swelling of the tube itself, where the beak of the catheter is directed, with its gravity against the anterior swelling of the tube, and here it hooks into it and can be clearly felt to be grasped by it upon quickly withdrawing it. The catheter lies here quite conveniently, being in no way a source of annoyance to the patient, even in speaking, in swallowing or in any of the movements of the head. For the sake of security we now elevate the beak of the catheter above the horizontal line, directing it upward and outward, the position of the beak being deter- mined and rendered evident by the direction of the ring upon the funnel- shaped end." After a successful introduction of the instrument, the operator blows either with his mouth or by means of an india-rubber ball into the tube, through which the current of air is transmitted into the middle ear. On lis- tening during this operation by either putting the ear to the ear of the patient, or by means of an otoscop, we hear the air rush in and beat on the drumhead, which produces a harsh sound when the drumhead is very dry, and a soft or moist sound when the drumhead is moist. A thin, interrupted 192 EXAMINATION OF THE MIDDLE EAR. or whistling sound indicates an obstruction of the Eustachian tube; a rattling noise, as from some distance, indicates that the Eustachian tube is lined with mucus; a rattling sound, which appears to originate nearer, indicates a col- lection of mucus or pus in the middle ear; a fine, sharp whistling, with ejection of pus into the external meatus, indicates perforation of the drum- head; a distant, faint and indistinct noise proves that the air does not reach the middle ear at all, either because the catheter is not correctly inserted into the outlet of the Eustachian tube, or because there exists an obstruction in the tube which the air-douche cannot overcome. 5. By Means of the Watch. — If we want to ascertain the distance at which a patient is able to hear, we must use an instrument which gives a sound always of the same nature and strength, and which can easily be held at different distances from the ear to be examined. Such an instrument is the watch. We commence by holding it at a distance and bring it gradually nearer to the ear until its tick is perceived; the reversed order might give rise to mistakes. As soon as the patient can indicate the tempo of the tick, we are sure that he hears it, and we know the distance in which he hears by exact measurement. 6. By Means of the Tuning-fork. — It is a known fact that the sound of a watch or a vibrating tuning-fork, when placed on the bony structure of the head or on the teeth, is heard at once louder as soon as we shut the ears, by lightly inserting one finger into each ear. If we close only one ear, we hear the sound louder on this side than on the other. This physiological fact has been made use of in the diagnosis of ear diseases, where, in some cases, it gives valuable hints. The same effect, namely, which is produced by closing the ear with a finger, must be brought about by any morbid obstruction within the ear which interferes with the normal conduction of sound. And what prevents the sound from entering into the ear must necessarily prevent the sound- waves also from passing out of the ear, when produced by and conducted to the inner ear by vibrations of the skull bones; consequently they must be reflected back to the labyrinth and thus be perceived doubly as loud. The causes, which may act similar to an artificial closure of the external meatus, are various. It ma}* be a collection of cerumen, a foreign body, or a furuncle in the external canal, or obstruction of the Eustachian tube, or myringitis, or thickening of the drumhead; it ma}- be a collection of secre- tion about the ossicula, or a want of flexibility, or even t a partial destruction of the same, or a softening or thickening of the membranes of the fenestrae to the labyrinth. In any of these conditions the patient will surely hear the tuning-fork, which, by the way K gives the best and truest results, when placed on the median line of the top of the head, loudest in that ear which is thus affected. If the patient, on the contrary, should hear the tuning-fork better in the sound or comparatively well ear, and less distinctly in the affected one, OTITIS MEDIA. 1 93 we may assume with tolerable probability that the affection of the bad ear consists of a loss of sensibility of the Acusticus in the labyrinth. However, even here we must not be too rash in our conclusions, and remember that there is a great difference in the capacities which patients, and even persons in health, manifest with regard to their power of distinguishing the vibrations of a tuning-fork placed upon the head. Aged persons as a rule have much less capacity of perceiving the vibrations of a tuning-fork than persons below fifty years of age. It will be well in all cases to place the tuning-fork, as a controlling experiment, also upon the front teeth of the lower jaw. A peculiar observation of Von Trcelsch is, that the tuning-fork, when placed on the head, very quickly ceased to vibrate in cases of a very unfavorable nature. Otitis Media. Under this name I intend to treat what Von Trcelsch has separately and elaborately described as simple catarrh and purulent catarrh of the middle ear. Both forms represent an inflammatory state of the mucous lining of the cavit}^ of the middle ear, the mastoid cells and the Eustachian tube, either in part or in toto. The first is the lighter form, producing a mucous secre- tion which, however, at times may be mixed with pus and blood; the second is the more serious form, characterized by its purulent secretion, and mostly ending in perforation of the drumhead. It may be the result of simple catarrh, and I do not find any characteristic signs by which the two could positively be distinguished from each other at the commencement. The catarrh of the middle ear is either acute or chronic. Its Acute form is mostly very painful; only exceptionally it runs its course without pain, especially in tuberculous individuals. The pain is felt deep in the ear, is sometimes excruciating and extends over the whole of the affected side of the head; it is usually not increased by pulling at the auricle or by pressure upon the parts before the ear, but gets decidedly worse from swallowing, or any quick movement of the head, or any concussion from a hard step, and at nights. If the mastoid process becomes involved, there is pain in that region and sensitiveness to pressure, and according to Cooper, even at an early stage ' ' we can find a little gland situated midway over the mastoid process and on a line with the anterior opening of the auditory canal, im- mediately behind the auricle, become tender and swollen, while its immediate surroundings are insensitive to pressure." This inflammatory process is further attended by high fever and sleeplessness, when it may indeed simulate an acute meningitis; by deafness of various degrees, developing either sud- denly or gradually, and caused by the exudation which covers the ossicles and destroys their natural mobility; by " catarrh in the head." In fact it may have spread from a catarrhal inflammation of the naso-pharyngeal mucous membrane, through the Eustachian tube into the middle ear. There is no age exempt from it, but in childhood it is especially preva- lent, though it is often not recognized. *3 194 THERAPEUTIC HINTS TO OTITIS MEDIA. I might for its diagnosis in little children draw the attention to the fol- lowing Symptoms : high fever; great restlessness; crying and screaming without apparent cause, sometimes in spells or incessantly for days. The child gets worse from any motion, especially of the head, from being rocked, from swallowing and especially when sucking. In fact it cannot be made to suck, it lets the nipple go at each attempt of drawing. Often the little ones bring their hands automatically to the affected side of the head. In some cases the pressure of the exudation within the ear causes vomiting, somnolence alternating with great restlessness, delirium, partial or entire loss of con- sciousness, convulsions of the limbs or of the facial muscles. If all this is complicated with an exanthematic fever, or typhoid fever, pneumonia or bronchitis, its diagnosis is indeed difficult. A nasal catarrh or an angina might better lead to its discover}'. At all events it will be well to try the application of warm water to the ears in suspicious cases, which gives more or less relief if the ears are affected. An examination of the auditory canal in otitis media by the ear speculum reveals a slight redness of the canal near the drumhead; the drumhead itself appears slightly reddened from its con- gested mucous layer inside, or sometimes shining and red, like a polished copper-plate; afterwards or sometimes from the first its mild lustre grows dimmer or is lost entirely and with it also the cone of light. When the se- cretion in the middle ear increases, the drumhead is marked by single radiat- ing blood-vessels and partial bulging, especially of its upper and posterior portion. Sometimes the collected pus shines through the drumhead and gives it a yellowish appearance. Externally we find swellings of the glands around the ear and redness and swelling of the naso-pharyngeal mucous membrane. Otitis media terminates often in perforation of the drumhead. Its Causes are exposure to cold, which, especially in persons prone to catarrhal affections, will often excite this complaint. We find it frequently associated with tuberculosis, syphilis, exanthematic fevers, typhoid fever, diphtheritis and croup; we must not lose sight of it during the process of dentition. It yields in most cases kindly to homoeopathic treatment. Therapeutic Hints. Aeon. Excruciating pain often in the whole affected side of the head with high fever, dry skin, anguish, crossness and restlessness; great sensi- tiveness to noise; auricles hot and red; meatus externus dry and red; drum- head red, almost copper-colored, with visibly engorged and throbbing ves- sels; after exposure to wind and cold. Arg. nitr. Ulceration of the drumhead; muco-purulent discharge from the ear; naso-pharyngeal inflammation. Arnica. Deep pain and heat extending to the mastoid process; feeling of being bruised about the ear; stitches in and about the ear; hardness of hearing. Traumatic origin; from getting chilled after being heated; typhoid fever; pysemic symptoms. THERAPEUTIC HINTS TO OTITIS MEDIA. 1 95 Arsen. Typhoid symptoms, with suppression of discharge; lymphatics inflamed; high temperature; collapse; profuse, cold perspiration; pysemia; pain relieved by warm applications. Burning, itching and crawling in external meatus; red, burning pustules in the canal and upon the auricles. Bel lad. Sticking in and behind the ear; digging, boring and tearing; coming and going suddenly, extending to the throat; inflammation of the throat; ringing, buzzing and roaring in the ear; face flushed; eyes brilliant and staring; congestion to head; delirium; deafness or sensitiveness to light and noise; auricle red and sensitive to touch; erysipelas of scalp. Drum- head congested, enlarged vessels covering its entire surface. After exposure to cold draughts; cold foot-baths; having the hair cut; dentition. 11 The frequent instillation of warm water (as warm as it can be borne), either alone or with the addition of a few drops of Bellad., will usually relieve the terrible pains while the remedy is administered internally." (Norton.) Borax. Stitch-pains, with involuntary starting; lancinating headache; itching in the ear; mucous discharge; hot ear; external meatus swollen. Children fret and cry and fear downward motion. Calc. carb. Beating pain, with knocking, buzzing and roaring; pain from ear to neck and under jaw; w r orse from evening till midnight; better from perspiration; thick discharge; swelling of lymphatic glands about ear and neck; perspiration about the head; scrofulous subjects; sensitiveness to cold and damp air; period of dentition; teeth carious and bluish-black at the roots. Cap sic. Itching deep in ear; shooting, pressing pain in and about the ear; deep-seated pain under the ear, opposite the angle of the inferior max- illary, not extending down the jaw; mastoid process swollen; middle ear and mastoid cells filled with pus; external meatus closed; drumhead per- forated. ' ' Cap sic. is specially valuable in acute necrosis of mastoid process, or in acute symptoms arising in chronic diseases of the mastoid. The full pulse, fever and haggard look of the patient are marked features of the picture of the drug. In abscess of the mastoid in very young children it has not proved as effective. ' ' (Houghton. ) Chamom. Catarrhal inflammation; pain in paroxysms; excruciating; patient beside himself from pain; irritable and cross; screaming. Auricle red and hot; face changing color, now red and hot and then again pale; or only one cheek red and the other pale; hot sweat about the head; green, colicky discharges from the bowels; dentition. Ferr. phosph. Catarrhal affection of the Eustachian tube and ear, often combined with catarrh in chest, or bowels, or both. Gelsem. Catarrhal inflammation at the beginning; cold in head and closure of Eustachian tube; tense, dull, bound, giddy sensation in head with chilliness; stupor, drowsiness. Hydrast. After frequent gatherings and earache, deafness. The right 196 THERAPEUTIC HINTS TO OTITIS MEDIA. membrane is bulged outward, looks purplish, and the malleus handle is of a pinkish suffusion; left membrane of the same character, though not bulged. (R. T. Cooper.) Kali carb. Stitch-like pain and drawing, especially behind the right ear; head and right ear hot; face pale, sometimes flushed; strong fever, with dizziness; chilliness, shuddering; anxiety in chest; weary in all the limbs. Kali. hydr. Otitis in rickety children with great tenderness of the head. Merc. sol. Deep-seated, tearing and shooting pain, extending to the malar or inferior maxillary bone; worse from evening till midnight, by warmth in bed; enlarged, sensitive cervical glands; stomatitis or ulcerated sore throat; tongue large, flabby, indented; fauces inflamed; perspiration from least exertion; otitis, accompanied by facial paralysis. Merc. dulc. Especially when the Eustachian tube and mucous mem- brane of the pharynx are affected. Natr. sulph. Sharp, lightning-like stitches in the ear; catarrhal affec- tion from damp and rainy weather, cold bathing, playing on wet ground; hydrogenoid constitution. Nux vom. Great pain in ear; hardness of hearing, with roaring, sing- ing and other noises; auditory canal dry and sensitive; cold in head; itching in Eustachian tube; headache; vertigo; periodical nausea and vomiting; constipation; creeping chilliness. Better in warm, worse in cold and damp weather. Phosphor. Painful gathering, first in left and then in right ear, and shooting pains through ear, worse at night; stopped up feeling in ear; itching in ears; rather deaf in left ear; deafness to human voice; re-echoing of his own words. When the ear gets better, styes appear on eyelids, or eruption at the septum of the nose; constipation. Plant, maj. Pain in the ear, with pain in the teeth and face. The pains are sharp, twinging, running. (Houghton.) Pulsat. Sharp pain, increasing gradually to great intensity, then ceas- ing suddenly, but soon increasing again; shooting pain; hardness of hearing; headache and toothache; carious teeth; auricle sensitive; external meatus red and swollen; profuse discharge; phlyctenular inflammation on drum- head, or ulceration and perforation; dryness of auditory canal; catarrh of Eustachian tubes; swelling of cervical glands; mild disposition; thirstless- ness; constant change of position; shifting pains on different parts of the body; catamenial irregularities. Worse in the evening; from heat or close room; better in open air. Rhus. tox. Pain worse at night and at rest; from cold, damp and rainy weather; deafness to human voice. Sulphur. Drawing, shooting pain; heavy pressure and heat at vertex, extending to both ears, with soreness of the brain ; hot flushes of the face, followed by cold sweat; hardness of hearing, especially for the human voice. THE CHRONIC FORMS OF OTITIS MEDIA. 1 97 In children who suddenly cry out with pain, while they appear listless and unobservant, and where it seems doubtful whether the irritation be in the brain or in the intestinal canal. Styes ; swollen nose ; eruptions on different parts of the body. In complication with meningitis, eruptive fevers. Tcllur. Pain day and night, of a dull, throbbing character ; itching and swelling (left ear), with painful throbbing in the external meatus ; dis- charge of a watery fluid, smelling like fish-pickle, which causes a vesicular eruption upon the external ear and neck, wherever it touches the skin ; the ear bluish-red, as if infiltrated with water; hearing impaired; rough, angu- lar disposition; after scarlet fever. Tereb. Dental caries and otitis ; dental irritation, with symptons either of cerebral or abdominal irritation; burning soreness and interstitial disten- tion of the gums; suppression of urine and convulsions; wakeful at night, screaming as if frightened; staring look; clenching of fingers; twitching of different parts of the body; picking of nose; dry, short cough; aching of limbs and head; feverishness; changeable temper; cross and irritable. Eczema in front of left ear. (Cooper.) Ver: vir. Acute otitis. ' ' Paracentesis of the membrana tympani is advisable, if the pains are not readily relieved by remedies, and if there is an accumulation in the middle ear, causing the drumhead to bulge; for a spontaneous rupture may leave a permanent perforation, while a simple puncture leaves no bad results, besides at once giving the patient relief from the agonizing pain." (Norton,) Digest after chronic forms of Otitis media. The Chronic Forms of Otitis Media. Chronic catarrh of the middle ear and its appendices is often developed in consequence of acute attacks, sometimes, however, without these. It con- sists either of an interstitial solidification or sclerosis of the middle ear tissue (dry catarrh), or of a swelling, tumefaction and thickening of the lining membrane, either of the middle ear or the Eustachian tube alone, or of both together, or of an ulcerative destruction of the mucous membrane and con- sequent perforation of the drumhead (chronic suppurative catarrh). The Sclerosis of the middle ear tissue yields no discharge, therefore it is called " dry catarrh." Its nature is quite obscure, and only from post- mortem examinations we know that this pathological process gradually pro- duces a stiffness and unyieldiness of the lining membrane of the middle ear, that greatly interferes with the normal vibrating capacities of the drumhead, the ossicula and the membranes of the fenestra rotunda et ovalis. Many cases of deafness produced in this wa}^ have, no doubt, formerly been classed under ' ' nervous deafness. ' ' The Moist catarrh is characterized by hypersecretion and tumefaction of the mucous membrane. This originally thin transparent and smooth membrane gradually becomes whitish or bluish- gray, its substance thickened, and its vascularity increased; patches of granulations form upon its surface. I9S THERAPEUTIC HINTS TO CHRONIC FORMS OF OTITIS MEDIA. and fatty, cheesy or calcareous deposits in its periosteal layer. The whole lining of the middle ear ma}- thus be changed,. and the pathological process may extend into the Eustachian tube, making it impervious for ventilation. The Suppurative form manifests itself by its purulent otorrhcea ; the mucous membrane appears, in some cases, greatly swollen and red, in others only moderately so and pinkish-yellow, and in still others, whitish-gray and cicatrized; it is covered with pus. At times we find this morbid process at- tended with caries of the bony structure and almost always with perfora- tion and greater or less destruction of the drumhead. The patient with chronic catarrh does not often know when his trouble began; only by a gradually increasing hardness of hearing his attention is drawn to it. The grade of deafness depends not so much on the extension of the catarrhal affection as on its location, by which it is apt to interfere more or less with the conduction of sound waves to the labyrinth. A slight degree of catarrh, if it destroys the mobility of the fenestral membranes, caused greater deafness than a much more extensive catarrh, if it affects the walls of the middle ear or even the drumhead. Impaired hearing, when it is better in clear and dry and worse in damp and rain}- weather; when it is momentarily relieved by Valsalva's or Po- litzer's method, or after an act of swallowing from which the patient perceives a kind of crack in the ear; when the own voice gives a more resonant sound, or the tuning-fork on the vertex is perceived louder in the affected ear — it usually denotes an affection of the Eustachian tube. When, on the con- trary, under all these conditions, the degree of hearing is not altered, we may infer that the trouble is located in the articulations of the ossicula or in the fenestral membranes. A perforation of the drumhead is not necessarily attended with great impairment of hearing, even an entire destruction of the same does not cause entire loss of hearing; of greater importance in regard to hearing are the changes from aural catarrh already referred to, which affect the articulations of the ossicula or the fenestral membranes on the labyrinth wall. The drumhead, if perforated, as a rule, heals kindly, but if it is kept open from continued inflammation and discharge, or even de- stroyed the middle ear loses its protection against external influences and is thus continually subjected to new irritations. Chronic otitis media suppurativa often leads to the formation of polypi and caries. Caries of the temporal bones may lead to abscesses in the brain or meningitis purulenta, to paralysis of the face, to haemorrhages, emboli, septic infection and phlebitis. Its Prognosis must be made according to these different characters and states. Therapeutic Hints. Valsalva's or Politzer's method, or catheterism, will prove beneficial in cases of imperviousness of the Eustachian tube, where it is important to pro- cure a better ventilation of the middle ear, or in cases of perforated drum- THERAPEUTIC HINTS TO CHRONIC FORMS OF OTITIS MEDIA. 1 99 head and copious collection of slime and pus in the middle ear, to cleanse it of these secretions. The main work even here will have to be done by care- fully selected remedies. Besides those mentioned under the acute form of aural catarrh, compare: Arsen. Profuse, ichorous, cadaverously-smelling discharge; sinking and prostration. Asaf. Purulent discharge; after abuse of mercury. Au rum. Fetid discharge; caries of mastoid process with pain like a bruise, worse at night, by uncovering and at rest; better by motion in the open air. Meatus externus lined by fetid pus, like decay of necrosed bone; drum perforated; ossicula destroyed; middle ear denuded; fistulous openings through mastoid processes; offensive nasal discharge. Syphilis and abuse of mercury. Bar. carb. In cases involving the external meatus, Eustachian tube and structures of the pharynx, especially tonsils. Bar. mur. " Has served me better than Bar. carb. after long trials with the latter. Baryt. corresponds to an extra patency of Eustachian tubes caused by pharyngeal weakness or paresis. Clacking sound on swallowing, sneezing, or eructation, and by the two latter actions air is forced into the tympanum. Large tonsils reduced under its action." (Houghton.) Calc. carb. Profuse discharge; chronic deafness; sensitive to shrill sounds; crackling sounds when chewing; singing in the ears, with snapping as from electric sparks; roaring in the ears. Drumhead perforated; edges covered with granulations, extending to external meatus; polypous growths. Sore eyes; sore, ulcerated nostrils; smell of rotten eggs as gunpowder in the nose; nasal discharge; catarrh of Eustachian tube. Ca? r b. veg. Offensive discharge; aural meatus and drumhead inflamed; pain from ear down to neck; after itch-like eruptions. Caustic. Offensive discharge; paralsis of face; hardness of hearing; own voice re-echoes; roaring and whizzing in ear; throat reddened, with increased mucus; meatus dry, with little brown wax. Cinchona. Haemorrhage from ear after prolonged suppuration. Conium. Hardness of hearing; ears stopped up by dark brown wax and pus; pain in head; ringing in ears; enlarged liver, with pain on pressure; jaundice; urine scanty, brown and bilious; constipation, alternating with bilious diarrhoea; cervical glands hard and tender. Elaps. Deafness; offensive, yellow-greenish discharge; buzzing in ears; frontal and occipital headache, worse from motion and stooping. Dull pain from nares to ears; when swallowing, pain goes to the ears; posterior wall of pharynx dry, mucous membrane fissured and covered with crusts ; offensive discharge from nose; subject to epistaxis and eruption about nose and face; snuffles and pain from root of nose to forehead. Skin dry and hot, but always complains of feeling cold. Ferr. met. Discharge from left ear; chlorotic complexion; impaired hearing; murmur in left jugular vein; palpitation of the heart. 200 THERAPEUTIC HINTS TO CHROXIC FORMS OF OTITIS MEDIA. Fluor, ac. Hardness of hearing, with rheumatism; ringing in the ears and numb feeling in the bones of face, near the right ear. Hearing is bet- ter on bending the head backwards; scalp sensitive; hair matting. Gelsem. Deafness after massive doses of morphine or quinine. Graphit. Deafness; hears better when riding in a carriage; catarrh of right tube; roaring in right ear; feeling as if a skin were covering the ear inside; sensation as of a valve opening and closing in the ear; detonation and cracking in the ear when swallowing or sneezing; own voice resounds; roof of mouth and fauces red. Eruption behind the ears, with sticky secre- tion; eczematous eruption of the face; mucous membrane of meatus red and excoriated; or dry and scabby; or oozing of water and pus, or blood; or thin, watery offensive discharge from both ears after scarlet fever, with deafness. Hepar. Detonation in the ear when blowing the nose; drawing, tear- ing, stitching pain, worse in night and cold air; soreness of surface in spots when touched; skin ulcerates from slight injury; scabs behind the ears; on ulcerated surface white shreds, which are removed with difficulty; wants to be wrapped up warmly even if hot. Abuse of mercury. J odium. Deafness, with tonsillitis and catarrh of Eustachian tube; in- dolent ulceration of the drumhead; glandular enlargement in front of the tragus; pinched, dried- up look of the face. Kali. bich?'. Thick yellow discharge, mixed with stringy mucus ; sharp pain coming and going quickly and changing location; stitches from ear up into the head and down into the neck; better from heat. Naso-pharyngeal catarrh; rop}^ mucus; " clinkers " in nose. Kreosot. Deafness with hereditary syphilis. Laches. Dryness of left ear; roaring and drumming in the ear; sense of coldness in the affected ear and side of head; dry, scurfy condition of nostrils; discharge of blood and pus from the nose. Lycop. External meatus excoriated by an offensive discharge; drum- head destroyed. Patient cannot bear to be covered. After scarlet fever with affections of the parotid glands, e/uptions and abdominal troubles. Mercur. Deafness; offensive discharge; polypi; external meatus and drumhead inflamed; itching in the ears; vesicular eruption in the face and itching pimples on legs. Syphilis. Me?r. bijod. Follicular catarrh in pharynx; enlarged tonsils. Merc. dale. "Is more effective than the other forms of Mercur. in overcoming closure of Eustachian tube, and probably it is in this way that it relieves the deafness of advancing years. " (Houghton.) Merc, prcec. rub. Purulent discharge; leaden heaviness in occiput; fall- ing out of hair. Mezer. Deafness after the suppression of an eruption of the scalp char- acterized by the formation of crusts, beneath which, when pressed, oozes a purulent or semi-purulent fluid. Natr. carb. Hardness of hearing and roaring in left ear with caries of DIGEST TO ACUTE AND CHRONIC OTITIS MEDIA. 201 the left molar teeth; pain in left side of face; stiffness of neck and left shoulder; pain in small of back and left leg, worse from motion, better in rest; menses irregular, scanty; all worse before the monthly. Nitr. ac. Difficult hearing; obstruction of tube with swollen tonsils after scarlet fever; caries of the ossicula or mastoid process, from syphilis or abuse of mercury. Shooting pains; pain in bones, worse from every change of temperature, at night, on washing, on rising from a seat and from touch; better while riding in a carriage. Phosphor. Deafness to the human voice; resounding of own voice; sensation as if a foreign body were lodged in the ear; great itching in the ears. Picric ac. Noises in the head and sinking in the pit of the chest, being worse when tired and fatigued; deafness. (R. T. Cooper.) Psorin. Offensive discharge; offensive exhalation from whole bod}^; itching in ths ears; tinea capitis; scabs over fetid ulcers on and behind the ear. Similar to Sulphur but not reached by it. Pulsat. Catarrh of Eustachian tube with hardness of hearing. Sepia. Sensitive to musical sounds; herpes on the lobe, behind the ear or on the nape of the neck. Silic. Hardness of hearing, worse from washing and changing linen; otorrhcea and bad cough after scarlet fever; constant watery, curdy and ichorous discharge, without pain, except after a fresh cold. Ulceration, caries and necrosis; pain drawing and shooting, worse at night and from change of weather or movement; also after being long seated. Wants to have the head wrapped up. External meatus dry at outer portion, ulcerated further in and at drumhead. Child bores into its ear with its fingers when asleep, causing a discharge of blood and pus; it enjoys having the ear cleansed. Feeling of sudden stoppage in the ear relieved by gaping or swallowing. ' ' Silic. is especially curative in cases in which the ulceration covers with a firm scab, under which pus abounds. One subjective symptom I have found a guiding one; hissing sounds in the ear which is perforated." (Houghton.) Sulphur. Deafness, especially for the human voice; purulent, offensive discharge, worse in damp weather, after meningitis. Drawing, shooting pains in the ears; pressure in the ears when swallowing or sneezing; ulcers in the middle ear; rusty ulcers on the drumhead. Frequent styes; swollen nose; eruptions on different parts of the body; worms and itching of anus; hot and sleepless in the night; hot feet and burning of soles in bed with in- clination to uncover the feet; disinclination to being washed. Thuja. Discharge which smells like putrid meat; granulations in the middle ear similar to condylomata; polypi. Digest to Acute and Chronic Otitis Media. PAIN AND SENSATIONS. | Burning : Arsen. Beating, with knocking, buzzing and Cold sensation in ear and side of head: roarinsr : Calc. carb. Laches. Bruised feeling about ear : Arnica. Digging, boring and tearing : Bellad, 202 DIGEST TO ACUTE AND CHRONIC OTITIS MEDIA. Drawing", shooting : Sulphur. , , worse at night and from change of weather, or movement : Silic. , stitching, worse in night and cold air : Hepar. Dull, throbbing, day and night : Tellur. Foreign body, as if lodged in ear : phor., Psorin. Itching, Borax, Capsic, Mercur. ^ Phos- phor. Pain in ear : Nux zvm., Plant, maj. , when swallowing : Elaps. Pressure, when swallowing or sneezing : Sulphur. Paroxysms, excruciating, patient beside himself from pain : Aeon., Chamom. Sharp, twitching, running : Plantago. , increasing gradually to great inten- sity, then suddenly ceasing, but soon commencing again : Pulsat. , coming and going quickly: Bellad. ; and changing location : Kali bichr. Shooting : Nitr. ac, Pulsat. , worse at night : Phosphor. , pressing in and about ear : Capsic. Sticking in and behind ear : Bellad. Stitches in and about ear : Arnica. , with involuntary startings : Borax. , sharp, lightning-like : Natr. sulph. Stitch-like and drawing, especially be- hind ear : Kali card. Stopped-!) p feeling in ear : Phosphor. EXTENT AND DIRECTION. Deep pain and heat extending to mas- toid process : Arnica. , tearing and shooting, extending to malar or inferior maxillary bone : Merc, sol. Pain from ear and neck : Card. veg. , and under jaw : Calc. carb* , to throat, coming and going sud- denly : Bcllad. Stitches up into the head and down to neck : Kali bichr. Deep-seated pain under the ear, oppo- site the angle of the inferior maxillary, not extending down the jaw : Calc. carb. Painful gathering first in left and then in right ear : Phosphor. Excruciating pain often in the whole affected side of the head : .Icon. Dull pain from nares to ears : Elaps. Heavy pressure and heat at the vertex, extending to both ears, with soreness of the brain : Sulphur. AURICLE. Sensitive Pulsat. Hot: Borax, Sulphur. , right ear and head : Kali carb. and red : Aeon., Chamom. Bluish-red, as if infiltrated : Tellur. Itching and swelling (1. ear) with painful throbbing in external meatus : Tellur. Red, burning pustules, outside and in- side : Arsen. Vesicular eruption outside from dis- charge : Tellur. Herpes on lobe, behind the ear, or on nape of neck : Sepia. Ulceration covers with a firm scab under which pus abounds : Silic. Scabs over fetid ulcers : Psorin. Behind ears, scabs : Hepar. over fetid ulcers : Psorin. eruption with sticky secretion : G rap hit. In front Of tragus : Glandular enlarge- ment : Iodum. of left ear : Tereb. EXTERNAL MEATUS. Burning, itching and Crawling : Arsen. Dry : Pulsat. , Silic. left ear : Laches. and scabby : Sulphur. with little brown wax : Caustic. and red : Aeon. and sensitive : Nux zvm. Inflamed: Bar. carb., Carb. veg., Merc. Red and swollen : Borax Pulsat. Closed: Capsic. Red and execriated : Graphit. Ulcerated, white shreds, which are re- moved with difficulty : Hepar. Lined by fetid pus : Aurum. Polypi: Calc. carb., Mercur., Thuja. DRUMHEAD. ' Inflamed : Carb. veg. , Mercur. Bulging and purplish : Hydrast. Copper-colored, engorged, throbbing vessels : Aeon. Enlarged vessels all over : Bellad. Phlyctenules upon it : Pulsat. DIGEST TO ACUTE AND CHRONIC OTITIS MEDIA. 203 Ulceration: Arg. nitr., Pulsat., Silic. , indolent : Iodum. Rusty ulcers : Sulphur. Perforation: Aeon., Capsic, Lycop., Pulsat. , edges covered with granulations, extending to external meatus : Calc. card. MIDDLE EAR. Feeling 1 as if a skin were covering the ear inside : Graph it. Denuded: Aurum. Ulceration: Silic, Sulphur. Caries, necrosis: Aurum., Nitr. ac, Silic. Granulations like condylomata : Thuja. MASTOID PROCESS. Swollen: Capsic. Caries : Aurum. Fistulous opening : Aurum. Necrosis: Capsic, Silic. Abscess : Capsic. in children not proved successful : Capsic. EUSTACHIAN TUBES. Itching" : Nux. vom. Catarrh: Bar. carb., Calc. carb., Ferr. phosph., Pulsat. , right side : G 'rap hit. with hardness of hearing : Pulsat. with catarrh of pharynx : Merc dulc Obstruction with swollen tonsils : Nitr. ac. Closure: Gelsem., Merc dulc. DISCHARGE. Discharge from left ear : Ferrum. like decay of necrosed bone: Aurum. mucous : Borax. muco-purulent : Arg. nitr. offensive, fetid : Arsen., Aurum., Carb. veg., Caustic, Flaps., Graphit., Mercur., Psorin., Sulphur. , excoriating parts : Lycop. , Tellur. , smelling like putrid meat : Thuja. Discharge, smells like fish pickle : Tel- lur. , yellow-greenish : Flaps. Haemorrhage after prolonged suppura- tion : Cinchona. Otorrhoea: Silic Profuse: Arsen., Calc. carb., Pulsat. Purulent : Asa/. , Merc prcec. rub. , Sul- phur. Pus and blood, after boring with fingers in ears during sleep : Silic. Thick : Calc carb. Watery, ichorous: Arsen., Graphit., Silic, Tellur. , yellow, mixed with stringy mucus: Kali bichr. Water, pus or blood: Graphit. Suppressed discharge with typhoid symp- toms: Arsen. HEARING. Buzzing: Calc carb., Flaps. Clacking on swallowing, sneezing or eructation: Bar. mur. Cracking when eating: Calc. carb., Graph it. Deafness, impaired hearing, hardness of hearing: Arnica, Bellad., Caustic, Conium, Flaps., Ferrum, Graphit., Mercur., Nitr. ac, Pier, ac, Pulsat., Silic, Tellur. , chronic: Calc. carb., Pier. ac. , in left ear: Phosphor. , for human voice: Phosphor., Rhus tox., Sulphiir. , with hereditary syphilis: Kreos. , with tonsilitis: Iodum. , with roaring in left ear: Natr. carb. , with rheumatism: Fluor, ac. , after suppression of crusts on scalp, with purulent secretion underneath: Mezer , of advancing years: Merc. dulc. Detonation, when swallowing or sneez- ing: Graphit. , when blowing the nose: Hepar. Hearing better on bending head back- wards: Fluor, ac , when riding in a carriage: Graphit. Hissing in perforated ear: Silic Resounding of own voice: Caustic, Graphit., Phosphor. Ringing : Conium. , buzzing and roaring: Bellad. and numbness in bones of face near right ear: Fluor, ac. Roaring: Bellad., Calc. carb., Pier. ac. and drumming: Laches. and whizzing: Caustic. in right ear: Graphit. Sensitiveness to musical sounds: Sepia. 204 DIGEST TO ACUTE AXD CHROXIC OTITIS MEDIA. to shrill sounds: Calc. card. to noise and light: B til ad. Singing" with snapping as from electric sparks: Calc. carb. Steppage by dark-brown wax and pus: Coniutn. relieved by gaping or swallowing: Siiic. As of a valve opening and closing in the ear: Graphit. SYSTEMIC SYMPTOMS. Stupor: Gd st ui. Listless and unobservant: Sulphur. Delirium : Bellad. Suddenly cry out with pain, otherwise listless: Sulphur. Fret and cry: Borax. Screaming : Chamom. Disinclined to being washed: Sulphur. Enjoys having the ear cleaned: Si lie. Pear downward motion: Borax. Anxiety in chest: Kali carb. Anguish: Aeon. Mild disposition : Puhat. Changeable temper : Tereb. Rough, angular disposition: Tellur. Cross : Aeon. and irritable: Chamom., Tereb. Headache : Bellad., Conium l Nux vom. , frontal and occipital, worse from motion and stooping: Flaps. , lancinating: Borax. , tense, dull, bound, giddy sensation, with chilliness: Gelsem. , and toothache: Puhat. , and aching of limbs: Tereb. Noises in head and sinking at pit of chest: Pier. ae. Leaden heaviness in occiput : Merc. prcrc. rub. Vertigo : Gelsem., Nux vom., Pier. ae. Congestion : Bellad. Meningitis : Sulphur. Perspiration about head : Calc. carb., Silic. , hot : Chamom. Scalp sensitive : Fluor, ae., Kali hydr. Erysipelas : Bellad. Tinea : Mi zer., Psorin. Palling out of hair : Merc, prcrc. rub. Matting of hair : Fluor, ae. Brilliant and staring : Bellad. Staring look : Tereb. Frequent styes : Pier, ae., Sulphur. Styes appear when the ear gets better : Phosphor. Sore eyes : Calc. carb. Smell of rotten eggs or gunpowder : Calc. carb. Cold in head : Gelsem, Nux vom. Discharge : Calc. carb. , offensive : Aurum. of blood and pus : Laches. Snuffles and pain from root of nose to forehead : Flaps. Ropy mucus, " clinkers :" Kali bichr. Dry, scurfy nostrils : Laches. Ulcerated nostrils : Calc. carb. Eruption at septum : Phosphor. about nose and face and subject to nosebleed ; Flaps. Swollen nose : Sulphur. Picking of nose : Tereb. Pain in face and teeth : Plantago. in left side : Natr. earb. Paralysis : Caustic., Merc. sol. Flushed : Bellad. Hot flushes followed by cold sweat : Sul- phor. One cheek red. the other pale: Chamom. Changing, now red, then pale: Chamom., Kali carb. Chlorotic complexion : Ferrum. Jaundice : Conium. Eruption, vesicular : Merc. sol. , eczematous : Graphit. Pinched, dried-up look : Lodum. Haggard look : Capsic. Stomatitis : Mere. sol. Tongue large, flabby, indented : Merc, sol. Roof of mouth and fauces red : Graphit. Gums sore, burn and swollen : Tereb. Teeth and face painful : Plantago. . carious: Pulsat., Tereb. , left molar : Natr. carb. , and bluish-black at roots : Calc. carb. Dentition, period of : Bellad., Calc. carb., Chamom. with cerebral or abdominal irrita- tion : Tereb. DIGEST TO ACUTE AND CHRONIC OTITIS MEDIA. 205 Nasopharyngeal inflammation : Arg. nitr., Kali bichr. Fauces inflamed: Bar. card., Bellad, Merc. sol. , with increased mucous : Caustic. , follicular : Merc. bij. , mucous membrane fissured and covered with crusts : Elaps. Tonsils enlarged : Bar. card., Merc. bij. reduced under its action : Bay . mur. Thirstlessness : Pulsat. Cervical glands swollen : Merc, sol., Pulsat. , hard and tender : Conium. Lymphatic glands about ear and neck swollen : Calc. card. Neck and left shoulder stiff : Natr. carb. In left jugular vein murmur : Ferrum. Periodical nausea and vomiting : Nux vom. Green, colicky discharge : Chamom. Constipation : Nux vom., Phosphor. , alternating with bilious diarrhoea : Conium. catarrh in bowels or chest, or both : Ferr. phosph. Abdominal troubles : Lycop. Enlarged liver : Conium. Worms and itching of anus : Sulphur. Urine, scanty, brown, bilious : Conium. suppressed, with convulsions : Tereb. Menses, irregular and scanty : Natr. carb., Pulsat. Cough, bad : Silic. , dry, short: Tereb. Palpitation : Ferrum. Full pulse : Capsic. Dry skin : Aconite. , but always complains of feeling cold : Elaps. Eruptions : Lycop. , on different parts : Sulphur. Pimples, itching on legs: Mercur. Soreness of skin in spots when touched : Hepar. Ulcerates from slight injury : Hepar. Chilliness : Nux vom. , shuddering : Kali carb. Feverish : Tereb. Fever : Aeon., Arsen., Capsic. , with hot soles and inclination to un- cover feet : Sulphur. , with dizziness : Kali carb. , typhoid : Arnica. , eruptive : Sulphur. Perspiration from least exertion : Merc, sol. , profuse, cold : Arsen. Exhalation offensive from whole body : Psorin. Drowsy : Gelsem. Sleepless : Sulphur. Wakes up screaming as if frightened : Tereb. Restless : Arsen. Changes position constantly : Pulsat. Pains shifting in different parts : Pulsat. Weary in all limbs : Kali carb. Twitching of different parts : Tereb. Clenching of fingers : Tereb. Sinking, prostration, collapse : Arsen. Anaemia : Arsen. Hydrogenoid constitution : Natr. sulph. Lymphatics inflamed : Arsen. Pysemic symptoms : Arnica. Rickets : Kali hydr. Scrofulous children : Calc. carb. Syphilis : Kreos., Merc. sol. CIRCUMSTANCES THAT CAUSE IT. Cold bathing : Natr. sulph. foot-baths : Bellad. Chilled after being heated : Arnica. Exposure to cold draughts : Bellad. wind : Aeon. Having hair cut : Bellad. Itch-like eruptions : Carb. veg. Meningitis : Sulphur. Mercury, abuse : Asa/., Aurum, Hepar, Nitr. ac. Morphine and quinine : Gelsem. Playing on wet ground : Natr. sulph. Scarlet fever : Nitr. ac, Tellur. with deafness : Graphit. with swollen parotid glands : Lycop. Sulphur, after if not sufficient : Psorin. Syphilis : Aurum, Nitr. ac. Traumatic : Arnica. Vaccination: Silic, Thuja. Weather damp, cold and rainy ; Natr. sulph., Rhus tox. 206 POLYPI. WORSE. Being tired and fatigued : Pier. ac. BETTER. In evening : Pulsat. till midnight: Calc. card., Merc. so j Cleansing the ear is enjoyable : Silic. At night and at rest : Rhus tox. Motion in open air : Aurum. Damp weather : Calc. card., Nitr. ac, Riding in a carriage : Nitr. ac, Graphit. Xu.v vom., Sulphur. Washing and changing linen : Silic. Heat or close room : Pulsat. Warmth in bed : Merc. sol. , cannot bear covering : Lycop. Before monthly : Natr. card. After being long seated : Silic. On rising from a seat : Nitr. ac Warmth : Nux vom. , wants head wrapped up : Silic I erspiration : Calc. card. , wants to be wrapped warmly Hepar. Heat '• Kali bichr. Warm applications : Arsen. Open air : Pulsat. Polypi. These morbid growths are more frequently found in combination with chronic suppurative catarrh of the middle ear. It is probable that in most cases they are the product of this morbid process, although it is possible, also, that having originated primarily, they ma}* by constant irritation cause in- flammation, ulceration and perforation of the drumhead. Their substance is yen* vascular, soft, red and easily bleeding when being touched; sometimes the}' are of greater consistence, have a smooth and shining surface, and grow grape-like on pedicles. Their size differs greatly. From mere tiny excres- cences they may increase to masses which fill the entire external meatus and even overlap it. They have been found to grow from the surface of the ex- ternal meatus, from the drumhead and from different parts of the surface of the middle ear. According to Von Trcelsch their most frequent origin is the middle ear; Toynbee and Wilde, on the contrary, observed them most fre- quently to originate on the posterior part of the external meatus. In regard to their histological nature, they are either a hyperplasia of the mucus lining of the middle ear — Mucous polpyi — or a proliferation of connective tissue — Fibrous polypi — or a growth of a jelly-like substance — Gelatinous polypi. The first are the most frequent, the last the rarest form. Therapeutic Hints. Alumen usia, 3d cent., "will reduce granulation on the drumhead or inner extremity of meatus. ' ' (Houghton. ) Calc. curb. Large polypi, filling the whole external meatus and over- lapping it; bleed occasionally; chronic nasal discharge. Calc. jod. Offensive, thick, yellow discharge from the ear; deafness; pain in region of the heart, worse on going up stairs; frequent urging to urinate, as if the bladder were full, worse in afternoon and evening. Merc. sol. Offensive discharge; polypi in external meatus, which is inflamed. Sa ng u in ., Ten criu m . Thuja. Large polypi with otorrhcea; bleed easily. Shooting pain in ear. Granulations in middle ear. NERVOUS DEAFNESS. 207 Nervous Deafness. Under this name a number of ear affections have heretofore been classed, which now are diagnosed as one or the other form of chronic middle ear catarrh. Other affections still remain, which must be favored with this title, until bj~ further experimentation and improved means of diagnostic researches, we shall have gained a more precise knowledge of their nature. 1 ' Nervous deafness ' ' comprises all those defects of hearing which take their origin in affections of the labyrinth, of the acoustic nerve and its origin, or of the brain. Various as these affections are and may be, we seldom have the means of accuratel} T defining their nature during the life of the patient. We meet nervous defects of hearing after the abuse of Quinine; in hysteria and chlorosis; in consequence of injuries to the head; various affections of the brain. Meniere's Disease. The following are Meniere's observations: "1. Attack of noises of various kinds, intermitting or continuous, and impairment of hearing coming on suddenly in heretofore well organs of hearing. 2. These functional dis- turbances have their seat in the inner ear and are capable of producing apparent brain-symptoms, such as vertigo, stupefaction, uncertain gait, turn- ing motions of the body and sudden falling down, attended with nausea or vomiting and fainting. 3. These attacks recur from time to time and are always followed by a higher or lower grade of deafness, even sudden entire loss of hearing. 4. It is most probable that the material change which lies at the botton of these sudden disturbances, has its seat in the semi-circular canals." In one case post-mortem revealed an apoplectic effusion in these parts. This affection is also known under the name of Labyrinthine or Auditory vertigo, and according to Hinton is at times attended with uncon- scious divergence of the eyes and "seeing double" when inattentive. It seems, however, that not in all cases the primary affection lies in the laby- rinth. The same symptoms have been observed when in consequence of obstruction of the external meatus, or of catarrhal affections of the middle ear, with profuse exudation, or with sudden stoppage of the Eustachian tube — an undue pressure is exercised upon the labyrinth. It is clear that in this case the prognosis is much more favorable than when the labyrinth is originally affected. We can distinguish a primary affection of the labyrinth from one secondarily caused by external pressure, by the suddenness with which it attacks without any premonitory symptoms, and by the absence of all obstructions, either in the external meatus or in the Eustachian tubes. Therapeutic Hints. A case of suppurative inflammation of the labyrinth after cerebrospinal meningitis is recorded by Dr. Searle. Total deafness; straddling, gathering 20S TINNITUS AURIUM. gait. Xo conduction of sound of a heavy tuning-fork through forehead and head. St'ltc. 30 improved. Kali brom. -^ cured. There are recommended by R. T. Cooper: Salicylate of soda, Chin. sulpk.j Comum, Cicuta, Amyl nitr., all of which produce more or less deaf- ness and vertigo, the leading symptoms of Meniere's disease. "Salicylate of soda seems to correspond most closely to the usual symptoms and has served me better than any other remedy." (Norton.) Arnica. Vertigo worse when rising and walking, but also when lying. Great thirst; belching and vomiting of sour masses; feeling of coldness in occiput. (J. Leeser.) The secondarv form must be treated according to its causes, which com- pare. Tinnitus Aurium. Variable as sounds and noises, so also is the character of tinnitus aurium. We might, however, discern two distinct groups of tinnitus aurium: i, noises in consequence of an irritability of the auditor}' nerve, and 2, noises in consequence of irritation in or on the blood-vessels or adjacent parts of the hearing apparatus which the normal auditor}- nerve perceives. The first class — so-called subjective sounds or noises — are the conse- quence of cerebral disorders, as hyperemia of the brain, intoxication by quinine or alcohol, faulty composition of blood in chlorosis, and exaltation or depression of the nervous system in general. But even here we may already have trespassed the proper boundary line between the two groups; irritation of the nervous and vascular system cannot be kept asunder, as the one is dependent upon the other. The second class — objective sounds or noises — are much more frequent and manifold in their causes. All kinds of irritations of the drumhead, or middle ear, or Eustachian tube, or labyrinth, either from circulation, inflam- mation, exudation, alternation of tissue, or foreign bodies, may give rise to it. Pulsating noises are probably mostly of a vascular origin; ringing noises may be caused by clonic or tonic spasms of the muscles in the middle ear or of the Eustachian tubes; the crackling noise in the ear during an act of swallowing originates by the contraction of the abductor tubes; many other and various noises may be caused by vibrations of pus or dried scales of mucus, or by foreign bodies on the drumhead, or by the bursting of small bubbles of slime in the ear, when shaking the head, etc. Tinnitus aurium is often aggravated by worriment, mental and bodily depressions; by sudden changes of weather, especially damp weather; in illy- ventilated rooms; after sumptuous meals, the use of spirituous drinks and tobacco, and from bodily exertions if long continued. The patient usually feels better in the open air and in the company of friends, when a lively conversation withdraws his attention from the constantly annoying OTALGIA NERVOSA. 209 noise, provided he hears well enough to participate in the conversation and the room be not overheated or badly ventilated. Pressure with the finger upon the mastoid process or upon the first cer- vical vertebra changes and often ameliorates the noise in ears, while in many cases by reflex action an irritation of the trigeminus causes an irritation of the acusticus, so that many patients complain of an increase of the noise as soon as the}- touch single parts of the face, or are being shaved. To this reflex action from the skin we must count also those aggravations which fre- quently take place in consequence of changing the linen, of standing with bare feet upon a cold floor, and so on. Tinnitus aurium is, as may be seen from its various causes, often asso- ciated with various degrees of deafness. In chronic catarrh of the middle ear a continuous noise is an unfavorable sign. Sometimes tinnitus and deaf- ness increase and decrease in like proportions; other times tinnitus increases as the deafness decreases. Therapeutic Hints. It is obvious that special hints cannot be given. We must necessarily in each case consider its cause, for which necessary hints will be found in the foregoing chapters. Tinnitus, however, may in some cases by its peculi- arity hint to a remedy by which the entire aural affection may be removed. Here I must refer to our repertories and Materia Medica. Otalgia Nervosa Is a hypersesthesia of the sensible nerves of the ear, and must not be con- founded with the pain caused by inflammatory processes in the ear, as met with in otitis media. It is of much rarer occurrence than otalgia accompany- ing otitis. It characterizes itself frequently by its typical course. Often it is associated or caused by caries of a molar tooth on the same side, or by ulcera- tion of the epiglottis, as a reflex action -of the vagus. Therapeutic Hints. Compare facial neuralgia, toothache, etc. Plant maj. , "is our sheet-anchor for otalgia independent of organic lesions." (Houghton.) Sodium seleniate™ ', has just relieved a pure otalgia of years standing. (Norton.) H NOSE. General Observations. 1. Concerning the indications from its form and shape. A thick, swollen nose is either a sign of inflammation (if accompanied by pain, heat and redness) or of rachitic and scrofulous diseases. Lovers of intoxicating drinks are generally blessed with a suspicious looking nose of such a shape. The nose becomes pointed, pinched, during spasms; during a chill, and in collapse. When in children the nose becomes suddenly pointed, it is a sign of im- pending spasms; an habitually pointed nose denotes derangement in the mesenteric glands, and general atrophy. If the nose becomes pointed suddenly during the act of parturition, it is a sign of internal haemorrhage, or complete exhaustion, or threatening con- vulsions. The pointed nose of a nursing mother indicates her complete unfitness for being wet-nurse. When it sets in suddenly in severe illness, it is always a bad symptom; being a sign of extreme exhaustion and collapse. A heavy motion of the nasal wings during respiration is a sign of impeded respiration, either from asthma, pneumonia, croup, dropsy in the chest, or incipient paralysis of the respiratory muscles, and utter prostration. 2. In regard to color. A red nose ma}' result from a variety of causes: extremely cold air, con- gestion, crying, being overheated, cold in the head, worms, scrofula, in- temperate use of ardent spirits. In young girls it denotes the setting in of menstruation. Circumscribed redness of the point of the nose, of the cheeks, and of the forehead, with paleness and coldness of the other parts of the face, denote, in pneumonia, that suppuration has taken place. A coppery shining redness of the root of the nose is a sign of existing syphilitic ulcers within the nose. The copper nose of wine and liquor drinkers is well known. A pale nose is found in various morbid affections; during a chill, during syncope, in spasms, from nausea, after great exertions, from sexual excesses, profuse haemorhages, and so on. In women it is a sign of approaching menses or disturbed menstruation; profuse leucorrhcea; chlorosis. During pregnancy it is a sign that the foetus is dead. In eruptive fevers it denotes a disturbance in the exanthematic process and probably metastasis to internal EXAMINATION OF THE CAVITY OF THE NOSE. 211 A grayish, lead-colored nose is found in dropsy of the chest and peri- cardium, in induration of the lungs and some malignant typhoid fevers. Single lead colored stripes have been observed in the obstinate obstruc- tion of the portal vein. A bluish color of the nose is found in some cases of apoplexy; in croup, in catarrhus suffocativus, in diseases of the lungs, heart and larger blood- vessels; in short, in all morbid conditions which cause a stagnation of blood, cyanosis. Brownish, yellowish spots on and over the nose, like a saddle, indicate mostly a diseased liver or chronic leucorrhcea. A blackish fur at the nostrils is found in typhus, epidemic dysentery, cholera, altogether in conditions of great prostration. 3. In regard to temperature. A hot nose we find in violent coryza, inflammation, before bleeding, dur- ing delirium, sopor, apoplexy. Coldness of the nose we find during a chill, spasms, nausea; from loss of blood, exhaustion, and in consequence of inflammation of the bowels. An habitually cold nose is found in disordered states of the abdominal viscera, in dropsical complaints and in chlorosis. To all this I have to add one more pathognomonic sign: The constant picking and boring at the nose, which is found frequently in consequence of irritation in the intestinal canal from worms, or in typhoid fevers and cerebral affections. In these latter cases there is always a want of natural secretion in the nose; it is as dry as a powder-horn; its getting moist again is one of the favorable signs in such cases. Examination of the Cavity of the Nose. In order to get a full view of the Anterior nasal cavity, it is necessary to dilate the nostrils. This is best done by means of Fraenkel's or Von Troeltsch's speculum narium, instruments which after being introduced into the nose can be made to expand so as to push off the side walls of the nose from the septum. If we now place the patient in a position where the direct rays of the sun fall into the dilated nostrils, or in the absence of sunlight, It concentrate by a reflector the rays of candle-light or diffused da}dight into the nasal cavity, we will be able to seethe entire anterior part of it, from the superior turbinated bone to the floor; the anterior portion of the middle turbinated bone; the anterior and inferior surface of the inferior turbinated 212 EXAMINATION OF THE CAVITY OF THE NOSE. bone; the surface of the septum, and in many cases the posterior wall of the pharynx through the inferior meatus. The turbinated bones appear in a normal state as pale, red protuberances, covered with mucus. Any alteration from the normal color, any swelling or hypertrophy, or change in configura- tion, the amount of secretion, the presence of ulceration, etc., will thus be admitted to our view. In order to get a view of the Naso-pharyngeal cavity and the Posterior portion of the nasal cavity, we must inspect these parts through the pharynx. For this purpose we need a tongue spatula, a reflector and a pharyngeal mirror which, in some cases, may be substituted by an ordinary laryngoscopic mirror. The tongue ma}' be held down with the spatula by the patient him- self, if he be intelligent enough, after the physician has depressed it in a manner that it cannot obstruct our view and still remain behind the lower incisor teeth. Free passage being thus provided the physician "introduces the mirror into the pharynx by passing it as closely as possible over the lower teeth and along the back of the tongue in the median line, until it is in the free space between the base of the tongue, the laryngeal opening, the posterior wall of the pharynx, and the velum palatinum. It should not stand directly in the median line, on account of the uvula, which would lie in front of it and obstruct the view, but rather on the right or left side, under one or the other of the arches of the soft palate, with its upper edge brought close to the posterior wall of the pharynx. The problem to be solved in introducing and placing the mirror is, not to touch the patient." — (Fraenkel.) This requires practice, and it is not an easy matter to handle the instrument in such a manner as to receive clear pictures from the parts above and behind the velum palati. The illumination is best achieved by a reflector fixed upon the forehead of the examiner, as mentioned under the examination of the ear. If successful in our operations, we will see posteriorly in the rhinoscopic picture the fornix pharyngis or vault of the pharynx, which is attached to the base of the skull; its surface is covered with ridges, running irregularly, and its structure consists of a dense adenoid tissue, on which account this region is called tonsilla pharyngea. Laterrally we will see the recessus pharyngei, or the fossa of Rosenmuller, from which anteriorly rise on either side the pharyngeal openings of the Eustachian tubes. In front and above we see the posterior nares, the septum, the posterior portion of the middle tur- binated bone, and part of the middle meatus of the nose. With the exception of the septum, the mucous membrane, covering the walls of this region, has a fresh red color; the turbinated bones, usually covered with more or less mucus, appear as steel-gray or yellowish-red protuberances. The erectile bodies found on the posterior portion of the turbinated bones frequently lead to sudden swellings. Further down we see the posterior surface of the velum, on the sides of which run downward and inward two folds of mucous membrane. CATARRH, CORYZA, COLD IN THE HEAD. 213 Catarrh, Ooryza, Cold in the Head. Catarrhal inflammation of the mucous membrane, lining the nasal cavity, is characterized by redness and swelling of this membrane, and a discharge from it, which at first is watery and lastly becomes muco-purulent, therefore the name Catarrh, meaning a flowing down, namely of impurities from the head, according to the Ancients' idea of this trouble. It is usually preceded by a feeling of lassitude and chilliness, and a sensation of weight and pressure in the head, which latter symptom gives rise to the name of Gravedo or Coryza, while Cold in the head expresses its principal cause. The hyper- baric state of the mucous membrane is at first attended with prickling and dryness of the nose and a frequent disposition to sneeze; then follows the discharge, at first, as mentioned above, watery and by-and-by muco-purulent. If mild, the morbid process may end with this. But often it spreads from the mucous membrane to the epidermis, inflaming the nose wings and upper lip, or may even provoke erysipelatous inflammation of the face; or it spreads upwards into the frontal sinuses; or through the lachrymal duct to the lachrymal sac and conjunctiva; or sideways into the Highmorian cavities; or backwards into the retro-nasal cavity, where it not unfrequently affects the Eustachian tubes; causing ringing in the ears, difficulty of hearing, etc.; or it extends downwards into the larynx, trachea and bronchial tubes pro- ducing cough, or diarrhoea when it affects the mucous lining of the intestines. Nasal catarrh is often attended with neuralgia of the fifth pair of nerves. Coryza occurs sporadically and in the form of an epidemic. There is no doubt that some persons show a decided predisposition to it. Taking cold by means of sudden changes in the temperature, or exposure to sudden cooling of the surface after being heated, is one of the principal causes of this affection, but also irritants of various description, vapors of iodine or acrid gases, or the pollen of plants, compare "hay fever," are fruitful sources of this complaint; we find it also associated with the initial stage of measles, while typhoid fever and scarlatina exclude it. The epidemic form seems to have its cause in peculiar (unknown) states of the atmosphere — deficiency or superabundance of ozone ? "The question of the contagiousness of coryza must, in spite of the negative result of inoculation, be considered as one and the same with the question of the contagiousness of catarrhal or purulent secretions in general, and in the light of clinical observations must, for the present, be answered in the affirmative, especially as regards purulent secretions." (Fraenkel. ) The duration of a simple catarrh is usually from two to three days. Complicated cases last much longer. An acute attack, if neglected, or if dependent on some dyscrasia, may run into the chronic form. The Purulent nasal catarrh, or Nasal blennorrhcea, characterized by its purulent secretion, we find often in new-born children, as the consequence of infection by the leucorrhoeal discharge of the mother; it may be caused also by the action of gonorrhceal matter; it develops itself during the course 214 THERAPEUTIC HINTS TO CATARRH, &C. of scarlet fever or variola, in diphtheria and in consequence of cauterizations of the mucous membrane. It is a much graver form than simple catarrh and may also lead to chronic catarrh. Therapeutic Hints. Aeon. In the commencement, dry state; from cold winds. Headache, sneezing; running of the nose; watering of the eyes; roaring in the ears, flushed face; thirst; scant}', hot urine; dry, short cough, with crying; accelerated pulse and breathing; hot, dry skin; sleeplessness or dozing, with starting. Amm. card. Stoppage, especially at night; acrid, water}', burning dis- charge; congestion of blood to tip of nose when stooping. Amm. mur. Coryza, with stoppage; great soreness and tenderness of nose; loss of smell. A'nac. Fluent; frequent sneezing, sense of smell acute, or illusory, like pigeon dung or burning tinder. Aral. rac. Coryza, with frequent sneezing, soon followed by asthma; excessively sensitive to slightest depression of temperature. Arsen. Burning, excoriating, watery discharge, w T ith a feeling of being stopped up; or stoppage alternating with running of nose and burning. Cold, worse in morning, with throbbing headache; frequent sneezing; hoarseness; rawness and burning in throat; tickling in throat-pit and dry cough at night. Xosebleed; pale face; great thirst; sleepless and restless; lassitude. Great inclination to catarrhal affections. Arum triph. Discharge of burning, ichorous fluid, excoriating nostrils, upper lip and corners of mouth. Stoppage. Constant boring and picking at nose and lips. Asar. Fluent coryza, with deafness and sensation as if the ears were plugged with something. Bellad. Watery and acrid discharge, with burning in nose; or dryness of nose, with acute or dull smell; frequent sneezing, which painfully shakes the head; erysipelatous redness and swelling of the nose, with chilliness and heat in the face; intense redness of face; severe throbbing headache; dull pain in frontal sinuses; hallucinations or delirium, with injection of con- junctiva, photophobia and lachrymation. Great dryness in fauces; difficulty of swallowing ; soft palate, inflamed and glistening; tonsils swollen. Children either cry continually, and nothing seems to please them, or they are drowsy, apathetic and desire nothing; grown persons are either very sensitive to slightest noise, excited or stupefied. Worse afternoon and evening. Bryon. Extending into frontal sinuses or chest; stitch-pain. Calc. carb. Sudden colds, with dropping of clear water from the nose in spells; mouth dry, fauces rough; heat and dullness of head; frequent and profuse urination; great liability to catarrhs in scrofulous children; stoppage of nose. THERAPEUTIC HINTS TO CATARRH, &C. 215 Camphora. Fluent coryza, with chilliness at commencement; thin, sal- low, nervous, sensitive people with cold hands and feet. Cepa. Profuse watery discharge, with sneezing, excoriating nose and lip; itching, burning and stinging in eyes; flow of tears; headache. Worse in evening and warm room; better in open air. Laryngeal cough, with pain, as if the larynx would be torn. Northeasterly storms. Ckamom. Chilly, feverish; thirsty; one cheek red, the other pale; rattling cough. Cyclam. Sneezing and profuse discharge; loss of smell and taste; pain in head and ears. Eupat. perf. Hoarseness; cough, worse in evening; aching in all the bones. Euphi-as. Profuse discharge of mild mucus; upper lip stiff, as if of wood; eyes inflamed and full of acrid tears; cough, only throughout the day. Gelsem. Summer colds, with violent sneezing in the morning; edges of nostril red and sore; pharyngeal inflammation, with pain on swallowing, shooting up into the ear; deafness. Hands and feet cold in p. m.; then drowsy; fever until morning; half waking and talking in sleep during night. Disposition to catch cold at any change in the weather. Hepar. Nose swollen and red, sensitive to touch; blowing the nose causes whizzing and snapping in the ear and a raw feeling inside of nose; feverish and sensitive to cold air; wants to be covered, even when hot. When fluent coryza suddenly stops and is followed by hoarseness and croupy cough. Disposition to taking cold after the abuse of mercury. Hydrast. Posterior nares clogged with mucus; obstruction of nasal passages; frontal headache. Iodium. Glassy mucus; watery discharge at night, with sneezing; stop- page worse in evening; loss of smell. Eustachian tubes affected with dull- ness of hearing and noises in the ears. Kali bichr. A sense of tight pressure at the root of the nose, and dull, heavy headache in forehead, better from pressing tightly the bridge of the nose; discharge is acrid, excoriating nose and lip. Worse in warm, better in cool temperature. Kali hydr. Inflammation of Schneiderian membrane, extending to frontal sinuses, Highmorian cavities, lachrymal ducts and fauces. Nose red and swollen; discharge watery, acrid, continually, with violent and painful sneezing. Eyelids swollen, conjuctiva injected; lachrymation. Sticking pain in ears. Red face, with anxiety and restlessness; hammering pain in forehead with a sensation as if the head were compressed from both sides, or enlarged three times its size. Frantic excitation; fever with great thirst, hot, dry skin, alternating with drenching sweat; heat preponderates with intermitting shuddering, and dark, hot urine. Laches. Profuse discharge of a thin, watery slime, soreness of nostrils and lip; preceded often for a few days by a feeling of soreness, rawness and 2l6 THERAPEUTIC HINTS TO CATARRH, &C. scraping in the throat. Violent headache in forehead, when the discharge suddenly dries up. Lycop. Inflammation of frontal sinuses with tearing headache, worse evenings; nightly stoppage, with breathing through the mouth. Merc. sol. Sneezing and dropping of watery fluid from the nose, which is swollen, red and sore. Inflammation of eyes, frontal and Highmo- rian cavities, of larynx, trachea and bronchi, of tonsils and fauces. Profuse sweat at night, not relieving. Rheumatic pains, worse in the night; in warmth and in cold. Epidemic form or common colds. Ntix vom. Ordinary colds at the commencement; when dry or fluent only through the day and stopped up at night; tingling in nose, scraping in throat; heat in head and pain in forehead; hot and feverish and chilly on moving. Smell as of old cheese, sulphur or tinder. Constipation. Colds of newborn children. Phosphor. Frequent alternation of fluent and dry coryza; obstruction often in the morning; or discharge from one and stoppage of the other nos- tril; sneezing causes pain in throat or head and constriction of chest. Fauces feel raw and burning and appear dry and glistening. Hoarseness and bronchial catarrh. Smell and taste gone. Phytol. Flow of mucus from one nostril, while the other is stopped; total obstruction of nose when riding. Pidsat. At the commencement, w T hen dry and fluent alternately, or stopped up in the evening, with loss of smell and taste and appetite; thirst - lessness; chilliness; or later with profuse, thick, yellow or greenish discharge, nosebleed. Conjunctiva inflamed; pressure at root of nose; tearing in High- morian cavity extending to ear. Dry cough at night when lying down, better on sitting up; stomachache; slimy, painful diarrhoea. All symptoms are worse in the evening and in a warm room; better in open air. Rhus tox. Thick, yellowish discharge; eczema on both sides below nose; nose swollen and now and then bleeding. Aching in all the bones, worse in rest. Scmguin. Pain over root of nose; eyes sore to touch; sore throat; cough, and finally diarrhoea. Sepia. Profuse and mild discharge, coming on suddenly, combined with rheumatic pains in the limbs and intense occipital headache. Spigel. Copious discharge, badly tasting and smelling; flows during night from posterior nares down into the throat, and causes choking. The snuffles of infants require : Amm. carb. When the child in the act of going to sleep starts up again on account of not getting any breath. Chamom., Nuxvom., Pidsat. If of a syphilitic nature, compare Chronic Catarrh. CHRONIC CATARRH. 217 Chronic Catarrh, Ozaena. An acute atack may in consequence of bad management or neglect be- come chronic, especially in its purulent form, or when there is a scrofulous or syphilitic dyserasia in the person. At first ' ' the mucous membrane be- comes thickened and livid," later it seems to shrink, "becomes thin and pale, apparently consisting of connective tissue and blood-vessels alone, and hardly worth the name of mucous." "The epithelial cells are partly de- stroyed or they become turbid, and the mucous membrane, losing its natural lustre, appears opaque and uneven." The secretion is generally of a purulent character, profuse or scanty. Often it forms crusts, which adhere firmly to the membrane underneath; their color is frequently of a greenish cast, or they are mixed with blood. And when the secretion undergoes a specific decomposition, a peculiar, pene- trating stench is produced, which is communicated to the expired air. From this symptom the complaint has been called Ozaena, or Stinknose. Mostly ozaena grows on a dyscratic soil, although cases occasionally occur without either syphilis or scrofula being present. Chronic catarrh is prone to frequent acute exacerbations. It may assume a suppurative character, destroy the periosteum and cause caries; or it may lead to polypoid excrescences. It may spread to the frontal and Highmorian cavities, or to the skin surrounding the nostrils, causing excori- ations of upper lip and infiltration of the cervical glands. It usually is attended with loss of smell, either partial or total, and its annoying and intractable character is well known to both patient and physician. Therapeutic Hints. Agar. Profuse fetid discharge; accumulation of mucus in nose, with sensation as if the nose were entirely filled with it; bad smell from mouth. Alum. Soreness and scabs in the nose; thick, yellow mucus. Ant. crud. On inhaling cold air, it feels as if it went over a raw, very sensitive surface. Nostrils crusty and corners of mouth cracked and sore. Arg. nitr. Discharge of pus, with clots of blood. Chilliness, lachry- mation and stupefying headache. Violent itching of nose. Asa/. Greenish, offensive discharge. Mercurial complication. Aurum. Nose inflamed; nasal bones sore to touch; caries of nasal bones; fetid discharge; nostrils ulcerated and agglutinated; whole nose pain- ful, worse at night. Mercurial and syphilitic complication. Aur. mur. Small, painful sores inside of nose; blowing out of blood; mucus from head to throat; headache; constipation; haemorrhoids. Bar. carb. Scabs form in posterior nares and behind the uvula. Berber. Extending to antrum Highmorianum, especially left side. Calc. carb. Purulent discharge fetid, thick, yellow-reddish, making lip sore: slimy discharge through the day, with sensation of stoppage; stop- page and dryness at night; stoppage worse in morning on getting awake. 2l8 THERAPEUTIC HIYTS TO CHRONIC CATARRH. Xose swollen, especially at root; soreness on edges and septum, also ulcera- tion; upper lip swollen. Smell dull, or like rotten eggs, dung or gun-pow- der. Hoarseness in morning; rough voice, which improves from hawking. Scrofula. Coral. Discharge resembling molten tallow. Profuse secretion of mucus through the posterior nares, obliging to hawk frequently. Cuprum. Affection of frontal sinuses, with pain in forehead, worse over left eye and root of nose, worse from motion, better when lying. Nose feels stuffed, and yet sometimes discharges yellow and again watery matter. Smell gone; taste imperfect. Curare. Fetid lumps of pus; scanty menses; pain in os uteri; slight, watery, starch}' leucorrhcea. Elaps. Partial stoppage and stuffiness high up in the nostrils, with dull aching to forehead; worse in wet weather, occasionally bad smell from the nose; offensive discharge; posterior wall of throat covered with a dry, greenish-yellow scab, wrinkled and fissured, extending to the nose; occasional nosebleed; pain from root of nose to ears on swallowing; sneezing at night; sense of smell gone; profuse and dark catamenia. Graphit. Stoppage with secretion of tough, fetid slime; stoppage with periodical attacks of fluent coryza of short duration; hard masses of slime, or crusts in nose; purulent, fetid discharge worse during the menses; bloody discharge; smell as from an old cold in nose, or as of burnt hair; ulcerative nostrils; moist eruption behind the ears; eruptions around anus and genitals. Great inclination to take cold. Hepar. Nose extremely sensitive to touch; swollen and red; the nos- trils feel raw 7 after the discharge of mucus; the interior of the nose is sensi- tive to air. Iodum. Fetid discharge; nose swollen and painful. Scrofula. Kali bichr. Constant snuffing in warm, damp weather; discharge of crusts slightly tinged w 7 ith blood; perforating ulcers on septum; ulceration of mucous membrane; ulceration of frontal sinuses with violent pain in that region, if discharge stops. Fetid smell from nose; loss of the sense of smell. Kali card. Obstruction worse in the room, better in open air; yellow- green or bloody discharge; or purulent and fetid from one nostril; crusts closing the nostrils; collection of mucus in throat and feeling of a lump in the throat; convulsive and tickling cough at night with choking and gag- ging, especially in the morning; rheumatic and gouty symptoms. Kali hydr. Syphilitic origin after abuse of mercury with pain in shin bones, especially at night. Kaliphosph . — Schiissler . Lycop. Stoppage at night, breathing with open mouth; <( discharge of elastic plugs; " catarrhal headache and despondency. Merc. prof. " Dark redness of the fauces; elongation of the palate, with collection of the mucus behind; enlargement of the tonsils, which are THERAPEUTIC HINTS TO CHRONIC CATARRH. 219 sometimes covered with yellowish or whitish patches, small in size; collection of tough, yellow mucus in the posterior nares which partially drops into the throat, causing constant inclination to hawk and spit in order to clear the throat and nose." (Fisher.) Natr. Card. Profuse discharge of thin, white mucus; or thick, yellow- greenish, musty smelling mucus, ceasing after a meal, or at night; stoppage of nose at night. Worse from exposure to slightest draught, or when re- moving an article of clothing. Loss of smell and taste. Natr. 17I7W. Stoppage high up in nose, with sudden dribbling at times of clear water from nose; posterior nares feel dry in the morning, with scraping in larynx and rough voice. Continual lachrymation from obstruction of the nasal duct; roaring and buzzing in the ears and head with inability to work, read, or think. Loss of smell and taste. Nitr. ac. Often mucous discharge only from posterior nares; red, scurvy tip and nostrils, feels like splinter on touching it; fetor. Mercurial poisoning. Petrol. Obstruction of posterior nares; copious collection of slime in the fauces with a feeling of dryness. Eustachian tubes obstructed, with whizzing, roaring and cracking in the ears; hardness of hearing. Bad smell from mouth. Phosphor. Discharge yellow, or yellow-green, or bloody; nose swollen and sore to touch; nostrils ulcerated. In scarlatina, with swelling of neck and staring eyes, icy-cold and bluish hands; discharge flows down into the throat on lying. Psori7i. Great fetor; bad smell of all secretions and excretions. In- tractable cases where other remedies have failed. Pulsat. Thick, yellow or green and fetid discharge; nose swollen and itching in the evening; wings ulcerated; oozing of watery fluid from nose; loss of smell and taste. Young girls with menses too late, scanty and pale, followed by leucorrhcea; chilliness, intermingled with heat. Timid, whining mood; disposed to internal vexation and grievance; mild, yielding disposi- tion; slow, phlegmatic temperament. Rhodod. One nostril stopped, the other free; unpleasant tingling up in the nose to forehead; follicular catarrh in forehead; constant hemming and hawking. Sepia. Greenish crusts with bloody borders; eczema behind the ears; symptoms of portal congestion. Silic. Secretion tough, slimy, purulent; stoppage in the morning fol- lowed by hawking of thick, green-yellow, fetid masses after getting up. Acrid water from nose making it sore and bloody; septum sore, and smart- ing crusts high up in nostrils; frontal sinuses inflamed with pounding and throbbing pain in forehead; fauces dry and painful; uvula swollen; Eusta- chian tubes itching; chronic inflammation of tonsils and swelling of sub- maxillary glands. Sulphur. Slimy, acrid discharge with burning in eyes and upper lip; 220 DIGEST TO ACUTE AND CHRONIC CATARRH IX HEAD. or dryness of nose like parchment and a feeling of stiffness of the nose followed by discharge of thick, bloody slime and then again dryness with sneezing. Inclination to draw the phlegm down through posterior nares. On blowing the nose the ears feel obstructed, or it feels as if air were entering the ears. Soreness inside of nose and of septum. The interior of nose is sensitive to the inhalation of air in a warm room ; not in open air. Besides compare therapeutic hints under acute catarrh. Digest to Acute and Chronic Catarrh in Head. Common cold at commencement: Nux vo VI. of newborn children: Nux vom. , epidemic: Merc. sol. Dry at first: Aeon. , with acute or dull smell: Bell ad. or fluent only through day, stopped up at night: Nux vom. , with stiff feeling of nose, followed by discharge of thick, bloody slime and then dryness, with sneezing: Sulph. Fluent: Aeon., Anac. , alternating with dry: Phosphor. only through day, stopped at night: Nux vom. in spells: Calc. carb. in one and stopped up in other nos- tril: Phosphor., Phytol., Rhodod. , with chilliness at commencement: Camphor. , with deafness and plugged up feel- ing in ears: Asar. , with sneezing: Cyelam. , with frequent sneezing, followed by asthma: Aial. rac. , if suddenly stopped, is followed by hoarseness and croupy cough: Hepar. Discharge acrid, watery and burning: Amm. carb. , with burning in nose: Bellad. in eyes and upper lip: Cepa. , with excoriating nose and lip: Cepa, Kali bichr. and of corners of the mouth: Arum. triph. , with making nose sore and bloody: Silic. , with swollen, red and sore nose: Mere. sol. , with sneezing: Cepa, Iodnm, Kali hydr. , with stopped up feeling: Arscn. Bloody: Graphite Kali carb., Phosphor., PulsaL, Sulphur. Burning: Amm. carb., Arsen., Arum triph. Fetid: Agar., Asa/., Aurum, Elaps, Iodum, PulsaL, Spigel. Fetid lumps of pus: Curare. and purulent from one nostril: Kali carb. , worse during menses: Graphit. , thick, yellow-reddish, making lip sore: Calc. carb. Purulent, tough, slimy: Silic. , with clots of blood: Arg. nitr. Greenish, offensive: Asa/. or yellow, thick: Pulsat. and nosebleed: Pulsat. Yellowish, thick: Rhustox. Yellow-green or bloody: Kali carb., Phosphor. During Day, with stoppage: Calc. carb. MUCUS, slime, glassy: Iodum. , like molten tallow: Coral. , profuse, mild: Euphras., Sepia. , thin and watery: Laches., Natr- carb. , thick, blood}-: Sulphur. , yellow: Alum. , thick, yellow-greenish, musty smell- ing, ceasing after a meal, or at night: Nat r. carb. , thin, watery: Laches. , white: Natr. carb. Oozing of watery fluid: Pulsat. Blowing out of blood: Aur. mur. Nosebleed occasionally: Elaps, Arsen. Crusts, tinged with blood: Kali bichr. , greenish, with bloody borders: Sep ia. , or masses of hard slime: Graphit. Elastic plugs: Lycop. POSTERIOR NARES. MUCUS clogs posterior nares: Hydrast. from head to throat: Aur. mur. discharges only from posterior nares: Nitr. ae. DIGEST TO ACUTE AND CHRONIC CATARRH IN HEAD. 221 discharges into throat on lying: Phosphor. , at night, causing choking: Spigel '. , obliging to hawk: Coral. yellow: Merc. prot. , inclination to draw phlegm down through posterior nares: Sulphur. Dryness in the morning, with scraping in larynx and rough voice: Nal. mur. Scabs in posterior nares behind the uvula: Bar. carb. , dry, greenish; wrinkled and fissured on posterior wall of throat, extending up to nose: Elaps. Stoppage, obstruction: Arum triph., Calc. carb., Hydras I. , evening: Iodum. , morning on getting awake: Calc. carb., Phosphor. , followed by hawking of thick mucus: Silic. , night: Amm. carb., Natr. carb., Nux. vom., Silic. and dryness: Calc. carb. , must breathe through mouth: Lycop. when falling asleep, starts up to get breath: Amm. carb. , when riding: Phytol. , in warm room, better in open air: Kali, carb., Pulsat. , alternating with fluent coryza: Amm. mu?., Ar sen., Cuprum, Graphit, Nux. vom., Pulsat. , with tough, fetid slime: Graphit. , as if nose were entirely filled with mucus: Agar. of posterior nares: Petrol. , with dull aching in forehead: Elaps. , with sudden dribbling of clear water from nose: Natr. mur. of one side and the other free: Rhodod. Constant snuffing in warm, damp weather: Kali bichr. INTERIOR NOSE. Sensitive to air: Hepar. to cold air, as if it went over a raw surface: Ant. crud. to air in a warm room, not in open air: Sulphur. Soreness and scabs: Alum. , and of septum: Silic, Sulphur. Sores, small and painful: Aur. mur. Tingling: Nux. vom. worse even- worse over worse from Cuprum. Ulceration: Kali bichr. , perforating septum: Kali bichr. Crusts on nostrils: Ant. crud. , closing nostrils: Kali carb. Rawness of nostrils from discharge: Hepar. Soreness of nostrils and septum: Calc. carb. and lip: Laches. and redness: Gelsem. Ulcerated nostrils: Aurum, Calc. carb., Graphit:. Phosphor., Pulsat. Inflammation extending into frontal sinuses or chest: Bryon. , Highmorian cavities, left side: Ber- ber. lachrymal ducts and fauces; Kali hydr. , with tearing headache, ing: Lycop. , with pain in forehead left eye and root of nose, motion, better when lying , with pounding and throbbing pain in forehead : Silic. Dull pain in frontal sinuses: Bellad. Pain in frontal sinues, after suppressed coryza: Laches. Ulceration in frontal sinuses with violent pain there, when discharge stops: Kali bichr. Pain over root of nose: Sanguin. and ears on swallowing: Elaps. Pressure at root of nose: Pulsat. , and dull, heavy headache, better from pressing tightly the bridge of nose Kali bichr. Caries of nasal bones: Aurum. EXTERNAL NOSE. Red and swollen: Aurum, Bellad, Hepar, Kali hydr. and sensitive to touch: Hepar. and scurvy tip and nostrils, feels like splinter on touching it: Nit. ac. Erysipelatous redness and swelling with chilliness and heat in the face: Bellad. Swollen and itching in evening: Pulsat. and painful: Iodum. and especially at rest: Calc. carb. and sore to touch: Phosphor. and now and then bleeding: RJnts tox. 222 DIGEST TO ACUTE AND CHRONIC CATARRH IN HEAD. Congestion to tip when stooping: Amm. card. Soreness and tenderness: Amm. mur. to touch: Hepar. , worse at night: Aurum. of nasal bones to touch: Aurum. Wing's ulcerated: Pulsat. Violent itching of nose: Arg. nitr. Boring" and picking at nose and lips: Arum, triph. SMELL. Loss of smell: Amm. mur., Cuprum, Elaps, lodum, Kali bichr. and taste: Cyclam., Natr. card., Natr. mur., Phosphor. , Pulsat. Illusory, like pigeon dung or burning tinder: Anac. . like dung, rotten eggs or gun- powder: Calc. card. , like from an old cold, or burnt hair: Graph it. , like old cheese, sulphur or tinder: Xux. vom. Fetor from nose: Kali bichr., Nitr. of. , worse in wet weather: Elaps. , and of all secretions and excretions: Psorin. SNEEZING. Frequent: Aeon., Anac, Aral, rac, Arsen. , night: Elaps. , morning in summer colds: Gelsem. , with profuse discharge: Cyclam. , which painfully shakes head: Bellad. , causing pain in head or throat, and constriction of chest: Phosphor. Blowing" the nose causes the ears to feel obstructed, or as if air were entering the ears: Sulphur. , whizzing and snapping in ear, and a raw feeling inside of nose: Hepar. SYSTEMIC SYMPTOMS. Stupefied: Bellad. Inability to work, read, or think: Natr. mur. Excited: Kali hydr. Delirium or hallucinations with injected conjunctiva: Pel lad. Anxiety and restlessness: Kali hydr. Children cry continually and nothing pleases them: Bellad. Timid, whining mood, internally vexed and grieved; mild disposition: Pulsat. Drowsy, apathic, desire nothing: Bellad. Desponding with headache: Lycop. Headache: Aeon., Aur. mur., Cepa. and despondency: Lycop. and earache: Cyclam. in forehead: Hydrast, Kali hydr., Laches., Xux. vom. when discharge suddenly dries up: Laches. as if compressed from both sides, or enlarged ten times its size: Kali hydr. in frontal sinuses: Bellad, Laches , Lycop. in occiput with rheumatic pain in limbs: Sepia. , stupefying: A/g. nitr. , throbbing: Bellad. Heat and dullness: Calc. card. and pain in forehead : Xux. vom. Conjunctiva inflamed: Kali hydr., Pulsat. Eyes inflamed with acrid tears: Euphras. Eyelids swollen: Kali hydr. Inflammation of eyes, frontal and High- morian cavities, larynx, trachea, bronchi, tonsils and fauces: Merc. sol. Itching, burning and stinging in eyes: Cepa. Lachrymation: Aeon., Arg. nitr., Cepa. from obstruction of nasal duct: Natr. mur. and photophobia: Bellad. Soreness to touch: Sanguin. Eustachian tubes itch: Si He. obstructed, with noises in ears: Lodum, Petrol. Dullness of hearing: Gelsem, Lodum, Petrol. Sensitive to slight noise: Bellad. Eczema behind ears: Sepia. Eruption, moist, behind ears: Graph it. Roaring in ears: Aeon. and buzzing, with inability to read or think: Natr. mur. Sticking pain in ears: Kali hydr. Tearing from Highmorian cavity to ear: Pulsat. Rodness of face: Aeon., Bellad., Kali hydr. DIGEST TO ACUTE AND CHRONIC CATARRH IN HEAD. 223 of one, paleness of other cheek: Chamom. Paleness: Arsen. Eczema below nose: Rhus tox. Comers of mouth cracked and sore: Ant. crud. Upper lip stiff, as if of wood: Euphras. swollen: Calc. carb. Mouth dry: Calc. carb. Thirst: Aeon., Arsen. y Chamom. Thirstless: Pulsat. Taste imperfect: Cuprum, Pulsat. Bad smell from mouth: Agar., Petrol. Fauces dry: Bellad. , glistening, raw and burning: Phos- phor. and painful: Silic. , with collection of slime in fauces: Petrol. inflamed, with pain on swallowing, shooting up into ear: Gelsem. dark red: Merc. prot. Throat, feeling of lump and collection of mucus in: Kali carb. , raw and burning: Arsen. , scraping in: Nux vom. , sore: Sanguin. , and scraping, raw before coryza: Laches. Swallowing" difficult: Bellad. Palate elongated, with mucus behind: Merc. prot. inflamed and glistening: Bellad. swollen: Silic. Tonsils inflamed and submaxillary glands swollen: Silic. , swollen: Bellad. Tonsils sometimes covered with yellow- ish or whitish patches: Merc. prot. Stomachache: Pulsat. Portal congestion: Sepia. Slimy, painful diarrhoea: Pulsat. Ending" with diarrhoea: Sanguin. Constipation: Aur. mur., Nux vom. Haemorrhoids: Aur. mur. Eruptions around anus and genitals: Graphit. Scanty, hot urine : Aeon. Frequent and profuse urination : Calc. carb. Pain in os uteri : Curare. Scanty menses : Curare. , too late and pale in young girls : Pulsat. Profuse and dark menses : Elaps. Leucorrhcea follows menses : Pulsat. , slight, watery, starchy: Curare. Hoarseness: Arsen., Eupat. perf. in morning: Calc. carb. with bronchial catarrh: Phosphor. Roug"h voice which improves from hawk- ing: Calc. carb. Cough only through day: Euphras. , worse in evening: Eupat. perf. at night: Arsen. Kali carb., Pulsat. , convulsive with choking and gag- ging in the morning: Kali carb. , dry: Aeon., Arsen., Pulsat. when lying down, better on sitting up: Pulsat. from tickling in throat-pit: Arsen. , with crying: Aeon. , with pain in larynx as if it would be torn: Cepa. , followed by diarrhoea: Sanguin. , rattling: Chamon. Inclination to catarrhal affection: Arsen. Stitch pain in chest: Bryon. Accelerated pulse and breathing: Aeon. Chilly: Arg. nitr., Chamom., P til sat. , intermingled with heat: Pulsat. Cold hands and feet in p. m. : Gelsem. Feverish: Chamom. in morning: Gelsem. and hot, and chilly on moving: Nux vom. , intercurrent shuddering: Kali hydr. Hot, dry skin: Aeon. , alternating with drenching sweat, and hot, dark urine: Kali hydr. Profuse sweat at night, not relieving: Merc. sol. Scarlet fever with swelling of neck, staring eyes, icy-cold and bluish hands: Phosphor. Rheumatic and gouty symptoms: Kali carb. pains worse in night: Merc. sol. Aching" in all the bones: Eupat. perf. , worse in rest: Rhus tox. Pain in shin bones, worse at night: Kali hydr. Lassitude: Arsen. 224 YEARLY COLD, &C. Drowsy: Gelsem. Sleepless or dozing with starting: Aeon., Bellad. Half waking" and talking in sleep dur- ing night: Gelsem. Phlegmatic: Gelsem. Scrofulous: Iodnm. with inability to catarrhs: Calc. carb. Nervous, thin, sallow, sensitive with cold hands and feet: Camphor. Disposition to take cold: Graph it., He par. at any change in weather: Gelsem. from slightest depression of temper- ature: Aral rac. BETTER AND WORSE. > In open air: Cepa, Pulsat. > in cool temperature: Kali bichr. > when covered even when hot: Hepar. < in warm room: Cepa, Kali carb., Pulsat. < from exposure to slightest draught, or when removing an article of clothing: Natr. carb. Calcar., Card, veg., Chamom., Coffea, Laches., Mercur., Natr. mur., Nux vom., Phosph. ac, Pulsat., Silic, Sul- phur. Eating warm things. — Bryon., Calcar., Chainom., Nux vom., Phosphor., Pulsat., Silic. Something hot. — Bellad., Calcar., Phosph. ac. Drinking warm things. — Bryon., Chamon., Laches, Mercur., A T ux mosch., Nux vom., Pulsat., Rims, Silic. Warm bed. — Bellad., Bryon., Chamom., Mercur., Nux vom., Phosphor. Phosph. ac, Pulsat., Rhus. Getting warm in bed. — Chamom., Mercur., Phosph. ac, Phosphor., Pulsat. Drinking. — Chamom., Calcar., Caustic, Laches., Mercur., Pulsat., Rhus, Silic. cold or warm. — Laches., Natr. sulph. water. — Bryon., Calcar., Card, veg., Chamom., Mercur., Nix vom., Pulsat., Silic, Staphis , Sulphur. wine. — Aeon., /gnat., [Nux vom. after wine.] malt liquors. — Nux vom., Rhus. coffee. — Bellad., Card., veg., Chamojn., Coccul., Ignat., Mercur., Natr. sulph., Ntix vom., Pulsat., Rhus. tea. — China, Coffea, Ignat.. Laches. Smoking tobacco. — Bryon., Chamom., China, Ignat., Mercur., Nux vom. Salty things. — Card. veg. Eating. — Ant. crud., Arnica., Bellad., B?yon., Calca?., Carb. veg., Caustic, Chamom., Coccul., Hepar, Hyosc, Laches., Mercur., Nux mosch., ODONTALGIA. 243 Nux vom., Phosphor., Phosph. ac, Pulsat., Rhus, Silic, Staphis., Sulphur. Only while eating. — Coccul. After eating. — Ant. crud., Bellad., Bryon., Calcar., C/iamom., China, Coffea, Ignat., Laches., Mercur., Natr. mur., Nux vom., Rhus, Staphis., Sulphur. Chewing. — Arnica, Arsen., Bellad., Bryon., Card, veg., Caustic, China, Coccul., Coffea, Hyosc, Ignat., Mercur., Natr. mur., Nux vom.. Phosphor., Phosph. ac, Pulsat., Silic, Staphis., Sulphur.. Only while chewing. — China. Swallowing. — Staphis. Biting. — Arsen., Bellad., Bryon., Calcar., Card, veg., Caustic, China, Coffea, Hepar, Hyosc, Laches., Mercur., Nux vom., Phosphor., Phosph. ac, Pulsat., Rhus, Silic, Staphis., Sulphur. something soft. — Veratr. soft food — Coccul. hard food. — Mercur. • Touched by the food. — Bellad., Ignat., Nux vom., Phosphor., Staphis. Picking. — Pulsat. Cleaning. — Carb. veg., Laches., Phosph. ac, Staphis. Touching. — Ant. crud., Arnica, Arsen., Bellad., Bryon., Calcar., Carb. veg., Caustic. , China, Coffea, Hepar, Ignat., Mercur., Natr. mur., Nux mosch., Nux vom., Phosphor., Pulsat, Rhus, Staphis., Sulphur. with the tongue. — Carb. veg., China, Ignat., Mercur., Phosphor., Rhus. even very softly. — Bellad., Igyiat., Nux vom., Stapis. Pressing on the teeth. — Caustic, Chi?ia, Hyosc, Natr. mur., Staphis., Sulphur. Sucking the gums. — Bellad., Carb. veg., Nux mosch., Nux vom., Silic. Rising. — Ignat., Mercur., Platina. Moving the body. — Arnica, Bellad., Bryon., China, Mercur., Nux vom., Phosphor. , Staphis. the mouth. — Caustic, Chamom., Mercur., Nux vom. Talking. — Nux mosch. Deep breathing. — Nux vom. Being at rest. — Arsen., Bryon., Chamom., Pulsat., Rhus, Staphis., Sulphur. Sitting. — Ant. crud., Mercur., Pulsat., Rhus. too much. — Aeon. While lying down. — Arsen., Bellad., Bryon., Chamom., Hyosc, Ignat., Mercur., Nux vom., Phosphor., Pulsat., Rhus., Staphis., Sulphur. on the painful side. — Arsen., Nux vom. on the painless side. — Bryon., Chamom., Ignat., Pulsat. in bed. — Bryon., Chamom., Nux vom., Pulsat. In bed. — Ant. crud., Bellad., Bryon., Chamom., Mercur., Nux vom., Phos- phor., Pulsat. 244 ODONTALGIA. Sleep with yawning. — Staphis. When going to sleep. — Ant. crud., Arsen., Mercur., Sulphur. While asleep. — Mercur. When awaking. — Be/lad., Bryon., Calcac, Carb. veg., Laches., Nux vom. y Pnosphor., Silic, Sulphur. Mental emotions. — Aeon. Vexation. — Aeon., Chamom., Rhus, Staphis. Passion. — Nux vom. Mental exertions. — Bellad., Ignat., Nux vom. Reading. — Ignat., Nux vom. Noise. — Calcar. Being talked to by others. — Arsen., Bryon. For women. — Aeon., Ap. vir., Be/lad., Calcar., Chamon., China, Coffea, Hyosc., Ignat., Nux mosch., Pulsat. Menstruation, before. — Arsen. , during. — Calcar., Carb. veg., Chamon., Natr. mur., Laches., Phos- phor. , after. — Bryon., Calcar., Chamom., Phosphor. During pregnancy. — Ap. vir., Bellad., Bryon, Calcar., Hyosc., Mercur. „ Nux mosch., Nux vom., Pulsat., Rhus, Staphis. While nursing. — Aeon., Arsen., Bellad., Calcar., China, Dulcam., Mercur., Nux vom., Phosphor., Staphis., Sulphur. For children. — Aeon., Ant. crud., Bellad., Calcar., Chamom., Coffea, Ignat. , Mercur., Nux mosch., Pulsat., Silic. For irritable, nervous persons. — Aeon., Bellad., Chamom., Coffea, China, Hyosc, Nux mosch. For persons who have taken much mercury. — Carb. veg., Bellad., Hepar, Laches., Staphis. who drink much coffee. — Bellad., Carb. veg., Chamom., Coccul. y Mercur., Nux vom., Pulsat., Silic. Getting better from: Cold air. — Nix vom. , Pulsat. Wind. — Calcar. Uncovering. — Pulsat. Drawing air into the mouth. — Nux vom., Pulsat. Cold washing. — Bellad., Bryon., Chamom., Pulsat. External cold. — Bellad., Bryon., Chamom., China, Mercur., Nux vom., Phosphor., Pulsat., Staphis., Sulphur. Cold hand. — Rhus. Finger wet with cold water. — Chamom. Holding cold water in the mouth. — Bryon., Cepa, Coffea, Cle?nat., Natr^ sulph . Cold drinking. — Bellad., Bryon., Chamom., Mercur., Nux vom., Phosphor. , Pulsat., Rhus, Sulphur. In the open air. — Ant. crud., Bryon., Cepa, Hepar, Nux vom., Pulsat. ODONTALGIA. 245 In the room. — Nux vom. , Phosphor. , Sulphur. External warmth. — Arsen., Bellad., Calcar., Chamom., China, Hyosc, Laches., Mercur., Nux mosch., Nux vom,, Pulsat., Rhus, Staphis., Sulphur. Wrapping up the head. — Nux vom., Phosphor., Silic. Eating something warm. — Arsen., Bryon., Nux mosch., Nux vom., Rhus, Sulphur. Drinking . — Nux mosch., Nux vom., Pulsat., Rhus, Sulphur. Getting warm in hed. — Bryon., Nux vom. Drinking. — Bellad. Smoking tobacco. — Mercur. When eating. — Bellad., Bryon., Chamom., Phosph. ac, Silic. After . — Arnica, Calcar., Chamom., Phosph. ac, Rhus, Silic. When chewing. — Bryon., China., Coffea. Biting. — Arsen., Bryon., China, Coffea. Picking the teeth, so that they bleed. — Bellad. Picking the teeth. — Phosph. ac. Rubbing . — Mercur. , Phosphor. Touching the teeth. — Bryon., Nux vom. Sucking the gums. — Caustic. Pressing upon the teeth. — Bellad., China, Bryon., /gnat., Natr. mm., Pulsat., Phosphor., Rhus. Moving. — Pulsat., Rhus. When walking. — Pulsat. , Rhus. When at rest. — Bryon., Nux vom., Staphis. Sitting up in bed. — Arsen., Mercur., Rhus. Getting up. — Phosphor., Nux vom. When lying down. — Bryon., Mercur., Nux vom. on the painful side. — Bryon., Ignat., Pulsat. painless . — Nux vom. lying down in bed. — Mercur., Pulsat. In bed. — Sulphur. When going to sleep. — Mercur. After sleep. — Nux vom., Pulsat. The pains extend to the jawbones and face. — Hyosc, Laches., Mercur., Nux vom., Rhus, Sulphur. to the cheeks. — Bryon., Chamom., Caustic, Mercur., Silic, Sta- phis., Sulphur. into the ears. — Arsen., Bryon., Calcar., Chamom., Hepar., Laches., Mercur., Staphis., Sulphur. The pains extend into the eyes. — Caustic., Chamom., Mercur., Pulsat., Staphis., Sulphur. into the head. — Ant. crud., Arsen., Chamom., Hyosc, Mercur., Nix vom. , Rhus, Staphis. , Sulphur. 246 ODONTALGIA. With headache. — Ap. vir., Ghnoin., Laches. rush of blood to the head. — Aeon., Calcar., China, Hyosc, Laches. , Pulsat. swollen veins of the forehead and hands. — China. heat in the head. — Aeon., Hyosc., Pulsat. burning of the eyes. — Bellad. flushed cheeks. — Aeon., Arnica, Bellad., Chamom., Mercur., Nux mosch., Nux vom., Phosphor., Pulsat., Rhus tox., Sulphur. pale face. — Aeon., Arsen., Ignat., Pulsat., staphis., Sulphur. swelling of the cheek. — Arnica, Arsen., Bellad., Bryon., Chamom., Laches., Mercur., Natr. mur., Nux vom., Phosphor., Pulsat. , Phosph. ac, S tap his., Sulphur. salivation. — Bellad., Dulcam., Mercur. dry mouth and thirst. — China. without thirst. — Pulsat. dry throat and thirst. — Bellad. chilliness. — Pulsat., Rhus. heat. — Hyosc. , Rhus. warm perspiration. — Hyosc. chilliness, heat, thirst. — Laches. diarrhoea. — Chamom., Coffea, Dulcam., Rhus. constipation. — Bryon., Mercur., Nux vom., Staphis. 1. Arnica. After extraction of a tooth; it will stop the bleeding and accelerate the healing of the gums. After the insertion of artificial teeth, it relieves the pain in the swelling; after filing out carious teeth — which is sometimes a very useful operation — mix a few globules of it in a teaspoonful of water, and put some of it on the parts which have been filed. In very intense pain, occurring after the tooth has been drawn, sometimes Hyosc. is of use. Arnica is sometimes good for throbbing toothache, w 7 ith a sensation as if the tooth were being forced out from its socket by the blood; hard swelling of the cheeks. 2. Coffea. Will remove the severest pains, wdiich drive the patients almost frantic; the} 7 cry, tremble and do not know w 7 hat they do; the pain is indescribable; it is momentarily relieved by holding cold water in the mouth. For stinging, jerking pain, or intermitting aching and pain when chewing, it is to be preferred to all other remedies. 3. Aeon. Must be given in all those cases where the patients are almost frantic with pain, which is indescribable, and which Coffea has failed to re- lieve; also for throbbing pains, occasioned by taking cold, with determina- tion of blood to the head; burning in the face; it is particularly suitable for children; when it is no longer efficacious, give Chamom. or Bellad. 4. Glonoin. For toothache from taking cold, after having been over- heated, if the beating of the pulse is felt in all the teeth, or a drawing in all the teeth; pain extending to whole right side of face, having waves of spon- taneous exacerbation, without being influenced by anything specially. ODONTALGIA. 247 5. Chamom. Particularly in children — and in persons who are fre- quently vexed, and who drink much coffee — also in females before menstrua- tion; pain in hollow teeth, after taking cold when in perspiration, or when the patient is very irritable afid inclined to cry; when the pain is insupport- able, and aggravated periodically, worse during the night; when no particu- lar tooth can be pointed out as the painful one; or when the tooth is hollow and loose, and feels as if too long; or when the pain extends through the whole set, and every tooth feels too long; also when it extends through the jaws into the ear, and through the temples into the eyes; when there is crawling continually, or scraping sensation in the nerve of the hollow tooth, after which the pain increases; drawing and tearing, or boring and throbbing pain; when at its height, the pain is stinging and jerking, and extends to the ear; the patient cannot bear the warmth of the bed, and the pain generally commences^oon after meals, particularly after eating or drinking anything warm; when it grows much worse after drinking cold water — also after coffee; cannot be relieved by anything but dipping a finger into cold water and applying it to the tooth; when, while the pain lasts, the cheek is red and hot, or the cheek and gums are swollen and of a painful red color; when the glands under the chin are painful and swollen, accompanied with great weakness, particularly in the joints; with pain in the articulation of the jaw on opening the mouth, extending to the teeth. 6. Nux mo sch. Suits children, women — particularly during preg- nancy — and all people with a cool, dry skin, who never perspire; for pains from taking cold in damp, cold weather, or from the night-air; for pains which get worse if air, particularly cold, damp air, is drawn into the mouth; if warm water or warm applications ease the pain; for toothache which is increased by the shaking of the body in going up or down stairs; if the pain commences on the right side and goes to the left; for pains as if a tooth were wrenched out; worse from much talking; the teeth become easily blunt. Frequent yawning, sleepiness and swooning; profuse menstruation. 7. Nux vom. For toothache in persons of a hasty temper, with ruddy complexion, who love coffee and ardent spirits — have little out-door exercise, or who have taken cold; when a healthy tooth is painful and feels loose, or the teeth seem too long, with jerking, shooting pains in the lower jaw; a drawing pain extending into the temple, or a pain from a hollow tooth, affecting the whole face and even the bones, or extending over the whole side; or for drawing and burning pains in the nerves of a tooth, as if it were wrenched out, accompanied by violent stitches, which affect the whole body, particularly on inspiration'; when a dull pain in the bones changes to a tear- ing pain, which passes through the teeth and jaws, or where there is a bor- ing, gnawing, tearing pain on one side; sometimes jerking or rheumatic pains, attended with a prickling sensation; when they chiefly commence in bed or in the evening, preventing chewing, grow worse or return as soon as the mouth is opened in the cold air; or when reading or thinking; or when the tearing pains become worse from drinking anything cold and better from 248 ODONTALGIA. external warmth; in general the pains are worse after eating and exercise; when along with the tearing pains the glands beneath the lower jaw are painful and particularly when a swelling appears on the gums, which seems about to burst. 8. Pulsat. For persons of a mild, quiet, timid disposition, or for women and children of a fretful temper; when the pain is only on one side; for toothache which is prevalent in the spring, accompanied by earache and headache, confined chiefly to one side; when there is a stinging pain in the decayed tooth, accompanied by great sensitiveness of the left side of the face, extending to the ear, with heat in the head and chills over the whole body; but particularly when there is a gnawing pain in the gums, and pricking as of pins, with tearing and jerking in the tooth itself, as if the nerve were stretched and then suddenly relaxed; or for jerking or tearing in the tooth as if it would start from the jaw, and aggravated by cold water, the heat of the bed, a warm room, or by taking anything warm into the mouth; cold air relieves it — the toothache always ceases in the open air, but returns in the warm room and gets worse; worse when sitting, better w T hen walking about — w T orse from picking the teeth, better from pressure — chew- ing does not make it worse; it comes on mostly towards evening, rarely before, and is accompanied by chilliness and pale face, or with congestion of blood to the head; or with heat without thirst; especially for toothache caused by drinking chamomile tea. 9. Ignai. In cases where the foregoing remedies appear to be indicated, but are insufficient, and the patient is of a more tender and sensitive dispo- sition, sometimes cheerful, at other times inclined to tears; particularly for persons who grieve much; when the jaw-teeth feel as if crushed; when there is a boring pain in the front teeth, and a soreness in all the teeth; worse after drinking coffee, after smoking, after dinner, in the evening, after lying down, and in the morning on waking. 10. Hyosc. In very sensitive, nervous, excitable persons; the pain almost drives the patient mad — it is a tearing or throbbing, extending to the cheeks and along the lower jaw; or there is a tearing, raging pain in the gums, with a buzzing sensation in the tooth, which is loose, and feels, when chewing, as if it were coming out; or jerking, throbbing, drawing, tearing, which extends to the forehead; violent tearing pains in different teeth, as if the blood were pressed into them, occasionally accompanied by flushes of heat, with determination of blood to the head; it is aggravated b5 T cold air; generally comes on in the morning, and is sometimes accompanied by jerking in the fingers and arms, especially in persons who are subject to convulsions. 11. Bellad. Is frequently best adapted to females or children, particu- larly when the pain and anguish cause great restlessness, running about, or where there is depression, and a disposition to cry; when the teeth and gums are painfully sensitive; when biting produces a feeling as if there were ulcers at the roots, with stinging, cutting, jerking, tearing pain; and more especi- ODONTALGIA. 249 all}' for a drawing pain, which is worse after going to bed, and during the night; or for pricking pains in a hollow tooth, day and night; or pain in a hollow jaw-tooth, as if too much blood were forced into it, with heat in the gums and throbbing in the cheeks — nothing mitigates the pain but picking the gum until it bleeds; or the gums are swelled, with burning and stinging pains, discharge of much saliva, the cheek swelled, sometimes the eyes hot and the throat dry, with great thirst — frequently the pain returns in the morning on awaking, or recommences some time after dinner; the teeth ache when exposed to the open air, when touched, from biting, when food or hot liquids come in contact with them — pressing hard upon the cheeks some- times gives relief. 12. China. For mothers who are nursing — or persons, who, otherwise cheerful, become cross and irritable; the teeth are covered with dark sordes; the pain comes on periodically, and is throbbing, tearing, jerking or drawing, wdth great pressure, as if the blood were forced into the teeth, or boring and numbness about the teeth — worse on motion or when touched, and returning on exposure to a draught — the gums swell, the mouth is dry, there is thirst, the blood rises to the head, veins of the forehead and hands swell, and the sleep during the night is uneasy, although the pain is not so great. 13. Mercur. For children; in general when there are tearing pains in several teeth at once, in hollow ones and those adjoining them — the pain affects the whole side of the face, or drawing and stinging pains extend to the ear; it is particularly troublesome during the night; or for excruciating jumping pains in the teeth, especially at night, with stitches extending to the ear and the head, which drive the patient out of bed; also for stinging pains in a decayed tooth, worse after eating or drinking anything cold or warm; the pain is generally increased by cold, and particularly by damp air, is less severe when in a warm place, or when the cheek is rubbed — sometimes the air, when rushing in, causes pain in the front teeth; or the toothache is only felt during the day and ceases during the night, and is followed by perspira- tion, and in the morning the same pains return again, in paroxysms, with longer or shorter intervals, alternating with giddiness or tearing in the limbs; the teeth are almost always loosened, the gums swell or become white and ulcerated, are detached from the teeth, burn and ache when touched; or they begin to itch, to bleed and to suppurate, with tearing through the roots of the teeth, or with painful swelling of the cheeks. 14. Hepar, after Mercur. or Bellad. When the painful swelling of the gums continues, or for a throbbing pain as if blood were entering the tooth, or a drawing pain; the pains worse after eating, and in a warm room, or at night. 15. Card. veg. When Mercur. or Arsen. gives some relief, without effecting a perfect cure; also in persons who have taken much calomel, par- ticularly when the gums bleed, and are detached from the teeth; the teeth are loosened, become ulcerated, and ache when touched by the tongue; worse after eating, with drawing and tearing pains in the incisors. 25O ODONTALGIA. 16. Sulphur. Is most suitable for jumping pain in hollow teeth — ex- tending to the upper and lower jaw, or to the ear; for swelling of the gums, attended with throbbing pain, bleeding of the gums and swelling around old stumps; for toothache in the evening, or in the air, from draught, worse when rinsing the mouth with cold water. 17. Phosphor. For toothache from washing or from having had the hands in cold or warm water. 18. Cepa. For toothache with cold in the head, which gets better when the catarrh becomes worse, and which gets worse when the catarrh ceases; from damp, cold weather, and wind; it commences on the left and goes to the right side; is worse in the warm room; throbbing, drawing, pressing pains, with swelling of the cheek; worse when chewing; better from cold water; the teeth become yellow; for people who have an offensive breath, or who are fond of being in the open air and like to wash themselves fre- quently. 19. Arsenic. When the teeth are loose and elongated, with constant jerking or burning, and tearing in the gums, worse when touched, when ly- ing on the affected side, and when at rest, and also from cold; the pains are mitigated by the heat of the stove, by hot applications, or by sitting up in bed; it is particularly indicated when the pains are very debilitating. 20. Ant. crud. Is the principal remedy for pains in hollow teeth, of a boring, digging, tearing, jerking character, which sometimes penetrate into the head; the pains are aggravated in the evening in bed, after eating, by cold water; and better when walking in the open air. 21. Bryon. For passionate, irritable, cross, obstinate people; pain oc- casionally in hollow, but more frequently in healthy teeth; shooting pains with twitching towards the ear; tearing pain extending to the cheek, and acute pains as if caused by an exposed nerve ; sensitiveness and pain in the decayed teeth from contact with the air; the teeth feel as if too long and loose, and when chewing the}' feel as if they would fall out. The pains are aggravated by smoking or chewing tobacco; from the introduction of any thing warm into the mouth — better in open air — sometimes relieved by cold water, but only momentarily, and also when lying on the affected cheek, but worse when lying on the other. Likewise when the pain shoots from one tooth into the other, and also into the head and cheeks. 22. Rhus. For the same painful sensation of elongation and looseness of the teeth, as Bryon., and also when they feel as if they were asleep (Chi?ia, Dulcam.), and hollow, or sensitive to the air; the gums are swollen, burn, and itch like an ulcer, or they are sore and detached from the teeth; for jumping, shooting, or drawing pain, as if the teeth were being torn out (Put sat.), or pressed into their sockets (Staphis.), or for slow pricking or throbbing or tearing in all the teeth, extending into the jaws and temporal bones, with a painful soreness of one side of the face, from taking cold, or from vexation; worse in the air; insufferable during the night and mitigated by heat; sometimes accompanied by an offensive smell from the carious ODONTALGIA. 25 1 teeth. It suits best for quiet persons (unlike Bryon.), who are disposed to sadness and melancholy, or are easily agitated and frightened (similar to Bellad.). 23. Staphis. When the teeth become black and hollow, the gums pale, white, ulcerated and swollen — aching when being touched; intense gnawing, drawing or tearing pains in decayed teeth, particularly in the roots, or ex- tending through a whole row, or when the pain shoots from a hollow tooth into the ear, with throbbing in the temple — worse in the open air, from drinking anything cold, from eating, and particularly during the night or toward morning. 24. Laches. Pain in all the decayed teeth during rush of the blood to the head; drawing, tearing, throbbing, boring pain in the jawbones; hollow teeth feel too long; pain extending down the throat; better when pus is discharged; gums swollen, bleeding easily, or they are bluish-red, beating and burning, worse from anything warm; toothache worse after warm and cold drinks, after eating and awaking; with headache, beating over the eyes, stitches in the ears, swelling of the cheek; pains in the limbs of the opposite side, chills, fever and thirst. It is particularly suited for colds in damp, warm, spring weather; during menstruation, the smaller the discharge the greater the pain, at the cessation of the menstruation; for melancholic and choleric persons, for persons of vivid imagination; after long-continued grief, and after the abuse of mercury. 25. Phosph. ac. Is suitable for bleeding and swollen gums; tearing pains, which are worse when warm in bed, and also from heat and from cold; burning in the front teeth during the night; pains from hollow teeth, ex- tending into the head. 26. Ap. vir. For the most violent pains in the gums, also for jerks and throbbing in the molars, with involuntary, sudden biting together of the teeth, headache and bleeding of the gums. 27. Silic. For tedious, boring, tearing pains, day and night, worse during the night, spreading over the whole cheek, also into the bones of the face; discharge of offensive matter from openings near the roots of the teeth or from the gums; swelling of the jaw. 28. Dulcam. Is sometimes useful for toothache proceeding from cold, particularly when accompanied by diarrhoea, and when Chamom. does not answer; also when there is at the same time confusion of the head, or when the toothache is accompanied by profuse salivation (similar in this to Bellad. and Mercur. ) and the teeth feel blunt. 29. Calcar. For toothache in pregnant females; pains in hollow teeth, especially around loose stumps; pressing, drawing, jerking soreness; draw- ing, pricking, rooting, gnawing, grubbing, throbbing pains, with swelled gums, which are sore, bleed easily, throb and pain; it is only suitable when there is determination of blood toward the head, particularly during the night; when the pains are caused by taking cold, or are aggravated by cold or a draugh of air; the patient can neither bear warm nor cold drinks — even noise makes it worse. Fistula dentalis. 252 SWELLED FACE. 30. Caustic. For toothache arising from breathing in the open air, generally attended with stinging, throbbing pain, and a feeling of soreness; or the teeth feel painfull}' loose and lengthened, as if forced out of their sockets {Arnica, PJwsph. ac); when there are ulcers at the roots of the teeth, the gums suppurating are swollen and very tender. The pain fre- quently affects the whole of the left side of the face, especially at night when the patient lies on it, and is equally sensitive to heat and cold; in long-con- tinued or often-returning colds. After grief; melanchol}- mood; profuse, badly-smelling sweat at night. 31. Clemat. Drawing, stitching, worse at night; better for a short time by holding cold water in the mouth or sucking at the tooth, and in the open air. 32. Kali birchr. Pain in molar bones, worse from coughing. 33. Kali carb. Stitch pain and tearing up into the head and eye, with dizziness; chilliness, dry skin and bad alkaline smell from mouth; worse from chewing. 34. Mag. carb. and Phosph. Pain is worse at night, drives out of bed. 35. Natr. sidph. Pain is better from holding cold water in mouth, and is brought on again by taking hot water or hot coffee in the mouth. 36. Petrol. Abscess at root of tooth, with swelling of left lower jaw, painful to touch and on stooping. 37. Plant, maj. Aching in decayed teeth, or shooting up left side of face; face red. Is a popular remedy. 38. Sabad. Hot or cold food or drink, also cold air produce or increase the pain. 39. Sepia. Chronic cases; caries; waterbrash during pain ; meclimaxis; leucorrhoea. 40. Spigel. Pain leaves during eating and reappears afterwards, with palpitation of the heart. 41. Sulph. ac. Pain begins slowly to increase, growing to an almost unbearable degree when it suddenly ceases. 42. Thuja. With decay of teeth commencing close to the gums. Swelled Face. When the cheek remains swollen after the toothache has ceased, it may be removed by giving Pulsat., if Mercur. or Chamom. have been previously taken for the pain; or Mercur. after Pulsat. or Bellad.; or Bellad. after Mercur.; or Sulphur, after Bellad., Bryon., Arsen., etc. If the swelling is red, as in erysipelas, Mercur. should be given; if less red, but hard and stiff, Arnica. Hcpar, when the swelling begins to soften, and appears as if about to suppurate, followed by a dose or two of Laches. , if Hepar does not affect a speedy abatement of the swelling, and then by Hepar again or by Mercur. , if the latter have not been taken before. THE TONGUE. 253 THE TONGUE. To this remarkable piece of furniture of the human economy great atten- tion has been paid by physicians of all shades and in all times. And, indeed, it often presents quite characteristic diagnostic as well as therapeutic hints. The most important of these features are the following: 1. Its Color. It is either too red all over, as in scarlet fever, with considerably raised papillae — whence the name strawberry tongue — or red and dry, as in inflam- mations of the brain and its membranes; in inflammation of the thoracic viscera and mucous membranes of the stomach and intestines; or red on the edges and on the tip, or a red, dry streak in the middle of the tongue in typhoid fevers, or red, clean and glossy, indicating great fever heat, conges- tion to the head, impending delirium, and in gastric fevers, the transition into the typhoid state; and if, at the same time, cracked, ulceration of the bowels; or red, moist and smooth, in chronic affections of the stomach. A pale tongue is found in chills; in spasms; after loss of vital fluids; in chlorosis, dropsy and general exhaustion. When it sets in in exanthematic, gastric or bilious fevers, it denotes a fatal issue. A lead-colored tongue is found in cholera, in mortification of the lungs and stomach, in scirrhus of the tongue. A lead-colored tongue, with thrush, denotes impending death, under all circumstances. A bluish tongue is a sign of impeded circulation of the blood, and, there- fore, it may be found in paroxysms of asthma, whooping-cough, croup, bronchitis, pneumonia, heart disease, dropsy of the chest and cyanosis. Scurvy and mercurial inflammation of the tongue have also a bluish hue. 2. Its Humectation. A moist tongue is, in general, a favorable sign. But in putrid fevers, with exhausting perspiration, it has no such favorable meaning. A constantly moist tongue in soporous conditions denotes great exhaus- tion. % A dry tongue is found in a great many different morbid conditions, espe- cially in feverish affections, particularly in such as have a tendency to senso- rial disturbances. Great dryness of the tongue in typhus cerebralis is, according to Schoen- lein, an unfavorable sign. Dryness of the tongue in infants is a forerunner of thrush or internal in- flammation. 3. Its Temperature. A hot tongue is found in congestive and inflammatory states of different parts of the body; in infants before thrush appears. A cold tongue is found in chills, violent spasms, after great loss of blood. 254 IT S COVERING OR COATING. internal mortification, apoplexy, cholera. In fevers it denotes greatest pros- tration and impending death. 4. Its Covering or Coating. We must bear in mind that the tongue is coated or furred without indi- cating any disordered state of the system — in the morning by an empty stomach; after siesta; after night-watching, and with habitual smokers of tobacco. A coating of the root of the tongue does not mean much; in a slight de- gree every one has it, even in the best of health. A coating on the tip of the tongue is said to be found in phthisical per- sons. One-sided coating is said to be found in one-sided complaints, as proso- palgia, paralysis; in one-sided lung diseases; in affections of the liver and spleen. A patchy or map tongue, the so-called pityriasis linguae, is produced merely by a stouter layer of epithelium around the places of thinner cover- ing. A systematic cause for this affection is not known, although it may possibly be connected with some abnormal states of the stomach. A thick, white coating occurs most extensively in affections of the fauces; but also in gastric derangements. The yellow-coating is generally believed to be bilious; single yellow streaks on a white-coated tongue indicate obstinacy of the disease. A peculiar buff leather appearace is presented in cases of enteritis and hepatitis; also in tonsillitis. A dark brown coating exists in malignant fevers, and in haemorrhages from the mouth. A black coating, in dysentery, indicates exhaustion — mortification — death. In jaundice it denotes organic diseases of the liver, spleen, such as induration, tubercles, abscesses. In small-pox it is quite an unfavorable sign. 5. Its Form and Size. We find a large, long tongue most conspicuously in chronic hydrocepha- lus and cretins. A small tongue, if not congenital, in atrophy, consumptive diseases, and long-standing paralysis of the tongue; especially if caused from an irritation of the brain or spinal marrow. A sudden dimunition in size denotes, in inflammatory diseases of the lungs and liver, formation of abscesses; also general exhaustion; especially in putrid and typhoid fevers. A gradual decrease, in acute diseases, denotes gravity and obstinacy of such diseases, and is a sign of a dangerous affection of the brain. (Sprengel. ) ITS CONSISTENCY. 255 A broad tongue is found in rachitis, scrofula, inclination to abdominal affections and in intermittent fevers. A narrow, pointed tongue is said to be found in persons who are subject to spitting of blood, tuberculosis, and internal inflammations. A thick, swollen tongue is found in rachitis, cretins, chronic dropsy of the head, in obstinate dyspnoea and chronic inflammation of the mucous membrane of the stomach; also in intermittent fevers, catarrhal affections, mercurial salivation, inflammation of the tongue, in old drunkards; after death b}^ strangulation or suffocation. A swollen and heavy tongue in old age is the forerunner of apoplexy; the same in drunkards. In fevers, if associated with dryness and stammering speech, it denotes congestion of the brain. In croup, pleurisy and pneu- monia, it is a bad sign, just as bad as its sudden dimunition, without improve- ment of the other symptoms. (Hippocrates.) A thin, like a small, tongue is found in atrophy, consumptive diseases. Tumors on the tongue, if hard, brownish-red, with bluish blood-vessels interwoven, are of a scirrhous nature. Single lumps and fleshy excrescences on the tongue are found in elephan- tiasis. 6. Its Consistency. We find a hard tongue associated with great dryness of the tongue in congestion, inflammation, in fevers, in tonic spasms, in scirrhus and other degenerations of the substance of the tongue. A soft tongue we find in catarrhal affections, in chronic mucous diar- 'rhoea, gastric derangements and in paralysis of the tongue. When soft, the teeth generally show their imprints on its sides — often found after mercurial poisoning. In brain diseases a soft tongue is a bad sign. 7. Cracks and Fissures On the dry tongue, sometimes deep, bleeding and suppurating, are found in typhoid fever, in small-pox, dysentery. 8. Paralysis Of the tongue, which manifests itself by an imperfect, stammering speech, is often the consequence of apoplexy, softening or other affections of the brain. Its immobility and its trembling are signs of torpor of the brain, espe- cially in consequence of typhoid conditions, puerperal fever and septicaemia. Therapeutic Hints. A red tongue all over with considerable raised papillae. Arum, triph., Bel/ad., Hyosc, Merc, corr., Tart. emet. Red, glistening tongue: Kali bichr., Laches. Red tip: Arg. nitr., Morphium. 256 THERAPEUTIC HINTS TO THE TONGUE. Red tip in the shape of a triangle: Rhus tox. Red tip, undefined and red borders: Sulphur. Red borders: Bellad., Bryon., Morphium, A T ux vom., Sulphur. Red streak in the middle of a yellowish-coated tongue: Ver. vir. Lead-colored tongue: Arsen. Bluish tongue: Arsen., JJigit., Mur. ac, Thuja. White thick coating: Ant. crud., Arsen., Bryon. and many others. Whole tongue as if painted white : Glonoin. White coating and cracks across the middle: Kobalt. White coating only on one side: Rhus tox. A white streak on both sides: Caustic. In the middle only: Bryon., Phosphor. On the root only, strongly marked: Sepia. Map tongue: Arsen., Lac. vac, Laches., Natr. mur., Nitr. ac, Tarax. Yellow coating : Many remedies. Brown coating: Arsen., Bellad., Cactus, Coccul., Kali bichr., Merc, prot., Plumbum, Secale, Silic, Spongia, Sulphur. A dry, white tongue, without thirst: Bryon., Pulsat. Dry, white, without thirst and paralyzed : Nux mosch. Dry, white, and feeling as if burnt or scalded: Psorin., Pulsat., Sepia. Diy and cracked: Arsen., Bellad., Chamom., Kali bichr., Rhus tox. , Ver. alb. Dry and red; Arg. nitr., Bellad., Chamom., Hyosc, Laches., Lycop., Morphium. Dry, red and cracked at the tip: Kali bichr., Laches., Rhus tox., Sulphur. A black coating: Arsen., China, Elaps, Laches., Mercur., Opium, Secale, Ver. alb. A soft tongue, with imprints of teeth: Mercur., Rhus tox., Stramon. A clean tongue, with gastric and other derangements: Cina, Digit. Trembling and inability to protrude the tongue in typhoid conditions: Laches. Heavy, trembling tongue, with falling of lower jaw in typhoid conditions: Lycop. Spasmodic darting of the tongue out of mouth in typhoid conditions: Lycop. Protruding of tongue, with silly expression in diphtheria : Lycop. Protruding, cold and lame : Hydr. ac Paralysis of tongue: Aeon., Arsen., Bar. carb., Bellad., Caustic, Dul- cam., Graphit., Hyosc, Laches., Nux mosch., Opium, Plumbum., Stramon. Difficulty of moving the tongue: Anac, Bellad., Calc carb., Lycop. Heavy tongue: Anac, Bellad., Carb. vcg., Colchic, Lycop., Mur. ac, Natr. mur., Plumbum. Stiffness of tongue: Borax., Colchic, Euphras., Laches., Natr. mur. GLOSSITIS. 257 Glossitis, Inflammation of the Tongue. We understand by this name an infiltration of the parenchyma of the tongue, which is either confined to only- a portion of the tongue, Partial glossitis, or pervades the entire organ, Glossitis diffusa universalis. A mere superficial inflammation of the mucous membrane of the tongue belongs as part to inflammatory processes of the general mucous membrane of the mouth. The most important symptom of an Universal glossitis is the rapid swelling of the tongue, which in a day or two may acquire such dimensions as to prevent by its pressure upon the pharynx and epiglottis not only swal- lowing, but also breathing and to cause death by suffocation in a few hours. The patient is seized with paroxysms of asphyxia, as in croup, becomes cyanotic and suffocates, if breathing is not restored. The tongue, not hav- ing room in the mouth, also protrudes and presses sideways between the back teeth, causing deep indentations, with immediate disposition to the formation of ulcers. The neighboring lymphatic and salivary glands also become swollen. The pain is severe, and extends to the ears and throat. Its course is rapid, terminating either, as before stated, in death by suffoca- tion, or in a gradual subsidence of the swelling, or in the formation of an abscess, which mostly breaks through the surface of the tongue. Even gangrenous destruction of large portions of the tongue has been observed as a result of mercurial glossitis, and at times there remain circumscribed indurations, with a disposition to renewed attacks. Partial glossitis usually commences as a painful tumor, from the size of a pea to that of a bean, on the back part of the tongue, which gradually suppurates, finally breaks and discharges. It is not attended with any special disturbance of the general health. The Causes of a genuine parenchymal glossitis are not clear by any means. Some have recorded epidemics of this disease; others have observed it as a consequence of anthrax poison ; others as a result of mercurial poison- ing, and still others as the effect of the sting of a wasp, bee, or hornet. Sporadic cases of glossitis have in nowise been etiologically explained. The most fatal are those caused by the poison of anthrax — Grlossanthrax — or car- buncle of the tongue. Therapeutic Hints. If anthrax, bee, wasp and hornet-stings, and mercurial poisoning are set down as causes of glossitis, we naturally will find powerful remedies for this disease in: Anthrac. Especially when there is great burning and a disposition to gangrene; after A rsen. Apis. When there is a stinging and burning pain, with blisters on the tongue. 17 258 CANCER OF THE TONGUE. Merc. sol. When there is ulceration, and great fiabbiness of the tongue, with salivation. Besides compare: Plumbum, Ran. seel., Sepia, and Arse?i. Great burning and tendency to gangrene. Laches. Blisters which change into ulcers. Petrol. Fetid salivation. Sulphur. Ulcerated tongue. Camphora, or Natr. mur. When caused by an insect sting. Cupr. ac, Calc. Carb., Hepar, Nitr. ac, Sulphur. After abuse of mercury. Canthar. After scalding the tongue. Calc. carb., Carb. veg., Conium, Hepar, Lycop., Mezer., Silic, Sulphur . When indurations remain and the case becomes chronic. Arnica, Hypericum. Traumatic origin. Asaf. , Hepar, Nitr. ac. , Staphis. Mercurial poisoning. Cancer of the Tongue Is of the epithelial kind and commences usually at the edge, near the tip of the tongue, as a small, hard lump, which after awhile forms an ulcer of a roundish shape, with raised edges and uneven bottom. It distinguishes itself from every other ulcer by its continuous encroachments, by its hard, larda- ceous bottom, by the visid, milky juice which can be squeezed out by press- ure upon its edges, and by the lancinating, boring, burning pains, with which it is attended, robbing the patient of rest at night, and not unfre- quently leading him to suicide. By-and-by the adjacent parts of the tongue begin to swell, and the cancer itself spreads either upon the superior or inferior surface of the tongue. In its further progress the motion of the tongue becomes impeded, and the swallowing of solid food impossible. A great deal of saliva is secreted, and as the swallowing is painful and difficult, the patient spits all the. time. The glands under the tongue, and also the lymphatic glands of the neck become affected; they swell and harden; the tongue becomes firmly attached to the bottom of the mouth, so that its motion is almost destroyed; it gradually is transformed into a thick, short- ened, misshapen lump, with round protuberances upon it, which break and emit a terrible smell. Sometimes the glands of the neck and the region of the parotid glands swell to such an extent that it is impossible for the patient to open the mouth, and he gradually sinks under excruciating suf- fering, starvation and exhaustion. The disease is slow, lasting from one to three years. Therapeutics Hints. Compare Arsen., Caustic, Carb. an. and veg., Conium, Hydrast., Laches., Nitr. ac, Phytol., Sepia, Silic, Sulphur. Galium ap. (Clifton and Bailey), Mur. ac. (Cooper). Sedum acre, sempervivum tectorum. THE SAXIVARY GEANDS AND THEIR DUCTS. 259 THE SALIVARY GLANDS AND THEIR DUCTS. There are three pairs of such glands: the parotid, which is situated near the ear on each side; the submaxillary, lying in the posterior angle of the submaxillary triangle of the neck on each side; and the sublingual, which is imbedded beneath the mucous membrane of the floor of the mouth on each side of the fraenum linguae. The excretory ducts of the parotid, called Stenon's ducts, open at the internal surface of the cheeks, opposite the second molar tooth of the upper jaw; those of the submaxillary, called Wharton's ducts, open by the side of the fraenum linguae; and those of the sublingual, w T hich are seven or eight in number, also open in this same locality. The product which they pour forth into the mouth is the saliva. This very im- portant fluid is greatly altered by disease; but still, all the microscopical and chemical researches have failed to reveal any facts which can be con- sidered of diagnostic value. The saliva varies in Quantity. There is normally less secretion in the first four months of infancy, and also in the last years of old age. But its secretion may be abnormally les- sened by deficiency of beverage, or by different pathological conditions, wmich induce copious secretions of fluids, either through the skin, or kidneys, or serous membranes. An increase of saliva (salivation, ptyalism) may be caused by various drugs, as our Materia Medica shows; but the most known and the most virulent is that caused by mercury, being accompanied by a most sickening, penetrating smell from the mouth, swelling and inflammation of the gums, loosening and falling out of the teeth, stomatitis, and ulceration of the mucous membrane. We find an increase of saliva also in many diseases of the cavity of the mouth, of the tongue, in caries of the teeth, in necrosis of the jaw, during the eruption of the milk teeth, in acute and chronic irrita- tions of the parotid and submaxillary glands, during the eruption of small- pox in the mouth; sometimes at the commencement of typhus; in conse- quence of irritation of the trifacial, the facial and the glosso-pharyngeal nerves; in consequence of diseases of the stomach, of the pancreas and spleen; in intermittents; during pregnancy, menstrual disturbances, climaxis and in many hysterical conditions. The color of the saliva may also be changed. A blue color has been observed in slow poisoning cases by lead. Yellow, even greenish saliva has been found in liver complaints and jaundice. A red, bloody saliva in different morbid conditions, when it becomes mixed with blood, as in haemorrhage from the mouth or nose, inflamed and bleeding gums, etc. But has also been found in suppression of haemorrhoidal discharges. After external injury of the head, bloody saliva is, like bleed- ing from the ears, a sign of fracture of the skull bones. Its Chemical reaction in a healthy state is slightly alkaline ; if it be acid, 260 THE TONSILS. it indicates a disturbance in the digestive organs. It may also become acid in diseases of the intestines, in rachitis, gout and in scrofulous conditions. In a normal state saliva contains more or less sulphocyanide of potash or soda, which can be easily detected by adding a drop of sesquioxide of iron to some saliva, which changes it to a deep red color. During smallpox this substance seems to be wanting in the saliva, and be present in the contents of the pustules. Ranula, Frog. It consists of a swelling on the floor of the mouth under the tongue, either in the middle or on one side of the fraenum linguae, caused by a widen- ing of Wharton's duct in consequence of obstruction by minute foreign bodies which have become lodged there and incrustated. It presents itself on inspection as a soft, elastic, fluctuating and transparent kind of blister or bag, whose sheath is similar to a fine serous membrane, and the contents of which consists of a gluey, transparent, pale-yellowish or brownish fluid, of alkaline reaction, and without microscopic elements. It varies considerably in size and form, the latter depending somewhat on the former. When small it is globular; but as it increases its shape is modified by the surround- ing tissues. C} r sts and abscesses are also formed in this locality, with which ranula must not be confounded. Therapeutic Hints. Compare Apis, Be/lad., Calc. carb., Fluor, ac, Mcrcur., Mezer., Nitr. ac, TJutja. Ambra grisea, "excoriating feeling in mouth, preventing eating, with an insipid, rancid taste." (Gilchrist.) THE TONSILS Lie between the two palatine arches and generally project distinctly be} T ond them, though in a variable degree. Their form is that of an oval disc, sometimes of a flattened globe. Their size varies much, so that no positive volume can be determined on. Their free superior surface, being moderately red, presents from ten to sixteen round or linear openings, which are barely visible; sometimes they are wider and more like fissures. They lead into longer or shorter fissures (lacunae, sinuses), running perpendicularly or obliquely in various directions, and sometimes giving off branches. The lacunae are lined with a thin but uniform layer of epithelium. The tissue surrounding the lacunae consists of follicles and interfollicular tissue. The follicles are composed of reticular tissue, with few capillaries, and of small, round cells imbedded in them. The interfollicular tissue is of an essentially similar character, only it is richer in capillaries and contains small arteries and veins. The framework of the tonsils consists of a fibrous connective tissue, by which they are also surrounded and fastened to different pharyn- geal muscles. INFLAMMATION OF THE TONSILS. 26 1 Inflammation of the Tonsils; Amygdalitis; Tonsillitis; Angina Tonsillaris. There is a Simple catarrhal inflammation of the mucous membrane cov- ering the tonsils, which is in most cases only part of a general pharyngeal catarrh. A Lacunal or Follicular catarrh of the tonsils is deeper, produces a thin or thick whitish, yellowish, curdy substance, which, when thick, adheres tightly and consists of epithelium and pus. It may be confounded with herpetic angina, mild diphtheritis, or even with superficial abscess of the tonsil. The tonsils in such cases are always more or less swollen and the palatine arches inflamed. This morbid process yields mostly in a few days after a spontaneous evacuation of the epithelial and purulent contents; or the contents may dessicate, and then become foul, or calcareous. Those little, cheesy lumps, which at times, with some patients, when hawking for- cibly, fly out of the mouth, are of this origin. In still other cases it may give rise by extension to a Parenchymatous amygdalitis, which is character- ized by a high grade of congestive hyperemia and serious infiltration, in con- sequence of which the tonsil or tonsils — for it may be unilateral or bilateral — become enormously swollen. This state of things results either in a return to the normal form by absorption, or in an infiltration of small cells both in the interior of the follicles and between them, and a consequent new for- mation of reticulated substance giving rise to permanent hypertrophy of the tonsils; or in the formation of several abscesses. Sometimes an abscess forms in the connective tissue surrounding the tonsils — Peritonsillar or Eetro- tonsillar abscess — most frequently between the tonsil and the affected pala- tine arch, usually the anterior arch. This affection ordinarily involves but one tonsil, sometimes the other, several days afterwards, forms a walnut-sized protuberance, which usually terminates in perforation, followed by a rapid return to the normal condition. This formation of abscesses is commonly known under the name of Quinsy. In clinical practice we cannot always distinguish between these different pathologico-anatomical forms; neither does it matter. Either of them, with the exception of the superficial catarrhal form, may be accompanied with great pain, swelling of one or both tonsils, impossibility of swallowing and talking, of opening the mouth or moving the head. They are mostly asso- ciated with hyperaemia, or collateral oedema of the pharynx, extending sometimes into the Eustachian tubes, with pain in the ears, or to the larynx, with dyspnoea or paroxysms of suffocation, especially on lying down. Fever attends all more severe cases, especially those with suppuration; the temper- ature may rise to 104 F., with morning remissions and evening exacerba- tions. There is loss of appetite; sometimes headache, delirium, and even convulsions have been observed in children at the commencement. The duration of a superficial and lacunal tonsillitis varies between three and eight days, while a parenchymatous amygdalitis and a tonsillitis with abscess lasts at least eight days, frequently a week and a half, and even 262 THERAPEUTIC HINTS TO INFLAMMATION OF THE TONSIES. as long as two or three weeks. Persons once affected by tonsillitis are liable to repeated attacks. Fatal terminations are exceedingly rare. Therapeutic Hints. ' ' The much recommended timely opening of tonsillar abscesses is of little use, because it is very seldom successful, and, even when it succeeds, hardly ever relieves the patient. It is somewhat different in* anterior periton- sillar abscess; but even then the relief to the patient is seldom as great as after spontaneous discharge. Deep incisions are not advisable, owing to the contiguity of carotid artery." (Wagner, allopathic authority.) It is strange, that in some "homoeopathic" works we find the use of the Bistory still advocated. Amm. mur. Both tonsils swollen; can neither swallow, talk, nor open the mouth; after taking cold. Apis. Stinging, burning pain when swallowing; dryness in mouth and throat; red, highly inflamed tonsils; oedematous swelling of fauces and glottis. Fears open air, yet cannot stand the warm room; thirstlessness. Bar. carb. Liability to tonsillitis after slight cold, or suppressed sweat of feet; tonsils tend to suppurate; especially right side. Bellad. Especially right side; parts bright red; also swelling of the neck, externally, painful to touch and motion; cerebral symptoms. Hepar. Sticking pain as from a fishbone in the throat when swallowing ; tendency to suppurate; after mercury. Ignat. In follicular catarrh, almost specific. Kali hydr., or Iodium. (Kafka.) Laches. Especially left side; choking when drinking; fluids are driven out through the nose; worse in afternoon, after sleep, from slightest touch; can't bear bedclothes near the neck. Mercur. Dark redness; fetid ptyalism; very offensive smell from mouth; aphthae or thick coating on the tongue. Phytol. ' ' Pain at the root of the tongue or to the ears when swallow- ing, much dryness of the throat, with soreness, fauces and tonsils appear dark, perhaps of a bluish cast." (Win. Jeff. Guernsey.) Plumbum. Angina on left side, with copious flow of purplish saliva and spasms. Silic. In stubborn cases where abscesses are forming, yet don't break, especially left side. Sulphur. When, after the bursting of the abscess, the parts still remain irritated, and the patient does not recover as fast as he should. For chronic enlargement and induration: Bar. carb. and mur., Calc. carb. andyW. , Ignat., Lycop. Phosphor. Mucus in throat removed with difficulty; it is white, nearly transparent, in lumps and quite cold when it comes into the mouth. Phytol. Enlarged tonsils and uvula; tonsils of a bluish cast; harrassing, hawking cough, after every cold. Psorin. and Sulphur. THE UVULA AND SOFT PALATE. 263 THE UVULA AND SOFT PALATE. These parts ma}^ be variously affected, being always more or less involved in diseases of the neighboring tissues. We have anaemia, hyper- emia, haemorrhage, inflammation, oedema, ulceration, phlegmon, thrush, diphtheritic exudations, atrophy, syphilitic affections, morbid growths and cancer presented to our observation, and also motor and sensory disturb- ances. Paralysis may be limited to the muscles of the soft palate, or may occur with paralysis of other muscles, most frequently those supplied by the facial nerve, or in connection with catarrh, phlegmonous inflammation, morbid growths, etc., and in consequence of diphtheritis, the most frequent form. Its various forms interfere more or less with swallowing, talking and breathing. Anesthesia of the soft palate, mostly with diminished reflex irritability, is found in insane patients, and also in consequence of the influence of some substances upon the periphery (ice bromide of potassium, morphine, lye, etc.). Diphtheritic paralysis is almost always combined with anaesthesia. Hyperesthesia occurs as w r ell with the maintenance of a normal ap- pearance of the parts, as in the various disturbances of circulation and the inflammations. What in common life is styled ' ' falling of the palate " is an inflamma- tion and oedema of the uvula, by which it becomes greatly enlarged, causing a constant hacking and hemming, and interfering with swallowing and breathing. Therapeutic Hints. The remedies which act especially upon the uvula and soft palate, are: Aeon., Argent., Bellad., Coffea, Crot. tigl., Gelsem., Hepar, Igyiat., Iodium, Kali bichr., Laches., Merc, sol., Merc, subl., Natr. mur., Nitr. ac, Nux vom., Phosphor., Phytol., Sulphur. Angina Faucium, Angina Catarrhalis, Sore Throat. This catarrhal affection frequently involves the mucous membrane which covers the soft palate, tonsils and back part of the throat (fauces). The parts redden and swell, are at first dry and afterwards covered with a whitish tough phlegm, which especially assumes on the tonsils to a certain degree an appearance of diphtheritis. In its acute form it is mostly attended with some fever, painful deglutition, a heavily coated tongue, bad taste and an increase of saliva. Deglutition in bad cases, where the palatine and pharyngeal mus- cles are involved, becomes utterly impossible, so that an attempt at swallow- ing causes either choking or an expulsion of the fluid through the nose. For this reason, also, the voice of the patient assumes a nasal twang in talking. Sometimes the inflammation extends higher up into the naso-pharyngeal 264 THERAPEUTIC HINTS TO UVULA AND SOET PALATE- cavity, affecting the Eustachian tubes and causing hardness of hearing and stitch-pain in the ears. It is caused either by atmospheric influence and a constitutional dispo- sition {idiopathic form), or is part and portion of certain acute diseases, such .as scarlet fever, smallpox, measles, etc. {symptomatic form). At times an- gina faucium prevails epidemically. Therapeutic Hints. Aeon. Dryness with burning, stinging and drawing in the throat, making swallowing painful, feverishness, impatience and restlessness. Cold west and northwest winds. Apis. Burning, stinging pain, or pressing as from a hard body; redness and swelling of tonsils, uvula and tongue; abundant collection of soapy saliva; painful deglutition or impossibility to swallow. Bellad. Scarlet redness; stitches extend into the ear; painful deglu- tition or impossibility to swallow, the fluid escaping through the nose; swell- ing of cervical glands; red face; congestion to the head; headache; fever. Bryon. Gastric derangement; tongue heavily coated, dirty yellowish; insipid, pappy taste; constipation; chilliness; motion increases the pain; irritableness. Ignat. Lump in throat; pain in throat worse between the acts of swal- lowing; whitish tough mucus in spots on tonsils, simulating diphtheria. Laches. Throat feels constricted; lump in throat; constant desire to swallow, though difficult and painful; neck sore to touch; all symptoms w T orse on left side, in the morning after sleep, and in the afternoon. Merc. sol. Redness and swelling of the parts; whitish, smeary concre- tions on tonsils; tongue thickly coated, whitish; flow of slime and saliva from mouth; constant inclination to swallow; pain in parotid glands and muscles of the neck. Fever exacerbation in the evening. Merc. corr. snbl. When there is no swelling of the tonsils. Very often subdues the inflammation quickly wmen given at the commencement. (Bolle.) * Nux vo?n. Catarrh in head and throat, with a feeling of soreness, raw- ness, scraping and the sensation of a lump in throat on swallowing; after taking cold. Petrol. Feeling of great dryness in the throat, with abundant accumu- lation of mucus at the same time. Stinging, burning pain in throat during deglutition, extending into the ears and neck. Great thirst and costiveness. Pulsat. Dark, bluish redness with varicose veins, scraping rawness and dryness in throat, without thirst. Sanguin. Throat feels sore and as if scalded by hot drinks; dry and constricted; drinking does not relieve the dryness; mucous membrane feels as if it would crack, is red and inflamed. CHRONIC SORE THROAT. 265 Chronic Sore Throat, Angina Granulosa or Follicularis. It is characterized by little, roundish, elevated spots, like peas split in half, which stand either singly, scattered over the pharyngeal wall of the fauces, or in rows or ridges extending from above downwards; or the mucous membrane of that locality appears smooth, but dry and glistening, or it is covered with a tough, whitish or yellowish-greenish mucus, or brownish and blood}' crusts or skinnj^ substance, which is very difficult to detach. In these cases the catarrhal affection extends up into the naso-pharyngeal cavity, and is mostly connected with chronic nasal catarrh; but it also may spread downwards to the larynx, where its presence causes laryngeal irrita- tion and cough. The color of the fauces varies from a bright redness with enlarged veins radiating in various directions, to a deep brown-red hue; in still other cases there is very little redness. Usually it is attended with very little pain, perhaps some raw feeling or scraping, and with scarcely any diffi- culty in swallowing. The great annoyance of the patient is a feeling of dryness and the accumulation of tough phlegm which he constantly tries to remove by hemming and hawking, especially in the morning. In conse- quence of these, sometimes very violent efforts of cleansing the throat, small blood-vessels burst, which may unnecessarily alarm the patient, when he finds himself spitting blood. It is a very stubborn complaint and exercises a depressing influence upon the patient, who is kept in constant fear of going into consumption. This kind of chronic catarrh is frequently found with public speakers, clergymen and the like, wherefore it has received the popular name of preacher's sore throat, an application which, like many popular definitions, is not altogether well defined. For although the so-called preacher's sore throat in many cases may be attended with a chronic catarrh of the fauces, the sudden giving out of the voice, or hoarseness after loud and forced speaking, is mainly the effect of overstraining the muscles of the soft palate or vocal cords. Therapeutic Hints. Alum. Soreness, rawness, hoarseness, dryness, or secretion of thick, tough phlegm; worse in the afternoon and evening, better from eating and drinking warm things. Aium triph. Constant hawking; profuse secretion from posterior nares and fauces; hoarseness, worse from talking. Arg. nitr. Collection of thick, tough phlegm, causing gagging; wart- like excrescences; feeling of a pointed body in the throat when swallowing, belching, breathing, or moving the neck. Arnica. Great hoarseness from preaching or public speaking. Caustic. Burning in the throat, worse on stooping; hoarseness from singing. Elaps. Sore throat, offensive discharge from the nose, occasional epis- 266 THERAPEUTIC HINTS TO CHRONIC SORE THROAT. taxis. Posterior wall of throat covered with a dry, greenish-yellow mem- brane, wrinkled and fissured, which extends to the nares. Occasionally portions of it become detached and are expelled either by mouth or nose. Stuffiness at root of nose and dull aching from there to forehead. Smell gone. Catamenia generally profuse and dark. Kali bichr. Secretion of very ropy or stringy phlegm through the pos- terior nares and fauces. Laches. Much inclination to swallow, although it is very painful, with spasmodic contraction of the throat; worse on left side, and worse after sleep; can't bear any pressure about the neck. Lycop. The fauces look brown-red; worse on right side; sometimes a hard green-yellowish phlegm is hawked up in the morning. Natr. carb. Slight redness and continual sensation of rawness and scraping; diminished secretion, with constant desire to hawk and hem; collec- tion of mucus in the night; painfulness of throat on swallowing and gaping. Natr. mur. Always after local applications of nitrate of silver; feel- ing of great dryness in the throat, and yet a constant hawking up of a trans- parent, thin mucus. Sensation of a plug in the throat; uvula elongated; the action of the muscles of deglutition is diminished; the food goes the wrong way, or does not go down at all. Petrol. In dry, sore throat, with mucous secretions; stitches into the ears during deglutition, and burning in the neck. Phosphor. When the throat is very dry, fairly glistening. Plumbum. When the disease spreads from left to right. Phytol. Dryness, feeling as if a ball of red-hot iron had lodged in the fauces when swallowing; can't eat hot fluids; choking sensation. Sapo sodcE. After scalding the throat by swallowing hot things. The following hints in the form of a repertory have been prepared by Dr. F. M. Selfridge: Uvula and fauces dark red, Arg. nitr. Uvula elongated, Bromium, Vlyethia. Swelling and elongation of the uvula, /odium, Kali hy dr. Uvula relaxed, with a sense of a plug in the throat, not relieved by swallowing, Kali bichr., Laches. Uvula elongated, fauces purple and swollen, Laches. Thick, tenacious mucus, obliging him to hawk, Arg. nitr. and Merc, iod. ; mucus cannot be raised by hawking, Caustic. ; mucus in fauces and posterior part of the pharynx, mornings, difficult to hawk up, Kali carb. Rawness, soreness and scraping in the throat, Arg. nitr., Caustic. Wart-like excrescences in the throat, feel like pointed bodies when swallowing, Arg. nitr. Posterior wall of the pharynx dark red, glossy, puffed, showing pale red vessels, Kali bichr. Burning and dryness of fauces and pharynx, Arg. nitr., Sanguin., Wyethia. THERAPEUTIC HINTS TO CHRONIC SORE THROAT. 267 Burning in pharynx, extending to stomach, Kali bichr., Sanguin., Wyethia. Dryness of roof pf mouth, fauces and throat, Bellad., Wyethia. Throat feels raw and sore, looks red and shining, Bellad., Sanguin. Throat feels constricted, as if tied, Laches, or Iodium. Dryness of the throat posteriorly, Caustic., Wyethia. Constant hemming to clear the throat, Wyethia; of tough phlegm, Iodium. Must swallow continually; feels as if the throat was too narrow, Caustic. Must swallow on account of the dryness of the throat, yet without affording relief, Wyethia. Throat dry, with frequent empty swallowing, Iodium, Mercur., Wyethia. Salivary glands much swollen, Iodium, Mercur. Constant urging and desire to swallow, Bellad. Increased flow of tough, ropy saliva, Wyethia. Dryness in the posterior nares, Wyethia. Sensation as if something was in the nasal passages; an effort to clear them through the throat affords no relief, Wyethia. Difficult deglutition, Bellad., Wyethia. Swelling of mucous membrane of fauces and pharynx, Bromium, Wyethia. Mucous follicles swollen, giving a granular appearance to pharynx, Wyeth ia. (Clinical . ) Tonsils swollen and inflamed, Bromium. Inflammation of the throat, with burning pain, Iodium. Ulcers on fauces, discharging cheesy lumps of offensive smell, Kali bich? . Hawking of mucus, with pain in throat-pit, Caustic. Hawks copious blue mucus in the morning, Kali bichr. Dry cough, with tickling in the larynx, Bellad. ; in the throat-pit, San- guin. ; large quantities of mucus, Iodium. Paroxysms of cough, brought on by phlegm in the larynx, Kali car b.\ by fits of passion or laughing, Arg. nitr. Cough, with copious green sputa, Kali hvdr. Cough, with involuntary discharge of urine, Caustic. Internal soreness of larynx and throat-pit; worse in morning, Arg. nitr. Internal soreness of larynx, painful to touch, Bromium. Hoarseness, Arg. ?iitr., Bellad., Bromium, Kali bichr. Hoarseness, with rawness and dryness of larynx, Laches. Hoarseness, worse in morning and evening, Caustic. Hoarseness, lasting all day, Iodium. Hoarseness, with pain in chest, Kali hydr. Chronic laryngitis of singers, raising the voice causes coughing, Arg. nitr. Dry hacking cough, caused by tickling of epiglottis, Wyethia anH Bellad. 268 DIGEST TO ACUTE AND CHRONIC INFLAMMATION OF THROAT. Digest to Acute and Chronic Inflammation of Throat. Dryness of fauces: Aeon., Alum., Arg. nitr., Caustic, Pulsat., Sanguin., Wyeth. , glistening, shining; Bel lad., Phos- phor., Kali bichr., Sanguin. and constricted: Sanguin. , feels as if mucous membrane would crack: Sanguin. , with burning, stinging and drawing in the throat, making swallowing pain- ful: Aeon. , with frequent empty swallowing: Iodinn, Mercur., Wyeth. , with abundant mucus at the same time: Petrol. , not relieved by drinking: Sanguin. of posterior nares: Wyeth. of roof of mouth and throat : Bel I ad. , Wyeth. Burning 1 : lodum. and stinging: Aeon., Apis. Soreness, rawness and scraping: Arg. nitr., Bellad., Caustic., Natr. carb., Nux vom., Sanguin. , without thirst: Pulsat. and red: Bellad., Natr. carb , guin. Redness, dark: Arg. nitr. and bluish with varicose Pulsat. , puffed, pale red vessels: Kali Redness, brownish: Lycop. , purple and swollen: Laches. , scarlet: Bellad. and inflamed: Sanguin. , with burning: lodum. and swelling: Mercur. without swelling of tonsils: Merc. corr. subl. Swelling of mucous membrane of fauces: Bromium, Wyeth. MUCOUS follicles swollen, granular ap- pearance: Wyeth. Ulcers on fauces discharging cheesy lumps of offensive smell: Kali bichr. Wart-like excrescences, feel like pointed bodies when swallowing: Arg. nitr. Alum., Elaps, S#n- bichr , thick and tough: Alum. , causing gagging: Arg. nitr. , obliging to hawk: Arg. nitr., Merc. sol. , hard and green: Lycop. , dry, greenish-yellow membrane, wrinkled and fissured, extending to nares: Elaps. Secretion in fauces and posterior nares, ropy, stringy, Kali bichr. , difficult to hawk up: Kali carb. , profuse: Arum triph. of soapy saliva: Apis. , tough, ropy saliva: Wyeth. , slime and saliva flowing from mouth: Merc. sol. Uvula elongated and swollen: Bromium, Lodum, Kali hydr., Wyeth. and fauces purple: Laches. , dark red: Arg. nitr. , with a sense of a plug, not relieved by swallowing: Kali bichr., Laches. Redness and swelling of uvula, tonsils and tongue: Apis. Tonsils swollen and inflamed: Bromium. with a smeary concretion on them: Merc. sol. , with whitish, tough mucus on them in spots, simulating diphtheria: Lgnat. Salivary glands swollen: Lodum, Mercur. Secretion in fauces of mucus, in the night: Natr. carb. , large quantities: lodum. , copious, blue: Kali bichr. Throat feels constricted: Laches. , as if tied; Lodum, Laches. , sore to touch, can't bear any pressure about neck: Laches. Choking sensation: Phytol. Lump, plug, hard body, as of a: Apis, Lgnat., Laches., Natr. mur. , when swallowing: Nux vom. Pointed body when swallowing, belching, breathing or moving head: Arg. nitr. Ball of red-hot iron, as of a, when swallowing: Phytol. Hoarseness : Alum., Arg. nitr., Bellad., Bromium, Kali bichr. , < morning: Caustic. , < evening: Carb. veg. , all day: Lodum. , from public speaking, talking: Arnica, Arum triph. , sinsrinsr: Caustic. DIGEST TO ACUTE AND CHRONIC INFLAMMATION OF THROAT. 269 , with rawness and dryness of larynx: Laches. , with pain in chest: Kali hydr. Constant urging to swallow: Bellad., Laches., Mercur. Constant desire to swallow, though diffi- cult and painful, with spasmodic con- traction of throat: Laches. Must swallow, feel as if throat were too narrow: Caustic. , on account of dryness of throat, affording no relief: Wyeth. Deglutition painful: Apis., Bellad., Natr. card. , cannot eat hot fluids: Phytol. , with dryness and a feeling as if a ball of red-hot iron had lodged in throat: Phytol. , as if a pointed body in the throat: Agr. nitr. Throat painful on swallowing and gap- ing: Natr. card. , and belching, breathing and moving the neck: Arg. nitr. Deglutition difficult: Bellad., Wyeth. , the food goes the wrong way, or does not go down at all: Natr. mur. impossible: Apis. , fluid escaping through nose: Bellad. Pain in throat, worse between the acts of swallowing: Capsic, Ignat. Hawking" and hemming constant: Arum triph., Natr. card., Wyeth. of tough phlegm: Loduni. , with pain in throat -pit: Caustic. of transparent, thin mucus with great dryness in throat: Natr. mur. , caused by a feeling as if something were in the nasal passages, which is not, relieved by hawking: Wyeth. , does not raise the mucus: Caustic. Irritable: Bryon. Impatient and restless: Aeon. Headache, and congestion to head: Bellad. Stitches extend to ears: Bellad. Red face : Bellad. Stuffiness at root of nose and dull ach- ing from there to forehead: Elaps. Offensive discharge from nose, occasional epistaxis: Elaps. Pain in parotid glands and muscles of neck: Mercur. Swelling of cervical glands: Bellad. Tongue heavily coated, whitish: Merc. sol. , dirty, yellowish: Bryon. Insipid, pappy taste: Bryon. Great thirst and costiveness: Petrol. Gastric derangement and costiveness: Bryon. Catamenia generally profuse and dark: Elaps. Cough, dry, hacking from tickling of epiglottis: Bellad., Wyeth. , with tickling in larynx: Bellad. in throat-pit: Sanguin. in paroxysms from phlegm in larynx : Kali carb. from fits of passion or laughing: Arg. nitr. , with copious green sputa: Kali hydr. , with involuntary discharge of urine: Caustic. Internal soreness of larynx and throat- pit, better in morning: Arg. nitr. , painful to touch: Bromium. Chronic laryngitis of singers, raising the voice causes coughing: Arg. nitr. Fever: Aeon., Bellad. , better in evening: Merc. sol. Throat symptoms worse on left side: Laches. , right side: Lycop. , spread from left to right: Laches. Plumbum. , right to left: Lycop. , worse in afternoon: Laches. , and evening: Alum. , in morning after sleep: Laches. , from motion: Bryon. Better from eating and drinking warm things: Alum. Brought on by taking cold: Nux vom. cold west and northwest winds: Aeon., Hepar. swallowing hot things: Sapo sod. After local applications of Nitrate of silver: Natr. mur. 2JO ULCERS IN THE FAUCES. Ulcers in the Fauces, Ulcerated Sore Throat. Chronic catarrh may terminate in ulceration; or the ulcers may be the consequence of a scrofulous diathesis; or they may have a syphilitic origin. The diagnosis of these different conditions might be accurately determined by a correct history. Besides, the diagnosis will be facilitated by considering that catarrhal ulcers are superficial; the scrofulous ulcer is deep, but has flabby, perhaps jagged edges, which do not project, the syphilitic ulcer, however, is deep and rounded, with elevated serpiginous and defined bor- ders. Therapeutic Hints. Compare Angina Faucium. Alum. The inflamed parts are spongy; the ulcerated surface secretes a yellow-brownish, badly-smelling pus; a boring pain from the fauces to the right temple and head. Aiirum. Putrid, cheese-like smell from the mouth; deep ulcers affect- ing the bones; after the abuse of mercury. Baptis. Putrid, dark-looking ulcers; fetid breath; great prostration. Hepar. After the abuse of mercury in syphilis. Hydrast. Extensively used by western Homoeopathic physicians for ulcerated sore throat; no characteristics given. Kali bichr. Deep ulcers, eating even through the velum palati; bones of the nose affected ; fetid discharge from the nose; sypihlitic origin. Kali hydr. Syphilitic and mercurial cachexia combined. Laches. Spasmodic contraction of the fauces when swallowing, etc. Compare Inflammation of Fauces. Mercur. Ptyalism, fetid smell; secondary syphilis. Nitr. ac. After the abuse of mercury ; syphilis. Sanguin. Rush of blood to the head; flying heat; throbbing in the head, from the nape upwards; distended veins in the temples. Retro-pharyngeal Abscess. This affection is either an acute suppuration of the connective tissue between the posterior wall of the fauces and the vertebrae, occurring not unfrequently in children up to the tenth year of age, or it is the consequence of diseases of the cervical vertebrge, such as caries, fracture, especially of the atlas and axis. Acute suppuration of the retro-pharyngeal connective tissue usually takes a rapid course and develops symptoms like phlegmonous sore throat, in varying degrees of intensity, such as fever, sleeplessness, dyspnoea, difficulty in deglutition, pain increased on motion of the head, stiffness in holding the head, spasms in young children, and convulsive par- oxysms. Suppuration from vertebral affections is much slower in its course and its symptoms are less prominent, with the exception of an inability to turn the head and the difficulty of swallowing. DEEP INFLAMMATION OF CONNECTIVE TISSUE OF THROAT. 27 1 The abscess, left to itself, opens spontaneously and discharges its contents into the lower pharynx; or fistulous tracks are formed towards the thoracic cavity, or towards the skin of the neck. A fatal termination may ensue by suffocation from the discharge into the larynx, especially during sleep; or from compression of the larynx by the enormous size of the tumor; or from secondary disease of the larynx or thoracic organs caused by descent of pus in the thorax. These various possibilities determine our prognosis. Its Diagnosis we can make out by inspection and palpation, as its location (posterior wall of fauces) distinguishes it from amygdalitis; or the symptoms of vertebral affections render it at once distinguishable from other complaints. Therapeutic Hints. Main remedies: Hepar., Silic. Acute suppuration of the connective tissue: Apis, Bellad., Bryon., Laches., Mercur., Pulsat., Rhus tox. Affection of cervical vertebrae: Arnica, Asa/., Calc. carb., Hepar., Lycop., Mercur., Mezer., Phosphor., Silic, Sulphur. Impossibility to swallow; fluids regurgitate through the nose: Aurum, Bellad., Laches., Lycop., Mercur., Nitr. ac, Phosphor. Deep Inflammation of the Connective Tissue of the Throat; Angina Ludovici. " It is a very acute inflammation and suppuration of the cellular tissue beneath the chin, in the environs of the submaxillary glands, which has been named after its earliest describer, 'Ludwig,' and which has appeared epidemically at various times." The inflammation generally begins on one or the other side of the hyoid bone, rarely in the middle, just over the bone. There is extensive infiltration, with disposition to undergo purulent or even ichorous degenera- tion. Post-mortems have shown the connective tissue and muscles of the entire submental region transformed into a semi-fluid, brownish mass, mixed with necrotic shreds of connective tissue; the submaxillary and parotid glands destroyed by gangrene; the neighboring parts intensely infiltrated, even as far as the pharynx and larynx; and the periosteum of the lower jaw loosened. m , The swelling in the hyoid region sets in with lighter or severer, or even complete typhus symptoms; it grows rapidly, gets harder and larger until it covers the entire anterior half of the throat as far down as the sternum. The skin over it is tightly stretched and reddened; the lower jaw be- comes immovable and deglutition impossible. Respiration and circulation are greatly interfered with by compression of the laVynx, trachea and the 272 THE MUCOUS MEMBRANE OF THE MOUTH. main internal jugular vein, and speech is made difficult or impossible by the pressure of the tumor under the tongue, which pushes it to the roof of the mouth and renders it immovable. It is attended with headache, vertigo, delirium. In some cases the swelling may entirely subside without suppuration, although absorption goes on but slowly ; in most cases suppuration sets in and the result is a shreddy pus, or gangrenous ichor, with subsequent gan- grenous destruction, septicaemia, embolism in various organs, death; or in more favorable cases fistulous ulcerations, strongly contracting cicatrices, which produce torticollis and impeded mobility of the neck, as also caries and necrosis of the jaw-bones. Its Causes are said to be: topical irritations, catching cold, especially during times of prevalent rheumatism and erysipelas; and exanthematic, typhoid and puerperal conditions. Of late no epidemics of this kind have been observed. Therapeutic Hints. I find only one case mentioned in our literature, by Dr. J. C. Burnett, which was cured by Aeon, and Iodic m, and later Nux vom. and Iodum, in alternation. Compare Raue's Annual Record, 1874, page 108. I should suppose that Anthrac. and Laches, might be of great service in this destructive disease. THE MUCOUS MEMBRANE OF THE MOUTH IN GENERAL. This is a continuous membrane covering the inside of the cheeks and all the organs within the cavity of the mouth except the teeth, lining the fauces, and extending thence upwards into the nose and downwards into the oesophagus, stomach, and intestines, and by way of the larynx and trachea into the finest bronchial tubes. Stomatitis. The term stomatitis designates an inflammation of the buccal cavity. It is most commonly met with in children suffering from gastro-intestinal dis- turbances induced by unfavorable hygienic surroundings, hot weather, or artificial feeding. It may, however, result from mechanical, thermal, or chem- ical irritation; certain drugs; or it may be parasitic in origin. Again it is found in certain dyscrasiae such as syphilis, scorbutus, etc. Catarrhal Stomatitis, Is the simple acute variety characterized by a diffuse swelling of the buccal mucous membrane, and does not terminate in ulceration. Slight constitu- tional disturbance generally co-exists. Parasitic Stomatitis ; Thrush. This affection is produced by a parasitic fungus, the oidium albicans, and is characterized by the formation of numerous, milk-white patches or PARASITIC STOMATITIS. 273 elevations which are difficult to remove. They are not the result of an exudative inflammation, but due to the extensive development of the above named fungus within the mucous membrane. We may frequently foretell its coming, when we observe that the mouth of the infant is getting dry, hot, red and sticky and its secretion gives an acid reaction. Then after a few hours white points of the size of a pin's head appear mostly at first on the inner surface of the cheeks, quickly spreading over various other places and soon covering in some cases the entire buccal cavity, and even the pharynx and oesophagus with a white membrane. After a while its white color turns yellowish or brown if bleeding occurs from rough handling. The first few days this membrane adheres firmly to the mucous membrane; later, on about the third or fourth day, it becomes loose and can easily be wiped away. According to Reubold this fungus confines itself to the squamous epi- thelium solely, and therefore the larynx, trachea, and the nasal cavities, the stomach and intestines remain free from it. It has been found, however, on the lowest portions of the rectum, upon the female genitals, and excoriations of the external skin, especially in the vicinity of the mouth, on the chin and neck. During the continuance of this fungous growth the mouth of the nurs- ling is hot, has an acid reaction and is sensitive to touch in a degree that even nursing sometimes is painful to the child. But as long as the affection is not complicated with intestinal catarrh, its course is quite mild and short, and passes away in a few days if proper attention is paid to cleanliness. Even if a reproduction should occur, it offers no special difficulty to cleans- ing and leaves the substance of the mucous membrane intact. It is different with artificially fed children when an intestinal catarrh is superadded to the trouble. Under it the child may sink with signs of a follicular enteritis. Causes. — The formation of this fungus is favored by acid fermentation. The secretion of the mouth is a mixture of saliva and mucus. The saliva is of alkaline reaction, more so after a meal, less so on an empty stomach. The buccal mucus, however, has an acid action, which is visibly increased on con- tact with atmospheric air, when acid fermentation at once begins. In young infants the secretion of mucus is in preponderance over the secretion of saliva; there is therefore a physiological tendency to acidity in a young child, and if, in addition to it. the child is nourished artificially and improperly by sub- stances which easily undergo acid fermentation (sucking-bags, poor milk from badly cleansed bottles, etc.,) an outbreak of thrush is sure to follow. We find, therefore, that thrush attacks more frequently children artificially fed than those who suck their mothers' breast, and for this additional reason that the latter in sucking draw the saliva out of their salivary glands, while the easy flow from the bottle requires nothing but swallowing. I would rather have the baby fed by the spoon, as in this way chewing motions are induced and a more thorough mixture of the food with saliva is insured. 18 274 STOMATITIS ULCEROSA. We find thrush also in adults, but it is of rare occurrence, and then always in consequence of protracted and exhausting diseases, such as phthisis, diabetes, cancer, etc. — setting in shortly before death. Its pathological character is identical with that described above, and its causes are the same — anomalies in the chemical composition of the fluids of the mouth, accele- rated acid fermentation and absence of the movements of chewing. Therapeutic Hints. The remedy must be chosen according to existing symptoms which ac- company this affection. Wash the mouth always after nursing with a rag dipped in water or a mixture of wine and water. sEthusa. Vomiting of milk in lumps; diarrhoea. Arsen. In adults and children; great burning, exhaustion, deep illness. Baptis. Last stage of consumption. Borax. Great heat and dryness in the mouth. Chamom. Child is fretful, wants to be carried about all the time; has colic, and green, sour stools. Hepar. When worse on inside of lower lip. * Mercur. Confluent thrush, changing into cankers; ptyalism; bad smell from the mouth; feverishness; green slimy stools. Staphis. Thrush changing into canker-sores with a bluish-red or yel- lowish bottom; more or less flow of saliva and bad smell. Sulphur. Sour smell from the mouth; stools slim}' with much straining, or painless; worse in the morning. Sulph. ac. After borax, increased flow of saliva, yellowish color of the skin. Stomatitis Ulcerosa ; Formation of Ulcers in the Cavity of the Mouth. Aphthae, or Cankers of the mouth. They are either the consequence of Catarrhal erosions, forming ulcers of a superficial nature; or of Follicu- lar inflammation, producing ulcers of greater depth; or in connection with Labial herpes or Hydroa, when they evidently have the same etiological significance. Aphthae occur chief!}' in children. The follicular form is fre- quently found in women during menstruation, pregnane}* or lactation. Often a few 7 hours are sufficient to bring about aphthous ulcers. They are chiefly situated on the mucous membrane of the lips and cheeks, especially where it is reflected on the gums, less frequently on the gums themselves, on the palate, or on the tongue. Their floor is whitish, yellow, their edges are reddened, somewhat raised, on account of the adjoining catarrhal stom- atitis; they are of an oval form and may attain the size of a bean. The follicular ulcers are small, circular and excavated. All cause great sensi- tiveness of the mouth, interfere materially with speaking and chewing, and are attended with an increased secretion of mucus and saliva, which, how- THERAPEUTIC HINTS TO STOMATITIS ULCEROSA. 275 ever, is not marked by any great intensity of nauseous odor, as we always find in Stomacace, or Putrid sore mouth, which is a destructive ulceration of the border of the gums, producing extensive swelling of the entire mouth and a cadaveric breath. It is mainly a disease of children, after their first dentition has been completed, but not found very frequent in private prac- tice. Apart from children it has appeared epidemically among soldiers. Very often, when it appears sporadically, its cause can be traced to the abuse of mercury, or an enfeebled state of the S3^stem, uncleanliness, poor food, and atmospheric influences. The morbid process usually begins at the mar- gin of the gums of the lower jaw, creeps gradually backwards, and attacks somewhat later those portions of the mucous membrane of the lips, cheeks, and tongue, which are in direct contact with the affected gums. The surface of the tongue, the hard and soft palate, as well as the pharynx, remain free from it. It is characteristically marked by great fetor, and a profuse, dis- tinctly acrid secretion, flowing constantly from the mouth. On pressure the gums bleed easily, or bleed spontaneously, coloring the saliva brownish-red. The tongue is thickly coated and swollen, showing distinct impressions of the teeth. The adjacent lymphatic glands are also tumefied. The fever attending it is ordinarily but slight. Ulcers dependent on some dyscrasia, such as syphilis, scrobutus, etc., will be spoken of in their respective places. Therapeutic Hints. Aphthae. Cleanliness and attention to the general hygiene of the patient is of great importance in treating these affections. The indicated remedies are: Arum triph. Superficial ulceration; tumefaction of lips; catarrhal burning and biting sensation in mouth and throat. Calc. catb. During dentition. Hydrast. Follicular and catarrhal ulcers with exceedingly tenacious mucus in the mouth. Laches. Canker sores on tip of tongue. Lycop. Under the tongue near the fraenulum. Mercur. On the gums, with ptyalism. Natr. mur. On tongue, gums and cheeks with great burning and im- peded speech. Nux vom. Gums inflamed, putrid smell from mouth; constipation. Sulphur. After Nux vom., or Mercur. ; bloody saliva; disturbed sleep. Sulph. ac. On gums which bleed readily; ptyalism; great weakness; ecchymosed spots on skin. Stomacace. Arsen. Edges of tongue ulcerated with great burning and pain; diar- rhoea and great prostration. Baptis. Gums ulcerated, loose, dark red or purple; intolerable fetid breath; can swallow only liquids; loose, offensive stools; after abuse of mercury. 276 NOMA. Hcllcb. Sores flat, yellowish, with raised edges upon an inflamed basis; ptyalism; fetid smell from the mouth; glands swollen on neck and under the jaw. Hepar. After abuse of mercury. Kali mur. Main remedy of the old school. Mercur. Ulcerated gums, tongue and cheeks; loose teeth; fetid smell. Burning pain, worse at night; diarrhoea with tenesmus. In fact it is proven to have produced this disease in its worse forms; it must, therefore, in many idiopathic cases, be almost specifically indicated. Nitr. ac. After the abuse of mercur}' with fetid and acrid saliva, which causes sores on lips, chin and cheeks. Pustules with red circumfer- ence, here and there on body. Nux vom. Ulcerated gums, foul and painful swelling of gums; pim- ples and painful blisters in the mouth; ptyalism at night, bloody saliva; fetid odor from mouth; constipation. Phytol. Edges of tongue ulcerated, tip very red; secretion of mouth very thick and tenacious. Mercurial ptyalism. Rhus tox. Great restlessness, especially in the night; bloody saliva runs out of the mouth. Rhus venenata. The mucus membrane of cheeks, tongue and fauces is reddened, and feels as if it had been scalded, with stinging pains. Staphis. Ulcers with a bluish-red or yellowish bottom; gums swollen, painful, spongy, bleeding readily; increased bloody saliva; fetid breath. Sulphur. Gums ulcerated, swollen, receding and readily bleeding; bloody saliva; fetor; diarrhoea; sleeplessness. Frequently indicated after Nux vom. Noma, Gangrene of the Cheeks. The first symptom of this malignant but rare disease is a small blister, situated in the middle of the cheek or toward the corner of the mouth on the inside of the cheek. It is filled with a pale reddish or turbid grayish or brownish fluid. It bursts so soon that its formation is mostly overlooked, and appears afterwards as a superficial ulcer with an unclean basis, soon assuming a gangrenous character. Simultaneous^ 7 with this blister, under- neath it, a small lump is found, which may be felt even outside on the cheek, which consists of infiltrated cellular and adipose tissue. Now the gangre- nous destruction goes on rapidly, and on the outside appears an cedematous swelling of the diseased cheek, often shining, fatty or oily, or appearing livid, pale or marbled. By and by there is also formed outside, mostly on the middle of the cheek, an inflamed spot or blister upon a hard basis, which soon covers itself with a dark crust. This crust being removed, gangrenous ulceration appears under it, like that on the inside of the cheek, which spreads with the same rapidity, destroying in a short time the greater part of the affected side of the face. The general and concomitant symptoms seem at first to indicate nothing NOMA. 277 alarming. Generally the glands of the neck swell and the face has a pale, cachectic aspect. Eventually, however, there is a general sinking of strength, diarrhoea sets in, and death may ensue from exhaustion, before the gangrenous destruction extends over the whole cheek. This disease is mostly found in childhood, and always in sickly chil- dren, or after scarlet fever, measles, typhus, and sometimes after smallpox. Adults are ver} T seldom attacked by it, and then it appears only after typhus or puerperal fever, and especially after the abuse of mercury. Therapeutic Hints. The main remedies recommended are: Arsen., Helleb., Secale, China, Card, veg., Kali phosph. (Schiissler.) NECK General Observations. Ocular inspection of the neck externally, as a whole, presents various noticeable features. A short and thick neck, in consequence of hypertrophy of its muscles, is found in emphysema of the lungs. A long thin neck mostly accompanies tuberculosis. A spasmodic contraction of the neck backwards denotes meningitis, with exudation on the base of the brain. The external jugular vein puffs out in the triangular space, which is called the interstitium intersterno-cleido-mastoideale, in all cases where the free circulation of the blood through the thoracic cavity is interfered with, as in diseases of the heart, and in consequence of continued violent coughing, screaming, singing and the like. A pulsation of this vein is observed in insufficiency of the tricuspid valve. The carotid artery is seen to pulsate more strongly in feverish condi- tions, and where there is obstruction in the circulation within the brain; its jumping pulsation is a sign of insufficiency of the valves of the aorta; The Acromial and suprasternal regions sink in when the upper parts of the lungs shrink; and These regions become inflated during inspiration or expiration, when emphysema or caverns exist in the upper parts of the lungs; also during capillary bronchitis of infants. Swellings of the neck are of various nature: They are emphysematous when, in consequence of internal or external injuries of the larynx or trachea, air penetrates into the subcutaneous cellular tissue; or when, in consequence of a rupture or laceration of the lungs, the air is forced through the mediastinum into the cellular tissue of the neck. They are oedematous in case of general dropsy, or when, by tubercular or scirrhous tumefaction of the lymphatic glands, the vena jugularis or anonyma becomes compressed; this causes at the same time an oedema of the face, or of the arm. There is a swelling of the lymphatic glands, either by infiltration with tubercular or scirrhous masses, or by becoming involved, secondarily, in inflammatory processes of the mouth, throat, face or scalp, of which we have spoken. Parotitis or mumps appear on the upper part of the neck in front and below the ear, while BRONCHOCKIvK. 279 Bronchocele, Struma or Goitre, Which is an enlargement of the thyroid gland, appears lower, sometimes on one, sometimes on both sides of the neck. Simple enlargement or hyper- trophy of this gland is, according to Porta, found only in children and young persons, while in older persons struma is always a degeneration of this gland, consisting in formations of cysts, which contain a thick, gummy, jelly-like substance, of a yellow or brownish color, and which are known under the name of colloids. According to Schuh, these colloids are either interspersed between the substance of the gland, or they form separate round or oval appendages upon the gland, without involving the gland itself into the morbid process. The struma of new-born children consists, as above mentioned, in a sim- ple enlargement of either the entire gland or of one of its lobes, and inter- feres, sometimes seriously, by its pressure upon the trachea, with the child's respiration. In severe cases it may produce death in a day or two, or even a few hours after birth. This is especially the case should the swelling extend under the sternum, or the sternal portion of the clavicle, or in case the muscles underneath the hyoid bone prevent its extension exteriorly. In regard to the combination of struma with tubercolosis we may say that, where struma is developed, there tubercular affection of the lungs may be found, but they do not reach the stage of softening or phthisis, so that struma excludes tubercular phthisis. Basedow's or Graves' disease has been treated of, under the chapter on the eyes. Therapeutic Hints. Bellad. Heat and rush of blood to the head; pain in swallowing; gland painful to touch. Bromium. In juvenile subjects, with light hair, blue eyes, fair skin. Calc. carb. In scrofulous persons, worse towards new moon. Egg shell, divested of its inner coating, finely triturated, has been used successfully. Fitcus vesiculosus. (R. N. Foster. ) Iodium. Inveterate cases; the harder they feel, and the more other symptoms are wanting, the more Iodium is indicated; dark hair, dark eyes, dark skin. Natr. carb. Pressing pain; round, hard swelling on the upper right part of the gland. Natr. mur., and also Natr. sulph. have been given with success. Spongia. Is recommended by Hahnemann for goitre in persons who live in valleys. Besides compare: Ambra, Amm. card., Badzaga, Calc. flour,, Calc. Jod., Caustic, Hepar, Kali, jod., Laches., left side; Lycop., right side; Rhiis tox., after hard straining; Sulphur. 28o OESOPHAGUS. (ESOPHAGUS. The lower part of the pharynx narrows back of the laryngeal entrance into a tube through which the food in the act of swallowing is carried into the stomach. This tube is called oesophagus. Its inner wall lies entirely out of the reach of ocular inspection; and we must infer from other symptoms what its conditions are. The introduction of the probe, or bougie, teaches by mediate palpation merely, whether the passage is open or closed, and if closed, at what point; and if it brings up in its fenestra some morbid prod- ucts encountered during its passage, it may also aid us in our diagnosis. Auscultation, first practiced by Hamburger, has thus far had no great prac- tical results. (Esophagitis, Dysphagia Inflarnmatoria. The mucous membrane of the oesophagus, although a continuation of the mucous lining of the fauces, is little disposed to inflammation, because of its thick epithelial covering. Still inflammation may set in even here from thermal influences (taking cold), from mechanical irritation (by the lodg- ment of foreign bodies), and from chemical causes (the destructive action of corrosive substances swallowed by accident or design). It may also be in- duced by spreading from continuous parts of its mucous membrane (of the pharynx or the stomach), or from inflamed parts outside of it, such as the vertebrae, the mediastinal connective tissue, or the lymphatic glands. And lastly it is found sometimes in cholera, typhus, pyaemia, variola, and scarla- tina. All these different forms of inflammation may produce ulcers of the oesophagus; the catarrhal form, although the most favorable in this respect, may in its protracted chronic form produce dilatation of this organ. Worse are the forms produced by corrosion, scalding, foreign bodies, etc., especially if they extend to the deeper layers, when danger of stricture from cicatricial contraction of the ulcers is always at hand. One of the most constant symp- toms of inflammation of the oesophagus in any of its forms is painful deglu- tition or even entire impossibility of swallowing with regurgitation of food or drink, hence the name Dysphagia inflammatoria. Therapeutic Hints. Aeon. Violent pain in the middle of the chest through into the back, worse from motion. When swallowing, it feels as if the food remained lodged in the region of the heart; lying on back impossible. After mechanical injury. Arg. nitr. After burning with caustic ammonia; fauces red and swollen; pain under the manubrium sterni; face red and pupils contracted. Arnica. After mechanical injury. Arsen. Cramp in oesophagus; burning when swallowing; food ejected as soon as it reaches the region of larynx. Chronic form with burning sore- STENOSIS CESOPHAGI. 28 1 ness behind lower end of sternum, worse when swallowing food; can't bear closure of dress. Baptis. Inability to swallow anything but liquids; great aversion to the open air. Oesophagus feels constricted from above down to stomach. Bcllad. Pressing pain, like contraction, and a feeling as though a foreign body had lodged fast in the oesophagus. Canthar. If caused by a burn. Capsic. Has caused a dysphagia inflammatoria. Kali bichr. Burning in the entire oesophagus; solid food is painful and difficult to swallow, leaving a sensation as though something remained there. Kali carb. liquids, still less solids, do not descend further than half way of the oesophagus, with pressure, stinging and burning in the middle of the chest and opposite vertebrae ; gulping and coughing up of watery phlegm ; chilliness, dry mouth, nausea. Laches. An attempt to swallow solids causes a feeling as though some- thing had gone the wrong way, bringing on violent gagging. Mezer. Violent burning and soreness in the upper half of the oesoph- agus; deglutition painful and difficult, especially after the abuse of mercury. Natr. mitr. Only fluids can be swallowed; solid food reaches only a certain place, whence it is ejected with fearful gagging and suffocation; hawking up of phlegm in the morning; obstinate constipation. Nitr. ac. In syphilitic persons. Phosphor. Inability of swallowing nourishment; weak and empty feeling across the abdomen with occational shooting pain in that region; sen- sation of heat extending up the back; great nervous irritability. Plumbum. Fluids can be swallowed without difficulty; solids come back into the mouth again; some hours after eating, burning in stomach and oesophagus; constipation; prostration; emaciation. Rhus tox. If caused by corrosive substances. Stramon. Constriction and spasm of the muscles of the throat on each attempt to swallow; also paralysis of the muscles of the pharynx. Stenosis CEsophagi, Narrowing of the (Esophagus. This state of things may be congenital (a very rare occurrence) or the consequence of compression from morbid changes of neighboring organs, such as the glands of the neck and mediastinum, or large strumous masses when they extend far back so as to surround the tube; or be caused by foreign bodies of various kinds which in the act of swallowing have stuck fast, or have gradually grown there, to which latter class belong all fungoid, polypous and carcinomous growths; or it may be the consequence of previous inflammation and its consequent contracting cicatrices, causing True stric- ture of the oesophagus; or it is a mere transient contraction of the muscular layer of the oesophagus, chiefly observed in hysterical or hypochondrical patients, constituting Spastic stenosis. In all these cases the characteristic symptom is difficulty of deglutition. Where the occlusion forms gradually, 282 DILATATION OF THE OESOPHAGUS. the patient at first merely feels some obstruction to the free passage of the food, especially if solid, which, however, is overcome by drinking a little water or other fluid; gradually, however, when the stricture becomes greater, the food does not go down by these means and it is either kept in that region of the oesophagus until it gradually works its way through the nar- rowed space, or it is ejected. The higher the stricture, the sooner will re- gurgitation follow. , Therapeutic Hints. Bellad. When too large a morsel or a bone incites contraction of the oesophagus and holds it fast, Bellad. generally relieves this spasm and lets the incarcerated body down. Bryon. The patient feels the swallowed food remaining about the middle of the chest, in the region of the upper third of the sternum, with choking sensation. Solid food must be washed down with water. Cicuta. When, after swallowing a sharp piece of bone, the cesephagus closes and there is danger of suffocation. Cundurango. First dilution; true stricture; burning at the spot where the food is arrested in its downward course; the obstruction is constant; lips very pale and tongue exsanguine. (J. Compton Burnett.) Fluor, ac. The impediment to the swallowed food appears to be in the region of the cardia. The swallowed morsel seems to touch a sore spot, causing considerable pain. Gelsem. Warm fluids, spirituous fluids can partially be swallowed; cold drinks come up immediately. (Dr. Erwein.) Hydroph. Periodical spasms of the oesophagus, with constant painful urging to swallow, but impossibility of doing it; abhorrence of fluids, espe- cially of water; burning, stinging in the throat; cough; gagging; difficult and incorrect speech. Hyosc. Spasmodic contraction after a previous injury of the oesopha- gus; solid and warm food can be swallowed best; fluids cause spasms in the throat, stop respiration and talking; hiccough, nausea, spasmodic cough, and stiffness of the muscles of the neck. Naja trip. Spasmodic contraction of the oesophagus. Oxal. ac. When there is a great deal of burning in the oesophagus. Ver. alb. Spasmodic contraction with suffocation. Compare also the remedies under the foregoing chapter. Dilatation of the CEsophagus. Where there is stricture, the parts of the oesophagus above sometimes become dilated from the lodgment of food in that locality; but not always, because the muscular layers eject again what cannot pass down. But when these muscles lose their contractile power, a dilatation of the tube above the stricture is unavoidable. It is greatest just about and above the stenosis and DILATATION OF THB (ESOPHAGUS. 283 diminishes as it ascends. These dilatations of the oesophagus have been called Stagnation aktesice. Then again dilatations of the oesophagus have been observed without any stenosis, either of the whole canal or of only a portion of the same; they are usually widest near the middle of the tube. The wall of the oesophagus is in some cases thinned, in others thickened by muscular hypertrophy and the course of the tube is crooked, its lining membrane at times affected with erosions and ulcers, and its inner space filled with a brownish, pulpy mass, or small particles of food. " The greater number of these patients had suf- fered for many years from severe dysphagia, vomiting, regurgitation of food shortly after eating, and repeatedly from actual rumination." (Zenker and Von Ziemssen.) Of their remote cause nothing is known. A last variety of oesophageal dilatation are the Diverticula, which con- sist of protrusions or bulgings of a limited portion of the oesophageal wall, forming blind appendages to the normal canal. They are of two kinds: first, those which arise from pressure within the canal outward (Pressure diverticula,) and secondly, those in which the wall of the oesophagus is pulled out by something exercising traction from without (Traction diver- ticula.) The first are very rare and almost exclusively situated at the lowest part of the pharynx, just at the upper boundary of the oesophagus, and on the posterior wall, sometimes exactly in the median line, and some- times somewhat laterally. Here the arrangement of the muscular fibres greatly favors a separation between their bundles, as they run in parallel lines in a very thin layer, transversely, from one side to the other, without being interlaced by oblique as above, or by longitudinal fibres as below this spot. Here foreign bodies are easily lodged, the continuous pressure from swallowing does satisfactorily explain the widening out of this portion of the oesophagus. It is an affection of advanced age, and causes great difficulty in swallowing, regurgitation of food, and the consequent symptoms of star- vation. The Traction diverticula are of more frequent occurrence and always found at the anterior wall of the oesophagus, mostly at a point corresponding to the bifurcation of the trachea, or else close by, above or below it, but sometimes also higher up or lower down. The}^ are mostly funnel-shaped and of only a moderate depth. Their outside apex is grown to a firm, con- tracted tissue by which traction is exercised as from a cicatrix. The start- ing point has been an inflammatory swelling of the parts immediately ad- joining the oesophagus, leading at first to adhesion with a limited portion of the oesophageal wall and afterwards by shrinkage to a pulling out of that portion of the oesophagus. It is in fact a disease of the tracheal and bron- chial glands, especially those at the bifurcation, incidental even to childhood. They do not cause dysphagia, but their ulceration and perforation at the apex, which may be set up by irritating substances, pieces of bones, etc., collected therein, causes a destructive process in the mediastinum and in its further progress may perforate the bronchi, and cause bronchitis, gangrene 2S4 LARYNX AXD TRACHEA. of the lungs, ichorous pleuritis, pericarditis or even perforation of arterial trunks. The existence of these traction diverticula is in most cases not even suspected during life. However a frequent detention of food at a fixed spot, pretty low down, particularly the slight delay of granular food, like barley or rice, should at least direct the attention of the careful practitioner in that direction, notwithstanding such sj'mptoms may have several other explana- tions, and be sufficient reason to enjoin upon the patient the use of soft food and the habit of drinking after eating in order to wash out any remains of food from the diverticulum. Therapeutic Hints. As dilatations are frequently associated with loss of muscular contractile power, the following remedies which have proved beneficial in paralysis of the throat, should be consulted: Arsen., Bar. carb., Caustic, Conium, Calc. carb., Hepar, Iodium, Mur. ac, Stramon., Ver. alb. LARYNX AND TRACHEA. Auscultation. On putting the ear to the stethoscope, which must be evenly placed upon the larynx, we hear the rushing in and out of the air during the act of respiration much louder than on an}- other place. It may be imitated by blowing with compressed lips through the bore of the stethoscope, and is called laryngeal or tracheal respiration, for at the trachea too, it is heard in the same degree. Some authors lay great stress upon the necessity of auscultating these organs. I cannot attach such great importance to it, either diagnostically, or still less therapeutically. The only benefit afforded by auscultation in diseases of the larynx and trachea, properly so called, is the possibility of localizing by it the source of obstruction, if there be any; but whether that obstruction arise " from inflammaton' engorgement of the lining membrane, from solid effusion upon the internal surface, or from fluid effusion beneath it, or in consequence of preceding ulceration any contraction exist, either in the rima glottidis, or in the course of the trachea, which gives rise to con- striction of the tube, and thereby impedes the free ingress and egress of air, or whether a foreign bod}', fixed in the oesophagus and pressing upon the trachea, or situated in the trunk itself of the air-passages, or a tumor, or a mere spasmodic action, be the cause of this constriction — auscultation telleth not. In each of these cases the noise is usually sufficiently obvious, and the evidence of obstruction is sufficiently clear, independently of auscultation. By the stethoscope we are enabled merely to say that obstruction exists and to indicate its seat; but the nature of that obstruction is not revealed by it." (H. M. Hughes.) Inspection, Laryngoscopy, is of much greater importance. We need LARYNX AND TRACHEA. 285 for its execution a throat mirror and suitable illumination. The throat mirror is round and consists of white glass thoroughly polished and well silvered, and securely fastened at an angle of 45 ° to a strong rod, one-sixteenth of an inch thick and six inches long, which terminates in a suitable handle, five or six inches long. The size of the mirror must be suited to the capacity of the patient's throat, from four-tenths of an inch to one and a quarter inches in diameter is its boundary; the intermediate sizes, say seven-eighths of an inch in diameter, are probably the most convenient for general use. The illumination may be secured from the direct rays of the sun, from diffused daylight, or from artificial light (oil lamp, candle or gaslight). The direct rays of the sun and diffused daylight, the best of which comes from a window facing the north, thus being reflected from the northern sky need no reflectors. With artificial light, reflectors are necessary. They are either held with one hand, which scarcely ever is practiced on account of its inconvenience, or the}' are fastened upon the forehead of the examiner (compare the examination of the nose), or they are screwed, movable in ever\- direction, on the handle of the throat mirror (an invention of Dr. Els- berg, Clinical Professor of Diseases of the Throat in the University of New York), or they are added in different ways to the illuminating apparatus, generally complicated and expensive contrivances. Of all these means, Dr. Klsberg's seems the simplest and the one most easily applied. His directions for the employment of this apparatus, which he calls the pocket laryngoscope, are the following: " I will first suppose the examination is to be made in the daytime, in the absence of direct sunlight. Seat the patient with his back to the window, let him open his mouth and protrude his tongue by a strong effort of his will, and let him hold the tongue out with his index-finger and thumb of his right hand, covered by a handkerchief. As I want to give minute practical direc- tions, I must say here that a great deal of awkwardness is prevented by placing the handkerchief between the middle and index-fingers, turning it over so as to cover the index-finger and thumb spread far apart, and closing the little and ring finger upon the handkerchief; the thumb and index-finger then taking hold of the tip of the tongue, the thumb should rest against the chin, and by an outward and downward movement arch out the tongue. When the patient does not succeed in properly holding out his tongue, the examiner must hold it with his left hand. The little mirror is warmed until the film of condensation which settles upon it passes off; its temperature may be ascertained by bringing its metallic back into contact with the examiner's cheek or the back of his hand; it is then, without touching the tongue, intro- duced into the mouth, taking the uvula upon its back. Keeping the parts well illuminated by means of the reflector, on depressing the handle a little, the epiglottis will be seen in the mirror; and getting the patient to breathe deeply, say "a," laugh " hah, hah, hah! " as heartily as possible, etc., and very slightly moving the handle, the various parts of the interior of the larynx and neighboring organs will be brought into view. 286 ACUTE CATARRHAL LARYNGITIS. 11 When artificial light has to be employed, the patient should sit so that it is a little back of him, and on his right side. In all other respects the mode of examination is unchanged. The pocket laryngoscope may be used with sunlight, or diffuse daylight, or oil lamp, candle or gaslight; and in the latter case the ordinary high gas fixture answers the purpose almost as well as a drop light or stand. Ten minutes practice familiarizes anyone with its use. " For auto-laryngoscopy an extra looking-glass is necessary which, when the mouth can be illuminated by direct sun or artificial light, may be in the handle instead of the reflector; otherwise it must be placed in any convenient manner in front of the examiner." It will be well to commence practicing this little art either on one's selt or another health}* subject, in order not only to aquire the skill of intro- ducing the throat mirror and holding it in a suitable position for a full illumination of the larynx, but also on account of acquiring a thorough knowledge of the parts, their color and movements when in a healthy con- dition; abnormal condition will then at once spring into notice. Acute Catarrhal Laryngitis, Catarrh of the Mucous Lining of the Larynx. It ma}* not amount to much more than a rosy injection of the posterior ends of the vocal cords and some of the parts adjoining; it may extend to the ventricular bands (false vocal cords),- to the arytenoid cartilages, upon the epiglottis and into the trachea, causing swelling, redness and ecchymotic spots of these parts; it may even terminate in oedema of the larynx and hemorrhagic extravasation upon its free surface, or h senior rhagic infiltration of the mucous membrane and the submucous connective tissue. These dif- ferent states naturally produce different symptoms of the disease. From a mere slight huskiness of voice the hoarseness may increase to aphonia, in consequence of the greater or less swelling of the vocal cords and the parts around them, and the innervation or alteration of the laryngeal muscles. The difficulty of breathing, which in adults rarely attains to any great degree, may in children increase to gasping and struggling for breath, sim- ulating croup, wherefore the name of Pseudo-croup has been adopted by most recent writers for this state of affairs. These attacks of stenosis are due partly to the relatively great amount of swelling of the mucous membrane in comparison with the narrowness of the true and false glottis, and partly to the secretion, which dries upon the parts during sleep and increases the obstruction. The child then awakens suddenly in the middle of the night with a harsh, croupy cough and struggling respiration; the stridor, however, is solely inspiratory, and the expiration takes place noiselessly. After the secretion is liquified, these symptoms abate. The cough, too, varies in its character. We observe paroxysmal, spas- modic attacks, resembling whooping-cough, followed by a drawn inspiration, THERAPEUTIC HINTS TO ACUTE CATARRHAL LARYNGITIS. 287 also cough of various sounds and timbre, or without tone, in consequence of the greater or less swelling of the vocal cords and their adjoinings. At first it always sounds dry but becomes looser as the secretion of the inflamed parts increases. In the beginning it is very scanty, clear and transparent, some- times mixed with blood in the form of fine streaks, later it becomes more abundant and consistent, changing to yellow from the increased number of pus-cells. There is always more or less pain in the larynx, a disagreeable feeling of dryness or irritation, as if from a foreign body. Its severity does not always correspond to the amount of the inflammation; the latter may be trifling and yet its annoyance great. Difficulty in swallowing occurs only when the epiglottis and the pos- terior surfaces of the arytenoid cartilages and ary-epiglottidean folds are con- siderably implicated in the inflammation. Such an acute attack lasts in some cases from five to nine days, in others weeks, and in still others it becomes chronic. Its Causes are very numerous. A predisposition to it seems to exist in persons who perspire easily, who are weakly, cachectic, and who keep them- selves too warmly clad, or too much housed up. Exciting causes are all irritating agents, such as breathing of cold air, dust, acrid vapors, screaming, singing, etc.; taking cold; getting the feet cold; sudden exposure of the neck to cold air, etc.; catarrhs, colds in the head, influenza, pharyngitis after drinking strong drinks; persons get hoarse after debauchery, all showing a spreading from contiguous parts; and some constitutional diseases, as measles, exanthematic typhus, syphilis, and especially tuberculosis, which latter generally causes a constant disposition to "catch cold in the throat." Therapeutic Hints. Aeon. In the beginning, after exposure to cold west winds ; fever, with hot, dry skin, great restlessness and impatience. Waking up in middle of the night with croupy cough and breathing, pain in the larynx and great anxiety. Also after straining the voice in singing. Bellad. Spasmodic barking cough, waking suddenly about midnight; pain in larynx, headache, fever, drowsiness; sudden loss of voice. Bromium. Rough, scraping feeling in the throat, with oppression of breathing; husky, hoarse voice; croupy cough; fair skin. Bryon. Cough worse from motion, from entering a warm room, and with pain in pit of the stomach. From changes in the weather, either to warm or cold. Calc. carb. Teething infants; rachitic children. Cough during sleep. Carb. veg. Hoarseness worse in the evening; cough coining in spells, usually far apart. Caustic. Entire loss of voice, or great hoarseness, worse in the morn- ing, with rawness and burning in the throat. 288 LARYNGITIS CATARRHALIS CHRONICA. CJiamom. Continued dry cough from tickling in the larynx, worse at night; cough during sleep; feverishness; restlessness; impatience; irritable- ness. One or both cheeks flushed; hot perspiration about the head. Droscra. Constant tickling in the larynx, causing cough and prevent- ing sleep at night, ist dil. in water. ( Baumann.) Dulcam. When the trouble gets renewed on every sudden change of the weather from warm to cold. Hcpar. Croup}' cough, worse in the morning; hoarseness; in fall and winter from dry, cold west winds. Iodiitm. Tickling cough; husky voice; constriction of larynx; worse in morning. Ladies. Dryness in throat; sore spot on left side of larynx; feeling as of a lump in the throat; choking sensation in the throat; cough excited from talking, laughing; irritation as if in pit of stomach. Mercur. Chilliness during the fever whenever moving the feet to a cool place in bed; easily perspiring without improvement; cold in the head. Nux vom. In the commencement with chilliness, headache, stoppage of nose. From exposure to draughts, or sitting in a cold room. Phosphor. Constant tickling cough from the larynx, also with head- ache, as though it should burst; cough dry; worse from evening until mid- night, with tightness across the chest. Pulsat. Chilly, thirstless; worse in the evening and in a warm room. Rhus tox. Tickling under the middle of the sternum; worse from talk- ing or laughing; pain in all the bones worse when being quiet. After strain- ing the voice in singing or speaking. Rumex. Dry cough in paroxysms, induced by hurried or deep inspira- tions, speaking, inhaling of colder air than usual, or any pressure upon the trachea in the pit of the throat. Sanguin. Highly recommended by Dr. Nichol. Spongia. Fever and irritation in throat, with hoarse, croup}' cough, worse from evening; breathing wheezy; spells of choking in the middle of the night. Tart, enict. Rattling cough and breathing; trembling pulse; sticky perspiration; no thirst; pale face; peevishness; drowsiness. Laryngitis Catarrhalis Chronica. The chronic catarrh of the larynx results often from continued exposure and neglect of an acute attack, or from a continuous series of irritations by overexertion of the voice in talking and singing, or from a chronic pharyn- gitis in consequence of the abuse of tobacco and alcoholic stimulants. We find swelling and injection of the mucous membrane either limited to certain parts, or diffused over the whole organ, with a velvety sponginess of its lining membrane. The redness shows less distinctly on the vocal cords than upon the other portions of the mucous membrane; the swelling and THERAPEUTIC HINTS TO LARYNGITIS CATARRHALIS CHRONICA. 289 thickening of the vocal cords give to their surface a granulated, and to their edges an uneven appearance. The tumefaction of the epiglottis or of the ventricular bands, or of the ary-epiglottidean folds, amounts sometimes to distortion of these parts. With all this the affected parts are usually covered with dilated veins. Ulcerations, except in follicular inflammation, perichondritis and oedema, are very rare results of this disease, but on the other hand, secondary chronic laryngitis almost always accompanies syph- ilis, ulcerative processes, neoplasms, traumatic irritations and perichon- dritis. This state of things necessarily causes various alterations of the voice from slight huskiness, to deep hoarseness and loss of tone. It is always at- tended with clearing, hemming and hawking, when speaking, on account of the collection of phlegm in the throat, and the sensation of something there that ought to be removed. The secretion is either clear, transparent or whitish -gray, frothy with minute bubbles, or viscid, ropy or yellowish from numerous pus-cells. There is also more or less cough excited by the laryn- geal irritation, which, like the voice, is hoarse and of an unusual timbre. The subjective sensations are mostly those of rawness, scraping, soreness and burning in the larynx, aggravated by use of the voice. Therapeutic Hints. Any of the remedies detailed under the foregoing chapter may be indi- cated here. Besides these, one or the other of the following may be re- quired: Arg. nitr. Pharyngo-laryingeal catarrh. Weakness and tremulousness; palpitation of the heart. Arsen. The lining of the larynx more or less injected, puffy or swollen; voice oftener husky than hoarse, or dull without resonance or timbre. Sen- sation of dryness, fatigue and tickling in speaking; burning in throat. Delicac}^ of constitution; disposition to tubercular deposits. Calc. carb. The lining of the buccal cavity extremely pale; soft -palate and pharynx covered with dilated veins, coloring the parts bluish; throat dry, tongue white. Speaks in a whisper; an attempt to talk loud gives a muffled sound and causes a short, hoarse barking cough; cough worse from evening till midnight. Complexion waxy; lips almost white; face puffy, particularly the eyelids, with dark rings around the eyes; hands and feet cold and moist. listless disposition; disagreeably impressed by music and noise; inability for mental or physical exertion, so weak, is hardly able to walk; exertion causes palpitation and breathlessness; night sweats. Carb.veg. Swelling of the vocal ligaments; the lining of the larynx, and particularly of the ventricular bands, of a dingy purplish tint; hoarse- ness w T orse in damp weather and in the evening; loss of voice; expectoration moderate; lumpy and easy. Reduced vitality; venous capillary dilatation of pharyngo-laryngeal parts, and prevailing torpor of all functions, cold knees in bed. 19 29O DIGEST TO ACUTE AND CHRONIC LARYNGITIS. Caustic. Loss of voice; great hoarseness, worse in the evening; as soon as he tries to raise his voice to a higher pitch, it gives ont, or becomes a squeak. Hoarseness of singers and speakers. Hepar. Tuberculous disposition; scanty, tenacious, mucopurulent secretion, with difficult expectoration. Seated pain in one spot of the larynx, aggravated by pressure, speech, cough and breathing. Iodium. Follicular catarrh, with ulceration; constant tickling cough. Great hunger and yet emaciation. Kali bichr. Pharynx bluish and with varicose veins; the vocal cords and the posterior parts of the larynx are red and puffy and covered with grayish mucus; sensation of dryness; tickling in larynx when speaking; voice rough and hollow; cough, with scant}-, stringy expectoration, pro- voked by speaking or laughing. Kali hydr. Arytenoids of a purplish color, tumefied and granular; fol- licular ulceration; voice hoarse; sounds above the middle key impossible; dry cough; sensation of dryness; burning and tickling in larynx. Mangan. Venous dilatation in the throat and pharynx; partial injec- tion of the ventricular bands; hoarse voice in the morning, better after clear- ing up lumpy mucus; weak, anaemic individuals with disposition to tuber- culosis. Natr. mur. Follicular inflammation of pharynx; after swabbing the throat with Nitrate of silver. Nitr. ac. Ulcers in the larynx; toneless voice; previous mercurial abuse. Phosphor. Lining of vocal cords highly injected with ulceration; sup- pressed voice; talking provokes tickling in larynx and spasmodic cough, fol- lowed by great dryness and burning in the throat. Sanguin. Sensation of dryness, soreness and swelling in the larynx, and expectoration of thick mucus; redness in the throat; stoppage of the nose, with headache across the eyebrows. Sulphur. Cough in the evening, before and when going to bed; catarrh of other mucous membranes; disposition to skin affections; suppressed eruptions. Digest to Acute and Chronic Laryngitis. LOCAL SYMPTOMS. , scraping, rough with oppressed breathing: Bromium. irritation: Spongia. red and swollen: Mercur. Pharynx red: Sanguin. , catarrh: Arg. nitr. . follicular inflammation: Natr. mur. ulceration: fodum, Kali hydr. ~? h " ° f * ^^ Ch ° king: , venous dilatation, bluish color: Calc. aces. l /- / z^ i-i;.u^ ir„.,,„„., , spell of chokinsr, in middle of nieht: carb., Carb. veg., Rah bichr., Mangan. c ■ Throat dry: Arscu., Calc. carb., Laches., tyongia ^ Larynx, dryness, burning and tickling: Kali bichr., Kali hydr. Phosphor. Throat burning: Arsen. and raw: Caustic. , soreness and swelling: Sanguin. , constriction: loduni. DIGEST TO ACUTE AND CHRONIC LARYNGITIS. 2QI , pain: Aeon., Bellad. , seated sore spot, worse from pres- sive cough, speech and breathing: He par. , sore spot on left side: Laches. , injected, puffy: Arsen. , ulcers: Nitr. ac. Vocal cords, swelling: Card. veg. , injected and ulcerated: Phosphor. , red and puff}* and covered with grayish mucus: Kali bichr. Ventricular bands, injection: Mangan. and purplish: Card. veg. Arytenoids, purplish, tumefied, granu- lar: Kali hydr. Voice, loss of: Card, veg., Caustic. , sudden: Bellad. , toneless: Nitr. ac. , whisper: Calc. card. , rough and hollow: Kali bichr. , suppressed: Phosphor. , husky: Bromium, lodum. and hoarse: Bromium. , oftener than hoarse; Arsen. , dull without resonance or timbre: Arsen. , sounds above middle key, impossi- ble: Kali hydr. , raising voice to a higher pitch, it gives out, or becomes a squeak: Caus- tic. hoarse: Bromium, Hepar, Kali hydr. , worse in evening: Carb. veg. , worse in morning: Caustic. , worse in morning, better after clear- ing up lumpy mucus: Mangan. , worse in damp weather: Carb. veg. of singers and speakers: Caustic. Breathing", wheezy: Spo?igia. Cough, worse from evening till midnight: Calc. carb., Phosphor., Spongia. , barking, spasmodic, waking about midnight: Bellad. , croupy: Bromium, Spongia. , worse in morning: Hepar. , waking up in middle of night, with pain in larynx, anxiety, fever: Aeon. dry: Kali hydr., Phosphor. in paroxysms: Rumex. from tickling in larynx: Chamom. , tickling: lodum. from larynx: Dorsera, Phosphor. under middle of sternum: Rhus tox. , with headache, as though it should burst: Phosphor. , followed by great dryness and burn- ing in throat: Phosphor. , with pain in pit of stomach: Bryon. , with expectoration, lumpy and easy: Carb. veg. of thick mucus: Sanguin. scanty and stringy: Kali bichr. and tenacious, muco-purulent: Hepar. from irritation in pit of stomach: Bryon., Laches., Pulsat. , excited by laughing: Kali bichr., Laches., Rhus tox. , by speaking, talking: Arsen., Calc. carb., Kali bichr., Laches., Phosphor., Rhus tox., Rumex. , by hurried or deep inspiration, or inhaling colder air than usual: Rumex. by motion: Bryon. by pressure upon the trachea in pit of throat: Rumex. by entering a warm room: Bryon. is worse in the morning: Lodum. in the evening, before and when going to bed: Pulsat., Sulphur. from evening until midnight: Phos- phor., Spongia. at night: Chamom. during sleep: Calc. carb., Chamom. in spells usually far apart: Carb. ATTENDING SYMPTOMS. Inability for mental and physical exer- tion: Calc. carb. Disagreeably impressed by music and noise: Calc. carb. Irritable: Chamom. Impatient: Aeon., Chamom. Peevish: Tart. emet. Restless: Aeon.,, Chamom. Listless deposition: Calc. card. Headache: Bellad., Nux vom., San- guin. Cold in head: Mercur. Stoppage of nose: Nux vom. with pain across eyebrows : Sanguin. Face pale: Tart. emet. puffy, particularly eyelids, with dark rings around: Calc. card. waxy, lips almost white: Calc. card. 292 CROUP. , fair skin: Bromium. Cheeks, one or both flushed: Chamom. Teething: Bellad., Calc. card., Chamom. Tongue white; buccal cavity very pale: Calc. carb. No thirst: Pulsat., Tart. emet. Hunger and yet emaciation: Iodum. Tightness across the chest; Phosphor. Tuberculosis disposition: Arsen.,Hcpar, Mangan. Palpitation of heart: Arg. nitr. and breathlessness caused by exer- tion: Calc. carb. Pulse trembling: Tart, evict. easy without improvement: Mercur. sticky: Tart. emet. Night-sweats: Calc. Catb. Pain in all the bones, worse when quiet: Rhus to.v. Weakness, can hardly walk: Calc carb, and tremulousness: Arg. Nitr. and anaemic: Mangan. Torpor of all functions: Carb. veg. Vitality reduced: Carb. veg. Delicacy of constitution: Arsen. Drowsiness: Bellad., Tart. emet. Chilliness: Pulsat. in the commencement: Nux vom. during fever, whenever moving the feet to a cool place in the bed: Mer- cur. Cold knees even in bed: Carb. veg. Cold and moist hands and feet: Calc. carb. Fever: Bellad., Chamom., Spongia. , with hot and dry skin: Aeon. Perspiration about head: Calc. carb. hot: Chamom. Rachitic children: Calc. carb. Catarrh of other mucus membranes and disposition to skin affections: Sulphur. Laryngitis brought on by exposure to cold west winds: Aeon., Hepar. , draughts, as sitting in cold room: Nux vom. by any sudden change from warm to cold: Bryon, Dulcam. from cold to warm: Bryon. from mercurial abuse: Nitr. ac. , abuse of nitrate of silver: Xatr. mur. , suppressed eruptions: Sulphur. Feels worse in a warm room: Pulsat. Croup. The two affections belonging under this heading are Pseudo-membra- neous Laryngitis, or True croup, and Acute Catarrhal Laryngitis of children, known as False, or Spasmodic croup. In the first, pseudo-membranous, or croupous laryngitis, there is formed fibrinous exudation upon the mucous surface, which coagulates and forms a false membrane, loosely attached, but frequently regenerated. It is there- fore nearly related to diphtheria, which in some cases also extends to the larynx, causing all the sj'mptoms of true croup. It differs, however, from diphtheria, in that the exudation never leaves scars behind. In diphtheria, especially in severe cases, the mucus membrane as well as the submucous tissues are destroyed, and cicatrize on healing. Croup may commence in the fauces and extend downwards, or in the larynx and spread upwards. In al- most all cases there is a hypersemic state of the whole mucous membrane of the trachea and bronchial tubes, which at times terminates in a croupous ex- udation in these parts. Ocular inspection reveals the pseudo-membrane in the fauces, if it com- mences or extends there; laryngoscopy is in most cases impossible; ausculta- tion reveals nothing but what we can hear, even at a distance — labored breathing with a sawing sound. CROUP. 293 Croup generally attacks children in early childhood, — from two to seven years, and seldom more than once. Its Premonitory Signs consist at times in peevishness, feverishness, soreness of the throat, inflammation of the tonsils and fauces, with patches of exudation, as in diphtheria. In other cases there are no such forebod- ings. The child is aroused suddenly from a sound sleep, generally about midnight, by a hoarse, dry, croupy cough. It exhibits restlessness and fright, and frequently puts its hands to the windpipe. Soon, however, it falls asleep to be again . awakened by the same dry, hoarse cough, alter- nating in this wa.Y until morning, when usually a remission takes place, and the child seems to be lively and playful. When evening approaches, the child becomes worse again, and, in addition to the cough, we observe that the breathing is becomming impeded between the coughing spells. Not only can we see the labored action of the respiratory muscles, but we can also plainly hear a sawing noise, which the ingress and egress of the air causes in the stuff ed-up air-passages. This difficulty increases from hour to hour. The child involuntarily bends its head and neck backwards, in order to free the windpipe as much as possible from all pressure; the alae nasi move strongly up and down like wings; the epigastric region does not, as is usual during the act of inspiration, bulge out, but is drawn in, in consequence of a defi- ciency of air in the lungs on account of the obstruction in the larynx. For the same reason we find the xiphoid process and the cartilages of the lower ribs during inhalation drawn strongly inwards, instead of gliding gently downwards, as is natural. When we find inhalation and exhalation equally difficult, there is surely coagulated exudation around the glottis; when, how- ever, as is sometimes the case, only the inspiration is difficult and expiration easy, it is probable that the difficulty does not lie in the presence of a pseudo- membrane, but in a paralytic state of the muscular structure of the glottis, whereby the epiglottis, during inspiration, is not lifted up from the glottis, thus hindering the free ingress of air; while during exhalation the paralyzed parts easily give way to the returning stream of air. Thus the child struggles terribly for air; stis up, wants to be carried about, until from sheer exhaustion and the carbonized state of the blood, it sinks into drowsiness and stupor. The face, being at first red, grows pale, finally cyanotic and is covered with cold sweat; the pulse, at first quick, hard and strong, grows very frequent, small, irregular, intermitting, until at last this fearful scene is closed by general paralysis or suffocation. The temperature may not exceed 101.3 F. in some cases, while in other, especially in complications with bronchitis or pneumonia, it may rise from 104 to 105. 8°. In those cases in which dissolution of the false membrane, or the tear- ing, loosening and ejection of it, permits recovery, we frequently find a long- continued hoarseness, caused by catarrh of the larfnx, or bronchitis or pneumonia, the latter being complications which did already exist during the attack, and made it so much the more serious. 294 THERAPEUTIC HINTS TO CROUP. Secondary croup occurs during the course of acute, infectious or gen- eral constitutional diseases. Of the acute exanthemata, Measles is the one most frequently complicated with it, and especially during the stage of desquamation, while false-croup occurs usually as a prodromal symptom of measles. Some authors have observed secondary croup during the height of whooping-cough, and in the course of typhoid fever, pneumonia and cholera. True croup is most readily confounded with Acute Catarrhal laryngitis or False-croup ; the latter, however, is frequently attended with other catar- rhal symptoms, such as sneezing, coryza, etc., and apt to occur frequently. Diphtheria is thought by some writers (Wagner and others) not to be an essentially different affection from croup, and that there is no sharp dividing line between the two. But if we take into consideration that in croup the exudation takes place upon the free surface of the mucous membrane, and in diphtheria also within it, causing necrosis and loss of substance, that diph- theria is contagious while croup is not, and that in many cases of diphtheria a peculiar penetrating smell from the mouth claims at once our attention, we shall hardly find an>- difficulty in distinguishing between the two, notwith- standing the close similarity of symptoms betweed them. The Prognosis of true croup is much more favorable under homoeo- pathic treatment than undei allopathic. ' ' While practitioners of the old school of known ability and honesty confess to the most dreadful losses ' ' (Steiner), we of the Hahnemannian school have a right to boast of brilliant cures, if boasting it be when physicians of ' ' known ability and honest}- ' ' state their successes. How a man like Johann Steiner can call these men swindlers and ignoramuses, men who at least in therapeutic science stand far above him, is explainable only when we understand the beclouding influence of bigotry over sound judgment. Therapeutic Hints. Acid. ac. Has been used succesfully by Dr. Krebs. I have found it curative in a case that did not yield to other remedies, and which was characterized by a remarkable bright redness of the face. From five to ten drops of acetic acid in half a tumblerful of water with some sugar make a pleasant acidulated drink. I gave a teaspoonful of it every two or three hours with speedy effect. Aeon. High fever, dry skin, restlessness; the child is in agony, impa- tient and throws itself about. Arsen. Worse about midnight; great restlessness, notwithstanding prostration; bloated face, covered with cold perspiration. Bellad. Sawing* whistling breathing, frequent barking, croupy cough; skin dry and hot; face red; pulse full and sharp; very restless; tonsils red and swollen; patches of exudation on the fauces; midnight attacks. THERAPEUTIC HINTS TO CROUP. 295 Bromium. When after Spongia aggravation again sets in next evening; especially in children with blue e3 y es and light hair. Calc. carb. In a case of marked calcarea constitution. (H. V. Miller.) Cct7ithar. In cases where the voice was entirely gone, and there was whistling breathing and tossing about in bed with the greatest agony. Caustic. Sensation of rawness in the larynx. (E.C.Price.) Hepar. Cough worse in the morning; mucus rattling and yet no get- ting rid of the phlegm; hoarseness; dry, barking cough; the child cries when coughing; after exposure to cold west wind. Iodium. As Bromium follows well after Spongia, so does Iodium after Hepar; cough worse in the morning, rattling and not getting loose; hoarse- ness; especially in children with black eyes and dark hair. Kaolin. First recommended by Aegidi; it seems to be especially indi- cated where the croupous inflammation has its seat in the lower portion of the larynx or in the upper part of the trachea, which may be recognized by the much more laboring and sawing respiration. (I. I^andesmann. ) Kali bichr. Worse early in the morning; inflamed fauces; membranous deposition; hoarseness; fat, chubby children. Laches. The child cannot bear anything touching its throat; aggrava- tion in the afternoon, after and during sleep; patches of exudation in the fauces; commencing paralysis of the lungs. Lycop. Spasmodic motion of the alae nasi; crossness after sleep; can't bear to be covered. Phosphor. In combination with bronchitis; great weakness; aggrava- tion evening up to midnigh; lying on back provokes the cough. Sanguin. In a case with whistling cough, or of metallic sound, as though coughing through a metallic tube. Spoyigia. Very dry, crowing sound of cough; always commencing to get worse in the evening; sawing sound of respiration even during remis- sion. Tart. emet. Face cold, bluish, covered with cold perspiration; pulse very frequent; rattling as if the chest and trachea were full of mucus with- out expectoration; great sinking of strength; commencing paralysis of the lungs. Von Grauvogl advises: Cuprum. When spasmodic affections, such as asthma spasmodicum, whooping-cough, chorea, or cholerine, etc., are prevalent (epidemic) at the time with other people. Ipec, Iodium or Bromium, when intermittent affections prevail. Hepa? . When panaritise, anginse, urticaria or erysipelas are the pre- vailing diseases. Schussler advises: Kali mur. At first, or Fer?. phosph. When there is violent fever. Calc. sulph. I^ater, if required. 296 CEDEMA GLOTTIDIS. Kali phosph. In cases coming too late under treatment, with great weakness, pale bluish face, etc. Tracheotomy. — "Out of quite a large number of cases occurring in my practice, before I had adopted the operation of tracheotomy, I saw but three recoveries; since 1863, however, this discouraging rate has been so much improved by the employment of tracheotomy that the mortality has at dif- ferent times amounted only to sixty, sixty-five and seventy per cent. Bricheteau states it at sixty-nine, Franque at sixty-eight. Trousseau at fifty, and Greve in Sweden at twenty-three per cent." (Steiner. I >c Among the 1,698 cases of tracheotomy collected by Ducheck, a favorable result occurred in 428 operations, a proportion of 1 to 3.9 (25.2 per cent.;, which is probably the correct average." (Steiner.) " In fatal cases of croup, where the symptoms consist of great dyspnoea, pallid face and lips, cold extremities and very feeble pulse, post-mortem examination will disclose fibrous deposits in the heart, and such cases, if operated upon, are sure to die; while if there be turgescence and lividity of the face, with blueness of the lips, accompanied with extreme dyspnoea, the obstruction is evidently in the trachea, and the case, therefore, offers much greater hope of recovery by operation." (Dr. Richardson, of London.) " Tracheotomy is no more curative of croup than are emetics; it cannot even arrest the croupous process; its only office is to establish a new provi- sional air-passage, while the danger of death from laryngeal stenosis lasts, and to assist Nature in her efforts to cure; and no other means fulfil these indications so certainly and so directly." (Steiner.) In short, although tracheotomy is not a sure cure for croup, it may in violent cases procure time for the selection and action of the medicine which finally will subdue the croupous process and thus be a means of saving the child. This is applicable even to Homoeopathic treatment. (Edema Glottidis, CEderaa Laryngis Consists of a serous or sero-purulent infiltration of the submucosa, following either inflammatory or non-inflammatory processes. The inflammatory form has been designated as Laryngitis phlegmonosa. embracing all such inflammations of the larynx which have their seat princi- pally in the submucous connective tissue. It is always of a secondary nature, and may be the consequence of a catarrhal laryngitis when renewed attacks or new injuries spread the inflammation in depth to the submucous connective tissue, or it is connected with laryngeal diphtheria, or the conse- quence of chemical or thermal irritants or mechanical irritations by foreign bodies; or it is an extension of inflammatory processes from neighboring parts, such as wounds of the larynx and its vicinity, or retro-pharyngitis, tonsillitis, pharyngeal diphtheria, angina Ludovici and parotitis. The most frequent cause is inflammation of the perichondrium of the laryngeal car- tilages, in consequence of tuberculosis, syphilitic, typhous and carcinomatous ulcerations. At last we find it in connection with pyaemia and septicaemia, THERAPEUTIC HINTS TO (EDEMA GEOTTIDIS. 297 with ulcerative endocarditis, typhus, variola, scarlatina, measles and ery- sipelas. The inflammatory process may be diffuse, or limited to the aryteno- epiglottideau folds, and is then more marked on one side than on the other; it affects the submucous tissue of the vocal cords alone only rarely, and exists below the cords still more rarely. The non-inflammatory form, a simple, serous infiltration of the submu- cosa, or dropsy, is either apart of general dropsy, in consequence of nephritis, malarial cachexia, amyloid degeneration of the kidneys, etc. ; or a dropsical manifestation from diseases of the heart, emphysema and cirrhosis of the lungs; or the result of compression of the superior and inferior thyroid, or facial, or internal jugular and the innominate veins by enlargement of the thyroid gland, or the swelling of the lymphatic and salivary glands, or by new formations about the neck, aneurism of the aorta, etc. The oedema will be unilateral or bialateral, according to the site and extent of the hindrances to the circulation. The cedematus parts appear pale or pale red, translucent and flabby; the mucus membrane is neither injected nor swollen. By means of the laryngoscope, we can best decide the nature of the affection. The most prominent symptom of either form is Laryngeal dyspnoea, which at first is only inspiratory, while the expiratory stream of air passes the larynx without any difficulty. The reason of this is, that during inspi- ration, the air presses the swollen parts around the introitus laryngis together, thus closing its aperture, while during expiration the out-rushing air pushes them asunder. However, this difference ceases when the infiltration spreads to the aryteno-epiglottidean folds, to the epiglottis and the superior cords. There is also hoarseness and barking cough. The intensity of the laryngeal stridor depends always on the grade of swelling of the soft parts, and it ter- minates in suffocation if the obstruction can not be relieved. The inflamma- tory form may result in abscesses or ichorization. Therapeutic Hints. In general I must refer to the various causes of this affection above de- tailed. In special compare: Aeon. Apis. When it occurs in connection with erysipelas or eruptive fevers. Arse?i. When in connection with general dropsy, following kidney dis- eases, etc., with great restlessness and prostration. Arum triph. When in combination with diphtheria or scarlet fever. Bellad. Sudden attack; fauces deep purple; all the parts of the larynx cedematously swollen; pain deep in throat; stiff neck; wild expression of eyes; great prostration. One drop of tincture in pint of water, by teaspoon - fill. (P. J. Valentine.) Canthar. When in consequence of burns. China. When in connection with drops}-; inspiration short and difficult , expiration easy. 298 PERICHONDRITIS LARYNGEA. Laches. When in connection with albuminuria; dark, almost black urine, like coffee-grounds. Phosphor. In connection with heart disease. Sanguin. Tonsils and pharynx swollen; sawing, rasping respiration; expiration easier than inspiration; cough dry and harsh, relieved by sitting, aggravated by eating or lying down; difficult expiration of tough, glairy mucus; inflammation of cervical glands. 1st trit. (Th. Nichol.) Swallowing of small pieces of ice has been found beneficial b}~ Niemeyer in the inflammatory form. If in bad cases medicine does not quickly relieve, scarification of the swelling must be tried, and if that does not succeed, tracheotomy is the only means to prevent suffocation and gain time for further medical treatment. Perichondritis Laryngea. The inflammation of the perichondrium of the laryngeal cartilages is not easih' recognized in the beginning, because pain, swelling, cough, hoarseness and laryngeal stenosis are symptoms of various laryngeal affections. When, however, the inflammation has reached the stage of an abscess which has broken, a diagnosis may be more readily formed. The cartilages most liable to be affected are the cricoid and the arytenoids. If it be the cricoid, the swelling will be found on the posterior wall of the laryngeal opening, or when seated in one of its lateral portions, somewhat towards the one or the other side of the posterior wall; if it be one of the arytenoid the swelling will be seen more anteriorly either on the right or the left side in the neighborhood of the cartilages of Santorini and Wrisberg. Thyroidal perichondritis may exist either on its inner surface, or pene- trate to its outer surface and form a larnygeal fistula. Perichondritis of the epiglottis is of rare occurrence, usually in connection with the same process in the cricoid and thyroid cartilages, or with other ulcerative processes. The Causes of laryngeal perichondritis are various. It may arise from traumatic influences, for instance from the frequent introduction of the oesophageal sound in old persons; from tuberculus, typhous, syphilitic or cancerous ulcerations; from primary laryngeal chondritis. Therapeutic Hints. All in all the disease being more of a secondary nature, the accompany- ing primary disease will have to be studied first; therefore a number of remedies will offer themselves for consideration. As acting especialry upon the cartilage, Yon Grauvogl designates Silk. In cases where the abscess closes the larynx, tracheotomy will have to be resorted to. Phthisis Laryngis, Tubercular Ulceration. As a rule, tubercular ulceration of the larynx is secondary to pulmonary tuberculosis and co-existing with it; in exceptional cases it may precede pul- THERAPEUTIC HINTS TO PHTHISIS EARYNGIS. 299 monary manifestations, at least palpable ones. Commencing with slight hoarseness, lack of ring and easy giving way of the voice on taking a slight cold, which, however, gradually subsides, the trouble is often overlooked. The laryngoscope shows at this time partial injection and swelling of the vocal processes, of the inter-arytenoid region and the cartilages of Santorini. In other cases there is a striking anaemia of the mucous membrane and not seldom paresis of the muscles. Gradually by renewed colds, ulcers form on these places; they may be single, they may spread to the epiglottis and to the ventricular bands and vocal cords, and form an extensive ulceration all around the glottis. The hoarseness increases, often to total aphonia; the cough is generally without tone or power, and there is usually soreness on swallowing, and burning and stinging pain in the region of the larynx. The ulcers of phthisical subjects present no characteristic signs by which they could be recognized as such, we must consider the whole history of the case (whether there be any syphilitic taint) and its present state (co-existing pulmonary tuberculosis), in order to form our diagnosis. The Prognosis is that of tuberculosis in general, a poor one; still, if the course of the disease is slow, and the frequency of the pulse does not, for any length of time, exceed 96 to 100; if the ulceration is not too extensive and the co-existing tubercles in the lungs are not in an extensively softening process, and no new infiltrations occur, and also if the patient can and does implicitly follow our advice, we surely will be able by a careful study of the case to prolong life, at least. Therapeutic Hints. The treatment of pulmonary tuberculosis must be studied. For the prominent laryngeal symptoms, compare Laryngitis Chronica; besides con- sider: Arg. 7iitr. Swelling of the parts; ulcers with luxuriant granulations; titillation in the larynx; much hawking, or spasmodic cough, and accumu- lation of phlegm. Arsen. "Dirty red, or anaemic appearance of the laryngeal lining, with bluish-red patches, or general discoloration of the tissues; indolent, or burning extensive ulceration, with more or less sero-purulent secretion. Pulse small and feeble; progressive emaciation and weakness." (Meyhoffer.') Bellad. For intercurrent "colds," with difficult and painful degluti- tion; spasmodic or barking cough. 300 SYPHILIS LARYNGIS. Carb. an. Greenish expectoration ; lungs affected, especially right side; enlarged glands; copper colored spots on face and bod}*; earthy colored face; great exhaustion. Carb.veg. Evening hoarseness; bloatedness; rancid belching; the most innocent food disagrees. Great tendency to perspire about the chest and to take cold on least change of temperature; knees always cold but especially at night in bed. Iodium and Kali hydr. In scrofulous subjects; follicular swelling of throat; extensive ulceration. Laches. Ulceration on left side of glottis; bluish inflammation of fauces; voice and cough without tone. Merc. jod. , after Be/lad. ' ' Dark red inflammation and swelling of the parts with much hawking, coughing and purulent expectorations worse in the morning." (Meyhoffer.) Nitr. ac. ' ' Great irritation; redness and ulceration of the epiglottis and larynx, with difficult and painful deglutition, violent dry cough and nocturnal perspiration . ' ' ( Meyhoffer . ) Phosphor., Sepia, Silic, Stramon., and Sulphur ought not to be over- looked. Syphilis Laryngis May consist of a mere Catarrh, scarcely distinguishable from an ordinary catarrh; or of Condylomata, which are flat wart-like papules, with a thick, whitish-gray, adventitious covering of epithelium; or of Gummy tumors or Syphilomata, consisting of little roundish swellings of the size of a pinhead to that of a small pea, usually of the color of the rest of the mucous membrane, and frequently found in rows; or of actual Ulcers of various extensions and depth. The diagnosis of all these must be made from the history of the case, from the evidence of other syphilitic affections, especially in the phar- ynx, on the skin and in the bones, and by the laryngoscope. Ulcers may lead to syphilitic perichondritis, to haemorrhages and papillomata, which often form in the vicinity of syphilitic cicatrices. Therapeutic Hints. Aurum. Accompanied by ulcers on the roof of the mouth; previous mercurial treatment; affections of the bones. Merc. sol. When ulcers appear also on the tonsils. Merc. jod. Painless ulcers. Kali hydr. Previous mercurial treatment. Kali bichr. Ulcers on the soft part of the fauces. Nitr. ac. Painful ulcers; abuse of mercury; condylomata. Thuja. Condylomata. Neoplasms of the Larynx. Of these, the Papilloma or Fibroma papillare occurs most frequently; it is a proliferation of the connective tissue, commencing by preference on the NEUROSES OF THE LARYNX. 301 anterior extremities of the vocal cords. The Papillomata are in fact hyper- trophical- papillae, covered with a thick layer of epithelial cells. Their size and form varies, representing either little buttons or pegs, or warty forma- tions like a cock's comb; in some cases they attain to huge growths similar to a berry, grape, or cauliflower, which may partly or entirely fill the upper and middle laryngeal cavity. The Fibroma, or Fibrous polypus is also of frequent occurrence, appears mostly single, rarely multiple, takes its origin on the vocal cords. It pre- sents itself as a little, generally pedunculated, roundish or pear-shaped tumor, of a dirty whitish or reddish, or dark red color, sometimes with dis- tinctly branching vessels on its surface. Its size may attain to that of a hazel-nut, and its consistence is either hard or soft. Fibrous polypi usually are of slow growth. Mucous polypi and Cystic tumors are of not so frequent occurrence. They take root in the ventricle of Morgagni by preference, being attached to a broad base; they grow slowly and seldom attain an}^ considerable size. When incised, they slowly empty their more or less thickened contents. Cancinoma or Cancer occurs tolerably often within the larynx, and especially in its epithelial form. Its seat is almost invariably the upper and middle portion of the laryngeal cavity. laryngoscopy examination seldom shows very characteristic conditions at the beginning, especially in those cases in which cancerous infiltration into the submucous tissue produces a uniform intumescence of the soft parts, with strong vascular injection of the mucous membrane. I^ater, however, when the intumescence becomes con- siderable and extensive ulceration takes place, with enlargement of the lymphatic glands of the neck, and an extension of the morbid process to the pharynx or oesophagus, its diagnosis is easy enough. Therapeutic Hints. Usually, that is since the laryngoscope has been in use, the neoplasms have been treated surgically either by cauterization or by extirpation, or by still more complicated surgical operations. We are sadly in want of observa- tions gained by pure homoeopathic treatment. If it, however, is beyond doubt that similar morbid growths on other parts of the body have been removed by the administration of homoeopathic remedies alone, there is no reason why a similar treatment should not succeed in these cases. Compare, for instance, polypi in ears, nose, etc. For cancerous disorganization even extirpation is of no avail. Neuroses of the Larynx. These are either neuroses of sensation (anaesthesia* or hyperesthesia, neuralgia of the laryngeal mucous membrane), or of motion (paralyses or spasms of certain muscles of the larynx). Ansesthesia, or diminution or total extinction of sensibility in the laryn- geal mucous membrane, is an ordinary symptom of approaching death; it 302 THERAPEUTIC HIXTS TO NEUROSES OF THE LARYXX. occurs in diphtheritic paralysis of the organs of the throat, and at times in hysteria. Its degree and extent vary, and can only be ascertained, by care- fully testing the parts by the probe under guidance of the laryngeal mirror. Therapeutic Hixts. — Argent., Gelsem., Kali brom. Electricity. Strychnine. Hyperesthesia and Neuralgia occur most frequently in inflamniatory and ulcerative conditions of these parts. When it is a symptom of general nervousness, as in hysteria, it is frequently attended with a spasmodic cough of longer or shorter duration, and at times periodically recurring at a given hour. Hypochondriasis, too, especially in persons suffering from seminal emissions, is at times attended with great sensitiveness of these parts. Therapeutic Hints. Ignat. Meets frequently the hysterical cough. Other symptoms must necessarily be taken into consideration. If in connection with inflammatory conditions compare these. Paralysis may be bilateral in consequence of a paralysis of the trunk of the recurrent of both sides. The recurrent innervates all the muscles con- cerned in the locomotion and tension of the vocal cords, except the crico- thyroid muscles. Such a paralysis is therefore characterized ' ' by absolute loss of voice; inability to cough or expectorate with force; undue expendi- ture of breath on making attempts at phonation, or at forcible expiration, for instance in coughing; the absence of dyspnoea during quiet breathing, at least in adults; laryngoscopically, the cadaveric (widely opened position) of both vocal cords, the edges of which still further approximate each other on forced inspiration." (Von Ziemssen.) It may be unilateral when the trunk of the recurrent of one side only is paralyzed. This causes the voice to lose its ring and become impure (rattling), being rendered so by tremors; on straining it in speaking loud, the voice readily breaks into a falsetto, and the patient becomes wearied. The vocal cord of the paralyzed side remains motionless during phonation, while the healthy cord and arytenoid cartilage pass over the median line. When the posterior crico-arytenoid muscles, the office of which is that of widening the glottis during respiration, become paralyzed, the inspirator}' opening of the glottis is extinguished, and true stenosis of the glottis of the highest grade, with danger of asphyxia, is es- tablished. The mirror shows the glottis transformed into a narrow slit, which is still further narrowed by the external atmospheric pressure during inspiration, while during expiration the glottis returns to its original size. Inspiration, therefore, causes loud sounding vibrations of the vocal cords, which are pushed forward to the middle, while expiration takes place un- hindered, is short and noiseless. The voice seldom undergoes any change. Still other individual muscles may be paralyzed, but they are of less importance. spasm of the glottis. 303 Therapeutic Hints. Compare: Bellad. Bryon., Caustic, Coccul., Cuprum, Ignat., Plumbum, Zincum. China and Stramon., difficult inspiration and easy expiration. Electricity. Paralytic or Paretic Aphonia, may require: Amm. caust. When attended with bronchial and asthmatic symptoms, great general muscular debility, exhaustion and tremors. Ant. crud. Loss of voice from getting heated by exertion; return of voice by resting. Arg. met. Hoarseness after singing and preaching; anaesthesia of the fauces. Arum triph. Aphonia after singing or speaking; voice changes in tone frequently. Bellad. Aphonia comes on suddenly. Caustic. Sudden loss of voice after taking cold, often combined with catarrhal symptoms. Cina, Peculiar twitching of the right hand when coughing; right side of chest constricted, with difficult breathing; gurgling noise down along the oesophagus. (Kafka.) Cupr. met. Aphonia from central causes after convulsions. Gelsem. After diphtheria; during catamenia. Ignat. In hysteria. Laches. Paralysis of left vocal cord; worse after sleep; tenderness to touch. Nux mo sch. Aphonia from walking against the wind; hysterical, gastro- intestinal and cardiac derangements. Nux vom. Coming on suddenly and combined with catarrhal symptoms. Opium. Loss of voice from fright. Phosphor. Vocal cords broad and relaxed ; tired ; pale; chest oppressed; menses too often. (Welch.) Platina. In uterine disturbances. Rhus tox. After straining the voice. Stramon. From cerebral disease and great mental excitement. Sulphur. Chronic cases of all kinds. Spasm of the Glottis. In books this affection has been described under various names : Asthma spasmodicum or Laryngeum infantum, asthma periodicum acutum infantile, Laryngimus stridulus, Laryngitis stridulosa. The most prevalent, however, and at the same time the most inappropriate names are Asthma Millari and Asthma thymicum Koppii. It is quite difficult to understand haw the descrip- tion which Millar gives of a certain affection of children, and which he him- self styles Asthma acutum, could ever have been applied to spasmus glottidis, as it portrays quite clearly what we may express by the term of Laryngitis. 304 THERAPEUTIC HINTS TO SPASM OF THE GLOTTIS. He even recognizes the "white, tough, jelly-like stuff," with which the windpipe was found filled after death. The term Asthma thymicum Koppii is likewise inadmissible; for the assumption which it implies, that these spasmodic fits be caused by a swelling or enlargement of the thymus glands has, in consequence of late pathologico-anatomical researches, become un- tenable. The Symptoms of spasmus glottidis are as follows : It commences with slight and short attacks of dyspnoea, attended by a wheezing noise during inspiration, whereby the children move uneasily and show an anxious ex- pression. Soon all is over; and if the attacks happen during the night they may be overlooked altogether. By and by, however, these spells increase in number, intensity and duration. The child is suddenly attacked in conse- quence of a little fright, or whilst crying, laughing, drinking, or especially in the moment of getting awake; its inspiration becomes whistling, crowing and so difficult that it strains all the respirator}' muscles to draw the air through the spasmodically closed glottis into the lungs. Expiration is quite impossible, and thus respiration ceases for a while altogether. The face of the child expresses the greatest agony and sense of suffocation, and becomes purple; cold perspiration appears upon the forehead; the veins of the neck becomes turgescent and the thorax is motionless. The pulse falls at this stage and is small and intermitting. This fearful condition lasts in severe cases a minute or two at* the utmost, general!}* only a few seconds; then with a loud, crowing cry the child again catches its breath, is exhausted; cries and sobs, but shows no signs of fever or any catarrhal affection. The num- ber of attacks may amount to ten, twenty, even fifty, in the course of a day; and if the complaint be not arrested it ma}* terminate in general convulsions and death. The age in which children are attacked by this disease lies, in most cases, between their fourth and fourteenth month; as they grow older and stronger, the spells grow* milder. In adults it is of rare occurrence, and then much less severe, on account of the larynx being more developed at that age. The female sex during the age of puberty, is the most frequently attacked amongst grown persons. Its pathological character is a disturbed action of the nervus vagus or recurrens, either from central or peripheral irritation. In children rachitis is the principal cause. Post-mortem ex- amination shows the larynx entirely free from any morbid changes. Therapeutic Hints. Bellad. Congestion to the head; throbbing of carotids; teething process; drinking excites the spasms. Bromium. Gasping and snuffing for breath. Chlorine (the gas in water), crowing inspiration and expiration im- possible (Dunham). The respiratory acts consist of a succession of crowing inspirations, each one followed by an ineffectual effort at expiration, the whole serving to inflate the chest to a most painful extent. (\V. S. Searle.) THERAPEUTIC HINTS TO SPASM OF THE GEOTTIS. 305 Cuprum. Blueness of face and lips; convulsions; after fright of mother or child. Cold perspiration at night; cough relieved by a swallow of cold water. Gelsem. Inspirations long, with crowing sound; expirations sudden and forcible. Ignat. Difficult inspiration with easy expiration; hysteria. Iodium. Tightness and constriction about the larynx, with soreness, hoarse voice, etc. Enlargement . and induration of the glands, cervical and mesenteric; absence of appetite; utter indifference to food; scanty, high colored urine; clayey evacuations; emaciation; yellow skin; action of heart feeble and much increased by motion. (Dunham.). Rachitic children; swelling of bronchial glands; thymus gland (perhaps) enlarged. Ipec. Blueness of face and coldness of extremities, at the commence- ment. Laches. Sensitiveness of larynx and trachea to the touch. Mephit. Similar to Chlorine, has suffocating feeling with inability to exhale; bloated face and convulsions. (W. S. Searle.) Moschus. In hysterical women. Phytol. "Frequent spasmodic closure of the larynx; drawing of the thumbs into the palm; flexion of the toes; distortion of the face; muscles of the eyes affected so that the motions of one eye were independent of the other." (Kapp. ) Plumbum. Spasmodic closure of the rima glottidis; mucus rattling in throat, with sudden difficulty of breathing and asphyxia. Sambuc. Able to inhale but not to exhale; becomes livid in the face; gasps in great anguish and very slowly recovers its breath; awakes from sleep with suffocation. (C. Wesselhoeft. ) Burning red, hot face, hot body, with cold hands and feet during sleep ; on awakening, the face and body break out into a profuse perspiration, which continues as long as the patient is awake; on falling asleep again, the dry heat returns. Veratr. Cold perspiration on forehead, and cold extremities. The following remedies may also be indicated in individual cases : Arsen., Calc. carb. and p/wsp/i., Chamom., Coral, rubr. (Meyhoffer), Hydr. ac, Lauroc, Phosphor., Silic, Spio?igia, Sulphur. The rachitic conditions requre : Calc. carb., Hepar, Iodium, Silic, S21I- phur. 20 THORAX This is a chapter of great importance, and at the same time of difficulty. Its exploration we will have to undertake on different roads. We must know what is to be learned by inspection, palpation, percussion, and auscul- tation. I. Inspection — Ocular Examination. If we consider that the thoracic cavity holds within itself the lungs and heart, the organs of respiration, and of circulation, we shall understand why it is that the first phenomenon which strikes the eye is the continuous motion in which we find its walls engaged. This Respiratory motion of the chest in men is greatest in the region of the lower ribs on each side; in women, on the upper part of the chest; and in children, towards the abdomen. The number of respirations varies according to age, sex, and individu- ality; so that we might put down the normal number of respirations per minute in grown people at from twelve to twenty; in young persons, from fourteen to twenty-four; in children, about twenty-six, and in infants about forty-four. But there are other conditions which may materially modify the frequency of respirations — such as mental excitement, bodily exertions, di- gestion, temperature, and other conditions of the air. As a rule, however, if compared with the pulsations of the heart, it may be said, that during one respiratory act there are three or four beats of the heart; but these respiratory motions of the lungs and pulsations of the heart never correspond in rhythm, as you may easily ascertain by counting your pulse, and observing your breathing at the same time, the pulse being a little too fast or a little too slow to make up an even count between respiration and pulsation. This is a very interesting fact, which it is well to bear in mind. When respiration and pulsation become synchronous — that is, when upon each act of respira- tion for a length of time fall precisely two, three, four, five, or six pulsa- tions — we may be pretty sure that death is near. My attention was first drawn to this interesting fact by Dr. Hering. Since then I have found it verified many times. Its explanation is another matter. We might, per- haps, explain it, if we remember that the heart's action is governed mainly by the sympathetic nervous system, while the lungs are under the control of the vagus, though each of them send branches to these organs, the sympa- thetic to the lungs, and the vagus to the heart. The sympathetica is the great nerve of organic life, and under its direction all the functions of the THORAX. 307 body are performed, which are entirely out of the reach of the will. It arises from a series of ganglia, extending along each side of the vertebral column from the head to the coccyx. The vagus has its origin in the brain, and its fibres may be traced through the fasciculi of the corpus restiforme into the gray substance of the floor of the fourth ventricle, and therefore the parts to which it is distributed are more or less under the control of the will. When death approaches, or, in other words, w T hen the separation of soul and body commences, those functions which are more or less under the control of the will are most probably the first to cease. The vagus losing its influence upon the lungs, their action is now continued under the sole direc- tion of the sympatheticus as long as organic or vegetative life still continues; thus respiration, and pulsation act in full harmony — become perfectly synchronous. " ' ' The respiratory motion of the chest itself in ordinary health is com- paratively slight in consequence of the thoracic cavity being enlarged in ever}- direction nearly simultaneously. It resembles the easy ebb and flood of a soft wave. When, however, a deep respiration is taken, it is observed that the sternum is slightly but steadily projected forward, the abdominal parietes gently dilated. The lower ribs are first and most considerably raised, and the elevation of each separate rib takes place gradually, evenly, and regularly upwards, notwithstanding which, each and all appear to move at the same time. Every part acts separately, but each in perfect harmony with the other." (H. M. Hughes.) Without any deviation in form, a remarkable stillness and w T ant of movement may be observed either in an entire side or only a part of it. This is a sign of inflammation of the pleura in its early stage. The thoracic breathing, when the diaphragm is not moved, is a sign or peritonitis; the abdominal breathing-, when the ribs are not moved, is a sign either of inflammation of the chest, or of paralysis of the respiratory nerves, except the phrenic, from injury of the upper part of the spinal cord. The Form of the thorax must also be taken into consideration, and this must always be done by comparing one side with the other. To accurately determine a difference which may exist in the semi-circumference of the thorax, as indicated by apparent bulging or retraction of a side Mensuration must be employed. For this purpose a tape-measure is used. The normal infantile chest is almost cylindrical but becomes more and more oval during maturity. In the adult the following types of abnormal development will be met with: Paralytic Chest. — In this type the antero-posterior diameter is shortened and the thorax is long and flat, due to a great obliquity of the ribs. Rachitic Chest. — This is produced by lateral compression of the costal cartilages when rickets exists, making the sternum stand out prominently (pectus carinatum.) Barrel chest. — The antero-posterior diameter is greatly increased, there 308 LOCAL ABNORMALITIES. is very slight motion of the thorax during respiration and the intercostal spaces are abnormally wide. It is found in emphysema of the lungs, that morbid state in which the volume of the lungs is increased in consequence either of the dilatation of the air cells, or, what is of rarer occurrence, by the escape of air into the space between the lobules or beneath the pleura. Local Abnormalities. If we bear in mind the natural motion and the natural shape of the thorax, ocular inspection will reveal the following noticeable facts: i. The upper ribs sink away from the clavicle, become flattened and motionless, while, in man)' cases, the movement of the lower ones is not inter- fered with, and, as a general rule, the change is more evident on one side than on the other. This is a sign of advanced phthisis. (Barclay.) 2. Only one side may bulge, the intercostal spaces are obliterated and the respiratory motion is annihilated. This is a sign of a collection of serum — hydrothorax, or of pus — pyothorax, or of gas — pneumothorax— into the pleural sac. A local prominence may also be indicative of an aneurism, tumor or compensatory emphysema. " But in many advanced cases of pleuritic effusion, of empyema (collec- tion of pus) and of pneumothorax, with effusion, not only, as before stated, is the side not enlarged, but it is, on the contrary, contracted; and not only are the intercostal spaces not widened and prominent, but the}* are actually much narrowed. Herein exists a notable example of that which is so neces- sary to bear constantly in mind, that the results of one mode should be care- full) 7 compared with those deduced from other modes of physical examination, and the whole weighed together with the observations derived from the history and the constitutional symptoms of the case under examination. Because the side is contracted, and the intercostal spaces narrowed, as observed upon inspection, it might be hastily assumed that there was no fluid in the chest, while in truth the contracted side might be actually filled with pus or serum, and the other, supposed from its greater size to be the one diseased, might be quite healthy." (H. M. Hughes.) 3. A general fullness or roundness of the precordial region may be some- times observed. This is the case when the heart has been enlarged for a considerable time, or when fluid effusion has long existed in the pericardium. Nota bene : A broken rib may bulge out too! II. Palpation — Manual Examination. This is a method of using the hand with its sense of touch, for the elimi- nation of certain conditions of the thorax. We may merely tap with one finger, or lay the whole hand upon the parts to be examined, press or glide gently over the surface, according to the requirements of the case. In this way we become cognizant of temperature, form, resistance and motion of these parts. The Temperature, if raised to calor mordax, fairly burns and stings the II. PALPATION. 309 examining hand, and is found on the chest in far advanced pulmonary com- plaints. We feel at the same time the condition of the skin, whether it be dry or moist, harsh or soft. The Form. When it is convenient to expose the chest of a patient, the appressed fingers of one hand placed flatly and pressed firmly upon the in- fraclavicular region of one side, while the other is similarly . placed and pressed upon the corresponding region of the other side, are often capable of distinctly appreciating a flatness of one side, or a difference in the pliability or expansibility of the two sides, even in the early stages of phthisis. The Resistance depends upon the character of the parietes and the con- tents of the thorax. The resistance of the parietes is greater, the more con- vex, stiff and strong the thoracic bones, and the narrower the intercostal spaces are. It is more yielding where the contrary conditions exist. In the acromial region the resistance to pressure increases when the muscles are put upon the stretch. The resistance of the contents of the thorax increases in the ratio as they are compressed. Whether there be much or little air, water or pus collected in the cavity, it has no influence upon its resistance to external pressure. But when this air, water or pus becomes compressed, and in consequence the walls which contain it are put upon the stretch, its resist- ance increases in the same ratio, and such swelling within the chest may feel as hard as a stone. Hepatization of the lungs gives a considerable resistance, but it is greater in exudations under the above-mentioned conditions. Palpation lastly reveals different kinds of Motions which originate within the cavity of the chest. The most important of these is the Vibration of voice, or the Vocal fremitus, of which we become cognizant by placing our hand upon the thorax of a person who is in the act of talking or singing. Its force corresponds with the power and depth of the voice, so that we feel it much stronger in men of a deep bass voice than in other persons, whose voices are of a higher pitch. Singing and screaming causes fremitus even in the highest-toned voice. The localities in which it is perceived, arranged according to the strength of the vibration, are as follows: 1. Larynx and trachea down to the sternum in front and laterally. 2. The last four cervical and first three dorsal vertebrae of the adjacent portions bet vveen the scapulae, especially in thin persons and children. 3. The acromial and subclavian regions down to the liver and spleen, on the right side much stronger than on the left. 4. The lateral regions, from the axillae down to liver and spleen ; to the fifth rib stronger on the right side; below the fifth rib stronger on the left side. 5. The posterior inferior regions from the edges of the shoulder-blades downwards. 6. The shoulder-blade region. 7. The manubrium sterni. 8. Where the liver or the enlarged heart or spleen lie close to the tho- racic wall, the fremitus is not felt at all. 3IO II. PALPATION. The mammae of women decrease the vibration of the voice, but do not suppress it altogether. In thin persons with a long thorax, the fremitus is stronger than in persons with a broad but short thorax. It is felt more in the horizontal than in the upright position. This is its normal condition in health. In disease it may be increased or decreased. It is Increased when the bronchial walls become thickened by chronic inflammation; or when the lungs become hepatized, or infiltrated with tuber- cles, or indurated and consolidated. It is also increased by cavities, which lie near the periphery, contain air and not much fluid, and which are sur- rounded by walls of good conducting quality; in short, its increase depends npon good conductors of vibratory motions. The Fremitus is decreased by the presence of large abscesses or gan- grenous destruction or softening of the substance of the lungs; it is decreased or even suppressed when gas or serum fills the pleural sac; and it is de- creased when the bronchial tubes are filled with mucus, pus or blood; in short, in all cases where the vibratory undulation has to pass through differ- ent media, air, fluids and solids. For here, too, is the physical law of the conduction of sounds applicable; the more equal the media in respect to density and elasticity, the better do they conduct sounds ; the greater their inequality of substance, the less is their conductive power. Another vibratory motion within the cavity of the chest, which mani- fests itself to manual examination, is the Rhoncus vibration, caused by tough mucus lodged in the larynx, trachea or bronchial tubes, and brought into vibratory motion by the in-going and out-going current of air. This vibra- tion very often extends over the whole chest, although only a little tough phlegm may be the cause of it, which can be thrown off by a single cough. When, however, the cause of this vibration consists of phlegm* lodged in the bronchial tubes, the rhoncus vibration is not felt in the trachea and larynx, but may extend all the way down to the bronchial periphery. For this reason we can never judge from the extension of the vibration to the extension of its cause; in other words, it does not follow that because we feel the rhoncus fremitus all over the chest, that there should be phlegm all through the chest. This would be a mistake which could be made only by those who do not understand the propagation of rhoncus vibration. A third vibratory motion, recognizable by manual examination, is the peculiar rubbing or grating sensation which occurs when the surface of the pleura pulmonalis and costalis — which naturally glide smoothly over each other — are roughened by solid effusion between their contiguous surfaces, as in pleurisy. It is mostly of short duration, but may last in some cases months and even years. The same motion is caused by fibrous deposits within the pericardium, in consequence of pericarditis; it resembles very much the purring of a cat. A fourth motion which the examining hand discovers upon the thoracic III. PERCUSSION. 31 T walls is the Pulsation of the heart. "While the body is erect, the heart, when in a natural condition, is constantly felt to strike the parietes between the fourth and fifth ribs about an inch below and to the inner side of the nipple. While rying upon the back, its impulse is greatly decreased, and is usually felt somewhat nearer to the sternum. When the body is turned to the left side, the impulse is felt in a direct line with, or often nearly an inch to the outer side of a line passing vertically over the nipple; while, on the contrary, when the body is turned to the right side, it is felt between the cartilages of the ribs, close to the sternum, or sometimes cannot be felt at all. " When the parietes of the heart are thickened, or hypertrophied, and the force of its impulse is consequently increased, the hand, placed over the precordial region, becomes at once sensible of its abnormal force, though the pulse at the wrist ma}' at the very same time be small and feeble. In con- siderable hypertrophy of the, left ventricle the apex of the heart strikes not only lower, but also outside, or to the left of the nipple line. "When the cavities of the heart are dilated, with or without any increase of the thickness of their walls, the impulse is often perceptibly extended over a larger space than natural, and may be felt not only above, below, and around its ordinary site, but also in the scrobiculus cordis; and sometimes even on the right of the sternum. It must, however, be recol- lected, that in nervous and excitable persons of spare habit, the impulse of the heart is often very extensively diffused, even when no disease of the heart exists; and, therefore, that a widely extended or diffused impulse is by no means a proof of the existence of disease in the heart, or in any other organ. ' ' When the heart is removed from its natural situation by gaseous or fluid effusions into the pleura, by tumors, abscesses, etc., it is by manual examination that the fact can generally be best determined. ' ' When obstruction exists in the valves, a trembling motion or ' purring tremor ' is frequently communicated to the hand, and the tumultuous action, or trembling motion, existing in the more advanced stages of disease in the heart, can often be best appreciated by palpation." (H. M. Hughes.) HI. Percussion. A casual examination of the different works on this subject is amply sufficient to'cause total confusion in the mind of the beginner, and a loathing of the task of wading through such contradictory assertions of the different authors. For whilst the one pretends to hear the grass grow, and to find out every little nook and crook in the lungs that is abnormal, b3^ knocking, another asserts coolly, that such talk is a mere flatulent phraseology, refer- ring simply to the fact that the most skilled and experienced in this knock- ing art themselves confess of having made the most glorious mistakes. What are we to do then in such perplexity? Shall we throw the whole overboard, as a fashionable craziness of the profession? It would be a short process of getting rid of the trouble. But then, that is not the thing. There 312 III. PERCUSSION. has been so much labor and ingenuity bestowed upon this subject, that there must be some guiding truths in this heap of collected experiments and re- searches, no matter how badly mixed with contradictory assertions. In the following pages I shall try to state the fundamental principles, by which we must be guided in the application of this kind of examination. There is an immediate and a mediate mode of percussion. It is immedi- ate when the finger of the examiner strikes directly upon the parietes of the chest. It is mediate when some solid material, such as a disc of wood or ivory, a piece of leather, or the finger of the left hand, is interposed between the parietes and the striking body. The striking body may be one or more fingers pressed together and bent slightly, or a little steel hammer, whose head or striking surface is covered with leather or caoutchouc. In regard to the merits of these different modes I have to say that much depends upon what we may have become accustomed to; still the one or the other may be preferable under certain circumstances, which practice will soon teach. What does percussion reveal? If we strike different objects we receive different sounds. There is, however, a marked difference between those bodies w T hich contain air and such as do not. As extreme examples of this difference we may cite the sounds which we obtain when we percuss the chest or stomach, and when we percuss the thigh. In the first case w T e obtain a sound wdiich reverberates — has resonance, whilst in the other case we hear a mere noise, a clap, without any resonance or tone w T hatever. This latter, which we may call the flat, dead or fleshy sound, is everywhere the same, where we strike upon an organ not containing air; such as the liver, the spleen, the kidneys, hepatized lung, or lung completely deprived of air by compression and fluids; a hard liver yields the same sound as a soft liver, a hard spleen as a soft spleen. But it is different with organs and bodies which contain air; there the sound varies quite considerably. Take for example an open jar or bottle, and percuss it at its mouth, you will hear a sound similar to that of a drum; this is the sound which Skoda has called the Tympanitic sound, and which we also might call drum sound. Its variations are as follows: i. If we percuss an open jar or bottle, this drum sound will be deeper, the higher or longer the bottle or the column of air which it contains; it will be higher, the shorter the column of air which is within. 2. If we percuss an open jar or bottle, we find that the wider the mouth of the vessel, the higher is its tympanitic tone; and, the more we contract the mouth of the vessel, the deeper becomes this tone. In short, it depends on the volume of air which is set into vibration; a larger volume gives a deeper, a smaller gives a higher tone. 3. If we, however, percuss closed cavities, there comes into consideration another circumstance. A drum or jar, whose mouth is closed tightly with a piece of bladder, can exemplify it. We perceive at once that the tenser the III. PERCUSSION. 313 skin is drawn over the drum or the bladder over the jar, the higher becomes its tympanitic tone, and vice versa, the looser, the deeper. Here, however, it must be remarked, that this comes to pass only when the surrounding air, and the air within, is of equal density and expansion. As soon as either is set out of that equilibrium, just so soon the tympanitic sound is lost, because this diversity hinders the regular vibrations of the membrane, which are necessary for the tympanitic sound. Thus we find that the tympanitic sound varies in height and depth of its tone. It becomes higher in the ratio — 1. As the column of the percussed air is shorter; 2. As the mouth or aperture by which the percussed air stands in con- nection w T ith the external air is wider; and 3. As the enclosing membrane is drawn more tense over the cavity. It becomes deeper in the same ratio — 1. As the column of the percussed air is longer; 2. As the mouth or aperture by which the percussed air is in contact with the external air is narrower; and 3. As the membrane w T hich closes the vessel becomes looser. Applying these principles to the living organism, we come to the follow- ing results: 1. The tympanitic sound is heard over the larynx. The wider the person under examination opens his mouth, the higher is its tone; in closing the mouth it becomes deeper and weaker, and when closing the nostrils also, it becomes still deeper and weaker. 2. The tympanitic sound is heard where there exist superficial cavities in the lungs, which contain air. If it happens that such cavities are in immediate connection with the trachea, larynx and mouth, by means of large bronchial tubes, then w 7 e have the same phenomena in opening and shutting the mouth, as above detailed. In opening the mouth the tympanitic sound has a higher, and, when shutting it, a deeper tone. If the cavity is in no such connection, then opening or shutting the mouth does not alter the tympanitic sound. 3. It is heard on the thorax in all those conditions of the lungs in which the external air presses equally strong within upon the substance of the lungs, by means of its air-cells and bronchial tubes, as it does from the outside upon the thorax; that is, where there is a perfect equilibrium between the pressure of the internal and external air. This, however, in a normal state is never the case. The inner pressure of the air minus the contractility of the pul- monary tissue, is like the external. But the disease may deprive the lung tissue of this elasticity and contractility by compressing it, whereby this equilibrium becomes established. This we find, for example, in partial emphysema, in the neighborhood of infiltration, as happens in pneumonia, where, not unfrequently, the tissue around the hepatized portion, and especially at the borders of the lung, is emphysematous, and also during pneumonia, as long as the air-cells are not infiltrated, but have lost their natural elasticity. In these conditions we hear a decidedly tympanitic 314 in. percussion. sound. It is heard in pneumothorax — a collection of air or gas in the pleural sac. However, when the pleurae are much distended the tympanitic sound is lost and we get either a high-pitched flat tympany or entire flatness. We hear it again distinctly and invariably at the upper portion of the chest, when the lower portion of a lung is entirely compressed by a pleuritic effusion and its upper portion is reduced in volume. 4. The tympanitic sound is heard lastly in those parts of the chest in whose neighborhood the stomach lies, namely, in the lower part of the left mammary, left lateral, and left infrascapular regions, provided the stomach be not too much distended with air; because otherwise a regular vibration of its walls, and hence the tympanitic sound, would be impossible. The same is true of the abdomen; and thus we come directly to the following result : The tympanitic sound on percussion is heard at the larynx; at the collapsed or compressed lungs; at the relaxed stomach, and at the com- pressible abdominal walls. Quite different from this tympanitic sound is another sound elicited by the percussion of bodies containing air: the Non- tympanitic sound of Skoda, which we might perhaps more intelligibly call the resonant sound of the lungs, or, by abbreviation, the lung-sound. The best example of this sound is obtained by percussing a health} 7 thorax; and, in doing this, we perceive at once that there are different degrees of resonance in it. It varies in clear- ness from a very resonant to a muffled sound; and, in duration, from a long resonance to a short snap. In the normal state of the lungs we find this sound very resonant in the superior sternal, the axillary, and the upper part of the infrascapular regions; resonant in the subclavian, the upper part of the mammary, and lateral, and interscapular regions; muffled in the acromial, and the lower part of the right mammary, and lateral, infrascapular regions; flat, dead, fleshy in the inner edge of the left mammary (where the heart lies), and in the regions of the liver, spleen, kidneys. Pathologically altered states of the lungs alter also this natural resonance of the percussion sound. It is Muffled ; dull— 1. On an}- portion of the lung which is deprived of air, if it is, at least, the size of a half-dollar, and about half an inch in thickness. 2. In the subclavian regions from tubercular infiltration. 3. In the inferior posterior regions, as the favorite seat of pneumonic hepatization; other parts not excluded from the same cause. 4. Diffused over a considerable portion of the chest in haemorrhages and destructive processes within the substance of the lungs. 5. In malignant diseases of the lungs, where the pulmonary tissue is pushed aside and the air is excluded from the parts affected by cancerous or fungous growth. Diseases of the pleura cause a dull percussion sound — 1. "In pleuritic effusion, no matter whether the fluid be blood, serum IV. AUSCULTATION. . . 315 or pus. The dullness in either case may, and generally does, primarily, affect only the lower part of the serous cavity, gradually extending upwards as the fluid increases, and by its increment displacing the lung. But it may also, on the contrary, in either case, extend over only a limited space, to which it is confined by previously existing pleuritic adhesions. " When the pleura is free from such adhesions, the fluid, from whatever part of the membrane it proceeds, may in each case gravitate to the lowest part of the cavity, and its site may be changed according to the varying position of the patient's body. In each case, therefore, the part in which the dullness is observed may also vary with the change of position. The change in the situation of the fluid and of the consequent dullness, according to the position of the body, is, however, far more common in hydrothorax than in either simple pleuritic effusion or empyema, in which diseases the fluid is much more frequently confined to a limited space by surrounding adhesions, or gravitaties with less facility." 2. "In malignant disease of the pleura, as in that of the lung, the pul- monary tissue is pushed aside, and the dullness and resistance exist on per- cussion commensurate with the extent of the solid deposit." (H. M. Hughes. ) Hyper-resonance is found when the air vesicles are abnormally dilated, the sound becoming more tympanitic in character and higher pitched. It is met with in such conditions as emphysema and is practically what Flint calls vesiculo-tympanitic resonance, on account of its mixed quality. The Metallic ringing percussion sound, or Amphoric Resonance. This is the same sound which we elicit by striking empty or nearly empty vessels. The presence of water is not required, but does not hinder its production. Accord- ing to Wintrich it originates in smooth cavities, where the vibrations of the sound are reflected from wall to wall in a regular manner. It is heard in pneu- mothorax, over large cavities, and such cavities as are connected with each other, whose walls must be fit for the reflection of sound; that is, they must be smooth and curved. The Cracked pot sound is similar to the metallic ringing sound, only not so perfect — a spoiled metallic ringing. It may be produced on any healthy chest by knocking forcibly with the fist during loud speaking or singing. Pathologically it is indicative of a cavity communicating with a bronchus. However, Wintrich points out how disappointing it is to have diagnosed a cavity by this sign and not find any existing on post mortem examination. There are some who consider it an infalliable sign of a cavity, but is unwise to put too much confidence in a single physical sign if there are not other signs present to verify the condition suspected. IV. Auscultation. You may auscultate a patient either by applying your ear immediately to his chest, or by interposing a stethoscope between it and your ear. The first is called immediate and the latter mediate auscultation. 316 THE NORMAL SOUNDS OF RESPIRATION. Much has been said in books about the superiority of each method over the other; but there is no need of such long disquisitions. I hear best with the naked ear, and so will anyone else who faithfully tries both methods. But I prefer the stethoscope decidedly, if I have to examine an unclean per- son, or a person with skin disease, or in an}' case where great delicacy must be observed, or when I cannot easily apply my ear to to the parts to be ex- amined. There has also been a great talk in books about the form and material of the stethoscope. It is all the same, whether it be made a little shorter or longer, straight or bent, out of one piece or of several pieces of wood or metal, if only its bore be smooth and adapted to conduct and reflect the sound perfectly. That is all that is required. In order to know anything about abnormal sounds in the respiratory organs, we must first become acquainted with those sounds which we can hear in a normal state of these organs. The Normal Sounds of Respiration. They must be distinctly considered as inspiratory and expiratory sounds. The Inspiratory sound heard at the larynx, trachea and large bronchial tubes ma}' be imitated by forcing air against the hard palate, as is done in- voluntarily in hard breathing, or in pronouncing the guttural consonant ch. The height or depth of this sound (its pitch) depends upon the width of the opening through which the air passes. This sound is called Bronchial respiration or Tubular breathing, and is found in a normal state at the larynx, trachea, large bronchial tubes under the upper part of the sternum, the inner side of the subclavian, the interscapular regions, and occasionally, though less distinctly, in the axillary regions, especially the right one. It is loudest in the larynx, less loud at the trachea, and still less loud at the superficial bronchial tubes, sounding as if coming from a distance. If this bronchial or tubular breathing be heard in other localities than the above named, it may, with tolerable certainty, be regarded as morbid. An altogether different sound is heard during inspiratior, when we put the stethoscope upon any other part of the chest than those previously speci- fied. It may be imitated by narrowing the opening of the mouth and then drawing in the air. The consonant of this murmur is v or b, and it is called the Respiratory or Vesicular murmur of the air-cells and finer bronchial tubes. " It varies considerably in intensity in different regions of the chest. It is most distinct in the acromial, the central and lower part of the superior sternal, the subclavian, the axillary and the subscapular regions. It is less distinct in the lateral, the right mammary, the scapular regions, still less in the hypochondriac, and least of all in the inferior sternal and the inner part of the left mammary region. ' ' Independently of the variation of the intensity of the sound in the different regions of the chest, whether the variation arise from the position THE NORMAL SOUNDS OF RESPIRATION. 317 of the organs, the amount of pulmonary tissue beneath the ear, or the facility or difficult}' with which the inspired air reaches the pulmonary cells, the two sides of the chest frequently vary a little in respect to the loudness of the respiratory murmur. Thus it is rather louder in the acromial, scapular and infraclavicular regions of the right side, but in so slight a degree as to be scarcely worth}* of consideration in a practical point of view. ' ' The respiratory murmur may, both locally and generally, be more or less loud than natural in persons who are quite free from any appreciable disease. It may also be harsh or rough, scarcely audible, or altogether absent. Thus in childhood and in youth, the respiratory murmur is louder than in adult life, and especially than in old age. From this circumstance a loud inspiratory murmur is called (whether normal as in childhood, or youth, or abnormal, from any cause, in age ) puerile or supplementary respiration : puerile, because it is the normal state of respiration in children, and supple- mentary, because it is thought that when one lung or part of a lung is disabled the increased activity of the other lung, or another part of the same lung, supplies the defective action of the diseased organ or part. " It is always heard when the healthy respiration is more than ordina- rily active, as in persons ' out of breath,' as it is called, from strong exertion, as running, dancing, etc., or after the respiration has been voluntarily sus- pended for a time, and the individual breathes quickly to restore the normal balance of the circulation through the pulmonary organs; we hear it, there- fore, also after the sudden termination of an asthmatic paroxysm. The strength of the inspiratory murmur, instead of being increased, may be diminished, though no disease exist in the chest. This imperfection of the respiratory murmur is usually observed either in parts of the lungs which have been little used, as in the lower regions of the chest of females accus- tomed to tight lacing, or in persons suffering from deformity, whether con- genital or acquired; or in the chest of persons considerably advanced in life, also after long illness when the patient for a long time has been obliged to lie on his back. In the first two and last instances the defect results from want of use and consequent imperfect expansion of the lung. In the case of deformity it proceeds from atrophy and consequent defective functional activity of the pulmonary tissue. It may, indeed, be regarded as the natural char- acter of the respiratory sound in old people, and may therefore be called ' senile,' as that existing in children is termed ' puerile respiration." ' ' Occasionally the inspiratory murmur is entirely absent from one or a part of one lung, though no disease be present in the organ itself. This condition, however, probably never exists without some mechanical obstruc- tion to the ingress of air, either in the air tubes or upon the exterior of the organ (spasm, foreign body, apparent death)." (H. M. Hughes.) The murmur of expiration in the normal state of the respiratory organ causes little or no sound in the air-cells and finer bronchial tubes; whatever sound is heard differs from the murmur of inspiration, and resem- bles rather a gentle aspiration or blowing. It can be imitated only bv the 3l8 PATHOLOGICAL DEVIATIONS. mouth during expiration; the consonant which .represents it falls between/" and k. In the larynx, however, it is louder than in inspiratory murmur. Laennec and Skoda, attribute the sound of the vesicular breathing to the friction of the air against the walls of the finer bronchial tubes and the air-cells, the contractile power of which it has to overcome. The reason why the inspiratory murmur of the air-cells is much louder than the expira- tory is, that the air, when it enters into them, meets with resistance from their contracility, but does not meet with any in its passage out of them. It is different, however, in the large bronchial tubes, and particularly in the trachea and larynx; here the air, during inspiration, meets with no opposition; it has, indeed, rather a tendency to expansion; but during expiration the stream of air coming from all parts of the lung out of the air-cells, collecting in the trachea and larynx, becomes compressed and causes friction on the walls of this tube, and especially in the narrow glottis; hence, the expiratory murmur of the larynx, trachea and large bronchi is, as a rule, louder than the inspiratory. Pathological Deviations from the Normal Vesicular Respiration. 1. The inspiratory murmur. The presence of the vesicular murmur at any part of the thorax indicates the entrance of air into the air cells of that part of the lung which lies beneath the spot auscultated. Its absence, therefore, indicates those abnormal conditions which prevent the passage of air into the air-cells; such are compression of the air-cells by exudations or tumors in the pleura, enlargement of the heart and other diseases; infiltration of the lung tissue by plastic or tuberculous matter, by blood, serum, pus, etc. ; atrophy of the air-cells and obstruction of the bronchial tubes by mucus, blood, or by swelling ot the mucous membrane. The vesicular murmur becomes harsher, when the lining membrane of the air-cells and finer bronchial tubes is roughened, swollen and thickened. The presence of a harsh vesicular respiration, which may amount sometimes even to a hissing sound, indicates, therefore, a swelling of the mucous mem- brane of the finer bronchial tubes and air-cells, as exists in catarrh; or soli- tary tubercles thickly scattered through the tissue of the lungs; and oedema of the lungs. 2. The expiratory murmur. In a healthy condition of the lungs it is very soft and somewhat shorter than the inspiratory murmur, sometimes scarcely audible. Its abnormal conditions are, therefore, harshness and pro- longation. The causes hereof must be sought in a roughened and narrowed condition of the finer bronchial tubes and air-cells, by which greater friction of the egressing air is produced. This prolongated and harsh expiratory murmur is rarely heard extending all over the lungs in a uniform manner, but is mostly confined to portions of the lungs, and then is of the highest diagnostic importance. If it extends over a large surface of the lungs, it indicates a more gen- PATHOLOGICAL DEVIATIONS. 319 erally swollen and uneven surface of the bronchial mucous membrane, as we find in acute and bronchial catarrh, with or without emphysema. If it, how- ever, is confined to the apex of the lungs, between the first and third ribs, and more in front than behind, and more on one side than on the other, it indicates tuberculosis. Dr. Jackson, of Philadelphia, was the first who, in the year 1832, drew attention to this prolonged, harsh, expiratory murmur, as a sign of tuber- cular infiltration, and it has been extensively confirmed since. Flint calls this broncho-vesicular, as the bronchial element is added. This prolonged, expirator} T murmur is sometimes broken into two or three jerks, and is observed in tuberculosis; also in old people and children w T hen frightened; also during the chilly stage of fevers. The inspiratory murmur also exhibits such interruptions. It is necessary to listen in such cases to the larynx, whether the interruption is heard there too, otherwise it might easily be mistaken for a friction -sound of the pleura. 3. Bronchial respiration. When we auscultate the larynx or trachea, the respiratory sound is louder than in any other part of the chest, if it be in a healthy condition. It may be imitated, as said before, by forcing the air against the hard palate, so as to produce the consonant c/i, guttural. This respiratory sound has been termed bronchial respiration. If heard in any other part than that above specified, it denotes a change in structure, which subdues the vesicular breathing, and serves as a good conductor of sound from the larger bronchial tubes. Such conditions are: hepatization and tubercular infiltration (the most frequent); next in frequency, thickening- of the bronchial tubes, with atrophy of the lung tissue; pulmonary oedema and pleuritic effusions ; hydrothorax, and cavities freely communicating with a bronchus. In the latter case it is often distinguished as cavernous from its hollow quality and low pitch. As a general rule it may be said that bronchial breathing is present in such conditions of the lungs giving rise to a tympan- itic sound on percussion. 4. Rhonchi or rattling noises in the respiratory organs; Rales. When the bronchial tubes are partly constricted, or when tough mucus exists therein, which is set into a vibratory motion by the rush of air during respi- ration, or, if sticking tightly to the walls, is suddenly torn, then we have all kinds of noises within the thorax. Such noises may be high, deep, clear, husky, harsh, or hollow; may be short like a snap, and return at intervals; or continuous for a longer time, like the purring of a cat. ' ' These noises, ' ' says Dr. Wintrich, " have been called, strange enough, dry rattling noises, and have been divided into rhonchi sicci, graves, sonori, sibilantes and canori. The poetical talent of some authors has had ample opportunity to force them by comparison into the most singular and fanciful classes, of which a cool reflection has might} T little to think," and, I may add, by which the beginner is thrown into utter confusion. They originate within the respiratory tubes, exactly in the same manner as sounds originate in any other kind of tubes. The sound is high, shrill, when the tube is nar- 320 PATHOLOGICAL DEVIATIONS. row or constricted in one or more places; it is deep, in tubes of large lumen and when the vibrating column of air is long, or when the vibratory undula- tion is low; it is loud, strong, when the stream of air is of great force; and vice versa, it is weak, faint when the stream of air is weak. These rhonchi often extend over a large portion of the chest; if deep they occasion a vibration of the thoracic walls, perceptible to the touch; if high, not. Still we cannot, as has been mentioned already under the head of vocal fremitus, from its extension, draw any conclusion as to the extent of its cause, because this sound may be propagated, like the fremitus, from a single point where it originates, to all parts of the chest. These rattling noises generally have their origin in catarrhal affections, and change constantly according to the location and the different nature of phlegm, which is shifted from one place to another by breathing and cough- ing. Exceptions to the above are hissing sounds, which sometimes exist con- tinuously for weeks, and even months. These hissing sounds, or rhonchi sibilautes, must have, therefore, a more persistent cause, the nature of which seems to be constriction in some- of the finer bronchi; and we find them in such a persistent manner only in tuberculosis of the apices of the lungs. The so-called moist sounds are thought to originate in the presence of a fluid, which, by the rush of air, is stirred up into large and small bubbles, which burst. We may distinguish the following varieties: i. Rhonchus crepitans, vesicular crepitation, or crepitant rale. It is quite similar to the noise wmich is produced when a lock of hair is tubbed between the fingers. It is heard only during inspiration. I^aennec and all his followers, even Skoda, explained it in this way: that the rush of air during inspiration into the finest bronchial tubes and air-cells, if the) 7 contain a fluid, stirs this fluid into bubbles, which burst and thus cause the crepitant rattle. Walshe, an English author, not being satisfied with this explanation, formu- lated the theory that it originated through the sudden expansion of the interstitial spaces around the air-cells by a full inspiratory action. He thought these interstitial spaces glued together by the exudation of a tough matter in pneumonia, so that a sudden expansion would tear them asunder and cause this crepitation. This opinion of Walshe w T as later refuted .by Davies in his lectures, who explained that in pneumonia the exudation does not take place outside but inside of the air-cells, as the tough sputa sufficiently show, and that the same crepitating sound is also found in oedema of the lungs. Dr. Wintrich gives, no doubt, the best explanation of this sound. He says: "This crepitating sound is nothing else but the noise which is caused by the sudden inspiratory expansion of the air-cells and finest bronchial tubes when their walls have become glued together by means of a stick} 7 ex- udation. ' ' It is therefore not heard in a sound lung, because here the air- cells, even during the fullest expiration, never contract to such an extent that their walls touch each other and stick together. Wherever it exists, there is a morbid swelling and tough secretion within these air-cells and finest bronchial tubes, which bring their w T alls during expiration in such near PATHOLOGICAL DEVIATIONS. 32 1 contact that, by means of the sticky secretion within, they are glued together and then torn asunder by the following inspiratory act. The intensity of this crepitation depends upon the toughness of the secretion and upon the force with which inspiration tears the adhering walls asunder. It does not cease after coughing and expectoration, because it de- pends upon a swelling and a secretion of the air-cells and finest bronchial tubes which no cough can remove. It is heard at the commencement of pneumonia, just when exudation takes place, and at its resolution; in capil- lary bronchitis and in oedema and sometimes in emphysema of the lungs. In oedema the crepitant rattle is much softer and distant, because the transuda- tion is of a much less sticky nature than in pneumonia or bronchitis. It is heard, lastly, in sound lung under the following condition, as Walshe describes it: "If individuals whose lungs are healthy, or diseased only at the apices, and whose breathing is habitually calm, are made suddenly to respire deeply, a peculiar, fine dry crepitation, accompanying inspiration only, may often be detected at the basis posteriorly. But after two or three, or, at most, five or six acts of respiration, it totally disappears. This pseudo-rhonchal sound seems to depend on the sudden and forced unfolding of air-cells, which are unaffected by the calm breathing habitual to the individual; and its only importance arises from the possibility of confounding it with crepitant rhonchus. ' ' It is frequently heard in patients who have lain long on their backs, especially after typhoid fevers, and may be explained in the same manner. The pulmonary secretion collects mostly in those places which lie deepest and are used least. By these means the air-cells gradually collapse and stick together. A few deep inspirations tear them asunder and at the same time remove the secretion, so that, as there is no morbid swelling in these parts, the crepitant sound ceases after two, three, or at most, after five or six acts of respiration. 2. The subcrepitant rale. This is a sound which appears to arise from the bursting of very small bubbles in the air-passages. It is heard most dis- tinctly during the act of inspiration, weaker during expiration. It denotes a fluid secretion in the finer bronchial tubes. 3. The mucous rale. There is sometimes a great deal of mucus in the respiratory organs, and yet, on auscultation, no rattling sound is perceptible. It seems, then, that certain conditions must exist in order to render the bursting of large and small bubbles in the air-passages audible. These con- ditions are: that the walls, wherein the sound originates, must be good reflectors of sound, like the larynx, the trachea, cavities, and bronchi, if they are surrounded by walls which do not contain air; and also, that fluid (mucus, pus, blood, serum) be contained in them, which, by respiration, is set into bubbling motion. The mucous rattle varies much in character; is -a sound of large or small bubbles, high or deep in pitch; confined to a small spot, or extended over the whole lung. By the extension of the sound we can never judge of the extent of the fluid which gives rise to it; because this 21 32 2 PATHOLOGICAL DEVIATIONS. sound is propagated quite a distance from its origin, if there exist good reflecting media. It therefore does not indicate any particular disease, but only certain conditions, like consolidation of the lung tissue, either by infil- tration or hepatization, compression or atrophy. 4. The metallic tinkling. " When in consequence of a communication with a bronchial tube, or a portion of the lung, the pleural sac contains a considerable portion of air, and also a small quantity of fluid, or when a phthisical cavity of large size is similarly circumstanced, there is every now and then heard a very peculiar sort of tinkling noise upon examining the chest. It resembles very nearly the sound caused by shaking a pin in a decanter. This is the metallic tinkling. It is most commonly heard only at intervals; that is, it may occur once in three, four or forty respirations. It rarely, if ever, attends the expiration. It may cease altogether and reap- pear after a considerable time. In this respect it seems to be influenced by the position of the patient's body. It is most probably produced by the con- tinued and rapid reverberation of a delicate sound against the firm and vibrating walls of a large cavity. It is in fact an echo in a small space. The original sound from which the echo proceeds appears most commonly to arise from the bursting of a bottle of air, or from a drop of liquid falling upon the surface of fluid in the bottom of the cavity. But it sometimes seems to be likewise produced by the passage of air over a loose portion of membrane or thick secretion situated in a tube at or near the entrance of the cavity. The physical conditions necessary for its production appear to be a large cavity with resonating walls, and containing a large portion of air, with a small quantity of fluid." (H. M. Hughes.) In pneumothorax much depends upon the position of the patient. Often, when nothing can be heard while the patient is lying down, the metallic tinkling appears at once on assuming the sitting posture. In those cases in which tubercular infiltration extends to the diaphragm in the left lung, it not unfrequently happens that sounds within the lungs are conducted into the cavity of the stomach, where they cause exactly the same metallic tinkling. Any one who is not aware of this fact, might easily diagnosticate pneumo- thorax where, upon post-mortem examination, none could be found. Another practical and interesting sound is: 5. A sort of click, which is heard occasionally, perhaps not oftener than once in four or six inspirations, resembling the sticky noise produced by the removal of the tongue from the roof the mouth. It is generally observed at the apex of the lungs, when there is a deposition of tubercles, and according to Wintrich, especially when these tubercles commence to dissolve. Cough sometimes breaks it up; but often it is of a very persistent nature. 6. Friction sound. This sound originates when both pleural surfaces (pleura pulmonalis and costalis) become roughened, and in the absence of gas, fluids or adhesions between them, rub upon each other. It generally accompanies both inspiration and expiration; being at one time most distinct during inspiration, at another during expiration. It ma}' be heard during AUSCULTATION OF VOICE. 323 inspiration only, or the reverse. It resembles the creaking of leather; ap- pears at intervals, and in most cases it is recognizable by the finger as well as by the ear, and the patient generally experiences the sensation of some- thing rubbing within his thorax. This sound is most commonly caused by pleurisy and pericarditis. It is sometimes heard at the commencement of this disease, when fibrous deposits have settled on the surfaces of the pleura, and the contact of the surfaces is not prevented by serous effusions. It is also heard, and sometimes more distinctly, at a later period of the disease, when absorption of the serous effusion has taken place, and the surfaces, covered by a firm plastic exudation, have once more come in contact. In this case the friction sound continues until either the pleura has formed adhesions to the thoracic walls, or its surfaces have become perfectly smooth. It is also heard in tuberculosis; especially in the left infraclavicular region, where it continues to be sometimes for months, even years; because tuberculosis is more or less always attended by partial pleuritic inflammations. Here, how- ever, it must not be confounded with the above-mentioned interrupted or jerk- like expiration. Both may easily be distinguished, as already stated, by listening to the larynx. If heard there, too, it is no friction sound, but inter- rupted expiration. Auscultation of Voice. The voice, as heard in a normal condition of the respiratory organs. If the stethoscope be placed upon the larynx of a healthy person, and we listen through it whilst the person is talking, his voice sounds nearly as loud as though he were talking immediately into our ear; but the words are not so clearly articulated. The same is true if we place the stethoscope upon the trachea. This normal sound, heard at the larynx and trachea during talk- ing, has been called Laryngophony and Tracheophony — -laryngeal voice and tracheal voice. If the stethoscope be placed upon the upper part of the sternum, or upon the cartilages of the second and third ribs or upon the interscapular regions, we will still hear the voice when a person speaks, but not nearly so loud, and the words will be still less clearly articulated than over the larynx and trachea. This normal sound of the voice, as we perceive it over the larger bronchial tubes, is called Bronchophony — bronchial voice. If, lastly, the stethoscope be put upon any part of a healthy person's thorax, the voice of the person is heard simply as a buzzing or humming, or is not heard at all. Such then are laryngophony, tracheophony, bronchophony and the distant humming or buzzing of the voice (vocal resonance), when heard over the respiratory organs in a normal condition. It must not, however, be supposed that there exists any defined line of demarcation between each, so that it could be said, here ends laryngophony, and here begins broncho- phony. They all gradually merge into each other; they are not distinct species of sounds, but merely variations of intensity of the same sound. 524 AUSCULTATION OF VOICE. We may convince ourselves of this gradual lessening of intensity and clear- ness of articulation, if we gradually move the stethoscope from above down- wards, and listen at the same time, whilst the person is talking. Further, it must be remarked and borne in mind, that the thoracic voice is very generally more distinct upon the right side, and particularly below the right clavicle and over the right scapula, then in the correspond- ing situations upon the left side; also, that a shrill or acute, high-toned voice, generally sounds clearer and more distinctly modulated than a deep bass voice, though not so loud and strong as this; and that the thoracic voice is usually more audible in thin persons than in those who thoracic walls are loaded with fat; and in persons with contracted chests, than in those in whom the thoracic cavity is largely developed; and, other things being equal, it is also more distinct in females than in males. The voice as heard in abnormal conditions of the respiratory organs. Pathological changes and conditions multiply these variations in intensity and articulation of the voice still more. We will frequently have to make nice distinctions, and this is only possible, if we compare constantly both sides and different parts with each other, for it rarely ever happens that both lungs are affected alike. Thus, in listening to the sound portion we obtain a standard by which we are enabled to judge of the corresponding portion. There is a threefold alternation of the thoracic voice from its normal condi- tion possible: it is either — 1. Decreased in its intensity or suspended alto- gether; or, 2. Its intensity and clearness of articulation is augmented; or, 3. It is changed altogether in its character. 1. Its decrease is caused by any and all such solid, fluid or gaseous sub- stances as may form or collect between the lungs and the thoracic walls, and which interfere with the transmission of the natural humming or buzzing of the voice on those parts of the thorax mentioned above. This is the case in moderate effusion of lymph or pus into the pleural sac, and in moderate pneumothorax, in so far as it separates the lungs from the thoracic walls. It is the case in widely-extended emphysema, if the bronchial tubes are not widened and thus made good conductors of sound. It is the case, where large cavities, as it were, swallow up the sound. It is quite important that all this be borne in mind, lest we might make mistakes. The natural thoracic voice is entirely subdued, when massive exudations and transudations in the pleural sac cause a separation of the thoracic organs from the thoracic walls. The same is produced by pneumothorax, if it does not cause metallic tinkling. The most total suppression, however, of the thoracic voice is caused by the closure of the bronchial tubes, either by foreign bodies, tough mucus, large quantities of pus, phlegm, or serum, etc. The higher up towards the larger bronchi such stoppage exists, the larger is the circumference in which the natural thoracic voice is wanting. 2. Its increase in intensity as well as in clearness of articulation. At first I have to remark, that in no case of morbid affection, and on no part of the thoracic cavity, does the voice sound as loud as at its origin, the mouth. AUSCULTATION OF VOICK. 325 But it may sound as loud, or nearly as loud, as we hear it in a normal con- dition at the larynx. This increase of the thoracic voice we may call Laryngophony. French authors have called it Pectoriloquy, which means a speaking out of the chest. If it exists in a degree, as on those places where the larger bronchial tubes lie, near the thoracic walls, it is called Bronch- ophony. Neither pectoriloquy nor bronchophony are always of the same strength or loudness, and therefore the authors speak of a perfect and an imperfect pectoriloqu3 T , and of a loud and a weak bronchopony. The question arises, what causes this increase of the thoracic voice to bronchophony and pectoriloquy in places where there should naturally exist only a humming or buzzing of the voice. The answer is : This increase of the thoracic voice depends entirely upon a greater or le-ser degree of aptness of the bronchial tubes to reflect and con- duct sounds, or, as we remarked of vocal fremitus, its increase depends upon good conductors of vibratory motion. This aptness of the bronchial tubes grows in the same degree as their walls become tenser and more solidified, approaching the walls of the trachea and larynx; and further, when these tubes are surrounded by fluids or semi-solid exudations (as in pneumonia); or even by solid masses (as in tuberculous infiltrations); or when the sub- stance of the lungs around them has become compressed, and thus deprived of air. All these requirements for an increase of the thoracic voice we find more or less realized in the following pathological conditions: In tubercular infiltration, if it surround several bronchial tubes up to their last extremities (this is of the most frequent occurrence); in pneumonic infiltration, where the semi-fluid or coagulable exudation causes hepatization of the substance of the lungs; in strongly developed oedema, especially of interstitial lung tissue, and this only in rare cases; in dilatation of the bronchial tubes, if sur- rounded by indurated and shrinking, airless lung tissue; in tumors of all kinds, if they compress the lung tissue, or by their own nature and situation around the bronchial tubes become good conductors of sound; in all kinds of fluid exudations into the plural sac, pleuritic exudation, haemothorax, em- pyema, etc., when they compress the lung to such a degree that the periphe- ric portions of it become deprived of air — in such cases, however, the lung must not be pushed too far from the parietes of the thorax, as; for example, during the period of dilatation in pleuritis, in which, in the majority of cases, no sound is heard at the corresponding wall of the thorax, in cavities, which stand in unbroken connection with the larynx, trachea, and larger bronchial tubes, which have smooth walls that are good reflectors, which are neither too large nor too small, and which are situated so near to the periphery that but little previous lung tissue intervenes between them and the thoracic walls — the nearer they are to the periphery and the tenser and harder their walls, the greater is the intensity of the thoracic voice heard over them. This increase of the thoracic voice, in consequence of these pathological conditions over parts which, in a normal state, afford only a humming or 326 AUSCULTATION OF COUGH. buzzing of the voice, has been called, as already stated, according to its degree, weak or loud bronchophony, and imperfect or perfect pectoriloquy. Bronchophony has always a kind of nasal twang, is never so clearly modu- lated as sounds or words which come immediately from the mouth. 3. The thoracic voice is changed in its character. Such a peculiar deviation from bronchophony is the so-called oegophony, a tremulous sound, which resembles the bleating of a goat, and which is nothing but a modified bronchophony, with the nasal twang of quick, successive, tremulous inter- ruptions. (Wintrich.) It is heard sometimes without any pathological change, in old people, if their voice has become of a trembling character. Otherwise it is found under conditions similar to those which produce bronch- ophony, and does not designate any particular condition or disease. It corresponds to the cracked-pot sound. Another deviation from bronchophony is the cavernons voice, which is well modulated, without nasal twang or goat-bleating. It originates in moderately large cavities, which are situated near the thoracic wall and adhere to it; which have thin, smooth walls, capable of good reflection; which are, by the larger bronchial tubes, in uninterrupted connection with the larynx and trachea, and which do not contain too much fluid. If these cavities are large, another deviation from mere bronchophony is occasioned, which is spoken of under the name of amphoric echo and metallic tinkling. These phenomena may be imitated by a person speaking and directing his voice into a jug. When he does so, a peculiar humming is heard in addition to the voice. Besides this humming, there is also occasionally heard a metallic after-tone, both of which represent what Laennec describes under amphoric echo and metallic tinkling. It is pro- duced in tolerable large cavities, and also sometimes in pneumothorax. Auscultation of Cough. As cough is nothing else than a loud and forced expiration, it is clear that all which has been said about respiration and voice is likewise applica- ble to the cough. It is heard weaker or louder under the same conditions which decrease or increase the sound of respiration and of voice. In some cases it may make the auscultatory signs clearer and more distinct, and thus be a help to a more accurate diagnosis. Special Diseases of the Respiratory Organs. Having thus far explained, step by step, the phenomena which respira- tory action, in normal as well as abnormal conditions, offers to the senses of sight (inspection), touch (palpitation ». and hearing (percussion and auscul- tation), we now come to consider certain forms of abnormal conditions of the respirator)^ organs which occur again and again; and although varying con- stantly as individual cases, present, nevertheless, some common, persistent features by which they may be arranged, considered and recognized, as defi- nite and marked forms of pathological alterations and conditions in these AFFECTIONS OF THE BRONCHIAE TUBES. 327 organs. What we have learned concerning the respiratory action in normal and abnormal conditions, we shall now have occasion to apply to certain diseases, and in this way demonstrate its practical use. a. AFFECTIONS OF THE BRONCHIAL TUBES. Bronchitis, Bronchial Catarrh. This, like all other catarrhal inflammations, is characterized by a hyper- aemic state of the mucous membrane in the bronchial tubes, causing abnormal secretions, and, if long continued, gradual changes in their texture. The membrane appears injected, ecchymosed, infiltrated, opaque, swollen and covered with secretion. In this way the finest tubes may become entirely closed, preventing the renewal of air in the air-cells, and causing a poisoning of the blood by uneliminated carbon. This generally, however, happens only with infants, who are not strong enough to free themselves of the secreted phlegm. In such cases, during post-mortem examination, the lungs swell out of the thorax, not having room enough inside without being com- pressed by the parietes of the thorax, because their alveoli remain filled with the inhaled air. In chronic cases the mucous membrane grows hyper- trophic, the muscular fibres lose their elasticity, and the tubes enlarge in width, either evenly throughout, or only in short tracks, sac-like, — Bronchiectasia. The inflammation may be confined to the trachea and the larger bronchi, or to the smaller ones, or be diffused all over. In the first case it is accompanied more or less by a troublesome tickling under the sternum, or a sore feeling or burning; while in the second no such sensations exist, as the finer bronchi are less liberally supplied with sensory nerves than the larynx and trachea. The cough is usually much more violent in the case of inflam- mation of the larger bronchi; it is most readily excited at the point of bifur- cation. If the catarrhal inflammation is located in the smaller bronchi, it is always attended with more or less dyspnoea, which, in an affection of the larger bronchi alone, is never found, and for obvious reasons: the swelling and phlegm, if ever so great, cannot easily occlude these large tubes, while in the smallest a little swelling and a small quantity of phlegm may easily prevent the ingress and egress of air. The sputum is at first viscid, mucous, transparent, poor in cells, often frothy, because mixed with air from the severe efforts of coughing required for its detachment; often it is mixed with small quantities of blood for the same reason; in the spit-cup it is readily confluent and corresponds to the sputum crudum of older writers. As the catarrh progresses, more and more cellular elements become freed, and this is a sign that the culmination of the process is passed; the sputum now is richly cellular, non-translucent, and consists chiefly of mucus and pus cells — it is the " sputum coctum " of older writers. If the disease enters the chronic stage, the sputa become more puriform, and appear either in greenish or yellowish clumps of muco-pus in 328 AFFECTIONS OF THE BRONCHIAL TUBES. a sero-mucous fluid, of which, when poured into water, one portion remains floating on account of the admixture of air, while the rest sinks to the bottom; or the purulent masses run together in the spit-cup, of which the heavy portion settles to bottom, the sero-mucous part floats upon it, and the whole is covered by considerable froth; this sort of expectoration is often fetid in a high degree; or the sputa consist of roundish, coin-like masses, which lie separate beside each other in the spit-cup; this sort of expectora- tion is often the product of a cavity in the lungs, but is also observed in chronic bronchitis. At still other times the sputum is sero-mucous, being characterized by its thin, thread}* consistence, frequently copiously mixed with air-bubbles which cover the entire surface of the expectorated mass. Its quantity is often very considerable, amounting to actual bronchorrhcea, and is principally observed in the chronic forms of bronchitis. The ashes of these various kinds of sputa have been found to contain: Chlorine, sul- phuric acid, phosphoric acid, potassa, soda, lime and magnesia, oxide of iron and silicic acid. The same constituents are found in the ashes of the lungs, but their quantitative composition differs greatly. Phosphoric acid, for instance, and oxide of iron are found in much less amount in the sputa than in the ashes of the lungs, whereas potassa exceeds greatly in amount in the ashes of the sputa. Bronchitis, whether confined to the larger or smaller tubes, is mostly always attended by fever. It generally sets in with chilliness, alternating with a feeling of burning heat, without a corresponding rising of the mercury when the thermometer is applied. Thus we ma}' already in the commence- ment of a fever be able to distinguish a catarrhal from an inflammatory fever; the latter, generally commencing with only one chill, is followed by a fever- heat that indicates a much higher degree by the thermometer. Catarrhal fevers are sometimes epidemic, when they are called Influ- enza or La Grippe; involving the whole system and especially the* mucous membranes, even those of the bowels. In old people, or otherwise exhausted persons, catarrhal fevers take at times a bad turn, and assume a typhoid character. The patient becomes delirious and comatose, his tongue dry, pulse small and frequent, and his body covered with exhausting perspiration. To the comatose state is added at last, a rattling in the trachea from the bursting of big bubbles, which is caused by the inability to throw off the phlegm, in consequence of paralysis of the muscular fibres of the bronchi. This is the so-called death- rattle; after the setting in of which the scene soon closes. This form of bronchitis is termed by the older writers Pneumonia notha. Another form is the so-called Catarrh on the chest of infants, especially during dentition It involves the smallest branches of the bronchi, whence it is also called Bronchitis capillaris. Its character is the same as any other form of catarrh; but as the swelling attacks the finest tubes, it soon makes them impervious to air, and consequently prevents the expulsion of carbon, and the inhalation of oxygen. Such children are in great distress, AFFECTIONS OF THE BRONCHI AE TUBES. 329 breathing heavily, with hissing and rattling noises in the chest. The cough- ing spells are painful and violent, driving the blood to the face, and when still further progressed, the epigastric region and lower ribs are drawn in during inhalation, as in croup, a sign that the air cells are no longer filled by the inspiratory act; so also do we find the supra-and infra- clavicular region bulging out, protruding, as the air contained therein is not removed by expiration, and there is consequently a noticeable stillness of the upper part of the chest during expiration. When such an attack befalls newborn children from their having been exposed to cold by washing, bathing, etc., it soon develops itself into a higher stage, as the child is too 3 T oung and too weak to clear away the accumulating secretion by its own efforts. The child turns bluish and grayish; the nose becomes pointed; the eyes dull; the respiration quite superficial. It is nothing more nor less than a clogging up of the finest bronchial tubes, and in consequence of that, an overcharge of the whole system with carbon. A superficial observer might confound it with cyanosis from some organic lesion of the heart. The chronic forms of bronchitis differ but little from the acute forms. A chronic bronchial catarrh aggravates usualty in spring and fall, and leaves the patient comparatively free through the summer. In some cases where the sputa are very tough, it is attended with painful straining fits of cough- ing, in others the cough is much lighter, as the secretion consists of a more fluid and yellowish substance. Very frequently bronchial catarrh is attended with dyspnoea on account of constrictions which, by the chronic inflamma- tion, have been formed within the air-tubes. So also originate by the gradual change of texture of the bronchi, dilatations here and there (Bron- chiectasias), which in most cases contain masses of puriform sputa of a very fetid odor. In other cases, especially where the catarrhal inflammation is located in the larger bronchi, the expectoration is of great abundance, and consists of a thin, sero-mucous substance, mixed largely with air-bubbles. Such abundant discharge from the air-tubes is called Blenorrhcea of the Bronchi, or Bronchorrhoea. In some cases there is no great dyspnoea, in others where the inflammation invades the finer tubes, dyspnoea will not be wanting. A long continuance of chronic catarrh often becomes associated with hypertrophy and dilatation of the right ventricle of the heart. A particular form, the so-called "Dry Catarrh" of Iyaennec, which is associated with severe paroxysms of cough with but a trifling amount of expectoration, is often combined with emphysema. Physical Signs. — Percussion reveals nothing in these affections; its sounds are everywhere the same as in a healthy condition. Ascultatory signs depend upon the condition of the bronchial tubes. As soon as their mucous lining becomes inflamed and swollen, the vesicular murmur is loud, harsh and coarse; the expiratory murmur, usually scarcely audible, also partakes of this character, and may be even louder than the in- 330 THERAPEUTIC HINTS TO AFFECTIONS OF BRONCHIAL TUBES. spiratory murmur. When, however, the inflammation affects the larger bronchial tubes, the vesicular murmur is frequently oversounded by the loud bronchial breathing which originates there; but, when the breathing is slow and weak, there may be, at the commencement of the disease, no sound at all perceptible. As soon as the mucous membrane becomes covered with secretion, we hear all sorts of mucous rattling, fine bubbling, large bubbling, hissing and whistling sounds, according to the nature and location of the secretion. When the secretion is located in the larynx, trachea or larger bronchi, the rattling noise originating here may be heard all over the chest; hence we cannot, from the extent of the noise, judge of the extent of the secretion. On the contrary, the finer bronchi may be filled with mucus, and no rattling noise be perceptible when the breathing is weak and feeble. When, during vigorous respiration, the vesicular murmur is absent, it denotes the presence of a large quantity of mucus, or the closure of the finest bronchial tubes by swelling, which prevents the air from entering into the air-cells. We may also hear the sub-crepitant rale, when the inflammation invades the finest bronchi. In regard to differential diagnosis, bronchial catarrh differs from other acute lung diseases by the absence of acute pain — it produces only a sore, raw and burning sensation; by the absence of all abnormal percussion signs; and by its commencing with frequently repeated chills. Therapeutic Hints. Catarrh on the chest of infants, Aeon., Be/lad., Bryon., Calc. card., Ferr. phosph., Ipec., Laches., Opium, Phosphor., Sulphur, Tart. emet. Catarrh of old people or exhausted persons, Bar. carb., Bryon., Cafb. veg., Hydrast., Laches., Phosphor., Rhus fox., Sepia, Tart, emet., Veratr. Compare Catarrh 'of Nose and Larynx. Acute Forms. — Aeon. In the commencement, especially if brought about by exposure to cold west winds, or sudden suppression of perspiration, with high fever, dry skin, restlessness and irascibility. Act. rac. Cough excited by every attempt to speak, so that one is obliged to desist. (Guernsey.) Ant. crud. Especially if caused by bathing. The cough seems to start from the abdomen; gastric derangement. A£sc. hipp. When complicated with gouty diathesis, and a tendency to piles with constipation. Arnica. Cough excited in children from crying; sputa difficult to loosen, or bloody. Arse?i. Cough attended with dyspncea; worse about and after mid- night; from drinking cold water; from lying down; from mental excitement; sometimes attended with cold in the head, diarrhoea, rheumatic pains in the limbs, palpitation of the heart, restless anxiety in the night. When cough- ing a pain extends from the small of back down into the thighs. The cough THERAPEUTIC HINTS TO AFFECTIONS OF BRONCHIAL TUBES. 33 1 is excited by an intense tickling in trachea and under sternum, from cold air: it is whizzing with difficult expectoration of frothy, tough sputa. lively exercise brings on the cough. Badiaga. Spasmodic cough, with sneezing and lachrymation; during the paroxysms, crying and pressing hands upon head; sometimes strangling, face turning dark, and thick, yellow viscid mucus flying out of mouth and nostrils. Cough loose A. m., tight p. m. (H. V. Miller.) Bellad. Barking cough; crying when coughing; hot skin, inclined to be moist; drowsy; sleepy, but cannot sleep; starting in sleep. Bryon. Crying when being moved, and when coughing; cough tight, sometimes with blood-streaked expectoration; worse through day, at times worse in the night, compelling to sit up; worse from motion; when entering a warm room; from sudden changes of the atmosphere, either to warm or to cold; from eating and smoking. Pain in the pit of stomach, and in the muscles under the short ribs, or in the sides of the chest, or in the head when coughing; spurting of urine when coughing. The cough is at times excited by a tickling in the pit of the stomach. Calc. ca?-b. Teething children; loose cough; rattling of mucus; bowels moved more frequent towards evening; profuse head sweat, especially during sleep. Card. veg. Evening hoarseness; burning under sternum; soreness of chest, and heat of body when coughing; itching from throat down to centre of chest when coughing. The cough comes mostly in spells far apart; is ex- cited by going into the cold air out of a warm room. Cold knees in the warm bed. Pyrosis with a great flow of water from the mouth during the day. Caustic. Morning hoarseness; cough worse on getting warm in bed; also better in bed and from a swallow of cold water; is attended with pain over the left hip; involuntary discharge of urine. Heartburn and acidity after fat, saccharine and farinaceous food; sudden cramps in heel-cords in the night; stiffness and lameness of jaws. Chamom. During teething; cough during sleep without waking; child wants to be carried and is very cross. Suffocative constriction of the chest as if the throat were throttled, with constant desire to cough. Cina. Dry hacking cough, especially at night, followed by swallowing, as if something were rising in the throat; the child becomes stiff during the cough, and afterwards there is a clucking noise in the throat down to the stomach. Cinchona. Tickling cough worse from talking or laughing. Conium. Cough worse from horizontal position, speaking or laughing. Cuptum. Cough better from taking a sip of cold water; trembling after coughing; suffocating spells. Drosera. The cough seems to come from the abdomen and convulses the muscles of the chest and abdomen; the patient tries to relieve the pain in chest and hypochondriac regions by holding them tightly; perspires im- mediately on waking from sleep. 332 THERAPEUTIC HINTS TO AFFECTION'S OF BRONCHIAL TUBES. Eupat. per/. Rough, scraping cough; violent cough with soreness in the chest; the patient supports the chest with his hands; cough before and after meals; pain in all the limbs and back; palpitation of the heart. Euphras. Dry, tickling cough only in daytime, better from eating and drinking small quantities of beer or water. After the cessation of haemor- rhoidal flow. Ferr. met. Cough better while eating, especially during supper. Ferr. phos. Often relieves the catarrh on the chest of children; similar to Aeon. Hepar. Cough tight or loose, worse in the morning; from uncovering any part of the bod}*; better from wrapping up and keeping warm. Re- pelled eruptions. Hyosc. Nightly, dry, spasmodic titillating cough, worse in lying. Ipec. Titillating cough with dyspnoea, nausea and vomiting, diarrhoea; face pale, even bluish during cough. Iodium. Tickling, dry cough; young persons subject to spitting blood; palpitation of the heart; swelling of cervical and bronchial glands; progress- ive emaciation with good appetite. Kreos. During dentition, when the child is extremely fretful, irritable, much agitated, and screaming in the night. Dry cough excited by a crawl- ing^sensation below the larynx. Laches. Cough is worse during and after sleep; in afternoon and even- ing; there is tickling in the pit of the throat and great sensitiveness of the throat to any touch; during cough, stitch pains in the hemorrhoidal tumors; the stools are fetid even if formed. Mangan. Spasmodic cough from afternoon till bedtime, ceasing on lying down, worse from motion; expectoration scanty and difficult, causing long efforts of coughing for its expulsion; in the morning easy. Sore and bruised feeling through the chest. Merc. sol. Catarrh of the whole mucous membrane from the nose down; chilliness and heat alternately; feels hot in bed and chilly when moving his feet to a cooler place; sweats without relief; cannot bear either warm or cold air; cough worse when lying on the right side; tongue coated thick, yellow- ish; great thirst for ice water, although it aggravates the cough. Nux mosch. Cough worse on getting warm in bed; excited by a creep- ing sensation from the chest to the throat; especially during pregnancy. Nux vom. Always after previous use of cough mixture; cough worse in the morning; excited by beer, relieved by warm drinks. Nose stopped up in the evening; headache; fever with chilliness from slightest motion; irritableness; oversensitiveness to light, noise and smells. Involuntary mic- turition when coughing, laughing or sneezing. Opium. Convulsive, dry tickling cough in paroxysms worse at night, with bluish redness and sweat in the face, and yawning after the cough. Drowsiness and inability to go to sleep. Phosphor. Tight cough, worse from evening till midnight; tightness THERAPEUTIC HINTS TO AFFECTIONS OF BRONCHIAL TUBES. 333 across the chest; pain in the head, larynx and chest when coughing. Cough worse from speaking, laughing, eating, motion and on going into the cold air. Useful after onion syrup. Pulsat. Chilliness; thirstlessness; loose cough with yellow or greenish expectoration; tight in the evening on retiring to bed, often causing vomit- ing. After measles. Rhus tox. Cough excited by a tickling under the middle of the sternum, worse from uncovering any part of the body; from laughing, talking, sing- ing, and cold drinks; better from warm drinks. Pain in the limbs during rest, which feel stiff and lame on first moving, but get better during exercise; restlessness. Rumex. Dry cough in long paroxysms, brought on by any irregularity in breathing, taking a deeper breath than usual, talking; or from external pressure upon the throat-pit; worse in the evening after retiring; the patient covers his head all over, because the slightest draft of cold air at once brings on a distressing tickling in the throat-pit and behind the sternum, more towards the left side; in walking he covers mouth and nose. (Dunham.) Senega. Tough mucus causes the greatest, often ineffectual efforts of coughing and hawking for its expulsion. Sepia. Cough seems to come from stomach or abdomen; nausea during and after cough. Tickling cough before midnight in bed, coming in rapid concussions until breath is exhausted, followed by expectoration of mucus w T ith temporary relief. Worse in cold, wet weather. Eruption of hard papulae on a red base with burning and itching; herpetic eruptions and pas- sive congestion of the womb. Spongia. Cough wheezing and asthmatic, relieved by eating or drink- ing; oppression and breathing worse from lying with the head low. Sticta. Dry, racking cough, with splitting frontal headache, from tickling in right side of trachea, below larynx; cough excited by inspiration. Sulphur. Cough worse in evening on tying down, with itching in the bronchi, accompanied with retching. Hot flushes; cold feet; or hot palms and soles, hot vertex. Rheumatic pains in knees and hips at night, with coldness and soreness; itching of skin on retiring. Tart. emet. Rattling mucus; cough is followed by yawming; cough worse when lying; child wants to be carried about; worse after eating, with vomiting. Drowsiness; sticky perspiration; dyspnoea; cyanosis. Ver. alb. Capillary bronchitis, with livid face, blue nails, cold extremi- ties and tumultuous, irregular contractions of the heart; cold perspiration on forehead wdien coughing; eyes half open during sleep. Zincum. Child grasps the genitals when coughing. The Chronic forms may require any of the remedies above detailed; they may require one or the other of the following: Alum. Cough worse about 6 o'clock in the morning, on and after " getting up; raises but little after considerable coughing; sometimes the cough is troublesome at night; it often recurs with the cold season and lasts until 334 THERAPEUTIC HINTS TO AFFECTIONS OF BRONCHIAL TUBES. the warm season sets in again; the cough is relieved by lying flat on the face. Irritable persons and women who easily laugh or cry. Follows well after Bryon. Ambra gris. Cough dry in the evening, gray sputa in the morning; excited by exertion and music. Aged people. Amm. carb. Cough dry, tickling, with a sensation of heat and burn- ing in windpipe under sternum, as of having swallowed alcohol; rough voice; from taking cold in rough, rather dry air. Aged people; adynamic state. Amm. mur. Cough, with profuse, thick, whitish expectoration, some- times in lumps, with heaving; mucous rattling in the chest, worse when lying, either with or without difficult expectoration; burning in the chest; dyspnoea on moving and when lying; rawness and soreness in fauces; cold- ness between the shoulders. Old age; bronchiectasias ; emphysema. Arg. nitr. Rattling cough; hoarse voice; marasmus, the legs are especially emaciated; child cries much, unless carried about; craving for sugar. Arse?i. ~Dry, spasmodic cough, with dyspnoea, asthma, suffocating spells, cardiac troubles; exhaustion, nervous irritability, hydrsemia. Worse at night; from lying down, drinking, and change of weather. Calc. carb. Expectoration yellow, lumpy, sweetish, sometimes fetid; when thrown into water, a lump is seen shooting to the botton, with a mucous trail behind, like a falling star. ( Fellger. ) For scrofulous indi- viduals and such who have to talk a great deal, who are subject to hoarse- ness, to perspiration from an} T exertion, and palpitation of the heart after eating. Carb. an. Cough, with hoarseness or night-sweats, very fetid and debilitating, following chill and fever in the evening; coldness and aching in lumbar region and lower extremities. Carb. veg. Burning in chest, heat and perspiration; great weakness; oppression; want to be fanned. Coldness of skin; pointed nose; rattling of large bubbles: cold knees in bed. Exhausted and aged persons. Cinchona. Black, difficult expectoration; cough worse with head lying low, or when lying on left side, or when moving, talking, etc.; better with head lying high. Coral, rubr. Cold expectoration. Hepar. Dirt}' yellowish expectoration, badly smelling; cough worse in the morning and when uncovering any part of the body; bronchiectasia. Iodium. Compare Acute Forms. Kali bichr. Ropy expectoration; cough excited from eating or drinking. Kali carb. Dry cough, as if excited by a dry membrane in the trachea, which cannot be detached; slimy, salty expectoration; cough worse about 3 o'clock A. M., also from eating and drinking, with pain in lower part of the chest. Dry skin; dry stool; eyelids red and swollen, especially between the brows and upper lids. After measles. THERAPEUTIC HINTS TO AFFECTIONS OF BRONCHIAL TUBES. 335 Laches. Compare Acute Forms. Lauroc, Short, titillating cough from cardiac affections. Lobe/, infl. "Spasmodic contraction of the diaphragm in emphysema, accompanied by pain in epigastrium, tympanitis of the abdomen, impossi- bility of deep inspirations; extreme dyspnoea and cyanosis." (Meyhoffer.) Lvcop. " Chronic pneumonia; bronchitis, with copious muco-serous, or muco-purulent secretion; emphysema; dilatation of the air- tubes; senile catarrh. Congestion of the liver, flatulency, constipation, cachectic com- plexion, red gravel, acid dyspepsia." (Meyhoffer. ) " Cough dry day and night in feeble, emaciated boys." (C. Wesselhoeft. ) The cough ends with a loud belch; salt}' expectoration. Natr. earb. Cough is excited by coming into a warm room. (Bryon.) A T atr. mur. Transparent, viscid sputa; weak voice; fluttering of the heart; worse on the seashore; cutting pain in the urethra after urination. Natr. sulph. When coughing at night has to sit up and hold his chest with both hands; asthmatic spells worse towards morning. Aggravation always from cold, damp and rainy weather. Nitr. ac. Cough with thirst in the morning. Phosphor. Besides a dry cough, there is in chronic cases often a free expectoration of abundant, tough mucus, especially in the morning. At times the expectoration is cold. Tremor when coughing. Phosph. ac. Cough in overgrown youths. Platina. Chronic cough dependent on uterine diseases with mental dis- turbances. Plumbum. Copious muco-purulent, or purulent expectoration. Sanguin. Cough worse at night; circumscribed redness of the cheeks; burning dryness of the mouth and throat, not relieved by drinking. Secale. Concussive cough ; profuse perspiration; sleepless nights; colic, diarrhoea, and bloatedness of the abdomen. Emphysema. Sepia. Compare Acute Forms. Silic. Expectoration of pus, which when thrown into water, falls to the bottom and spreads like a heavy sediment. (Fellger. ) Cough w T orse from cold, and better from warm drinks. Spojigia. Compare Acute Forms. Stannum. Bronchial dilatations with purulent expectoration; excessive muco-purulent expectoration; weak feeling in the chest. Staphis. Cough is excited by eating meat, or cleaning the teeth. Very sensitive, feeling easily hurt when being reproached. Cervical and axillary glands swollen. Sulphur. Often indicated in rheumatic, gouty, herpetic and scrofulous individuals, also when seemingly well indicated remedies refuse to act. Sensation as of ice in the chest whenever chilled, or perspiration is checked. Compare Acute Forms. Tart. emet. Compare Acute Forms. 36 DIGEST TO BRONCHITIS. Digest to Bronchitis. COUGH. CHARACTER OF: Barking : Bellad. Concussive : Seeate, Sepia. Convulsive: Opium. Dry in evening, gray sputa in morning: Ambra^ . with heat and burning in windpipe under sternum, as of having swallowed alcohol: Amm. card. . spasmodic, with dyspnoea, asthma, suffocating spells: Arsen. , hacking, especially at night: Cina. , tickling, only in daytime: Euphras. , spasmodic, titillating, nightly: Hyosc. . as if excited by a membrane in the trachea, which cannot be detached: Kali curb. , day and night, in feeble, emaciated boys: Lycop. , convulsive, tickling, in paroxysms: Opium. , or with free expectoration of tough mucus, especially in the morning: Phosphor. , in long paroxysms: Rumex. , before midnight, in rapid concus- sions, followed by expectoration: Sepia. , racking: Sticta. Loose, a.m., tight, p.m.: Badiaga. , or tight: Hepar. , from evening till midnight: Phos- phor. and rattling of mucus: Calc. carb., Tart. emet. Rattling: Arg. nitr. Rough, scraping: Eupat. per/. Spasmodic: Badiaga, Hyosc. , from afternoon till bedtime: Man- gan. In spells, far apart: Carb. veg. Tight: Phosphor. , or loose: Hepar. , in evening on retiring to bed, caus- ing vomiting: Pulsat. Titillating or tickling: Amm. earb., Chamom., Euphras., Ignat., /pee., Iodum, La it roe.. Sepia. , worse in lying: Hyosc. , with dyspnoea: I pee. Titillating, from cardiac affections: La it roe. before midnight, followed by ex- pectoration: Sepia. Wheezing and asthmatic: Spongia. Whizzing with difficult expectoration: Arsen. Expectoration, badly smelling: Calc. carb., Hepar. , black and difficult: Cinchona. blood-streaked sometimes: Brvon. , bloody: Arnica. , cold: Coral, rubr. , cool at times: Phosphor. , difficult: Alum., Atuica, Arsen., Cinchona, Mangan. . easy: Mangan. . frothy and tough: Arsen. , gray in the morning: Am bra gris. , mucous: Kali earb., Sepia. , muco-purulent: Calc. carb., Lycop., Plumbum, Stannum. , when thrown into water, a lump is seen shooting to the bottom, with a mucous trail behind, like a falling star: Calc. carb. . profuse: Amm. mur., Lyc^p., Stan- num. . purulent: Lycop. , Silic, Stannum. , when thrown into water, it falls to the bottom and spreads like a heavy sediment: Silic. , ropy: Kali bichr. . salty: Kali carb., Lycop. , scanty: Mangan. , sweetish: Calc. carb., Phosphor., Stannum. , thick, lumpy: Amm. mur., Calc. carb. , transparent, viscid: Natr. mur. , yellow, Calc. carb. , or greenish: Pulsat., Sulphur. , dirty yellowish : Hepar. COUGH, EXCITED BY : Crawling sensation below larynx: Kreos. Creeping sensation from chest to throat: Nux moseh. Suffocating constriction of throat, as if throat were throttled: Chamom. Tickling in pit of throat: Laches., Rumex. in right side of trachea below larynx: Sticta. DIGEST TO BRONCHITIS. 337 in trachea and under middle of ster- num: Arsen. under middle of sternum: Rhustox., Rum ex. in pit of stomach: Bryon. in abdomen: Ant., crud., Drosera, Sepia. Itching" in bronchi Sulphur. Tough, mucus in throat: Senega. Cold air : Phosphor, Si lie. Uncovering' any part of the body: Hepar, Rhus fox. Going into cold air: Carb. veg., Phosphor* Slightest draught, covers his head all over: Rumex. At seashore : Natr. mur. Entering a warm room: Bryon., Natr. carb. Getting warm in bed: Caustic., Nux mosch. Drinking: Arsen., Kali bichr., Kali carb., Hepar. cold water: Arsen. cold drinks: Rhus tox. ice water: Merc. sol. cold beer: Nux vom. Eating : Bryon., Kali bichr., Kali carb. meat: Staphis. , after: Kali carb. before and after meals: Eupat. fer. Smoking: Bryon. Motion: Bryon., Mangan., Phosphor. Crying in children: Arnica. Laughing, singing, talking: Act. rac, Cinchona, Conium, Laches., Phosphor., Rhus tox., Rumex. Inspiration: Sticta. Any irregularity in breathing, taking deep breath: Rumex. Exertion and music: Ambra. Lying : Conium. , Hyosc. , Tart. emet. down: Arsen. in evening, with retching: Sulphur. with head low: Cinchona. Lying on right side : Merc. sol. on left side: Cinchona. During sleep without waking: Arnica, Bellad., Calc. carb., Chamom. and after: Laches. Mental excitement: Arsen. Cleaning the teeth: Staphis. External pressure upon the pit of the throat: Rumex. Cough, < in the morning: Bellad. , Hepar, Nux vom., Pulsat. , < about 6 o'clock a. m. : Alum. , from covering mouth and nose when walking: Rumex. , > in bed: Caustic. , > while eating, especially during supper: Ferr. met. , > from eating or drinking: Spongia. , > from drinking small quantities of beer or water: Euphras. , > from drinking sips of cold water: Caustic. , Cuprum. , ^> from drinking warm drinks: Nux vom., Rhus tox., Silic. , > from lying down: Mangan. , /• from lying fiat on the face: Alum. Cough > from lying with head high: Cinchona. COUGH, ATTENDED WITH : Crying: Bellad., Bryon. and pressing hands upon head: Badiaga. Pain in head: Badiaga, Bryon., Nux vom., Phosphor. in forehead, splitting: Sticta. 22 338 DIGEST TO BRONCHITIS. in chest, which he supports with his hands: Drosera, Eup. per/., Natr. sulph. in sides of chest: Bryon. in lower part of chest: Kali card. in chest, head and larynx: Phosphor. over left hip: Caustic. in pit of stomach and under short ribs: Bryon. in epigastrium: Lode/, infl. from small of back down into thighs: Arsen. Stitch pain in hsemorrhoidal tumors: Laches. Soreness in chest: Eup. per/. and bruised in chest: Mangan. Heat and burning in windpipe under sternum: Amm. carb. Itching" from throat down to centre of chest: Carb. veg. Convulsing the muscles of chest and ab- domen: Drosera. Dyspnoea: Arsen. Spurting of urine: Bryon., Caustic, Nux vom. Child grasps the genitals: Zincum. Strangling, face turning dark, and yellow, viscid mucus flying out of mouth and nostrils: Badiaga. Face pale, even bluish: Lpec. Bluish redness and sweat in the face: Opium. Cold perspiration on forehead: Ver. alb. Heat of body: Caib. veg. Tremor: Phosphor. Becoming stiff: Cina. COUGH, FOLLOWED BY: Swallowing as if something were rising in the throat: Cina. Clucking noise in throat down to stom- ach: Cina. Belching: Lycop. Nausea: Sepia. Vomiting: Pulsat. Yawning: Opium, Tart. emet. Trembling: Cuprum. GENERAL SYMPTOMS. Wants to be fanned: Carb. veg. carried about: Arg. nitr., Chamom., Tart. emet. Screams in the night: Kreos. Restless anxiety in the night: Arsen. Irritable: Arsen., Chamom., Kreos., Nux vom. persons and women who easily laugh or cry: Alum. Fretful: Kreos. Sensitive, feeling easily hurt, when be- ing reproached: S tap his. Irascibility and restlessness: Aeon. Oversensitive to light, noise and smells: Nux vom. Mental disturbances: Platina. Much agitated : Kreos. Headache : Nux vom. Eyelids red, and swollen between eye- brows and upper lids: Kali carb. Lachrymation and sneezing: Badiaga. Nose stopped in evening: Nux vom. Cold in head and diarrhoea: Arsen. Circumscribed redness of cheeks: San- guin. Livid face: Ver. alb. Cyanosis: Lobel. infl., Tart. emet. Cachectic complexion: Lycop. Pointed nose: Carb. veg. Stiffness and lameness of jaws: Caustic. Tongue coated thick, yellowish: Merc. sol. Burning dryness of mouth and throat not relieved \>y drinking: Sanguin. Rawness and soreness in fauces: Amm. mur. Cough with thirst in the morning: Nitr. ac. Thirst for ice water: Merc. sol. Thirstlessness : Pulsat. During Teething : Calc.carb., Chamom. Cervical and axillary glands swollen: Staphis. and bronchial glands swollen : Lodum. Sensitiveness of throat to any touch: Laches. Hoarseness: Arg. nitr., Carb. an. in the morning: Caustic. in the evening: Carb. veg. Rough voice: Amm. carb. Weak voice: Natr. mur. Burning in chest: Amm. mur. Carb. veg. under sternum: Carb. veg. Soreness of chest: Carb. veg. Tightness across the chest: Phosphor. DIGEST TO BRONCHITIS. 339 Asthma: Arsen., Natr. sulph., Spongia. Dyspnoea: Ipec, Tart. emet. with cyanosis: Lode/, infl. when moving and lying: A nun. mur. Oppression: Carb. veg. , worse from lying with head low : Spon gia. Impossibility of deep inspiration: Lobel. infl. Rattling in chest: Tart. emet. worse when lying, without or with difficult expectoration: Amm. mur. of large bubbles: Carb. veg. Catarrh on the chest of children: Aeon., Ferr. phosph. of the aged: Lycop. Capillary bronchitis: Ver. alb. Chronic pneumonia: Lycop. Bronchiectasia or bronchial dilatation: Amm. mur., Hepar., Lycop., Stannum. Emphysema: Amm. mur., Lycop., Secale. with spasmodic contraction of dia- phragm: Lobel. infl. Palpitation of the heart: Arsen., Eup. per/., Lodum. after eating: Calc. carb. Fluttering of the heart: Natr. mur. Tumultuous, irregular contractions: Ver. alb. Cardiac affections: Arsen., Lauroc. Craving for sugar: Arg. nitr. Pyrosis with great flow of water from mouth during day: Carb. veg. Heartburn and acidity after fat, saccha- rine and farinaceous food: Caustic. Nausea and vomiting: Ipec. Gastric derangement: Ant. crud. Acid dyspepsia: Lycop. Congestion of liver: Lycop. Flatulence: Lycop. Tympanitis : Lobel. infl. Colic, diarrhoea and bloatedness: Secale. Diarrhoea: Arsen., Lpec. Bowels moved more frequently towards evening: Calc. carb. Dry stool : Kali carb. Stools fetid even if formed: Laches. Tendency to piles with constipation: JEsc. hip p. Cutting in urethra after micturition: Natr mur. Red gravel : Lycop. Passive congestion of womb: Sepia. Uterine diseases with mental disturb- ances: Platina. During pregnancy : Nux mosch. Rheumatic pains in limbs: Arsen. during rest and on first moving, better from continued exercise: Rhus tox. in knees and hips at night, with coldness and soreness: Sulphur. in limbs and back: Eup. perf. Aching in lumbar region and lower ex- tremities, and coldness: Carb. an. Gouty diathesis: sEsc. hipp. Sudden cramps in the heel-cords in the night: Caustic. Drowsiness : Tart. emet. with inability to go to sleep : Bell ad. , Opium. Sleepless nights: Secale. Restlessness : Rhus tox. Starting in sleep: Bellad. Eyes half open during sleep: Ver. alb. Chilliness: Pulsat. in bed when moving the feet to a cooler place : Merc. sol. Chilliness and heat alternately: Merc.sol. Coldness of skin: Carb. veg. in bed: Carb. veg. Cold feet : Sulphur. knees in warm bed: Carb. veg. extremities with blue nails: Ver. alb. Sensation as of ice in chest whenever chilled or perspiration is checked : Sul- phur. Coldness between the shoulders: Amm. mur. and aching in lumbar region and lower extremities: Carb. an. High fever : Aeon. with chilliness from slightest motion: Nux vom. Fever followed by perspiration: Carb. an. Heat and perspiration: Carb. veg. Hot flushes : Sulphur. skin, inclined to be moist: Bellad. 34Q BRONCHIAL ASTHMA. in bed and chilly when moving feet to a cooler place: Merc, sol . palms, soles and vertex: Sulphur. Perspiration, profuse: Secale. , sticky: Tart, ciuet. , without relief: Merc. sol. , immediately on waking from sleep: Drosera. , on head during sleep: Calc. card. , fetid and debilitating, after chill and fever in the evening: Card. an. from anv exertion : Calc. card. Dry skin : Kali card. Itching of skin on retiring: Sulphur. Hard papulae on a red base, with burn- ing and itching: Sepia. Exhaustion: Arsen. Weakness : Card. veg. Adynamic : Amm. card. Hydraemia: Arsen. Marasmus, especially legs emaciated: Arg. nitr. Progressive emaciation with good appe- tite: Iodum. Catarrh of the whole mucous membrane from nose down: Merc. sol. Cannot bear either warm or cold air: Merc. sol. During dentition: Bel lad., Calc. card. y Chamom., Kreos. Persons subject to hoarseness and who have to talk a great deal: Calc. card. Young persons subject to blood-spitting: Iodium. Too fast growing youths: Phosph. ac. Aged people : Ambra. % Amm. card., and mur., Card, veg., Tart. emet. Scrofulous individuals: Calc. card. Rheumatic, gouty, herpetic and scrofu- lous persons: Sulphur. Repelled eruptions: Hcpar. herpetic eruptions: Sepia. perspiration: Aeon. After measles : Kali card., Pulsat. cessation of hemorrhoidal flow: Euphras. Taking cold in rough, dry weather: Aeon., Amm. card., Hepar. in cold, wet weather: Xatr. sulph. y Sepia. Recurs with the cold season, lasting till warm season: Alum. Change of weather: Arsen., Bryon. Caused by bathing: Ant. crud. After the use of cough -mixtures: Nux vom. onion syrup: Phosphor. Alumina follows well after Bryon. Bronchial Asthma, Asthma Bronchiale Nervosum seu Convulsivum. Bronchial asthma is characterized by attacks of sudden dyspnoea, com- ing on after longer or shorter intervals, increasing rapidly in severity, and lasting for a few hours or for several days. Its nature is thought to be a spasm of the bronchial muscles (Biermer and others); a tonic spasm of the dia- phram (Wintrich); a tumefaction of the bronchial mucous membrane in consequence of dilatation of its blood vessels through vasomotor nervous in- fluence (Weber); a presence of fine-pointed crystals found in the sputa of asthmatic expectoration, which irritate the peripheral termination of the vagus nerve in the bronchial mucous membrane, and cause a reflex spasm of the musculature of the smaller bronchi (Leyden). It is quite likely that in individual cases these various conditions ma}' exist singly or conjointly, or may be produced either by a direct irritation of the vagus nerve, or in a reflex manner by irritation of various organs. For the first speak cases in which asthmatic and epileptic paroxysms, or asthmatic attacks with hemi- crania and with angina pectoris alternated. The reflex manner bj T which the bronchial branches of the vagus may be excited is by far more frequent. We see it originate in the sexual organs (uterine asthma), in the sensitive BRONCHIAL ASTHMA. 34 1 nerves of the intestinal tract, as in disorders of digestion, irritation from worms (dyspeptic, verminous asthma), in the sensitive nerves of the skin (asthma from taking cold), in the sensitive nerves of the mucous membrane of the respiratory tract (asthma from nasal polypi); after measles and whooping-cough; from the smell (inhalation) of different drugs (ipecacuanha, 3 T ellow oak, fresh coffee, violets, lamp-black, etc.); of the pollen of certain grasses (hay asthma). Essential anatomical alterations on post-mortem examination are not found. But Stork has demonstrated by tracheoscopic examinations that the mucous membrane of the trachea and main bronchi is intensely reddened during the attack. It is, therefore, scarcely to be doubted, that the mucous membrane of the smaller ones must be in a like condition, if not more so. It is also clear that long- continued and frequently recurring attacks will lead to changes which are characteristic of chronic bronchial catarrh, or to emphysema. Like all neuroses, bronchial asthma generally attacks in paroxysms, the intervals between which may amount to weeks, months and even years. It not unfrequently commences during sleep; then the patient gets restless; the gradual increasing difficulty of breathing causes terrible dreams and awakens him. On getting awake the patient has a desire to draw a long breath, but feels that the inhaled air does not reach and satisfactorily fill his lungs. We hear, and so does the patient, all sorts of hissing, whistling and rattling noises during inspiration, and especially during expiration. The dyspnoea increases; the respiratory and especially the expiratory muscles labor; the alse nasi move up and down; the sterno-cleido-mastoid muscles are put upon the stretch; the head is drawn backwards; the arms are pressed firmly upon the chair to widen the chest; or the patient leans forward, resting with head and arms upon a chair or table; but all in vain. The vesicular murmur ceases, and in place of it we observe here and there a hissing noise, sonorous and sibilant rales, coming and going suddenly; the inspiratory noise in the larynx and trachea, however, continues even stronger than normal. There is an anxious expression of countenance; the eyes are wide open; cold per- spiration covers the forehead. The color of the face is pale; the impulse of the heart is violent, uneven, irregular; the pulse at the wrist is weak and small; the hands and cheeks are cold. After some time, varying from an hour to several hours, with short intervals, the paroxysm ceases, either sud- denly, when the air rushes into the bronchial tubes, which are suddenly relieved from spasm, causing puerile respiration, or the relief is only gradual, attended with belching, yawning or increased secretion within the bronchial tubes, which excites cough and rattling of mucus for some time afterwards. On percussion, we will find the clear lung-sound extending on the right an- terior side of the chest, some two inches or more below the sixth rib, show- ing that the inflated lung has pressed the liver down into the abdominal cavity; while on the left side the cardiac dullness is sometimes diminished in consequence of the distention of the edges of the lung. There is also only a 342 THERAPEUTIC HINTS TO BRONCHIAL ASTHMA. very slight change of the limits of the lower edges of the lung during inspi- ration and expiration, for the reason that during expiration the lung cannot rid itself of the air within on account of the spasmodic closure of the finer bronchi. So also shows the percussion sound a tympanitic quality, usually in the lower portions of the thorax, especially posteriorly and on the sides, which is due to the greater distention of the alveolar tissue. Its Diagnostic difference from spasm of the glottis lies in the difficulty of its expiration, similar to that of bronchial catarrh and emphysema, while the dyspnoea in croup, in oedema of the larynx, in stenosis of the trachea, in spasms of the glottis, and in paralysis of the dilators of the glottis is an inspiratory one. Its Prognosis is favorable. Asthma alone does not cause a fatal issue, but when complicated it ma}'. It has its own remedy within itself. The accumulation of carbon relaxes all the muscles of the body, and, of course, the contracted bronchial muscles. As soon, therefore, as they relax, respira- tion is free, and the paroxysm ceases. (Niemeyer.) Therapeutic Hints. Apis. Chest feels bruised; worse from heat; nettle-rash disappears. Arg. nitr. Must rise and walk about ; an effort to breathe deeply takes away the breath ; cannot talk ; drinking suffocates ; agony, thinks of killing himself. Aral. Dry, whistling respiration ; cannot lie down, must sit up ; gradual loosening and discharging of acrid mucus from nose and throat. (Hay asthma.) Arsen. Paroxysms from midnight till daybreak ; has to leave the bed, sit up bent forward ; great restlessness and anxiety, w T ith feeling hot and cold in turns ; fear that he will be compelled to destroy his own life ; sweat of whole body ; burning pain in chest ; prostration ; attacks from cellar-air, stormy weather, heavy atmosphere, change of temperature, rapid walking. Bellad. Paroxysms in the afternoon and evening, with sensation of dust in the lungs ; worse in hot, damp weather, and after sleep. Bromium. Asthma of sailors as soon as they go ashore. Cist. can. Feeling as if the windpipe were too narrow, must open the window and breathe fresh air, which relieves ; worse again on lying down. Card. veg. Attacks come during sleep, always after midnight ; must sit up by a table ; is full of wind, but cannot raise it; for old people; weakness, w 7 ith trembling; look as if dying. Cupriim. Attacks come on suddenly and after some hours cease suddenly; worse at night, when coughing, laughing, leaning backwards and after drinking ; also before and during menses, after fright, chagrin, or a cold. Fcrrum. Attacks after midnight, driving out of bed; better from, mov- ing slowly about and talking, from uncovering the chest. THERAPEUTIC HINTS TO BRONCHIAL, ASTHMA. 343 Graphit. Paroxysm every night, wakes him out of sleep, usually after midnight ; he has to jump out of bed quickly, must hold himself fast at something and quickly eat a piece of bread, after which the paroxysm passes off. Hyper, Attacks return with changes of the weather, from clear to damp, or before storms; after lesion of the spine by a falh Ipec. Constriction of throat and chest; gasps for air at the open window; worse from least motion; constant cough, no phlegm yielding, although the chest seems full of it; cough causes gagging, vomiting, followed by relief; stiffness of the body; pale face; cold extremities and cold perspi- ration. Kali card. Must lean forward, with head on table; worse from motion and drinking; pressure and tension in pit of stomach, after eating the least; belching, nausea, vomiting; puffy around the eyes; dry stools; dry skin. Laches. Feeling of constriction in the throat and chest, as though a cord were tight around it, necessitating the loosening of the covering of the neck and epigastrium. Heart feels as if it turned over and ceased beating for a while, after which the pulsations increase. Dyspnoea worse after sleep, after eating, from moving the arms, and touching the throat; cannot lie, must sit- up; bent forward, with head thrown back. Lob el. infl. Worse from exertion; disordered stomach, especially a feeling of weakness in the pit of the stomach ; asthmatic attack, often pre- ceded by prickling all over, even to fingers and toes. Mephit. Inspiration difficult, expiration almost impossible; asthma as from inhaling vapor of sulphur; in sleep; of drunkards. Natr. sulph. In the morning, about 4 or 5 o'clock, with cough, and raising of glairy slime, and vomiting after eating; always worse in damp and rainy weather. Nux vom. For persons who drink much coffee or liquor, and who are very irritable; they feel full in the pit of the stomach, belch a good deal, and feel better after it. Asthma worse in the morning, after eating, from cold air or exercise. Spasms of the chest from vapor of copper or arsenic. Opium. Short inspiration, long, slow expiration with a marked draw- ing in of the epigastric region; fine rales, constant cough, soporous condition, bluish face; extreme anguish, with dread of suffocation; looks as if dying; slight relief from cold air and bending forward; worse from eating, drinking wine and smoking. Pulsat. Worse in the evening; constant chilliness; dizziness when ris- ing from a seat; nausea and vomiting; palpitation of the heart; deranged menstruation; suppressed rash. Sa7igai?i. Asthma with hay fever. Sepia. Long, difficult, noisy expirations. Silk. Breathing so difficult that eyes protrude from their sockets ; cloors and windows must be opened; always during thunder-storm. 344 AFFECTIONS OF THE PULMONARY PARENCHYMA. Stannum. Attacks increase and decrease gradually. Sulphur. Attacks come on every eight days. Stooping posture; hunger and weakness every forenoon about 10 or n o'clock. Tart. and. Great difficulty in expiration; must be supported in a sitting posture; great rattling of mucus. Children and old people. Thuja. Little cough, but sensation as if something were grown fast in the region of the Teft lower rib. Pulmo vulpis. Has been recommended hy Von Grauvogl in asthma humid urn of old people when other remedies failed. b. AFFECTIONS OF THE PULMONARY PARENCHYMA. Lobular Pneumonia, Catarrhal Pneumonia. Catarrhal pneumonia never originates primarily in the alveoli, unless it be brought on by an irritant, such as chlorine, for instance, when an inflam- mation may arise in the alveoli and the bronchi simultaneously; otherwise it is always a secondary morbid process to bronchitis, which compare. For this reason it has received the name of Broncho-pneumonia; and as the in- flammatory process presents itself at first in isolated nodules, from the size of a pea to that of a hazel-nut within the collapsed portions of the lung tissue which still contains isolated portions accessible to air, it has also been named Lobular pneumonia. This morbid process may diffuse all over the lungs in the form of isolated infiltrations, and usually progresses from behind and below, forwards and upwards. According to all observations its most frequent occurrence is found in the first three years of life, and those of old age, and as indirect causes we may set down all disturbances that favor the development of bronchial ca- tarrh — such as measles, whooping-cough, diphtheria, influenza, rotheln; sometimes typhus, variola and scarlatina; also foreign bodies in the bronchi and inhalation of gases. The bacillus of tuberculosis, diplococcus of Fraenkel, streptococcus pyogenes aureus, and pneumococcus of Friedlander have repeatedly been discovered in the lobular consolidations. It presents no regular type of fever; the physical diagnosis is of great difficult)'; we must mainly rely on the presence of a capillary bronchitis; on the consolidation of the lung, beginning at its base, arising slowly, at first without any prominent signs and mostly bilateral; on the retraction of the lower ribs seen during inspiration; on the indefinite limitation of the disease, the absence of all critical periods and the fluctuations which occur in general and local symptoms. Therapeutic Hints. Compare Bronchitis and Croupous Pneumonia. Serous pneumonia, see (Edema of the lungs. Pneumonia from embolism happens only in otherwise diseased persons. The emboli are formed either from clots which have originated in the cavities LOBAR PNEUMONIA. 345 of the right side of the heart, or in the viens of the systematic circulation. In the first place there is disease of the heart, and in the latter their sources are either large external wounds, venous thrombi of the uterus in puerperal women, or bed-sores, ulcerations and suppurations of various kinds. When these plugs are non-infectious, the}' produce mere hemorrhagic infarction; when they are of an infectious nature, they result in embolic or metastatic abscesses, which may perforate into the bronchi, or into the pleural cavity, or even break through the chest walls. Simple infarctions are often accom- panied with an effusion into the pleural sac, and are much oftener found in the right lung than in the left. Lobar Pneumonia, Croupous Pneumonia, Lung Fever. This is an acute infectious disease characterized by a fibrinous inflam- mation of the lung parenchyma, with infiltration and consolidation of the same. We classify it under affections of the lungs, owing to its marked clinical features. The exciting causative micro-organism is now generally conceded to be Fraenkel's diplococcus pneumoniae; some bacteriologists, however, particu- lar!}' Weichselbaum, think that other bacteria may also excite pneumonia, such as the streptococcus et staphylococcus pyogenes aureus and the pneu- moccocus of Friedlauder. The chief predisposing cause is unquestionably exposure to cold. It is a frequent sequela to other acute infectious diseases. It attacks in preference the inferior lobes of the lungs, especially on the right side; very rarely both lungs at the same time. It very rarely pervades one whole lung, being much oftener confined to limited portions, which may even be too small to be detected by percussion. It is also of rare occur- rence that the inflammation remains confined to a central portion of a lobe only (central pneumonia), but generally spreads to the surface of the lobe which joins the pleura. In aged persons and cachectic individuals the pos- terior parts of the lungs are most frequently attacked. When normally pro- gressing, pneumonia offers tjhree distinct stages for consideration: 1. The in- flammatory stage, or hyperemia of the capillaries in the lung tissue with ex- udation of the coagulable lymph. 2. Hepatization, or infiltration of the lung tissue with coagulable lymph. 3. Its resolution, or purulent infiltration. The characteristic signs of these different stages are as follows: First state. As a general thing the disease sets in with a violent chill, often attended with vomiting and followed by an intense fever, with a tem- perature of 104 to 105 ° in the evning and from 0.9 to 2.7 less in the morn- ing; the pulse rises to 100 or 1 10 and the respiration to 40 or 50 per minute. In other cases the disease sets in with several light chills or chilliness, or the chill is entirely absent and the scene opens with convulsions and complete loss of consciousness. The skin is at first very drv, but becomes moist usu- 346 LOBAR PNEUMONIA. ally about the third day, though only temporarily. The face is purplish-red, and frequently only on that side which corresponds to the diseased side of the lungs. The lips become covered with hydroa (fever blisters) and also very often only on the affected side, or, at least, more marked on that side. The alae nasi make corresponding movements with respiration; the voice of the patient is low and he speaks in broken sentences. Cough is, in almost all cases, present, although in some less marked than in others; the patient generally tries to suppress it, on account of the pain which it gives. At first it is dry, but after a time it yields a tough, jelly-like, viscid sputum, difficult to expectorate, and adhering to the lips, from which it has to be wiped off; it soon changes to the characteristic color of rust, from an admixture of blood. When the patient complains during the coughing spells of stitch-pain in the chest, it is more or less a sign that the pleura participates in the morbid process; when he complains of dull, heavy pains, they probably originate in the bronchial tubes. In consequence of the disturbed circulation through the lungs, the blood being either not sufficiently oxygenized, or being prevented or retarded in its return from the brain, different brain symptoms originate, such as delirium, stupor, etc. , so that the case may take the appearance of t3 7 phoid fever, from which, however, it is easily distinguished by the hydroa on the lips, which are scarcely ever found in typhoid fever. In rare cases we observe jaundice combining with pneumonia. In such cases the liver appears enlarged on account of the engorgement which is brought about by the impeded circulation. As the hepatic veins cross the gall-ducts the latter become compressed and the gall retained. In other cases is seems that pneumonia is complicated with a parenchymatous inflam- mation of the liver, or a catarrh of the duodenum, causing in either case, icterus. The urine is scanty and concentrated, and deposits on cooling, a sedi- ment of brick-dust urates. The bowels are usually constipated. The Physical Signs of the first stage are the following: Inspection discovers decreased mobility of the diseased side of the thorax. In cases where both the lower lobes are engorged, the patient moves only the upper part of the thorax in breathing, whilst the abdomen remains quiet on account of the impossibility to retract the diaphragm. Palpation shows an increased vocal fremitus, unless the bronchial tubes should be stopped up by mucus. The impulse of the heart is also increased, but felt in its normal position. Percussion yields generally a short, tympanitic sound over the parts in- volved, as long as they still contain air. Ascultation reveals the crepitant sound which, according to Wintrich, arises in consequence of the sticking together of the walls of the air-cells, and their separation by inspiration. It is therefore heard only on inspiration. Second stage, hepatization. The above-mentioned symptoms — fever heat, LOBAR PNEUMONIA. 347 dyspnoea, cough, pain, and brain symptoms — continue. The thorax appears, on inspection, still less movable during respiration; the vocal fremitus is strong, provided there does not intervene a pleuritic effusion between the hepatized lung and the thoracic wall. Percussion gives forth a dull sound, and the resistance of the thoracic walls to the percussing finger is increased, provided the hepatized portion of the lung have the thickness of about one inch, and a superficial extent of several inches. A central location of the hepatization alters the percussion sound very little, if an}- , on account of the intervening portion of lung con- taining air. Auscultation yields neither the natural vesicular breathing, nor the crepitant sound of the first stage, but bronchial breathing, bronchophony, and even pectoriloquy, provided the bronchial tubes, which are contained in the hepatized portion of the lung, be not stopped up by mucus, blood -coagula, etc. There are also heard all sorts of rattling noises, if mucus exists in the bronchial tubes. Third stage, resolution. This sets in sometimes with a sudden relaxation of all the violent symptoms — the temperature falls in from twelve to thirty- six hours to the normal, and at times even below the normal; the congested, even purplish face becomes pale, the skin moist, the dyspnoea ceases, the sputa becomes copious, frothy, yellowish, easily expectorated; the urine in- creases and becomes again natural. On inspection, we observe that the thoracic walls regain their natural mobility; the percussion sound again becomes tympanitic, and by means of auscultation we observe the bronchial breathing and bronchophony becoming weaker; the crepitation sound reappears, until, at length, the natural vesic- ular respiration is re-established. This is the regular process of simple pneumonia, lasting, on an average, from fourteen to twenty- five days, of which two, three, or five days are con- sumed by its first development, five to eight days by exudation progressing to perfect hepatization, and seven to fourteen days by the resorption of the exudation and convalescence. But, after the first invasion of inflammation, new invasions often follow, so that it is not uncommon to find in one lung all three stages united. Or, the adjoining portion of the healthy lung becomes ©edematous; that is, infiltrated by a serous exudation, in which case the dyspnoea increases to suffocation. There is, at the same time, a frothy expectoration and fine rattling noises in the lung not affected with croupous pneumonia. The im- possibility of breathing, on account of the serous infiltration, causes an ac- cumulation of carbon in the blood, and in consequence, death by suffocation. Or, the disease takes an asthenic form when the symptoms of the central nervous system assume great prominence from the beginning, so that the whole process might be mistaken for meningitis or typhus; still the infiltra- tion of the lung progresses slowly, and in severe cases is often attended with pleuritis, jaundice, albuminuria, and considerable enlargement of the spleen. This form is called Typhoid pneumonia. 348 THERAPEUTIC HINTS TO LOBAR PNEUMONIA. Or, the morbid process combines with diseases of the heart, such as endocarditis, pericarditis or valvular affections, all of which lessen a favor- able prognosis considerably. Abscesses may form in the third stage of the disease, which, if small or deeply seated, offer no physical signs, and may discharge and heal. When large, and forming large cavities, we may hear pectoriloquy, and, in somo cases, metallic tinkling. The hepatization ma}' change into tubercular infiltration, which is espe- cially the case when the seat of inflammation is in the upper regions of the lungs. In such cases the fever does not leave altogether, but shows some aggravation every night; cough, dyspnoea and the dull percussion sound of hepatization continue, while auscultation reveals bronchial breathing and bronchophony. Again, the inflammation may assume a chronic form, and the hepatized lung become indurated or cirrhosed, the interstitial tissue growing tense and rendering the air-cells impervious to air. The patient is almost free from fever, but recovers very slowly in strength, and we observe, for a long time, the dull percussion sound and the bronchial breathing; whilst, the thorax, in these places, gradually sinks in. Or, the whole morbid process may end in gangrene, which happens very seldom, and which may be diagnosticated by the sudden general collapse and the cadaverous smell of the breath and expectoration; which is dark-blackish and copious. The mean or average time which it takes for pneumonia to run its course, if it is not interfered with by medicines, is, as above stated, twenty-five days. But this average may, by judicious treatment, be considerably shortened ; for pneumonia can be arrested in each of its stages. The most interesting data in this respect have been brought forth by Dr. Eidherr, of Vienna, who has collected all cases of pneumonia out of a large hospital practice, which had been recorded there for ten years. From these data it appears that under the application of the sixth decimal attenuation of the appropriate remedies the average came down to nineteen, under the application of the fifteenth potency to fourteen, and under the application of the thirteenth potency to eleven days. The Diagnosis must be based on the above detailed physical signs; but one of the most constant and characteristic signs is the great frequency of respirations compared with the pulse, which in very severe cases may approach that of the pulse, usually, however, amounting to one respiration for two or three beats of the heart, while in health the ratio is about 2 to 9, that is 1 respiration to 4^ pulsations. The most fatal days of pneumonia are those between the fifth and eighth days. Therapeutic Hints. Sulphur. According to Eidherr, when exudation sets in, that is; when auscultation reveals the crepitation sound. THERAPEUTIC HINTS TO LOBAR PNEUMONIA. 349 /odium or Kali hydr. According to Kafka, at the beginning, when the disease localizes itself. Bromium. In extersive hepatization of the lower lobes. Phosphor. In capillary bronchitis, or catarrhal pneumonia. Tart. cmct. In pleuro-pneumonia. Schiissler recommends Ferr. phosph. for the first, Kali mur for the second, and Calc. sulph. for the third stage. All this is very well, but will not suffice for all cases ; we will still have to consider the following : Aeon. First stage, high fever; must lie quietly upon the back; cannot lie on the right side, by stitching pains in the left. Raising is difficult, the expectoration being tenacious, falling in a round lump and of a dark cherry- red color. (C. Pearson.) Arnica. Traumatic cases. Arsen. Great anxiety and restlessness with tossing about; great thirst, but drinking little at a time; burning and heat in the chest; pale face; cold extremities; prostration. Baptis. " If I could only get my cough together; it seems to be in pieces, all scattered about, and I want to get it together." Typhoid form. Bell ad. Nervousness, delirium, threatening convulsions; drowsiness; inability to go to sleep; starting from sleep. Face flushed, eyes congested; congestion towards the brain. Dry, tickling cough, worse in the night. Bryon. Expiration shorter than inspiration; inclination to lie perfectly still; the slightest motion increases all the symptoms; great thirst, wanting large draughts of water; desire for acid drinks; or little or no thirst with dryness of the mouth. Better on lying on the painful side; sometimes the reverse. " Expectoration falling in round, jelly-like lumps, and of a yellow or soft brick shade." (C. Pearson.) Calc. card. Gray hepatization v/ith sputa, which fall in water to the bottom, leaving a trail of mucus behind, like a shooting star. (Eellger.) Perspiration about the head. Capsic. "When coughing, the air from the lungs causes a strange, offensive taste in the mouth, and a badly-smelling breath rushes out of the mouth." (A. R. Wright.) Card. veg. Third stage ; cough by spells, or no cough; hippocratic face, eyes half open, nose pinched and cold, lips blue, pupils insensible, no complaining or crying; pulse small, quick, difficult to count; body emaciated and marbled; feet and hands blue and cold; abdomen distended with gas; respiration frequent and superficial; breath cold — a perfect picture of collapse. Chelid. Right side; bilious symptoms; pain under right shoulder- blade; great and quite irregular palpitation of the heart. Cuprum. After a previous catarrh in the chest or in the bowels; sudden attacks of dyspnoea to suffocation; face earthy, dirt}', bluish, seldom red; roof of mouth always red; sweat not profuse, sometimes sour-smelling, with- out relief; diarrhoea. 350 THERAPEUTIC HINTS TO LOBAR PNEUMONIA. Ferr. met. No ailments previous to the chill; dyspnoea increases slowly; face pale, and in adults it becomes collapsed, hippocratic or expres- sionless, stiff and stupid; the roof of the mouth always white; skin neither cold nor burning hot; pulse neither full nor hard; stool consistent, brown. Ferr. phosph. The expectoration is clear blood. Gelsem. After a sudden check of perspiration, with pain under the scapulae of both sides. (A. E. Small.) Hyosc. Typhoid pneumonia; sees persons in the room who are not there. Kali carb. Cough worse towards 3 o'clock a. m., almost choking; pain in lower part of chest, with dull percussion sound; pulse small and some- what irregular; face pale; skin and stool dry. Kali hydr. After shaking chill, fell in a deep sleep, out of which he could not be roused; snoring loudly with closed eyes, injected conjunctiva, hot head, dry tongue, bluish lips, sunken lower jaw, bluish finger-nails; irregular and intermitting pulse; lies upon his back; the extremities, when raised, fall back as if paralyzed; has not voided urine nor asked for any drink. Both upper portions of the lungs hepatized. (Kafka.) Laches. " Great dyspnoea, worse in the afternoon or after sleep; left side; badly-smelling stools, even if formed. Lycop. Circumscribed redness of the cheeks; lips and tongue ulcerated, red and dry; fan-like motion of the alae nasi; cannot bear to be covered; sweat without relief; cross on getting awake. ' 'The patient raises a whole mouthful of mucus at a time, of a light rusty color, stringy and easily sep- arated . " ( Pearson . ) Merc. sol. Right side; bilious symptoms; jaundice; diarrhoea. Nitrum. Annoying feeling of heaviness in the chest, as though some great load were pressing the thorax together; can drink only in little sips for want of breath; dyspnoea to suffocation. Nifr. ac. In protracted cases; in weak, cachectic individuals, where there is a sudden abatement of pain, and yet an increase of the pulse in smallness and quickness. Opium. Mr. H. F., aged 40 years, of a phlegmatic temperament; double pneumonia. At times feels as though he were not in his house .which he expresses by saying: "I wish I could be in the house with my family." Although in a desperate condition he is not much alarmed and wants to sit up a great part of the time, because the bed feels too hot. His whole body, except the lower extremities, perspire profusely, the sweat is very hot. The perspiring parts are covered by a heavy crop of sudamina. He gropes with his hands about the bed as though he were hunting something. Inasmuch as Opium is not one of the routine remedies in pneumonia, I wasted time in giving Bryon., Phosphor., etc. About the eleventh day Opium 6 was given, which was followed by a sudden change and a most satisfactory recovery, without the aid of any other remedy. If it is objected that pneumonia gets well without treatment, I reply that the time when resolution generally takes DIGEST TO PNEUMONIA. 35 1 place had passed when Opium was given, and that in all likelihood nature was inadequate to the task in this case, where not only the whole left but a considerable part of the right lung was hepatized. I have treated another very similar case where the same remedy yielded the same results. (C. Bernreuter. ) Phosphor. ' 'Stupor with burning hot head; red, hot cheeks, red' ears, contracted pupils, closed mouth. Murmuring and gesticulating in delirium. Takes water when offered greedily, but cannot swallow more than one sip, on account of shortness of breath. Wing-like motion of alae nasi. The carotids pulsate violently; the heart beats strong; the pulse is very quick; the skin dry and hot. The lower portion of the posterior right lung is hepatized." (Kafka.) Great tightness across the' chest; diarrhoea. ''The expectoration, when falling on paper, will break and fly like thin batter." (Pearson.) Pulsat. Lies on the back, can't lie on the sides; semilateral perspira- tion (left side of the chest); can scarcely speak above a whisper; respiration 50 per minute. Rhus fox. Restless moving, because lying still increases pain and dysp- noea; tongue red at tip. Typhoid pneumonia. Sa?iguin. Second and third stage; extreme dyspnoea; tough, rust- colored sputa; the patient lies upon his back; there is not much pain in his chest, and that of a burning, stitching character; pulse quick and small;' face and extremities inclined to be cold, or hands and feet burning, with circumscribed redness and burning heat of the cheeks, especially in the afternoon. Senega. Right side; violent stitches; sinking of strength; small, scarcely perceptible pulse; rare cough, without expectoration, but great rattling of mucus in the chest; somnolence; dejected features. Sulphur. May be indicated in any stage; sometimes also when other remedies fail. Its indications may be found in: hot palms and soles; hot vertex; faint, weak spells, especially in the forenoon; diarrhoea, especially early in the morning; suffocating spells, wants doors and windows open; restless and sleepless nights; cutaneous eruptions. Tart. emet. Great rattling of* mucus; much coughing, with copious, frothy expectoration, or else no expectoration; oedema of the lungs; impend- ing paralysis of the lungs; greatest dyspnoea and fits of suffocation; cyanosis. Pleuro-pneumonia . Ver. vir. Face flushed; red streak through the centre of the tongue; sinking, faint feeling in pit of stomach; regularly intermitting pulse; expec- toration of pus and florid blood. Digest to Pneumonia. First stage : Aeon., Ferr. phosph., Kali hydr., Sulphur. Second stage : Kali mur., Sanguin. Hepatization, gray: Calcar. — , lower lobes: Bromium. — , posterior lower lobes, right side: Phosphor. — both upper portions: Kali hydr. DIGEST TO PNEUMONIA. Pneumonia, right side: Chelid.. Merc. sol., Phosphor.. Senega. . left side: Laches., Rhus fox. Double pneumonia : Lycop.^ Opium. Catarrhal pneumonia: Phosphor. Third stage: Cole, sulph., Card. :eg.. Sa ngu in . , Su/ph ur. Pleuro-pneumonia : Tart, entet. Typhoid pneumonia: Baptis., Hyosc, Rhus tox. (Edema of lungs: Tart, entet. Cough, drv, tickling, worse in night: Bellad. . almost choking, worse towards 3 a. m. : Kali car 1 . in spells, or no cough: Card. veg. rare, without expectoration, but great rattling in chest: Senega. , much, with copious, frothy expecto- ration, or none: Tart, entet. Expectoration when falling on paper will break and fly like thin batter: Phosphor. . difficult, tenacious, falling in a round lump, of a dark cherry-red color: Aeon. . falling in round, jelly-like lumps, and of a yellow, or soft brick shade: Bryon. falling in water to the bottom, and leaving a trail of mucus behind like a shooting star: Calc. card. rust colored: Sanguin. Expectoration rust colored, whole mouthful at a time, stringy and easily separated: Locop. . pus and florid blood: J'er. vir. . clear blood: Ferr. phosph. Stitches, violent: Senega. Stitching, burning, or little pain: San- guin. Burning and heat: Arsen. Pain in lower chest with dull percussion sound: Kali card. Respiration frequent and superficial: Card : ... 50 per minute : Pulsat. Can scarcely speak above a whisper: Pulsat. Expiration shorter than inspiration: Bryon. Great rattling of mucus: Tart, entet. Heaviness, as though a great load were pressing the thorax together: Xiir. ac. Great tightness: Phosphor. Dyspnoea, great, extreme: Senega, Tart. entet. . increases slowly: Ferr. met. . worse in afternoon or after sleep: Laches. unto suffocation: Nitr. ac. . sudden attacks: Cuprum, Tart. em.-::. Suffocating spells, wants doors and win- dows open: Sulphur. Impending paralysis of lungs: Tart. entet. Heart beats strong: Phosphor. Palpitation great and irregular: Chelid. Carotids pulsate violently: Phosphor. Pulse quick : Phosphor. and small: Sanguin. small, scarcely perceptible: Senega. Pulse quick, difficult to count: Cat b. veg. irregular: Kali card. irregular and intermitting: Kali hydr. regularly intermitting: J'er. vir. every third beat: Xitr. ac. neither full nor hard: Ferr. met. ATTENDING SYMPTOMS. Stun or with burning hot head, red hot cheeks, red ears, contracted pupils, closed mouth: Phosphor. Delirium, nervousness: Bellad. . with murmuring and gesticulating: Phosphor. . -"if I could only get my cough to- gether; it seems to be in pieces, all scat- tered about. I want to get it together:" Baptis. . ' " I wish I could be in the house with my family:"' Opium. . he gropes with his hands about the bed as though he were hunting some- thing: Opium. , he sees persons in the room who are not there: Hyosc. Although in a desperate condition, he is not much alarmed: Opimn. No complaining or crying: Card. veg. Dejected features : Senega. Great anxiety and restlessness with toss- ing about: Arsen. Congestion towards the brain: Bellad. Hot head : Kali hydr. DIGEST TO PNEUMONIA. 353 Hot vertex: Sulphur. Eyes congested: Bellad., Kali hy dr. half open: Card. veg. Pupils contracted: Phosphor. insensible: Card. veg. Face flushed: Bellad., Ver. vir. Cheeks red and hot: Phosphor., Sanguin. circumscribed redness: Lycop. , especially in afternoon: Sanguin. Face pale: Arsen., Ferr. met., Kali catb. earthy, dirty, bluish, seldom red: Cuprum. expression stiff and stupid: Ferr. met. Face pale, hippocratic: Card, veg., Ferr. met. Cyanosis : Tart. emet. Nose cold and pinched. Card. veg. Fan-like or wing-like motion of alae nasi: Lycop., Phosphor. Lips bluish: Card, veg., Cuprum, Kali hydr. and tongue ulcerated, red and dry: Lycop. Lower jaw sunken: Kali hydr. Roof of mouth red: Cuprum. white: Ferrum. Tongue dry: Kali hydr. red at tip: Rhus tox. red streak down the centre : Ver. vir. Thirst, drinking little at a time: Arsen. , wanting large draughts: Bryon. Takes water greedily when offered: Phosphor., Sulphur. Cannot swallow more than a sip for want of breath: Phosphor., Nitr. ac. Little or no thirst with dryness of tongue : Br yon., Pulsat. Does not ask for drink: Kali hydr. Desire for acid drinks: Bryon. When COUghing", the air from the lungs causes a strange, offensive taste in the mouth; the breath smells badly: Capsic. Breath cold : Card. veg. Bilious symptoms : Chelid. , Merc. sol. Jaundice : Merc. sol. Diarrhoea: Merc, sol., Phosphor. worse in the morning: Sulphur. Stool brown, consistent: Ferrum. dry : Kali card. badly smelling, even if formed: Laches. \ 23 Abdomen distended with gas: Card. veg. Pain under right shoulder-blade: Chelid. Drowsiness and inability to go to sleep: Bellad. Somnolence : Kali hydr., Senega. Sleepless and restless: Rhus tox., Sul- phur. Starting in sleep : Bellad. Snoring loudly : Kali hydr. Lying upon his back: Kali hydr. Cross on getting awake: Lycop. Cold extremities: Arsen. and face: Sanguin. feet and hands blue: Card. veg. Bluish under nails: Kali hydr. Chill, previous to, no ailment: Ferr. met. , often, deep sleep, can't be roused: Kali hydr. High fever, first stage: Aeon. Hot palms, soles and vertex: Sulphur. and dry skin: Phosphor. Skin neither cold nor burning hot: Ferrum. Sweat, whole body except lower extremi- ties: Opium. , very hot: Opium. , not profuse, sometimes sour smell- ing: Cuprum. , semilateral (left side of chest): Pulsat. , without relief: Cuprum, Laches., Merc. sol. , Lycop. , with sudamina: Opium. Cutaneous eruptions : Sulphur. Skin dry : Kali card. Faint, weak spells, worse in forenoon: Sulphur. Prostration: Arsen. Sinking of strength: Sanguin. The extremities, when raised, fall back, as if paralyzed : Kali hydr. Body emaciated and marbled: Card. veg. Threatening convulsions : Bellad. Inclination to lie still: Bryon. Better on lying on the painful side; some- times the reverse: Bryon. Lies upon his back: Sanguin., Kali hydr. , can't lie on the sides: Pulsat. Must He quietly upon the back: Aeon. 354 PULMONARY TUBERCULOSIS. Cannot He on the right side by stitching In traumatic cases: Arnica. pains in the left: Aeon. After a sudden check of perspiration with Slightest motion increases all symptoms: pain under the scapulae (both sides): Bryon. Gel son. Lying" still increases pain and dyspnoea: Rhus fox. Cannot bear to be covered: Lycop. After previous catarrh in the chest or bowels: Cuprum. In protracted cases of weak cachectic Wants to sit up, because the bed feels too individuals, where there is a sudden hot: Opium. abatement of pain, and yet an increase of the pulse: Nitr. ac. Pulmonary Tuberculosis, Phthisis Pulmonum, Pulmonary Consumption. Pulmonary tuberculosis may be defined as an infectious disease, charac- terized by consolidation and disorganization of lung tissue, great emaciation and febrile phenomena; and is due to the activity of the bacillus tuberculosis of Koch. It may pursue an acute or chronic course, and be due to either primary or secondary infection, in the latter case developing after tubercu- losis of the bones and joints, rectal fistulae, and other local tubercular lesions. It usually commences in the apices or the upper lobes of the lungs. Through the irritative action of the bacilli a hyperplasia of the fixed con- nective-tissue cells takes place together with an infiltration of leucocytes. The former are the epitheloid cells, and in the centre of groups of these, giant cells develeop, while on the periphery numerous lymphoid cells (leucocytes) aggregate. This constitutes a small gray tubercle, and as there is no vascular supply the entire mass soon undergoes caseation, which begins in the central portion of the nodule. The result of this process is the formation of a yel- lowish, cheesy mass, the yellow tubercle. When the process begins in the lobules, as is the case in primary infec- tion through the air passages, a proliferation of the epithelial cells takes place leading to a diffuse consolidation with subsequent inter-lobular changes, as mentioned above. Numerous tubercles in the diseased lung blend, the entire mass softens and breaks down. This is ejected through the bronchial tubes leaving a cavity behind, or the surrounding structure may become vascularized and in- flamed with round cell infiltration, the fluid portions of the degenerated mass being absorbed and the remaining dry cheesy mass becoming encapsuled; this occurs in the chronic forms. In the acute form there is a rapid infiltration and tubercle formation, followed by extensive destruction and degeneration (phthisis florida). Formerly fibroid phthisis and pneumonic phthisis were described as dis- tinct diseases and considered to be not necessarily of tubercular origin; they are now classed under the chronic form of pulmonary tuberculosis, and are names given to cases which present more or less fine clinical or pathological variations. Its characteristic symptoms ma}' be summed up as follows: PULMONARY TUBERCULOSIS. 355 Cough, may not always be present, or at least not in a marked degree in the beginning, but once present it contiues to the end. Its severity is pro- portioned to the extent of the disease, and increases and decreases with the phases of the disease. Its character varies in different individuals, but towards the last it assumes a peculiar toneless sound, owing to the ulcerated state of the vocal cords and great muscular weakness. Expectoration is at first usually absent, and when it makes its appear- ance it is of no distinctive character; later with the increase of pneumonic infiltration it becomes glassy, glutinous and at times tinged with blood. Still later, and in some cases earlier, the sputa contain opaque grayish-white striae and granules, mixed with the rest of the yellow viscid mass. On pour- ing the whole into water the granules sink to the bottom, while the striae remain suspended; there appear also about this time elastic fibres of the lung tissue in the sputa, which sink to the bottom, if the sputa be mixed with an equal quantity of caustic soda, and be boiled in distilled water (18: ioo), to which, under frequent stirring, water three or four times its bulk is added, and the whole allowed to stand and settle in a conical glass. Still later, and by degrees, the sputa become globular and compact; they sink in water or hang attached to a thread of mucus; they come from cavi- ties formed by bronchiectases, and as the destructive process still further pro- gresses and cavities form, the sputa changes to purulent matter, which is often expectorated in large quantities. The presence of Koch's bacillus in the sputum is one of the earliest diagnostic signs of consumption. Haemoptysis may occur at any period of the disease, and is due either to a degeneration of the blood-vessels or to hard, straining spells of coughing. It may amount to a very small quantity of blood, merely staining the expec- toration, and it may be so profuse that it kills the patient instantaneously. I^arge haemorrhages take their origin from a rupture of larger vessels, mostly in cavities. Phthisis is rarely accompanied with any particular pain in the chest, unless accompanied with pleurisy, which causes a sharp stitch-pain; so also is the dyspnoea of little account, unless induced by supervening pleuritic exu- dation or pneumothorax; but the breathing is in all cases greatly accelerated and especially from any exertion. Inspection. The subclavicular region of the thorax sinks in, and the clavicles become prominent; the whole thorax is flat and elongated, and the shoulder-blades stick out ; the respiratory motion decreases or ceases alto- gether in those places, and in far advanced cases the respiratory motion takes place only at the lower portion of the thorax. The whole body of the patient is emaciated, pale, and covered by a loose, thin skin. But there are cases where the thorax shows no such aspect, but appears finely developed. Palpation reveals stronger fremitus in one or the other subclavicular region, and in the commencement an increased impulse of the heart. Percussion affords, at the beginning of the disease, no results whatever, because minute infiltrations cannot alter the sound, as they are surrounded 356 PULMONARY TUBERCULOSIS. by healthy, air-containing lung tissue. Only when the}* increase in size, and thus deprive the lung of air, the percussion sound will grow duller accord- ingly, and this is observable most apparently in the infraclavicular, acromial and suprascapular region. If at a still later period cavities have formed, with tense, smooth walls, well adapted for reflecting sound, and if they are near enough to the thoracic walls, percussion ma}* yield a tympanitic sound, or a metallic tinkling, or even a cracked-pot sound (if the cavity be con- nected with large bronchi), so that through percussion the air is forced out of the cavitv into the bronchial tubes. Tuberculous Infiltration. a. Fleshv and dull sound. After Bock.) c. Cavity with tympanitic sound, or metallic tinkling, etc. b. and e. Lung sound. Tuberculous Infiltration. (After Bock.) a. Fleshy percussion sound. •b. and d. Short dull sound. c. Lung sound. e. Heart. f. Liver. Auscultation at first yields an increased and prolongated expiratory mur- mur (Jackson), which is often heard in two distinct jerks; also fine rattling noises, which, from coughing, disappear only for a little while (Xiemeyer), and a systolic murmur in the subclavian artery on the affected side during expiration . ( Ruehle . ) When the tubercles commence to dissolve, we often hear the " click sound. 1 ' After the lung tissue has become infiltrated by tubercular masses, we hear, on auscultation, bronchial breathing and bronchophony, and all kinds of rattling noises. When cavities exist, which, with their smooth and tense walls, are well adapted for the reflection of sound, we hear the emphoric echo and metallic tinkling, also the cavernous respiration. The pulsation of the heart is generally heard, even on the right side, quite distinctly. Phthisis is almost always attended with laryngeal symptoms, such as hoarseness, difficulty of swallowing (food or drink go the wrong way), in consequence of tuberculous ulceration and inflammation. The circulation is accelerated; the pulse is rapid, soft and empty, the action of the heart is increased, causing palpitation, and all this at first with- PULMONARY TUBERCULOSIS. 357 out an}- corresponding elevation of temperature. In short, the signs are those of any form of anaemia, which ultimately develops hydraemia; amen- orrhcea. In the digestive organs we frequent^ meet with loss of appetite, and in some cases even at the beginning; with nausea, occasional vomiting, especially after coughing, with pain or oppression in the pit of the stomach, in the bowels, with diarrhoea. The latter is of very frequent occurrence, at times showing itself at the commencement of the disease, at other times during its whole course in recurring spells; most commonly, however, it belongs to a later period, quickly exhausting the vital forces, or ending with a rapidly fatal peritonitis when the tuberculosis ulceration terminates in perforation. Phthisis is at times complicated with fatty liver and amyloid liver, with amyloid degeneration of the spleen and of the kidneys. The skin is conspicuous by its transparency and paleness, and by the distinctness of the veins; by its great sensitiveness to the slightest changes of temperature; by the easily flushing of the face on the slightest excite- ment, and the profuse perspiration with even moderate fever. The nails grow curved like claws, and there is a bulbous enlargement of the third phalanx. This symptom, however, is also found in other chronic diseases of the respiratory organs, such as emphysema, etc. The pink-red line on the lower gums occurs often at a very early period, though it is not found exclusively in phthisical persons. Pityriasis versicolor appears often at the * very beginning. One of the most constant signs of phthisis is emaciation noticeable from the very beginning and advancing steadily with the progress of the disease. During the periods of remission the loss is made up again, but if loss of weight should set in again without assignable cause, a renewed attack may be ex- pected. The total loss produced by the disease is generally from one-fourth to one-third part of the initial weight, and it involves not merely the fat, but also the tissues and the blood. On account of this wasting away the disease has appropriately been called consumption. The fever also is a conspicuous feature of phthisis. In acute cases — florid phthisis — it is of a continuous type, the morning temperature falls but little below 102 , and the evening temperature rises above 104 . In chronic cases it is intermitting, its minima are generally normal, or a little below the normal, while the maxima average from 101.3 to 102. 2 ° F. At last must be mentioned the brilliant eyes of the phthisical patient and his unchangeable hopefulness even to the last. Its Predisposing Cause is a scrofulous diathesis, therefore a tendency to phthisis is so frequently inherited. Still it may be acquired from lack of pure air, light, warmth and exercise, and from a deficiency and poor quality of food; in short, by anything that impairs the nourishment of the bod}', induces poverty of blood or depresses the nervous system. In scrofulous subjects these conditions of course will hasten the outbreak of a pulmonary lesion. The maximum of its occurrence lies between the fifteenth and twenty-fifth years. 358 THERAPEUTIC HINTS TO PULMONARY TUBERCULOSIS. The bacillus tuberculosis of Koch is of a rod-like shape, and is best demonstrated by staining with the carbol-fnchsine solution of Ziehl-Neelsen, followed by Grabbet's acid methyl blue counter-stain. Such bacilli have been found in sputum, even before any physical signs of consumption are present, and they are carried by the air and inhaled when the sputa of tuber- cular patients are allowed to dry and to be converted into dust-form, or are taken in food, such as milk from tubercular cows, meat, etc. Elevated positions are known to protect against phthisis. A height of at least 1,000 or 2,000 feet above the sea seems to be requisite for this pur- pose. So also are goitre, emphysema, valvular diseases of the heart and con- siderable contractions of the chest by spinal curvatures said to be antago- nistic to the development of phthisis, although exceptions to this rule surely occur. As regards the contagiousness of consumption opinions have been at variance. Of late, however, experiments on animals seem to leave no doubt that the disease is communicable, and cases are met where through the in- timate relations existing between husband and wife the disease has been communicated; it is certainly good advice to be cautious in attending of and associating with those who are far advanced in the disease. Consumption furnishes the largest percentage of deaths amongst all other diseases; nevertheless man}- cases are cured, and the disease cannot be called incurable, though favorable conditions necessarily are required for a successful treatment. Therapeutic Hints. General rules, which may serve as preventives: Fresh air, and plenty of it; exercise in the open air, and gymnastic exercises, which tend to widen and strengthen the chest; methodical breathing exercises for the same pur- pose, which consist in regular, slow, and full inspirations and expirations; singing; a good and nourishing diet, and a careful attention to the skin by rubbing and washing, in order to keep up its activity and to harden it against atmospheric changes; rubbing the skin with olive oil has also been recommended, and a change of climate has certainly proved beneficial in many cases. About the time of puberty all efforts should be made to prevent the excitement of sexual desires, such as reading loose literature. Masturbation is in the highest degree hurtful; mental exertions, and depressions of all kinds, are also injurious. When catarrhal affections set in they must be treated according to their special symptoms, and so also all other features, changes and processes of the disease. When a well-selected remedy is allowed to act, it manifests itself— ac- cording to Nusser's observations — generally in one of the following symp- toms, which are favorable: SPECIAL HINTS. 359 i. Swelling of the glands in the axilla. 2. Rheumatism in the muscles of the neck, shoulders, thorax, hips or extremities. 3. Swelling of the glands on the neck and ear. 4. The materia peccans rises from within towards the outside, contrary to the air which passes during respiration from without inward. The chest feels lighter, but the trachea and larynx become affected in a manner to pro- duce hoarseness, which subsiding, the nose becomes sore and finally ends with pimples and pustules around the nose. 5. The ears become affected, from a mere ringing in the ears to suppur- ation within them. 6. The eyes become inflamed. 7. Headache and toothache set in; in such a case let the patient suffer; a sudden suppression of them would quickly bring back all the troubles to the chest. 8. An eruption on the thorax, with or without itching on the chest or back. 9. Sweating of the feet. 10. Hemorrhoidal irritations and tumors. 11. Violent colds in the head, which may indicate Aeon, or Phosphor., and which almost always act beneficially. 12. The morbid action goes down into the intestines, and throws out gall, acid, mucus or gas, until finally it develops itself in a cutaneous dis- ease, first attacking the head, the upper extremities, the thorax, and so all the way down, like small-pox. When a well-selected remedy brings forth any of these symptoms, never disturb its action by change or repetition. Special Hints. Compare the foregoing chapters on catarrhal and inflammatory diseases of the. respiratory organs, which may contain the hints just needed for the individual, case. Besides compare : Aeon. Intervening pleuritic stitches and blood-spitting. Act. rac. Intercurring congestions and inflammations from exposure, with dry, harrassing cough; night-sweats and diarrhoea. Arsen. Acute pain in the upper third of right lung; hurried respiration upon moderate exertion, or dyspnoea on lying down; cough dry, or with expectoration of frothy, glairy and transparent mucus, or yellow and grayish- yellow sputa; cough worse in the evening on lying down, and in the morning on rising; haemorrhage from the lung with burning in the upper portion of the right lung. (R. R. Gregg.) Prostration; exhausting diarrhoea; inter- mitting chills, fever and sweat; thrush in the mouth. Ars. jod. Soreness in larynx; hoarse, racking cough, day and night, with profuse purulent expectoration. (H. V. Miller.) Baptis. Chill in the forenoon or afternoon, followed b}' heat and pers- 360 SPECIAL HINTS. piration, as in ague; general weakness and languor; sometimes loss of hope- fulness. (J. S. Mitchell.) Bellad. In the beginning of chronic lung disease, hollow, barking cough; often worse at midnight; violent stitching pains from right side of abdomen, upwards through the right lung to mamma, point of right shoulder of inner border of right scapula; also chronic nasal or bronchial fluent catarrh, attended with rattling respiration, in nervous or mentally active subjects. (R. R. Gregg.) Bryon. Pleuritic pain and exudation; chills and fever afterwards; cough all day, also in the night. Cole. card. Pain in upper half of right lung; cough with purulent sputa, worse in the morning on rising, and in the early evening, with par- oxysms during the day, less during the night. Loud breathing through the nose; bleeding from right nostril; rapidly growing children and youths. (R. R. Gregg.) Easily perspiring, with fatigue from an}' little exertion; dizziness and want of breath on going up stairs; paleness of face, with fre- quent flushes; nightly seminal emissions; too early and too profuse, or sup- pressed catamenia; inclined to loosenees of the' bowels, especially towards evening; damp, cold feet. " Expectoration falls to the bottom in water, with a trail of rough mucus behind, like a dropping star." (A. Fellger. ) "The patient appears gaunt, hollow-eyed, great emaciation; coughs little, but complains of stitching pains in the upper chest; loss of appetite; constipa- tion; fluttering of the heart upon the slightest exertion; weary of living; constant coldness and dampness of the feet; tongue covered with a thick, white, past}' coating; bad taste in mouth; dull, heavy, stupid feeling in head, particularly in the morning; pulse 94. Believes her chief troubles are uterine. Suppression of menses; complete loss of sexual desire, border- ing at times upon absolute aversion; leucorrhcea. Formerly troubled with chronic diarrhoea. Calc. ca?b., 30, brought out for a while diarrhoea again, and also the menses. Six weeks later, Calc. carb., 200. Soon recovered entirely." (H. R. Arndt., Weekly Med. Counsellor, June 7, 1882, p. 155.) Card. veg. Nosebleed in the night; cough, in hard spells, not Ceasing until masses of green or yellow, or purulent and offensive sputa are dis- charged; hoarseness in the evening; cool skin; cold knees at night in bed; great prostration; hippocratic face. Cinchona. After loss of blood, long-continued nursing, seminal emis- sions; intermittent fever; sweats when dropping asleep. Crocus. " Asthmatic or wheezy cough, attended by frothy expectora- tion, containing threads of translucent, whitish or yellowish mucus, of the size of coarse spool cotton or fine twine; worse in hot weather, a warm room, lying down, etc." (R. R. Gregg*) Dulcani. After taking cold from any change of weather; tough, greenish expectoration, with moderate cough; stitching pain here and there in the chest; diarrhoea. Ferr. met. Flying pains in the chest; nosebleed; spitting of blood; SPECIAL HINTS. 36 1 feeling of fullness and pressure in the pit of the stomach ; vomiting of ingesta; paleness of the buccal cavity; painless diarrhoea; watery menstruation; hectic fever. Especially in persons who, in consequence of any little emotion or exertion, flush easily in the face, or get epistaxis, or cough, dyspnoea, spit- ting of blood, or palpitatiou of the heart; the symptoms are relieved by moving slowly about, and while eating. Guaiac. Pleuritic stitch-pains in the chest. Hepar. Cough excited when any part of the body gets cold from being uncovered; chilliness in the open air; keeps tightly covered even during pro- fuse sweat; paleness after any exertion; perspiration easily excited; after- wards burning redness of the face and dry heat in the palms of the hands. After pneumonia. The cough is barking, wheezing, choking, worse towards morning. Iodium. Cough from constant tickling in the windpipe and under the sternum, with expectoration of a transparent mucus, sometimes streaked with blood; morbid hunger even soon after a meal and yet loss of flesh, or else total loss of appetite; remarkable sense of weakness and loss of breath in going up stairs; emaciation of the mammae; copious menstruation; morning sweats; dark hair and eyes. Kali curb. Stitching pain in temples, eyes, ears, teeth, chest and different parts of the body; after dinner nausea, faintishness, sleep; about noon, chilli- ness; at night, heat; about 3 o'clock a. m., cough worse than ever. Puffi- ness of upper eyelids. Easily frightened; a slight touch of the feet causes the patient to jerk them up in affright; nursing mothers. "Expectoration of firm white globular masses of the size of a pea, flying from the mouth with considerable force when coughing or hawking; eruption of minute vesicles upon the soles of the feet, with extensive itching. Burning in top of head and soles of feet; sweaty paleness; circumscribed red spot on one cheek; gastric derangement, with belching, tasting like rotten eggs; hungry and faint about 10 A. m.; contraction of the heel cords; trembling sensation through the entire body, especially through the pelvic region." The 3d trituration cured, whereas the 200th had failed. (O. W. Smith.) Laches. Cough worse after sleep, sometimes only through the day, but also during sleep without wakening; expectoration difficult, has to hawk, hem, cough and spit a good while before he succeeds in getting a little tough phlegm away. Fever worse in the afternoon; stools smell very offensive, even if of a natural consistency. Sore mouth in last stage. Ledum. Phthisical symptoms, alternating with rheumatism. Lycop. After neglected pneumonias, expectoration of large quantities of pus; the expectoration tastes salty; cough day and night; hectic fever, circumscribed redness of the cheeks; worse from four to eight p. m. ; cannot bear covering; night-sweats. Merc. sol. "Great aggravation from, or utter impossibility of, lying upon the right side; fugitive pains, now here, then there, or anywhere, and changing place every hour, few hours, or day or two." (R. R. Gregg.) Myrtus com. • Stitching pain in the left chest, from the upper portion 362 SPECIAL HINTS. straight through to the left shoulder-blade, worse from breathing, yawning and coughing; spitting of blood. Natr. bcnz. Has lately been employed successfully in consumption; special indications wanting. Natr. mur. Great dryness in the mouth; follicular catarrh of fauces; fluttering of the heart; the patient gets worse on the seashore. Nitr. ac. Patients tainted with syphilis or mercurial cachexia. Ulcers in mouth and throat; fetid breath; colliquative night-sweats, very offensive; morning thirst; habitual looseness or constipation of the bowels; fissures of the anus. Nux vom. "Violent racking paroxysms of cough, with or without expectoration; worse after eating and in the morning or forenoon; attended by severe headache, pain or bruised sensation in stomach, hypochondria or bowels, and a dull or subacute soreness of the abdomen under pressure." (R. R. Gregg.) 01. jecor. aselli. The genuine article, which has not been "purified," has been of great use where scrofulous diathesis is conspicuous. Phosphor. Cough worse, dry and tight before midnight, tormenting; excited by talking, laughing, moving, eating or cold air; during cough, bursting pain in the head, and sore, burning pain in chest and larynx; pain in the left side of the chest; heat or burning in the back between the shoulders; evening chill, followed by heat and sweat during sleep till next morning; in the morning the cough is loose. Puffmess around the eyes; diarrhoea alternates with constipation; stool and flatus very fetid. Phosph. ac. For young persons that have grown very fast. Psorin. The exhalation from the body, its secretions and excretions have an offensive odor; after suppressed itch. Sambuc. Profuse sweats, but only while awake; during sleep the skin becomes dry and hot. Sanguin. Breath and sputa smell badly, to the patient himself dis- agreeable; before and after cough, belching of wind; after the cough, heat, and after the heat, gaping and stretching; circumscribed redness of the cheeks; diarrhoea; night-sweats; pain in the lower left side of chest, extend- ing upwards to left shoulder. Sepia. "Stitching or darting pains through the central portion of the right lung; cough dry in the evening; free expectoration in the morning, or expectoration only at night, none during the day; excessively fetid sputa." (R. R. Gregg.) Cough better when lying down; the cough sounds loose, but there is no expectoration, or only a little after great efforts. Silk. Profuse discharge of fetid pus; formation of cavities; profuse night-sweats; pale, wax-like appearance of the skin; stone-cutter's con- sumption. Spongia. Cough worse from evening until midnight, from cold air, from talking, singing or moving; better from eating or drinking; dyspnoea on lying down with the head low. DIGEST TO PHTHISIS. 363 St an num. Feeling of great weakness in the chest; can talk only a few words at a time, from want of breath; pressure and bloatedness of the stomach always after eating; great lassitude; hands and feet feel heavy and are cold, or else burning hot; constant chilliness, alternating with flushes of heat; profuse night and morning sweats; profuse expectoration, mostly of a sweetish taste. Sulphur. Dryness and burning in the throat; the breath appears hot to the patient; cough mostly dry, only now and then profuse discharge of purulent matter, which relieves for awhile; the patient complains constantly of being too hot, puts his feet out from under the cover; congestion towards the head and chest, with palpitation of the heart; profuse sweating at night; diarrhoea early in the morning; after suppressed chronic skin eruptions; pain in left side of chest in lower portion through to left shoulder-blade. Sulph. ac. Stitch-pain through the upper part of the left chest to the shoulder-blade. Tai'antula cubensis. ' ' It soothes the dying sufferer as I have never seen any other remedy do." (J. T. Kent.) Tuberculinum or bacillinum has been used by homoeopathic physicians with success in this disease. Dr. Burnett especially has given a whole list of cases in which he used it more or less successfully. Digest to Phthisis. LOCAL SYMPTOMS. Cough, barking: Bellad. , , choking, wheezing, worse in the morning: Hepar. , hoarse, racking: Ars. jod. , asthmatic wheezing: Crocus. , dry: Arsen. , in evening: Sepia. , , harrassing: Act. rac. , and tight, tormenting, before midnight: Phosphor. , paroxysmal during day, less during night: Calc. carb. , , not ceasing until masses of green and yellow, or purulent and of- fensive sputa are discharged : Carb. veg. , , racking: Nux vom. , all day: Bryon. , only through the day: Laches. , day and night: Lyc^p. , evening: Arsen., Spongia. , midnight: Arsen., Bellad. , morning at 3 o'clock: Kali carb. , during sleep without wakening: Laches. , worse on lying down: Arsen., Cro- cus. , on right side: Merc. sol. , on rising in the morning: Arsen. , after sleep: Laches. , from cold air: Phosphor., Spongia. , from a part of body being uncov- ered: Hepar. , in hot weather, a warm room: Cro- cus. , after eating and moving: Nux vom., Phosphor. , talking, laughing: Phosphor., Spongia. , better from eating or drinking: Ferritin, Spongia. , while lying down: Sepia. , with bursting pain in head: Bryon., Nux vom., Phosphor. , headache, or bruised sensation in stomach, bowels, hypochondria: Nux vom. , with sore, burning pain in chest and larynx: Phosphor. After cough, heat: Sanguin. Expectoration free in the morning: Phosphor., Sepia. >6 4 DIGEST TO PHTHISIS. only at night, none during the day: Sepia. difficult, has to hawk, hem and spit a good while before a litle phlegm is brought away: Laches. , the cough sounds loose, but there is no expectoration, or only a little after great efforts: Sepia. frothy, with threads of whitish or yellowish mucus of the size of common spool cotton or fine twine: Crocus. , , glairy and transparent mucus: Arsen. , transparent mucus sometimes mixed with blood: Iodum. , firm, white globular masses, of the size of a pea, flying from the mouth when coughing or hawking: Kali card. falls to the bottom in water, with a trail of tough mucus behind like a drop- ping star: Calc. card. yellow, or grayish -yellow: Arsen., Card. veg. green or yellow: Card. veg. tough, greenish, with moderate cough: Dulcam. fetid, offensive: Card, veg., San- guin., Sepia, Si lie. , , with cough in hard spells: Card. veg. purulent: Ars. jod., Card, veg., Calc. card., Lycop., Si lie, Sulphur. , , worse in the morning on rising and early in the evening: Calc. card. , , with barking cough day and night: Arsen., Iodium. , , which relieves for a while; Sulphur. salty: Lycop. sweetish: Hamam. Spitting" of blood: Aeon., Arsen., Fer- ritin, Ferr. phosph., Myrt. com. , with burning in upper portion of right lung: Arsen. Breathing" hurried upon moderate exer- tion: Arsen. Loss of breath on going up stairs: Calc. card., /odium. , and dizziness: Calc. card. , sense of weakness: Podium. Dyspnoea on lying down: Arsen. with the head low: Spongia. Loud breathing through the nose: Calc. card. Breath appears hot to the patient: Sul- phur. of bad smell, fetid: Nitric ac, San- guin. Throat dry and burning: Sulphur. Larynx sore: Arsen., Iodium. Hoarseness in evening: Coccyx. Stitching" pain in upper third of right lung: Arsen. in upper half of right lung: Calc. card. through the central portion of right lung: Sepia. from right side of abdomen upwards to the right chest, mamma and right shoulder: Bel lad. through upper part of left chest: Sulph. ac. , worse from breathing, yawning and coughing: Myrt. com. Pain from lower portion of left chest through to the shoulder: Bryon, Sul- phur. from left lower chest up to left shoulder: Sanguin. in left chest: Phosphor. Stitching" pain here and there in chest: Dulcam. in chest and different parts of body : Kali card. , pleuritic: Guaj. , and blood-spitting: Aeon. , and exudation: Bryon. Flying pains in chest: Ferr. met. Congestion in chest and head, and pal- pitation of heart: Sulphur. from exposure : Act. rac. Feeling" of weakness in chest; can scarcely talk: Stan num. Chest symptoms alternate with rheu- matism: Ledum. Bronchial catarrh with rattling respira- tion: Bel lad. Formation of cavities: Si lie. Fluttering of heart: Natr. mur. upon slightest exertion: Calc. card. GENERAL SYMPTOMS. Dull, heavy, stupid, worse in morning: Calc. card. DIGEST TO PHTHISIS. 365 Thinks her troubles uterine: Calc. card. Loss of hopefulness, sometimes: Baptis. Easily frightened; a slight touch of the feet causes the patient to jerk them up in affright: Kali card. Burning in top of head and soles of feet : Art// cat b. Dark hair and eyes: Iodium. Pnffiness of upper eyelids: Kali curb. around eyes: Phosphor. Nasal catarrh: Bellad. Nosebleed: Ferrum. , right side: Calc. carb. , in the night: Carb. vcg. Burning" redness of face: Hepar. Circumscribed redness of cheeks: Lycop., Sanguin. of one cheek: Kali carb. Paleness: Kali carb. after any exertion: Hepar. with frequent flushes: Calc. carb. Hippocratic face: Carb. veg. Tongue white, pasty, thick: Calc. carb. Dryness of mouth: Natr. mur. Paleness of buccal cavity: Ferrum. Thrush in mouth in last stage: Arsen., Laches. Ulcers in mouth and throat: Nitr. ac. Follicular catarrh of fauces: Natr. mur. Bad taste: Calc. carb. Belching tasting like rotten eggs: Kali carb. Vomiting" of ingesta: Ferrum. Morning thirst: Nitr. ac. Hungry and faint about 10 a. m. : Kali carb., Sulphur. Morbid hunger even soon after a meal and yet loss of flesh: Iodium. After dinner nausea, faintishness: Kali carb. Loss of appetite: Calc. carb., Iodium. Pressure and bloatedness of stomach after eating: Stannum. and fullness in pit of stomach : Fer- rum. Soreness of abdomen on pressure: Nux vom. Diarrhoea: Dulcam., Sanguin. , exhausting: Arsen. , painless: Ferrum. and night-sweats: Nitr. ac. worse early in morning: Sulphur. worse towards evening: Calc. carb. , or constipation : A T itr. ac, Phosphor. Constipation: Calc. carb. StoOl Offensive: Laches. and flatus very fetid: Phosphor. Fissures of anus: Nitr. ac. Trembling" sensation through pelvic re- gion and all over: Kali carb. LOSS of sexual desire: Calc. carb. Nightly emissions: Calc. carb. Menstruation copious: Iodium. and too early: Calc. carb. watery: Ferrum. suppressed: Calc. carb. Leucorrhoea: Calc. carb. Emaciation of mammse: Iodium. Fugitive pains anywhere: Merc. sol. Contraction of heel cords: Kali carb. Coldness and dampness of feet: Calc. carb. and heaviness of hands and feet, or heat: Stannum. Cool skin: Carb. veg. Cold knees even in bed: Carb. veg. Chilliness, about noon: Kali carb. in open air: Hepar. constant with flushes of heat: Stan- num. Chill in forenoon, followed by heat and sweat in afternoon : Baptis. evening, followed by heat and sweat during sleep till morning: Phosphor. and fever afterwards: Br yon. Dry heat in palms of hands: Hepar, Stannum. Heat and burning in back between shoul- ders: Phosphor. Skin dry and hot during sleep: Sambuc. Heat at night: Kali carb. Hot all the time, puts feet from under cover: Sulphur. After heat, gaping and stretching: San- guin. Intermitting fever: Arsen., Baptis., Cinchona, Natr. mur. Hectic Fever: Ferrum, Lycop. Fever worse in afternoon: Laches. Easily perspiring: Calc. carb. , Hepar. Sweaty paleness: Kali carb. Sweats when dropping asleep: Cinchona. only while awake: Sambuc. keet tightly covered even during profuse. Night-sweats: Lycop., Sanguin. and diarrhoea: Act. rac. 3 66 EMPHYSEMA PULMOXUM. profuse: Silic, Sulphur. offensive and colliquative: Nitr. ac. and morning-sweats profuse: St an- num. Morning-sweats: Iodium. Eruption of minute vesicles upon soles of feet with excessive itching: Kali carb. Pale, wax-like appearance of skin: Silic. Exhalation from body, secretions and excretions of offensive odor: Psorin. Fatigue from any little exertion: Calf. card. Great lassitude: Stannum. General weakness and languor: Baptis. Prostration: Arsen., Carb. veg. Emaciation: Calc. carb., Iodium. Young" persons growing too fast: Calc. carb., Phosph. ac. Gaunt and hollow-eyed persons: Calc. carb. Nervous, active subjects: Bellad. Persons who from little emotion or ex- ertion flush easily, get epistaxis, cough, dyspnoea, spitting of blood, palpitation of heart; better from moving slowly about: Ferrum. After loss of blood, long-continued nurs- ing, seminal emissions: Cinchona. Scrofulous taint: 01. jecoris aselli. After suppressed itch: Psorin, Sulphur. Syphilitic or mercurial cachexia: Nitr. ac. After pneumonia: Hepar, Lycop. Stone-cutter's consumption: Silic. Worse in general from warm weather, warm room: Crocus. Cannot hear covering: Lycop. Worse from being uncovered and in cold air: Hepar, Phosphor. - on seashore: Arsen., Carb. veg., Natr. mur. from any change of weather: Dul- cam. from 4 to 8 p. m. : Lycop. Emphysema Pulmonum. It is an enlargement of the air-cells, either from distention, or from a union of seven into one, by destruction of their partition walls; or it is a transmission of air into the interlobular, or subpleural cellular tissue. Ac- cordingly, we find on post-mortem examination the lungs swell out of the thoracic cavity like a cushion filled with downy feathers; and if rubbed be- tween the fingers we do not feel that peculiar crepitation of a healthy lung; the air-cells are widened, sometimes to the size of peas (vesicular emphsema). In the second case, where it consists in an escape of air into the interlobular or subpleural cellular tissue, the pleura pulmonalis is raised into little blisters, which, by pressure with the fingers, can be shifted; in rare cases only is the pleura separated and filled by air to a large extent (interlobular emphysema.) The Vesicular emphysema originates always in the neighborhood of such portions of the lungs, the air-cells of which have been destroyed by morbid processes, such as tuberculosis and interstitial pneumonia. The vacant space caused by this loss of substance has to be filled up by a dilatation of the neighboring alveoli; it is therefore of a vicarious nature, and would often amount to a much greater extent, were it not that the thoracic walls them- selves sink in, and thus obliterate to a certain degree the vacant space caused by loss of substance inside. This same widening of the alveoli takes place when the two pleural blades have grown together to a large extent in conse- quence of pleuritis, and especially is this the case in the anterior and lower edges of the lungs, because the adhesion does not permit the upper portions EMPHYSEMA PUEMONUM. 367 of the lungs to extend as fully, as is the case when the two pleural blades move freely upon each other; the inspiratory act then overfills the lower anterior portions of the lungs and dilates the air-cells. The same result is effected when, in consequence of catarrhal inflammation of the finer bronchial tubes, their swollen state prevents the free ingress of air, or in pneumonia, where the sound portion of the lungs has to perform the office of the entire lung. But also forced expirations as during spasmus glottidis, spasmodic asthma, blowing wind-instruments, bearing-down efforts during parturition, etc., may cause dilation of the air-cells. The Interlobular emphysema originates in consequence of rupture of the alveoli. The air then escapes into the interlobular and subpleural connective tissue. It is mostly the consequence of violent coughing spells, bronchitis and croup. If we bring all this clearly before our minds, we can easily perceive the consequences which must follow from such conditions. For instance, that portion of the inhaled air which occupies the distended air-cells, is never fully replaced by the acts of respiration, the blood coursing here remains unoxy- genized. In the further progress of the disease still more of the air-cells perish as their partition. walls become destroyed, consequently still more of that surface is lost by which the oxygenization of the blood takes place, and, therefore, the insufficiency of respiration and the accumulation of carbon in the blood grow greater in the same ratio. This the patient shows by his dyspnoea, by his great hunger for air. He strains all the muscles to widen Emphysema (After Bock.) a. Heart, b. Etnig sound, c. Liver, d. Stomach. the thorax and to get breath, and, in consequence, the thorax becomes arched, barrel-shaped, permanently dilated, and the muscles of the neck voluminous. Another consequence, though later in appearing, is disturbed circulation. Hand-in-hand with the destruction of the air-cells goes the obliteration of the capillaries. The blood from the right ventricle does not find room within the lungs. Stagnation follows, and, in consequence, hypertrophy of the right ventricle with all its usual consequences, viz.: undulation of the right jugular vein; cyanosis of the face; varicosed veins on the cheeks and alee nasi, 368 THERAPEUTIC HINTS TO EMPHYSEMA PULMONUM. swelling of the liver; catarrh in stomach and bowels; swelling of the haemor- rhodial veins; scanty urine, etc. Its Physical Signs, on inspection, are the arched, barrel-shaped, per- manently dilated thorax from its upper region down to the sixth rib. How- ever, this condition does not obtain in all cases. We find it only in those persons in whom the emphysema originated in forced expirations and closed glottis, at a time when the bony structure of the chest was yet yielding. In other persons, with a long, flat, so-called paralytic thorax, emphysema may exist, to a large exteut, without any such alteration of form. The hollow places above and below the clavicles bulge out during a fit of coughing, the neck appears short and thick, and the respiratory motion, notwithstanding the greatest exertion, is short, superficial, and, instead of being a successive motion of the single ribs, is a movement of the whole surface at once, a mask-motion. The intercostal spaces do not bulge out; on the contrary they often sink in during inspiration. Palpation, if emphysema exists in the left lung, discovers the point of the heart lower down and towards the pit of the stomach, on account of the lower position of diaphragm. Percussion affords the best diagnostic sign of emphysema, inasmuch as we may with certaint}^ ascertain by it whether the dull sounds of the heart and liver exist in their proper places or not. If we hear lung sound where we ought to hear the dull sound of the heart or liver, we may be sure that the heart or liver are covered by the distended lung. Characteristic of emphysema, therefore, is an abnormal extension of the lung sound over the heart and liver. The percussion note is an exaggerated resonance or vesiculotympanitic, because the air-cells are forcibly distended. Auscultation affords- no very positive information. In the presence of a catarrh, which is a frequent complication, we hear no vesicular breathing, but rattling and bubbling noises. The inspiratory murmur is weaker, while the expiratory sound is prolonged. An emphysema which is confined to a small place only is not diagnosti- cable, and the interlobular and subpleural form runs its course without any characteristic symptoms. The progress of this disease is always of a chronic nature, and its more acute attacks depend upon an increase of bronchial catarrhs, which more or less, alwa}~s accompany it. It usually ends in general dropsy, as a natural consequence of those obstructions in the circulation which have been detailed above. The patient may live to a good age. Therapeutic Hints. Compare Spasmus Glottidis, Croup, Whooping-cough, Bronchial Catarrh, Consumption. Arsen. Highest degree of dyspnoea, even to suffocation, with great anxiety and restlessness; face cyanotic, and covered with cold perspiration; consumptive symptoms, with pain through upper part of right lung. THERAPEUTIC HINTS TO EMPHYSEMA PUEMONUM. 369 Bell ad. Disturbed circulation; dizziness, headache; palpitation of the heart; fullness of the abdomen. Bromium. After pneumonia, asthma; pressure in the stomach; must sit up in bed at night. Camphora. Asthma, worse after bodily exertion; cough from talking, inhaling of air, and a feeling of coldness, which commences in the pit of the stomach, and spreads from here over the chest is and exhaled as cold breath. Card. veg. Often after Arsen. ; great dyspncea; cough in violent spells, with great anxiety, with watery, profuse expectoration, and under great exertion. Chin. ars. Regularly every forenoon, at nine o'clock, attacks of suffo- cating spells in tuberculosis; limbs icy cold; cold, clammy sweat all over; greatest anxiety and unquenchable thirst; must sit up, bent forward, if pos- sible, at the open window. Chlorine. Easy inhalation; exhalation impossible. Cuprum. Asthmatic S3 T mptoms worse after walking against the wind. Digit. Complications with heart disease; better in lying perfectly quiet in a horizontal position. Hepar. Combined with bronchial catarrh, worse from slightest ex- posure; coughs from midnight till morning; sleeps with head thrown back. Ipec. Dry, spasmodic cough of old people; collection of mucus; diffi- cult to expectorate, and giving only temporary relief; nausea. Kali carb. D3'spncea worse at night; strong beat of the heart; loss of appetite; vomiting; dry skin. Laches. All covering around the neck and even chest unbearable; worse after sleeping; cough torturing until some little tough phlegm is raiseci; stool smelling badly; follows well after Arse?i. and Carb. veg. Lob el. infl. Inclination to sigh and take a deep breath. Naphthal. Recommended by V. Grauvogl for empl^sema in conse- quence of forced expirations in buglers, etc. , and after bronchial asthma without catarrh. Opium. Nightly asthma, with whizzing and rattling during expiration, which is long and attended with retraction of the epigastric region; inhala- tion short, without noise. Sarsap. Asthma worse after eating or motion. Senega. Feeling as though the thorax were too narrow, with constant inclination to widen it by deep inhalation; burning in the chest. Sepia, and Sulphur. Both worse after sleep; getting suddenly roused by asthma from a deep sleep. Difference between both, see Gross' Compara- tive Materia Medica. Tereb. Asthma worse from motion. Besides these compare Aspar. , Bryon., Lobel., Natr. mur., Nux vom. y Pulsat., Tart, emet., Veratr., and all that is mentioned under Asthma Spas- modicum. 24 370 HYPEREMIA AND CEDEMA OF THE LUNGS. Hyperemia and (Edema of the Lungs. This affection consists of a serous exudation into the air-cells and finest bronchial tubes of the lungs, and is either acute or chronic. Sometimes it is confined to a small portion, and sometimes it extends over both lungs. When acute, the lung appears strongly injected with blood, tense, leaving no dent on pressure; when cut in two there oozes out of it a blood}- serum, which contains a great deal of albumen. All the air is driven out by the serum, and the lung tissue is easily torn. On account of this similarity with pneumonia, acute oedema is also called Serous pneumonia. In chronic oedema the lung appears pale and tough; upon pressure a dent remains; the serum is pale yellowish, thin, and contains little albumen; it fills the air-cells and finest bronchial tubes. The lung is heavy and puffed similar to any dropsical swelling, and it is deprived of air as far as the infil- tration of serum extends. The acute form is generally the product of hyperaemia or active con- gestion — a fluxion of blood to the lungs, which may be caused i, by an in- creased action of the heart, during the period of puberty, or in consequence of passions, or bodily exertions, or the use of stimulants; or, 2, by direct irritations from inhaling cold air, or hot and irritating substances; or, 3, by obstruction of the free circulation in some portions of the lungs by pleuritic effusions, pneumonic or tubercular infiltrations — producing a collateral fluxion. The chronic form is generally the product of stagnation in consequence of heart diseases, especially of stenosis and insufficiency of the mitral valves; also of a weakened action of the heart, due to asthenic fever in the course of acute exanthemata, typhoid or puerperal fevers, etc., to fattj- degeneration of the heart, or myocarditis. • Its most prominent Symptoms are: 1. Dyspnoea, which oftentimes reaches such a height that the patient, in the greatest distress, tries all possible positions to get breath — now sitting erect, now bending forward and supporting the head with the arms, etc. 2. Spasmodic cough, with a great deal of frothy and serous, sometimes bloody expectoration. 3. Cyanotic symptoms, in consequence of the obstruction to the circula- tion; and, finally, if the breathing is still more impeded and the blood be- comes overcharged with carbon. 4. The patient sinks, his cheeks grow livid, and he dies of asphyxia — Apoplexia pulmonum vascularis. Physical signs. — Inspection and palpation show, notwithstanding the greatest efforts of the patient to draw in air, a decrease in the respiratory motion of the thoracic walls. Auscultation reveals all sorts of rattling and bubbling noises, at times a weak crepitant sound. Percussion, however, gives no results, unless the lung has become de- GANGR^NA PULMONUM. 37 I prived of air to a large extent, when, of course, the sound is dull, or tympa- nitic, when the lung tissue becomes compressed, so that it loses its natural elasticity. Therapeutic Hints. In acute oedema, compare: Aeon., Nux vom.,' Scilla, Sulphur, Tart, eniet. Amm. card. Somnolence; poisoning of the blood by carbon. Arsen. Great anxiety; restlessness; always worse towards midnight or soon after. Card. veg. Collapsed state. Cinchona. After debilitating losses. Ipec. Spasmodic cough; sickness of stomach; fine rattling noises in the chest. Kali hydi . Sputa like soap-suds. Laches. Suffocating fits; worse after sleep; dark, almost black urine; offensive discharge from the bowels. Phosphor. If worse before midnight, with tightness in the chest. Tart. emet. Large bubbling rattling; chest appears full of phlegm without capability of relieving itself. Besides may be indicated: Aurum, Bellad., Cactus, Cimicif., Gelsem., Glo?ioi?i., Sanguin., Spongia, Ver. vir. Compare Asthma, Pneumonia, Heart Diseases. Gangraena Pulmonum Is a process of mortification and putrefaction of the lung tissue, owing to the admission of air, as it occurs in all lifeless animal tissues when under the in- fluence of air, moisture and a certain temperature. It is either circum- scribed — that is, confined to one or several foci of various sizes — or diffused, without accurate lines of demarcation; the first form may degenerate into the latter. Its Causes are: interruption, or weakness of the blood-currents, by pneumonic infiltrations or emboli; putrid suppuration in the neighborhood of the air passages by perforation into a bronchus; decomposing foreign bodies, which have found their way into the lung through the trachea; putrid contents collected in dilated bronchial tubes; injuries caused by stabs or gunshot wounds. Its most characteristic symptom is the sputum, which consists of a greenish-gray or brownish-colored fluid, with an exceedingly offensive smell. The breath, too, or forced expiration, exhibits the same disgusting smell. There is almost always a racking cough attending the disease, and dangerous haemorrhages may ensue from the gangrenous erosion of blood-vessels. The temperature is usually very high. The diffused form runs a very rapid course with all signs of an asthenic fever, delirium, stupor, hiccough, colliquative diarrhoea and collapse. Physicial examination yields at first generally a tym- 372 HEMORRHAGES OF THE LUNGS. panitic sound on percussion, which at a later period grows dull. Small gangrenous masses, or larger ones, which do not communicate with a bronchus, or which, from some other cause, cannot discharge their contents, are out of reach of diagnosis. The circumscribed gangrene may discharge and heal; the diffused form usually is fatal. Therapeutic Hints. Compare: Arsen., Card, ac, Card, veg., Kreos., Silic. Haemorrhages of the Lungs, Haemopotoe, Haemoptysis. Haemoptoe — haemorrhage of the respirator)' organs, Haemoptysis — expectoration of blood, consists either of mere exudation of blood- corpuscles through the uninjured walls of the capillaries — Diapedesis, or of a pouring out of blood through ruptured vessels. Haemorrhages occur most frequently in the smaller and terminal bronchi — Bronchial haemorrhages ; parenchymatous bleeding is less frequent, and is either confined and sharply outlined, without destruction of the parenchyma — Hemorrhagic infarction, — or, is diffuse; abundant and associated with destruction of the lung tissue, and causing the formation of cavities — Pul- monary apoplexy. Bronchial haemorrhages may be caused in the main by all such morbid conditions as will produce either active or passive congestion of the bronchial mucous membrane, for instance: bronchitis, whooping-cough, pneumonia, tuberbulous infiltrations, acute exanthemata, inhalation of irritating gases, excessive heat or cold, severe strains and bodily exertions, suppression of menstrual or haemorrhoidal flows, disorders in the circulation resulting from heart disease, and peculiar altered conditions of the blood, which impair the nutrition of the vascular parietes, and manifest themselves in scorbutus, hcemophilia, scarlatina, typhus, variola, etc. , also in bleedings from other portions of the body. Haemorrhagic infarctions are most frequently due to organic heart diseases, especially of the right heart, to pulmonary emphysema, senile or early acquired atrophy of the lungs, and thrombosis of the peripheric veins of the body. Pulmonary apoplexy arises from the rupture of large, generally arterial vessels, most frequently in consequence of injuries, gun-shot and penetrating wounds, contusions and concussions of the thorax; rarer from endarteritis and aneurismal changes of the walls of pulmonary arteries, or their erosion by cancer, abscesses and pulmonary gangrene. In order to decide whether the blood comes from the nose, larynx or trachea, a close inspection of these parts will best decide. If in doubt whether the haemorrhage comes from the stomach, we will have to inquire about the conditions of the digestive organs and those of the portal circula- tion. THERAPEUTIC HINTS TO HEMORRHAGES OF THE LUNGS. 373 Small haemorrhages issue usually from capillaries, profuse ones from a large vessel; Hemorrhagic infarction is, as a rule, associated with a high degree of dyspnoea, the physical signs of a circumscribed pulmonary solidi- fication and heart disease. Pulmonary apoplexy kills, so to say, on the spot. Therapeutic Hints. Aeon. In many cases; but best indicated by restlessness, agitation, fright, expression of anxiety in the face, palpitation of the heart, congestion towards the chest and head, fear of death; after wine. The blood comes hot and fresh with every little cough. Arnica. After mechanical injury; from slight bodily exertion; in tuber- culous individuals; constant tickling cough, starting either from the larynx or from under the sternum. Arsen. After venesection or loss of blood otherwise; great weakness and fainting; restlessness, must walk about; burning in chest and stomach; suppressed menstruation. Bellad. Cough from constant tickling in the larynx; congestion to head and chest; stitching pain in chest, worse from motion; suppressed menstruation. Cad. grand. With heart disease. Card. veg. Pale face; cold skin; slow pulse, intermitting, scarcely per- ceptible; mostly attended with violent cough in paroxysms and hoarseness, worse towards evening; sometimes burning in chest. China. After great loss of blood or vital fluids; during nursing, etc.; with all the signs of weakness which arise from want of blood; continual pain in chest and stomach, worse from touch. Collin. Blood dark, tough, coagulated, enveloped in viscid phlegm; previous discharge of blood per annum; subsequent costiveness. Co7iium. Especially after masturbation. Croc. sat. Blood dark and stringy. Digit. Haemoptysis before menstruation, with pain in the chest, back and thighs; from obstruction of the pulmonary circulation in consequence of heart disease and tuberculosis. Engorged veins about the head, pale, livid complexion, coldness of skin, with cold sweats, irregular pulse and palpita- tion of the heart. Eriger. Dark coagula, passive haemorrhage. Ferrum. Always better from walking slowly about, notwithstanding weakness obliges the patient to lie down; quick motion and talking bring on cough; there is pain between the shoulders; the face has a yellowish tint; sleep is poor at night, and there is frequent palpitation of the heart. Hamam. Blood is venous; comes into the mouth without any effort, seemingly, like a warm current from out of the chest; mind calm; sometimes taste of sulphur in the mouth. Iodinm. Annoying tickling cough in phthisical persons; oppression and palpitation; trembling and coldness of the extremities. 374 AFFECTIONS OF THE PLEURA. I pec. Blood froth}' and bright colored; gasping for breath, pulse small and frequent; face livid and anxious. Led. pal. Where there is stagnation in the liver and portal veins; congestion towards the head and chest; hardness of hearing; tickling in the larynx; spitting of bright red blood. Haemoptysis, alternating with rheu- matism. Millef. In tuberculosis. It bubbles up in the chest, as if warm blood were ascending, which is raised without cough. After injuries. Myrt. com. In phthisical persons; sharp pains through the upper part of the left lung, from front to shoulder-blade. Nitr. ac. According to Goullon, the best remedy. Nux vom. Especially after high living, suppressed haemorrhoidal dis- charges, and after fits of passion, etc. Opium. Blood is thick and frothy, mixed with phlegm; absence of all pain; slumber, with starting. Phosphor. Vicarious spitting of blood for the menses; tubercular diathesis, dry, tight cough, worse from evening till midnight; bronchitis. Phosph ac. Phthisis; typhoid fever, with diarrhoea and great rumbling in the bowels; fast growing youths. Pidsat. Dark, coagulated blood; chilliness; loose stools; suppressed menstruation; crying spells. Rhus tox. After straining, lifting, blowing of instruments, or worri- ment and mental excitement immediately renewed; blood bright. Senec. In suppressed menstruation; after venesection. Sulph. ac. In climacteric period; also habitual haemoptysis excited from least fright, vexation, talking, running, in persons who flush easily, have palpitation, perspire easily, are easily excited. Also in scorbutic, alco- holic affections, adynamic fevers, tuberculosis. Stannum. In phthisical patients, when at the same time there exists copious expectoration. Tart, evict. When, after the attack, there remains for a long time a bloody slimy expectoration. In suppressed menses, compare Arsen. , Bellad. , Millef. , Phosphor. , Senec. , Sulphur. After the suppression of habitually bleeding haemorrhoids, compare Aeon., Nux vom., Sulphur. After wine, Aeon. After whiskey, Mercur., Pulsat. After coffee, Nux vom. c. AFFECTIONS OF THE PLEURA. Pleuritis, Pleurisy, Inflammation of the Pleura. When we examine, post mortem, a case of pleurisy, we observe on the pleural surf aces pinkish dots or streaks here and there, consisting of enlarged AFFECTIONS OF THE PEEURA. 375 capillaries, also irregular, dark red, ecchymosed patches of extravasation. The surface of the pleura, instead of being smooth and shining, appears dull and swollen, rough and villous from fine granulations and new cells upon it. This is the most frequent^ occurring form of pleurisy without exudation, and therefore called pleuritis sicca, dry pleurisy. In other cases, we observe, in addition to the above-stated features, which are, in fact, the ground-type of all forms of pleurisy, a scanty, fibrinous exudation, covering, like paste, or, (if in greater abundance) like a soft, croupous membrane, the inflamed pleural layers. During the progress of re- covery it gradually becomes dissolved by a fatty metamorphoris and is ab- sorbed ; but those fine granulations and new cells which lie underneath, and which are inherent parts of the inflamed pleura, frequently give rise to adhesions of the pleural surfaces. This fibrinous exudative pleurisy accom- panies almost always croupous pneumonia. In still other cases we observe an abundant serous fibrinous exudation, varying in amount from a few ounces to ten or more pints. It consists of a greenish-yellow serum, of coagulated fibrinous masses and pus corpuscles, which partly float in the serum and partly are deposited upon the pleural surfaces, where they adhere like croupous membranes. At times the pus corpuscles are in such abundance, that the exudation assumes a purulent character; and when from rupture of the finer blood-vessels, or simply by transudation in consequence of a hemorrhagic diathesis, large masses of blood-corpuscles mix with the exudation, we have a hemorrhagic effusion. In consequence of, and according to, the mass of the pleuritic effusion, the lung of the affected side becomes compressed at times to the fourth, sixth, or even to the eighth part of its normal volume; its arched costal portion is flattened down, and its substance appears pale reddish, or bluish-gray, or lead-colored, and becomes tough like leather, bloodless and airless. Heart or liver become displaced accordingly, as the effusion is either on the left or right side. The sound lung always shows more or less congestion, and in fatal cases a collateral oedema of high degree. In case of recovery the exudation is gradually absorbed, frequently leaving }^ellow cheesy masses behind, which are residues of unabsorbed pus- globules and fibrinous substances. In the same degree in which absorption takes place, the lung regains its normal volume and condition; provided the air-cells be not glued together, or closed by fibrinous deposits. In these conditions air cannot enter, and the lung, or such part of the lung, cannot regain its normal expansion. This would cause a vacuum in the thorax, were it not for the pressure of the external air, which at once flattens down the corresponding portion of the thoracic walls, or pushes heart or liver higher up in the thoracic cavity. The purulent exudation, which is so rich in pus-globules that it forms an opaque, yellow, thickish fluid, is called empyema or pyothorax. Even in such cases absorption is possible. Should, however, the pleural substance in consequence of the suppurating process be softened and perforated, the puru- 376 AFFECTIONS OF THE PLEURA. lent matter would then escape either through the thoracic wall, in case the pleura costalis were destroyed, or through the bronchial tubes, if the pleura pulmouum were perforated. These four different forms of pleurisy must of course manifest them- selves by different symptoms. The first form pleuritis sicca, when, in consequence of inflammation, new cells form upon the pleural surfaces, but without exudation, seems to take place frequently without any particular signs. This statement is founded upon the existence of man)- adhesions, found in post-mortem examinations, in persons who had never complained of symptoms that could possibly have been taken as indications of pleurisy. The second form, with Scanty fibrinous exudation, is generally coupled with pneumonia or tuberculosis. It is characterized by a sharp stitching pain, which hinders deep inspiration, coughing, sneezing and motion, and for this reason the patient can breathe only superficially. If not compli- cated with pneumonia or tuberculosis, there is scarcely any cough attend- ing it. On inspection we observe, in consequence of the pain which is caused by breathing and moving, that the patient bends his body towards the affected side, in order to bring the ribs of that side nearer together to prevent their respiratory motion, in consequence of which the spine itself becomes curved, its convexity being directed towards the sound side. Palpation merely confirms the superficial breathing, and may yield the perception of a grating feel; more, however, towards the end than at the commencement of the disease, after the exudation has been absorbed, when, therefore, the surfaces are dryer and the breathing deeper again, so that the rough surfaces glide more forcibly one upon the other. For this same reason, auscultation reveals the friction sound more de- cidedly towards the end of the disease. The third form, with Abundant serous-fibrinous exudation, usually com- mences with a strong chill, followed by high fever. The chill is frequently repeated, and the whole affection may look very much like a tertian inter- mittent fever. It is also characterized, like the second form, by violent stitch- like pains in the sides of the chest, which, however, often subside, or at least diminish, before the inflammation and exudation has reached its full height. The subsidence of pain is therefore, in this form, not always a sign of conquered disease. Generally it is accompanied by dyspnoea as long as the fever lasts, and in such cases, and where an extensive exudation compresses the lung, and causes a hyperaemic state and catarrh in the adjoining portions of the lung, there is also cough. Otherwise the cough may be absent altogether. The disease generally reaches its height in about six or eight days, and commences its gradual decline from that time. Fever, pain and cough cease, and absorption of the pleuritic exudation takes place, diminishing at first AFFECTIONS OF THE PLEURA. 377 much more rapidly than towards the last, so that sometimes, even after weeks, some fluid can still be detected. In some cases this form comes on quite stealthily, without either promi- nent fever, pain or cough. The patient feels only a gradual loss of strength, some difficult}' of breathing; he grows pale, and loses flesh, and thinks that the source of all his troubles lies in his abdomen, especially when, by exuda- tion on the right side, the liver has become dislocated downwards. Even the physician may be astonished when he, by closer examination, finds the whole pleural sac filled with fluid, amounting to from ten to fifteen pints. Such an enormous quanthry, of course, can be absorbed at best only very slowly, being alternately augmented and decreased in the meantime. It terminates finally, in a great number of cases, in tuberculosis. Exudation on Right Side. (After Bock.) a. Exudate. b. Heart. c. Compressed lung with tympanitic sound. d. Lung sound. e. Displaced liver. Exudation on Left Side. (After Bock.) a. Exudate. b. Displaced heart. c. Compressed lung with tympanitic sound d. Right lung with normal sound. e. Liver. Inspection discovers an enlargement of the thorax in breadth and depth on the diseased side, if the exudation is sufficiently large. The intercostal spaces are wider, and are on a level with the ribs, or even bulging, out be- tween them. The respiratory motion is much less, or ceases altogether on the diseased side. Palpation reveals the absence of the vocal fremitus, which is the neces- sary consequence of the intervening fluid between the thoracic walls and the lung; it reveals dislocation of the heart or of the liver, and also sometimes the friction of the roughened pleural surfaces above the exudation. Percussion yields a somewhat duller sound, in case the exudation be moderate, so as not to compress the lung tissue to such a degree as to drive all air out of it; it yields a tympanitic sound, if the pressure upon the lung be just sufficient to deprive it of its natural tension and elasticity; it yields a flat, fleshy sound, if the secretion augments to such a degree as to deprive the lung of all the air; above the level of the liquid we hear again the tym- panitic sound (Skoda's sign), for here the lung, although compressed, is not 37§ AFFECTIONS OF THE PLEURA. entirely without air. Variation in position does not always change the result of percussion, because the exudation is usually enclosed and bordered by adhesions. Auscultation reveals an absence of the respiratory murmur over the whole part that is covered by exudation. In other cases, however, w T e hear a loud bronchial breathing all over the thorax, especially in case of dyspnoea; no matter how much fluid intervenes between the thoracic walls and the lungs, or how much the lungs may be compressed. The auscultatory signs are therefore not very characteristic. The fourth form, Empyema or Pyothorax, differs from the latter only by the abundance of its pus-globules, and is frequently found in consequence of infectious diseases and a general pyaemic condition. Its physical signs are all the same, as above stated. When empyema is about to discharge through the thoracic walls, we observe, in the region of the fourth or fifth, rib, an oedematous swelling, which soon changes into a hard, tense swelling, protruding from between the ribs; by and by it becomes fluctuating, and lastly it bursts and discharges an immense quantity of pus. This opening sometimes remains for years, forming a thoracic fistula, and discharges every now and then larger or smaller quantities of pus. When empyema is about to discharge through the bronchial tubes there may appear, at first, symptoms of pneumonia, or the bursting takes place suddenly, when, with violent fits of coughing, the patient throws up large quantities of pus. Even here recovery is possible, though it may happen that the patient suffocates, or sinks under the influence of pyaemic poisoning. The empyema may also discharge downwards through the diaphragm into the abdominal cavity, where it occasions a violent peritonitis. When the course of pleuritis is very acute, the morning and evening temperatures rise to above io4°F., and the pulse to 120 and higher; there is frequently great disturbance of the sensorium, often violent delirium, great dryness of the tongue, excessive thirst and total loss of appetite; the anterior extremity of the spleen, even in the early days, can be distinctly felt, and diarrhoea may set in at this time, thus simulating a case of typhoid, though the deeply cyanosed complexion, the constant abnormal elevation of temperature and pulse, and the physical examination will soon correct an error of this kind. When in the first week of illness an unusual pallor presents itself, ac- companied with the rapid loss of strength, high fever and a considerable degree of pain in the affected side, we ma}' assume that a hemorrhagic exu- dation has taken place, in consequence of a tubercular pleuritis, in young persons; in old people the same symptoms hint to a tendency of the exuda- tion to become purulent. When the inflammation attacks the diaphragmatic portion of the pleura — known by the ancient physicians under the name of paraphrenias, then the pain is usually in the hypochondriac region, about the cartilages of the THERAPEUTIC HINTS. TO AFFECTIONS OF THE PLEURA. 379 false ribs, at the level of the diaphragm; the respirations are short and quick, the inspirator}' expansion is confined to the upper ribs, the body is inclined forwards, the countenance is much altered, with twitchings about the lips, and occasionally risus sardonicus; there is also, at times, hiccough, nausea, and even actual vomiting. Still, these symptoms are not constant; there are cases of diaphragmatic pleurisy without the one or the other of these signs, or they appear in consequence of inflammation of one or more of the organs lying beneath the diaphragm. Pleurisy ma) r become complicated with many acute and chronic diseases, such as: pericarditis, tuberculosis (when it usually appears simultaneously on both sides), pneumonia, bronchial catarrh, inflammation of the mediasti- num and of the peritoneum (in purulent pleuritis), caries of the ribs and spine (also in its purulent form), scarlet fever, measles, smallpox, articular rheumatism. Its SequEL-E are: adhesions of the two pleural layers, inveterate bron- chial catarrh, caseous pneumonia, bronchiectasis, etc. The Differentiae Diagnosis between Pleurisy and Croupous pneu- monia is: Pleurisy. Repeated chills. Catarrhal sputa. Stitch-like pain. Enlargement of the thorax. Absence of vocal fremitus. Dislocation of heart, liver or spleen Friction sound. Pneumonia. One chill. Rust-colored sputa. No pain, or dull, when the bronchial tubes, and stitch-like when the pleura is involved. None. Increased vocal fremitus. None. Crepitant sound. Its Prognosis varies greatly according to its character. As unfavor- able signs, Fraentzel considers the following: "1. A double-sided pleuritis, as it almost always indicates tuberculous disease of the pleura. 2. Continued high fever. 3. Rapid increase of the effusion, accompanied with high fever and with great displacement of adjacent organs, unless, after a course of from four to six weeks, signs of commencing absorption are observed. 4. Symptoms of impending suffocation. 5. Discharge of the pus, either into the bronchi, with simultaneous production of pyo-pneumothorax, or externally through one of the intercostal spaces. 6. The rapid increase of an effusion, which for a long time remained stationary, because in that case the pleuritis, as a rule, has assumed a tuberculous and hsemorrhagic character. 7. A return or increase of the effusion after spontaneous, or a single or repeated artificial discharge of the same, especially where the quality of the dis- charged fluid degenerates and becomes purulent, bad-smelling, ichorous, chocolate-like, etc." Therapeutic Hints. Aeon. Chill; fever; great thirst; quick pulse; dry skin; anxious rest- lessness; agonizing tossing about; stitching pain in chest; inability to lie 380 THERAPEUTIC HINTS TO AFFECTIONS OF THE PLUERA. on the right side; dry, hacking cough. Traumatic form, with torn pleurae and consequent external emphysema. Arnica. After mechanical injuries; bruised feeling in chest; expector- ation of bloody foam. Is followed well by Sulph. ac, in the traumatic form. Nervous persons; torpidity, even to sepsis; dry, cold extremites; head hot, remaining body cool: constant change of position on account of a feeling as though the bed were too hard. Arsen. Profuse serous effusion; great dyspnoea and little pain; weak and cachectic persons; drunkards; intermittent paroxysms; pyothorax. Bell ad. When the inflammation ascends from the diaphragm; plethoric, lymphatic persons, tuberculous women with affections of the cerebral mem- brane; in exan thematic, typhoid, puerperal phlogosis; after scarlet fever. Br yon. Stitching pain in chest, worse from slightest motion; better when lying on the affected side, not always, however; tongue white; thirst great. Calc. carb. Has rapidly diminished the pleuritic exudation. Canthar. Profuse serous exudation; frequent cough; dyspnoea; palpi- tation: profuse sweats; great weakness; tendency to syncope; scanty urine. (E. Faivre.) Carb. veg. Prostration; sunken features; sallow complexion; emacia- tion; hectic fever; purulent or ichorous degeneration. Colchic. Arthritic form; sour-smelling sweat not alleviating; scanty, turbid, red urine, with acid reaction and containing albumen. Hepar. Croupous exudation, with a yellow or yellowish-brown tint in face, in scrofulous and lymphatic persons; hectic fever, with intermittent paroxysms; empyema. Kali carb. When the violent stitching pain does not yield to Bryon., especially on the left side, with violent palpitation of the heart; the cough is dry and worse towards three o'clock A. m. Pain in epigastrium; throbbing and stitching pain in back up to the nape of the neck. Kali hydr. In pleuritic exudation. (Grubenmann.) Lauroc. For drunkards and melancholic persons at the beginning, with continuous suffocating cough; the pain in the pleura is severe and localized; pulse soft, though quick. Mercnr. In syphilitic or rheumatic patients when the pain persists after the fever, with copious, not alleviating sweats; frequent chills (feels chilly whenever moving the feet to a cooler place in bed); considerable thirst; gastric and intestinal catarrh, with icterus. Stitching pain through to the back when coughing or sneezing; right side. Nitr. ac. For old people, when the pain leaves and the pulse increases; great weakness and diarrhoea. Phosphoi . In complications with bronchitis; tightness across the chest; dry, tight cough, which is worse from evening until midnight. Later stages; purulent infiltration; hypertrophy of the right heart; Bright" s disease. Rhus lox. After exposure to wet, or from straining, lifting, wrestling, PNEUMOTHORAX. 38 1 etc.; tip of tongue red; fever-blisters around the mouth and nose; very rest- less, notwithstanding the pain. Senega. After the inflammation has passed; copious mucous secretion, with difficult expectoration; tightness and burning in the chest. Sepia. Recommended by Kunkel, on the ground of the symptoms 1005 to 1 1 90 in Hahnemann's Chronic Diseases. The changing of localities of the pain {Bell., Puis., Snlph., etc.,) hints often to this remedy. Squilla. Stitching pain in left side; short, rattling cough, disturbing sleep; inability to lie on the left side; grating of teeth; twitching of the lips, which are covered w T ith thick } T ellow crusts, more on left side; cheeks bright red; perspiring profusely, especially on forehead; red tip of tongue, yellow- ish covering on the back part. Sulphur. When the pain is in the left side, lower region, going through to the shoulder-blade and of a more steady nature; lips bright red; in con- nection with acute articular rheumatism or gout; fibrinous pleuro-pneumonia. Follows w 7 ell after Bryon. or Rhus tox. Tart. emet. In pleuro-pneumouia at the commencement, according to Kafka, specific. Dyspnoea, must sit up; palpitation; tingling and pinching in the pit of the stomach. When the healthy side is attacked by oedema. In neglected or badly treated cases, where the exudation is abundant, or in cases developed in cachectic constitutions, with a pyaemic tendency, we shall have to compare; Arsen., Cale. earl?., Camphora, Card, veg., China, Ferritin, Hepar, Iodinm, Kali hydr., Kreos., Laches., Lycop., Sepia, Senega, Si lie., and others. Paracentesis has seldom proved beneficial in acute cases; in chronic cases it may in rare instances be the indicatio vitalis, when the rapidly in- creasing purulent exudation threatens suffocation. The emptying ought to be effected by aspiration, in order to prevent the entrance of air into the pleural cavity. If, after several tappings, the purulent exudation persistently and profusely returns, the old school of late years opens the pleural cavity and washes it out with warm distilled water until every trace of purulent matter has disappeared, when injections of iodine, or carbolic acid, or other similar substances are made, until by granulation the pleural folds have healed together. "Radical cure," as it is termed. Compare Frsentzel on pleuritis, in Ziemssen's Cyclopaedia, Vol. IV. Pneumothorax. This consists of a collection of air or gas within the pleural sac. As air alone, however, is rarely found in this locality, but mostly in combination with pus, blood or serum, it is calle'd, according to the nature of the co-exist- ing fluid, either pyo-, or haemato-, or hydro-pneumothorax ; when an exudation of pus or blood follows a collection of gas in the pleural cavit}^, it is termed pneumo-pyo', or pneumo-haematothorax. Pneumothorax, whether it be in combination with fluids or not, isalwavs 382 PNEUMOTHORAX. characterized by an enormous extension of the thoracic wall of the affected side, the intercostal spaces of which bulge out. When on the left side, it pushes the heart towards the right; if on the right, it presses the liver down into the abdominal cavity. The lung itself is compressed to a small volume, containing little or no air, and lying close to the spine. The gas, which is collected within the pleural sac, consists mostly of carbonic acid gas and nitrogen, with very little oxygen; and in cases where decomposition has taken place, of sulphuretted hydrogen. These gaseous substances ma)' be diffused and fill the whole pleural cavity of one side, or the}' may, in rare cases, be limited therein to a certain portion, in conse- quence of previous pleuritic adhesions. The entrance of air into this cavity almost always causes, in a short time, a pleuritis with either sero-fibrinous or purulent exudation, and is occasioned either by a perforation of the pleura pulmonum, in consequence of lung diseases, especially pulmonary consumption and empyema, in which case the air enters from the air-cells of the lungs; or by a perforation of the thoracic wall, by traumatic causes, when the air enters from without; that gaseous substances may be formed by means of decomposition in a pyo- thorax has of late been greatlv doubted. Pneumothorax ox Right Side. (After Bock. a. Heart displaced. b. Liver displaced. c. Stomach. d. Distention by gas. e. Compressed lung and tuberculous deposit. Pxeumothorax ox Left Side. (After Bock. ) a. Heart displaced. b. Right lung. c. Compressed lung and tuberculous deposit. d. Distention by gas. e. Stomach. f. Liver. g. Spleen displaced. In cases in which the air fills the pleural sac through the lungs, it takes place almost always quite suddenly, and the patient has a sensation as though something had burst in the chest, which is in fact the case. At the same time he experiences great difficulty in breaching; he is obliged to sit erect, and can lie only on the diseased side, and for an obvious reason — to keep the sound lung free from any pressure. The worst cases are those which exist in consequence of tuberculosis, gangrene or carcinomatous degenerations of the lungs. Those in consequence of emphysema or external perforations are not so violent. HYDROTHORAX. 383 Inspection. Enormous enlargement of the diseased side of the thorax; its intercostal spaces bulge out; perfect want of respiratory motion. Palpation. Total absence of vocal fremitus; liver or spleen displaced downwards; heart towards the middle or the right side of the thorax. Percussion. Tympanitic sound, unless greatly distended, when it loses the tympanitic quality and becomes dull. Dull sound in the upper posterior region, where the compressed lung lies, and in the lower regions of the thorax, when effusion exists, changing locality with the patient's change of position. Auscultation. Absence of respiratory murmur with fall resonant percus- sion sound; metallic tinkling when the patient talks, coughs or inhales deeply. Bronchial breathing and bronchophony, where the compressed lung lies. In cases where air and fluids co-exist we hear a splashing sound when- ever the patient moves quickly, just like water in a half-filled bottle, if it be shaken. Likewise do we sometimes hear a falling of drops with a metallic tink- ling sound, when the patient rises from a recumbent position. Differential Diagnosis. — Pneumothorax differs from emphysema by its dyspnoea coming on suddenly and growing worse steadily; by its one- sided distention of the thorax, the intercostal spaces of which bulge out; by its want of vocal fremitis, the absence of the vesicular murmur, and the presence of the metalic tinkling sound. It differs from large superficial cavities by the distention of the thorax and the displacement of heart, liver or spleen, and the absence of vocal fremitus. Therapeutic Hints. For the sudden dyspnoea, Arsen. When caused by external injury, A con., Arnica, Staphis., and others. When in connection with consumption, compare the remedies mentioned there. For the subsequent inflammation of the pleura, compare Pleuritis and Pneumonia. Hydrothorax, Dropsy of the Chest. This is a collection of serum in the pleural sac, without any inflamma- tory process in that locality. It is mostly found on both sides of the chest at the same time, although one side may contain more fluid than the other. The serum is clear, yellowish or greenish; sometimes reddish, when mixed with blood; it never contains fibrinous substances, as an exudation of pleu- risy always does, but in place of it a great deal of albumen. The pleura itself looks pale and dull, without any sign of inflammation; the lung is pressed towards the spine whenever a large amount of such fluid exists, and generally appears ©edematous. 3S4 THERAPEUTIC HINTS TO HYDKOTHORAX. Hydrothorax originates mostly in consequence of lung and heart dis- eases, which cause obstruction to the venous circulation within the lungs; or in consequence of such morbid states of the body as cause the blood to be- come thin and watery, as is the case in Bright 's disease, in certain spleen and liver affections, in anaemia, in intermittent cachexia. It is, therefore, almost always attended by other dropsical conditions. From this it is apparent that its symptoms must vary greatly. Its most prominent feature, however, is dyspnoea, which is always worse in a lying, and better in a sitting position, and this for obvious reasons: when sitting the fluid settles to the lower part of the thoracic cavity and leaves the upper part of the lungs free for respiratory action; whilst in a horizontal position the whole lung becomes overflown and compressed by the fluid. Where there is a great deal of serous effusion the patient seems to suffocate whenever he tnrns in bed. Niemeyer explains this important sign in the following man- ner: as the fluid is not limited to a certain place, as in the case of pleuritic effusions, it changes its position freely whenever the patient changes his position, following the law of gravitation. Wherever it locates, there it naturally compresses the lungs, makes them unfit for respiration, whilst the uncompressed portion fulfils this office undisturbed. A turn of the body reverses at once the location of the fluid: it now compresses those portions of the lungs which were breathing, and sets others free that were com- pressed. Ere these can be pervaded by air, the patient has no breath. This explains fully those suffocating fits which such patients experience when turning in bed. Inspection. Enlargement of the thorax. Palpation. Absence of vocal fremitus and displacement of heart, liver, spleen. Percussion. Dull sound as far as the fluid reaches, changing locality in different positions of the patient. Auscultation. Absence of vesicular breathing where the fluid covers the lungs, but bronchial breathing about the spine, where the lungs are compressed. Therapeutic Hixts. Apis. Great oppression; inability to lie down; absence of thirst; urine dark, like coffee; after taking cold, during desquamation in scarlet fever. Apoc. cann. Inability to speak; catching of the breath: irritability of stomach so great that even a draught of cold water is rejected; suppression of urine. Asclcp. syr. Recommended especially after scarlet fever. Arsen. Dyspnoea, worse from any exertion; when lying down at night, if ever so carefully, the patient experiences a sense of suffocation; also when turning in bed: with great anxiety; palpitation of the heart and great dry- ness; drinking constantly but little at a time. A spa)-. Old people with heart diseases. H.EMATOTHORAX. 385 Br von. Pain in the side; cough, with contraction of the diaphragm; vomiting and splitting pain in the head, excited by any motion; retarded stool and frequent desire to pass water, but only a few drops flow. Colchic. Asthma; cedematous swelling of hands and feet; constant urging to pass water, as from spasm of the bladder, but only a little is voided, and that with great pain; heart disease in consequence of acute rheumatism. Digit. Intermitting pulse; pale face; cold skin; flabby, cedematous swelling all over; difficult urination; cyanotic symptoms, with fainting. Helleb. Slow comprehension; slow in answering questions; pale face; griping pain in the bowels, with diarrhoea of a jelly-like slime. Kali carb. Whizzing breathing; oppression worse about three o'clock in the morning; cedematous swelling between the eyebrows and lids, looking like a little bag; insufficiency of the mitral valves; great dryness of the skin. Laches. Suffocating fits, waking from sleep, with throwing the arms about; cyanotic symptoms; swelling of the liver; black urine; offensive smell of feces. Lycop. Dyspnoea worse when lying on the back; constipation; rumb- ling in the left iliac region; red urine; exceedingly cross after getting awake. Mercnr. After scarlatina; cedematous swelling all over; sweating with- out improvement; dry, hard cough; inflammation of the genital organs. Squilla. Strong urging to urinate, with scanty and dark urine; con- tinous cough, with mucous expectoration; cedematous swelling of the body. Senega. Loose, faint, hacking cough, with expectoration of a little phlegm. Spigel. Dyspnoea during motion in bed; can lie only on the right side and with the trunk raised; danger of suffocation when making the least motion or raising the arms, with anxiety and palpitation of the heart. Sulphur. Sudden arrest of breathing at night in bed when turning to the other side, relieved when sitting; constipation, or diarrhoea in the morning; liver complaint; red lips. Tart. emet. Much coarse rattling in the chest; expectoration not equivalent to the secretion within; drowsiness; cyanotic symptoms. Haematothorax Is an effusion and accumulation of blood within the pleural cavity without inflammatory symptoms, brought on either by external injuries of the chest, from stabbing, gunshot wounds, fracture of the ribs, contusions, or from internal ruptures of blood-vessels, carcinoma and tubercles. The patient complains of sudden dyspnoea, with or without cough; his face grows pale ; he faints, has ringing in the ears; darkness comes before his eyes, and the skin is cold. Physical signs the same as in Hydrothorax. Therapeutic Hints. When from external causes, compare Aeon., Arnica, Cale?id., Eriger. y 25 386 THERAPEUTIC HINTS TO H.EMATOTHORAX. Hamam., Rhus fox. and the like. When from internal causes, they must be considered in each individual case, and reference should be taken to those remedies which are indicated in haemorrhages from the lungs. Great loss of blood indicates China, and a nourishing diet. For the subsequent pleuritis, compare the corresponding chapter. THE HEART Auscultation. First step: To know how the heart acts. The heart consists of four apartments: two antechambers (auricles) and two chambers (or ventricles), which are respectively named from their posi- tion, right and left. Into the right auricle the venae cavae empty all the blood which has been used in the body for its sustenance. From this antechamber a large aperture leads into the right ventricle, which is called the auriculo-ventricular open- ing, and which is guarded by a kind of gate, consisting of three triangular folds (the tricuspid valves), opening inwards. In the right ventricle we observe another opening, which leads into an artery called the pulmonary artery, because it conveys the deoxygenized blood to the lungs. This opening is likewise guarded by a set of valves, which, from their half -moon shape, are called semi-lunar valves, and which open outwards. This arrangement we find repeated in the left auricle and ventricle. Into the left auricle the pulmonary veins empty all the blood which has been oxygenized in the lungs. From this cavity a similar aperture leads into the left ventricle, which is likewise guarded by valves, consisting, however, of only two segments (the bicuspid or mitral valves), opening inwards. In the left ventricle we observe also an opening, which leads into an artery called the aorta, and which distributes the blood all over the body. This opening is likewise guarded by a set of valves of semi-lunar variety, which open outwards. Now let us study the action of this apparatus. The ventricles being fully distended, they immediately and simultaneously begin to contract. On account of the relation of the several valves to these two cavities, the action of the blood under the great pressure from this contraction forcibly shuts the tricuspid and mitral valves, thus closing the auriculo-ventricular openings, and the same action opens both sets of semi-lunar valves for the escape of the blood. Through the pulmonary artery the dark blood is propelled into the lungs, whence it is returned through the pulmonary veins to the left auricle, thus making the lesser circuit — the pulmonic circulation. Through the aortic valves and artery the red blood is propelled thiough the whole body, whence it is returned through the venae cavae to the right auricle, thus mak- ing the greater circuit — the systemic circulation. As the two ventricles contract, the two auricles dilate, and vice versa. The contraction of the ventricles and simultaneous dilation of the auricles is called the heart's systole, and by causing a forcible closure of the auriculo-ventricular valves produces 3 88 AUSCULTATION. the first sound of the heart. The dilatation of the ventricles and simultaneous contractions of the auricles is called the heart's diastole, and the forcible closing of the two sets of semi-lunar valves produces the second sound of the heart. This explanation of the two sounds of the heart suffices for my purpose, and may be demonstrated to the eye by the following diagram: We must firmly fix in our mind, if we wish to get along at all in reach- ing the goal of diagnosticating heart diseases, that the first sound is produced by the shutting of the tricuspid and mitral valves and the muscular con- traction of the ventricles. The second sound is the consequence of the shutting of the semi-lunar valves. Second step: How to find the exact situation of these different valves in the living subject. In order to find out the position of the heart, and its parts, we must first ascertain where it strikes against the thoracic wall. It does this with its apex, and in the majority of cases between the fifth and sixth ribs, about one inch to the right of a line drawn vertically through the left nipple, the person being in an upright position. In persons of short stature, we find the heart's impulse between the fourth and fifth ribs; and in persons with a long thorax, it may be felt much lower. So also different positions of the body change the place of impulse. In a person lying upon the back, it is observed nearer to the medium line; while lying upon the left side causes it to tilt over more towards the nipple line. This point of impulse we must take as a fixed point for determining the position of the left ventricle, which it never fails to represent. The other parts have a constant relation to this. The base of the heart, and consequently the aortic and pulmonary valves are almost invariably situated behind the middle of the sternum. The ascending aorta lies somewhat to the right of the vertebral column AUSCULTATION. 389 and consequently its sounds and murmurs must always be sought for over the middle and somewhat to the right of the sternum. The mitral valves are situated nearly one inch below those of the aorta, and on the left side of the sternum. The tricuspid valves are to the right of and anterior to the mitral, and they are for the most part covered by the sternum. The position of the right ventricle is variable, and cannot be determined, unless that of the left ventricle and aorta has been previously ascertained; it lies mostly under the lower part of the sternum. The valves of the pulmonary artery are situated under the cartilage of the third rib to the left of the sternum. The diagram below shows the exact position of these parts. Now, if we remember all this, we shall hear those sounds which originate in the left ventricle, in the mitral valves, most distinctly at that part of the thorax against which the apex of the heart strikes; those sounds which originate in the ascending aorta we shall hear best a little to the right of the centre of the sternum, and from thence upwards; those sounds which origi- nate in the pulmonary artery we shall hear best a little to the left of the centre of the sternum; those sounds which originate in the tricuspid valves we shall hear loudest over the central and lower part of the sternum. If we now consider that diseases of the pulmonary valves and the tricus- pid valves are of very rare occurrence, we may centre our attention upon only these two points: 1 . Upon the sounds of the mitral valves; heard best at that part of the thorax against which the apex of the heart strikes; and 390 AUSCULTATION. 2. Upon the sounds of the aortic valves ; heard best a little to the right of the centre of the sternum, in the second intercostal space, and thence up- wards. Third step : Of the different morbid sounds and murmurs of the heart. I. The left chamber during its systole. The first sound, heard clearly and most prominently at the apex, is proof, 1. That the mitral valves shut perfectly, not allowing any blood to regurgitate into the auricle; and, 2. That the aortic valves and orifice offer no obstacle to the direct pas- sage of the blood out of the left ventricle. But, if the mitral valves be deficient, so that they will not shut per- fectly during the rush of blood against them, what would be the consequence of this deficiency? Simply, the stream of blood would not be stopped there, but would re-enter the auricle and produce a noise, unlike the normal systolic heart sound. Or, suppose the aortic valves be stiffened or roughened, or the aortic opening constricted, so that the stream of blood in its course onward would be interfered w r ith, what would be the consequence of such obstruction? The stream of blood would rub against the obstacle and cause a noise or murmur at the same time when the closure of the mitral valves would give the first tick. Or, suppose the mitral valves be deficient, and, at the same time, the aortic valves stiffened and roughed, or the aortal opening constricted, what would be the consequence of this deficiency and obstruction? Well, the stream of blood would regurgitate through the auriculo- ventricular opening, and also rub against the obstacles in the aortic opening, and thus cause a noise without any tick. How then can we distinguish between these three different affections? In case of insufficiency of the mitral valves, the blood regurgitates at each contraction of the heart into the left auricle; and thus it becomes retarded in the whole lesser circuit. In consequence of this the right ventricle must make stronger efforts to drive it onward, and the pulmonary artery, becom- ing largely distended, contracts the more, thus causing a more violent shock backwards against its semi-lunar valves, and consequently a louder diastolic sound of the pulmonary artery. An increase of the second or diastolic sound of the pulmonan- artery is, therefore, almost invarably attending an insuf- ficiency of the mitral valves. We must, then, when we hear a noise instead of the systolic sound at the heart's apex, make sure whether there is also an increased second sound of the pulmonary artery. The valves of this artery are situated under the cartilage of the third rib to the left of the sternum — there we put the stethoscope, and if it turns out so, we may be sure that the noise which we hear at the apex, instead of the systolic sound, is caused by an insufficiency of the mitral valves. . In case of constriction of the aortic opening we hear the systolic sound and a noise besides. If we put our ear over the aorta, towards the right of AUSCULTATION. 39 1 the centre of the sternum, we hear the noise there even plainer than at the apex, and it is transmitted into the carotids. In case of insufficiency of the mitral valves and constriction of the aortic orifice combined, we shall find these features united; an increased second sound of the pulmonary arten T , and a noise over the aorta. 2. The left ventricle during diastole. The diastole or second sound of the heart, is proof — i, That the aortic valves shut well, not allowing any blood to regurgitate into the left ventricle; and 2 , that the mitral valves or the auriculo-ventricular opening offer no ob- stacle to the passage of blood out of the left auricle into the left ventricle. But, suppose the aortic valves be insufficient so that they would not close tightly after the blood had been driven through them; what would be the consequence of this insufficiency? The contraction of the aorta would drive some of the blood back into the left ventricle, and thus cause a noise or murmur instead of the second sound. Or, suppose the mitral valves be stiffened, roughened, or the auriculo- ventricular opening constricted, so that the passage of the blood into the ventricle were interfered with, what would be the consequence of such obstruction? The stream of blood would rub against the existing obstacle and cause a noise or murmur during the diastole of the ventricle at the same time when the closure of the aortic valves would give the diastolic sound. The murmur is generally heard most pronounced during the systole of the auricle, and as this occurs just before the contraction of the ventricles we get a presystolic murmur. Or, suppose the aortic valves be insufficient, and, at the same time, the mitral valves or auriculo-ventricular opening obstructed, what would be the consequence of this insufficiency and obstruction? Surely the stream of blood would regurgitate through the aortic valves into the left ventricle, and also rub against the obstacles in the mitral valves and auriculo-ventricular open- ing, and thus cause a noise or murmur, but no diastolic sound. And how can we distinguish between these different affections? In case of insufficiency of the aortic valves, we shall hear a noise or murmur instead of the second sound most distinctly over the aorta to the right of the centre of the sternum. In case of thickening of the mitral valves, or constriction of the auriculo- ventricular opening, the blood accumulates in the lesser circuit, produces hyperthrophy, with dilatation of the right ventricle, and an increased dias- tolic sound of the pulmonary artery much more readily than mere deficiency of the mitral valves. The more constricted the mitral orifice is, the longer will be the time necessary for the flow of the blood into the ventricle, and the more prolonged and louder the murmur. In cases of this kind the vibra- tions may even be felt and seen. In case of insufficiency of the aortic valves and constriction of the mitral orifice combined, we shall, of course, find both features united — a noise in- 392 AUSCULTATION. stead of the second sound over the aorta and a murmur over the mitral valve, with an increase of the diastolic sound of the pulmonary artery. 3. The left ventricle during its systole and diastole. The clear systolic sound indicates that the mitral valves close perfectly, and that the aortic opening is not constricted. The clear diastolic sound indicates that the aortic valves shut well, and that the mitral orifice is not constricted. But suppose the mitral valves be insufficient, and, at the same time, the auriculo-ventricular opening constricted, what would be the conse- quence of such insufficiency and constriction at the same time ? The systole would cause a regurgitation of the blood into the auricle, and the diastole a friction of the blood during its passage through the constricted mitral open- ing, and thus we would hear a see-saw, a noise instead of the first, and a noise accompanying the second sound. Or, suppose the aortic valves be insufficient, and, at the same time, the aortic orifice constricted, what will be the consequence of such a state? Undoubtedly the contraction of the heart would cause a noise by driving the blood through the constricted orifice, and during the dilatation of the heart the blood w T ould regurgitate and cause a murmur instead of the second sound. And how are we to distinguish between these two different affections? When the mitral valves are insufficient, and the auriculo-ventricular opening is at the same time constricted, we must find also an increased second sound of the pulmonary artery. When, however, insufficiency of the aortic valves and constriction exist in the aortic opening, we hear the murmur most distinctly over the aorta. A comparison of the diagram on circulation, page 427, will help much in elucidating these complicated states. All that I have said here of the left ventricle and its valves during its systole and diastole is almost verbally applicable to the right ventricle and its valves. As, however, valvular diseases on the right side of the heart are exceedingly rare compared with those of the left side, and even when present on the right side, they almost always exist to a greater extent upon the left than upon the right side (H. M. Hughes)', I think it best to break off here, so that I may not bring confusion upon, instead of elucidation to the subject. I shall now proceed to speak of those morbid sounds, resem- bling murmurs, but which have nothing to do with the valves of the heart. 1. Anaemic murmurs. "They are ordinarily of the softer kind and resemble the blowing of a pair of bellows, but are sometimes harsh and re- semble the rougher morbid sounds, as that of filing or sawing." (H. M. Hughes. ) They are generally confined to the situation of the aortic or pul- monary valves, or both. They do not follow the course of the large vessels so fully or so frequently as do the murmurs arising from disease of the valves. The}' occur only during the systole of the ventricles; they are not generally heard below the left nipple, because the}' do not originate in the mitral open- ing. They are almost always accompanied with a smart, smacking impulse. AUSCULTATION. 393 They generally disappear for a time, while the individual is quiet mentally as well as bodily, if by that quiet the heart assume a natural impulse; and they are always diminished and generally disappear entirely under suitable treatment. (H. M. Hughes.) The origin of these anaemic murmurs have been attributed: i, to a watery condition, or a diminution of ordinary viscidity of the blood, in con- sequence of which the particles of the fluid are more easily agitated and thus give rise to the vibrations which produce the murmur; 2, to the remarkably quick and sudden contraction of the ventricles, in consequence of which the fluid contents of the cavities are propelled quicker through the arterial open- ings than in health, and thus give rise to greater friction, which produces the murmur, although no actual constriction exists there. (H. M. Hughes.) 2. Venous murmurs, (nun's murmur, top-murmur) are heard in many young persons in the anterior triangular space in which the external jugular vein descends. It is a continuous murmur, and is generally more audible on the right than on the left side. This murmur disappears when the cur- rent of blood is interrupted by pressure upon the jugular vein, by a deep expiration, or by any position of the body in which the head lies lower than the thorax. It is heard loudest in an erect position and during inspiration. It is thought to be in connection with anaemia, but Skoda says that he has found it also in young and quite healthy individuals. 3. Pericardial murmurs. As long as the inner surface of the pericar- dium is in its natural condition, slippery and glistening, the heart moves within it without any sound; just as the two blades of the pleura glide over each other inaudibly as long as they are in a natural condition. Not so, however, wmen this slippery and glistening surface becomes roughened in consequence of inflammation and subsequent fibrinous exudation. Then we hear at once a friction sound, which, according to Skoda, may resemble per- fectly an endocardial murmur. How are we then to distinguish between a friction sound caused in the pericardium and a sound caused within the heart ? Skoda says: "I know no sign by which the friction sounds of the peri- cardium can be distinguished from the internal murmurs of the heart, ex- cepting this — that the internal murmurs correspond pretty exactly to the rhythm and to the natural sounds of the heart; whilst the pericardial friction sounds seem to follow upon the movements of the heart. This distinctive sign is only available when the murmur is somewhat prolonged; if it be of short duration, we cannot determine whether it is endocardial or pericardial." Skoda, p. 253. To this difficulty still 'another maybe added, viz.: the friction sound may also arise from a roughened condition of that portion of the pleura which covers the unattached parts of the pericardium. The sound is pro- duced by the rubbing of the pleura which covers the free portion of the pericardium, either against the thoracic walls or against the surface of the 394 DISEASES OF THE PERICARDIUM. lungs. Being caused by the action of the heart, it coincides with its move- ments as completely as though it had been produced within the pericardium. The murmur thus arising external to the pericardium exactly resembles the murmur arising within it, and here we have no means of distinguishing. The special diseases of the heart I shall arrange under the following heads: i. Diseases of the pericardium. 2. Diseases of the endocardium and its valves. 3. Diseases of the heart muscle itself . 4. Nervous diseases of the heart. I. DISEASES OF THE PERICARDIUM. Pericarditis, Inflammation! of the Pericardium. The internal layer of the pericardium being a serous membrane, like the pleura, its inflammation presents precisely the same anatomical character as that of pleurisy. We find injection, swelling, and exudaton of either a serous or sero-fibrinous, or for the most part fibrinous fluid. In this latter case the fibrin is precipitated upon the walls of the pericardium, and forms net-work -like, villous masses, which have given rise to the name of cor villo- sum or hirsutum. most frequently found in pericarditis complicated with articular rheumatism. During the process of inflammation, sometimes the injected capillaries burst and thus cause a blood}' exudation. When pus globules form in great abundance, the exudation becomes purulent, and, if it undergoes decomposition, it becomes a fetid, discolored, ichorous fluid, as in empyema. In some cases the inflammation does not result in exudation of any kind — pericarditis sicca — in consequence of which adhesions form without any noticeable symptoms. The mere serous exudation is most thoroughly absorbed again, while the fibrinous fluid gives rise to adhesions between the heart and the pericar- dium. A large quantity of this fluid hinders the heart in its movements and pushes it back from the thoracic walls; at the same time it may compress part of the lung and the large vessels. It causes also congestion of the lungs, the brain, and the liver, serous exudation into the lower lobes of the lungs, the pleura, and the membranes of the brain and oedema of the lower extremities. Pericarditis may set in primarily in consequence of external injuries or taking cold; such, however, is very rarely the case; or, secondarily, during the progress of acute rheumatism, which is its most frequent occasion. But it may result also from pleurisy, pneumonia or ulcerative processes of the ribs, vertebrae, oesophagus, stomach, liver, etc.; or it may accompany mor- bus Brightii, tuberculosis, disease of the valves, cancer, intermittent fevers, etc. It occurs, too, in typhus, variola, pyaemia, puerperal and exanthematic fevers. DISEASES OF THE PERICARDIUM. 395 Chronic forms of pericarditis are caused by long-continued mental de- pressions, abuse of spirituous liquors, violent exertion of the body, and chronic, gouty affections. Its Symptoms, if it is a primary affection, or in combination with acute rheumatism, are — i. More or less violent fever, sometimes commencing with chills, fol- lowed by heat, great acceleration of pulse and palpitation of the heart. 2. As in pleurisy, we must consider the stitch or sharp cutting pain in the region of the heart as a characteristic, subjective sign, which is increased by motion, deep inspiration and external pressure. 3. Dyspnoea is present in almost all cases; sometimes to such a degree that the patient is incapable of lying down at all. 4. Cough is sometimes wanting, but in most cases we find a short, dry, hacking cough. Pericarditic Exudation. (After Bock.) Pericardial sac filled with fluid, b. Diaphragm, c. Right lung. d. Compressed left lung. e. Iyiver. /. Stomach. 5. The position of those patients who can lie down is on their left side or on their back. Pericarditis in combination with pleurisy or pneumonia may in some cases not be diagnosticable during its development even by the most careful physical examination. In complication with tuberculosis, Bright' s disease and chronic heart diseases, only careful physical examination will lead to its detection, which is also true if pericarditis sets in during the course of grave blood diseases, such as scarlatina, puerperal fever, etc. Auscultation reveals the heart sounds very weak, sometimes scarcely audible. This weak impulse of the heart's action is characteristic if we find at the same time on percussion the dull heart sound cover a larger space than normal. But the first physical sign which appears (although seldom during the first two or three days of the disease) is the friction sound, pro- duced by the deposition of fibrinous masses upon the smooth pericardial folds. The now roughened surfaces give this friction sound during their continual gliding over each other in consequence of the motion of the heart. It is frequently heard first and loudest over the base of the heart, but may also be 396 DISEASES OF THE PERICARDIUM. heard first and loudest over any other part of the heart; it does not only accompany the heart sounds, but is prolonged beyond them, is interposed, as it were, between them (Skoda), and may occupy the whole duration of the cardiac movement. When the exudation increases largely, it grows weaker, and may disappear altogether, but on the decrease of the fluid, it reappears again. It may also be made audible again in some of such cases, by changing the position of the fluid by causing the patient to sit upright, or to bend his body forwards. Inspection shows in young persons a swelling or bulging out of the pre- cordial region in advanced cases, with a large quantity of exudation. In older persons, where the cartilages of the ribs have become ossified, such enlargement cannot take place. Palpation discovers in the beginning of the disease a stronger impulse of the heart at its normal place; but later this impulse becomes weaker and finally ceases altogether, when the collection of fluid pushes the heart back from off the thoracic walls. When there is a loud friction sound, this becomes noticeable also to the sense of touch, and feels like the purring of a cat. Percussion at first reveals nothing. There must be already a consider- able quantity of fluid exudation before we perceive the natural dull percus- sion sound of the heart spread over a larger circumference; and if the lung happens to be in a position that it covers the filled pericardium, we cannot get a dull sound in spite of even a very large quantity of fluid. At first the exudation is confined to the base of the heart and the origin of the arteries. Here then we have at first to look for an increase of dullness of the percussion sound. Later, the dull percussion sound may increase in the long diameter, down the heart; and if the effusion is very considerable, also in its transverse diameter, so that if, according to Skoda, the pericardium contains as much as two pounds of fluid, the percussion sound becomes com- pletely dull from the second left costal cartilage to the lower border of the thorax, and from the right edge of the sternum to the middle of the left lateral region. Secondary pericarditis of course develops itself differently. Being a mere additional symptom or consequence of, or complication of some other disease, its first onset is hidden by the symptoms of that disease. But, when once developed, its presence must of necessity be indicated by the same physical signs which I have detailed above. Uncomplicated pericarditis is, of course, much more easily cured than when complicated. In the latter case our prognosis has to be based alto- gether upon the nature of that complaint with which it is combined. Therapeutic Hints. Aeon. Chill at the commencement, followed by fever-heat; stitching pain in the region of the heart; impossibility to lie on the right side; great restlessness: frequent sighing and taking a deep breath; feeling of fullness in the chest, dyspnoea; fainting. HYDROPERICARDIUM. 397 Arsen. In consequence of repelled measle or scarlet fever-rash; inex- pressible anguish and restlessness; worse at night; the patient finds no ease in an}' position; flushed face; paralytic feeling in the upper extremities; tingling in the finger; cold perspiration. Bryon. Stitching pain in the region of the heart, preventing motion and even breathing; wants to lie perfectly quiet. Cact. grand. Sensation of constriction in the heart, as if an iron hand prevented its normal movement; acute pains and stitches in the heart; diffi- culty of breathing; attacks of suffocation; with fainting; cold perspiration in the face, and loss of pulse; palpitation when walking, and at night when lying on the left side. Digit. Copious serous exudation, rheumatism; irregular, intermitting pulse; brick-dust sediment in the urine. Iodium. In complication with croupous pneumonia; purring feeling in the region of the heart; violent palpitation, increased from the slightest motion, better while lying perfectly quiet on the back; fainting spells. Kali card. Stitching pain in the region of the heart; swelling between the eyebrows and the upper lids, like little bags; jerking up of the limbs, much frightened when having the feet touched; everything worse about three o'clock in the morning. Laches. Restless and trembling; hasty talking; great oppression; anguish about the heart in rheumatism; irregularity in the beats of the heart. Psorin. Psoric nature; better while lying quietly. Pulsat. The patient weeps easily, is thirstless, often changes position, has a loose, rattling cough, worse on first going to bed; rheumatic pains, which quickly change locality; inclination to looseness of the bowels; sup- pressed menstruation. Rumex. During rheumatism; burning, stinging pain in the left side of the chest near the heart when taking a deep inspiration, when lying down in bed at night. Spigel. When, notwithstanding the use of Aconite, the fever continues and the rubbing sound commences; stitching pain in the chest from the very slightest motion. Sulphur. Palpitation after going up stairs, with shortness of breath; steady pain in the left side through to the shoulders; red lips; sleeplessness; after suppressed itch. Tart. emet. In complication with pleuro-pneumonia. Ver. vir. Faintness after rising from a recumbent position; syncope when walking: relieved only by lying down. Existing complications will no doubt hint to many other remedies: Hepar, etc. Hydropericardium. Dropsy of the Pericardium. The pathological character of this disease consists of a collection of serum without fibrin. A fibrinous exudation never takes place without an 398 DISEASES OF THE ENDOCARDIUM. inflammatory process. The serum is a yellowish, clear fluid; sometimes, if mixed with blood, it is brownish or reddish, and always of alkaline reaction. In renal diseases it contains some urea, and in general icterus the coloring matter and acids of the bile. A small quantity of such fluid is found in most post-mortem examinations. To constitute dropsy of the pericardium, this sac must contain at least several ounces of serum, and it amounts in some cases even to over one pound. When such is the case, the pericardium is dis- tended, is of a dull whitish color, without lustre; the fat upon the heart is gone, and the cellular tissue appears oedematous; the lung becomes com- pressed and the thorax enlarged. Dropsy of the pericardium is generally the consequence of a hydraemic condition of the blood, or of diseases which cause dropsical affections in other parts also, such as chronic affections of the spleen, morbus Brightii, cancer, anaemia, dilatation of the right ventricle, etc. It is also found in consequence of conditions which prevent the necessary oxygenation and free circulation of the blood, as in emphysema, in cirr hosed lungs, in defects of the valves of the heart. Hydropericardium is, therefore, altogether a disease of secondary nature, and its symptoms do not become very prominent, unless a very considerable quantity of fluid collects within the pericardium. Then we observe great dyspnoea, which prevents the patients from lying down; any effort to do so at once causes an attack of suffocation; they have to sit up day and night with their bodies bent forwards. The jugular veins swell and dropsical affections appear also on other parts of the bod}*; first in the lower extremities; then in the genitals; later, within the peritoneum and the pleurae; finally, the dropsical swelling invades the whole bod}*, and the impeded respiration and circulation cause stupor and death. The physical signs are: no friction sound; distention of the precordial region in young subjects; impulse of the heart either absent or weak; weak sounds of the heart ; and dull percussion sound in a wider circumference than the heart alone would give rise to. Therapeutic Hints. Compare Hydrothorax. The leading features will have to be taken from the fundamental disease. H. DISEASES OF THE ENDOCARDIUM. Endocarditis. Inflammations of the endocardium end either in ulcers, in thickenings of the membrane, or in villous formation of the connective tissue, which in course of time undergo further changes. i. The Acute ulcerative form is usually found in the left side of the heart, most frequently affecting the mitral and aortic valves, although the walls of the auricles and ventricles are not exempted. ENDOCARDITIS. 399 At first the lining membrane appears only dirty gray, opaque and dull, but soon shows proliferations in the connective tissue, and a deposition of fibrin- ous masses, which, after softening and crumbling away, leave ulcers on the surface. As the ulceration eats through one lamella of the valves, the lamellae underneath stretch and bulge out by the strain of circulation and cause the so-called Valvular aneurisms, which, when situated on the auriculo- ventricular vhlves, project into the auricles, or when on the semi-lunar valves, into the ventricles; they may enlarge to such a degree, as to form an acute stenosis of the ostium. Ulceration in the ventricles, when complicated with myocarditis, may lead to a so-called Partial cardiac aneurism ; when situated at the septum, may cause perforation of the same and establish a communi- cation between the two ventricles; the particles of the crumbling masses in the left ventricle may be swept into the terminal arteries and valveless veins of the spleen, kidneys, brain or eyes, producing infarctions in these organs, or when arising from the right side of the heart, bring about abscesses from embolism in the lungs. The sj'mptoms of ulcerative endocarditis may be similar to typhoid fever; the heart symptoms are not characteristic. Usually, however, we hear a loud, systolic and occasionally a diastolic murmur, loudest at times over the apex, at other times over the base, and especially in the neighbor- hood of the aortic ostium. Of course, in complication with pericarditis the physical signs change accordingly. For this reason endocarditis may easily be confounded with typhoid fever, for in both the spleen is almost always enlarged, and a roseolar or petechial exanthema is very often present, and frequently accompanied by meteorism. But endocarditis has not the charac- teristic typhoid curve of temperature, exhibits a remarkable frequency of the pulse and is usually found as complication of acute articular rheumatism or in connection with puerperal fever, pyaemia, diphtheria, scarlatina, chronic valvular disease and infectious diseases in general. It is most frequently met with as a complication of acute articular rheumatism. 2. The Verrucose form of endocarditis is also more prevalent on the left side of the heart, and takes its favorite seat on those surfaces of the valves which face the current of the blood; then we see it occur on the chordae tendineae and relatively seldom on the lining of the ventricles. The verrucose products are the fruit of inflammatory changes in the parenchyma in con- sequence of irritation. They consist of proliferations of the connective tissue, and appear either as a mere velvety coating on the smooth valvular surfaces, or amount to opaque spots with wart-like, papillous, knotty and cauliflower-shaped excrescences of a red or gray-red color, firm at the base and soft or jelly-like at their points. Parts of these growths may be driven into the general circulation and form emboli. From the left side the kidneys are the organs most liable to infarction, while in affections of the right heart the inferior lobes of the right lung are most liable to be invaded. Verrucose endocarditis is almost alwa} T s accompanied by pericarditis, and most frequently complicated with rheumatic arthritis; it also has been 400 THERAPEUTIC HINTS TO ENDOCARDITIS. found the offspring of childbirth and pregnancy, of old valvular affections, and of acute exanthematic diseases. Its invasion, during these different affections, generally takes place un- noticed ; because it is quite seldom that the patient complains of pain in the region of the heart when attacked in this way. But once established, we observe the following symptoms: i. Palpitation of the heart, and soft, easily compressible and small pulse. 2. Dyspnoea, which is the greater the more the respirator}' organs be- come involved in the morbid process, causing quick and unequal respiration, fainting, or congestion of the brain, with headache, delirium, sleeplessness, sopor. 3. Higher degrees of endocarditis are frequently attended by icterus. Its physical signs are the following: 1. The normal sounds of the heart are stronger, and audible over a larger space than natural — in the beginning of the disease. 2. In place of the first tick we hear, at the apex of the heart, a noise, which shows that the mitral valves have become diseased. 3. The second tick of the pulmonary artery is increased in consequence of the insufficiency of the mitral valves, causing an overflow in that artery. 4. Percussion at first reveals nothing, but at a later period yields a dull sound over a greater space than natural, because of the dilatation of the right ventricle in consequence of impeded circulation. Both forms of endocarditis may result in recovery, but generally leave diseases of the valves, either thickening, adhesion, or perforation, and in consequence hereof, dilatation and hypertrophy of the heart. Therapeutic Hints. Compare what has been said under Pericarditis. The characteristics of the remedies acting upon the heart must be applied here to. In addition, I shall mention only — Spigel. The most important; waving palpitation, not synchronous with the pulse; pulsating and trembling carotids; purring feel over the heart; rheumatism. Allium. Rheumatic pains, previously wandering from joint to joint, become fixed in the region of the heart and cause great anxiety; the patient has to sit perfectly quiet in an upright position; palpitation, with irregular, intermitting pulse and short breath, feeling as though the heart ceased beat- ing for a while, and then at once one hard thump is felt. Bismuth. Has not yet been tested in practice, but its pathological effects seem strongly to indicate it; the}' are: inflamed spots in the endocardium, black coagulum in the heart. Iodium. According to Kafka, if Spigel. has failed to act favorably during twenty-four to thirty-six hours. Kali card. Where, in place of the first tick, a blowing noise and a louder INSUFFICENCY OF THE MITRAL OR BICUSPID VAEVE. 4OI second tick of the pulmonary artery is heard (Kafka); where there conse- quently exists already a stagnation in the pulmonary circulation. Spo?igia. In consequence of endocarditis, attacks of severe oppression and pain in the region of the heart; all symptoms worse from lying with the head low; inability to lie down at all. In consequence of Endocarditis originate diseases of the valves, which consist either in — 1. Insufficiency of the valves; or — 2. Constriction of the valvular openings. 1. Insufficiency of the Mitral or Bicuspid Valve. Mostly in consequence of endocarditis the valves become shortened and thickened, sometimes by flat calcareous substances stiffened and the fine fringes on their free borders obliterated; at other times the valves are torn from the chordae tendineae; seldom are the chordae tendineae grown fast to the wall of the ventricle; not unfrequently the capillary muscles are in a state of callous degeneration. There are also characteristic changes of other parts of the heart attend- ing this disease, namely: always a dilatation and hypertrophy of the left auricle, of the pulmonary veins and artery and of the right ventricle and auricle. In consequence of these defects of the mitral valves, the blood regurgi- tates during the systole into the left auricle, thus checking the normal flow of the blood through the pulmonary vein. This causes an accumulation of blood in the lungs, in consequence of which the blood is pressed backwards into the pulmonary artery, causing here a widening of its volume, and, in consequence, a louder second tick. This increased second tick of the pul- monary artery is the most characteristic sign of insufficiency of the mitral valves. The check of circulation in the lungs causes further dilatation and hypertrophy of the right ventricle, because it requires greater power to force on the accumulated and obstructed blood. By-and-by, however, this increase of power in the right ventricle diminishes again, and thus the veins of the lungs become permanently overcharged with blood; the same result takes place in the venae cavae, and, in consequence, the liver, spleen and kidnej-s grow hyperaemic, which finally ends in dropsy. This stagnation of blood in the lungs causes also dyspnoea, bronchial catarrhs, periodical haemorrhages from the lungs, passive hyperaemia of the brain, an undulation of the jugular veins, cyanosis, jaundice and dropsy, which usually commences in the lower extremities growing gradually upwards. The characteristic physical signs are the following: 1 . In place of the S3^stolic sound we hear a murmur at the point where the apex strikes at the thoracic wall. 2. The diastolic of the pulmonary artery is much increased. 26 4-02 CONSTRICTION OF THE LEFT AURICULO-VENTRICULAR OPENING. 3. The dull percussion sound of the heart extends further in breadth, to the right, on account of the dilatation of the right ventricle. 2. Constriction or Stenosis of the Left Auriculo-Ventricular Opening. It originates mostly in this way — the mitral valves shrink and grow harder and narrower, or that their points grow together, or that the chordae tendineae adhere to the valves, or that the valves become covered with cal- careous substances. This state of things naturally produces at the same time insufficiency of the mitral valves and therefore we find in the great majority of cases stenosis complicated with insufficiency. The other changes in the heart are like those of insufficiency; the left ventricle, however, grows smaller and the aorta narrower on account of the diminished flow of blood through them. As in this case the narrowed and roughened orifice does not allow the blood to enter freely into the left ventricle, its passage through this opening is perceptible to the ear — we hear during the diastole a noise at the apex of the heart. At the same time the narrowed opening prevents the normal quantity of blood from passing through into the left ventricle, which causes an accu- mulation of blood in the left auricle; hence, a check of flow in the pulmonary vein; hence, an overfilling of the lungs; hence, a greater backward pressure into the pulmonary artery; and hence all the consequences which I have detailed under the head of defective mitral valves, only much more rapid and much more intense. Its characteristic physical signs are the following: 1. We hear at heart's apex a presystolic murmur. This noise is some- times similar to the purring of a cat, so that it even may be felt. 2. The diastolic sound of the pulmonary artery is louder. 3. The dull percussion sound of the heart extends further to the right, on account of dilatation and hypertropy of the right ventricle. In cases where the mitral valve is defective and the left auriculo-ven- tricular opening constricted at the same time, when we hear a noise during the systole as well as before it. The sound of the aorta is mostly weak. The pulse is in most cases weak, not corresponding to the violent palpitation of the heart. 3. Insufficiency of the Aortic Valves. As soon as these valves do not shut tightly, the blood which has been driven during the heart's systole into the aorta, rushes, during its diastole, back into the left ventricle, causing an abnormal quantity of blood to collect there. To get rid of this the left ventricle has to make greater efforts to rid itself of it: and, in this way, it gradually grows wider and thicker — eccentric hypertrophy of the left ventricle. By this increased capacity of the left ven- tricle the consequences of the defective aortic valves become, so to speak, counterbalanced. For a good while it prevents an overfilling with blood in CONTRACTION OR STENOSIS OF THE AORTIC OPENING. 403 the pulmonary veins; we observe no slowness of pulse, no decrease of arterial blood, no cyanosis or dropsy. For, although the defective valves retard the circulation and tend to make the blood venous, the hypertrophy of the left ventricle hastens the circulation and compensates for it. Therefore, we find that patients thus affected suffer at first comparatively little; the most frequent signs are: congestion of the brain, which manifests itself as dizziness, noise in the ears, flickering before the eyes, headache, hallucinations, red face, etc., as a consequence of the hypertrophied left ventricle. Later, however, the increased capacity of the left ventricle is not suf- ficient any longer to overcome the consequences of the defective valves, and thus all the symptoms of impeded circulation, as described above, commence to set in. The characteristic physical signs of defective aortic valves are the following : 1. Diastolic murmur of the aorta, in consequence of the regurgitation of blood into the left ventricle during the heart's diastole. 2. Greater extension of the dull percussion sound in the heart's long axis and to the left, on account of the hypertrophy of the left ventricle. 3. Arched appearance of the region of the heart for the same reason. 4. The impulse of the heart's apex is felt lower down and outside of the nipple line. 5. Strong, jumping pulsation of the carotid arteries. 6. Pulsus celer et alius; strong, full pulse, with sudden collapse. Traube adds: 7. The sounding of the crural artery. 8. The rough systolic after-noise in the carotids. 9. The want of the systolic sound at the heart's apex. 4. Constriction or Stenosis of the Aortic Opening. The disturbance of circulation is, in such a case, of course, still greater than by mere defect of the valves; and therefore the. patient soon shows symptoms of deficient circulation; such as paleness, small, thread-like pulse; fits of fainting; coolness of the extremities; anaemia of the brain. At a later period the veins become overcharged with blood, and in consequence we find the patient suffer with dyspnoea, cyanosis, and all the other symptoms of heart disease. Its characteristic physical symptoms are: 1. Systolic murmur, which is often heard in the carotid. 2. Dull percussion sound, somewhat extended in the direction of the longitudinal axis of the heart, in consequence of dilatation and hypertrophy of the left ventricle. 3. Apex lower down and outside of the nipple line. 4. Pulse small, wiry, irregular and thread-like. In case there exists at the same time a defect in the aortic valves, we may also hear a diastolic noise. 404 IXSIFFICEXCV OF THE TRICUSPID VALVES. 5. Insufficiency of the Tricuspid Valves. This defect allows the blood to regurgitate into the right auricle, when the heart contracts. Thence the retrograde stream of blood goes into the venae eavae and jugular veins; hence we feel a pulsation of the jugular vein, synchronous with the arterial pulse. This retrograde motion of the blood causes overfilling of all the veins, and its consequent results are hyperaemia, cyanosis, hydrops, etc. Its characteristic physical signs are: 1. Systolic noise in the right ventricle. 2. Swelling and pulsation of the jugular veins. 3. More extended dull percussion sound in the direction of the breadth of the heart on account of its right auricle having become enlarged and hypertrophied . This complaint is generally a secondary affection, due to dilatation of the right ventricle, in consequence of diseases of other valves, and then, of course, is attended by all the above-mentioned disturbances and signs. 6. Stenosis of the Right Auriculo-Ventricular Opening, 7. Insufficiency of the Pulmonary Valves, 8. Stenosis of the Pulmonary Opening Are, uncomplicated, of such rare occurrence, that even Skoda did not observe them on the living. Skoda, p. 371. The Treatment of all these different valvular affections has to be adapted to each single case, and it is not the diseased valve which points to any par- ticular remedy, but the individual symptoms by which the whole morbid process manifests itself. Still I might give some general dietetic rules, which are of great importance for'the treatment of those different affections. Patients in whom we find symptoms of congestion of the brain or chest ought not to eat much animal food; must avoid all sorts of stimulants, and especially coffee and all kinds of spices. Mental excitements and depressions are alike hurtful to them; and neither too high nor too low a degree of tem- perature is advisable. Patients, however, in whom anaemia and debility prevail, ought to eat animal food and drink beer or wine; ought not to overexert themselves, and ought to have all the fresh, pure air they can get. Aeon. Usual symptoms of great restlessness, anxiety, fear of death, stitch-pains, haemoptysis, with hacking cough, etc. Act. vac. Catching pain in region of heart, worse on moving or bending forward, preventing inspiration; palpitation and faintness; sexual disturb- ances in females. Arnica. Heart feels as if bruised; palpitation from any exertion. STENOSIS OF THE RIGHT AURICULO- VENTRICULAR OPENING. 405 Arsen. Precordial anxiety and oppression; palpitation at night, with anguish, cannot lie on back; after suppressed eruptions or foot-sweat. Cact. grand. Livid complexion, sunken face; difficult breathing, worse from exertion; constant pain, darting and cutting from region of heart to the left shoulder and down the arm, worse from damp weather or any emotion; oedema, especially of left hand and legs up to the knees; icy-cold feet; inter- mittent pulse. Insufficiency of mitral valves. Calc. card. Trembling pulsation of the heart, worse after eating, at night with anguish; inclination to take deep breaths; menses too early and too profuse. Digit. Irregular, intermittent beats of the heart; very slow when keeping still, but easily accelerated by any exertion; feeling at times as if the heart stood still, with great anxiety, oedema of the lungs; bluish-red face, or death-like appearance. Ferrum. Chlorotic symptoms; congestion of the head; spitting blood; palpitation, better from slowly moving about. Gelsem. "Fears that unless constantly on the move her heart will cease beating. ' ' Kali hydr. Darts in the region of the heart when walking; after mer- curial poisoning; after repeated attacks of inflammation of the heart. Laches. Restless, trembling; anxiety about the heart; hasty speech; suffocating on lying down; weight on the chest; heart feels constricted; numbness of the left arm. * Lauroc. Persistence of the ductus Botalli (arterial duct), in conse- quence of which there exists a cyanotic discoloration of the face, fingers and feet, worse from external cold; dyspnoea; acute or dull pain in the heart, worse from a deep inspiration. Heart's action irregular; blowing sound on the heart's apex. (Bibliotheque homceopathique, September, 1881.) Lil. tigr. Heart feels as if grasped, with pain and heaviness of left mamma to scapula; pulsations over whole body, and outpressing in hands and arms, as if blood would burst through the vessels; fluttering; awakens her at night, with cold hands and feet covered with cold sweat, with sharp, quick pain in left chest. Lithium. Soreness about the heart, worse stooping; pain in the limbs; finger-joints tender and painful; sleeplessness. Natr. mur. Irregularly intermitting pulsation; fluttering of the heart, with weak, faint feeling and necessity to lie down; coldness of hands and feet; numbness of hands relieved by rubbing; cutting pain in the urethra after micturition; scanty menses. Phosphor. Congestion of the lungs; tightness across the chest and tight cough; spitting of blood; palpitation worse after eating, or mental emotion; yellow spots on the chest; painless diarrhoea. Psorin. Stenosis of left osteum venosum; purring in the region of the apex; cyanotic lips; dyspnoea and shortness of breath when walking in open air; better when lying down. 406 HEART-CLOTS. Rhus tox. Palpitation worse during rest; pain from region of the heart into left arm, with numbness; rheumatism. Spigcl. Stitches about the heart; anxiety and oppression; can only lie on right side, or with head very high; least motion aggravates. Spongia. Violent palpitation, awakens after midnight with a sense of suffocation; loud cough, great alarm, agitation, anxiety and difficult breath- ing; violent gasping respiration; pain in the heart. Zincum. Cyanotic face; great dyspnoea; drops}* of the lower extremities, ascites and anasarca of the upper extremities. Dilatation and hypertrophy of heart; insufficiency of mitral valve; urine scanty with albumen; appetite tolerable; bronchial catarrh. (Dr. A. Pfander. ) Besides compare : Anac, Iodium, Kali carb., Lycop. , Xaja, Plumbum, Pulsat., Sepia, Sulphur, Veratr. Heart-clots. Fibrinous coagulations, especially in the right ventricle and auricle, are very frequently found on post-mortem examinations. If they have originated recenth', either soon after death or during death-struggle, they are of a whitish-yellow, generally translucent appearance, frequently jelly-like in consistency, moist and shiny, as if cedematous, and infiltrated with blood on their lower surface; they may extend into the vessels and be drawn out like strings or cords, and aan easily be separated from the subjacent parts without injury to either; they are the result of the natural coagulation of the blood during the retardation and final cessation of its current. But clots ma}* also form during life, either in consequence of a slacken- ing in the current of the blood from some obstruction or loss of propelling force; or in consequence of gradual deposition of fibrine on roughened sur- . faces produced by vegetations or inflammatory processes of the inner wall of the heart; or in consequence of fibrinous coagula from distant portions of the vascular system, serving as nuclei for more extensive fibrinous clots; or perhaps also in consequence of an increase of fibrine in the blood during certain diseases, or a greater tendency of the blood to coagulate. These clots, called True polypi of the heart, are dull in appearance, dry, rotten, friable, of a whitish-yellow, or gray color, consist of various layers of different color and contain at times deposits of lime salts and in their centre a purulent fluid. They are of various sizes, and usually firmly attached to the inner walls of the heart; they are found particularly at the apex of the left ventricle and in the appendices of the auricles. The Symptoms of this affection are not characteristic enough to distin- guish it from other heart affections, with which it may be complicated. Heart- clots may occasion sudden death in patients previously in apparent good health. In other cases they may produce dyspnoea, cyanosis, or pallor of the whole surface, expectoration of bloody sputa, coldness of the extremities, DISEASESES OF THE HEART-MUSCLE. 407 stupor, convulsions, loss of consciousness, death. The heart's action usually is slow, seldom irregularly violent. Dropsical effusions may occur if the patient survives long enough. The physical signs which are occasioned by the clots are of no diagnostical value. The presence of heart-clots may, therefore, be guessed at but cannot be proven positively. m. DISEASES OF THE HEART-MUSCLE. Myocarditis, Carditis, Inflammation of the Heart-muscle, Is found always in connection with peri- or endocaditis; and then its seat is generally the left ventricle. The substance of the muscle appears yellowish, sometimes fatty degenerated. Its most frequent occasion is acute rheumatism of the joints, but it has also been observed in the course of puerperal and exanthematic fevers. There are no characteristic signs of this complaint, because it is almost always mixed up with peri- or endocarditis. Mild forms pass over without any consequences; but if it extends to the formation of abscesses, it may cause widening of the heart-muscle (partial aneurism), or bursting of the heart-muscle, and consequent sudden death. When the abscess discharges into the ventricle it causes the formation of emboli, with their consequences. Hypertrophy and Dilatation of the Heart. Hypertrophy consists of an increase in mass of the heart-muscle, or a thickening of its walls, whereby the inner cavity becomes narrower: this is the so-called concentric hypertrophy; or the heart-muscle is increased in Hypertrophy of L,eft Ventricle. a. Heart elongated. b. Liver. c. Stomach. d. L,ungs. Eccentric Hypertrophy of Right Ventricle. a. Heart widened. b. Left lung. c. Right lung. d. Enlarged liver. e. Stomach. f. Enlarged spleen. thickness, and the inner cavity widened at the same time: this is the so- called eccentric hypertrophy. When, however, the inner cavity is widened, and the heart-muscle at the same time has grown thinner, it is called dilatation of the heart. 408 THERAPEUTIC HINTS TO DISEASES OF THE HEART-MUSCLE. The most frequent of these three forms of altered conditions is eccentric hypertrophy. But it is not always the whole heart that is enlarged or dilated; it is generally only one-half of it that is thus affected. A hypertrophied left ven- tricle makes the heart longer, reaching further down in the left thorax, while an eccentric hypertrophy of the right ventricle makes the heart broader, so that it reaches further over into the right thorax. Both, hypertrophy and dilatation, are most frequently caused by dis- turbed circulation, in consequence either of diseases of the valves or diseases of the arteries, like aneurism, or obstacles in the capillaries in the lungs. Also pericarditis and myocarditis, mental excitements, strong coffee, tea, and spirituous liquors have been found exciting causes of this complaint. Eccentric hypertrophy of the left ventricle manifests itself by an increased impulse of the heart, either heaving in character or jarring the chest- wall, more or less towards the left of the nipple-line and further down, in some cases even as far as the seventh and eighth intercostal space; it is an enlarge- ment of the heart in its long axis, and causes sometimes an intensification of the sounds, especially of the second sound in the aorta, sometimes a metallic clink, increased pulsation of the carotids, murmurs in the larger arteries and also in the small vessels far removed from the heart, and a pulse perceptibly larger in volume under the finger. "In hypertrophyof the right ventricle, the heart's impulse is not increased, except occasionally near the lower portion of the sternum; the apex beats further to the left, but not lower down. The area of dullness is increased in breadth, and the second sound in the pulmonary artery is accentuated." 1 ' In total hypertrophy we find a combination of symptoms corresponding to the hypertrophy of the ventricles. It is seldom, however, that w 7 e can succeed in declaring with accuracy which half of the heart is the more enlarged." (Schroeter. ) Dilatation is found more frequently of the right than of the left ventricle. The impulse of the heart is, as a rule, weaker than normal. There follows retardation of circulation, and consequently dyspnoea, cj^anosis and dropsy. Pulsation of the veins of the neck are characteristic to a dilatation of the right auricle. Therapeutic Hints. Compare what has been said of the different affections of the heart. As hypertrophy is more or less a consequence of the one or the other, tig char- acteristic indications of the different remedies there described must also fit here. I have only to add: Arsen. Dilatation of right ventricle, with swelling of legs and vertigo; scanty urine without albumen. Plumb, ac. Stitch in the region of the heart during an inspiration, with anxiety; heat and redness of the face; rushing of blood in the region of the heart during a rapid walk; anguish about the heart, with cold sweat; palpitation of the heart. FATTY DEGENERATION OF THE HEART. 409 Post-mortem, after poisoning, has shown -that the serous coat of the pericardium is lined with a layer of reddish-gray, fine villous, meshy, firm, exuded lymph. The heart is more than double its natural size. The wall of the left ventricle is more than an inch thick. Kalmia lat. After rheumatism; hypertrophy; palpitation; dyspnoea; pain in the limbs; stitch-pain in the lower part of the chest; prosopalgia on right side. ■ Fatty Heart and Fatty Degeneration of the Heart. Under Fatty heart is understood an accumulation of fat in the sub- pericardial connective tissue, at the apex, in the ventricular furrows along the course of the vessels, at the base around the junction of the auricles and ventricles, at the origin of both the great vessels, and at times embracing the whole heart like capsule of fat. By its spreading along the course of the fibres of the connective tissue in between the muscular bundles it causes the latter to atrophy and appear as thin pale stripes and layers. It is usually accompanied with a simultaneous deposit of fat throughout the system, espe- cially in drinkers. The Fatty degeneration of the heart takes place in the primitive bundles of the muscular fibres themselves; they appear cloudy and their transverse striae disappear; the heart substance thereby becomes pale and yellowish in color, and its texture flabby and friable. It may be acute and chronic. Its Causes are: various chronic diseases, protracted suppuration, great loss of blood, tubercular and cancerous cachexia, severe forms of syphilis, profound anaemia, and also diseases of the heart itself, such as pericarditis, endocar- ditis, valvular lesions, chronic parenchymatous myocarditis. Its acute form occurs after puerperal, typhoid, remittent and exanthematous fevers, after yellow atrophy of the liver and Bright' s disease, also in consequence of poisoning with phosphorus, mineral and vegetable acids and alcohol. The Symptoms of this disease are in no way very characteristic. Its acute form is usually obscured by the attending primary disease, and a de- posit of epicardial fat, which leads to atrophy of the muscular tissue, cannot be distinguished from the true fatty degeneration. Still its occurrence, es- pecially in advanced age, in corpulent people, its usually feeble impulse and pulse, its occasional attacks of dizziness and fainting, the presence of the arcus senilis may, by a careful exclusion of all other diseases in which simi- lar symptoms occur, lead to a correct diagnosis. Both forms may exist for many years if they act only partially destruc- tive to the heart-muscle, or are kept in check by judicious treatment; death may occur from paralysis or rupture of the heart. Therapeutic Hints. An undue accumulation of fat should be prevented by a judicious diet, avoiding fat meat, butter, milk and such articles which consist principally of 4IO NERVOUS AFFECTIONS OF THE HEART. starch and sugar. Allowable are lean meats, fish, vegetables. Of drinks, malt liquors should be forbidden, while red wines, claret and the like mod- erately used ma\- be of benefit. Water is the safest drink. In case of syncope an alcoholic stimulant may be of use, and for the spells of dizziness, the stooping with the head low down between the knees has been found of great benefit, because it helps mechanically to bring a sufficient quantity of blood to the brain, which the weakened propelling force of the heart alone is not capable of doing. For the same reason in case of syncope the head should be put low. Among the remedial agents we ma}' especially turn our attention to remedies that have proved beneficial to persons in whom a tendency of growing fat was manifest, e. g., Arsen., Calc. carb., Ferritin, Sulphur. Arnica. Recommended by Kafka. Aur. niur. Has relieved when there was a peculiar hacking cough with weak impulse, also where a pain existed as if from angina pectoris attended with blood-spitting. Digit. Where there is slow or irregular action of the heart. Phosphor. Produces all the symptoms of fatty degeneration in different parts of the body. IV. NERVOUS AFFECTIONS OF THE HEART. Nervous Palpitation of the Heart Is an increased action of the heart without any detachable organic lesion of that organ. The heart's activity is accelerated by irritation of the ganglia which we find imbedded in its substance; by irritation of the cardiac branches of the ganglion stellatum, w 7 hich take their origin from fibres of the cervical por- tion of the sympathetic; by irritation of the nerve fibres which originate in the medulla oblongata, run down the spinal cord, pass out from the cord with the spinal nerves and become entwined with the sj T mpathetic; and by irritation of the sympathetic in general, causing a contraction of the vessels, and thereby an increased blood pressure in the aortic system with conse- quent increased labor of the heart. These are the exitor nerves of the heart's activity; its restraining or inhibitor}' forces rest in the pneumogastric and its ramifications. An irritation of the vagus slackens the movements of the heart in frequency, but a division of the vagi increases this frequency for the reason that then the exitor nerves have no restraining power to over- come. The blood too, as regards its quantity, as well as its quality, has a powerful influence on the action of the heart. The Special Causes of palpitation are mental excitements of all kinds, such as fear, joy,, anger and the like; diseases of the brain and spinal cord of various kinds, amongst them: hyperaemia and inflammation of these THERAPEUTIC HINTS TO NERVOUS AFFECTIONS OF THE HEART. 411 organs, psychoses, hypochondria, hysteria, exhaustion from protracted night- watching, or venereal and other excesses; diseases of the abdominal cavity, such as accumulation of gas in the intestines, worms, gall-stones, renal cal- culi and affections of the genital apparatus; partial hyperaemia from sup- pressed menstrual or haemorrhoidal flow; chlorosis and anaemia, and first stages of consumption, gout and different drugs, especially alcohol, coffee, tea and tobacco. Nervous palpitation of the heart is at times attended with dyspnoea, dis- tress and even pain in the chest, with throbbing of the carotids, flushing of the face, or (oftener) with pallor and cold sweat, with dizziness, faintness, and specks or flashes of light before the eyes. Some persons cannot lie down, must sit up, or cannot lie on the left side. Auscultation often reveals the first sound increased and of a metallic quality; " the second sound is wanting only in cases of tremendous acceleration of the heart's movements, where the heart has not had time fully to complete its diastole." (Schroeter. ) After the attack the absence of murmurs, or of enlargement of the heart, establishes its Diagnosis. The presence of a diastolic murmur excludes the diagnosis of a simple nervous palpitation, because such murmurs never occur without organic changes in the heart. Its Prognosis depends entirely on the nature of the underlying cause; if that is removable, its effect will cease. In old people with atheroma of the arteries, it may end with apoplexy. Therapeutic Hints. Aeon. In young subjects; after fright; after wine. Arsen. After suppressed herpes circinatus and suppressed perspiration of the feet. Aurum mur. Palpitation, sleeplessness, depression of spirits, with thoughts of suicide, constipation. Motion, wine or beer have no influence. Asaf. In women, after suppressed discharges, or bodily exertions, with small pulse; breathing not oppressed. Be Had. With congestion of the head. Benz. ac. Worse at night and when lying; alternating with tearing rheumatic pains in the extremities. Cad. grand. Palpitation is preceded by rumbling in the stomach; pains in shoulders and arms; change of life. Calc. carb. After suppressed eruptions and pimples on the face; onan- ism. Cold lower extremities; vertigo on going up stairs, or up a hill; bloat- ing in the pit of the stomach; craving for boiled eggs; copious menstruation. Camphora. When attended with coldness of the skin; cold extremities; pale face; and sudden oppression of breathing. China. Great weakness from loss of vital fluids; long-continued nurs- ing. Coccul. Tremulous palpitation from quick motion and mental excite- ment with dizziness and faintness. 412 AXGIXA PECTORIS. Coffea. After excessive exaltation, joy, surprise. Digit. Attended with apncea, danger of suffocation; yellow and blue face, worse from motion, from moving the arms. Ferrum. Anaemia; throbbing in all the blood-vessels; soft bellows- sound at the apex, with anxiety in chest and heat rising from pit of stomach; with fear; after bodily exercise; also must move about, can neither sit nor stand. Graphit. Amenorrhcea; pimples on the face about the menstrual period. Kali card. Throat feels as if squeezed, as if the lungs came in the throat; stitch-pain and anxiety in pit of stomach and through the chest; pale grayish color of the face; dizziness in walking; cold feet; scant}' menses. Merc. sol. Wakes with nervous trembling; thumping of the heart and agitation as if he had been frightened; weakness at the heart as if dying. Moschus. When combined with hysterical symptoms. Nux mosch. Paroxysms after midnight, as if the heart were stopping, and then beating violently, with loud belching; better from drinking hot water and keeping warm; must walk about. Hysteria. Nux vom. After coffee, wine, liquors, spices. Nab . mii?\ Fluttering, long-standing chlorosis, with torpid skin and suppressed menses. Nitr. ac. When caused hy the slightest mental excitement. Opium. After alarming events, causing fright, grief, sorrow, etc. Phosphor. Dyspnoea, tightness across the chest, great weakness, and after any little mental excitement; violent hammering in the chest, aggra- vated by motion, benumbing all over. Phosph. ac. In children and young persons who grow too fast; after self-abuse, long grieving. Pulsat. Young girls during the time of puberty; from suppressed menses. Rhus tox. Always worse when being quiet. Secale. With profuse menstruation of a watery discharge; after sexual excesses; comes in paroxysms with spasmodic shocks from right side of chest into right arm and leg; coldness and numbness of right hand and stinging in fourth and fifth fingers; worse at night, after each meal; better in open air. Sepia. Tremulous, intermitting pulsation; suppressed menstruation. Silic. Always after quick or violent motions, such as playing ball, etc. ; panaritia. Thea. After exciting talk and mental exertions, with sleeplessness. Ver. alb. Headache, nausea, vomiting, diarrhoea; bleeding of the nose occasionally; cold perspiration on forehead. Angina Pectoris, Stenocardia, Is characterized by: " Pain in the region of the heart, occurring in parox- ysms, which usually radiates over the left side of the thorax and the left THERAPEUTIC HINTS TO ANGINA PECTORIS. 413 arm, more rarely over both sides and arms; the pain is associated with pecu- liar sensation of anxiety and constriction, and often also with other motor, vasomotor and sensitive disturbances." (Eulenburg. ) It is often complicated with organic diseases of the heart, such as: faults in the valves, or fatty degeneration of the heart, or atheromatous processes in the aorta, or ossification and contraction of the coronary arteries. In its real nature, however, it is a neurosis and may be classed according to its symptomatology, with the visceral neuralgias, including cardialgia, colic, hysteralgia, etc. For this reason it may be divided: 1. In a Ganglionic angina pectoris, when there is either an irritation of the excitomotor nerves with acceleration of the pulse, or a paralysis of the same with retardation of the pulse. 2. In a Regulator angina pectoris, when there is either an irritation of the vagus with retarded but full and hard pulse, increased force of impulse of the heart, sometimes a temporary arrest of the same and disturbance of phonation and deglutition; or, more rarely, a paralysis of the vagus with acceleration of the pulse. 3. In a Reflex angina pectoris, when there is a reflex neurosis of the vagus from diseases of the abdominal organs with the symptoms of irritation of the vagus. 4. In a Vaso angina pectoris, when there is either an irritation of the vasomotor nerves which run in the sympathetic, with contraction of the vessels and increased pressure causing arterial anaemia, paleness and coldness of the skin and but little acceleration of the pulse, if any; or, more rarely, a paralysis with opposite symptoms. These principal t}'pes will, in given cases, not always be so clearly ex- pressed, that a recognition or distinction between them could be called an easy matter; the great variability of the circulatory symptoms during an attack of angina pectoris, on the contrary, hints to the possibility that there exist manifold complications between these diiferent types. Of greater prac- tical importance, however, is it to find out whether these attacks be com- plicated, as they often are, with an organic disease of the heart, or of an abdominal organ, or whether they be a pure neurosis. If the latter, the prognosis is more favorable than in the case of such complications where it entirely depends upon the nature of the latter. Therapeutic Hints. B. T. Blake advises the patient on the advent of an attack to take a deep inspiration, and if possible to hold the breath; to use no tea, tobacco, etc., and to avoid all unusual exertions or violent emotions. Kafka gives the following hints: Aur. mur? Where there is hyperemia in consequence of stagnation of blood in the heart. Glonoin? As an intercurrent remedy to prevent the orgasm from get- ting accustomed to the influence of Aur. mur. 414 THERAPEUTIC HINTS TO AXGIXA PECTORIS. Agar.'' In the gastralgic or spasmodic form. Kali curb. When Agar, seems to lose its favorable influence; in other cases, however, Card, veg., or Lad. vir., or Lycop., are better indicated than Kali carb. Sambuc} Where the pressure proceeds from the spine; in individuals formerly fat and robust and now emaciated in consequence of mental emo- tions or sexual indulgence. Phosphor;' As an intercurrent remedy, if the pressing pain is worse under the sternum. Petrol. 7 ' If the pressing pain is worse between the shoulder-blades. Kali carb. Is likewise indicated in this form, either alone or in alter- nation with the above. This change of remedies is best resorted to after eight or twelve days, if improvement seems to come to a standstill. Chin, sidph. Where marasmus is a prominent symptom. So may also Phosphor., or Cuprum, or Ipec, or Veratr., be indicated. Arsen., Laches., Chin, ars., are indicated when dropsical symptoms, with venous hyperaemia and cyanosis make their appearance. Nux vom., Carb. veg., are important when there is loss of appetite and accumulation of £as in the bowels. &' The following remedies have also proved beneficial: Aeon. Anxious restlessness with fear of death; general and local tingling. Amy I. 7iitr. Arnica. Bruised pain in region of heart; fatty degeneration. Arsen. Anxious restlessness with great weakness; great thirst, but drinks little at a time; great oppression; attacks worse after midnight; worse from motion. Cact. grand. Suffocating constriction at throat, with full, throbbing carotids; wants to lie perfectly quiet on the back; mental or physical exer- tion causes palpitation; attacks come on also in sleep with anxious and frightful dreams. Fear of some organic lesion of the heart which will cause sudden death. Coca. A girl, climbing a mountain, was seized with an attack and be- came quite cold. (Richter. ) Cuprum. Attacks from excitement and exertion; slow pulse. Digit. Indescribable deathly anguish; death-like feeling in pit of stomach; vertigo and fainting. Pulse feeble, irregular, slow, intermitting; heart's action more vigorous than pulse. Diosc.vill. Neuralgic pain in stomach ; cannot speak; laborious breath- ing; sudden severe pain in middle of sternum, extending to both arms and hands; cannot move; cold, clammy sweat all over; impulse very feeble; pulseless. (F. E. Brown.) Hcpar. When after the attack: dyspnoea; dry, nervous cough all night; pain in neck; faintness and inability to recline. DISEASES OF THE AORTA. 415 Laches. Choking constriction and rising in the throat; worse after sleep. Lact. vir. Tightness and oppression of the chest waking from sleep; feels as if suffocating, must get out of bed. Lauroc. Suffocation and gasping for breath; violent pain in stomach with loss of speech; eructations tasting of bitter almonds; cold, moist skin; convulsions of the muscles of the face. Naja trip. Similar to Laches. Ox. ac Violent irritation of the alimentary canal; costiveness; diffi- culty of breathing; jerking inspiration, and sudden and forced expiration, as though the patient made a sudden effort to relieve himself of intense pain by expelling the air from the lungs. Oppression of the chest, especially towards the right side; pain on expiration; sharp, darting or lancinating pains in the heart and left lung, also in the arms; jerking pains like short stitches, con- fined to a small space, lasting for a few seconds. Numbness and weakness in back and limbs; peculiar numbness of whole body, approaching to palsy; coldness and complete loss of power of motion in the limbs. Movement ex- cites and aggravates pain. Periodical remission for some hours or days. After other remedies had failed. (P. Dudley.) Phytol. Pain goes to the right arm, or right side. Rhus tox. Pain extending to the left arm; painful stiffness all over, worse in rest. Spigel. Exceedingly sharp pain worse from any motion; frequently indicated; also in complication with other heart affections. Spongia. Suffocating spells at night; worse with head lying low; has to sit up. Tabac. Neuralgia up into the neck; pain between the shoulders; pulse small, irregular, imperceptible; lividity of the skin; features drawn. Deathly nausea with cold perspiration. Ver. alb. Periodical attacks of crampy pain in left chest; or cutting pain with excessive agony, extending to the shoulders; general prostration, skin cold and clammy. To all these may be added for further consideration: Amm. carb., Amy I. nitr., August., Apiol, Arg. nitr., Act. rac, Bellad., Bryon., Cinchona, Caustic, Hydr. ac, Ipec, Juglans ci?i., Moschus, Sepia, Stramon., Sulphur and Tar ant. V. DISEASES OF THE AORTA. Aneurism of the Thoracic Aorta. Aneurism means a dilatation of a short piece of an artery forming a kind of sac at that place. Such dilatations are more frequently found in the aorta ascendens than in the aorta descendens. It can be diagnosticated only when it reaches the exterior thoracic wall. In such a case it renders that part of the chest perfectly dull on percussion and more resisting to the touch. 41 6 INFLAMMATION OF THE DIAPHRAGM. Also, we often observe on that part a pulsating swelling with a peculiar kind of purring in it, which extends up into the carotid arteries. We find this swelling on the right side of the sternum, between the second and third rib, if the aneurism is an enlargement of the convex part of the aorta. It makes its appearance, however, on the left side of the sternum in the same intercos- tal space when the aneurism has formed on the concave part of the aorta. Its symptoms are; palpitation of the heart, dyspnoea, asthma, bronchial ca- tarrh, haemoptoe, swelling of the jugular veins, with cyanosis, oedema of the upper extremities, difficulty in swallowing, hypersemia of the brain — all symptoms in consequence of its pressure either upon the lungs or the oesopha- gus, and in consequence of disturbed circulation. The aneurism of the arch of the aorta has its seat behind the manubrium sterni, and a deep pressure with the finger into the fossa jugularis may detect its pulsation and purring. The aneurism of the aorta descendens must be very large in order to cause a duller sound on percussion, or swelling between the left shoulder- blade and the spine. Its symptoms are the same as those of aneurism of the ascending aorta; and, in addition, it may cause paralysis of the lower ex- tremities, rectum and bladder. Therapeutic Hints. Ergot. Has been used hypodermically with success by Yon Langen- beck "' on account of its power to contract muscular fibres. Two cases (both women I of aneurism of the mesenteric artery are reported as having been cured by Secede™. (T. M. Pearce, Med. Inv., 1875, Vol. I., p. 48.) Gallic ac. In drop doses of the tincture cured a case of aortic aneurism. ( Helmuth , Gilchrist . ) Evcop 11 . Is reported by R. Hughes as having cured a carotid aneurism in four days. {British Journal, 70, p. 792.) Spigel., then Carb. i'eg., and later Bryon. and Spigel., have cured a thoracic aneurism. ( C. F. Nichols, Xezc Eng. Gazette, March, 1873, p. 106.) Spongia. Has relieved the paroxysmal, dry, suffocative cough, coming at irregular intervals, especially on lying down or drinking hot tea, also a distressing fullness in the stomach after eating which attended an aneurism of the descending aorta. < T. C. Fanning, Amer. Jour, of Horn. Mat. Med., Vol. III., p. 10.) To finish the morbid affections of the thoracic organs I have yet to speak of the affections of the diaphragm, that muscle which forms the partition be- tween the thoracic and abdominal cavity, and which participates greatly in the acts of respiration. 1. Diaphragmitis, or Inflammation of the Diaphragm. The substance of the diaphragm being a muscular, tendinous tissue, is scarcely ever primarily affected, while its serous lining on its upper surface, THERAPEUTIC HINTS TO INFLAMMATION OF THE DIAPHRAGM. 417 a continuation of the pleura and pericardium, and on its lower surface a con- tinuation of the peritoneum, frequently participates in inflammations of these membranes. Symptoms, such as impossibility of taking a deep breath, hic- cough, yawning, risus sardonicus, pain in the shoulders, vomiting of green masses, great difficulty in swallowing, even hydrophobia, denote in pleuritis, pericarditis, or peritonitis, an extension of the inflammatory process to the diaphragm. Physical signs, are none. Therapeutic Hints. Aco?i. Hard, feverish pulse; thirst; anxious impatience; restless toss- ing about; painful cough; difficult} 7 in breathing, and pain and heat in the upper region of the abdomen. Apis. Burning pain; must bend forwards from a contractive pain in the hypochondria. Bellad. In plethoric persons with sympathetic affection or inflamma- tion of the liver; or in consequence of concrements in liver or kidneys; in pylephlebitis; in puerpural affections; in violent headache with active hyperemia. (Buchner.) Bryon. Stitching pain in the region of the diaphgram, worse from any motion, from coughing; white, dry tongue without thirst, or else great thirst with drinking large quantities of water. Cad. grand. Feeling as of a cord around hypochondria; congestion to the chest; shooting pains through to the back and up each side of the chest; cannot lie down; dry, tickling cough as from dust in throat. Chamom. Throbbing, burning pain in the region of the short ribs and pit of the stomach, worse from pressure; short and anxious breathing; short, dry cough; vomiting; belching; restlessness; tossing about; loud complain- ing, etc. Colchic. Similar to Bryon., for gouty persons; albuminuria. Digit. After pleuritis; grasping pain; nausea and vomiting; oppression in middle of the chest, difficult breathing; pulse at first suppressed, then quick; nails blue; face long and cold. In spite of ansemia the patient can bear no high temperature. Better in sitting than in lying. (Buchner.) Dulcam. In rheumatic affections of the spinal cord. (Buchner.) Hepar. After Bryon., in fibrinosis, promotes resorption. (Buchner.) Lycop. Sense of constriction from the right side all around the short ribs; cannot stretch himself or lie upon the back; neither stand upright. Nux vom. Muscular pain of a grasping, rooting nature, with nausea or vomiting. Rims tox. Worse when lying still; or disposition to move notwithstand- ing the pain caused by it; commencing on the left side and going to the right. Str anion. Mixture of hyperemia and spasm in consequence of affec- tions of the spine and the diaphragm with hiccough, sympathetic spasms of the epiglottis and the similar symptoms. (Buchner.) 27 41 8 SINGULTUS. Sulphur after Bryon., in fibrinosis, promotes resorption. Tabac. Muscular pain caused by renal calculi when incarcerated in one of the ureters; it contracts the longitudinal (Be/iad., the circular) fibres. (Buchner.) Compare Pleuritis and Peritonitis. 2. Singultus, Hiccough. Hiccough consists in a spasmodic contraction of the diaphragm, by which the air is suddenly drawn in, causing that sound peculiar to hiccough. Its causes may be of a cerebral origin, as in diseases of the brain; it may be the consequence of anaemia from long-standing, weakening diseases, after great loss of blood and vital fluids; of strong mental affections, like fright, anger, etc. Or, it ma}* be a mere reflex from diseases of the pleura or pericardium; or it ma}* accompany different affections of the stomach, the liver, the intes- tinal canal. If it takes place in consequence of exhausting diseases, like morbus Brightii, tuberculosis, typhus, cholera, pleurisy, with abundant exu- dation, large abscesses, etc., it is always a dangerous symptom, continues for days and may be the forerunner of a fatal issue. According to the different causes many remedies may be indicated. Therapeutic Hints. Buchner gives the following: Arsen. After cold fruit. Hyosc. When there is inflammation of intestinal organs. Ignat. Especially in children. Nux vom. After cold drinks. Pulsat. After cold fruit. Ruta. When associated with depression. Str anion. In the most obstinate forms; in children when attended with restlessness in the night and screaming during sleep. Ver. alb. After hot drinks. Also the following remedies may come into consideration: Amy I nitr. y Bismuth., Curb, veg., Crot. tigl., Ferrum, Laches., Marum ver., Moschus. y Niccol., Ranunc., Ratan., Staphis., Zincum. 3. Neuralgias of the Diaphragm Require Atrop., Rhus tox., Mezer. ; in inveterate cases: Silic. ; in inter- mittent cases: Ignat. and the Alkalies in combination with arsenious acid. (Buchner.) 4. Rupture and Perforation of the Diaphragm. Ruptures are caused by violent concussions or heavy lifting; whilst perforations are the result of suppurating processes either in the thoracic or RUPTURE OF THE DIAPHRAGM. 419 abdominal cavity. When ruptures take place from out of the thorax they are generally attended by dyspnoea, cough, hiccough, suffocating spells and fainting. When from out of the abdomen, by vomiting, colic, obstinate con- stipation. Perforation takes place from suppurating processes in the thoracic cav- ity; for example, in consequence of pyothorax; when the fluid discharges into the abdominal cavity it causes peritonitis. ABDOMEN When we examine the abdomen by sight or inspection, we have to take into consideration the following conditions: 1. Its appearance in regard to size. a. Enlargement of the abdomen may be partial or general. Partial enlargement depends upon abnormal sizes of the abdominal vis- cera; either the stomach, liver, spleen, uterus, ovaries, kidneys, glandular structures, bladder, and so on. Also upon pathological products, as tumors of all kinds, encysted exudation, extra-uterine pregnancy, hernia, and so on. General enlargement may arise from ©edematous infiltration of the abdominal walls; or from accumulation of fat in the subcutaneous cellular tissue, and the omentum; from an accumulation of gas in the stomach and intestines; from a collection of gas or fluid in the peritoneal sac; from large tumors, which fill the whole abdominal cavity; from pregnane}- , and some- times in consequence of frequent pregnancies, the so-called pot-belliedness, and likewise in scrofulous children from enlarged mesenteric glands. b. The abdomen appears smaller — sunken in — sometimes to such a degree that the spinal vertebrae may be felt through the abdominal walls. This we observe in persons' who have been starving for a considerable time ; also in cases of general marasmus; in strictures of the oesophagus, the cardia, the pylorus, or the duodenum; after severe and long-continued diarrhoea and cholera; it is also a sign of painter's colic from poisoning with lead, and quite characteristic in brain diseases, especially tubercular meningitis. 2. Its appearance in regard to motion. a. Respiratory motion. The diaphragm, moving up and down, makes, as we know, the abdomen participate in the respiratory motions of the chest. This respiratory motion of the abdomen is increased in such affections of the chest as prevent a normal extension of the thorax, as pneumonia, pleurisy, etc. It is decreased, or ceases altogether, in inflammation of the peritoneum, in large effusions of fluids or gas in the abdominal cavity, in consequence of large tumors which fill the abdomen, and also from injuries of the dia- phragm. b. Pulsation. We observe it generally in the pit of the stomach, some- times lower down, nearly to the umbilical region, rarely below the navel. This palpitation may have different causes: i. Abnormal position of the heart, its apex lying towards the pit of the stomach. In this case we hear, on auscultation, both ticks of the heart, or noises, if there are any, in the pit of the stomach and not at the normal place below the nipple. ABDOMEN. 42 1 2. It is caused by the right ventricle, which communicates its motion to the left lobe of the liver. In this case we hear also, on auscultation, both ticks of the heart at the pit of the stomach, and at the same time at the normal place. 3. It is caused by the descending aorta, and the pulsation extends then further down towards the navel. In this case we hear, on auscultation, only one sound, or one noise, if there be any; this, however, appears a little later than the impulse of the heart at its normal place. The causes of this abdominal pulsation may be — a. Relaxed and thin abdominal walls; collapsed state of the abdomen. b. A curvature of the spine forwards, whereby the aorta comes nearer to the abdominal walls. c. A thickened left lobe of the liver. d. Increased impulse of the heart, as in hysteric individuals; or hyper- trophy of the left ventricle in consequence of insufficiency of the aortic valves. 3. Its appearance in regard to the elasticity of its external walls. We find it greatly relaxed, hanging down like a loose sack, in old women, or in those who have given birth to many children; also after absorption of large quantities of fluids, by which the abdominal parietes had been largely distended. A similar effect is produced by a large accumulation of fat within the subcutaneous cellular tissue. Great distention of the abdomen, especially pregnancy, sometimes causes the straight muscles of the abdomen (the m. recti) to be driven asunder, so that a space of several inches occurs between them, which is very thin, consisting merely of the fasciae of the oblique muscles, the peritoneum, and the external covering; whilst the recti muscles lie on the sides of the abdomen, forming there a pad-like protuberance. The thin, yielding space in the middle between them, however, bulges out as soon as the person as- sumes a standing position, not being strong enough to keep the abdominal viscera in their normal position. 4. Its appearance in regard to the development of its subcutaneous veins. We observe these veins largely distended whenever there exists an obstacle to the free circulation of the blood through the vena cava inferior. This may be caused by stricture or obliteration of the vein itself, or by pres- sure of enlarged abdominal organs, or abdominal tumors upon it. Some of the blood which cannot pass there is brought by way of the venae inter- costales, mammarise or axillares, from the lower portion of the bod} T into the superior vena cava. The so-called Caput Medusae, which is a network of enlarged veins around the navel, arises from the umbilical vein, which has not become obliterated. 5. Its appearance in regard to changes of color. Here I have to men- tion the straight line which we observe in pregnant women, extending from 422 SPECIAL FORMS OF ADOMIXAL DISORDERS. the navel to the symphysis pubis, either of a pale yellowish, brownis hor even blackish color. This line has been observed quite exceptionally, how- ever, in men, children and also such women as never had been pregnant. We sometimes observe also, whitish or bluish- white stripes like cicatrices on the sides of the abdomen, which are generally signs of a previous pregnane}', as other distentions of the abdomen rarely cause them. On further examination of the abdomen by means of Palpation, we may learn, first, the seat of the, affection. a If in the abdominal walls, we are able to raise the affected part during a relaxed state of the abdomen; or if the abdominal walls be put upon the stretch, we shall observe the swelling in it becoming more prominent. b. If the seat of the affection is in one of the abdominal organs, the swelling feels deeper and cannot be raised by lifting the relaxed abdominal walls. In order to decide which organ is affected, we, of course, must be entirely familiar with the normal positions of these different organs. Palpation teaches further the nature of the swollen parts in the abdomen. A solid swelling we feel as such, whilst a fluid exudation gives to the examaining hand a sense of fluctuation; provided the sac which contains it be not too much distended, in which case it feels as solid and hard as a stone, and without any fluctuation. Palpation is also important to become certain of the character of pain which the patient experiences on pressure. If the pain is increased by slight pressure and ameliorated by gradual deeper and deeper pressure, the affection is mostly of a nervous nature. When, however, the pain increases as the pressure is increased, generally it indicates an inflammatory affection. Pressure upon the stomach frequenth* causes sickness and belching; pressure upon the colon, desire for stool; and pressure upon the bladder, desire to urinate. Percussion gives a tympanitic tone whenever there is gas or air in the abdomen, unless the enclosed walls are too greatly distended; and a dull tone wherever there are solid bodies or fluid effusions in the abdomen. In this way we are enabled to determine the extent of the enlarged liver, spleen, hardened stomach, tumors and fluid effusions of the peritoneum or ovaries; also, the accumulation of gas in the stomach and intestines, or the peritoneal sac. Auscultation teaches very little, except what I have mentioned already , in regard to the visible pulsation of the abdomen. Fcetal pulsations. a. SPECIAL FORMS OF ABDOMINAL DISORDERS. There are many organs in the abdominal cavity; each of them may be differently affected; consequently the special forms of abdominal affections must amount to quite a considerable number. I shall speak at first of the pathological conditions of the stomach. DYSPEPSIA. 423 Dyspepsia, Indigestion. Dyspepsia signifies difficult digestion; indigestion implies a failure to digest. If we consider for a moment all the causes by which dyspepsia may be brought about, we will comprehend at once the wide mouth and the big belly of that bag which is called dyspepsia. Still, if, according to Pope, "One truth is clear, whatever is, is right," I shall not attempt to destroy this convenient bag, but shall merely endeavor to divide it, for a more intelli- gent use, into the following four departments: 1 . Dyspepsia may be caused b}' anatomical changes in the digestive ap- paratus, such as catarrh, inflammation, thickening, ulceration, eruptions on the membranes of the stomach. 2. D}'spepsia may be caused by quantitative or qualitative alterations of the digestive secretions, such as alteration of the gastric juice, of the secre- tion of the pancreas, or of the secretions of the liver and of the intestines. 3. Dyspepsia may be caused b}^ an abnormal condition of the nervous system, as we observe in consequence of mental excitement, of too great mental exertion, and all such influences as disturb the normal action of the nervous system. It is a notable symptom of neurasthenia. 4. And lastly, dyspepsia may be caused by the use of irritating or stim- ulating food or drink; so that we find a whiskey-dyspepsia, a pepper-and- mustard-dyspepsia, a coffee-dyspepsia, and all sort of other dyspepsias, among which we ought not to forget the ice-cream dyspepsia and the sugar dyspepsia. The symptoms of a disease which has so many different causes, must, of course, be variable, and I shall try to state only its most prominent features. Dyspepsia is characterized by — 1. Want of appetite, or morbid appetite: craving for sour, acrid, spicy things, etc. 2. Accumulation of wind in the stomach, and, in consequence of which, belching, oppression, palpitation of the' heart. 3. Formation of acids in the stomach, and, in consequence, sour, rancid eructations, pyrosis or heartburn, waterbrash. 4. The food may not digest at all, causing vomiting or diarrhoea. 5. The pit of the stomach is mostly sore to the touch; very sensitive to the pressure of clothes; it feels full, and is oftentimes swollen. 6. The patient feels unfit for mental and bodily work: he is morose, irri- table, sleeps badly; and, if asleep, his sleep is full of dreams. 7. His face shows a relaxed, tired, weary, sad expression, with sunken, dull eyes; pale grayish or yellowish color and pale lips. 8. His hands and feet are generally cold, and he is very sensitive to the cold. 9. Gradual falling away in flesh and strength. 424 vomiting. Therapeutic Hints. When we find, in an acute disease, a patient strongly craving a particu- lar thing to eat or drink, it is well and wise for the physician to satisfy this desire. In chronic cases, however, such as dyspepsia, which may have grown big by yielding to morbid desires, it is absolutely necessary to strictly forbid the use of all irritating nourishment, otherwise we feed the animal which we want to destroy. For special hints, compare Gastric Catarrh, acute and chronic; Liver Affections, Pancreatic troubles, Neurasthenia, etc. Vomiting. Vomiting consists pathologically in an antiperistaltic contraction of the stomach, and a spasmodic contraction of the diaphragm and abdominal mus- cles, caused either by a direct influence of the brain, or, which is much more frequently the case, an irritation of the nervus vagus, either in the stomach or in the pharynx, or by irradiation — (sympathetic). In cases of sudden and violent vomiting, especially if it happens to other- wise healthy persons, we ought to think: Of poison: to ascertain which we must examine chemically what the patient throws up or what remains of what he partook. It may be arseni- cum, corrosive sublimate, nitrate of silver, zincum, or stannum, tartarus emeticus, phosphorus, iodine, different kinds of acid, sulphuric, nitric, or muriatic, alkalies, as caustic potash, or vegetable or animal poisons. Of pregnancy: it sets in sometimes immediately after conception, some- times not before the first menstrual discharge should come on and does not. It lasts, in many cases, through the first half of pregnancy, in some longer, and in some it passes over quickly or does not set in at all. During partu- rition I have frequently observed vomiting shortly before the birth of the child. Of incarcerated hernia, intussusception, or invagination, which is gener- ally attended with obstinate constipation. Vomiting from affections of the stomach may have its cause in a simple overloading of the stomach with indigestible food, or in catarrh of the mu- cous membrane of the stomach; for example, in drunkards; or, in an ulcer- ated state of this membrane, and in cancer of the stomach. Vomiting may also be caused by diseases of the peritoneum and intesti- nal canal; from affections of the liver, spleen, pancreas, and urinaty organs. Sometimes it ma}' be merely the effect of the mechanical concussion during hard coughing, laughing, etc. Vomiting from affections of the brain is found in consequence of exter- nal injuries of the head and concussion of the brain; may be caused by strong impressions upon the sensorial and sensitive nerves; the swinging motion of a ship, seasickness, etc. ; is found in hypersemia and anaemia of ACUTE CATARRH OF THE STOMACH. 425 the membranes of the brain; in inflammation of the brain and its membranes; in different organic diseases of the brain; in megrim and sick headache. Therapeutic Hints. If vomiting be caused by poison, the poison should be removed or neutralized as soon as possible. The stomach-pump is often greatly prefer- able to emetics. The antidotes of the different poisons may be found in the Materia Medica, and they are well arranged in Dr. Hering's " Domestic Physician." If it be caused by an incarcerated hernia, the hernia sac should be put back by taxis or surgical operation. Compare: Aeon., Lycop., Nux vom., Opium., Plumbum, Sulphur, Tabac. For vomiting in pregnancy, Nux vom., Veratr., and many others. Stramon. Vomiting of grass-green masses, aggravated by raising the head, and, at times, by light. (S. A. Jones.) For all other kinds of vomiting we must select the remedy in accordance with the indications in each individual case, and its underlying cause. Acute Catarrh of the Stomach, Gastritis. Pathologically gastritis is similar to catarrhal inflammation of any other mucous membrane. We observe redness and velvet-like swelling of the mucous membrane, which is oftentimes covered with a tough, transparent or whitish-gray slime. In severe cases the mucous membrane appears sof- tened so that it may easily be scraped off like a mushy covering; but this change may be the result of self- digestion after death, due to the specific contents of the stomach. (Compare Softening of the Stomach.) Primarily, catarrh may be caused by taking cold or getting wet, like any other catarrh; but principally it is caused by either too cold or too hot food or drink; or certain kinds of food, like too fat or old meat and fish, pork sausages, cheese, alcoholic drinks, ice cream, ice water; iced milk is still worse than ice water. Starvation is not less a cause of it. Also mental exertions and excite- ment, fright, grief, worriment and the like may cause it. Secondarily, we find it in combination with the perforating round ulcer of the stomach; cancer of the stomach; as a continuation of inflammation of the fauces and the oesophagus; inflammation of the intestines; or as a con- comitant of typhus, pneumonia, exanthematic fevers and erysipelas. The heat of the summer is most favorable for its development ; no doubt on account of the free use of ice water in a heated stomach; but it also fre- quently occurs in spring and fall. Symptoms. — The patient is morose; feels weak and chilly, with paleness of the face and cool extremities. The chilliness alternates with flushes of heat, red face and febrile motions. The pit of the stomach feels full, and sore to the touch, so that even the pressure of the garment feels uncomfortable- 426 THERAPEUTIC HINTS TO ACUTE CATARRH OF THE STOMACH. The appetite is gone; thirst, however, is generally present. At the same time the patient feels nauseated; frequently gulps up a sour or flat-tasting fluid: and generation of gas in the stomach swells the region of the stomach and causes belching of wind. In the cases in which the catarrhal affection extends into the bowels, it causes rumbling flatulency, escape of fetid flatus, and mushy, fetid discharges. At the commencement of the disease the bowels are mostly constipated and the urine is dark-colored. Toward the close we frequently observe the formation of herpes labialis or hydroa. In some cases gastritis is attended with a higher or less degree of fever, and then it goes under the name of Gastric fever. The fever generally aug- ments in the first days, shows evening exacerbation, and may last from one to two weeks, when the patient gradually recovers. In other cases, which generally are characterized by great obstinacy, there is an abundant secretion of tough mucus, not only throughout the ali- mentary canal, but also in the bronchial tubes and the urinary organs. This form is known under the name of Febris mucosa. The patient becomes greatly exhausted and apathic, and after a slow recovery is very liable to relapses. Still another form is the so-called Bilious fever, when the gastric catarrh is complicated with an abundant secretion of bile. Here the pulse is much more frequent and the temperature much higher than in an ordinary gastric fever; there is vomiting of bitter and green masses; the liver is somewhat swollen, and a light icteroid coloring of the white of the eyes may appear, until finally, after a week's duration, the whole train of symptoms is wound up with a bilious diarrhoea. In the first days it is often difficult to discern between these forms of gastric catarrh and Typhoid fever. However, gastric fever is generally preceded by dietetic faults; its temperature ranges never very high, nor does it show the characteristic step-like increase of a typhoid fever temperature and the typhoid roseola, while the fever blisters around the mouth, a frequent occurrence in gastric catarrh, are extremely seldom met with in typhoid fever. Therapeutic Hints. Aeon. After taking cold; stitch-like, burning and pressing pain in the pit of stomach, with anguish and fear of death; fever, with great thirst and vomiting. Ant. crud. Total loss of appetite; tongue thickly coated, yellow or white; great thirst at night; nausea; belching, with taste of what had been eaten; vomiting; after bad, sour wine; after bathing. Apis. Painful sensitiveness in the pit of the stomach, with burning; painless, yellow diarrhoea. Arnica. After a blow or fall; sense of fullness in the pit of the stomach; belching, with taste of putrid eggs; hot head, remainder of body cool. Arsen. Nausea and vomiting, worse from rising up; quick prostration; anxious restlessness; great thirst, but drinking little at a time; after abuse THERAPEUTIC HINTS TO ACUTE CATARRH OF THE STOMACH. 427 of ice, ice water, ice cream, vinegar, sour beer, tobacco (chewing), alcoholic drinks. Bel lad. Cutting pain in stomach, worse from motion and pressure; vomiting; gagging; hiccoughing; great thirst, but drinking makes it worse, consequently the patient abstains from drinking. Bryon. Stitching pain in the region of the stomach, worse from motion, and especially from a misstep; tongue coated; dry without thirst; or else great thirst day and night, and drinking large quantities; constipation. In warm weather and after eating of flatulent food. Card. veg. Great deal of belching, sour and rancid; burning in the stomach; bloatedness of the abdomen; disgust for meat; desire for acids; after debauch. Chamom. Bitter taste in the mouth; vomiting of bile or green "mucus; belching; rumbling in the bowels; hot and red face; much excited, as if beside himself; sleeplessness; after offence, vexation, anger. China. Feeling satiated all the time; however, when trying to eat, he can eat something, but feels bad afterwards and cannot say how; fullness in the stomach and bowels; belching; sour rising; cold feeling in the stomach, great lassitude and weakness. Euphorb. cor. Sudden nausea, vomiting and diarrhoea of watery fluid, with sinking, anxious feeling of the stomach; faintness; slow and weak pulse; cool skin; cool hands and feet, which become affected with cramps. Hydrast. Dull, aching pain in the stomach, which causes a very weak faintish feeling, "goneness" in the epigastric region; acidity; constipation. ''After drugging." (W. Goodno.) Ipec. Constant nausea proceeding from the stomach, with empty eruc- tations and accumulation of much saliva; easy vomiting; diarrhoea; after eating sour, acrid things; sour, unripe fruit, berries, salads, etc. Iris ver. Great burning distress in the epigastric region; vomiting with diarrhoea, accompanied by great prostration; burning in the mouth, fauces and oesophagus; and headache. Kali carb. Emptiness and gone feeling in pit of stomach; after eating, fullness, heaviness and pressure in pit of stomach; vomiting; dry stool; tur- bid urine; constantly chilly. Lycop. Great fullness in pit of stomach, after taking the least food. Nux vom. Always after the use of tinctures, mixtures, tonics, vege- table pills, coffee, wine, condiments; after mental overexertions; in leading a sedentary life; bitter or sour taste; sour belching; fullness and pressure in the stomach; constipated bowels; dizziness, headache; irritable, cross; all worse in the morning, in the open air and after eating. Podoph. Food turns sour after eating; belching of hot flatus, which is very sour; great thirst; vomiting; the stomach contracts so hard and rapidly in the efforts to vomit, that the wrenching pain causes the patient to utter sharp screams; vomiting of bilious matter, mixed with blood. Pulsat. No appetite; no thirst; bitter taste in the mouth; everything 428 CHRONIC CATARRH OF THE STOMACH. tastes bitter; dizziness when rising from a chair; chilliness; after fatty sub- stances — pork, pastry, rancid butter, etc. Rum ex. Shootings from the pit of the stomach into the chest in various directions; aching pain in the pit of the stomach, and aching and shoot- ing above it in the chest; fullness and pressure in the pit of the stomach, extending towards the throat-pit; it descends towards the stomach upon everj T empty deglutition, but immediately returns; flatulence; eructations; pressure and distention in the stomach after meals. Sa?igui?i. Xausea, with headache, chill and heat; vomiting, with severe painful burning in the stomach, and intense thirst; red tongue; red and dry lips; hot and dry throat; tickling cough. Sepia. Sensitiveness of the pit of the stomach to touch; bloatedness of the abdomen; congestion and heat of the head; headache; tongue coated without lustre; often sore and covered with little blisters on the edges and tip; sour smell from the mouth, and likewise of the urine, which is clear like water, or pale yellowish; constant drowsiness; anxious dreams, and great fever heat; especially in children from taking cold when the weather changes. Chronic Catarrh of the Stomach Is, in many cases, only a continuation of an ill-managed, acute attack, but it may grow out of too free a use of spirituous liquors, coffee, chewing and smoking of tobacco; it may have its origin in gluttony, sedentary habits, mental exertions, long-continued mental emotions, etc. Secondarily, it has been observed accompanying heart, liver, lung and pleural affections; anaemia, chlorosis, Bright' s disease, marasmus, tuberculosis gout, cancer, haemorrhoids. Its most permanent symptoms are, indigestion or dyspepsia, belching" after eating, mostly sour, and attended with heartburn; pressure and full feeling in the epigastric region, with actual distention of the same. Other symptoms are, nausea and vomiting, loss of appetite, or perverted appetite, or ravenous hunger, with gaping and faintness; after eating always pain in the stomach. Such patients feel weak; they are morose, irritable and quite sleepy through the day. By-and-by their skin becomes pale and dry, and they become emaciated. Its progress is a slow one, and whether curable or not curable, depends entirely upon its combination with other diseases. On the authority of Kafka I shall give the following therapeutic re- marks : Aching or burning pain in the pit of the stomach: increased from palpa- tion or pressure of the clothes; and distention of the epigastric region, Bel lad. y Phosphor., Arnica, Arsen. Aching in the pit of the stomach, not much increased by external pressure: Bellad., Phosphor., Hepar, Ignat., Nux vom., Arnica, Calca/., Ziiicum. GASTRITIS TOXICA SKU CAUSTIC A. 429 Aching in the pit of the stomach, not increased by external pressure: Card, veg., China, Chin, sulph., Capsic, Nat?'. i?iur., Lycop., Sulphur. Sour stomach, with sour belching and taste, heartburn; gulping up and vomiting of sour matter: Nux vom., Calc. carb., China, Phosphor., Sulphur, Kalicarb., Carb. veg. Sour stomach always after eating: Nux vom., Kali carb., Natr. mur., Sulphur, Phosphor., Sepia. Rancid belching: Pulsat., Carb. veg., Magn. mur., Sulphur, Asa/. Foul belching: Sepia, Phosphor., Arsen., Arnica, China, Ferr. ac, Mercur. Much mucus in mouth and stomach: Pulsat., Amm. mur., Natr. mur., Arnica, Sulphur. Accumulation of bile in the stomach, with bitter taste, bitter belching, and vomiting: Chamom., Pulsat., Arsen., /pec, Nix vom., Veratr. Much wind in the stomach, with distention: Nux vom., Carb. veg., Ig?iat., Ar?iica, Sulphur, Arsen., Phosphor. Distention of the abdomen: Carb. veg., Nux vom., China, Arnica, Natr. mur., Phosphor., Sepia. Relief from Eructations: Laches., Carb. veg., Ignat., Lycop., Tart, emet., Nux vom., Sulphur. Relief from wind passing down: Nux vom., Carb. veg., Pulsat., China, Chamom., Lycop. Worse from accumulation of flatulence: Nux vom., Carb. veg., Pulsat., Ignat., Natr. mur., Phosphor., Arnica, China, Chamom., Kalicarb., Coloc. Slow digestion: Nux vom., Ignat., Phosphor., China, Opium. Total loss of appetite: Nux vom., China, Sepia, Natr. mur., A? r sen. Feeling of emptiness and hunger in the stomach without desire for food : Natr. mur., Opium, Arsen. Ravenous hunger: Nux vom., Calc. carb., China, Iodium, Natr. mur., Phosphor. Worse after eating: Nux vom., Calc. carb., Lycop., Phosphor., Natr. mur., Sepia, Sulphur. Disgust against meat: Sulphur, Sepia, Petrol., Mur. ac, Natr. mur., Carb. veg., Arsen. Sleepiness in the daytime: Natr. mur., Pulsat., Sepia, Calc carb., Carb. veg., Chinin., Kalicarb. Great weakness and loss of energy: China, Chin, sulph , Arsen., Phos- phor., Iodium, Ferr. ac Gastritis Toxica seu Caustica, Inflammation of the Stomach in consequence of Poisoning. Such poisoning is caused by concentrated or diluted mineral acids, caus- tic alkalies, salts and metals, acrid, vegetable or animal poisons, and ethereal oils. 430 GASTRALGIA. Diluted mineral acids change the epithelium and the superficial layers of the mucous membrane of the stomach into a soft, brownish, even blackish mass. Concentrated mineral acids change all layers of the mucous mem- brane into a blackish mass; the other coats of the stomach become softened, and, in some rare cases, perforated — eaten through. The blood in the ves- sels of the stomach and in the adjoining larger vessels is black and tough, like tar. Caustic alkalies — for example, the Kali causiicum or Ammonium caustic urn — change the epithelium and the mucous membrane of the stomach to a pappy, discolored mass; they destroy and perforate the coats of the stomach much more readily than acids do. Salts of metals, like verdigris, corrosive sublimate, Argentum nitricum, Tartarus cmcticus, likewise Arsenicum and Phosphorus , cause brown scurfs, surrounded by injected and swelled portions of the mucous membrane of the stomach. Acrid, vegetable and animal poisons, and ethereal oils cause a highly inflamed state of the mucous membrane of the stomach. Poisoning is characterized by the following symptoms: Violent pain in the stomach and bowels; vomiting of slimy or bloody masses; slimy, diar- rhceic discharges from the bowels, mixed with blood, and tenesmus; the fea- tures of the face become distorted; there is sudden loss of strength; coldness of the extremities, and cold, clammy perspiration; the pulse is small and thread-like. If the patient informs us what he has swallowed, our diagnosis is safe enough. If not, the ejected masses will have to be examined. Mineral acids and caustic alkalies leave their traces also upon the mucous membrane of the mouth and fauces. Therapeutic Hints. If we see a case soon after the swallowing of poison, this poison must be either removed or neutralized — acids hy alkalies and alkalies by acids. Chronic consequences require: after acids, Calc. carb.; after alkalies, Nitr. ac; after ethereal oils, Nux vom., At sen. \ after metals, Hepar. Gastralgia, Oardialgia Nervosa, Cramp of the Stomach. This affection is characterized by attacks of great pain in the stomach, which come at intervals, leaving the patient free from pain between the at- tacks; there is no structural change of the stomach effected by it. We fre- quently find this complaint, however, in connection with anaemia, chlorosis, tuberculosis or great loss of vital fluids; also with chronic catarrhal affections of the stomach, the round perforating ulcer, and cancer of the stomach; also with diseases of the womb, as falling or dislocation of the womb; catarrh or ulceration of the mouth of the womb; too scant3^ or too profuse menstruation; also with diseases of the spine, especially such forms as present an inter- mittent character; and finally we observe it frequently in consequence of depressing mental emotions; chilling the stomach by drinking ice water or eating ice cream while being heated; or after the use of lemon juice, or other THERAPEUTIC HINTS TO GASTRAEGIA. 43 1 acid fruits, coffee, fresh bread and hot cakes, and other things which are difficult to digest. The attack usually commences with a feeling of pressure in the pit of the stomach, frequent yawning, coldness of the extremities, and an uncom- fortable feeling in the middle of the spine, which induces the patient to bend backwards frequently. Sometimes, without such premonitory signs, a violent pain in the stomach sets in at once, which may be various in character — pressing, drawing, burning, boring, gnawing, cramp-like, etc., amounting sometimes to such a degree of severity that the patient faints away; his face appears collapsic, his extremities become cold, and his pulse small and thready. The pain seems to radiate from the spine and reflect up to the chest, where it causes asthmatic symptoms; or, it reflects up to the oesophagus, causing the so-called globus hystericus; or, to the larynx, causing chok- ing; or to the sympatheticus, causing spasmodic laughing and crying; or, to the nerves of the cranium, causing hemicrania; or, to' the intestines, causing pain in the bowels and diarrhoea. The pain is oftentimes relieved by hard pressure upon the stomach, but sometimes the patient cannot even bear the pressure of the clothing. The pit of the stomach is, in some cases, distended, in others it is drawn in; often we observe a pulsation in the epigastrium. The attack generally ends with belching of wind, vomiting of watery, sour fluids, passing of pale urine, and with a gentle perspiration. In some cases there is a great accumulation of wind in the stomach, so that the pit of the stomach and the bowels are greatly distended, with constant belching and rumbling in the bowels. Belching and passing wind generally brings relief. Therapeutic Hints. Abies nigra. Continual distressing constriction just above the pit of stomach, as if everything was knotted up, or as if the hard lump of undi- gested food remained there. Abrot. Feeling as if the stomach were hanging or swimming in water, with a sense of coldness. Pains cutting, gnawing, burning, contracting, stinging, mostly worse at night. Never entirely free from pain. Arg. nitr. Between the xyphoid cartilage and the navel a small spot, which is very sensitive to the slightest pressure; from this spot a very se- vere pain spreads to the hypochondriac region into the back, up into the shoulders, even to the head; gradually increasing in intensity, and as gradu- ally leaving again. Arsen. Burning pain, as of red-hot coal; pit of stomach sensitive to slightest touch; vomiting of ingesta as soon as taken; anguish; restlessness; dyspnoea; fainting; pale, earthy face; worse from eating and touching; bet- ter from warm applications; brought on by eating ice cream or drinking ice water. Asa/. Pressing, cutting, stitching pain in spells; eructations of a smell 432 THERAPEUTIC HINTS TO GASTRALGIA. like garlic or feces; accumulation of gas; constantly pressing upwards, none downward; gulping up of rancid, acrid fluids; obstinate constipation. Pain in paroxysms; better from eating; worse when stomach is empty. Bellad. Gnawing, pressing, crampy, drawing, wrenching pain, which compels the patient to bend backwards, and to hold his breath; pain extend- ing through to the spine, with tired feeling in the spine; great thirst, but feels worse after drinking; face hot, red, bloated; pupils enlarged; especially for the female sex, when the menstrual period has been disturbed. Bismuth. Sense of heaviness like a weight in stomach; intense press- ure in a denned spot with pain in the spine, compelling the patient to bend backwards. Bryon. Pressing pain as of a stone or a load in the stomach; worse from eating or drinking; from any motion; better when lying quiet on the back. Calc. carb. Pressing pain as of a load or stone in the stomach; or from the abdomen rising up into the throat; sour belching and vomiting; better from motion; too profuse catamenia. Calc. hypophosph. Sudden appearance of the attacks; absence of gastric catarrh; entirely free at intervals; sensation as if the pain and distress were caused by wind; spreading of the pain upwards, never downwards. Attacks appear suddenly two hours after each regular meal, and are appeased by tak- ing a cup of milk or other food carefully chewed. Without this the pain steadily increases, extends to the spine, into the chest and throat, and is accompanied hy a rising of clear, white, brackish, sour froth, and a gnawing in the stomach. (F. G. Oehme.) Carb. veg. After Nux vom., burning pain, extending down to the small of the back and up to the shoulders; sour, rancid belching; cold limbs; cold sweat; worse from lying down; after rich living; drinking of spirituous liquors. Chaviom. When sitting or standing the pain doubles him up; in bed he tosses about in great agony; hands and feet cold; after anger or vexation. Chelid. Gnawing, grinding pain, ameliorated by constantly eating some- thing. Coloc. Violent cutting, tearing pains, which, from different parts of the chest and abdomen, concentrate in the pit of the stomach; relieved by hard pressure and bending double; after vexation and indignation. Ferritin. Pressure in the stomach; vomiting of ingesta, and better afterwards; worse after drinking milk; chlorotic and anaemic individuals. Gelsem. Sensation of a heavy load with weight; tension and dull pain; sometimes with empty, faint sensations in the epigastrium, and a false hun- ger — a kind of gnawing. Graphit. Anaemic, chlorotic patients. Dysmenorrhcea; constant yawn- ing and bloatedness of the stomach. Ignat. Gnawing, cutting pain in the stomach; faint feeling; false hunger; collection of water in the mouth; nausea and vomiting of mucus; poor di- THERAPEUTIC HINTS TO GASTRALXHA. 433 gestion; bloated stomach; pale, watery, profuse urine; after grief or poor living; habitual smoking. Leptand. Sharp, cutting pains at intervals in the lower part of the epigastrium; constant aching distress; worse from drinking cold water; after rising; great desire for stool, that cannot be retained one moment. Lycop. Brought on by eating fruit; flatulency; flowing saliva; con- stipation; pain better from bending. Nux vom. Pressing, constricting, clawing pain in the pit of the stomach, extending into the chest, or towards the small of the back and to the anus, which is drawn in; worse after eating and drinking; better from belching, after vomiting, from bending forward and rubbing the pit of the stomach; great irritability; headache; loss of appetite; or hunger, with fear of eating; belching, vomiting and gulping up of sour substances; constipa- tion; haemorrhoids; suppressed menstruation; complaints from the use of coffee or liquors; sedentary life; night-watchings; anger and worriment; always after previous use of nostrums. Petrol. Pressing, drawing pain, ameliorated by constantly eating some- thing. Compare Chelid. Phosphor. A singular rising of the swallowed food by mouthfuls; gnawing pain; worse from motion; pain worse after eating; during the pres- ence of morbid hunger eating relieves for a short time; decidedly better when keeping warm in bed. Phosph. ac. Violent pressure in pit of stomach through to the back; worse from touch. Urine white and almost as thick as milk. Plumbum. The patient bends backwards during the spell; gets better from hard external pressure upon the stomach; afterwards yellow appear- ance of the white of the eyes; badly-smelling sweat of the feet; during paroxysm, abdomen hard like a board; pharynx feels constricted; hands and feet cold. Pulsat. Dizziness when rising; loss of appetite; no thirst; sour or bit- ter vomiting; after eating fat meat, cakes, pastry, and drinking whiskey; the attacks are worse in the evening. Rumex. "Shootings from the pit of the stomach into the chest in various directions; aching pain in pit of stomach, and aching and shooting above it in the chest; fullness and pressure in pit of stomach, extending toward the throat-pit; it descends toward the stomach with every empty deglutition, but immediately returns. Pressure and distention of stomach after eating; stitching, cutting pain in pit of stomach; worse on movement." (W. K. Knowles.) Staphis. After indignation. Sulphur. Pain in right hypochondrium extends over stomach to left- cannot lie on either side; when lying on back the pain spreads to chest under sternum and hinders respiration; must get up and walk about. Ver. alb. Pains radiate to back and shoulders; increase slowly and de- 28 434 DIGEST TO GASTRALGIA. crease slowly, and are attended with a shaking chill, and cold hands and feet. Digest to Gastralgia. Paroxysms: Asa/. , sudden, two hours after each regu- lar meal, relieved by taking a cup of milk or other food carefully chewed. Without this the pain steadily increases, extends to spine, chest and throat, and is accompanied by a rising of clear, white, brackish, sour froth and a gnaw- ing in the stomach: Calc. hypoph. increase slowly and decrease as slowly: Arg. nitr., Stannum, Ver. alb. entirely free intervals: Calc. hypoph. Never entirely free from pain: Abrot. Sensations, aching: Leptand., Rumex. , burning: Arsen., Carb. veg. , bloatedness: Ignat. , , with constant yawning: Graphit , clawing: Nux vom. , constriction: Abies nigra, Nux vom , cutting: Abrot., Asa/, Coloc, Ig- nat., Leptand., Rumex. , crampy: Bellad. , distention after eating: Rumex. , drawing: Bellad., Petrol. , dull: Gelsem. , faint feeling: Gelsem., Ignat. , fullness: Rumex. , gnawing: Abrot., Bellad., -Calc. hypoph., Chelid., Gelsem., Ignat., Phos- phor. , and grinding: Ignat. , hunger, false: Gelsem., Ignat. , heaviness, like a weight: Bismuth., Gelsem. , lump or stone, of a: Abies nigra., Bryon., Calc. carb. , pressing: Asa/., Bismuth., Bryon., Calc. carb., Ferrum, Petrol., Phosph. ac, Rumex. , shooting: Rumex. , stinging: Abrot. , stitching: Asa/., Rumex. , soreness in a small spot: Arg. nitr. , , to slightest pressure: Arsen. , tearing: Coloc. , tension: Gelsem. , water, as if stomach were swimming in, with sense of coldness: Abrot. , wind, as if caused by: Calc. hypoph. Direction of pain, in pit through to the back: Phosph. ac. with tired feeling in spine: Bellad. , and shoulders: Arg. nitr., Ver. alb. , into chest: Nux vom., Sulphur. , and throat-pit: Rumex. from abdomen into throat: Calc. carb. always upwards, never downwards: Asa/, Calc. hypoph. from pit to hypochondria, up in chest, even head: Arg. nitr. down to small of back: Carb. veg. and anus: Nux vom. descends toward stomach with every deglutition, but immediately returns: Rumex. from right hypochondrium over stomach to left: Lycop., Sulphur. from different parts of chest and ab- domen, concentrating in pit of stomach: Calc. carb. Attended with belching of smell like garlic or feces: Asa/ , , sour, rancid; Carb. veg. and vomiting: Calc. carb. gulping up of rancid, acrid fluids: Asa/ singular rising of swallowed food by mouthfuls: Phosphor. rising of clear, white, brackish, sour froth: Calc. hypoph. Nausea and vomiting of mucus: Ig- nat. vomiting, sour or bitter: Pulsat. of ingesta and better afterwards: Ferrum. , as soon as taken: Arsen. flatulency: Lycop. constipation: Asa/, Lycop., Nux vom. great desire for stool that cannot be retained: Leptand. GENERAL SYMPTOMS. Anguish: Arsen. Irritability: Nux vom. Dizziness when rising: Pulsat. ULCUS VENTRICULI PERFORANS. 435 Headache : Nux vom. Pupils enlarged : Bel lad. Yellowishness of white of the eyes: Plumbum. Face hot and bloated: Bellad. pale and earthy: Arsen. Collection of water in mouth: Ignat. Flowing" saliva: Lycop. Pharynx constricted : Plumbum. Loss of appetite : Nux vom., Pulsat. Hunger, with fear of eating: Nux vom. Thirst, but worse after drinking: Bellad. Poor digestion: Ignat. Abdomen hard like a board during par- oxysm: Plumbum. Haemorrhoids : Nux vom. Urine profuse, pale, watery: Ignat. white and almost as thick as milk: Phosph. ac. Menstruation suppressed: Nux vom. Dysmenorrhea : Graphit. Catamenia to profuse: Calc. Carb. Respiration hindered by lyin< back: Sulphur. Dyspnoea: Arsen. the Shaking Chill : Ver alb. Cold sweat : Carb. veg. Badly-smelling sweat of feet: Plumbum. Cold hands and feet: Plumbum., Ver. alb. limbs: Carb. veg. Fer- Fainting: Arsen. Chlorotic and anaemic individuals: rum., Graphit. For females with disturbed menstrual period: Bellad. Worse after eating: Nux vom. , Phosphor. and drinking: Bryon., Nux vom. and touching: Arsen. from drinking cold water: Leptand. milk: Ferrum. two hours after each regular meal: Calc. hypo ph. when the stomach is empty: Asa/. from lying down: Carb. veg. on back: Sulphur. on either side: Sulphur. When sitting or standing the pain dou- bles him up; in bed he tosses about in great agony: Chamom. Worse from motion: Bryon., Phosphor., Rumex. after rising: Leptand. from touch: Arsen., Phosph. ac. in evening: Pulsat. Better from belching: Nux vom. after vomiting: Ferrum., Nux vom. from eating: Asa/. taking a cup of milk or other food carefully chewed: Calc. hypoph. by constantly eating something: Chelid., Petrol. by eating during the presence of morbid hunger: Phosphor. from warm application: Arsen. when keeping warm in bed: Arsen. from external pressure upon the stomach: Plumbum. and bending double: Coloc. lying quiet on back: Bryon. motion: Calc. carb. must get up and walk about: Sul- phur. must bend backwards: Bellad., Bromium, Plumbum. bending forwards: Coloc, Lycop., Nux vom. Caused by grief: Ignat. anger or vexation: Chamom. indignation: Coloc, Slap his. sedentary life: Nux vom. night-watching: Nux vom. rich living: Carb. veg. poor living: Ignat. ice cream or ice water: Arsen. fat meat, cakes, pastry: Pulsat. spirituous liquors: Carb. veg., Nux vom., Pulsat. fruit : Lycop. smoking: Ignat. quack medicines: Nux vom. Ulcus Ventriculi Perforans (rotundum, chronicum), the Round Perforating Ulcer of the Stomach. In four-fifths of the cases the ulcer is situated in a region bounded by the posterior wall, the lesser curvature and the pyloric region; the rest of 436 ULCUS VEXTRICULI PERFORANS. the surface of the stomach appears to be affected in only one-fifth of the cases; it was also frequently observed in the duodenum, in cases of Chicka- hominy diarrhoea. Only one ulcer is usually found; exceptionally there are two, three or more. Its size varies: it may be smaller and also much larger than a three-cent silver piece; its shape is round, sometimes oval; and in cases where several ulcers join, it is irregular. On the inside of the stomach it is largest, and grows smaller in its progress of eating through the different layers of the stomach, so that it assumes a funnel-shaped appear- ance. When it reaches the serous membrane of the stomach it causes peri- toneal inflammation and fibrinous exudation, which cause adhesions with the adjoining organs, as the pancreas, liver, omentum and colon. When even this last or external membrane is eaten through, it causes peritonitis. This ulcer ma}' heal in any of its different stages, in which event new granulations are formed, and the whole is shut by a flat, radiated cicatrix, in consequence of which it sometimes happens that the pylorus becomes con- stricted, so that the exit of the food into the intestines is impeded. Such a cicatrized induration of the pylorus can generally be detected by palpation in the pit of the stomach as a hard swelling. In regard to its origin we are quite in the dark. Rokitansky considers as the nearest cause hsemorrhagic erosions. They consist, according to Virchow, in obstruction of arterial vessels, in consequence of which the mucous mem- brane becomes deprived of its necessary nutriment and dies off, and by the corroding effects of the acids of the stomach is eaten out deeper and deeper. Of special interest is its occurrence after extensive burns of the skin and its coincidence with trichinosis. The Symptoms are as follows: pain, exactly as in gastralgia, in the pit of the stomach, often extending to the spine, coming in spells mostly after eating, ameliorated, sometimes ceasing, after vomiting of slimy, tough or waterj', clear, tasteless or sour fluid, often containing blackish or brownish flakes. Vomiting is found not only during cardialgic spells, but also between these spells, although in exceptional cases it is not a prominent symptom. It generally happens soon after eating, and frequently without previous nausea and without great exertion. Acrid, sour, indigestible food causes it most frequently. The vomit often contains particles of decomposed blood in the form of blackish or brownish flakes and masses, and sometimes even clear blood in large quantities. But even this bloody vomit is not a constant symptom; in cases of slow bleeding the blood ma}- pass into the intestines and be carried off in the form of tarry faeces. Indigestion. In some cases the appetite is little or not at all changed, but in severer cases it is diminished, or altogether absent. Eating usually causes pain and digestion is very slow. Milk and white meat are best digested. Eructations, nausea, pyrosis or water brash, are symptoms of the chronic catarrh attending the disease; and obstinate constipation is of fre- quent occurrence. Sooner or later, the face of the patient assumes a pale, THERAPEUTIC HINTS TO ULCUS VENTRICUEI PERFORANS. 437 sallow aspect, his spirits become depressed, he loses flesh, and grows weaker and weaker. When perforation takes place, which may happen either spontaneously or in consequence of a strong concussion of the body, or from overloading the stomach, or during a hard attack of vomiting, we have in a very short time all the symptoms of peritonitis. The patient experiences a stitch-like or cutting pain, altogether different from that of a cardialgic spell; he is seized with a violent chill and vomiting, and his features become collapsie, distorted, pale, expressing deep pain and agony. The abdomen distends largely and is very painful, especially when touched. Respiration is short, superficial, without any respiratory motion of the diaphragm. There is sin- gultus; violent action of the heart; frequent, small pulse; fainting; decrease of natural temperature; great prostration and collapse. Some chronic cases take to the end a latent course, until at last dis- covered as cicatrices on post-mortem examination. This surely proves the curabilit3 T of this disease. The disposition to it seems to be greater during middle life, and is by no means of rare occurrence. Differential Diagnosis. — It may be confounded with chronic catarrh of the stomach. The round ulcer, however, generally shows a clean, red tongue, has much more frequent vomiting; and the vomit is often tinged with either fresh or decomposed blood, and the soreness in the epigastrium is confined to a circumscribed spot with frequent cardialgic spells. It may be confounded with cardialgia. The round ulcer, however, has a falling away of flesh and change in features, pale, yellowish face, and vomiting between the cardialgic spells, which we do not observe in gastralgia. It may be confounded with cancer of the stomach; cancer, however, comes at a later period of life; its pain in the stomach, although often severe, never extends to the spine; it tells much quicker upon the general constitu- tion by the wasting away in flesh; it is often marked by a hard swelling in the pit of the stomach, which is observed in cases of round ulcers, only when the pylorus becomes cicatrized; it commences with feverish attacks and ends with a cachetic fever. Therapeutic Hints. Milk and mutton or beef -broth must be considered as the best diet. Arg. nitr. Pain below and to the left of the xyphoid process in a small spot extending to a corresponding point in spine, where pressure aggravates it. Looks as if dying. Arsen. Vomiting of black, decomposed blood; burning pain; always worse after eating or drinking; gray-yellowish color of the face. Chlorotic patients, with anaemic murmui in the large blood-vessels, and scanty menses. A tropin. Pressing pain after eating; and vomiting of acrid, sour masses which set the teeth on edge; hard swelling in the region of the pylorus, just 438 THERAPEUTIC HINTS TO ULCUS VENTRICULI PERFORANS. above the navel towards the right, very sensitive to touch; excruciating pain in the stomach; constant vomiting; deadly paleness of the face, with cold perspiration; hands and feet icy-cold; pulse very small. Peritonitis in conse- quence of perforation of the stomach. Compare Be Had. Carbveg. Gray, yellowish face; dry tongue; vomiting of sour, bilious or bloody masses; burning in the stomach; worse after eating; better from drinking cold water; eructations; distortion of stomach and bowels; cos- tiveness. Conium, co?iiin. Vomiting of black masses like coffee-grounds in clear, sour water; violent pain in the stomach, always two or three hours after eating, but also at night; somewhat relieved in the knee-elbow position; swelling in the region of the pylorus. Ferritin. In anaemic and chlorotic patients, with murmurs in the large blood-vessels and scanty menses. Haemorrhage from stomach and pain in stomach through to the spine. Kalibichr. Ulcers are oval; they corrode and become deeper without spreading in circumference; pressure and heaviness in the stomach after eating; giddiness, followed by violent vomiting of a white, mucous, acid fluid, with pressure and burning in the stomach; vomiting of sour, undigested food; of bile, with pinkish, glairy fluid; of blood, with close perspiration on the hands; burning in the stomach; heat of the face; all of which symptoms decidedly suggest its application in the round, perforating ulcer of the stomach. Lycop. Earthy color of the face; rising ot sour, acrid fluid; vomiting of sour water and mucus; fullness of stomach and abdomen; pain in the stomach after eating; rumbling and gurgling in the abdomen; constipation; scanty urine; worse from sitting bent; better from rising and walking about; no pain at night, when warm in bed. Mezer. Constant, violent pain and pressure in the stomach after eating, no matter what, even simple things like broth, milk, bread; a constrictive squeezing pain with much belching from on? to two hours after eating; the pain reaches its height and ends with vomiting and gulping up of what has been eaten; constipation; circumscribed redness of the face; skin cool, pulse very small and frequent; chilliness alternating with flushes of heat. Nux vom. Frequently indicated at first when the patient has already been drugged. Vomiting in the morning before breakfast. Phosphor. Regurgitation of food by mouthfuls without nausea; re- gurgitation of cold drinks as soon as they become warm in the stomach; excessive acidity; flatulency; constipation. Sepia. Yellow bridge over the nose; earth}' complexion; sour taste in the mouth after eating; vomiting of mucus; pain in the stomach after eating the simplest kind of food; hardness in the region of the pylorus; constipation; stitching all over the body, with breaking out of little pus- tules; menses scanty. CARCINOMA OF SCIRRHUS VKNTRICUU. 439 Silic. Yellowish complexion; screwing, pressing, twisting pain after drinking; pyrosis and vomiting after eating. Stannum. The pain commences mildly but increases steadily to an almost unendurable height, when again it gradually lessens and dies away for a short time. Sulphur. Constant pain in stomach and back after suppressed itch; sour taste in the mouth and sour vomiting; constipation; piles; cold legs. Compare also Gastralgia and Haematemesis. Carcinoma or Scirrhus Ventriculi, Cancer of the Stomach. According to pathological researches there are three different forms of cancer of the stomach: 1. Scirrhus, a fibrous growth in which the connec- tive tissue stroma predominates over the cell formation, generally originates in the submucous cellular tissue; 2. Carcinoma medullar is, a marrow-like growth, in which the cancer-cells predominate over the stroma, forms round isolated lumps in the mucous membrane of the stomach, and spreads sponge- like upon the inner surface of the stomach; and 3. Carcinoma alveolaris, a jelly-like growth, in which we observe a colloid degeneration of the can- cercells, invests at first the submucous cellular tissue, but penetrates fre- quently to the peritoneum, and forms large tumors upon it. All three kinds of cancer may often be seen together; and they mostly invest the pylorus, sometimes the lesser curvature, still rarer the cardia, and most rarely other parts of the stomach. It is often the case, that the diseased pylorus forms adhesions with ad- joining organs, such as the pancreas, liver, kidneys and colon, which are mostly invested by the same morbid product, keeping the stomach in a fixed position. When, however, such adhesions do not take place, the stomach sinks, in consequence of its increased weight, lower dowm into the abdominal cavity; remaining there, either perfectly free and movable, or adhering to organs low r er down such as portions of the intestines, the uterus, or its ap- pendages. The inner cavity of the stomach is much changed by this disease. It becomes greatly enlarged by stricture of the pylorus, or much diminished by stricture of the cardia ; there is cancerous degeneration of the coatings of the stomach. The mucous membrane, in the neighborhood of the cancer, ex- hibits chronic catarrhal inflammation, which is sometimes spread all over it; and, in the further progress of the disease, ulceration and erosion of smaller or larger blood-vessels w T ith consecutive haemorrhage obtain. The causes of carcinoma of the stomach we do not know, just as little as the causes of cancer in any other part of the body; heredity seems to deserve some amount of consideration. The disease has been observed most frequently between the years of fifty and seventy. Symptoms. — i. General cancer-cachexia: emaciation; paleness of the skin and the mucous membranes; ash-colored or yellowish color of the face; 44-0 CARCINOMA OR SCIRRHUS VEXTRICULI. brittle, dry, harsh and wrinkled skin; peeling off of branny scales, especially from the lower extremities. The expression of the face is sad; the eyes are fallen in ; the malar bones stick out ; the ankles are cedematous. 2. Tumor in the pit of the stomach. This is present, however, only when the cancer invests the pylorus. In this case we observe a roundish, or oval, or irregular lump to the right above the navel under the upper part of the right rectus abdominalis muscle. It is always there, and cannot be moved, if the pylorus should have formed adhesions with neighboring organs; but it changes position and is movable, when those adhesions are not formed. In this latter case it gradually sinks down into the abdominal cavity, and may appear below the navel, or even but little above the symphisis pubis, either as a movable or fixed tumor. But when the pylorus-carcinoma is covered by the left lobe of the liver, or by a distended colon, it cannot be felt. The same is true, when carcinoma has its seat on the cardia or on the lesser curvature. Cancerous degeneration of the anterior wall of the stomach is felt as a resisting mass in the epigastrium, changing position, however, ac- cording to the position of the patient; and according to the fullness and emptiness of the stomach, may be felt more towards the right or towards the left side, higher up or lower down, even below the navel. 3. The stricture of the pylorus causes, further, a sinking in of the ab- domen; the intestines are empty, because the food is prevented from going through the pylorus; the abdominal walls are thin, wrinkled, like parchment; they may be lifted up in folds which remain; the subcutaneous cellular tissue is wasted away, and the full percussion sound is wanting. The spine even may be felt through the abdominal walls, and the aorta descendens pulsates perceptibly. When there is a stricture of the cardia the epigastric region is fallen in because not sufficient nourishment is allowed to enter the stomach; the intestines are likewise empty, only the ribs and the processus xyphoideus protrude. 4. Vomiting. This happens if there is a stricture of the pylorus, gener- ally from four to five hours after eating. The masses which are thrown up are digested. In case of stricture of the cardia, the vomiting takes place immediately after or even during eating, without nausea or exertion; it is only a regurgitation of the swallowed food. If diverticles or widenings of the oesophagus exist at the same time, the vomiting follows a little later. The masses which are thrown up are the same as swallowed. If the cancer has its seat at another part of the stomach, the vomiting may be entirely absent; or it may, after having been regular for a time, slacken off and cease altogether. So also, the vomiting may cease if the stricture of the pylorus, by softening, gets removed, or if the walls of the stomach, by diffused cancer- ous degeneration, lose all power of contraction. 5. Haemorrhages from the stomach. The blood is thrown up either decomposed as a brownish, chocolate-like mass, or when larger blood-vessels have been destroyed, as clear blood. 6. The pain in the epigastrium, which has its seat generally in the can- CARCINOMA OR SCIRRHUS VENTRICUU. 44 1 cerous tumor, is worse from eating, usually of a lancinating or burning character, and never extending to the spine; it may be absent altogether. 7. The appetite is generally diminished; in some cases, however, it is increased; but the patients are afraid to eat, because of the following pain and vomiting. S. The stool is usually retarded; but when the cancerous growth softens and dissolves, we observe colliquative diarrhoea, and when there is haemorrhage in the stomach, bloody evacuations. Differential Diagnosis. — At its commencement it can hardly be dis- tinguished from a chronic catarrh of the stomach ; but in its progress cancer has the following distinguishing features: often a tumor in the epigastrium; now and then coffee-ground looking emesis; rapidly developing marasmus; asfi5 T or yellowish color of the face ; and the age of the individual — over forty 3 T ears; all of which is not applicable to chronic catarrh of the stomach. The symptoms of cancer are also very similar to those of the perforating ulcer of the stomach. Both have pain; both may have coffee-ground emesis; both may have haemorrhages from the stomach, and even a tumor in the epi- gastrium. But cancer never sets in before the fortieth year of age, lasts on an average not longer than one year, shows a steady progress in general decay, and its pain does not extend through to the spine, but is often com- bined with swelling of the lymphatic glands, especially in the axillae and on the neck, and with sleeplessness; while the ulcer befalls persons mostly under forty years of age, may last for several years and may be cured, or end quickly by perforation and subsequent peritonitis, and does not so rapidly develop a cachectic appearance of general decay; its pain usually extends from the stomach through to the spine. Cancer is distinguished from cardialgia in that it grows uninterrupt- edly and gradually, whilst cardialgia comes in spells, with intervals of health; further, by the age of the person, and its inroads upon the general constitution. How can we know what kind of cancer it is ? A very slow progress of the disease, together with additional ascites, make it probable that it is a jelly-like cancer — carcinoma alveolaris. An acute progress and rapid growth of tumor, with frequent and large haemor- rhages, point to carcinoma medullaris. A slow progress and considerable hardness and nodulated appearance of the tumor indicates a scirrhus. This latter is by far of the most frequent occurrence. Therapeutic Hints. Arsen. Burning pain in the stomach; better from warm applications; vomiting of all he takes; vomiting of black substances; prostration; emacia- tion; restlessness. Arsen. jod. Violent burning in stomach. (E. Huber.) Bellad. Cutting, clawing pain; nausea, gagging and vomiting; staring eyes; dryness in mouth and throat; fainting. 442 THERAPEUTIC HINTS TO CARCINOMA. Bismuth. Violent, crampy pains; burning and stinging in the region of the stomach; stomach enlarged, hanging down to the crest of the ilium; hard lump between the navel and the edges of the lower ribs on the right side; scirrhus of the pylorus; abdomen bloated in ridges, with great rumbling of wind along the colon, which is rarely passed off, but then gives relief; vomiting, only at intervals of several days, when the stomach has become filled with blood, and then of enormous quantities, and lasting a whole day. Card. veg. Burning pain, extending from the pit of the stomach into the small of the back; anxiety; cold extremities; cold, stick)' sweat; inter- mitting pulse. Card. an. Saltish water rises from the stomach and runs out of the mouth, accompanied by retching, and followed by violent, empty eructa- tion; cold feet and hiccough; pressure, clawing, griping and burning in the stomach; scanty, hard stools in lumps; copper-colored eruption on the face. Conium. Vomiting of chocolate-colored masses, sour and acrid; press- ing, burning, squeezing pain, extending from the pit of the stomach into the back and shoulder. Cundur. A case well diagnosticated by Friedreich improved remarka- bly under the administration of the tincture. Hydrast. Vomits everything, except water with milk; pain in pit of stomach; emaciation. Kreos. Painful, hard place on the left side of the stomach. Laches. Gnawing pressure, relieved after eating, but coming on again in a few hours, and the more violent the emptier the stomach; great sensi- tiveness to contact, especially to that of his clothes; drunkards. Lycop. After eating or drinking, vomiting of dark, greenish masses; bloatedness of the stomach and bowels; rumbling in the bowels; obstinate constipation; hard swelling in the epigastric region. Mezer. Great emaciation; the muscles of the face are tensely drawn, like strings; constant vomiting of chocolate-colored masses, with great burn- ing in the throat; violent retching, accompanied with the agon}* of death; sleeplessness and exhaustion; obstinate constipation; hard lumps in the epigastric region. Phosphor. Epigastric region sensitive to the touch; constant nausea and fullness in the stomach; after eating, or drinking even a swallow of water, vomiting of a sour, foul-smelling fluid, which looks as though it had been a mixture of water, ink and coffee-grounds; in the sunken abdomen, a circumscribed, hard swelling; pale, earthy complexion; great emaciation; sleepiness; peevishness; fine gurgling noise in the abdomen; urine scanty, red or brown, with reddish or yellowish red sediment; bowels constipated, dry, rumbling stools. Sepia. Sour taste after eating; vomiting of mucus, caused by taking even the simplest food; the pain in the stomach increases b}* vomiting, and HEMORRHAGE FROM THE STOMACH. 443 extends to the back, with anxiety; oppression of the chest and cold perspi- ration; hard places in the region of the pylorus; constipation. In addition, compare the Round Perforating Ulcer, Glastralgia, Catarrh of the Stomach and Haematemesis. Haemorrhage from the Stomach, Haematemesis, Consists of an effusion of blood, either from the arteries, veins or capillaries of the stomach, and may have two distinct causes, viz. : i. An increased pres- sure in the blood-vessels. Such is the case, a. In all congestive, catarrhal and inflammatory affections of the mucous membrane of the stomach. The bleeding in such cases is not very considerable, and comes from the capillary vessels, b. In all those cases in which the free circulation of the blood is interfered with, as in diseases of the vena porta, liver or spleen, in conse- quence of constriction of the inferior vena cava, in heart and lung diseases, all of which cause a mechanical interference to the free circulation, and, in consequence, a stagnation and greater pressure of the blood in the mucous membrane of the stomach. The bleeding in such cases is mostly capillary only; but it may amount to large quantities, if the pressure be great enough to rupture larger blood-vessels, c. In cases where habitual bleedings have been suppressed, menstrual or hsemorrhoidal. Such bleedings are called vicarious. The second distinct cause of haemorrhage from the stomach depends upon morbid alterations of the coats of the blood-vessels; these may arise — a. From chemical or mechanical influences, such as alkaline or corroding substances, or pointed objects within the stomach; from violent vomiting, straining, or from the effects of a fall or a blow; b. From pathological conditions, such as varicose veins, and aneurismal arteries; c. From general diseases, such as scurvy, yellow fever, and acute exanthematic fevers; d. From ulcerative pro- cesses, such as the round perforating ulcer, hsemorrhagic erosions and cancer of the stomach. Post-mortem examinations exhibit the mucous membrane of the stomach pale and anaemic, especially after capillary haemorrhage. At times we find the mucous membrane infiltrated with blue or darkened patches here and there, from which the blood oozes on slight pressure. On such places the membrane is softened and easily removable, whereby slight depressions are formed, called hsemorrhagic erosions. After profuse haemorrhages we find clots of blood, after slow bleeding or oozing the blood generally is altered by the gastric juice into a substance like coffee-grounds. Symptoms. — Slight haemorrhages usually cause no particular signs, ex- cept traces of blood in the masses which are thrown up. Profuse effusions cause a feeling of warmth and fullness in the stomach, nausea and vomiting, and soon all the signs of depletion, such as paleness, small pulse and cold extremities, great weakness, anxiety and oppression, singing in the ears, flickering before the eyes, dizziness and fainting. 444 THERAPEUTIC TO HEMORRHAGE OF THE STOMACH. The vomiting brings up the blood clear, in lumps, or already decomposed into a chocolate or coffee-ground-like substance. After the vomiting there is great thirst. Sometimes no blood is thrown up, but it is carried off through the bowels, making the feces appear dark, black or tar-like. Differential Diagnosis. — It may be confounded with haemoptoe. Haemoptoe is preceded by heart or lung affections, attended by cough. We hear rattling noises in the chest. Haematemesis is preceded by affections of the stomach, liver, etc., and is attended by nausea and vomiting. Haemoptoe generally yields bright, froth}- blood; haematemesis mostly dark or decomposed blood. When the blood is carried off through the bowels, how can we discern whether it comes from the stomach or from the intestines ? In the first case the blood is always mixed thoroughly with the feces; while in the latter case it generally comes without fecal masses. Therapeutic Hints. Aeon. In congestion and inflammation of the mucous membrane of the stomach; in scarlet fever, sometimes during desquamation, with excruciat- ing pains in the stomach, gagging, retching, gasping for breath; distressed face; anguish; cold sweat on the forehead. Arnica. When caused b}^ external injuries; overexertions; soreness all over the body. Arsen. Headache; roaring in the head; fainting; cold, distressed, yellowish or deadly pale, collapsed face; cold perspiration on the forehead; constant nausea; retching; great thirst; burning in the stomach; bloated abdomen; stitching pain in the spleen; black stools; groaning and moaning breathing; quick, trembling, thread-like pulse, 120 to 130 per minute; cold- ness over the whole body; great weakness; trembling, anxiety. Bellad. Congestion of the head and stomach; singing in the ears; flickering before the eyes; red cheeks; feeling of fullness and warmth in the stomach. Card. veg. Frequent fainting; hippocratic face; icy-coldness of the extremities; intermitting, small, scarcely perceptible pulse. China. Great loss of blood, and in consequence excessive weakness; paleness and coldness of the hands and feet, like marble; sensitiveness to touch in the pit of the stomach. Colchic. In a case with bloody discharge from the bow T els, and deadly nausea from smelling the cooking of food. Eriger. Violent retching and burning in the stomach. Ferr. ac. Pit of the stomach sensitive to touch, and soreness all over the abdomen; pulse full, excited; face pale; greatly exhausted. Hamam. Previous fullness and pain in the abdomen; feverishness hy spells; bloody vomiting and stools; weak, cold, profuse sweat; weak and quick pulse; restlessness; fullness and gurgling in the abdomen. Hyosc. Dizziness; stupefaction; eyes red; face bloated; pit of stomach GASTROMALACIA. 445 sensitive; dull aching in the region of the liver; abdomen bloated; limbs numb, weak, trembling; during vomiting convulsions, with loud shrieks on account of crampj T pains in the stomach. Ipec. Sudden attack; blood dark, black, sour; paleness; coldness; pulse scarcely perceptible; fainting; anxiety; pressure in stomach; great thirst; oppression of breathing; constipation or bloody stools. Mosclncs. When the patient becomes pulseless and collapsed. Nux vom. Throbbing pain in the head; pale, distressed face; belching; constant nausea; stomach full and distended, sore to the touch; burning anxiety and pressure in the precordial region; pain in the region of the spleen; constipation, with black stools; urine turbid, dark; fainting; weak- ness; temperature of the skin increased ; pulse full, hard, quick. Phosphor. Bright blood; drowsiness; sleepy; face, lips, gums and tongue are pale; thirsty, better from drinking cold water; loathing of food; heaviness and heat at the pit of the stomach, which is distended; abdomen soft; urine dark; skin warm, with partial perspiration; pulse quick, ener- getic. Secale. The patient lies still, with great weakness but no pain; face, lips, tongue and hands deadl} 7 pale; skin covered with cold sweat; pulse fre- quent, thread-like; oppression; abdomen soft, without pain. Veratr. Slow pulse; cool temperature of the skin; chilliness; fainting fits; inability to stand; moving or rising causes sickness in the stomach at once; cold sweat; even fainting. When in connection with suppressed menstrual discharges, compare Conium, Ipec, Millef., Pulsat., Sulphur ; with suppressed haemorrhoidal dis- charges, Carb. veg., Millef., Nux vom., Sulphur ; after mental emotions, Aeon., Hyosc, Natr. mur., Phosph. ac. When in combination with scurvy, typhus: Alum., Arsen., Carb veg., Nitr. ac, Phosph., Phosph. ac, Sulph. ac. In consequence of destructive processes within the stomach, compare Carcinoma et Ulcus Rotundum Ventriculi. Gastromalacia, Softening of the Stomach. Post-mortem examination reveals the coats of the stomach softened, changed into a kind of pappy mass; it can easily be scraped off. The affec- tion is more or less extended and almost exclusively confined to the greater end of the stomach, or fundus ventriculi. And, notwithstanding such a complete decay, there is never found any sign of any catarrhal or inflamma- tory or ulcerative process in the whole mucous membrane of the stomach; neither is the decayed portion sharply defined, but passes gradually over into the healthy tissues. Its symptoms are such as are described under hydrocephaloid, or cholera infantum, the most prominent of which are con- stant vomiting and diarrhoea. The latest observations on this disease make it more than probable that gastromalacia is no disease, but a chemical process of decay after death. The reasons for this opinion are the following: 446 GASTROMALACIA. i . Softening of the coats of the stomach have been found in perfectly healthy individuals, who died suddenly or were executed after they had a short time previously partaken of food. Elsasser observes that the food which had been taken was easily prone to an acid fermentation, or contained already a natural acid, as wine, beer, etc. 2. Experiments which Elsasser made show that substances which easily undergo the acid fermentation, such as sugar, milk, starch, etc., bring on this softening in a healthy stomach, taken out of a corpse under application of the same degree of heat which the bod}' retains for some time after death. 3. The softening of the stomach is never found in a perfectly empty stomach, but always only in the presence of sour contents, and it is almost without exception found at the fundus ventriculi, that part of the stomach which lies deepest, if the body lies stretched out on its back, on a part, therefore, on which the fluid contents of the stomach must collect. Further- more, the size of the softened tissue has been found to correspond with the surface that has been covered by these contents. Furthermore, Elsasser found that, if he brought the bodies of children who died with cholera infantum into another position, that then other parts of the stomach were softened, and the fundus perfectly free from so-called gastromalacia. 4. The symptoms during lifetime which are ascribed to gastromalacia are so inconsistent and var3 T ing, that it would be almost impossible to make a differential diagnosis. Some writers describe it as an acute, others as a chronic disease; some under the form of cholera, others under the form of gastritis; others under the form of irritation, or congestion, or inflammation of the brain. Who is right ? And the most constant symptom ascribed to this disease — the constant vomiting — does not very well agree with a softened condition of the stomach as is found after- death. For it is almost impossible to realize that a stomach so far decayed could bear such contractions and revolutions without bursting. 5. There is one symptom entirely absent during life which we should naturally suppose would necessarily occur, if such softening were really present during life, viz., the vomiting of blood. Imagine the entire destruc- tion of so large a piece of membrane, which is full of blood-vessels, without any bleeding! And yet, if this same organ is artificially injected after death, the injected matter escapes from all parts of the softened surface, why should not the blood during life do the same ? 6. According to latest observations it appears that in extremely rare cases the softening of the stomach may begin before death, and even proceed to complete perforation. (Lauber.) I will close by simply suggesting that time and research ma)' reveal the fact, that many other conditions, now considered to be the result of morbid processes in the living organism, are but the products of changes which the body undergoes after it has been given over to the sole influence of chemical and mechanical agencies. DISEASES OF THE INTESTINAL CANAE. 447 b. DISEASES OF THE INTESTINAL CANAL. Catarrhus Intestinalis, Enteritis Catarrhalis, Intestinal Catarrh. In its acute form this affection presents the same appearance as that by which a catarrhal inflammation of any other mucous membrane is character- ized — injection, swelling, infiltration of the submucous tissue; besides there is almost always swelling of the solitary and Peyer's glands, also frequently hyperemia and enlargement of the mesenteric glands; the serous fluid is mixed with epitheial cells changing gradually into a thick, turbid phlegm, which adheres to the walls of the intestines. Primarily, it may take place after overloading the stomach, the use of purgative medicines, taking cold, and after mental emotions. Secondarily, it accompanies tuberculosis, cancer, typhus, puerperal fever, pneumonia, dentition, and wide-spread external inflammations in consequence of burns. The Symptoms vary according to the locality of the affection. A ca- tarrhal inflammation of the duodenum, is almost always found in connection with catarrhal inflammation of the stomach, and is characterized by obstruc- tion of the ductus choledochus and consequent icterus. A catarrhal inflam- mation of the colon almost alwa} 7 s extends to the rectum, and is characterized by colicky pains, also pains in the sphincter ani, tenesmus, and burning at the anus. A catarrhal inflammation confined to the rectum alone offers the same symptoms. In all cases, however, diarrhoea is the most permanent symptoms, except where the inflammation is confined to the upper portions of the small intes- tines, when there may be no diarrhoea at all. The color of the discharge is at first usually green, from an admixture of bile which has not been changed by the normal digestive process; later, when the discharges become more abundant, the dejections grow pale and whitish. In cases of affections of the lower portion of the colon and of the rectum, the evacuations are slimy and even bloody. The frequency of stools varies according to the severity of the case. The evacuations are usually preceded by sharp, cutting pains in the abdomen, which subside after each evacuation. Severe cases are attended with fever, headache, delirium, want of appetite, sickness of the stomach, and thick coated tongue. Secondary catarrh of the intestines, according to its seat, presents the same symptoms, but modified by the original affection and sometimes dis- guised by it. That which ensues in consequence of severe external burns, according to Curling, usually sets in at or about the tenth day after the in- jury, and is characterized by a sharp pain in the epigastrium and towards the region under the right ribs, and sometimes by a severe diarrhoea. In most books we find a chapter on ''enteritis," or inflammation of the bowels. The term is too wide. It embraces what we have to diagnosticate specially: as dysentery, ulceration of the bowels, peritonitis; in short, any 448 THERAPEUTIC HINTS TO DISEASES OF THE INTESTINAL CANAL. inflammatory affection of the bowels, and is, therefore, worth about as much as the enchanting term of "liver complaint.'' Therapeutic Hints. Aeon. After checked perspiration: frequent, scanty, and loose stools with tenesmus: green stools, like spinage; jaundice. Aloes. Pain and rumbling in the bowels before stool; escape of large quantities of wind with the stool; pain in the small of the back. Ant. erud. Disordered stomach from sour wine or beer; white tongue; watery discharges; thirst at night. Aranea. Colicky pain and diarrhoea daily at the same hour, with a feeling as if the arms and legs were asleep. (Nunez.) Arsen. After chilling the stomach by taking cold substances; painful or painless diarrhoea; worse about midnight; sudden prostration and great thirst; also diarrhoea in consequence of severe external burns. Benz. ac. Fetid, white, froth}' stools, like soap-suds; urine high-colored and very offensive; child weak and very cross; wants to be nursed all the time. (A. Korndoerfer. ) Bryon. When the weather changes suddenly from cold to warm, or from warm to cold; in the summer season; after eating fruit or sour-krout; after vexation and anger; painful diarrhoea, worse from motion and in the morning. Calc. carb. During dentition, with vomiting and diarrhoea, which is generally worse in the after part of the day. Chamom. Painful diarrhoea of little children; they draw their limbs up; their belly is bloated, hard; the discharges are water}', or greenish and slim}', or undigested, looking like chopped eggs; there is rumbling in the bowels, and soreness of the anus; jaundice. China. Frothy diarrhoea, generally painless; after sour beer; with a great deal of fermentation in the bowels; worse after eating, and in the night. Collin. Diarrhoea of children, accompanied with colic, cramps, flatu- lence, etc. Coloc. With every pain he doubles up, or presses the belly against a hard object. Corn. circ. Dark and bilious stools, with griping and tenesmus; gen- eral debility and nervous excitability; chilliness, followed by flushes of heat and sweat. Crot. tigl. Suddenly gushing out of yellowish watery substances, with pain before. Cupr. arsen. With abdominal pains. Dulcam. When the weather changes suddenly to cold; cold, chilly feel- ing in the small of the back: griping in the region of the navel, with nausea in the stomach. Fcrrum. Painless, large, watery discharges, with a good appetite. Ipcc. Diarrhoea and vomiting during dentition; in consequence of eating CHRONIC INTESTINAL CATARRH. 449 sweet, fat, or sour things (raisins, pound-eakes, pastry, salad, etc.); accompa- nied by pain in the bowels; paleness of the face; cold extremities; even spasms. Iris vers. Burning in the rectum and anus after a passage; painful, green discharges; periodical spells of diarrhoea; always at night about two or three o'clock. Jatropha. Painless diarrhoea, worse in the morning, thin, watery, with loud rumbling, and gushing out of stools. Leptand. Profuse, watery stools, followed by severe cutting pains in the small intestines; after exposure to wet, damp weather. Magn. carb. Stools green, like scum on a frog pond; sour, frothy; or with white, floating lumps, like tallow. Colic before, better after stool. Mercur. Great straining, cannot get done; discharges slimy, green or blood}' ; from taking cold; worse in the evening; jaundice; chafed at anus. Nux vom. Always after previous use of quack medicines, teas, lauda- num, brandy, lavender, peppermint, etc., frequently worse early in the morning. Podoph. Diarrhoea, which changes constantly in appearance, now green, now yellowish, now whitish, slimy, etc.; always worse in the forepart of the day; during teething; rolling the head from side to side. Pulsat. Chilliness; thirstlessness, bitter taste in the mouth; coated tongue; diarrhoea worse at night; disordered stomach; nausea. Rheum. During dentition; the whole child smells sour; sour discharges, green, brown, fermented; great pain in bowels and crying; pain worse at once from uncovering an arm or leg. ' ' The child asks for many things with vehemence and tears; is temporarily satisfied after its whims are gratified, attended by pallor of countenance, occasional twitching of eyelids, soreness of mouth, lips and fingers; sweat of the hairy scalp asleep or awake; sweat sour or not; crying desires for various articles of diet, but quickly satisfied. Colic often worse after a diarrhoeic stool; increased urging to stool, when moving about." (M. B. Tuller.) Rhus tox. Great pain in the bowels before evacuation, which is green- ish, and contains jelly-like globules or flakes; worse in the night or when keeping quiet. Rumex. Diarrhoea in the morning, with cough from tickling in the throat-pit. Sulphur. Either without pain or with straining; always worse in the morning, driving out of bed; excoriating the anus. Veratr. In summer season with vomiting, coming on suddenly at night, generally painless; white. Great thirst; feels worse after drinking. Chronic Intestinal Catarrh. Its pathological features differ much from those of the acute form. The mucous membrane of the intestines appears livid, brownish-red, or gray, slate-colored; it is thickened and swollen; its follicles are hypertrophied, and 29 45° THERAPEUTIC HINTS TO CHRONIC INTESTINAL CATARRH. the whole surface is covered with a tough, grayish, sometimes transparent and jelly-like slime. In some cases all the coats of the intestines are hyper- trophied, and polypous excrescences found upon it. Sometimes the mucous membrane appears pale, anaemic, and the submucous cellular tissue infiltrated. It is usually diffused over large tracts of the canal, but may be confined to the lower part of the small intestines or to portions of the colon. This form develops itself either in consequence of repeated acute attacks, or the frequent use of purgative medicines, or is a concomitant of various other complaints, such as cancer, tuberculosis, typhus, obstructed circulation in the vena porta, cirrhosis of the liver, organic diseases of the heart and lungs, or obstruction in the gut itself. Its Symptoms are the following: i. Diarrhoea or constipation, frequently in alternation. The diarrhceic stools consist mostly of thin, fecal matter, of all colors and consistencies, mixed with considerable quantites of slimy, jelly-like matter. The hard evacuations are always covered with tough or jelly-like phlegm. 2. Copious development of gas in the bowels, which causes partial or general distention of the abdomen and great distress to the patient. Its pass- ing off gives great relief, and for that reason the patients make much account of it. 3. Hypochondriacal mood. Such patients do not think or speak of any- thing but their own sufferings; tormenting everybody with the same sorrow- ful tale. 4. Gradual emaciation, and, in severe cases, sinking in of the abdomen, in which the thickened intestines can be felt through the abdominal walls. As regards its location, we may conceive the inflammation as situated: 1. In the upper part of the small intestines, if the patient complains of a dull pain in the middle of the abdomen and constipation. 2. In the lower part of the small intestines — the ileum — if it is attended with greenish-yellow, or yellowish-gray, watery stools, which, w T hen left standing, form a sediment. 3. In the large intestines, if the evacuations contain large quantities of slime or pus mixed with blood, and are attended with a great deal of tenesmus. Therapeutic Hints. Arg. nitr. Diarrhoea, worse at night; watery, slimy; always after drinking or eating soup, immediate discharge from the bowels, as though the fluid were rolling through without stopping; soreness and burning in the region of the sigmoid flexure; fever; emaciation; desire for sugar. Arsen. Worse about midnight; burning pain in the abdomen; dis- charges burning, cadaverously-smelling, excoriating the anus; thin, lumpy, of all colors; great thirst; restlessness; exhaustion and emaciation; old look in the face; very cross and despondent. B apt is. Stools dark, offensive, exhausting; pain in the liver and region of gall-bladder, sweat and urine extremely fetid; little or no thirst; gone feeling at pit of stomach; frequent faintings. THERAPEUTIC HINTS TO CHRONIC INTESTINAL- CATARRH. 45 1 Bryan. Pain in the bowels after eating or drinking; slightest motion brings on a discharge which looks like dirty water, showing, on standing, a whitish, fineh* granulated sediment of undigested food at the bottom of the vessel. Calc. card. During dentition; scrofulous individuals; diarrhoea, worse toward evening; whitish, chronic, soft stools; emaciation. Card. veg. Great collection, of wind in the abdomen, frequent dis- charges of very fetid flatus without relief; stool, even if soft, is passed with great difficulty, similar to. Cinchona. Coccul. Diarrhoea ovXy through the day, thin, yellowish, without pain; great rumbling in the bowels; hectic fever; general emaciation. Coloc. Chronic diarrhoea in the morning; watery; with pain in the sides of the abdomen. Crot. tig I. Diarrhoea, with nausea; watery discharges gushing out forcibly; worse after drinking, and in the summer season. Gelsem. When diarrhoea is always brought on by exciting news, fright or emotions of the mind. Graphit. A quantity of white mucus is expelled with the stool, or the hard feces are covered with slime. Gummi gutt. Pain in ileo-caecal region, which is sensitive to the touch; discharges watery, slimy, undigested, without smell; during stool, bearing down and colicky pain, prolapsus ani, and cold sweat on the limbs. Also thin, yellow, fecal or watery, frequent, copious stools, coming out all at once; worse in the forenoon; sudden urging; after stool great relief in abdomen. Hepar. Especially after the abuse of mercury, with longing for sour or strong-tasting things; empty, sinking feeling in stomach, relieved by eating. Ipec. Cured a chronic diarrhoea with clean tongue and frequent nausea, constant pain at umbilicus; miasmatic origin. Aided by milk diet. ( W. L. Dodge.) Laches. Ileo-csecal region very sensitive to touch; after great strain- ing, discharge of a mass of croupous exudation; stools very offensive; heat of abdomen. Mercur. Discharge mostly slimy and with straining; worse towards evening and in the night; gums swollen; teeth loose; sickly smell from the mouth; the mere putting the hands upon something cold, causes pain in the bowels; debility; sweat without relief. Natr. mur. Diarrhoea mostty through the day; greenish, bloody; or watery; perceptible falling away in flesh on the neck; the neck becomes quite thin . ( Hering . ) Nitr. ac. Acute pain in the abdomen during stool; worse in the morn- ing; discharge brown and slimy. Nuphar hit. Stool liquid, light yellow; the call is urgent, must go quick, every morning at six o'clock, and followed by two or four more pas- sages in a few hours, and no more until next morning. (J. L. Gage.) 452 DIGEST TO ACUTE AND CHRONIC INTESTINAL CATARRH. CEnoth. bicn. Relieves the melancholy and low spirits which accom- pany the chronic form. (J. S. Douglass.) Petrol. Slimy discharge; also, brown fluid or pappy evacuations; pain in the bowels; before dusk a sensation of unpleasant motion and grasping in the bowels; disgust for meat, especially fat; bitter-sour taste in the mouth; cold feeling in the abdomen. Diarrhoea, sometimes only during the day. Phosphor. Painless, watery discharges; especially in the morning after getting up; in debilitated, consumptive patients; lying-in women, etc. ; burning of the palms of the hands; great weakness; emaciation. Worse in warm weather. Phosph. ac. Painless, watery discharges, with great rumbling in the bowels; during cholera epidemics. Sepia. Jelly-like stools, with colic; debilitating diarrhoea; worse after milk; the whole aspect of the patient indicates a deep-seated disturbance in the digestive functions. Sulphur. Diarrhoea; worse in the night or early in the morning; stools yellow or brownish or greenish, mixed with blood, slime or pus; feces pass off while the patient intends to relieve himself of flatus; the abdomen is sore to the touch; during stool, pain in the small of the back; palpitation of the heart; congestion of the head; prolapsus ani; itching, burning, smarting in the anus and rectum. Frequent alternation of costiveness with diarrhoea suggests: Ant. crud., Arg. nitr., Arsen., Bryon., Graphit., Natr. mur., Phosphor., Rhus tox., Ruta, Sepia. Copious development of gas: Card, veg., Coecul., Graphit., Nib. ac., Phosphor., Pulsat. The patients think and talk of nothing but their ailments: Arsen., Calc. carb., Coecul., Mercur., Nitr. ac, Phosphor., Sepia, Sulphur. Emaciation and sinking in of the abdomen: Arsen., Borax, Calc. carb., China, Ferrum, Graphit., Iodum, Laches., Lycop., Natr. mur., Nitr. ac, Nux vom., Phosphor., Phosph. ac, Pulsat., Silic, Staphis., Sulphur, Veratr. Digest to Acute and Chronic Intestinal Catarrh. DISCHARGES. Green: Chamom., Iris, Mercur., Rheum. Bloody: Aeon., Mevcus., Natr. mur., > like scum on a frog-pond: Magn. carb. spinage: Aeon. and changing constantly in color: Podoph. Greenish: Chamom., Natr. mur., Rhus tox., Sulphur. Jelly-like: Sepia. globules of flakes: Rhus tox. Lumpy: Arsen. Offensive, fetid: Baptis., Ben-, ac, Laches. , cadaverously: Arsen. Sulphur. Brown: Nitr. ac, Petrol., Rhus tox. Brownish: Sulphur. Colors, of all: Arsen., Podoph. Croupous masses after great straining Laches. Dark: Baptis., Corn, circ Eggs, chopped, like: Chamom. Fermented: China, Rhus tox. Frequent: Aeon., Gummi. Frothy: China, Magn. carb. like soap-suds: Benz. ac. DIGEST TO ACUTE AND CHRONIC INTESTINAL CATARRH. 453 Pappy: Petrol. Pus, containing': Sulphur. Slimy: Arg. nitr., Chamom., Gummi, Mercur., Nitr. ac, Podoph., Sulphur. , a quantity of white mucus is ex- pelled with the stool, or covers hard feces: Graph it. Smell, sour: Magn. carb., Rheum. , without: Gunnni. Thin: Arsen., Coccul.,Jatropha. Undigested: Bryon., Chamom., China, Gummi. Watery: Ant. crud., Arg. nitr., Chamom., Color., Crot. tigl., Ferruvi, Gummi, Jatropha, Leptand., Natr. mur., Phosphor., Phosph. ac. Water, like dirty, with whitish, finely granulated sediment of undigested matter: Bryon. White: Ver. alb. floating lumps, like tallow: Magn. carb. Whitish, soft stools: Calc carb. Yellowish: Coccul., Crot. tigl., Gummi, Nuph. lut. PASSAGE. Sudden urging: Gummi. every morning at 6 o'clock, fol- lowed by two, four or more passages in a few hours and no more until next morning: Nuphar. Coming on suddenly at night: Veratr. out all at once: Gummi. Gush OUt: Crot. tigl., Jatropha. Stool is passed with difficulty, even if soft: Carb. veg., China. involuntarily while passing flatus: Sulphur. without pain : Arsen., China, Coccul. , Ferrum., Iris, Jatropha, Phosphor., Phosph. ac, Sulphur, Ver. alb. with pain: Arsen., Bryon., Chamom., Coloc, Ipec, Ins., Nitr. ac. and crying: Rheum, Rhus tox. Before stool pain: Crot. tigl., Magn. carb. and rumbling in bowels: Aloes. During stool colic: Aranea, Chamom., Collin., Coloc, ipec, Gummi., Sepia. , with doubling up and pressing the belly against a hard object: Coloc. , with drawing the limbs up: Chamom. , daily at same hour, with feeling as if arms and legs were asleep: Aranea. griping: Corn. circ. , pain in the sides of abdomen: Coloc. , in small of back; palpitation of heart; congestion to head: Sulphur. , with bearing down, prolapsus ani: Gummi, Sulphur. , burning and smarting in anus and rectum: Sulphur. , with paleness of face and cold ex- tremities: Arsen., Ipec. cold sweat on limbs: Gummi. , rumbling, flatulence: Collin., Jatropha. , escape of much flatus: Aloes. Passage, with straining and tenesmus: Aeon., Corn, circ, Mercur., Nux vom., Sulphur. , cannot get done: Mercur. , nausea and vomiting: Crot. tigl., Ipec, Ver. alb. , during dentition: Bellad., Calc. carb. After stool, relief in abdomen: Gummi, Magn carb. , colic: Rheum. , severe pain in small intestines: Leptand. , burning in rectum and anus: Iris vers. GENERAL SYMPTOMS. Patients think, talk of nothing but their ailments: Arsen., Calc. carb., Coccul., Mercur., Nitr. ac, Phosphor., Sepia, Sulphur. Low-spirited and melancholy: CEnanth. bien. Cross and despondent: Arsen. , child wants to be nursed all the time: Benz. ac. , carried about: Chamom. , many things with vehemence and tears, and is satisfied for a short time if its whims are gratified : Rheum. Rolling head from side to side: Podoph. Hairy scalp perspiring; sweat sour, or not: Rheum. Old look of the face: Arsen. 454 DIGEST TO ACUTE AND CHRONIC INTESTINAL CATARRH. Pallor of countenance, occasional twitch- ing of eyelids, corners of mouth, lips and fingers: Rheum. Gums swollen, teeth loose, sickly smell, from mouth: Mercur. Tongue clean: Ipec. coated: Pulsat. white: Ant. crud. Taste bitter: Pulsat. bitter sour: Petrol. Thirst great: Veratr. at night: Ant. crud. Thirstless: Baptis., Pulsat. Appetite good: Ferrum. Desire for sugar: Arg. nitr. sour or strong-tasting things: Hepar. various things, quickly satisfied: Rheum. Disgust for meat, especially fat: Petrol. Stomach disordered: Ant. crud. , Pul- sat. Deep-seated disturbance of digestive functions: Sepia. Nausea: Ipee., Pulsat. Empty, gone, sinking feeling in stom- ach: Baptis. relieved by eating: Hepar. Pain in liver and region of gall-bladder: Baptis. Jaundice: Aeon., Chamom., Mercur. Griping about navel with nausea: D id- ea m. Pain constant about navel: Ipee. Soreness and burning in region of sig- moid flexure: Arg. nitr. Pain in ileo-caecal region, sensitive to touch: Gi/mmi, Laches. Cold feeling in abdomen: Petrol. Burning pain in abdomen: Arsen. Heat of abdomen externally: Laches. Unpleasant motion and grasping in bowels before dusk: Petrol. Soreness of abdomen to touch: Laches., Sulphur. Rumbling in abdomen: Chamom., Coc- cul., Phosph. ac. Fermentation in bowels: China. Copious development of gas: Card. i'eg., Coccul., Craphit., Nitr. ac., Phosphor., Pulsat. Belly bloated and hard: Chamom. Frequent discharges of very fetid flatus without relief: Card. veg. Frequent alternation of costiveness with diarrhoea: Ant. crud., Arg. nitr., Arsen., Bryon., Graph it., Natr. mur., Phosphor., Rhus tox., Ruta, Sepia. Emaciation and sinking in of abdomen: Arsen., Borax, Calc. card., China, Ferrum, Graphit., Iodium, Laches., Lycop., Natr. mur., Nitr. ac, Nux z'om., Phosphor., Phosph. ac, Pulsat., Silic, Staphis., Sulphur, Ver. alb. Urine high colored and very offensive: Benz. ac. fetid: Baptis. Chafed, excoriated, sore anus: Arsen., Chamom., Mercur., Sulphur. Cough from tickling in the throat-pit: Rumex. Cold, chilly in small of back: Did cam. Chilliness: Pulsat. , followed by flushes of heat and sweat: Corn. circ. Hectic fever: Coccul. Burning of palms of hands: Phosphor. Sweat fetid: Baptis. without relief: Mercur. Restlessness: Arsen. Nervous excitability: Corn, circ, Rheum. Weakness: Phosphor. Debility: Corn, circ , Mercur., Sepia. Exhaustion: Arsen., Baptis. Prostration, sudden: Arsen. Emaciation: Arsen., Calc card., Coc- cul., Phosphor. , especially of neck: Natr. mur. Whole child smells sour: Rheum. aspect indicates deep-seated disturb- ance of digestive organs: Sepia. Worse in the morning: Coloc, Jatropha, Nitr. ac, Rumex. , early 2 or 3 o'clock a. M. : Iris. , early: Nux vom. , driving out of bed: Sulphur. , after getting up and moving about: Bryon., Phosphor. in forenoon: Gum mi, Podoph. in afternoon and evening: Calc card., Mere. sol. TYPHLITIS, PERITYPHLITIS AND APPENDICITIS. 455 through the day: Coccul., Natr. mur., Petrol. in the night: Arg. nitr., China, Mercur., Pulsat., Rhus tox., Sulphur. about midnight: Arsen. after drinking: Crotal., Ver. alb. Worse after drinking or eating: Bryon. or eating soup, as though the fluid were rolling through without stopping: Arg. nitr. after eating: China. from slightest motion: Bryon. from moving about: Rheum. when keeping quiet: Rhus tox. from uncovering an arm or leg: Rheum. Aided by milk diet: Ipec. Brought on by disordered stomach, from sour wine or beer: Ant. crud., China. from sour krout, sour fruit: Bryon. from milk: Sepia. from sweet, fat or sour things (raisins, pound cakes, pastry, salad, etc.) : Ipec., Pulsat. by chilling the stomach with ice cream, iceis, Borax, China, Coffea, Phosph. ac, Sulphur. Griping: Rheum. Painful: Apis, Merc, sol., Sulphur. Colicky, with drawing up the legs: Chamom. Sudden, forcible: Crot. tigl. Involuntary stool and urine: Arsen. DURING STOOL. Colic and fermenting in bowels: China. and drawing up limbs: Chamom. Straining, with prolapsus ani: Merc, sol., Podoph. , anus remains open: Phosphor. * , retching: Ferr. phosph. Much flatulence: Calc phosph. AFTER STOOL. Great exhaustion and cold sweat on forehead: Ver. alb. Dozing, with plaintive cries: JEthusa. SYSTEMATIC SYMPTOMS. Half stupid and senseless: Camphora. Stupor: Borax. , interrupted with shrill shrieks: Apis. Delirium, with convulsive motions of eyes and lips: Ignat. Moaning: Ferr. phosph., Kreos., Podoph. Crying: Aeon. Biting fists: Aeon. Rolls head: Ferr. phosph., Ignat., Podoph., Zincum. Makes anxious face when being carried down stairs and put from the arms into cradle: Borax. when being taken up or carried up stairs: Calc carb. Will not be quiet unless carried over the point of the mother's shoulder: St annum. Cannot bear of being touched or looked at: Ant. crud. 476 DIGEST TO SUMMER-COMPLAINT. Wants to be carried about: Chamom., Rhus tox. Fretful: Psorin. and irritable: Br you. Cross: Charnom. Appears frightened on awaking: Zin- Sudden metastasis from bowels to brain during dentition: Ignat. Hydro cephaloid: sFthusa, Apis, Arg. nit v., Arsen. y Bellad., Borax, Bryon., Calc. phosph., Camphora, China, Cup- rum, Ferr. phosph., Helleb., Ignat., Laches., Lycop.. Phosphor., Podoph., Silic, Sulphur, Ver. alb., Zincum. Head hot: Podoph. and cold feet; Bellad. and remaining body cool: Arnica. and sophorous condition: Bryon. Sweat On head in thin, screaming chil- dren: Silic. during sleep: Calc. curb. hot: Chamom. Open fontanelles: Calc. carb. andphosph. Skull soft and thin, crackling like paper when pressed upon: Calc. phosph. Boils about the head: Iris vers. Eyes red: Apis. fixed and staring: AEthusa. half open: Ferr. phosph. Pupils dilated: Arg. nitr., Arsen. Convulsive motion of eyes and lips: Ignat. Eruption behind ears and between legs: Sulphur. Difficult hearing: Arsen. Nostrils sooty: Arsen. Face, cheeks flushed: Podoph. One cheek red, the other pale: Chamom., Ignat., Sulphur. Dirty white or brownish complexion, scrawny children: Calc. phosph. Sudden paleness, with rolling, tossing motion of head: Ignat Paleness, with a painful expression around the mouth: Aithusa. Face cold: Calc. carb. , with a pale bluish tinge on temples and around nose and mouth: Kreos. Anxious look when being lifted up; Calc. carb. carried down: Borax. Old, wrinkled face: Arg. nitr., Arsen., Calc. carb. and phosph. Face pinched: Ferr. phosph. Convulsive motion of eyes and lips: I gnat. Mouth generally dry; Sulph. ac. and lips dry: Bellad. , thrush in: Borax, Kali brom. aphthous condition: Sulph ac. Tongue dry: Apis, Arsen. coated white: Ant. crud. white, with red margin: Bellad. cold: Ver. alb. Speaking and swallowing difficult: Arsen. Dentition, during: Aeon., Calc. carb. Calc. phosph., Chamom., Coffea Podoph. , , sudden metastasis from bowels to brain: Ignat. Swallowing difficult: Arsen., Ignat. , can swallow, only liquids, no solids: Baptis. Thirst: Laches., Natr. mur. , but drinks little at a time: Arsen. , drinks large quantities: Bryon. , drinks hastily and greedy: Kreos., Sulphur. drinking increases nausea and diar- rhoea: Ver. alb. Longing for bacon or ham fat: Calc. phosph. boiled eggs: Calc. carb. Milk disagrees and is thrown up in coag- ulated lumps: Aithiisa. , boiled, disagrees: Sepia. Belching or hiccoughing, especially when being carried: Kreos. Nausea and vomiting predominates: Ipec. Gagging, retching or vomiting: Borax Podoph. Vomiting sour: Calc. carb., Iris vers. of frothy, green mucus or food: Podoph. , white matter, or coagulated lumps of milk: A^thusa. of mucus, followed by spells: Cu- prum. DIGEST TO SUMMER-COMPLAINT. 477 immediately after drinking: Arsen. as soon as the water has become warm in the stomach: Phosphor. after taking food or drink: Ant. crud. and greedy drinking: Kreos. after drinking milk which comes up in coagulated lumps: A^thusa. and purging, the latter predominat- ing: Ver. alb. may be present or absent: Cam- phora. Pain in bowels: Magn. card. Griping". Rheum. Colic, relieved by lying on the stomach: Coloc. Violent abdominal spasms, during which the abdomen gets hard: Kali brom. Abdomen sunken: Apis., Arsen. , soft and flabby: Borax. and tender: Apis. big and bloated: Calc. carb. hard: Kali brom. hot: Laches. Urine profuse: Bellad. scanty: Ferr. phosph., Helleb. and stool involuntarily: Arsen. suppressed: Apis. fetid: Benz. ac. dark: Helleb. Respiration and pulse accelerated: Ferr. phosph. Pulse quick, scarcely perceptible: Kreos. thread-like: Apis. Impulse of heart violent: Apis. Neck stiff: Arsen. emaciated: Natr. mur. Arms cold up to elbow: Calc. carb. Hands cold and blue: Apis. Feet cold, head hot: Bellad. Body cool, head hot: Arnica. Skin cold as marble, yet the child will not remain covered: Camphora, Secale. Feet sweaty, offensively: Silic. fidgety: Zincum. High fever and restlessness: Aeon. Skin dry: Apis, Calc. phosph. , eruption behind ears and between legs: Sulphur. Whole child smells sour: Rheum. disagreeably: Psorin. Sleep with starting: Bellad., Ferr. phosph., Zincum. with crying out: Apis, Zincum. Drowsy: Bellad. Sopor: Arg. nitr. , with hot head: Bryon. , or coma vigil, with staring, spas- modically moving eyes: Arsen. Sleeplessness: Aeon., Bellad., Chamom., Rhus tox. Trembling of whole body, periodically: Arg. nitr. Convulsions: Cuprum. with clenching the thumbs and turn- ing the eyes downward: JEthusa. Convulsive motions of eyes and limbs: Kali brom. of eyes and lips: Ignat. Palsy of the extremities: Arsen. Weakness and prostration: JEthusa, Arsen. Exhaustion follows after some time: Phosph. ac. Emaciation: Borax, Calc. carb., Kreos. Worse after midnight: Arsen. early in the morning: Nux vom., Sulphur. during early part of day: Podoph. after part of day: Calc. carb. the day: Natr. mur. the night: China. day and night: Bap lis. after eating: China. and drinking, or while mov- ing: Crot. tig I. after drinking: Veratr. milk: JEthusa, Sepia. fluids and sweet things which he craves: Arg. nitr. from motion: Bryon., Chamom. Caused by heat of summer: Crot. tigl. catching cold during hot weather: Dulcam. sudden changes to hot or cold weather: Bryon. errors in diet: Nux vom. eating fruit: China. or sour things: Ipec. Sulph. ac. is indicated when Chamom. has not relieved the excessive restless- ness. 478 CONSTIPATION. Constipation. Constipation has a relative meaning. Some persons feel perfectly well if they have a stool in two or three days. I know women who, in perfect health, have not more than one evacuation in a week. With most people one discharge every day seems to be the normal. Retarded action of the bowels is frequently accompanied with dizziness, headache, palpitation of the heart, hypochondriacal symptoms, haemorrhoids and flatulency. If long continued it ma)^ lead to dilatation and hypertrophy of the intestine and in some rare cases, where actual impaction of hardened and dried feces ensues, to inflammation, ulceration, and even perforation of the gut. Constipation may be brought about: by a diet containing too large an amount of indigestible matter (beans, corn and the like coarse food), which forms dry feces difficult to evacuate; by diseased conditions of the mucosa in consequence of chronic catarrh, which diminishes the peristaltic action of the bowels; D3 7 muscular weakness of the intestines in consequence of anaemia, chlorosis, long-continued diarrhoea, the use of purgative medicines, or the im- proper suppression of the desire for stool at regular hours; by paralytic affections of the intestines in consequence of opium, lead or other poisons, or cerebral or spinal diseases; by abnormal losses of fluids in diabetes, profuse lactation or sweats; by mechanical obstructions outside of the intestines from tumors, the enlarged or displaced womb; or by the presence of foreign bodies within the intestines, such as biliary stones, fruit stones, etc. Retarded action of the bowels in acute diseases, such as typhoid fever, scarlatina, measles, etc., is always of benefit to the patient, and should never to be interfered with in any crude manner. Therapeutic Hints. If frequent resort has been had to purgative remedies, this bad habit must at once be stopped. A careful regulation of diet, drinking of cold or hot water before retiring and after rising in the morning, a strict adherence to the rule: ''try to have the bowels moved at a regular hour every day or every other day;" the administration of injections of lukewarm water, and the occasional kneading of the abdominal walls by the fist will go a good way in helping to improve many cases of habitual constipation. But all this will not do in all cases, remedial agents will often be required, as may readily be inferred from the numerous causes by which constipation may be induced. For lazy chaps and wise ones, who either do their whole business with nux vom. and castor oil, or sneer at the symptom under Alumina: " the rectum is inactive," because they imagine that in constipation the rectum must necessarily always be inactive ! — the following special hints are not written: s£sc. hipp. Dry, uncomfortable feeling in the rectum, as if it were filled with small sticks; very painful haemorrhoids, with little bleeding; aching and lame feeling in the small of the back, extending to the sacrum "Smd hips; worse when getting up after sitting. THERAPEUTIC HINTS TO CONSTIPATION. 479 Alum. The rectum is inactive, there is no desire for stool; the evacua- tion can be effected only try straining the abdominal muscles, even when the stool is soft; stools hard, knotty and scanty, or sticking to the anus like putty; ailments from lead. Amm. mur. Hard stools, crumbling to pieces when evacuated, re- quiring great effort to expel them, followed by soft stools; feces covered by glairy mucus. Anac. Urging without being able to expel anything; the rectum feels as if stopped up with a plug; the expulsion not taking place immediately, he experiences a painful twisting and turning in the intestines across the ab- domen. Bryon. Hard, dry stools, as if burnt; of large size and passed with difficulty; rheumatic tendency; irritable and prone to fits of anger; after castor oil; during hot weather. Calc. carb. Hard, large, partially undigested stools; after stool feeling of faintness; oozing of a fluid from the rectum, smelling like herring-brine; too early and too profuse menstruation; restless sleep after three o'clock A. m. ; scrofulous diathesis. Capsic. After drinking, urging too stool, but only slime is passed; feel- ing of heat in the abdomen. Carb. veg. Urging with tingling in the rectum and pressure on the bladder; labor-like pain; discharging feces in fragments, which are tough and scanty; burning in bowels; tympanitis. Caustic. Frequent and unsuccessful urging, causing a good deal of pain, anxiety and redness of the face; stool comes off in pieces; at last soft, and of the size of a goose-quill; stool passes better while in a standing position. Chelid. Stools like sheep's dung; pain in liver and csecal region gurgling in abdomen, which is distended; crawling and itching in rectum; and reddish urine. China. Large accumulation of feces in the intestines, with dizziness and heat in the head; difficult stool, even when soft. Conium. Frequent urging without stool, or a small quantity being ex- pelled at a time; chilliness during stool; palpitation of the heart and tremu- lous weakness afterwards; the flow of urine suddenly stops and continues after a short intermission; dizziness when turning in bed. Ferrum. Flushed head and face with cold hands and feet; anaemia. Graphit. Hard, knotty stools, with tenesmus and stitches in the rectum; sometimes the stool is only of the size of lumbricoides; a quantity of mucus is expelled with the stool, or the hard feces are covered with mucus; itching blotches about the body, which secrete a glutinous fluid; erysipelatous or ulcerative processes of the legs. Hepar. Sluggishness and inactivity of the bowels, in consequence of which the abdominal muscles must bear down in order to effect an evacua- tion, which is hard or not, but insufficient; after mercurial dosing. Hydrast. Constipation, headache and piles; after stools, for hours se- 480 THERAPEUTIC HINTS TO CONSTIPATION. vere pain in the rectum and anus; colic pains with fainting turns and heat in the bowels; anaemia; remittent fever; "after purgative medicines." (Goodno.) Iris vers. Constant nausea, bitter eructations and vomiting; burning in epigastrium; colic with cutting pains and piles; hemicrania. /odium. Desire for stool, without evacuation; it takes place with great facility after taking some cold milk; discharges of thick mucus, or purulent matter; part of the feces being retained. Kali bichr. Stools dry, scant} 7 , knotty; painful retraction of trie anus; debility, headache, coldness of the extremities; tough secretion from any of the mucous membranes. Kali card. Too large-sized feces; inactivity of the rectum; severe lan- cinating, tearing and cutting in the anus; violent pain in the small of the back, as if broken. Ladies. Constipation of years' standing; the anus feels closed; the feces press against it all the time without passing; only single flatus are passed; the feces have a cadaverous smell; haemorrhoids, with stitching pain in the varices when coughing or sneezing. Lycop. Ineffectual urging, owing to contraction of the rectum (sphinc- ter ani); distressing pain in the rectum for hours after evacuation; excessive and painful accumulation of flatus in the abdomen; red, sandy deposit in the urine. Irritable and restless in the afternoon. Magn. mur. Stools hard and in large lumps; urgent pressure in the rectum, the stool comes out in small pieces and seems as if burnt; shudder- ing for a short time after stool. Pain and distress every few days in the hy- pogastric region. Natr. carb. Insufficient stool, with tenesmus, followed by burning in the eyes and urethra, with great sexual excitement. Natr. mur. Pressure from the navel downwards into the pelvis, or a leaden heaviness through the pelvis and across the bladder; worse when walk- ing, and better when sitting in a bent forward position; hard, dry stools As- suring the anus, making it bleed; a number of bad feelings in the anus after stool ; also cutting in the urethra after micturition. Nitr. ac. Hard, scanty stools; long pressing when going to stool; pain- ful burning in the rectum, especially after stool; urine emitting an intoler- ably strong smell. Nux vom. Constant, ineffectual urging to stool; large, hard feces; piles; headache; unrefreshing sleep; after previous use of purgative medi- cines; coffee and liquor drinkers; use of high-seasoned food; sedentary habits. Opium. Stools in hard, black, round balls; decided torpor and inertia of the rectum ; vomiting of stercoraceous substances in consequence of intus- susception; incarcerated hernia; lead poisoning. Phosphor. Stools narrow, dry, long, and difficult to expel; exceed- ing!}' painful cramps in the rectum after stool. THERAPEUTIC HINTS TO CONSTIPATION. 48 1 Phytol. Constipation of long standing; pain shooting from the anus and lower part of the rectum along the perineum to the middle of the penis. Platina. Difficult expulsion of scanty stool; adhering to the part like soft clay; after poisoning with lead; traveling in railroad cars. Plumbum. Stools consisting of small hard balls; constriction and drawing up of the anus; frequent, violent colic; drawing in of the abdomen in the region of the navel; numb extremities; knife drops from his hands. Podoph. Constipation with great difficulty; prolapsus ani; frequent micturition; weakness and soreness of the back; especially after washing. P?un. spin. Hard stool; intermitting stool, looking like the excrements of dogs, in small lumps, with stitches in the rectum, extorting cries. Pulsat. With menstrual disorders, or after suppression of intermittent fever b} r quinine. Ratan. Urging sensation in the small of the back, as if there would be stool; hard stool with straining; and sudden stitches in the anus; fissures of the anus. Ruta. Scanty, hard stool; frequent urging to stool, with protrusion of the rectum, also during stool; the rectum protrudes when stooping ever so little, and especially when squatting; a considerable quantity of flatulence is emitted whenever the urging takes place. Sabad. Violent urging to stool, with noise like the croaking of frogs; necessity of sitting a long while, then passes an immense quantity of flatu- lence, which is followed by an enormous evacuation, after that, burning pain in the abdomen. Sarsap. Obstinate constipation, with violent urging to urinate; urging to stool, with contraction of the intestines, and excessive pressure from above downwards, as if the bowels would be pressed out; during stool vio- lent tearing and cutting in the rectum; afterwards a repetition of the same symptoms. Selen. Stool so hard and impact that it has to be removed by mechanical aid; the feces contain threads of fecal matter like hair. Sepia. Unsuccessful urging to stool, only wind and mucus being passed, with sensation in the rectum as of a lump having lodged in it ; contractive pain in the anus; thence in the perineum and vagina; oozing of moisture from the rectum. During pregnancy. Silic. Stools composed of hard lumps; after long straining the protrud- ing feces suddenly recede into the rectum. Sulphur. Constant urging, pressing on the rectum as if it would pro- trude, with pressing on the bladder; prolapsus ani; palpitation of the heart; after stool excessive stinging and sore pain in the anus, preventing lying or sitting down; rush of blood to the head; cold feet; faintness regularly, towards 10 or 11 o'clock A. m. Sulph. ac. Hard stool, consisting of small black lumps mixed with blood, and with such violent pricking in the anus that she has to rise on ac- 3i 482 DIGEST TO CONSTIPATION. count of the pain; climacteric period; constant flashes of heat; tremulous sensation in the whole body without trembling. Tabac. Constipation; tympanitic bloating of the abdomen; dyspnoea. Thuja. Obstinate constipation, fever, inactivity, or intussusception; hard balls; violent pain in the rectum, which prevents the passage; offensive per- spiration at the anus and in the perineum. Verbasc. Scanty discharge of stool, like sheep's dung, with straining. Ver. alb. Chronic costiveness with heat and pain in the head; stools in black, round balls, or large and hard, or first portion of the stool of large size, the latter coming out in thin strings, although of the same consistence and color. During stool turning pale and faint, chilly with anxiety and cold sweat on forehead. Zincum. Dry, hard, insufficient, and difficult stool; afterwards violent bearing down in abdomen, relieved by passage of flatus up or down. Digest to Constipation. Constipation of longstanding: Laches., Phytol., Sarsap. , with violent urging to urinate: Sar- sap. , chronic: Ver. alb. , obstinate: Thuja. Sluggishness, inactivity, torpor of bow- els, abdominal muscles must bear down: Hepar. , of rectum: Alum., Opium. , no desire for stool: Alum. Large accumulation of feces: China. Urging, ineffectual :Anac., Lodium, Nux vom. , causing pain, anxiety and redness of face : Caustic. , with contraction of sphincter ani: Lycop. , with pressing on rectum, as if it would protrude, and pressure on the bladder: Sulphur. , with contraction of intestines as if the bowels would be pressed out : Sarsap. , only a small quantity being expelled : Conium. , only single flatus are passed: Laches, , only wind and mucus being passed, with a sensation in rectum as if a lump having lodged in it: Sepia. - , large quantity of wind is emitted: Ruta. , followed by an enormous evacuation and burning in abdomen: Sabad. , in small of back: Ratan. , with tingling in rectum and pressure on bladder: Carb. veg. , with protrusion of rectum: Podoph., Ruta. Urging, with noise like croaking of frogs: Sabad. , i «with labor-like pain: Carb. veg. , pressure from navel downwards into pelvis: Natr. mur. , with sudden receding of feces into rectum: Silic. , after drinking, but only slime is passed: Capsic. Evacuation difficult: Am. mur., Podoph. , with straining abdominal muscles: •Alum., Hepar. , followed by soft stools: Amm. mur. , even when stool is soft: Alum., China, , stools stick to anus like soft clay or putty: Alum., Platina. , part of feces being retarded: Lodium. Stool passes easy after taking some cold milk: Lodium. in a standing position: Caustic. Before Stool painful twitching and turn- ing in the intestines: Anac. During stool, violent pain in rectum, preventing passage : Th uja. , violent pricking in anus, must rise: Sulph. ac. , violent tearing and cutting in rectum: Kali carb., Sarsap. DIGEST TO CONSTIPATION. 483 , painful retraction of anus: Kali bichr. ■ , contractive pain in anus, in perineum and vagina: Sepia. , stitches in rectum: Print, spin. , stitches in rectum: Graphit. Ratan. , anus feels closed, feces presses against it: Laches. During 1 stool, Assuring the anus and making it bleed: Natr. mur. , chilliness: Com' inn, Ver. alb. , pale, faint, chilly with anxiety and cold sweat on forehead: Veratr. After stool, burning in eyes and urethra with sexual excitement: Natr. carb. , stinging and sore pain in anus, pre- venting lying or sitting: Sulphur. , pain in rectum and anus: Hydrast. , burning in rectum: Nitr. ac. , cramps in rectum: Phosphor. , distressing pain in rectum for hours: Lycop. , number of bad feelings in anus: Natr. mur. , bearing down in abdomen, better from passage of wind up or down: Zin- cum. , palpitation of heart and tremulous weakness: Conitnn. , feeling of faintness: Calc. carb. , shuddering: Magn. mur. NATURE OF DISCHARGE. Stool of large size: Br yon., Kali curb., Ver. alb. , later in thin strings: Ver. alb. and hard: Calc. carb., Magn. mur., Nux vom., Ver. alb. , dry and hard as if burnt: Biyon, Magn. mur. so hard and impact that it had to be removed by mechanical aid: Selen. scanty, insufficient: Alum., Carb. veg., Hepar, Kali bichr., Natr. carb., Nitr. ac, Ruta, Verbasc, Zincum. knotty: Alum., Graphit., Kali bichr. hard lumps: Si lie. small, black lumps mixed with blood: Sulph. ac. small hard ball: Plumbum Thuja. round blackball: Opium, Veratr. like sheep's dung: Chelid., Verbasc. , like excrements of dogs in small lumps: Prun. spin. narrow, dry, long: Phoshor. in pieces: Caustic, Magn. mur. , which are tough: Carb. veg. , crumbling to pieces when being evacuated: Amm. mur. Stool containing threads of fecal matter like hair: Selen. , feces covered with mucus: Amm. mur., Graphit., Lycop. , consists of thick mucus, or purulent matter: Iodium. of the size of lumbricoides: Graphit. a goose-quill : Caustic. , latter portion consisting of thin strings: Ver. alb. of cadaverous smell: Laches Rectum feels as if stopped up with a plug: Anac. , as if filled with small sticks: JEsc. hip p. , crawling and itching in: Chelid. Anus contracted and drawn up: Plum- bum. , lancinating, tearing, cutting in : Kali carb. , shooting pain along perineum to middle of penis: Phytol. , prolapsed: Nux vom., Pod op h., Sulphur. protrudes when stooping or squattng down: Ruta. Piles: Alsc. hipp., Hydrast., Iris, Nux vom. , stitch-pain in, when sneezing or coughing: Kali carb., Laches. Fissures of anus: Lgnat., Nitr. ac, Nux vom., Ratan. Oozing 1 of moisture from anus: Sepia. , smelling like herring brine: Calc carb. Offensive perspiration at anus and in perineum: Thuja. SYSTEMIC SYMPTOMS. Anxiety and redness of face from fre- quent and unsuccessful urging: Caustic. , cold sweat on forehead, face pale and faint during stool: Ver. alb. Irritable and prone to fits of anger: Bryon. and restless in afternoon: Lycop. Dizziness when turning in bed: Con i inn. 4 8 4 HERNIA. and heat in head: China. Heat and pain in head: Ver. alb. Flushed head and face with cold hands and feet: Ferrum. Rush of blood to the head: Sulphur. Hemicrania: Iris. Headache: Hydrast, Kalibichr., Nux Tough secretion from any of the mucus membranes: Kali bichr. Constant nausea, bitter eructations and vomiting: Iris. Vomiting" of stercoraceous substances: Opium. Burning' in epigastrium: Apis. Abdomen, bloating: Card veg., Lycop., Tabac. , heat in: Capsic, Hydrast. , burning: Carb. veg. Colic: Plumbum. , with fainting: Hydrast. Drawing in of abdomen in region of navel: Plumbum. Leaden heaviness through pelvis and across bladder: Natr. mur. Pain and distress every few days in hypo- gastric region: 3Iagn. mur. in liver and caecal region: Chelid. Menstruation too early and too profuse: Calc. carb. Menstrual disorders: Pulsat. Frequent micturition: Pod op h. Cutting in urethra after micturition: Natr. mur. Flow of urine stops and continues again after a short emission: Conium. Urine of intolerable strong smell: Nitr. ac. reddish: Chelid. makes a red, sandy deposit: Lycop. Dyspnoea: Tabac. Palpitation of the heart; Sulphur. Back, weakness and soreness, especially after washing: Podoph. Small of back, pain as if broken: Kali carb. , aching and lame feeling, extending to sacrum and hips: A^sc. hipp. Extremities, numb; knife drops from hands: Plumbum. cold: Kali bichr. Hands and feet cold: Ferrum. Feet cold: Sulphur. Rheumatic tendency: Bryon. Erysipelatous or ulcerative processes of legs: Graph it. Itching blotches about body, which emit a glutinous fluid: Graphit. Tremulous sensation in body without trembing: Sulph. ac. Sleep unrefreshing: Nux vom. restlessness after 3 a. m. : Calc. carb. Flushes of heat: Laches., Sulph. ac. Fever, inactivity: Thuja. Debility: Kali bichr. Faintness towards 10 or n a. m. : Sul- phur. After castor oil: Bryon. mercury; Hepar. lead: Alum., Opium, Platina. quinine: Pulsat. purgative medicines: Hydrast., Nux vom. During hot weather: Bryon. traveling in the cars: Platina. pregnancy: Sepia. climacteric age: Laches., Sulph. ac. incarcerated hernia: Opium, PI inn- bum. intussusception: Thuja. Scrofulous diathesis: Calc. carb. Anaemia: Ferrum, Hydrast. Hernia; Internal and External Strangulation. Both consist of a ' ' constriction or nipping of a portion of bowel by the edges of some natural or artificial orifice through which it protrudes, with consequent arrest of the circulation of blood in it, and impediment to the passage of fecal matters along it." (Bristowe.) Internal strangulation may take place in the foramen Winslowii or the foramen ovale, or in any abnormal fissure or opening which has been THERAPEUTIC HINTS TO HERNIA. 485 formed by inflammation and consecutive adhesion, and formation of bands and strings within the cavity of the abdomen. External strangulation may take place in the inguinal or in the crural canal, in the opening which gives passage to the infrapubic vessels, in the sacro-sciatic notch and in the umbilicus. But it does not follow by any means, that the displacement of a portion of the bowel in any of these by- wa3^s should always be followed by strangulation. If, however, strangulation does result, the symptoms are the same whether it be internal or external strangulation: there is acute pain in the region of the lesion, which is fol- lowed by obstinate constipation and vomiting at first of yellow and greenish and later of fecal matter — Miserere. The Diagnosis of internal strangulation is obscure, because its symp- toms are common to any kind of occlusion of the intestinal tract. External strangulation in cases of ordinary herina may always be detected by careful examination. Therapeutic Hints. The first endeavor in any case of hernia, whether strangulated, incar- cerated, or merely protruded, must be to reduce it. The manipulations used in this endeavor are called taxis, and consist of various procedures. The patient is laid on his back, with the shoulders low and the pelvis elevated; the leg of the affected side is flexed upon the thigh and the thigh upon the abdomen, and then by rotating the limb inward the columns of the ring are relaxed. Or the patient is raised by his feet, so that by its own gravity the pro- truded bowel is retracted into the abdominal cavity. Or the patient is placed in a semi-prone position towards the affected side with the thigh flexed upon the body; his eyes are covered with a towel, and then some cold water is suddenly dashed upon the chest and epigastrium, which causes by its shock a quick and deep inspiration, in consequence of which the hernia slips back. Or, according to Baron Sentin's method, "seek with the index-finger for the aperture giving issue to the hernia, pushing up skin sufficiently from below in order not to be arrested by its resistance. Pass the end of the finger slowly between viscera and herniary orifice, depressing the intestine or omentum with the pulp of the finger. This stage demands perseverance. Now curve the finger like a hook, exerting enough traction on the ring to rupture some fibres, causing a cracking very sensible to the finger, sometimes to the ear. When this crack is not produced, submit the fibres to a continuous forced dilatation." Or place a jar filled with hot air over the abdomen, when, by cooling, the contents of the abdomen are drawn up into the jar and the hernia out of its enclosure — dry cupping. Or draw the hernia gently outwards with the right hand in order to dis- engage it from the neck of the sac, and then push gently with left thumb and 486 THERAPEUTIC HINTS TO HERNIA. index-finger upon the upper part of the tumor, thus emptying its upper por- tion first, when the rest will follow. A gentle, but persistent, pressure is necessary. A peculiar gurgling noise in the abdomen pronounces the reduc- tion of the hernia. Next to taxis the emptying of the lower bowels is of great importance, in order to restore the peristaltic motion of the intestines. Dr. Hensler recommends large and repeated injections of sugar- water, as not only soften- ing the impacted feces, but also as nourishing to the mucous membrane of the gut. Dr. Finkelnstein recommends the external application of oil and ether in the proportion of 20 parts to 100, every fifteen minutes, which in a number of cases will reduce the hernia in one hour. Any of these methods may succeed; but the carefully selected remedy may do it without them, or at least faciliate our success greatly and diminish more and more the necessity of the knife. Aeon. Soreness, burning and heat and throbbing in tumor; excessively sensitive to touch; after fright and cold. Arsen. When the tumor assumes a dark red or livid appearance, with great restlessness and prostration. Aurum. The testicles are slow in lowering down into the scrotum; in- guinal and umbilical hernia in children from crying. Bellad. Soon after strangulation, which is caused fry spasmodic action of the muscular fibres, and before inflammation has set in. Borax. If in children the anxious face is present during any downward motion. Calc. carb. Rachitic children; big-bellied and prone to diarrhoea. Coccul. When the prostration takes place very slowly, as if from a paralytic state of the abdominal ring. Laches. Livid appearance of the tumor; coughing or sneezing goes like a knife through the tumor. Lycop. Has been very effective in hernia of right side, with rumbling in abdomen and great fullness; also in women of a gentle disposition. Magn. carb. Scrotal hernia. Nux vom. Sudden violent pain in hernial region; drawing and tear- ing, and spasmodic constriction in the abdomen, with nausea, vomiting of sour mucus; constipation with constant ineffectual urging to stool; or, similar to Coccul. , slow protrusion in aged persons, with squeezing pain in the hernial region, fullness in abdomen, periodical nausea; tumor not very sensitive, is soft and doughy; later comes pinching and griping in abdomen, periodical nausea, gulping up of salty or bitter water, vomiting, etc. Nux vom. is fre- quently indicated, and especially if errors in diet have preceded; if it fails Coccul. follows well. Opium. Soporous condition; red face; distended abdomen with flatus; antiperistaltic motion, belching and vomiting; bowels absolutely closed, with constant urging to stool and urine. TORSION. 487 Plumbum. Has relieved strangulation where Aeon., Bellad. and Nux z'om. failed, in many cases. (Baumann. ) jR/ius tox. After straining or lifting heavy loads. Silic. " Frequent colic, relieved by the discharge of offensive flatus; tenderness about the hernial tumor; vomits much milk after nursing." (Guernsey.) Boils; abscesses; offensive sweat of feet. Stannum. "Inguinal hernia; the child has curdy stools and much colic, which is relieved by laying its abdomen across the nurse's knee, or against the point of her shoulder." (Guernsey.) Sulph. ac. Left side, in melancholic and phlegmatic persons; after carrying heavy loads. Von Bcenninghausen considers it as one of the most important remedies in inguinal hernia. Thuja. " Sweat only on the uncovered parts, while covered parts are dry and hot. ' ' (Von Bcenninghausen. ) Vet. alb. Antiperistaltic action, hiccough, cold sweat, nausea, with sensation of fainting and violent thirst. Torsion or Twisting of the Bowels. This takes place most frequently at the sigmoid flexure when, by a dis- proportion (mostly congenital) between the length of the S-loop and the smallness of its mesenterial root, the overdistended sigmoid flexure, filled with gas and feces, is rendered liable of rolling about its axis, and by its own w r eight and inactivity is prevented from straightening or untying itself again. This occurs most frequently in advanced life. Twists also take place not unfrequently when by unusually long mesen- tery portions of the ilium are rendered freely movable and are thus made liable to twist around their own axis. Peritoneal false ligaments or omental adhesions running directly across the pedicle of the twisted loop may fix it in its twisted position, causing, by degrees, a permanent occlusion of the bowels, which is often preceded for a long time by colic, meteorism and con- stipation. " Occlusion itself comes on acutely, with severe symptoms of in- ternal incarceration, rapid collapse, vomiting, meteorism, and usually violent tenesmus, with frequent, sometimes bloody diarrhoea, followed by death within the first twenty-four hours — on the average on the fourth day." (Leichtenstern. ) A lateral kinking, the result of dislocation, is seen most frequently in the caecum and ascending colon, when they are rendered movable by an unusualty long meso-colon and become displaced inward or into the left hypochondrium. " But the kinking is, in itself, insufficient to produce definite impermeability, which requires the addition of some compressing cause, most frequently the mesentery of a convolution of the small intestine, which overlies the bent point and obstructs it by compression." (Leichtenstern.) Intussusception ; Invagination. By this is meant ' ' the prolapse or slipping of a tuck of intestine into 488 INTUSSUSCEPTION. the cavity of the portion of intestinal tube immediately below it, wherewith it is continuous." (Bristowe.) It takes place in consequence of paresis of a limited portion of the intestine associated with vigorous peristaltic action of the portion below, just as prolapsus recti may follow violent anal tenesmus. It has been observed in all parts of the large and small intestine. The ileo- caecalis is the most common form in childhood; in adults, ilium and ileo- cecal invaginations occur nearly as often. The ilium invaginations are found most frequently in the lower and lowest part of the ilium, while colon invagi- nations are more frequent in the descending colon and sigmoid flexure. The length of bowel involved in an intussusception varies from two to three inches up to three or four feet. The course of these lesions is also va- riable. Invaginations may be reduced spontaneously, or by suitable treat- ment; or the invaginated portion of the bowel, from being compressed, ma}' inflame, die and slough off either entire, or what happens oftener, in pieces or in shreds. This separation occurs, in the majority of cases, from the eleventh to the twenty-first day after the production of the invagination; in chronic cases it may not happen until after several months. Or, and this is by far the most frequent in chronic cases of ileo-caecal invaginations, the two cylinders be- come fixed by a solid union, when after the complete disappearance of the swelling the canal of the invaginated portion becomes again permeable; or in very acute cases in invagination leads to immediate and permanent oc- clusion. The patients die in from three to six days with the symptoms of internal strangulation, with or without peritonitis or perforation. The Symptoms are ushered in suddenly with violent colic, which is fol- lowed by vomiting, especially in children if the lesion be situated high up. Now follows diarrhoea, which lasts at least until all the contents below the lesion are discharged. These evacuations are always mixed with blood, which oozes from the compressed and congested portion of the invaginated bowel, and consist at last of mere bloody mucus with violent tenesmus, which appears earlier and is the more intense the nearer the intussusception is to the* rectum. In this case there frequently follows a paralysis of the rectal sphincter and patulence of the anus, through which the bloody passages escape involuntarily, a symptom especially found in children. The next and quite important symptom is the usually cylindrical, sausage-like tumor, which can be felt in the abdomen almost always in colon and ileo-caecal invagina- tions, but seldom in those of the ilium. In some cases the intussusception extends so low down into the rectum that its lower extremity may be detected by the finger inserted into the anus. Invaginations, especially in the small intestines, are frequently found in the bodies of children, but unaccompanied by any inflammatory changes; they seem to be produced during the last struggle, and must therefore be considered as mere cadaveric changes. Ileus or Miserere are terms which denote stercoraceous vomiting, in consequence of any kind of occlusion of the intestine. therapeutic hints to intussusception. 489 Therapeutic Hints. Ileus or Miserere hint to: Aeon., Arsen., Bellad., Chamom., Coccul., Coloc., Cuprum., Diosc, Lycop., Nitr. ac, Nux vom., Opium, Platina, Plumbum, Raplian., Rims lox., Sambuc, Silic, Sulphicr, Thuja, Ver. alb., Zincum. Aeon. Inflammatory symptoms; restlessness and impatience. Alum. Pinching pain in the bowels; obstruction from inactivity and dryness of rectum; dry retching, or mucous vomiting; low-spirited, weeping, hopeless mood. Arsen. Burning pain; restlessness and prostration; better from hot applications. Bellad. Pain in right ileo-caecal region; cannot bear any touch; claw- ing around the navel; vomiting, can keep nothing down, is pale and weak. Prolapsus ani; paralysis of the sphincter ani. During teething. Carb. veg. In slow 7 cases, when other remedies have failed and the pulse is intermitting. Coloc. Neuralgic pain in bowels; obstruction, as if from dryness of the bowels; serous, bilious vomiting without nausea; angry mood; thrown things out of his hands; indignation. (Hayward.) Cuprum. Violent pain in iimbilical region; total obstruction of bowels; violent, continued convulsive vomiting of blood and feces; singultus; great agony. Kali bichr. Pain as in enteritis; vomits in rapid succession bilious, blood} 7 matter; the blood is bright and clotted. Listless, indifferent, languid mood. (Harvard. ) Nux vom. Crampy, remittent pain in bowels; contraction or restric- tion of bowels; sour, mucous and bloody vomiting; quick, spasmodic pulse and hot skin; irritable, sullen, quarrelsome mood. Opium. Constipation; vomiting of fecal matter; excessive thirst; dis- tended abdomen, painful to touch; crampy motions of the intestine, at times like a rolling up of a hard body in right hypochondrium; frequent hiccough; small, frequent pulse; cold extremities; distorted face. Phosphor. Paralysis of sphincter ani. Plumbum. Violent colic in region of navel, with complete obstruction of bowels and stercoraceous vomiting; anus feels as if drawn upward; swell- ing in the ileo-csecal region; depressed and restless disposition. Thuja. Ileus; spasmodic stricture, as if something alive was pushing out; ineffectual urging to stool, with erections. Sweats only on the uncov- ered parts of the body, while the covered parts are dry and hot. Ver. alb. Colic; burning, twisting, cutting pain, with nausea and vomiting, worse from food, better after wind passes; cold skin; cold perspi- ration; small, spasmodic pulse; restless and anxious. As mechanical means to reduce invaginations, injections of air have been used by means of an ordinary bellows attached to an oesophageal sound 490 H.EMORRHAGIA INTESTINALIS. until a consideral abdominal tension and the desired effect was produced. Dr. W. Danforth procured, in a desperate case, the same effect by injecting one ounce and a half of soda, dissolved *in a pint of water, and followed by the injection of a dessertspoonful of tartaric acid in a cupful of water. The thus suddenly generated gas untied the knot. A copious enema will often achieve the same result. Haemorrhagia Intestinalis, Intestinal Haemorrhages, Malaena, Takes place in consequence of either — i. Obstructed circulation of blood through the vena porta, as in the case of cirrhosis of the liver, diseases of the heart and lungs, compressions of the blood-vessels by large abdominal tumors; or, 2. Erosions or degeneration of the blood-vessels from intestinal ulcers during typhus, yellow fever, scurvy, etc.; or, 3. Lesions caused by corroding or cutting substances, wounds, etc. ; or, 4. Suppressed normal, or habitual, bloody discharges, as menstrual or haemorrhoidal. A copious, internal haemorrhage is characterized by sudden paleness, coldness of the body, collapsed features, weak pulse, fainting, fits of chilliness, and dis- charges of blood from the bowels. The discharged blood, when it comes from the upper portion of the intestines, is generally dark and mixed with intestinal contents like tar. It is generally red and fluid when it proceeds from the lower portions. The exact seat of the haemorrhage, however, can- not be determined, as physical examination gives no hint whatever in regard to it. The bleeding may occur even within the stomach, as I have men- tioned when I spoke of haematemesis; and a black, tar-like appearance of stool is not a sign that it contains blood, as it may be colored by bile. This, however, may soon be settled. Throwing the passage into water, it colors the water red when it contains blood; and when it contains bile the water is colored green or yellowish. Therapeutic Hints. Compare the above-stated morbid conditions, which are the causes of the intestinal haemorrhage. ■ As generally indicated, the most important remedies are Alum., Arse?i., Carb. veg., China, Eriger., Hamam., Ipec, Nitr. ac. } Sulphur. Haemorrhoids, Piles, Consist of a dilatation of the haemorrhoidal veins, to which belong chiefly the plexus of veins lying in the submucous tissue of the lower part of the rec- tum, and in the adjoining subcutaneous connective tissue, also the venous radicles in the mucous membrane, the perirectal plexus, and the adjoining venous plexuses of the bladder, uterus, vagina, and the sacral canal. These dilated veins form tumors of different sizes, according to the amount of venous turgescence, from the size of a pea to that of a cherry or walnut, which sometimes encircle the entire anal opening like a bunch of grapes. When thus situated outside the anal margin they are called external, when within the anal margin internal haemorrhoids. HEMORRHOIDS. 49 1 There are usually longer or shorter intervals between these spells of turgeseence, during which the patient feels comparatively free from hsemor- rhoidal inconveniences. However, repeated attacks of turgeseence will gradually change either the mucous membrane or the submucous tissue, and produce catarrhal swelling of the mucous membrane, or hyperplasia of the connective tissue, or atropfty of these tissues under the influence of the pres- sure of the varices. The natural rugosities of the rectal mucous membrane become permanently thickened and inflamed, polypous growths are formed and associated with more or less pedunculated tumors, resulting finally in suppuration and consequent purulent discharges — white or slimy hemor- rhoids. The principal predisposing cause of the piles seems to be the position of the hsemorrhoidal veins, as the lowest branches of the abdominal vessels, and in their want of valves to sustain the return column of blood in its course towards the vena porta. When a retardation or stagnation by some means or other in this backward moving column takes place, it is obvious that its whole weight must press downwards upon its lowest branches, overfilling and dilating them. Such retardation of the refluent stream of blood may arise from different conditions: i. From tumors within the abdominal cavity, which press upon the veins of the rectum; a gravid uterus, etc. t>. From diseases of the liver, which obstruct the vena porta. 3. From diseases of the lungs, by which its capillaries become either obstructed or destroyed. 4. From diseases of the heart, by which the veins become overfilled with blood. 5. From a general relaxation of the abdominal veins, in consequence of using too much wine, coffee, tea, or leading a sedentary life. The fact, however, that frequently all members of the same family suffer with this complaint, seems in favor of the assumption that piles are of a hereditary nature, probably consisting of a congenital weakness or yielding of the walls of the hsemorrhoidal veins. Symptoms. — As forerunners to their local appearance we observe: full- ness and pressure in the epigastrium, disturbed digestion, bloating of the abdomen, costiveness, dull pain in the small of the back, also in the head and nape of the neck, hypochondriacal disposition, disinclination to work, and especially to mental occupation, all symptoms which denote a disturbed action in the abdominal organs. After a shorter or longer duration of these symptoms, we find a gradual development of the local symptoms at the anus — the beginning of varicose veins, their gradual growth, their turgeseence and their collapse, alternating in longer or shorter intervals. Thus the whole complaint is of a slow and tedious nature, changing constantly from better to worse. The occasional spells of bleeding are frequently attended with a feeling of relief, though they do not better the morbid process itself in any way; they become in some cases habitual, assuming a regular type of 492 THERAPEUTIC HINTS TO HAEMORRHOIDS. from three to four weeks intervals. In such eases the organism becomes so much accustomed to them, that when they are suppressed in consequence of mental emotions, or taking cold, or by external medical applications, etc., other disturbances set in, such as congestion of the head, lungs, stomach, liver, kidneys, etc., which may result in nosebleed, haemoptysis, bloody urine, apoplexy, etc. In consequence of thes tagnation of the return stream of blood, which is caused by liver, heart or lung diseases, ma}' arise, also, especially in older individuals, a varicose state of the veins of the neck of the bladder, of the uterus or vagina, causing haemorrhages from these organs, or slim)' dis- charges, painful micturition, etc. ' ' Dilatation of the sacral plexus is revealed by pain and a feeling of weight in the sacral region. When the communicating plexus of the spinal canal is affected, it may, by compressing the roots of the nerves, give rise to sensations of weight, numbness, formication and pain in the lower extremi- ties, or in the lumbar region, so as to simulate sciatica or a lesion of the cord itself." (Quinke.) The Prognosis depends upon its predisposing and proximate causes. Actual danger can only exceptionally arise from its local manifestations. Therapeutic Hints. Aeon. Bleeding piles; stinging and pressure in the anus; abdomen feels full, with tensive, pressive and colicky pains; bruised feeling in back and sacrum, inflammatory stage. sEscul. hipp. Protruding piles, purple, bleeding slightly, attended with constipation and a sensation as if sticks were in the rectum; severe fullness and bearing down; aching pain and lame feeling in the back. Aloes. Protruding piles, like bunches of grapes; hot and sore; relieved by cold water; when urinating he has a feeling as though some liquid dis- charge from the bowels would take place at the same time; much flatus with stool. Alum. S'':ool hard, and of the shape of laurel-berries, attended with cutting pain in the anus, as if it were too narrow; succeeded by a jet of blood from the rectum, followed by soreness in and along the rectum; perineum sweats and is tender to the touch. Amvi. carb. Varices protrude during stool, and without stool; they are moist, and with a pain as from excoriation; discharge of blood during and after the evacuation; burning pain in the rectum, itching of anus. Ant. crud. Tingling, itching and burning of the varix; mucous secre- tion from the rectum, staining the linen yellow; alternate constipation and diarrhoea. Apis. Small protruding varices, which sting, burn and smart intoler- ably, making one very irritable and fidgety; stool constipated, urine scanty. Arscn. Varices, which burn like fire, particularly at night; fissures of the anus, with impossibility of voiding urine; urine blood)-; small of the THERAPEUTIC HINTS TO HEMORRHOIDS. 493 back feels as if broken; impossibilit3 T of stooping; burning in the skin and veins; great weakness and restlessness; useful in case of drunkards. Bell ad. Bleeding piles with severe pain in the small of the back, as if it would break; incarcerated varices from spasmodic constriction of the sphincter ani, with great pain from the slightest touch; on this account the patient must lie with nates separated; dysuria; congestion of the head; fever- ish restlessness. Calc. carb. Profusely bleeding piles; protruding; painful when walk- ing, better when sitting; too early and too profuse menstruation; habitually cold, damp feet; after suppression of the hemorrhoidal flow, constant giddi- ness, especially on going up stairs; heaviness and fullness of the head; swelling of the pit of the stomach; palpitation of the heart; offensive sweat of the feet, making the soles raw. Cap sic. The varices bleed a long time; the flowing blood causes a burn- ing pain in the anus; the stool is mixed with bloody mucus; there are draw- ing pains in the back and cutting pains in the belly. Carb. veg. Protruding piles, blue, even suppurating, emitting a ter- rible smell; burning in the rectum ; oozing of humor from the rectum; flat- ulence; congestion of the head, and nosebleed; after high living. Cascar. Frequent and excessive bleeding from the rectum during and after hard, brown stool in large lumps, and without stool. Caustic. Varices large, painful, stinging; burning when touched, hin- dering stool; increased by walking and reflection; fistula ani. Chamom. Bleeding haemorrhoids with colic; frequent urging and diarrhoea; pain in the back, worse at night; ulcerating fissures at the anus; great restlessness, crying, screaming, tossing; sweating; angry, peevish and ill-humored. Colchic. With spasms of bladder and discharge of blood from it. (Stens, Sr. ) Collin. Flowing piles, incessant, though not profusely, or protruding piles with bleeding; sensation in the rectum as if sticks, sand or gravel had lodged there; growing worse as evening approaches till late at night, better in the morning; constipation of the bowels and pain in the epigastrium, with loss pf appetite; or diarrhoea. Chi?ia. Bleeding piles; burning and burning-itching; tingling in the anus, with creeping and itching extending into the urethra, attended with burning in the glans. Eriger. Bleeding piles; hard, lumpy stools. Ferr. phosph. With catarrh of stomach and bowels. Graphit. Varices and prolapsus of the rectum, even when there is no desire for stool, as if the rectum had lost its contractile power and had be- come paralyzed; painful, burning cracks (rhagades) between the varices; chronic constipation with hardness in the region of the liver; stool hard, knotty with blood and slime; scanty and delayed menses; leucorrhcea like water. 494 THERAPEUTIC HINTS TO HEMORRHOIDS. Hamam. Profusely bleeding haemorrhoids, characterized by burning, soreness, fullness and weight; at times rawness of the anus; the back feels as if it would break off; pricking pain, worse from pressure, from the wrist to the shoulder along the course of the superficial veins; the same pricking pain in the region of the heart; scanty menses. Hcpar. Inflammation and suppuration of the hemorrhoidal tumors. Hydrast. When a small loss of blood is followed by excessive weak- ness. (H. F. Hunt.) Ignat. Bleeding piles; violent, shooting pains high up into the rectum; prolapsus recti during stool; cutting, tearing in the rectum, continuing for hours after stool; for quiet people, or such as get easily excited and easily depressed. After confinement. Kali carb. In consequence of constipation with too large stools; the haemorrhoidal tumors swell and become large and very painful; they bleed, especially during micturition, and emit slime afterwards; riding on horse- back ameliorates the pain considerably for the time being. After confine- ment. Laches. Protruding haemorrhoids, very painful; a stitching pain is felt to go through the haemorrhoidal tumors, especially during coughing or sneezing; also at the critical age, with scanty menstrual flow. Leptand. Frequently bleeding piles; constipation and distressing pain beneath the sacrum. Lycop. Protrusion of varices; painful when sitting; distention of the whole abdomen, and rumbling after stool; cutting in the rectum and bladder; long-continued pain after stool; itching eruption around the anus, painful to touch; grayish-yellow color of the face; depressed spirits; frequent urging to urinate; slim}^ or reddish-sandy sediment in the urine. Mercur. Large, bleeding piles during stool, which is watery; haemor- rhage from the rectum during micturition; falling of the rectum, which is black and bleeding; inflammation and suppuration of the haemorrhoidal tumors. Mar. ac. Largely protruding piles, which look bluish and are exceed- ingly painful to contact — even the sheet is insupportable; prolapsus ani on passing loose stool during micturition. Natr. mar. Varices, painful, stinging and humid; protrusion of the rectum; smarting and beating in the rectum; burning at the anus; herpes about the anus; herpes on the boundaries of the hair in the nape of the neck; cutting pain in the urethra after micturition. Nitr. ac. Bleeding piles, protruding after each stool; the sharp-cutting pain in the rectum lasts four hours after an evacuation, and is much worse after a loose stool. Nux vom . Haemorrhoidal symptoms after purgative medicines and exter- nal and internal allopathic treatment; in persons of sedentary habits, or addict- ed to the use of coffee, wine, liquors, spices, etc. ; ineffectual urging; constipa- THERAPEUTIC HINTS TO HEMORRHOIDS. 495 tion; headache; sleeplessness early in the morning; hyochrondriac mood; fissures of the anus, with great sensitiveness of the rectum. Petrol. Burning and stitching in the anus and rectum; scurf on the border of the anus; titillating and smarting; itching herpes on the peri- neum. Phosphor. Varices protrude during emission of flatus; mucous dis- charges from the anus, which is constantly open; discharge of dark, coagu- lated blood; vertigo, especially on looking up or down. Phosph. ac. Bleeding piles, with tolerable pain in sitting. Podoph. Piles and prolapsus ani, with diarrhoea of long standing; worse in the morning; or constipation with flatulence and headache. Pulsat. Blind and flowing haemorrhoids; discharge of blood and slime with the stool; colicky pain; painful pressure upon the hemorrhoidal tumors; backache; fainting spells; mild, gentle and tearful disposition; dry- ness and bad taste in the mouth every morning; no thirst. Ratan. Protrusion of the varices after hard stool, with straining and violent pressing in the rectum; burning at the anus before and during a diarrhoeic stool; fissures of the anus, with great sensitiveness of the rectum. Rhus fox. Sore, blind haemorrhoids protruding after every stool; drawing in the back from above downwards, with tension and pressing in the rectum, as if everything would come out; labor-like drawing towards the uterus, when standing; pain in the small of the back, as if bruised, when lying or sitting still; going off when moving about. Sepia. Protrusion of piles and rectum, even after soft stool; worse after drinking milk; continual straining pain in the rectum; difficulty of urinating, especially in the morning; a feeling as if drops came out of the bladder, which is not the case; heat, burning and swelling of the anus; the varices become hardened; oozing of moisture from the rectum; soreness between the buttocks. S tap his. Intense pain in the back and through the whole pelvis; en- latgement of the prostate gland. (Preston.) Silic. Inflammation and suppuration of the hemorrhoidal tumors. Sulphur. Haemorrhoids; constant ineffectual urging to stool; or thin, bloody stool, worse in the morning, with soreness of the anus, or single vio- lent stitches in the rectum, also between stools, arresting the breathing and causing him to start; prolapsus ani during stool, particularly when hard; tensive pain and stiffness in the small of the back, as if the parts were too short; inability to stand erect; burning micturition. After suppression of habitual bleeding: congestion of the head; dizziness; palpitation of the heart; pain in the pit of the stomach, with difficulty of breathing; loss of appetite; sudden hunger, with faintness before dinner; sleepiness through the day, and sleeplessness at night. Thuja. The haemorrhoidal tumors are painful when touched ever so slightly; sycosis. 496 DIGEST TO HEMORRHOIDS. Digest to Hemorrhoids, Piles. Bleeding 1 : Aeon., sEsc. hipp., Amm. card., Bcllad., Calc. card., Capsic, Chamom., China, Collins., Eriger., Hamam., Hydrast., Ignat., Kali carb., Leptand., Mercur., Nitr. ac, Phosph. ac, Pulsat., Sulphur. frequently: Lepland. during stool, which is watery-: Mer- cur. during stool, and slime: Pulsat. and after: Amm. carb., Cascar, during micturition, and emit slime afterwards: Kali carb. , with colic: Chamom. , with pain in small of back, as if it would break: Bellad. , with shooting pain up into the rec- tum: Ignat. , with burning, soreness, fullness in rectum: Hamam. , with burning in anus: Capsic. , with burning and burning itching: China. , with stinging and pressing in anus: Aeon. • is followed by excessive weakness: Hydrast. Suppression of bleeding is followed by giddiness, worse on going up-stairs: Calc. carb. Blind or flowing: Nux vom., Pulsat., Sulphur. , sore, protruding after every stool: Rhus tox. Moist, with pain as from excoriation: Amm. carb. Protruding": yEsc hipp., Aloes, Amm. carb., Apis, Calc. carb., Carb. veg., Caustic, Collins., Kali carb., Laches., Lycop., Mur. ac., Nitr. ac, Phosphor., Ratan., Rhus tox. , like bunches of grapes: Aloes. , blue, even suppurating, terrible smell: Carb. veg. bluish, painful to slightest contact: Mur. ac. , purple, bleeding slightly: yEsc hipp. during and without stool: Amm. carb. after each stool: Nitr. ac, Rhus tox. even after soft stool: Sepia. after hard stool, with straining: Ra- tan. during emission of flatus: Phosphor. Inflamed: Aeon., Eerr. phosph. and suppurating: Carb. veg., Hepar, Mercur., Sepia, Silic Incarcerated from spasmodic constric- tion of the sphincter ani: Bellad. The varices become hardened: Sepia. Cracks between the varices: Graphit. Painful: Kali carb., Laches., Pulsat. -, hindering stool: Caustic. , from slightest touch: Bellad., Thuja. in sitting: Lycop., Phosph. ac. Hot and sore: Aloes. Burning" when touched: Caustic. like fire, worse in night: Arsen. Stinging, burning and smarting: Apis. Titillating" and smarting: Petrol. Tingling", itching and burning: Ant. crud. Stinging: Caustic and humid: Natr. mur. Stitching" when coughing or sneezing: Laches. ACCOMPANYING SYMPTOMS. Crying", screaming, tossing, restless: Chamom. Depressed spirits: Lycop. Hypochondriac Mood: Nux vom. duiet nature, or easily excited, or de- pressed: Lgnat. Mild, gentle, tearful: Pulsat. Irritable and fidgety: Apis. Angry, peevish and ill-humored: Cha- mom. Vertigo: Sulphur. , worse looking up or down: Phos- phor. Congestion to head: Bellad., Carb. veg., Sulphur. Heaviness and fullness: Calc carb. Headache: Nux vom., Pulsat. Herpes on boundaries of hair in nape of neck: Natr. mur. Grayish-yellow color of face: Lycop. Dryness and bad taste in mouth every morning: Pulsat. DIGEST TO HEMORRHOIDS. 497 No thirst: Pulsat. Loss of appetite: Sulphur. Sudden hunger, with faintness before dinner: Sulphur. Pain in pit of stomach, with difficulty of breathing: Sulphur. Swelling of pit of stomach: Calc. card. Catarrh of stomach and bowels: Ferr. phosph. Colicky pain: Pulsat. and feeling of fullness: Aeon. Flatulency: Card. veg. Distention of abdomen and rumbling after stool: Lycop. Fullness and bearing down: ALsc. hipp. Ineffectual urging: Nux vom., Sul- phur. Frequent urging and diarrhoea: Cha- mom. Constipation: Apis, Kali card., Nux vom. , with flatulence and headache: Po- doph . and pain in epigastrium, and loss of appetite: Collins. , with hardness in region of liver: G rap hit. and feeling as of sticks in rectum: Aisc. hipp. and alternate diarrhoea: Ant. crud. , and pain beneath the sacrum: Lep- tand. Stools hard, lumpy: Casear., Eriger. , knotty, with blood and slime: Graphit. , like laurel-berries, with cutting in anus, followed by a jet of blood and soreness in rectum: Alum. thin, bloody, with soreness of anus, or stitches in rectum, also between stools, arresting breathing and causing him to start: Sulphur. Diarrhoea: Ant. crud., Collins. Flatus with stool: Aloes. After stool, cutting, tearing in rectum for hours: Ignat. , , worse after a loose stool: Nitr. cutting pain long continued: Ly- cop. Anus, burning in: Natr. mur. , and swelling: Sepia. 32 , before and during diarrhceic stool: Patau. Rectum, burning in: Card. veg. and anus, burning and stitching in: Petrol. , burning in, and itching of anus: Amm. card. Cutting in rectum and bladder: Lycop. Smarting and beating in rectum: Natr. mur. Sticking pain in rectum as of sticks or gravel: A£sc. hipp., Collins. Straining, continual, in rectum: Sepia. Tingling in anus, creeping and itching extending into urethra, with burning in glans: China. Prolapsus recti: Nat. mur. during stool: Lgnat., Sulphur. , with diarrhoea: Podoph. during loose stool and during mictu- rition: Mur. ac. , rectum is black and bleeding: Mer- cur. , without desire for stool, as if rec- tum had become paralyzed: Graphit. Oozing of moisture from rectum: Card. veg., Sepia. mucus from rectum: Ant. crud. Discharge of mucus from anus, which is constantly open: Phosphor. , mixed with blood: Capsic. dark, coagulated blood : Phosphor. Fissures of ani, ulcerating: Chamom. , with great sensitiveness: Nux vom., Ratan. , with impossibility to void urine: Arsen. Cracks between varices, burning: Gra- phit. Eruption around anus, itching, painful: Lycop. Rawness of anus: Hamam. Fistula ani: Caustic. Herpes about anus: Natr. mur. Scurf on the border of anus: Petrol. Sweat on perineum; tender to touch: Alum. Itching Herpes on perineum: Petrol. Soreness between buttocks: Sepia. Spasms of bladder, with bloody dis- charge: Colchic. Urging to urinate, frequent: Lycop. Urination difficult: Sepia. impossible: Arsen. 498 FLATULENCY Dysuria: Bel lad. Burning during micturition: Sulphur. Cutting" in urethra after micturition: Natr. mu v., Sepia. Discharge from bowels, feeling of dur- ing micturition: Aloes. Haemorrhage from bowels during mictu- rition: Mercur. Feeling as if drops came from bladder: Sepia. Urine bloody: Arsen. y Co l chic. scant}-: Apis. Sediment slimy or reddish-sandy: Ly- cop. Prostate gland enlarged: Staphis. Labor-like drawing towards uterus, when standing: Rhus tox. Scanty menses: Hamam. and delayed, leucorrhcea like water: Graphit. Too early and too profuse menses: Calc. card. Palpitation of heart: Calc. card., Sul- phur. Pricking pain in region of heart: Ha- mam. Back, pain in, worse at night: Chamom. feels as if it would break off: Bel I ad. , Hamam. , pain in and through pelvis: Staphis. , , and cutting pain in bowels: Cap sic. , drawing in, from above downward, with pressing in rectum: Rhus tox. , bruised feeling in, and sacrum: Aeon. , aching pain and lame feeling in: A^sc. hi pp. Small of back, as if broken: Arsen., Kali card. , as if parts were too short: Sulphur. , as if bruised, when lying or sitting still: Rhus tox. Pricking pain in superficial veins from wrist to shoulder: Hamam. Burning in skin and veins: Arsen. Sweat, offensive, of feet: Calc. card. Habitual cold, damp feet: Calc. card. Cannot stand erect: Sulphur. Feverish restlessness: Bellad. Sweating: Chamom. Sleepy through day, sleepless at night: Sulphur. Sleepless early in morning: Nux vom. Weakness and restlessness: Arsen. Fainting spells: Pulsat. After constipation with too large stools: Kali card. purgative medicines, highly seasoned food, etc. : Nux vom. high living: Card. veg. habitual drinking: Arsen. confinement: /gnat., Kali card. scanty menses at critical age: Laches. suppression of habitual bleeding: Sulphur. sycosis: Thuja. Worse from evening till late in night: Collins. on stooping: Arsen. on walking: Calc. card., Caustic. after drinking milk: Sepia. after reflection: Caustic. on lying, must lie with nates sepa- rated: Bellad. Better from cold water: Aloes. when moving about: Rhus tox. when riding on horseback: Kali card. when sitting: Calc. card. Flatulency, Meteorism of the Abdomen. We mean by these terms an abnormal collection of gas in the intestinal canal. It may be caused: i. By certain kinds of food, such as not well-fermented beer, sweet cider, fresh bread, green peas, unripe fruit, cabbage and the like. 2. By a morbidly changed condition of the digestive juices, which allow fermentation of the intestinal contents. THERAPEUTIC HINTS TO FEATUEENCY. 499 3. By a relaxed state of the mnseular coat of the intestines, in conse- quence of which the contents of the bowels are not properly moved forwards, and become decomposed into gaseous substances. For this reason we fre- quently observe meteorism in severe cases of typhoid pneumonia, acute exanthematic and puerperal fevers, peritonitis, after the abuse of purgative medicines, in diseases of the brain and spine, also in hysteria, and hypochondria. 4. By mechanical obstructions of the intestinal canal, like strangulated hernia, intussusceptions and twistings of the gut around its own axis. Symptoms. — The abdomen appears bloated, puffed out, feels either elastic, or more or less inelastic and hard, according to the degree of com- pression of the gas within. Percussion generally yields a tympanitic sound, unless there be a greater tension of the gas within than of the external air, in which case the percussion sound is not tympanitic, and may be even dull. Auscultation reveals here and there gurgling noises, and even the metallic tinkling may be heard when the fluid contents move within the expanded gut. Such abnormal expansion of the intestines forces the liver, stomach and lungs higher up into the thoracic cavity, causing oppression, dyspnoea, palpi- tation of the heart, anxiety, fainting and congestion of the head. The ex- pansion downwards causes pressure upon the bladder, difficult urination, pressure upon the rectum, and frequent desire for stool, and pressure upon the uterus. This abnormal collection of gas is frequently associated with spells of violent colic, loss of appetite, nausea, etc. Belching, or the passing off of flatus, often gives great relief. The gas generated consists mostly of carbonic acid, or hydrogen, or sulphurretted hydrogen gas. It is obvious that the Prognosis depends entirely upon the cause, of which meteorism is the consequence. It is of little consequence if produced merely by improper food, or the improper condition of the digestive juices. It becomes a more serious symptom when caused by a relaxed state of the muscular coat of the intestines, and is most serious in cases of intestinal obstruction. Therapeutic Hints. Carb. veg. Much bleching, sour and rancid; bloatedness of stomach and bowels; oppression of the chest; palpitation of the heart; consequences of high living. China. Distention of the abdomen; oppression of the stomach; eructa- tions, especially after eating; great fermentation in the bowels; after new or sour beer and fruit. Chamom. Attended with severe colic; the abdomen is swollen like a drum; the gas passes off constantly, but in small and insufficient quantities. Laches. Eructations of gas affording relief; distended stomach; incar- ceration of flatulence. Lycop. Constant rumbling and gurgling of wind in the bowels, especially in the left hypochondrium; incarcerated flatulence, which bears •downwards upon rectum and bladder, causing a number of bad feelings. 500 COLICA, ENTERALGIA. Nux vom. Pressure towards the chest and head; oppression of the chest; constipation, with constant ineffectual urging; after spirituous drinks, coffee, condiments, etc., in consequence of sedentary life. Pulsat. Especially in consequence of spoiled stomach from eating fat things, pastry, warm cakes, fruits, etc. Besides, compare Gastric and Intestinal Catarrh, Constipation and Colic. Colica, Enteralgia. We understand by this term a paroxysmal pain in the abdomen of a purely neuralgic character, without any discoverable pathological change within the structure of the intestines, although it may attend different morbid processes which consist of such pathological changes. The Causes are numerous; they may be classed under the following head : i. Such as are dependent upon anomalies of the intestinal contents: ab- normal quantity or quality of food, colica saburralis; or abnormal develop- ment of gas, colica flatulenta, wind colic ; or accumulation of hard feces, colica stercoracea ; or foreign irritating bodies, like worms, colica ferminosa ; or metallic poisons, like lead, colica saturnina ; or copper, colica aeruginosa. 2. Such as are dependent upon a disturbed innervation, either — a. Prim- arily within the great centres of innervation themselves, from mental emo- tions, in cases of hysteria, hypochondria, and spinal diseases — colica nervosa; or, b. Secondarily, in consequence of diseases of other organs, which may cause a pain in the bowels sympathetically on the principle of ' 'reflex action. ' ' Hence, authors speak of colica hepatica when the liver, of colica uterina when the womb, of colica renalis when the kidneys are thought to be the starting point of the colic. Still, we ought to remember, that in such cases the pain may not be an intestinal colic at all, but merely an irradiation from the primarily affected parts. 3 . Such as are dependent upon structural changes in the intestines, among which we may reckon colicky pains in dysentery, catarrhal affections, typh- litis, hernia, intussusception, strangulation, twisting, etc. There is also a kind of colic produced by taking cold, especially of the feet and abdomen, and which is called colica rheumatica. Symptoms. — i. Pain. It is of a crampy, severe griping, or twisting nature, coming and going in paroxysms, either in the umbilical region or in the side of the abdomen; oftentimes shifting from one place to another. Ex- ternal pressure sometimes gives relief and sometimes aggravates the pain; in other cases it shows no influence. External application of warm things re- lieves in a majorit}^ of cases, wmilst cold things almost always aggravate the pain. 2. Rolling and gurgling in the abdomen, occasioned by irregular con- tractions of the intestines and the moving of their fluid and gaseous contents, which may be felt by the examining hand. 3. Bloatedness of the abdomen where there is a great collection of gas; or contraction of the abdomen, especially in lead colic. COLICA, ENTERALGIA. 501 4. Constipation ; it is only in rare cases that colic is attended by diarrhoea. 5. Nansea, vomiting and belching. 6. Cold perspiration and extremities; small pnlse. 7. Anxious, frightened expression of countenance, contraction of eye- brows and compression of lips. 8. Great restlessness ; the patient tries all possible positions to obtain relief — now lying on the stomach, now drawing up the limbs, now bending and pressing the abdomen against a hard object, a chair, table or bed-post; now sitting down, now walking about, now trying to evacuate the bowels, etc. In some cases, however, the slightest motion increases the pain. The spells usually last some hours, in some cases longer. Wind colic ceases as soon as the incarcerated gas finds vent and passes off. Colic from indigestion is relieved by vomiting or diarrhoea; colic from hard feces by a sufficient evacuation from the bowels. Colic from taking cold is always relieved by a general warm perspira- tion. As there are so many causes for, and so many different affections with which colicky pains may be associated, it is absolutely necessary in each par- ticular case to make as close an examination as possible, in order to find out what lies at the bottom of the painful affection. Colic from indigestion, or colica saburralis, is brought on either from overloading the stomach, or from improper or unhealthy food. Here are indicated — Nux vom. After coffee, brandy, large meals. Pulsat. After fat food, pastry and flatulent food. Ipec. After sour and unripe fruits and salads. Arse?i. After ice water and ice cream. Flatulent colic is characterized by distention of the abdomen, gurgling and rolling in the bowels, or pressure upwards towards the thoracic cavity, causing pain there and shortness of breath, or pressure downwards upon bladder and rectum. Here are indicated — Bellad. If associated with congestion of the head. Carb. veg. When there is a great deal of sour and rancid belching, without much relief. Chamom. When the abdomen is distended like a drum, and wind passes off only in small quantities without relief. Lycop. In cases of habitual costiveness and great pressure down- wards upon rectum and bladder, and gurgling under the left hypochon- drium. Nux vom. When there is great pressure upwards toward the thoracic cavity. 502 SPECIAL HINTS TO COLICA, ENTERALGIA. Opium. When there is great pressure downwards upon bladder and rectum, without any passing off of feces, gas or urine. Rheumatic colic follows upon suddenly taking cold, getting wet, etc. Here are indicated — Aeo?i. After suppresssed perspiration, exposure to sharp northwest wind. Coloc. Cutting, pinching, contracting pain, with hot or cold skin > irritated pulse, and a disposition to double up and press hard upon the abdomen. Dulcam. After taking cold; the griping is attended wdth nausea in the stomach, and followed by diarrhoea. Pulsat. After getting the feet wet. Rhus fox. After getting wet all over. Nervous colic is a consequence of morbid innervation arising suddenly, sometimes without any known causes, showing no abnormity in the abdomi- nal cavity. Here are indicated — Bellad. Clawing around the navel; better from pressure. Coloc. After indignation. Ignat. After grief and fright. Opium. After sudden fright. Plumbum. Contracted abdomen. Lead colic — poisoning by lead. Bluish-gray line along the gums; retracted abdomen; pain lessened from external pressure; obstinate costive- ness; slow pulse. Antidotes. — Opium, Platina, Nux vom., Alum., Ant. crud., Coccul., Arsen., Bellad., Podoph., Zincum. Copper colic, poisoning by copper. Distended abdomen; pain worse from slightest touch; nausea; vomiting; tenesmus. Antidotes. — Hepar, Nux vom., Bellad. All other secondary forms of colic are mere attendants upon other dis- turbances, w T hich either have been considered already, or will be considered later. Special Hints. Aeon. Intolerable, cutting pains in the belly, so violent that he screams, tosses about, and is almost beside himself; after taking cold; menstrual colic. Alum. Lead colic, with dyspnoea, or pressing down in the groins like hernia. Arsen. Pains in the whole abdomen, excessive; worse at night, after eating and drinking; better from warm application; with vomiting, or diar- rhoea, or costiveness; great anguish, lamentations, tossing about; internal restlessness, which does not allow one to lie still; despair of life; after the use of ice water, ice cream; bad sausages, cheese; lead poisoning. In colic after severe burns. SPECIAL HINTS TO COUCA, ENTERAI,GIA. 503 Asa/'. Distention of the abdomen, with severe pain and a feeling as though something were rising from below upward into the chest and throat; during the height of the paroxysm, fainting; pain better from external press- ure; in hysteric and hypochondriac persons. Aurum. Painful accumulation of gas below the left ribs, causing a stitching pain there; coming on even after eating the simplest food. Bellad. During the pain the traverse colon protrudes like a pad all the way across the belly; while sitting or standing and walking, much worse, with a feeling as though the intestines were loose and dragging downwards; external pressure and bending double relieves somewhat; protrusion in the inguinal region as thick as a finger, which, when pressed upon, dissappears with a gurgling sound; pain below the navel, as though a portion of the intestines were seized with the nails, clawing it together; thin purulent stool; congestion of the head; copper colic. The pain comes suddenly and dis- appears suddenly. Bryon. After taking cold; cutting, lancinating pain in the abdomen; worse from motion and drinking cold water; bowels constipated; feces hard, as if burnt; tongue coated, white, dry, without thirst; or else great thirst. Calc. carb. Severe spasms in the intestines, especially in the evening and at night, with coldness of the thighs; feeling of coldness in the abdomen; enlargement and hardness of the abdomen, particularly in teething children; diarrhoeic, clay-like stools, smelling sour or fetid; sweat on the head. Carb. veg. Fullness and distention of the abdomen, with a feeling as though it would burst; squeezing and pressing in the left side of the epi- gartrium, or in the region of the bladder; oppression of the chest; belching, tasting sour and rancid; headache; chilliness over the back; hypochondriac mood; worse from eating, if ever so little; better from emission of flatus or hard stool; colic from riding in carriage. Caustic. Crampy colic of a chronic character; pain from the stomach through to the back, up into the chest, down into the abdomen; belching; rumbling in the bowels; obstinate constipation; tongue coated whitish on both sides. Chamom. Flatulent colic; the abdomen is distended like a drum, or the wind presses here and there against the abdominal walls, with a feeling as if it would pierce through; or the patient has a feeling as if the whole abdomen were hollow, with continual rolling in the bowels and blueness around the eyes; or the excessive pain simulates a sensation as if the parts were rolled up into a ball; vomiting; diarrhoea, green and slimy; or continual passing of small quantities of flatus without relief; great restlessness, anxiety; sticky or hot perspiration; after chargin, or taking cold. Very irritable mood. China. Distention of the abdomen, with pressing under the short ribs; rumbling and cutting pain in the bowels; worse at night; brought on by eating fruit or drinking new beer; after exhausting illness, loss of vital fluids, profuse perspiration; gall-stones. 504 SPECIAL HINTS TO COLICA, ENTERALGIA. Chin, sulph. Flatulent colic of an intermitting type. Coccid. Flatulent colic, about midnight, with incessant formation of flatulence, distending the abdomen, going off without relief and obliging to turn from side to side; belching relieves; the pain is most severe in the epi- gastric, umbilical and right iliac region; nausea, vomiting; yellow face; cold perspiration, anxiety and restlessness. Coffea. Excessive pains with anguish, great nervousness, loud crying and grating of teeth; suffocative fits; coldness of limbs; convulsions. Colchic. Great distention of the abdomen; also when the abdomen is empty, aggravated by eating; the stomach feels icy cold; after flatulent food. Coloc. All sorts of violent pains, mostly in the umbilical region, or from the sides concentrating in the middle; the patient doubles up or seeks relief by pressing the belly against the bed-post or any other hard object, or by lying on the belly; likewise a tight, cramp-like pain in the left iliac and inguinal region, which is worse after (not during) external pressure, espe- cially observed in women after excess in venere; after indignation; abuse of opium; a cup of coffee generally relieves the pain for a while. Ctiprum. Violent spasms in the abdomen and in the upper and lower limbs, in spells; cutting pain in umbilical region, as if a knife were thrust through into tpe back; screams as though he were being killed, throwing himself upon the floor; singultus and stercoraceous vomiting. Diosc. Remitting, griping pain in the epigastric and umbilical region; or severe pain in left iliac region, running upwards to left kidney, better from crouching together with the hands clasping the knees; or pain in a small spot which feels as if it were drawn forcibly upwards and backwards towards the spine. Constant desire to defecate and urinate without accom- plishing much. Dulcam. Colic when the weather changes suddenly from warm to cold; griping in the bowels, with nausea, and coldness in the small of the back; diarrhoea. Hyosc. Colic as if his abdomen would burst, he presses his fists into his sides; spasmodic cutting, vomiting, belching, hiccoughing and screaming. Igiiat. Periodical abdominal spasms, particularly at night, waking out of sleep, with stitches running up into the chest and to the sides; in sensitive and hysteric women. Ipec. Colic of children, with diarrhoea, uneasiness, screaming, and toss- ing about; after acid or unripe fruit, beer, etc. Iris. Colic of infants with flatulency and constipation, where Chamom., Coloc. and Nitx vom. had failed. Kali carb. Colic, as if the intestinal canal were full of water. Lycop. Bloatedness in consequence of incarcerated flatulence and con- stipation, with urging to stool; a feeling as if the abdomen must burst; belching without relief; passing flatus downwards relieves; renal colic, where the pain is felt along the ureters into the bladder, especially in the right side. SPECIAL HINTS TO COUCA, BNTKRAEGIA. 505 Magn, phosph. Intermittent pain, relieved by bending double, by rubbing, and by external warmth and eructations. Mercur. Colic occasioned by the cool evening air, with diarrhoea, chilliness and shuddering. A T ux vom. Flatulent distention of the abdomen, with pressure upwards into the chest, and downwards upon the rectum and bladder; would like to belch, but cannot; constant urging to stool without effect, and frequent de- sire to make water; wind colic, haemorrhodial, renal and lead colic; "yellow color of face and more around the mouth; pinched nose; offensive breath; tongue broad and soft, with a dirty white coat of a creamy consistence, and a very vivid scarlet redness around the edge of the tip. Thin, yellow, very badly-smelling stools." (J. C. Kilgour. ) Opium. When flatulence accumulates in the upper portions of the bowels, causing a distention of the abdomen, especially in the umbilical re- gion, with antiperistaltic motion, belching and vomiting; the bowels seem perfectly closed, but there is a constant urging to stool and to urinate; the pain is cutting, pressive and twisting; painter's colic. Oxal. ac. From eating sugar. Piper meth. Agonizing pain, with tossing, twisting and writhing; pa- tient driven irresistibly to change position, without relief; better for a while when his attention is absorbed by something else. (Hiller.) Platina. Painter's colic; pain in umbilical region, extending through into the back; the patient screams and tries to relieve the pain by turning in all possible positions. Plumbum. Frightful pain, particularly around the umbilicus; the um- bilicus drawn in towards the spine; obstinate constipation. Podoph. Cramps in the bowels, with retraction of the abdominal mus- cles, or crampy drawing of the muscles into lumps and knots; lead colic. Pulsat. Colic worse in the evening and at night; pale face; white tongue; no thirst; wants to uncover; grayish diarrhoea; tearful disposition. From eating fat and greasy food. Rheum. In infants with sour diarrhoea; the child smells sour all over. Rhus tox. Worse at night, and when being quiet; better from moving about, or lying on the stomach. Sabad. Sensation as if a ball of thread were moving and turning rapidly through it. tc Oh, my bowels! it runs like a wheel! " Sepia. Boring, burning pain, with great distention and sensitiveness of the abdomen; anxiety; typically recurring towards evening; scrofulous per- sons. Stannum. Stitches from both sides through the abdomen and through the hips; worse from slightest motion or touch, and when lying on right side; vomiting of water when smelling any kind of cooking. Sulphur. Spasmodically contractive colic, extending into the chest, the groin, and the genital organs; from piles; from flatulence; from eating sweet things; relieved by sitting bent; psoric individuals. ;o6 DIGEST TO COLIC A, ENTERALGIA. Tart. emet. Violent colic, as if the bowels would be cut to pieces; violent cutting and labor-like tearing from above downwards; across the groin through the thighs down to the knees; nausea; accumulation of water in the mouth; shifting of flatulence, with rumbling in the bowels and diar- rhoea. Thuja. Hemorrhoidal colic, with very acute and violent pain in the lower bowels; much flatus, w T ith or without stool; feces hard or fluid and scant}*; when fluid there is a sensation in the rectum as if boiling lead were passing through. Veratr. Abdomen swollen and very sensitive; violent pinching pains; no discharge of flatus either up or downwards; the intestinal canal seems closed; nausea; inability to swallow*; cold perspiration; anxiety; restless- ness; after eating fruit or vegetables. Zincum. Flatulent colic, worse from wine, towards evening, and when at rest; loud rolling and rumbling; retraction of the abdomen; hot, moist flatus passing off without relief; lead colic. Digest to Colic a, Exteralgia. Whole abdomen. Aeon., Arsen., Asa/., Bryon., Calc. carb. , Carb. veg. , Ckamom., China, Colchic, Cuprum, Dulcam., Hyosc, Lycop., Nux vom., Podoph, Sepia, Tart. emet. Umbilical region. Bellad., Coccul., Co- loc., Cuprum, Diosc., Opium, Platina, Plumbum. Below navel, as though a portion of in- testines were clawed together: Bellad. Epigastric region. Caustic, Coccul., Diosc. Below left ribs. Aurum. Sides of abdomen. Aurum, Carb. veg., Coloc, Stannum. Inguinal region. Alum. , Bellad. , Coloc , Sulphur, Tart. emet. Iliac region, left: Coloc, Diosc. , right: Coccul. — , downwards across the groin, into thighs to knees: Tart. emet. — into groins like hernia: Alum. — left iliac region to left kidney: Diosc. From navel to back. Cuprum, Platina. sides to navel : Coloc. , through abdomen and hips: Stan- num. stomach to back, chest and down into abdomen: Caustic. a small spot which seems to be drawn upwards and backwards to spine : Diosc. up into chest and sides: Ignat. abdomen up into chest, down in groins and genital organs: Sulphur. , dragging downwards: Bellad. Pain agonizing, with tossing, twisting and writhing: Piper meth. , cutting: Bryon. , , screaming as if beside him- self: Aeon. , , pressing and twisting: Opium. , , as if a knife were thrust through into the back: Cuprum. , , vomiting, belching, hiccough- ing and screaming: Hysoc. , and rumbling in bowels: China. , , and labor-like from above downwards to knees: Tart. emet. , stitches, from both sides to abdo- men and through hips: Stannum. , , up into chest and sides: Ignat. griping, remitting: Diosc. , , with nausea and coldness in back: Dulcam. , pinching: Ver. alb. , squeezing and pressing in left side: Carb. veg. , colic, as though bowels would burst: Carb. veg., Chamom., Hyosc, Lycop. , , would be cut to pieces: Tart. emet. , , were full of water: Kali carb. , crampy, chronic: Caustic. DIGEST TO COLICA, ENTERAEGIA. 507 — , , in gion: Co/oc, left iliac and inguinal re- , , as if clawed together with nails: Bel lad. , spasmodically contractive, extend- ing np and downwards: Sulphur. , spasms: Calc. card. , spasms in spells in abdomen and in upper and lower limbs: Cuprum. , boring, burning with distention and sensitiveness of abdomen: Sepia. Feeling" of coldness in abdomen: Calc. card. looseness of intestines, dragging downwards: Bellad. , as if parts were rolled up into a ball: Chamom. , as if a ball of thread were turning through bowels: Sabad. , as if abdomen were hollow, with rolling in bowels and blueness around eyes: Chamom. Pain comes suddenly and disappears sud- denly: Bellad. Umbilicus drawn in towards spine: Plumbum. Abdominal muscles retarded: Podoph., Zincum. Transverse colon protrudes like a pad : Bellad. Abdominal muscles are drawn into lumps and knots: Podoph. Protrusion in inguinal region, which dis- appears under pressure: Bellad. Distention of abdomen: Colchic, Opium. , like a drum: Chamom. with pressing and stitching under left ribs: Aurum, China. , with feeling as though something were rising into throat: Asaf. , with pressure upwards into chest and downwards upon rectum and blad- der: Nux vom. , with urging to stool: Lycop. , with passing of flatus without re- lief: Coccul. , with rumbling and diarrhoea: Tart. emet. , with sensitiveness of abdomen: Sepia, Veratr. Enlargement and hardness of abdomen : Calc. carb. Feeling" as if abdomen were hollow with eyes: Sulphur, , Arsen. Podoph. rumbling and blueness around Chamom. Wind colic: Chamom., Coccul., Nux vom., Sulphur, Zincum. , of an intermitting type: Chin. sulf. Hemorrhoidal: Nux vom. Thuja. Renal: Lycop., Nux vom. Gall-stone colic: China. Menstrual: Aeon. Lead, or painter's colic: Alum. Nux vom., Opium, Platina, Zincum. Copper colic: Bealld. ACCOMPANYING SYMPTOMS. Fainting: Asaf. Screaming: Aeon., Hyosc. , throwing himself upon floor: prum. , tossing about: Ipec. , in all possible positions: Piper meth., Platina. Loud crying and grating of teeth: Coffea. Tearful disposition: Pulsat. Anxiety: Coccul., Chamom., Sepia, Ver. alb. Hypochondriac mood: Carb. veg. Despair of life, anguish, lamentations, tossing about: Arsen. Anguish, nervousness: Coffea. Irritable mood: Chamom. Restlessness: Arsen., Chamom., Coccul., Veratr. Head, congestion of: Bellad. , sweat on: Calc. carb. Cu- Headache: Carb. veg. Blueness around eyes: Chamom. Pale face: Pulsat. , yellow: Coccul., Nux vom. Nose pinched: Nux vom. Tongue white: Nux vom., Pulsat. on both sides: Caustic. , dry: Bryon. , broad and soft: Nux vom. Offensive breath: Nux vom. Accumulation of water in mouth: Tart. emet. Thirst great: Bryon. No Thirst: Bryon., Pulsat. ;o8 DIGEST TO COLICA, EXTERALGIA. Inability to swallow: Veratr. Belching: Card. veg., Caustic, Lycop. and vomiting: Opium. , cannot: Nux vom. Singultus and stercoraceous vomiting : Cup) n m. Nausea Coccut., Dulcam., Tart, emet., I 'cratr. and vomiting: Coccut. Vomiting and diarrhoea: Arsen., Chamom. of water when smelling any kind of cooking: St an num. Stomach feels icv cold: Colchic. Gall-stones: China. Rolling and rumbling in abdomen: Caus- tic, Zincum. Flatus, with or without stool: Thuja. , passes continually without relief: Chamom., Coccut., Zincum. , discharges neither ~up nor down- wards: Veratr. Flatulence: Iris. Ineffectual urging to stool and to uri- nate: Diosc, Nux vom., Opium. Constipation: Bryon., Caustic, Iris., Plumbum. Feces hard: Bryon., Thuja. fluid and scanty, with feeling as if melting lead were passing: Thuja. thin, purulent: Bellad. yellow, badly smelling: Nux vom. Diarrhoea: Dulcam., Ipec, Mercur. , clay-like: Catc. card. , grayish: Pulsat. Feces smelling sour, or fetid: Calc card. Oppression of chest: Alum., Carb. veg. Suffocative fits: Coffea. Coldness in back: Dulcam. of thighs: Calc. carb. of limbs: Coffea. Chilliness over back: Carb. veg. and shuddering: Mercur. Perspiration hot and sticky: Chamom. cold: Coccut., Veratr. Wants to uncover: Pulsat. Child smells sour all over: Rheum. Convulsions: Coffea. CAUSED BY: Indignation, chagrin: Chamom., Coloc Cold, taking: Aeon., Bryon. Cool evening air: Mercur. Sudden change of weather from warm to cold: Dulcam. Use of ice water or ice cream: Arsen. sweet things: Sulphur. sugar: Oxal. ac acid or unripe fruit, beer: China, Ipec. fruit or vegetables: Veratr. flatulent food: Colchic. — — fat and greasy food: Pulsat. bad sausages, cheese: Arsen. Riding in carriage: Carb. veg. Exhausting illness, loss of fluids and profuse perspiration: China. Severe and large burns: Arsen. Sensitiveness, hystery: Ignat. Hystery and hypochondriasis: Asa/. Excess in venere in women: Coloc. Scrofula: Sepia. Psora: Sulphur. Children: Ipec, Rheum. , teething: Calc. carb. WORSE. Eating, ever so little, or simplest food: Aurum., Carb. veg. Eating: Colchic and drinking: Arsen. Drinking cold water: Bryon. wine: Zincum. Towards evening, typically recurring: Sepia. evening: Zincum. Evening and night: Calc carb., Pulsat. Night: Arsen., China, Ignat, Rhus tox. Midnight: Coccut. At rest, or being quiet: Rhus tox., Zin- cum. While sitting, standing or walking: Bellad. Motion: Bryon. Slightest motion, touch, or lying on right side: Stan num. After (not during) external pressure: Coloc BETTER. External pressure: Asa/'., Bellad. Coloc TUBERCULOSIS IKTESTINALIS. 509 Bending double: Bell ad., Magn. ph osph . , Su Iph u i : Crouching" together with hands clasping the knees: Diosc. Lying on belly: Coloc, Rhus lox. Rubbing: Magn. phosph. Moving about: Rhus lox. Eructations: Coccul , Magn. phosph, Passing flatus downwards: Lycop. and hard stool: Carb. veg. External warmth: Arsen., Magn. phosph. Drinking coffee: Coloc When attention is absorbed by some- thing else: Piper meth. Iris helped where Chanwm., Coloc. and Nux voni. had failed. Tuberculosis Intestinalis, Consumption of the Bowels. Tubercles form not only in the lungs; they are as well deposited in the mucous and submucous membrane of the ilium, especially in Peyer's patches and the solitary glands, in the colon, the caecum, rarely, however, in the jejunum and duodenum. The tuberculous material, wherever deposited, consists either of yellowish, cheesy masses, or of grayish, half-transparent, so-called miliary granules, which, by a gradual dissolving process, produce tuberculous ulcers. Intestinal tuberculosis is rarely a primary disease, but generally part and portion of — 1. Pulmonary consumption, to which it adds the finishing blow. In some cases, however, intestinal tuberculosis seems to so predominate over the pulmonary complaint that the latter is overshadowed by the abdominal trouble. 2. In other cases intestinal tuberculosis attends acute miliary tubercu- losis, a form of blood-poisoning, which, under the symptoms of typhus, deposits a great number of fine granules in different organs and tissues. It cannot be distinguished from typhus by its symptoms. deposition inflames the pia mater. Lastly, intestinal tuberculosis may be part and portion of the tubercular formations in the peritoneum, the mesenteric glands, and the retro-peritoneal glands, all of which are difficult to define. The Symptoms are not very prominent or characteristic, only when the tubercles commence to soften in the. last stage, an obstinate diarrhoea is one of the most prominent symptoms. With it are associated great loss of strength, night-sweats, and partial oedema; the patients finally die with the signs of marasmus. Obstinate diarrhoea, in conjunction with pulmonary tuberculosis, sug- gests the following remedies: Arg. nitr., Arsen., Bryon., Bar. carb., Calc. carb., Calc. phosph., Carb. veg., China, Ferruni, Hepar, Mercnr., Nitr. ac, Phosphor., Phosph. ac, (Plumbum), Pulsat., Sulphur. Compare Con- sumption. Cancer of the Intestines, Appears either in the form of scirrhus, or fibrous cancer, or as medullary cancer (which is of a softer, marrow-like growth), or as alveolar cancer (which is of a jelly-like nature, but of rare occurrence). [Compare Cancer of 5IO POLYPUS OF RECTUM. the Stomach.] It originates primarily in the submucous and mucous coats of the intestines, or reaches over secondarily from a cancer of the stomach, or of the peritoneum, the liver, ovaries, uterus, or other neighboring organs. Primary cancer is found most frequently in the rectum, also often in the flexura sigmoidea, very rarely in the remaining parts of the intestinal tube. As it grows, it causes a swelling or tumor from the size of an egg to that of a fist; and by its growth gives rise to intestinal obstruction. Never- theless its diagnosis may, in certain cases, be one of great difficulty. It may be suggested by partial intestinal obstruction; rarely by total obstruction; also by the general symptoms of cancer, cachexia. Or in younger indi- viduals it may cause intestinal obstruction alone, without these general symptoms of cancer-cachexia. Or it may produce merely the general cancer- cachexia without any sign of intestinal obstruction; but in place of it diar- rhoea, colicky pain, flatulency, etc., the dejections containing blood, a gan- grenous, stinking fluid, and pus. The main points of diagnostic importance are these: The presence of an uneven, potato-like tumor; the slow but steady development of intestinal obstruction; the peculiar dry and ash-colored skin; the fast wasting away in strength and flesh; and the age of the patient, as cancer very rarely appears before the age of forty. Cancer of the rectum is the most frequent in occurrence. In the begin- ning of its development, when it causes a pressure upon, and a consecutive swelling of the haemorrhoidal veins, with occasional bloody discharges, and pain from the os sacrum down into the thighs, it is most easily confounded with haemorrhoids. Later, however, the obstruction of the rectum becomes more apparent by the form of the discharged feces, which appear pressed, flattened, angular, or pass off in small, hard nuts, like sheep-dung. Manual examination reveals now a knotted tumor, which encircles the gut like a ring. In its still further advanced stage this tumor suppurates, and the bursting of blood-vessels may occasion profuse haemorrhages. We some- times observe in combination with it indurated inguinal glands; and I have seen a case where hard scirrhous infiltrations existed disseminated through the glutaeus muscles. # Its Prognosis is, like that of all cancers, very discouraging. Death occurs either in consequence of ileus, or peritonitis after perforation of the gut, or exhaustion. By means of the following remedies we ma}' succeed in alleviating much suffering: Apis, Arsen., Bellad., Cannab., Card, an., Card, veg., Clemat., Graphit., Hepar, Hydrast., Kreos., Laches., Phosphor., Phosph. ac, Rhus tox., Sepia, Silic., Sulphur, Thuja. Polypus of Rectum. The follicular or soft polypus occurs generally in childhood, very rarely in the adult, is attached to the mucous membrane by a narrow peduncle FISSURA ANI. 511 and usually protrudes in children after a stool, resembling a small straw- hern' ; it causes no pain but may produce bleeding sufficient to weaken the patient. The fibrous or hard polypus is pear-shaped, with a peduncle more or less long and thick, protrudes if low down or attached to a long peduncle, causes some slimy discharge, but rarely bleeds, produces frequently the sensation of unrelief after stool, and its peduncle may be strangulated by the sphincter, which causes great pain. Therapeutic Hints. Calc. carb. and Phosph. are the main remedies. Ligature is the best surgical means. Fissura Ani. An anal fissure consists of an abrasion or ulcer usually at the posterior part of the lower circumference of the rectum, although it may occur in any other part of this portion of the anal mucous membrane, which here forms folds or pouches. When looked at without distending the rectum, the lateral edges onl} T being presented to view, the ulcer appears like a fissure, but is in reality an abrasion or a superficial ulcer. On defacation its surface is irri- tated, exciting spasm of the sphincter muscle, and causing sharp, cutting, burning and straining pains which last at times for two or three hours after stool. This trouble occurs usually in middle life and is more frequent in women than in men. Therapeutic Hints. Aloes. When complicated with piles. Alum, P. S. Ulceration of rectum, even fistula. Arum triph. With retention of urine. Coloc. Burning, sticking and excoriated pain in the anus, with dis- charge of moisture from the rectum; frequent pressure at the anal sphincter, which ceases on the escape of some mucus. Graphit. Severe cutting pain during evacuation, followed by constric- tion and aching contraction for several hours, especially severe at night. Ignat. Haemorrhoids; moderate effort at stool causes prolapsus recti; after stool stitching pain upward into the rectum; recurring pains in the anus of soreness and constriction. Nitr. ac. Very painful, especially after loose stool. Nux vom. With constipation and great sensitiveness of rectum. Pcson. off. Burning and biting several hours after stool, preventing sleep; must walk the floor nearly all night; exudation of offensive moisture. Platina. With crawling and itching in anus every evening, frequent urging with scanty stool, painful sensation of weakness. Ratan. Burning in ano before and several hours after stool with pro- trusion of varices; burning in urethra during urination. 512 FISTULA RECTI. Rhus fox. With periodical profuse bleeding from anus. Silic. Great pain half an hour after stool, lasting several hours. Besides compare: Amm. card., Caustic, Gratiola, Mezcr., A T atr. mur. 9 Phosphor., Plumbum, Sabad., Sepia, Thuja. Fistula Recti Is produced by the forming of an abscess in the loose areolar tissue around the lower part of the rectum. After bursting outside near the anus its walls contract and become fistulous, forming a blind external fistula. If the sup- purating process has at the same time opened a way through the rectal parietes into the bowel, it is a complete fistula. Blind internal fistulae, in which an opening leads into the bowel without an external orifice, are rarely met with, though it ma)' happen that the original ulcerated opening in the rectum is so large as to allow the matter from the abscess in the areolar tissue to escape readily into the bowel without the necessity of burrowing its way through to the outside. Sometimes the sinuses are tortuous or pass in differ- ent directions and there may be more than one internal opening. At other times there is an external orifice on each side of the anus which leads to the back of the rectum and communicates with the gut at this part by a single orifice, so as to form a sort of horse-shoe fistula. In phthisical subjects a fistula ma}' originate in consequence of tubercular ulceration and perforation of the bowel. The forming of a fistula is always attended with pain, heat, redness and swelling before it breaks externally. Later, after the subsidence of inflam- mation and tenderness, it remains a constant annoyance by its discharging, more or less copiously, a thin purulent fluid when coming from a blind external fistula, or a brownish fluid from an admixture of feculent matter, when it issues from a complete fistula. At times the discharge becomes so thin and scant}' that it appears as if the sinus were healing, when a fresh irritation again disappoints the sufferer. Therapeutic Hints. The old school knows nothing but the knife, and the modern view that all such affections are but of a local nature, does not make them hesitate in using it, notwithstanding the fact that a large percentage of those operated on in a short time after succumb to tuberculosis of the lungs. Man}' anal fistulas have been cured by the sole use of internal remedies, and others have been so decidedly relieved, that so doubtful a relief as operation could afford, was never afterwards craved for. The remedies here needed are: Alum. P. S. Ulceration of the rectum, with painful excrescences and fetid, ichorous discharges. Arscn. Despondent; chilly up and down the back; relief from heat; large purple swelling on right gluteal muscle. PROLAPSUS RECTI. 513 Berber. Great soreness and pain throughout the entire back, from the sacrum to the shoulders, worse from exertion. Calc. sulph. (Schiissler.) Hydrast. With constipation, piles and ulceration. Silic. Aching, beating, throbbing in lumbo-sacral region; occasional swelling in perineum discharging blood and pus; constipation, stool slips back after much effort. Thuja. Blind external fistula with cauliflower excrescences at the verge of the anus; offensive perspiration around the parts affected. Besides, compare: Calend., Caustic., /gnat., Nux vom., Petrol., Sepia, St aphis., Sulphur. Prolapsus Recti. The protrusion of the hypertrophied mucous membrane, often observed in haemorrhoids, is not a true prolapsus. This, on the contrary, consists of a real falling down and out of all the coats of the rectum, is in fact an ever- sion of the gut, similar to intussusception, with this difference: that the falling portion of the intestine becomes uncovered and projects externally, while in intussusception it becomes invaginated into that portion of the intestine which is just below it. The extent of the protrusion varies greatly, from an inch to six inches, or even more. When not constricted by the sphincter it has the usual florid appearance; when strangulated it appears livid, purple and tumid from congestion. After long exposure the mucous membrane becomes thickened and granular and sometimes ulcerated. Prolapsus recti is most frequently observed in children in consequence of protracted diarrhoea; less often is it found in adults, and then oftener in women than in men, in consequence of a weakened state of the sphincter, after child-bearing, etc. The protrusion takes place usually during stool, sometimes after any movement, even when standing. The gut may remain constantly protruded, being fixed so as not to admit of replacement. In some cases the protruded portion has even sloughed off. Therapeutic Hints. Bel lad. The protruded bowel looks bright red; during dentition. Ferrum. (R. T. Cooper.) Ignat. Has helped most frequently. Indigo. (Schiissler.) Mercur. When there is great straining. Mur. ae. When urinating. Nux vom. Frequently in children. Podoph. With morning diarrhoea. Ruta. Frequent, lumpy, slimy stools, at times bloody; feces often escape while bending over; much flatus; prolapsus always at stool, sometimes without stool. (Mera. ) When stooping or squatting down. 33 514 INTESTINAL WORMS. Sulphur. Worse on standing; morning diarrhoea; after easy stool; weak, scrofulous children. Besides: Apis, Arsen., Calc. card., Carb. veg., Ha??iam., Lycop., Mezer. y Phosphor., Sepia, Silic, Thuja. Proctalgia, Or neuralgic pain in the rectum, here oftentimes as violent as in other places, is relieved by Kali carb. , when the pain is stitching and pressing. Phos- phor. , in violent spasmodic pains, driving the patient about. Intestinal Worms, Entozoa, Helminthes. Of the twent}~-one intestinal parasites, three are infusoria, nine belong to the tape-worm class, two to the leech tribe and seven to the round worms. Of these only the following deserve a closer mention in this place: 1. Oxyuris vermicularis, the thread, seat, or pin- worm, is found in the intestine, from the jejunum down to the anus; the young animals in their various stages of development, and the mature males chiefly inhabit the small intestine; the pregnant females seem to prefer chiefly the caecum as their habitat, until their uteri are filled to bursting with eggs, when they gradually descend the large intestine and deposit the chief part of their eggs in the rectum, and occasionally even leave the latter and creep about on the moist skin around the anus. All eggs, males and females, are finally ex- pelled mechanically with the feces. New crops of oxyurides can originate only if ripe eggs are being introduced again into the stomach where, by the action of the gastic juice and the heat of the stomach, they are hatched in a short time, and the young, very small, fine delicate worms betake themselves at once to the upper portion of the small intestine, increasing rapidly in size to their full maturity. The ripe eggs may be brought to the mouth of infants even during birth and later, b} 7 the dirty hands of the mother or nurse, or in larger children and grown persons hy their own hands, as a kind of self-infection; they may be imparted by bakers, fruit dealers, cooks, waiters, etc. This is the view taken by Leuckhaj't, Zenker and others, resting on numerous experiments, while Vix conceives " that all the transformations from the embryo to the adult form take place within the intestine of the infested persons without any necessary migration," a view which is not in accord with the general law of development in parasitic animals, nor does it explain all the known facts. Symptoms appear not until the ox3 7 urides come down to the rectum, where they, by their active boring movements, cause an intolerable tickling and painful itching just within the sphincter and within the folds of the anus, which sometimes, especially at night, becomes almost unbearable. In the female it is particulatly distressing, from the habit which the worm has of wandering into the vagina; it may produce inordinate sexual excitement in INTESTINAL WORMS. 515 both sexes by sympathetic irritation, and cause erections, pruritis, even nymphomania with consequent masturbation. Cleanliness of the most scrupulous kind, and injections of cold water are generally sufficient for the removal of these parasites, which have not a very long life. The nightly restlessness and intolerable itching which they produce as long as they exist, is mostly always relieved by Aeon. 2. The Ascaris lumbricoides, round worm, is of a cylindrical form, tapering at both extremities. The female reaches, according to I^euckart, 15 inches in length by \ inch to \ inch in breadth, and the male 10 inches b}~ \ inch. It is of a light brownish or dirty reddish-yellow color. Its head consists of three semi-circular lips, the bases of which are separated from the remainder of the body by a well-marked circular furrow. The mouth con- sists of the triangular opening formed by the three lips. The tail of the male is always bent towards the abdomen like a hook, on which is seen the cloacal aperture with two spiculae, which frequently project. The female sexual organs open in a vulva externally at the termination of the anterior third of the body. The ova have a conical form when unripe and are oval when ripe, and have a dark, tough, double shell, and very dark granular contents; they measure 3^0 inch by -^-$ inch, and their number has been calculated by Kschricht and I^euckart at about sixty millions in a single female, of which over 160,000 are daily discharged into the intestines of its bearer. If now a person is the possessor of several of these worms, it can easily be seen that his evacuations must become so thoroughly charged with these eggs, that their discovery by the microscope cannot be of any difficulty. But their further development is not yet fully understood. It may be that the ova hatch in the stomach after being conveyed there directly; it may be that an intermediate host be necessary for their development. However this may be, the development of the worm, once introduced, must be very rapid, for it is quite seldom that very young animals are found in the intestine. The round worm normally inhabits the small intestine, but has a marked tendency to wander and creep into small apertures, so that it is led sometimes through fistulous channels to quite remote cavities or organs; it has been found in the pleural sac, the gall-bladder, the biliary ducts, the spleen, the kidney, the bladder, the muscles of the loin or neck, the spinal cord, the lung, the glottis, the trachea and the Eustachian tube. In the Surgical Museum, at Washington, I have seen the preparation of a larnyx, into which a round worm had entered and caused death by suffocation. Symptoms. — When this worm is present in moderate numbers, and oc- cupies its normal habitation in otherwise healthy persons, there is often no disturbance discoverable; but when present in greater numbers or infecting a delicate person it may give rise to abdominal griping, increased secretion of mucus, diarrhoea, vomiting, irregular appetite ; or, they cause reflex or sym- pathetic symptoms, as, itching of the nose, anus, genitals ; enlargement of the pupils, squinting, increased flow of saliva, restless sleep, with frequent start- ing and grating of teeth. 516 TAPE -WORMS. Symptoms like the following: Cachectic countenance; blue rings around the eyes; enlarged abdomen, fever, irritation of the brain, fits, convulsions, etc., which have been ascribed to worms, are rather doubtful. In such cases a careful examination will, no doubt, lead to other exciting causes. Therapeutic Hixts. Symptoms of irritation are easily subdued if we choose homoeopathically between Bellad., China, Spigel., Sulphur, and other remedies. Cina or its alkaloid will often exterminate round worms; Teucrium is recommended for thread worms. Tape-Worms. 1 1 The tape-worm must be looked upon as a colony of animals having an alternation of generation. The so-called head is the larva-like nurse; the segments of the worm — the proglottides — are the animals with sexual organs. From the head (scolex), without any mingling of the sexes, are produced the segments by a process of budding. The segments remain joined together for a considerable time, but, after they have come to maturity, they separate from the rest of the colony. The head is provided with either two or four suckers, and very frequently with a circlet of numerous small hooks. By means of this apparatus it fastens itself to the mucus membrane of the in- testine of its host. As the segments of the chain, the sexual animals, increase the distance from the head, by the development and insertion of fresh seg- ments, the}* become sexually more developed, increasing at the same time in size. They are hermaphroditic, and generate eggs, in which a six-hooked embryo becomes developed. If eggs containing these embryos find entry into the stomach of a suitable animal, their envelopes become softened or undone, and the embryos are set free. By some way or other they leave the digestive canal and make their way to different parts of the body. If the}- now meet with conditions favorable to their further growth, ' ' nurses ' ' are developed in them. Should these again happen to be introduced into the intestinal tract of another animal, they fasten themselves on, and another tape- worm colony becomes developed by budding. The time required for the development of the tape- worm colony, viz., till the sexual organs are fully developed and segments are given off, is from eight to twelve weeks. The tape- worm in- habits the small intestine, where, folded into many coils, it lies surrounded with chyme; it can move but little from its original position. Its muscular system seems, in the total absence of anything like an alimentary canal, to serve chiefly as a means of imbibing nourishment, the alternate contraction and relaxation of several groups of muscles having an effect similar to that produced by a force-pump." (Heller.) This is charactersistic of all kinds of tape-worms, of which we have separately to consider: 1. Taenia solium, or the Armed tape-worm, which attains a length TAPE- WORMS. 517 of from 7 to 10 feet, seldom much more. Its head is about the size of a small pin's head, somewhat quadrilateral, owing to the four prominent suck- ing discs. On the top front is a moderately prominent rostellum, on which is placed a coronet of small hooks arranged in two circles, an outer and an (After Kuchenraeister.) a. Taenia Solium, b. Natural size. c. Taenia Mediocanellata, or Saginata. inner one. Its slender neck is nearly an inch in length, but exhibits to the naked eye no segmentation, it only gradually passes into distinctly visible segments, which at first are so much shorter than broad, that one-half of the whole are found in the anterior ninth part of the entire worm. From this point the segments gradually increase in length more than in breadth, so that finally mature segments, Proglottides or Cucurbitina measure about one- half inch in length and one-quarter inch in breadth. From this point also the sexual organs are distinctly visible, and in about another ninth lower down, the impregnated eggs enter the uterus. The taenia solium being her- maphroditic, both male and female sexual organs are present in the same joint, and open by a common aperture on the margin and a little behind the middle of each segment, alternating irregularly from one side to the other. The uterus forms a straight line passing down the centre of the segment, from which seven to twelve branches are given off on each side. Running along the whole length of each side of the worm is a vessel, with transverse communicating branches, which contains a liquid. The eggs are roundish, and measure when free about yi-g- inch. The ripe egg encloses the embryo, a delicate mass of protoplasm, armed with three pairs of fine, glistening hooks. After the ripe segments with their eggs have separated and been discharged with the feces — it has been calcu- lated that one moderate sized tape- worm contains about five millions of ripe ova — the free joints move about for a time, especially in moist and warm situations, and disseminate their ova widely. No doubt the vast majority of them perishes, but those which happen to be taken with the food into the stomach of a pig, or much more rarely into that of a man, are hatched under the action of the stomachic juices, and the freed embryo (pro-scolex), by a diligent use of its armature perforates the tissues of its present location, 518 TAPE- WORMS. and ultimately settles, most generally, in the cellular tissue of the muscles, or in rare cases in the liver or brain. Here it remains and gradually develops into the well-known cysticercus cellulosoe of measly pork. This metamorphosis requires about two months and a half for its completion. In this condition the animal remains unchanged for a period not yet certainly known, but which has been estimated at from three to six years. If during this time one or several of the cysticerci happen to be transplanted into the stomach of man, which only can take place by the eating of raw or imper- fectly cooked measly pork, it or the}' are developed into the taenia solium, which takes its abode in the small intestine, and may infest the bearer for man}* years. 2. Taenia saginata (Goeze), Taenia canellata (Kiichemneister), the unarmed or fat tape-worm, is much larger, when fully developed, and much stronger, thicker, fatter and less transparent than the taenia solium. Its head measures about -^ inch and has neither rostellum nor coronet of hooks, but four powerful and prominent suckers. Its larval form, the cisticercus taeniae saginatae, infests the flesh and organs of the ox, a fact which at once points out the chief difference between its life history and that of the taenia solium. It abounds in Abyssinia and South Africa, and is also common in Europe and in this country, and fully as frequent as taenia solium. 3. Bothriocephalus latus (Bremser), the broad tape-worm, is the largest of all the tape- worms and commonly reaches a length of 17 to 26 feet, and sometimes 60 feet or more. Its head is oblong, or club-shaped, measures y ¥ inch by 2V inch, and has on each side a fissure-like groove in which its suction apparatus is placed. When fresh, the worm has a dull bluish-gray color. Its joints are much broader than long, until towards the end of the chain they become square. The genital pores are situated in the centre of the segments, and all are on the same side. "The ovum, after a prolonged sojourn in water, develops a ciliated embryo, which escapes through the aperture in the shell, by forcing open the lid, and is furnished with three pairs of hooklets. On analogical grounds, it is very probable that it enters into the body of some aquatic animal, possibly a fish, but probably a mollusc, and then assumes the larval form, which is at present unknown. The intermediate bearer is probably eaten by man, and the larva assumes the adult form in his intestine. Of both- riocephalus latus there are usually several together; it has a somewhat limited geographical distribution; never having been found beyond the limits of Europe, in some countries of which only it is indigenous. It is common in the western cantons of Switzerland, Northwestern Russia, Sweden, Poland, Holland, Belgium and Eastern Prussia; it is less often met with in other parts of Germany, and has occasionally been imported into Britain. Low- lying damp regions near the borders of seas and lakes are those in which it is most often abundant. It is found in persons of all ages and sexes, even children at the breast are not free from it." (W. H. Ransom.) Symptoms. — Some individuals experience not the slightest inconveni- TRICOCEPHAIvUS DISPAR. 519 ence from tape-worm. Others complain of pain in the stomach and bowels, especially after certain articles of food, nausea, variable appetite, slight diarrhoea or constipation. As reflex phenomena are mentioned: itching of the nose, headache, dizziness, getting dark before the eyes, noises in the ears, palpitation of the heart, even chorea and epilepsy. All, or at least many of these symptoms may as well arise from some hysterical or hypochondriacal affection of the patient. However, in the case of taenia solium, which in its embryonic state may infest the most different organs of the human body, it is clear that such and other serious disturbances may arise from its presence. Hahnemann says: "Two symptoms I have often observed to attend worms: the deeply wrinkled countenance and the sensation of a cold stream winding itself towards the back immediately after a meal. ' ' Thkrapkuttc Hints. If no offence is given, why should we use the cudgel ? The above- mentioned symptoms are often relieved by a well-selected remedy, which may even cause the parasite to leave. But at times persons have made up their minds to get rid of the "critter," no matter what it costs. As the safest and most expeditious of all the numerous tapeworm remedies, many have recommended — Koicsso, or the flowers of Bray era anthelmintica, 2 or 3 drachms put into a tumblerful of water well stirred, so that none of the flowers swim on the top. This done in the evening, let it stand over night. Administer a cup of coffee before taking it in the morning, to prevent nausea. Then one- half of it is taken, and the other half, half an hour later. If inclination to vomit should set in, it is best subdued by lemon juice. The taenia saginata requires a larger dose. Often tapeworms have been removed by the seeds of the common pump- kin, mashed up to a mush, or by the use of the cocoanut. The male shield- fern (Aspidium filix mas), or the bark of the Pomegranate root (Punica granatum), are other remedies frequently and often successfully applied. The surest prevention consists in avoiding the use of raw or not well- cooked pork and beef. Tricocephalus Dispar, Or the whip-worm, is from one to two inches long, thin in front, like a thread, while its posterior portion is thicker. Its chosen residence is the caecum. There are no symptoms known by which it could be diagnosticated during life. Its life-history, as far as known, is similar to that of the seat- worm. Anchylostomum Duodenale, Dochmius s. Strongylus Duodenalis. It is a small, cylindrical worm, with its anterior portion, in which the head is situated, curved backwards. Its mouth is provided with a bell- shaped capsule and at its anterior margin with four strong, claw-like hooks 520 TRICHINA SPIRALIS. and two smaller ones at the opposite side. The males measure T \ inch, and the females T % inch in length. The tail of the male terminates in a three lobed bursa, in which are placed two thin spicula. The female's extremity is pointed, and their genital opening lies somewhat behind the centre of the body. The eggs are oval, and measure -^ inch by T oVo inch. They prob- ably under favorable circumstances hatch, and the embryo enjoys a free existence, for a time, in mud and muddy warer. If taken into the stomach it grows and passes down to the duodenum or jejunum, and attaches itself by its powerfully armed mouth to the villi of the mucous membrane, and sucks the blood of its host. It has been found only in Italy, in Egypt, in the countries bordering the Nile, on the Comoro Islands, in Madagascar, in Brazil and Cayenne. It produces dangerous haemorrhages in the bowels, followed by an anaemic condition, which is often fatal, and is the cause of the so-called Egyptian chlorosis, the true nature of which was pointed out by Griesinger. Griesinger recommends turpentine against them. Trichina Spiralis. Only within the last twenty years trichinas have become an object of pathological researches, although they had already been discovered by Hilton in the year 1821 as numerous white specks visible to the naked eye, in the muscles of the human body, but considered by him as cisticerci. Later, under the microscope, they proved to be calcined trichinae capsules, and about 1835 Paget detected in them a minute round worm, which was accu- rately described and named by Owen Trichina spiralis, on account of its form being like a hair and of a spiral shape. However, everything concerning the life-history of these animals remained unknown until Zenker, of Dresden, in the year i860, called public attention to the fact that this little parasite was the cause of a very painful and even fatal disease. - Since then by the labor of numerous investigators the following has been brought to light: "The trichina spiralis is met with under two forms, the intestinal-trichina and the muscle-trichina. The former or mature trichina is an extremely fine, round, thread-like, slightly coiled worm, with a still finer head, which gradually decreases in thickness towards its point; its hinder extremity is rounded off rather abruptly. " (Heller.) The males are from one-half to one-third smaller than the females, and are furnished at the caudal extremity with two pointless, lobular appendages and a genital opening. The females have their vulva at about the termination of the anterior fourth part of their whole length; their eggs after being fructified develop in the uterus to embryos which are born free and living. The birth of the embryos begins on the seventh day after the introduction of muscle-trichinae into the stomach, and may continue, as it appears, for weeks. Soon after birth the embryos commence to migrate, piercing either, as some assume, through the intestinal wall and wandering from thence through the loose connective tissue towards the muscles; or they enter, as others suppose, the blood-vessels — either directly or by way of the lymph current, in which they are carried to the TRICHINA SPIRALIS. 521 different muscular parts of the body. As soon as they reach the muscles they force themselves into the primitive fasciculi, cause disintegration of the same, increase in length and thickness, and finally roll up in coils of greater or less size and become encapsuled. After a time a deposition of lime-salts takes place in the capsules, by which they become opaque and visible to the naked eye as little white specks; previous to this calcification only experi- enced observers can detect them. Under certain circumstances the muscle- trichinae die and may decay, or they petrify, break into pieces, and their former nature can be recognized only by the peculiar position occupied by the fragments. But as a general thing the vitality of the muscle-trichinae is almost unlimited and ends even not with the death of their host, while the intestinal trichinae very rarely live longer than from five to eight weeks, when their propagation has been finished. If it happens that the muscle-trichinae, by eating the meat of its host, be introduced into the stomach of a man or a proper animal, they will be freed from their capsules, become sexually mature within about two and a half days, copulate, and after five days more the females will bring forth living embryos, which soon commence to migrate as above described. Trichines Trichinae. (After Heller.) Muscle-trichinae, magnified. Capsulated and calcified muscle-trichinae, sli Calcified and broken. Capsulated, magnified. rhtly magnified. are found especially in swine, but have been observed also in the cat, rat, mouse, marmot, polecat, fox, marten, badger, hedgehog and raccoon, and have successfully been bred in rabbits and guinea-pigs, but exceptionally successful only in sheep, calves and dogs. 522 TRICHINOSIS. From this it can be seen that the infection of man is principally carried on by the eating of raw or not thoroughly boiled pork. The disease caused by the propagation of the trichina in man has been called Trichinosis, Which commences, as a rule, with disturbances of the digestive apparatus, sometimes a few hours, at other times not before several days after the in- fecting meal, with variable symptoms, such as: uneasiness, fullness, nausea, retching, vomiting, diarrhoea, or constipation. In most cases there is an un- pleasant and pasty taste in the mouth, and in many a loathsome, putrid odor. The muscular symptoms are the most important and painful. A constant symptom from the outset is a flabby condition of the muscles and painful sensation on motion, a muscular lameness. After the invasion of the muscles the symptoms ma}' be trifling, even absent in light, or extremely violent in moderate and severe cases. Commencing seldom later than on the tenth day, they consist of various degrees of swelling and hardness and extreme sensi- tiveness to pressure of the muscles in general, or, a permanent contraction of the flexors of the extremities, or a difficulty of chewing and swallowing in a degree that only fluid nourishment can be taken, or a hoarseness when the muscles of the larynx, and a difficulty of breathing when the diaphragm and the respiratory muscles are invaded. The fever in light cases is insignificant, in severe forms resembles that of an ordinary case of typhoid fever, or pre- sents in lighter cases almost an intermittent type. There is seldom a chill at the onset, oftener slight shivering. The pulse varies at the beginning be- tween So and 90, and rises later to 100 or 120 beats in a minute. The tem- perature ma}* rise to 105 ° F. Perspiration is usually very profuse, and continues throughout the whole disease. The nervous symptoms consist especially of sleeplessness, neuralgic attacks in the bowels, hyperaesthesia of the skin in the form of pruritus or formication, either extending over the whole body or limited to single portions of the lower extremities, and in some cases of loss of hearing. The circulatory symptoms consist of cedematous swelling of the eyelids and face, which is the most characteristic sign of trichinosis, setting in most frequently on the seventh day, and at times dis- appearing after from two to five days, and reappearing again in some cases after a few weeks. CEdema of the extremities is often quite marked and lasting. The incubation varies from a few hours to several weeks, and it appears that some persons can tolerate a considerable number of trichinae without experiencing any special disturbance. The muscle-trichinae must have attained a certain maturity in order to be capable of sustaining themselves in the stomach and of developing and reaching the muscles, their ultimate abode. If transplanted too young into the stomach, they will be either de- stroyed by digeston. or will have to make up their deficiency in the intestine and require therefore a longer time for the development of embryos. Also, THERAPEUTIC HINTS TO TRICHINOSIS. . 523 if the capsulated trichinae are much calcified, it will take a longer time to set them free. Just such uncertainty exists as to the duration of the disease itself. In some very light cases the whole course of trichinosis passes over in two or three weeks without even confining the patient to bed; while in somewhat severer cases convalescence begins in the fifth or sixth week, and grave cases take some four months, and even then the convalescent frequently do not regain their full strength for a long time. A fatal termination occurs most frequently in the fourth, fifth or sixth week, and generally as a conse- quence of paralysis of the respirator}^ organs. The percentage of deaths has been as high as thirt3 7 in a hundred. The Diagnosis in single cases is very difficult in the beginning of the disease, easier when several persons become diseased at the same time. The onset resembles closely a gastro-intestinal catarrh, from which it differs, how- ever, by a constantly increasing perspiration. The oedema of the face and eyelids, appearing on the seventh day, is another important feature, inasmuch as other diseases in which this symptom occurs (morbus Brightii, diseases of the heart, lungs or pleura) can easily be excluded. The urine in trichinosis is always free from albumen. But the diagnosis becomes indisputable on the discovery of single trichinae in the stools, or upon the observation of muscle -trichinae in excised portions of muscle, or also in the proven fact that the patient has partaken of trichinous pork. Therapeutic Hints. \ The best prophylaxis is not to eat any pork, ham, sausages, etc., which is not well boiled or roasted. The old school has ordered laxatives, turpen- tine, kali picroniticum and benzine, but without any marked effect. Dr. Hering has recommended the Tellurite of Potassa in half grain doses. For in accordance with the provings of Hansen and Mohler, this substance caused at once such a strong, garlic-like odor of the breath, that the prover had to withdraw from society for several weeks. This odor is owing to a volatile organic compound, or perhaps telluretted hydrogen, into which the tellurite of potassa is converted, and may, by its pervading the whole system, be the means of destroying the intruders. There are a few cases on record which have been treated homcepathi- cally by Apis, Arsen., etc., but likewise without any striking effect. Al- though I have never treated a case of trichinosis, yet, considering the totality of the symptoms of trichinosis, I feel strongly inclined to recommend Z^w palustre. For in the first place the herb has been used successfully to keep insects away from clothing. Secondly, it has been given successfully for insect stings and wounds caused by needles, and what can the wandring trichinae be better compared to than millions of the finest needles piercing the muscles ? And lastly, Ledum has the following s3'mptoms which correspond to trichinosis: Bloated face; want of appetite; nausea; constipation; violent tension in the hypochondriac region during inspiration and retention of breath ; 524 SPECIAL HINTS TO HELMINTHIASIS. oppressed painful breathing; pain and drawing in the outer parts of the chest, especially during inspiration, accompanied by single stitches. Painful stiff- ness of the muscles; sensation as if the muscles had not their proper length, with pain as if sprained in every position, but especially when touching the parts and when walking. Swelling, with tension and stinging hardness of the whole leg. Swelling of the leg extending to beyond the calves, with tensive pains; swelling of the feet; inflammatory or cedematous swelling of the feet and legs. Pain in the soles of the feet when walking, as if ecchymosed. Pressure in the soles of the feet, more violent during a walk. Bruised pain in the heel when walking. The limbs of the whole body are painful, as if bruised and contused. Chilliness. Languor and weariness when sitting, standing or walking; fainting. Pimples and boils, pustules on the forehead and other parts. CEdematous swelling, also of the skin of the whole body. Special Hints to Helminthiasis. Aco?i. Pain in the bowels; the umbilical region is hard and the whole belly bloated; urging to stool without discharge, or slime only; nausea; ac- cumulation of water in the mouth; or restlessness at night on account of intolerable itching and tingling at the anus, throwing the child into fever (seat-worms). A?-g. nitr. Periodical pain in the region of the liver and around the navel, with sickness at the stomach, retching, vomiting of tough mucus; menses irregular, but always discharge of thick, black, coagulated blood; gray-yellowish color of the face. Bellad. Drowsiness; starting in sleep, grating of teeth, involuntary discharge of feces and urine, or dysuria; squinting. Calc. cai'b. Headache, dark rings around the eyes; pale, bloated face; thirst; thick, bloated belly; aching about the navel; diarrhoea; easy per- spiration from motion; scrofulous diathesis. China. Pain in the belly, worse at night, after eating; fullness of the abdomen, pyrosis, pressure in the stomach and retching; tremulous weakness all over. Cicuta. Frequent hiccough and crying; pain in the nape of the neck; spasmodic drawing of the head backwards, and tremor of the hands. Cina. Restless sleep with rolling of the eyes, dark rings around the eyes; squinting; enlarged pupils; constant rubbing the nose; bleeding of the nose; face pale, cold or red and hot; loathing of food, or great hunger; nausea; vomiting; pain in the umbilical region; belly hard and distended; constipation; dry, hacking cough at night; feverishness ; convulsive motions of head and limbs. Euphorb. Loss of appetite, or voraciousness at times; furred tongue, feverishness; fetid breath; bloated stomach; constipation or diarrhoea; ema- ciation, peevishness, wakefulness. SPECIAL HINTS TO HELMINTHIASIS. 525 Ferrum. Pale, wretched complexion, easily flushing; itching at the anus from seat-worms at night; involuntary micturition. Filix mas. Frequent pain in the bowels, a kind of gnawing and boring; constipation; loss of appetite; furred tongue; pale face; blue rings around the eyes; itching of the nose; irritable and cross. Ignat. Itching at the anus from seat- worms; convulsions, with loss of consciousness and temporary inability to speak afterwards. Konsso. Indigestion; loathing; sleeplessness; weakness with fainting; profuse and cold perspiration; emaciation; dull pain in the bowels; bloated- ness; constipation, tape- worm and other worms. Lycop. Arthritic pain and stiffness; chronic eruptions; wretched, dirty, pale, earthy complexion; flatulence; bloating the stomach and abdomen; sensation of something crawling and moving in the bowels and stomach up and down; constipation. Mercur. Continuous greediness for eating; he becomes weaker and weaker withal; bad smell from the mouth; itching of the anus; inflamma- tion of the vulva; seat and round- worms. Punica granatum . Vertigo, wavering before the eyes, enlarged pupils, yellow complexion; grating of teeth; accumulation of water in the mouth; changing appetite; gulping of watery fluid; vomiting; sensation of some- thing moving in the stomach; bloated bowels; colic; palpitation of the heart; spasms; syncope. Sabad. Vomiting of round- worms, or nausea and retching, with a sen- sation of a worm in the pharynx; or, in case of tape- worm, burning, boring and whirling in the umbilical region; accumulation of water in the mouth; chilliness and sensitiveness to cold; sensation as if the abdomen were sunken in. Spigel. Nausea every morning before breakfast, always better after breakfast; dilated pupils; squinting; pale face; smarting in the nose; sen- sation of a worm rising in the throat, better after eating; or vomiting of all she takes, with sour rising like vinegar from the stomach; pain in the bowels; dry, hard cough at night; palpitation of the heart. Silic. Colic in children from worms. Sulphur. After A co n. or Mercur. \ creeping in the nose; creeping and biting in the rectum; passage of lumbricoides, ascarides and taenia; nausea before meals and faintness before dinner; restlessness at night. Stannum. Hahnemann and others have mentioned it as palliating the symptoms caused by tape and round- worm. Tereb. Burning and tingling in anus and rectum, lessened by applying cold water; hunger after a square meal; foul breath; choking sensation; dry, hacking cough; spasms and convulsions; wakeful at night; screaming as if frightened; staring look, clenching of fingers; twitching of different parts of the body. Teucrium. Is said to be specific against the terrible itching in the anus from thread- worm. In addition the following remedies may be merety mentioned as vermi- 526 PERITONITIS. fuges: Apocyn. andr., Asclcp. syr. and tuber., Chclone, Dolich. pruriens, Ge/sem., Gnaphal., Helon., Podoph. Peritonitis. Its pathological character is like that of pleuritis or pericarditis — injec- tion of the capillary vessels followed by exudation. This exudation is either — ist. Of a serous nature, and then generally profuse, distending the ab- domen to a considerable extent. Owing to its serosity it is easily absorbed. Or the exudation is — 2d. Of a fibrous nature, coagulable lymph, at least predominantly so. This is apt to cause adhesions, not only between the layers of the peritoneum at different places (thus forming sacs wherein the remaining fluid is retained) , but it may create, also, strings or bands of fibrin, which fasten one portion oj the intestine to another, and which may give rise to strangulation of a por- tion of the intestines. Or the exudation is — 3d. More or less mixed with blood globules, called hemorrhagic, mostly found in diseases which predispose to bleeding in different organs, as for in- stance scurvy, typhus, delirium tremens, exanthematic fevers, etc. Or the exudation consists 4th. Of pus or ichor, when it is called purulent or ichorous. The latter takes place only under the most unfavorable conditions, when there is an in- fection of the blood, as in puerperal fevers, pyaemia, or when urine passes into the cavity of the abdomen. It is thus clear that a peritonitis is not necessarily cured simply because the inflammation has passed away; its product, the exudation, may yet give considerable trouble before it is removed. Peritonitis does not always involve the whole peritoneum, is not always general or diffused, but much oftener only partial or circumscribed, attacking only single portions, for instance those which cover the liver, spleen, kidneys, uterus or some parts of the intestines, being more or less complicated with inflammations of these organs. Its Causes are various. Primarily, it is most frequently brought on by external injuries; a blow, a fall, a penetrating wound, or by surgical opera- tions, or by exposure to cold and wet. Secondarily, it may be a mere continuation of an ahead}' existing in- flammatory process of the liver, spleen, womb, bladder, caecum, etc., or it may arise in consequence of ulcerative processes within the intestines and subsequent perforations; also childbed fever and metritis are frequent causes of peritonitis. Symptoms. — Owing to these diverse causes peritonitis, considered as a general form of disease, it exhibits a great variety of manifestations which will change in individual cases. Indeed, this is so with all forms of disease. I can point out only those symptoms which are most apt to occur in all forms. PERITONITIS. 527 i. Pain is never absent and always severe; it is described as sharp and lancinating, and is increased by the slightest motion or touch. Therefore the patient lies quietly on his back with his thighs flexed, breathing only with the thorax, instinctively avoiding all action of the diaphragm. The slightest pressure increases the pain; even that of the bedclothes seems at times un- bearable — a distinctive sign between peritonitis and colic. 2. Vomiting; at first, of the usual contents of the stomach, then of slimy and bilious, and lastly of green masses, as though verdigris had been taken into the stomach. It becomes stercoraceous only when peritonitis is associated with obstruction of the bowels. The vomiting never relieves, but increases the pain considerably. 3. Singultus sets in especial^ when the serous covering of the diaphragm becomes involved in the inflammatory process. 4. Constipation — owing to the paralyzed state of the intestines — is a fre- quent symptom; but in cases of peritonitis puerperalis, or in combination with catarrhal inflammation, or ulceration within the intestines, there is almost always diarrhoea. 5. Great distention of the abdomen in consequence of accumulation of gas and fluid. This causes the diaphragm to rise into the thoracic cavity and to compress the lungs, producing congestion, short breathing, 40 to 60 times a minute, and a disturbance of the circulation which may bring on cyanosis of the face. 6. Constant desire to urinate; painful micturition or retention of urine; always where the serous covering of the bladder is involved. 7. Fever; more or less intense according to the extension of the inflam- mation. The temperature may rise to 104 or 105 F., and higher, and the pulse from 120 to 130 in a minute. Gradually, however, as the disease pro- gresses, the pulse becomes small and flickering; the extremities cool and covered with cold sweats; the features collapse. 8. Physical signs are not very readily elicited; as the patient can bear neither touch nor motion; although, of course, we may expect a dull sound on percussion where there is effusion, and a tympanitic sound where there is meteorism. Auscultation gives no signs, except rumbling in the bowels, which may be heard at a distance. That it is a dangerouse disease we may conclude, if we consider for one moment its nature, and again, that this danger varies according to cause, complication and extension of the disease. Simple idiopathic cases, with- out other complications, are the least dangerous. Those caused by wounds are more or less dangerous, according to the nature of the wound. And the danger of those which are the secondary result of other inflamma- tory processes depends upon the nature of these processes. It is a good sign when, in the progress of the disease, the pain gradu- ally abates and the pulse rallies. It is a bad sign when the pain abates and the pulse gets weaker and quicker. It is a sign of imminent danger when 528 THERAPEUTIC HINTS TO PERITONITIS. the pain suddenly subsides and the pulse becomes flickering and the features collapse. Cases which have become chronic terminate frequently in marasmus and a variety of consecutive sufferings. It is possible that in such cases the purulent exudation perforates either some part of the intestine, or discharges outside through the abdominal wall. Therapeutic Hints. Aeon. Hot, dry skin; quick, hard, small pulse; high, inflammatory fever; mouth and tongue dry; great thirst; bitter taste; vomiting; no stool; urine scanty, red and hot; lower extremities cool; short, quick breathing; very restless; anxious expression in the face; burning, cutting, darting pain in the bowels, worse from slightest pressure, motion and lying on the right side; abdomen hot to the touch. After taking cold, drinking cold water when being heated. Apis. Burning, stinging pain in the bowels, very sore to the touch; when exudation has taken place; urine scanty, dark; oedematous swelling of the feet; burning, stinging in the region of the ovaries; metritis. Arnica. After contusion. Arsen. Later, when there is a sudden sinking of strength, cold, clammy perspiration, anxious, internal restlessness, insatiable thirst with drinking but little at a time; constant vomiting; burning in the bowels; all worse in the middle of the night. Bellad. After A con., great congestion to the head; strong^ pulsating carotid arteries; light and noise unbearable; colicky pains in the bowels; painful retching and vomiting, worse from motion and contact; great anxiety and d3 T spncea. Especially when in complication with metritis or perityphlitis. Bryon. Stitching pain or pressing, lancinating in the bowels, worse from slightest motion; when exudation has taken place; tongue white and dr}'; great thirst; bowels constipated; the patient lies perfectly still, don't want to move. Especially in complication with diaphragmitis. Calc. carb. When about the seventh day a red rash appears; also when the pain is alleviated by cold water applications, so that the patient wants them renewed constantly. Abdominal tuberculosis. Canthar. Abdomen burning hot; tympanitic distention in its upper region; lower portion yields a dull sound; bloody, slimy stools; painful, ex- torting cries; tenesmus of the bladder; strangury; great anguish and rest- lessness; distressed face; sunken features; cold extremities. Especially when the serous covering of the bladder is the seat of inflammation. Carb. vcg. Excessive tympanitis with paralysis of the bowels. Laches. Abdomen hot and sensitive to touch; painful stiffness from the loins down into the thighs; scanty, turbid urine with reddish sediment; strangury; constipation; necessity of lying on the back with drawn-up knees. Especially in complication with typhlitis. Lycop. In complication with diaphragmitis or hepatitis; when lying ASCITES. 529 on the left side, a feeling as if a hard body were rolling from the navel to that side; or when after three or four days the face assumes a yellowish color; troublesome flatulence and constipation; sleeplessness and constant distress. Mercur. At a later period, if the exuded fluid becomes purulent, with frequent starts; creeping chills; perspiration without relief; pale, wretched complexion, foul smell from the mouth; vomiting of slime and slimy stools, with straining; cedematous swelling of the feet; great weakness and emacia- tion. Especially when in complication with typhlitis and the formation of abscesses. Nitrnm. Stitching and sticking pains; predominating coldness of the lower extremities; kind of numb and stiff feeling in the affected parts, as if they were made of wood. Nux vom. Belching, vomiting and constant pressure upon the rectum, as if urging to stool. Oputm. Distention of the abdomen; anxiety, with a feeling of flying heat internally, and stupefaction of the head; somnolence; antiperistaltic motion of the intestines; constant vomiting and belching; retention of stool and urine; complete inactivity of the lower bowels. Rhus tox. Great restlessness; changing position, notwithstanding the pain it causes; tongue red at the tip; pressive cutting pain in the abdomen; typhoid symptoms; febris lente; metritis. Sulphur. After Aeon, and Bry on.,, or when the disease takes a pro- tracted course. Veratr. Vomiting and diarrhoea; coolness of the skin; sunken features; pulse small and weak; thirst great; restlessness and anxiety. Ascites, Dropsy of the Peritoneum. Its pathological character is like that of hydro thorax, a collection of fluid within the peritoneal sac, which is of a yellow, or yellowish-green, or (if blood be mixed with it) of a reddish color, and contains a great deal of albumen, saline constituents, and flakes of coagulated lymph. The quantity of fluid sometimes exceeds forty pounds. The peritoneum is opaque, with- out lustre, and thickened, but without any signs of inflammation. Liver and spleen are pale, sometimes smaller than normal; the kidneys appear anaemic, and the diaphragm is pushed upwards into the thoracic cavity. Dropsy of the belly is never a primary disease, but always the con- sequence of some morbid action, such as diseases of the lungs, heart, larynx, blood-vessels, liver, spleen, kidneys, of intermittent fever and cancer- cachexia. It may result from mere local troubles, such as impediments of circula- tion within the peritoneum by obstructions of the vena portae, cirrhosis, and tumors of the liver, tubercular and carcinomatous degeneration of the peri- toneum. Frequently several of these causes are in operation, and sometimes it may be difficult to find out the true cause. If it develops without any 34 530 ASCITES. oedema of other parts, we may conclude that it is caused either by an ob- struction of the portal circulation, or by a degeneration of the peritoneum. If by disturbance of the portal circulation, we generally find signs of a dis- turbed action of the liver, and the urine containing bilious coloring matter; if by degeneration of the peritoneum there are signs of cancer-cachexia, or tumors in the abdomen, the urine usually retaining its natural color. Symptoms. — i. Swelling of the abdomen. This alters its form accord- ing to the position of the patient. When standing, the hypogastric region swells out the most; when lying, the most dependent portion of the abdomen bulges out. This distinguishes ascites from any other swelling within the < abdominal cavity. 2. Fluctuation, which is easily discovered by palpation. 3. Diminution of urinary secretion and alvine evacuations (the latter -ex- cepted, where there is an intestinal catarrh co-existing). 4. Dull percussion sound, also variable according to the patient's position. 5. Pressure towards the thoracic cavity, with dyspnoea and palpitation of the heart. 6. Enlargement of the veins in the lower extremities,, and dropsical swelling of the external genital organs and lower extremities, in consequence of the pressure which the accumulation of fluid within the abdominal cavity exercises upon the vena cava and venae iliacae, causing obstruction of circu- lation in these parts. The Prognosis depends entirety upon the nature of its cause. If that is not removable, it is hardly to be expected that its consequences will be. The patient does not die in consequence of dropsy, but in consequence of the primary disease, if that be fatal, although dropsy by impeding the respira- tion, or by excoriations or superficial gangrene may hasten this result. Ascites differs from dropsy of the ovaries by its causes, which close ex- amination must elicit; by its form, being a uniform distention of the lower abdomen, rising gradually upwards. In dropsy of the ovaries, the swelling is more on the one or the other side, exending gradually sideways over the whole abdomen; by its changing form by change of position, which never oc- curs in dropsy of the ovaries, where the fluid is encysted. In our Therapeutic management of each individual case, therefore, we shall have to select remedies from those which are indicated for dropsical affections in general; as Apis, Arsen., Bryon., China, Dulcam., Ledum, Lycop., Phosphor., Pulsat., Rhus tox., Sepia, Strontium. Vomiting and diarrhoea suggests: Ant. crud., Apis, Apoc. cann., Ar- gent., Arse?i., Asar., Borax, Chamom., Cuprum, Ipec., Mercur., Phosphor., Senega, Sulphur, Ta?'t. emet., Veratr. Ulcers on the legs: Arse?i., Graphit., Helleb., Lycop., Mercur., Rims tox., S cilia, Sulphur. (Edema of the lower limbs, with constant oozing out of the water from sore places without formation of pus: Rhus tox., afterwards Lycop. Cough, with dropsy: Amm. card., Apis, Arsen., Colchic, Helleb., Nit. ac. special hints to ascites. 53 1 Special Hints. Apis. Urine scant}*, dark, like coffee-grounds; thirstlessness; great soreness of the abdominal walls; stinging, burning pains in different parts of the body; can't get breath, except when sitting; even leaning backwards causes suffocating feeling; in complication with scarlet fever, uterine tumors, and inflammatory processes of the bowels. Apoc. cann. Has heen given abundantly by western physicians for 11 drops}*" of all kinds; seems to be indicated by a sinking feeling at the pit of the stomach; an irritable condition of t>he stomach, that cannot retain even a draught of water; muddy urine; diarrhoea; bloatedness of the face after lying down, passing off after sitting up; dropsy after scarlatina. Arsen. Complexion pale and earthy, or greenish; great weakness, ex- haustion; faint feeling from slight motion; tongue dry; great thirst, with frequent drinking, but only little at a time; suffocative spells, especially at night; great anxiety; must jump out of bed; skin cool; burning heat inside; post-scarlatinal dropsy; in complication with heart diseases. Aurum. Has been recommended when ascites is the consequence of functional disturbance of abdominal organs, in combination with albuminuria. Bryon. Congestion of the head; giddiness when rising after stooping; loss of breath when moving in the least; lower eyelids cedematously swollen; lips bluish; great thirst and scanty urine, with burning in the urethra, pass- ing off drop by drop; obstinate constipation; after scarlet fever. Canthar. Cured many cases according to Faivre. China. Indicated in organic disturbances of liver and spleen, and after loss of blood. Colchic. Palpitation of heart, and dyspnoea from n to 3 o'clock in the night, burning in pit of stomach, afterwards nausea, finally vomiting with subsequent weakness and sometimes ravenous hunger. Skin dry and pale. (F. Pollock.) Urine scanty, looking like bits of decomposed blood, with offensive smell. (W. McGeorge.) Convulvulus arv. Constipation; abdominal disturbances, weakness, appetite good; he would eat more if there were more room, the abdomen being filled with water; urine almost entirely suppressed. Digit. Difficult micturition; pale face; intermitting pulse; cold skin; doughy swelling, which easily yields to the pressure of the finger. Fluor, ac. Enlarged and indurated liver, in consequence of drinking whiskey. Graphit. Great oedema of lower extremities with profuse watery exu- dation below knees; exudation gelatinous. (H.V.Miller.) * Helleb. In acute cases; after scarlet fever; drowsiness; slow in answering questions; griping in bowels, with jelly-like discharges; frequent but scanty micturition; great thirst; fever; sympathetic neuralgia of face into teeth on left side; preventing chewing. Kali card. In complication with liver and heart affections. 532 TYMPANITES ABDOMIXALIS. Laches. In complication with liver, heart and spleen diseases, scarlet fever; black, scanty urine. Lycop. Liver affections; abuse of alcoholic drinks; after venesection, or intermittent fever; oozing out of water from sore places in the lower extrem- ities, without formation of pus; urine scant)*, with red sediment; upper portion of the body emaciated, lower enormously swollen; one foot cold, the other hot; restless sleep; cross w T hen getting awake. Mangan. ox. Intermittent fever; cachexia; palpitation of the heart, strong, irregular, tumbling, without abnormal sounds. Mercur. In consequence of organic lesions of the liver and other ab- dominal viscera, the swelling of the abdomen is tense, hard; thirst not prominent. Senec. Abdomen very tense; lower extremities cedematous; urine scanty and high-colored, or alternating with profuse and watery discharge; pain in the lumbar region and in the ovaries. Sulphur. After suppressed eruptions, rough skin; bluish spots; sleep, with moaning; quick pulse; cold feet; easily sweating, especially in the face; painless diarrhoea; drawing together of the fingers; very forgetful; inclina- tion to sit still and to lie down. Paracentesis with the usual trocar causes adynamia, rapid return of the fluid and often peritonitis. Capillary punction allows a slow withdrawal of the fluid, causes less adynamia and less frequently peritonitis. (L,eudet.) Tympanites Abdominalis Corresponds to Pneumothorax, and consists of a collection of gas within the peritoneal sac. It is caused by ruptures or perforations of the stomach or of the intestines, in consequence of which the gas which is contained therein diffuses itself within the peritoneal sac. More rarely the air finds its way into the abdominal cavity from out of the lungs (in consequence of abscesses and pneumothorax); and still more rarely it enters from the uterus or the vagina in consequence of destructive processes in these organs. Cases have been observed where the gas originates within the peritoneal sac itself, in consequence of a decomposition of ichorous fluids contained therein, especially in combination with puerperal peritonitis. Symptoms. — Swelling of the abdomen. Its development is rapid if it be caused by perforation; slower, if by gradual decomposition. Full tympanitic sound all over, even in the region of the liver. This or- gan is pressed backwards, if it be not adherent to the diaphragm; this is quite characteristic and serves to distinguish tympanitis from meteorism, i. e. y a collection of gas within the intestines. All signs of peritonitis, which develops itself soon after the entrance of air into the peritoneal sac. Therapeutic Hints. Compare Peritonitis and those other affections of which it is a mere consequence. DISEASES OF THE LIVER. 533 DISEASES OF THE LIVER. Physical Examination. — The upper border of the liver extends into the space between the fifth and fourth, sometimes even to the edge of the fourth rib. Being, however, overlapped here by the lower edge of the right lung, which reaches down to the sixth rib, we find on percussion the perfect, dull liver-sound commencing onfy from the sixth rib, while above it to the fourth rib the dull sound can be elicited only by hard strokes, sounding through the layer of the lung tissue that covers the liver. Inferiorly the liver reaches to the tenth rib in the right hypochondrium, whence it ascends in a some- what semi-lunar line across the epigastrium, midway (or often a little higher than midway) between the ensiform cartilage and the navel, towards the left hypochondrium. Percussion in a horizontal line from the ensiform cartilage towards the left, a little under the region where the apex of the heart strikes, tells us how far into the left hypochondrium the left lobe of the liver reaches. This normal position, however, may be changed without indicating any disease of the liver itself. The liver is dislocated downwards by emphysema, pleuritic effusions, pneumo-, pyo- or hydrothorax of the right lung; it is dis- located upwards by fluid or gaseous collections, or tumors within the ab- dominal cavity, or in consequence of a shrinking of the right lung. Its sur- face becomes grooved by tight lacing of corsets and waists of petticoats in females, and of pantaloons in males. Part of the right lobe may, by this long-continued process, be brought down to the anterior superior spinous process. Pigment Liver, Melanaemic Liver resulting from Malarial Fevers. The liver presents a steel-gray, or blackish, or chocolate color, in con- sequence of an accumulation of pigment matter in its vascular apparatus. These deposits are either uniformly distributed, or limited only to certain portions. Similar appearances are constantly found also in the spleen, fre- quently in the capillaries of the lungs, also in the brain, especially in its cortical substance, and in the kidneys. Even the other organs and tissues, such as the external integument, the mucous membranes, the muscular tissue, etc., remain by no means exempt, as may be seen by their gray tint. The pigment seems to be carried everywhere by the blood, and the effects upon the system of this morbid process in consequence of malarial fevers will, of course, vary according to the organs which are most specially attacked. We will find cases with predominant brain symptoms, others with predominant symptoms of the kidneys, others with predominant derangements of the gastro-intestinal tract and the liver, and others where anaemia and hydremia, resulting from affections of the spleen, constitute the most important morbid conditions. Hyperemia, Congestion of the Liver. One of the most frequent causes is obstruction to the circulation of 534 HYPEREMIA. blood in consequence of valvular diseases of the heart, such as constriction of the left auriculo-ventricular opening, insufficiency of the mitral and still more of the tricuspid valves, and further, affections of the lungs, such as emphy- sema, extensive induration or atelectasis, great pleuritic effusions, etc., which all give rise to accumulations of blood in the venae cavae, by which the branches of the hepatic vein continue permanently distended, and cause a general enlargement of the liver. On section, the organ presents a nutmeg- like appearance. The dark spots correspond to the situations of the hepatic veins, and the light colored portions of the parenchyma, exhibiting upon closer inspection pale, delicate ramifications, correspond to branches of the portal vein, and constitute the so-called Nutmeg liver. From the persist- ence of this obstruction the hepatic parenchyma gradually atrophies and at last acquires a finely-granular structure, which frequently has been con- founded with cirrhosis of the liver. This is the atrophic form of nutmeg liver. Besides the symptoms of the cardiac or pulmonary disease, which constitutes the primary cause of the circulatory obstruction, we observe derangements of digestion, pains and tension in the epigastrium, nausea, etc., and occasion- ally haemorrhoids. Sooner or later it leads to death from pulmonary oedema, apoplexy, general dropsy, etc. Congestion of the liver may be induced also by rich living, especially in persons of a sedentary habit. Stimulants and irritants, such as alcoholic drinks, pepper, mustard, coffee, etc., in large quantities frequently give rise to this trouble, and quite marked is the influence of hot climates and of miasmatic effluvia. The hepatic hyperaemias of the tropics are often associated with d3 r sentery or malarious fevers. In the latter case there is also swelling of the spleen or kidneys. Its acute form is characterized by more or less painful distention of the region of the liver, with dyspnoea and pain stretching towards the right shoulder, by headache, nausea and vomiting of mucous or green matter; by constipation or diarrhoea, which is bilious or even bloody. This state of things, by proper treatment, may entirely subside; if neglected, it ma}' give rise to a chronic form which shows more or less periodical exacerbations of these symptoms, and finally runs into structural changes of the liver, such as softening, or pale and jaundiced or fatty degeneration, or induration, cir- rhosis and abscesses. In temperate climates this affection is much less violent than in the tropics, but may also assume a chronic form and produce enlargement of the liver by fatty deposits, or infiltration of its parenchyma with albuminous substance, which gradually passes into colloid degeneration, and in rare cases becomes cirrhosed. A hyperaemia of the liver in consequence of the suppression of habitual haemorrhages, for instance during the climacteric period of life, has frequently been observed; it usually does not give rise to any serious derangement in the nutrition of the liver. therapeutic hints to hyperemia. 535 Therapeutic Hints. In acute cases : Bcllad. High fever; congestion of the head; severe headache; vomiting of the wate*ry, slimy and bilious fluid; great thirst; region of the liver pain- ful and sore to the touch. Bryon. Bilious vomiting; bitter taste; white tongue; great thirst or only dryness in the mouth; inclination to keep still; soreness of the liver to pressure; costiveness. Card. mar. When constipation frequently alternates with diarrhoea; liver sensitive to pressure; pressing, drawing, stitching pain in liver, worse on lying on left side; catarrh of gall-passages; swelling and induration of left lobe, with dyspnoea and cough; jaundice. Chamom. After anger or chagrin; very annoying pressure in the region of the liver; colicky pains in the bowels; vomiting of bile; feverish restlessness; crossness; icteric color of the face. China. Pale, wretched complexion; diarrhoea, worse at night or after eating; sensitiveness to external cold; great weakness and lassitude; after severe illness, loss of vital fluids, or abuse of mercury. Ignat. After grief or fright, especially in the female sex; menstruation profuse and irregular; leucorrhoea, with bearing-down pain. Mercur. Bad taste; bad smell from the mouth; tongue white, flabby, showing the imprints of the teeth; feverishness; sweating without reiief. Nux vom. Fullness; pressure; stitches in the liver, worse from motion or contact; swelling of the liver; yellow color of the face, especially if the color of the face is florid with a yellowish tinge; all worse in the morning; great irritability and hypochondriac mood; costiveness. Ptelia trif. ''Anorexia; sleeplessness; frequent emissions at night of small quantities of perfectly colorless urine; yellow coated tongue; nausea; sour taste and constant thirst; constipation, the feces discharged every fourth day consisted of dark colored, hard, irregular lumps. Swelling of the liver, most exquisite tender to jar or pressure, which caused nauseating pains shooting towards epigastrium. Worse from motion; cannot turn in bed, must lie on right side with abdomen supported by a pillow. Circumscribed flushing of cheeks in the afternoon; no perspiration at any time. Jaundice sets in on second day of attack. Menstruation had ceased three years previous. Mental condition was one of quiet resignation. Has received at various times the following remedies: Arnica, Arsen., Bryon., China, Hepar, Kali carb., Laches., Lauroc, Nux vom., Sulphur, with rarely any relief of any of the symptoms. Ptelia trif. was given on account of the symptoms detailed in Allen's Materia Medica under Abdomen -H}q?ochondria, Nos. 471-486, with entire success." (F. Preston, Weekly Medical Counselor, May 31, 1882, P- 133.) In chronic cases: Calc. carb., Carb. veg., Graphit., Lycop., Magn. mur., Natr. mur., Natr. sulph., Sepia, Sulphur. 53^ PERI-HEPATITIS. Compare also the diseases of the heart and lungs, of which congestion of the liver is more or less a consecutive symptom ; also the chapters on acute and chronic catarrh of the stomach and intestines. Besides all this, the following require special study — Card. mar. Swelling and hardening of left lobe; sensitive to pressure; painful on lying on left side; oppression of chest with cough and expectora- tion, sometimes bloody; urine scanty, dark red and yellowish, with bile satura- ted; jaundice; dropsy. (Wolf.) Laches. Cannot bear tight clothes around the waist; has even to loosen the night- jacket to relieve the oppression, which is occasioned even by lying the arm on the bod}-; tension; contractive tightness in the region of the liver. Lauroc. Distention of the region of the liver, with pain as from sub- cutaneous ulceration, or as if an abscess would burst; earth}' complexion; yellowish spots in the face. Lycop. Tension around the hypochondria as from a hoop; sore aching in the region of the liver, as if caused by a shock, worse from contact. Nux viosch. Feeling of heaviness in the region of the liver; swollen liver; blood}' stools. Podoph. Fullness, with pain or soreness in the right hypochondrium ; chronic hepatitis, with costiveness; the patient is constantly rubbing and stroking the region of the liver with his hands. Quassia. Gastric catarrh and liver complaint with diarrhoea and dropsy ; spasmodic cough, like whooping-cough; rapid sinking of strength; spleen affection. (Wolf.) Peri-Hepatitis, Inflammation of the Capsule of the Liver and of Glisson's Capsule. It may be part of a general peritonitis, or the consequence of an abscess of the liver, of simple, or cirrhotic induration, of cancer, or of echinococci in the liver; it is at times the result of external violence, or a mere extension of an inflammatory process of some neighboring organs, such as right-sided pleurisy, and simple and cancerous inflammation of the stomach. Its most characteristic symptom is, tenderness of the hepatic region on pressure, motion and deep inspiration, without any change in the volume or situation of the liver. In itself it is not a dangerous disease, but may pro- duce thickening of Glisson's capsules and of the portal vein. Its treatment compare under peritonitis and the diseases of which it may be the conse- quence. Hepatitis vera circumscripta, seu Suppurativa. This is an inflammation of the hepatic tissue limited to one or several isolated patches, without implicating the remaining portions of the gland to HEPATITIS VERA CIRCUMSCRIPTA, SEU SUPPURATIVA. 537 any great extent. In their centre these inflamed spots are soft and yellow- ish, at their periphery they show hyperemia, swelling and softening of the liver tissue. In the progress of the disease pus corpuscles form in the middle of the inflamed spot, they increase in number, unite and form a small abscess, which again unites with other small abscesses, and thus, in the course of time, the greater part of the liver may become an irregular cavity filled with pus. Such abscesses are found in the posterior portion of the right lobe. When they reach the surface of the liver they break through and discharge their contents into the abdominal cavity; or, if the surface of the liver has formed adhesions, in consequence of previous inflammation, with neighboring organs — either with the abdominal walls, the diaphragm, the stomach, the gall-bladder, or a part of the intestines — it perforates these organs, and dis- charges itself either through the abdominal walls, or into the thoracic cavity, stomach, gall-bladder, or intestines, according to its situation and adhesion. Hepatitis is primarily a very rare disease, and is mostly brought on by external injuries — a fall, a blow, a wound, etc. Secondarily it is caused by the irritation of hardened concrements within the gall-ducts, or by ulcerative processes within the stomach and the intestines, which perforate and spread upon the surface of the liver. In tropical climates it has most frequently been found in connection with dysentery. Pyaemia, in consequence of wounds on the. head or any other part of the body, is also cause of it. Symptoms. — A primary hepatitis caused by a blow, fall, or other mechanical injury occasions pain in the right hypochondrium; frequently very acute, as its lining portion of the peritoneum is likewise inflamed; it is worse from any motion. There is also a pain in the right shoulder, and on tension, in the right straight abdominal muscles. The liver is swollen; the skin more or less yellowish discolored (icterus); fevers alternate with rigors. A secondary hepatitis, in the course of ulcerative processes in the stomach and intestines, manifests itself by shaking chills, pain in the liver, swelling of the liver and icterus, though the latter is not always present. Hepatitis in consequence of pyaemia manifests itself likewise in swelling of the liver, icterus and shaking chills. Formation of abscesses on the con- vex portion of the liver often bulge out, and may be detected by palpation. Those on its concave side compress the portal vein, and cause swelling of the spleen and ascites. Small abscesses may pass over without any marked symptoms. Large abscesses cause fever, shaking chills, wasting away, cachectic appearance. Perforation through the abdominal walls, after previous adhesion of the inflamed portion of the liver with the abdominal parietes, is the most favor- able, as in this case, the pus is discharged outside. Perforation into the pleural sac causes pleuritis; a perforation into one of the larger bronchi causes the pus to be expectorated; a perforation into the pericardial sac causes pericarditis, which is fatal. If the perforation 53 8 SPECIAL HINTS. takes place into the stomach, it is thrown up; and if into the intestines, it is discharged through the bowels. A discharge into the abdominal cavity pro- duces fatal peritonitis. All this shows that hepatitis and its consequences must cause quite a variety of symptoms; that its prognosis generally is unfavorable; and lastly, that a successful treatment, without a close study of the individual case, is quite impossible. Still, I may mention the following remedies, which have proved themselves more or less beneficial in abscesses of the liver: Bellad., Bryon., China, Hcpar, Kali carb., Laches., Merc, sol., Nux vom.\ Pulsat, Rut a, Sepia, Silic. Special Hints. Compare what has been said under the head of Peritonitis. Arnica. In traumatic cases. Arsen. Painful bloatedness in the right hypochondrium, with violent burning pain; violent thirst; vomiting of black masses; black stools; burn- ing heat of the skin; anxiety and restlessness; very quick pulse; perforation into the stomach or intestines. Bellad. Especially with acute pain in the region of the liver, worse from pressure, breathing, coughing and lying upon the right side, extending upwards towards the shoulder and neck; congestion of the head; getting dark before the eyes; fainting and giddiness; bloatedness of the pit of the stomach; tension across the epigastrium; agonizing tossing about; sleepless- ness or wanting to sleep, with inability to go to sleep. Bryon. Burning and stitching pain, worse from motion and contact; after chagrin or anger; fullness of stomach and abdomen; pain in the right shoulder; yellowish face; white tongue; great thirst; constipation. Chelid. Crampy pain in the inner angle of the right shoulder-blade; shooting pain from the liver into the back; pressive pain in the back part of the head; towards the left ear; pressure in the eyeballs; bitter taste in the mouth; nausea; palpitation of the heart, with very quick and irregular pulsation and without abnormal sounds; constipation. China. Pain as from subcutaneous ulceration, worse from touch; liver swollen; diarrhoea; distended veins on the face and head. Hepar. When suppuration takes place. Kali carb. Pain through to the back; abscess; dryness of the skin. Laches. After Bellad. , or Mercur. , very sensitive to any pressure upon the hypochondriac region; much flatulence; palpitation of the heart; forma- tion of abscesses. Leptand. Yellow-coated tongue; constant nausea and vomiting; ach- ing in the region of the liver; dark brownish urine; black stools. Lycop. In slow 7 cases; complication with pneumonia; fan-like motion of the nostrils when breathing; one foot hot, the other cold. Mercur. Pressive pain and stitches in the liver; inability to lie on the right side; when coughing or sneezing a stitch-pain through middle of the CIRRHOSIS. 539 chest from front to back; yellowish tinge of the face; perspiration without improvement; during fever feels chilly when changing the feet to a cooler place in the bed. Nux vom. Pain, stitch-like, or throbbing, or pressive, worse from ex- ternal pressure; sour or bitter taste in the mouth; nausea; vomiting; short- ness of breath; the dress seems oppressive; the removal of it, however, does not relieve; great deal of headache. Previous use of allopathic medicines, coffee, liquor, etc.; sedentary habits. Phosph. ac. P} T aemic symptoms. Pulsat. Spells of great anxiety at night; green, slimy diarrhoea; thirst - lessness. Silk. Hardness and distention of the region of the liver; throbbing, ulcerative pain, increased by contact and motion; formation of abscesses. Sulphur. Especially after Nux vom. and Me? cur. ; red tip of the tongue; red lips; sleeplessness. Cirrhosis, Hob-nail Liver, Interstitial Inflammation of the Liver, Granulated Liver, Gin- drinkers' Liver. It is a chronic inflammation of the areolar tissue, which, being of a fibrous texture, forms a capsule over the entire liver, enters as Glisson's capsule into the interior of the gland and accompanies the vessels, nerves and bile-ducts to their finest ramifications. The first consequence of inflam- matory action of this tissue is exudation of coagulable lymph, which forms new areolar tissue and adhesions between its ramifications, causing the se- creting cells of the liver to become isolated and compressed, and producing in this way larger or smaller granulations, which have been compared to hob-nails. In the further progress, the new formation compresses also the biliary ducts and blood-vessels, and the whole organ shrinks, becomes hard, tough, pale, anaemic, and, if cut, appears gray-yellowish, v/herefore the name cirrhosis. Its most frequent Cause is the abuse of alcoholic drinks; still it has been observed in individuals who were not addicted to drinking, and where it seemed to be in connection with syphilis, intermittent fever, sup- pressed menstruation, poor living. Heart diseases, according to Bamberger and others, do not cause it. It is much more frequently found in males than females, rarely in children, and most frequently in persons over thirty j^ears. Symptoms . — i . The liver is , during the stage of exudation , considerabl}- enlarged, and, during the stage of contraction, loses quite considerably in bulk, so that the left lobe disappears entirely. If we have an opportunit} 1 - to observe its progress long enough, we can witness this increase and gradual decrease of the liver, and in this way gain one of ■ the most important aids in our diagnosis. 2. Enlargement of the spleen is met in many, not all cases, in conse- quence of the obstructed circulation of the blood within the portal vein and its 54° CIRRHOSIS. branches, which impairs the free reflux of blood through the vena lienalis. This is an early symptom. 3. Ascites appear later, but is a more constant accompaniment of granular induration, and depends upon the same obstruction of the portal circulation; still later oedema of the lower extremities occurs. 4. Meteorismus, if strongly developed, causes difficulty in breathing. 5. Dilatation of the abdominal veins, caput medusae, appears not until an advanced stage of the disease. It is caused by the obstructed portal circu- lation. The blood in its way from below up, being stopped, forces its way through neighboring veins, widening and dilating them, and thus forms a collateral circuit around the liver, until it reaches the vena cava. These widened and dilated veins appear sometimes like a large network over the walls of the whole abdomen, and even above it. 6. Functional disturbances of the intestinal canal are of a varied nature. The appetite is, in some cases, not altered till very late; in others, again, want of appetite, nausea, belching of wind and vomiting predominate. The bowels are either constipated or diarrhceic. In severe cases we find vomiting of blood and bloody stools. 7. Loss of flesh and strength sets in quite early, as a necessary conse- quence of imperfect circulation. 8. Jaundice is, according to Bamberger, a prominent symptom of cir- rhosis, other authors have not found it so frequent. It depends upon catarrh of the bile ducts, or upon compression of the hepatic duct, or upon constric- tion of the minute biliary ducts by the newly-formed connective tissue. If we consider these symptoms, together with the preceding abuse of spirituous liquors, we shall be enabled, in most cases, to make out a sure diagnosis. But for the sake of Differential Diagnosis I shall compare a few forms of disease which might be confounded with it. Stricture of the biliary duct is usually caused by gall-stones, and has its peculiar colicky spells, but no swelling of the spleen. Nutmeg liver is always the consequence of heart and lung diseases, and has no enlargement of the spleen. Cancer and tuberculosis of the peritoneum, with highly- developed ascites, may be sometimes difficult to discern; still we have here a quicker wasting away; perhaps also signs of cancer or tubercles in other organs, and a devel- opment of oedema of the lower limbs prior to the development of ascites; whilst in cirrhosis we have first ascites and afterwards ©edematous swelling of the lower extremities. Cancer of the liver distinguishes itself by the peculiarly potato-shaped surface of the enlarged liver and the normal size of the spleen. Hydatids of the liver give, on palpation, the sense of fluctuation; they do not impair the general nutrition, nor do they cause an enlargement of the spleen. Inflammation of the portal vein, with coagula forming in it, is a much more rapid process, and is not caused by previous abuse of spirituous liquors. SYPHILITIC INFLAMMATION OF THE LIVER. 541 Inflammation of the areolar tissue surrounding the bilary ducts is char- acterized by the highest degree of icterus and the complete discoloration of the stools. Colloid or fatty infiltration of the liver never decreases in size, causes no icterus, and is found in scrofulous, rachitic, or syphilitic individuals, or as a consequence of mercurial poisoning. Prognosis is favorable as long as the disease is still in its first stage. After granulations have formed throughout the organ, I do not believe that its parenchyma can be reorganized. Therapeutic Hints. If the disease is brought on mainly by the abuse of spirituous liquors, especially whiskey and brandy, the first prescription, of course, must be, ' ' stop drinking. ' ' And, in order to destroy the appetite for alcoholic stimu- lants, our second prescription should be, "drink milk," and nothing but milk; live on milk diet. After this we shall have a choice between these remedies, which are antidotes to alcohol: Arsen., Bryon., Card, veg., Nux vom., Pulsat., Sulphur, etc. In its second stage we must be guided entirely by the characteristic symptoms of the individual case, and may choose from the following: Arg. nitr., Aurum, Card, mar., Chelid., Cinchona, Conium, Iodium, Laches., Leptand., Lycop., Magn. mur., Mercur., Natr. mur., Nitr. ac, Phosphor., Plumbum, Podoph., Quassia, Selen., Sepia, Tax bacc. Syphilitic Inflammation of the Liver Manifests itself either as an interstitial hepatitis and peri-hepatitis, which leave white depressions, like cicatrices, consisting of fibrous tissue and ex- tending from the thickened capsule more or less deeply into the interior of the gland, the secreting tissue of which is atrophied, thus producing an ir- regularly, lobulated form of the liver; or as hepatitis gummosa, when the tissue of the cicatrices just described is seen to contain whitish or yellowish nodules, which usually vary in size from a linseed or a bean up to a walnut, and resemble the nodes or gummata of syphilitic patients found in the sub- cutaneous areolar tissue beneath the peritoneum, in the testicles, etc. The symptoms during life of syphilitic hepatitis are not at all character- istic. A dull, temporary pain and tenderness in the region of the liver, in rare cases jaundice, also enlargement of the spleen and frequently co-existing albuminuria, may hint to this complaint, especially when other unmistakable signs of the secondary and tertiary stage of syphilis are present. Its treat- ment belongs to the chapter of Syphilis. Acute Yellow Atrophy- Is a rapid wasting of the liver in all its diameters, but especially in its thick- ness, sometimes preceded by a preliminary stage. Its capsule appears opaque 54 2 ACUTE YELLOW ATROPHY. and puckered; its parenchyma is flabby and shriYelled and of an ochre- yellow or rhubarb-like color; the blood-vessels, the gall-bladder and bile- ducts are empty in most cases, the gall-bladder containing only a small quantity of gray mucus or a turbid, pale yellow, rarely brown or greenish fluid. The spleen is frequently greatly enlarged and congested, and there are considerable extravasations of blood in various organs and tissues. The kidneys, especially in pregnant females, are in a state of fatty degeneration and their tissue flabby and shrivelled. The urine is characterized by the absence of urea, which has accumulated in the blood, and by temporary presence of albumen. The nature of this disease is still quite obscure; several theories have been advanced, but that which considers the whole process as one of diffuse inflammation is the one most generally accepted. The Precursory Symptoms usually resemble the symptoms of an acute gastro-enteric catarrh, which' sooner or later, sometimes not until after the lapse of several weeks, becomes associated with a slight jaundiced tint of the skin. Even this may exist from eight to fourteen days or longer before the characteristic changes in the liver and spleen, the haemorrhages and the nervous disturbances become apparent. However, in other cases, these symp- toms appear simultaneously with the jaundice, and as soon as the} 7 do appear, the progress of the disease is rapid and violent, terminating in the worst cases at the end of twelve or twenty -four hours, in other cases after two or five days, latest and in rare cases only, after a week. The disease sets in with vomiting first of ingesta and mucus, later of blood and ultimately of coffee- ground substances. This is attended with headache, which, as a rule, soon passes into delirinm, followed by convulsions and a tremulousness of the muscles of the extremities and trunk. Finally the state of excitement passes into stupor and deep coma; the pupils enlarge, the respiration becomes sigh- ing, intermittent and stertorous. The pulse, at first slow, rises with the nervous symptoms to 120, or keeps at 70 or 80 as long as the patient is dozing, and rises to 120 or 130 when the patient is roused. The abdomen is tender, especially in the hepatic region. The extent of the hepatic dullness dimin- ishes as the disease advances, while that of the spleen increases at the same time. The bowels are almost always confined; the stools are dry and clay- like, later the} 7 become dark colored and tarr\< from the presence of blood. There appear, as the jaundice increases, numerous extravasations of blood in the skin in the form of petechiae and ecchymoses, and haemorrhages from the nose, the vagina, the stomach and bowels, and the bronchi. The urine is brown and contains bile-pigment, at times small quantities of albumen. Its deposit, upon exposure to cold, is greenish-yellow, which differs greatly from all other kinds of deposits. The disease is most frequently observed in the female sex, and then especially during pregnancy. Further are mentioned as exciting causes: mental emotions, venereal excesses, syphi- lis, miasmatic influences and typhus. hepar adiposum. • 543 Therapeutic Hints. Aeon. Acute, feverish icterus, especially during pregnancy. Bcllad. Congestion to the head; headache; dizziness; sopor; pupils at first contracted, and afterwards dilated; spasmodic jerkings; grating of teeth, etc. Bryon. Chill first and fever afterwards; typhoid symptoms; bitter vomiting; constipation. Crot. horr. Yellow color over the whole body; convulsions with trem- bling of the limbs; haemorrhages from all the orifices of the body. Ipec. Vomiting of blood, and bloody discharge from the bowels. Leptand. Delirium; complete prostration; heat and dryness of the skin; coldness of the extremities; fetid and tarry stools; tongue thickly coated, with a black streak down the centre. Phosphor. Ought to be compared. Compare also Haemorrhage from the Stomach and Bowels, and Jaundice. Hepar Adiposum, Fatty Liver. A fatty infiltration of the liver cells is found very frequently on post- mortem examinations without ever having shown its presence during life by any signs of diseased action of that organ. A diet of fatty substances, or of large quantities of food containing an abundance of carbo-hydrogens, pro- duces such infiltration, which, however, disappears again when the food is changed. This accounts for the frequent occurrence of fatty liver in indi- viduals who have died suddenly in the bloom of good health. For this kind of infiltration there is no known line of demarcation between health and disease, inasmuch as the liver cells are not altered by it in their character, the fat being merely deposited therein. Altogether different is the fatty liver as found in connection with pulmonary tuberculosis, drunkard's dys- crasia, chronic dysentery, cancer and other wasting diseases. Here the liver cells cease entirely to perform their function, their nutrition becomes im- paired; it is indeed a fatty degeneration of the liver cells. Its production is not fully explained, except by the broad statement that it is owing to ab- normal conditions of the metamorphosis of matter. But whether it be mere infiltration or degeneration, the blood is always loaded with fat and the sebaceous glands of the skin secrete abundantly, causing a greasy or velvety character of the cutis. The Symptoms of fatty liver are not very well marked. Still, as a con- siderable accumulation of fat in the liver must impede the flow of blood through the portal vein, and the excretion of bile, we find fatty liver natur- ally associated with chronic congestion of the gastrointestinal mucous mem- brane, which may be exaggerated by slight causes into catarrhs, derange- ments of digestion, diarrhoea, and haemorrhoids; and with stools more or less deficient in bile; but an intensely jaundiced color of the skin is never pro- duced by it and seldom a high degree of ascites. The liver is at first enlarged 544 COLLOID LIVER. but gradually becomes reduced to even below its normal size; its outer surface is smooth. The general appearance of the patient gradually assumes the character of general cachexia, and there is usually an enlargement of the spleen attending it. Its Treatment will in the case of infiltration consist of a strict regula- tion of diet and habit, and in the case of degeneration will fall entirely under the treatment of those diseases with which it is associated. Colloid Liver, Lardaceous Liver, Waxy Liver, Amyloid Degen- eration of the Liver. This is a degeneration of the liver cells into a waxy, translucent mass, so that b} 7 degrees the parenchyma of the gland presents a uniform, smooth, yellowish-red, somewhat glistening surface, interrupted only by the patent orifices of the blood-vessels pouring out a little thin blood. This morbid change may occur sometimes only in isolated places, but is most frequently distributed more or less marked throughout the entire organ. The nature of this substance is thus far still unknown. From the blue color produced by a solution of Iodine in conjunction with Sulphuric acid, Virchow supposed it to be an " anryloid" bod} T , but the proof from elementary analysis is still wanting. Waxy degeneration is often found combined with fatty deposit in the liver, especiall} T in cases of pulmonary tubercle, with cirrhotic induration, with syphilitic cicatrices and fibroid nodules (gummata), with simple atroph} 7 of the liver. It is scarcely ever restricted to the liver, but is almost in- variably found also in the kidneys and spleen, and often likewise in the lymphatic glands and the mucous membrane of the gastro-intestinal canal. Moreover we can usually, at the same time, discover the remains of chronic diseases of the bones, the indications of constitutional syphilis, tubercle or cancer, suppuration, etc. The injurious effects of this degeneration upon the elaboration of blood and nutrition causes, as a rule, a pale, cachectic appearance of the patient and symptoms of anaemia and Irydraemia. The symptoms vary, however, according to the cause which has excited the morbid process and the direc- tion in which it extends; the} 7 differ naturally in cases where the kidneys and the mucous membrane of the intestines are attacked at an early stage, and in other cases where the spleen and lymphatic glands are chiefly im- plicated. The liver is in most cases enlarged, at times very greatly, at others not at all, and in still others it is even reduced in size. There is usually an abnornal tenderness in the hepatic region, or a mere feeling of fullness; in rare cases of the syphilitic form an acute pain consequent upon an attack of peri-hepatitis. Jaundice and ascites are found only exceptionally. The spleen is commonly enlarged to a considerable size, though not alwaj's, and the derangement of the gastro-intestinal canal manifests itself frequently by loss of appetite, vomiting, with a clean tongue, diarrhoea with alternation of CARCINOMA HEPATIS. 545 pale and dark stools. The same degeneration of the kidneys manifests itself in the majority of cases by enlargement and albuminuria. Mild cases, based upon chronic diseases of the bones, hint to: Calc card., Lycop. , Si lie. , Sulphur. Syphilitic cases require: Iodhim, Kali hydr. and the different Mercurial preparations. Other cases will resist all treatment according to the base upon which they grow. Carcinoma Hepatis, Cancer of the Liver. There are three different forms of cancer of the liver. i. The carcinoma fasciculatum, a rare form, characterized by the pale, yellowish-red color, its glassy, transparent mass, which is enveloped in a bag of fibrous tissue. 2. The alveolar cancer, the rarest of all, which is characterized by its jelly-like substance, developing within the areolar tissue around the ramifi- cations of the portal vein. 3. The medullary or encephaloid cancer, the most common form, is char- acterized by its marrow-like substance, which is mostly of a whitish color; sometimes it is red from hsemorrhagic effusion, and, at other times, dark, even black, from a deposition of pigment. The liver appears uneven from nodules of various sizes, which, for the most part, feel hard to the touch, al- though, in some cases, the sense of touch may detect fluctuation. They in- crease more or less rapidly in size, and sometimes undergo changes of fatty degeration, or, in still rarer cases, of softening and decay, or formation of ichor. We do not know any cause for this malignant disease. It is found sometimes as a primary affection of the liver, but more frequently it accom- panies cancerous deposits in other organs. Its most frequent occurrence and its most rapid development have been observed after extirpation of can- cerous growths from other organs, especially from the mammae. Persons between the ages of fifty and sixty are most liable to its invasion. Symptoms. — i. Enlargement and uneven surface of the liver. Its size is sometimes enormous, reaching far over into the left hypochondrium and far down into the abdomen; in fact, no other disease except that of colloid liver causes such extensive enlargement of this organ. Its enormous size makes the right hypochondriac region bulge out, and its uneven surface is then easily detected by inspection and palpation. In such prominent cases there is no difficulty in the diagnosis. But there are cases where the cancerous nodules lie out of reach of palpation, either deep in the substance of the liver or on its opposite surface. So is also the enlargement of the liver at the beginning of the disease very incon- siderable, and, in cases of few and small cancerous deposits, attended with general anaemia and marasmus, the liver may appear even smaller. 2. Tenderness in the region of the liver is almost always manifest, at 35 546 CARCINOMA HEPATIS. least on deep pressure, but it varies much in degree. A radiating pain towards the spine and the right shoulder-blade, as in other liver complaints, may be present. 3. Icterus is present only when the situation of the tumors implicate the biliary ducts or when the cancer is associated with catarrh of the ducts. If once developed it never disappears. The skin generally presents a peculiar ash-colored, dirty-yellowish hue, and, being dry and brittle, peels off in mi- nute scales. 4. Ascites results in those cases where the morbid mass is sufficiently large, and so situated that it impedes the portal circulation, by pressure upon its vessels, or it comes and grows with general dropsy, or it is due to chronic peritonitis, extending from the liver over the peritoneum. 5. Disturbed nutrition and gastric symptoms are almost always present, but show nothing characteristic of this complaint. 6. The Spleen is very rarely enlarged. 7. Fever is, as a rule, quite slight, amounting at the most to febrile mo- tions. Where we find high fever, it is occasioned by some other compli- cation. 8. Haemorrhages in the lower stages we find in the interior of the tumor, and from this into the abdominal cavity, also from the stomach and intes- tines, from the mouth, nostrils and vagina, and in the form of petechiae and ecchymoses upon the skin, similar to those of purpura and scurvy. The Diagnosis of cancer of the liver is by no means always easy. Where the characteristic enlargement and uneven surface of the liver has not yet keen developed (in the incipient state of the disease), or where it does not develop sufficiently to be recognized, we will have to balance the following points: 1. Can it be colloid liver? No; because it is not the result of syphilitic or mercurial cachexia, nor is it attended by enlargement of the spleen and albuminuria. 2. Can it be fatty liver ? No; because it is not the result of tuberculosis or overfeeding. 3. Can it be syphilitic inflammation of the liver? No; because there is no constitutional syphilis present. 4. Can it be cirrhosis? No; because there is no enlargement of the spleen. 5. Can it not be nutmeg liver? No; because there is no heart or lung disease for its foundation. After having thus narrowed the field of possi- bilities, we now observe, in addition, swollen jugular glands, which Virchow considers of great diagnostical importance, we ascertain whether there is any cancerous formation in any other organ, or a hereditary tendency to it. Further, it is among the rarest events that cancer of the liver co-exists with tuberculosis, organic heart diseases, typhus or acute exanthematic fevers; while, on the contrary, it is frequently associated with other cancer- ous affections, especially within the abdominal cavity. Finally, we consider HYDATIDS OF THE TIVER. 547 the age of the patient. Cancer seldom happens before the thirty-fifth year of age; usually between the years of fifty and sixty. Therapeutic Hints Are rather a scarcity in this complaint. I do not know of a well-attested case that ever has been made known as cured. The principal remedies promising the best alleviating results are: Arse?i., Be/lad., Carb. an., Co?iium, Hydrast., Lycop., Sepia, Sztic, and others according to special indications. Hydatids of the Liver, Echinococcus- cysts. They consist of a thick, fibrous, wdrite-glistening or yellowish sac of a roundish shape, and of various sizes, attaining even that of a child's head. The sac is lined on its inner surface by a half -transparent, gelatinous blad- der, which contains a watery, somewhat turbid fluid, in large quantities, and at the same time a number of smaller crysts, of the same structure, which again contain still smaller crysts, and so on to the fourth generation. Be- sides this, we observe, within these crysts and adhering to some part of their interior surface, groups of whitish granules, which are the scolices of taenia echinococcus. Under the microscope they appear with head similar to that of the taenia solium or the common tape-worm; having four sucking cups, in the middle of each of them a nozzle or snout, which is encircled by a double row of hooks. This echinococcus-cryst has been found in any and every part of the liver, sometimes singly, sometimes two, three or more in number. The parenchyma of the liver retains its integrity, and only where it is compressed by the foreign growth, its cells obliterate, and that part of the liver assumes, according to Rokitansky, sometimes a nutmeg-like appearance. The cysts themselves may undergo different changes. Their fluid contents may be converted into a cheesy substance, whereby the inmates perish, or the inner surface of the sac may become inflamed and lead to obliteration of the cyst, or the cyst may burst and pour its contents either into the abdominal cavity where it almost always causes a fatal peritonitis, or into other organs, with which, by previous inflammation, adhesions have been formed, exactly as in the case of an abscess of the liver. There are cases on record, w T here echino- coccus-cysts, by perforating the diaphragm, emptied their contents into the pleural cavity, from which they were discharged through the bronchial tubes, by means of abscess-formation in the lungs. There are cases also where they were discharged through the abdominal walls, or into the intestines, gall- bladder, or a large blood-vessel. Almost always such perforations are fol- lowed by a fatal termination, although, in favorable cases, where, for exam- ple, the discharge took place into the intestines, or through the abdominal walls, the cysts obliterated and a perfect cure followed. The echinococcus, when found in the liver, is also frequently found in other organs: the spleen, lungs, kidneys and the omentum. The essential Cause of the formation of hydatids is the swallowing of 548 CATARRHAL INFLAMMATION OF THE BILIARY PASSAGES. the ova or embryos of the taenia echinoeoecns, which pass from the stomach or intestine into the liver and there undergo development. This taenia echinococcus is a small tape-worm belonging to the dog, which explains the fact that hydatids are most frequently found in Iceland, where the dog is an indispensable domestic animal. Symptoms. — Of all liver diseases this complaint causes the least dis- turbance in the system, and the occasional symptoms, caused by its pressure upon this or another organ, are of the least diagnostic value. Only when rupture and perforation take place, we observe, as in the case of liver ab- scesses, a series of violent symptoms, all of which are consequences of inflammation of those organs into which the perforation or rupture takes place. Our diagnosis is therefore confined to its physical signs alone. These are the following: i. A round, smooth, elastic swelling in the region of the liver. 2. A sense of fluctuation on percussing the part in short, abrupt strokes, while the examining fingers of the other hand are held in close neighbor- hood. What Piorry has called the vibratory sense of hyatids is nothing more nor less than the above-mentioned sense of fluctuation; ascites or ova- rian cysts yield it just as clear, under certain conditions even clearer. Differential Diagnosis. — Liver abscess is attended by fever, "pain and great constitutional disturbances. Distended gall-bladder is preceded by colicky pains, is usually accom- panied by jaundice, and the swelling corresponds to the normal position of the gall-bladder. Encysted pleuritic exudation does not alter the place of dull percussion sound on deep inspiration; while the outline of the dullness on percussion lowers considerably by deep inspiration in hydatids. Catarrhal Inflammation of the Biliary Passages. Anatomically it is characterized by similar changes as appear in catarrhal inflammation of other mucous membranes. Post-mortem exami- nation reveals the lining membrane to be pale or livid, softened, tumid, and covered with a tenacious, vitreous, or grayish-yellow, purulent secretion, which often produces firm plugs of mucus in the duodenal opening of the ductus choledochus, and a total stoppage to the flow of bile into the intestines. These changes are particularly found in the lower portion of the ductus cho- ledochus and in the gall-bladder, less frequently in the hepatic duct and its roots. In chronic cases the walls of the ducts become thickened and dilated, either uniformly over long tracts or in the shape of oval sacs. In these pools of stagnant secretion concrements are sometimes deposited, and in rare cases the walls of the ducts ulcerate. Catarrhal inflammation of the biliary passages is most frequently in- duced by inflammation of the stomach and intestines, sometimes by hyper- cholelithiasis. 549 aemia and chronic inflammation of the lower, and more rarely, by fatty and waxy degeneration. Its Symptoms correspond, therefore, with the symptoms of those ailments of which it is the result, always associated with the symp- toms of more or less intense jaundice and tenderness in the region of the liver. In a few cases the gall-bladder can be felt as a pear-shaped tumor at the margin of the liver. The jaundice lasts in most cases for some time after the gastric symptoms have disappeared. In cases dependent upon diseases of the hepatic parenchyma, the jaundice is of a fainter tint, and the digestion suffers less, but the symptoms are more apt to return. Therapeutic Hints. Compare catarrh of the stomach and intestine, also jaundice and the other affections of the liver. In children the following are most frequently indicated: Chamom., or Merc. sol. Besides compare Be/lad., Bryon., Nux vom., etc. Cholelithiasis, Gall- Stones. Gall-stones are made up of substances which are all contained in a state of solution in normal bile, with the exception of epithelium and mucus, both being furnished by the mucous membrane of the biliary passages. The prin- cipal constituent of gall-stones is cholesterine, although it is only sparingly contained in the bile; but in virtue of its insolubility it contributes, as uric acid does, to the formation of urinary calculi, the main portion to the forma- tion of gall-stones. Other constituents are the bile-pigments (cholepyrrhin of a brownish, cholechlorin of a green color) and their combinations with lime, the biliary acids and their calcareous salts, fatty acids and soaps, mucus and epithelium, uric acid and earths. In the biliary passages gall-stones occur in most cases, in numbers from five to ten or thirty, and occasionally even to more than a thousand. All of them which thus occur together, have almost invariably the same characters and composition, inasmuch as all of them owe their origin and growth to the same morbid process; still exceptionally dissimilar calculi have been found in the same gall-bladder. Their size varies from that of a millet-seed to that of a hen's egg; their form is primarily globular, but changes during their subsequent growth in many ways; very large stones usually assume an egg- shaped or cylindrical form, corresponding to the form of the gall-bladder; some stones present a warty or mulberry form, others but rarely found, are flattened, leaf -like concretions with black, metallic glistening surfaces, and still others are the branched varieties which form a cast of the bile-ducts in which they are developed. Their color is in most cases brownish or greenish- yellow, but all shades of color are met with, from snow-white to coal-black. Their specific gravity is heavier than water, but dried specimens will float on water because they contain air. Their structure varies exceedingly. In simple homogeneous calculi it is of a uniform texture, and presents an earth}-, saponaceous, or crystalline fracture, according to their composition of earthy 550 CHOLELITHIASIS. matter, or of bile-resin and its calcareous compounds, or of pure crystallized cholesterine. In compound calculi, we observe a central portion or nucleus, a shell of greater or less thickness surrounding the nucleus, and an outer crust covering the shell. The nucleus consists either of the compound of chole- pyrrhin and lime, or of foreign bodies (a small clot of blood, a worm, a needle, a plum-stone). The shell is usually striated, and consists of crystals of cholesterine, or in rarer cases it surrounds the nucleus in concentric laminae, like the layers of an onion, or it is devoid of all structure, of a soapy or earthy character. The external crust is of various thickness; it covers the shell either in a uniform manner, or is thicker at one portion than at the other; it is not unfrequently covered with warty prominences, and its composition and color varies greatly according to the constituents of which it is composed. In addition to the gall-stones proper, pulverulent or gritty deposits, similar to those which are met with in the urinary passages, are found in the excretory apparatus of the liver. Not unfrequently gall-stones exhibit indications of commencing dis- integration; their angles and edges disappear, and their substance is eaten away by erosions, resembling caries of the teeth, penetrating through several layers, an effect undoubtedly produced by chemical action. Gall-stones may also be destroyed by cleaveage. Their mode of origin is still not fully explained. However, stagnation and decomposition of bile seems to constitute the primary cause of the forma- tion of gall-stones. The stagnation of bile is favored by repeated attacks of catarrh of the biliary passages, by cancer of the liver and other hepatic affections, and also by sedentary habits of life. The decomposition of bile is dependent upon physiological processes, the nature of which has thus far not been revealed. The tendency to gall-stones increases with the advance of life; before thirty years of age the}- are rarely observed. Females are more liable to gall-stones than males. Gall-stones are found rarely in the hepatic duct and its branches, but most frequently and in largest numbers in the gall-bladder, which they may leave by passing through the cystic duct into the ductus communis and from this into the duodenum; or they may escape by fistulous openings into the stomach or intestine, or externally through the abdominal wall. Through the ductus choledochus all concretions pass which leave the liver, whether they have their origin in the hepatic duct or in the gall-bladder; the)', as a rule, obstruct the duct and interrupt the excretion of bile. Symptoms. — Gall-stones may lie for years in the gall-bladder without giving rise to any symptoms whatever. But if the}' are washed from the gall-bladder, into the cystic duct, they cause, unless they are very small, the most violent symptoms, known under the name of " Gall-stone colic." Usually a few hours after a meal, when the contents of the gall-bladder are poured into the duodenum, or in consequence of lifting a heavy load, or after mental emotions, an excruciating pain, of a boring and burning character, is felt in the right hypochondrium and epigastrium, radiating down to the THERAPEUTIC HINTS TO CHOLELITHIASIS. 551 navel, back to the spine, upwards into the chest, to the shoulder-blades and neck, and even down the arms to the very fingers' ends. The slightest touch increases the pain. It is attended by vomiting, great restlessness, singultus, even convulsions, delirium, S3 r ncope and speechlessness. In some cases the attack commences with rigors, often followed by heat and sweating, the temperature rising to between 99. 5 and 104.9 F., and the pulse to between 92 and 120. Oftener, however, the pulse is small and of normal frequency, or even slower than normal. Jaundice is absent at first, or only slight, and becomes marked only when the calculus fills up the ductus choledochus. The duration of hepatic colic varies greatly; it may pass off in a few hours, or last for many days. In the latter case the pain recurs in paroxysms until the duct becomes so far dilated as to permit the calculus to pass. Sometimes, the calculus, after entering the cystic duct, may return into the gall-bladder, when the pain likewise ceases, and in such cases no concretions are found in the stools. But when the calculus remains firmly impacted in the cystic duct, and completely closes up the neck of the gall-bladder, the collicky pains gradually subside, and there only remains a sensation of tightness or pricking, while the gall-bladder, incapaciated of emptying itself, gradually becomes largely distended (Hydrops cystidis felleae), which may terminate at last in a destruction of this organ and consequent fatal peritonitis. Stones in the ductus choledochus usually excite less pain on account of the greater capacit}^ of this duct, and when entering the ductus communis the pain ceases altogether; but reaching the abdominal opening, the pain returns with renewed severity until the excretions have passed into the in- testine. As long as a stone remains in the ductus choledochus, the bile is more or less completely shut off from the bowel, and jaundice makes its ap- pearance, growing the more intense the longer the obstruction lasts. The Diagnosis is easy, where we find the gall-stones passed off in the stools, or where we can feel them in the gall-bladder. The whole row of symptoms as described above is characteristic. Jaundice, although not a constant symptom, is nevertheless, connected with the other symptoms, of great diagnostical value. Therapeutic Hints. Bellad. During the colic is the most important remedy. Baptis. Pain in the region of the gall-bladder, forcing the patient to stir about, although motion is painful. Berber, Has been advised as curing quickly and permanently. (J. Angell. ) Chelid. With pain through under the right shoulder-blade. China. Is indicated by " all the symptoms which arise from obstruction in the gall-bladder; the colic; the periodicity of its recurrence, though the periods of its return are often very unequal and irregular; the yellowness of the skin and conjunctiva; the constipated state of the bowels; the scybalated character of the dark, greenish stools, the scybala varying in size from that 552 THROMBOSIS AND OCCLUSION OF THE PORTAL VEIN. of the largest nutmeg to that of sheep-dung, and even smaller than the smallest peas." " I give usually China*, six pills twice a day, till ten doses are taken; then six pills every other clay till ten doses are taken, etc., till at length the dose is taken only once a month." " I have not failed in a single instance to cure, permanently and radically, every patient with gall-stone colic who has taken the remedy as above directed." (David Thayer.) Coloc. Twisting, boring pain in the stomach, relieved by pressure; rending, tearing pain, extending up to the right mamma; nausea with cold- ness of the extremities. (R. Arnold.) Cczsm m . ( Baruch . ) Besides these the following remedies have been recommended: Alum., Apomorph., Arsen., Calc. carb., gall-stones triturated (German physi- cians), Card, mar., (Rademacher), Chionauthus , Evon., Chlorof., Hepar, Laches., Lycop., Mercur., (Porges), A T ux mosch., Nux vom., Opium, Osmium, Podoph., Silic, Sulphur, Teyeb. (Mossa), Thuja, Ver. alb. Olive oil is believed to dissolve some kinds of gall-stones, if taken in doses of three to four ounces each night for four nights. (C. D. Fairbank.) Thrombosis and Occlusion of the Portal Vein; Pylethrombosis; Pylephlebitis Adhsesiva Chronica. The portal vein derives its venous blood from the stomach, intestines, spleen and pancreas. It is divided into two chief branches for the right and left lobes of the liver in front of the transverse fissure. These two branches are further subdivided till they finally end in the terminals, or the so-called interlobular veins from which the capillary system of the hepatic lobules originates. From the capillaries of each acinus the blood is carried by the so-called vena centralis lobuli into the hepatic veins, and from the latter into the inferior vena cava. The radicles, trunk, and the hepatic ramifications of the portal vein are all destitute of valves. The blood flows in the portal vein under very slight pressure and with slight rapidity. Stasis of blood in its territory, therefore, occurs ver}' readily, giving rise to ectasia, dilatation, and sinuosity of the vessels, and to coagulation of the blood contained in them. In addition to the slight vis a tergo, inspiration acts as a motive force, accelerating the blood-current in the portal vein, while expiration rather retards it. From this it may be seen that coagula or thrombi may be developed in the portal vein as well as in other parts of the venous system. Their most frequent Causes are local disturbances of the circulation of blood, resulting from granular induration, cirrhosis and chronic atrophy of the liver, by which a destruction of numerous capillaries or a constriction of the branches of the portal vein is induced. Less often the same effect may be produced in consequence of weakened force of the circulation, from diminished action of the heart; or from maras- mus, and cases have also been observed where thrombosis of the portal vein PYLEPHLEBITIS SUPPURATIVA. 553 was the result from compression of the vessel below the liver by contracted connective tissue, and by tumors of various kinds. The Symptoms of occlusion of the portal veins are, besides those which are characteristic to the diseases which lead to it: ascites, which in a few days attains an extraordinary amount, and which immediately returns after the performance of paracentesis; the superficial veins of the abdominal pari- etes enlarge and extend in the form of thick cords from the abdomen over the lower part of the thorax towards the axillae; the spleen increases in size; diarrhoea supervenes, of a watery, or often bloody character, not unfrequently accompanied by vomiting; the urine is scant}^ and dense; the patients de- cline rapidly and present a pale, cachectic appearance. The termination of the disease is, perhaps, without exception, fatal. Pylephlebitis Suppurativa, Purulent Inflammation of the Portal Vein. In this affection the thrombus softens from the centre into a dirty grayish-red pulp and afterwards dissolves more or less completely into a purulent fluid. The wall of the vein is thickened, softened, and infiltrated with exudation; its inner coat is discolored, red, brownish, or greenish- yellow, wrinkled, and not unfrequently torn and covered with fibrinous layers, or fluid pus. These alternations may spread to the hepatic branches of the portal vein, and even to its roots. It may be Produced by a direct lesion of the vascular walls (traumatic pylephlebitis), to which the pylephlebitis of the newborn belongs starting from the umbilicus; or by an inflammatory or ulcerative focus within those organs from which the radicles of the portal vein start; or by suppuration in the vicinity of the caecum and its vermiform appendix (appendicitis) ; or by a purulent or ichorous focus in the spleen; or by purulent deposits be- tween the layers of the mesentery, due to disease of the lymphatic glands; or by diseased conditions of the liver, the bilary passages, or in Glisson's capsule and the hepatico-duodenal ligament. Besides the Symptoms which belong to the disorders of which pylephle- bitis is the result, its commencement is marked by pains in the epigastrium, the right or left hypochondrium, the csecal or umbilical region, according as the trunk or one of the radicles of the vein is first diseased. This is soon followed by rigors, heat and profuse sweating, often recurring without any certain type. Liver and spleen, as a rule, increase in size, and the skin and urine become jaundiced. The stools are copious, thin and bilious, only ex- ceptionally constipated. Later S3anptoms of diffuse peritonitis, painful dis- tention of the abdomen, vomiting, etc., usually supervene; the patients rapidly lose flesh and strength; the fever assumes a hectic character, and ul- timately delirium or somnolence is developed and terminates in death. This series of symptoms may run its course in one or two to four or six weeks, oftentimes with several deceiving remissions. If its development cnanot be prevented its cure will scarcely be possible. 554 ICTERUS, CHOI^EMIA, JAUNDICE. Icterus, Cholaemia, Jaundice. Jaundice is not a disease, but only a symptom, and consists of a yellow discoloration of the skin by the deposition of the coloring constituents of bile, namely: biliary pigment, biliphsein, cholepyrrhin. The so-called liver-spots (chloasmata, maculae hepaticse) have no relation to the diseases of the liver, but are partial deposits of pigment from various causes; and in some cases yellow discoloration is a disease of the skin of the chest, pityriasis versicolor, which consists of vegetable parasites. The yel- low discoloration of icterus varies greatly in degree, from a slight and light yellow through all shades to a blackish, and greenish-brown color. It is now conceded on all sides, but still not fully explained by experi- ments, that jaundice may originate in two different ways. First, by obstruc- tion to the escape of bile from the secreting gland (hepatogenous cholaemia), and secondly, bj- some alteration in the metamorphosis of substances con- tained in the blood (hematogenous cholaemia, or blood icterus). i. Hepatogenous Cholaemia which owes its origin to a mechanical impediment to the excretion of bile, and its resorption into the blood, is the best understood form of the two. The passage of the bile into the circula- tion seems, according to recent demonstrations, to take place almost exclu- sively b} T way of the thoracic duct, which would afford additional support to the theory, that there is between the secretory cells and the blood-capillaries of the liver, quite an extensive system of channels for the flow of lymph, and obviate at the same time the difficulty of understanding the mode how the bile could be infiltrated into the blood-capillaries which are everywhere separated from the gall-capillaries by the cellular substance of the liver. The Causes, of which stagnation of bile is the result, are very manifold. The ductus choledochus and hepaticus may become obstructed; by catarrh of their lining mucous membrane, as in icterus catarrhalis; by accumulation of fecal matter in the large intestines, or a pregnant uterus; by enlargement of the lymphatic glands in the fissure of the liver from lardaceous, tubercular, or cancerous infiltrations; by concretions in their own channel, usually at- tended with colic; by adhesions of their walls in consequence of exudative processes; by carcinomatous growths from the lining mucous membrane of their walls, or of the pylorus, of the duodenum, of the head of the pancreas, or by tumors in the liver. The biliary passages within the liver may become compressed, or con- stricted by a large number of morbid alterations of the liver, such as cancer, echinococci, cirrhosis, etc.; by stagnation of blood in the hepatic vein in con- sequence of organic cardiac diseases, and diseases of the lungs and pleura, in which affections the acceleration or retardation in the respirator}- movement of the diaphragm exerts also a great influence, which may be sufficient to cause an obstruction to the flow of bile. The Symptoms of a stoppage of bile and its accumulation in the blood, manifest themselves in a jaundiced discoloration of the liver, of the serous ICTERUS, CHOL^MIA, JAUNDICE. 555 exudations, and of the secretions, especially those of the kidneys and skin. The urine becomes saffron- yellow, reddish-brown, dark brown, greenish- brown, or brownish-black, according to the quantity and quality of the bile- pigment which enters into it. The best reagent is nitric acid which is not altogether free from nitrous acid. By adding the concentrated acid, drop by drop into a small glass containing urine, the well-known play of colors from brown to green, blue, violet and red will be seen arranged in layers one above another, like a rainbow. The sweat, especially of the axilla, colors, the white linen 3 T ellow, and so also have the sputa in bilious pneumonia a brown, or usually, a leek-green color. With this tinging of the secretions with pigment goes hand in hand the discoloration of the tissues. The skin assumes a pale, sulphur yellow, later a saffron or citron yellow, or an olive or bronzed color, according to the intensity and duration of the disease. This discoloration is seen first on those places where the epidermis is thin, for instance on the nose wings, the angles of the mouth, the forehead and neck. As the coloring proceeds from the deeper layers of the epidermis, the yellow color of the skin remains until desquamation of the epidermis has been accomplished, which does not take place sometimes till long after the removal of the causes of the jaundice and the disappearance of the coloring- matter from the urine. The mucous membranes become only slightly tinged, but the coloring matter penetrates into all tissues : the adipose cellular tissue, the serous and fibrous membranes, the areolar tissue, the walls of the blood- vessels and of the lymphatics, and the substances of the bones and of the teeth. The cartilage, brain and nerves are less affected. When the brain appears yellow, the discoloration proceeds from infiltration of the cerebral substance with yellow serum. In the eye the jaundice color extends over all membranes, humors, and especially the vitreous body. In pregnant women even the foetus participates in the yellow color. The nervous system exhibits occasionally the following abnormal conditions: Itching of the skin; de- rangement of the general sensations, such as sadness and peevishness of temper, headache, giddiness, great exhaustion and debility; yellow sight or xanthopsy, bitter taste with clean tongue; slow pulse, in most cases 50 or 40 beats in a minute, in some cases still lower; the temperature in simple cases remains unchanged. The symptoms of the digestive organs, the most important in a practical sense, is the change in color of the feces. A total absence of bile makes the stools ash or clay-colored, with a tendency to constipation; a partial want of bile merely makes them paler than usual. The Duration and Prognosis of jaundice depends principally upon its primary causes. 2. Hematogenous cholaemia, blood-icterus, seems to be caused by some alteration in the metamorphosis of substances contained in the blood not fully understood as yet; it runs its course independently of any influence ex- erted by the liver and without any detectable mechanical impediment to the excretion of bile. To this class belong jaundice from the effects of ether, 556 ICTERUS, CHOU-EMIA, JAUNDICE. chloroform and phosphorous, from snake-bites, from pyaernic infection of the blood, from swamp fever, typhus and relapsing fever, and from yellow fever. Jaundice from violent mental emotions, especially vexation, anger, fright, etc. , seems likely to be produced by interruptions of the circulation of blood through the liver in consequence of the influence of the nerves controlling the calibre of the branches of the portal veins, and. by interruptions of the heart's action, the respiratory movements and the renal secretion. Icterus menstrualis is probably produced by sudden changes in the blood pressure in the portal vein. Icterus gravidarum, which makes its appearance in the latter months of pregnane}', is produced by the pressure of the distended uterus, or by ac- cumulation of fecal matter in the colon, upon the biliary ducts, or it is char- acterized by serious derangements of the nervous system, and, so far as cases of this kind have as yet been examined, depends upon acute atrophy of the liver and diseased kidneys. Icterus neonatorum appears soon after birth, and in ordinary cases seems to be produced by the diminished tension of the capillaries in the hepatic tissue, which takes place upon the stoppage of the influx of blood from the umbilical vein, and which gives rise to an increased transfusion of bile into the blood. A graver form is that in consequence of phlebitis umbilicalis fol- lowing by purulent infection. In some cases it may be produced by a catarrh of the duodenum or an accumulation of mucus within the gall-ducts. Jaundice of newborn children must not be confounded with the slight yellowish discoloration of the skin, which, in most children, is seen a few days after birth and is nothing but a change of color of the hsematin, which, in consequence of the great hyperemia of the skin after birth, becomes de- posited in the skin. In such cases the yellow color of the white of the eye is absent. Dr. Quine makes the following remarks upon the significance of jaun- dice in diagnosis: " 1. Jaundice occurring suddenly in apparent health, and painlessly, is usually of emotional origin and transitory. 2. When it depends on disease or injury of the brain, acute atrophy of the liverj snake-poisoning, or infectious fever, it is always associated with mental disturbances. 3. If it be attended with fever and well marked, it is secondary to inflammation of the biliary passages, pneumonia, toxaemia, or infective inflammation of the portal vein. 4. If it occur suddenly and is preceded by paroxysmal pain and vomiting, it is caused nine times out of ten by biliary calculi. 5. If it is preceded by typical symptoms of gastro-duodenitis, it is obviously of catar- rhal origin. 6. Impassable obstruction of the common duct is shown by great intensity of jaundice, clay-colored stools, and in recent cases by disten- tion of the gall-bladder. 7. Jaundice caused by sudden obstruction of the biliary passages is always associated with paroxysmal pain and nausea, but there is no means of ascertaining the nature of the obstructing body except its discovery in the stools. 8. In the rare cases of sudden obstruction by cancerous, hydatid and aneurismal tumors, there is almost always a history THERAPEUTIC HINTS TO ICTERUS, CHOL^EMIA, JAUNDICE. 557 of impaired health, enlargement and deformity of the liver, ascites, etc., which, aided by the revelations of physical exploration, will lead to a correct differentiation. 9. Sudden return to normal coloration of the feces confirms the diagnosis of obstruction. 10. Occlusion of the cystic duct may be attended with as much pain, nausea and distention of the gall-bladder as occlusion of the common duct, but there is no jaundice. In occlusion of the hepatic duct, the same symptoms are present, including jaundice and excluding distention of the gall-bladder. It is often impossible to distinguish between occlusion of the hepatic and of the common duct. The former is rare because the duct increases in size from above downwards. 11. If jaundice persists after the sj'mptoms of biliary colic or catarrhal inflammation have a month since dis- appeared, or if jaundice has disappeared after a biliary colic to return slowly and painlessly, it may be assumed that stricture of the duct has resulted from inflammatory thickening, adhesion of the walls or cicatrization of an ulcer. 12. A history of repeated attacks points to the probability of gall-stones. 13. If jaundice comes on slowly without antecedent colic or catarrh, and without attendant evidence of impaired health or portal obstruction, it is probably caused either by pressure upon the duct or by the growth of a tumor within its walls. The pressing body, when large enough, may be readily appreciated, as in the case of ovarian tumor, aneurism, distended colon, etc. , but when it is small or constituted by enlargement of lymphatics in the fissure of the liver, it is apt to escape detection. 14. Slight but per- sistent jaundice may be due to incomplete occlusion of the common duct, or to complete occlusion of a branch of the hepatic, but usually it is found asso- ciated with either valvular diseases of the heart, some disease of the lungs which obstructs the circulation, or cirrhosis of the liver. 15. If ascites be associated with it, the disease is either cirrhosis or cancer of the liver; if the liver be abnormally small, the disease is cirrhosis; if it be large, the disease is either hypertrophic cirrhosis or cancer. Differentiation between the two is seldom attended with difficulty. 16. Absence of jaundice does not imply absence of hepatic disease, since the liver may be destroyed by disease or extirpated by operation without jaundice ensuing. 17. It is not a prominent symptom of hepatitis, if catarrhal inflammation of biliary passages be rigidly excluded. It is not characteristic of hepatic abscess when at most mere mud- diness of the complexion is usually seen. It is not a symptom of waxy or fatty liver or of hydatids excepting as an extraordinary complication." {Medical Times and Gazette. ) Therapeutic Hints. Aeon. Pain changing about from the stomach to the liver, or to the navel; fever, great thirst; catarrh of small intestines; constipation or diar- rhoea, sometimes in alternation; during pregnancy; in newborn children; after fright. Arsen. In different liver affections; in consequence of intermittent fevers; heat, restlessness, anxiety, irritable mood alternating with low-spir- itedness. 558 THERAPEUTIC HINTS TO ICTERUS, CHOL.EMIA, JAUNDICE. Auruvi. Pain in the liver and upper part of the abdomen; bowels con- stipated; stool grayish, ashy; urine scanty, green, brownish; lower extremi- ties, from the knees down to the feet, painful and tired. Bellad. After the abuse of Peruvian bark or mercury, in complication with stones in the gall-bladder; hardness of the liver; congestion to the head. Berber. Spells of icterus with pale, tough alvine discharges, or profuse, acrid, water}* diarrhoea; urine dark, turbid, with copious sediment; morbid hunger alternating with loathing of food, or great thirst alternating with aversion to all kinds of drink; constant, troublesome bloatedness of the ab- domen, with occasional forcible and noisy discharge of flatus. Bryon. Stitching pain on pressure in the liver; pressure in the pit of the stomach; pain in the limbs, worse from motion; obstinate constipation; thick, white, coated tongue; nausea; gagging; vomiting after eating and drinking; general malaise; disinclination to move. Calc. carb. Stitches in the liver during or after stooping; cannot bear tight clothing around the waist; enlargement of the liver; habitual constipa- tion; grayish, whitish feces; indigestion; pit of the stomach swollen out like a saucer turned bottom up. Card. mar. In complication with gall-stones; great sensitiveness of the head to cold; loss of memory and smell; colicky pains in the stomach, with waterbrash; vomiting. Carb. veg. Psoric taint; scorbutic and intermittent fevers; cachexia; irritable, vehement disposition; loathing of meat, butter, fat; constipation, or pale, whitish stools; dark red, bloody-looking urine. Chamom. After chagrin, imprudent diet, or taking cold; in newborn children. Chelid. Pain in the liver, and in the back under the lower corner of the right shoulder-blade; very irregular pulsations of the heart. China. Gastro-duodenal catarrh, particularly after great loss of animal fluids, or after heavy illness; dullness and muddled condition of the head; oppressive, tearing headache, particularly at night; restless, unrefreshing sleep; yellow coating of the tongue; dry lips; loss of appetite; loathing of meat; loathing, and yet canine hunger; bitter or sour eructations and taste; gagging; oppression of the stomach and chest, especially after eating; fre- quent whitish stools; emission of fetid flatulence without relief; great languor, out of humor, and vehement. Gall-stones. Coniitm. Hard swelling of the liver; glandular swellings elsewhere; the flow of urine stops suddenly, but continues again after a while; cough worse after lying down. Digit. Constant nausea and gagging, with a clear tongue covered with white slime; soreness and bloatedness of the pit of the stomach; soreness and hardness in the region of the liver; stool delayed, chalky; urine scant}*, thick, turbid, blackish; pulse full, slow; chilliness and shuddering alternating with heat; tearful, low-spirited. THERAPEUTIC HINTS TO ICTERUS, CHOI^EMIA, JAUNDICE. 559 Fel tauri. Violent paiu in the bowels with thin stools, which are fol- lowed after straining by crumbling masses. Gelsem. Prostration; clay-colored, creamy stools. Hepa? . Especially after mercurial poisoning. Hydrast. Gastro-duodenal catarrh; sense of sinking and prostration at the epigastrium, with violent and continued palpitation of the heart. Ignat. Silent melancholy; twitching of one muscle at a time. (Gushing. ) Iodiuvi. Dirt}', yellowish skin; great emaciation; downcast, irritable mood; yellow, almost dark brown, color of the face; thick coating of the tongue; much thirst; intense canine hunger all the time, with vomiting after eating; white diarrhceic stools alternating with constipation; dark yellowish- green, corroding urine; after mercurial poisoning; organic lesions of the liver; dyscratic states of the system with hectic fever. Kali carb. Swelling of the liver; stitch-pain in the right side of the chest through to the shoulder; pressive, sprained pain in the liver; can lie only on the right side; complete exhaustion; neither thirst nor appetite; purulent sediment in the urine; abscess of the liver. Laches. In different liver complaints; during the climacteric age; after intermittent fevers; pain as if something had lodged in the right side, with stinging and sensation as if forming into a lump moving towards the stomach; inability to bear anything tight around the waist, not even the pressure of the night-jacket; pain when coughing as if ulcerated. Leptand. Full, aching pain in the region of the gall-bladder; hot aching pain in the liver extending to the spine; with chilliness along the spine; clay-colored diarrhoea. Lycop. Chronic liver complaints; after fright; obstinate constipation; incarcerated flatulence; chronic intestinal catarrh. Magn. mur. Chronic hard swelling of the liver, with pressive pain extending to back and stomach; face dirty, dark yellow; tongue dirty, yellowish; bowels distended and hard with pressure and heaviness; stool hard, gray; urine turbid; dyspnoea; palpitation of the heart; oedema of the feet up to the calves of the legs; weak, emaciated; fearful, easily frightened. Mercur. One of the most frequently indicated remedies, with and with- out fever; duodenal catarrh, with thickly coated, flabby tongue, showing the imprints of the teeth; bad smell from the mouth; nausea; loathing; vomit- ing; soreness in the region of the liver; diarrhoea; gall-stones; jaundice of newborn children; after abuse of Peruvian bark. Myrica cerif. Dragging pain in the back; miserable feeling all over; dull pain in the hepatic region; tongue thickly coated of a dirty white or yellowish color; no appetite, loathing of food, strong desire for acids; sleep- lessness, unrefreshing sleep. Nitr. ac. In consequence of chronic derangements of the liver; costive- ness; great tearing pain in the rectum, continuing a long time after stool, even more intense after a loose stool. Nux vom. Gastro-duodenal catarrh; after allopathic dosing, overloading 560 THERAPEUTIC HINTS TO ICTERUS, CHOU^EMIA, JAUNDICE. the stomach, the use of coffee, liquor, in sedentary habits, after anger. In complication with gall-stones. Headache, dizziness, loss of appetite, bitter taste; nausea, vomiting, gagging; pressure in the stomach, better from belching, soreness of pit, stomach and bowels; unsuccessful urging to stool, constipation. Itching of the skin in the evening; restless sleep; wakes about three or four o'clock in the morning and falls again into a heavy, unrefresh- ing morning sleep; peevish, irritable. Phosphor. In complication with pneumonia or deep seated brain diseases. Atrophy of the liver; during pregnancy, with dry cough and in- voluntary discharge of urine; constant chilliness, even in a warm room; dejected spirits; aphonia and hoarseness. Plumbum. Nausea in evening or at night; vomiting of food; restless, broken sleep. Podoph. In complication with gall-stone; then the pain extends from the region of the stomach towards the region of the gall-bladder, and, when at its height, is mostly attended with excessive nausea; or in complication with inflammatory or hyperaemic states of the liver; then there is a fullness, with pain and soreness, in the right hypochondrium; chronic costiveness or alternate constipation and diarrhoea. Pulsat. In consequence of chronic susceptibility to hepatitis and de- rangement of the secretion of bile, with looseness of the bowels; duodenal catarrh; disordered digestion; feverishness and thirstlessness; after quinine. Rheum. In consequence of eating unripe fruit, and accompanied with white diarrhoea. Sepia. With pain confined to the liver; yellow saddle across the bridge of the nose; brown, yellowish color of the eyelids. Silic. Hardness and swelling of the region of the liver; throbbing, ul- cerative pain in the right hy pochondrium , increased by contact and walking. Sulphur. In psoric persons, with or without hardness and swelling of the liver; vomiting of ingesta or blood; pain in the pit of the stomach and right hypochondrium; abdomen bloated; stool constipated; sleeplessness; nightly itching of the skin; hetic fever; red lips. According to Hartman compare, if icterus be caused by chagrin or anger: Aeon., Bryon., Chamom., China., Ignat., Nux vom., Natr. viur., Sulphur. By taking cold in conseqnence of sudden changes of temperature : Chamom., Dulcam., Merc, sol., Nux vom. By improper food and overloading the stomach: Ant. crud., Bryon., Card, veg., Chamom., Natr. card., Nux vom., Pulsat. By the abuse of chamomile tea : China., Ignat., Nux vom., Pulsat. By the abuse of mercury: Arsen., Asa/., China, Hepar, Iodium, Nitr. ac., Sulphur. By the abuse of Peruvian bark: Arsen., Ipec., Mercur., Pulsat. If being attended with much flatulence, according to Bcenninghausen: Card, veg., Chamom., China, Ignat., Lycop., Nux vom., Plumbum. DIGEST TO JAUNDICE. 561 Digest to Jaundice. Tearful: Digit. Silent, melancholy: Ignat. Anxiety: Arsen. Fearful and easily frightened: Magn. mur. Low-spirited: Arsen., Digit., lodium, Phosphor. Irritable: Arsen., Card, veg., lodium, Nux vom. and peevish : Nux vom. Out of humor and vehement: China. Miserable feeling all over: Myrica. Dizziness : Nux vom. Dull and muddled in head: China. Congestion to head: Bellad. Headache worse in night: China. Head sensitive to cold: Card. mar. Eyelids brown, yellowish: Sepia. Face yellow, almost dark brown: lodium. , dirty: lodium, Magn. mur. Yellow saddle across bridge of nose: Sepia. Loss of smell and taste: Card. mar. Lips dry: China. red: Sulphur. Tongue clear, covered with white slime: Digit. coated thick: Bryon., Ionium, Mercur. white: Myrica. yellowish: China, Magn. mur., Myrica. flabby, showing imprints of teeth: Mercur. Taste bitter: China, Nux vom. Bad smell from mouth: Mercur. Appetite, loss of: Kali carb., Myrica, Nux vom. Loathing of food: Mercur., Myrica. meat, butter, fat: Carb. veg. food and yet morbid hunger: Berber., China. Canine hunger with vomiting after eat- ing: lodium. Desire for acids: Myrica. Thirst : Aeon., lodium. Thirst alternating with aversion to all kinds of drink: Berber. Thirstless : Kali carb., Pul at. Eructation, bitter: China. Nausea • Bryon., Plumbum., Podoph. 36 and vomiting: Card, mar., Nux vom., Plumbum. Vomiting after eating with canine hun- ger: lodium. or drinking: Bryon., Sulphur. Gagging: Bryon., China, Digit. Pit of stomach sinking with palpitation: Hydrast. sore: Digit., Nux vom. , pressure in: Bryon. , better from belching: Nux vom. swollen out like a saucer turned bot- tom up: Calc. carb. Oppression of stomach and chest, after eating: China. Abdomen bloated: Berber., Sulphur. , hard, with pressure and heavi- ness: Magn. mur. Duodenal catarrh: Aeon., Chamom. y China, Hydrast., Mercur., Nux vom. y Pulsat. Colicky pains with waterbrash: Card. Liver, hardness of: Bellad., Coninm, Magn. mur., Silic, Sulphur. , swelling of: Calc. carb., Conium, Kali carb., Magn. mur., Silic, Sul- phur. , pain: Sepia. , dull pain: Myrica. , soreness in: Mercur., Podoph. , sprained, pressive pain: Kali carb. , stitching on pressure or motion: Bryon. , , during and after stooping: Cad. carb. , ulceration, worse from contact and walking: Silic. , pain in, and pit of stomach: Slphur. Liver, like a lump moving towards stom- ach: Laches. , pain in, and upper part of abdomen: Aurum. , pain changing to stomach or to navel: Aeon. , pain in, and stomach and gall-blad- der: Podoph. 562 DIGEST TO JAUNDICE. , aching in, and gall-bladder: Lep- tand. ,pain in, extending to spine: Leptand. , , extending to back and stom- ach: Magn. hi ur. stitch-pain through to shoulder: Kali card. , pain in, and lower corner of right shoulder-blade : Chelid. Cannot bear anything tight around waist: Calc card., Laches. Constipation: Aurum, Bryon., Calc. card., Card, veg., Lycop., Nitr. ac, Nux vow., Podoph., Sulphur. and diarrhoea in alternation: Aeon., /odium, Podoph. Diarrhoea: Berder., Leptand., Mercur., Pulsat., Rheum. with straining, with passing crumb- ling masses: Fel tatiri. , with long-continued pain in rectum afterwards: Nitr. ac Stool, ashy, grajnsh, clay-colored, creamy, pale, whitish: Aeon., Calc. card., Card, veg., China, Digit., Gelsem., Leptand., Rut a. Flatulence: Berder., Card, veg., China, /gnat., Lycop., Nux vom., Plumdum. Urine, its flow is suddenly interrupted for a short time : Conium. , squirting when* coughing: Phosphor. , turbid: Berber., Digit., Magn. mur. , scant} 7 : Aurum, Digit. , thick, blackish: Digit. , brownish, green: Aurum. , dark, yello wish-green, corroding: /odium. ■ , dark red, bloody looking: Card. veg. Sediment, copious: Berder. , purulent: Kali card. Aphonia and hoarseness: Phosphor. Dyspnoea: Magn. mur. Cough worse after lying down: Conium. with pain as if ulcerated: Laches. dry with squirting of urine: Phos- phor. Palpitation of heart : Hydroph . , Magn . mur. Irregular pulsations of heart: Chelid. Pulse full and slow: Digit. Back, dragging pain in: Myr. cerif. Limbs, pain in, worse from motion: Bryon. From knees to feet, pain and tired: Aurum. (Edema from feet to calves: Magn. mur. Twitching" of one muscle at a time: /gnat. Itching of skin in evening: Nux vom. Sulphur. Emaciation: /odium, Magn. mur. Exhaustion: Gelsem., Kali card. Disinclination to move : Bryon. Fever : Aeon., Arsen., Pulsat. or no fever: Mercur. , hectic: /odium, Sulphur. Chilliness : Pulsat. even in a warm room: Phosphor. and shuddering alternating with heat: Digit. Sleeplessness : Sulphur. Sleep restless, uurefreshing: China, Myr- ica, Nux vom. , broken: Plumdum. , wakes about 3 or 4 o'clock A.M., and then heavy, unrefreshing morning sleep: Nux vom. Restlessness : Arsen. CAUSES. Abuse of chamomile tea: China, /gnat., Nix vom., Pulsat. mercury: Arsen., Asa/., Bell ad., China, Hepar, /odium, Nitr. ac, Sul- phur. Peruvian bark: Arsen., Bel lad. /pec, Mercur., Pulsat. quinine: Pulsat. Allopathic dosing : Nux vom. Chagrin or anger: Aeon., Bryon., China, Chamom., /gnat., Natr. mur., Nux vom., Sulphur. Improper food or overloading stomach: Ant. crud., Bryon., Card, veg., Chamom., Natr. card., Nux vom., Pulsat. Unripe fruit : Rheum. Coffee, liquor: Nux vom. Intermittent fevers : Arsen., Card.veg., Laches. Sudden changes of temperature : Chamom., Dulcam., Merc sol., Nux vom. DISEASES OF THE SPLEEN. 563 COMPLICATIONS. I Nitr. ac, Phosphor., Podoph., Pulsat. Brain diseases : Phosphor. Sulphur. Catarrh of small intestines: Aeon., Cha- mom., China, Hydroph., Lycop., Mercur. y Nux vom. Gall-stones: Bellad., Card, mar., China, J/ercur., Nux vom., Podoph. Liver-COmplaints of different nature: Arsen., Bellad., Conium, Iodium, Kali card., Laches., Lycop., Magn. mur. s Pregnancy: Aeon., Phosphor. Pneumonia : Phosphor. Climaxis: Laches. Newborn children: Aeon., Chamom. Mercur. Dyscratic states of system: Iodium, Psoric taints: Card, veg., Sulphur. DISEASES OF THE SPLEEN. Physical Examination. — When of normal size — which in an adult is as follows: Length, four to five inches; breadth, three to four inches; thick- ness, one to one and a half inches — the spleen yields on percussion a dull sound, bounded as follows: posteriorly by the body of the eleventh dorsal vertebra; in front by a vertical line drawn from the anterior border of the axilla to the free end of the eleventh rib; superiorly by the ninth rib; and inferiorly by the free end of the eleventh rib. In order to obtain a clear result by percussion the patient ought to be placed upon his right side. It must likewise be considered whether the stomach be not filled at the time of percussion. In cases of accumulation of fluids in the left thoracic cavity, either pleuritic or pericardial, in accumulation of gas, abdominal or thoracic, in tumors of neighboring organs (liver, omentum, kidney), it may sometimes be next to impossible to define the size and position of the spleen. A considerabty enlarged spleen, however, under ordinary circumstances is easily detected by percussion. And it is sometimes enormously enlarged and displaced, reaching inferiorly to the os pubis and anteriorly to the median line of the abdomen; in some cases even filling almost the whole abdominal cavity. In such cases it is also accessible to palpation. Even a moderate en- largement may be felt, if it extend below the eleventh rib. Its surface, except when invaded by cancer, is always smooth; and its form oval and sometimes wedge-shaped. Its rounded apex, and the notch which corre- sponds to the middle line of the spleen, and which becomes the more marked the larger the spleen grows, are characteristic signs by which to distinguish it from any other abdominal tumor. Notwithstanding great and laborious experiments, we know as 3'et but little concerning the functions of this organ. Only so much seems to be certain, that it bears an important relation to the formation of white blood- corpuscles, and the disintegration of the red corpuscles. And this seems to be corroborated by the fact, that diseases of the blood always affect the spleen, altering it in size and consistence and, vice versa, that lasting- diseases of the spleen lead to a diseased state of the blood, causing anaemia, leucaemia, hydrops, scurvy. Cases in which such a connection does not seem to exist, prove, perhaps, 564 ANATOMICAL PECULIARITIES OF THE SPLEEN. only that the function of the spleen ma}', under certain circumstances, be performed by some other organ or organs vicariously. Anatomical Peculiarities of the Spleen. It consists of a much softer and looser texture than any other glandular organ of the body; its areolar framework is made up of the elastic tunic which forms sheaths for the vessels in their ramifications through the organ, which again are loosely connected by small fibrous bands, issuing in all directions from said sheaths. In this way a multitude of interstices is formed, which contain a soft, granular substance. This peculiarly loose construction makes the organ pre-eminently fit for the reception of large quantities of blood; and the more so as its capsule is also of a yielding nature, offering little resistance to extension; so that, on the other hand, if once overdistended, it regains its previous normal state very slowly; and this on account of the inelasticity of its tissue. The veins of the spleen constitute, by their numer- ous dilatations, the principal part of its bulk; they pour their blood, after uniting with the veins of the stomach, and other less important vessels, into the portal vein. The whole organ is held loosely in its position by a duplicature of the peritoneum. The knowledge of these anatomical peculiarities of the spleen at once explains its participation in various abdominal and pectoral affections. x\ll hepatic troubles, and all diseases of the heart and lungs which obstruct the portal circulation, must necessarily retard or prevent the normal egress of blood from the spleen, and cause it to swell; a stagnation of blood in the splenic vein must cause .a like stagnation in the veins from the stomach, and thus bring on vomiting of blood, and its loose connection explains at once the possibility of its sinking quite low down into the abdominal cavity under certain circumstances. Hemorrhagic Infarction; Splenitis, Lienitis, or Inflammation of the Spleen. Hemorrhagic infarction is of much more frequent occurrence in this organ than in any other. It consists of blocking-up of the smaller splenic arteries by fibrinous coagula, which have formed in the left ventricle of the heart in consequence of endocarditis, and which have been washed away by the stream of blood, and carried through the splenic artery into its smaller branches, where they stick fast. This is of such frequent occurrence that it is very rare not to find hemorrhagic infarction in the spleen, in all cases where post-mortem examination reveals valvular destruction to any con- siderable degree; much more rarely, such emboli come from gangrenous places of the lungs. In such cases they have to pass through the pulmonary veins, the left ventricle, aorta and splenic artery. Hsemorrhagic infarction forms also in consequence of malarial infections, typhus, septicaemia, and HEMORRHAGIC INFRACTION. 565 acute exanthematic fevers; in these cases, it seems, by a stagnation of circu- lation within the splenic veins. These hemorrhagic coagula or thrombi are usually situated at the periphery of the spleen, and are roundish or wedge- shaped, their broad base being nearest to the periphery, while their apices point toward the interior. The}' appear at first of darker color and harder than the surrounding tissue, which appears perfectly sound. By-and-by, however, they become discolored and changed into a yellow, firm, homogeneous mass, which during the further progress of the disease may undergo several changes. It may shrink and leave a cicatrix, or suppurate and form abscesses of the spleen, which, if the}' are many, may transform the whole spleen into a mass of cor- ruption. These abscesses again may go on to different terminations. They may, by fibrinous exudation, become encysted, or they may cause pyaemia, or they may burst and discharge their contents, like abscesses of the liver, into the peritoneal sac; or when adhesions have been formed with neighboring or- gans, they may, by perforation, discharge their contents into the stomach, colon, or the pleural cavity. A primary inflammation of the spleen is of very rare occurrence ; even external injuries, a blow, a fall, a wound, are apt to cause a rupture, rather than an inflammation. Its Symptoms are frequently quite obscure and of an uncertain character, so that it is often not recognized until post-mortem examination brings it to light. We have a better chance of discovering its presence when it is pro- duced by cardiac diseases, and there is also an enlargement of the spleen, which, however, never reaches more than double its normal size, and in many cases is so insignificant that it cannot be discovered by percussion. Pain in the region of the spleen originates not in the substance of the spleen itself, but in its enveloping membrane or in the neighboring organs, and is, therefore, sometimes entirely wanting. When it does exist, it is of a dull character, and is increased by deep inspirations, different movements of the»body, and percussion. A sharp pain denotes an inflammation of its peritoneal covering. A radiating pain into the left shoulder is likewise sometimes observed. Fever is usually entirely or partly dependent on the original disease; but when suppuration has taken place, the characteristic rigors make, as a rule, their appearance. Peritonitis follows in case of rupture or perforation. On the whole a certain diagnosis can only be made when, after traumatic causes or in conse- quence of pyaemia, endocarditis, etc. , local and general symptoms arise which can be referred to the spleen. And the diagnosis increases in probability if metastatic inflammation of other organs are developed at the same time, for instance in the kidneys with albuminuria and haematuria. 566 ACUTE TUMOR. Therapeutic Hints. Compare such remedies as are pointed out under the heads of those diseases which are either the cause or complications of splenitis, as endocar- ditis, valvular derangements of the heart, etc. Acute Tumor, or Hyperemia of the Spleen. This consists of a more or less copious accumulation of blood within the gland, by which its volume may become enlarged to three or four times its normal size. The color of its tissues varies from red to brown or violent, and in case of a long duration it changes to a dirty gray or slate color. This acute swelling of the spleen is an almost constant attendant upon typhus, intermittent, remittent, yellow and puerperal fevers; likewise upon cholera in its stages of reaction, and of a number of other complaints, such as pylephlebitis and cirrhosis, by which a stagnation in the portal circulation causes stagnation of blood in the spleen. We find it likewise attending anomalies of menstruation. It is therefore always of a secondary nature, and its symptoms must vary accordingly. Symptoms, which belong exclu- sively to it, are — i. The conspicuous enlargement, which can easily be discovered by per- cussion and palpation. 2. A dull pain in the region of the spleen, which is generally increased by motion, pressure, deep breathing, and lying on the left side. 3. A conspicuous anaemic appearance of the patient which, especially in intermittent fevers, sets in very quickly and keeps pace with the enlarge- ment of the spleen. All other symptoms belong to the primary disease which causes it; for therapeutic hints compare these diseases. Hyperemia of the spleen leaves with the primary disease; in some cases, however, it assumes a permanent form; and thus originates — Chronic Tumor, or Hypertrophy of the Spleen. The spleen sometimes attains a weight of ten, fifteen to twenty lbs., fill- ing almost the entire abdominal cavity. Its resistance is often like that of a board, and its substance appears dark brown red. This is simple hypertrophy, consisting of an increase of granular substances in the interstices, formed by the numerous fibrous bands of the splenic structure. In other forms it has, as a rule, the appearance of waxy or colloid degeneration, and consists in- deed of the same homogeneous colloid mass, which the colloid liver presents, and then is called amyloid degeneration of the spleen. A peculiar variety of this affection is the so-called Sago-spleen, where the whole organ appears to be infiltrated with half-solid, transparent, round globules, which can be taken out, and very much resemble boiled sago. It seems that the development of this* peculiar appearance depends upon the in- filtration of the same colloid mass into the vesicles of Malpighi. CANCER OF THK SPOKEN. 567 The chronic tumor resulting from intermittent fevers is of a slate color. The Causes of this chronic enlargement of the spleen, when it is simple hypertrophy, are, all such disorders as cause a stagnation of blood within the venous circulation, to wit: heart and lung diseases, inflammation and obliter- ation of the portal veins, and cirrhosis of the liver; but when it consists of an amyloid degeneration, a number of diseases, which depend upon a morbid state of the blood — so-called dyscrasias — malaria, constitutional syphilis, mercurial cachexia, rachitis, scrofulosis, Bright' s disease, in a lesser degree, chlorosis, scurvy and leukaemia. Symptoms. — Enlargement of the spleen, usually very great, and charac- terized by its roundish apex and the notch on its inner edge. All other symptoms belong more or less to the primary affection, and are therefore of no diagnostic value for the tumor itself. Therapeutic Hints Must be looked for under the respective heads of causes; however, the following remedies have a special relation to the spleen: Arnica, Asaf., Arse?i., Borax, Bromium, Card, veg., Ceanothus in spleen pain, China, Dul- cani., Ferrum, Ignat., Laches., Lauroc, Mercur., Mur. ac, Natr. carb., Natr. mur., Nux mosh., Platina, Plumbum, Ran. bulb., Rhus tox., Ruta, Stannum, Sulphur, Zincum. Spleen affections and obstinate diarrhoea: Anac, Asaf., Bryon., China, Dulcam., Ignat., Pulsat., Rhux tox., Sulph ac. Cancer of the Spleen Is a very rare disease; is generally of the medullary or encephaloid form, and sometimes attains a pretty large size; it is always connected with cancer in other organs, especially those of the abdomen. Its Diagnosis is easy, when the existence of cancer in other organs has been proved, and when the enlarged spleen shows on palpation that charac- teristic cancer-unevenness. Echinococcus- cysts Are of very rare occurrence; they may exist in the spleen alone, and also in other organs at the same time. Its Diagnosis is difficult, being possible only under those favorable cir- cumstances in which the echinococcus-cyst is accessible to percussion and palpation, when it may be discovered as a roundish fluctuating tumor. Rupture of the Spleen May be caused by external injuries, violent concussions of the body, or by pathological changes of the gland itself, as in its rapid enlargement, especially in typhus, or during the chilly stage in intermittents. Symptoms. — A sudden very intense pain in the region of the spleen, spreading over the whole abdomen. And in consequence of the internal 568 DISEASES OF THE PANCREAS. haemorrhage: paleness, collapse, cold extremities, small pulse, vanishing of sight and hearing, syncope, distention of the abdomen, death. Its Diagnosis must be founded upon the sudden pain in the region of the spleen, and a knowledge of the previous ailments. A perforation of the stomach or of the intestine always causes tympanitis by its air rushing into the peritoneal cavity, and peritonitis. The latter is also caused by ruptures of the liver, gall-ducts, and of the bladder; and besides, the pain which is hereby produced is not in the region of the spleen. A fatal termination usually follows, generally within twenty-four hours. DISEASES OF THE PANCREAS. The pancreas, the abdominal salivary gland, is situated behind the left lobe of the liver and the stomach, and discharges its secretion by a main duct into the duodenum in the vicinity of the opening of the ductus chole- dochus into the duodenum. Sometimes the pancreatic and biliary ducts become united just before the}' enter the duodenum. Its secretion assists in the transformation of starch into dextrine and sugar, and in the digestion of albumen and of fat. It shares its saccharify- ing power with the saliva, perhaps also with the secretion from Brunner's glands, its peptonizing properties with the gastric juice and succus entericus, and its power of emulsifying neutral fats with the bile; while its power of breaking up fat into fatty acids and glycerine is the only one which, as far as our knowledge of to-day goes, can be said to be peculiar to the pancreas. From this statement it may easily be seen why a diagnosis of diseased conditions of this gland is in most cases very difficult and in some altogether impossible. The following symptoms, however, may hint to affections of the pancreas without being pathognomonic: Emaciation of the whole body be- ginning early and proceeding to an unusual degree; a flow of saliva-like fluid from the mouth, either as eructations or by frequent spitting; the pres- ence of fat in the stools, sometimes in the urine floating upon it on cooling, like masses of butter; the presence of large quantities of undigested striped muscular fibres in the fecal discharges; the presence of diabetes mellitus and also chronic jaundice. The pain in the epigastrium is shared by a great number of other disturbances, and even the results of palpation are in many cases negative on account of the deep position of the pancreas, and its being covered by the stomach and liver. Occasionally, however, palpation may lead to positive results, when performed with both hands by lateral pressure on the hypochondriac regions, or in the knee-elbow position, when the altered pancreas ma}?- be discovered lying crosswise in the epigastric re- gion as a slightly movable swelling, or as a round, firm, or fluctuating tumor, either smooth or nodular on its surface. Among these symptoms the most important are: fatty stools, mellituria, darting pains in the epigastrium (cceliac neuralgia), together with a palpable tumor. Just as little certainty exists as to the Causes of pancreatic diseases. PANCREATITIS. 569 In most cases, as far as we know, these affections are of a secondary nature, arising from diseases of neighboring organs. Fortunately pancreatic diseases are of great rarity. From among the special forms of morbid conditions of the pancreas as discovered principally on post-mortem examinations, the following may be mentioned: Pancreatitis, Inflammation of the Pancreas. Pathologically, it is characterized by swelling, redness and softening of the areolar tissue, which surrounds the lobules of the gland; in a higher de- gree it alters the whole gland into a firm mass. It results either in resolution or suppuration, or leads to induration of the areolar tissue and obliteration of the glandular structure. It may be of an acute or chronic nature. Fatty Disease of the Pancreas Consists of a fatty degeneration of the gland-cell, analogous to fatty degen- eration of other glandular organs, which destroys the secreting cells and causes atrophy of the entire organ, of which often nothing remains but a flacid band of connective tissue. Cancer of the Pancreas May be primary, orginating in the gland, or secondary, spreading from neighboring organs to the gland. It causes no characteristic symptoms be- sides the general cancer-cachexia, and is, therefore, not distinguishable from other co-existing cancerous affections. DISEASES OF THE KIDNEYS. The kidneys being the organs for secreting urine, any morbid state within them will, of necessity, cause changes in the product of their physiologi- cal function, although disease of the kidneys does not attend every abnormal state of the urine. Before we enter upon a considersation of the different renal disturbances, it will be expedient first to collect those symptoms which we may gain by — Examination of Urine. 1. Its Reaction. Urine is naturally acid, which is easily tested by dipping into it blue litmus paper. This acidity varies much even in normal urine; it is increased before meals, decreased after meals; during digestion it is augmented by sulphuric, nitric, phosphoric, tartaric and oxalic acids when taken into the system. An alkaline reaction may take place sometimes during digestion without being a sign of disease; or it results from taking an excess of fixed alkalies, such as the salts of soda and potassa. In this case the red test-paper is col- 57° DISEASES OF THE KIDNEYS. ored blue and retains this blue color when exposed to heat. When it exists as a permanent condition it generally indicates nervous depression, resulting from exhaustion by mental anxiety, spermatorrhoea, etc. It is said to be pro- duced temporarily by the juice of lemons and oranges. An alkaline urine may be caused also by a volatile alkali such as carbonate of ammonia, in consequence of decomposition. This is generally recognizable by its odor and the test-paper at once loses the blue color and takes on its original red tint when exposed to a gentle heat. This alkalinity of the urine denotes pathological disturbances, such as the presence of mucus or pus in the urine, in consequence of disease of the mucous coat of the bladder, or in conse- quence of paraphlegia, whereby the urine is too long retained in the bladder. 2. Its General Appearaace. A light, pale color is usually found in chlorotic and anaemic states of the system; in neuraigia; in hysteria (urina spastica); in diabetes mellitus, with much increased quantity and gravity; in chronic morbus Brightii; in leukaemia; in consequence of wear and tear of the nervous system, with a dash of white in it, containing phosphates. A deep, dark color may be caused — i. By an increase of urea in the urine, which appears perfectly clear and transparent when freshly voided, and its foam when agitated is perfectly colorless. 2. By an admixture of blood. In this case the urine is opaque It is found: #, in haemorrhages from the kidneys; b, in haemorrhages from the bladder; and c, during menstruation or haemorrhages from the womb, when it is of mere accidental occurrence. 3. By an admixture of bile. In this case the freshly voided urine is usually clear and transparent; its foam, when agitated, is intensely yellow; white paper and linen, when dipped into it, become yellow, even olive-green „ and a drop of nitric acid, when permitted to fall on a thin layer of such urine, causes at once an interesting play of colors — commencing with green and blue, passing to violet, red, and finally to yellow or brown. It is found: a, in icterus; &, in the highest state of pyaemia; c, in the acute yellow atrophy of the liver; d, in some cases of pneumonia, especially on the right side. 4. By different drugs, such as santonin, rhubarb, sena, turpentine, dyer's weed, beets, tar, kreosote, etc. A turbid appearance of the urine, when freshly voided, ma}- result — 1. From an admixture of epithelium, thrust off by catarrhal processes of the mucous linings within the urinary organs. It is of a flocculent appear- ance and does not alter the specific gravity of the urine. 2. From gonorrheal or leucorrhceal discharges, appearing in the other- wise transparent urine as whitish flakes. ♦ 3. From cylindrical casts from out of the uriniferous tubuli, during the acute or subacute stages of Bright' s disease. The}- soon settle to the bottom of the vessel, and form a light, downy sediment. 4. From blood, as stated above, or chyle. 5. From pus, which settles as an opaque, creamy or clayey mass; re- DISEASES OF THE KIDNEYS. 571 action, generally alkaline; it is dissolved into a dense gelatinous mass, when agitated with an equal quantity of liquor of potassa, and smells foul and ammoniacal in consequence of decomposition. It is a sign of suppuration somewhere in the genito-urinary system, or a proof that an abscess has opened into and is being discharged through this channel. In chronic catarrh of the bladder pus forms a layer of grayish- white sediment. 6. From earthy salts, generally, however, on^ after cooling, a, Uric acid settles in little red granules of a crystalline character, visible to the naked eye, while urates constitute more of a pinkish or yellowish sediment; the urine appears dark, shows an acid reaction, and becomes transparent by the application of heat. When a few drops of nitric acid are added, and the mixture is slowly evaporated nearly to dryness over a lamp, the addition of a drop of ammonia instantly produces a rich purple (Dr. Prout's Purpurate of Ammonia), b, Phosphates — a combination of phosphoric acid with soda, lime or magnesia. Such urine always jaelds an alkaline reaction, is usually of a whitish milky color with whitish sediment of an offensive odor, and clears up at once by the addition of a few drops of acetic acid. 3 a . The urine contains one or the other of its normal con- stituents in excess or in decreased quantity — (Compare CI. Mitch- ell's " Clinical Significance of the Urine and its Normal Constituents.") Urea, C H 4 N 2 O, may be suspected in excess if the urine is of a deep yellow color, of a strong urinous smell, and of high specific gravity, and may be chemically demonstrated as follows: " Pour an equal bulk of nitric acid upon the given specimen, which has not been boiled, and which ought to be part of the entire quantity of urine passed in twenty-four hours. ' ' This will produce the formation of crystals of nitrate of urea. Urea is increased in all fevers (except yellow fever), in acute febrile states with emaciation, in inflammations generally, also those of thoracic vis- cera often, in nervous diseases, such as epilepsy, chorea, progressive muscular atrophy, in pyaemia, diabetes, atrophy from dyspepsia (in children), and dif- fuse bronchial catarrh (without fever). The amount of urea is diminished in paralysis, cholera, yellow fever, albuminuria, acute yellow atrophy of the liver, long- continued organic dis- eases, chlorosis, ovarian tumors and uterine cancer. Chlorides of Sodium (Na CI) and Potassium (K CI) are soluble, hence do not appear as a deposit in the urine. Sodium chloride is largely in excess of the two. If a sample of urine is evaporated and the residue placed under the microscope, there appear octahedral crystals, which can be distinguished from oxalate of calcium by their solubility in water. If urea be present instead of octahedral crystals the sodium chloride may assume the form of stars or daggers. Or after filtering a sample of urine, then boiling and acidulating it with two to three drops of nitric acid, in order to remove the albumen, and adding to this solution, free from albumen, a solution of silver nitrate (strength one to ten), a white precipitate, silver chloride, which is 57 2 DISEASES OF THE KIDNEYS. insoluble in nitric acid but soluble in ammonia, indicates the presence of the chlorides. The chlorides are increased in intermittents only during the chill and fever, and in progressive muscular atrophy; they are decreased in acute diseases, including especially inflammations with exudations, fevers, cholera, diabetes insipidus (not invariably) and dyspepsia (also not invariably). The Phosphates, as sodium bi-phosphates or sodium phosphate, and po- tassium, calcium and magnesium phosphate. The alkaline phosphates (so- dium and potassium) are soluble, and therefore not found as a deposit. The earthy phosphates are insoluble in alkaline liquids, and hence appear as a de- posit when the urine is alkaline; the deposit is whitish in color, the urine is of alkaline reaction and of a fetid odor. If some of this whitish deposit is diluted with distilled water, then acidulated with a few drops of nitric acid, and to it is added ammonium molybdate and heat applied, a yellow precipi- tate indicates the presence of earthy phosphates. The alkaline phosphates may be detected by the addition of a little ammonium hydrate (ammonia) to the urine and heat applied, which precipitates the earthy phosphates. After these are filtered off, and we add to the filtrate ammonium carbonate and magnesium sulphate, we obtain a white flocculent precipitate which consists of alkaline phosphates. The total amount of phosphates may be increased in phrenitis, meningitis, mania (acute paroxysms), paralysis following injury to the head, paralysis in general, especially if spinal cord be affected, chorea, apoplexy and epilepsy (after the attack), acute febrile diseases, Bright's diseases and cholera. The calcium phosphate may be especially increased in rachitis, molli- ties ossium, extensive burns, nervous exhaustion from severe study and loss of sleep, diabetes (when thirst is satisfied by drinking water), tertiary syphi- lis, cerebral and spinal tumors, osseous tumors; cancer, caries, meningitis. The magnesium phosphate may be especially increased in meningitis and in progressive muscular paralysis, while the ammonio-magnesium phosphate, the so-called "triple phosphate," is found largely present in the urine in cal- culus, paralysis of bladder, retention of urine, diseases of the spinal cord. Urine containing this "triple phosphate" is apt, wmen passed, to be alkaline, putrid, whitish in color. The total amount of phosphates maybe decreased in functional disturbances of kidneys, as in Bright's disease, in disease of the digestive organs (food not thoroughly absorbed), in intermittent fever during the interval, in chronic diseases of the brain, mania (exhaustion stage), in acute dementia (least amount when mind most feeble), in pneumonia (when grave), in gout, ar- thritis deformans, delirium tremens. We find magnesium phosphate lessened in amount in the urine of typhus fever and of grave fevers generally. The Sulphates of potassium and sodium are soluble in water, hence do not appear as a deposit. They are detected by acidulating a small quantity of urine by a few drops of hydrochloric acid, and then adding barium chlo- DISEASES OF THE KIDNEYS. 573 ride, which causes a precipitate of sulphate of barium, insoluble in nitric acid. Yogel finds but little satisfaction in investigating the clinical import of the sulphates in disease. The Urates of sodium, potassium and ammonium are soluble; acid urine, however, on cooling may contain them as a deposit in which the urate of sodium is generally the most abundant of any. If such deposit disappears again on heating, it consists of urates. If a heavy, yellow or pink deposit oc- curs in acid urine on cooling, place a few grains or crystals of it on a porce- lain disk, add a drop of nitric acid, heat gently, add a drop of ammonium hydrate; magnificent red color indicates presence of urates or uric acid. (Uric acid is crystalline under the microscope, but urates are not). The amount of urates may be increased in ordinary fevers, pulmonary emphysema, capillary bronchitis, diphtheria, dysentery, influenza, intermit- tent (febrile stage), nephritis, scarlet fever (at eruption), and chiefly free uric acid deposit, as in tetanus, acute polyarthritic rheumatism, chronic af- fections of heart, liver and spleen, atrophy from dyspepsia in children, in- cipience of gravel or of calculus. The amount of urates may be diminished in yellow fever, remittent fevers, diabetes, albuminuria, cholera, chlorosis, anaemia, hysteria, gout (before the paroxysms), progressive muscular atrophy. 3 b . The urine contains other than normal constituents, of which the most important are: i. Grape sugar. — This substance increases the specific gravity of the urine up to 1040 and higher; in one case it was changed as high as 1074. To detect it, Trommer's test with caustic potash and sulphate of copper is still considered the best. "If a solution of sugar is treated with a little caustic potash and a few drops of a solution of sulphate of copper, either no precipi- tate occurs, or that which takes place dissolves again to a beautiful blue fluid. If this mixture be heated the fluid is first colored orange-yellow, soon becomes cloudy, and finally a beautiful red precipitate of cuprous oxide separates." (Neubauer.) "This, then, is what happens when sugar is actu- ally present; when sugar is absent, the addition of caustic potash solution causes, perhaps, a cloudiness to appear; then, when the sulphate of copper is added, the beautiful blue color may or may not be present, according to the quantity of copper sulphate added, but when heat is applied, there re- sults either ( 1 ) , a liquid, generally of a color slightly darker than normal urine, containing dirty, white flocks of phosphates, or else (2), a bluish liquid containing these same flocks of phosphates; when there appears no orange-yellow, which soon becomes cloudy, ending in a beautiful red precipi- tate, there is no sugar." (Clifford Mitchell.) Or, "if a solution of grape-sugar be warmed with caustic potash, it be- comes a beautiful brown-red color; if nitric acid is then added, a piercing, sweetish odor is evolved, which reminds one of caramel or of formic acid." (Neubauer.) "In the case of urine containing sugar then, caustic potash solution added, heat applied, and further nitric acid added, converts the 574 DISEASES OF THE KIDNEYS. liquid into a substance strongly resembling molasses." (Clifford Mitchell.) 2. Albumen. — In general its presence ma}' be looked for if the specific gravity of the urine is persistently below 1015, and it may be detected by heating the urine up to a boiling point which coagulates sero-albumen, if only the urine itself be acid and has been rendered clear by previous filtra- tion. Neutral or alkaline urine must be rendered acid before the operation by addition of nitric acid. Or to avoid all possible chance of confounding albumen with phosphates or urates, fill a test-tube one-third full of a solution of picric acid, and pour one or two drops of the urine to be examined into it. If it contain albumen, a cloudiness will at once be seen in the previously clear fluid, which, on the application of heat, balls into a compact mass and rises to the surface. 3. Chyle. — "In tropical regions, especially in the Brazils and in the Southern States of North America, the urine presents, on exceptional occa- sions, at rare and long intervals of time, an aspect that might easily be mis- taken for milk. This appearance depends upon a quantity of fatty matters, stirred up into a fine emulsion, and mixed with the secretion from the kid- neys; in fact, the fat is sometimes so abundant as to form a thick cream upon the surface of the fluid. Looked at under the microscope it does not present the form of fat-cells or fat-drops, such as we see in ordinary milk, but appears as a finely granular opacity that pervades the fluid, and is capable of being entirely separated from the urine by treating this with ether. We find invariably associated with it a considerable quantity of albumen, also red and white blood-cells, all characteristic, formed elements of chyle. For this reason the affection thus manifesting itself has been termed chyluria. The exact nature of it is still unknown." (Bartels.) 4. Blood. — Its presence can usually be recognized by its characteristic colors, which may, however, vary from that of pale, raw meat up to brown- black, in accordance with the quantity present. Bloody urine is oftener sooty or dark colored than bright red, and the liquid is more usually cloudy than clear. Small quantities may be recognized by allowing the urine to stand in a funnel-shaped glass when the blood-corpuscles will sink to the bottom. By means of the microscope the blood-cells can be distinguished in the sediment. Bloody urine is invariably albuminous. 5. Urinary Casts of Cylinders, when found in the urine, always denote an abnormal condition of the kidneys; the)' are, as a general rule, associated with the excretion of albumen in the kidneys. There are different kinds of cylindrical formations. a. Epithelial casts consist of simple pipes formed of the epithelia of renal tubes which are shed in their natural continuity in the course of acute inflam- mation. They are not often seen. b. Blood casts consist of coagulated fibrine with a large amount of en- tangled red blood- corpuscles, and are derived from the renal tubules in hematuria. c. Hyaline casts consist of a perfectly homogeneous, transparent and DISEASES OF THE KIDNEYS. 575 colorless mass; their outlines are only with difficulty rendered apparent in the fluid surrounding them, but may be made visible by adding a solution of iodine or iodide of potassium, which colors them yellow, or a weak solution of carmine, which stains them red. d. Dark granular casts consist of granular masses and are less trans- parent than the hyaline casts. e. Waxy casts consist of a homogeneous mass which exhibits under the microscope a peculiar glistening aspect and they often have a distinct yellow staining. f. Cylindriform casts consist of a homogeneous, colorless and very pale mass; they present under the microscope more the appearance of strips of ribbon than of real cylinders, and their edges run parallel to each other, their ends are either frayed out or tattered, or pointed at one edge, or folded or twisted up in a spiral. The presence of such casts proves the presence of albuminuria, but does not point out the nature of the cause in producing albuminuria. However the following remarks may assist in the diagnosis of kidney diseases. A great number of pale or dark granular casts comes from an inflamed kidney. In the acute form the pale casts with an abundance of red or white blood-corpuscles — in the chronic form the dark granular casts prevail. The waxy casts alwaj'S point to chronic and deep-seated renal affection and are never present in recent cases of nephritis, nor in transitory albu- minuria. With them are generally found at the same time the other forms in the sediment. The dark granular casts always indicate a notable impairment of the nutrition of the organ, such as chronic nephritis and amyloid disease of the kidneys. Narrow hyaline colorless casts can appear in any albuminous urine, and they are always found in company with the dark granular and waxy cylinders. The Sediments of the urine may be distinguished in the • following manner: i. A light, flocculent, cloudy deposit is commonly mucus, entangling epithelial cells or spermatozoes. 2. A yellow, orange, or pinkish deposit, dissolving by the application of heat (urine acid) is almost always due to urates. In very rare cases a dark citron-yellow color is caused by the great abundance of renal casts. 3. A dense, abundant, white deposit, dissolving by the addition of acetic acid (urine alkaline) consists of phosphates. 4. A granular, or crystalline deposit of reddish color and small in quantity is uric acid. 5. A dark, sooty and dingy-red deposit is blood. The Quantity of urine varies, even in health, considerably. It is increased, however, in diabetes, chronic diuresis, hysteria, and by drinking large quantities of water or other fluids. Decrease: Fevers of all kinds, 5J6 DIABETES. deep functional disturbances, profuse excretions other ways, such as sweat or diarrhoea; in consequence of heart diseases, liver diseases, dropsy. Its secre- tion ceases altogether in cholera, and in typhus at times. Its Specific gravity is also greatly variable. According to Clifford Mitchell's observations upon fifty analyses of urine, an iacrease in specific gravity simply means an increase of solids. In most febrile conditions, urea, phosphates, sulphates and urates are increased in amount, and with them the specific gravity of the urine. The presence of earth}' phosphates ma}' raise it to 1037. When the specific gravity is 1040 or upwards, we are very sure of finding sugar in the urine. When the specific gravity ranges from 1015 to 1030, we need not expect, as a rule, to find either sugar or albumen, although we may find blood or pus. When the specific gravity is persistently below 1 01 5, we are warranted in looking for albumen. The lowest specific gravity has been observed in diabetes insipidus and renal cirrhosis, varying between 1004 and 10 10, and sinking at times to 1002, or even to 1001. Diabetes, Mellituria, Glycosuria. This disease is characterized by the presence of sugar in the urine, and although not strictly a kidney disease, it may as well be treated of here as under any other heading, especially as the modes of its development are still under discussion. The most probable modes, as applying to the majority of cases of diabetes, Senator states in the following language: (1) " An ab- normally heightened sacchaiinity of the chyle, or of the blood in the portal vein, or of the two together, in consequence of an impeded conversion of the sugar present in the intestine into lactic acid, or in consequence of accelerated absorption of the sugar; (2) an unnatural acceleration of the portal circula- tion, whereby, on the one hand, more sugar reaches the liver — a part of which, without being changed into glycogen, passes on into the circulation; and, on the other hand, the glycogen formed from sugar or other materials passes into sugar more rapidly and in greater quantity and is washed away." Under the first proposition is taken into account that the saccharinity of the blood may originate in the intestine by an abnormally large ingestion of starch or sugar with the food, or by an abnormally heightened transit of sugar from the intestine into the lacteals even without increased ingestion, all of which would explain those symptoms so common in diabetics which point to an implication of the gastro-intestinal canal, and which exists often even before the outbreak of the disease and during its development. Under the second proposition is taken into consideration the theory of Claude Ber- nard and others that the saccharinity of the urine may originate a, in some disturbance of the nervous system (Bernard's puncturing the fourth ventricle on the floor of the fossa rhomboidea, immediately above the point of origin of the vagi nerves, or Scruff's section of the optic thalami and the great crura cerebri, or the destruction of the pons Varolii and the middle and posterior crura cerebelli, or the complete division of the spinal cord at the level of the DIABETES. 577 second dorsal vertebra, or in its lumbar portion, or Pavi's section of the me- dulla oblongata, etc. ), causing either a dilatation of the blood-vessels by par- alyzing the vasomotor nerves, or a specific irritation of the nerves which govern the formation of sugar (both views being hypothetical), or b, from the action of the liver by which sugar, glycerine, gelatine, and probably albumi- nates, are converted in its cells into glycogen, and that the latter is trans- formed* into grape-sugar by reaction with the blood which bathes the cells, that it then passes into the general circulation, and if its quantity exceeds a certain limit, is finally excreted by the kidneys. These modes of develop- ment, which we may designate as gastro-enterogenic, the neurogenic and the hepatogenic, do not exclude each other, but ma}^ for the most part, or altogether, occur simultaneously, or the one may proceed and the other may join in. Post-mortems have shown various morbid changes in the corresponding and other organs, although these changes are by no means constant. In the brain tumors, extravasations of blood, softenings, and on microscopic axami- nation, a wasting of the gray substance, degeneration and striking pigmenta- tion of the ganglion cells and fatty degeneration of the vessels have been found. The sympathetic nerves in the abdomen were found thickened and also of the vagus. The lungs frequently showed signs of chronic inflammations, tuberculosis and pleuritic exudations. The stomach and the intestinal canal frequently bore signs of chronic catarrh, hypersemia, thickening, tumefaction of their mucous membrane, slaty pigmentation and haemorrhagic erosions. The liver has frequently been found hypersemic, uniformly enlarged and hypertrophied. The pancreas has frequently been found atrophied, or, in addition, degenerated; and the kidneys appeared, as a rule, abnormally en- larged, heavy, firm and containing an abundance of blood, but without more profound textural changes. The pelvis of the kidneys and the ureters were frequently found in a state of catarrhal inflammation; and in some cases of young persons the testes were found atrophied. Diabetes is not of frequent occurrence, seems to be to a certain extent hereditary, is often connected with diseases of the nervous system, particularly epilepsy and mental affections, occurs at every period of life, but far more rarely in childhood than in middle age; after the age of sixty or sixty-five it scarcely ever develops; men are much oftener attacked than women; also obesity seems to predispose to the disease. As Exciting Causes the following have been mentioned: mechani- cal injuries, especially concussions of the whole body or of the brain and spinal cord in particular; diseases of the nerve-centres, such as inflammations, degenerations, softenings and tumors of the brain; violent mental emotions, such as fright, anxiety, anger, grief, solicitude, care, immoderate mental strain; errors in diet; exposure to cold and moisture; severe bodily exertions; sexual excesses; and not unfrequently diabetes has been observed to make its first appearance during the convalescence from febrile diseases of greater or less gravity, especially after intermittent fever. Besides these exciting causes the following substances, which, whether introduced into the general blood- 37 57§ DIABETES. current or into the portal circulation, have been found to cause mellituria with more or less certainty: Curare, cantharis, carbonic oxide, chloride of carbon, nitrite of amyl, nitro-benzole, phosphoric acid, turpentine, corrosive sublimate, nitrite of oxide of uranium, morphia and strychnia; injections into the veins of solutions of common salt, of carbonate, acetate, phosphate, hyposulphite, valarianate and succinate of soda; of ether, alcohol or ammonia into the portal vein, and of large quantities of lactic acid into the stomach. The Symptoms of diabetes set in at times suddenly, but in general very gradually, with an increase of the urinary excretion and of thirst. Its initial stage, if there be any, is characterized usually by loss of appetite, nausea, vomiting, pyrosis, eructations, irregular actions of the bowels, headache, sleeplessness, and even mental aberration. But perhaps much oftener the disease invades the system unnoticed, until the frequent desire to pass water, the constant dryness of the mouth, the increased debility, or an impairment of sight, force the attention of the patient upon it. In the proportion as the urine increases in quantity, its color becomes lighter, verging on greenish or looking almost entirely colorless and as clear as water; it is free from sediments. Its odor is often peculiarly aromatic, likened by the older physicians to that of hay, being derived, according to recent observations, from acetone and alcohol. Its reaction is not only acid while fresh but remains so much longer than health}' urine generally does. Its specific gravity very commonly rises to 1035 or 1040 and even to 1060 or 1074. Its quantity is greatly increased, and generally in proportion to the severity of the disease, amounting to six or eight litres daily. Next to the altered state of the urine there is increased thirst and hunger. The thirst particularly is in direct ratio to the excretion of sugar. Farina- ceous and saccharine food not only increases the sugar but also the thirst. The appetite is usually largely increased, so that even unusually hearty food, especially the saccharine and starch} 7 , seems able to appease the hunger only for a short time. Still at times temporary disturbances with signs of gastric and intestinal catarrh set in, restricting the use of an exclusively animal diet. The patient's breath commonly emits a peculiar, apple-like odor, and chronic pneumonia leading to phthisis is of frequent occurence, although in patients under favorable surroundings and good dietetic conditions it is de- veloped exceedingly slow. The nervous system shows many disturbances, of which are to be men- tioned: pronounced mental affections and aberrations, delusions of rapidly approaching financial ruin, (becoming parsimonious, avaricious,) varying moods, irritability, sadness, melancholy, disinclination to bodily or mental exertion, headaches, sensations in the limbs as being asleep, formication, neuralgic pains, partial anaesthesia, muscular twitchings, and a decrease of the sexual instinct. The most common form of disturbance of vision is oc- casioned by the formation of cataract, less often by partial paralysis of ac- commodation, by amblyopia, gradually passing into progressive atrophy of THERAPEUTIC HINTS TO DIABETES. 579 the optic nerve, by haemorrhagic and inflammatory affections of the retina. The hearing is rareb T impaired; oftener there is a nervous roaring in the ears. Blunting of the senses of smell and taste have also been observed. The skin is usually dry, and hectic sweats set in only as concomitants of pulmonary phthisis. As a general thing, there is a great tendency to the formation of furuncles and carbuncles, also at times to gangrene of the skin, or of the toes or even a whole limb. CEdema, especially of the lower limbs, is the result of advanced cachexia, exceptionally only of a complicating severe affection of the kidneys. Fever, in the absence of inflammatory complications, does not occur; on the contrar} T , the temperature is very commonly somewhat below the normal, between 95. 9 ° and 97. 7 ° F., and even temperatures as low as 93. 2 ° F. have been observed. The duration of the disease is, in rare cases, extraordinarily brief, last- ing only some weeks or months. Such cases occur, without exception, only in children and young persons. Usually the disease lasts for years. No doubt a number of cases have been cured by different modes of treatment, or have at least been greatly relieved. Therapeutic Hints. The diet, as recommended on physiological grounds, should be selected from the following articles: the flesh of mammalia and birds, fishes, oysters, clams, crabs, lobsters, etc., cheese, eggs; salads, cucumbers, water-cresses, spinach, asparagus, cabbage, oyster-plant, radishes, beets, truffles; butter, lard (oil to a certain extent); fruits, especially peaches, cherries, strawber- ries and currants; nuts. Bread, although containing a great deal of starch, can never be entirely omitted. Milk is allowable, but exclusive use of skimmed milk can only be exceptionally borne ; some have seen nothing but detriment from it. Among the spirituous drinks the red wines are allowable; sugared brandies, sweet wines, champagne and cider should be entirely avoided. Dr. During, of Hamburg, treats his patients in the following manner: At six o'clock, A. m., the patient is wrapped in wet sheets and being well covered with blankets, he remains lying by open windows for one to two hours. After having been rubbed until dry, he gets his breakfast consisting of milk, with the addition of one tablespoonful of lime-water to one cupful of milk, and stale bread. This is followed by one or two hours walk in the open air. At about 10^ ton a.m., the patient receives another piece of stale bread with some meat, or a soft-boiled egg and half a glass of good red wine mixed with water. Should this not agree he receives instead a plateful of rice or farina soup, with or without milk, the milk being always mixed with lime-water. This lunch is again followed by a walk in the open air of one- half to one hour's duration. Before dinner the patient takes a nap or rest for one hour. For dinner at two o'clock p. m. , he receives rice and roasted meat, or ham or smoked meat, or venison — but without spices or vinegar. In some cases dry peas or white beans, well boiled, are allowed. Dried 580 THERAPEUTIC HINTS TO DIABETES. apples, prunes or cherries, also asparagus, green beans, cauliflower and car- rots boiled in water, not in broth, and without butter or fat, constitute other articles for dinner. A moderate allowance of green apples or cherries is given only in exceptional cases. The dinner is followed again by a walk of one or two hours' duration. Supper takes place at seven o'clock p. m., con- sisting of rice, grits, pearl-barley or water soup, with salt, but without but- ter, and is followed by another half-hour's walk. At nine or latest at ten o'clock the patient retires to bed. This mode of treatment of Dr. During' s has produced undoubtedly the most gratifying results in diabetic patients, and it clearly demonstrates that the exclusive ' ' meat diet, ' ' recommended on ' 'physiological grounds, ' ' is very much like the treatment of chlorotics with ' ' iron preparations' ' on physio- logical grounds, both of which lack merely in this important point, that they do not cure, because the human body is not a chemical laboratory, but a living organism. Prout's experience, probably the largest of an} r observer, and drawn principally from the well-to-do class, is to this effect: "Within the last thirty years I have seen more or less of nearly seven hundred instances of diabetes, and of this great number, as far as minor and concomitant symptoms have been concerned, no two cases have been exactly alike, or have been benefited by exactly the same treatment, so greatly diversied in this apparently simple form of disease." Therefore a specific remedy for diabetes does not exist, and a homceop- athist w r ill only feel gratified to find the special hints extended over a large number of remedies. Arg. met. Hahnemann says, some forms of diabetes may be cured by silver if the other symptoms correspond to the symptoms of this remedy. Ruckert mentions a case which he cured by Arge?it., but which died of phthisis afterwards. He mentions: urine, turbid, of a sweetish taste and profuse, especially at night; scrotum and feet cedematously swollen; anxiety and pressure in the pit of the stomach and w r ant of breath. Ars. alb. In a drunkard, horrible thirst, emaciation and exhaustion, with odd hallucinations. Eruptions on the skin and tendency to boils; vulva and vagina become red and swollen, with pruritus; teeth loose; skin dry and mealy; cachexia; kidneys affected; oedema of legs. Asclep. vin. Five cases reported as essentially improved by it; arthri- tis; bleeding of gums; impotence. Berber. Sticky, saliva, like cotton; pale yellow urine with a gelatinous sediment; pulse slow and weak; paralyzed, bruised sensation in the back; intense coldness of knees. Canthar. One case improved as reported by Goullon, with frequent and profuse urination, rapid loss of strength and great dejection of spirits. (30th potency in water every two hours.) And one case was cured by Can- thar., given on account of existing satyriasis. (Fellger.) Carb. ac. One case with short, dry, hacking cough. (Haesseler — THERAPEUTIC HINTS TO DIABETES. 58 1 j-^ and later yg- dilution.) Goullon thinks it one of the most important remedies. Chelid. Enlargement of liver and icteric color of face, bloated face; great weakness, emaciation. (In ten-drop doses of tincture.) Coloc. Urine when voided is white and turbid, when getting cold it coagulates and becomes a milk-white, jelly-like mass, which, when poured out, glides in a compact cake out of the vessel. (Chyluria?) Cuprum. Recommended, but no cures. Curare. Recommended for acute cases. Dig-it. Recommended, but no cures. Helon. dioic. Several cases reported as cured. Dull, gloomy and irritable; melancholy; complete impotence; pain and lame feeling in back; numbness in the feet, going off by motion. Hepar. After previous abuse of mineral drugs. " The slightest thing made him break out into great violence; he could have killed some one without hesitation." (Thos. Skinner Berridge.) Iodiu?n. Appears to have all the peculiar symptoms of diabetes; unap- peasable hunger with steadily increasing emaciation; violent thirst; hepatic and gastric troubles; increased secretion of urine; pulmonary inflammatory symptoms; tendency to eruptions and furuncles. I cannot find that it has ever been given. Kali brom. Tongue red and tender; gums spongy and bleeding; liver tumid and tender; bowels constipated, urine loaded with sugar. Kali hydr. In complication with pneumonic troubles, recommended by Kafka. Kreos. Three cures and one improvement. Heaviness all over with drowsiness; dimsightedness; impotence; bruised sensation of chest and all along the back; physical exhaustion. Laches. Recommended. Lact. ac. Recommended by Cantani and used with considerable suc- cess by others. Tongue dry, parched; sticky; feeling of emptiness and sink- ing at stomach; bowels costive, feces hard and black; debility; aversion to move; chilliness, especially extremities. (First dil. in five-drop doses morn- ing and evening. J. E. Wittemore.) Lycop. Excessive micturition in gushes; fluor albus drops out in clots; drawing pains in right groin on rising from seat, better after motion. (Eippe.) Sexual desire and power gone; pulmonary phthisis, with hectic fever; gouty lithaemia. Lye. virg. From central and sympathetic nervous system; bronchial irritation, with sighing respiration; cardiac depression. Magn. usta. Relieved in one case. Magn. sulph. Cured one case. Mineral waters. Karlsbad, Gastein, Wildungen, in Germany; Vichy, in France; Bethesda and Gettysburg, in United States. Moschus. One case with impotence cured. 582 THERAPEUTIC HINTS TO DIABETES. Natr. mui'. Despondency; excessive dryness of mouth; no sweat; skin cool; sallow complexion; constipation, with sensation of contraction of the anus. Natr. sitlph. One case cured by Aegidi, with 3d dil., five drops four times a day. Hydrogenoid constitution. Nux. vojti. Spinal lesions exciting cause; irritable temper; odd sensa- tions in the limbs, fidgets; numbness and paretic condition of the lower ex- tremities;- stomach and liver complaints. High living, sedentary habits, previous abuse of liquors and drugs. Opium. And its derivatives. Dullness, sadness, weak memory; atfter mental shocks, or injuries. Phosphor. Gout}* diathesis; disease of the brain; cerebral symptoms; cheesy degeneration of the lungs. Phosh. ac. Urine like milk, mixed with jelly-like, bloody mucus, or clear like water; pain in the back and region of the kidneys; sleeplessness; excessive emaciation; great prostration. After loss of animal fluids; after grief, anguish, sorrow and care. ' ' When the starting point lies in the nervous S3 T stem . " ( Prout. ) Plumbum. I^owness of spirits, anguish and melancholy; diminution of sight; dryness of mouth; dry, cracked tongue; suppuration of lungs; hectic fever; impotence; dryness and brittleness of skin; gangrene. Dr. Hering considered it one of the most important remedies in this form of disease. Ratan. Case much improved. Sec. com. Is similar to Plumbum; furuncles, petechia, gangrene. Silic. Successful in several cases. Sizygium jam. Has cured diabetis. Sulphur. Cured one case. Sulph. ac. A case much improved. Tarant. Profound grief and anxiety; loss of memory and dimness of sight; violent pain in lumbar region and paralysis of the lower extremities; miliary eruptions and furuncles. Tereb. Caused sugar in the urine, and cured diabetes. Uran. mur. and nitr. Many cases have been cured or much improved by either of these preparations, usually administered in the 1st or 2d tritura- tion or dilution, several times a day for weeks. It is indicated, according to Prout, w T hen the disease originates in assimilating derangements. Tongue reddish at edges; dyspepsia. Dr. Francis Black recommends: For debility: Phosphor., Phosh. ac, Arsen., China, Moschus, Camphora, Pier. ac. For Hepatic symptoms: Digit., Kali bichr., Merc, sol., Iod. m., Hepar, Sulphur, when there is diminishedbile in the feces. Euvonymin, Iridin, Leptaud., Podoph., Merc, corr., Iod. m., Nitr. ac, when there is increased flow of bile. Nux vom., Lycop,, Nitr. ac, Merc, corr., Iod. m., Chelid., when there DIABETES INSIPIDUS. 583 is no marked disturbance in the secretion of bile, but headache, frontal or occipital, vertigo, languor, weariness in limbs, uneasiness about the liver or scapular regions, furred tongue, often indented at sides, loss of appetite, flatulence, great depression and irritability of temper, constipation, with dark or pale motion, or normal color, sometimes alternating with diarrhoea, in- termitting pulse and palpitation of the heart. A mm. mur. when there is lithaemia, and catarrh of the fauces extending to stomach. Col chic, Nux vom., Kali iod., when there is gouty disposition. Kali iod., in syphilitic taint. For urinary and sexual symptoms: Arsen., Aeon., Camphora, Tereb., Canthar. , Kali bithr. , when there is rapid decrease in the secretion of urine with strangury, or excessive itching and sense of fullness in the vagina. For pulmonary affections: Phosphor., A? sen., Iodium, Hepar. For nervous symptoms: Aeon., Atropia, Phosphor., Argent., Aurum, Kali hydr. , if cerebral. Nux vom., Veratr., Silic., Phosphor., if spinal, and Aeon., Atropia, Opium, Nitrite of Amy I, if tendency to apoplexy. For furuncles and carbuncles: Arnica, Phosphor., Arsen., Silic, Hepar. This list may be enlarged from the above given special hints. Diabetes Insipidus, Also known under the name of polyuria, hyperuresis, urinse pronuxio, poly- dipsia, ' ' is applied to every chronic, morbidly increased excretion of urine, free from sugar, which is caused by no profound structural changes of the kidney, and which constitutes either the sole or at least the most prominent and primary morbid phenomenon." (Senator.) The term diabetes insipidus excludes any temporary increase of urine which is caused by excessive ingestion of fluids, by the use of diuretics, by interference with the loss of water through the lungs and skin, by the ab- sorption of watery exudations, during convalescence from febrile diseases, or during hysteria or other diseases in the nervous system. The amount of urine evacuated in twenty-four hours varies greatly in different cases and in the same case at different times; it may vary from a point only slightly above the physiological maximum to ten or twenty times that amount. Its color is pale and clear, resembling water with a slight greenish tint; the peculiar odor of the urine is scarcely to be perceived, and its reaction is very faintly acid; it becomes neutral and alkaline more rapidly than usual, and turbid from earthy phosphates and bacteria. Its specific gravity varies, as a rule, between 1004 and 1010, thought it may approach the lower physiological limit, or sink lower than in any other disease, viz., to 1002, and even to 1001. This low grade of specific gravity is not the result of an absence of solid urinary constituents, but of the rela- tively too great amount of water with which they are diluted. Compara- 584 HEMATURIA. tively there is as great an amount of solid urinary constituents excreted as in healthy persons, at times even a greater. A diminished amount occurs only exceptionally and temporarily, and for any great length of time, or during the whole disease only in consequenc of the association of some other malady. With the amount of urine excreted stands in direct proportion the thirst of diabetic patients; it is almost inappeasable. As a very peculiar phenom- enon may be mentioned a great flow of saliva at the same time, in a case ob- served by Kuelz. The skin is generally dry and the temperature insignifi- cantly lowered, but on the other organs and on the general health, diabetes insipidus has, so far as its direct influence is concerned, no effect worth men- tioning, if the patients are allowed to drink freely. A sudden deprivation of drink may seriously endanger the life by the drying of all the tissues, and would cause besides a scarcely endurable distress to the patient. Diabetes insipidus is much more frequently observed in youth and middle age than in later life. As Exciting Causes have been mentioned: injuries of the skull, violent and sudden emotions, chronic diseases of the brain and spinal cord, and a single excessive ingestion of cold beverages or other fluids. The patients very rarely die of this disease if uncomplicated; it Taay last for 3 T ears if not an intercurrent disease, or the malady in the course of which the diabetes has arisen, and which is to be regarded as its cause (affections of the brain or spinal cord), terminates in death. On the other hand recovery has been sometimes brought about by an intercurrent disease, by pregnane} 7 , etc. Therapeutic Hints. The single case will have to be studied, and it is quite likel} 7 that a remedy might be found to suit the case without having the two prominent signs of the disease: "profuse urination and insatiable thirst," in a very high degree. The following remedies are to be recommended: Apis, Bellad. y Cepa, Ferr. phosph. (Schiissler and Huber), Nitrum, Phosph. ac, Squilla^ Compare also Diabetes Mellitus. Hematuria, Passing Blood with the Urine. The blood mixed with the urine may be derived : 1. From the substance of the kidney. — In this case the coagula present will be few, if the haematuria be produced by venous stasis; there will be a large number of renal casts and entangling blood-cells present, if the bleeding be caused by inflammation of the kidneys; and there will be profuse bleed- ing which leads to the formation of large clots in the pelvis of the kidney or in the bladder, only in the rare instances of traumatic lesion of one kidney (for example, crushing or rupture of a kidney by a kick or the like), or in cases where a highly vascular cancer has grown into the pelvis of the kidney. 2. From the pelvis of the kidney. — In this case the haemorrhage may be THERAPEUTIC HINTS TO HEMATURIA. 585 more profuse and form blood-clots corresponding to the shape and size of the caliees, being most generally caused by renal calculi, preceded by renal colic and attended with calcareous deposits in the urine. If the entire pelvis of a kidney be filled with blood or with masses of cancer, it may happen that the corresponding ureter becomes blocked up and distended with a thrombus, which assumes the shape of the ureter, measuring often more than a finger' s length, and being of about the size and shape of a lumbricoid worm when finally passed. 3. From the bladder. — In this case the blood-clots may form of so large a size that they cannot pass through the urethra without being first com- pressed by the contraction of the bladder or broken up by instruments. Haemorrhages of this kind may be caused by traumatic lesions (urinary cal- culi, external violence upon the bladder), by catarrh and ulceration of the bladder or by suppressed haemorrhoidal or menstrual flow. 4. From the prostate gland or urethra. — In this case the blood often dis- charges from the urethra without micturition and on examination will reveal the sore and swollen parts from which it issues. Its causes are most fre- quently external injuries or inflammations, especially gonorrhceal. The presence of blood in the urine can best be demonstrated by the mi- croscope, which shows the cells in the sediment. However, there are cases where only the coloring matter of the blood is present, but no cell, where, therefore, a dissolution or destruction of the blood-corpuscles has taken place, as in the case of graver forms of typhoid fever, in haemmorhagic small-pox, in scorbutus, in morbus maculosus Werlhofii, in septicaemia and in poisoning by phosphorus, arsenic and its compounds, and sulphuric acid. The source of the bleeding in these cases has been traced to one or the other kidney pelvis, or, more rarely, to both, or to the bladder, or the dissolution of the red cells has taken place even before they leave the renal vessels. The Causes of re- nal haemorrhage, apart from the effects of injuries and cancerous growths, are: different kinds of inflammations of the kidney substance; active congestion, like that produced by turpentine or cantharides, or in some persons by asparagus, or in rare cases by the action of cold upon the integument of the body; by venous or passive congestion, like that (although but rarely induced) by car- diac insufficiency, or by haemorrhagic infarction of the kidney, the result of embolism in consequence of heart disease. Therapeutic Hints. Ar7iica. When caused by external violence. Arseyi. Haemorrhoids of the bladder; very painful micturition; scanty secretion; burning pain in the urinary organs; paralytic symptoms of the bladder; great anguish and restlessness; dissolution of blood-copuscles. Calc. carb. In chronic cases; haemorrhoidal affections; polypi; leuco- phlegmatic persons. Campho7 r a. After irritating drugs, especially cantharides, and after exanthematic fevers. 586 THERAPEUTIC HINTS TO HEMATURIA. Canthar. Violent cutting, pressing and cratnpy pains in the bladder, extending into the urethra and into the kidneys; strangury, burning pain before, during, and after micturition; cylindrical exudations in the urine; pain increased from drinking water, even from the sight of water. Colchic. After being drenched when sweating. Chim. viae. In consequence of severe and long-continued gonorrhceal inflammation. Crotal. Haemorrhage from all the orifices of the bod)'. Eriger. Empirically used, without an}' characteristic indications; gon- orrhoea. Ha77ia??i. Haemorrhoids of the bladder; passive congestions. Ipec. Profuse bleeding, with fainting, deadly paleness, sickness of the stomach; oppression of the chest. Laches. The urine looks black like coffee-grounds; scarlet fever. Lycop. Especially in connection with gravel or chronic catarrh. Mercur. Painless discharge of blood; also very violent urging to urinate, and painful micturition, whereby sweat easily breaks out. Mezer. Crampy pain in the bladder; and, after that, bloody urine is voided. Millefol. Pain in the region of the kidneys, with chilliness, necessity to lie down; the blood forms a sediment in the vessel like a blood)' cake; pres- sive pain in the urethra during the flow of blood. Nitr. ac. According to Goullon, specific in active haemorrhage, also after mercury; urging after micturition, with shuddering along the spine during micturition; gonorrhceal affections, dissolution of blood-corpuscles. Nux vom. After the abuse of alcoholic stimulants, or allopathic drugs: suppression of haemorrhoidal or menstrual discharges; full, tensive feeling, pressure and distention in the abdomen, loins and region of the kidneys; signs of stagnation in the portal circulation. Phosphor. Dissolution of blood-corpuscles; after sexual excesses; after poisoning with turpentine; haemophiles. Pulsat. Drawing, cutting pain around the navel into the small of the back; penis and scrotum drawn up; crampy pain in the right leg from the knee to the groin. Secale. Passive haemorrhage; blood thin; blood-corpuscles wanting in consequence of dissolution; or painless discharge of thick, black blood in consequence of kidney disease; coldness of the body; cold perspiration on forehead; great weakness. Sulphur. After suppressed cutaneous eruptions and haemorrhoidal dis- charges; stinging and burning in the urethra. Tereb. The blood is thoroughly mixed with the urine, forming a dirty, reddish-brown or blackish fluid, or a coffee-ground-like sediment; burning, drawing pains in the kidneys; pressure in the bladder, extending up into the kidneys when sitting, disappearing when walking about; before urination, pressing and straining in the bladder when sitting, going off when walking; ALBUMINURIA. 587 burning in the bladder, worst during micturition; in complication with scor- butic affections, and if caused by living in damp, moist dwellings. Uva ursi. Constant urging to make water and straining, with discharge of blood and slime; or constant straining without an}^ discharge at all, or only a few drops of urine, after this burning and cutting in the urethra, which is succeeded by a discharge of blood; hard stools. Zinciim. Vicarious bleeding through the urethra in consequence of sup- pressed menstruation, with pain in the bowels, diarrhoea, and night-cough with expectoration of mucus. Compare also the corresponding diseases, of which Hematuria may be the consequence. Albuminuria. Albumen in the urine is not only derived from the kidneys; it may come from the renal pelves, from the ureters, from the bladder, or even from the urethra, when the mucous membrane of these passages has become inflamed, or when some abscess has burst and poured its matter into these channels; but then the percentage quantity of albumen present is only trivial. A highly albuminous urine has been observed after the application of large Spanish fly-blister, in consequence of the inflammation of the urinary passages caused thereby. A transitory presence of albumen in the urine, secreted by the kidneys, is usually due to an abnormal increase of the blood-pressure with perfectly healthy kidneys, as we find, for instance, in heart disease, especially mitral stenosis, or extensive muscular degeneration, in pleuritic effusions, in ob- literation of several branches of the pulmonary artery, as follows upon cir- rhotic degeneration of the lung substance, in emphysema. Still, as a rule, the above affections of the respiratory organs do not often lead to congestive albuminuria. Much more frequently we meet albuminuria, as an entirely temporary symptom, during attacks of severe fever, as occur in the course of severe angina, in pneumonia, in typhoid fever and the congestive stage of the acute exanthemata, in pyaemia, and occasionally in cerebro-spinal meningitis. This febrile albuminuria is not attended with any specific disease of the kid- neys, and must, therefore, not be confounded with albuminuria in conse- quence of acute diffuse nephritis, which so often occurs in diphtheria, relaps- ing and scarlet fever. This inflammatory albuminuria is the prominent symptom of inflammation of the kidneys, and especially that form which runs a chronic course. It furnishes the largest percentage amount of albumen to the urine, which we find also usually containing, at the same time, fibrine and white and red blood-cells. It seems that by the inflammatory process the walls of the capillaries within the glomeruli are so changed as to con- stitute a special perviousness to albuminous substances from the blood. Other diseases of the kidneys, such as fatty degeneration of the renal epi- thelium, cirrhosis, granular atrophy, amyloid disease of the kidneys, are not particularly characterized by the presence of albumen in the urine, although 588 UREMIA. it may not entirely be wanting in these affections. It is the diffuse inflam- mation of the kidneys (the acute and especially the chronic form) which furnishes the largest amount of albumen to the urine, and to which the term albuminuria is particularly applicable. Therapeutic Hints. According to Bucher, when in consequence of gonorrhoea or syphilis: Thuja, Sabina, Nitr. ac, Aurum, Cuprum, Tart. emet. (Natr. sulph., Be?iz. ac. , Kali bichr. ) . Nitr. ac. Worse at night; nausea; sour taste; bilious diarrhoea or con- stipation; dry skin; fever; headache; dull systolic sound of the heart (similar to Arsen.); pressure in the kidneys; turbid, fetid urine; oedema of the feet. Albuminuria being merely a symptom, but pre-eminently a symptom of acute and chronic nephritis, further special hints will be given in these chapters. Uraemia. Notwithstanding the most strenuous efforts by a host of inquirers to dis- cover the essential nature of uraemia, only conflicting views have thus far been the result of the labors of the different experimenters. The most probable of all theories seems to be this, that ' ' uraemia arises in consequence of imperfect depuration of the blood in renal disease, the results of the reten- tion in the blood of the dross of the capillary interchanges, namely, nitroge- nous substances and specific urine contents/' (Bartels.) Acute uraemia. In acute as well as chronic kidney diseases, it manifests itself in the form of epileptic convulsions, which are succeeded by coma, or in some instances, by a condition of maniacal excitement. Xot unfrequently a series of such epileptic attacks terminate at last in death. At times these uraemic fits are preceded by dropsy, dyspepsia, obstinate vomiting, and even amaurosis, which latter, however, ma}' subside as suddenly as it comes. In the Chronic form of uraemia the epileptiform fits are usually absent or amount only to twitchings of certain groups of muscles, or the)' close the scene after long-continued, complete coma. The principal symptoms are in- creasing somnolence, apathy, or stupefaction, advancing at last to complete coma, frequently preceded by stubborn and incessant vomiting of masses which contain carbonate of ammonia. Often there is in this form a most tormenting itching of the skin, which compels the patient to scratch himself incessantly, even when lying in a state of unconsciousness. This symptom has been observed in patients who had crystals of urea upon the surface of their skins, or exhaled a urinous odor from their persons. Lastly there have been observed in chronic renal affections, a long while before the fatal ter- mination, paroxysms of asthma, most frequent at night, with intervals of com- plete freedom. bright's disease. 589 Therapeutic Hints. According to Biichner: Main remedies: Arsen., Cuprum., Phosplwr., Aurtim, Tereb, Ctcp. ars. Cuprum. Eclamptic form; alternation of convulsions and nervous asthma with talkative delirium, which is interrupted by amaurosis or deaf- ness; the most violent paroxysms are followed by apathy and greatest in- difference. During the paroxysm: face distorted, often red; eyes projecting, staring; spasms most prominent in the extensors; tongue and breath cold; long, shrill screams; finally exhaustion, sweat, torpor, and cessation of con- vulsions. Arsen. In the narcotic form, with oedema of the brain. Phosphor. Where there is acute atrophy of the brain and medulla oblongata. Hydr. ac. Action of heart diminished; pulse accelerated, soft; stag- nation of circulation in heart and lungs; palpitation, with indescribable anguish and dyspnoea; depression of sensibility; first convulsions and after- wards paralysis; extreme apathy; slow moaning breathing; rattling in trachea; paralysis of larynx or sudden paralysis of heart. Nicot. Paralysis of diaphragm; indifference; want of reaction; cold forehead; thirstlessness; serous transfusion in the intestines, without diar- rhoea; want of secretion in liver and kidneys. Bright's Disease. Bright 's disease is a generic term embracing the various forms of organic kidney disease of inflammatory origin, with resulting albuminuria and dropsy. Strictly speaking the acute and chronic forms of diffuse nephritis constitute this group, although chronic interstitial nephritis is generally con- sidered here also for anatomical and clinical reasons. Acute Parenchymatous Nephritis. This is the First stage of Bright's disease of many writers, also known as acute diffuse nephritis, or Traube's hemorrhagic nephritis, or the catarrhal of some, and the croupous nephritis of other recent pathological hand-books. Its PathoeogicaIv Changes consist in the following: dropsical effusion into the substaneous cellular tissue, at times also into the pleura, the peri- cardium, or the peritoneal cavity; still less frequently extensive pulmonary oedema; and rarest of all oedema of the mucous membranes of the folds at the upper part of the larynx. The kidneys are enlarged and swollen, espe- cially the cortical substance, so that the capsule is tightly stretched; the color of the cortical substance on section is paler than normal; it has a dull, grayish-red aspect, and gives a doughty feel; the glomeruli distended with blood, contrast with the paler ground as dark red points and streaks; the pyramids are always greatly congested, sometimes blueish-red in color. In 590 ACUTE PARENCHYMATOUS NEPHRITIS. other cases no very essential deviation is exhibited from the normal appear- ance of the kidneys, with the exception of the swelling of the cortical sub- stance, and even this is in some cases, when the patient died from other causes than the attending nephritis, very slight in degree. Between these extremes many differences in degree appear which correspond to the differ- ence in the intensity of the functional disturbances observed at the bedside previous to death. The epithelial cells are cloudy and swollen, owing to a deposit of gran- ular masses in them; the interstices between the renal tubules, which are distended and dilated by the swelling of their epithelial lining, appear wider, and contain lymphoid elements in varying numbers; there appear drops of fat in the cellular stroma, and in more protracted cases yellow patches seem to indicate fatt}^ degeneration. In all cases there is an infiltration of the epithelial cells and an albuminous transudation from the blood-vessels. Acute cases are usually attended with haemorrhages into the tubuli uriniferi, where the}' form blood-casts, which are also found in the urine; also homogeneous, small and pale cylindrical plugs have been observed filling here and there the lumina of the tubuli. The Etiology of acute inflammation of the kidneys embraces specific and mechanical causes. As Specific Causes must be mentioned: poisoning with cantharides and similar irritating drugs; but scarlet fever is the most common cause. Yet not all scarlatina epidemics furnish a like percentage of this disease. For although malignant epidemics, generally speaking, show the largest per- centage, yet there are epidemics in which even bad cases produce no nephritis, and others where quite light cases are followed by it; and this is not referable to any imprudent exposure of the patient, as the disease may attack a child which never has left the bed. The onset of the disease, if an average be taken, occurs about the twentieth day from the first appearance of the rash; the earliest date of its occurrence was the tenth, the latest the thirty-first day. With this renal inflammation we must not confound febrile albuminuria (compare Albuminuria), which generally appears at the height of the ex- anthem and disappears again with the subsidence of the fever. Next to scarlet fever follows diphtheria as a specific cause of nephritis; and like scarlet fever it does not excite a renal affection in every instance; nor does the renal affection stand in direct proportion to the intensity of diphtheria. Measles, rubella (Rbtheln), small-pox excite nephritis far less frequently than either scarlet fever or diphtheria, but relapsing fever is, according to Ponfink, almost without exception attended by nephritis. Besides these principal specific causes are yet to be mentioned: erysipelas, carbuncles, phleg- mons, profuse suppurations in cavities where decomposition of the pus begins in consequence of the admittance of atmospheric air, and very rarely cases of dysentery. The Mechanical Causes which act upon the vessels and thus affect the ACUTE PARENCHYMATOUS NEPHRITIS. 591 circulation of the blood through them, are: Cholera, which leads to complete stoppage of the circulation in the kidneys and a consequent anuria; catching cold, which contracts the cutaneous vessels and drives the blood into the in- ternal parts of the bodj^ where it produces an elevation of the blood-pressure; extensive burns of the surface of the body, which cause a general depression of the temperature of the body in consequence of the great loss of heat; ab- dominal typhus and other diseases attended by an unbroken continuous high temperature, which causes dilatation of the vessels and other alterations in the walls of the vessels (of rare occurrence) ; and acute rheumatism, when complicated with endocarditis. Pregnancy also is a cause of acute parenchy- matous nephritis. Usually its appearance takes place in the last months of pregnancy, and it attacks primiparse more frequently than women who have already borne children. Its first S3 7 mptom in the majority of cases is drop- sical swelling not confined to the lower extremities, but attacking face and hands as well. The percentage of albumen is greater than in nephritis of any of the other causes, and its fearful terminal symytoms: epileptiform con- vulsions, amaurosis and maniacal excitement are well known under the name of eclampsia gravidarum, parturientium et puerperarum. However, it must not be surmised that every case of eclampsia must be ascribed to disease of the kidneys and uraemia, not even if there should be found albumen and a few casts in the urine after the attacks, inasmuch as cases of this kind have been observed which showed after death not a sign of diseased kidneys. The Symptoms of acute parenchymatous nephritis are in the majority of cases accompanied by the symptoms of the primary disease — the febrile movement especially must often be ascribed to the latter. In cases from catching cold, however, the temperature has been observed to rise above 104 F. lasting commonly but a short time; the outbreak of uraemic convulsions or of secondary inflammatory processes, too, heighten the temperature. Ach- ing pains in the lumbar region is not at all a constant symptom and frequently is absent altogether. But a tenderness in the region of the kidneys upon deep pressure is often present. Frequent and excessively urgent desire to mic- turate, with the voidance of only a few drops, often of bloody urine, is also not a constant symptom and is apt to disappear very quickly. The quantity of urine is always diminished at the commencement; the urine may even be entirely suppressed; later, when the case takes a favorable turn, the quantity increases above the normal quantity or may for some time alternately in- crease and diminish. The urine is at first always cloudy from the presence of urates and other elements. Its color is, from the admixture of blood, tinged reddish, or is quite dark blackish-red, when a thick sediment of chocolate-brown color is formed, consisting of urates and blood-corpuscles. Its reaction is always acid and its specific gravity varies with the quanthvy passed. At first it may rise as high as 1031, and later, when the quantity increases, sink as low as ion, 1009 and even 1006. The urine always con- tains albumen, although in no case as much as in chronic parenclrymatous nephritis, and also casts of a hyaline nature with epithelial cells from the 59^ THERAPEUTIC HINTS TO ACUTE PARENCHYMATOUS NEPHRITIS. tubuli uriniferi attached to them, or covered with small drops of fat, also white and red blood-globules and their debris, epithelial cells from the uniferi tubules, and granular masses, the latter being probably the detritus of broken- down epithelial cells. The danger of acute nephritis consists in the retention in the blood of the special constituents of the urine, causing acute uraemia, and in the insuf- ficent excretion of water, which leads to dropsy, a symptom which is scarcely ever absent, except in very mild cases. The cedema commences usually at first in the lumbar region of the back or in the face; later often an accumu- lation of water fills the serous cavities of the trunk; in rare cases there is cedema of the glottis. Vomiting is occasionally at the commencement severe and obstinate; at a later period it may be ursemic in its character .- The Prognosis of acute nephritis depends much upon the cause from which it is derived. That following scarlet fever is the most dangerous. Its transition to a chronic renal affection is only exceptional; that fol- lowing catching cold or articular rheumatism is perhaps the most prone to became chronic. Total suppression of urine, except in cholera, is a very grave symptom, often fatal; uraemic attacks do not always prove fatal. Therapeutic Hints. In complication with scarlet fever compare: Apis, Arsen., Ascl. syr., Bellad., Bryon., Colchic, Helleb., Kali carb., Laches., Lycop., Me) cur., Rhus tox., Secale, Senega, under the head of Scarlet Fever. After the abuse of cantharides, or balsam of copaiva, the best antidote is Camp ho ra; after turpentine, Phosphor. Aco?i. High fever; restlessness; dark, scanty urine; consequence of exposure to cold. Apis. After scarlatina or diphtheria. Arsen. After burns. Bellad. Skin sweaty; renal region very tender to pressure: uraemic spasms. Canthar. High fever; pulse frequent and hard; drawing, tearing pain in loins and testes, worse from motion; sometimes in spells, stopping breath- ing; micturition exceedingly painful, drop by drop; scanty, dark urine, with burning in the bladder and urethra; the urine contains cylindrical casts of fibrinous exudation, epithelial cells and blood, and is therefore easily coagulable; constipation; uraemic, cerebral symptoms, like stupor, numbness; after exposure to cold, or mechanical injuries; complication with prostatic derangements, inflammation of the bladder, and stricture of the urethra; after burns. Chelid. With pneumonia on right side. Balsam of Copaiva and Cubebs. Have been observed to cause inflam- mation of the kidneys, though their sphere of action is not sufficiently known. Colchic. After getting thoroughly wet; articular rheumatism. CHRONIC PARENCHYMATOUS NEPHRITIS. 593 Hclon. In connection with pregnancy, and symptoms of approaching convulsions. Hepar. Is recommended by Kafka on the ground of its having a de- cided relationship to croupous exudations elsewhere. Kali card. Tensive pain in the region of the left side; swelling of the inguinal glands; oedema of the left foot, extending gradually to the right foot and upwards over the whole body; oedema of upper eyelid; blackish urine, which, on shaking, foams, and on standing leaves a thick, reddish, sliiny sediment; frequent, soft, palish evacuations from the bowels; after a blow upon the left side and staying for hours in wet clothes. Kali hydr. Scanty, dark urine; painful micturition; sediment dirty, yellowish; great thirst; heat in the head. likewise recommended by Kafka on the same ground as Hepar. Laches. After scarlet fever or diphtheria; dark, almost black urine; difficulty of breathing. Merc. corr. Great dyspnoea; colic and tenesmus, offensive secretions; puffiness of face and feet. Phosphor. The skin is pale and anaemic; frequent watery diarrhaea; in complication with pneumonia, bronchial catarrh, ulceration of the bones, amaurosis. Antidote to turpentine. Rheum. " Bloating around the eyes, pallor of face, covered with cool sweat; forehead and hair sopping wet, lips, eyelids, fingers twitching; urine scanty, hot, with slimy shreds and strings of blood on diaper; renal region tender to pressure. After diphtheria." (M. B. Tuller.) Rhus tox. Tearing pain in the region of the kidneys; cedematous swelling all over; after exposure to wet. Tereb. Scanty secretion of dark (occasionally), bloody urine, which coagulates on addition of nitric acid under the application of heat; oedema all over; intestinal catarrh and diarhcea; bronchial catarrh with expectora- tion of much mucus. Amaurotic symptoms may especially require: Apis, Arsen., Colchic, Gelsem., Hepar, Kalmia, Merc, corr., Phosph. ac, Plumbum. Chronic Parenchymatous Nephritis. This is the Second Stage of Bright's disease of most writers, also chronio diffuse nephritis, or the non-desquamative nephritis of Johnson. Being, as stated in the last chapter, occasionally developed from acute nephritis, its anatomical changes may certainly be expected to correspond to a certain ex- tent to those described there. We find the kidneys still more enlarged than in the acute form, and being exceedingly anaemic, they look strikingly pale, almost white, with a strong tinge of yellow, wherefore Wilks called them the "Large white kidney." With this yellowish -white color of the surface as well as of the cortical substance contrast sharply the bluish-red, stellate venous radicles, and the enlarged, but often dark red pyramidal substance. The microscopical examination reveals the same changes as described under 38 594 CHRONIC PARENCHYMATOUS NEPHRITIS. acute nephritis. The long-continued inflammatory hyperplasia of the inter- stitial tissue finally results (in consequence of the pressure which the callous tissue exerts upon the blood-vessels) in a gradual obliteration of the glomeruli and a secondary atrophy of the secreting parenchyma of the kidneys, although such kidneys are rarely found much smaller than normal kidneys. In cases like these the left ventricle of the heart becomes hypertrophied. The bodies are always more or less dropsical. The Etiology of chronic nephritis shows a small percentage of cases to have grown out of some acute forms, but the great majority of cases develops insidiously during the course of affections that are accompanied by persistent suppuration, such as diseases of the bones and joints, the more severe forms of inveterate syphilis, phthisical, ulcerative destruction of the lungs; in consequence of long-continued exposure to cold and moisture (a sudden catching cold is more apt to produce acute nephritis, and therefore almost all writers on the causes of chronic Bright 's disease, mention living in cold and wet habitations, occupations in which the body is frequently wetted and chilled through, etc., as one of the causes); and in consequence of marsh miasm. Young persons are decidedly more frequently attacked with this disease than those who are advanced in years. Symptoms of chronic parenclrymatous nephritis are on account of its insidious inroad at first entirely wanting; not even a pain is felt by those persons who enjoyed previous good health. When no examination of urine has been instituted, the first sign that betrays the s malady is dropsy, and at the same time the patient appears pale and anaemic, and complains of losing bodily strength. The dropsy, beginning either in the feet or in the face, ex- tends gradually over the whole body; the external genitals in particular, and also the abdominal walls are greatly swollen, before any perceptible quantity of fluid is collected in the peritoneal, pleural or pericardial cavity. The general anasarca develops to a higher degree than in any other disease of the kidneys, often to such an extent that the epidermal layer bursts, and the dropsical fluid trickles out of the cracks in enormous quantities. In such places where the corium has been deprived of its epidermis, frequently fol- lows a gangrenous destruction of the parts. Even the lining mucous mem- brane of the intestinal tract becomes involved in the dropsical swelling, which manifests itself by vomiting of watery masses and profuse watery diarrhoea. The advance of the drops} 7 will not be checked until the excretion of urine again becomes abundant, and even then it may take a long time before it entirely and permanently disappears. When this is accomplished the patients appear skeleton-like, for not only the subcutaneous adipose tissue, but also the muscles have been reduced to the merest remnants; there is extreme anaemia. Should complete recovery take place, which is rarely the case, the convalescence is very slow. Dropsy is absent only in the very mildest cases. The urine invariably contains albumen, and when the disease is at its height, in greater quantity than under any other circumstances; it also con- tains casts of various description, epithelium, debris, white blood-cells, urates THERAPEUTIC HINTS TO CHRONIC PARENCHYMATOUS NEPHRITIS. 595 and uric acid. Red blood-corpuscles appear only transitorily in cases which commenced acutely, for instance, after catching cold. In consequence of and according to the presence and quantity of these contents, the color of the urine is ordinarily dirty brown, and darker in proportion to the smallness of the quantity. The scantier the excretion, the more clouded it is — even before cooling. The urates are held in suspension after cooling, when there is a large amount of albumen present, and make the urine thick and muddy- The uric acid crystals fall to the bottom and adhere to the vessel. The specific gravity of the urine is highest at the height of the disease — in some cases above 1040, and it falls below the normal weight as soon as a more abundant excretion of urine sets in, even before the diurnal quantity of urine has reached its normal point. With this fall in specific gravity is not found a like fall in the amount of albumen, while it may be taken as a rule that the relative quantity of urea to a certain extent rises and falls with the rise and fall of the specific gravity of the urine. The pulse at the beginning is usually remarkably slow, full and tense, and the heart-sounds loud and sharp, in persons who, previous to the attack, were robust and vigorous, but later becomes weaker and more frequent, while in enfeebled persons the pulse and action of the heart are weak from the first. Respiratory difficulties set in only in consequence of dropsy in the serous cavities, or of pulmonary oedema. Digestion may and may not be disturbed; but vomiting and diarrhoea are frequent symptoms when the dropsy is at its height; the latter may ter- minate in secondary dysentery and ulceration of the bowels. Epileptiform attacks, coma, amaurosis, are much less frequently observed than in acute nephritis. When secondary atrophy has taken place, a hypertrophy of the left ven- tricle develops, with its train of symptoms, in consequence of the obliteration of so many peripheral arterial branches. The Prognosis of this disease is a bad one, when the affection has lasted already for a long time, or is complicated by some incurable constitutional or organic disease, or when the urine is very scanty, high in specific gravity, with a large amount of albumen; or when the urine, after the subsidence of dropsy, is pale, of low specific gravity, never even temporarily attaining a normal density, and still containing albumen and casts in extraordinary number, with commencing secondary hypertrophy of the left ventricle; or when oedema of the glottis or lungs, pneumonic infiltrations of the pulmonary tissue, phlegmonous inflammations of the subcutaneous cellular tissue are added to the already poor condition of the patient. Therapeutic Hints. Compare Acute Nephritis. Arg. nitr. Is said to have caused albuminuria. Arsen. Great anxiety at night, driving out of bed; vomiting of brown- ish masses, with violent pain in the bowels, pressure and burning pain in the 596 THERAPEUTIC HINTS TO CHRONIC PARENCHYMATOUS NEPHRITIS. stomach; swelling of the genitals; palpitation of the heart, left side of heart predominantly affected. Aurum. When complicated with gout, renal calculi, protracted suppu- rations, syphilis, liver degenerations, mercurial affections. (Buchner.) Melancholy; desires death. Benz. ac. Gout}- diathesis, with strong-smelling urine. Brachiglottis repe?is (puke-puke). Highly recommended by Dr. C. F. Fisher. Bryon. Intercurrent inflammation and exudation of serous membranes. China. Stands next to Arsen. (D. Thayer.) Colchic. Damp rooms; relapses from taking cold in damp weather; suppressed perspiration; affection of salivary glands; cannot bear the smell from cooking. Digit. Peculiar, seemingly rheumatic pains, and catarrhal affections of the lungs, with serous secretions. Helleb. Indifferent, sad, silent; anasarca and effusion in the pericar- dium or pleura; black urine. Hepar. After abuse of mercury; renal region sensitive to slightest touch; incessant, painful urging to urinate, with voiding of a few drops of thick urine; fever; thirst; colliquative diarrhoea; night sweats. Lycop. Hydropericardium ; ascites; anasarca, especially lower limbs; oozing of water from sore places of the cedematous legs; urine dark red, scanty, albuminous, w 7 ith strangury. Very irritable after sleep; scarlet fever. Nitr. ac. Pulse intermits every third or fourth beat; urine scanty, dark brown, smelling strong, like horses' urine; turbid urine; syphilis; abuse of mercury. Phosphor. Tuberculosis; diseases of right heart and of the pulmonary artery. (Buchner.) Phytol. After diphtheria in rheumatic and syphilitic patients. When in consequence of exposure to cold and wet: Calc. ca?'b., Colchic. , Ditlcam., Kali carb., Mercur., Nux vom., Rhus tox., Sepia. When in consequence of suppuration, cachectic states of the system: Asa/., Aurum., Calc. phosph., China, Ferrum, Hepar, Mezer., Phosphor. , Silic, Sulphur. Buchner recommends for: Anasarca: Arsen., Dulcam., Helleb. Hydro-thorax: Arsen., Bryon., Colchic. Hydropericardium: Arse?i., Digit., Lycop. Ascites: Arsen. , Aurum. Affections of the liver: Aurum, Cuprun),, Lycop. After taking cold: Arsen., Calc. carb., Dulcam. INTERSTITIAL INFLAMMATION. 597 Interstitial Inflammation or Induration of the Connective Tissue of the Kidneys. This is the so-called Third Stage of Bright's disease of many authors, or genuine contracting kidney, or the granular atrophy of the kidney, or renal cirrhosis, or renal sclerosis of other writers. It is, according to Bartels, "the result of a primary growth or pro- liferation of the intertubular connective tissue, and commences and pursues its course quite independently of the other forms of renal inflammation pre- viously described. It is, in fact, an altogether independent form of the disease. This process leads from its commencement steadily to the dwindling of the substance of the gland, a wasting preceded by no anterior inflammatory swelling of the organ. And this wasting does not affect the whole mass of the cortical substance simultaneously, but commences in scattered spots upon the surface of the kidney and extends very gradually from the spots first im- plicated both upon the surface and into the depth of the organ." Post-mortem examinations show, in most cases, both kidneys atrophied principally in their cortical substance, though the medullary substance also takes part in it. The pelvis is occasionally distended to a pouch, but oftener drawn together into narrower dimensions than normal. The capsule is tough and thick, and portions of the renal substance are always found adhering to it. The surface of the gland, after being freed from the capsule, appears finely granulated, and its entire substance is very tough; occasionally small cysts are found in the scanty cortical substance. The color of the kidneys is sometimes dark colored throughout, at other times pale, nearly grayish- white, but in no case is that marked yellow color exhibited which we find in the secondary contraction after nephritis. The microscope shows an extensive wasting away of the glandular structure proper, of the renal tubes with their epithelium and of the vessels attached to them. There are extensive layers of very firm and chief! y fibrinous organized connective tissue, and between them here and there some well preserved renal tubules. The great number of wasted glomeruli appear like dark round bodies, in which the outline of the capillary coils is still plainly perceptible. The cysts in the cortical sub- stance above mentioned, appear to be developed from partially dilated and strangulated renal tubules, the contents of the tubes having subsequently suffered colloid metamorphosis, and the granules upon the surface of the kid- ney seem to be the remains of the renal tubuli still beset with epithelium. However, such general degeneration is not found in every case. In some only a partial contraction has taken place, while other portions retain their normal appearance; neither are both kidneys always affected alike. In al- most every instance, however, there is found, hypertrophy of the left ventricle of the heart. Other features often met with are: retinitis albuminurica, thickening of the skull cap, apoplectic effusions, and occasionally dropsical effusions usually of small amount. The Etiology of renal cirrhosis is not very clearlv understood. It is 59° INTERSTITIAL INFLAMMATION. of rare occurrence in youth, more frequently in middle life, and at any age most frequent in the male sex. As exciting causes are mentioned: spirituous liquors, especially gin, lead-poisoning, gout and inveterate gonorrhoea. Symptoms. — Its commencement eludes diagnosis. As the first symptom which draws attention to itself is the frequent desire to pass water, especially at night, and without pain or ache. In some cases the patient experiences occasional attacks of palpitation, accompanied sometimes with vertigo, or a sense of great uneasiness, or suffocation, or want of breath, also principally at night. In such cases the heart will be found hypertrophied. There also occur occasional paroxysms of headache under the form of hemicrania, re- curring often and lasting for several clays. A terrible itching of the skin with more or less extended so-called rheumatic pains sets in frequently toward the end of life, but visual disorders under the form of retinitis albuminurica, also occasionally a most repulsive smell of the breath are symptoms of an earlier stage. At first, appetite and strength are not affected, later, however, the appetite fails, especially for meat-diet, with occasional vomiting after eat- ing, and an increased thirst for large quantities of water, with increased exertion of urine. This is followed by emaciation, anaemia, and loss of strength; the skin acquires a peculiar dryness and assumes a dirty, faded color, and the sexual power is either greatly diminished or lost altogether. The larger number of patients die either of anaemia or apoplexy, or of inflamma- tory exudations into the servus cavities, or of inflammatory infiltra- tion of the lung tissue, or else of erysipelatous and phlegmonous inflam- mations of the general surface of some part of the body. Dropsy may be entirely wanting, except when the disease advances to its most extreme grade, in which the kidneys become incapable of performing their function, or when intercurrent diseases of the lungs or heart, especialty mitral insuf- ficiency, bring it about independently of the kidney affection. Diarrhoea is often found toward the end of the disease, and then very profuse, watery and fetid. Haemorrhages from different parts of the body (nose, mouth, bronchi, stomach, intestines, and the skin principally of the extremities in the form of petechiae or ecchymoses) occur likewise in the later stages of the disease. But the most important indications can only be gained by frequent and care- ful examinations of the urine. "As a general rule, the genuine process of contraction of the kidney is associated with polyuria. But neither does this symptom at once become prominent at the very beginning of the malady, nor does it persist absolutely to the very end of the case. In fact, in the progress of the disease it may entirely subside for a longer or shorter interval of time, whenever, from an} 7 debilitating influence, the vigor of the heart's propulsive power is diminished for a longer or shorter period, or the urinary secretion may be completely arrested for several days before death, if the patient loses much water by any other channel, or severe collapse precedes death for some time." (Bartels.) The color of the urine is pale yellow, or yellowish-green. It is clear without sediment, only occasionally crystals of uric acid, and still more rarely THERAPEUTIC HINTS TO INTERSTITIAL INFLAMMATION. 599 urates are found upon cooling. Its specific gravity is, as a rule, below nor- mal, fluctuating between 1004 and 1012, and its reaction slightly acid, but may become alkaline by decomposition, dietetic or medicinal treatment, or vesical affections. It contains albumen in the vast majority of cases, though this abnormal constituent may be wanting at the beginning, or for a greater length of time during the course of the disease, or be absent altogether in exceptional cases. On the whole, however, the percentage of albumen in this disease is much less than that furnished by the inflammatory processes in the kidneys before described; its amount changes greatly according to the mode of life, the food and the general state of nutrition, and there is no con- stant ratio between the percentage of albumen and the total quantity of urine. The percentage of solid constituents, especially of urea, is abnormally small; epithelieal cells from the renal tubes are seldom found; red blood-cor- puscles, few in number, may be found scattered in the sediment, but never to an extent as to make the urine red or sooty; and white blood-corpuscles or pus-cells seem to derive somewhere from the mucous membrane of the urinary passages. The Diagnostic Signs then of renal cirrhosis are: the large quan- tity of urine daily secreted, its pale color, its low specific gravity, and the comparatively small amount of albumen it contains, combined with hyper- trophy of the left heart. From this the secondary atrophy of the kidneys in consequence of diffuse nephritis, differs in the smaller amount of daily secre- tion of urine; in the urinary sediment consisting of numerous casts of different character and of large quantities of granular detritus; and in the presence of considerable dropsy for a long time. Therapeutic Hints. I find only one case as having been cured, which can be classed under this head, although neither albuminous urine nor hypertrophy of the left heart are mentioned in it, yet both may have been present according to the symptoms. The case is this: Iy. K. M., aet. 52, of robust frame; family his- tory good. The past and present absence of any oedema, the general pro- fuseness of urine, with all else, led to the diagnosis of Bright's disease, — variety, granular degeneration. Perspires all over the body, as soon as he gets into bed; perspiration comes and goes all through the night. Cough on first waking. Cough comes as he gets out of bed; continues until he has had his breakfast. It is occasioned by a sensation as if he had a " wheat hull" low in his throat, just behind the manubrium sterni. Ikying on his back makes him cough; on right side also. When lying on his back, feels as if fluid rolled from one side of his chest to the other. (Purely subjective, no fluid there.) In the morning, mouth and lips are dry, and lips swollen. Tongue also dry. Iyips crack open when coughing. Drinks at night on ac- count of dry mouth. Oppressed for breath; breathes with difficult}', espe- cially after waking. Going upstairs causes it. Is markedly weak now. Rash as it may appear, considering that the sweat did not break out each 600 AMYLOID DEGENERATION OF THE KIDNEYS. time he awoke, I gave him one drachm of Sambuc, first dec. dil., in half a glass of water, a dessertspoonful ever)' hour. Result: No sweat that night. Ma} T 1 8th, Bryon. 30 , for pleuritic pains in the right lateral thoracic wall. This was an old trouble of his — sinapisms and cantharides-blisters having hitherto been applied for them. The action of Bryon. won his heart. He had thought the effect of Sambuc. on his night-sweats a "coincidence;" but the Bryon. dispelled the pain inside of fifteen minutes. May 23d, his pre- scription was Plumb, met., 30th trit., a powder (two grains) every four hours. He has exchanged his pasty yellow look for the ruddy hue of health, for he is a rudd}' man now again. (S. A. Jones, Am. Obs., Nov., 1875, p. 561.) Compare also the previous chapters. Amyloid Degeneration of the Kidneys, Lardaceous or Waxy Kidney. Amyloid degeneration is scarcely ever confined to the kidneys alone, but exists at the same time in the spleen, the liver, the abdominal lymphatic glands, the blood-vessels of the mucous membrane of the intestines, as well as those of the various other organs, and is invariabl}' the local manifestation of a general constitutional disease, of a cachexia which arises from prolonged suppuration, in consequence of scrofula, chronic tuberculosis or inveterate and hereditary siphilis. Intestinal ulcerations favor the development of the dis- ease more than ulcers of any other mucous membrane. Post-mortem examination shows in lighter cases no abnormal appearances of the kidneys to the naked eye. In extreme cases the kidneys are greatly enlarged, heavy, tough and firm; the color of their surface is pale, at times almost white, and so is their broadened cortical substance; upon the cut sur- face in the cortex appears a peculiar polish; but there is no sign of yellow coloration, as is always observed in the equally enlarged and anaemic kidney of chronic parenchymatous inflammation. If a watery solution of iodine or iodide of potassium is applied to the cut surface there soon appear bright reddish-brown points and branching lines, denoting the Malpighian tufts and the arteries with their branches, which have undergone amyloid degeneration, and on adding a drop of concentrated sulphuric acid the reddish-brown structures at once turn blue. Amyloid degeneration often occurs together with chronic parenchyma- tous nephritis in both kidneys, and as it is furthermore the result of other constitutional troubles, it is scarcely possible to separate its Symptoms from those produced by the coincidental diseases. In fact it develops itself quite insidiously, or, so to speak, without symptoms. The urine, as a rule, is aug- mented, and then always clear and pale like water; but when scanty it is darker and occasionally clouded with urates. Its specific gravity may sink to 1003, when passed freely, and may rise to 1030 and over, when passed but scantily. It contains albumen, and more at the beginning than later, when SUPPURATIVE NEPHRITIS. 6oi polyuria has set in. Casts are seldom found in any considerable number. Dropsy may or may not be present; but if it does appear, it usually remains persistent, especially the ascites, even in spite of abundant urinary secretion. Diarrhoea is very common and nearly always fatal, being induced by ulcera- tion, as in phthisis and S3^philis. Vomiting is less frequent and consists of watery masses of a faintly acid reaction. Other ursemic symptoms, if the vomiting may be considered as such, are still rarer, and the cardiac hyper- trophy is altogether absent, but in some cases the heart has been found small and atrophied. As a rule the fatal issue is brought about by gradual ex- haustion. The Prognosis is entirely dependent on the fundamental disease and its Diagnosis is always quite difficult, and in most cases impossible. Therapeutic Hints Must be derived from a study of the constitutional malady of which amyloid degeneration is the result. Suppurative Nephritis, Renal Abscess. This may be produced: 1. By renal concretions, which irritate the renal tissue and cause sup- puration. 2. By injuries, for instance gunshot wounds, bruises, etc. 3. By chronic retention and decomposition of the urine, which affects the renal pelvis and parenchyma almost always simultaneously strictures. 4. By metastasis through embolism of smaller renal vessels with infecting substances, in consequence of endocarditis sinistra. 5. By the so-called pysemic affections. 6. By the extension of suppurative processes from neighboring organs, especially from the perinephritic tissues, the psoas muscle, the liver, etc. 7. By the misuse of diuretics, especially of cantharides. 8. By unknown causes, perhaps exposure to cold, etc. The Diagnosis of traumatic nephritis rests upon the history of the case; of all other forms it is exceedingly difficult, often impossible. Therapeutic Hints Must entirely be derived from the special symptoms of the individual case. Nephrolithasis, Renal Gravel or Calculi; Nephralgia, Oolica Renalis. Renal gravel and larger renal concretions consist of and are developed from both normal and abnormal ingredients of the urine. Renal sand con- sists of fine powdery deposits: renal gravel at most attains the size of a pin- 602 . NEPHROLITHIASIS. head; renal stones are or" larger size, but seldom exceed that of a bean. The chemical composition of these concretions is various. Of the most frequent occurrence are those consisting of uric acid; those consisting of urates, es- pecially of urate of ammonia, are found much more frequently in nurslings than in adults; they are soft. Oxalate of lime calculi are very hard, thorny and warty, and very irritating to the tissues; they are rare, and occur more frequently in alternate layers with urates. Calculi of basic phosphate of lime (bone earth) or of ammonio-magnesium phosphate, or of the two mixed, are white or yellowish- white and of not unfrequent occurrence, while concretions of carbonate of lime are very rarely found. Cystine stones are of a dull yellow color, with scarcely any variation in the shade; they are rare; and still rarer are those composed of xanthine, which have a light brown or dark brown color, and a smooth surface. Concretions of fibrine are the result of renal haemorrhages with subsequent secretion of fibrine; they are often found mixed with other kinds of concretions; they have a dirty white or yellowish- brown color, and their consistency is that of wax, tough and elastic. We know little of the Etiology of nephrolithiasis. Heredity and family idiosyn- crasy, also habits of life and conditions of nutrition, are among the predis- posing causes mentioned. Symptoms — Renal sand usually causes no inconvenience to the patient; it is w r ashed away with the urine. Gravel and calculi are often attended with more or tess pain in the region of the kidneys, and when entering the ureters may cause the most severe paroxysms of pain, known under the name of lenal colic or nephralgia. Most usually the pain is only on one side, fol- lowing the course of the ureter down into the bladde, and in males, into the corresponding testicle w T hich is generally drawn up, often radiating to the glans penis, and causing a feeling of numbness in the corresponding lower extremity. These paroxysms of pain often alternate w T ith remissions, but w r hen at their height cause vomiting, cold perspiration, cold exremities, small pulse, great agony, collapsed features, even fainting fits and general convulsions. Pregnant women often abort under these circumstances. The urine is voided only drop by drop, with burning in the urethra, is scanty, red, brown or blackish, exceedingly loaded with blood, often mixed with mucus or pus, or is suppressed altogether, with subsequent uraemic symptoms, when the ureters of both kidneys are obstructed at the same time. The urine is often colorless, as clear as water, when only one kidney is affected and its ureter obstructed, and it is of very rare occurrence that complete anuria will take place, if only one kidney be diseased. During the inter- vals of renal colic the urine shows at times single crystals or particles of the urinary components constituting the renal calculi. The paroxysms of ex- treme pain cease, as soon as the calculus has completed its way through the ureter into the bladder; this occurs suddenly in most cases. In other cases the colic abates only slowly and gradually, when for instance the stones are of but slight consistency and crumble by degrees into smaller particles within the ureter. In some persons attacks of renal colic appear periodically and at THERAPEUTIC HINTS TO NEPHROLITH ASIS. 603 regular intervals of time. The later attacks are milder than those previous, if the size of the calculi be not larger than the ones previously discharged, because the accumulation of fluids accompanying each attack result in en- largement of the calibre of the ureter. Nephrolithiasis is a chronic affection. A fatal termination may occur when, the result of the arrest of renal stone during its passage through the ureter, a rupture of the latter takes place, which is followed by fatal perito- nitis; or when, as the result of the complete arrest of the urinary secretion by obstruction of the ureters, uraemia is developed. Hydronephrosis, that is a dilation of the pelves and ureters by the retained, urine, or suppuration of the renal parenchyma in consequence of the presence of renal calculi, as- sumes a very chronic course, as one sound kidney usually is capable for a long time of performing the normal functions of both. Therapeutic Hints. A prevention of the formation of renal sand and calculi will be possible only by a deep study of the single case, and a long course of treatment based thereon. The physician is called in most cases only to prescribe for the present emergency, the renal colic, and here Homoeopathy has won many victories. The following remedies have been applied in many cases most successfully. A prescribing of opium or morphine in large doses or hypo- dermic injections is not at all the highest aim to which a student of Homoe- opathy should aspire. Arnica. Piercing pains as if a knife were plunged into the region of the kidne3*s; violent tenesmus of the bladder; chilly and inclined to vomit. Sulphate of morphia had been given large doses without relief. Arnica, 1st. dec. dil. , in water, relieved in half an hour. (A. K. Small) Arse?i. Passage from time to time of gravel with dull pain in renal region, extending down to ureter; gastralgia; tickling and itching in urethra; difficult micturition; sediment of uric acid. (Bourgeois.) Urine alkaline, dark yellow, with sediment of mucus and crystals of urate of lime. (Schadler. ) Bell ad. Spasmodic, crampy straining along the ureter, through which the calculus makes its way. After Opium or morphine. Berber. When there is red sediment in urine, pain in back, etc. (S. K. Newton.) Canthar. High; intense pain above crest of ilium. (S. Swan.) Diosc. Has relieved the writing, twitching and crampy pains. (E. M. Hale.) Lycop. After Nux vom.; colicky pain in the right side of the abdomen, extending into the bladder, with frequent urging to urinate. Urine incrust- ing the vessel with red sand. Nux vom. Always the best remedy after the palliative use of so- called anodynes; pain, especially in the right kidney, extending into the genitals and right leg; nausea; vomiting; constant urging to urinate; insuf- 604 PYELITIS. ficient urging to stool; inability to lie on the right side; better while lying on the back; rising and walking increase the pain. Opium, or Morphine. Is given by the old school in large doses, to lull the pain; it is indicated where there are pressive, squeezing pains, as though something had to force its way through a narrow space; shooting pains from different places into the bladder and testicles; vomiting of slime and bile; obstinate constipation; dysuria; greatest anxiety and restlessness; constant changing position; face hot; pulse slow. Piper meth. Pain agonizing; irresistably impelled to try all sorts of motions and positions for relief, without finding it. (Hiller.) Tabac. Constant deadly sickness of the stomach and retching, with cold perspiration; violent colicky pains in the region of the ureter, right or left side. The following may also be mentioned: Calc. urinaria, Cannab., Eriger., Eupat. per/., Galium., Sarsap., Si lie., Zincum. Pyelitis, Inflammation of the Renal Pelvis. In the catarrhal form the blood-vessels of the mucosa are distended, and the surface of the mucous membrane is covered with mucus or a muco-puru- lent secretion. In the diphtheritic form we find upon the mucous mem- brane yellow spots, which consist of mortified tissue. In the calculous form ston} T concrements are always present. Pyelitis may be excited by the abuse of balsam of copaiva, cubebs, tur- pentine, cantharides; by catching cold; by the presence of urinary concre- ments, animal parasites; by the ammoniacal decomposition of the urine; in women after obstetrical operations, in the puerperal stage and during preg- nane}-; by inflammation of neighboring parts; and it is often a complication of typhus, typhoid, and exanthematic fevers, of diphtheria, cholera, car- buncle and scurvy. It usually runs a latent course, when it is the accompaniment of some severe constitutional affection. In the catarrhal form the urine is always acid, often contains some blood, mucus and pus, and at times epithelial cells of the renal pelves. A sense of weight or pain in the region of the kidneys extending downward to the bladder, slight febrile movements and digestive disturbances are often, but not always present. When it is caused by ammoniacal decomposition of the urine, it is al- ways a complication of some other chronic disease, strictures, hypertrophy of the prostata, catarrh of the bladder, spinal diseases, etc., which cause a reten- tion of urine. Its symptoms are finally those of uraemia. The inflammation of the renal pelvis sometimes extends to the paren- chyma of the kidneys, when it is called Pyelonephritis. The most characteristic symptom of pyelitis is the presence of epithelial cells of the renal pelvis in the purulent urine. But these are not always found, and the maladies which accompany pyelitis are often of so grave a MORBUS ADDISONII. 605 nature that the morbid manifestation in the kidneys is altogether over- looked. Therapeutic Hints. Purulent sediment: Canthar., Merc, corr., Nux vom., Petrol., Phosphor. , Pulsat., Sepia, Sulphur. Gravel in the urine: Lycop., Sarsap. Compare the preceding chapter. Perinephritis, Paranephritis, Inflammation of the Renal Capsule. The capsule appears injected and infiltated with exudation, or covered with purulent secretion, in consequence of which adhesions are formed with neighboring organs. It may lead to a thickening of the capsule, or to the formation of abscesses. Primarily, it is caused by external injuries, and exposure to cold. Secondarily, It may be a continuation of an inflammatory process in its vicinity, or of pj-aemia. Its Symptoms very much resemble those of other inflammatory affec- tions of the kidneys. There are rigors, followed by fever, and a temperature usually reaching io3 T 1 - -° F. ; there is a dull and often acute pain in the re- gion of the kidney or kidneys; there is constant desire to urinate, with but little discharge; the urine is highly colored and hot, but contains no blood, thus differing from nephritis, nor purulent sediments, thus differing from pyelitis. There is vomiting, and when an abscess is formed, the pus dis- charges either into the peritoneal cavity, or, in consequence of adhesion, gradually burrows downward in different directons between the different fascias, or works towards the surface and breaks through the lumbar region, In the latter case we observe a gradual increasing swelling in the renal re- gion, which fluctuates, points and bursts. Therapeutic Hints. Aeon., Arnica, Bellad., after exposure to cold or external injury; Hepaj , Mercur., Si lie., for abscess. Morbus Addisonii. Quite a number of well observed cases have been recorded, in which the symptoms of this disease have been found in connection with disease of the supra-renal capsules, so that the probability of a relation of cause and ef- fect between the two becomes almost a certainty. The morbid changes found in the supra-renal capsules consist of a proliferation of small cells in conse- quence of chronic inflammation and final breaking down of the structure into caseous masses of various sizes. In this way gradually ever}- trace of proper tissue disappears and we have nothing left but a firm caseous mass, which has grown from the middle of the medullar}^ portion towards the sur- 606 MORBUS ADDISONII. face. There also have been observed in many cases of undoubted Addison's disease haemorrhages into the tissue of these bodies, which ma}* be so severe as to .swell one of them up into a tumor the size of a child's closed fist; less frequently new formations are found, comprising carcinoma, sarcoma and echinococcus. The changes met with in the sympathetic nervous system, such as: de- position of pigment in ganglion cells, fatty degeneration, proliferation of the connective tissue, excessive hyperaemia and dilatation of the vessels, are changes which also have been observed in connection with pathological pro- cesses. Symptoms. — Among the first signs of the disease which the patient can recall after ailing for months and longer, are great weariness throughout the body, and tearing, dragging pains in both hypochondria (frequently more intense in the right), along the back, in the sacrum and especially in the joints, which latter resemble most closely the arthritic neuroses of hysterical individuals and which might be mistaken for acute rheumatism, if it were not for the absence of any swelling or alteration in the shape of the joints. With these are associated dyspeptic symptoms, such as cardialgia, eructations, loss of appetite, nausea, vomiting and distention of the stomach and abdomen. The fat of the body is at first well preserved, but the loss of muscular power is apparent very earl}*, manifesting itself by a slight tremor of the hands, an inability to squeeze tightly and a tiredness after very little exertion. These symptoms may be considered as the prodromal stage. Further on we observe an exceedingly soft, small, weak and generally rapid pulse, weak cardiac impulse and a want of sharpness, or of faint casual murmurs here and there, in the case of all the valves as also of the larger vessels. Resulting from this there is a remarkable paleness of the skin, sometimes amounting to cyanosis, a somewhat quickened respiration and a temperature generally somewhat below the normal. The dyspeptic symptoms increase and an alternate constipation and diarrhoea is often present. The urine remains normal. Along with these symptoms, a more or less dis- tinctly marked discoloration of the skin gradually develops, commencing as a light dusky gray and passing on to dark brown, first on the hands and face, either as a mottling, or diffusely, or occasionally in streaks. The areola of the breast, the genitals and the fold of the axilla color most intensely. On the mucous membrane of the lips and cheeks, irregular bluish or blackish spots occur; the sclerotic, the nails, the palms of the hands and the soles of the feet, however, remain perfectly clear. With this associates quickly or more slowly an intense anaemia and debility, painful deglutition, profuse diarrhoea and vomiting, headache, dullness of the sensorium, difficulty in col- lecting his thoughts, weakness of memory and actual fainting fits, and epilep- tic seizures. Meanwhile the discoloration of the skin attains to an intensely dark bronze color, through all the shades from an ashy-gray, darkly icteric, mulatto and even copper color, while the sclerotics still remain strikingly white. DISEASES OF THE BE ADDER. 607 There are cases in which the symptoms run a more acute and tumultuous course, when the patient, after ailing for some time, is suddenly confined to bed with great prostration, trembling of limbs on being raised, confusion of mind, dry tongue and lips, covered with sordes, a frequent and small pulse, and a temperature of 104 F., similating precisely a case of enteric fever, if it were not for the absence of rose spots and enlargement of the spleen. Pulmonary consumption is the most frequent complication, which mixes itself up with the peculiar characteristics of Addison's disease, that we are often induced to look upon the double set of symptoms as almost inseparable. The Prognosis is thus far considered fatal. We have not, to my knowledge, an authenticated case of this disease cured in our literature. Trerapeutic Hints. J. Payr recommends: Be/lad., Natr. mur., Iodium, 01. jec. asel., Cin- chona, Ferritin, Phosphor., Cuprum Lycop, Card, veg., Arg. nitr., Ars. hydr. Hughes mentions: At sen., Calc. ars., Kreos. Lilienthal refers to: Psori?i., Therid., according to Baruch, and Natr. sulph., to which I may add Kali carb., on account of the paretic effects upon the heart-muscle of potassa salts; Sepia and Stdphur, especially for the earlier stage. A. Rockwell has seen beneficial effects from the application of the Fara- day current. DISEASES OF THE BLADDER. Cystitis, Inflammation of the Bladder. As the walls of the bladder consist of a mucous lining interiorly, a mus- cular coat exteriorly, which is partly covered by the peritoneum, and con- nective tissue between them, it is clear that an inflammatory process may have its seat more or less exclusively in any of these tissues, or involve the whole structure. Pathologsts speak therefore of: Cystitis catarrhalis, when the mucous membrane; of Cystitis submucosa, when the submucous connective tissue; of Cystitis subserosa, when the subserous connective tissue; of Pericystitis or Paracystitis, when the peritoneal or cellular covering; and of Cystitis parenchymatosa, when the whole structure is the principal seat of the inflammatory process. But these forms are always more or less mixed up with one another. # The catarrhal form-, when recent, is characterized by congestion of, and mucous secretion from, the mucous membrane, when chronic, by a livid ap- pearance of the membrane, and slate colored spots on it; the membrane itself gradually disorganizes, is found softened, thickened, infiltrated, and covered with a thick, grayish, purulent secretion, which by decomposition makes the urine ammoniacal. The inflammation rarely stays confined to the mucosa, but spreads to the submucous connective tissue, causing the formation of 608 DISEASES OF THE BLADDER. abscesses, or involves the muscularis, inducing hypertrophy of the same. In this way the walls of the bladder ma}' attain great thickness; the bladder may enlarge in size generally, reaching often as high up as the navel (eccen- tric hypertrophy) ; or its size may shrink down to that of a walnut (con- centric hypertrophy) . Sometimes, when the bladder is capacious, the muscu- lar bundles are pushed asunder and the mucous membrane prolapses between them, and becoming in time more and more distended by urine, forms diver- ticula of the bladder, which by degrees may attain the size of a fist and over. As the urine contained therein is scarcely ever completely evacuated, these diverticula of the bladder form exceedingly fit places for the retention of con- crements and the consequent formation of stones. The abscesses which form in the connective tissues may burst internally, and before bursting, if they be situated in the posterior or lateral walls of the bladder, may by their bulging into the bladder greatly obstruct the flow of urine from the ureters, and cause regurgitation of the urine to the kidneys, or if situated in the neighborhood of the neck of the bladder, may lead to complete retention of urine. An abscess may also burst externally, either into the peritoneum with rapidly following peritonitis, or into the cellular tissue surrounding the bladder, giving rise to infiltration of urine, inflamma- tion, intense congestion, cedematous swelling of the ano-perineal region, per- foration of this region, or the rectum or vagina, and escape of urine through the fistulous openings subsequently remaining. In other cases fistulae may form at the side of the pubic symphisis. Cystitis maybe caused by exposure to cold and wet, by external injuries, by irritating drugs (cantharides, copaiva balsam, etc.), either administered internally or injected, by calculi, by retention of urine, by extension of in- flammatory processes in neighboring organs (diseases of the prostata, strict- ures and inflammation of the urethra, etc.), by infectious diseases. Symptoms. — The acute form is characterized by severe pain in the region of the bladder, which isw T orse from external pressure and motion, and frequently extends along the ureters upwards into the kidney's, or downwards through the urethra, by frequent painful micturition and strangury. The urine is voided drop by drop, under great straining, and a feeling of scald- ing; it is highly colored, hot, and occasionally mixed with blood, mucus and pus. By fever, associated with a temperatuure of 100.4 to 102. 2 F. , vomit- ing, prostration, cold perspiration, singultus, etc. , in severe cases. The chronic form is not so acutely painful, but always attended with frequent urging to micturate, and the passing of turbid urine which, after standing, yields a heavy, thick, glairy, viscid sediment of muco-purulent matter, which, on being poured from one vessel into another, falls out as a ropy mass. The specific gravity of the urine is not remarkably increased; its reaction is at times slightly acid, at other times neutral, or alkaline; its smell is often offensive, ammoniacal. The chronic form is subjected to fre- quent acute exacerbations from any irritating cause, and is generally found in advanced age. Its Prognosis, if once advanced to a high degree of dis- organization of the bladder, is very doubtful. therapeutic hints to diseases of the bladder. 609 Therapeutic Hints. The most infamous practice is the administration of morphine, which not only gives no real relief, but destroys all chances of recovery by paralyz- ing the whole nervous system. High fever; restlessness; constant urging, yet fearful of voiding the urine on account of the painfulness of the act, Aeon., Bellad. Violent burning in the bladder, Aeon., Arsen. Burning and pressure in the bladder, Nux vom. Violent tenesmus and burning, Canthar. Bladder largely distended, Arsen. Congestion of the head; tongue red and dry, Aeon. If attended with vomiting, cold perspiration and anxiety, Arsen. Vomiting and nausea, Canthar.; great thirst, A? sen., Canthar. Frequent small pulse, Canthar. After a fall, blow, etc., Arnica. After taking cold, Mercur., Pulsat. After irritating drugs, Camphora. In chronic cases, Calc. carb., Catb. veg., Coloe., Dulcam., Lycop., Phos- phor., Pefrol., Sarsap., Sulphur, Uva ursi. Aeon. In all acute catarrhs, characterized by high fever, restlessness, and brought on by exposure to cold, dry winds. The urine is scalding hot, dark red or turbid; micturition painful, difficult, sometimes only drop by drop; children reach with their hands to the genitals and cry out. Apis. Urine scanty, smoky, bloody; if caused by cantharides. Arse?i. Burning pain, especially at the commencement of urinating; fever; great restlessness; cold perspiration; face and extremities cold; or in chronic cases with inability to void the water; bladder greatly distended and paral} T zed; urine turbid, mixed with pus and blood. Bellad. If not better some twelve hours after Aeon.; rapid sinking of strength; the region of the bladder is very sensitive to the touch; the urine hot and fiery-red, clear at first, but soon becoming turbid on standing, and depositing a copious, slimy, bright red, bran-like sediment. Berber. Stitching, recurring, crampy pain; constrictive pain in blad- der; thick mucous and bright red, mealy sediment. Cantphora. If caused by cantharides, balsam of copaiva, turpentine, etc. ; after measles. Ca?inab. If not better after Canthar. within about twelve hours gonorrhceal inflammation; urine loaded with mucus. Canthar. Spasmodic pain in the perineum along the urethra down into the testes, which are drawn up; intolerable burning pain in the bladder; cramping pain in the thighs; cutting through the abdomen; burning pain in the glans penis, the orifice of which is reddened; micturition difficult, only droy by drop, with a feeling as though melted lead were passing through the urethra, with violent straining, which increases the pain; urine at first clear, 39 6lO THERAPEUTIC HINTS TO DISEASES OF THE BLADDER. but afterwards turbid, bloody, scanty, or only blood; painful erections of the penis; great restlessness and fever; thirst, but drinking or even the sight of water increases the pain. Card. veg. In old people and chronic cases where the acute inflamma- tion has subsided and only blennorhcea exists. Caustic. When in consequence of long retention of the urine the mus- cular coat becomes paralyzed; compare Arsen., Gelsem., Helleb., Hyosc. Chimaph. Urging to urinate after micturition; the urine is high colored, depositing a copious, mucous sediment; constipation. Coloc. After alleviation of the most violent symptoms, when the pain during micturition extends all over the abdomen, and the urine looks turbid when first voided, depositing, on standing, a tough, mucous sediment, which can be drawn into strings. Copaiva balsam. Swelling and dilatation of orifice of urethra. Dulcam. In chronic cases, with constant desire to urinate, deep in the abdomen; urine is limpid when voided, but assumes an oily consistence on cooling, and contains a tough, jelly-like, whitish or reddish mucus inter- mixed with little lumps of blood; it smells foul. All symptoms grow worse when the weather changes from warm to cold. Elater. Constant heat at neck of bladder, with extremely painful mic- turition, inducing even convulsions. Gelsem. Detrusor and sphincter muscles paralyzed; bladder distended; urine constantly drippling off involuntarily; not a drop by straining; no pain. Helleb. The inflammatory process increases slowly to the greatest vio- lence, with constant desire to urinate, causing spasms; little urine is voided; constant nausea; distended abdomen. Hydrast. Thick, ropy mucus and bloody sediment. Hyosc. Retention of urine, so that the bladder becomes largely dis- tended; urine turbid, depositing a mucous or purulent sediment; great thirst; dry tongue; delirium; subsultus tendinum. Kali bichr. Urine alkaline and ropy. Laches. Discharge of bad-looking mucus during micturition; dull pain in the bladder; sensation as if a ball were rolling in the bladder. Lycop. Dull, pressing pain in the region of the bladder and abdomen; the urine is turbid, milky, depositing a thick, purulent sediment of a most nauseating smell; chronic cases; disposition to urinary concretions. Mercur. Fever with chilliness; great soreness in the region of the bladder when touching it; violent urging; the urine flows in a thin steam, or only drop b\- drop; contains mucus, blood, even pus; during micturition sweat breaks forth; gonorrhceal inflammation. Natr. mur. Pain is greatest after micturition. Nux vom. Painful, ineffectual desire to urinate, or discharge of urine drop by drop, with burning and tearing; pale urine followed \>\ thick, whit- ish, purulent matter, with violent, burning pain; spasmodic retention of THERAPEUTIC HINTS TO DISEASES OF THE BLADDER. 6ll urine; constipation, with ineffectual urging; after drugs, or suppressed gonor- rhoea. Pareira brava. Constant urging to urinate, with violent pain in the glans penis and straining; the pain is so great that it extorts loud screams from the patient; " he can emit urine only when he goes on his knees, press- ing his head firmly against the floor; remaining in this position from ten to twenty minutes, perspiration breaks out, and finally the urine begins to drop off with interruptions, with great pain at point of penis." (lyippe.) Always worse after midnight till morning; the urine has a strong ammoniacal smell, and contains large quantities of thick, tough mucus. Phosph. ac. When the urine looks like milk, and quickly becomes de- composed. Popul. Chronic catarrh; chronic gleet; elderly persons. Pidsat. After exposure to cold, the urine deposits a slimy sediment, which sticks to the vessel; tenesmus and stinging in the neck of the bladder; the pain continuing a while after micturition. Senega. Urging and scalding before and after micturition; urine loaded with mucous shreds. Sepia. In chronic cases; distention of the lower portion of the abdo- men; annoying, itching sensation in the region of the bladder, with urging to urinate, especially in the night; the urine does not flow until sitting on the vessel for some time; during and after micturition chilliness and heat in the head; the discharge of mucus does not take place at each evacuation of urine, but comes on periodically; sometimes pieces of coagulated mucus clog up the urethra; admixture of a kind of dark brown pigment; constipa- tion. Sulphur. Constant desire to urinate, day and night; the urine drops slowly out of the urethra; it deposits thick, tough mucus, which sticks to the bottom of the vessel; purulent sediment; after micturition, the pain con- tinues in the urethra until a new urging ensues; stools likewise painful; feverish and sleepless through the night; cutaneous eruptions here and there •on the body; suppressed itch; gonorrhoeal discharges; hemorrhoidal dis- position. Tereb. Sensitiveness of hypogastrium ; tenesmus of bladder; stran- gury; burning in region of kidneys; urine deposits a slimy, thick, muddy sediment. After drinking cold water while being heated. Uva ursi. Frequent urging with a little discharge, and a burning, cut- ting pain afterwards; the urine is yellow, but deposits a tough mucus; some- times blood and mucus are voided at the same time with great straining; se- vere spasm of bladder before micturition; at all times burning and tearing pain in region of bla,dder; constipation. A number of other remedies may present themselves for consideration: Calc. carb., Capsic., Conium, Eriger., Graphit., Hepar., Nitr. ac., Phosphor., Sarsap. Compare also the remedies mentioned under the head of Kidney Diseases. 6l2 CALCULI VESICA. Calculi Vesicae, Stones in the Bladder. Calculi vary from the size of gravel to conglomerations of the size of a man's fist, and even larger. In shape they are either round, or flat, or rough, irregularly shaped. In regard to their chemical composition, the} 7 consist either of crystals of clear uric acid, or a combination of uric acid and ammonia, soda, magne- sia or lime. These are hard, heavy, brown, yellow or grayish- white, and are mostly smooth, roundish, rarely irregular in shape. Next in frequency are those which consist of phosphates. The}' are not so compact, but are brittle, crumbly and light, of a whitish, grayish, sel- dom yellowish color, and of a roundish shape, with a smooth but sandy surface. Still rarer are those which consist of oxalate of lime. They are the hardest and heaviest of all, have a dark brown or blackish appearance, an uneven, wart-like surface and are therefore called mulberry stones. Conglomerates which consist of carbonate of limr, or cystine, or xanth- oxide are of very rare occurrence, while mixtures of urates and phosphates are quite frequently found. They generally present a striated appearance, or the one material forms nucleus and the other the periphery. Such urinary concretions may be very numerous. Liston extracted five hundred from one bladder. They are usually formed in the renal pel- vis, and work their way gradually through the ureters into the bladder, where they remain and increase in size. Stones which are formed primarily in the bladder are generally solitary. They are either movable in the blad- der or they are entangled between the folds of its mucus membrane, or they have formed by their weight an extension of the bladder, where they are held stationary, or they have originated in a diverticle of the bladder. Those which roll about freely in the bladder are always of a roundish shape and smooth, while those which are stationary assume an uneven and jagged surface. Very large stones nearly fill the cavity of the bladder; they have been found to weigh from five to six pounds. Gravel passes away without much difficulty. Xeither do smooth and movable stones, if not too large, cause much inconvenience. But when they are of larger size, and of a rough and irregular shape, they cause consider- able trouble. Symptoms. — i. In rare cases the patient feels a heavy body in the blad- der moving about when changing position. 2. Pain in the neck of the bladder when walking, standing, sitting or during stool; still worse when riding in a carriage or on horseback, but much less during rest, and especially while lying on the back or on the face. This symptom becomes quite characteristic when, after riding in a carriage or on horseback, there follows — 3. A discharge of bloody urine and an increase of catarrhal inflammation of the bladder. HYPERESTHESIA. 613 4. Sometimes the pain is not felt in the bladder at all, but in the glans penis and along the urethra, which constantly tempts the patient to squeeze and pull at the penis. This constant irritation may lead boys to the habit of masturbation, and the frequently repeated pulling may produce an elonga- tion of the penis and hypertrophy of the prepuce. 5." Strangury commences when the last drops of urine are voided and continues for a while afterwards. 6. Sudden stoppage in the flow of urine (although the bladder be not emptied) by the rolling of a calculus before the opening of the bladder. In other positions, especially that of lying on the back, the urine flows again. 7. Sometimes a distinct feeling, as though something were wedged into the neck of the bladder, causing difficulty in making water, when a calculus has been driven into the opening at the neck of the bladder. 8. Reflected pains, as spasms in the rectum, vagina, testicles, kidneys, perineum, legs, etc. 9. In rare cases, when there are many stones in the bladder, on succus- sion of the body they may even be heard and felt rattling in the bladder. 10. Examination by the metallic sound reveals a hard body, which, on being struck, gives a metallic sound. Therapeutic Hints. Large stones, it is true, cannot be dissolved again, but belong into the domain of surgery. But it is a question whether we cannot do something to prevent their formation. According to our records a number of remedies have shown themselves efficacious in expelling gravel and in restoring a normal secretion of urine. If such be the case, is it not equal to preventing larger conglomerations ? and is not one pound of preventing worth more than ten pounds of cure ? Moreover it is true that all who suffer with gravel need not necessarily become affected with stone in the bladder; just as every one who falls need not necessarily break his neck. But who can tell beforehand the result in either case ? The remedies, after the use of which gravel and small stones have been observed to be discharged, are: Aspar., Berber., Calc. card., Calc. urinaria, Cannab., Ipom. (Jeanes), Lycop., Lith. carb., Nitr. ac., Nux vom., Petrol., Phosphor., Pidsat., Sarsap., Sulphur, Tabac., Uva 117 si. Among the new remedies are mentioned: Aln. rub., Chimaph., Collin., Corydal., Eriger., Eryng., Eupat. arom. and per/., Frasera, Galium, Gossyp., Pooloph. For particulars, study Iyithiasis Renalis, Catarrh of the Bladder and the Materia Medica. Hyperesthesia, or Irritability of the Bladder; Spasm of the Bladder. Hyperesthesia shows itself as an increasing intolerance, especially of the neck of the bladder, for the normal irritation of the urine, so that even 6 14 ATONY, PARESIS. a small quantity of urine excites a more or less painful urging to pass water. Such a condition may often be traced to a rapid fall of temperature, or to too often repeated sexual indulgence. Spasm of the sphincter is much severer; it is attended with strangury, that not a drop of urine is allowed to escape; or if by reflex action, the de- frusor urinse be alternately irritated, the urine is squirted out in jerks, with frequent interruptions, or passes slowly, drop by drop, with much trouble and pain. It is often attended with neuralgia pains in the hypogastrium and in the ano-perineal region, which may spread to the urethra, glans, testes v clitoris, thighs, loins and inguinal region, and upwards to the epigastrium and lowest ribs. These vesical spasms may occur at each attempt to pass water, or only occasionally; sometimes the urine escapes involuntarily. The paroxysms may last from a few minutes to half an hour or more, and usually subside when the urine flows; when very severe, they may be accompanied by great excitement, anxiety, nausea, vomiting, clonic convulsions, small pulse and cold perspiration. In uncomplicated cases the urine is usually of a normal condition, at times remarkably pale, like urine in spasmodic affec- tions generally. Spasm of the bladder occurs in children and adults, and may be caused by mental excitement, excessive sexual indulgence, onanism; drugs, sour wine, young beer, sitting on damp and cold ground; the} 7 ' may be connected with disease of the rectum, such as fistulae, fissures, ulcers, hcemorrhoids, etc., or with other neuralgic affections and various cerebro- spinal diseases. Therapeutic Hints. The irritability of the bladder is frequently met by: Arnica. Feeling of great fullness of the bladder. Bryon. Worse from moving. Colchic. Gouty diathesis. Ferr. phosph. Worse in daytime. Nux vom. After taking cold. Ox. ac. Worse when thinking of it. Rhus tox. Worse in the night and when at rest. Sabina. Gouty diathesis. Sulphur. Irresistible desire to urinate on seeing water running from the hydrant, similar to Canthar. and Lyssin. Spasms of the bladder principally: Bellad., Hyosc, Nux vom., Opiu??i, Pulsat. , Rhus tox., Ruta, Sulphur. Other remedies will be suggested by the causes and connections of this trouble. Atony, Paresis, Paralysis of the Bladder. The detrusor urinae loses its power to contract, and in consequence the urine is only partially or not at all expelled. This causes great distention of the bladder. The patient complains that he can only make water slowly; THERAPEUTIC HINTS TO ATONY, PARESIS. 615 the desire to pass water becomes less frequent, is felt only when the bladder is greatly distended, and then only for a short time, if not soon attended to. The stream of the water grows feebler, is frequently interrupted, and at last voluntary efforts are unavailing, but the presence of the accumulated mass of urine becomes so great that the sphincter yields and the urine escapes in drops involuntarily, and has a disagreeable ammoniacal odor. By and by the paralysis also extends to the sphincter, and now the urine flows away un- interruptedly, which constitutes true Incontinentia urinae. But even in these cases the bladder is never fully emptied, and it occasionally happens that, in consequence of this prolonged retention of urine, ursemic symptoms supervene. The Diagnosis is readily made out by percussing the region of the bladder, which will be found greatly distended, and by introducing the catheter, which will drain off immense quantities of urine. Paralysis of the bladder is found in diseases of the brain and spinal cord, in typhoid fever, in consequence of the bad habit of suppressing urgent calls to urinate, in old age, in diseases of the prostate, after injuries to the bladder or urethra, or spine. Therapeutic Hints. Care should be taken to drain off, by the catheter, the accumulated urine in time, and, if possible, at regular hours. Arnica. Feeling of fullness of the bladder with urging and impossibility to void urine. (Aegidi.) Arse?i. Urging in the bladder and bowels without success; great anxiety and restlessness; after taking cold. (Gauwerky.) Paralysis of bladder in old people. (Krummacher. ) Canthar. After having retained the urine too long voluntarily. Caustic. From long retention of urine. Cicuta. Paralysis of the bladder with great anxiety about it. Gels em. Constant dribbling of urine, but not a drop flows on making the greatest effort; bladder distended up to the navel; no pain, not even on pressure. Helleb. Paralysis of the detrusor; oedema of the legs; vomiting of all he eats; constipation; sleeplessness; despair of getting well. (Mossbauer.) Hyosc. After labor, and in children with affections of the head. (Small.) Iodium. Incontinence of urine in the aged. Nux. mosch. Hysteria with strangury. Nux vom. After catching cold; after sexual excesses. Opuim. Retention of stool and urine. Phosphor. In spinal troubles. Staphis. Involuntary discharge of urine, acrid and corroding, with burning; worse from motion; constipation; straining or external pressure causes no discharge; after difficult confinement. (Wm. Gross.) 6l6 ENURESIS NOCTURNA. Compare also: Bar. card., Bellad., China, /gnat., Lycop., Natr. mur., Phosphor. , Podoph., Rhus fox., Rata. Enuresis Nocturna. Wetting the bed may be a bad habit with some children, or the con- sequence of their sleeping too soundly, but in most cases it depends upon a local atony associated with increased sensitiveness of the neck of the bladder. It is more frequently found in boys than in girls, and it ceases on the average about the tenth or twelfth year, latest at puberty. Therapeutic Hints. Rough and harsh treatment will be of no avail. Amm. carb. Enuresis occurring at any time at night; pale urine; red sediment. (Greeley. ) Arg. nitr. Incontinence of urine during the day. Bellad. Starting in sleep; moaning and screaming during sleep; scrofu- lous glandular swellings. Benz. ac. When the urine has a very penetrating smell. Calc. carb. Scrofulous children, who sweat and catch cold easily. Caustic. Enuresis during first sleep; chronic, periodic swelling of the tonsils; sequelae of itch; sweat on genitals; green halo around the candle- flame. (Wm. Gross.) Blepharitis ciliaris of herpetic nature. (Goullon.) Chamom. Child cross, has to be carried; whooping-cough as a complica- tion. (Miller.) Chloral. Enuresis in the later part of the night, even if they have urinated during the night and drank no water. (Oehme.) Cina. Urine profuse and of strong ammoniacal odor; great appetite soon after leaving the table. (O. M. Pierson.) Equisetum. When there is no tangible cause except a habit. Ferr. met. When the child presents an anaemic appearance with pale face which flushes easily from excitement or pain. (Hering. ) Frequent wetting the clothes during the day. Ferr. phosph. Similar. Kreos. When it is very difficult to waken the child out of sleep. (Boenninghausen. ) Pla?itago. Copious enuresis; atony of the sphincter. Sepia. Follows well after Caustic, same symptoms. Silic. Complication with worms or chorea. Sulphur. Disagreeable sensation of hunger with flushes of heat about ii A. m. (Goodno. ) Pale, lean children with large abdomen, who love sugar and highly seasoned food, and abhor to be washed. Thuja. When the urine is highly colored and of a strong smell; warts here and there. (I^insley.) RETENTION OE URINE. 617 Retention of Urine, Ischuria Vesicaiis, May be the consequence of spasm of the sphincter, of paralysis of the detrusor urinae, of haemorrhoidal swellings about the sphincter, of clots of blood, or mucus, or calculi, obstructing the passages, of inflammation and consequent thickening of the bladder. We find the bladder distended above the pubis. In such cases it will often be necessary to introduce the catheter, and that may sometimes be attended with great difficulty, especially in men. The patient may be placed on his back, with a pillow under his head, holding his thighs slightly flexed upon the abdomen; or he may sit up on the edge of the bed, slightly bent forward; or he may stand up, leaning the body for- ward, and supporting himself on the back of a chair, or some other object, Sometimes the introduction of the catherer could be affected only in the standing position; the horizontal position is the one usually preferred. The catheter may be of metal or caoutchouc; either kind may be prefer- able in certain cases; they are of various sizes, numbers 7, 8 and 9 of the English scale are those most frequently called for in grown persons. Before entering the catheter, it should be warmed and oiled; some fill the catheter with oil, so that it may lubricate the parts before it. Sometimes it will be well to inject first some oil, or warm water into the urethra, to make the parts more pliable. Now the catheter should be held with the thumb and forefinger of the right hand on its handle, so that it is parallel with and touching almost the abdomen of the patient, on whose left side the operator is sitting, while the thumb and forefinger of the left hand grasp the penis and draw it up toward the abdomen, so that the movable portion of the urethra is put on a stretch and the folds of the lining mucous membrane become obliterated. The instrument is now inserted and allowed to follow the urethral channel until it reaches the triangular ligament. Here we find often the first obstacle; the instrument has to enter the fixed curve of the urethra, and the handle of the catheter should be held parallel to the linea alba, and gently raised from off the abdomen, so that its curved portion be brought in the direction of the fixed curve of the urethra, and be carried along in it. The next obstacle we will often find at the sphincter vesicae, especially when there is a spasmodic affection of the same; a gentle, but per- sistent pressure exerted upon the instrument will gradually overcome it in many cases. Simple as this operation appears to be, it is nevertheless fre- quently attended with great difficulties, and even experienced surgeons have been foiled in the attempt; it requires great gentleness, dexterity and per- severance. ' ' (Helmuth. ) In some cases the retention of urine may be overcome by the external application of wet, hot cloths to the genitals, or hot sitz-baths, or injections of hot (of course not scalding) water into the urethra. Therapeutic Hints. Aeon. Common cases, especially in children, with frequent unsuccessful urging, crying, screaming, and putting the hands to the genitals; no dis- 6l8 RETENTION OF URINE. charge, or scanty, dark and turbid discharge. Also in cases of hemor- rhoidal patients, when there is great pain and burning and the urine passes off only in drops, sometimes bloody. (Hering.) Apis. After repelled eruptions, with stinging, burning and itching here and there; abdomen is sore and tender to touch; chilly from slightest motion, worse in evening; heat without thirst; yawning, but sleepless. (Hering.) Arnica. After a fall or knock upon the back or region of the bladder. Bel lad. Stitching pain from the back into the bladder; in spells with great anxiety, restlessness and colic. It is followed well by Hepar, if it only relieves but not cures. (Hering.) Camphora. After the abuse of fly-blisters; also after measles. Cannab., Canthar. Inflammatory states of the bladder with bloody urine. Coloc. Thick, jelly-like urine, with labor-like pain in the abdomen, extending down into the thighs. Sepia. Retention and suppression of urine often occurring in fevers, when there is delay in voiding, after the desire is felt, along with scanty, muddy discharge, the sediment of which sticks to the vessel and the odor of which is abominable. (Edw. Cranch.) Sulphur. Often if Aeon, or Pulsat. have failed to relieve. ORGANS OF GENERATION MALE GENITALS. VENEREAL DISEASES. We understand by this term all those morbid affections of the genitals in particular, and of the whole system in general, which originate ex usu veneris in consequence of the absorption of a specific poison. The nature of this poison is as little known as that of smallpox, or of scarlet fever and measles; only that it is not volatile, but fixed to the morbid secretion. As to the rest, like either of them, it produces, when introduced into a healthy organism, a certain series of symptoms specific in their nature, by which pro- cess the same virus is produced anew, capable of further propagation. The principal forms caused by this specific contagion are: gonorrhea, chancre, and constitutional syphilis in all its various forms. It lies entirely beyond the limits of this work to go into any details in regard to the different views about the identity or non-identity of the venereal virus and its effects, as have been set forth in the last fifteen years by a num- ber of renowned syphilodologists. Their works alone would make up a small library. I shall merely give what seems to be the result of these contro- versies adopted by the majority at present. Gonorrhoea. We understand by it a virulent catarrh of the genital organs, which in appearance is entirely analogous to any other catarrhal inflammation of any of the mucous membranes; but which entirely differs from all the others by being the result of a specific virus, acquired during coition with an individual thus affected. The Exciting Cause is the gonococcus of Neisser, which is characteristic, being found grouped in the substance of the pus-cells and around the nuclei. Its seat is usually the fossa novicularis, and that portion of the urethra which lies back of the glans; sometimes, however, the inflammation extends further back to the bulbus, the membranous portion of the uretha, and even to the neck of the bladder. In women the inflammation and secretion extend over the vulva, vagina and urethra, sometimes spreading even into the womb* Symptoms. — The first symptoms generally appear from one to two, 620 GONORRHOEA. rarely from six to eight days or more, after the infection. The)' consist of a tickling sensation at the orifice of the urethra and in the fossa navicularis. Soon there is an increased secretion of mucus in the urethra, which pastes the lips of the orifice together; the tickling changes into burning, and the mucus, at first transparent, becomes thick, whitish, j-ellowish, greenish, or even bloody, and more or less profuse. The orifice of the urethra is in- flamed and swollen; a tensive pain extends all along the urethra into the testicles and inguinal regions; micturition is very painful and frequent. Iu some cases, the so-called synochal or phlegmonous gonorrhoea, the in- flammation extends into the parenchyma of the glans, which appears dark- ened and swollen; and into the corpus cavernosum, with exudation, which forms ha^d places in the penis. This gives rise to the so-called Chordee, by which, during erections, the penis is bent either downwards or sideways. The urine can be passed only drop by drop, with the most intense pain and great strain. The discharge becomes still more discolored — dark or bloody, even ichorous; or it is not discharged at all, on account of the high state of inflammation. The prepuce is contracted and cannot be brought back over the glans — Phimosis; or it is contracted behind the glans, and cannot be brought forward — Paraphimosis. The inflammation spreads even to the neck of the bladder and the neighboring areola tissue, in consequence of which abscesses may form and break through the perineum, giving rise to fistula urinse. Other cases, the so-called indolent or torpid gonorrhoea, are attended with very little pain; and the only symptom, which is of an}- inconvenience to the patient is a more or less profuse mucous discharge. This indolent form is usually found in persons who have had the disease several times. It seems, that the system gets accustomed even to the most violent poisons, as may be seen in prostitutes. Yet, innocent as it seems, it is generally very obstinate, and is apt to become chronic; and if transferred to other per- sons not quite so hardened, it may cause the most virulent symptoms. In still other cases — the so-called erysipelatous gonorrhoeas — the glans and pre- puce are cedematously swollen and inflamed, as in erysipelas. The pain is not so great as in the synochal form, and the discharge is of a more watery, ichorous nature. Mild forms of acute genorrhcea are said to run their course in about five or six weeks; but most cases assume a chronic form and are then called Gonorrhoea secundaria or Gleet. This form is usually without pain; when there is any, it is a fixed pain in the fossa navicularis. The discharge is mostly watery, sometimes thick and yellowish. Usually there is only a single drop, and that to be seen in the morning; at other times the lips of the meatus urinarius merely stick together; sometimes, however, the dis- charge continues to be more or less profuse. This state of things may last, with various degrees of severity, for months, even years. In the female the symptoms of gonorrhoea are nearly the same; gener- ally, however, they are less painful, because the vagina, the part principally THERAPEUTIC HINTS TO GONORRHOEA. 62 1 affected, is wider and less sensitive than the urethra in the male. Still, in higher degrees of inflammation and when extending to the female urethra, the clitoris and the labia, it may become quite as painful. The discharge is then quite profuse and discolored, excoriating the external parts. Frequently it is associated with condylomata on the inside of the thighs and around the anus. Excoriations and ulcers also exist on the neck of the uterus, and sometimes the morbid process extends into the womb and ovaries, causing chronic catarrhal affections there. Its cause is, as stated above, an infection by a specific virus. Catarrhal inflammation of the mucous membrane of the sexual organs maybe brought on by a variety of causes — irritation by foreign bodies, sexual excess, coitus with menstruating women, or such women as suffer with acrid leucorrhcea. Even drinking new wine or sour beer may cause strangury and a gonorrhoea-like discharge. Such inflammations are of a much lighter nature, and cease in a few days without medication; but as we cannot dis- tinguish between a chronic gonorrhceal discharge and a mere acrid leucor- rhcea, it is ver} T well to know that a gonorrhoea-like discharge may be caused by a mere acrid leucorrhcea, if for nothing more than to preserve the peace of a family. The gonorrhceal virus is transferable by the muco-purulent discharge of a gonorrhceal patient whenever it comes in contact with the mucous mem- brane of the urethra or vagina of a healthy person. None are proof against the contagion, although some persons are more easily infected than others; and any one who has once had gonorrhoea is very liable to have it again. Therapeutic Hints. The number of recommended remedies for this complaint is great, but yet the curing of it is often a difficult task. For its very first stage Grauvogl has recommended Natr. sulph.; Jahr, Sepia; Wahle, Bryon.; Baehr, Merc. sol.; Kafka, Sulphur; a number of others, Cannab. Schiissler: Ferr. p/wspk., later Kali mur. and Kali sulph. In this, as well as in all other cases, we must closely individualize: Aeon. Inflammatory stage. Agave Americana. Excruciating, painful erection; chordee, stran- gury; drawing in the spermatic cords and testicles, extending to the thighs, so violent that he wishes to die. Ag?i. cast. Gleet, yellow purulent discharge; old sinners with sexual inability. Alum. P. S. Gleet. Ant. crud. Urine mixed with blood; suppression of urine. Apis. "Scanty, painful micturition, with a burning, stinging in the urethra, and a smarting in the meatus; prepuce swollen, perhaps cedematous; pus profuse . " ( Gilchrist . ) Arg. nitr. Burning in the urethra during micturition, with a feeling as though the urethra were swollen and sore inside; the last portion of the 62 2 THERAPEUTIC HINTS TO GONORRHCEA. urine remains in the urethra; discharge of blood and pus from the urethra; chordee; sensation as if the urethra were drawn into knots; swelling of penis; feverishness. Arscn. " Deficient discharge, but intense urethral inflammation, which seems to closa the urethra; intense heat and burning in the parts; urine scalding hot; the whole penis swollen without erection, and hot." (Gil- christ. ) Calc. card. Gleet, after Sulphur; fat, lymphatic persons. Camphora. Sticking together of the meatus; chordee; testicles relaxed; want of erections. Cann. ind. Priapism; chordee; involuntary erections and emissions; nymphomania. Ca?in. sat. Great swelling of the prepuce, approaching to phimosis; dark redness of glands and prepuce; light red spots on the glans, of the size of a lentil; inflammatory stage with all its painful symptoms, especially vio- lent burning in the urethra during and after micturition. Canthar. When the inflammation has spread to the bladder, with intense tenesmus; bloody discharge and soreness of the urethra during the flow of gonorrhoeal mucus; violent and very painful erections at night. Capsic. White discharge like cream; cutting, stinging pain in the urethra without, burning during micturition; chordee. Clemat. After great straining a few drops of urine pass awa} r , which is followed by a full stream without pain; after this sometimes dribbling of urine. Colchic. Scanty, dark, albuminous urine; constant urging with burn- ing in urethra when urinating; whitish, flocculent or purulent sediment in urine. Copaiva. Soreness, smarting, itching and swelling of urethra; purulent discharge; violet smell of urine; eruption like measles, or urticaria with great itching. Cubeb. Dark and reddish discharge as if mixed with blood; violet smell of urine; cutting and constriction after micturition. Doriph. Glans swollen and bluish-red; gleet. Ferrum. Gleet, painless discharge like milk. Ferr. phosph. Inflammatory stage. Fluor, ac. Gleet, little discharge during the night, which makes a yel- low stain on the linen; oily transpiration of the genitals with a penetrating smell. Gelsem. Whitish discharge; severe erections; burning when urinating; rheumatism; orchitis. Graphit. Gluey, sticky discharge at the meatus urinarius. Hydrast. Acute and chronic form; feeling of debility and faintness after each passage from the bowels. Kali bichr. A drop of urine seems to remain after micturition, which cannot be expelled and troubles for a long time. THERAPEUTIC HINTS TO GONORRHOEA. 623 Kali mur. Gleet combined with eczema (latent or visible); or a dispo- sition to glandular swellings. Mat i co. In acute and chronic forms — no particulars given. Mercur. When complicated with chancre; or in gleet, after Cannab., when the discharge is yello wish-green and purulent; discharge more profuse at night than during the day. Phimosis, bloody pollutions. Mezer. Gleet; hematuria during gonorrhoea; tearing pains from front to back. Millef. Swollen penis; discharge of blood and watery slime. Naphthalin. In a chronic case with cough similar to whooping-cough. (Haupt.) Natr. mur. After injections of nitrate of silver, in gleet; in gonorrhoea- like discharges from acrid menstrual discharges; cutting and burning after micturition. " Malarial combination; strong impulse of the heart; irregular or intermitting pulse by clear sounds of the heart; often great prostration, lameness of the lower extremities, especially in the knees; dejected, tearful mood, frequently changing; anaemic state with thirst, horripilations. All worse in the forenoon, better towards evening; pain in small of back, con- stipation, sleepiness during day; weak digestion; pain in stomach better from eating." (Kunkel.) Nitr. ac. In complication with chancres, balanitis and fig- warts; small blisters on the orifice of the urethra and inner surface of the prepuce, form- ing chancre-like ulcers; painful brown spots of the glans; after mercurial treatment; gleet; ulcerating buboes; condylomata. Nux vom. After the use of copaiva and cubebs, and after allopathic treatment, dull pain in the back part of the head; haemorrhoidal disposition; constipation; suppressed discharge, with swelling of the testicles; high living. Petj'ol. Chronic cases with stricture of the urethra; prostatitis; frequent emissions and imperfect erections; itching and humid eczema on scrotum, perineum, or between the scrotum and thighs. Petros. Troublesome tickling and itching in the urethra, with constant desire'to urinate, worse in the morning in bed; better when sitting or stand- ing, chronic cases; suitable for old persons; " intense, maddening, biting- itching, deep in the urethra, the patient being almost wild with it; and feels as if he must push some rough article down to the spot and rub it for relief. Profuse discharge, and chordee of common occurrence." (Gilchrist.) Phosphor. Gleet; every morning a drop of watery fluid at the orifice of the urethra, sticking its lips together; also in case of hypertrophy of the prostata. Phosph. ac. Gleet; every morning a few drops of a white discharge from the ueethra, and in the evening discharge of prostatic juice. " Similar to Thuja." (Kunkel.) Pulsat. In consequence of suppression of a gonorrheal discharge, swelling of the testicles and prostate gland; inflammation of the eyes. 624 COMPLICATIONS AND SE0UELLE. Sarsap. Rheumatism of the joints after suppression. Sepia. Gleet, no pain, no discharge, except through the night a drop or so, staining the linen yellowish; or milky or greenish discharge, attended with pain in the back; frequently quite important for women. Sulphur. The orifice of the urethra is red and feels hot; whitish dis-' charge; no pain, or some slight burning in the urethra; rheumatic pains; chronic inflammation of the eyes; chronic prostatic affections; hemorrhoidal disturbances; psoric cutaneous eruptions; gleet. Tarant. Chronic form; loss of memory; timidity; weakness; great nervous agitation; burning of soles of feet and palms of hands; shaking, twitching and incessant movements of legs, worse when quiet. Tereb. Chordee; gleet; gonorrhceal rheumatism. Thuja. Gleet; condylomata; prostatic affections; discharge thin and greenish; red spots and erosions on the glans; sudden stitches along the urethra from back to front; or a sensation as if a drop of urine were passing along the urethra with cutting pains; " dejected mood, prostration, weakness, lame feeling in lower extremities; sleeplessness. The next best following remedy is Phosph. ac." ( Kunkel. ) Besides these, a number of remedies are mentioned and praised by eclectics (see Hale's New Remedies), but without the slightest characteristic indications. COMPLICATIONS AND SEQUELS. 1. Epididymitis; Orchitis. Usuall}- only one side is affected at a time; but the inflammation some- times goes also to the other. The scrotum of the affected side becomes greatly enlarged, is hard, red, shining and very painful to the slightest touch or move; it is usually attended with fever, and follows either upon undue ex- ertions, taking cold, and most frequently after the suppression of gonorrhceal discharges by injections. Compare Agn. cast., Aurum, Bromium, Clemat., Hamavi., Mercur., Nitr. ac, Nux vom. t Phytol., Pulsat., Rhodod., Rhus fox., Tussil. 2. Prostatitis Gonorrhoica, Inflammation of the Prostata, Is of rare occurrence, and only in those cases in which the inflammation spreads to the neck of the bladder, or in consequence of suppression of the discharge b} T injections. It is attended with a sensation of heat in the peri- neum, in the region of the bladder and .towards the rectum, and with tenes- mus in bladder and rectum. It may end in suppuration and the formation of an abscess, which may discharge its contents into the bladder or urethra, or through the perineum, or it may end in chronic induration of the prostatic gland. Compare Mercur. , Nitr. ac. Phosphor., Pulsat., Selen., Sulphur, Thuja. GONORRHOEA VESICA. 625 3. Gonorrhoea Vesicae, That is, a transmission of the disease to the neck, or into the body of the bladder, consequent upon suppressing the discharge by injections. The pa- tient feels violent pains in the region of the bladder, the perineum and anus, with constant urging to urinate. By dint of the greatest straining, a few drops only of a turbid urine, mixed with blood and pus, are discharged. Main remedy: Canthar. Compare Cystitis. 4. Buboes. Inflammatory swelling of the inguinal glands, which generally grow very slowly, and are brought on either by overexertion or suppression of the discharge. Compare Iodium, Laches., Mercur., Nitr. ac. 5. Ophthalmia Gonorrhoica. One of the most dangerous inflammations of the eyes. The infection may be caused either by the direct contact of the poison with the eyes, by means of the fingers or soiled handkerchiefs, or by metastasis. Compare Aeon., Arsen., Bellad., Hepar., Merc. sol. and subl., Nitr. ac. y Pulsat., Tussil. 6. Gonorrhoea of the Rectum. Pain in the rectum; mucous membrane inflamed; sphincter spasmodi- cally closed; discharge of purulent mucus mixed with blood. Compare Mercur., Nux vom., Pulsat., Sepia, Sulphur, Thuja. 7. Strictures of the Urethra. They consist of a fibrous or callous hardening of certain portions of the urethra, whereby the canal becomes narrowed and the passage of urine diffi- cult or altogether impossible. Their main seat is the membranous portion of the urethra and the fossa navicularis, although other parts may likewise adhere or become constricted in consequence of inflammation. The first and main symptom is difficulty in making water. The stream is thin, twisted, split and flows in jerks. The bladder cannot be fully emptied and there is a continued dribbling oT urine for a great while after micturition. They are caused frequently no doubt by the use of injections, misman- aged introductions of bougies, the long continuance of chronic gonorrhoea and excessive indulgence in sexual intercourse. Compare Clemat., Digit., Dulcam., Petrol., Pulsat., Rhus tox., Sulphur. Gradual dilatation by bougies. 8. Gonorrhoeal Rheumatism. It is sometimes acute, attacking muscles and joints, and sometimes chronic. It has been frequently observed to follow the use of copaiva bal- 40 626 GENERAL CONTAMINATION. sam, or the sudden suppression of the gonorrhoeal discharge by other means, and after taking cold. Those of a rheumatic or gouty disposition are, of course, the most subject to it. Compare Hepar, Mercur., Mezer., Phytol., Sarsap., Thuja. 9. General Contamination of the System in Consequence of Gonorrhoea. Although modern writers deny such consequences of gonorrhoea upon the whole system, there is not the slightest doubt that a suppression of it is followed in many cases, by severe and deeply-seated ailments. We find cases on record where its suppression brought on tuberculosis; in others dyspnoea, lasting for many years — until, under homoeopathic treatment, an old gonor- rhoeal discharge suddenly appeared again and the dyspnoea disappeared. Schcenlein, Autenrieth and others acknowledge this, whilst Ricord denies a specific gonorrhoea- virus altogether, which seems to be driving the thing rather to its smallest point, on which it cannot stand. Grauvogl, in his Pro- phylaxis, gives a whole list of constitutional disorders growing out of gonor- rhoeal poisoning, among which we find: glandular-like swellings upon the membranes of the brain, on the neck and tongue; in the axillae and ab- domen, and its viscera; deafness; paralysis and mental derangement, etc. The most important remedies which ought to be borne in mind, and which cover this gonorrhoeal contamination of the system, as Sulphur does psoric, and Mercurius syphilitic affections, are, according to Grauvogl, Natr. sulph. and Thuja. Balanitis, Gonorrhoea Spuria, or Praeputialis. This affection is a profuse secretion of mucus between the glans and prepuce, which is formed only in men with a long foreskin. It is sometimes associated with genuine gonorrhoea, but ma}' just as well originate from un- cleanliness, friction, coitus with women who suffer with acrid fluor albus. In most cases it is altogether an innocent affair, although at times it may be of a poisonous nature. Symptoms. — Itching underneath the prepuce, which appears red and moist. In a few days there appear heat, pain and swelling of the prepuce, with considerable discharge of a yellowish, purulent mucus. Sometimes it is very difficult to push the prepuce back, in which case the glans appears excoriated. If allowed to remain, ulceration and adhesion may form be- tweeti'the glans and the prepuce and cause considerable trouble. If of an innocent nature, it is easily managed by cleanliness and perhaps one dose of Mercur.; if it is in connection with gonorrhoea or chancre, it of course assumes the nature of its companions and requires the same treatment. Chancre. The name chancre is derived from cancer, meaning a corroding ulcer, with hard bottom and callous edges. Its seat is at the point where the poison CHANCRE. 627 gained access, in men chiefly the glans, prepuce, fraenum, front part of urethra, the penis external^, the scrotum, or the groins; in females the labia, vagina, urethra, or the neck of the uterus. But the poison may also be transferred to other parts, such as the lips, tongue, nipples, or fingers, if through wounds, cracks, or denudations, it can enter into the circulation. There are two theories about the nature of chancre-poison. The one maintains that all is but one kind, which may or may not produce constitu- tional syphilis; the other has tried to prove a duality of the chancre- virus, meaning that there are in realit3 T two totally different kinds of sores, of which each propagates only its own kind. These two different kinds of chancre have become known under the name of soft and indurated or Hunter's chancre. The soft chancre is according to this theory only a local affection, and inoculable upon the bearer, and upon others, both healthy and syphilitic, to an almost unlimited extent. It develops without incubation in twenty-four hours. Through resorption an irritation of the adjacent glands takes place, which has an acute inflammatory character and usually leads to suppuration, but is not followed b3^ constitutional syphilis. The pus of the glandular suppuration has the same properties as the chancre pus. The hard chancre produces and is produced by true syphilitic poison; it is, notwithstanding the assertions of Ricord, inoculable upon the bearer and upon others syphilitic, but produces then a soft chancre, to which Clerc, as Maratray had done before him, gave the name of "chancroid." Whether the poison of this chancroid, when communicated to a healthy person, is capable of producing syphilis, or only local sores, has not been positively de- termined. The syphilitic poison (of a hard chancre) when inoculated upon healthy subjects, causes after a period of incubation of three to four weeks, a papule, which gradually hardens or superficially ulcerates, or at other times immediately inflames and ulcerates, as in the soft chancre, being followed later by induration together with general syphilis. The minute anatomy of chancre does not show any marked differences between the two; the one thing common to both is a dense cellular infiltra- tion of the tissue of the cutis or mucous membrane. Induration, therefore, will not hold good as a positive distinction between the two, especially in the female genitals, where it may be very inconsiderable, even in so-called genuine hard chancres. Only if an affection is seen to begin as a papule, at a certain time after a possible occasion for infection, and afterwards gradually enlarg- ing, it may be considered as true syphilis; but if, following immediately after an infection, a pustule appears, with subsequent ulceration, which is, perhaps, afterwards neglected by the patient, or irritated in various ways, as by im- proper treatment, it should be classed under the soft chancres, but in such cases it is often impossible to decide whether it is a specific induration or a mere inflammatory infiltration, because the beginning of it has not come under observation; and if we add to this what has been stated before, that a syphilitic or so-called hard chancre or ulcer may originate immediately after 628 CHANCRE. infection like a so-called soft chancre, the diagnosis between the two becomes a complete conundrum. Neither hardness nor incubation prove to be entirely satisfactory. There remains only the subsequent development of constitu- tional syphilis for a distinction between the two; but then the chancre has usually disappeared, and our wisdom comes post festum. In praxi then the so-called soft and hard chancre resemble each other frequently very closely, at least while being under observation; but even if we consider the theory of duality of chancre poison as true above all doubt, this conviction can have no other use than to confirm pli3 r sicians who believe in mere local affections, in the bad practice of cauterizing, burning and slashing away, which is not in accord with the spirit of Homoeopathy. The external appearance of chancre varies. It may, as stated before, commence at the infected point as a papule or a pustule, which by degrees, en- larges, becomes harder, and at last ulcerates, secreting a gray, slimy pus, which adheres to the bottom. This sore at times remains quite superficial, at other times the middle of the tubercle becomes excavated, and at still other times the surrounding tissues become involved in a wide-spread destruction of tissue, when it is called phagedenic chancre. If sores form on the inside of the prepuce, or far back on the glans, it soon becomes impossible to retract the foreskin; the ensuing phagedenic process may possibly cause a destruction of the entire prepuce, and even of the glans, in a short time. On the mucous membrane of the female genitals chancres appear as simple erosions, which the patient hardly notices, with parchment-like thickening; real tubercular indurations are rare. From being constantly moistened and irritated when on the labia majora or minora, they are gradually transformed into moist hyperplastic growths — the condylomata lata. The syphilitic poison is contained in the primary ulcers, in the condylo- mata lata, in the blood of syphilitic persons, in the semen of a man with latent syphilis. Whether the milk, saliva, urine and perspiration of syphilitic per- sons be also carriers of the poison, is doubtful; but pathological secretions, such, for instance, as contained in the vaccine pustules, have, unfortunately, too often proved their infectious nature. The transmission of syphilis by inheritance, is another well established fact. It maj' be transferred by the semen to a healthy ovule; or bj- the ovule developed in the ovary of a syphilitic woman, or later during the time of gestation, if the mother acquires syphilis during that time. Whether syphilis be transmissible into the third generation, remains still an open question. Infection takes place when the syphilitic poison gets underneath the epi- dermis or beneath the epithelium of the mucous membrane of a healthy person. This may be effected in direct ways, by sexual intercourse, by kiss- ing, by wet-nurses, by vaccination, by obstetrical examinations; in mediate ways, by the use of articles which have been soiled by syphilitic poison, such as eating and drinking utensils, tobacco-pipes, cigar-holders, cigars, blow- pipes, surgical instruments, etc. CONSTITUTIONAL SYPHILIS. 629 The susceptibility to the syphilitic poison seems in some cases to be diminished by previous infection, but immunity to it is by no means so ab- solute as Ricord claimed; neither is inherited syphilis a shield against infec- tion. Age does not essentially modify the susceptibility to the syphilitic virus. For practical purposes there may be made a division of the symptoms of syphilis into groups, according to the order in which they gradually develop, if not checked by proper treatment. The first or primary stage comprises the gradual development of the local symptoms at the point of infection, and the indolent swelling of glands in the vicinity. Some six or eight weeks from the first appearance of the primary affection, signs of Constitutional Syphilis or general blood-poisoning make their appearance, frequently accompanied by an eruptive fever. These signs of the secondary stage consist of: " super- ficial eruptions of the skin and mucous membrane, distributed symmetrically over both halves of the body; falling out of the hair and disease of the nails; often anaemia; lymphadenitis universalis; irritative processes in the peri- osteum and interstitial cellular tissue of internal organs, which subside spon- taneously without loss of tissue," or terminate sometimes in permanent de- rangements of functions through adhesions and contractions. The duration of this stage varies from several months to a year, being followed by an intermediate stage of uncertain duration, during which the disease remains either entirely latent or shows itself from time to time in various eruptions upon the skin and mucous membrane, but of less extent and intensity than in the previous stage. The blood-poisoning still existing, is transmissible to the offspring. The tertiary stage is characterized by ' ' local affections, for the most part asymmetrical, often occasioned by external causes, and consisting in cell- growth, having a tendency either to disintegrate or to become encysted with caseous metamorphosis and new formation of connective tissue. Gummata of the various organs, ulceration, necrosis, and caries of the skin and bone. General state of nutrition usually, though not always bad." Its limits are uncertain; in some cases it may be mixed up with the secondary stage; as a rule, many years intervene between the infection and its outbreak; it at last develops into confirmed syphilitic marasmus, where irremediable changes, as amyloid degeneration, destructive caseous pneumonias, dysenteric and other ulcerative processes, have taken place. Therapeutic Hints for Chancre. Merc. sol. Ulcer the size of a pea on the glans near the frsenum; pain- ful itching, sore to the touch, and discharging offensive pus; or several painful ulcers on the glans, on both sides of the fraenum, bleeding easily on retracting the prepuce or handling the parts; pain in the inguinal region on 63O THERAPEUTIC HINTS FOR CHANCRE. walking or on pressure upon the parts; or, ulcer the size and shape of a small bean on the glans near the fraenum of some depth, and its base covered with a thin layer of yellow pus; painful to the touch; prepuce red and swollen. (A. Fellger.) Merc, cinnab. The ulcer on the glans is surrounded by a red-yellow- ish or red ring; there are lentil-sized red-yellowish, or scarlet-red spots on the glans and prepuce. (A. Fellger.) Also in old, neglected or badly treated indurated chancres, Prccc. rub. was of no avail; elevated chancres; exuberant granulations of the base of the ulcers; hard, callous, raised, indolent edges of the ulcer; mucous condylomata on the genitals, anus and lips; indolent buboes. Merc, prcec. rub. When Solubilis affects no change within eight or ten days; indurated, old, obstinate chancres; indurations after cauterization; excoriations on the glans; extuberances of the ulcers; inflamed buboes. Merc. prot. Painless chancres with great swelling of the inguinal glands, without disposition to suppurate; swelling of tonsils; affection of tes- ticles; also secondary eruptions. (J. H. McClelland.) Merc, biniod. Chancre and bubo particularly indolent; other symp- toms corresponding to the preceding. (J. H. McClelland.) Hard, red swell- ing of front of prepuce, appearing as thick and hard as a lead-pencil, with a hard chancre in its centre, entirely painless. (A. Fellger.) Merc. sub/, corr. Phagedenic chancre, secreting a thin, ichorous pus. Merc. ?iitr. In old obstinate cases; dry fig- warts on thread-like pedicles; soft, pointed condylomata. Mercury. Its oxide and chloride corresponds to chancres with steep, sharp cut edges; the bottom of the ulcer appears lardaceous; hard infiltra- tion of the surrounding tissue. (Von Villers. ) Arg. nitr. Little ulcers on prepuce, spreading and becoming covered with a tallowy substance. Arsen. Gangrenous degeneration with burning, restlessness and thirst. Caustic. Acrid, corrosive secretion or watery and greenish; complica- tion with eruptions, gout or scurvy. Cora//, rubr. Ulcers flat and extremely sensitive to touch, sometimes bleeding; chancres on any part of the penis, or scrotum, very sensitive to touch. (A. Fellger.) Hepar. Chancres secreting watery pus with diffuse borders and red bottoms, elevated above the surface. (Von Villers.) Is indispensable where Mercury has been abused. Kali bichr. When the ulcer is round and deep, as if chiseled out by a sharp instrument. Kreos. The prepuce becomes blue and black with haemorrhage and gangrene. Let the penis remain hanging in a vessel filled with water, which is medicated by a drop or two of the first or second dilution. Laches. The areola of the ulcer assumes a purplish color; phagedenic chancres. THERAPEUTIC HINTS FOR CONSTITUTIONAL SYPHILIS. 63 1 Nitr. ac. Ulcers are painful on slightest touch as if sticks were jagging them. (A. Fellger. ) Chancres with raised edges and a disposition to bleed easily and profusely; inclined to spread in circumference with tendency to fungous growth; pains as of splinters; corrosive discharge; buboes threaten to suppurate. (J. H. McClelland.) Chancres with rhagades, characterized \y\ fetor. (Von Villers.) After the abuse of Mercury; unpainful ulcers, with gray, wasted edges, easily bleeding; or superficial or elevated ulcers, with zig-zag edges; or ulcers with hard, callous edges; or ulcers with a dark bluish, dirty basis, covered with a crust from underneath of which ichor issues, or with exuberant granulations, forming a red, spongy basis, like raw flesh; mucous, moist and other condylomata, like cauliflowers or pin- heads on thin pedicles; or phagedenic, ulcerated condition of the entire surface; fistulous ulcer into the urethra; inflamed buboes. Silic. Excessive discharge, foul-smelling diarrhoea, bloody and thin; inflamed, irritable, sore, with unhealthy granulation. Sulphur. Chancres with boar-like hardness of the red and swollen prepuce; intermediate remedy in psoric persons. Thuja. Round, unclean, elevated ulcers, surrounded with redness, usually moist and painful; condylomatous excrescences. (A. Fellger. ) Moist condylomata; elevated ulcers, with exuberant granulations; after Nitr. ac, erosions on the female genitals, with abundant mucous secretions; erosions and rawness between the legs and on the sides of the scrotum; constantly oozing of moisture; ulcers on the penis, cavity of mouth and throat. Besides the following are recommended: Jacara?ida caraba, Myrica cerifera, Phytol., Sa?iguin. Therapeutic Hints For Constitutional Syphilis. — Arg. nitr. Chancre-like ulcer on the prepuce; urethra swollen, hard and knotty; sexual desire gone, the genital organs having become shrivelled; cock's-comb-like fig- warts around the vulva; horn-like excrescences. Arse?i. Gangrenous and serpiginous ulcers; tubercular syphilitic skin diseases. Asa/. Affections of the long bones with severe nocturnal pains. Aur. fol. and mur. After the abuse of mercury; secondary ulcers on the scrotum; nightly pain in the bone; swelling of the skull-bones; swelling of the periosteum of the forearms and shin-bones; caries of the roof of the mouth and nose; ulcers on the tongue; falling out of the hair and great nervous weakness; utter despair and prostration of soul and body; attempts at suicide. Badiaga. Whole convolutes of hard glandular swellings; buboes. Card. an. Buboes becoming phagedenic; gummata; skin tubercles. Card. veg. Suppuration of bubo; the parts are livid and mottled; partial falling off of hair, with furfuraceous desquamation; 3 T ellow skin; pain in liver and spleen; palpitation of heart. (J. H. McClelland.) 632 THERAPEUTIC HINTS FOR CONSTITUTIONAL SYPHILIS. Caustic. Fistulous ulcers; corrosive ulceration of skin tubercles; lupus; complication with gout and scurvy. Conii^vi. Syphilitic sarcocele. Coral/, rubr. Syphilitic erosions, exuding a thin, badly-smelliug ichor; constant trickling of mucus from the posterior nares into the fauces; smooth, copper-colored spots on palm of hand and finger. Coryd. Nodes on skull; ulceration of fauces; profuse secretion of mucus; fetid breath. Euphras. Old, broad condylomata at the anus, with much burning; especially at night. Ferr. iod. Recommended for mercurial cachexia. Fluor, ac. Skin tubercles on the forehead and face, even when ulcerat- ing; elevated red blotches on palms of hands; squamous eruptions on the body (psoriasis guttata); syphilitic erosions, mucous tubercles; exostoses and nightly pains in the bones. Guaiac. Tearing and stinging in the limbs; aching in the bones with swelling; tearing pains in the skull and bones of the nose; itching, tetter-like eruptions. Hecla lava. Destructive ulceration of the nasal bones. Hepar. After the abuse of mercury; falling out of the hair; painful lumps on the head, and nightly pain in the skull-bones; soreness of the nose on pressure, with red, inflamed eyes; eruptions around the mouth; ulcerated gums, with flow T of saliva; swollen tonsils and hard glandular swellings on the neck, with sticking when swallowing, coughing, breathing, or turning the neck, as though a fish-bone had stuck fast; suppurating buboes in the in- guinal region and axilla; green, slim}-, bloody stools; inflammatory swellings of the knees, hands, and fingers; ulcers, with nightly burning, throbbing and stinging, bleeding easily; nightly pain in the limbs, with chilliness; great nervous weakness. Iodium. Mercurial cachexia; salivation; ulcers in the throat; chronic buboes very hard. Kali bichr. Deep ulcer on the edge of the tongue; ulcer on the velum palati, eating through; fetid discharge from the nose; caries of the bones of the nose, with profuse purulent discharge from the nose; suppurating, soli- tary skin-tubercles, forming deep holes. Kali hydr. Bubo very hard with a curdy, offensive discharge, if sup- purating; thickening of the spermadic cord; ulceration of nose, mouth and throat with corroding, burning discharge; lancinating pains in throat; system depressed; effusion of serum into the cellular tissue; induration of liver. (J. H. McClelland.) After abuse of mercury; tuberculous pustules on the face; roseola on chest and extemities; discolored, large ulcers on the skin; swelling of the bones; nightly bone-pain; bloody stools, with tenesmus; falling out of the hair. Laches. Mercurial syphilis, with ulcerated sore throat, causing a con- stant provocation to cough, with retching; painful deglutition; regurgitation THERAPEUTIC HINTS FOR CONSTITUTIONAL SYPHILIS. 633 of drink through the nose; earth}-, yellowish appearance of the face, with small red blood-vessels shining through the skin; coryza, nose red and sore; terrible headache; nighly pain in the limbs. Lycop. Secondary, tettery-like eruptions and ulcers in the throat of a dark, yello wish-gray color; cough and hoarseness, from similar affection of the larynx; coppery eruptions on the forehead, and cachectic appearance of the face; dry, pediculated, painless condylomata on the sexual organs; nightly pain in the limbs during wet weather; low-spirited; desponding; nervous weakness. Mercurial preparations. Compare Chancre. Mezer. Mercurial syphilis, with or without affection of the bones; chronic sore throat; dark redness of the fauces; worse every winter, with burning dryness extending into the larynx; hoarseness; hawking of phlegm. Natr. mur. If the primary sores have been burnt by nitrate of silver or lunar caustic. Natr. sulph. Granulated inflammation of the inside of the eyelids; swelling and suppuration of the axillary glands; ulcer on the outer side of the thigh; knotty, wart-like eruption on the anus, between the thighs, on the forehead, scalp, back of the neck and chest; swelling of the ribs near the sternum; stiffness of knees, and cracking of joints; pain in the bones. Com- pare Thuja. Nitr. ac. Mercurial syphilis; tonsils red and swollen, uneven, covered with little ulcers of the size of a pin's head; soft palate, highly inflamed; deep, irregular-shaped ulcer on the edge of the tongue; foul breath; single, moist sores on the scalp, burning; suppurating pustules all over the face, with broad red circumference, forming crusts; large, soft protuberance on the wings of the nose, covered with a crust; brown spots on the glans, of the size of a lentil, peeling off; squamous eruption, like psoriasis;, hard, brownish, little knots on the scrotum and perineum, which suppurate. Petrol. Brown spots on the arms, neck, chest and lower limbs; falling off of hair; rheumatic stiffness of shoulders and ankles. (Bell.) Phosph. ac. Mercurial syphilis; ulceration of the lips, the gums, and the soft palate; swelling of the bones; pain in the bones; condylomata; car- buncle-like ulcers of the skin, with a copper-colored circumference. Phosphor. Falling out of the hair, leaving exposed ulcers on the scalp, implicating the cranial bones; syphilitic psoriasis in the palms of the hands and the soles of the feet; syphilitic roseola; squamous eruptions; mer- curio- syphilitic ulcers on the prepuce; bone-pain and exostosis. Phytol. Sore throat; ulcers on the genitals; severe pains in the arms and legs, from the elbows and knees down to the fingers and toes, with cedem- atous swelling of the affected parts; pain aggravated by motion and con- tact; feet and legs covered with pale, red spots, about the size of a dime; more scattered on the arms, face and neck; previous use of mercury. Psorin. Moist, itching and burning condylomata on the prepuce; sore corners of the mouth; dry, tetter-like eruptions in the hollow of the knees. 634 DIGEST TO CHANCRE AND CONSTITUTIONAL SYPHILIS. Sabina. Fig- warts with intolerable itching and burning; exuberant granulations. Sanguin. Roundish or oval, whitish and raised patches on the mucous membrane of the mouth, nose, prepuce and anus; a diphtheritic exudation, which, when wiped off, leaves a raw surface behind; congestion of the head; throbbing headache from the nape of the neck to the head; swollen veins in the temples. Sarsap. Mercurial syphilis; squamous eruptions; bone-pain. Sepia. Syphilitic erosions in women. Silk. Mercurio-syphilitic ulceration of skin and bones. Staphis. Mercurial syphilis; dry, pediculated fig- warts and mucous tubercles; nervous weakness. Stilliu. Extreme bone-pains; nodes on head and legs. Sulphur. Mercurial syphilis; itching ulcers, which are soon covered with a crust, discharging pus from underneath; cock' s-comb-like excrescences on glans, soft, spongy, easily bleeding; excoriations on the genitals, with burning; copper-colored spots on forehead; hard, large and inflamed buboes. Thuja. Erosions in the female genitals, with profuse gonorrhceal dis- charges; erosions between the thighs and on scrotum; in the fauces, with mucous tubercles; condylomata; tubercula mucosa; decay of teeth near the gums. Digest to Chancre and Constitutional Syphilis. Low-spirited, desponding: Lycop. , leaving exposed ulcers on scalp, Despair: attempts of suicide; prostration implicating the cranial bones: Phos- of soul and body: Aurum. phor. Nervous weakness: Aurum, Hepar, Lycop., Staphis. Eyelids granulated: Natr. sulph. Eyes red, inflamed: Hepar. fetid discharge from: Kali bichr. burning discharge from ulceration Congestion of head, with throbbing headache from nape of neck up to Nose red and sore, coryza: Laches. head: Sanguin. Headache, terrible: Laches. Tearing pain in skull and bones of of: Kali hydr. nose: Guajac. Nose, trickling of mucus from posterior Pains in skull-bones, in night: Hepar. nares into fauces: Corall. Painful lumps or nodes on skull: Coryd., , soreness of: Hepar. Hepar, Stilling. large, soft protuberance on wings of, Swelling of skull-bones: Aur. fol. and covered with a crust: Nitr. ac. nuir. , pains in bones of: Guajac. Single, moist sores on scalp, burning: , caries, ulceration of bones of: Nitr. ac. Aurum, Hecla lava. Knotty, wart-like eruption on scalp: , , , with purulent discharge: Natr. sulph. Kali bichr. Hair, falling out of : Aurum, Hepar, , roundish, whitish and raised patches Kali hydr.. Petrol. on mucous membrane of: Sanguin. , with fururceous desquamation: Carb. veg;. Face earthv, vellowish, with small DIGEST TO CHANCRE AND CONSTITUTIONAL SYPHILIS. 635 blood-vessels shining through the skin: Laches. cachectic: Lycop. , pale red spots on, and neck: Phytol. , tuberculous pustules in: Kali hydr. , suppurating pustules with broad, red circumference, forming crusts: Nitr. ac. , lupus: Caustic. Forehead, copper-colored spots on: Ly- cop. , Sulphur. and back of neck, wart-like erup- tions on: Natr. sulph. Temples, swollen veins on: Sanguin. Mouth, eruptions around: Hepar. , sore corners of: Psorin. Lips, ulceration of: Phosph. ac. — — , mucous condylomata: Cinnab. Gums, ulceration of: Phosph. ac. , , with flow of saliva: Hepar. , scurvy: Caustic. Teeth, decay of, near the gums: Thuja. Tongue, deep ulcer on edge of: Kali bichr. , , irregularly shaped: Nitr. ac. , ulcers on: Aurum. Tonsils swollen: Merc. prot. , hard, with stitching pain on swal- lowing: Hepar. , red, covered with little ulcers: Nitr. ac. Soft palate, ulceration: Phosph. ac. , , eating through: Kali bichr. , highly inflamed: Nitr. ao. Mucous membrane, roundish, whitish patches, wmen wiped off leaving a raw surface: Sa7iguin. , ulceration of, and throat: Thuja. , , with corroding, burning dis- charge : Kali hydr. Throat, lancinating pain in: Kali hydr. sore : Mezer. , Phytol. , ulcers in and salivation: Iodium. , , causing cough with retching: Laches., Lycop. Fauces, dark redness of, with burning dryness, extending to larynx, worse every winter: Mezer. , erosions: Thuja. , ulceration of: Coryd. , , and tettery-like eruptions of a dark, yellowish-gray color: Lycop. Phlegm, hawking of: Mezer. — — , profuse secretion of: Coryd. Deglutition painful, with regurgitation of drink through the nose: Laches. Breath fetid: Coryd. foul: Nitr. ac. Hoarseness: Lycop., Mezer. Cough from ulceration in larynx: Lycop. Liver indurated: Kali hydr. and spleen, pain in: Carb. veg. Stools foul-smelling, bloody and thin: Silic. green, bloody: Hepar. bloody, with tensemus: Kali hydr. Heart, palpitation of: Carb. veg. Genitals, chancres or ulcers on prepuce: Arg. nitr., Phosphor. * gangrenous: Arsen., Kreos. phagedenic: Laches., Merc. subl. co'rr., Nitr. ac, Thuja. secondary on scrotum: Aurum. on outer side of thigh: Natr. sulph. Basis exuberant: Cinnab., Merc, prczc. rub., Nitr. ac, Sabina, Silic, Thiija. red, elevated: Hepar. lardaceous: Oxide and Chloride of Merc. Basis covered with a tallowy substance: Arg. nitr. covered with a thin layer of pus: Merc. sol. dark bluish, dirty, covered with a crust: Nitr. ac Edges steep, sharp cut: Kali bichr., Merc oxide and chloride. fistulous: Caustic zig-zag, superficial or elevated ul- cers: Nitr. ac. hard, callous: Cinnab., Nitr. ac. raised, easily bleeding: Nitr. ac raised, gray, easily bleeding: Nitr. ac , diffuse, with red bottoms: Hepar. Areola of ulcer red: Thuja red or red-yellowish: Cinnab. purplish: Laches. Surrounding tissue hard, swollen: Merc, binj., Merc prase, rub., O.vidc and Chloride of Merc. , Sulphur. 636 DIGEST TO CHANCRE AND CONSTITUTIONAL SYPHILIS. with rhagades, characterized by fetor: Nitr. ac prepuce, black and blue, with haemorrhage: Kreos. , red and swollen: Merc. sol. TJlcers discharging excessively: Si lie. watery pus: Hepar. — offensive pus: Merc. sol. greenish, corrosive secretion: Caustic. thin, ichorous pus: Merc, sub I. corr., Nitr. ac. moisture: Thuja. easily bleeding: Corall. rub., Hepar, Merc, sol., Nitr. ac. painless: Cinnab., Merc. binj.,Nitr. ac. , Merc, pi'ot. painful: Merc, sol., Thuja. , as of splinters: Nitr. ac. nightly burning, throbbing, sting- ing: Hepar. sensitive to touch: Corall rub., Merc. sol. , Nitr. ac. itching: Merc, sol., Sulphur. Condylomata, fig-warts: Phos. ac, Thuja. — — , , and anus: Ciunab. , , at anus, old, broad, with burn- ing, worse at night: Fuphras , , with intolerable itching and burning: Sabiua. , , pointed: Mere. nitr. , , tubercula mucosa: Thuja. , , moist: Nitr. ac, Thuja. , , moist on prepuce, itching and burning: Psoriu. , , dry, pediculated: Lycop., Merc nitr., Staph is. Excrescences, cock's-comb-like around vulva: Arg. nitr. , on glans, easily bleeding: Sulphur. , like cauliflowers, or pin-heads on thin pedicles: Nitr. ac , horn-like: Arg. nitr. Spots, lentil-sized, red-yellowish, or scar- let-red on glans and prepuce: Ciunab. , , brown, glans peeling off: Nitr. ac. Erosions: Fluor, ac. , in women: Sepia: , , with abundant mucous secre- tion: Thuja. , exuding a thin, badly-smelling ichor: Corall. rub. ■ between thighs and on scrotum, with mucous tubercles: Thuja. Excoriations, with burning: Sulphur. on the glans: Merc prcrc. rub. Patches, roundish, whitish, raised, on prepuce and anus: Sanguin. Urethra swollen, hard and knotty: Arg. nitr. , fistulous ulcers in: Nitr. ac. Knots, hard, brownish, suppurating on scrotum and perineum: Nitr. ac Testicles affected: Merc prot. and genital organs shrivelled: Arg . nitr. , syphilitic sarcocele: Conium. Spermatic COrd thickened: Kali hydr. Inguinal region painful on walking or pressure: Merc sol. Buboes inflamed: Mercprcsc. rub., Nitr. ac. inflamed, hard and large: Sulphur. threaten to suppurate: Nitr. ac. suppurate: Carb. veg. in inguinal region and axilla: Hepar. axillary glands: , with curdy, offensive discharge: Kali hydr. without disposition to suppurate: Merc prot. indolent: Cinnab. chronic and very hard: Iodium. becoming phagedenic: Carb. an, , whole convolutes of hard glandular swellings: Badiaga. Bones aching: Guajac, Natr. sulph., Phosphor., Phosph. ac, Sarsap. nightly: Asa/., Aur. fol. and mur., Fluor, ac, Kali hydr. , swelling, exostosis of: Fluor, ac, Guajac, Kali hydr., Phosphor., Phosph. ac , of ribs near sternum: Natr. sulph. , ulceration of skin and: Silic Periosteum of forearms and shin-bones: Aur. fol. and mur. Limbs, pain in, worse from motion and contact: Phvtol. CONDYLOMATA, SYCOSIS. 637 , , nightly: Laches., Lycop. , tearing and stinging in: Guajac. , gout and scurvy: Caustic. Shoulders and ankles, stiffness in: Pet- rol. Hands and fingers, and knees, inflamma- tory swelling: Hepar. Arms and legs, pain and oedematous swelling: Phytol. Knees, stiff, and cracking of joints: Natr. sulph. Legs, nodes on: Stilling. Skin yellow: Card. veg. swollen from effusion: Kali hydr. , eruptions, secondary: Merc. prot. squamous, like psoriasis: Fluor. ac, Nitr. ac, Phosphor., Sarsap. , tetter-like, itching: Guajac. , , dry in hollow of knees: Psorin. , roseola: Phosphor. , on chest and extremities: Kali hydr. , spots pale, red on feet, legs, arms: Phytol. , spots copper-colored, smooth, on palms and fingers: Corall. , spots brown, on arms, neck, chest, lower limbs: Petrol . , blotches, elevated, red on palms: Fluor, ac. , knotty, wart-like eruptions on anus, between thighs: Natr. sulph. , tubercles: Arsen., Card. an. , on forehead and face: Fluor. ac. , , mucous: Fluor, ac, Staphis. , , ulcerating: Caustic, Fluor. ac , , , forming deep holes: Kali bichr. , ulcers, large: Kali hydr. , , carbuncle-like, with copper^ colored circumference: Phosph. ac. , ulceration of skin and bone: Silic. Mercurial syphilis cachexia: Aur.fol. and mur., Ferr. jod., Hepar, Iodium, Kali hydr., Laches., Mezer., Nitr. ac, Phosphor., Phosph. ac, Phytol., Sar- sap., Silic, Staphis., Sulphur. Cauterization, after: Merc prczc. rub., Natr. mur., Nitr. ac. Psoric persons: Sulphur. Merc, praec. rub., when Solubilis has failed. Cinnabaris, when Merc prcsc. rub. has failed. Natrum sulph., similar to Thuja. Besides, the following are recommended: Jacaranda caraba, Myrica cerifera. Condylomata, Sycosis, Fig-warts. These excrescences are a morbid growth of the skin and mucous mem- brane, or, better denned, of the subcutaneous and submucous cellular tissue. They are of different external appearance, according to their coating. When they are covered by the epidermis, they appear dry, hard, horny, like com- mon warts; when covered with thin epithelium, or when they are entirely bare and excoriated, they appear soft, moist and secrete more or less of a slimy, acrid, badly-smelling fluid. These latter are the genuine syphilitic condylomata or tubercula mucosa. Their forms are likewise various; some are flat, upon a broad basis; others are conical, growing on a pedicle; others appear like a cock's-comb. The flat fig-warts are chiefly found around the anus, between the glutseus muscles; on the perineum, scrotum, external skin of the penis, glans penis and on the external surface of the labia in women; whilst the conical and pediculated are usually found in the entrance of the vagina, on the clitoris and even far back in the vagina, and on the neck of the womb; in males on the interior surface of the prepuce; also between the nates. They some- 638 THE IXGUIXAL BUBO. times grow so luxuriantly that the whole vagina and interior surface of the prepuce is covered by them. A third kind is quite small, in the shape of pin-heads, which are generally found around the corona in men, and on the interior surfaces of the labia in women. In secondary syphilis they appear also in other localities, especially on the tongue, corners of the mouth, chin, face, forehead, eyelids, iris, scalp, meatus auditorius, axillae, nipples and be- tween the toes. Soon after the outbreak of this pest in the middle ages we read of condylomatous excrescences in the face, which were of a finger's length, and which caused for their bearers more ridicule than compassion. Therapeutic Hints. For the mucous tubercles the main remedies are: Cinnab., Sublim., Nitr. ac, Thuja. Fig-warts, when complicated with gonorrhoea, require Thuja, Sublim., Cinnab., Nitr. ac, Sulphur, Lycop. When complicated with chancre, Cinnab., Nitr. ac, Piwsph. ac, Staphis., Tluja. When flat, Magnes., Nitr. ac When exuberant, like cauliflowers or mulberries, Thuja, Staphis. When fan-shaped, Cinnab. When growing on pedicles, Lycop., Nitr. ac. When conical, Solub. When dry, Thija, Staphis., Solub., Sublim., Nitr. ac, Lycop. When moist, suppurating, Nitr. ac, Thuja, Sulphur, Euphras. When soft, spongy, Sulphur. When intolerably burning and itching, Sabina. The Inguinal Bubo Consists of a swelling of the inguinal lymphatic glands, with a tendency to form abscesses in consequence of venereal infection. As chancres may ap- pear on other parts than the genitals, so, also, may buboes appear in other parts; in the axilla, under the maxilla, on the neck. Buboes ma)* also form primarily (without previous chancre on the penis) by immediate absorption of the syphilitic virus. The period of time which elapses between the first appearance of chancre and that of bubo varies from eight days to six weeks. Svviptoms. — Before anything can be seen the patient experiences a painful tension in the inguinal region, which sometimes extends into the thigh, making walking quite difficult; soon after the patient feels feverish, chilly, and there appears a roundish swelling in the inguinal region, which is painful to contact and motion. It is usually hard, grows in the course of some days to the size of a pigeon's egg, and larger, and becomes dark red. If not arrested in this stage it soon commences to assume a more doughy feel, with painful throbbing; finally it fluctuates, breaks, and discharges a quan- tity of thick pus, which at last becomes watery; now it heals, either like any other abscess, or the wound assumes a chancre-like aspect, with hard, callous THERAPEUTIC HINTS TO INGUINAL BUBO. 639 edges. In bad cases it ma}' even assume a phagedenic or gangrenous form, and cause terrible destruction of the surrounding parts. All buboes do not run this acute course. The so-called indolent, torpid or atonic buboes form quite slowly, without pain or fever, and continue so until they reach a certain size, which they retain in a seemingly unaltered condition for weeks, or even months, until they finally suppurate and dis- charge. The so-called scirrhous bubo may remain for years in the same condition. Its Diagnosis is easy enough, if we ascertain the pre-existence of chancre. It may, however, be confounded with an incarcerated testicle within the abdominal ring; therefore Ricord advises first to count the tes- ticles before pronouncing an inguinal swelling a bubo. The inguinal glands ma}- swell from other causes. In children scrofulous swellings of these glands are not unfrequent. We shall, in some cases, no doubt, have to fall back on the history of the case, which may tax our skill in cross-examination. Therapeutic Hints. Apis. Red, hot, shining, swelling, with great stinging pain and sensi- tiveness. Arsen. When the open bubo assumes a greenish aspect. Aurum. After the abuse of mercury, with nightly pains in the bones. Badiaga. Bubo stone-hard and uneven, a conglomeration of indurated glands; violent stitching pain through it at night, as though a red-hot needle were thrust into it. Suppressed chancre by cauterization and mercurial oint- ments, leaving elevated and discolored cicatrices; general cachectic appear- ance and rhagades of the skin, here and there. Card. an. For hard buboes which threaten to suppurate; it causes re- sorption where there is even some fluctuation discoverable; old, maltreated buboes, cut open or cauterized, presenting large, terrible ulcers, with callous edges and a secretion of offensive ichor. Hepar. After the abuse of mercury, for open buboes, which do not heal, and when there is a psoric taint of the system. Kali hy dr. After mercurial treatment; ulcerating bubo, with fistulous openings, and discharge of dark, thin, offensive and corroding ichor; scrofu- lous individuals. Laches. Old protracted syphilitic mercurial buboes; hectic fever, sore throat and the most violent headache, either in the back or front of the head. Mercurial preparations. Compare what has been said under the chapter on Chancre. Nitr. ac. After the abuse of mercury, when Card. an. has not been sufficient to reabsorb the swelling, and especially if the still existing chancre presents exuberant granulations on its base. Sulphur and Silic. Are especially indicated for old, discharging buboes which do not heal, although other syphilitic symptoms have disappeared. Besides these remedies, there have been recommended Buboin, Phvtol., Sanguin. 640 SYPHILITIC SKIN DISEASES. Syphilitic Skin Diseases. The various affections of the skin in consequence of syphilis go under the name of Syphilides. Syphilides as a rule are characterized by a peculiar red color, which is perhaps best designated by the term " coppery red." It is most pronounced in persons with dark complexions; in persons with very pale, anaemic skin it may at first be wholly wanting, or appear only as the exanthem begins to wane with a yellowish color. The syphilides consist of a cellular infiltration proceeding from the blood-vessels; but developing only gradually and at different localities, they appear frequently in different forms, so that we see macules, papules, vesicles and pustules side by side in one person, at different stages of development, all of which may ultimately assume the form of ulcers. This polymorphous character, however, belongs not exclusively to syphilides, we find it also, though in a less degree, in eczema and scabies. Another characteristic mark of the syphilides is their annular form, similar to that observed in herpes circinatus. It is often very distinct, too, on the mucous membrane, especially on the tongue, on the hard and soft palate, and on the glans penis. Syphilides finally are characterized by an abscence of itching, or any other sensation, although exceptions do occur, especially when the exanthem comes on very acutely. The various forms of syphilides are: 1. The Macular syphilide, or Roseola syphilitica consists of a circum- scribed hyperemia with but slight infiltration, and appears in perfectly even, rose-colored, or darker colored spots, of a size varying usually from that of a lentil to that of a pea, with a roundish or irregular shape. After it has ex- isted for several days it leaves under pressure a yellowish stain, and gradually assumes a coppery hue. When the spots are elevated it is called erythema papulatum. Roseola syphilitica is usually the first of all skin affections, and some- times the sole eruption that occurs during the earlier course of the disease. It may appear in only a few spots upon the sides of the chest and in the groin, and again it may be disseminated over the whole body like an erup- tion of measles. 2. The Papular syphilide consists of a circumscribed infiltration of the papillary bodies of the cutis. It varies from the size of a barley-corn to that of a split pea, and in color from red to brownish-red; it is hard to the touch, but smooth upon the surface. Later its epidermis loosens and is rubbed off when its summit presents a dark and shining appearance, which again is covered by a thin crust from the oozing of a little serum. In the palms of the hands and the soles of the feet the papules are not very prominent on account of the thickness of skin, but they appear only as red circular spots, which become denuded of their epidermis, and which are usually designated bv the name psoriasis paimaris and plantaris. SYPHILITIC SKIN DISEASES. 64 1 The papular syphilide may appear anywhere upon the surface of the skin, but is mostly seen on the borders of the scalp, on the forehead (corona veneris"), on the back of the neck, especially in women, and in all places where the skin forms folds or depressions, for instance on the chin, between the nose-wings and cheeks, behind the ears, on the borders of the axillae, in the elbows and in the hollows of the knees. Where these folds of the skin are in continual contact with each other, for instance on the external female organs, the scrotum, beneath the dependent breasts, in the navel, about the anus, at the preputial orifice, the angles of the mouth, between the fingers and toes, these papules are very apt to assume the form of condylomata lata. The eruption of the papular syphilide is often attended with fever, thus simulating somewhat an outbreak of smallpox, wherefore syphilis received from the French the name of verole grass or verole. It is either one of the first constitutional signs of syphilis or develops gradually from a roseola syphilitica, or does not appear until some weeks after this has disappeared. It is often accompanied by violent pains in the bones or iritis. 3. The Squamous syphilide consists of a coalescence of several pap- ules, or a gradual enlargement of a single papule with desquamation of the epidermis, thus bearing close resemblance to the patches of a common psoria- sis. However, it is covered, especially towards the borders, with loose epi- dermic scales, or rather thin yellow crusts, by which it may be distinguished from the white thick desquamation of psoriasis vulgaris. Besides, it does not appear on the knees or elbows, which is the favorite seat of common psoriasis. The squamous syphilide also becomes transformed into flat condylomata in favorable situations. 4. The Lichen syphiliticus consists of an infiltration of the follicular walls, with scanty, or no exudation in the follicles. In their simplest form they resemble those enlargements of the follicles which occur in many persons upon the dorsal surface of the upper arm, in consequence of an ac- cumulation and desiccation of the secretion, as hard granules like dried gum, which can be excavated with the finger-nail. The lichen appears usually in groups, at first slightly reddened, assumes soon a yellowish color, peals off and leaves no pigment spots behind (Miliary papular syphilide). When there is exudation into the follicle, groups of little vesicles form, which turn into pustules. These crust over and, after drying, leave small, dark scars behind (Herpes syphil.). Or the infiltra- tion spreads further around, and causes the entire surface of the skin, which was occupied by the papular group, to be converted into a desquamating, psoriasis-like group (Eczema syphil.). Or, there is an acute suppuration in the follicle in connection with the infiltration, causing acuminate pustules upon a red or copper-colored base (Acne syphilitica). This form is so similar to common acne that the distinction between the two must be based upon other syphilitic symptoms present or past. 5. The Pustular syphilide consists of an infiltration with subepithelial 4i 642 SYPHILITIC SKIX DISEASES. suppuration and superficial ulceration. The pus in these eruptions is not situated in the follicles, but underneath the epidermis, independently of the follicles. The pustules develop rapidly in places where the skin is tender, namely, beside the face, in the flexor surfaces of the extremities, on the sides of the trunk, and in the palm of the hand where there are no follicles. They are also more superficial and leave only very shallow depressions, even im- mediately after the crusts have fallen off (Pemphigus syphiliticus). Some- times the epidermis is raised by a cloudy fluid, which soon becomes purulent and is often tinged with blood, over a reddened base. Such bullae appear in isolated spots, in preference on the legs below the knees (Ecthyma syphiliti- cum). After desiccation there forms at times superficial excoriations beneath the scabs, and at other times deep ulcers, which extend at the edges and oc- casionally assume a serpiginous form (Ecthyma superficiale and profundum). It is a manifestation of the later periods of syphilis and an evidence of a poor constitution. When the epidermis of a bulla forms a scab, while the ulcerative process underneath advances slowly beyond its edge, there gradu- ally is produced a large, dirty, brownish-green, stratified crust in the shape of a cone, which rests upon a flat, ulcerated surface (Rupia syphilitica). Such ulcers, proceeding from rupia, may continue to extend for years, and convert extensive tracts of skin into cicatricial tissue. Rupia is often manifestation of the later periods of syphilis, though it ma}' break out within the first six months after infection. 6. The Tubercular syphilide consists of deep infiltration and disinte- gration, or a gummous formation. At the commencement only a papule is felt in the skin, without redness. Gradually the papillary body becomes likewise involved, and the tubercle approaches the surface, when it causes redness of the skin, desquamation of the epidermis or scanty serous exuda- tion, which, on drying, forms a small crust upon the summit of the tubercle. These tubercles often develop in groups of a circular or semi-circular form (Dry tubercles). Or, the epidermis above the tubercle is raised in the form of a pustule which quickly desiccates, while underneath ulceration pro- ceeds, simulating a rupia or assuming at once the form of a serpiginous ulcer. Or, the process of softening ma}* be similar to the development of a furuncle; it generally becomes bluish-red, and when it breaks discharges a grayish- yellow, gummy-like matter, instead of a core of connective tissue, as in the true furuncle. The remaining cavity gradually either granulates and cica- trizes, or enlarges and assumes a serpiginous character (Softening- and disintegrating tubercles). These forms of the syphilitic tubercles present a marked similarity to different forms of lupus, whence the name Lupus syphiliticus. The tubercular syphilide belongs to the tertiary group of syphilis. 7. The Loss of hair, Alopecia, occurs without any visible change in the skin. The hair merely loses its lustre, becomes dry, and often discolored, and falls out in large quantities when combed. It is an early symptom of constitutional syphilis, but may not occur until in the later stages. SYPHILITIC AFFECTIONS OF THE MUCOUS MEMBRANES. 643 8. Alterations of the nails, such as growing thinner, becoming fur- rowed or brittle, may take place without any obvious affection of the matrix; but deformities of the same may also be brought on by various syphilides attacking the matrix. Therapeutic Hints. Mercurial preparations. Nitr. ac, T/iuj'a, Aurum, Lycop., Staphis., Kali hydr., Laches., Sulphur, Hepar, Sarsap., Petrol., Cuprum, Corall. rubr., Arsen., Graphit., and many more. Syphilitic Affections of the Mucous Membranes. Some of the just described syphilides may also affect the mucous mem- branes, for instance: The Erythematous syphilide occurs in the throat in the form of a diffuse redness, sometimes accompanied by a slight oedema of the mucous membrane. The Papular syphilide appears as moist or mucus patches in the mouth and throat, bearing the greatest resemblance to the effect produced by a very superficial cauterization of the mucous membrane by nitrate of silver. Upon the tongue the S3?p>hilitic papule forms usually round level spots which often enlarge in circumference while receding in the centre, and thus assume the annular form. The same occurs on the hard palate. In the female genitals and in places where surfaces lie in contact with each other, the mucous patches become flat condylomata, which often are converted into condyloma- tous ulcers, simulating closely the primary affection. The secretion of the flat condylomata is in the highest degree infectious. The Squamous syphilide also becomes often transformed, in favorable situations, into flat condylomata. The Ecthyma is often accompanied with aphthous-like sores in the mouth, deep ulcers of the tonsils, or destructive ulcerations upon the soft palate. The Syphilitic tubercles of the mucous membrane of the mouth and throat are usually not seen until ulceration has taken place. The ulcers have sharply cut edges, a yellowish purulent base with great swelling and redness around them; they spread often extensively upon the posterior pharyngeal wall; they occur also in the large intestine, especially in the lower part of the. rectum and in the trachea. Therapeutic Hints. Mercurial preparations, Aurum, Kali bichr., Kali hydr., Laches., Lycop., Mezer., Nitr. ac, Sanguin., Thuja. Syphilitic Affections of the Periosteum, of the Bones and Carti- lages. They are always attended by severe pains in the bones, of a boring, grinding nature, and always worse at night from evening till towards morn- 644 SYPHILITIC CONTRACTIONS. ing, when, with a slight perspiration, they usually abate. Gradually a struc- tural change is observable; the % periosteum commences to swell, forming so- called tophi, and when the inflammation spreads to the bones, causing swell- ing of the bones (exostosis), which may terminate in necrosis and caries. Such structural changes attack the skull-bones, which, when they are on the inside, ma}* cause convulsions, paralysis, amaurosis and deafness. Those which attack the bones of the nose cause horrible disfigurations of the face. It also attacks the vertebrae, destroying portions of them, and the cartilages, although not so frequently. The cartilage of the nose is destroyed as well as the bones, and so have the cartilage of the sternum and the cartilages of the larynx been found destroyed. Therapeutic Hints. Pain in the bones: Arsen., Aurum, Fluor, ac, Guaiac, Laches., Mer- cur., J\Iezer., Nitr. ac, Phosphor., Phosph. ac., Phytol., Staphis., Stilling. , Sulphur . Tophi and exostoses : Asa/., Aurum, Fluor, ac, Lycop., Mezer., Phos- phor., Phosph. ac, Ruta, Sabina, Silic, Staphis., Sulphur. Caries and necrosis: Asa/., Aurum, Calc carb. and jod., Fluor, ac, Hepar., Kali hydr., Lycop., Mercur., Mezer., Nitr. ac, Phosphor., Silic, Sulphur. Syphilitic Contractions of Muscles and Tendons. These take place in rare cases, where the syphilitic virus attacks the muscles and tendons, causing plastic exudation within and around them, and thus shortening them. Gummata in the Subcutaneous and Submucous Cellular Tissue. These usually form at a later period, and appear as little, painless, mov- able kernels under the skin. They grow slowly and commence finally to suppurate, leaving deep, cicatrized holes, or chronic ulcers. Arsen., Aiwum., Bellad., Calc carb., Carb. veg., China, Graphit., Mer- cur., Mezer., Phosph. ac, Plumbum, Ruta. Syphilitic Affections of Inner Organs. a. Brain affections. They manifest' themselves in various ways, as, violent headaches, hemicrania, sleeplessness, dizziness; or as hemiplegia, im- becility of mind, amaurosis, deafness, epilepsy, catalepsy, and are caused either by chronic inflammation of the membranes, or formations of tubercu- lar masses, or syphilitic exostoses on the inner plate of the skull-bones. The diagnosis is difficult. We may suspect such changes, if we find a right to do so from the history of the case. b. Lnng Affections set in frequently in consequence of suppressed chancres, either as ulcerative processes, as bronchitis and asthma. c. Liver, Spleen, Intestinal Affections are of varions kinds and have been spoken of under the corresponding chapters. SYPHILIS CONGENITA SIVE HEREDITARIA. 645 Syphilis Congenita sive Hereditaria. In some cases the child is detroyed by syphilitic infection while yet a foetus; or it may be born alive prematurely; or be still-born at full term; or be born at full term apparently healthy, when some time afterwards the consti- tutional taint develops itself. The infection ma} 7 have been transmitted, as stated before, by the semen, by the ovule, or later during gestation. The more recent the syphilis in the parents at the time of conception, the greater will be the liability to abortion. When the foetus dies in utero, it is usually born in a state of maceration; if carried nearly to its full term, it shows the syphilitic'signs either on the surface of the body, or in internal organs, and invariably in the epiphysis of the long bones, where the cartilage layer is enlarged and softened, the zone of ossification is thickened, projecting with irregular prolongations into the cartilage layer, whereby the union of the two becomes less firm, so that the epiphysis is liable to separate entirely from the shaft of the bone, or the rib from its cartilage. When the child is born alive, it usually is small, undeveloped and pre- sents a peculiar oldish appearance, has a weak, plaintive voice, a stoppage of the nose, sore corners of the mouth, and its skin is either already covered with a rash, or shows, in a few days, papules or pemphigus. Such children perish in a short time from diarrhoea, or suppurations with all signs of marasmus. Sometimes the only apparent symptom of a seemingly healthy child is a nasal catarrh with stoppage of the nose, and coincident with it or following soon after a macular, or oftener a papular eruption, which may be limited to a few bright red papules upon the buttox, or cover the entire body, but especially the face, acquiring by degrees the coppery tint. By and by the nasal discharge becomes purulent and excoriates the neighboring parts, and in the mouth and throat mucous patches appear. Bad cases soon lead to destruction; mild cases ma} 7 improve, but develop a most striking depression or flattening of the nasal ridge and a marked prominence of the frontal pro- tuberances with symptoms of hydrocephalus. The children become very restless, cry a great deal, especially at night; later manifest themselves a want of proper intellectual unfoldment and striking idiosyncrasies of charac- ter, and the upper permanent incisor teeth appear as if they were scooped out at their lower surface. The outbreak of these symptoms is very uncertain; the latest period, as stated by different observers, is at from one week to several months, occurs most frequently, however, from the fifth to the eighth week after birth. The sooner the symptoms appear, the worse for the child. If it live through the acute stage there may occur, commonly during the period of the second den- tition, or at the time of puberty, especially in girls, another train of symp- toms of which may be mentioned: interstitial keratitis, eruptions, serpiginous ulcerations of the skin, or affections of the bones, epilepsy, chorea, paralysis. The treatment find under Constitutional Syphilis. 646 DISEASES OF THE TESTES. DISEASES OF THE TESTES. Hydrocele. The testicles and epididymis are enclosed within a serous membrane, like the peritoneum, from which, in fact, it is a mere continuation. As such, it is a closed sac, and consists, like the pleura and the peritoneum, of two layers, the tunica vaginalis propria and the tunica vaginalis reflexa. Like all serous membranes, it is liable to exudation, and if that takes place, it constitutes what is called hydrocele or dropsy of the scrotum. It is either a symptom of general dropsical disposition, in consequence of hydraemia, as found in old age, or in consequence of tuberculosis or other chronic diseases, corresponding entirely to hydrothorax and ascites; or it is the result of some inflammatory or mechanical irritation, in consequence of orchitis, urethritis, or in consequence of external injuries — a bruise, a fall, a kick, etc. , as found in otherwise healthy and young persons, even in children, and then it corresponds to pleuritic and peritoneal effusions. This latter may become chronic, and the secretion of serum continue so that the swelling attains the size of a head. The scrotum then appears smooth, tense, glisten- ing; the testicle is compressed, becomes atrophied, and may gradually dis- appear; then it presents the appearance of a transparent bladder. In con- sequence of undue irritation, the testicle may grow larger, become indurated, form into cysts; the exuded fluid may coagulate, become turbid by the ad- mixture of blood or pus globules; adhesions may form, etc. All these are circumstances by which the original nature of the disease may become deeply concealed. The exuded fluid consists chiefly of a colorless, clear or yellowish fluid, which, however, now and then becomes turbid by admixture of pig- ment, blood, fibrine, fat, mucus, epithelium and semen, so that it assumes different colors, greenish, dark green, brown and even black. The presence of semen is a remarkable phenomenon, the solution of which has been found only by the latest researches of Luschka, on the ap- pendages of the testicles. According to Luschka, there is, under the head of the epididymis, a roundish vesicle of the size of a pea, w T hich stands in im- mediate connection with the seminiferous tubuli of the epididymis. It there- fore almost always contains seminal fluid. The vesicle or cyst now seems, under certain circumstances, to enlarge to such a degree that it forms an en- cysted, spermatic hydrocele; or it bursts, and diffuses its seminal fluid into the already-existing collection of serous fluid. In an ordinary hydrocele, the testicle always lies in the upper and pos- terior part of the scrotum, whilst the lower cavity of the scrotum is filled with the respective fluid. In exceptional cases, however, a previous inflam- mation may have caused adhesion between the testicles and the lower part of the scrotum; then, of course, the testicle is fastened down and the collection of fluids gathers above it. It is well to bear this in mind. The diagnosis rests on these points which have been detailed. In external appearance it ORCHITIS. 647 resembles mostly a scrotal hernia; but is easily distinguished from it, if we compare the history of both; the neck of the hernia, which is traceable into the abdominal ring; the impulse which is felt in the hernia when coughing; the symptoms of strangulated hernia, etc. ; so that hesitation between the two is scarcely possible. Hydroceles which are dependent upon a general hydremic state of the blood must be treated with reference to this whole general state and its symptoms. Hydrocele, in consequence of a blow, require Arnica, Coninm, Pulsat. Those of unknown causes, Apis, Aurum, Calc, card., Digit., Graphit., Iodium, Kali hydr., Mercur., Psorin., Pulsat., Rhodod., Rhus tox., Silic, Sulphur. Orchitis, Inflammation of the Testicles. Pathologically speaking, the inflammation may attack the testicle itself, or the epididymis, or their lining, the tunica vaginalis. It may be caused either by external violence or by an extension of in- flammatory processes of related organs, such as the prostata, the neck of the bladder, the urethra, or, what is most frequently the case, by gonorrhoea or syphilis. There is also an orchitis caused by a metastasis in parotitis or mumps. The product of inflammation is either : 1, A serous exudation, especially in epididymitis and vaginalitis, and it is the same thing with the above- described acute serous hydrocele; or, 2, A fibrous, plastic exudation, which causes infiltration, swelling and induration of the epididymis; or, 3, A serous hemorrhagic exudation in acute specific inflammations; or, 4, A purulent exudation, which takes place in the parenchyma of the testicle itself. The plastic exudation generally gives rise to chronic enlargements of the epididymis, which may reach a considerable size and hardness. The purulent exudation may be reabsorbed, or may form abscesses, which gradually break through the scrotum. Such abscesses heal only very slowly, usually forming fistulous openings. A genuine orchitis very much resembles an incarcerated scrotal hernia. The pain is very acute, running along the spermatic cord, causing colicky pains and vomiting. We have in such cases to ascertain where the swelling commenced. In orchitis it grows from below upwards; in hernia it comes from above down. Sarcocele, Hydrosarcocele is a chronic inflammation of the testicles, with infiltration of the parenchymal substance, in consequence of which the tubuli seminiferi become obliterated. It is slow in growing, usually without pain, and may involve the epididymis or start from it. In appearance it is an inelastic, smooth, oval tumor which, upon pressure, does not show an}' sensitiveness so natural to the healthy organ. In the later stages of its de- velopment it is sometimes accompanied with an effusion within the tunica vaginalis, constituting wjiat is called hydrosarcocele. It may be the result of 648 CARCINOMA TESTIS. an incomplete resolution of an acute orchitis, or the consequence of gonor- rhoea. The syphilitic form often attacks both testicles, one after the other. Therapeutic Hints. Inflammation in general: Aeon., Arnica, Aurum, Bellad., China, Clemat., Euphras., Mercur., Nuxvom., Pulsat., Rhodod., Rhus fox., Staphis., Spongia., Zincum; from bruises: Arnica; Baryta, Pulsat., Zincum; from taking cold: Cle?nat.; Pulsat., Rhus tox.; from gonorrhoea; Cannab., Clemat., Gelsem., Me) cur., Pulsat., looking bright red: Bellad.: dark red: Euphorb., Rhus tox.; chronic hardeaing and swelling: Arsen., Aurum, Baryta, Bellad., Calc. carb., Carb. an., Clemat., Conium, Graphit., Iodium, Kali carb., Kali hydr., Lycop., Nitr. ac, Plumbum, Spongia, Thuja. Carcinoma Testis. The most frequent form is the medullary cancer, which generally attacks young persons, even children. The fibrous cancer, or scirrhus testi ., is found more in old age. Cancer usually attacks but one testicle. Its causes are not known. Bellad. f Carb. an.? Co?iiumf Phosphor. ? Phytol.f Thuja? Varicocele. This consists of a varicose enlargement of the veins of the spermatic cord, epididymis and testicle, and gives rise to a knotty swelling, which feels between the fingers like a convolution of earth-worms. It gets smaller under compression or in a horizontal position, and enlarges again on standing up- right. It is almost always found on the left side, because the spermatic vein of that side has a longer and more tortuous course than that of the right side, and is also more liable to compression by accumulation of feces in the sigmoid flexure. The affection is therefore similar to the varicose state of the hemorrhoidal veins, and may have similar causes. In some cases it pro- duces no inconvenience; in others it is very troublesome, producing a draw- ing, dragging sensation, extending from the loins into the limb, especially w 7 hen walking or standing, and in hot weather; also weakness, prostration, paleness and great dejection of spirits. Arnica, Bellad., Calc. carb., Collins., Flour ac, Hamam., Eaches., Eycop., Nux vom., Pal sat., Sepia, Sulphur. Spermatocele Is a swelling of the spermatic cord and especially of the epididymis in con- sequence of a retention and collection of semen in persons who have been addicted to excesses in venere or masturbation, and suddenly stop this bad habit without being able to stop also their lascivious thoughts. The testicle is drawn up towards the abdominal ring, the epididymis and spermatic cord is swollen, and painful to touch, also on standing and walking. The penis is usually in a state of semi-erection. All may pass off in the course of sev- DISEASES OF THE PROSTATA. 649 eral hours, when the mind is differently employed, but the swelling may become stationary by frequent repetitions, and then it is often accompanied with varicocele. Pulsat. Is often of use, also cool sitz-baths. DISEASES OF THE PROSTATA. Prostatitis, Inflammation of the Prostate Gland. Primarily it is of rare occurrence, but it is occasionally brought on by traumatic causes, as a blow, riding on horseback upon a hard saddle, or by sudden suppression of perspiration, excesses in venere, masturbation. Secondary forms are much more frequent, and are then an extension of inflammatory processes from neighboring organs; for example urethritis, stone in the bladder, gout, rheumatism. Its most frequent cause, however, is gonorrhea, and the abuse of irritating medicines, like cubebs, balsam co- paiva, turpentine, etc. Symptoms. — Pain in the region of the neck of the bladder; heat, press- ure, throbbing in the perineum and rectum; frequent stitches from the peri- neum into the pubic and lumbar regions and down into the limbs. Constant desire to urinate, with annoying, sharp pains around the corona glandis; the urine, after long straining, flows slowly, drop after drop, a quantity remaining still in the bladder, and, therefore, micturition is never attended with a feeling of entire relief. Severe cases cause perfect retention of urine. The dis- charges from the bowels are likewise painful and difficult, especially hard stools, on account of the swollen and inflamed gland being pressed upon by the rectum, where it may easily be detected by the introduction of a finger per anum. In favorable cases prostatitis ends in resolution. Badly managed cases suppurate and form abscesses, which perforate, either into the rectum, bladder, or urethra, and discharge accordingly. Therapeutic Hints. Ar?iica. After injuries. Arg. nitr. Bellad. With severe pain, or Atroph. sulph. If Bellad. does not relieve. Mercur. For promoting resolution. Thuja. Bellad., Canthar., Hoysc, Sframom., in case of retention of urine. (Kafka.) Enlargement and Tumors of the Prostata. The gland may, in consequence of infiltration or deposition of tubercles, or calcareous substances, become in whole or in part enlarged. A total hypertrophy may reach the size of a fist or more, whilst the normal glands is not larger than a Spanish chestnut; it may be so uniform that the normal 650 THERAPEUTIC HINTS TO TUMORS OF THE PROSTATA. shape of the gland remains unaltered, or it may become quite considerably deformed. Partial hypertrophy alters in size and shape only single lobes of the gland. As the prostate gland surrounds the urethra, reaching, with its base, over the neck of the bladder, and with its anterior extremity to the pars membranacea of the urethra, it is obvious that an increase of its size or an alteration of its form must likewise modify the mechanical proportions and relations of the prostatic portion of the urethra, of the neck of the bladder and the ejaculatory ducts. For example, an uniform- enlargement of .the gland necessarily pushes the bladder further back and upwards, elongating, in this wa3 T , the involved part of the urethra quite considerably, which ex- plains the fact, that in old people sometimes the neck of the bladder is only with difficulty reached by the catheter. The enlargement of the lateral lobe, or an irregular enlargement of both lateral lobes, causes irregularities in the direction of the enclosed part of the urethra, compressing it more or less here and there, thus forming a kind of zig-zag passage. Or the posterior part of the enlarged lobe presses into the bladder, and thus shuts the neck of the bladder inside, or gives it an oblique turn. The enlargement of the middle lobe or isthmus, which is the deformity most frequently found in old age, is capable of closing the neck of the bladder partially or entirely, and preventing the passage of urine in part or entirely. Symptoms. — An examination per anum reveals the swollen gland, and, on introducing a catheter into the urethra, we find more or less obstruction in its prostatic portion. There is difficulty in urinating, which is sometimes possible only in a stooping posture with legs spread asunder; dribbling of urine, and frequent discharge of prostatic fluid during stool. The form of alvine discharges is often flat or irregular, instead of being cylindrical. Old age is particularly subject to chronic enlargement of this gland. Therapeutic Hints According to Iyippe: Pulsat. Inflammatery origin, painfulness in the region of the bladder; frequent desire to urinate; dull stitch in the region of the neck of the bladder after micurition spasmodic pains in the bladder, extending to the pelvis and thighs; feces flat, of small size. Thuja. Syphilitic origin, especially suppressed, or badly treated gonor- rhoea; stitches in the urethra from behind; also from the rectum into the bladder. Digit. Fruitless effort to urinate, or discharge of only a few drops of urine, and continued fullness after micturition; throbbing pain in the region of the neck of the bladder during the straining efforts to pass the water; in- creased desire to urinate after a few drops have passed, causing the patient to walk about in great distress, although motion increases the desire to urinate. DISEASES OF THE VESICUL^ SEMINAEES. 65 1 Frequent desire to evacuate the bowels at the same time; very small, soft stools are passed without relief. Cyclam. In and near the anus and in the perineum, drawing, pressing pain, as from subcutaneous ulceration of a small spot, while walking or sitting. Selen. While sitting and also while walking, a drop of viscid, trans- parent fluid presses out of the urethra, occasioning a peculiarly disagreeable sensation; the same sensation is experienced shortly before and after stool. Caustic. Pulsations in the perineum; after a few drops have passed, pain in the urethra, bladder, and spasms in the rectum and renewed desire. Lycop. Pressing in the perineum, near the anus, during and' after mic- turition; stitches in the neck of the bladder and anus at the same time. Iodium. Hardness of the gland. (Kafka.) Copaiva bals. Urine is emitted by drops. Apis. Frequent desire and pressing down in the region of the sphincter. Discharge of prostatic fluid during a stool: Agnus cast., Alum., Anac, Calc. carb., Carb. veg., Conium, Cora/I., Hepar, Ignat., Natr. carb., Sepia, Silic, S tap his., Sulphur, Zincum. Fullness in the perineum: Alum., Berber., Bry on., Cydam., Nux vom. Sensation of heaviness in the perineum: Copaiva, Graphit. Pulsation in the perineum: Caustic. Continual desire to urinate: Amm. carb.\ndmur., Anac, Apis, Asar., Awum, Bellad., Canthar., Colchic, Copaiva, Digit., Guaiac, Ignat., Iodium, Mercur., Millef., Mur. ac, Phosphor., Pulsat., Scilla, Sepia, Sulphur, Sulph. ac, Thuja. Impossibility to urinate: Digit., Sepia. The desire to urinate continues after micturition: Bar. carb., Bovista, Bry on., Calc. carb., Carb. an., Caustic, Crot. tig I., Digit., Guaiac, Laches., Mercur., Natr. carb., Ruta, Sabina, Staphis., Thuja, Viol, trie, Zincum. While urinating, burning in the region of the neck of the bladder: Cha- mom., Nux vom., Petrol., Sulphur. The steam of urine is small: Graphit., Olea?id., Nitr. ac, Sarsap., Spongia, Staphis., Sulphur., Tax. bacc, Zincum. Difficulty in voiding the urine — must press a long time before the urine flows: Alum., Apis, Hepar., A T aphthal., Secale, Tax. bacc. Escape of urine involuntarily, drop by drop: Arnica, Bellad., Digit., Mur. ac, Petrol , Pulsat., Sepia. DISEASES OF THE VESICUL^E SEMINALES. The vesiculae are two little, oblong bladders, sometimes divided into two or three branches, which lie on the posterior and inferior surface of the blad- der, and consist of an external contractile and an internal or mucous mem- brane. They are receptacles of semen, whence the latter is ejaculated during sexual excitement. In consequence of their location near the bladder and 652 POLLUTIOXES NOCTURNE ET DIURNiE. their functional relation to the sexual organs, it frequently happens, tha affections of the bladder, urethra, prostata and testes are communicated to these vesicles. They are, like all mucous membranes, prone to inflammation and consequent derangements. Their morbid secretions mix with the semen, which loses its healthy appearance and nature. A clear diagnosis of such affections is seldom possible during life; although bloody, yellow, involuntary emissions, attended with acute, cutting and burning pains, may lead us to suspect the existence of inflammation in these vesicles. Pollutiones Nocturnae et Diurnae; Spermatorrhoea. Inasmuch as the seminal secretion of a healthy man may naturally be supposed to be a continuous one, it appears as a physiological necessity, that there should occur from time to time an overflow of semen involuntarily, when not irritated voluntarily by coition or masturbation. As long as such discharges happen at night during sleep, with erotic dreams, accompanied by erection and voluptuous sensations, and followed by a sense of relief and buoyancy, these nocturnal pollutions are certainly within the boundaries of health. They do not occur regularly even in the same individual, but vary greatly in frequency from temporary causes, or certain constitutional pecu- liarities. However, if they occur too often, say several times a week or oftener, and are followed next day by a general dullness and weakness, diminution and mental activity, etc., instead of buoyancy, they can scarcely be looked upon as health} 7 occurrences. This is still more so if they occur without erection and sensation in the night during sleep. But if they occur even in the daytime — "diurnal pollutions" — while the individual is awake, without the usual mechanical causes (coition or masturbation), from any trifling or external cause; for instance, from dallying with a female, riding on horseback, during evacuation of the bowels or bladder, or from lascivious imaginations, then there surely exists an irritation and weakness in the sex- ual organs which is pathological; for a healthy man never loses semen in- voluntarily when awake. Such diurnal seminal losses have also been termed Spermatorrhoea, a rather hyperbolic expression, as a continuous flow of semen scarcely ever exists. And it should further be stated, that very often inex- perienced young men, frightened by reading miserable and designing trash upon this subject, take for spermatorrhoea what is no flow of semen at all, but a secretion from the mucous membrane of the urethra, and perhaps also from Cowper's glands, or a prostatic secretion; neither of which contains any trace of spermatozoa, the only sign of true semen. The principal Causes of abnormal seminal losses are masturbation and excessive indulgence in venere. In both ways the frequent irritation not only produces an excessive irritability of the sexual organs and an undue stimula- tion for the secretion of semen, but also an intensive excitement of the nerv- ous system, which by degrees grows into permanent overexcitability, so that ejaculations at last are not only provoked by peripheral, but also by central THERAPEUTIC HINTS TO POLLUTIONES NOCTURNES. 653 stimuli, such as lascivious thoughts, etc. That actual degeneration of the spinal cord can be produced by sexual excess alone, is still to be proven. Further causes of abnormal seminal losses are: chronic inflammation of the neck of the bladder and the prostatic portion of the urethra, often pro- duced by suppressed gonorrhoea, in consequence of which a higher degree of irritability of the parts ensues; inflammatory affections of the bladder, but especially lithiasis; chronic inflammation of the seminal vesicles, especially when connected with gleet; great length and narrowness of the prepuce, which prevent thorough cleansing of the parts from smegma and promote undue ir- ritation; itching eczema on the scrotum or about the anus; habitual constipa- tion and hemorrhoidal tumors. The Symptoms which accompany abnormal losses of semen are not caused by them, but owe their origin to the same causes which produce them. Of these may be mentioned: a hypochondriacal mood, with despair of recovery, a dislike for society, and even suicidal thoughts, which are sel- dom executed for want of courage; or quarrelsomeness and irritableness; loss of energy and courage, depressed state of mind, impairment of memory; vertigo, headache; deafness and noises in the ears; indistinct vision; fatigue; stiffness in limbs and back; trembling in limbs; numbness along the spinal cord, in the lower extremities, or in the fingers; or hyperesthesia; coldness in the back or some other part; sometimes alternating with flushes of heat; palpitation, and shortness of breath; indigestion, with consequent disturb- ances of nutrition, such as paleness, emaciation, sallowness and dryness of skin; or pasty and bloated appearance; impotence. Now, this gloomy picture should not be taken as applying to all or even to single cases precisely; for happily these symptoms are only partially con- stant and severe in cases of abnormal pollutions. A hypochondriacal mood is perhaps the most common to all of them. The termination of spermatorrhoea in insanity or epilepsy is quite unproved. On the contrary, a hereditary disposition to insanity or epilepsy ma}^ be in many cases the cause of masturbation and the consequent sperma- torrhoea. The Prognosis depends upon its causes. Of these the local irritations are relatively the most favorable, while the psychical causes are deeper and more difficult to eradicate. Therapeutic Hints. First of all, remove the cause. This applies not only to sexual abuse, but also to those exciting causes above mentioned, w 7 hich ought to be found out by the physician and serve as leading symptoms for the selection of the remedy. Aur. met. or mur. Settled melancholy with suicidal mania; discharge of prostatic fluid from a relaxed penis, during stool or micturition; great sexual weakness with great lasciviousness; or strong erections which cease on the attempt to copulate; affections of the testicles and spermatic cords. Calc. carb. After pollution, headache and backache; cold, clammy 654 THERAPEUTIC HINTS TO POIXUTIONES NOCTURNE. hands and feet; scrofulous subjects; shattered constitutions; sweating from any little exertion, especially on head. Cinchona. Nocturnal emissions, frequent and debilitating; lascivious fancies; after masturbation. Digitalis or Digitalin. Great irritability and weakness of the genitals; after an emission a sensation in the urethra as if something were running out of it; frequent palpitation and trembling of the limbs; in conversation wfth strangers he commences to stammer and becomes embarrassed. Prostatic troubles. Gclsem. Weak, irritable sexual organs; emissions without erections, also during stool; genitals cold and relaxed; or profuse warm sweat on scro- tum; after suppressed gonorrhoea, orchitis, with dragging pains in the testicles. Graphit. Nocturnal emissions, with flaccid penis and without voluptuous sensation; sense of weakness in the genital organs; herpetic eruption on scrotum; after sexual abuse. Lycop. Excessive and exhausting pollutions, also without erection; afterwards burning in urethra; itching of inner surface of foreskin; soreness between the scrotum and thigh; constipation; haemorrhoids. Impotence, with cold and shriveled penis; after masturbation. Nux vom. After quack-medicine, wine or coffee; sluggish action of. abdominal organs; constipation; haemorrhoids; suppressed gonorrhoea; mas- turbation. Phosph. ac. Debilitating emissions from weakness of the parts, with onanism; during stool; hypochondriacal; distressed on account of the culpa- bility of his indulgence. Youths who grow fast and tall; herpes preputialis, with tingling; urine turbid, with heavy sediment. Sarsap. Nocturnal emissions, with lascivious dreams, followed by pain from the small of the back down along the spermatic cords, in the morning, with general prostration; or, great anguish of mind, inability to apply him- self to mental work; smoky mist before the eyes, when reading in the even- ing; prostration; soft, flabby muscles. The least excitement causes ejacula- tion of the fluid without sexual feeling. (J. B. Hunt.) Offensive odor about the genitals; herpes on the prepuce; gonorrhoea checked by cold, wet weather, or by mercury, followed by rheumatism. Selcn. Nocturnal emissions with lascivious dreams, followed by weak- ness and lameness in the loins. (J. F. Greenleaf. ) Semen thin without normal^odor; prostatic fluid oozes while sitting, during sleep when walking and during stool; itching of the scrotum. Silic. Aching in sacrum; sweat of scrotum; heat in head; burning of feet with sweat; weakness and heaviness of arms; melancholy; all worse in forenoon and before an emission, and relieved after an emission. (\V. P. Wesselhceft.) Thuja. Painful spermatic cord; suppressed gonorrhoea; renewed gonor- rhoea after coition; prostatic affections; impotence; heaviness and ill-humor after emissions. IMPOTENCE. 655 Zinc ox. With hypochondriasis, full of fears of the consequences; nervous system shaken; restless, sleepless and generally miserable. Besides compare: ( Arnica. When coition has been practiced in a standing position, lame weakness in lower extremities. Bellad. With gleet. Cap sic. Impotence; atrophy and coldness of the genitals. Card. vcg\ Heartburn, acidity and flatulence. Caustic. Memory deficient; continual loss of prostatic fluid. Cuprum. Great nervousness of young men; prematurely old; cramps in the calves of the legs and feet on trying to have a connection with a woman. Dioscorea. Kali brom. Want of sexual instinct. Kobalt. Lewd dreams; only partial or no erections. Mercur. After emission burning pain in the back and icy-cold hands. Natr. mur. Poor digestion and spinal irritation. Nuphar. Lascivious thoughts without sexual capacity. Phosphor. Nervous prostration; oppression and pain in chest; para- lytic or spasmodic symptoms in extremities. Picric acid. Sepia. Ejaculation too soon; semen watery; catarrhal affections; bloated and earthy -colored face. Sulphur. Erection complete, but discharge of semen before he succeeds in inserting the penis. Bloody emissions: Mercur., Cannab., Ledum., Sarsap. Impotence; Sterility in the Male. Impotence, a diminuition or complete loss of the power of sexual inter- course, is always associated with either incomplete, or two short, or entirely absent erections. It may be Caused by: certain congenital or acquired mal- formations and defects of the genital organs, such as: absence of the penis, or considerable diminution in its length, tumors of the penis, indurations and knots in the corpora cavernosa, loss of the testicles either by castration al- though cases are on record which show that the sexual act could be accom- plished after castration, (this quasi- virile power, however, diminished more or less speedily and finally disappears entirely), or such disease as is equiva- lent to their loss. It may be a symptom of certain acute or chronic diseases, such as tabes dorsales, spinal meningitis, diabetes; or the consequence of certain medicines, if taken in too large doses and indiscriminately, among which are best known: Camphor, Bromide of Potassium, Lupuline and Ar- senic. It may be produced by certain mental conditions, such as: bash- fulness, fear of failure, nervousness, or the absence of certain modes and ways to which they have become habituated with prostitutes and which they cannot indulge in with their wives. 656 THERAPEUTIC HINTS TO IMPOTENCE. A very prominent cause is sexual excess and masturbation, by which a functional weakness of the genital organs and of the nervous apparatus con- , nected with them is brought about, in consequence of which only short erec- tions, too short even for the introduction of the penis, so-called irritable weak- ness, or no erections at all, are possible under any circumstance, the so-called paralytic form of impotence. A man impotent is also sterile, that is unable to procreate, even if his semen should be of a natural quality, because he cannot locate it where alone it could fructify. But sterility has other causes; which are: 1. Aspermatism, which means not only a variety of conditions in which no semen is formed (as certain malformation or injuries of the genital organs, absence or malposition of the testes), but also those conditions in which the formed semen is not ejaculated, because its passage is barred by changes in the substance of the prostate, or in the ejaculatory ducts embed- ded in it, or in the urethra, from whence it is diverted into the bladder. The causes of this retention of semen are strictures of different places in the seminal passages produced by inflammatory processes mostly in consequence ot gonorrhoea, or wounds, or they are congenital. 2. Azoospermism, in which copulation with ejaculation may be possi- ble, but in which either no seminal bodies are produced, on account of an ab- normal state of the testicles, or in which they are retained on account of strictures in the passages which conduct the semen, in consequence of bilat- eral inflammatory processes of the epididymis and vasa deferentia, a condition similar to aspermatism, only that in the latter the stricture is lower down in the genital passages. Therapeutic Hints. Compare the preceding chapter, especially in regard to those transient forms: Agar., Agn. cast., Baryta, Ca/ad., Lycop., Natr. mur., Nitr. ac, Phospor., Selen. Among the new remedies: Eupat. pur., Gelsem., Hamam., Helon., Phy- tol., Stilli?ig. FEMALE GENITAE ORGANS. 657 FEMALE GENITAL ORGANS. Examination of the Parts. By means of palpation and percussion of the abdomen we may be able to detect the presence, shape and consistency of abdominal tumors, and aus- cultation will serve to distinguish between pregnancy and other large tu- mors; however, the so-called uterine souffle, which originates in the large arteries, is heard, but very seldom, in large fibroids, and also, but rarely, in ovarian tumors. The digital examination per vaginam consists of the introduction of the well-oiled forefinger through the ostium into the vagina, by which we ascer- tain the condition of the walls of the vagina, whether they are dry, moist, sensitive, encumbered by protrusions of the rectum or bladder, or by mor- bid growths, etc. ; the state of the anterior and posterior cul-de-sac; the po- sition and condition of the cervix and os uteri and of the lower part of the womb. In cases of vaginal occlusion or hyperesthesia, but especially in all kinds of retro-uterine tumors, a digital exploration per rectum is a most valuable aid for diagnosis. The bimanual examination consists in an exploration by means of the one hand through the abdominal walls, while the forefinger of the other hand within the vagina rests on the neck of the womb. In this way the en- tire organ may be brought between the exploring fingers of both hands, so that its shape, consistency and mobility, etc., or the existence of any tumor within the true pelvis, can easily be ascertained. This conjoined method of examination, as it is likewise termed, is best performed in the dorsal position on an unyielding couch. Care should be taken that the outside hand is only slowly pressed into the abdominal wall above the symphysis pubis, which is best done by taking advantage of each expiration; and by inserting the hand not too close to the symphysis, in order to avoid the pushing back- ward of the uterus. Examination by means of the uterine sound (of which those most in use are the steel, Simpson's and Skene's sounds) consists in the introduction of a curved metallic instrument into the cavity of the womb, guided by the fore- finger which has been inserted into the vagina. This exploration gives a measurement of the length of the uterine cavity, discloses the course taken by it and the sensitiveness of its walls, and tells whether the uterus is empty or not. This sort of examination should never be resorted to so long as there exists the slightest doubt as to the possibility of pregnancy. 42 658 OVARIES. Ocular examination requires vaginal specula in order to bring the os and cervix uteri into view. There are bivalvular, trivalvular and tubular specula, of which those most in use are Cosco's or Wocher's bivalve, Nel- son's trivalve and Ferguson's or Mayer's tubular speculum, all of course of different sizes. For retracting the posterior wall of the vagina we have Sim's duckbill, also his folding speculum and Dowson-Sim's improved spec- ulum, instruments which the specialist may need for certain operations. There are undoubtedly cases where an examination by either of these means is absolutely necessary. But it is certainly beyond the lines of even medical decency to subject every woman who shows any signs of uterine disturbances at once to digital or ocular examination, especially if that woman be a virgin. It is a curse of vanity to show one's ability to handle or mishandle an instrument at the expense of an innocent or inexperienced person, and it is the highest degree of ignorance to look or feel for something which by better information we would not expect to find there, or which we should know to find without fingering. It is therefore not to be wondered at that many thoughtful medical gentlemen have condemned the use of these physical examinations almost in toto. Almost — for the helping hand and the seeing eye will even here be needed in certain cases as anywhere else. OVARIES. Oophoritis, Ovaritis. This affection has its seat either in the parenchyma (the Graafian fol- licles), or in the connective tissue, or in the peritoneal covering, of the ovary. If in the glandular part (parenchyma) the mature Graafian follicles have a milk} 7 turbidity, and the cells of the membrana granulosa are in a state of cloud} 7 swelling and subsequently break down into fine granules; the layer of the stroma surrounding the follicle is likewise inflamed. This form of inflammation occurs frequently in acute febrile diseases in which we also meet with parenchymatous inflammation of other abdominal glands; it may cause destruction of all the follicles and so result in sterility. If in the connective tissue there is hyperemia, swelling and infiltration of this tivssue which may terminate in the formation of abscesses, generally, however, results in cicatricial shrinking with consequent sterility. It is most frequently found in the puerperal period, or as an extension of a peritonitis, and in consequence of suppression of the menses. If in the peritoneal covering (Perioophoritis), it leads to pseudomem- branous deposits upon the ovary and to adhesions with neighboring organs. Its Causes are : taking cold ; getting w T et during menstruation ; sexual intercourse during the menstrual period ; onanism ; or, secondarily, in- flammatory processes of neighboring organs — the peritoneum, or the uterus; THERAPEUTIC HINTS TO OVARIES. 659 gonorrhoea. It is therefore most frequently found in serving girls, who are exposed to all kinds of rough influences (scrubbing of pavements, washing, etc.), in prostitutes and other lewd women. Women who have once had an attack are liable to a repetition during their menstrual periods. After the cessation of menstruation, the disposition to it ceases likewise. Its Symptoms are not at all well marked, when the connective tissue alone is the seat of the disease. We meet with symptoms of partial peritoni- tis, however, if the serous covering becomes inflamed; violent, sharp, colicky pains, vomiting, fever, etc. ; and so also may the bursting of a Graafian fol- licle be attended with inflammatory symptoms. As the ovaries lie deep in the lesser pelvis, covered completely by the small intestines, pressure down- wards from above the symphysis pubis will reach the sore spot only when the abdominal walls are greatly relaxed. Bimanual examination or an ex- ploration per annum may become necessary in chronic cases. We may, how- ever, diagnosticate an acute attack pretty safely when the above-mentioned symptoms have set in during menstruation, after an exposure to cold or wet, followed by a sudden cessation of the menstrual flow. Where the inflamma- tion spreads over adjoining organs, we find it accompanied by painful urging to urinate and to evacuate the bowels; by utero- vaginal blenorrhceas, or a numbness in the lower extremity of the affected side. An acute attack rarely lasts longer than eight days, generally subsiding within twelve to twenty-four hours. In unfavorable cases it becomes chronic, and may terminate in the formation of serous cysts, induration of the ovary, or in suppuration. Therapeutic Hints. Aeon. Headache, backache, colic, fever, great restlessness and tossing about ; after exposure to cold winds or a sudden fright during the monthly period, by which the flow ceases ; painful urging to urinate and to evacuate the bowels. Ant. cmd. When menstruation has been checked by taking a bath. ; nausea and vomiting, white tongue ; great thirst at night ; alternate costive- ness and diarrhoea. Apis. Right side; swelling, with stinging pains, from sexual intercourse during the monthly period ; numbness in the right side of the abdomen, extending into the thigh, or upwards to the ribs ; scanty urine, retarded stool ; cough, with soreness in the upper portion of the left chest. Arsen. Drawing, stitching pain from the region of the ovary into the thigh; which feels numb and lame, worse from motion, bending or sitting bent ; burning pain in the back while lying quietly upon it ; the menses con- sist of a thin, whitish, badly-smelling discharge; pale, yellowish face; ema- ciation; febrile action; thirst, with drinking little at a time; restlessness. Bellad. Hard swelling of the ovary, with stitching, throbbing pains; constant bearing down, as if everything would issue out; fever, with perspir- tion; glistening eyes; red face and delirium; after child-birth. 660 THERAPEUTIC HINTS TO OVERIES. Bryon. Stitching pain, worse from the slightest motion and contact; sup- pression of the menses, with[bleeding from the nose; inclined to constipation Canthar. Stitches, arresting the breathing; or violent pinching pains, with bearing down towards the genitals; or great burning pain in the ovarian region; constant urging and straining to urinate, with painful discharge of but a few drops of urine, which sometimes is blood}-; after suppressed gonor- rhoea. Coloc. Cramp-like pain in the left ovarian region, as though the part were squeezed in a vise; colicky pain all over the abdomen, which causes the patient to bend double; pain in the left foot; worse before menstruation, w T hich is more profuse. Conium. Chronic cases; induration; lancinating pains; pain in the mammae before the menses, which are feeble; smarting, excoriating leucor- rhcea; giddiness when turning in bed; intermitting flow of urine. Hamam. After a blow, the ovary swollen, with a diffuse agonizing soreness over the whole abdomen; menses irregular, very painful, with ex- acerbation of all the sufferings at the catamenial epoch; retention of urine. Hepar. When suppuration takes place, indicated by frequent chills. Ignat. Disappointed love; constant running of thoughts in that direc- tion; sighing, despondency; leucorrhcea, which passes off with labor-like pains. lodium. When indurated. Laches. Left ovary; tensive, pressing pains and stitches; inability to lie on the right side, on account of sensation as if something were rolling over to that side; menses scanty, with labor-like pressure from the loins downward; swelling of the ovary; suppuration. Mercur. Stitching, pressing pains in the lower region of the abdomen, left side; upper portion of the abdomen distended; stool with great tenes- mus; constant urging to urinate, with scanty emission of a thick, brown-red urine, causing burning in the urethra; perspiration without relief; great weakness and emaciation; nightly aggravation and restlessness; menses suppressed. Nux vom. After previous use of different allopathic drugs. Platina. Excessive sexual desire, from an incessant tickling within the genitals; painful pressing toward the genital organs, as if the menses would make their appearance; profuse or suppressed menses, with palpitation of the heart, headache, restlessness and weeping; haughtiness. Pulsat. After getting the feet wet; suppression of the menses, with nausea, coldness of the body, chilliness and trembling of the feet; pressure on bladder and rectum; thirstlessness, weeping, meek disposition. Rhus tox. After getting wet, straining or lifting. Zincum. Boring pain, relieved by pressure and during the menstrual flow. Compare A urum, China, Clcmat., Hedeoma, lodium, Phosph. ac, Phy- tol., Podoph., Sabina, Sepia, Staphis., Thuja. HYDROPS OVARII. 66 I Hydrops Ovarii, Ovarian Dropsy; Formation of Cysts in the Ovaries. Most of these cysts originate, according to some authors, out of a de- generation of the Graafian follicles, which become distended, in rare cases, even to the size of a child's head; containing a clear, yellowish, serous, or thick, limpid fluid. There may be one or several of such cysts. The multiloeuiar tumors consist of a formation of multiple- cysts, growing out of the parenchyma of the ovaries. They sometimes attain an enormous size and contain either a serous or jelly-like fluid, which is dark if mixed with blood. The alveolar degeneration of the ovary destroys all the original structure of that organ; its whole substance becomes transformed into larger and smaller cavities, which are separated by a fine tissue. Some of these cavities attain the size of a fist, while others remain quite small. At first the organ retains its roundish shape; later, by the extension of some of these cavities, it becomes uneven. The contents of these cavities is mostly a yellowish, tough, honey-like substance, though the larger ones sometimes contain a thinner fluid. This degeneration is often complicated with cancer of the ovaries. There are yet cysts to be mentioned, which, instead of a fluid, contain hair, teeth and bones; their interior walls present a structure which is quite similar to that of the cutis, having an epidermis with sudorific and sebaceous glands, and sometimes a hairy growth. Such cysts are called dermoid cysts; they sometimes attain the size of a walnut, or even a fist. They are, per- haps, products of ovarian conception. There are also fibrous, cartilaginous and osseous tumors of the ovary which, like the purely cystic, may be the consequence of subacute inflamma- tor}^ action in these organs. The Symptoms of ovarian cysts, in the first stage, may be identical with those of an oophoritis; but usually all such signs are wanting, and the cysts, as long as they remain small, give no inconvenience whatever. When at- taining a certain size, however, they exercise a pressure upon the bladder and the rectum, causing difficulties in micturition and defecation. When pressing upon the nerves, which run down on the posterior wall of the lesser pelvis, they cause pain in the small of the back, or pain and numbness in the lower extremities; and when pressing upon the veins in the pelvis, they cause cede- matous or varicose swellings on the lower extremities. At the same time we observe, in some cases, a swelling of the mammae and a darkening of the rings around the nipples, with sympathetic vomiting and general malaise, thus simulating very closely the commencement of pregnancy. When the cysts grow further, they rise out of the pelvic cavity, and most generally the patient feels relieved of those symptoms which are caused by their pressure upon the pelvic organs; in some cases, however, all these symptoms continue, as the 662 THERAPEUTIC HINTS TO HYDROPS OVARII. cysts or portions of them within the pelvic cavity still continue to exercise the same compression upon the pelvic organs. Increasing still more, they gradually fill the abdominal cavity, press against the diaphragm and compress the abdominal organs; the natural con- sequences of which are: vomiting, shortness of breath, palpitation of the heart, bronchial catarrh, disturbed secretion of urine, deficient nutrition, and consequently anaemia and hydraemia, which ends in general marasmus. Their growth is not a steady one; they are frequently observed to increase and decrease in size periodically; the first taking place generally before and the latter after menstruation. As frequently intervening symptoms may be mentioned those of peritonitis, which are the more severe the more rapidly the cysts grow. If a cyst bursts, either by its own excessive distention or by external violence, its contents issue into the abdominal cavity and cause a general peritonitis; or it may in consequence of previously formed adhesions and inflammatory processes, find its way into another of the abdominal or- gans, and be thence discharged. Physical Signs. — As long as the tumor remains in the true pelvis, it may be diagnosed by an examination per vaginam or rectum, where it is felt as a well-defined swelling, which dislocates the uterus in one or another di- rection, according to its position. The less the tumor takes part in the mo- tions of the uterus the more sure is its diagnosis. When the tumor rises out of the true pelvis there appears a painless, well-defined swelling over the horizontal ramus of the pelvic bones; later it inclines more towards the middle line of the abdomen, and yields, more or less, a sense of fluctuation; the distended abdomen appears arched and changes its form scarcely any during different positions of the body. Percussion gives a complete flat sound, where the tumor touches the parietal walls, being dullest wdiere the swelling is most prominent; thus it differs from ascites, which gives a full sound, where the distended abdominal w r alls appear highest; for underneath that place lie, in ascites, inflated in- testines; and furthermore, the fluctuation of a cystic tumor never extends further than that portion of the abdomen which yields a flat percussion sound, because the fluid is confined in a sac, while in ascites the fluctuation is felt also where there is no flat percussion sound, because the fluid is driven further on within the peritoneal cavity by the concussion of the palpating hand. Therapeutic Hints. Compare Oophoritis and Peritonitis. Apis. Sudden stitches, like bee-stings, in the tumor, or sharp, cutting pains, with scanty urine and constipation; bearing down, and pain in the small of the back, as if the menses would come on; numbness of the cor- responding lower extremity; thirstlessness; pale skin; oedema; right side. Arsen. Burning pain; restlessness; anxiety; oppression; sinking of strength; great thirst, but little drinking at a time; dropsical swelling all over; pain in the corresponding leg; cannot keep the foot still. UTERUS. 663 Calc. card. Distention and hardness of the abdomen; pressure in the rectum, and bearing down in the womb; profuse and too early menses. Canthar. Burning pain; great sensitiveness of the abdominal walls; constant, painful urging to urinate and defecate; tenesmus in the bladder and rectum; wretched, sickly appearance. China. After great loss of fluids; general anasarca; meteorism. Coloc. A firm, elastic tumor occupies the space between the uterus and the vagina anteriorly and the rectum posteriorly, completely occluding the vagina and rendering defecation very difficult. Paroxysms of acute pain across the hypogastrium, in the sacral region and around the hip- joint when attempting to walk; the pain extends down the groin and along the femo- ral nerve; it is relieved by flexing the thigh upon the pelvis, and always induced or aggravated by extending the thigh; but there are frequent and severe paroxysms without any provocation. (C. Dunham.) G rap hit. I odium. Pressing, bearing down towards the genitals; constipation; acrid leucorrhcea, corroding the linen; dwindling and falling away of the mammae; strumous constitution. Lil. tigr. Bearing down in the uterine region, worse walking, better holding up the abdomen with the hands; tenderness of the swollen left ovary; stinging, burning pains from ovary up into the abdomen and down the thigh; shooting pains from left ovary across the pubes; urine causes a smarting sen- sation; prolapsed and sensitive uterus. (E. A. Farrington.) Lycop. Painful boring stitches in the left ovarian region; pressure on the rectum and bladder; pain in the sacral region, especially when rising from a seat; red, sandy sediment in the urine; ascites; varicose veins on the legs. Plumbum. The patient wants to stretch the upper and lower limbs during ovarian pains. (Young.) Podoph. Tumor on right side ; pain and numbness extending down the corresponding thigh. (Hawley.) Pains extend upward to the shoulder. (Seward. ) Stramon. Tumor attended with some lancinating pains and hysterical convulsions. During the convulsions the patient shrinks back with fear on seeing any one. (Miller.) In cases where proper homoeopathic treatment fails to show any influence in staying the growth of such tumors, or in improving the general health of the patient, operative surgery (tapping with subsequent iodine injections, electrolysis, ovariotomy) is indicated. UTERUS. Endometritis, Catarrh of the Uterus, Leucorrhcea. Always at the time of the catamenial period the mucous membrane of the uterus is found in a hyperaemic state, its overfilled blood-vessels burst 664 UTERUS. and occasion what is called the menstrual flow ; this normal hyperemia might be called the physiological catarrh of the uterus. It becomes patho- logical when it occurs at a time when no ripe ovula are cast off. A predis- position to uterine catarrh lies, therefore, between the time when menstrua- tion begins and until it ceases. Exciting Causes are, all such disorders which cause a stagnation in the proper circulation of the blood, as heart and lung diseases ; chronic constipa- tion, etc. ; direct irritations, such as sexual excesses, masturbation, pessaries, etc. ; or a general weakness of the system and general morbid conditions, such as typhus, cholera, small-pox and other infectious diseases; chlorosis ; scrofu- losis ; tuberculosis, etc. Its Pathological features are like those of any other catarrh ; hyper- emia, swelling, decreased at first, and afterwards increased secretion of mucus. When becoming chronic, the mucous membrane thickens and hypertrophies, and is sometimes studded with polypous excrescences ; its color turns brown- ish or slate-colored ; the secretion attains a more or less purulent character ; the follicles of the portio vaginalis swell on account of the closure of their excretory ducts, while secretion inside is still going on ; ithey form little round bodies of the size of a hemp-seed or larger, and are known under the name of ovula Nabothi. Furthermore, w T e find, if the process lasts long enough, diffuse catarrhal erosions, mostly on the posterior lip of the mouth of the womb ; or follicular ulcers, which originate in the bursting and suppura- tion of the above-named ovula Nabothi ; and also granulating ulcers, which differ from the rest by their exuberant granulations, which bleed easily. Symptoms. — An acute attack is characterized by drawing pain in the small of the back and in the inguinal region, a feeling of fullness and heavi- ness in the pelvis, dysuria and tenesmus. External pressure upon the lower part of the abdomen is painful. There is more or less fever. After three or four days the patient observes a discharge from the genitals, which at first is transparent and sticky, staining the linen grayish ; by and by it becomes opaque and more or less purulent. In the further course of eight or ten days the fever gradually subsides, and after that the discharge diminishes until it finally ceases. In chronic cases, the commencement is not easily ascertained. The pa- tients have had, long before the} r attach much importance to it, a discharge from the womb, which varies considerably in different cases. Still it is of the same nature as that above-mentioned, staining the linen grayish, and making it stiff ; sometimes, even, clots of a gelatinous mass issue forth. That is characteristic of a uterine catarrh. A purulent discharge is just as liable to have its source in the vagina ; and if the discharge be corrosive, the pre- sumption is that it originates there. In some cases, the os uteri closes, owing to the sticky discharge and the swollen state of the neck of the uterus ; and, in consequence, a collection of large masses of mucus within the uterus takes place, which are finally expelled by labor-like contractions of the uterus — uterine colic. The longer the catarrh exists, the more it changes the mucous UTERUS. 665 lining of this organ, and the greater, of course, must be its effect upon the monthly period. In some cases, the now is very profuse, and in others, very scanty ; almost always it is attended with more or less pain. Conception is not necessarily prevented, if the catarrh does not extend to the tubes or causes them to be closed ; but it has been observed that women suffering with chronic uterine catarrh are very prone to miscarry. A chronic uterine ca- tarrh may be endured for a long time ; but it finally betrays itself by pale- ness and an earthy color of the face, weakness and relaxation of the muscles, anaemia and hydrsemia. The most frequent expressions of chronic uterine catarrh are hyperesthesia, neuralgic and spasmodic complaints; all of which we find united under the popular expression of hysteria. The progress of the disease is always slow ; and among its complications we find a chronic parenchymatous metritis, inflections of the uterus, and closure of the cervical canal of this organ, which results in hydrometra. In regard to the diagnosis of the various leucorrhceal discharges, the following may be said : Watery discharges appear during the greater part of pregnancy, without being injurious to the fcetus ; also in connection with hydatid moles, where, after a certain time, moderate discharges repeat themselves off and on, ac- companied by bearing-down pains; in connection with cauliflower excrescences, where the serous discharges are often quite copious and of a brown color; in connection with uterine polypi, where the watery discharges alternate with blood} 7 ones, and profuse menstruation; in connection with adhesion of an ovarian cyst to the Fallopian tube, where the fluid of the cyst enters the tube and discharges slowly through the vagina. Mucous or purulent discharges are more or less opaque, gluey or gelati- nous, creamy or quite fluid. They all arise from the mucous membrane either of the neck of the womb, or of the uterine cavity, or of the vagina, or of the three combined. The discharge from the cervix is gluey, creamy and more profuse; from the womb it looks soapy or like glassy pieces of coagulated mucus; from the vagina it is coagulated, has an acrid reaction and contains tesselated epithelium. Continuous purulent discharges originate in the vaginal mucous mem- brane, in the cervical glands of the uterus, on the surface of a cancerous or other ulcer; in suppurating membranes remaining after an abortion, in re- tained placenta or membranes. Gonorrheal discharges are also continuous and often difficult to diagnose from leucorrhcea, if the history is wanting. Interrupted purulent discharges take their origin in the uterine cavity, in suppurating polypi, in abscesses seated in the neighborhood of the vagina. Sanious discharges consist of a reddish, bloody fluid, arising from tumors inside of the uterine cavity, from organic diseases of the uterus, such as fungoid degeneration of the uterine mucous membrane, malignant ulceration of the os, from pelvic hematocele, when a communication exists between cyst and vagina. Foul-smelling discharges occur where the leucorrhcea is profuse and 666 THERAPEUTIC HINTS TO UTERUS. purulent, accompanied by hectic fever and general loss of strength, and where the secretion is retained for some time in the vagina by a contraction of the ostium vaginae. In uterine cancer the discharge is always fetid. In giving the Therapeutic Hints, I shall unite both uterine as well as vaginal catarrh. Both are known under the popular name, leucorrhcea or whites, as the most prominent and some- times the only symptom of the two. sEsc. hipp. Pain in the small of the back and hip, with a lame feel- ing; the pain extends from the abdomen to the small of the back, which makes it almost impossible to get up and to walk after sitting; constipation and piles. Alet.far. In cases of debility from protracted illness, loss of fluids, defective nutrition, etc.; great disposition to abortion. Alum. Profuse, purulent, yellow, corroding discharge, worse before and after the menses; during the day only; vertigo, constipation. Ambra. Discharge only at night; thick mucus with stitches in the vagina before the discharge; pieces of bluish-white mucus. Amm. carb. Watery, burning discharge from the uterus; profuse, acrid or milky leucorrhcea; menses every fortnight, black, coagulated, pro- fuse ; weight in stomach; urine reddish ; flow often interrupted ; flushes. Amm. mur. Leucorrhcea with distention of the abdomen, without ac- cumulation of wind; discharge like the white of an egg, after previous pinching around the navel; brown, slimy, painless leucorrhcea, after every discharge of urine; stools hard, crumbling, Aralia rac. Offensive discharge, with pressing-down pains in the uterus. Arsen. Discharge, dropping out while standing, and passing flatus; burning, corroding; weak persons; old women; nervous restlessness. Aur met. and mur. Chronic metritis with malposition; induration; excoriation, with great sensitiveness of vagina; utter despair. Bapt. tinct. Acrid, fetid discharges; ulceration of the os uteri and vagina; debilitated state of the system. Bellad. Acute catarrh; bearing down as if all the contents of the abdomen would issue through the genitals, which is followed by a discharge of white mucus; colicky pains coining and going suddenly. Berber. Burning and smarting after micutrition, with a constant sore- ness along the urethra. (F. Baker.) Borax. Midway between the menses; albuminous discharge; cannot bear downward motion. Bovista. After the catamenia; while walking, thick, slimy, tenacious mucus, like the white of an egg; also yellow, green, acrid, corrosive; during the night only. Calc. cai-b. Milk-like discharge during micturition, or flowing pro- THERAPEUTIC HINTS TO UTERUS. 667 fusely only in spells; or purulent discharge with soreness and swelling of the vulva; too early and too profuse menstruation; paleness of the face; weak feeling in the chest, especially when talking; weakness in the knees; emacia- tion; constant cold, damp feet.. Card. veg. Discharge only in the morning, when rising; soreness and rawness in the pudendum; cold knees in bed; flatulence. Cauloph. Profuse secretion of mucus in the vagina; yellowish spot on the forehead, commonly called "moth;" bearing down with tardy or absent menses; drawing pains in the lower extremities. Caustic. Weakening leucorrhcea, with too scanty or too profuse menses; discharge, particularly at night; yellow face; disinclination to coitus, China. Leucorrhcea instead of the menses; painful pressing towards the groins and anus; bloody discharge, occasionally clots of black blood; or fetid, purulent matter, with itching and spasmodic contraction of the inner parts; great weakness from loss of blood. Coccul. Flesh-colored, watery discharge, instead of the menses, mixed with a purulent and ichorous liquid; on bending or squatting down, the fluid gushes out; distention of the abdomen and pain, as of a heavy stone; on sitting down, bending, treading or any other motion, a pain, as of internal ulceration; great debility. Collins. Leucorrhcea in connection with pruritus, obstinate constipation, and dysmenorrhcea. Conium. White discharge, burning, smarting, excoriating; suppression of the menses; itching at the vulva; contractive, labor-like colic, from both sides of the abdomen; weaknes and lameness in the small of the back and subsequent lassitude; old maids; hysteric paroxysms, swelling and indura- tion of glands. Ferrum. In chlorotic patients, thin, watery discharge, at first smarting and corroding; palpitation of the heart; earthy, yellowish face; painfullness of the vagina during an embrace; swellings and indurations in the vagina. Gelsem. White discharge; feeling of fullness in the hypogastrium; aching across the sacrum. Graphit. Perfectly white discharge, very profuse, especially in the morning on rising from bed, also in gushes by day or night; scanty menses; irritable skin; weakness in the back and small of the back when walking or sitting. Ha?nam. Especially in those profuse discharges which simulate a haem- orrhage and constitute a drain on the system as severe as a bleeding; sore- ness of the abdomen. Helon. Has been recommended in cases of general atony, anaemia and torpid condition of the system. Hydrast. Tenacious discharge; erosions and superficial ulceration of the cervix uteri and vagina; great sinking and prostration at the epigas- trium, with violent and continued palpitation of the heart. Ignat. Violent, crampy pressing in the region of the womb, resembling 668 THERAPEUTIC HINTS TO UTERUS. labor-like pains, followed by a purulent, corrosive discharge; mild disposi- tions who bear sufferings, even outrages, without complaining. Iodium. Old leucorrhcea, most abundant at the time of the menses, rendering the thighs sore and corroding the linen; dwindling and falling away of the mammae; goitre; induration of cervix and womb. Kreasot. Leucorrhcea before and after the menses, especially when standing and walking, not when lying or sitting the yellow discharge is acrid and corroding, offensive, causing redness and itching in the vulva; menses too early, too profuse and too long. Laches. Leucorrhcea before the menses, copious, smarting, slim} 7 , stif- fening and staining the linen greenish; the menses appear at the regular time, but are too short and too feeble; the abdomen is hot and tender to touch; feels bad after sleeping. Lil. tigr. Abundant, thin, excoriating discharge, staining the linen brown, worse p. m. ; bearing down relieved in lying down or sitting, or press- ing with the hand against the parts; frequent micturition with smarting or burning in urethra afterwards; depression of spirits; pain, distress and flut- tering of heart; menses flow as long as she keeps moving; sometimes come on too early and are scanty; feels all the time in a hurry without accom- plishing anything. Lycop. Profuse, greenish, thick discharge, not constantly, but in spells, which are always preceded by a sharp cutting pain in the hypogas- trium; pale face, with frequent flushes of circumscribed redness of the cheeks; discharge of gas from the vagina; the least quantity of food fills her up to the throat; jerking of the lower extremities. Magn. mur. Early in the morning after urinating and after stool; constipation. Mercur. Inflammation of the genitals; discharge of variable nature, always worse at night; gonorrhoea; syphilis. Murex purp. Watery, greenish, or thick bloody discharge; profuse and too earl) 7 menses; increased sexual desire. Natr. mur. Leucorrhceal discharge after contractive colic, pressing downwards, early in the morning, at night, when walking; itching and sore- ness of the genitals; cutting pain in the urethra after micturition; yellow- ness of the face; and especially after local application of nitrate of silver. Nitr. ac. Mucus — which can be drawn out — flesh-colored, greenish, cherry-brown, fetid; after mercurial treatment; worse after menses. Nux vom. Fetid discharge, tinging the linen yellow; after all sorts of allopathic nostrums. Pallad. Pain in the right ovary; urgency to urinate, with scanfy emis- sion, and sensation of weight and bearing down in pelvis, relieved by lying down; prolapsus uteri; forgets every pain in society, but is worse next day; attaches great weight to other people's opinion; likes to be flattered. Phosphor. In consequence of chlorosis; watery slime, especially during or instead of the menses; acrid, smarting, corrosive, drawing blisters. DIGEST TO LEUCORRHCEA. 669 Platina. During daytime; genitals excessively sensitive; can't bear to be touched; will go into spasms from an examination; will almost faint during intercourse; or excessive sexual desire; haughty disposition, or low- spirited. Podoph. Discharge of thick, transparent mucus, attended with con- stipation and bearing down in the genitals; .prolapsus uteri and ani. Puhat. Burning discharge, thin and acrid; milky, thick and white, without pain ; when lying, or before and during the menses, which are scanty ; inclination to looseness of the bowels ; chilliness ; thirstlessness ; peevishness ; sadness ; mild and tearful. Sepia. In the climacteric period ; during pregnancy ; during puberty, when there is a sense of pressure and bearing down in the pelvis, stinging pain in the ovarian region, frequent urging to urinate, and itching in the genital organs ; painful coitus, little sexual desire ; the discharge is of a varied nature, thick, creamy or yellowish, bland or excoriating, offensive, worse during the day and after coitus. Silic. Acrid, excoriating discharge ; or milky, in paroxysms, with cut- ting in the umbilical region ; frequently, also, discharge during mictur- tion. Sulphur. Discharges of all sorts, mild or excoriating; in most chronic cases, just as in all other chronic catarrhal affections ; burning of the soles of the feet, and heat in the crown of the head ; too much animal heat ; feel- ing of faintness, with strong craving for nourishment, about eleven o'clock every forenoon ; vulva sore, burning and smarting. Digest to IyEucoRRHceA. DISCHARGE. Abundant, copious, profuse: Alum., Amm. carb., Cauloph., Graphit., Lil. tigr., Lycop., Laches. , simulating haemorrhage with drain on system: Hamam. Thin: Ferrum, Lil. tigr., Palsat. Watery: Amm. Carb., Coccul., Ferrum, Murex, Phosphor. Thick: Ambra, Bovista, Lycop., Murex, Podoph., Pulsat., Sepia. Milky: Amm. carb., Pulsat. , during micturition: Calc. carb. Creamy: Sepia. Slimy: Amm. mur., Bovista, Laches., Fhosphor. Mucus: Ambra, Bellad., Cauloph. , tenacious: Bovista, Hydrast. , can be drawn out: Nitr. ac. , transparent: Podoph. White of an egg, like: Amm. mur., Borax, Bovista. Purulent: Alum., Calc. carb., China, Coccul., Lgnat. Fetid, offensive: Aral, rac, Baptis., China, Kreos., Nitr. ac, Nux vom., Sepia. Bloody: China, Murex. Brown: Amm. mur. , staining linen: Lil. tigr. Cherry-brown: Nitr. ac. Bluish- white: Ambra. Flesh-colored: Coccul., Nitr. ac. Green, greenish: Bovista, Lycop., Murex, Nitr. ac. , stiffening and staining linen: Laches. White: Bellad., Conium, Gelsem., Graphit. Yellow: Alum., Bovista, Kreos., Sepia. , tinging linen: Nux voin. Acrid: Amm. carb., Baptis., Bovista, Kreos., Phosphor., Pulsat., Silic. 670 DIGEST TO EEUCORRHCEA. Burning": Amm. card., Arsen., Con- ium, Pulsat. Corrosive: Alum., Arsen., Bovista, Fer- rum, lgnat., Kreos., Phosphor. , causing redness: Kreos. , rendering thighs sore, and corrod- ing linen: Iodium. , drawing blisters: Phosphor. Excoriating: Conium., Lil. tigr., Sepia, Si lie., Sulphur. Smarting: Conium., Ferrum., Laches , Phosphor. Bland, mild: Sepia, Sulphur. ACCOMPANYING SYMPTOMS: Forgets every pain in society, but is worse next day; attaches great weight to other people's opinions; likes to be nattered: Pallad. Feels all the time in a hurry without accomplishing anything: Lil. tigr. Nervous restlessness: Arsen. Sadness: Pulsat. Depression of spirits: Lil. tigr., Pla- tina. Hysteric paroxysms: Conitim. Utter despair: Aurum. Mild and tearful: Pulsat. dispositions who bear sufferings, even outrages, without complaining: Lgnat. Peevishness: Pulsat. Haughty disposition: Platina. Vertigo: Alum. Heat in crown of head: Sulphur. Face pale: Calc. card. with frequent flushes of circum- scribed redness of the cheeks: Lycop. yellow: Caustic, Natr. mur. , earthy, yellowish: Ferrum. Yellowish spots, "moths," on forehead: Cauloph. Thirstlessness: Pulsat. Faint, hungry feeling in stomach about 11 a. M. : Sulphur. Sinking feeling at stomach with palpi- tation of heart: Hydras t. Least quantity of food fills her up to the throat: Lycop. Pain from abdomen to small of back, cannot get up to walk: ^sc. hipp. , colicky, coming and going sud- denly: Bellad. , labor-like colic from both sides of abdomen: Conium. , pinching around navel, before dis- charge: Amm. mur. , and distention, as of a heavy stone: Co ecu I. , pressing towards groins and anus: China. Distention of abdomen without accumu- lation of wind: Amm. mur. Flatulence: Card. veg. Soreness of abdomen: Hamam. Hot and tender to touch: Laches. Constipation: Alum., Collins, Magn. mur. , and piles: ^Esc. hipp. Stools hard, crumbling: Amm. mur. Looseness, inclined to: Pulsat. Urgency to urinate with scanty emis- sion: Pallad. Frequent urging to urinate, with sting- ing in ovarian region: Sepia. micturition with smarting and burn- ing afterwards: Lil. tigr. After micturition, burning and smarting: Berber. , cutting in urethra: Natr. mur. Constant soreness along urethra: Berber. Urine reddish: Amm. carb. Fullness in hypogastrium: Gelsem. Bearing, pressing down: Aral, rac, Bellad., Cauloph., Podoph., Sepia. , better by lying down: Lil. tigr., Bellad. , better by sitting or pressing with the hand against the parts: Lit. tigr. Like labor-pains before discharge: China, Lgnat., Natr. mur. Cutting pain before discharge: Lycop. in umbilical region: Silic. Pain in right ovary: Pallad. Chronic metritis with malposition; in- duration: Aur. met. and mur. Disposition to abortion: Alet.far. Wind from vagina: Lycop. Prolapsus uteri: Pallad. and ani: Podoph. Soreness and rawness in pudenda: Carb. veg. DIGEST TO EEUCORRHCEA. 671 Ulceration of os and vagina: Baptis., Hydrast. Excoriation with sensitiveness of va- gina: Aur. met. and mur. Induration of cervix: /odium, Aur. met. and mur, in vagina: Ferrum. Swelling and soreness of vulva: Calc. card. Inflammation of genitals: Merc. sol. Acute catarrh of genitals: Bellad. Gonorrhoea; syphilis: Mercur. Sense of internal ulceration, on sitting down, reading, bending or any other motion: Coccul. Soreness in genitals: Calc. card., Card, veg., Natr. mur., Sulphur. Itching: China, Collins., Conium, Kreos., Natr. mur., Sepia. Stitches in vagina before discharge: Ambra. Burning and smarting: Sulphur. Sensitive, excessively; cannot be touched: Platina. Painfulness during an embrace: Fer- rum, Platina, Sepia. No desire to coitus: Caustic, Sepia. Excessive sexual desire: Platina. Increased sexual desire: Murex. Menses, suppressed: Conium. , tardy or absent: Cauloph. , too scanty: Caustic, G7'aphit., Laches., Li I. tigr. , too early: Amm. card., Calc. carb., Kreos., Lil. tigr., Murex. , too profuse: Amm. carb., Calc. carb., Caustic, Kreos. , and too long: Kreos. , black, coagulated: Amm. carb. , flow interrupted : Amm. carb. , as long as she keeps moving: Lil. tigr. Dysmenorrhea: Collins. Weak feeling in chest when talking: Calc. carb. Palpitation of heart: Ferrum. Pain, distress and fluttering of heart: Lil. tigr. Weakness in back and small of back, when sitting or walking: Graphit. and lameness in small of back: Conium. Aching across sacrum: sEsc hipp., Gel- sem. Jerking of lower extremities: Lycop. Drawing pain of lower extremities: Cauloph. Weakness in knees: Calc. carb. Cold knees in bed: Carb. veg. damp feet: Calc carb. Burning of soles of feet: Sulphur. Chilliness: Pulsat. Too much animal heat: Sulphur. Skin irritable: Graphit. Glands swollen and indurated: Co?iium. Goitre: L odium. Dwindling and falling away of mammae: L odium. Debility: Alet. far., Arsen., Baptis. Coccul. from loss of blood: China. Atony, anaemia: Helon. Chlorosis: Ferrum, Phosphor. Emaciation: Culc. carb. Cannot bear downward motion: Borax. Feels bad after sleep: Laches. WORSE: Before menses: Alum., Kreos., Laches., Pulsat. During menses: Lodium, Phosphor., Pul- sat. Instead of menses: China, Coccul., Phos- phor. After menses: Alum., Bovista., Kreos., Nitr. ac Midway between menses: Borax. In the morning: Magn. mur., Natr. mur. , when rising: Carb. veg., During the day: Graphit., Sepia. only: Alum. In afternoon: Lil. tigr. In night: Caustic, Graphit., Natr. mur. only: Ambra, Bovista. In spells: Calc. carb., Lycop. By gushes: Graphit. When lying: Kreos. , Pulsat. bending or squatting: Coccul. walking: Bovista, Kreos., Natr. mur. urinating: Silic Graphit. Platina. Mercur Silic 672 PARENCHYMATOUS METRITIS. After urinating: Amm. mur., Magn. mur. stool: Magn. mur. While passing flatus: Arsen. Not while lying" or sitting: Kreos. climacteric period: Sepia. Old maids: Conium. Old women: Arsen. Chroni3 cases with other catarrhal affec- tions: Sulphur. During" puberty with bearing down: After Nitrate of silver: Natr. mur. Sepia. mercurial treatment: Nitr. ac. pregnancy: Sepia. all kinds of nostrums: Nux vom. Parenchymatous Metritis. In its acute form it is of rare occurrence, and consists of an inflammatory process of the entire substance of the womb, including often both the mucous lining inside and the peritoneal covering outside. The uterine substance is tumefied, infiltrated with serum and hyperaemic. Its most frequent causes are irritating applications, injections of too hot or too cold water into the vagina, or intra-uterine injections, pessaries, the introduction of the sound, etc. ; also, " catching cold," especially during the menses, etc. Commencing with a chill which is followed by fever-heat, it is character- ized by a deep-seated pain in the region of the uterus and an acute pain in the peritoneal covering, greatly increased by pressure, or movements, such as turning, walking, standing, coughing or straining at stool. Manual ex- aminations are scarcely endurable. If it commences during the menstrual period, it causes suppression of the flow, or at times flooding. It is often associated with ischuria, diarrhoea and tenesmus, nausea and in rare cases with vomiting. Uncomplicated cases may pass over in the course of several days ; a termination in an abscess is of rare occurrence. The chronic form of parenchymatous metrititis is also known under the name of infarction of the womb, and consists of a hyperplasia of the connective tissue of the uterus, out of its muscular tissue ; it is accompanied by a vari- able degree of sensitiveness. The womb is always enlarged ; its substance succulent and reddish, tumefied and hypersemic ; the os is generally broad, and the lips are swollen and elongated, often ulcerated. Its Causes are of a widely different nature. Only rarely it develops out of the acute form, and then only when the organ, by some cause or the other, has been prevented from undergoing a complete restitution into its normal state. By far the most frequent origin lies in a defective retrograde evolution of the puerperal uterus in consequence of too early leaving the bed and assuming household duties; or in consequence of retained secundines, or too early sexual intercourse, etc. This applies also to miscarriage and crimi- nal abortion; (sub-involution). Another variety of causes must be looked for in all these irritations which produce active hypersemia of the uterus, such as excesses in venere, fraudulent cohabitation and mastubation; also cauterization of the os by nitrate of silver or other means; and in all those conditions which produce a THERAPEUTIC HINTS TO PARENCHYMATOUS METRITIS. 673 venous stasis in the organ, such as retroflexion and prolapsus, adjacent tu- mors, retention of urine in the bladder, etc. Its Symptoms are not in all cases very characteristically developed; but as a rule we meet with frequent repetitions of acute and subacute exacerba- tions of at least some of the following symptoms: pain in the sacral region, in the abdomen, a sense of weight and bearing down in the pelvis, leucor- rhcea, menorrhagia, constipation and frequent urging to urinate; pain during stool, or coitus. During the menstrual period all the symptoms are aggra- vated. Gradually digestion and appetite begin to fail, and a whole train of hysterical symptoms develop, such as various kinds of pain in the lumbar region and lower extremities, vaginodynia, coccygodynia, paralysis of differ- ent organs, etc. It may bring on sterility, but not necessarily; is often complicated with endometritis, ovaritis, perimetritis and displacements, and terminates after the age of fifty at times in cicatricial induration of the womb. By means of the conjoined examination the uterus is found to be enlarged and its sensi- tiveness increased, especially during the periods of aggravation. The sound reveals an elongation of the uterine cavity. The disease is very tedious, but not dangerous to life. If the uterus cannot be entirely restored to its normal state, the sufferings at least can be greatly relieved by Homoeopathic treatment. Therapeutic Hints. Compare Uterine Catarrh, Peritonitis and Displacements. Aeon. High fever; dry skin; intense thirst; great restlessness; fear of death, and predicting the hour of death. Arnica. When induced by external violence. Arsen Burning pain; indescribable anguish and restlessness; sudden sinking of strength; burning thirst, drinks often, but little at a time; cold drinks make her worse; burning in the veins; aggravation about midnight, Bellad. Violent pains by spells; clutching pains, as if fingers with nails were clawing the intestines together; meteorism, with eructations; great sensitiveness and heat in the abdomen; painful bearing down in the pelvis towards the genitals and the rectum, with constant, ineffectual desire for stool; suppression of the lochial or menstrual discharge, or else vitiated, fetid discharge. Congestion of the head, with delirium, redness of face, and throbbing of the carotid arteries; drowsy dozing with startings, or drowsiness, with inability to go to sleep. Bryon. Wants to lie perfectly still; the slightest motion causes pun; in the head splitting pain; in the bowels, limbs and body stitch-like pain; great dryness in the mouth, without thirst, or else great thirst, drinking tumbler after tumbler; perspiration in short spells, and only on single parts of the body; constipation. Calc. carb. Fat persons, and those whose menses are too profuse and 43 674 THERAPEUTIC HINTS TO PARENCHYMATOUS METRITIS. return too soon; they sweat easily about the head, and are troubled con- stantly with cold and damp feet. Chronic infarction of the womb. Canthar. Constant painful urging and tenesmus of the bladder; like- wise, in worst cases, when the patient lies unconscious with her arms stretched out along the side of her body, interrupted by sudden starting up, screaming, throwing about the arms and even convulsions; all signs of erosions and ul- ceration of internal organs. Cauloph. Insomnia; paraplegia; atony and relaxed condition of the uterus; hysterical spasms; irregular menstruation; excessive uterine haemor- rhage. (M. M. Eaton.) Chamom. Great agitation of the nervous system; she seems beside herself, with red face and heat all over; she is ill-humored, and can scarcely restrain herself to treat people with civility; sometimes one cheek red and the other pale; after fits of passion. Coloc. Colicky pains in the bowels, with deadly color of the face and bending double; worse after eating or drinking; partial heat and partial coolness of the skin, with quick pulse, vomiting and diarrhoea; bitter taste in the mouth; after indignation. Conium. Swelling of the breasts; stitches in the breast, mostly at night; induration of the cervix, with sharp pains in the part; acrid leucorrhcea; prolapsus uteri. (M. M. Eaton.) Crocus. Black stringy discharge; rolling and bounding in the abdomen, as from a foetus; stitching in the abdomen arresting respiration. Gelsem. Hystery; hyperesthesia of a part of the body; tendency to hemiplegia; confusion of mind; sleeplessness; spasms; fever, without thirst, intermitting; nervous exhaustion. (M. M. Eaton.) Hyosc. Typhoid state; either complete apathy, or else great excit- ability, spasms, jerkings, delirium, wild staring, throwing off bedclothes, leaving herself naked; bright red clots after child-birth. Kreos. Putrid state of the womb after child-birth; confounding ideas; loss of memory; thinks herself well; discharge of dark, offensive blood from the womb. Laches. Constantly lifting the bedclothes from the abdomen, on ac- count of uneasy feeling caused hy it; the pain in the uterus is relieved by a flow of blood for the time being, but returns soon afterwards; in bad cases, unconsciousness, livid face, repeated shaking chills; skin alternately burning hot and cold; abdomen distended; lochial discharge thin, ichorous; stool and urine suppressed. Mercur. Inflammation of the genital organs and ulcers; moist, soft tongue, showing the imprints of the teeth, accompanied occasionally with great thirst; profuse sweat without relief; all worse at night. Nux vom. After taking cold, or using various kinds of drugs; in chronic cases, with bearing down into the vagina and towards the os sacrum; constant urging to urinate; constipation. Phosphor. Fair, graceful women; after frequent pregnancies; pyaemic state and inflammation of the veins. HYDROMETRA, H^MOMETRA. 675 Pulsat. After getting the feet wet; frequent chilliness; thirstlessness; deficiency of milk; suppression of the lochial discharge; mild, tearful dis- position. Rhus tox. Constant restless moving; can't lie still; dry tongue, with red tip; red rash on the breast; powerlessness of the lower limbs; the lochial discharge turns bloody again; typhoid symptoms. Sabina. In metritis hemorrhagica. Secale. Putrescence of the uterus; abdomen distended, not very pain- ful; discharge from the vagina, brownish, offensive; ulcers on the external genitals discolored and rapidly spreading; burning hot fever, interrupted by shaking chills; small, sometimes intermittent pulse; great anguish; pain in the pit of the stomach, vomiting decomposed matter; offensive diarrhoea; suppressed secretion of urine; the skin is covered with petechial and miliary eruptions, or shows discolored, inflamed places, with a tendency to mortifica- tion; the patient lies either in quiet delirium, or grows wild with great anx- iety and a constant desire to get out of bed. Sepia. Painful stiffness in the uterine region; bearing down; sense of weight in anus; sense of goneness in abdomen; yellowish spots in the face. Sulphur. Frequent weak, faint spells, especially before noon; bearing down, especially on standing; leucorrhoea; soreness of genitals. Ver. alb. If commencing with violent fits of vomiting and diarrhoea; hot body; cold extremities and deadly pale face, covered with cold perspira- tion; delirium and great anxiety; suppressed lochial discharge; nympho- mania. Ver. vir. Congestion of pelvic organs, tenderness of uterus; fever; heat; restlessness; palpitation of heart; local or general hyperesthesia. (M. M. Eaton.) For the chronic form, Baton recommends: Ars.jod., Merc, jod., Phytol., Ferrum, Merc, cor r. , Kali hydr., Nux vom., Ars. alb., Secale , Ignat., Iris vers., Hyosc, Ver. vir. Hydrometra, Hsemometra, Partial or Total Closure of the Womb. In consequence of the above considered inflammatory processes, it hap- pens now and then that exuberant granulations of the mucous lining or cicatrization of ulcers form adhesions within the neck of the uterus and thus cause a partial or total closure of its mouth. The same result may be pro- duced by pseudo-formations within the womb, or certain flexions of the cervix uteri. In such cases it is obvious that any secretion within this organ either cannot escape at all, or only with great difficulty, and under certain favorable circumstances. The secretion collects and distends the uterus sometimes to a very considerable size. This distention causes the mucus lining to grow thin, and its glandular structure, which naturally secretes mucus, to disap- pear; it now approaches the nature of a serous membrane, and secretes a serous fluid instead of mucus. Thus originates Hydrometra or dropsy of the womb. 676 DISPLACEMENTS OF THE WOMB. Hsemometra it is called, when blood, instead of serum, collects in the womb, in consequence of a partial or total closure of its mouth. This takes place in women who still menstruate; or the occlusion is a congenital imper- foration of the organ. In the first instance it is always attended with con- tractions of the womb, labor-like pains, or uterine colic at the period of men- struation, which may succeed in cases of a partial closure, to press the col- lected fluid out in gushes; in the latter case the menstrual discharge does not take place at all. The existing trouble may be suspected when repeated menstrual periods pass without any flow, although the patient feels all the symptoms of it: periodical colicky contractions; bearing-down sensation; and all the rest of the symptoms of amenorrhcea and dysmenorrhcea. The ab- domen commences to enlarge above the os pubis. Only by a physical ex- amination can we discover the occult complaint. Therapeutic Hints. It is clear that, if homoeopathic treatment of those inflammatory pro- cesses could not prevent adhesions and closure, medicines will not be likely to unclose them. Such cases require surgical treatment. Displacements of the Womb. The womb is by no means fixed immovably within the pelvic cavity; its fundus has almost entire freedom of motion antero-posteriorly ; the round ligaments having their insertion in soft parts, allow very considerable ex- cursions backwards. The cervix is more firmly connected, but only to the unstable bladder in front and to the rectum behind. The vagina too gives no firm support, 'but follows the movements of the cervix. Only considerable lateral motion is prevented by the lateral ligaments. It is, therefore, not very strange that displacements of this organ should frequently occur. Even within the boundaries of physiological correctness its position is greatly in- fluenced by the varying contents of the bladder and rectum. A full bladder presses it back, an empty bladder allows it to fall forward, and so also has the full or empty rectum, though in less degree, a certain influence upon its position. Anteversion and Anteflexion. In anteversion the entire organ inclines forward, has, so to say, fallen upon the bladder which it compresses, while neck and mouth point straight backward. There is but slight bending between neck and bod}', or none at all. This form is always complicated with metritis, and when it exists in an\ T considerable degree, it is accompanied by pain in the abdomen, haem- orrhages, leucorrhoea, urinary difficulties, neurose of the rectum and hysteria. It is easily detected by digital per-vaginam and conjoined ex- amination. In anteflexion the body and cervix form an angle, the body having RETROVERSION AND RETROELKXION. 677 fallen down and forward upon the bladder, while the cervix retains its posi- tion in the vagina, or is slightly pointing backwards. This form is usually attended with dysmenorrhea, in consequence of the obstruction to the menstrual flow at the point of flexion. The pain begins before the ap- pearance of the menstrual discharge, which has to be driven out by strong contractions of the womb, causing violent colicky pains, ending usually with a copious flow. There is usually difficulty of conception, the semen being prevented from entering the womb at the point of flexion; also fre- quent desire to pass water on account of the pressure of the womb upon the bladder. It may be complicated with metritis, perimetritis and endometritis. Here too digital and conjoined examination will reveal the nature of the disorder. Retroversion and Retroflexion. In retroversion the uterus dips backward towards the rectum and its neck and mouth point forward toward the symphysis, and in its most exag- gerated form the uterus may be completely turned over, the os looking directly upward. Slight degrees of this form may be free of symptoms; in- veterate cases may be complicated with chronic inflammation. In retroflexion the body and cervix form an angle, the body having fallen backward toward the rectum, while the cervix retains its position in the vagina or is slightly pointing forward towards the symphysis. This form is more apt to be attended by haemorrhages than by dysmenorrhea, and oc- curs as a general thing most frequently in women who have borne children ; it is further characterized by a pain in the lower part of the spine; by para- lytic or neuralgic symptoms of the lower extremities or elsewhere, in con- sequence either of direct pressure upon the motor nerves, or in consequence of reflex action ; by great irritation of the nervous system, showing itself as emotional, moral, or intellectual disturbances ; by urinary troubles, and dis- turbances in the function of the rectum. The Diagnosis of retroversion and retroflexion can usually be made out by digital examination per vaginam et rectum and by the conjoined method; only rarely it will be necessary to introduce the sound, which by no means is so free of danger as seems to be supposed by many. Prolapsus and Procidentia. In prolapsus the uterus slips downward into the vagina, approaching gradually with its os the mouth of the vagina. The uterus standing in its normal position about four inches above the vaginal entrance, its descent is one of degrees before it reaches the mouth of the vagina, and as it is fas- tened to adjoining parts, it drags along in its course downward the bladder, the ovaries, the Fallopian tubes, the small intestines, the walls of the vagina, and in some instances the rectum and portion of the colon. I am entirely of the same opinion as is expressed by Dr. Guernsey in his work on obstetrics, that " the peritoneum is the true uterine supporter," 678 INVERSION OF THE WOMB. and ' ' that the uterus can sink in the pelvis only so far as it is permitted by the relaxation of the peritoneum, its grand suspensory ligament." Recent authors come nearer and nearer to this same view. So says Schroeder> "the predisposing cause will almost invariably be found to consist in a relaxation of all the pelvic viscera," and M. M. Eaton : " the uterus is sustained mainly by the folds of the peritoneum constituting the broad ligaments, the cellular tissue surrounding it and the vagina, and by atmospheric pressure coming in through the vagina." The predisposing relaxation of the peritoneum being present, usually in consequence of some general weakness of the system or a sudden fright, any pressure from above, such as tight lacing, straining or heavy lifting, long- continued standing, the puerperal condition, etc., or insufficient support from below, such as lacerations of the perineum, will no doubt facilitate the de- scent of the womb. Symptoms. — In those rare cases where from a violent cause a sudden descent takes place, we have severe abdominal pain, fainting and profound nervous shock. The gradual descent causes: bearing and dragging down pain in the pelvis with pain in the small of the back, which is worse on standing, walking, lifting or doing any kind of bodily work, and better on lying down and resting; frequent desire to urinate and often inability to do it on account of the bladder being dislocated also; difficulties in defecation, and a number of nervous symptoms known under the name of hysteria. Digital examination reveals the organ more or less far down in the vagina, resting in some cases upon the perineum. In procidentia, which is a complete prolapse, the uterus escapes through the vagina and lies either in part or wholly outside of the external genitals between the thighs. The vagina having become inverted, covers the pro- truded organ, and drags down in its cavity the bladder and rectum, in con- sequence of which a retention of urine in the drawn down portion of the bladder (diverticulum) and difficult defecation are necessarily produced. The Diagnosis of this trouble can hardly fail to be correct, if an ex- amination by inspection and palpation is properly conducted. Inversion of the Womb. By this we understand a turning inside out of the uterus. It can only take place when the organ is greatly enlarged, for instance, during parturi- tion, when the foetus is suddenly expelled, or afterwards upon undue pulling at the cord to deliver the placenta, or in cases of tumors, polypi, etc., at its fundus, which have softened the fundus and by their weight draw it down within the uterine cavity, dragging, by degrees, the uterine walls after, until at last a complete eversion is established. This process is often accelerated by uterine contractions to expel the foreign bod}'. In the normal, unimpreg- nated uterus inversion never takes place. The degrees of inversion are as varied as those of prolapse, from a mere THEEAPEUTIC HINTS ON DISPLACEMENT OF THE WOMB. 679 depression of the fundus into the uterine cavity, to a complete turning inside out and protrusion of the entire organ outside of the vulva. Its Symptoms are usually grave haemorrhages, shock and urinary diffi- culties, but in some cases it is borne without any remarkable disturbance of the system. Therapeutic Hints. Many cases of these various kinds of displacements require, like hernia and other dislocations, taxis to reinstate the organ into its natural position; others yield easily to well chosen remedies. If taxis is necessary, it ougt to be executed with the utmost care and gentleness, and, if possible, by the hand alone. It is not necessary, nor even likely, in many cases, that we should succeed in one effort at restoration ; it took time for displacement; allow time also for replacement. With several gentle efforts, persistently followed up at reasonable periods, much more may be gained, than by one grand attack with ether and chloroform, and all kinds of instruments. He is the greatest artist who accomplishes most b}^ the simplest means. In anteversion or anteflexion, place the patient on her back, and elevate the pelvis; steady with one or two fingers of the left hand, introduced into the vagina, the cervix, and with the right hand try to get under the fundus above the pubis through the re- laxed abdominal walls, and force it gently upward and backward. In ret- roversion or retroflexion, place the patient on her left side or in the knee- chest position, raise the uterus gently by the introduced fingers of the right hand, and exercise at the same time upon the neck, which points towards the pubis, a steady pressure in a backward direction. The other hand may help either per rectum or through the abdominal walls in forcing the fundus forward. In prolapsus and procidentia, place the patient on her side or back, with the pelvis elevated, and push the organ gently upwards and in the direction of the natural curve of the pelvis, lest it might result in an arti- ficial retroflexion by being forced against the sacrum. In inversion, the fundus of the womb must be pressed back again through the os, and the entire organ replaced — a work sometimes very difficult to accomplish, especially in chronic cases, when it properly belongs in the domain of surgery. Some chronic cases of displacement are irreducible in consequence of adhesions with neighboring organs. In all cases of displacement, one of the first requirements for success is the removal of all pressure upon the womb from above, as is exercised by corsets, tight lacing, etc. ; supports from below by pessaries and supporters of all kinds have seldom proved themselves of great use, and often decidedly injurious; rest, in a suitable position, with hips elevated, and continued for some time after replacement, is often all that is needed. To secure the staying in place of the womb, we must so select a remedy that it fits the peculiarities of the individual case; it will certainly restore the necessary tonicity of the peritoneum. 68o special hints to displacements of the womb. Special Hints. Drs. Guernsey and Eggert have made valuable contributions here. Com- pare them, if the following do not suffice. Aeon. After a sudden fright; also when inflammatory symptoms pre- vail. Agonizing pain during the menses, with tossing about. Fear of death. Agar. muse. Prolapsus after cessation of menses; bearing-down pain, almost intolerable. A mm. mur. Pain as from sprain in the groin, obliging one to walk rrooked; menses appear too soon, with pain in the belly and small of the back; they flow more abundantly in the night; discharge of quantity of blood with the stool during the catamenia. Arctium lappa. Especially in old cases of prolapsus and procidentia. (S. A. Jones.) Alstonia constricta. i. Great debility, with loss of appetite from weak digestion. Tongue generally coated a dirty white, aggravated on toward the base, although it may be clean. Debility, dependent on a lack of diges- tive power of stomach or assimilative power of system. Not in debility of nervous type, or in consequence of la grippe. 2. Menses, aggravated mornings before breakfast, or at irregular times especially when depending on reflex irritation from pelvic organs. 3. An empty, gone feeling in stomach, or else in the whole abdomen, coming at irregular times, with bearing and dragging down sensation in the hypochondrium. Dr. W. G. Dietz, Hazleton, Pa. — Hahnemannian Monthly Note, 1890, p. 765. Argent. Pain in the small of the back, which extends towards the front and downwards; pain in the lett ovary and loins. Arg. ?iitr. Prolapsus, with ulceration of os or cervix uteri; painful coition, with bleeding from vagina. Arnica. After a bruise or concussion, which leaves a bruised and sore feeling in the lower part of the abdomen, so that she cannot walk erect. Aurum. After lifting a heavy load, a sense of weight in the pelvis, with ischuria and constipation, worse at each menstrual period; great dejection of spirits; longing for death, increasing to a desire for self-destruction; or vehement, the least contradiction excites her wrath. Bellad. Pressing early in the morning, as if all the contents of the abdomen would issue through the genital organs; drawing pain in the small of the back downwards; flow of blood between the periods; great dryness of the vagina; frequent, unsuccessful desire to urinate or to evacuate the bowels; only a few drops of urine are discharged from the bladder, and some mucus from the rectum; the uterus comes down when straining at stool; or while urinating, and rises again on walking about; back aches as if it would break; dizziness; roaring in the ears; congestion to the head. Calc. carb. Pressing on the uterus; aching of the vagina; stinging in the os uteri; the menses appear too soon, and are too profuse; milk-like THERAPEUTIC HINTS TO DISPLACEMENTS OE WOMB. 68 1 leucorrhoea; inclination to perspire easily abont the head, great liability to strain a part by lifting; easily tired by bodily exertions; in walking up stairs she feels dizzy and entirely exhausted; even talking makes her weak; great inclination to sigh; she cannot get her breath long enough; great suscepti- bility to catch cold; the feet feel most of the time damp and cold, or else the soles of the feet are burning hot; great desire for hard-boiled eggs; big- belliedness; scrofulous diathesis. Calc phos. Every cold causes pains in the joints, and in other places where the bones unite and form a symphisis or suture. Cauloph. Retroversion; menstrual colic; congestion and irritability of uterus; leucorrhoea profuse, mucus. Chamom. Abortus; colicky pain and bearing down, with frequent desire to urinate; frequent discharge of coagulated blood, with tearing pains in the veins of the legs, and violent labor-pains in the uterus; she is inclined to be quarrelsome and angry; can hardly stop talking about old vexatious things. China. General weakness in consequence of loss of vital fluids, either by haemorrhages, profuse diarrhoea, or debilitating illness; great disposition to sweat during motion and sleep; feels worse from exposure to the slightest current of air; all pains are worse from slightest touch. Conium. Pain in the mammae before the menses; pressure from above downwards, and drawing in the legs during the menses; feeble or suppressed menses, sterility; smarting, excoriating leucorrhoea; the flow of urine sud- denly stops; cough during pregnancy; cough worse at night, and when lying down; vertigo, worse when lying down, or looking round, or going down stairs; indurations in the mammae or other glands. Ferrum jod. Retroversion and consequent pressure upon the rectum, that she can neither stand nor walk; constant tenesmus, with frequent white slimy stools; scanty, deep-colored urine; nervous and hysteric spasms; scrofu- lous diathesis. Hydrast. Nosebleed before menses; backache and headache before and during menses; discharge like white of egg after menses for ten days with great sexual desire, although coition is painful; after these ten days fol- lows acrid, corroding leucorrhoea with great irritableness and aversion to coition; at times profuse discharge of hot water from the womb. Constant desire to pass water, with relief after passing it; constipation, dry, lumpy feces are followed by a matter like white of egg. After eating, regurgitation of food by the mouthful without nausea, with nervousness, irritability and headache; epigastric region tender to touch and a feeling as of a tight band around the waist, worse at night than in the morning; cannot sleep until after midnight. Prolapsus uteri with indurated os. (C. W. Boyce.) Ignat. Violent crampy pressing in the region of the uterus, resembling labor-pains, followed by a purulent, corrosive leucorrhoea; the menses are scanty, black and of a putrid odor; she seeks to be alone, is brooding to her- self and full of grief; all her pains are aggravated by drinking coffee or smelling tobacco smoke; gone feeling in pit of stomach. 682 THERAPEUTIC HINTS TO DISPLACEMENTS OF THE WOMB. Kali card. Pain in the small of the back, as though it were pressed in from both sides, with labor-like colic and leucorrhoea; also during the menses; the pains in the bowels are apt to recur about three o'clock every morning: bloated face in the morning, especially between the eyebrows and upper lids; great dryness and itchiness of the skin; great tendency to start when being slightly touched. Laches. Just as patients with a Lachesis sore throat cannot bear any- thing touching their neck, so do women afflicted with womb diseases con- stantly pull their dress from off the abdomen; violent labor-like pressing from the loins downwards during the menses, which are scanty; palpitation of the heart with numbness in the left arm; constant feeling of something in the throat which she cannot swallow down; feeling of a ball rolling in the bladder or abdomen, or in both places; climacteric period. LiL tigr. Feels as though she would drop asunder, must press with hand against vulva; worse in standing and sometimes when recumbent; fre- quent ineffectual urging to urinate and defecate. Menses scanty, flowing only as long as she is moving about; leucorrhoea profuse and corroding; she feels always in a hurry, yet cannot accomplish anything. Lycop. Chronic dryness of the vagina; pressing through the vagina on stooping; chronic suppression of the menses after fright; incarcerated flatu- lence; varicose veins on the lower extremities; jerking and twitching of single limbs or of the whole body, sleeping or waking; always wakes up very cross. Mercur. Peculiar weak feeling in the abdomen, as though she had to hold it up; close above the genital organs a sensation as if something heavy were pulling downward, accompanied hy a pulling pain in both thighs, as if the muscles and tendons w T ere too short. During the menses red tongue, with dark spots and burning; salt taste in the mouth; sickly color of the gums, and the teeth are set on edge; great tendency to perspire; all the symptoms worse at night; inexpressible feeling of some internal, insupportable illness. A T atr. Mur. Pressing and pushing from the side of the abdomen to- wards the genital organs early in the morning; she has to sit down to pre- vent a prolapsus uteri; dryness of the vagina and painful embrace; burning and cutting in the urethra after micturition; headache on waking every morning; faint, weak voice, and exhaustion from talking; after abuse of quinine, or the local application of nitrate of silver. A T itr. ac. Violent pressing in the liypogastrium, as if everything were coming out at the pudendum, with pain in the small of the back, through the hips and down the thighs; she feels so weak that she loses breath and speech. Inclined to looseness of the bowels; most violent, cutting pain after an evac- uation, lasting for hours; she feels, on the whole, better when riding in a carriage. Nux vom. Prolapsus after straining by lifting, or after miscarriage; constant, painful pressing and burning in the uterine region; pressive pain SPECIAL HINTS TO DISPLACEMENTS OF THE WOMB. 683 in the small of the back, worse when turning in bed; drawing in the thighs; constant, unsuccessful urging to stool and constant desire to urinate; the patient wakes after midnight and lies awake for hours, then falls into a heavy sleep again, constanth T dreaming until late in the morning, when she feels disinclined to rise. Always the first remedy after allopathic drug- ging. Platina. Great heaviness, pressing in the genitals, extending through the groins as far as the small of the back; profuse menses; great sensitive- ness of the parts, with pressing from above down; internal chilliness and ex- ternal coldness; constipation; feeling of numbness and rigidity here and there; also with trembling and palpitation of the heart; haughty dispo- sition. Podoph. Prolapse from overlifting or straining and often parturition; great costiveness; frequent micturition; weakness and soreness of back, es- pecially after washing; prolapsus ani. Pulsat. Chilliness and paleness of face; bad taste in the morning and dry tongue without thirst; is easily moved to tears. Rhus fox. After a strain of hard labor; she feels worse after any long walk; the pain in the small of the back is relieved by lying on a hard couch. Secale. After parturition; weakly, thin women. Sepia. Pressing in the uterus, oppressing the breathing, from above downwards, as if everything would come out of the vagina, accompanied with colic; she has to cross her limbs to prevent it, followed by a discharge of jelly-like leucorrhcea; sense of weight in the rectum not relieved after stool, slow and difficult evacuations from the bowels, although the excre- ments are soft; pot-belliedness; yellow saddle across the bridge of the nose; gone feeling in the pit of the stomach, great weakness, tiredness, despon- dency and disinclination to move, Sulphur. Weak feeling in the genital organs and pressure on the parts; troublesome itching of the pudendum, with pimples all around and burning in the vagina; she was scarcely able to sit still; the menstrual blood is thick, black, and so acrid that it makes the thighs sore; burning and smarting leucorrhcea; sudden, imperative urging to urinate to prevent an involuntary flow; weak, fainty, between 11 and 12 A. m., must have something to eat; restless and sleepless nights; or a heavy sleep which exhausts her; heat on the top of head with cold feet; always feels too hot, especially her feet, which compels her to put them from under the cover; walks stooping; all the symp- toms worse while standing; psoric diathesis. Ver. alb. After great fear of fright, with cold sweat, exhausting vom- iting and diarrhoea. Zincum. Usually feels best during menses; fidgety of feet. Besides compare the chapter on Iyeucorrhcea. 684 DIGEST TO DISPLACEMENTS OF THE WOMB. Digest to Displacements of the Womb. LOCAL SYMPTOMS. Prolapsus Uteri, when straining at stool or urinating; rises again when walking about: Bel lad. , after cessation of menses: Agar. muse. , with ulceration of os and cervix: Arg. nitr. , with indurated os: Hydrast. , with stinging in os: Calc. carl). Hetroversion : Cauloph., Ferr. jod. Bearing", pressing down : Agar., Calc, card., Chamom., Laches., Platina, Sul- phur. Pressing down, as if everything would come out: Bel lad., JS T il. ac, Sepia. , has to cross her limbs: Sepia. , must press with hand against vulva: Lil. tigr. , feels as though she had to hold it up: Merc. sol. through the vagina on stooping: Lycop. from loins down: Laches. from small of back down towards front: Argent. from side of abdomen early in morn- ing; has to sit down: Natr. mur. Pressing down, with burning in uterine region: Nux vom , with sensitiveness of parts: Platina. and drawing in legs during menses: Coniuni. and tearing pains in the veins of the legs: Chamom. and pulling in both thighs: Mercur. , extending through groins as far as the small of the back: Platina. Sense of weight in pelvis after lifting a a heavy load: Aumim. Labor-like, colicky pains: Chamom. pains during menses: Laches. and leucorrhcea: Lgnat., Kali card. Congestion and irritability of uterus: Cauloph. Inflammation : Aeon. Pain in left ovary and loins: Argent. in groin; has to walk crooked: Amm. mur. Pressure upon rectum, that she can neither stand nor walk: Ferr. jod. Vagina dry: Bellad., Lycop. , and painful embrace: Natr. mur. , aching: Calc. card. , burning and itching and pimples around pudendum: Sulphur. , bleeding from, after painful coition: Arg. nitr. Before menses, nosebleed: Hydrast. , pain in mammae: Conium. During menses, pressing down from loins: Laches. , agonizing pain, with tossing about: Aeon. , colic: Cauloph. , red tongue, with dark spots and burning: Mercur. Menses, scanty: Conium, Laches., Lil. tigr. , , black and of putrid odor: Lgnat. , thick, black and acrid: Sulphur. flow more abundantly in the night : Amm. mur. Menses flow as long as she is moving about: Lil. tigr. too soon, with pain in small of back and in belly: Amm. mnr. and too profuse: Calc. card. , profuse: Platina. , suppressed after fright: Lycop. , ; sterility: Conium. Flow of blood between the periods: Bellad. Frequent discharge of coagulated blood: Chamom. Profuse discharge of hot water from womb: Hydrast. Leucorrhcea, jelly-like: Sepia. , milk-like: Calc. card. , mucous, profuse: Cauloph. , like white of egg, with great sexual desire, although coition is painful: Hydrast. , smarting, burning, excoriating: Co- nium, Hydrast., Lgnat., Sulphur. , , , , with aversion to coition: Hydrast. , with pain in small of back: Kali card. DIGEST TO DISPLACEMENTS OF THE WOMB. 68 5 GENERAL SYMPTOMS. Desire to be alone, brooding to herself, full of grief: Ignat. to self-destruction: Aurum. Always in a hurry, without accomplish- ing anything: Lil. tigr. Disinclination to move: Sepia. Easily moved to tears: Pulsat. Despondency : Sepia. Dejected, longing for death: Aurum. Fear of Death : Aeon. Irritability and nervousness: Hydrast. Can hardly Stop talking about old vex- atious things: Chamom. Vehement, least contradiction excites her wrath: Aurum. Quarrelsome and angry: Chamom. Haughty : Platina. Inexpressible feeling of some internal illness: Mercur. Headache on waking every morning: Natr. mur. and backache: Hydrast. Congestion: Bellad. Heat on top of head, with cold feet: Sulphur. Dizziness and roaring in ears: Bellad. on walking up stairs: Calc. card. when lying down, looking around, or going down stairs: Conium. Paleness of face: Pulsat. Bloated, especially between eyebrows and upper lids: Kali carb. Yellow saddle across bridge of nose: Sepia. Red tongue, with dark spots and burn- ing during menses: Mercur. Taste salty: Mercur. • bad in morning, dryness without thirst: Pulsat. Desire for hard-boiled eggs: Calc. carb. After eating, regurgitation of food by the mouthful without nausea: Hydrast. Gone feeling in pit of stomach: Ignat., Sepia. between 11 and 12 a. m.: Sulphur. Voice weak, faint and exhausted from talking: Natr. mur. Feeling of something in throat which she has to swallow: Laches. Epigastrium tender to touch: Hydrast. Abdomen tender to touch; pull their dress or cover from off the: Laches. Feeling as of a tight band around waist,, worse at night: Hydrast. as of a ball rolling in abdomen or in bladder: Laches. Pains recur about 3 a. m. : Kali carb. Incarcerated flatulence : Lycop. Pot-belliedness : Calc carb., Sepia. Constipation : Platina, Podoph. , dry, lumpy, feces, followed by mat- ter like white of egg: Hydrast. and ischuria, worse during menses: Aurum. Looseness, inclined to: Nit. ac. Urging, unsuccessful: Bellad., Lil. tigr. y Nux vom. Tenesmus, constant, with frequent white slimy stools: Ferr. jod. Weight, sense of, not relieved after stool: Sepia. Slow, difficult stool, although soft: Sepia. Stool with blood during menses: Amm. mur. After stool, cutting in rectum for hours: Nitr. ac. Prolapsus ani: Podoph. Desire, unsuccessful, to urinate: Bellad. „ Lil. tigr., Nux vom. Urging, sudden, imperative: Sulphur. , frequent: Chamom., Podoph. , constant, with relief after passing water: Hydrast. Ischuria, worse during menses: Aurum. The flow Of urine suddenly stops: Co- nium. A few drops are only discharged and some mucus from rectum: Bellad. Scanty, deep-colored urine: Ferr. jod. Burning and cutting in urethra after micturition: Natr. mur. Cough at night when lying down and during pregnancy: Conium. Inclination to sigh, cannot get the breath deep enough: Calc. carb. Bearing-down pains take her breath away: Sepia. Induration in mammas and other glands: Conium. Palpitation of heart, with trembling: Platina. , with numbness of left arm: Laches. 686 MORBID GROWTHS WITHIN THE WOMB. Back aches as if it would break: Bell ad. sore and weak, especially after wash- ing: Pod o ph. Small of back, pain in, as though it were pressed in from both sides: Kali card. , drawing downwards: Bel lad. , pressing, worse when turning in bed: Nux vom. Small of back, pain in, through hips down the thighs: Nitr. ac. , pain in, relieved by lying on a hard couch: Rhus tox. body, Thighs, drawing in: Nux vom. Limbs, jerking of, or of whole sleeping or waking: Lycop. Feet, fidgety of: Zincum. damp and cold: Calc. card. cold or burning hot: Sulphur. Numbness and ridgidity here and there: Plalina. Varicose on lower extremities: Lycop. Heavy sleep exhausts her: Sulphur. Sleepless before midnight: Hydrast. and restless at night: Sulphur. Wakes after midnight and lies awake for hours; later heavy sleep with dreams till late in the morning: Nux vom. Wakes Tip very cross: Lycop. Peels bad after sleep: Laches. Heat especially of feet, which she un- covers: Sulphur. Tendency to perspire: Mercur. about head: Calc. card. during motion and sleep: China. Cold sweat, vomiting and diarrhoea: Ver. alb. Dryness and itchiness of skin: Kali card. Scrofulous diathesis: Calc. card., Ferr. jod. Weakness, loses breath and speech: Nitr. ac. from loss of fluids: China. Weak and tired: Sepia. Nervous and hysteric spasms: Ferr .jod. After fright : Aeon., Ver. aid. After Straining, lifting, parturition: Arnica, Aurum, Calc. card., Chamom., Nux vom., Pod op h., Rhus tox., Secale. Worse from bodily exertions: Calc. card. from too long walk: Rhus tox. from talking: Calc. card. from standing: Lil. tigr., Sulphur. from touch: China. from taking cold: Calc. card., Calc. phosph., China. at night: Mercur. Climacteric age: Laches. Better during menses: Zincum. when riding in a carriage: Nitr. ac. Chilliness: Pulsat. and external coldness: Platina. After the use of quinine and local appli- cation of caustics: Natr. mur. allopathic drugging: Nux vom. Morbid Growths Within the Womb. Mucous polypi are usually an outgrowth of chronic catarrh, and con- sist of enlarged follicles, which elevate the loosely textured mucous mem- brane, gradually forming club-shaped bodies, which hang on a slender pedicle or stem from the fundus down towards the os, or if situated near the cervix, protrude through the external os. Their covering membrane being very vascular, gives them a cherry-red color, and they bleed easily and often pro- fusely; their size varies from that of a pea to that of a hazel-nut, seldom much larger. Fibrous polypi consist of submucous fibroids, which project into the cavity of the uterus, and are covered by the mucous membrane which they push forward. They arise from the body of the womb, and remain more or less continous with the same by means of a more narrow or broader pedicle. Their size varies greatly, and mav attain to the dimensions of a child's head CANCER OF THE WOMB. 687 and over. Such growths should properly be called submucous fibroids, but are best known under the name of uterine fibrous polypi. If these morbid growths take during their development an outward direction towards the peritoneal covering, which they naturally push before them, they are called subserous fibroids, and if they develop within the uterine wall itself, consti- tuting a portion of the same, they are called interstitial, intraparietal or in- tramural fibroids. It is often the case that all three kinds of fibroids are associated with each other. These tumors do not direct^ endanger life, but may become dangerous through haemorrhage or suppuration and ichorous degeneration, and constitute at best a constant interference with the enjoyment of life. Therapeutic Hints. As the most important remedies compare Calc. carb., Calc. phosph., Co?it2tm, Lycop., Nitr. ac, Phosphor., Sanguin., Silic, Staphis., Teucriitm, Thuja. Many others may be indicated in individual cases. In case of haemorrhages compare the respective chapter. Operative means belong into the domain of surgery. Moles are fleshy bodies of various sizes, to which is attached a sac filled with fluid resembling the amniotic fluid; they are embryos not normally developed. The cause for this failure of normal development may lie in the ovum, being from some cause or the other incapable of a normal development ab initio, or in the semen, being not healthy enough to insure a normal growth, or, according to Eaton, in the too small number of spermatozoa, which penetrate the ovum. This latter may be the result of using a syringe after connection, or of withdrawing the penis before ejaculation, or of con- triction of the cervical canal in consequence of flexion, preventing the free ingress of semen into the uterus. Its Symptoms are usually those of pregnancy; and when the abnormal mass is expelled by the efforts of nature, the indications for remedial aid correspond to those of abortus. Hydatids are numerous cysts or vesicles attached to each other like a bunch of grapes, filled with a transparent fluid like water. Upon micro- scopical examination they were found to contain the heads of echinococci, and as hydatid developments are not confined to the uterus, but have been found also in the liver, lungs, testicles and mammae, they cannot be con- sidered as the result of imperfect impregnation. Cancer of the Womb. Carcinoma is, according to Waldeyer, " developed by normal pavement or glandular epithelium penetrating with its ramifications into the depths of the tissues in all directions like plugs, destroying the other tissues in all directions by pressure, and forcing apart the bundles of connective tissue- fibres, so as to form for itself a framework of connective tissue and an alveo- lar structure for the whole tumor. ' ' 688 THERAPEUTIC HINTS TO CANCER OF THE WOMB. 1 ' According to the preponderance of either this connective tissue frame- work, or the nests of cancerous epithelium, we distinguish the harder forms as Schirrus and the softer as Medullary caacer." The degeneration begins almost always at the vaginal portion, rarely extends to the fundus, is, however, very apt to spread down the vagina, over to the bladder and rectum, causing, at the period of its decay, a most horrid destruction of these parts. Its most important Symptoms are pains in the small of the back, loins and groins, which grow more and more violent; haemorrhages, at first only during the menstrual periods, later at any time; and leucorrhoea, which becomes more and more water}', corroding and offensive. The Cauliflower excrescence is a cancroid hypertrophy of the papillae in the mouth of the womb, which sometimes attains to an enormous size in the shape of cauliflowers. It looks bright red, bleeds easily and is prone to can- cerous degeneration, in which state it undermines the general constitution by pain and loss of blood, like cancer of the womb, to which it is similar in all its symptoms. A Differentiae Diagnosis between the two can be gained only by an examination with the speculum. Therapeutic Hints. Arsen. Great exhaustion; restlessness and fits of anguish, with terri- ble, sharp, burning pains; all worse about midnight; acrid, corroding and burning discharges, watery, light or dark colored, often very offensive. Ars.jod. (Wells.) Aw. mu? . Stinging, cutting, pressive pains in the uterine region; very offensive discharges; belching up of wind; craves nothing but sour things. Bel lad. Painful bearing down in the pelvis, as though everything would fall out of the genitals; a similar pain in the small of the back; fre- quent, transient stitches in the region of the womb; haemorrhages from the womb, profuse, often very offensive. Bromium. Eight cases. (Williams.) Calc. carb. Burning soreness in the genital organs; aching in the vagina; profuse menstruation; flow of blood between the monthly periods; cold feeling on the top of the head; great sensitiveness to cold air and liability to catch cold; scrofulous diathesis. Carb. an. Burning in the abdomen, extending into the thighs; labor- like pain in the pelvis and small of the back, extending into the thighs, with discharge of slim}', discolored blood; irregular menses; uterus swollen and hard; cachectic appearance of the face; earthy color of the skin; great weakness. Carb. vcg. Paroxysmal spells of burning in the uterine region; vari- cose veins on the external genital organs; cold knees in bed. Conium. Stitching pain in the womb, accompanied by such symptoms as accompany pregnancy; nausea and vomiting; craving sour or salt things; THERAPEUTIC HINTS TO CANCER OF THE WOMB. 689 pain and swelling of the mammae during the menses; dejection of spirits, etc. Graphit. Cauliflower excrescence; burning, stitching pains, like elec- tric shocks, through the womb, extending into the thighs; great heaviness in the abdomen when standing, with increased pains and faintness; menses only every six weeks, with a discharge of black, clotted, offensive blood, and an increase of all the sufferings; constipation; earthy color of the face; frequent chilliness; sad, desponding. Iodium. Cutting in the abdomen, with pains in the loins and small of the back; uterine haemorrhage at every stool; indurations of the uterus; painfulness and feeling of heaviness in both mammae; they hang down, re- laxed and lose their fat; dwindling and falling away of the mammae; the patient feels worse from external warmth; after abuse of mercury. Kreos. Cauliflower excrescence; awful burning as of red-hot coal in the pelvis, with discharge of clots of blood having a foul smell; bearing down and sense of weight in the pelvis; drawing pains in the small of the back and uterine region, extending to the thighs, intermingled with stitching pains; the vagina is swollen and burning hot; long-standing leucorrhoea, becoming more and more watery, acrid, bloody and ichorous all the time; frequent haemorrhages from the womb; dwindling and falling away of the mammae, with small, hard, painful lumps in them; wretched complexion; great debility; sleeplessness. Laches. Pain in the parts as if swollen, they do not bear contact, and have to be relieved of all pressure; coughing or sneezing causes stitching pains in the affected parts; tenacious and acrid menstrual flow with labor- like pains; discharge of a few drops of blood from the nose before menses, which are scanty and delaying; especially indicated during the climacteric period with frequent uterine haemorrhages. l^ycop. Drawing in the groin; burning and gnawing; chronic dryness of the vagina; pressing through the vagina on stooping; discharge of wind through the vagina; pain in the small of the back, extending down to the feet; incarcerated flatulence, with rumbling in the left hypochondriac region; red, sandy sediment in the urine; jerking of single limbs awake or asleep; feels worse in general from four to eight o'clock p. m. Magn. mur. Scirrhous induration of the womb; uterine spasms ex- tending to the thighs and occasioning leucorrhoea; discharge of black clots of menstrual blood, more when sitting than when walking; large, hard, diffi- cult stools which crumble off as they are expelled. Merc. sol. Syphilitic taint, prolapse of the vagina; swelling of inguni- nal glands. Mur ex purp. A* lively, affectionate disposition has turned to melan- choly from the effects of the disease; frequent, profuse menstruation, and strong sexual desire; soreness in the region of the cervix, or a feeling as though something was pressing on a sore spot in the pelvis; with pain in the right side of the uterus going into the abdomen or thorax; watery greenish 44 690 HYSTERALGIA. leucorrhoea, irritating the parts; dragging and relaxation in the perineum; pains in the hips, loins, and down the thighs, worse from exertion. (B. F. Betts. ) Nitr. ac. Irregular menstruation in shorter or longer intervals; during the intervals a profuse, discolored, brownish and offensive leucorrhoea; great debility, nervousness, and depression of spirits; haemorrhoidal ten- dency; great pain in the rectum after stools, lasting for hours, even worse after a diarrhceic evacuation; the urine is very offensive. During a ride in the carriage they feel much better. Natr. card. Induration of the neck of the womb; the os uteri is out of shape; pressing in the hypogastf^um towards the genital organs, as if every- thing would come out; metrorrhagia; putrid leucorrhoea; headache in the sun and from mental labor; she gets nervous from playing on the piano, and feels great anxiety during a thunder-storm. Phosphor. Frequent and profuse metrorrhagia, pouring out freely and then ceasing for a short time; heat in the back; chlorotic appearance; in- stead of menses, watery, slimy or acrid discharge, causing blisters. Phytol. Menses too frequent and too copious; mammae painful; ster- ility; constipation; syphilitic taint. Rhus fox. Great soreness in vagina preventing an embrace; the men- stual flow, being profuse, protracted and of light color, causes biting pain in the vulva. Sepia. Induration colli uteri or vaginae; painful stiffness in the uterus; pressing from above downwards, oppressing the breathing; must cross her thighs, in order to get relief; pot-belliedness; yellow saddle across the bridge of the nose; feels worse while riding in a carriage. Menses scanty; aversion to coitus; sad and indifferent. Silic. She feels nauseated during an embrace; diarrhoea or else great costiveness before the menses, increased menses, with repeated paroxysms of icy coldness over the whole body at the time of their appearance; indurations of the mammae; most of the symptoms make their apprarance about new moon. Tarant. Cancerous ulcer of os, induration of neck and fundus, chronic vaginitis with granulations. (Nunez.) Thuja. Cauliflower excrescences. Besides compare: Apis, Calc. carb., China, Clemat., Coccul., Hydi-ast., Sabina, Sfaphis., Sulphur and others. Hysteralgia. Under this term we understand a neuralgia uteri, or as it was formerly called, an irritable uterus, which consists of severe, oftentimes even excrucia- ting pains in the region of the womb, without our being able to prove the existence of corresponding changes in the uterus by our present methods of investigation. Hysteralgia, therefore, excludes all those cases where the existing pain can be traced to morbid alterations objectively demonstrable. METRORRHAGIA. 69 1 These attacks of neuralgic pains are prone to remissions and aggravations, greatly influenced by the state of the atmosphere, by mental or emotiona excitements, by indigestion, etc., and are generally found in women of a nervous temperament. Therapeutic Hints. Here, too, as in all neuralgias, the number of remedies which may be indicated is very large. In pains running upward: Laches., Lycop., Phosphor., Sepia. Downward: sEscid., Ipec., Nnx vom. From os ilii forward and downward : Bryon. From groins outward and backward : Sepia. From groins to back : Sulphur. From back to groins: Sabina. (J. C. Morgan.) Dreadful bearing-down, dragging-out feeling : Secale. (Burnett.) Compare the chapters on Abnormal Menstruation, especially Dysmenor- rhcea. Metrorrhagia, Haemorrhage from the Womb. We understand by metrorrhagia a more or less profuse flow of blood from the womb at any other time than that of the menstrual period. 1. It may occur in the not pregnant state of the womb, in consequence of abnormal fluxion to .that organ, or in consequence of morbid growths in the womb and disorganizations of the organ, as shown in the previous chapters, or (and that is, perhaps, its most frequent occurrence) in consequence of those conditions which lead to the so-called ' ' change of life ' ' in the female organ- ism; here it is, perhaps, not always distinguishable from a mere profuse menstruation. 2. It may occur during pregnancy. With some women it is almost a rule, that the menstrual period is repeated several times after conception, without apparent injmy to the child. In others, however, a haemorrhage during the first months of pregnancy is the forerunner of abortion. Haemor- rhages during the second half of pregnancy are often signs of a placenta previa, or likewise forerunners of miscarriage. 3. It may occur after the expulsion of the child, whether it is full- grown or not. Such bleedings are generally of great importance. They are almost always (if not occasioned by mechanical injuries) the conse- quence of insufficient contractions of the womb, the causes of which consist either of protracted or exhausting labors, or a too rapid expulsion of the child, or a partially- adhering placenta, or large blood coagula within the womb. 4. When occurring later, during the lying in time, the haemorrhages are usually not so profuse and happen chiefly in women who do not nurse the child. Sometimes, however, they may be caused by an inflammatory ir- ritation of the womb. 692 THERAPEUTIC HINTS TO METRORRHAGIA. 5. It may occur during an attack of typhus, variola, cholera, etc. Metrorrhagia sets in frequently with chilly spells. The bleeding is either in gushes, or a continuous flow of bright red or dark blood. The face turns pale, the extremities grow cold; there is anxiety, restlessness, labor-like pains or colic; sometimes difficulty in breathing; vomiting and even convul- sions. A great loss of blood brings on the signs of anaemia; coldness and deadly paleness of the face, chills; cold perspiration; darkness before the eyes; ringing in the ears; faintness. drowsiness, weak pulse, convulsions. Therapeutic Hints. Apocyn. cann. The flow is either continuous or paroxysmal; the blood fluid or clotted; there is nausea, vomiting, palpitation of the heart, great prostration and fainting when raising the head from the pillow. Arse?i. Pale, hippocratic face; sunken, lustreless eyes, and icy-cold ex- tremities, spots and blisters on the skin, with oozing of blood. Arnica. After difficult labor or external injuries; head hot; remaining body cool. Bellad. Great bearing down, as if everything would be pressed out, or a pain from the sacrum through the pelvis to the pubis; the blood feels hot; headache; loss of consciousness; darkness before the eyes; enlarged pupils; cold nose; oppression, groaning, 3^awning, jerkings of the arms; convulsive clenching of the thumbs. Calc. carb. Climacteric period; chronic; mixed with leucorrhcea; pre- viously always inclined to profuse and protracted menses. Cauloph. Threatening abortion, and with spasmodic bearing-down pains; great vascular excitement; passive haemorrhage after abortus or con- finement; tremulous weakness of the whole system. China. At the commencement or actual presence of the above described symptoms of anaemia. Chamom. Threatening abortus or actual abortion; labor-like pains from the small of the back extending to the genitals; blood dark and clotted. Crocus. Dark, viscid, stringy blood, in black clots; feeling as if some- thing alive were in the abdomen; nervous excitement; palpitation of the heart; fearfulness; after being overheated, straining and lifting; after abortus and delivery; worse from slightest motion; yellowish, earthy color of the face. Eriger. Uterine haemorrhage, with violent irritation of the rectum and bladder; after abortion, with diarrhoea and dysuria. Ferrum. Parti}- fluid and partly black, clotted blood; labor-like and colicky pains; fiery red face; frequent short shudderings; headache and dizzi- ness; constipation and hot urine. Hamam. Passive haemorrhage, with anaemia; soreness of the abdomen. Hyosc. Continuous flow of bright red blood, or in bright red clots, with spasmodic jerkings of the body and great vascular excitement; nausea; vomiting; hiccoughing. THERAPEUTIC HINTS TO METRORRHAGIA. 693 Ignat. After the abuse of chamomile tea; after mental excitement and depression; gone feeling in the pit of stomach. Ipcc. Especially after child-birth or the taking away of the placenta; the flow is continuous, and the patient gasps for breath and is deadly pale. Kreosot. Black blood in large quantities and of an offensive smell, dur- ing the climacteric period. Kali card. Threatening abortus and consequences of it; great weak- ness in the small of the back and lower extremities; pain in the small of the back as though it were broken; dry, hacking cough; obstinate sweating, with feverish chilliness; chronic inflammatory states of the womb, with nausea and vomiting. Ladies. Climacteric period. Lycop. Partly black, clotted, partly bright red blood, and partly bloody serum, with labor-like pain, followed by swooning; distention of the abdo- men in different places, changing localities; pain in the small of the back, extending into the thighs; worse in the afternoon from four o'clock, com- mencing with chilliness; restless sleep; dreams of falling down from a height; especially for women who habitually menstruate profusely. Mercar. Frequent fainting; profuse, cold perspiration on the face; collection of slime in mouth and throat; external swelling of the genitals. Nitr ac. After miscarriage or confinement; diarrhoea, with cutting pain in the rectum after stool; urine of an intolerably strong smell. Nux vom. During the climacteric period, and especially if such per- sons have been drugged previously by allopathic nostrums, or have used much coffee or alcoholic drinks, or too highly seasoned food; if they lead a sedentary life, complain much of costiveness and headache, suffer with piles, etc. Phosphor. Between the menses and during pregnancy; lame and bruised feeling in the small of the back; dry cough and tightness in the chest, worse before midnight; great heat on the top of the head or in the spine; a great deal of vertigo; chronic looseness of the bowels, worse in the morning, or else chronic constipation with dry, narrow stools. Plaiina. During pregnancy; after confinement; after great mental emotions; dark, thick, not coagulated blood; pressing pain from the small of the back downward upon the pelvic organs, as though they would come out, with great sensitiveness of the external organs, and nymphomania; sometimes a feeling as if limbs and body were growing larger. Plumbum. During the climacteric period; dark clots, alternating with fluid blood or bloody serum, with a sensation of fullness in the pelvis and slight bearing-down pains from the small of the back to the front; skin dry, pale, yellowish; here and there " liver spots;" great debility, short breath on going up stairs; depressed spirits. Poisoning with lead brings on abortus. Pulsat. Dark, coagulated blood emitted in paroxysms; worse in the evening, with labor-like pains; habitual looseness of the bowels; ordinarily rather scanty menses; yielding disposition. 694 MENSTRUAL ANOMALIES. Rhus tox. Bright red blood; threatening abortus, induced by strain- ing or lifting; trembling sensation in the middle of the chest; contractive pain around the hypochondria; drawing, tearing in the back, loins and hips; cramp-like contraction of the thighs; aching all over, worse during rest; heavy, unref reshing sleep, full of dreams. Sabina. Blood bright red or dark, also in clots, sometimes alternating, now dark, coagulated, and then, again, thin and bright red; flows mostly in paroxysms, which are brought on by the slightest motion; or it ceases when walking about; drawing, cutting, pressing pains from the small of the back to the genitals and into the thighs; women who menstruate early and almost always profusely; gout}' diathesis; when the patient feels better in cool and worse in warm temperatures; threatening abortus; after miscarriage a"d confinement. Secale. Atonic haemorrhages during the critical age; after confinement; dark, seldom coagulating blood, sometimes fetid; no pain, or only slight bearing down; or dreadful bearing-down and dragging- out feeling; flooding, worse from the slightest motion; trembling, convulsive jerkings of the limbs; cramps in the calves of the legs; general coldness. Sepia, Climacteric age, or during pregnancy, especially during the fifth and seventh months; congestion of the head; fullness and pressure in the chest; spasmodic contractions in the abdomen, with terrible bearing down; induration of the womb; varicose veins; yellow, sallow complexion. Such patients are very irritable, and faint from any little exertion. Sulphur . In chronic cases, when other remedies do not prevent its re- turn; psoric taint of the system; eruptions here and there, or previously suppressed eruptions; looseness of the bowels early in the morning, or else great constipation; fits of gnawing hunger before dinner; the patient com- plains of great heat, or flushes of heat; has sleepless nights, seemingly with- out cause, or on account of a tormenting itching all over the body; itching about the anus and genitals; chronic leucorrhcea, etc. Trillium. Gushing of bright red blood at least movement, at times dark clots; frequent desire to urinate. Sallow face with white lips and tongue; tossing in bed from evening until after midnight, with a feeling as if hips and small of back were falling to pieces and a desire to bind them up tightly. (F. G. Gilchrist.) Ustilago. At the climacteric period; active and constant flowing with frequent clots. Digest see under Menorrhagia. MENSTRUAL ANOMALIES. 1. Menorrhagia Is, like metrorrhagia, a profuse flow of blood from the womb; only with the difference that it occurs at the time of the menstrual period. This period may keep regular time, or it ma} 7 come too soon, or it may last too long; in some THERAPEUTIC HINTS TO MENSTRUAL ANOMALIES. 695 cases the menses are too profuse, too early and lasting too long. Its causes are various. We may trace it to different structural changes and morbid growths of the uterus; to stagnation of the blood in the uterine veins, de- pending upon heart and lung diseases; to fluxions to the womb, brought on by sexual excesses, or sexual excitements by loose literature or onanism; to haeinorrhagic diathesis, as in scurvy, purpura hsemorrhagica, hemorrhagic smallpox, measles, typhus, etc. Such cases, however, are of rare occurrence. The blood is either fluid or coagulated, and may differ greatly in color and character. Strong, plethoric women ma}^ endure monorrhagia for a long time; weak, feeble women soon show signs of anaemia. Therapeutic Hints. Compare the preceding chapter on Metrorrhagia, and likewise those which treat of its causes as stated above. Amm. card. Premature and very copious flow, especially at night, when sitting or riding, and after a ride in the cold air; with spasmodic pains in the belly and hard stools with tenesmus; cholera-like symptoms at the commencement of the flow. Arg. 7iitr. Congestion of the uterus; cutting pains in the small of the back and groins; cramp in the stomach; great debility of the lower limbs; vertigo and enlarged feeling of the head. Bryon. Menses premature and too profuse; dark red blood; tearing in the limbs; splitting headache from the least motion, even on moving the eyes; white-coated tongue; great thirst; bilious vomiting; tearing in the limbs; constipation; stools as if burnt; or diarrhoea in the morning. Calc. carb. Profuse, too early and lasting too long; anaemic symptoms and congestion of the head and chest; leucorrhoea afterwards; scrofulous diathesis. Calc. phosph. Menses every two weeks, black and clotted; before their appearance, griping and rumbling in the bowels; leucorrhoea; stitching pains in the left side of the head; sleepiness during the day. Cann. ind. Violent uterine colic; great nervous agitation and sleep- lessness; or cold hands and feet. (W. C. Richardson.) Chamom. Profuse discharge of dark, almost black, coagulated blood, with drawing, clawing pains from the small of the back to the os pubis; irritable; fainting spells; cold extremities. Cimicif. Profuse and too early; dark, coagulated blood; aching in the limbs; severe pain in the back, down the thighs, and through the hips, with heavy pressing down; weeping mood; nervousness; hysteric spasms; great pain in the head and eyeballs, increased by the slightest movement of the head and eyeballs. Coccul. Profuse and too often; when rising upon the feet it gushes out in a stream; paralytic feeling of the lower extremities. Cocc. cacti. Flow only in the evening after lying down, not when stirring 696 THERAPEUTIC HINTS TO MENSTURAL ANOMALIES. about; urging to urinate but cannot pass water until a clot of blood is dis- charged; nausea, vomiting. (C. B. Knerr.) Collins. Menorrhagia in connection with constipation and piles. Crocus. Profuse and lasting too long, but coining at the right time; dark, clotted, string}' blood; wretched, pale, yellowish color of the face; pal- pitation of the heart on going up stairs; great debility. Cyclam. " The flow almost ceased as long as she was moving about at work, but as soon as she sat down quietly in the evening the flow reappeared and continued after she went to bed." (H. Ring.) Digit. Venous, passive congestion, with pale or livid color of the face; coldness of the skin; swelling and painfullness of the feet; all in consequence of some cardiac anomalies. Eriger. Profuse and too frequent, with violent irritation of the rectum and bladder. Ferrum. Profuse, too frequent, and lasting too long; with a fiery-red face, whilst at other times the face is pale and earthy looking. Gelse??i. Almost continuous flow, without any pain. Hyosc. Piofuse, with delirium; convulsive trembling of hands and feet; silly manners, rage. Ignat. Profuse, too frequent and lasting too long; after great mental troubles, grief or fright; empty feeling in the pit of the stomach; great sen- sitiveness of mind without complaining. Iodum. Profuse and too early; ovarian region painful, or sensitive to pressure; emaciation, notwithstanding a good appetite; chronic catarrh of the lungs. Ipec. Very profuse, with heavy breathing; constant nausea. Kreos. Profuse and last too long; great distention of the abdomen before the menses, so that she appears as though she were pregnant; blood offensive; leucorrhcea between the menstrual periods; headache before menses; is very stubborn and irritable. " Worse in lying, better from walk- ing about . " ( Von Villers . ) Lycop. Profuse and lasting too long; sadness and melancholy before the menses; yellowish color of the face; frequent jerkin gs of the limbs; in- carcerated flatulence. Nux voni. Profuse and too early; great sensitiveuess of the nervous system; can't bear light or noise; is put out of patience when spoken to; gets angry and violent without any provocation; is head-strong and self- willed; or gets frightened easily, and is almost beside herself from the least thing that may happen; she shuns the fresh air. After coffee, liquors, high- seasoned food, drugs, sedentary life. Phosphor. Profuse, too early and lasting too long; or too late, but very copious; afterwards great weakness, blue rings around the eyes; losing of flesh and great fearfulness; tender, sensitive women, with frequent heat in the back, and cold legs. Platina. Profuse, too frequent and long lasting; dark blood; pressing- down pains; excited sexual desire. DIGEST TO METRORRHAGIA AND MENORRHAGIA. 697 Secale. Profuse dark, without pain, lasting too long, being aggravated by the slightest motion or mental emotion. Spitting of blood before the menses; leucorrhcea three da5 T s after menstruation; ischiatic pains better from bending the limb. Sepia. Profuse,, either too early or at the right time; venous congestion of the head; one-sided headache, with nausea and vomiting; loathing of all food; pot-belliedness after confinement; constipation; yellow spots on the face. Trillium. Menses every fourteen days, lasting seven and eight days; in the intervening time profuse leucorrhcea of a yellowish color and creamy consistence. The blood is at first bright red, but owing to anaemia, grows pale. Veratr. Profuse and too early; commencing with vomiting and diar- rhaea; sensation upon the top of the head as if ice lay there; nose, hands and feet cold; irritable, weeping mood. Digest to Metrorrhagia and Menorrhagia. Blood black: Calc. card., Chamom., Cro- cus, Ferrum, Kreos., Lycop., Plum- bum. and clotted: Calc. phosph., Chamom., Crocus, Ferrum, Lycop., Plumbum. dark: Chamom., Crocus, Platina, Sabina, Secale. and clotted: Chamo7n., Cimic, Platina, Plumbum, Pulsat., Sabina, Trillium. dark red: Bryon. clotted or fluid: Apoc. cann., Fer- rum, Plumbum, Ustil. fetid or offensive: Kreos., Secale. hot: Bellad. bright red: Hyosc, Lycop., Rhus tox., Sabina, Trillium. and clotted: Hyosc. stringy: Crocus. thin: Sabina. Bloody serum: Lycop. Flow continuous: Apoc. cann., Gelsem., Hyosc, Lpec, Ustil. paroxysmal: Apocyn., Pulsat., Sa- bina. Passive: Cauloph., Hamam. Chronic, mixed with leucorrhoea: Calc. Menses habitually profuse: Calc. carb., Lycop., Sabina. scanty: Laches., Pulsat. at the right time: Crocus, Sepia. too early: Amm. carb., Bryon., Calc. carb., Cimic, Iodium, Nux vom., Phosphor., Sabina, Sepia, Veratr. too often, frequent: Coccul., Eriger., Ferrum, Ignat., Platina. every two weeks: Calc. phos., Tril- lium. too long protracted: Calc. carb., Cro- cus, Ferrum, Lgnat., Kreos., Lycop., Phosphor., Platina, Secale, Sepia. lasting seven and eight days: Tril- lium. commencing with vomiting and diarrhoea: Amm. carb., Ver. alb. ACCOMPANYING SYMPTOMS. Loss of consciousness: Bellad. Delirium, silly manners, rage: Hyosc. Depressed spirits: Plumbum. Sadness and melancholy before menses: Lycop. Weeping mood: Cimic, Ver. alb. Fearfulness: Calc carb., Phosphor. Easily frightened: Nux vom. Irritable: Chamom., Kreos., Sepia, Ver. alb. Angry, violent, out of patience, without provocation: Nux vom. Stubborn: Kreos. Head-strong, self-willed: Nux vom. Yielding disposition: Pulsat. Tender: Phosphor. 698 DIGEST TO METRORRHAGIA AXD MENORRHAGIA. Sensitiveness, nervousness: Cimic, Nux vom.i Phosphor. , without complaining: Ignat. Nervous agitation and sleeplessness: Cann. ind. Dizziness, vertigo: Ferrum, Phosphor., Pulsat. , , and enlarged feeling of head: Arg. 7ii tr. Headache: Bel lad., Ferritin, Nux vom. before menses: Kreos. , splitting, from motion, even of eyes: Br yon. and pain in eyeballs, worse from motion: Cimic. , stitching in left side: Calc. phosph. , one-sided, with nausea and vomit- ing: Sepia. Congestion: Sepia. of head and chest: Calc. card. , venous: Sepia. Heat of head, remaining body cool: Ar- nica. of top of head, or in spine: Phos- phor. Coldness, as of ice, on top of head: Ver. alb. Darkness before eyes; enlarged pupils: Be/lad. Cannot bear light or noise: Nux vom. Blue ring's around eyes: Phosphor. Sunken, lustreless eyes: Arsen. Cold nose: Ver. alb. Face pale or livid: Digit. deadly: Ipec. yellowish: Crocus. earthy, with pain and fiery-red: Fer- rnm. hippocratic: Arsen. sallow r : Sepia, Trillium. yellowish: Lycop. yellowish, earthy: Crocus. , yellowish spots: Sepia. White lips and tongue: Trillium. Profuse cold perspiration: Ver. alb. White coated tongue and great thirst: Br yon. Collection of slime in mouth and throat: Mercur. Loathing of all food: Sepia. Nausea, constant: Ipec. and vomiting: Apec. conn., Cocc. cad., //rose. Kali carb. Vomiting, bilious: Bryon. and diarrhoea at the commencement of the flow: Amm. carb., Ver. alb. Hiccoughing: Hyosc. Fits of gnawing hunger: Sulphur. Empty, gone feeling in pit: Ignat. Cramp in stomach: Arg. nitr. Contractive pain around the hypchon- dria: Rhus tox. Spasmodic pains in belly: Amm. carb. , with bearing down: Sepia. Labor-like pain: Ferrum. , followed by swooning: Lycop. , from small of back to genitals: Chamom. Colicky pains: Ferrum. in uterus: Cann. ind. Griping and rumbling before menses: Calc. phosph. Soreness of abdomen: Hamam. Flatulence, incarcerated: Lycop. Distention of abdomen: Kreos. , changing places: Lycop. Something alive, as if, in abdomen: Crocus, {Thuja). Pot-belliedness Sepia. after confinement : Constipation: Bryon, Nux vom., Sepia. , stools as if burnt: Bryon. , chronic, with dry, narrow stools: Phosphor. , with tenesmus: Amm. carb. and piles: Collins. and hot urine: Ferrum. Irritation of rectum and bladder: Eriger. Looseness of bowels, habitual: Pulsat. Diarrhoea, worse in the morning: Bryon., Phosphor., Sulphur. , with cutting pain in rectum after stool: Nitr. ac. and dysuria: Eriger. Itching about anus and genitals: Sul- phur. Piles: Nux vom. Frequent desire to urinate: Trillium. Urging, but cannot pass water until a clot of blood is discharged: Cocc. cact. Urine of intolerable strong smell: Nitr. ac. Womb, with chronic inflammation of: Kali carb. DIGEST TO METRORRHAGIA AND MENORRHAGIA. 699 , congestion of: Arg. nitr. , induration of: Sepia. Ovarian region painful, sensitive to pressure: Iodum. Bearing", pressing down; Cauloph., Cimic, Platina, Plumbum, Secale, Sepia. , , as if everything would be pressed out: Bel lad., Sepia. , , dragging out feeling: Secale. Labor-like pain: Cann. ind., Chamom ., Per rum, Lycop., Pulsat. , from small of back to genitals: Cham oi)i. , to front: Plumbum. , upon pelvic organs: Platina. External organs sensitive: Plalina. swollen: Merciir. Sexual desire, nymphomania: Platina. Leucorrhcea: Calc. phosph. , chronic: Sulphur. between menses: Kreos., Trillium. after menses: Calc. carb., Nitr. ac. Lungs, chronic catarrh; Iodium. Chest, fullness and pressure in: Sepia. , tightness in: Phosphor. , trembling sensation in middle of: Rhus tox. Cough, dry, hacking: Kali carb. , , worse before midnight: Phos- ■ phor. Oppression, groaning: Bellad. Breathing heavy, gasps for breath: Ipec. short on going up stairs: Plumbum. Yawning: Bellad. Palpitation of heart: Apocyn. on going up stairs: Crocus. Cardiac anomalies: Digit. Back, heat in, and cold legs: Phosphor. , drawing, tearing in, and loins and hips: Rhus tox. Small of back, pain as if broken : Kali carb. , bruised and lame: Phosphor. and hips, as if falling to pieces, with desire to bind them up tightly: Trillium. , drawing, cutting, pressing from, to genitals: Sabina. , , clawing from, to os pubis: Chamom. , cutting from, and groins: Arg. nitr. , pain from, through hips and down the thighs: Clinic. , , to thighs: Lycop., Sabina. Pain from sacrum through the pelvis to the pubis: Bellad. Arms, jerking of: Bellad. Hands, convulsive trembling of, and feet: Hyosc. Thumbs, convulsive clenching of: Bel- lad. Lower limbs, debility of : Arg. nitr. , paralytic feeling of: Coccul. Cramp-like contraction of thighs: Rhus tox. Cramps in calves of legs: Secale. Varicose veins: Sepia. Swelling and painfulness of feet: Digit. Limbs, aching in: Cimic. , , and all over, worse in rest: Rhus tox. , tearing in: Bryon. , jerkings of: Lycop., Secale. , trembling of: Secale. , cold: Arsen., Cann. ind., Chamom., Ver. alb. and body feels as though they were growing larger: Platina. Itching all over .body, preventing sleep: Sulphur. Eruptions here and there, or suppressed eruptions: Sulphur. Skin dry, pale, yellowish; liver-spots: Plumbum. Spots and blisters on skin, with oozing of blood: Arsen. Chilliness, with obstinate sweating: Kali carb. from 4 p. m. Shudder ings : Ferrum . Coldness of skin: Digit. , general: Secale. of hands and feet: Cann. ind. of extremities: Chamom. Heat, or flushes of heat: Sulphur. Perspiration cold on face: Mercur. , obstinate, with chilliness: Kali carb. Sleepiness during day: Calc. phosph 'OO AMENORRHEA. Sleep heavy, unrefreshing, full of dreams: Rhus tox. restless, with dreams falling from a height: Lycop. Sleepless and nervous agitation: Cann. ind. , tossing in bed from evening until after midnight: Trillium. on account of itching: Sulphur. Vascular excitement: Cauloph. and spasmodic jerkings of body: Hyosc. Nervous excitement: Crocus. Anaemia: Calc. carb., China, Hamam. Debility: Apoc. cann., Cauloph., Crocus, Plumbum. Fainting": China, Mercur. when raising head from a pillow: Apoc. cann. from little exertion: Sepia. Losing flesh: Phosphor. , notwithstanding good appetite: Iodium. Hysteric spasms: Cimic. Scrofulous diathesis: Calc. carb. Psoric taint: Sulphur. Gouty diathesis: Sabina. CAUSES. Abortus, threatening or actual: Cauloph., Chatnom., Eriger., Kali carb., Plum- bum, Rhus tox., Sabina, Trillium. Abortus or confinement: Bellad., Cau- loph., Ci'ocus., Ipec, Nitr. ac, Sabina, PI a tin a. , after taking away placenta: Ipcc. Difficult labor, or external injury: Arnica. Straining, lifting: Rhus tox. , , overheating: Crocus. During" pregnancy, Phosphor., Platina. , at fifth or seventh month: Sepia. Climacteric age: Calc. carb., Kreos., Laches., Nux vom., Plumbum, Secale , Sepia, Us til. Between menses: Phosphor. After mental excitement, emotions: Ignat., Platina. After abuse of chamomile tea: /gnat., Pulsal. coffee, liquors, high-seasoned food, drugs; sedentary life, etc.: Nux vom. Worse from slightest motion: Crocus, Sabina, Secale, Trillium. rising upon the feet, gushing: Coc- cul. walking: Sabina. when lying down: Amrn. carb., Cocc. cad., Cyclam., Kreos. Better, when moving about; Cocc. cact., Cyclam , Kreos. Worse in evening: Pulsat. at night: Amm. carb. after riding in cold air: Amm. carb. in warm temperature: Sabina. in cold: Nux vom. Better in the cold: Sabina, Secale. 2. Amenorrhoea Consists of the absence of menstruation in women between the ages of puberty and climaxis, with the exception of the periods of pregnancy and nursing. The non-appearance of the menses at the age of puberty has its cause chiefly in chlorosis, scrofulosis, tuberculosis and rachitis. Rarer are those cases in which it depends upon a degeneration of the ovaries; more frequent those depending upon chronic infarctions or catarrhal processes of the womb in consequence of the above-stated constitutional diseases. It has been ob- served, likewise, as a consequence of spinal diseases, imperforation of the hymen, and closure of the os uteri. The cessation or suppression of the menses is usually a consequence of inflammatory processes, the causes of which have been detailed under the head of Metritis. Vicarious menstruation is that peculiar anomaly of the menstrual func- THERAPEUTIC HINTS TO AMENORRHCEA. 701 tion, by which, at the regular monthly period, haemorrhage takes place, not from the womb, but by way of some other mucus membrane (nose, lungs, bowels, eyes, ears), from wounds, and from telangiectasias. The reality of such abnormal action is established beyond any doubt. The Symptoms of amenorrhcea consists chiefly of headache, especially on the top or on one side; heaviness of the feet; dyspnoea; dyspepsia; lassitude; sadness; sleepiness in the daytime; oedema; palpitation of the heart; epis- taxis; haemoptysis; haematemesis; swelling of the veins on the lower ex- tremities, in combination with all the constitutional signs upon which the whole disturbance rests as a basis. Therapeutic Hints. Aco7i. During puberty frequent bleeding of the nose; great palpitation of the heart; congestion of the head. After fright or taking cold. Apis. In young girls, who are constantly busily engaged in this or that, but do nothing right; who let everything fall out of their hands or break it, and laugh over it; also great congestion of the head, and even delirium; ©edematous swelling of the lower extremities. Apoc. In young girls, attended with bloating of the abdomen and ex- tremities. Bellad. Haematemesis instead of the monthly discharge; congestion to the head. Bryon. Bleeding of the nose instead of the monthly flow. Calc. carb. In young girls of a plethoric habit, or a scrofulous diathe- sis, with different complaints, as if the menses would set in, but do not; sup- pression of the menses from working in water, with anasarca. Carb. veg. At the time the menses should appear, violent itching or old tetter y eruptions. Caustic. Epileptic fits during the time of puberty. China. After suppression by chagrin; secretion of milk in the breasts. Cimicif. In suppression from a cold, mental emotions and febrile symptoms; when rheumatic pains in the limbs, or intense headache, or uter- ine spasms are present. Coccul. Instead of the monthly flow: cramps deep in the abdomen; pressure in the chest; dyspnoea; groaning and moaning; great weakness, so that the patient is scarcely able to speak; paralytic feeling in the lower ex- tremities. Cyclam. Chlorotic state; great dizziness and headache. Cuprum. Typical paroxysms of the most violent cramps in the abdo- men, extending up into the chest, with nausea, retching and vomiting; con- vulsive motions of the limbs, with piercing shrieks. Digit. Age of puberty; dark, red, bluish color of the face; distended veins on eyes, ears, lips and tongue; constant yawning; irregular action of the heart; suffering feeling in bed; frequent desire to urinate; leucorrhoea; 702 THERAPEUTIC HINTS TO AMENORRHCEA. painful and swollen feet and limbs, with paralytic feeling in them. Bloody expectoration or nosebleed. Graphit. After Pulsat.; congestion of the head and chest; dark red- ness of the face; constriction of the chest, when lying, with anxiety; itching between the fingers, and tetters; nails grow thick and crooked; the limbs upon which she lies go to sleep. Hamam. Vicarious bleeding from nose or stomach, with great con- stipation and varices on the legs. Kali card. Age of puberty; spasms of the chest; swelling of the face especially over the eyes; stiffness and pain in the small of the back; dryness of the skin; is easily frightened; sleepless after 3 o'clock a. m., feeling worse in all respects at that time. Spitting of blood before the menses; corroding leucorrhcea; pain in the anterior part of the thigh. Laches. Nosebleed and cardialgia instead of menses. Lycop. Suppression from a fright; great agitation of the blood in the evening, or a feeling as though circulation had ceased; great desire for sweet things; sour belching; great fullness in the stomach and bowels; liver spots on the chest. Mercur. Cessation of the menses for several months; headache; weak- ness of sight; nervous trembling of the hands; earthy color of the face; pro- lapsus uteri; diarrhoea with tenesmus; oedematous swelling all over; tearing in the limbs, worse at night in bed, with constant sweating. Millef. Haemoptysis. Natr. mur. Age of puberty; melancholy and sadness, or hastiness and impatience; awakes with headache; has frequent fluttering of the heart; the tongue is covered with small blisters, or shows the appearance of a so-called map-tongue; the bowels are costive and move with great difficulty, and there is cutting pain in the urethra after urination. Phosphor. Menses too late, or dot appearing; tight feeling in the chest, with dry, tight cough, and spitting of blood, worse before midnight; bloatedness below the eyes; a great deal of vertigo; leucorrhcea during the menses. Platina. Menses suppressed after a voyage. Pidsai. Age of puberty, or suppression, especially from getting the feet wet; nervous, timid, tearful disposition; always anxious about domestic affairs; pale, yellowish color of the face; dyspeptic feelings from eating pork or anything fat; inclined to looseness of the bowels; thirstlessness and chilli- ness; always feels w r orse in a warm room; haemoptysis, haeniatemesis. Rhus tox. Suppression from getting wet. Senedo gracilis. Suppression; inability to sleep, nervous irritability; loss of appetite; coated tongue; bowels constipated; constant feeling of lassitude; disinclined to move about; wandering pain in back and shoulders. Is called ' ' the female regulator. ' ' Sepia. Age of puberty or later; headache, with nausea; jerking with the head; paralytic sinking down of the eyelids; yellowness around the DYSMENORRHEA. 703 mouth, across the cheeks and nose; loathing of all food, even the smell of cooking nauseates her; nausea when riding in a carriage; diarrhoea after drinking milk; cold hands and cold feet, with frequent flushes of heat to the head and face; pot-belliedness. Spitting of blood before the menses; leucor- rhoea three days after menses. Sulphur, Great congestion to the pelvic organs and to the head; cold feet, and heat on the top of the head; the patient is very irritable, and in- clined to religious reveries; chronic inflammation of the eyelids, or other psoric eruptions; dreads to wash with cold water; feels exhausted from talk- ing; all worse when standing; sleepy in the daytime; sleepless at night; great agitation of the blood in the whole bod}'. Xanthox. After getting the feet wet; nauseated by the sight of food; constipated, nervous, discouraged; shortness of breath; legs swollen. (J. W. Davis.) Digest see under Dysmenorrhcea^ 3. Dysmenorrhoea, Menstruatio Difficilis. We nnderstand by this, painful menstruation, without regard to the quantity of blood discharged, though in most cases the menstrual flow is scanty. The different complaints accompanying it set in either before or at the time when the menstrual discharge begins, and generally last a day or two, and sometimes through the whole menstrual period. We distinguish, according to its causes, three forms of dysmenorrhoea; 1. Dysmenorrhoea in consequence of strictural changes or flexions of the uterus, which has been termed by some writers mechanical dysmenorrhoea; compare the related chapters. 2. Dysmenorrhoea in consequence of congestion in the uterus, or con- gestive dysmenorrhoea; it usually commences with all the signs of congestion to the pelvic organs — strong action of the heart, congestion of the head, and febrile motions in general. These symptoms continue one, two, or three da} r s, until a more profuse discharge of blood has taken place. Not only plethoric individuals are prone to it, but also weakly and anaemic individuals. It is possible that, in some instances, this congestive state is induced by a thickened state of the peritoneal covering of the ovaries, and the consequent difficult perforation of a Graafian follicle. Very violent congestion may cause an exudate between the mucous lining and the parenchyma of the uterus, in consequence of which portions of the loosened membrane are thrown off and discharged — membranous dysmenorrhoea. 3. Dysmenorrhea in consequence of a morbid sensibility of the ner- vous system in general and the uterine nerves especially, or neuralgic dys- emenorrhcea. This manifests itself as a disturbance in the healty equilibrium of the mind's action and a dejection of spirits, which commences even before the menses; the menses are attended at their beginning with distressing pains in the uterine region, in the back and lower extremities, or with neuralgic 704 THERAPEUTIC HINTS TO DYSMENORRHEA. pains in more distant organs, or with cramps, spasms, etc. It is quite possi- ble that in some cases the violent, spasmodic, labor-like pains in the womb are caused by a spasmodic closure of the os uteri. Therapeutic Hints. Compare the following chapters, and likewise those on Metritis and Displacements of the Womb. A ton. Congestive type, with violent headache; labor- like pressing in the womb; headache; restlessness; necessity to bend double on account of pain, but finds no relief in any position; tossing about. Amm. carb. Cramp-like pain in the womb before the flow, with pallor of face. (Talbot.) Apis Congestive type; violent, labor-like, bearing-down pains, followed by discharge of scant}*, dark, bloody mucus; stinging pain in the ovaries; scanty, dark urine; wax-colored skin. Arsen. Attended with various kinds of complaints; lancinations from the rectum to the anus and pudendum; toothache; restlessness; fear of being left alone; the pains are worse about midnight, seem intolerable, drive to despair and frenzy; external application of warmth relieves. Asdep. syr. Neuralgic type; intermitting, bearing-down, labor-like pains, accompanied with a copious discharge of urine. Bel lad. Congestive and neuralgic type; violent bearing down, as if everything would issue out; violent throbbing headache, better from external pressure; throbbing toothache; enlarged pupils; throbbing carotids, drowsi- ness and inability to go to sleep; spasmodic twitchings; delirium; rage; frenzy; wants to bite; tries to escape, etc. Bromium. Violent contractive spasms some hours after the commence- ment of the menstrual flow, with subsequent soreness of the abdomen; loud emissions of flatulence from the vagina; hard swelling in the ovarian region; blue-eyed persons. Bryon. Congestive tj-pe; tearing in all the limbs, aggravated by motion; great thirst, white tongue; constipation, or diarrhoea in the morning; great irascibility. Calc. carb. Various complaints; toothache after the menses; nervous debility; pale bloatedness of the face; cannot bear anything tight around the waist; stiffness of the nape of the neck; pain in the back; cold hands and feet; sensitiveness to cold air; bad consequences from washing; scrofulous indi- viduals. Calc. phosph. When during puberty the patient has not been careful; and dysmenorrhoea has resulted from these causes. (J. T. Kent.) Cact. grand. Menstruation with most terrible pains, causing her to cry out aloud and to weep; the pains come on periodically, mostly in the evening; the menses are scanty and cease flowing when lying down; constrictive pain in the region of the heart, a feeling as if the heart were grasped and com- pressed, as by a band of iron. THERAPEUTIC HINTS TO DYSMENORRHCEA. 705 Caidoph. Painful contractions, congestion and irritability of the womb; scant} 7 flow; sympathetic cramps in the bladder and rectum; hysterical spasms of chest and larynx. Cliamom. Neuralgic type; drawing, clawing pain from back towards front, with discharge of dark, clotted blood; great impatience, with crying and screaming; bloated, red face, or one side red and the other pale; hot, sticky perspiration on the torehead; after chagrin. Cimicif. Aching in the limbs; severe pains in the back, down the thighs and through the hips, with heavy pressing down; labor-like pains, weeping mood; nervousness; hysteric spasms, cramps; tenderness of the hypogastric region; scanty or profuse flow of coagulated blood; between the menses, debility, neuralgic pains, tendency of prolapsus. Coccul. Cramp-pain deep in the bowels, instead of the monthly, with pressure in the chest, and anxiety, sobbing, moaning and groaning; great weakness and fainting spells; convulsive motions of the limbs whenever she wants to use them; after night-watching. Collin. When complicated with obstinate constipation, piles and pro- lapsus. Coloc. She draws the lower limbs up to the abdomen, to relieve the colicky pain; diarrhoea after indignation. Coniiim. Scanty menses; pressing downwards and drawing in the thighs; pain in the mammae; suppressed sexual instinct; globus hystericus; vertigo, especially when turning the head or lying down. Cuprum. Typical paroxysms of terrible cramps in the stomach, extend- ing to the chest, with nausea, retching and vomiting; also, general epilepti- form spasms, with piercing shrieks; great thirst; on swallowing any fluid there is an audible clucking noise in the throat, like that of emptying a bottle. Graphit. Scanty menses, with crampy pains in the bowels and chest, and labor-like pressing in the small of the back; she is full of despairing grief, with weeping; always wavering and hesitating; has vertigo unto fall- ing, and headache unto fainting, in the morning; pimply eruptions on the face about the monthly period; tettery eruptions, especially between the fingers, with great itching. Hamam. Severe pains through the lumbar and hypogastric regions, and down the legs; fullness of the bowels and brain, with severe pain through the whole head, resulting in stupor and deep sleep; varicosed veins on the legs; vicarious menstruation. Laches. Tearing in the abdomen, beating in the head, pain in the small of the back, and bruised feeling in the hips; all relieved by a full flow; bleed- ing of the nose before the menses; jealous disposition; craves coffee, and feels better after drinking it; ulcers on the legs, with a purplish circumfer- ence. Lauroc. Pain extending from sacrum to pubis; frontal headache, with 45 706 THERAPEUTIC HINTS TO DYSMENORRHEA. dizziness and dimness of vision; great melancholy; icy coldness of tongue, and coldness of extremities. (Osborn.) Magn. carb. During the pain no flow; flow more during night than during da3^; the blood is dark, acrid and thick; violent neuralgic pain in the face, right side, driving out of bed; or pain in the right shoulder or in the foot. Natr. mur. Menses scanty and dark; preceded by frontal headaches; often subject to fever-blisters on lips, and during summer to urticarious erup- tions. (R. E. Bilding.) Nux mosch. After suppression by bathing; fainting from pain; drowsi- ness, somnolence; changeable mood; does not know where she is; appears to herself as if changed to her surroundings; hands and feet icy-cold. Nux vom. Twisting pains moving about in the abdomen, with sickness of the stomach; crampy and stitching pains in the pelvic region; soreness across the pubis; cramps in the bladder; constant, unsuccessful urging to defecate; after all sorts of drugs and so-called pain-killers. Phosphor. Colicky pains; great fermentation in the bowels; a great deal of vertigo; chronic looseness of the bowels; or chronic constipation, with dry, narrow feces; slender-built women. Plati?ia. Great bearing down to the genitals, with profuse menstrua- tion; great fear of death; sadness and disposition to cry; or haughty disposi- tion; tetanous-like convulsions. Pulsat. Colicky pains, with tossing about; the blood flows by fits and starts; chilliness; thirstlessness; haemoptoe or hsematemesis; paleness of the face; mild, yielding, tearful disposition. Senecio. Cutting pains in the region of the sacrum, hypogastrium and groins, with too early or too profuse menses; she is pale, weak and nervous, and has a slight cough at night. Sepia. Colicky pains and scanty discharge; great bearing down, which obliges her to cross the limbs; morning sickness and great sensitiveness against any smell from cooking; toothache; half -sided headache; nausea; constipation. Sulphur. Scanty menses of a thick, acrid blood; crampy colic; terrible neuralgic pains in the face; much concerned about her salvation; congestion to the head and heat on the top of it; spotted redness of the face; cold feet; standing increases the pains; chronic eruptions here and there. Tarant. Before menses bearing-down pain; fidget}^ legs; must move about; better on riding horseback; during menses all worse with chorea-like restlessness, trembling and twitching of muscles. (P. Bender.) Viburn. op. Before menses pain in back, gradually extending to hypo- gastric region and down the thighs; headache with nausea and uneasiness; cramps and bearing down before discharge appears, lasting till after the flow has ceased. (J. C. King.) Xanthox. Neuralgic fever with pain along the course of the genito- crural nerve. (K. F. Blake. ) Abundant discharge. digest to amenorrhea. dysmenorrhea. Digest to Amenorrhcea, Dysmenorrhea. 707 Stupor and deep sleep: Hamam. Does not know where she is; appears to herself as if changed to her surround- ings: Nux mosch. Religious reveries : Sulphur. Delirium : Apis, Bellad. Frenzy: Arsen.-, Bellad. Hage, wants to bite; tries to escape: Bellad. Busy without accomplishing anything; let things drop out of their hands and laugh over it: Apis. Hasty and impatient: Natr. mur. Groaning" and moaning: Coccul. Cry out and weep for pain : Cact. grand. "Weeping*: Graphil. Crying", screaming: Chainom. Tossing" about, beside herself from pain: Aeon. Sad : Nat. mur., Blatina, Pulsat. Weeping" mood : Cimic, Platina. Melancholy: Lauroc, Nat. mur. Anxiety: Coccul., Graphit. about domestic affairs; Pulsat. about her salvation: Sulphur. Discouraged : Xanthox. Despair from pain: Arsen. Despairing grief : Graphit. Fear of being left alone: Arsen. of death: Platina. Changeable mood : Nux mosch. Yielding, mild disposition: Pulsat. Wavering, hesitating: Graphit. Irritable: Senec, Sulphur. Impatient irascibility: Bryon , Chamom. Jealous : Laches. Haughty : Platina. Nervous: Cimic, Pulsat., Secale, Senecio. Easily frightened : Kali carb. Vertigo : Phosphor. unto falling: Graphit. when turning head or lying down: Conium. and headache : Cyclam. unto fainting, worse in morn- ing: Graphit. ■ and frontal headache with dimness of vison: Lauroc. Fullness of brain with headache, result- ing in stupor and deep sleep: Hamom. Congestion to head: Aeon., Apis, Bel- lad. and heat on top, and cold feet: Sulphur. and chest: Graphit. Flushes of heat to head and face: Laches., Sepia. Headache: Aeon, Cimic, Mercur. , throbbing, beating: Bellad., Laches. , , worse from external pressure: Bellad. , frontal: Natr. mur. , half-sided: Sepia. , awakens with: Natr. mur. , with nausea and jerking of head: Sepia. , and uneasiness: Viburn. op. Hot, sticky perspiration on forehead: Chamom. Distended veins on eyes, ears, lips and tongue: Digit. Paralytic sinking down of lids: Sepia. Chronic inflammation of lids, and other psoric eruptions: Sulphur. Enlarged pupils : Bellad. Weakness of sight: Mercur. Dimness of vision: Lauroc. Nosebleed: Digit. during puberty: Aeon. before menses: Laches. instead of menzes: Bryon., Laches. , vicarious, or hsematemesis : Hamam. Cold nose : Bellad. Face flushes frequently: Sepia. dark red: Graphit. , bluish: Digit. red on one side and pale on other: Chamom. spotted redness: Sulphur. pale, pallor: Amm. carb., Calc. carb., Pulsat. earthy color: Mercur. yellow : Pulsat. around mouth, across che.eks and nose: Sepia. bloated and pale: Pulsat. and red: Chamom. above eyes: Kali carb. - below eyes: Phosphor. , pimply eruptions about monthly period: Graphit. , fever blisters on lips: Natr. mur. , neuralgia, terrible: Sulphur. 7o8 DIGEST TO AMENORRHEA, DYSMENORRHEA. — , on right side, driving out of fled: Magn. carb. Tongue coated: Senec. white, with thirst: Bryon. covered with blisters: Natr. mur. , map-tongue: Natr. mur. , distended veins on: Digit. icy cold: Lauroc. Toothache : Arsen., Be/tad., Sepia. after menses: Calc carb. Thirst ; on swallowing audible clucking noise in throat: Cuprum. Thirstless : Pulsat. , Sepia. Craves coffee and feels better after drink- ing it: Laches. sweet things: Lycop. Loss of appetite: Senec. Loathing" of all food: Sepia. Nausea when smelling cooking: Sepia. when seeing food: Xauthox. when riding in a carriage: Sepia. , with twisting pains in bowels: Nux vom. Hsematemesis instead of menses: Bet lad, Hamam., Pulsat. Sour belching: Lycop. Dyspeptic feeling from eating pork or fat: Pulsat. Fullness in stomach and bowels: Lycop. Cramps in stomach, extending to chest, with nausea, belching and vomiting: Cuprum. Cardialgia instead of menses: Laches. Cannot bear anything tight around the waist: Calc. carb. Tenderness of hypogastric region: Cimic. Pains through hypogastric and lumbar region down the legs: Hamam. Fullness of bowels: Hamam. Colicky pains : Sulphur. and fermentation in bowels: Phos- phor. and scanty menses: Sepia. , must bend double: Aeon. , must draw lower limbs up to ab- domen: Coloc. , with tossing about: Pulsat. Cramp-pain, deep in abdomen, instead of menses: Coccul. in bowels and chest, and pressing down in small of back: Graphit. and bladder and rectum: Cau- loph. , extending to chest, with nausea, retching and vomiting: Cuprum. before and during menses: Viburn. Contractive spasms some hours after commencement of flow: Bromium. Cutting pains in hypogastrium, sacrum and groins: Senec. Tearing in abdomen: Laches. Lancinations from rectum to anus and pudendum: Arsen. Bloating of abdomen and extremities in young girls: Apoc. Pot-belliedness : Sepia. Constipation: Hamam., Senec, Sepia., Xanthox, , dry, narrow feces: Phosphor. , bowels move with difficulty: Natr. mur. , with piles and prolapsus: Collins. , or diarrhaea in the morning: Bryo?i. Diarrhoea: Phosphor., Pulsat. Diarrhoea with tenesmus: Merc. sol. after indignation: Coloc. after drinking milk: Sepia. Constant unsuccessful urging to defe- cate: Nux vam. Urine copious: Asclep. Frequent desire : Digit. Cutting in urethra after urination: Natr. mur. Urine scanty, dark: Apis. Soreness across pubis, and cramps in bladder: Nux vom. Bearing down: Aeon., Bellad., Cimic. , must cross her limb: Sepia. , intermitting: Asclep. in small of back: Graphit. , with discharge of dark, clotted blood: Chamom. and drawing in thighs: Conium. before menses: Tarant. and during menses: Vibicrn. , followed by discharge of scanty, dark, bloody mucus: Apis. with profuse menstruation: Platina. Painful contractions : Cauloph. Cramp-like pain in womb before the flow: Amm. carb. Crampy and stitching pain in pelvic re- gion: Nux vom. DIGEST TO AMENORRHEA, DYSMENORRHEA. 709 Stinging" pain in ovaries: Apis. Hard swelling" in ovarian region: Bryon. Neuralgia along the genito-crural nerve: Xanthox. Congestion and irritability of womb: Cauloph. of womb and head: Sulphur. During" pain no flow; more flow during night than during day: Magn. carb. Blood flows by fits and starts: Pulsat. Menses too late or not appearing: Phos- phor. Instead Of menses, itching of old tettery eruptions: Carb. veg. , cramp-pain deep in bowels: Coccul. , different complaints: Calc. carb. Menses scanty: Cauloph., Cimic., Co- nium, Graphit. , dark: Natr. mur. , , acrid and thick: Magn. carb., Sulphur. , , bloody mucus: Apis. , cease flowing when lying down: Cact. grand. profuse: Hatina, Xanthox. , coagulated blood: Cimic. • and too early: Senec. suppressed: Calc. carb., Mercur., Senec. by chagrin: China. by fright: Lycop. by mental emotions, a cold and febrile symptom: Cimic. from getting feet wet: Pulsat. from working in water:, Calc. carb. from bathing: Nux niosch. Between menses, debility, neuralgic pains, prolapsus: Cimic. Prolapsus uteri: Mercur. Leucorrhcea: Digit. Emissions of flatulence from vagina: Bromium. Suppressed sexual instinct: Conium. Cough, slight at night: Senec. dry, tight feeling in chest: Phos- phor. , with spitting of blood: Digit., Mil- lef., Pulsat. , , worse before midnight: Phos- phor. Congestion of chest and head: Graphit. Pressure on chest: Coccul. Constriction when lying, with anxiety: Graphit. Spasms of chest: Kali carb. and larynx: Cauloph. Dyspnoea: Coccul. Suffocating feeling in bed: Digit. Shortness of breath: Xanthox. Exhaustion from talking: Sulphur. Constant yawning: Digit. Heart, fluttering: Natr. mur. , palpitation: Aeon. , irregular action: Digit. constricted as if grasped by a band of iron: Cact. grand. Secretion of milk in the breasts: China. Liver-spots on chest: Lycop. Back-ache: Aeon., Calc. carb. , wandering back and shoulders: Senec. before menses, extending to hypo- gastric region and down the thighs: Vi- burn. down the thighs and through hips: Cimic. , towards front, with discharge of dark, clotted blood: Chamom. Pain in small of back, with stiffness: Kali carb. , with bruised feeling in hips: Laches. through lumbar and hypogastric re- gion down the legs: Hamam. from sacrum to pubis: Lauroc. Hands trembling: Mercur. , tetters and itching between fingers: Graphit. Nails thick and crooked: Graphit. Cold hands and feet: Calc. carb., Nux mosch., Sepia. Lower extremities, cedematous swelling of: Apis. , paralytic feeling of: Coccul. Legs, varicosed veins of: Hamam. , swollen: Xanthox. , ulcers on, with a purplish circum- ference: Laches. , fidgety of: Tarant. Feet cold: Sulphur. Limbs, aching, rheumatic pains: Cimic. , coldness: Lauroc. , tearing in, worse at night: Mercur. , , worse from motion; Brvou. 710 DIGEST TO AMENORRHEA, DYSMENORRHEA. swollen, with paralytic feeling: Digit. , bloating of abdomen and limbs: Apoc. , convulsive motions of, when she wants to use them : Coccul. , , with piercing shrieks: Cup- rum. upon which she lies go to sleep: Graphit. Pain in right shoulder or foot: Magn. card. Sleepy in daytime: Sulphur. Drowsiness, somnolence: Nux mosch. Stupor, deep sleep: Hamam. Drowsy, with inability to go to sleep: Bellad. Inability to sleep: Senec. Sleepless at night: Sulphur. Chilliness and thirstlessness: Pulsat. Neuralgic fever: Xanthox. Constant sweating: Mercur. Chlorotic state: Cyclam. Plethoric habit: Calc. card. Agitation of blood: Sulphur. in the evening: Lycop. Feeling 1 as though circulation had stop- ped: Lycop. Restlessness: Aeon., Arsen. , must move about: Tara?it. Disinclined to move about: Senec. Lassitude: Senec. Weakness, debility: Calc. card., Coccul. Fainting spells: Coccul. , from pain: Nux mosch. Chronic eruptions: Sulphur. Old tettery eruptions, itch when monthly should come on: Card. veg. Urticarious eruptions during summer: Natr. mur. Dryness of skin: Kalicarb. Wax-colored skin: Apis. (Edematous swelling all over: Calc card., Mercur. Spasmodic twitching: Bellad., Tarant. Cholrea-like restlessness during men- ses: Tar ant. Hysteric spasms: Cimic. Letanous-like convulsions: Platina. Epileptic fits during time of puberty: Caustic. ' Epileptiform spasms, with piercing shrieks: Cuprum. Scrofulous individuals: Calc. card. Chlorotic state: Cyclam. Age of puberty: Apoc. cann., Digit. , Kali card., Natr. mur., Platina, PuU sat. Blue-eyed persons: Bromium. Slender-built persons: Phosphor. Chagrin: Chamom. Fright and cold: Aeon. Getting feet wet: Xanthox. Suppression of menses: Mercur. % Senec. from working in water: Calc. card. from getting wet: Rhus tox. from getting feet wet: Pulsat. from bathing: Nux mosch. from cold, mental emotions, and fever: Cimic. from fright: Lycop. from chagrin: China. Worse from washing with cold water: Sulphur. from cold air: Calc. card. from staudiug: Sulphur. about midnight: Arsen. from warm room: Pulsat. Better from riding on horseback: Tarant. from external warmth: Arsen. from a full flow: Laches. Congestive type: Aeon., Apis, Bellad., Bryou. Neuralgic type: Asclep. syr., Bellad., Chamom. After Pulsat. follows Graphit. all sorts of drugs: Nux vom. VAGINA. 711 VAGINA. Catarrh of the Vagina; Vaginitis. Like all other catarrhal affections of mucus membranes, it is character- ized by redness, swelling and increased secretion of mucus. There are here and there little protuberances, which consist of swollen papillae of the mucous membrane; it invests either a part of the vagina, or extends all over this organ. The secretion is at first scanty, but by degrees becomes more profuse and opaque. In chronic casss we find the vagina relaxed, its mucous lining bluish-red, and studded with swollen papillae. This relaxation not unfre- quently leads to prolapsus vaginae. The secretion is in such cases milky, more or less yellow, and sometimes of other appearances. It constitutes what is commonly called leucorrhoea, which is frequently the only sign of the exist- ing trouble. Its Causes are like those of the uterine catarrh, as recorded in their respective chapters: it is of quite rare occurrence during childhood, in which case it may be induced by the little thread- worms (oxyures) creeping from anus across the perineum into the vagina. Therapeutic Hints. Compare Uterine Catarrah. The virulent catarrh of the vagina is spoken of in the chapter of Gonorrhoea. Vaginismus Is defined by Schrceder as "an excessive sensitiveness of the orifice of the vagina, combined with spasmodic contraction of the constrictor cunni and the muscles of the floor of the pelvis." However, in some cases the introduc- tion of the finger for the purpose of examination has caused not only the most intense pain, but even hysterical convulsions, without contraction of the constrictor cunni. The anatomical changes are usually unimportant. In recent cases we find the affected parts usually swollen, with erosions, swellings of follicles and discharge from the mucous membrane; or papil- lary excrescences in the fossa navicularis, all of which may at a later period disappear again. These changes are most probably the consequence of mechanical irritation, brought about by unsuccessful attempts at coition; for the most usual source of vaginism is a small orifice and a want of moisture of the vagina, which, when associated with certain physical states, such as fear, apprehension, etc., and an existing oversensitiveness of the parts, may cause the whole series of distressing symptoms. Nettel mentions a case in which vaginismus seemed to be a symptom of lead poisoning, induced by the use of cosmetics. Therapeutic Hints. Coition ought not to be practiced until the hyperesthesia is in some measure overcome by hip-baths, injections of warm water, oiling the parts, 712 PRURITUS VULV^. and the application either of one or the other of the following remedies, as indicated: Arnica. After forced attempts at coition. Bellad. Dryness of the vagina; contraction of the sphincter muscle, Cactus grand. Merely touching the parts causes constriction of the vagina, and prevents coition. Ferr. phosph. Painful coition. Ignat. When the mental symptoms correspond, with great proneness to spasmodic troubles. Kreos. Painful coition. Lycop. Dryness of vagina, with pain during and after coition. Natr. viur. Dryness of vagina, painful coition, and aversion to it. Platiiia. The slightest touch causes constriction of the vagina, and is so painful that spasms may ensue. Plumbum. Has caused this complaint. Sepia. Tenderness of parts; painful coition. Pruritus Vulvae Is frequently a mere symptom of other diseased conditions of the sexual organs. We find it in the beginning of pregnancy, and also before the men- strual flow; but its most intense forms occur during the climaxis, especially of unmarried women. The itching is so intolerable and distressing that it takes away all sleep and rest, and causes a number of nervous complaints. Physical examination generally reveals no particular change of the parts, except perhaps some dryness of the vagina or slight eruptions on the labia. Such persons are often subject to hcemorrhoidal complaints, and it is possible that this terrible itching is dependent upon a stagnation of blood in the vaginal veins. Therapeutic Hints. Ambra. During pregnancy, with soreness and swelling of the parts; numb feeling of the whole surface of the body in the morning; perspiration of the abdomen and thighs in the daytime when moving about; falling out of the hair, and great sensitiveness of the scalp to the touch. Bell. Of great clinical value as a cerate. Caladium. According to the experience of others and my own the most efficient remedy; the terrible itching sometimes causes the habit of onanism. Calc. carb. Itching and soreness; offensive discharge from the ears; cold in the head, with soreness inside of the nose; scrofulous taint. Canthar. Climacteric age; from rubbing and scratching, the skin swells into little tumors; urinary difficulties. Carb veg. Itching and burning of the pudendum and anus, especially before the menses; itching, tettery eruptions on the body; leucorrhcea, with burning and soreness; hcemorrhoids. Collin. Distressing itching, in connection with prolapsus and consti- pation. MAMM4. 7 r 3 Conium. Violent itching of the pudendum and vagina, especially after the menses, followed by a pressing downwards of the uterus. Lycop. Itching, burning and gnawing, with chronic dryness of the vagina; varicose veins. Natr. mur. Falling out of the hair on the mons veneris; dryness or coolness and paleness of the vagina; aversion to an embrace; eruption on the boundaries of the hair on the neck. Nux. vom. Tingling and itching in the parts, which excites sexual de- sire and induces onanism. Plati?ia. When the sexual desire is greatly augmented, even to nympho- mania. Sepia. Swelling and itching eruption on the inner labia; leucorrhcea, with itching in the vagina and pudendum; ringworm- like eruptions on other parts of the body. Sulphur. Itching in the vagina and pudendum, with pimples all around; itching of the nose after menstruation; itching of the nipples; pimples here and there; haemorrhoids. Tab a cum. Tarant. Dryness and heat of the parts. Zincum. Excessive itching during the menses, inducing masturbation. MAMMAE. Mastitis, Inflammation of the Breasts. It develops itself chiefly during the period of nursing, and usually at the commencement; less frequently during weaning. Its cause is stagnation of milk within the gland or a tube of the gland, induced by sore or imper- fect nipples; or weakness of the child, in consequence of which the breasts are not thoroughly emptied of their contents; or undue pressure exercised upon the gland by misfitting dresses, producing obstructions in single tubes of the gland and final inflammatory symptoms. Here then we have an in- flammation of the milk-ducts of the mammae, which commences within and spreads outward. In other cases the inflammation begins in the subcutane- ous cellular tissue; a kind of erysipelatous inflammation, spreading inward, and caking a portion of the breast. This form may be caused by external in- juries, bruises, exposure to cold, and by fright; or it may be the result of the spreading of the above-named inflammation of the milk-ducts. It is a most painful affection in either case, and frequently results in the formation of abscesses. Thkrapkutic Hints. Apis. Burning, stinging pains in the breasts; considerable swelling and hardness; erysipelatous inflammation. Arnica. Soreness of the nipples; bruises of the breast. Bellad. During nursing and weaning, great hardness and swelling; 714 THERAPEUTIC HINTS TO MAJDLE. bright redness in streaks along the milk-ducts; throbbing, stitching pain: headache; fever; worse in the afternoon; bowels constipated, and urine scanty. Bryon. Sets in mostly with a chill, followed by fever; great stitching pain in the breast, worse from slightest motion; tense swelling; little or no redness; bursting pain in the head when rising, with dizziness; great thirst; thick-coated tongue; constipation: feces as if burnt; pain in all the limbs when moving. Graphit. Inflamed, cracked nipples; tetter y eruptions on the scalp, hands and between the fingers; indurated Meibomian glands; old cicatrices from former inflammations. Hamam. Bleeding nipples, with great soreness. Hepar. Pain in the upper arms and thighs, as if in the bones; great hastiness in drinking and speaking; also in persons who have taken a great deal of mercury; when suppuration commences with frequent crawls, or when, after the breaking or opening of the abscesses the discharge is scanty, and there still remains great hardness of the inflamed parts. Laches. When the inflamed breast has a purplish appearance. Mercur. Especially when after Bellad., notwithstanding, suppuration sets in; chilliness and profuse sweat, which does not relieve; great nervous weakness and trembling; also in cases where suppuration takes place in different parts of the breast. Nux vom. Xipples painful during suckling, with little or no soreness or rawness. Phosphor. Phlegmonous inflammation; breast swollen; red in spots or streaks; hard knots in different places, with fistulous opening, discharging a watery, discolored, offensive ichor; dry, hacking cough, with hectic fever and colliquative sweats; slender built women, with a white and tender skin; weakened by disease or loss of fluids. Phytol. Sore and fissured nipples, with intense suffering when putting the child to the breast; the pain seems to start from the nipple and irradiate all over the body, going to the backbone, and streaking up and down, with excessive flow of milk, causing great exhaustion; a few days after confine- ment sudden chill, followed by some fever and a painful engorgement and swelling of the mammae; the drawing of milk is impossible. In ordinary caked breasts it is called specific. Badly-treated " gathered breast," with large, fistulous, gaping and angry ulcers, filled with unhealthy granulations and discharging a watery, fetid, ichorous pus; the gland is full of hard, painful nodosities. Rhus fox. Soreness and swelling of the breast from taking cold, especially getting wet; pain in all the limbs; worse when at rest; great rest- lessness; the lochial discharge turns red again. Silic. Chronic cases; when Phosphor, is not sufficient to heal the fistu- SCIRRHUS SEU CARCINOMA MAMM^. 7 15 lous opening with callous edges, or to disperse the hard lumps in the breast' pale, earthy, color in the face; loss of smell; hectic fever. Sulphur. Sore and cracked nipples, with bleeding when nursing, the areolae are covered with yellowish scales, from underneath of which oozes an acrid fluid, with itching and burning in the night; hard lumps in the breast; ulcerating sore, with spongy excrescences and great itching; sleepless nights. Scirrhus seu Carcinoma Mammae, Scirrhus, or Cancer of the Breast. The scirrhous form is the most frequent; it appears either deep in the gland or nearer the surface, as a roundish tumor, which draws the region of nipple inward, causing a navel-like depression by its gradual contraction and its adhesion to the external skin. Its development is slow, but terminates finally in a deep ulcer, with callous, exuberant edges, and a foul, fungous opening. The medullary Cancer is of rare occarrence. It appears as one or sev- eral tumors, which destroy in a short time the surrounding parts of the gland, by ulcerating and producing fungous growths. The development of cancerous growths rest upon a constitutional con- tamination, the nature of which we do not know. Its development is, in most cases, slow, often intermitting, making halts for a long time. Finally, it perforates the skin, and appears as an open cancer, making rapid strides to final destruction. It is generally found in one breast at a time; sometimes in both, and often combined with scirrhous degeneration in other parts of the system. It causes the most intense, burning, stinging, lancinating pains, which deprive the patient of sleep and rest. The open ulcer discharges profusely an offen- sive ichor, or it bleeds easily and profusely when, by erosion, blood-vessels become destroyed. The nutritive action of the system is completely pros- trated, and we see the patient gradually lose strength and sink, with symptoms of marasmus, oedema of the lower extremities, colliquative diarrhoea or a sudden profuse haemmorrhage from the ulcer. Therapeutic Hints. Apis. When there is stinging, burning pain, whether in scirrhous tumors or in open cancers; pain in the ovarian region, with bearing down; scanty, dark urine; oedema of the lower extremities. Arsen. Nightly, burning pain like fire, with great restlessness; loss of strength and emaciation ; the pains grow better from the external application of warmth. Ars.jod. With swelling of gland in axilla. Asterias rub. Recommended by Petros for cancers of the left breast. Badiaga. Ought to be thought of, at least. 7l6 THERAPEUTIC HINTS TO SCIRRHUS SEU CARCINOMA MAMM^. Bellad. Scirrhous tumors, with, erysipelatous inflammation and stitch- ing pain; frequent bearing down in the genital organs. Bromium. " After the extirpation of a hard tumor in the left breast, there appears a hard, uneven tumor in the right breast, which is grown tight to its surroundings; periodical lancinating pains, especially at night, worse from external pressure; grayish, earthy complexion of the face; suppression of menses; emaciation, and great depression of spirits." Calc. card. Indurations of the breast; too early and too profuse men- struation; soreness and swelling of breast before the menses. Calc. ox. Has, more than an) T other remedy, relieved the terrible pains in open cancers. Card. an. Scirrhous tumor, hard and uneven; the skin over it is loose, on places of a dirty, blue-red appearance; the pains are burning and drawing toward the axilla; oppression of the chest; nightly perspiration of the thighs only; desponding. Chim. umb. Tumor broke and left a small, irregular ulcer, with wasted edges, sloughing, discharging fetid pus; auxiliary glands enlarged. (E. S. Coburn.) Clemat. Scirrhus, left side, with stitches in the shoulder; or when the whole gland is very painful, worse in cold weather and during the night; worse during the growing moon; while perspiring, she cannot bear to be un- covered. Conium. Particularly, if the origin of the tumor can be traced to a bruise; starting, lancinating pains. Graphit. When the tumor grows out of old cicatrices, which have been formed by repeated gatherings of the breast. Hydrast. Scirrhous tumor; hard, heavy, and adherent to the skin, which is dark, mottled and very much puckered; the nipple being retracted; pains like knives thrust into the part; cachectic appearance of the face. Laches. Tumor in the left breast, with lancinating pain; inconsequence of pressure upon the tumor the pain extends into the left shoulder and down the arm; there is a constant painful feeling of weakness and lameness in the left shoulder and arm, which is aggravated by using the arm. In open can- cer, when it has a dark, bluish -red appearance, with blackish streaks of co- agulated and decomposed blood; chronic leucorrhcea; painful menstruation on the first day. Lapis alb. Recommended by v. Grauvogl. Lycop. Hard tumors, with stitching or cramping pain; circumscribed redness of the face; worse from 4 o'clock p. m.; during the paroxysms of pain she is obliged to walk about and to weep; she feels better in the open air. Nitr. ac. (Woodward.) Phosphor. When the ulcer bleeds easily. Sepia. Indurations in the breast and ovaries; yellow, spotted face; chronic leucorrhcea. THERAPEUTIC HINTS TO SCIRRHUS SEU CARCINOMA MAMM^. 717 Silic. With great itching of the swollen gland. (J. B. Bell.) Compare besides, Aur. mur., Baryta, Card, veg., Chamom., Cistus, Hamam., Hepar, Natr. mur., Nitr. ac, Phytol., Rumex, Sulphur, Thuja, Zincum. SPINE. Anaemia, Is a diminution in the amount of blood contained in the cord, either in con- sequence of an insufficient supply of arterial blood, or in consequence of gen- eral anaemia. The insufficient supply may be due to weakness of the heart's impulse, to compression, thrombosis or embolism of the abdominal aorta, or of certain spinal arteries. General anaemia may be the consequence of great loss of blood, severe acute diseases, inanition, etc. Embolism of the aorta is usually followed by a rapid palsy of the legs, sphincters, reflex functions, etc. ; while in compression of the aorta the symp- toms of paralysis keep pace with the gradual development of the constriction. Anaemia caused by thrombosis and embolism of small arteries, gives rise probably to mere local and subordinate symptoms, of which nothing is known definitely. If general anaemia be the cause of spinal anaemia, the symptoms of the later will be so covered by the general complex of symptoms, that it will be hard to say what belongs to one or to the other, although motor weakness and slight tremor after exertion, later paresis and finally paralysis, first of the lower limbs and extending upwards to trunk and arms, may be attributed to spinal anaemia. The symptoms usually are relieved in a horizontal position. Therapeutic Hints. We will have to consider the various causes. There may be indicated: Arsen., Calc. carb., China, Cimicif., Ferrum, Gelsem., Ignat., Nux vom. y Phosphor., Phosph. ac, Secale, etc. Hyperaemia Is an increase in the amount of blood contained in the spinal cord and mem- branes, either in consequence of congestion (active or artificial fluxion) or stagnation (venous stasis). Congestion may be produced by overstimulation of the cord — from over- work, severe marching, sexual excesses, etc. ; by poisoning with strychnia, nitrite of amy], carbonic acid, alcohol, absinthe, etc.; by collateral fluxion in consequence of the suppression of menses, haemorrhoidal bleedings, foot- sweat, etc., or taking cold in general; by falls and bruises; and by febrile diseases. Venous stasis finds its causes in diseases of the heart and lungs, in ob- APOPLEXY. 719 structions of the portal system, and accompanies severe spasmodic affections, such as tetanus, eclampsia, etc. The symptoms of spinal hyperemia are, without exception, bilateral, and usually limited to the lower limbs; they change their seat and degree of severity frequently and quickly, and are often relieved in a horizontal posi- tion. They consist at times of pain in the loins and along the spine, or of tingling, formication, or tearing pain in the lower extremities; of hyperes- thesia of the skin, girdle sensation and transitory jerking of the muscles, and trembling of the limbs. At other times we find symptoms of depression, such as numbness and heaviness of the lower limbs and slight anaesthesia. Therapeutic Hints. Congestion may require: Aeon., Arnica, Arsen., Bellad., Cuprum, Hype?., Nux vom., Rhus tox., Sulphur, etc. Venous stasis: Compare heart and lung diseases; abdominal disorders. Apoplexy, or Extravasation of Blood Within the spinal canal. This may take place between the vertebrae and the dura mater, or between the different spinal membranes, or within the spinal marrow itself. It is, compared with apoplexy of the brain, of very rare occurrence. This may have its reason partly in the peculiarity of the structure of the spine and its circulation, having numerous outlets and in- lets, thus giving less occasion for stagnation in the circulation; and partly in the greater security with which a long cord like the spinal marrow is held by its membranes, than a larger bulk, like the brain. 1. Meningeal apoplexy, being an extravasation of blood between the spinal membranes, shows, when anatomically examined, a collection, usually of dark, coagulated, seldom fluid, blood, which extends over a smaller or larger surface within the spinal cord, sometimes filling the whole spinal column. Its Causes are manifold. The blood may, in consequence of apoplex}^ of the brain, or in consequence of the rupture of aneurismal swellings of blood-vessels in the brain, percolate into the spine. Its most frequent causes, however, are external injuries, either from excessive bodily exertions, or a fall, blow or wound, or diseases of the vertebrae. Trismus and tetanus seem to cause it secondarily. Symptoms. — If it sets in suddenly, the patient falls down, as in an apo- pletic fit, but without loss of conscioussness or sense. If it devolops slowly, it commences usually with headache and pain in the spine in the region of the exudation, which radiates in various directions, usually corresponding to the distribution of the nerve-roots first attacked; there is also formication, burning, tingling, etc., in the same regions, and characteristic jerkings of the muscles, occasionslly increasing to convulsions, trembling of the extremities, tonic tension and contracture of various groups of muscles, and tetanic stiff- 720 THERAPEUTIC HINTS TO APOPLEXY. ness and painfulness of the back, making it difficult or impossible for the patient to move. After this, especially in large effusions, we observe numb- ness, pithiness, sensation of swelling and heaviness in the limbs and trunk, which may increase to paresis or even paralysis of the parts which are gov- erned from the spot affected. If the cervical region is affected the attack begins with pain in the occi- put, shoulders and arms, and stiff neck; anaesthesia and paralysis of upper extremities; oculo-pupillary symptoms; difficulty of breathing and swallow- ing; violent dyspncea; retarded and weak pulse. If in the dorsal region, we have pain in the back and abdomen, and pain in the form of a girdle; stiff- ness of the back; paralysis of the legs and abdominal muscles. If in the lumbar region, there is a pain in the loins, tearing in the lower limbs, peri- neum, bladder and genitals; stiffness of the loins; paralysis of the lower limbs, of bladder and rectum. 2. Medullary apoplexy, an effusion of blood within the spinal marrow itself, is found chiefly in the gray substance of the marrow and is of various extent. It may be no larger than a pea, and it may reach the size of a hazel- nut or an almond. Such effusions have been found most frequently in the cervical, less frequently in the dorsal, and least frequently in the lower por- tion of the spine. Its Causes are chiefly inflammation, softening, or other lesions of the marrow which precede it. In some cases it seems to have been produced by external injuries (fall, concussion, with or wdthout fracture or luxation of the vertebrae, surgical operations), or by active congestion from taking cold, sexual excesses, overexertions of the body, etc. Symptoms. — As premonitory signs we find numbness in the fingers and in the feet; after exertion, great weakness and stiffness of the nape of the neck, extremities, or of the whole body. Its existence is characterized by a loss of voluntary motion, which maj^ come on suddenly or in the course of a short time more gradually. This paralysis affects all the parts which receive their nerves from that portion of the spine below the lesion, and it is always found on both sides. The paralyzed muscles are perfectly lax. Like motion, so is also sensation more or less impaired. The parts below the lesion become on both sides insensible to touch or partially so. If para- plegia lasts for some time it causes the limbs to shrink, and brings on gan- grenous bed-sores, sometimes quite rapidly. A lesion higher up affects the actions of respiration and deglutition, and the nearer to the medulla oblongata the more so, causing cessation of respira- tion and consequent death by asphyxia. Effusions in the dorsal and lumbar regions ma3 T exist for }^ears, and if not too extensive may allow even a partial recovery. Therapeutic Hints. The causes will hint to the appropriate remedies. Compare the fore- going chapters. SPINAL IRRITATION. 72 1 Guaco is, according to Dr. Krb, a specific for paralysis of the tongue and extremities in consequence of blood}^ extravasation within the spine. Spinal Irritation. This complaint has by some been stricken out of the nomenclature of special diseases; Hammond considers it due to spinal anaemia, especially of the posterior columns, probably dependent upon some derangement of the sympathetic system; Ollivier and others consider it due to spinal hyperaemia, and still others look upon it as a dynamic disease, a functional disorder of the spinal cord, as there does not exist a pathological anatomy of spinal irri- tation. Neverthess a certain group of symptoms, frequently found in women, seems to demand a separate consideration of spinal irritation, even if it be but a dynamic disturbance of the spinal cord. Its most prominent Symptoms are: Pain and discomfort in the back, most frequently between the shoulder-blades, next in the back of the neck, less frequently in the loins, always increased from bodily exertions. The sore or sensitive spot or spots of the spine are easily detected by pressure, tapping, the passage of a hot sponge down the spine, and other irritations; at other times the pain is deep seated and is produced by pressure upon verte- brae which are not sensitive, also by movements of the spinal column, by stand- ing, etc. With these pains in the spine are frequently associated neuralgic pains in different parts of the body, sometimes fleeting, sometimes more sta- tionar3^. There is usually great weariness and exhaustion upon slight efforts, so that walking or manual occupations, such as sewing, writing, piano-play- ing, etc., soon become unbearable on account of the pains they excite in back and limbs. Spasmodic s3^mptoms, such as twitchings, choreoid movements, singultus, etc.,. are often observed, and disturbances in the vegetative organs — belching, nausea, vomiting; palpitation of the heart, dyspnoea, spasmodic cough, frequent desire to urinate, with abundant discharge of pale, clear urine — are frequently met with; numbness, tingling and paretic symptoms are of less frequent occurrence. The patients are irritable, depressed and often sleepless; they complain of dizziness, noise in ears and an inability to read for any length of time; their hands and feet are usually cold and they flush easily. Spinal irriiation, if located in the cervical region, causes head and chest symptoms, if in the dorsal region, intercostal neuralgia, gastralgia, nausea, etc., if in the lumbar region, symptoms of the pelvic organs and lower ex- tremities; and if diffused, symptoms of all kinds in peripherical organs. Spinal irritation is of no stated duration; it may last for years with many fluctuations. Therapeutic Hints, A great number of remedies may be indicated and the treatment must be wholly symptomatical. The following remedies have proved successful in actual cases: 46 722 THERAPEUTIC HINTS TO SPINAL IRRITATION. Act. iac. Constant nausea and retching on pressure upon the spine, be- tween the fourth and fifth vertebra; frequent fainting; palpitation on least movement; amenorrhcea. Asa/. Great painfulness of spine; belching; palpitation of heart in the night. Bcllad. On pressure upon the dorsal vertebrae she cries out, gets pale, nauseated and belches wind; in the spine continual burning pain; stomach sore to touch, with nausea and vomiting after eating. Or, sudden shriek on pressure upon the fourth dosal vertebra, followed by a dry, violent cough, red face, headache in forehead, photophobia and perspiration. Coccul. Stiffness of neck; pain in lower portion of spine; oppression of chest; palpitation of heart; trembling of limbs; numbness of right upper and lower limb. (Small.) Great hyperesthesia of all the senses, and an exalted susceptibility to impressions; dreadful headache, sleeplessness; when her mind is turned away from herself, her sufferings are forgotten. (C. W. Boyce.) Hype7\ Tenderness of entire spine; paroxysms of pain in different joints, accompanied by mania; frightful illusions; attempting to hide from wild beasts; screaming if approached; no recollection of the attack; appeared as if just aroused from sleep. (A. L. Dornberg.) Natr. mur. Headache on waking in the morning; sleeplessness; consti- pation; salty taste and repugnance to food; trembling sensation in region of heart. Vision becomes dim and indistinct after reading a while; eyes sore on pressure upon them; occasional neuralgia in forehead, with nausea and sensitiveness of eyes to gaslight; at times only one-half of an object is visible; black spots and streaks of light before eyes; easily fatigued; weak- ness from slight exertion; restlessness of the limbs; pain in back and sensi- tiveness of spine. (Burr.) Piper meth. Pain in the back of the head and spine, and relief from all sufferings temporarily by change (mental or physical); slight excitement, or diversion of the mind to some other topic. Rhus fox, Violent pain in head from back to front, and down the spine; lies on her back; head and back drawn backward, the slightest touch or move causes excruciating pain. Pulse slow; obstinate constipation; com- plete sleeplessness; pain in paroxysms. After getting wet. (Dittrich.) Secale. Tenderness of lower cervical and upper dorsal spinous processes with stiffness of neck. Pressure upon it produces pain there and all through the chest, with irritation to cough. Tarant. A slight touch along the spine provokes spasmodic pains in the chest and indescribable distress in the cardiac region; at times the heart feels as if twisted over; intense headache, as though thousands of needles were picking into the brain; sensation of burning all over the body. She trembled so she could hardly talk. Headache relieved by rubbing the head against the pillow. (Farrington.) HYDRORRHACHIS CONGENITA. 723 Hydrorrhachis Congenita; Spina Bifida. This is an affection entirely analogous to congenital hydrocephalus. Being an imperfect development of the foetus, the latter is frequently ex- pelled before its full time. There are cases, however, in which children are born with this affection at full time. Its nature, like hydrocephalus congen- itus, is that of a dropsical effusion of serum, either between the dura mater and the vertebrae, or into the subarachnoidal space, or within the central canal of the spinal marrow. When such effusion takes place, before the vertebrae have perfectly closed, its pressure from within prevents their final closing; thus, from de- ficiency of the vertebral arches, the spinal column, posteriorly, appears cleft in two ; hence the name " spina bifida." This cleft may be of different de- grees. There may be only one of the vertebrae not closed. In the worst cases, this anomaly extends over the whole spinal column. In most cases, however, the split is confined to the lumbar or sacral region. Through this opening the fluid which collects inside presses out, and appears in the corre- sponding region as a smaller or larger tumor, according to the size of the opening and according to the quantity of fluid contained therein. In almost all cases this tumor grows rapidly after birth; it fluctuates; becomes denser and larger when the child cries, inhales, or presses at stool, or when it is held in an upright position; it sinks in, becomes smaller, when the child is quiet, lies in a horizontal position, or when it exhales. External pressure upon the tumor is painful to the child, often causes convulsions and, if combined with hydrocephalus, sopor and general paralytic symptoms. But these signs may all be wanting, when its communication with the spinal canal is very narrow. In some cases it is not fluid alone that protrudes through the opening of the vertebrae, but also portions of the spinal marrow itself, with its membranes and nerves. Such tumors are less fluctuating than those which consist of mere serum. In some cases the tumor or sac bursts during the birth of the child; in other cases, as alreadly stated, the tumor grows rapidly after birth; the in- teguments gradually inflame, become excoriated, and finally burst in a large circumference, which is followed by convulsions and death. In still others, only small openings form, and the fluid gradually oozes out of it; it may close and reopen again; most generally such cases terminate in death. Still there are cases on record in which individuals affected with spina bifida have lived to the age of puberty and longer. Therapeutic Hints. As the most important remedies, compare Arsen., Calc. card., Calc. phospk., Lycop., Silic, Sulphur. Case cured by Calc. phos. (Dr. H. P. Skiles). The Clinique, March 15, 1887, p. 105. 724 LEPTOMENINGITIS SPINALIS. Leptomeningitis Spinalis. We understand by this an inflammation of the soft membranes, the spinal pia mater and arachnoid ; inflammation of the dnra mater is rarely met with as a primary disease. Pathology. — The pia mater appears pale reddish, sometimes purple, swollen, and infiltrated with a jelly-like and frequently bloody exudation. After a while the redness disappears and the membrane looks dirty, yel- lowish and grayish, being covered with a coagulated, dirty-grayish and yellowish exudation, resembling inspissated pus. The inflammation some- times extends over the whole membrane; reaching -even into the cavity of the skull. In cases of recovery there are adhesions and thickening of the membrane, hyperemia, hydrorrhachis and atrophy of the spinal mar- row. The arachnoid is almost regularly involved in the inflammatory process. As Causes, we find mentioned, inflammatory processes of neighboring organs, either of the spinal marrow or of the vertebrae; external injuries; exposure to cold, etc. It is quite a regular attendant upon Tubercular basilar meningitis. Remarkable is its epidemic appearance when it is usually combined with cerebral meningitis, as in spotted fever, which compare. Symptoms. — A combination with cerebral affections of course tinctures the whole picture at once with brain symptoms, and may even disguise the spinal affection altogether. (See Brain Diseases. ) If the inflammation is confined to the spinal pia mater, we find: 1. A pain in the back, at the place of inflammation, which even extends over the whole spine, and which is aggravated by the slightest motion, as turning in bed or rising, or pressing at stool, or voiding urine; it is better during rest; least in lying on the back; sometimes it is combined with a feeling of constriction around the body, as though a bandage were fastened around it. 2. Pains in the limbs, aggravated by motion and touch. 3. Painful stiffness of the muscles, which may amount to opisthotonus, especially in cases where the inflammation extends over the cervical portion of the pia mater. Even the masseter muscles may be affected, so that the whole resembles tetanus. Respiration is difficult, and the higher the inflam- mation extends the greater is the d3'spncea, which may end in suffocation. It is a characteristic feature that these tonic spasms are always excited by the least motion of the spine, but not by reflex irritation of the peripheric nerves. Acute spinal meningitis may pass over into the chronic form, with ex- udation and consequent paraplegia. Tuberculization of the exudate is fol- lowed by oedema of the lungs, catarrh of the bladder and decubitus. Its Prognosis is therefore rather a doubtful one. therapeutic hints to leptomeningitis spinalis. 725 Therapeutic Hints. Aeon. After a sudden check of perspiration, or internal injury; high fever; crawling in the spine, as of beetles; cutting pain, extending in a circle from the spine to the abdomen; numbness of the small of the back, extend- ing into the lower limbs; the arms hang down powerless, as if paralyzed by blows; numbness, icy coldness and insensibility of hands and feet; all being accompanied b}^ despairing thoughts and dread of death. Atroph. sulph. Convulsions all over, if Bellad, did not prevent. Bellad. Drawing, burning and throbbing pain in the spine; drowsiness, with inability to sleep; frequent starting, as if electric shocks were running through the limbs. Bryon. Stitch-like pains from the slighest motion. Calc. card., and Phosph. When the inflammation proceeds from a disease of the bony structure of the spine. Cicitta. Frequent jerks in the upper portion of the body; through the dorsal vertebrae and arms; occasional jerkings of the head. Coccul. Unwieldiness of the lower exremities, the legs cannot be lifted in walking, but are dragged along; the hands feel pithy, lose their sensi- bility. Cuprum Clonic spasms, commencing in the fingers and toes and spread- ing further; before the spasms, painful jerkings in the hands and fingers and different parts of the body, commencing on the left side. Dulcam. Rheumatic persons who are always worse when the weather changes to cold; after taking cold; also during scarlatina and measles, when the eruption does not fully develop itself. Hyper. After a fall; slightest motion of the arms or of the neck ex- torts cries; the cervical vertebrae are very sensitive to touch; headache; desire for warm drinks; asthmatic spells, or spells of short, hacking cough. Kali hydr. After the abuse of mercury. Mercur. Paralysis of the lower extremities, of the bladder, or of the rectum, with occasional jerks in the paralyzed parts; violent pain in the spine, worse from motion; great restlessness and sleeplessness; aggravation at night in bed; insensibility of the skin. Nux vom. The seat of the pain is the lumbar region; the pain is worse when trying to move whilst lying on the back, also in the morning, stiffness of the lower limbs; great deal of belching; sensitiveness of the stomach and region of the liver to external pressure; stool seldom and hard. Plumbum. In chronic cases, where the paralyzed parts soon fall awa3 r in flesh, where the limbs become painfully contracted, and where there are frequent spells of colic with retraction of the abdomen; worse on right side. Rhus tpx. In combination with exanthematic processes; or in conse- quence of getting wet; high fever; great restlessness; tingling sensation in the limbs; paralysis of the extermities. 726 MYELITIS. Myelitis, Inflammation of the Spinal Marrow. This affection is much less frequent than meningitis; and when it does occur, it almost always is associated with meningitis. Its pathological features in the stage of hyperaemia (red softening) con- sist of swelling, redness, and exudation; in the stage of fatty degeneration and of resorption (yellow and white softening) the affected substance as- sumes a creamy or milk}' appearance, becomes softer and softer, until at last nothing remains but the vascular network, and a portion of the hypertrophied septa, the softened nerve- substance having been gradually absorbed. This leads in the terminal stage to the formation of cicatrices or cysts, induration and sclerosis or hardening. The meninges are always more or less impli- cated in the inflammatory process. Its localization in the spinal cord varies greatly. When acute, it usually commences in the gra}^ substance and ma3 T extend more or less in a vertical direction — (Myelitis centralis); it may pervade the entire thickness of the cord for a longer or shorter distance — (Myelitis transversa); it may involve only a small portion of the cord — both vertically or transversely — (Myelitis circumscripta); it may be spread over a large area, but only in circumscribed and scattered spots — (Myelitis disseminata); it may attack only the peripheral layers of the cord — (Myelitis peripherica). As its Causes are mentioned, chiefly external injuries, and exposure to cold, or extension of inflammatory processes from neighboring parts. Some- times it has been observed during the course of typhus, of the acute ex- anthemata, acute rheumatism, variola, pleuro-pneumonia, and other severe illnesses. Its Symptoms embrace deviations in sensibility and motion. i. Sensibility. The patient experiences at first a sensation of cold- ness, numbness, pricking and pain in single toes and fingers, which sensa- tion extends from the periphery gradually further up towards the body; at first, perhaps, only in one, but soon in both sides. If there be a complication with meningitis, the patient cannot bear the slightest pressure or motion of the parts. There is a pain in the spine where the inflammation exists, which is ag- gravated more by external pressure than by motion; and a feeling of con- striction in those parts of the body which are supplied with those nerves, the roots of which originate in and near the affected part of the spinal marrow (girdle pain). In some cases these parts are very sensitive, whilst those be- low are quite dull and insensible. A complete anaesthesia or insensibility, however, takes place only in those cases in which the lesion is a degenera- tion of the marrow through its whole diameter. 2. Motion. It shows itself at first as an unwieldiness of the peripheric muscles, which may end in complete paralysis. If the seat of the lesion be in the lumbar region, it causes paralytic symptoms of the lower extremities, which is of the most frequent occurrence; if it be in the dorsal region, it THERAPEUTIC HINTS TO MYELITIS. 727 causes, in addition, paralysis of the sphincter ani and vesicae; and if still higher up, violent agitation of the heart. A lesion in the cervical region af- fects the upper extremities, the respiratory motion, deglutition and even speech. Respiration is most seriously interfered with when the lesion exists just above the origin of nerves of the diaphragm. When below it, it is a characteristic symptom that the patient is able to gape, but he cannot cough or sneeze. As long as the marrow is not disorganized in its whole diameter, so long is it possible that the parts below the lesion may still remain intact; so that, for example, in a cervical myelitis only the upper extremities are paralyzed and the lower not. When, however, the lesion extends through the entire diameter of the marrow, then all the parts below the lesion lose sensibility and motion; so that in such a case the patient consists of two halves; an upper one, which is normal and sound, and a lower one, which is dead, and deprived of feeling and voluntary motion. A peculiar and frequent symptom of myelitis is a persistent erection of the penis. The penis is painfully stiff, but shorter than normal, and may re- main so for days. It occurs chiefly in those cases in which the lesion has its seat in the dorsal or cervical region. Thus far we have seen that the symptoms of myelitis vary quite con- siderably according to the higher or lower location of the lesion. They vary, likewise, if the seat of the inflammation is confined only to the one or the other lateral cord. In such cases the paralytic symptoms may be only on one side — at least for a while — with more or less insensibility; or insensi- bility may exist in one, and paralysis in the other side, as in some taumatic cases. The lower the seat of the disease, the more slowly it works. Many have lived more than ten years with paraplegia. Cervical inflammation may terminate fatally in a very short time by its paralyzing effect upon respiration. Therapeutic Hints. As myelitis is almost always accompanied by meningitis, compare Leptomeningitis. Angustura vera. Twitching and jerking along the back like electric shocks; tension of facial muscles; lockjaw. A? sen. Dyspnoea and anxiety; constriction and tightness of chest, as if bound with a hoop; twitching, trembling, violent starting, weariness in all limbs; tetanic spasms. Gelsem. Early stage; spinal weakness from exhaustion; confusion of head, spreading from occiput to forehead; dim sight; looks heavy, dull, drowsy; paresis of tongue and glottis; incontinence of urine; muscles feel bruised and will not obey the will; loss of voluntary motion. Mercur. Probably the most important. Compare Meningitis. 728 .MYELOMALACIA — MULTIPLE SCLEROSIS. Phosphor. After sexual excesses or getting wet; also when in connec- tion with an inflammatory process of the vertebrae; burning pain in the spine; some vertebrae sore to touch; dyspnoea and cough; weakness of sight; transient vertigo; constipation with narrow, dry stools; numbness and in- sensibility of the extremities. Physostigma. Tremors of young persons from emotional or physical disturbances; staggering gait, as if drunk; feeling of constriction around head and waist; feeling of weakness, as though paralyzed, passes downward from occiput through back to lower limbs, which feel as if asleep. Picric ac. Tonic and clonic spasms; keeps legs wide apart when stand- ing; looks steadily at objects as if unable to make them out; limbs too weak to support the body. Secale. Violent pain in the back, especially in the sacral region; anaes- thesia of the limbs; paralysis of the limbs; convulsive jerks and shocks in the paralyzed limbs; painful contraction of the flexor muscles; paralysis of the bladder and rectum. Silic. When the bony structure of the spine is affected. Sulphur. Burning and tensive aching between the scapulae; heat on the top of the head; palpitation of the heart; sleeplessness; often when other remedies do not seem to have any effect. Veratr. Painful paralytic weakness in the upper and lower limbs; he is scarcely able to drag them; tingling in the fingers, causing anxiety; pain- ful jerkings in limbs. Myelomalacia, Non-inflammatory Softening of the Spinal Marrow, Is a process of which we know scarcely anything. Its symptoms are quite obscure, sometimes covered by the symptoms of spinal apoplexy, or myelitis, or typhus, sometimes even wanting. Its pathological character is a non-in- flammatory degeneration of the marrow, by which it becomes converted into a soft, macerated mass of a whitish, 3^ellowish or reddish color. Inflammatory softening is the consequence of acute myelitis. Multiple Sclerosis "Is a form of chronic myelitis and encephalitis, which is characterized, anatomically, by the development of numerous insulated sclerotic nodules, varying in size and of a chronic inflammatory nature, which are scattered irregularly throughout the entire cord and usually also throughout the entire brain, but which seem to possess, nevertheless, certain spots of predilection. Sometimes a less intense, but more diffuse sclerosis unites the different nodules with one another." (Erb. ) It attacks women oftener than men, and most frequently makes its appearance during the second and third decades of life, scarcely ever after the forty-fifth year, and but few cases are known to have occurred in children under ten vears of asre. THERAPEUTIC HINTS TO MULTIPLE SCLEROSIS. 729 As direct Causes are mentioned: catching cold, excessive mental and bodily exertions and intense emotions, traumatic influences, pregnancy, hys- teria and acute diseases. Its Symptoms are extremely variable and manifold, as a natural result of the development of nodules in so many different localities. Disturbances of sensibility are of not constant occurrence; disturbances of co-ordination (ataxia) are frequently observed, but a peculiar tremor, which accompanies voluntary movements and progressively increases, is almost reg- ularly present. By this tremor, which appears at every attempt at moving a part of the body, head or limb, voluntarily, multiple sclerosis differs entirely from paralysis agitans, where the trembling is predominantly observed dur- ing perfect rest, and may, at least in the earlier stages, be even controlled by the will of the patient. Besides these symptoms we observe: alteration of speech and voice. The speech is slow, hesitating, more or less indistinct and the voice becomes weak and monotonous; the acts of laughing and crying are accompanied by pecu- liar, noisy inspirations, and the movements of tongue and lips are frequently impaired, interfering with mastication and deglutition. There is a temporary or permanent diplopia, also nystagmus, amblyopia and at last blindness from atrophy of the optic nerve. We meet also head symptoms in the form of vertigo, sleeplessness, violent headaches and in some cases repeated apoplecti- form attacks, which are accompanied by high fever and followed by temporary hemiplegia. This complex of symptoms fits only to typical cases; variations are ex- ceedingly numerous, because the accidental distribution of the nodules varies in each individual case. Therapeutic Hints. Compare Myelitis. Arg. nitr. Vertigo and staggering gait; trembling and tremulous sen- sation; general debility, with trembling of the limbs; chorea-like movements of limbs; transient blindness; sunken, pale countenance; sleeplessness. Nnx vom. Especially in the beginning, with gastralgic attacks, ver- tigo, etc. P/wsfi/ior. Weakness of extremities and trembling at making an effort; legs weak, gait tottering as if he were not sure of himself; speech embarrassed; amaurosis with widely dilated pupils and deafness. Physostigma. The will is strong, but a difficulty lies in the way of carrying out its purpose; the palsy is commonly preceded b}^ twitching or trembling of the muscles. Attacks of partial blindness; nystagmus; trem- bling all over. Plumbum. Tremor of right arm during voluntary motion ;' the arms are " shaky " when he attempts to use them; tremor of arms, at times pre- ceded by weakness and numbness; the tongue trembles when being protruded, or when he tries to articulate; speech dragging and slow. Diplopia; dim- 730 TABES DORSALIS. ness of sight; neuritis of optic nerve. There are man}' more symptoms which hint to multiple sclerosis. Tarant™ In water. Multiple scelerosis in consequence of fright and rheumatism. Trembling commenced in left hand, always aggravated by mental trouble. After a fright it affected all limbs. Intense pain during night prevents her rest and sleep, and an itching and crawling of left leg makes her rise and walk about. Bathing increases the pain, but fresh air ameliorates even at night. Intelligence and memory considerably dimin- ished; trembling and pricking prevents from doing any fine work. Motility and sensibility unaltered; neither paralysis, anaesthesia, nor hyperesthesia. The head trembles as much as the left hand and foot, and a slight tremor could be observed on the tongue, when opening the mouth. No appetite, chronic constipation. Since menopause, acne in face. The ophthalmoscope showed a slight hyperemia of the retina. (Cramoisy.) Tabes Dorsalis; Locomotor Ataxia; Sclerosis of the Posterior Columns; Leukomyelitis Posterior Chronica. All these different names have been given to " a disease of the spinal cord, which runs a slow course, which arises principally during youth and middle age, and which in all probability belongs to the group of Chronic myelitis." (Erb.) "It is anatomically characterized by ribbon-like sclerosis of the white posterior columns, leading to gray degeneration, and probably, also, by later participation on the part of the adjoining portions, of the white lateral col- umns and the gray posterior horns. " " The affection generally begins in the lumbar region, and may extend throughout the entire cord as far as the upper cervical portion, and even into the medulla oblongata." (Erb.) It attacks men much oftener than women, in the majority of cases be- tween the thirtieth and fiftieth year of life; before the twentieth and after the fiftieth year the disease is of rare occurrence. Its principal Causes are said to be: syphilis, sexual excesses and onanism, catching cold, bodily overexertions and hardships of all kinds, traumatic in- juries, emotional fits and passion; acute diseases, such as typhus, rheumatism, pneumonia, abortions, loss of blood, long-continued lactation, etc., diphtheria, etc. In many cases not any cause can be detected. Its Symptoms of the first stage consist of lancinating, neuralgic pains in the lower limbs, sometimes including the trunk, and more rarely in the arms, in paroxysms, frequently changing in severity and location, and often ex- tending over man}- months or even years; they at first appear at intervals, in the spring and fall, later the}^ are induced by every change of weather, or any overexertion or mental disturbance. With these pains become associ- ated, sooner or later, various kinds of parsesthesia, such as numbness, pithi- ness or formication in the feet, legs, thighs and on the trunk, and in the ulnar domain of one or the other hand — a characteristic symptom — in other cases, the sensation of a tight girdle at various heights on the trunk, or on the knee- TABES DORSAUS. 73 1 joint or ankle-joint; further motor weakness and insecurity, which gradually increases to real motor disturbances, such as inability to walk and stand with former ease; unsteadiness when standing and walking; a swaying to and fro when on the feet, all of which manifestations are more pronounced in the dark or by closed e}-es. Often, not in all cases, to these disturbances are added diplopia in consequence of paresis or paralysis of various eye muscles, especially those supplied by the oculomotorius, and amblyopia, even amau- rosis, in consequence of degeneration of the optic nerve. The pupils are small, do not respond to light, but act during accommodation. (Argyll- Robertson symptom.) In many cases we meet with disturbances of the bladder, such as difficulty of micturition, dribbling of urine, etc., and with weakness and irritability of the sexual functions, such as various grades of impotence, insufficient erections, premature ejaculations, nocturnal or diurnal pollutions, excitability on coming in contact with women, etc. Gastralgia and head symptoms (dizziness, psychical irritabilty, etc.) are of rarer oc- currence. The second stage presents, besides the symptoms just detailed, a charac- teristic disturbance in the co-ordination of motion, which usually commences in the lower limbs. The gait becomes ataxic, that is, insecure, swaying, staggering; the legs are unsteadily swung about, the toes pointing outward and upward, and the heels coming down to the ground with a stamp; the whole operation, in most patients, is done under the close supervision of the eyes, and does not succeed at all with closed eyes or in the dark. With this faultily and imperfectly controlled movement of the limbs goes hand in hand a diminution of their powers of endurance, and, although in a lying position at first, the gross strength of the legs seems but little reduced — the patient is yet able to execute single movements of the limbs with tolerable certainty and strength, while in a tying position — yet by and by even in this position the voluntary motions become more and more uncertain, and especially so, if the patient closes his eyes, while at last walking and standing become quite impossible without help. As the disease advances, the ataxy extends also to the arms and hands, so that complicated movements, such as writing, piano-playing, sewing, etc., become difficult, awkward, and at last impossible; the muscles do not obey any more the command of the will, but make all sorts of jerking and irregu- lar movements when under its stimulation. The reflex action of the tendons is extinguished; a knock or blow, for instance, upon the patella- tendon above the knee is not followed by a jerk of the leg upward, etc.; this absence of the patella reflex is probably always an early and almost pa- thognomonic symptom, and is due, according to Westphal, to a lesion involv- ing a definite zone in the centre of the posterior columns of the lumbar part of the cord; the reflex action of the skin, however, may or ma}' not be affected. All other symptoms of the first stage grow more and more intense, until at the final stage actual paralysis (paraplegia), muscular atrophy, contractures, 732 THERAPEUTIC HINTS TO TABES DORSAUS. troubles of the bladder and the digestive organs, bed-sores and general ma- rasmus finish the scene. The disease is of long duration, which is to be counted by years, and is characterized by considerable fluctuations for better or worse — sometimes gradually advancing to recovery; oftener, however, terminating in death. It differs from Chronic myelitis by its lancinating pains in the first stage and pronounced ataxy in its second stage, which myelitis has not. From Multiple sclerosis by the same, instead of which multiple scle- rosis presents a characteristic tremor on voluntary movement, attacking limbs as well as head and neek; From Progressive cerebral paralysis by the absence of disturbances of speech and physical changes, which are characteristic of cerebral paralsis; From Paralysis agitans by its disturbance in the co-ordination of motion, instead of which there is in paralysis agitans a tremor in perfect rest. Therapeutic Hints. Alcohol. Tremor worse in morning, cannot write; increasing muscular debility and paralysis; tingling, arthralgia, anaethesia, clonic and epilepti- form convulsions; locomotor ataxy. Alum met. Recommended by Von Bcenninghausen and verified by others. Soles of feet feel as if they were swollen and too soft; numbness of the heels; heaviness of limbs, can scarcely lift them; slow, staggering gait, as after a long sickness; inability to walk except with eyes open and in day- time; pain in the back as if bruised, or as if a hot iron were thrust through the lower vertebrae. Arg. nitr. Pains in the back, cannot walk with eyes closed, or in the dark; paralytic heaviness or weakness of the legs; staggering gait; legs feel as if made of wood, or padded, with insensibility to touch, diminished warmth, jerks in the toes, tottering, irresolute gait; emaciation of legs, with paralytic weakness; chorea-like convulsive motion of limbs; legs drawn up; arms jerked outward and upward. Arsen. Distressing pains; deadness in great toes, extending to foot and ankle-joint; feet feel large and heavy, and can be moved only by moving the whole limb; the gait is shuffling; feet are dragged along by lifting the legs; .slight numbness in hands. Paralysis with gressus gallinaceus, with atrophy of the muscles, especially of lower extremities. Bellad. Heaviness and lameness of legs and feet; he raises the feet slowly and puts them down with force; loss of co-ordination of muscles of both upper and lower limbs; trembling, twitching of limbs. Diplopia; amaurosis. Calc. card. Rheumatic pains in shoulders; loss of muscular power; atrophy of muscles of back, buttocks and lower limbs, with constant quiver- ing; dimness of vision, worse in right eye; cramps in feet and legs; exces- sively nervous; no appetite: constipation. (G. F. Butmau. ) THERAPEUTIC HINTS TO TABES DORSAUS. 733 Cupr. ac. Numbness and lameness of left hand, especially of the fingers as far as they are supplied with the nervus ulnaris. Dragging of left foot in walking; numbness and lameness in sole of left foot gradually extending up to knee; walking and standing difficult; foot and leg atrophied; constant sense of coldness in left foot, little relieved by the application of hot bricks. Sometimes dull pain from hip to knee. (Heinigke.) Gelsem. Acute, sudden, darting pains; shooting, tearing along the tracks of the nerves, aggravated by changes of the weather; paralysis of motion; muscles will not obe} T the will, feel bruised; tingling, prickling, crawling. Nux vom. Partial paralysis of lower limbs from overexertion and being drenched in rain; drags limbs in walking, cannot lift them from the ground; sensation of lower limbs impaired, feels the sticking with a pin only when it penetrates deep enough to draw blood; legs always cold, bluish; constipation; burning at anus; occipital headache; no painful spot in the whole length of spine. (Bojanus. ) Phosphor. Burning heat in back; hands and feet numb, clumsy; limbs tremble from every exertion; when walking makes missteps, from weakness; swelling of hands and feet, w T ith stinging pains; paralysis, formication and tearing in the limbs; anaesthesia; increased heat; sexual irritation; nocturnal emissions; great irritability and nervousness. Physostigma. Unsteady from knees downward on walking, he must look to see where he puts his feet; needs a cane to steady himself. Piaic ac. Mental and physical prostration; cannot read a line with- out becoming exhausted; on attempting to walk he presses his hand upon his loin and slides his feet along the ground as in a paretic condition, soon becoming exhausted; dull headache deep in occiput; bodily exhaustion with mental clearness; sleeplessness at night from sheer exhaustion; when asleep priapism and seminal emissions, with or without sexual dreams; during coi- tion ejaculation too quickly; constipation. (S. Iyilienthal.) Secale. Difficult, staggering gait; complete inability to walk, not for want of power, but on account of a peculiar unfitness to perform light move- ments with the limbs and hands; contraction of the lower limbs, on account of which the patient staggers; trembling of the limbs, sometimes attended with pains; formication of hands and feet. Excessive sensation of heat, with aversion to heat or of being covered. (S. Lilienthal.) Stramo?i. Totters as if giddy, cannot make a few steps without help; trembling of limbs; muscles will not obey the will; difficult to bring hand to tumbler or carry the latter to mouth; obscuration of vision. Sulphur. Unsteady gait; great debilit}' and trembling; limbs go to sleep. After Nux vom. (Jahr.) Tar ant. Difficulty of moving the legs, they do not obey the will; weakness of legs, etc. Aside of these compare; sPLscul. hipp., Coccul., Caustic, Laches., Ntix mosch., Pinus sylv., Plumbum, Rhus tox., Silic, and many more. 734 SPASMODIC SPINAL PARALYSIS. Spasmodic Spinal Paralysis. ' ' This disease is clinically characterized by a gradually increasing paresis and paralysis, generally advancing slowly from below upwards, with muscular tension, reflex contractions and contractures, with strikingly increased reflex actions of tendons, while at the same time there is entire, or al- most entire, absence of all disturbances of sensibility, or trophic disturbances, of all vesical or sexual weakness, and of all cerebral disturbances." (Erb.) Its anatomical basis is probably, according to Charcot and Erb, a chronic inflammatory process, a sclerosis of the posterior divisions of the lateral columns. Its Etiology is unknown; it seems to develop most frequently between the ages of thirty and fifcy, and also at times in earliest childhood. Its Symptoms begin with motor weakness in one or both lowei limbs, increasing to paresis and ending in paralysis. These symptoms of weakness are early associated with motor irritations, commencing with twitchings, or jerkings of the legs when sitting or lying, increasing to spasmodic stiffness when making certain movements, or to regular tension of the muscles on active and still more on passive motion, and ending in permanent and severe contractures, wdrich fix the limbs in a position of extension. With all this there is a marked increase of the reflex actions of the tendons, so that on merely placing the point of the foot on the floor, while sitting, a tremor very generally sets in, evidently in no respect different from the clonic trembling on passive dorsal flexion of the foot. These combined paralytic and spasmodic manifestations result in a very peculiar, the so-called spastic gait, when the patient tries to walk, which is described by Erb as follows: " The legs are somewhat dragged, the feet seem to cleave to the ground, the tips of the feet find an obstacle in every inequality of the ground; every step is accompanied by a peculiar hopping elevation of the whole body, dependent on a reflex contraction of the calf; the patient immediately gets upon his toes, and slips forward on them, showing a ten- dency to fall forward. The legs are close together, held stiffly, the knees somewhat depressed forward, the upper part of the body slightly bent for- ward. There is no throwing about of the feet as in ataxy. This gait depends on muscular tension and reflex contractions in the various groups of muscles, which are set in activity during the process of walking. ' ' Sometimes the disease extends from one leg to the arm of the same side (hemiplegic form), and much later to the other leg and arm. In some cases the trouble begins in one or both arms and gradually descends to the legs. This whole group of symptoms becomes quite conspicuous by the absence of every disturbance of sensibility, of vesical and sexual weakness, of muscular atrophy and bed-sores; of disturbances of the brain and cranial nerves, and is thus easily distinguishable from other spinal and cerebral af- fections already detailed. Its course is slow and of long duration, and most generally terminates fatally by some other intercurrent disease. polyomyeutis anterior acuta. 735 Therapeutic Hints. There is no case on record, as far as I am aware of, which has been diagnosed and treated as this particular form of disease. The special hints must be taken from special and peculiar symptoms of the individual case. Polyomyelitis Anterior Acuta, Acute Inflammation of the Gray- Anterior Columns (Anterior Horns). This affection has also been called: Spinal infantile paralysis, acute spinal paralysis of adults, acute atrophic spinal paralysis, paralysie atrophi- que de 1' Enfance, and is marked by the following group of characteristic symptoms: "It begins suddenly, usually with fever, with severe cerebral symptoms (deafness, coma, delirium, general convulsions); there is very rapidly developed and complete paralysis with entire relaxation of the muscles; this paralysis being of very variable distribution over the trunk and extremities, but generally in the form of paraplegia; there is an absence of any severe disturbances of sensation; no paralysis of the sphincters; nor bed- sores. A rapid improvement of the general condition soon follows; the pa- ralysis proves not to be of a progressive character; indeed, gradual improve- ment of the same begins, although the restitution of movement is not uni- form and remains in part lost forever. In some of the muscles there is ex- treme and rapidly progressing atrophy, with degeneration of tissue; the de- velopment of the bones is retarded; the extremities are cold and cyanotic. During the further course of the affection considerable deformities of the limbs and trunk arise (club-foot, curvatures of the spine, paralytic con- tractures, etc.). The general condition of the individual is admirable, in spite of the permanent defects in the motor apparatus, which almost invari- ably remain. The disease may occur at all periods of life, though it is by far the most frequent in children between the ages of one and four years. It is susceptible of an unusally large number of grades of severity. The anatomical lesion, although not yet quite certainly determined for all cases, may be regarded as most probably consisting in an acute myelitis of the gray anterior columns (anterior horns), which may extend more or less over the greater part of their entire length, but is disposed to be most heavily localized in the cervical and lumbar enlargements." (Erb.) Of its Etiology nothing is known with certanity. Therapeutic Hihts. The initial symptoms may require; Aeon., Bellad., Gelsem., ete. Compare Myelitis and Leptomeningitis. 736 POLYOMYELITIS ANTERIOR J5UBACUTA et chronica. Polyomyelitis Anterior Subacuta et Chronica; Subacute and Chronic Inflammation of the Gray Anterior Horns; Chronic Atrophic Spinal Paralysis. " Clinically the disease presents itself as a motor paralysis, usually de- veloped without fever, with but slight general disturbance and insignificant disturbance of sensibility. The paralysis more or less rapidly seizes the entire lower extremities — generally in the course of a few days, or at the most a few weeks — and soon extends to the upper extremities also (much more rarely showing the opposite order of development and beginning in the upper extremities); it is associated with complete flaccidity of the muscles and loss of their reflex excitability, and is followed by rapidly progressive atrophy in the bulk of the paralyzed muscles, with the well-marked reaction of degeneration. The disease has certainly, as a rule, an ascending course, though it is by no means always progressive; its development generally comes to a stand- still sooner or later, this arrest introducing a gradual retrogression of the disturbances, which may lead to more or less complete recover y. The anatomical limits of the disease cannot, as yet, be declared with absolute certainty; but according to all that we know, there is every proba- bility of its being located in the gray anterior horns. The two post-mortem examinations thus far made virtually confirm this, and thus, for the present, we may designate the disease as a subacute or chronic inflammation or degen- eraiton of the gray anterior horns, with extensive disappearance and atrophy of the large multipolar ganglion- cells. " (Krb.) Etiology unknown. Duration long. Therapeutic Hints. Plumbum. The symptoms of chronic lead-poisoning correspond very closely with the symptoms of this complaint. Paralysis Ascendens Acuta, Acute Ascending Paralysis. ' ' The disease is clinically characterized by a motor paralysis, which generally begins in the lower extremities, spreads pretty rapidly over the trunk to the upper extremities and usually also involves the medulla ob- longata, which sometimes runs its course without fever, sometimes with more or less active fever, which but slightly involves the general sensibility and the functions of the bladder and rectum, and which runs its course without any notable atroph} T of the muscles, and without any diminution or change of their electrical excitability. In the majority of instances the disease terminates fatally by asphyxia, paralysis of deglutition, and the like; but lighter cases may also end in re- covery. The anatomical characteristics of the disease are at present purely neg- COCCYODYNIA. 737 ative. No pathologico-anatomical alterations are to be found anywhere, and especially not in the spinal cord, which might explain the picture of the disease. In particular there are no signs of hypersemia within the spinal cord, of myelitis, of acute destruction of the ganglion-cells or nerve-fibres. If the disease is therefore to be localized within the spinal cord at all, it is a question of finer, so-called impalpable disturbances of nutrition, not ac- cessible to our present means of examination." (Erb.) Of its Etiology nothing positive is known. Most cases occur between the ages of twenty and forty, some later; men are most frequently attacked. Therapeutic Hints. Consider all the remedies which show paralytic affections. Many cases may have been cured homceopathically without having been recognized as just this particular form of disease. Ooccyodynia Signifies pains in the coccyx and cocc}^geal region (muscular and tendinous fibres of the parts attached to the coccyx), of great variety of character and especially felt on sitting down or rising up, or standing to defecate, or at- tempting to exercise, but even during perfect rest. It may be of a neuralgic or rheumatic, or inflammatory nature. It has been observed to originate from " catching cold," especially in damp and cold weather; from falls and blows; from riding on horseback; after parturition and delivery by forceps; after suppression of eruptions. It attacks most frequently the female sex, is often of but short duration, but may be a source of great annoyance for years. Therapeutic Hints. In injuries with crepitation: Calc phosph. For periodical aching: Fluor, ac. (Hering), Rhus tox., Ruta g?av., Silic. After a fall on the ice; pain worse after sleep: Laches. After a fall resulting in periostitis of the coccyx: Mezer. (Oehme.) During the first appearance of catamenia after confinement: Cicuta. (Bruckner.) After confinement, burning and smarting and painful uneasiness in the coccyx, better when standing, worse from slightest motion or pressure. Ta- rant. (Gonzales.) W. S. Searle gives the following hints: Bellad. Ischia feels sore, as if no flesh were on them, yet she feels better when sitting upon something hard; intense crampy pain in small of back and coccyx; can sit only a short time; cannot lie down well; wakes often at night, and has to shift her position; unable to lie at all upon the back, and is most relieved by standing or walking slowly. 47 738 THERAPEUTIC HINTS TO COCCYODYNIA. Caustic. Dull, drawing pain in region of coccyx; darting and bruised feeling in coccyx; pain in small of back from any movement; pinching, crampy pain in lumbar region and buttocks. Card. an. Pain in cocc} r x, which becomes a burning pain when the parts are touched; pressing, bearing-down pain in coccyx, as if bruised; pain as from subcutaneous ulceration, worse on sitting or lying down; pressing, drawing, or stiffness in the lumbar region, as if the back were broken. Thuja. Painful drawing in sacrum and coccyx, and in the thighs when sitting; after having been seated a while, the drawing hinders standing erect; sudden cramp-like pain in lumbar region after long standing, and then attempting to walk; it seems as if he would fall. Cann. sat. Pressure as if with a sharp point, on the coccyx. Canthar. Lancinations and tearings in the coccyx, causing him to start. Cicuta. Tearing, jerking in coccyx. Cist. can. Burning, bruised pain in coccyx. Droscra. Itching stitch in coccyx when sitting. Graphit. Dull drawing in coccyx in the evening; violent itching of coccygeal region, the part being moist with scurfy eruption. Kali carb. Violent gnawing, at rest and in motion. Kali hydr. Pain in coccyx as from a fall. Kreos. Drawing pains along the coccyx down to the rectum and vagina, where a spasmodic, contractive pain is felt; better when rising from her seat; subsequent milky leucorrhcea. Laches. Continual pain in sacrum and coccyx; drawing pain, or as if sprained, in small of back, hindering motion. Mag?ics. Sudden, piercing pain in coccyx; sudden, violent, concussive, tearing, stitching pain in this region as if the spine were bent back. Mercur. Tearing pain in cocc3 r x relieved by pressing the hand against the abdomen; pain in sacrum, as if one had been lying on too hard a couch. Min\ ac. Drawing, burning along the back, beginning at the coccyx, as if under the skin; burning stitch in sacrum, causing one to start. Paris quad. Tearing in coccyx when sitting; pulsative stitches in coccyx. Petrol. Pain in cocc3 T x while sitting; great uneasiness and stiffness in small of back and coccyx in the evening. Phosphor. Ulcerative pain, hindering motion, and followed by painful stiffness of nape of neck. Phosph. ac. Itching stitch in coccyx; fine stitches in coccyx and sternum. Platina. Numb feeling in coccyx as from a blow. Ruta. Pain from coccyx to sacrum, as if caused by a bruise. Zinaim. Pushing, aching, or at times, pinching pain in coccyx; lan- cination in sacrum; pressure, tension and weakness in lumbar and sacral re- gion; cracking in back when walking. MOTORY APPARATUS. Rheumatism. We may, as chacteristic of rheumatism, establish the following three points: i. It attacks either the fibrous tissues, joints, aponeurosis, the sheaths of the tendons, the neurilemma, the periosteum; or the muscles and tendons. 2. It is a peculiar, painful affection, caused no doubt by inflammation and nutritive disturbances; and, 3. It comes on independently of other acute or chronic diseases, or traumatic causes, etc. The principal Causes of its development are exposure to cold and at- mospheric influences, though they may not be the only causes; and thus it is agreed among the profession to call rheumatic all those affections which are of a very painful and inflammatory nature, which have become localized in any of the above stated tissues, and which are not of a secondary, or a sym- pathetic, or traumatic nature, but appear idiopathically; be they caused by exposure to cold and atmospheric influence or not. Its peculiar inclination to change localities is, although of frequent occurrence, not an invariable fea- ture of the disease. Rheumatism has been divided according to its location into — Rheumatismus Articulorum Acutus, Polyarthritis Rheumatica Acuta, Rheumatic Fever. Acute articular rheumatism is a constitutional disease, characterized by fever, inflammation of the joints and serous membranes in general. Regarding the etiology it is apparently becoming more and more recog- nized as a purely infectious disease, although exposure to cold and atmos- pheric influences have always been considered the chief exciting causes, and undoubtedly do play a most important role. The pathological changes are in the synovial membranes of one or several joints. They become inflamed, and yield a scanty exudation, which contains neither much fibrin nor a great many pus corpuscles. • The external visible swelling is the product of an inflamrnatoty oedema of the surrounding cellu- lar tissue. In severe cases, however, the inflammation may be very high, and the exudation quite rich in fibrin or pus globules. Accordingly, post- mortem examinations show either scarcely any inflammatory signs or a high state of hyperemia, and ecchymosed spots in the synovial capsule, which is filled with a quantity of purulent exudate; even the ends of the bones may foe injected and infiltrated by bloody extravasations. The heart and large 74-0 RHEUM ATISMUS ARTICULORUM CHRONICUvS. vessels, in all recent cases, contain a large amount of fibrin; and besides, we find different structural changes of the heart, such as pericarditis, endocardi- tis and myocarditis, as complications of the acute form of articular rheuma- tism. Predisposition to this complaint seem to lie between the years of fifteen and forty. Early childhood and old age are generally exempt. Those ap- pear most prone to the disease who have once been attacked by it; men more than women, and robust persons more than weak and debilitated ones. It is found in all climates, though more in the middle than in the hot or polar zones; and oftener in winter and spring than in summer and fall. Symptoms. — An attack of articular rheumatismus is frequently, though not always, preceded by a feeling of general debility and malaise, with oc- casional chilly sensations. Then the fever commences, and with it the pain in one or several joints. Soon these joints begin to swell, and sometimes to redden; the swelling is not, in all cases, proportionate to the pain. The dis- ease either stays confined in the joint first attacked, or it spreads from joint to joint, attacking even the spine and the symphysis ossium pubis, rarely, however, the joints of the toes. The pain is generally excruciating, worse from the slightest motion or contact, and yet the patient is sometimes tor- tured by a restlessness which compels him to move, notwithstanding the greatest pain. The fever, in some cases, runs very high, and the temperature of the body ranges at times between 104 and 104. 9 F. ; this is, however, excep- tional, as in most cases the temperature is. not more than one or two degrees above the natural standard, and the pulse not higher than ninety to one hundred beats in a minute. In some cases we hear murmurs in the heart, even if not complicated with endo-carditis; and the respiration is often ac- celerated. The skin transpires profusely without amelioration and is often covered with a red or white miliary rash. The urine is generally scanty and saturated with urates and uric acid, which, on cooling, make a thick de- posit. Its complication with endocarditis amounts, according to Bamberger, to about twenty, and with pericarditis to about fourteen per cent. Complica- tions with myocarditis are much less frequent, and those of pleuritis and pneumonia, meningitis cerebralis or spinalis, occur still less often. Its course is not at all a regular one, confined to a certain cyclus. It may pass off in from eight to twelve days, and may torment many weeks. It very seldom terminates fatally, and then only in case of severe complications with affections of the heart, lungs or cerebral meninges. Its worst features are an increased liability to new attacks, and chronic derangement of the valves of the heart. Rheumatismus Articulorum Chronicus, Chronic Rheumatism, of the Joints. The form consists of a subacute inflammation of one or more joints. Post-mortem examination, therefore, reveals the synovial capsule and liga- RHEUMATISMUS MUSCULARIS. 74 1 ments thickened, the cartilages of the bones spongiform, and the synovial fluid turbid. We may distinguish two forms. One in which single joints, often for months or even years, remain very painful to motion and contact, and show paroxysms of aggravation, chiefly in the night. On applying the hand to the diseased part, we often observe a sense of crackling or crepitation within on moving the limb. The swelling of the joint may be considerable, or it may be absent; or the joint may only appear swollen, because the adjacent mus- cles have become atrophied, not being used on account of the pain. This may lead to a false anchylosis of the joint, rarely to the development of a tumor albus or arthrocace. The second form or sub-acute, consists of frequently repeated attacks of acute articular rheumatism. Individuals subject to it are appropriately com- pared to barometers, as they feel, " in their bones," every little change in the weather immediately. It is often complicated with muscular rheumatism, and those forms of neuraglic and paralytic affections which are called rheu- matic. Rheumatismus Muscularis, Muscular Rheumatism. Myopathia; Myalgia Rheumatica. To this form are assigned all those rheumatic affections which are seated in the muscles, tendons, fasciae, periosteum, and other fibrous tissues, joints excepted. Post-mortem examination furnishes little positive information as to the nature of the complaint. In some cases the muscles have been found interspersed by hard fibrous callosities; in others, some of the peripheric nerves were found thickened and grown together; and in others, nothing at all could be detected. The pain is rather the most characteristic of all the symptoms; it is the so-called " rheumatic pain" — tearing, shooting, stitch- like, screwing, burning; sometimes aggravated, and sometimes relieved by motion, rest, cold or warm applications, etc. The swelling and redness is seldom prominent, often entirely wanting. Its seat is of course quite vari- able, as it may attack any set of muscles in the body. According to its location it has received different names, the principal of which are: Cephalalgia rheumatica, or that form which attacks the musculi fron- tales, occipitalis, temporales, the galea aponeurotica, or the periosteum of the skull. Torticollis rheumaticus, Myalgia cervicalis — "stiff neck" — has its seat in the cervical muscles, and interferes much with the free movements of the head; frequently draws the neck to one side, and may, if of long standing, cause a permanent contraction of the muscles of one side of the neck — "wry neck." Pleurodynia rheumatica, myalgia pectoralis et intercostalis, attacks principally the pectoralis major and intercostal muscles. In the first case, it hinders the motion of the arms; and in the second, it interferes with res- piration, and makes coughing and sneezing quite painful, simulating the pains of pleuritis. 742 THERAPEUTIC HINTS LO RHEUMATISMUS MUSCULAR IS. Omodynia rheumatica, myalgia scapularis. is of frequent occurrence,, having its seat in the muscles of the shoulders and back; it causes not only great pain on moving the arms, but also when moving the trunk to stoop or to turn. Lumbago rheumatica, myalgia lumbalis, kink in the back, attacks the lumbar muscles and the fascia lumbo-dorsalis. It is a peculiar feature of this affection that it frequently sets in instantaneously; the individual having been moving about freely and without an} 7 pain, may in the next minute be unable to rise from his chair; it comes like a shock, and may remain un- abated for eight or ten days. Therapeutic Hints. I have preferred to annex the necessary hints to the end of the chapter on the different forms of rheumatism, because it is not the pathologic form that indicates the special remedy; any one remedy may be indicated in either form , but it is the peculiarity of the individual case which points out the cor- responding remedy. Aeon. When there is synochal fever and restlessness; great thirst, dry, hot skin, and scant} 7 , fiery urine; stitching pains in the chest, hindering free respiration, and great agitation of the heart, with anxiety. Articular rheu- matism, with hot, pale or red swelling of the joints, shifting sometimes from one to another; after exposure to cold, dry wind. " Kink in the back hin- dering deep inspiration." (Wm. J. Martin.) Amm. phosph. Recommended by Kurtz for arthritis modosa; the joints of the fingers, hands and back are swollen and bent; there is loss of appetite, emaciation, sleeplessness, nervous irritability, evening-fever. Ant. crud. Acute rheumatism, also gout, with gastric symptoms; nau- sea, vomiting, white tongne and great thirst at night. Apis. Stinging, burning pain with great soreness and lameness of the affected parts, commences on right side and goes to left; cedematous swelling; profuse sweat brings relief. Apocyn. andr. Rheumatism and gout; pain especially in the right shoulder and knee; pain in the joint of the big toe; bilious vomiting, with or without diarrhoea; fever; nervous excitement; sleeplessness; constipa- tion. Arnica. Tearing pain, great soreness, numbness and swelling of the affected parts; worse on slightest motion, and especially when lying and get- ting warm in bed; fears even the possibility of being touched; complains constantly that the bed or couch whereupon he lies is too hard. Podagra; pleurodynia; pressing pain in region of left side below heart, day and night. Arsen. Burning, stinging, tearing pain, with pale swelling of the joints; great debility into fainting; restlessness, anxiety, especially at night; profuse sweat, which relieves the pain but leaves the patient terribly weak; frequent chilliness alternates with heat; the affected limb has to be moved THERAPEUTIC HINTS TO RHEUMATISMUS MUSCUEARIS. 743 constantly ; external application of heat relieves; metastasis to the heart; aggravation every other day. Aar. mur. Continued gnawing, boring pain deep in the joints after the inflammatory swelling has subsided. Bellad. Pressing, tearing, cutting pain deep in the bones, frequently running from the affected joint along the limbs like electric shocks; com- ing and going quickly; red, shining swelling of the joints; worse gener- ally at night, from touch and slightest motion, even talking; attended with high fever, hot, dry skin, thirst; throbbing headache and pulsation of the carotid arteries. Lumbago, intensely painful sensation of cramp in the lumbo-sacral region and coccyx; can sit only for a short time and while sit- ting becomes quite stiff and unable to rise again for pain ; crampy pains with stiffness in hip and ham, especially on left side. Torticollis, right sterno- cleido-mastoid contracted, no inflammation or pain. Benz. ac. Tearing pains as if in the bones, from left to right and from below upwards; irritable bladder, urine of ammoniacal smell; syphilitic and gonorrheal complications. Arthritis deformans. Berber. Lumbago, aching pain from above crests of ilia downward and inward to sacrum; aching pain in bladder before and after micturition; burn- ing micturition. (H. V. Miller.) Bryon. Stitching pain, tearing pain, worse from slightest motion; gener- ally the patient does not want to move, but sometimes he is compelled to move by an overwhelming restlessness, notwithstanding the pain. The swelling is not principally confined to the joints and chiefly of a faintish redness, streaking out in different directions. There is almost always loss of appe- tite, white tongue, feeling of dryness in the mouth without thirst, or else great thirst; nausea; pain in the liver or spleen; dry, hard stool, as if burnt; short breathing, with stitching pain in the sides of the chest; fever; sour sweats; easily irritated and angry. Pleurodynia, omodynia, lumbago, muscu- lar rheumatism in general; metastasis to the pericardium or pleura. Cact. gra?id. Metastasis to the heart, with a sensation of constriction in the region of the heart, as if the heart were grasped and compressed, as by a band of iron. Calc. carb. Chronic arthritis, with swelling of the joints, worse with every change of the weather; after working in water; also omodynia in right shoulder, or from the left shoulder down along the arm and towards the heart; lumbago, cold feeling in gluteal region and aching after Rhus fox., if it did not sufficiently relieve. Frequent sensation of coldness upon the top of the head; profuse sweat and coldness of the feet; great inclination to perspire; scrofulous diathesis. Calc. phosph. Rheumatic pains in various parts of the body, but especially in places where bones are joined by symphyses or sutures; worse in cold weather. Camphora. According to Kreussler, when the morbid process seems to yield under the influence of the proper remedies but for a short time and 744 THERAPEUTIC HINTS TO RHEUM ATISMUS MUSCULARIS. then comes back again, attacking part after part of the body, even internal organs. Carbol. ac. Pains feel as if they would be increased by motion, but are not; pains come and go quickly, are worst in hip and shoulder- joints. Cauloph. Rheumatism of the wrists and finger-joints, with considerable swelling; also when shifting from the extremities to the back and nape of the neck, with spasmodic rigidity of the muscles of the back and neck; panting breathing; oppression of the chest; high fever; nervous excitement; delirium. Caustic. Tearing pain with stiffness and swelling of the joints; con- traction of the flexors; the pain is worse on exposure to cold air, better in the warmth of the bed; great weakness and lameness of the lower limbs and trembling of the hands. Chronic arthritis; old warts on the eyebrows and nose. Chamovi. Drawing pain in the muscles of the upper or lower extremi- ties, much aggravated during the night, with tossing about, as if beside him- self, and great irritability of temper; hot perspiration, especially about the head; redness of one cheek and paleness of the other. China. Pain in all the limbs, worse especially from external pressure, so that he is even afraid of anyone coming near him. lest he might be touched; bears hard pressure better than slight touch; intermittent charac- ter; great weakness; paleness of the face; bloated abdomen; after severe illness, loss of blood, etc. Cimicif. Pleurodynia of the right side of the chest; pain worse from motion, extorting screams; articular rheumatism of the lower extremities, with much swelling and heat of the affected parts. Coccul. When the upper arm or thigh cannot be moved in their joints on account of a lame pain. Colchic. Burning, tearing, or jerking pains; shifting; without swelling and redness, or with only a moderate, pale swelling; constant chilliness even near the hot stove, intermingled with short flushes of heat; dry skin or pro- fuse sweat; gastric symptoms before and during the attack; Colchic. is said to be indicated especially when the acute form merges into the chronic, or when, during chronic rheumatism, acute attacks set in; also in metastasis to the heart. Collin. Has been given in diseases of the heart following acute rheu- matism. Coloc. All sorts of pains, with sense of formication and numbness; frequent urination; skin cool; chilliness with inclination to perspire. Digit. Hurried, small pulse, easily affected by motion; strong pulsa- tions of the heart, with an indistinct and muffled sound of the heart; hurried respiration, hurried, abrupt speech; almost complete suspension of the urinary secretion; shining, white swelling of the joints, not very sensitive to pressure; a number of joints are attacked at once; the whole bod}' is pale. (Baehr. ) THERAPEUTIC HINTS TO RHEUMATISMUS MUSCUXAKIS. 745 Dul cam. Chronic rheumatism, which gets worse from any little ex- posure to cold, or any change of temperature from warm to cold; also when rheumatic pains set in after acute cutaneous eruptions, or when the chronic form alternates with attacks of intestinal catarrh. Ferrum, omodynia. Either side; pain, especially in the deltoid muscles, of a constant, drawing, tearing laming nature, worse in bed; has to get up and to move slowly about; worse, also, from being too lightly covered for any length of time; face pale, flushing easily; no swelling. Ferr. phosph. Attacking one joint after the other without leaving the first; joints puffy but little red; high fever. Kink in the back. Gnaphal. Gouty pains in the great toes. Graphit. Arthritic nodosities on the fingers; swelling of the toes and balls of the toes; coldness of the dorsum of the feet. Guaiac. Arthritic lancinations and subsequent contractions of the limbs; the pain is excited by the slightest motion and accompanied by heat in the affected parts, especially when the patient has been injured by mer- cury. It also promotes the spontaneous breaking of gouty abscesses, reliev- ing greatly the sufferings of the patient. Hamam. Is recommended by Ludlam as " a local application to all kinds of articular rheumatism." The main characteristic of Hamam. is the great soreness of the affected parts; it may therefore, no doubt, act quite favorable in cases where this soreness is a prominent feature. Iodium. In chronic arthritic affections, when they are characterized by a violent, nightly pain in several joints, without swelling; previous abuse of mercury. Kali carb. Stitching, tearing pains in joints; shuddering; chilliness; nightly diarrhoea; fullness and pressure in stomach after eating; frequent waking and desire to urinate, with burning; cold feet; hearing impaired; noise in ears. (F. Schelling.) Lumbago, as if the small of the back were broken; pains shoot down back of thighs. Kali hydr. Large doses, in chronic arthritis with considerable spurious anchylosis. (Hirshel.) Kali sulph. Shifting from one joint to another, leaving the first with- out pain. (Schussler. ) Kahnia. The pains are shifting, changing location suddenly; deltoid rheumatism of both sides, but more particularly the right; tendency to affect. the heart; slow pulse. Kreosot. When the rheumatic pain in the joints, especially in the hip and knee-joints, is associated with a feeling of numbness, loss of sensation, and a feeling as though the whole limb were going asleep. Laches. Rheumatic swelling of the index-finger and wrist-joint; rheu- matic pains in the knees, stinging, tearing, and sense of swelling; swelling of the knees, with tension in the bend of the knees, difficulty in stretching the limbs, and pain of the thigh (posteriorly) as if swollen; bluish-red swellings. The pains are generally worse after sleeping; they do not im- 746 THERAPEUTIC HINTS TO RHEUMATISMUS MUSCULARIS. prove after profuse sweats; the left side is generally the most affected; or the affection commences on the left and goes over to the right side. Arthritic contractions of the limbs after the abuse of mercury and quinine; irregular action of heart, and valvular affection. Lachnanth. Torticollis, the neck is drawn to one side. Stiff neck. Ledum. Rheumatic pains in the lower extremities, in the hip and knee- joints, especially when they commence below and go upwards; pains alter- nating with spitting of blood; arthritic nodosities with violent pains, which grow worse in the evening, when getting warm in bed, and last till midnight. Lith. Card. Gout}' disposition; rheumatic soreness or sudden shocks in region of heart; pains in heart before and during micturition, also before and during the menses; trembling and fluttering of the heart from mental agitation; valvular deficiencies. Lycop. The pain is mostly tearing, oftener on the right side, with and without swelling. In lumbago, if Bryon. has not sufficiently relieved, and the pain is worse from the slightest motion. In chronic forms, especially in old people, attended by forgetfulness, vanishing of thoughts, congestion of the head, vertigo, wretched countenance, sour belching, nausea early in the morning, flatulence in the stomach and bowels, causing great distress, con- stipation of the bowels, urine dark and turbid; or with sediment of red sand, oppression of the chest from flatulence, palpitation of the heart, frequent flushes of heat with nausea, dry skin. The pain is generally worse at night; cannot bear covering. Mangan. Arthritis vaga, shifting from one joint to another, or affect- ing cross- wise, with shining redness and swelling of the joints; burning spots about joints; pain worse from touch and motion, and at night causing the patient to moan and groan costantly. Gout; left big toe swollen, with excruciating pain radiating upwards; must constantly change position. Menyanth. Painful, spasmodic jerking of the lower extremities in gouty persons, with calcareous deposits in the joints. Mercur. Tearing pain not relieved by sweat, which is often very pro- fuse and of a musty swell; worse at night and in the warmth of the bed; worse also in cold and damp air; attacking joints and muscles, with and without swelling; or a mere puffiness of the affected parts, of a pale or slightly pinkish color; collection of saliva in the mouth of a copperish taste; slim}' tongue; bitter or sweetish taste; foul breath; violent pain in decayed teeth; swollen gums; swollen glands of the neck, painful when swallowing; griping in the bowels with diarrhoea, especially towards evening, with fre- quent urging; constant feverishness; internal heat, with chilliness and per- spiration; sleeplessness and restlessness at night; great debility. Complica- tion with cardiac, pulmonary, pleural and meningeal inflammation. ' ' Lame- ness, weakness and swelling of the leg in the region of the ankle-joint, in fleshy old ladies with rheumatic or gouty tendency." (A. C. Rickey.) Nux vom. Especially in rheumatism of the trunk, limbs not excepted; gout, in its incipient stage, in habitual drinkers; oversensitiveness to pain; THERAPEUTIC HINTS TO RHEUM ATISMUS MUSCUEARIS. 747 constipation; during hard stool, violent pain in the affected part; scanty, dark urine; heat mixed with chilliness, especially when moving; perspiration relieves. Torticollis, head drawn to left side; after fright. Phosphor. Drawing, tensive pains, from slightest exposure to cold with vertigo, oppression and sense of lameness and weakness in the lower limbs. Phytol. Rheumatism of back and hip-joints. (A. E. Small.) Chronic form; obtuse, heavy, aching pain, generally worse in damp weather; with and without swelling; periosteal rheumatism with syphilitic taint; nightly aggravation; enlargement of the glands of the neck and axilla. Platina. Is recommended by Elb for the incipient state of endo- and peridarditis, in consequence of articular rheumatism, especially when there is intense anxiety and great palpitation of the heart. Pulsat. Drawing, tearing pain, frequently shifting from one part of the body to another, or attacking only one side; usually attended by swelling and redness; pale face; slimy mouth; bitter taste; loss, .of appetite; no thirst; constant chilliness, with heat in the affected part; chilliness of left side; mild, quiet, tearful disposition; worse towards evening and at night in the warm room; better from changing position and moderately moving about in the fresh air; from drinking cold water and from uncovering the affected part. Rhodod. Nightly drawing pains in the periosteum from wet, cold and stormy weather; worse during rest, disappearing when moving. Rhus tox. Drawing, tearing pains in fibrous tissues, joints, and sheaths of the nerves, attended with a sense of lameness and formication in the affected parts, with or without swelling and redness, caused by exposure to wet, damp weather, to rain, by bathing or straining; worse during rest and when commencing to move; better from continued motion and dry, warm, external applications; great restlessness. Lumbago. Ruta. Wrists and feet; puffy swelling about the insteps; sour sweat. Sabina. Chronic arthritis and gout; the patient cannot bear a heated room; he feels decidedly better in the cool air and in a cool room; better from sitting erect, from moving and stretching; feeling of deep-seated inward trouble; melancholy and sad. Salic ac. Inflammatory rheumatism of the joints, with great swelling and redness; high fever and excessive sensitiveness to the least jar; motion impossible. Salicylate of soda. Rheumatism especially of the upper extermities, with tinnitus aurium. H. I. Giragosian. Hahnemannian Monthly. Oc- tober, 1 89 1. Sanguin. Right arm swollen, can't be raised, but moved laterally; sensation of coldness in arm, which no amount of clothing can remove; stiff neck, pain in shoulder; trapezius sore to pressure and painful on movement. Secale. Kink in back. (Schiissler. ) Silic. In chronic gouty nodosities. 74-3 DIGEST TO RHEUM ATISMUS. Spigel. When complicated with endocarditis or pericarditis. Spongia. With heart affection, wakening after midnight with sense of suffocation. Sticta pulm. Inflammatory, articular rheumatism, especially of small joints, with circumscribed redness; subsequent synovitis, with exudation. (Price.) Sulphur. Chronic rheumatism; podagra; tearing, stitching pain; or when, after Bryon. y the stitch-pain leaves, and a dull, aching, pressive pain remains; sleeplessness; hot head and cold feet. Tarant. Articular rheumatism, attacking almost all the joints from below upwards to neck, attended with nervous symptoms, such as: spasmodic jerking of the head backwards or sideways; jerking, sighing breathing; palpitation of heart with pain in region of heart. Tart. emet. Lumbago; slightest effort to move causes retching, cold, clammy perspiration and excruciating pain. Tilia Eur. When during a rheumatic fever a warm profuse perspiration does not alleviate but aggravates the pain, and the swelling of the joints in- creases, with great thirst and a decided decrease of the urinary secretion. (A. Lippe.) Thuja. Rheumatic and arthritic pains, especiall}' of a sycotic or gonor- rhceal nature; sweating of the parts not covered; those which are covered keep dry; sensation as if the whole body were very thin and delicate, and could not resist the least attack, as if the continuity of the body would be destroyed. Ver. alb. Electric jerks in the affected limbs; worse in bed; necessity to sit up and let legs hang out of bed, or must walk about. Ver. vir. Rheumatism, especially in left shoulder, hip and knee; also recommended in endocarditis and pericarditis. High fever; red streak through centre of tongue, with coating upon either side. Zincum. General, articular rheumatism, especially of the smaller joints, with tearing pain, lameness, and trembling or crampy pain; or twisting in the affected limbs, and frequent jerking of the whole body during sleep; fidgety feet. Digest to Rheum atismus. ITS DIFFERENT FORMS AND LO- CATIONS. Acute articular rheumatism: Aeon., Ant. erud., Apoc. andr., Bryon., Cimie., Perr. phosph., Hamam., Platina, Put 'sat., Rhus tox., Salic, ac, Dulcam., I odium, Lycop., Phytol., Sabina, Sulphur. , with acute attacks: Colchic. Muscular, in general: Bryon. Torticollis, right sternocleidomastoid contracted, no inflammation or pain: Sticta pulm., Tarant., Tilia Eur op., Bel lad. Ver. vir., Zincum. > muscles of back and neck rigid: When the acute form merges into the Cauloph. chronic: Colchic. > head drawn to left: Nux vom . Chronic form: Calc. carb., Caustic, Stiff neck: Lachnanth., Sanguin. DIGEST TO RHEUM ATISMUS. 749 Pleurodynia : Arnica, Bryon, Nuxvom. , right side: Cimic Omodyilia: Bryon., Sanguin. , right side : Calc card. , either side : Ferrum. Lumbago, kink in back : Aeon., Bellad., Berber., Bryon., Calc. card., China, Ferr. phosph . , Kali card. , Lycop. , Rh us tox., Secale, Tart. emet. Kink in back, hindering deep inspira- tion : Aeon. Gout : Aeon., Amm. phosph., Ant. crud., Apoc. andr., Arnica, Arsen., Bryon., Calc. carb., Caustic, Coloc, Graphit., Guajac, Iodium, Lithium carb., Lycop. , Natr. mur., Sabina, Silic, Sulphur. , left big toe, with radiating pain up- ward : Man g an. , habitual drinkers : Nux vom. Arthritis nodosa : Amm. phosph., Benz. ac , Calc. phosph., Graphit., Kali hydr., Ledum, Menyanih., Silic. , promotes breaking of gouty ab- scesses : Guaiae. Trapezius, shoulder : Sanguin. Trunk and limbs : Nux vom. Back and hip : Phytol. Shoulder and hip : Carbol ac. and knee, left side : Ver. vir. and knee, right side : Apoc. andr. and knee : Kreos. Right arm swollen, can't be raised, but moved laterally : Sanguin. Deltoid muscles : Ferrum. , more the right side : Kalmia. Wrist and index finger : Laches. and finger- joints : Cauloph. and feet : Ruta. Back of hands and fingers swollen and bent : Amm. phosph. Lower extremities : Cimic, Ledum. Hip and knee-joints : Ledum. and ham, worse left side : Bellad. Ankle-joints : Memoir. Small-joints : Digit., Sticta pulm., Zin- cum. Where there are symphyses or sutures : Calc. phosph. Shifting, moving : Aeon., Colchic, Man- gan, Mercur., Pulsat. , suddenly : Kalmia. from one joint to another, without leaving the first : Ferr. phosph. , leaving the first without pain : Kali sulph. — from left shoulder down arm and towards heart : Calc carb. — from below upwards : Benz. ac, Ledum. — from extremities to back and nape of neck : Cauloph. , Tarant. — from right to left : Apis. — from left to right : Benz. ac. , Laches. One side only : Pulsat. Right side oftener : Lycop. Left side mostly : Laches. Crosswise : Mangan. Aching : Berber. , Phytol. Burning : Apis., Arsen., Colchic Crampy : Bellad, Zincum. Drawing : Chamom., Phosphor., Pulsat., Rhus tox. Formication and numbness : Arnica, Coloc, Kreos., Rhus tox. Heat : Aeon., Guajac, Pulsat. Jerking: Golchic. Lameness: Apis., Ferrum, Rhus tox., Zincum. Lancinating : Guajac Soreness : Apis, Hamam. Stinging: Apis, Arsen., Laches. Stitching : Bryon., Kali carb., Sulphur. Swelling : sense of : Laches. Tearing : Arnica, Arsen., Bellad., Benz. ac, Bryon., Caustic, Chamom., Col- chic, Ferrum, Kali carb., Laches., Lycop., Mercur., Pulsat., Rhus tox., Sulphur, Zincum. Twisting : Zincum. Quickly coming and going : Bellad., Carbol. ac. Aching from above crests of ilia down and inward to sacrum : Berber. in gluteal region : Calc carb. Boring, gnawing deep in the joints after the swelling has subsided : Aur. mur. Burning in spots about the joints. Coldness in arm, which no covering can remove : Sanguin. in gluteal region : Calc. carb. Cramp in lumbro-sacral region and coccyx : Bellad. Cutting, pressing, tearing deep in bones, running from affected joint along limbs like electric shocks : Bellad. 75° DIGEST TO RHEUMATISMUS. Drawing in periosteum, nightly : Rhodod, and tearing in muscles in upper and lower extremities : Chamom. , shifting from one part to an- other : Pulsat. in fibrous tissues, joints and nerve-sheaths : Rhus tox. Lame pain in upper arm and thigh : Coccul. Lameness and weakness in lower limbs : Caustic, Phosphor. of ankle-joints : Merc. sol. Pain in all the limbs : China. in thigh, posteriorly, as if swollen : Laches. Shooting" down back of thighs : Kali card. Stitching, tearing in joints: Kali card. Tension in bend of knees : Laches. Swelling : Apis, Arnica, Cauloph. Swelling and heat: Cimic. of joints; Calc. carb., Tilia Europ. and stiffness: Caustic. of index-finger, wrist-joint, and knees: Laches. about ankle-joints: Merc, sol, of toes and balls of toes: Graphit. or no swelling: Lycop. Phytol. of joints or muscles: Merc. sol. No swelling: Ferritin. Swelling and redness: Aeon., Pulsat., Rhus tox., Salic, ac. circumscribed: Sticta pitlvi. bluish: Laches. faintish, pale: Aeon., Arsen., Bryon., Colchic. , shining: Bell ad. , shining white: Digit. Puffiness about instep: Ruta. , but little red: Ferr phosph. , of a pale or slightly pinkish color: Mercur. Breathing, jerking, sighing: Tarant. , hurried, and abrupt speech: Digit. , panting: Cauloph. , short, with stitch-pain in sides of chest: Bryon. , hindered, from stitching pains in chest: Aeon. Oppression: Cauloph., Rhus tox. from flatulency: Lycop. Suffocation, sense of, after midnight: Spongia. Spitting of blood alternates with rheu- matic pain: Ledum. Inflammation pulmonary, pleural, men- ingeal: Bryon., Merc. sol. Metastasis to heart: Arsen, Bryon., Cact. grand., Colchic, Kalmia lat. Heart affection: Collins. , Mercur., Spongia. Endo- and pericarditis: Platina, Spi- gel., Ver. vir Valvular deficiencies : Laches., Lith- ium carb. Slow pulse : Kalmia. Hurried, small pulse, easily affected by motion: Digit. Palpitation : Colchic, Lycop., Platina, Tarant. Agitation with anxiety : Aeon. Strong pulsations, with muffled sound of heart: Digit. Trembling and fluttering of heart from mental agitation: Lithium carb. Irregular action : Laches. Pains in heart before and during mic- turition and menses: Lithium carb. Region Of heart, pain: Tarant. , constriction, as if heart were grasped by an iron hand: Cact. grand. , soreness and shocks: Lithium Carb. , pressing below heart, day and night: Arnica. ACCOMPANYING SYMPTOMS: Forgetfulness, old people; vanishing of thoughts: Lycop. Delirium: Cauloph. Sad, melancholy: Sab in a. Anxiety: Aeon., Arsen., Platina. Irritable: Amm. phosph. , beside himself: Chamom. . angry: Bryon. Mild, quiet, tearful: Pulsat. Nervous excitement: Apoc. andr., Cauloph. Restlessness : Arsen., Rhus tox. Vertigo : Lycop. , Phosphor. Congestion : Lycop. Throbbing headache : Bellad. Meningeal inflammation : Mercur. Hearing impaired, noise in ears: Kali Carb. DIGEST TO RHEUM ATISMUS. 751 Face pale : China, Pulsatt. , easily flushing: Ferrum. on one check, the other red: Chamom. Whole body pale: Digit. Wretched countenance : Lycop. Old warts on eyebrows and nose: Caustic. Carotid arteries pulsate: Bellad. Swollen glands of neck, painful on swallowing: Mercur. and axilla: Phytol '. Tongue white : Ant. crud. Bryon. coated on both sides, with red streak in middle: Ver. vir. slimy: Mercur., Pulsat. Teeth decayed, painful, swollen gums; foul breath: Mercur. Taste bitter: Mercur^, Pulsat. copperish or sweetish collection of saliva: Mercur. Thirst: Aco?i., Bellad., Bryon., Tilia., Eur op. at night: Ant. Crud. , none: Pulsat. , , with feeling of dryness in mouth: Bryon. Loss of appetite : Amm. phosph., Bryon., Pulsat. Nausea, vomiting: Ant. crud. , sour belching early in the morning: Lycop. Gastric symptoms : Colchic. Bilious vomiting, with or without diar- rhoea: Apoc. andr. Pain in liver or spleen : Bryon . Fullness and pressure in stomach after eating: Kali carb. Flatulence in stomach and bowels: Lycop. Bloated abdomen : Chamom. Constipation: Apoc. andr., Bryon., Lycop., Nux vom. Diarrhoea nightly: Kali carb. , with griping in bowels, worse to- wards evening: Mercur. alternares with rheumatic attacks: Dulcam. Aching in bladder before and after mic- turition: Berber. Irritable bladder : Benz. ac. Frequent waking and desire to urinate, with burning: Kali carb. urination: Coloc. Burning micturition : Berber. Urine scanty, dark: Nux vom. , fiery: Aeon. dark, turbid, red sediment: Lycop. decreasing: Tilia Europ. suppressed: Digit. Contraction of flexors: Caustic. Contraction of limbs: Guajac. Laches. Synovitis, with exudation: Sticta pulm. Jerking of head backwards and side- ways: Tarant. lower extremities: Menyanth. affected limbs: Ver. alb. whole body during sleep: Zincum. Trembling: Zincum. of hands: Cimic. Fidgety of feet: Zincum. Sensitive to pain: Nux vom. , as if body were thin and delicate and could not resist the least attack without being destroyed: Thuja. Weakness : China. Debility : Mercur. unto fainting: Arseu. Emaciation : Amm., phosph. Restlessness: Aeon., Arsen., Bryon., Mercur., IZhus tox. Tossing about : Chamom. Sleeplessness: Amm. phosph., Apoc. andr., Mercur., Sulphur. Must constantly change position: Man- gan. Affected limb has to be moved con- stantly: Arsen. Has to get up and move slowly about: Ferrum. Difficult to stretch the limb: Laches. Does not want to move: Bryon. Bed feels too hard: Arnica. Hard pressure feels better than slight touch: China. Coldness upon top of head: Calc. carb. in gluteal region : Calc. carb. of feet: Kali carb. and hot head: Sulphur. and profuse sweat: Calc. carb. of dorsum of feet: Graph it. Skin cool : Color. Chilliness, shuddering: Kali carb. of left side: Pulsat. alternating with heat: Arsen. 752 DIGEST TO RHEUMATISMUS. when moving during heat: Nux vom. even near stove, intermingled with flushes of heat: Colchic. Chilliness, with internal heat and per- spiration : Mercu r. , with perspiration: Coloc. Fever: Apoc. andr., Bellad., Bryon., Cauloph., Fer. phosph., Mercur., Salic, ac, Ver. vir. and restlessness: Aeon. in evening: Amm. phosph. Heat mixed with chilliness: Arsen., Merc, sol., Nux vom. Flushes of heat, with chilliness: Col- chic. - , with nausea: Lycop. Hot head and cold feet: Sulphur. Dry skin: Aeon., Bellad., Colchic, Lycop. Perspiration, hot about the head: Cha- mom. and cold feet: Calc. card. , with chilliness and internal heat: Mercur. and chilliness: Coloc. of parts not covered: Thuja. sour: Bryon., Ruta. brings relief: Apis, Nux vom. : , but leaves the patient very weak: Arsen. without relief: Laches., Mercur. , worse after: Tilia Europ. , inclined to: Calc. card., Mercur. breaks out suddenly and disappears again: Colchic. Worse in evening: Ledum. and night: Pulsat. at night: Bellad., Chamom., Lodium, Ledum, Lycop., Mangan., Mercur., Phytol., Rhodod. every other day: Arsen. intermittent: China. in bed: Ferrum., Ver. alb. from being covered: Ferrum, Lycop. lying and getting warm in bed: Arnica. in warm room: Pulsal., Sabina. from sweat: Laches., Mercur., Tilia Europ. after sleep: Laches. from cold air: Caustic, Dulcam., Phosphor. Worse from cold and damp weather: Calc carb. and phosph., Mercur., Phytol. from change of temperature from warm to cold: Dulcam. from slightest motion: Arnica, Bel- lad., Bryon., Cimic.,Guajac, Mangan., Salic, ac, Sanguin. from least jar: Salic ac when commencing to move: Rhus tox. from effort to move, causing retch- ing and cold perspiration: Tart. emet. , as if the pains would be worse from motion, but are not: Calc. phosph. from talking: Bellad. during hard stool: Nux vom. from sitting, can't rise after: Bellad. during rest: Rhodod., Rhus tox. from touch: Bellad., Mangan. , fears the possibility of being touched: Arnica, China. Better from warm external applications: Arsen., Rhus tox. the warmth of bed: Caustic uncovering: Lycop., Pulsat. cool air and in a cool room: Sabina, Pulsat. drinking cold water: Pulsat. sitting up and letting legs hang out of bed: Ver. alb. changing position: Pulsat. walking about: Ferrum, Ver. alb. moving about : Rhodod. , Pulsat. continued motion: Rhus tox. perspiration: Nux vom. CAUSES. Severe illness, loss of blood: China. Exposure to cold, dry wind: Aeon. Wet, cold, stormy weather: Rhodod. , , , bathing or straining: Rhus tox: Working" in water: Calc carb. After cutaneous eruptions: Dulcam. Scrofulous diathesis : Calc carb. After gonorrhceal or sycotic affections: Benz. ac, Thuja. • Syphilis : Phytol. Abuse of mercury: Guajac, Lodium, Laches. C amphora, when proper remedies seem ineffectual. GOUT, PODAGRA, ARTHRITIS. 753 Calc. Carb., when Rhus tox. did not suffi- ciently relieve. Lycop., when Bryon., was insufficient and pain is worse from motion. Sulphur, when Bryon., leaves a dull, ach- ing, pressive pain. Gout, Podagra, Arthritis. Gout differs entirely from rheumatism in the form of its attacks, by the presence in the blood of uric acid, by its never attacking children, and only grown persons after thirty years of age, and men oftener than women, especially such as are accustomed to a rich table and the habitual use of beer or wine, and who take very little bodily exercise. It is, there- fore, a very rare occurrence to find a poor man suffering with podagra. According to statistics its main cause is a hereditary disposition, which is general^ aroused into activity by overcharging the blood with ni- trogenized substances, and a want of exercise to consume the too-liberal supply. The repetition of diverse acute attacks of gout and its chronic form causes peculiar changes in the joints which it attacks. We find in and around them, besides the ordinary sign of inflammation, a chalky deposit, consisting principally of urate of soda, and less frequently of compounds of uric acid with lime, magnesia and ammonia. This deposit either lines the internal surface of the synovial capsule like a soft mush, or incrustates the cartilages of the bones as a hard mass, or even fills the whole joint as though it had been injected with plaster of Paris, growing hard and causing anchylosis. At the same time gouty deposits may take place on the external surfaces of synovial capsule, on the tendons and in the surrounding cellular tissue, and give rise to hard nodosities, tophi. In some persons similar deposits have been observed on other and different parts of the body, especially in the skin. The course of an acute attack of gout is as follows: The gentlemen in question generally does not dream of what may happen to him over night. He feels fine; he has enjoyed a good dinner and supper as usual, the proof of which we can read in his face; his cheeks are full, round and of a florid complexion, only his nose looks a little suspicious. There we observe a fine network of enlarged capillary blood-vessels, tinging it rather redder than would be necessarily required for a good-looking nose. He is fat, and his stomach and belly are in quite a prosperous condition, looking very well cared for. It may be, though, that in the last few days he did not feel al- together right; his appetite may not have been quite as sharp, his sleep not quite as refreshing; he may have had some palpitation of the heart and his urine may have been concentrated and turbid. All this, however, is gener- ally overlooked or attributed to some imprudence in diet. Then, all at once in the night, generally after midnight, the gentleman is aroused by a burning, screwing pain in one of his big toes, which gets worse from hour to hour. If the toe were screwed in a vise, the pain could not be worse, and the poor sufferer, unaccustomed to such severe handling, moans and groans and tosses about without avail. The toe soon commences to swell and redden; 48 y54 THERAPEUTIC HINTS TO GOUT, &C. there is great thirst, high fever, dry skin, concentrated urine and great mental irritability. Finally, towards morning, a remission of the violent pain takes place; the day passes along comparatively easy, until next night the same violent paroxysm recurs. In this way it goes on for about a week, when finally, the pain, redness and swelling gradually disappear, and, at last, the skin of the affected toe peels off. This is a first attack of Podagra. Gout almost always commences in this way. In later attacks, however, other joints may become involved. If, then, it attacks the finger-joints, it is called Chiragra; if the knee-joint, Gonagra; if the shoulder-joint, Omagra. These acute attacks are at first far apart. Years ma)' intervene between them, but finally the intervals grow shorter and the acute regular attacks become chronic and irregular. Such chronic, irregular attacks often last for weeks and months, and al- ways cause the above-stated deposits in and around the affected joints. They are generally not quite so painful, nor attended with as high a fever as an acute, regular podagra: they are always preceded by digestive derangements and they attack several joints at the same time. After the attack subsides, the swelling does not, but remains at first soft and doughy, until at last it changes into a hard tophus, which grows with each subsequent attack. Such hardened, chalky deposits within the joints frequently give rise to the forma- tion of abscesses, which break and discharge masses of pus mixed w T ith cal- careous substances. At still other times this morbid process attacks internal organs such as the stomach, brain or heart; then is called anomalous gout. Gout of the stomach manifests itself as a very severe cardialgia, with violent vomiting, frequently even of blood; Gout of the brain, as a kind of apoplexy, or violent headache, vertigo, furibund delirium, and subsequent stupidity and sopor; and Gout of the heart, as irregular palpitation of the heart, disturbed circulation, dyspnoea and syncope. It might be quite difficult to diagnosticate these spells as gout, if it were not that they are almost always preceded or succeeded by gout}' manifesta- tions of the peripheric organs. This settles the question. Gout is a stub- born disease, but is not fatal unless complicated with other diseases, or in consequence of the organic mischief which it produces in the course of time, in the form of a lingering cachexia, or apoplexia, or angina pectoris. Therapeutic Hints. As the principal exciting cause of its first development is high and lazy living, this, of course, ought to be stopped, as a first step. In acute attacks, the following are principally indicated: Aeon., Arnica, Arsen., Bryon., Calc. card., Sabina, Sulphur. In chronic gout the main remedies are: Amm. phosph., Calc. card., Caustic, Coloc, Guajac, /odium, Lycop., Mangan., Natr. ?nu?., Sabina, Silic, Sulphur. For special hints compare Rheumatism. ARTHRITIS DEFORMANS. 755 Arthritis Deformans. 11 This disease, also described under the names of Arthritis sicca, spuria, nodosa, pauperum, rheumatoides, arthroxerosis, Malum senile, articulorum, Rheumatismus nodosus, Polypanarthritis, Rheumatic gout, Nodular gout, is applied to an inflammatory process of the joint, which produces chronic changes but never suppuration of the joints. It affects the nutrition of all the constituent parts of the joint, causing, on one hand, abnormal prolifera- tion, on the other absorption; and so the whole shape of the joint becomes deformed. ' ' (Senator. ) There are two varieties of arthritis deformans, one beginning in the smaller joints of the extremities, and the other in the large joints of the trunk (vertebral column, hip), subsequently extending towards the peri- phery, and by preference called the " senile" form. The peripheric variety is much more common in women than in men, and is essentially a disease of the poorer classes. Developing towards the thirtieth year of life, it increases in frequency among women about the cli- macteric period, and is caused chiefly by prolonged exposure to cold and damp, by inadequate food, debilitating haemorrhages, unduly protracted lac- tation, grief and anxiety, by manual labor (sewing, knitting, laundry- work, in women; watch-making, in men). The senile variety is more common in men than in women; it begins at the age when senile changes (atheromatous degeneration of the arteries, cal- cifications, etc. ) commence to develop, and it attacks the rich no less than the poor. Thin people appear to be specially predisposed to it. The Symptoms consist of neuralgic pains in the parts affected, which lose by slow degrees their mobility; the articular ends of the bones become thickened, and gradually displaced, and when moved produce a peculiar grating, which can be distinctly felt through the soft parts. There are also not seldom excrescenses and nodular masses around the joints, while the muscles and soft parts in the neighborhood of the joint, or even of the en- tire limb, begin to waste. In the smaller, peripheral joints the, disease spreads invariably symmetrical, which appears not quite so obvious in the senile form. The fingers from the index to the ring fingers, more rarely the little finger also, are flexed and dislocated at the metacarpal end of the first phalanges, usually towards the ulnar side, less frequently towards the radial side. The thumbs generally remain free, while the great toes are more fre- quently and more severely attacked than their neighbors. An attack of the hip and knee, shoulder or elbow-joints shortens the respective limb; an at- tack of the vertebral column (spondylitis deformans) produces stiffness and rigidity of the spine, with pains radiating from the back; an attack of the cervical vertebrae prevents bending or rotating the head; an attack of the dorsal and lumbar spine shortens and twists the body. Cases occur where even the lower jaw, the clavicles, in fact all the joints of the body become implicated. 756 RACHITIS. The process of the disease is very slow, but steadily progressing in parox- ysms, which are usually attended with severe pain and slight febrile disturb- ances. The urine shows a diminution in the amount of phosphoric acid. Therapeutic Hints. Calc. phosph., Phosph. ac. Compare the hints under Rheumatism. Rachitis, Rickets. Other names by which this disease is known are: Rachitismus, Morbus anglicus, Articuli duplicati, Zweiwuchs, Doppelte Glieder. Its character con- sists essentially of an irritation of the osteo-plastic tissue in consequence of which there is an overgrowth of the same, with less earthy salts than are required for the formation of healthy bone. Heitzmann asserts that this ir- ritation of the osteo-plastic tissue can be brought about by the influence of lactic acid (phosphorus exerts a similar influence), and that, when combined with a deficiency of lime in the food, it is capable of producing true rickets. This supposition agrees with the frequency of its development during the first two or three years of life, and with the fact that an excess of lactic acid has been detected in the urine of rickety children. After the third year the dis- ease develops much more rarely, and between the age of five and puberty it is quite an exceptional phenomenon; sometimes it develops in utero. As Causes have been mentioned: hereditary influences, chronic tuber- culosis in the father, constitutional syphilis in the parents; cold, damp, ill- ventilated dwellings. Its Premonitory Symptoms are: intestinal and bronchial catarrh, feverishness and restlessness towards evening and through the night, perspi- ration about the head, slow, irregular teething. After a while changes in ' the bony structure become apparent. The articular ends of the long bones swell. The prominence of the contiguous epiphyses, for instance of the upper and lower arms, is so marked, that the joint between them forms a depression which gives the appearance of two elbows, hence the name Articuli dupli- cati, or Zweiwuchs (double growth). The fontanelles and sutures of the skull delay inclosure, and the occipital bone becomes soft and flexible, and may often be depressed by the finger as though it were of parchment. This soft- ness extends over the entire bony structure, and is the cause of the deformi- ties which the bones undergo in consequence of the force of the muscles at- tached to them and of the weight of the body. The legs usually exhibit an outward curve and become bow-shaped, while the thorax appears laterally compressed, causing the breast-bone to project like the keel of a boat (chicken breast). The junctions of the ribs with their cartilages become thickened and nodular, and appear like the beads of a rosary. The spine often becomes curved, the pelvis flattened in its antero-posterior diameter, or otherwise deformed, and the growth of the child in length delayed. The hairy part of the head is unchecked in its growth, and the head seems un- THERAPEUTIC HINTS TO RACHITIS. 757 duly big and often sinks down between the shoulders; the abdomen is very prominent , and in advanced cases the child looks like a dwarf. In mild cases, or such as come early under judicious treatment, the de- formities do not reach this grade; by a renewed activity of growth the mor- bid process may be checked without leaving any marked thickening of the bones behind. There have been observed some cases of an acute nature in which within a few weeks the epiphyses of all or of most of the long bones became swollen; there were swellings on the cranial bones, and a simultaneous swelling of the gums and palate, with digestive derangements and fever, the whole process running its course within a period of a few weeks, termi- nating either in recovery, or in death by complications, such as pneumonia, Therapeutic Hints. It ought to be ascertained, whether the milk which the child receives is of a proper condition. When the child has been fed on paps and other mere farinaceous food, its diet should be changed to nitrogenous substances, such as rare beefsteak, mutton chops, etc. When, notwithstanding, the most proper kind of nourishment, the dis- ease still develops itself, the child needs medicinal aid. For the preceding chronic diarrhoea compare the corresponding chapter. For the swelling of the bones compare — Alumina. Abnormal cravings, liquid stools, with much straining; absence of sweat, dry, lustreless hair; persistent strabismus; slow in walking, speaking, cutting teeth; large head; open fontanelles; bathed in cold sweat; voracious appetite; distended abdomen; progressive wasting; persistent watery diarrhoea. (Dr. Edward Fornias, in Horn. Physician, May 1887, p. 170.) Aselli jecoris oleum. This is best used in the form of a trituration with sugar. It is not at all necessary to give the oil by the spoonful. Bellad. Curvature of the lumbar vertebrae; squinting; enlarged pupils; pain in the throat when swallowing; thick, protruding belly. Calc. carb. Slow, difficult teething; profuse sweating about the head; fontanelles open; abdomen enlarged; whitish, frothy diarrhoea; curvature of the spine and deformities of the extremities. Calc. phosph. Not less important than carbonica; its principal in- dications are the fontanelles, which remain widely open, the diarrhoea and the emaciation of the child. Both the Calc. carb. and phosph. have been ad- minstered in large, crude doses with far less good results than in a homoeo- pathic preparation. Natr. mur. ' ' Particularly useful when the thighs are notably emaci- ated, and the disease in its early stages, with slight pliability of the bones. ' ' (Gilchrist.) Phosphor. Has been used even by the old school with great success. Previous abuse of mercury may call for Asaf., Aurum, Hepa>\ /odium, 75S MALACOSTEON. Sulphur; and still other peculiarities of the case may point to August., Flour, ac, Lad. ac, Lycop., Mercur., Mezer., Phosph. ac., Sepia, SiliC, Staph is., Symphytum, Theridion (Baruch) and others. Malacosteon; Mollities Ossium: Osteomalacia, Softening of the Bones. Rachitis consists of a deficient calcification of the growing bone; mala- costeon, on the contrary, of a gradual withdrawal of earthy. salts from the already formed bony structure. It is a chronic disease peculiar to adult life, and especially to women who have passed through one or more pregnancies. It usually begins during pregnane)-, with an active congestion and prolifera- tion of corpuscular elements, which is followed by the removal of earthy salts. The real cause of this decalcification of the bones is still a matter of conjecture. Damp dwellings, however, seem prominent among the exciting causes. Malacosteon is a very rare disease. In some cases the morbid process is confined to the pelvis and spine, in others it spreads over all the bones of the skeleton. The calcareous constituents being extracted, it is obvious that the whole frame loses its form. In this way originate curvatures of the spine; the pelvis, from the pressure of the legs, flattens in on both sides and projects in front with its pubic region; the extremities become flexible, yielding to any pressure in any direction, and in some cases it has been observed that women of a stately size gradually shrunk down to a dwarf's figure. The disease commences with severe boring and tearing pains in the affected bones, worse on motion and better at rest, and usually attended with more or less fever; the saliva and secretions of the skin are said to contain appreciable quantities of phosphate of lime; the general condition ma}% in some cases, for a long time be not essentially affected, while in others the system shows early signs of a deep-seated cachexia. Therapeutic Hints. I do not find a single case mentioned in our literature. However, Ar?iica, Rhus tox., or Symphytum, after difficult confinement; and Calc. carb. and phosph., Flour, ac, Phosphor., Silk., and others, as constitutional remedies, might be suggested. Progressive Muscular Atrophy. The character of this disease consists in a gradual atrophy and fatty degeneration of certain muscles, which in the course of time spread further, involving progressively more and more of th£ muscular tissue. On post-mortem examination, we find, therefore, (i ) the muscles dimin- ished in size; (2) the muscular fibres changed from red to a pale and yellowish color. On applying the microscope it appears that this process commences with a change of color of the muscular fibres, which are growing PROGRESSIVE MUSCUEAR ATROPHY. 759 paler, and a disappearance of their transverse striae. Later we observe fat- globules in the centre of the ultimate fibrils, and at last a disappearance of the fibrils themselves, so that the sarcolemma or sheath, which envelopes the ultimate fibrils, shrinks together, containing only single fat-globules. This degenerating process does not take place simultaneously in all the fibres of a muscle; we find on the contrary in the same muscle fibres thus degenerated and others perfectly healthy, until by degrees all are involved in the same morbid process. Some authors have thought, that this morbid process within the muscles is the consequence of a disease of the nerves at their roots, because in some cases there have been found on post-mortem examination quite conspicuous structural changes in the anterior roots of the spinal nerves. Yet in other cases nothing of the kind could be detected. And as the muscle retains its susceptibility to the electric currents as long as there are any muscular fibres left, whilst in the case of degeneration of the peripheric nerves this suscepti- bility to the electric current leaves at quiet an early stage: it seems to follow, that those authors are right, who have considered the progressive muscular atrophy as a primary affection of the trophic centres of the muscles themselves. It is found in all classes of people; seems, however, to attack women oftener than men; appears to be in some cases hereditary and in others brought on by overexertion of the muscles, qr by taking cold; whilst in still others it could not be traced to any special cause. This disorder creeps on very slyly, mostly without any pain or any other apparent disturbance of the body. Commencing generally in the muscles of one hand or one shoulder, or in the muscles of the neck, rarely in the muscles of the face; the first apparent symptom is a weakness in the parts involved, a loss of muscular power, which is associated by a diminution of their volume. The attacked parts grow flat and shrink away. We find therefore in such cases the prominent muscle of the thumb gone, and the spinal processes sticking out, when the muscles of the neck have become atrophied. If these atrophied muscles are exposed to a cold draught of air (if we, for example, blow upon them), we observe at once a vibratory motion of the muscular fibres, a jerking of single fasciculi. This is quite a constant symptom of the disease. Its pathognomonic sign, however, is the susceptibility of these muscles to the electric current, which causes a contraction in them, as long as there are any fibres left, distinguishing it thus from any paralysis which has its cause in a morbid condition of the nerves. The atrophy and fatty degeneration and consequent paralysis may stay confined to the parts first attacked, but in other cases it creeps on, involving progressively all the muscles supplied by the cerebro-spinal nerves, with the exception of the muscles of the heart and the intestinal canal. Thus gradu- ally, in these terrible cases, the patient becomes incapable of moving himself, of feeding himself, of expressing any mental emotion by his face; of talking, and lastly, even of swallowing. It takes years before death releases him out of this terrible bondage, if not intercurrent disease shortens his suffering. 760 osteitis. Therapeutic Hints. The electric current, by induction or faradization, persistently used, has improved cases where the disease remained confined to single parts of the body. Arg. nitr. y Arsen., Caustic, Cuprum, Laches., Plumbum, Sulphur. Osteitis, Caries, Necrosis, Exostosis. Osteitis is an inflammation either of the periosteum, or of the bone itself, or of its diploe or its medullary membrane, or of all these different structures together. It may be caused by external injuries, such as frac- tures, bruises, etc., or by chemical influences; or it may be the consequence of certain constitutional contaminations, like scrofulosis, arthritis, scurvy, syphilis, mercurial poisoning, or suppressed acute or chronic skin diseases. Its symptoms generally consist of a deep-seated, heavy, boring pain which assumes a tearing character when the periosteum is affected at the same time. This pain is usually worse at night (especially if of syphilitic origin) and worse also from pressure and motion. There is generally a feeling of heat in the bone, and if the inflamed bone is superficial, its in- teguments soon participate in the inflammatory process. Febrile actions are mostly wanting, except in acute cases. Such an inflammation may ter- minate in Caries, by which we understand an ulceration of the bony structure; or even in Necrosis, which means a dying off of a portion of the bony structure, which, in favorable cases, is gradually thrown off and replaced by a new for- mation. In other cases the inflammation causes an exudate upon the bone, which hardens and grows fast to the bone, thus augmenting its natural size more or less considerably; this is called Exostosis. Therapeutic Hints. Angus, t. Caries, especially of the long bones; great longing for coffee, the use of which must be entirely prohibited; great sensitiveness of mind, very touchy, easily irritated from the least provocation. Arse?i. " Excruciating pain in bones of legs and arms, like the gnaw- ing of rats, or boring with a gimlet into the bones; sudden and rapid pros- tration, with restlessness and emaciation." (Gilchrist.) Asa/. Osteitis, caries in scrofulous individuals, and after the abuse of mercury; bluish redness and swelling of the external parts; ulcer with bluish hard edges, which are very painful to the slightest touch ; discharge of thin, very offensive pus. Pulsations in the pit of the stomach, per- ceptible to the eye and hand; ill-humor and irritated mood. Aselli jecor. ol. In different affections of the bones, in scrofulous sub- THERAPEUTIC HINTS TO OSTEITIS. 76 1 jects, especially when the extremities of the bones are affected; fistulous ulcers, with raised edges, easiry bleeding, and discharging a flocculeut pus and ichor of a nauseating smell. An rum. Caries of the nasal bones in consequence of ozaena, diffusing a most horrrid odor; caries of the cheek-bones and exostosis of the skull and other bones; with boring pain, after the abuse of mercury. A ur. mur. Caries of the left external malleolus, after allopathic drugging. (Linsley.) Bell ad. Scrofulous individuals with glandular swellings, crusts on the corners of the mouth and sore, swollen and bent vertebrae; exostosis on the forehead, and caries of the palatine bones. Calc. card. Osteitis, with swelling; caries and necrosis of scrofulous individuals; diarrhoea, hard, bloated abdomen; chronic symptoms on the scalp; emaciation. Calc. phosph. For similar affections; and especially after fractures, when the callus does not ossify. Chi?ia. Caries, especially where there is profuse suppuration. Fluor ac. Caries in consequence of syphilis or abuse of mercury; caries of the temporal bone. I odium. Lycop. » Mercur. Osteitis, caries; pain, as if the part were broken. Mezer. Periostitis and swelling of the bones, especially on the tibia, with the most violent nightly pains in the bones. Nitr. ac. Especially in syphilitic affections and after the abuse of mercury. Phosphor. Exostosis on the skull, with violent tearing and boring pains, worse at night; swelling of the glands of the neck; sour belching and vomit- ing; burning in the mouth, oesophagus and stomach; constipation; emacia- tion; fainting when raising the head; lame weakness of the extremities. Phosph. ac. Osteitis, and also when after an external injury of the periosteum there remains a feeling as though the bone were scraped by a knife. Ruta. Periostitis and pains in consequence of external injury, with erysipelatous inflammation of the external parts. Silic. One of the most important remedies in the different affections of the bones, with fistulous openings and discharge of thin pus and bony frag- ments. Staphis. Is recommended, especially in osteitis of the phalanges of the fingers. Sulphur. After suppressed itch and mercurial poisoning. Theridion . ( Bar uch . ) 762 TUBERCULOSIS OF THE JOINTS. Tuberculosis of the Joints, White Swelling. Tuberculosis being a constitutional infectious disease, inay localize itself in various parts of the body. When localizing in the joints, it attacks by preference the hip-, knee-, ankle-, elbow-, or wrist-joints, and was called by older writers, on account of the peculiar glossy, shining appearance of the affected joint, "white swelling." "In its incipiency we find the synovial membrane injected, somewhat opaque, and here and there softened or thick- ened by fibrous exudation. There is effusion of lymph, which assumes a pulpy consistency of a pale yellowish or greenish color. The articular car- tilage is of a dull whitish or slightly grayish aspect, and somewhat thickened, softened and partially separated from its osseous connections. The cancel- lated structure of the bones is abnormally vascular, light, porous, humid, and at the same time easily broken and cut. Not unfrequently its cells are dis- tended, with yellowish tubercular matter, of a semi-solid, osseous consistency; or, this substance presents itself in the form of distinct masses, free or en- c)^sted, and, perhaps, not larger than a millet-seed. The ligaments appear abnormally red, tumefied and softened. The synovial fluid is generally increased in quantity, but rarely to any considerable extent. In its further progress, the lymph gradually increases in quantity and is often intermixed with a little sero-purulent matter, or thick, greenish-looking pus. The synovial membrane is partially destroyed, and what remains is of an opaque, muddy and ragged appearance. The cartilage is ulcerated, pulpified, dis- colored, perforated and almost completely detached. The boii3 T structure is very red, soft, carious, rough and easily crumbled. The ligaments exhibit well-marked signs of inflammation, being loose and spongy at one joint, attenuated at another, and perhaps thickened or hypertrophied at a third. In this way the structures of the joint are completely subverted, with hardly any trace of their original appearances. Pus is more usually seen, often, indeed, in large quantites, sometimes thick, pultaceous, caseous, ichorous or sero-sanguinolent. In some instances it is very thin and almost black, evi- dently from the effects of the necrosed condition of the bones. "In case of recovery, the joint will be found to be filled by a white, fibrous, organized substance; the extremities of the bones being anchylosed, or firmly attached by new matter to the surrounding structures. It is very rare that a new socket is formed; and yet this is not impossible. In time, the artificial joint may admit of considerable motion, but, in general, this is extreme^ restricted. Occasionally an imperfect ligament is formed round the bony remnants, and the surface of these bony remnants may even become slightly tipped with cartilage. Finally, osseous growths — short, irregular and friable — sometimes make their appearance upon the bones, in the vicinity of the former disease. ' ' ( Gross. ) This is the general character of the pathological changes which tubercu- losis causes, when located in the joints. I shall now speak of the several joints which it attacks in preference, causing affections which are not unfre- quently met with in practice. COXARTHROCACE. 763 Coxarthrocace, Coxalgia, Hip Disease. This affection is most frequently found from the third to the seventh year. Growing out of a constitutional diathesis, it may be excited by exter- nal injuries, exposure to cold, or different wasting diseases; sometimes it comes on stealthily without any appreciable cause. It seldom, or never, attacks both hip-joints, but is frequently complicated with psoas abscess, ophthalmia, pulmonary phthisis and degeneration of the lymphatic glands. In its first stage, we observe that the child is easily tired, and complains of a pain in the knee, on the inner side, which is worse from motion, so that the child limps when walking; this pain is likewise worse in the night, and frequently attended with spasmodic jerking of the extremity, disturbing sleep. The knee itself shows neither swelling nor discoloration. Gradually the pain extends to the thigh and leg, and in some cases it is felt most keenly in the tendo Achillis, or over the instep; or it shifts from one place to another; or may disappear for a short time entirely. Finally, after weeks and even months, the pain is also felt in the hip and its neighborhood; and then most intense and persistent directly over the articulation, deep-seated and of a dull, gnawing character. Up to this time there is no perceptible impairment of the general state of the system. By and by, however, during the second stage, when the pain in hip and knee increases still more in vio- lence, when the buttock flattens, the gluteo-femoral crease disappears and the limb apparently grow T s longer, with nightly spasmodic twitchings and wasting of its muscles: then we also find the sleep habitually disturbed by unpleasant dreams, and frequent starting of the patient out of sleep with crying and screaming; the appetite becomes impaired, the bowels often constipated, and there is more or less fever, especially at night, followed frequently by copious sweats. Now the patient begins to show a careworn countenance; he grows peevish and irritable, and loses flesh and strength. In the third stage matter forms within the diseased joint. "This is in- dicated by an increase of pain on the slightest motion; by a sense of throb- bing and tension, deep and persistent; by severe swelling of the gluteal region, generally most prominent at the centre of the articulation; by oedema of the subcutaneous cellular tissue; by a remarkably turgid and enlarged condition of the subcutaneous veins; by violent rigors, followed by high fever and copious sweats. As the matter increases in quantity, it gradualh- works its way towards the nearer surface; its approach being denoted by the appearance of a circumscribed, erysipelatous blush. Here there is generally distinct fluctuation, and the parts, feeling soft and baggy, soon j-ield at one or more points, followed by the escape of the contents of the sac. ' ' (Gross. ) These openings may in different cases form in different places: in the gluteal region, either directly above the joint, or in its immediate vicinit3~; on the upper and back part of the thigh, below the great trochanter; on the upper and inner .surface of the thigh; on the superior and external part or the groin; on the sacro-sciatic notch; or on several points, either simultaue- 764 THERAPEUTIC HINTS TO COXARTHROCACE. ously or successively. Or the matter may partially escape internally, when the bottom of the acetabulum is perforated, into the rectum, bladder or vagina; or it ma}' collect in a sort of pouch, between the inner surface of the iliac bone and the soft parts of the pelvis. By this time the limb has actually grown shorter from one inch and a quarter to several inches, and the foot points either directly forwards and outwards, but oftener inwards. The thigh is generally flexed upon the pelvis, and turned either towards the sound limb or is bent off from it. The great trochanter generally lies directly over the acetabulum, or in its immediate vicinity; whilst the head and neck of the femur are usually so much wasted as to exist only in a rudimentary form. Dislocations of the femur are ex- ceedingly rare; and are possible only in such cases where there is an exten- sive destruction of the soft parts; allowing the superior extremity of the bone to move about, and to insert itself into a new position. Therapeutic Hints. Arsen. Third stage; the child is emaciated, exhausted; very restless; has diarrhoea, worse in the middle of the night; wants to drink constantly, but little at a time. It is indeed going fast if Arse?i. should not soon change the scene for the better. Bel lad. Burning, stinging in the articulation; nightly aggravation, with starting in sleep, fever, and congestion of the head; or drowsiness, with in- ability to go to sleep. Cramps in glutei muscles; outer hamstring feels as if contracted; inability to walk. Calc. ca?'b. Second stage; sweat on the head during sleep; scratching the head impatiently when getting awake; frequent desire for boiled eggs; abdomen hard and bloated; inclined to diarrhoea, especially towards evening; glandular swellings on the neck. Calc. phosph. Third stage; it puts an end to the further destruction of the bone, stops suppuration and promotes new organization. Carb. veg. Third stage; ichorous, offensive, blackish discharge; deeply- sunken state of the whole organism. Chijia. Profuse suppuration, sweat and diarrhoea. Coloc. Second and third stage; difficult urination of dark urine; green diarrhoea; lies upon the affected side with bent-up knee; the pain is of a cramp}* nature, as though the parts were screwed in a vise. Hepar. Suppurating stage, with fever and sweat, where the patient wants to be tightly covered. Iodium. Intermittent, sharp, tearing pain between the left hip and the head of the femur, increased by moving the joint; glandular swellings; abuse of mercury. Kali carb. Third stage; crampy tearing in the hip joint and knee; bruised pain in the hip- joint when moving and sneezing; twitchings of the muscles of the thigh; dull pain in the side of the knee when walking, and especially when extending the limb; starting when asleep; twitching of the GONARTHROCACE. 765 limbs during sleep; all the symptoms worse towards three o'clock a. m. ; great tendency to start, especially when being touched. Laches. In any stage, if there be a regular aggravation of febrile motion in the afternoon about three o'clock, an aggravation of general malaise after sleep, a notable offensiveness of the alvine discharges, even if of a natural consistence, and previous abuse of mercurial preparations; before or after Laches, is frequently indicated. Lycop. When there is an aggravation of fever and suffering, especially from four to eight o'clock p. m. ; great fear of being left alone; violent jerking of the limbs and body, awake and asleep, and great crossness on awaking out of sleep. Mercur. First and second stage, with prominent aggravation in the night, restlessness and inclination to sweat; is frequently indicated before or after Bellad. , and when suppuration seems inevitable. Phosphor. Hectic fever; dry, hacking cough; chronic diarrhoea; urine turbid on voiding, precipitating a white sediment on cooling; thin watery pus oozing from the diseased joint. Rhus tox. First and second stage; on pressure upon the trochanter, pain in the hip-joint; pain in the knee predominant; swelling of the glands of the neck; crusty eruptions on face and head; after exposure to rain; worse in damp, cold weather; when keeping quiet, and on first moving. Silic. In suppuration and caries of the bones anywhere, one of the most important remedies; pale, earthy complexion; loss of smell and taste; stop- page of the nose or acrid coryza; the parts upon which one lies easily go to sleep; any little sores or wounds are apt to fester; glandular swellings. Stramon. According to Dr. Jeanes, always indicated when the left hip is affected. I have given Stramon. with great success wherever abscesses form, if attended with violent pain, driving one mad. Sulphur. Psoric individuals; frequent redness and inflammation of the eyelids; heat of the head, and cold hands and feet; frequent red spots in the face; is averse to being washed; morning diarrhoea, or constipation; sleepy in the daytime and wakeful at night; easily perspiring. Gonarthrocace, Tumor Albus Genu, White Swelling of the Knee. Gonarthrocace, growing upon the same constitutional contamination as hip- joint disease, runs through nearly the same phases as that disease, and is most frequently excited by an extenal injury, such as a fall, twist, or blow upon the knee. At first there is a severe, dull, heavy, gnawing pain at the inner condyle of the femur, at the lower part of the patella, or at the inside of the head of the tibia; seldom at the outer part of the joint; it may be intermitting, and it may be continuous in its character, extending up and down the limb, and depriving the patient of all sleep and rest. After a while the parts commence swelling, owing partly to interstitial deposits, and partly to an increase of synoval fluid. This swelling is at first 766 THERAPEUTIC HINTS TO GONARTHROCACE. most conspicuous in front and at the sides of the patella, effacing the normal depressions in that region, and replacing them by soft, fluctuating bags. " A similar prominence, often of great size, exists just above the joint, over the lower part of the femur, bounded inferiorly by the patella, and on each side by the lateral ligament, its anterior wall being formed by the tendon of the exterior muscles Yen- little tumefaction ever occurs in the popliteal region, even in the more advanced stages of the disease. The skin is tense and glossy; they subcutaneons veins are abnormally large; the knee is stiff, if not immov- able; and the leg, more or less flexed, is swollen and cedematous, while the thigh is remarkably atrophied. In proportion as the ligaments yield, the deformity of the joints increases, owing chief! y to the displacement of the head of the tibia, which allows the muscles to draw the leg outwards, so as to give it a twisted and contorted appearance. Occasionally, though rarely, there is an actual enlargement of the diseased bones. The fluctuation, which consti- tutes so prominent a symptom in the earlier periods of this complaint, often, in a great measure, if not entirely, disappears during its progress, owing to the adventitious deposits upon the synovial membrane, and the absorption of the redundant synovial fluid. Whenever this is the case, the swelling, instead of being soft and yielding, well be comparatively firm and resisting; but it still possesses some degree of elasticity, often so deceptive as to lead to the idea that the joint contains a good deal of fluid, and which nothing but the most careful examination can dispel." (Gross.) Lastly, though not always, the involved structure commences to suppu- rate, and the matter may either be absorbed, or may escape at different places about the knee — very rarely , though, in the ham — forming numerous fistulous openings, and leading to caries and necrosis of large portions of the diseased bones. Therapeutic Hints. Aeon. After exposure to severe cold. Arnica. After a fall or blow, and Rhus to. x., after a twist, sprain or strain, may severally be entirely sufficient to ward off all serious consequences. Arsen. Third stage; discharge of fetid pus; oedema of the legs; hectic fever; sleeplessness; emaciation; exhaustion. Bellad. Red, shining swelling, w T ith throbbing pain and enlarged blood- vessels along the limbs. Bryon. Pale swelling, with stitching pain from slightest motion. Calc. Carb. Scrofulous individuals; too early and too profuse menstru- ation; pot-belliedness; looseness of the bowels; glandular swellings. • Iodium. Second and third stage; fistulous openings, discharging a thin, watery ichor, and being surrounded by pale, spongy edges, which bleed easily: feverishness; emaciation. After the abuse of mercury. Kali hy dr. Doughy, spongy swelling of the knee, without fluctuation; skin tense at times, red in spots and hot. Inside a feeling of heat; gnawing, boring pain at night, necessitating a constant change of position. After a fall. Laches., Lycop. Compare the preceding chapter. BURSITIS. 767 Mercur. After suppressed itch; nightly pains, etc. Pulsat. Fever, dryness of tongue, without thirst; diarrhoea, scanty and delaying menses. Silic. Violent, lancinating pains; caries; fistulous openings; cachectic condition. Sulphur. Psoric individuals. Besides, compare Coxa?throcace. Bursitis. The bursse mucosae are closed sacs, analogous in structure to synovial membranes, and secreting a similar synovial fluid. Those concerning us now are situated over the patella and the inner side of the head of the tibia. Being greatly exposed to external pressure and irritation, they are subject to inflammations like the synovial membrane, constituting an affection known under the name of Bursitis, or House-maid's knee, the latter on account of its frequent occurrence among female servants, who induce it while working in a kneeling position. It is distinguished from synovitis by its superficial nature and the regularity of its tumefaction. In acute cases it is attended with severe pain, swelling and fever; it may terminate in suppuration, or, when becoming chronic, in the formation of a solid tumor. Therapeutic Hints. Ant. crud. " The integument is hard and horny, smooth and slightly discolored, with a sensation as if being pricked with needles, or of being destitute of feeling." (Gilchrist.) Apis mel. " Inflamed, fluctuating; biting, stinging in the part." (Gil- christ.) Arnica. And the remedies mentioned in the foregoing chapters may likewise need consideration in special cases. Arsen. " Dark color, bluish generally, with much effusion, and in- tense burning relieved by external warmth." (Gilchrist.) Fragraria vesca. " Burning-smarting, worse when warm and in warm weather." (Gilchrist.) Pulsat. " Smarting itching, relieved by cold." (Gilchrist.) Silic. In chronic bursitis; pain as if sticking or itching. Sticta puh?i. Has been found, by Dr. B. C. Price, of great efficacy. Sulphur. " Inflamed, with a feeling of formication." (Gilchrist.) Podarthrocace, Abscess of the Ankle-joint. Commencing with pain, this affection soon shows signs of a swelling- just in front of each malleolus, filling up the hollow which naturally exists there. So also gradually disappear the grooves at the side of the tendo Achillis, and the whole joint swells considerably. By and by, if suppura- tion takes place, the pus may escape at different places, forming, like in the knee-joint disease, fistulous openings, and may lead to considerable destruc- tion of the affected bones. 768 malum pottii. Therapeutic Hints. Compare the preceding chapters. Only one remedy, not mentioned there, I must add here, namely: August. In a case where none of the very carefully selected remedies seemed to have any effect, this remedy at once arrested the morbid process and brought it to a perfect cure. In this case, the condyles of the tibia were quite seriously involved, and it was on account of a remark of Aegidi, 1 ' Angustura acts especially upon the long bones, ' ' that this remedy was given with so happy a result. Malum Pottii, Kyphosis, Angular Curvature of the Spine; Spondy larthr ocace . When the disease has already developed to a visible backward curvature of the spine (hunchback), its diagnosis is easy enough, only that it comes too late. Of much greater importance are the symptoms of the initial stage: the child cries whenever it is taken hold of below the ribs, with spasmodic drawing up of the legs, and shortness of breath. Besides this there are: periodical pains in the epigastric region; listlessness and disinclination to move; disposition to lie flat on the stomach or side, only rarely on the back. Finally as the disease progresses, one or more spinal processes project back- ward in an acute angle, the head sinks backward between the shoulders, and when walking the child props the arms on the thighs or knees, instinct- ively supporting the spine, and avoiding all motions which would necessi- tate a bending of the spine. All this is produced by a tubercular affection, or according to other writers, by an inflammatory process of the vertebrae, causing the bones to become carious and to crumble away, or to form abscesses. Probably both views are correct. The tuberculous form seems hardly ever to induce congestive abscesses, which are more apt to occur in endosteitis. Both forms no doubt grow out of a general contamination of the system, scrofulosis, and where this condition exists, an unlucky fall or wrench may be sufficient to induce the development of the disease. So also it has been observed to often follow after measles, and especially whooping- cough. The disease is always of a slow and tedious nature. Therapeutic Hints. As the spinal column gradually loses its fitness to sustain the body in an erect position, the horizontal position will make itself in many cases necessary; but too long a confinement in bed has other quite serious objections, and it has, therefore, been an object of many physicians to invent means by which the strain of the spinal column may be relieved. The most simple and effectual of these means seem to be Sayre's starched bandage, by which chest and abdomen are enveloped in fold after fold, until a compact casing of the material surrounds the trunk, capable of retaining the bony column in a fixed position. This is done while the patient PANARITUM. 769 is suspended by the arm-pits, and the head held in an erect position; the weight of the body straightens the spine. As soon as the starch is well dried and stiffened, the patient is liberated and left to his freedom. Cede, card., or phosph. after Sulphur, when the known scrofulous symp- toms call for its use. Natr. mur. Has been recommended by Kafka a^s a constitutional ad- juvant to Phosphor. Phosphor. Main remedy of Kafka. Its symptoms will indicate its use in special cases. Psorin. Proposed by Iyilienthal as being fairly indicated by its symp- toms. Silk. Indicated by its characteristic action upon inflammatory processes of boiw structures, and also by the peculiar symptom: " sweating of the head only." Sulphur. Is according to Jahr, the remedy to commence with, if indi- cated by the general condition of the patient. If excited by external injury: Aeon., Arnica, Hyper., Rhus tox. Other remedies recommended: August., Arsen., Asa/., Aurum., Bellad., Calc. jod., Hepar., Lycop., Mercur., Mezer., Phosph. ac, Plumbum, Pulsat. Compare also Rachitis and the foregoing chapters. Panaritum, Paronychia, Whitlow, Felon. This is an inflammation of the thumb or of one of the fingers, which terminates in suppuration. There are two varieties, a superficial and deep. The superficial form, Whitlow or Run-around, is generally seated im- mediately around and beneath the nail, commencing either at the side of the finger, upon its dorsal surface, or its extremity. Without much if any swell- ing the part has a dusky, i^d aspect, tender on pressure and exquisitely painful, throbbing violently and incessantly, and causing more or less consti- tutional disorder. Two or three days after these phenomena present them- selves pus will be observed beneath the epidermis, involving the superficial structures. The inflammation generally extends some distance up the finger, and occasionally even over a considerable portion of the hand, which may be considerably swollen, stiff and painful. Not unfrequently a reddish line, indicating the course of an absorbent vessel, is seen running along the arm as high up, perhaps, as the axilla. In the deep-seated variety, Felon, the inflammation involves all, or nearly all of the structures of the finger, and is frequently followed by the destruc- tion of one or more of the phalanges. The pain is of extraordinary severity, depriving the patient of sleep for days and nights together, throbbing, ten- sive and diffused, often extending as high as the elbow, and even to the shoulder, steady and persistent, but greatly aggravated by a depending posi- tion, and only subsiding with evacuation of the inflammatory deposits, or the death of the parts. The swelling also is great, sometimes enormous, involving both finger, hand and wrist; the skin is red andcedematous, puffy, 49 770 THERAPEUTIC HINTS TO PANARITUM. erysipelatous in aspect, and the whole limb is often stiff and useless. In consequence of the inflammatory action, pus forms deep among the tissues, in the connecting cellular substance, within the sheaths of the tendons, and beneath the periosteum, and spreading in all directions, causes extensive destruction, burrowing along the finger and hand. In neglected cases even gangrene may occur, ^followed by sloughing of the tendons, and exfoliation of the phalanges. This grave form is always attended with well-marked constitutional disturbance. The patient, tortured with pain, is feverish and unable to sleep; his appetite is lost; his head, back and limbs ache; the face is flushed, and the pulse is strong, hard and frequent. In some cases delirium is present. (Gross.) Causes unknown; no doubt of an infec- tious nature. Therapeutic Hints. Amm. ca?-b. I have seen the nightly pain which had deprived the patient of sleep for several nights, relieved in a few hours, and the morbid process stayed at the same time by one or two doses of Amm. card. 500 Anthrac. Where there is sloughing, with terrible burning, and when Arsen. gives no relief. Apis. According to Wolf, specific especially after the abuse of Sulphur; the characteristic pain is burning-stinging. Arsen. When the sore assumes a gangrenous aspect; burning like fire, with anxious restlessness; worse about midnight. Bryon. In the commencement, where there is a gastric-rheumatic dis- position; white or yellowish-coated tongue; dry feeling in the mouth, with- out thirst, or great thirst; bitter taste in the mouth; dry, hard stool, as if burnt. Caustic. Recommended by Goullon, to t^e used externally and inter- nally . Graphit. According to Kreussler, superficial inflammation about the root of the nail, with burning and throbbing pain, and subsequent inflamma- tion and proud flesh. Hepar. Violent throbbing, "gathering" pain; it accelerates suppura- tion. The hand is kept wrapped up, because it ameliorates the pain. Iris vers. " An early application either in tincture, or the whole fresh plant bruised and bound on the part, will, in many cases, completely abort the felon . " ( Gilchrist . ) Juncus eff. Recommended by Minnichreiter, who applied the pith of this plant upon the panaritium with the greatest success. Laches. According to Hering, in severe cases, where the inflamed por- tion assumes a purplish hue, or becomes gangrenous. Ledum. When the whitlow is the consequence of the prick of a needle, a splinter, etc. Lycop. When there are the following constitutional disturbances: fre- quent belching, bloatedness of the region of the stomach and belly; pressure BUNION. 771 and heaviness, and sometimes throbbing in the precordial region, burning in the stomach and oesophagus; nausea; sensation of twisting, crawling and emptiness in the stomach, accompanied by frequent yawning; congestion to the head; cold feet; dry stool; red, burning urine; mental irritability. Maland. Suppuration of all the finger and toe-nails. (Straube. ) Mercur. When the inflammation extends to the sheaths of the tendons and ligaments of the joints, and in superficial whitlows. " The pain is re- lieved when the finger is exposed to the air." (Gilchrist.) Natr. siriph. Suppuration at the root of the nail, with deep red swell- ing of the whole phalanx, and great painfulness; the patient looks sickly and pale; feels weary and dull in the head, especially in the morning; has no appetite, and is chilly and feverish in the evening; the pain is easier out- of-doors than in-doors. Prominent causes: damp region, damp walls, damp cellars. Nitr. ac. "The hand is carried wrapped up, but the finger exposed, from a sensation as if a splinter or a piece of glass were in the part, which the friction of the wrappings aggravates." (Gilchrist.) Rhus tox. Where there are rheumatic pains in the limbs; worse during rest and on beginning to move; sensation in the limbs as of going to sleep, and formication; tired feeling and sweating from any little exertion; erysipe- latous redness of the inflamed part. Sa?iguin. Suppuration of the roots of all the finger-nails. St lie. Deep-seated inflammation; affection of the bone; proud flesh; terrible pain ; worse in bed; very important after Hepar. Stramon. Is most important when the pain is almost unbearable, driv- ing to despair. It ameliorates it at once, and hastens benign suppuration. Sulphur. According to Wolf, when Apis is not sufficient on account of latent psora. Bunion. What bursitis is to the knee, bunion is to the metatarsal joint of the great toe, an inflammation of the bursae situated in this joint, inconsequence <_>f undue pressure of shoes or boots. Arnica. Often relieves the acute symptoms, and Calc. carb. frequently cures chronic cases. Ingrowing Toe-nails. Compare Colchic. , Graphit. , Kali carb. , Magnet, austr. , Mar. ver. , Natr. mur., Phosphor., Silic. Perchloride of Iron has been used externally to dry the inflamed parts. (Wahle.) NERVES. The anatomical diseases of the peripheral nerves comprise: Neuritis, Inflammation of the Nerves. This may be acute or chronic. The acute form, usually brought on by. external injuries, or neighboring destructive processes (sloughing cancer), begins with chilliness, or an actual rigor, being followed by fever, tieadache and sleeplessness, and is attended by severe pain, starting and extending from the injured spot over the region to which the nerve is distributed. In some cases a red line in the skin indicates the course of the inflamed nerve, and the skin surface of its distribution exhibits a marked degree of hyperaes- thesia with the subjective sensation of numbness and formication. The chronic form is characterized by pain and paraesthesia in the area of distribution of a certain nerve, by motor and sensory irritation with sub- sequent paralysis, by painful swelling of the nerve. The most important * remedy for neuritis in consequence of external in- jury is Hyper, perf. (Hering.) Atrophy of the Nerves Is most frequently the consequence of inflammation, compression or central disease, and can only be reached so far as the original disease is amenable to treatment. Hypertrophy and Neoplastic Formations in the Nerves. Hypertrophy of peripheral nerves, that is an increase of the nerve- fibres in number, great thickness of the medullary sheath and even of the axis cylinder, or oftener an interstitial hypertrophy of the connective tissue, is of a mere anatomico-pathological, but of no clinical interest. Neoplastic formations in the nerves, also called neuromata, are made up either of true nerve-tissue (Neuromata vera), or are composed of any other tissue, giving rise to Fibromata, Myxomata, Sarcomata, Carcinomata, Syphilitic gummata, Lepra nervorum, all known under the general name Neuromata spuria. Their Etiology is obscure, and "an exact anatomical diagnosis can be accomplished with certanty only by means of the microscope. When no tumors can be demonstrated by external examination, their presence can be HYPERESTHESIA. 773 concluded only with some probability from the existing nervous disturb- ance." (Krb.") The functional diseases of the peripheral nerves comprise: Hyperesthesia, Anaesthesia. By means of the sensory nerves we receive external impressions. Light affects the optic, sound the auditory, perfume the olfactory, sapid substances the gustatory nerves, palpable things the nerves of touch, and heat, cold, etc. , the nerves of general feeling. These nerves are so constituted that they bear external influences to a certain extent with perfect ease, although we find in even healthy individuals a great difference in this respect. Some perceive the slightest, others only more powerful influences; but, as a general rule, the ordinary influences of the outer world are borne by all with equal ease. In this disease, however, it is often different. We observe that ordinary light, the slightest noise, the least touch, etc., are unbearable. This con- dition is called morbid sensitiveness. It is frequently in combination with a state of fidgetiness and restlessness, and then it is called nervousness. Post-mortem examinations do not reveal the least alterations of the nerves, and its seat ma}^ just as well be referred to the primitive forces of the mind, of which the corresponding nerves are merely the bodily organs, by which the mind lies open to external influences. Anaesthesia of the sensory nerves is the opposite to morbid sensitiveness — a want of natural sensibility; to which we might add numbness, pithiness, either in consequence of pressure upon a nerve, or in consequence of central disturbances, by which its normal action is interfered with. Therapeutic Hints. Compare Boenninghausen's Repertory. Sensitiveness to light: (principally) Aeon., Arsen., Bellad., Enphras., Me? r cur., Rhus tox., Sulphur. Sensitiveness to noise: Aurum, Coffea, Lycop., Sepia, Spigel. Sensitiveness to smell: Aurum, Bellad., Lycop., Mercur., Phosphor., Sepia. Sensitiveness to taste: Bellad., China, Coffea. Sensitiveness to touch: Arnica, Bellad., Coffea, Hepar, Lycop., Nux vom., Pulsat., Sepia, Spigel. Nervous debility: China, Coccul., Nux vom., Phosphor., Pulsat., Silic. Fidgety disposition: Anac, Bellad., Hyosc, Mercur., Rhus tox., Sepia, Staphis., Stramon., Zincum. Pithy, numb feeling: Coccul., Hyosc, Lycop., Oleand., Opium, Phosph. ac, Stramon. 74 NEURALGIA. Neuralgia. Neuralgia literally means a pain of the nerves. In this sense of the word, any and every pain would be a neuralgia; because there is no pain possible without sensitive nerves. This is not the sense in which the term neuralgia is used. Hasse defines it in the following language: " Neuralgia characterizes it- self physiologically as an irritation in the course of one or several sensory nerves, which irritation may exist on any part of the nerve, from its origin down to its termination, and which irritation is felt as pain; not, however, only in the place where the irritation exists, but also in different other places of the same nerve; sometimes even through its whole length." Such irrita- tion and consequent pain may be occasioned by the most different causes, so that neuralgia may be a symptom of very different conditions. Structural changes of the nerves themselves, however, are very rarely found, and then only in paralytic conditions. Those coarser structural changes which we have called tumors of the nerves, or neuroma, ma}^ exist without any neu- ralgia; and the most violent neuralgia may not show a trace of structural change on post-mortem examination. We cannot, therefore, so clearly define neuralgia pathologically as other forms of disease; as, indeed, it is only a symptom of the most different conditions. Such conditions are either peripheral or central. i. Peripheral Causes are either organic changes of the nerves them- selves — most frequently in consequence of external injuries — or organic changes in the neighboring parts of the nerves, as inflammation, caries, and exostoses of the bones, especially in the neighborhood of the foramina, through which the nerves make their exit, also tumors — especially carcinoma and aneurisma — and affections of the liver, uterus, ovaries, kidneys, etc. 2. Central Causes are structural changes in the brain and spinal cord, and their membranes, consisting of tumors, softening, sclerosis and deposits of morbid products. Besides these causes we may also mention exposure to cold, metallic poisoning — especially by mercury and lead — and miasmatic influences, which latter cause a periodical type, like intermittents. Symptoms. — i. Pain. It is of various kinds: boring, cutting, tearing, burning, like lightning, but always described as excruciating. It generally comes in paroxysms, and is felt in many cases distinctly running along the course of a certain nerve. It is often provoked or aggravated by softly touching or stroking the parts, whilst hard pressure frequently relieves it. 2. Concomitant symptoms. They consist of affections of the motory nerves, causing spasmodic motions in those parts in which the affected sen- sory nerve branches out, prosopalgia and almost always distortions of the face; of affections of the vasomotory nerves, which manifest themselves in paleness of the skin and chilly sensations, followed by heat and turgor, sometimes by profuse perspiration or profuse secretion or scantiness of urine; of affections of the trophic nerves, causing change of color in the hair, fall- CEPHALALGIA. 775 ing off of the hair, or thickening or atrophy of various tissues, or a dis- position of the skin of various inflammatory processes, such as erythema, erysipelas, pemphigus, urticaria and zona. The most important special forms of neuralgia are: Cephalalgia; Hemicrania or Migreena, or Nervous Sick Headache. Cephalalgia or headache, or pain in the nerves of the head, may be at- tended upon the most various morbid conditions of the body, to which some persons are more liable than others. We have headache from anaemia and from active hyperemia, also toxic, hysterical, rheumatic and sympathetic headache. Hemicrania or Migraena or nervous sick headache on the other hand is a peculiar form of half -sided headache, which, by some, has been considered as a neuralgia of the temporal, frontal and occipital nerves, or as a hyper- esthesia of the brain, or a cerebral neuralgia, or as a hysterical manifesta- tion of some derangement of the menstrual function, while Du Bois Ray- mond took it for a neurosis of the vasomotor nerves, consisting of spasms of the vascular muscles of the affected side, causing paleness and contraction of the features and dilatation of the pupils, and Moellendorff considered it as a paresis of the vascular muscles, which manifests itself in dilatation of the central retinal and choroidal vessels of the affected side, in a slower pulsa- tion of the heart, in a soft and large pulsation of the carotids and temporals, and in cold hands and feet. Both agree in this, that hemicrania is due to alterations in the cerebral circulation, in the one case produced by spasm and in the other by relaxation of the vascular muscles, both induced by a disturbance of the sympathetic nerve either in its cranial or cervical portion. Dr. G. C. Savage, of Jackson, Tenn. , says — that sick headache is often due to hypermetropia and astigmatism, either alone or combined, and offers as a cure properly fitted glasses. This view I can confirm. This complaint, which is so frequently met with, returns periodically. It generally commences in the morning, increases during the course of the day as the sun ascends, and reaches its culmination in the evening; very often it attacks only one side of the head, or passes from one side to the other, or is confined to the top of the head, or to the forehead or occiput. If often reaches an almost unbearable pitch, is associated with nausea, and generally ends with gagging and vomiting of bitter, greenish, or slimy masses. In some cases one thorough vomiting is sufficient to relieve the pain, while in others both retching and pain continue for several hours, until finally, a sound sleep relieves it all. During the paroxysms the patient is very sensitive to light, noise, strong smells and touch; he seeks a dark, quiet place where he can lie undisturbed. Migraena is most frequently met with in women of a hysteric, chlorotic, or ansemic tendency, and a weak and nervous constitution, also in married women who have no children, and in young widows. Men of weak con- 776 THERAPEUTIC HINTS TO CEPHALALGIA. stitution , who read and stud}- much in the night, or who lead a loose life, are likewise subject to migraena. In all, it seems that the habitual use of coffee and tea has a great deal to do with its periodical recurrence. Therapeutic Hints. In all obstinate cases the eyes should be examined, and if there is any hypermetropia or astigmatism, proper eyeglasses should be provided. Aeon. In full-blooded individuals; rush of blood to the head; the pain is centered in glabella, excruciating, driving to despair. " Crampy pain at root of nose, making her feel as if going crazy." ( Gilchrist.) Aithusa cyn. Pressing pain in the forehead, as though it would split; or as if there were a tight hoop around the head ; eyes appear protruded and the face is pale; great anxiety and restlessness drives into the open air, which relieves. At its height, vomiting, belching; hiccoughing; finally diarrhceic stool; some hours sleep and pain in the stomach for several days. Agar. Pressing pain in right temple, as if a nail were thrust in, worse sitting, better moving about slowly; dull, drawing headache, worse in morn- ing, extending into root of nose, with nosebleed or thick mccous discharge; headache from overwork at desk. Amm. carb. " Feeling as if the head would burst; anxiety and inclina- tion to weep; discharge of sharp, burning water from the nose; pale, bloated face; much thirst; debility, compelling to lie down; during the day and in the morning, perspiration, principally about the joints. Worse in the even- ing, and from wet poultices and pressing the teeth together; better from pressure and w 7 armth. ' ' (Gilchrist. ) Amy I, ?iit?-. Hemicrania, w T orse on left side; the affected side looks pale in comparison with the sound one. Anacard. "Loss of memory; fluent coryza; loss of taste; diminished sensibility, parti cularly of smell, sight and hearing; sensation as of a hoop around the parts; coldness internally, with external heat; clammy perspira- tion of palms of hands, worse in morning, periodically; also from rubbing; better during dinner. Leftside." (Gilchrist.) Ant. crud. Headache after bathing in the river, from deranged stomach by alcoholic drinks; thick, white coating on tongue. Aranea diad. When the spells come at regular hours; flimmering be- fore the eyes; dizziness in the head, which obliges the patient to lie down; on rising a feeling as though the head and hands were bloated and swollen. Arg. nitr. Pressive pain in the forehead on getting awake in the morn- ing, gradually extending from the supraorbital ridge upwards to the coronal suture, with heaviness in head and vertigo, which does not turn in a circle, but inclines the patient to reel to one or the other side; dimness before the eyes; ringing in the ears; sense of relaxation in the stomach, as though it were hanging down loosel)*; all the symptoms better after eating a good dinner and drinking a glass of wine; w r orse after drinking coffee; or the pain is half-sided in one of the frontal protuberances, or close to the side of the THERAPEUTIC HINTS TO CEPHALALGIA. 777 glabella near the supraorbital ridge, or in one of the temples, sometimes ex- tending down into the bones of the face; the pain is of a pressive, screwing, throbbing nature, and is always preceded by general indisposition; chilliness, loss of appetite; growing dim before the eyes, and nausea. At its height it is attended with trembling of the whole body and a deadly nausea, which ends with vomiting. Arnica. Periodical spells, commencing slightly in the morning in the forehead, with flickering before the eyes, which is aggravated by reading or writing, gradually extending through the temples into the occiput, and reaching its acme in the afternoon. A warm room is unbearable, but the open air does not ameliorate; must lie perfectly quiet, stretched out upon his back; worse from any motion, quick walking, bending, going up stairs, talking, thinking and after eating. Sour perspiration. Arsen. Hemicrania in persons with affections of the liver; alternating bilious colic and migrsena; great sensitiveness of the head to the open air; during the spells the patient is very restless, constantly moves the head and limbs to and fro, and imagines that he gets some relief from so doing; better from external warmth; from wrapping the head up in warm cloths; he feels extremely prostrated; thinks he must die; feels chilly and hovers near the stove. Aur. met. " Melancholy mood, dejected, inclined to weep, and longing to die, almost driven to suicide; fiery sparks before eyes; roaring in ears; very sensitive smell; bloated, shining face; hysterical spasms with laughing and crying alternately." (Gilchrist.) Swelling of cranial bones with bor- ing; syphilitic and mercurial origin. Bellad. One-sided pain, especially on the right side; throbbing, beating, attended with vertigo, congestion of the head and eyes, and throbbing of the carotid arteries; or great paleness of the face; pain worse on lying down, better on bending head backward, and external pressure. Bryon. Headache on first waking in the morning, gradually increasing until evening; pain as though the forehead would burst; worse from any motion, coughing or sneezing, Tongue thickly coated; violent thirst or only dry feeling in the mouth; gastric derangement; constipation or diarrhoea in the morning; the patient is very irritable and cross; gets angry easily. Cact. grand. Pain in right temple by spell, brought on often by a glass of wine, by attending the opera, getting his dinner at too late an hour; it commences in the morning and increases as the da}^ advances to an awful height, with vomiting. He must lie perfectly quiet; any attempt to keep up, any noise, light or exertion, increases the suffering terribly; constant dry nose. Calc. carb. Chronic cases; some da3'S before or after the menses, which are profuse, pain centering in top, as if she should go crazy; after suppressed eruptions; strange feeling of coldness in some part of the head, or in the whole head; pain worse from early in the morning after getting awake until afternoon; cold, sweaty hands and teet. / /' THERAPEUTIC HINTS TO CEPHALAGIA. Calc. phosph. Headache of. children from going to school; from change of weather with other rheumatic pains, especially along sutures and symphyses. (Hering.) Camphora. Throbbing pain like a hammer in the cerebellum, syn- chronous with the beats of the heart; after sunstroke. Icy coldness of the whole body; cold perspiration. Chamom. Commences with nickering and fiery zigzags before the eyes, so that one cannot see or read, followed by terrible headache. China. The pain is increased from slight touch, from opening the eyes, or from keeping them shut; sometimes the pain is relieved by lying down, at other times the patient cannot lie down; better while moving about gently, or sitting up erect. Nursing females after loss of vital fluids. Chin, sulph. Intermittent neuralgia at regular hours. Chionanthus. Sick headache, worse in left eye; pain in abdomen; nausea, and vomiting of dark green bile. The tincture and lower dilutions have been mainly used. Coccnl. The pain is worse after eating, drinking or smoking and at- tended with a sense of emptiness and hollowness of the head. Coffea. When the pain drives to despair and the patient runs wildly about the room. Coloc. Pain, tearing, and screwing together; great restlessness and anxiety, with sweat, which smells like urine; urine scanty and fetid; after chagrin and indignation. Ferrum. Congestion of the brain; throbbing; crimson face, which, at other times, is quite pale and earthy-looking. The pain drives one out of bed. Gelsem. Commences with dimness of sight and double vision; vertigo; heaviness or lightness of head; wild feeling, alternating with uterine pains; worse about 10 a. m., and when lying down; better from shaking head, from sitting and reclining the head on high pillow, from profuse emission of urine. G/onoiti. Congestion of the brain; throbbing, pulsating pain from below upwards, with fullness and feeling of enlargement of the head; it feels like the motion of waves in the brain; congestion of the eyes; ringing in the ears; palpitation of the heart. During pregnancy, before the menses, or when the menses do not appear; from heat of sun. He par. Headache over the eyes pressing down upon the eyes; covers tightly even when hot and perspiring; extremely vehement from slightest cause; could murder any one without hesitation. Ignat. Throbbing pain in the occiput, worse from pressing at stool; from smoking, from the smell of tobacco-smoke; for nervous subjects who get frightened easily, feel hurt easily, etc.; intermittent from 9 a. m. to 2 p. m., worse from washing hands in cold water, bending head forward, stepping heavily; better from soft pressure, lying on back, and heat. Iris vers. Beginning with a blur before the eyes; of hepatic or gastric origin, with nausea and vomiting; mostly on right side, or changing sides in different attacks. THERAPEUTIC HINTS TO CEPHALALGIA. 779 Laches. Temporal nerves of one side painful, with throbbing in the temples; heat in the head; vertigo with paleness of the face; pain in the left ovarian region; bloatedness of the stomach; frontal headache after suppressed coryza. Li I. tigr. Terrible, tearing, crazy pain running from back up into top of head, with a feeling as if she would lose her reason, or would lose her sole when dying. Squeezing feeling about the heart. Melilot. Congestive headache, better from bleeding of nose. Menyan. Pressing pain in forehead and temples from above downwards, relieved by firm pressue with the hand. Natr. micr. Commencing in the morning when getting awake; it gets worse from reading, writing and talking; and is frequently indicated when school-girls, who apply themselves closely to their lessons, get a severe head- ache. Nux vom. Pressive boring, dull pain, mostly over left eye, commenc- ing in the morning, increasing through the day, growing milder in the even- ing, attended with dimness of sight, stoppage of the nose, sour and bitter vomiting, constipation; palpitation of the heart; worse from mental exertion, light and noise, in the open air, after eating; brought on by masturbation, hysteria, with profuse menses, sedentary life, close mental application, abuse of coffee, with haemorrhoidal disposition, constipation, disturbances in the ganglionic system. Phosphor. Intense pain in eyes and whole head, worse in left eye, in forenoon, or from stooping, better while eating, lying down, and after sleep- ing. Bloated face; puffiness under eyes; blue rings around the eyes; pale, hippocratic countenance. Phosph. ac. Dreadful pain on the top of the head, as though the brain were crushed, after long-continued grief. For youths who grow very fast and slender. Platina. Cramping pain, as though the part were in a vise; especially above the root of the nose, with heat and redness of the face, tearful disposi- tion, and too early and profuse menstruation. Pulsat. Tearing, pressing, stitching pain, mostly on right side of head, worse in the evening and at night, in the w T arm room, better from external pressure and in the open air, with aversion to eating and drinking; water tastes bitter; nausea; vomiting; oppression of the chest, and chilliness; mild, yielding disposition; scanty, delayed menses; disposition to looseness of the bowels. Rhus rad. Commencing in the back of the neck, the muscles are sore to touch, it spreads up and over entire head; worse in rest and cold, better on moving and warmth; brought on by cold draught on back and neck, and cold, damp and rainy weather. Sanguin. The pain commences in the back part of the head, rises and spreads over the head, and settles especially above the right eye, with nausea, vomiting and chilliness; the patient is obliged to seek a dark room and to lie 780 digest to cephalalgia. perfectly still; flushes of heat; burning of the soles of the feet; scanty urine at first, later profuse flow of clear urine. Sepia. The pain is jerking upwards, like an electric shock, or boring; worse from motion, better from holding the eyes shut; pale, yellowish, dirty color of the face; white tongue; aversion to food; sour taste after eating; constipation; obstruction of the portal system; leucorrhcea between menses; irregular menses; bearing down of the womb. Silk. Pressing, throbbing pain in the occiput upwards, also from occiput to eyeballs, especially the right one, worse from every quick exertion, pressing to stool, etc., better from getting warm, and after sleep; the pain is attended with a peculiar exaggeration of the mind; when crossed, he has to restrain himself from doing violence; appetite good; while eating the pain is much milder, but grows so much the worse again afterwards; brought on by exposure of the back to any slight draught; better from wrapping the head up warmly. Spigcl. Different sorts of pains, frequently extending into the eye and side of the face, always worse from stooping, slightest motion, concussion, noise and during stool; they are apt to appear at regular hours, either in the forenoon or in the night, and are mostly attended with paleness of the face, palpitation of the heart and oppression of chest. Sulphur. Pain in the forehead and top of the head; heat in the head and coldness of the feet; flying heat in the face; nightly sleeplessness; itch- ing of the skin; suppressed eruptions; looseness of the bowels early in the morning, driving out of bed; haemorrhoids, etc. Thuja. Hemicrania of sycotic origin, mostly worse soon after midnight. " Intermittent from 9 p. m. to 4 or 5 A. M., commencing slightly on crown of head, gradually expanding over whole head, and increasing to an excruciat- ing height, with restlessness, must get out of bed. After the attack paralytic weakness of the legs. Has had thirty years ago an intermittent fever, which was suppressed . " ( Kbck . ) Veratr. Pain very violent, driving one to despair; or prostrating, causing fainting; cold sweat and great thirst; great nausea, vomiting and diarrhoea, or obstinate constipation. Zincum. In chronic cases of cerebral affections; great weakness of sight; stitching pain in the right eye; paleness of face; now and then vomit- ing; fidgetiness of the legs. Digest to Cephalalgia. Beating, throbbing: Arg. nit., Bel lad., Pressive : Arg. nit., Nux vom., Pulsat. Ferrum, Glonoin. Like a hoop around: JEthusa, Anac. , , like waves, from below up- Screwing" together : Arg. nitr., Coloc. wards: (Hanoi n. , as though in a vise: Platina. Boring, om., Silic. drinking: Coccul. coffee: Arg. nitr. smoking: Coccul., Ignat. Morning: Agar., Anac. Forenoon: Phosphor. , 10 o'clock: Gelsem., Natr. mur., St an num. Evening : Amm. carb. and night: Pulsat. After midnight : Thuja. CAUSES. Close mental application: Nux vom. , at school: Calc. phosph. , , girls: Natr. mur. Overwork at desk: Agar. Opera: Cact. grand. Grief: Phos. ac. Chagrin, indignation: Coloc. Cerebral affections : Zincum. Suppressed coryza : Laches. Gastric derangement : Bryon., Iris. , from alcoholic drinks: Ant. crud,, Nux vjm. Hepatic derangement: Arsen., Iris. Masturbation : Nux vom. Before menses, and if they do not ap- pear: Glonoin. , which are profuse: Calc. carb. During pregnancy : Glonoin. Nursing and after loss of fluids: China. Heat of sun: Camphora, Glonoin. Bathing: Ant. crud. Draft on back and neck: Rhus rad. Silic. Change of weather: Calc. phosph. Damp, rainy weather: Rhus rad. Sycosis : Thuja. Syphilis: Aur. met. Suppressed intermittent fever: Thuja. eruptions: Calc. carb., Sulphur. Mercurial poisoning : Aur. met. Full-blooded persons: Aeon. Youths, growing very fast: Phosph. ac. Nervous persons who get easily fright- ened, or feel easily hurt: Ignat. ATTENDING SYMPTOMS. Loss of memory : Anac. Wild feeling, alternating with uterine pains: Gelsem. Feeling as if going crazv, Aeon., Calc. carb. she would lose her reason: Lit. tigr. she must die: Arsen. Inclination to weep: Amm. carb., Aur. met., Plalina. Longing to die : Aur. met. Laughing and crying alternately: Aur. met. Runs wildly about the room: Coffea. Melancholy, dejected: Aur. met. , would lose her soul when dying: Li I. tigr. Anxiety: Amm. carb., Coloc. and restlessness: sEthusa. Despair: Aeon., Coffea, Veratr. , almost driven to suicide: Aur. met. Mild, yielding disposition: Pulsat. Irritable, cross, angry: Bryon. Has to restrain himself from doing vio- lence: Silic. Could murder anyone without hesita- tion: Hepar. Vertigo: Arg. nitr., Bellad., Gelsem. , inclines the patient to reel to the one or the other side: Arg. nitr. , obliges to lie down: Aran. diad. DIGEST TO CEPHALALGIA. 783 , and paleness of face: Laches. Congestion: Aeon., Bel/ad., Glonoin. Heat: Laches. and cold feet: Sulphur. Cold feeling in some part of head, or in whole head: Calc. card. Feeling of enlargement: Glonoin. as if head were bloated and swollen: Aran. diad. Feeling of emptiness and hollowness of head: Goccul. Heaviness or lightness of head: Gelsem. Swelling of cranial bones, with boring: Aur. met. Sensitiveness of head to open air: Arsen. Sensitive smell : Aur. 7net. Eyes appear protruded: sEthusa. congested: Glonoin. Blue rings around the eyes: Phosphor. Stitching pain in right eye: Zincum. Weakness of sight: Zincum. Dimness before eyes: Arg. ?iilr. Objects appear smaller than the'y are: Platina. Fiery sparks before eyes: Aur. met. Flimmering, flickering before eyes: Aran., Arnica. Ringing in ears: Arg. nitr., Glonoin. Roaring: Aur. met. Pllfnness under the eyes: Phosphor. Face bloated: Phosphor. and shining: Aur. met. and pale: Amm. carb. pale: A^thusa, Bellad., Sepia, Spigel., Zincum. , yellowish-dirty: Sepia. , hippocratic countenance: Phos- phor. on affected side: Amy I nitr. crimson during pain, at other times pale and earthy: Ferrum. , heat and redness: Platina. , flying in: Sulphur. Nose dry: Cact. grand. stopped up: Nux vom. bleeding: Agar. , fluent coryza: Anac. , sharp, burning water from: Amm. carb. , thick, mucous discharge Agar. from ; Loss of taste : Anac. Taste sour after eating: Sepia. , bitter, of water: Pulsat. Aversion to eating and drinking: Pulsat. , Sepia. Appetite good: Silk. Thirst: Amm. carb., Bryon. , great, and cold sweat: Veratr. Dry feeling in mouth, without thirst: Bryon., Pulsat. Tongue coated, thick white: Ant. crud., Bryon. white: Sepia. Nausea, vomiting: Arg. nitr . Lpec, Pulsat., Sanguin., Veratr. Vomiting now and then: Zincum. at its height: ASthusa, Arg. nitr. bitter, sour: Nux vom. Belching, hiccoughing: A^thusa. Stomach, pain for several days: AEthusa. bloated: Laches. relaxed, as though hanging down loosely: Arg. nitr. Diarrhoea: AS thusa, Pulsat., Veratr. early in morning, driving out of bed: Sulphur. early in morning: Bryon. Constipation : Bryon., Nux vom., Sepia Veratr. Obstruction of portal system: Sepia. Haemorrhoids : Sulphur. Urine scanty and fetid: Coloc. at first, later profuse and clear: Sanguin. Pain in left ovarian region: Laches. Bearing down of womb: Sepia. Menses scanty, delayed: Pulsat. too early and profuse: Platina. irregular and leucorrhcea between: Sepia. Oppression of chest: Pulsat., Spigel. Squeezed feeling about the heart: Lit. tigr. Palpitation of heart: Glonoin., Nux vom., Spigel Throbbing of carotid arteries: Bellad. Paralytic weakne?s of legs after attack : Thuja. Fidgety of legs: Zincum. Burning of soles of feet: Sanguin. 784 NEURALGIA OK THE TRIGEMINUS. Icy coldness of whole body: Camphor a. Covers tightly, even when hot and per- Coldness internally, with heat ex- spiring: Hepar. ternally: Anac. Cold, sweaty hands and feet: Calc. card. Itching of skin, sleepless: Sulphur. Chilliness: Arsen., Pulsate Sanguin. Restlessness: Arsen., Coloc. y Thuja. Flushes of heat: Sanguin. Debility, prostration: Arsen. Perspiration cold: Camphora, Veratr. , , compelling to lie down: A mm. sonr: Arnica. card. smells like urine: Coloc. , , causing fainting: Veratr. during day and in morning, about Trembling" of the whole body: Agr. nitr. joints: Amm. carb. Hysterical spasms: Aur. met. Perspiration of palms of hands: A nac Neuralgia of the Trigeminus or Fifth Nerve, Prosopalgia, Neu- ralgia, Neuralgia Facialis, Dolor Faciei Fothergilli Tic douleureux. It attacks one or the other branch of the trigeminus, sometimes the n. supraorbitalis or infraorbitalis, 11. facialis, 11. inframaxillaris, and, therefore, some authors speak of a neuralgia supraorbitalis, neuralgia infraorbitalis, etc. The affection is almost always confined to one side; rarely does, it at- tack both sides, but there appears to be no difference in favor of one or the other side. An extension from one side to the other has bee^n occasionally observed. The pain is generally spoken of by the patient as indescribable, excru- ciating, coming on in paroxysms of shorter or longer duration, sometimes irradiating into the back part of the head and neck, down into the shoulder, intercostal spaces, breast and even the lower extremities. We likewise find the motor}" nerves affected, causing jerking of differ- ent muscles of the face, spasmodic closing of the eyelids, bending of the body double, trembling of the whole body, etc. We also find the vaso- motor nerves affected, causing pulsation of the arteries, swelling of the veins, redness, or paleness, and heat of the face. The whole affected side of the face assumes a different expression, becomes shining, glistening, greasy, sometimes appearing puffed and at other times emaciated. When the ramus ophthalmicus is affected, we observe a redening of the conjunctiva and flowing of tears; if, at the same time, the second branch is also affected, we observe a water}- and slimy discharge from the nose; and when the second and third branches suffer, it is often attended with a flow of saliva. Sometimes there has been observed a partial sweat in the face during the paroxysm; the hair of the affected side grows brittle and splits, or falls out. Therapeutic Hints. Aeon. Cheeks red and hot; the patient seems besides himself for pain, screams and rolls about in the bed or on the floor. Allium cepa. "Pain violent and continuous: chronic neuritis, which is wearing the patient out." (Gilchrist.) THERAPEUTIC HINTS TO NEURALGIA OF THE TRIGEMINUS. 785 Arg. nitr. during the paroxysms, unpleasant, sour taste in the mouth. Wolf mentions Arg. nitr. as of general importance in this complaint. Asaf. " Hysterical restlessness and anxiety; sensation of numbness of bones of face; twitching and jerking in muscles, worse in afternoon; better in open air. Leftside." (Gilchrist.) Arseyi. Burning, stinging pain, as of red-hot needles, worse about midnight; face pale and distorted; puffed around the eyes; great restlessness; ameliorated by external warmth; typical paroxysms of a miasmatic orgin. Bellad. Cutting, tearing pain, shooting from the side of the face up into the temples, into the ear, and down into the nape of the neck; worse from touch and motion; hard pressure sometimes relieves; the paroxysms mostly occur in the afternoon; come and go suddenly; the face is generally flushed; the eyes water and the muscles of the face twitch; the patient cannot bear light or noise; the right side is the most fre- quently affected; after the abuse of mercury. Bismuth nitr. The most excruciating pains are somewhat relieved by taking cold water into the mouth and walking briskly about. Calc. carb. Pain from the right mental foramen along lower jaw to ear* attended with frequent urination; worse from cold air; better from warm air and warm applications. Caustic. Right side, from the cheek-bone to the mastoid process, worse at night; better from rubbing with a cloth dipped in cold water; chilliness; scanty menses. Cedron. " Unerring periodicity to the hour." (Gilchrist.) Chamom. The pain causes hot perspiration about the head, and ex- torts screams; the patient is wild and unruly, tossing and rolling about; menses unusually profuse. China. The pain is in the infraorbital and mixillary nerves, worse from the least touch, lying down, and in the night; great weakness after the par- oxysm. Chin, sulph. The paroxysms set in at the same hour every day; the in- tervals are free of pain, and there is no complication with gastric or other derangements. Cimicif. Especially when the neuralgia is a reflex pain dependent upon ovarian disturbances. "Pain in left jaw, in lower jaw, lower teeth and articulation of lower jaw; pain in right superior maxillary bone and teeth; heat in one side of face, with lassitude all over." (Gilchrist.) Coloc. Tensive tearing with heat and swelling, especially left side, also right side; motion and touch increase the pain; better in perfect rest, and from external application of warmth; brought on by chagrin and indigna- tion. Ferrum. During the paroxysms the face gets fiery red, sometimes only in one spot; cannot keep the head quiet, at the intervals the face looks earthy and pale. Gelsem. Orbital neuralgia in distinct parox}^sms of acute pain, accom- 50 786 THERAPEUTIC HINTS TO NEURALGIA OF THE TRIGEMINUS. panied with contractions and twitching of the muscles near the portion of the face affected; with extreme general nervousness and loss of control over the voluntary muscles, giving rise to odd, irregular motions. Hcpar. In chronic cases; the pain streaks from the cheek-bone into the temple, ear, alae nasi and upper lip of the affected side; it is worse in the fresh air, and better from wrapping up the face; at the same time coryza, hoarseness, much sweating and rheumatic pains elsewhere; especially after the abuse of mercurj^ or metallic preparations. Iris. Pain in the head, temples and eyes, attended with most distress- ing vomiting of a sweetish mucus, and occasionally (if attended by much straining) of some bile. Laches. Left side, orbital neuralgia; lachrymation; previous to the paroxysm rising of heat to the head; during the intervals a weak, nauseous feeling in the abdomen. Waking out of sleep the eyes feel as though they had been taken out and squeezed, and then put back again; malarial affec- tions. Magn. carb. Left or right side; shooting like lightning; worse from touch, draught, change of temperature; cannot stay in bed, must walk the floor. Mag7i. phosph. Supraorbital and infraorbital nerves pain at intervals and relieved by external warmth. Mercur. Tearing pains, worse at night in bed; it often starts from a decayed tooth and involves the whole side of the face, which may be red and swollen; profuse secretion of saliva; constant inclination to perspire; restless- ness and sleeplessness. Brought on by taking cold. Mezer. Ciliary neuralgia, especially after operations on the eye; pro- sopalgia, left-sided, from over the eye to the eyeball, cheek, teeth, neck and shoulder; lachrymation; conjunctiva injected; parts sensitive to touch; worse from warmth; periodical from 9 A. m., increasing to 12 m., and decreas- ing gradually until 4 p. m., leaving the patient perfectly free from pain. Also boring, pressive pains, coming like lightning, which leave the parts numb; they are worse from eating warm food, also from entering a warm room after walking in the fresh air; they are attended with chilliness and shuddering; twitching of the muscles of the affected parts, flow of saliva, redness of the fauces, burning in the throat, stiffness of the masseters, red spots on the nape of the neck, and formication in the skin of the chest; after the abuse of mercury, or in syphilitic patients. Natr. ?nur. Pain in the malar bones, worse when chewing; falling off of the whiskers; intermittent prosopalgia; after the abuse of quinine. Nux vom. Tearing pain in the course of the infraorbital and middle branch of the trigeminus, with redness and watering of the eye; flow of clear water from the nostrils and numbness of the affected side; the patient is morose, irritable, belches a great deal and is constipated; after the abuse of coffee, liquors, quinine, etc.; also intermittent prosopalgia, worse from noise, motion, cold air; better in a warm room, at rest and lying down. THERAPEUTIC HINTS TO NEURALGIA OF THE TRIGEMINUS. 787 Phosphor. Drawing and tearing pain in the jaws, root of the nose, eyes and temples, worse from slightest movement and touch, cannot speak nor eat, attended with bloatedness of the face, congestion of the head, tearing on the top of the head, vertigo, and ringing in the ears; from taking cold over the wash-tub. Platina. Boring-pain, cramp-like; painful feeling of numbness in the malar bones and the mastoid processes and chin, as if the parts w 7 ere between screws, attended with anxiety, w r eeping and palpitation of the heart; profuse menses. Pulsat. Twitching, tearing pain, worse in the evening and in a warm room; in persons of a mild, tearful disposition, and phlegmatic temperament; inclination to looseness of the bowels; scant} 7 menses; after getting the feet wet; after the abuse of quinine. Rhodod. Right side; by w T ind and changes of weather, better from w r armth, and relieved while eating and for some time after. Rims fox. Drawing, burning, tearing pain in the face, and a feeling as though the teeth w r ere too long, attended with great restlessness, necessity to move about; relieved somewhat by the external application of cold; dysenteric stools, with jelly-like evacuations; after exposure to rain. Saiiguin. In upper jaw extending to nose, eye, ear, neck and side of head; shooting, burning pains; kneel down and hold head tightly to the floor. (Hering. ) Sassap. Quickly, lightning-like changing pains, over leaping to differ- ent localities. Heyer — Allg. H. Z. Bd., 115, p. 30. Sepia. Intermittent prosopalgia, with congestion of eyes and head; also during pregnancy; jerking, like electric shocks, upwards. Spigel. Tearing, shooting, jerking or burning pain in all directions, suddenly coming and going, attended with dark redness of the affected side; flow of water from the eyes and nose; twitching of the muscles in the face; difficulty of breathing; palpitation of the heart; rheumatic pains elsewhere; w T orse in damp weather, from touch and motion; after suppressed inter- mittents. Sta?mum. Intermittent supraorbital neuralgia from 10 A. m. to 3 or 4 p. m., gradually increasing until attaining its acme, and then again de- creasing as gradually; after abuse of quinine. Staphis, The pain starts from the decayed tooth; is worse from slight and better from heavy pressure; it is attended with swelling of the gums, cold sweat in the face and cold hands. Stramo7i. Prosopalgia, with many nervous symptoms; spasms of the chest hindering breathing; swooning; weeping; twitching of the muscles of the face; frowning; jerks through the whole body; delirious talk, with open eyes. Sulphur. Intermittent periodic neuralgia every twenty-four hours, worse generally at 12 m. or 12 p. m., or midsummer or midwinter; chronic cases, when other remedies relieve, but do not cure; psoric tendency; scanty, black, tarry menstrual discharges. 788 DIGEST TO NEURALGIA OF THE FACE. Thuja. After suppressed gonorrhoea or eczema on the ear; worse after midnight. Veratr.. Drawing, tearing pain, attended with bluish paleness of the face; sunken eyes; coldness of the extremities; trembling and jerking; cold perspiration; great exhaustion; nausea and vomiting. Verbasc. Violent pain, jerking like lightning, or pressive, numbing; aggravated by pressure, sneezing, talking, chewing or a draught of air; ap- pears at the same hour every day, n a. m. till 4 p. m., and is attended with headache, redness of the face, vertigo, belching, and a discharge of tough saliva from the mouth. Zincum, Burning, quick stitches, and jerking along the course of the infraorbital nerve, right side, attended with bluish eyelids; numbness of the tongue; constricted sensation of the throat; worse from the slightest touch and in the evening. Digest to Neuralgia of the Face. NATURE OF PAIN. Boring". Mezer. y Platina. Burning: Arsen., Rhus tox., Sanguin., Zincuin. Cramp-like: Platina. Cutting: Bellad. Drawing: Phosphor., Rhus tox,, Veratr. Jerking: Sepia, Spigel., Verbasc., Zin- cum. Lightning-like: Magn. carb., Mezer., Verbasc. jumping (changing) quickly, loca- tion from head to back, etc., and back again: Sassap. (Heyer.) Like electric shock upwards: Sepia. Numbness in malar bones and mastoid process and chin, as if the parts were between screws: Platina. Pressive : Mezer. and numbing: Verbasc. Shooting : Bellad. Stinging, as of red-hot needles, worse about midnight: Arsen. Stitches along the course of right infra- orbital nerve: Zincuin. Tearing: Bellad., Mercur., Rhus tox., Spigel., Veratr. in the course of the infraorbital and middle branch of the trigeminus: Xitx vom. in jaws, root of nose, eyes and tem- ples: Phosphor. Tensive tearing, with heat and swelling, left side: Coloc. Twitching, tearing: Pulsat. Violent and continuous: Cepa. LOCATION AND DIRECTION OF PAIN. Ciliary, after operations on eye: Mezer. Orbital : Gelsem. , left side: Laches. From over the eye to eyeball, cheek, teeth, neck and shoulder: Mezer. Supra and infraorbital: Magn. phosph. Supraorbital: Stannum. Infraorbital and middle branch of tri- geminus: Nux vom. and maxillary: China. , right side: Zincum. Cheek-bone to mastoid process, right side: Caustic. and chin: Platina. Maxillary, superior: Natr. mur. , , and teeth: Chnic. , , to nose, eye, ear, neck and side of head: Sanguin. , , to temple, nose and upper lip: Hepar. Temples and eyes: Iris vers. Jaws, root of nose, eyes and temples: Phosphor. Right mental foramen along lower jaw to ear: Calc. carb. Left under-jaw, lower teeth, and articu- lation of lower jaw: Cimic. From decayed tooth : Staphis. , whole side of face red and swollen: Mercur. DIGEST TO NEURALGIA OF THE FACE. 789 Prom side of face into temple, ear, down nape of neck: Bellad. Right side: Bellad., Caustic, Coloc, Rh odod. , Zin cu m . Left side: Asa/., Coloc, Laches., Mezer. Right or left : Magn. card. PERIODICITY. Intermittent: Arsen., Gelsem., Magn. phosph., Natr. mur., Nux vom., Sepia. , at regular hours: Cedron., Chin. sul ph. Intermittent, from 9 a. m. to 4 p. m. ; Mezer. , from 10 a. m. to 3 or 4 p. m. : Stan- num. , from 11 a. m. to 4 p. m.: Verbasc. , 12 noon or 12 midnight: Sulphur. , afternoon: Asa/., Bellad. , after midnight: Thuja. Spells come and go suddenly: Bellad., Spigel. , gradually increasing to highest pitch and then again decreasing as gradually: Mezer. , St a nnum. AMELIORATION. External warmth: Arsen., Calc carb., Coloc, Magn. phosph., Rhodod. Warm room: Calc carb., Nux vom. Wrapping" up face: Hepar. In open air: Asa/., Pulsat. External application of cold: Rhus tox. Taking cold water in the mouth: Bism. nitr. Heavy, hard pressure: Bellad., Staphis. Rubbing with cold water: Caustic Moving head: Ferrum. Walking the floor: Magn. carb. Walking briskly about: Bism. nitr. Kneeling down and holding head tightly to floor: Sanguin. Rest: Coloc, Nux vom. While eating and for some time after: Rhodod. AGGRAVATION. Warmth: Mezer. Warm room: Pulsat. , after walking in fresh air: Mezer. Warm food: Mezer. Cold air: Calc carb., Hepar, Nux vom. Draught of air: Verbasc, Magn. carb. Change of temperature: Magn. carb. of weather: Rhodod. Damp weather: Spigel. Midsummer and midwinter: Sulphur. Evening: Pulsat., Zincum. Night: Caustic, China , in bed: Mercur. Touch: Bellad., Magn. carb., Spigel., Verbasc. , slightest: China, Mezer., Phosphor., Staphis., Zincum. Motion: Bellad. , Coloc , Nux vom.,- Phos- phor., Spigel. Talking: Verbasc Chewing: Natr. mur., Verbasc. Cannot speak nor eat: Phosphor. Lying down: China. Cannot stay in bed, must walk the floor: Magn. carb. keep head still: Ferrum. After sleep: Laches. CAUSES. Chronic neuritis: Cepa. Pregnancy: Sepia. Suppressed intermittents: Spigel. Malaria: Arsen., Laches. Taking cold: Mercur. , over wash-tub: Phosphor. Getting wet: Rhus tox. of the feet: Pulsat. Abuse of quinine: Natr. mur., Nux vom., Pulsat., Stannum. coffee, liquors: Nux vom. mercury: Bellad., Hepar., Mezer. Syphilis: Mezer. Suppressed gonorrhcea, or eczema on the ear: Thuja. Chagrin and indignation: Coloc. Chronic cases, when other remedies fail: Sulphur. ATTENDING SYMPTOMS. Swooning: Stamon. Delirious talk with open eyes: Stamon. Wild, unruly, tossing and rolling about: Chamom. Beside himself, screaming, rolling about: Aeon. Weeping: Platina, Stramon. Frowning: Stramon. Anxiety: Asa/., Platina. Tearful, mild disposition: Pulsat. Morose, irritable: Nux vom. Vertigo: Phosphor., Verbasc. 79Q CERVICO-OCCIPITAL NEURALGIA. Headache: Verbose. Heat in head before spell: Laches. Congestion of head: Phosphor., Sepia. Tearing on top of head: Phosphor. Hot perspiration about the head: Cha- Congestion of eyes: Sepia. Conjunctiva injected: Mezer. Redness and watering of eves: Nux vom. Bluish eyelids: Zincum. Lachrymation: Laches., Mezer. Flow of water from eyes and nose: Spigel. , and twitching of muscles of face: Bell ad. Sunken eyes: Veratr. Light and noise unbearable: Bel lad. Ringing in ears: Phosphor. Flow of water from nose: Nux vom., Spigel, Coryza: Hepar. Face, cold sweat in: Staphis. , bluish pale: Veratr. , pale and distorted: Arsen. , bloated: Phosphor. , puffed around the eyes: Arsen . , flushed: Bel I ad. , red: Verbasc. , dark red on affected side: Spigel. , fiery red, sometimes only in one spot; during intervals earthy and pale: Ferrum. , hot on one side: Cimic. , red and hot: Aeon. , numbness of affected parts: Asa/., Mezer., Nux vom., Platina. Twitching of muscles: Asa/., Bel lad., Gelsem., Mezer., Spigel., Str anion. Stiffness of masseters: Mezer. Falling off of whiskers: Natr. mur. Mouth, sour taste in: Arg. nitr. Flow of saliva: Mercur., Mezer base. \ 'er Swelling of gums: Staphis. Teeth feel as if too long: Rhus tox. Numbness of tongue: Zincum. Fauces red, burning in throat: Mezer. Constricted sensation of throat: Zin- cum. Hoarseness: Hepar. Red spots on nape of neck: Mezer. Belching: Nux vom. Nausea and vomiting: / 'eratr. Vomiting of a sweetish mucus, or bile : Iris. Nauseous feeling in abdomen: Laches. Constipation: Nux vom. Dysenteric stools, jelly-like: Rhus tox. Looseness of bowels: Pulsat. Frequent micturition: Calc carb. Menses scanty: Caustic, Pulsat. , black and tarry: Sulphur. profuse: Chamom., Platina. Neuralgia is a reflex from ovarian troubles: Cimic. Breathing difficult: Spigel., Stramon. Palpitation of heart: Platina., Spigel. Formication in skin of chest: Mezer. Chilliness: Caustic, Mezer. Coldness of extremities: Veratr. Cold perspiration: Veratr. in face and cold hands: Staphis, Inclination to perspire: Mercur. Much sweating: Hepar. Restlessness: Arsen. , must move about: Rhus tox. and sleeplessness: Mercur. General nervousness: Gelsem. Lassitude all over: Cimic Weakness after paroxysm: China. Rheumatic pains elsewhere: Hepar., Spigel. Jerks through the body: Stramon. Trembling and jerking: Veratr. LOSS of control over muscles, with odd, irregular motions: Gelsem. Cervico-Occipital Neuralgia. Its seat is in the region of distribution of the sensory fibres of the upper four spinal nerves, most frequently only on one side, extending, therefore, over the upper part of the nape of the neck and occiput, over the lateral CERVICO-BRACHIAL NEURALGIA. 79 1 region of the head, and in front towards the lower jaw. The occipitalis major frequently shows painful spots, one about half way between the mastoid process and the upper cervical spinous processes (occipital point), and the parietal point over the parietal eminence. Of the other nerves im- plicated such points can rarely be demonstrated. Compare Aeon., Be/lad., Calc. card., Caustic, Ignat., Kalmia lat., Laches., Nux vom., Pulsat., Rhus tox., Spigel., Sulphur. Cervico-Brachial Neuralgia Extends over the region of distribution of the four lower cervical nerves and a part of the first dorsal nerve, and may affect the back of the neck, the up- per, or the lower arm, even the hand and fingers. The painful points are nu- merous, but somewhat indefinite; they may be found: "over the brachial plexus from the axilla outwards; at the lower angle of the scapula; on the posterior surface of the shoulder; on the median at the elbow; at the emer- gence of the cutaneous medius and lateralis from the fascia of the forearm; on the ulnar above the internal condyle, and at the wrist; on the radial nerve where it winds around the humerus, and above the wrist, on the spinous pro- cesses of the four lower cervical, and two or three upper dorsal vertebrae, and at their sides where the posterior branches appear under the skin." (Erb.) Compare Aeon., Arnica, Arsen., China, Ferrum, Graphit., Ignat., Ly- cop., Phosphor., Rhus tox., Sepia, Staphis., Sulphur, Vetatr. Intercostal Neuralgia Has its seat in the region of distribution of the dorsal nerves, and not unfre- quently affects both sides of the chest, but most frequently the left side only between the fifth and ninth intercostal spaces. There is a feeling of tension, as though the patient were tightly bound around the chest, and occasional shooting pains in the direction of the intercostal nerves are occasioned by taking a long breath, by coughing, sneezing, sighing, or certain motions of the body; by pressure of the clothing or a slight touch, which generally is relived again by hard pressure. The painful points are in the region near the spinous process of the ver- tebrae, where the dorsal nerves emerge from the spine (vertebral points) ; in the middle portion of these nerves, where the ramus perforans lateralis emerges beneath the skin (lateral point); in the region close to the sternum, and in the abdomen over the rectus muscle (sternal and anterior point). Differential Diagnosis. — Pleurisy differs by its friction sound and fever. Angina pectoris by its fits of suffocation. ■Rheumatism of the muscles of the chest by its more general diffusion over the chest and its aggravation by slightest movement. 792 LUMBO- ABDOMINAL NEURALGIA. Compare Arnica, Arsen., Borax, Bryon., Calc. carb., Card, veg., Caus- tic, China, Cimic, Mercur., Rhus tox., Sepia, Spigel., Sulphur. After shingles: Mezcr., Secale corn. Lumbo- Abdominal Neuralgia Has its seat in the region of distribution of the lumbar nerves, and consists of pain in the lumbar region and on the abdomen, which is easily excited by raising a fold of the abdominal skin, or by touching it slightly, and by press- ure upon the region near the lumbar vertebrae. Frequently we find associ- ated with it a pain in different places of the crest of the ileum and on the seat; and also pain which extends from the inguinal region to the symphysis pubis and down into the scrotum or into the labia majora, which are refer- able to the superficial branches of the lumbar nerves. Its painful points are: " one or several in the lumbar region near the spinal column (lumbar point); one about the middle of the cresta ilii (iliac point) ; one or several above the symphysis pubis, at the side of the linea alba (abdominal point); not unfrequently one in the scrotum or labium ma jus; and lastly, and less constantly, one in the inguinal region or in the portio vaginalis uteri, or in the corresponding side of the vault of the vagina." (Erb.) Compare Argeiit., Bellad., Chi?ia, Kalmia /at., Nux vom., Put sat., Rhus tox., Spigel., Staphis., Sulphur. Mastodynia, Neuralgia of the Mammae. Its seat is in the mammary glands, which are supplied chiefly from branches of the intercostal nerves. The breast becomes very painful, often without any visible change in its structure. In some cases, however, small tumors (neuromata) have been observed, which appear to be the starting- points of the neuralgia, and they either disappear soon or remain unaltered for years. The pain radiates sometimes into the axillae, into the back and down into the hips, and may be attended with vomiting. Lying on the affected side is impossible. Painful points may be found on the nipples or on the sides of the breast, or on the spinous processes of the second, third, fourth, fifth and sixth dorsal vertebrae. Mastodynia seems mostly connected with irregularities of menstruation, at which time it is generally the worst. But also lactation, external injury, anaemia, chlorosis and hysteria are counted among its causes. Its most frequent occurrence seems to be be- tween the ages of sixteen and thirty. Therapeutic Hints. Painfulness of the mammae before or during menstruation: Arge?it., Calad., Calc. card., Canthar., Cimitif., Conium, Kali card., Murex purp., Nitr. ac, Rhus tox., Tabac. During the nursing of the child: Crot. ligl., Ferrum, Phcll. aquat., Phosphor., Silic. SCIATICA, NEURALGIA ISCHIADICA. 793 Sciatica, Neuralgia Ischiadica, Ischias postica, Malum Cotunnii. Its seat is in the sciatic nerve, though not always in its entire length. Most frequently we find the pain extending from the nates down the posterior part of the thigh to the bend of the knee, down along the fibula to the ex- ternal ankle, heel and external portion of the foot; the internal border of the foot is exempt ; sometimes the pain is felt only in the sole of the foot (neuralgia plantaris), and seldom in the dorsum of the foot and toes. In rare cases both extremities are affected at the same time. The pain generally commences mildly and gradually grow T s worse; sometimes it is paroyxsmal, generally worse towards evening and in the night, sometimes only during the day. Slight touch aggravates or provokes the pain, while a hard pressure sometimes gives relief. With some the pain is ameliorated by moving about constantly, while others cannot bear the slightest motion, so that coughing, sneezing, pressing at stool are almost killing operations to them. Sometimes the pain is attended with a cold sensation in the affected extremity, followed by heat. In other cases we find reflex symptoms of the motory nerves, mani- festing themselves as cramps in the calves of the legs and in the soles of the feet. It has even been observed that during violent paroxysms the heel was drawn up towards the buttock of the affected limb. Painful points are: "a point close to the sacrum, in the immediate vicinity of the posterior superior spine of the ileum ; a point where the sciatic nerve emerges from the pelvis; a point at the lower border of the gluteus, where the posterior cutaneous nerve emerges; a painful line corresponding to the course of the tibial nerve in the popliteal space; a point over the head of the fibula; a point behind the outer ankle-bone and another behind the internal malleolus; several points on the dorsum of the foot, and occasionally points on the posterior surface of the thigh and on the calf of the leg, where the cutaneous branches perforate the fascia." (Brb.) The following Diagnostic sign is mentioned by Beurmann in Arch, de Phys. Norm et Pathol.: ' ' The patient is made to lie in his bed on his back, and is told to allow the affected leg to lie perfectly passive. If now, with the leg fully extended the physician flexes it at the hip, the patient at once expe- riences acute pain, darting along the course of the nerve from the buttock downwards, and which is most severely felt in the neighborhood of the great trochanter. If, however, the leg be first flexed upon the thigh before the thigh is flexed upon the abdomen, it will be found that no such pain results from the movement. It would seem that this pain is due to tension of the sciatic nerve, which with the first of these movements is considerable, but which does not take place with the second. That this hypothesis is correct, Beurmann abundantly proves by various experiments which he conducted on the dead subject. This sign of sciatica appears to possess very considerable diagnostic value, and will probably suffice at once to disinguish sciatica from several conditions which may simulate it, such as crural neuralgia, hip- joint disease, etc." 794 THERAPEUTIC HINTS TO NEURALGIA ISCHIADICA. In regard to its Causes we are very much in the dark. Atmospheric influences, however, such as damp, cold weather, seem to be very apt to bring it on. Therefore w T e find among the exciting causes, getting wet, sleeping on the damp ground or within moist walls, or taking cold in general. Likewise are mentioned direct influences upon the nerves, such as pressure of narrow boots, wounds from blood-letting, carcinoma, aneurisms, pressure of the pregnant uterus, deliveries by the forceps, diseases of the vertebrae and neu- roma. Therapeutic Hints. Aeon. " The pain extended the entire limb, at first dull and dragging, soon becoming acute, tearing, lancinating, darting like lightning along the entire nerve, from above downward, and accompanied hy numbness and tingling. Feet cold with occasional cold sweat. In the toes sharp shooting pains, alternating with numbness and tingling. " (Thos. Xichol.) Arg. nit? . Periodical pain from hip down to knee, with paralytic weak- ness and wasting away of the limb; during paroxysm sensation of expansion in limb; worse morning and noon. Arnica. When caused by overexertion, marching, fracture of limbs, con- finement, etc., with formication and lame feeling; necessity to change the position of the limbs constanthy, because ever} T thing upon which he lies seems too hard. Arsen. The burning pain is attended with anguish and restlessness, and is worse about midnight; brought on \>y staying in cold, damp cellars; it is somewhat relieved by external warm applications; intermittent fever. Bellad. Feverish; inclined to weep; wants to sleep and cannot sleep; pain worse from touch and motion; from least draught of air; from after- noon till midnight; better from letting limb hang down, and after perspiring; from warmth and when in erect position. Bryon. Better during rest and worse on motion. Chamom. Pain excruciating; the patient acts as if beside himself; after anger or vexation. Calc. carb. If caused by working in water; or in case of complication with affections of the spinal bones; the pain starts from the small of the back, extends down into the limbs and keeps them in constant uneasiness. Caustic. Tearing pain on the outer side of left limb from above down, as if the muscles were pinched; constant desire to move the foot. (Maren- zeller. ) Cimicif. Causes many reflex pains in different parts, dependent upon ovarian or uterine irritation. Coffea. Tearing, stitching pain, in irregular spells, worse in the night, with restlessness and sleeplessness. Coloc. Tearing downward, posteriorly, from hip to thigh, leg and foot, left or right side, during the day, not at night; worse from motion and press- ure; must limp when walking, and be careful not to press the limb when sit- THERAPEUTIC HINTS TO NEURALGIA ISCHIADICA. 795 ting; feels best when lying still. During paroxysm sweat and thirst. Eye- lids burn even after sound sleep. After indignation. Dioscorca. Pain in right leg, worse on motion; entire relief when lying still. (W. J. Martin.) Ferrum. Remitting pains; worse in the night, driving out of bed; al- though at first scarcely able to stand upon the affected limb, by continued motion and walking about, the pain gradually becomes milder; pain in the left shoulder; the face is pale, emaciated, but flushes easily. Gnaphal. Intense pain along the sciatic nerve, which is continued to its larger ramifications; feeling of numbness, occasionally taking the place of the sciatic pains, and then exercise on foot is excessively fatiguing. Hepar. The pain is worse from motion, touch and exposure to air; better from being wrapped up and keeping quiet. Ignat. Throbbing pain in the hip, as though the joint would burst; in- termittent, at first every other day — later, daily, attended with chilliness and thirst, followed by heat without thirst; disappearing during the summer season and reappearing in the winter. Iris vers. Burning and sudden shooting down the limb, causing lame- ness; worse from moderate, not altered by violent motion. Kali bichr. Pain relieved by walking and flexing the leg; worse from standing, stitting or lying in bed. Kali hydr. Nightly tearing in right thigh and knee, worse lying on affected side; abuse of mercury; syphilitic taint. Laches. Pain constantly changing locality, now in the head, now in teeth, now in the sciatic nerve, attended with nervousness, palpitation of the heart; burning like fire in the hypogastrium, lumbar region and behind the sternum; flushes of heat; suppressed menses; constipation. Ledwn. Laming pain in the hip-joint, worse in bed, when getting warm; the affected limb is cooler than the remainder of the body; general coldness and chilliness. The pain frequently commences below and ascends. Great tenderness of the soles of the feet. Lycop. Pain in the hip, stiffness and weakness, and formication of the affected limb; cold feet; incarcerated flatulence and constipation; urine high colored, turbid, or depositing a red, sandy sediment. Menyanth. The pain is of a crampy nature, and when sitting, the limbs are jerked upwards spasmodically. Mertur. Drawing, tearing pain, worse at night in bed; restlessness; great inclination to sweat, without any relief; syphilitic taint. Mezer. Drawing pain through the affected limb, with sensation of in- ternal heat in the limb by external coolness of the skin; worse from touch and motion, in evening and at night; better in the open air. Natr. mur. Chronic cases with contraction of hamstrings; intermittent; abuse of quinine. Nux vom. The pain is drawing, tearing, from below upwards, better from hot water application; constipation; during stool, great pain along the 796 DIGEST TO SCIATICA. affected limb down into the foot; sedentary life; alcoholic drinks; previous use of all sorts of liniments, etc. 1 Plumbum. Drawing, pressive pains in the sciatic nerve in the posterior part of the thigh, down to knee, with difficult walking and great exhaustion after walking; tubercular diathesis, with dry hacking cough. Phytol. Neuralgic pain on the outer side of the thigh; right side; press- ing and shooting, drawing and aching; worse from motion and pressure, and worse in the night; syphilitic taint. Pulsat. Pain getting worse towards evening and in the night with in- clination to constantly change position; worse in warm room; better in open air. Rhus tox. The pain is attended with numbness, formication, paralytic stiffness of the affected limb; it is worse during rest, and when commencing to move; better from dry heat; it is mostly brought on by exposure to wot, by straining and lifting. Ruta. Pain as if in the bones, worse in rest, must constantly be mov- ing about during the paroxysm; hamstrings feel shortened; after injuries, contusions, etc. Sepia. During pregnancy, pain in paroxysms from three to five o'clock a. m., with considerabe swelling of the veins of the affected limb; also in chronic cases, w T hen the pain localizes itself in the heel of the affected limb; better during rest. Stilli?ig. Left side; syphilitic and gonorrhceal origin, Sulphur. In chronic cases, when all other remedies fail; after the sup- pression of tetters. Tellur. Worse when lying on the affected side. Vale?\ The pain is unendurable while standing, with a feeling as if the thigh would break off. Zinc. ox. Pain in the small of back at night, on turning in bed; feeling of lameness extending to hips; bruised pain especially in left lower limb, or in hip and knee; painful tension of muscles when moving; pulsation and buzzing in ears. (F. W. Payne.) Digest to Sciatica. PAIN. Excruciating.' Ghamom. Aching": Phytol. Formication: Arnica, Ly rop., Rhus tox. As if in the bones : Ruta. Lame feeling": Arnica., Ledum, Zinc. Bruised : Ztnc. ox. ox. Burning: Iris. Intense, changing with numbness: Gra- , with anguish and restlessness: phit. Arscn. Numbness : Aeon., Rhus tox. Crampy ; Menyanth. Intermittent, periodical, remittent: , with stiffness in hip and ham: Arg. nitr., Arsen., Ferrum., /gnat., Bellad. Natr. mur., Sepia. Drawing: Mercur., Mezer., Nux vom.. Irregular spells : Coffea. Plumbum, Phytol. Pressive : Plumbum, Phytol. Dragging: Aeon, Shooting: Iris, Plumbum. DIGEST TO SCIATICA. 797 , like lightning downwards: Aeon. Stiffness and weakness: Lycop. Stitching: Coffea. Tearing: Aeon., Caustic, Coffea, Coloc., Kali hydr., Mereur., Nux vom. Tingling: Aeon. Throbbing, as though joint would burst: Ignat. LOCATION AND DIRECTION. Right side: Calc. earb., Diosc., Kali hydr., Phytol., Tellur. Leftside: Bellad., Calc. card., Caustic, Stilling: , lower limb, or in hip and knee: Zinc. ox. Hip-joint: Ignat., Ledum. Lycop. Hamstrings feel shortened: Ruta. Outer side of thigh: Phytol. Heel: Sepia. Changing locality, now in head, now in teeth, now in sciatic nerve: Laches. Down the limbs: Aeon., Graph it., Iris vers. , outer side of left limb: Caus- tic. from the small of back, keep- ing them in constant motion: Calc. earb. From hip down to foot: Coloc, Nux vom. to knee: Arg. nitr. , on posterior part: Plumbum. From below upwards: Ledum, Nux vom., Zinc. ox. Lame feeling extending to hips: Zinc, ox. BETTER. During rest: Bryon., Sepia, Hepar. When lying still: Coloc , entirely relieved: Diosc. When letting limb hang down: Bellad. When walking : Bellad., Ferrum, Kali bichr., Rhus tox. When flexing the leg: Kali bichr. Constant desire to change position: Pulsat. to move the feet: Caustic, Zincum. Warm applications: Arsen. Hot water application: Nux vom. Dry heat: Rhus tox. Wrapping up: Hepar. From warmth: Bellad. In summer : Ignat. In open air: Mezer., Pulsat. After perspiring: Bellad. WORSE. Morning and noon: Arg. nitr. During day only: Coloc Evening and night: Mezer., Pulsat. Afternoon until midnight: Bellad. Night: Coffea, Kali hydr., Mereur., Phy- tol., Zinc ox. , driving out of bed: Ferrum. Midnight: Arsen. 3 to 5 A. M. : Sepia. Getting warm: Ledum. In warm room: Pulsat. In bed: Ledum., Mereur., Kali bichr. Driving out of bed: Ferrum. Least draught of air: Bellad. Exposure to air: Hepar. In winter: Ignat. In rest: Rhus tox. Must change position, couch feels too hard: Arnica. Must constantly be moving: Rhus tox., Ruta. In lying on affected side: Kali hydr., Tellur. While sitting: Bellad., Kali bichr. , must be careful not to press the limb: Coloc. While standing: Kali bichr. , thigh feels as if it would break off: Valer. When walking: Coloc , fatiguing: Graphit., Plumbum. When commencing to move: Rhus tox. From moderate, not altered by violent motion : Iris. Motion: Bryon., Diosc. and pressure : Coloc. , Phytol. and touch: Bellad., Hepar, Mezer. On pressing at stool: Nux vom. On turning in bed: Zinc. ox. BROUGHT ON BY : Indignation: Coloc Grief: Ignat. Anger or vexation: Chamom. During pregnancy: Sepia. Intermittent fever: Arsen. Tubercular diathesis: Plumbum. Spinal affections: Calc. earb. 79 8 CRURAL NEURALGIA. Syphilis: Kali hydr., Jfercur., Phytol., Stilling. Suppression of tetters: Sulphur. Alcohol and quack medicines: Mux vom. Quinine: Natr. mur. Mercury: Hepar, Kalihydr. Cold, damp cellars: Arson. Working" in water: Calc. card.. Rhus tox. Straining 1 , lifting, overexertion: Arnica, Rhus tax. Injuries, contusions: Arnica, Ruta. Sedentary life: Nuxvotn. ATTENDING SYMPTOMS. As if beside himself: Chamom. Weeping: Bellad., Pulsat. Anguish and restlessness: Arsen. Eyelids burn: Coloc. Pulsation and buzzing in ears: Zinc. ox. Face pale, flushing easily: Ferrum. Hypogastrium, lumbar region and be- hind sternum burning like fire: Laches. Constipation: Laches., Nux vom. and flatulence: Lycop. Urine bigh colored, depositing red sand: Lycop. Left shoulder, pain in: Zinc. ox. Affected limb, paralytic, weak and wast- ing away: Arg. nitr. , paralytic stiffness: Rhus tox . , painful tension of muscles when moving: Zinc. ox. , lameness: Iris. , stiffness in hip and ham: Bell ad. , sensation of expansion: Arg. nitr. , swelling of veins: Sepia. , contraction of hamstrings: Natr. mur. , tenderness of soles of feet: Ledum. Limbs are jerked upwards when sitting: Menyanth. Chilliness: Pulsat. and thirst: Lgnat. and coldness general: Ledum. Cold feet : Aeon., Lycop. Cooler, affected limb, than the rest of body: Ledum. Feverish: Bellad. Heat without thirst: lgnat. , internal, in limb, and external cool- ness: Mezcr. Flushes of heat: Laches. Sweat and thirst: Coloc. without relief: Mercur. Restlessness and sleeplessness: Arsen., Bella d., Coffea, Mercur. Cold sweat of feet: Aeon. Crural Neuralgia, Ischias Antica. Its seat is the crural nerve; the pain is felt from the inner and lower portion of the thigh, down to the inner portion of the knee, the inner ankle, the inner portion of the foot, and the big and second toe. As Causes have been named : uterine swellings, especially of a cancerous nature; inflammation of the hip- joints, and crural hernia. Therapeutic Hints. Coffea, Phytol, Staphis. Compare Neuralgia and Sciatica. Anaesthesia. Anaesthesia takes place from two causes: i. Either from an inability of the sensory nerves to convey the external impressions to the central organs; or — 2. From an inability of the central organs to perceive external impres- sions. The first is the case, for example, where a nerve has been cut through. Any irritation below that cut, towards the periphery, is not perceived any ANESTHESIA OF THE TRIGEMINUS. 799 more by the central organs; that part may be pinched, burned, etc., but pain is not felt. The latter may have its source in a disease of the spine or of the brain. In both cases the want of feeling is chiefly associated with paralysis of the corresponding parts. The degree of such anaesthesia varies from a mere numbness to torpor and deadness of the part. Its influence upon the vegetative functions in the affected parts shows itself as: decrease in natural warmth; slowness of capil- lary circulation; want of perspiration; subcutaneous oedema; livid color of the skin; brittleness of the nails; ecchymosis, and blisters filled with bloody serum, especially on the toes and fingers. Of the different forms of this affection I shall mention only the follow- ing: Anaesthesia of the Trigeminus. According to the extent to which this nerve has lost its ability to convey external impressions to the sensorium, we find a want of feeling in the corre- sponding portions of the skin and mucous membranes. The patient does not feel any external irritation in these parts; when eating, knows not whether he holds anything in the affected side of the mouth or not; the saliva runs out of the mouth without his knowledge; and the glass held on his lips seems to him broken off where it touches the affected side. In addition, there is likewise found weakness of sight, loss of smell and taste. The reflex motion of the muscles of the face is gone, the eyelids do not shut when the conjunctiva is touched, and the patient does not sneeze when the mucous membrane of his nose is irritated. Also the voluntary muscular motions of the affected side are more torpid, and the pupil is con- tracted and immovable. The seat of the affection is, according to Romberg's observations, more towards the periphery of the fifth pair of nerves, when the anaesthesia is limited to some of its fibres. When, however, the anaesthesia affects not only the external surface of the face, but also the corresponding cavity of the eye, then the cause lies in one of the main branches of the trigeminus, either before or after its exit from the skull. When the anaesthesia extends over the whole ramification of the trigeminus, the cause of the affection then lies in the ganglion Gasseri, or immediately below it in the nerve. When, however, the affection is combined with disturbances of other cranial nerves, its seat lies in the base of the brain. A central anaesthesia affects crosswise, and involves at the same time other sensory and motory nerves of the head and body. Central Causes are: apoplexy, softening and tumors of the brain. Peripheric Causes: inflammation; softening; hardening and atroplry of the nerve and of the ganglion Gasseri. Likewise the severing of the nerve or of one of its branches by surgical operations, or other external injuries, blows, wounds, etc.; or pressure upon it in consequence of tumors or foreign bodies, like musket balls, or fracture of the petrous portion of the parietal bone. BOO SPASM. These causes show at once all that might be said about its prognosis and curability. Just as the sensory nerves may be morbidly affected in a two-fold man- ner, either by an increase or a loss of their sensibility, so also are the morbid affections of the motory nerves of two kinds, either spasm, cramp, hyper- kinesis : or paralysis, akinesis — that is, increased or lost motility. Spasm, Convulsion, Cramp, Hyperkinesis. Spasms manifest themselves under different forms: i. Either as short, slight jerks of certain muscles; or, 2 as, violent, frequently-repeated contrac- tions of the same or different sets of muscles (clonic spasms); or, 3, as hasty motions which, although regular, are deficient in purpose and rhythm or are automatically repeated; or, 4, as irregular, misdirected motions (in-coordi- nated spasms); or, 5, as trembling or tremor; or, 6, as a continuous rigidity of one or more sets of muscles (tonic spasms); and, 7, as a permanent con- traction of certain muscles (contractures). Their violence and extent are very different, and do not always correspond to the importance of their cause. Grave disorders in the central organs may be attended with but slight spasms; whilst, vice versa, 2. slight reflex irritation may cause the most vio- lent convulsions. Their Causes are various: I may mention as predisposing ones, the age of childhood — the younger the child, the greater the predisposition. Almost any acute disease may be attended by spasms at the age, and frequently is preceded by them. Even in chills and fever, little children have spasms in- stead of a chill. As special forms of spasms in this early age I may mention eclampsia and trismus. In later years, up to the time of puberty, we find a predominating disposition to the different forms of chorea, stammering and squinting, and likewise the beginning of epilepsy. From the time of puberty to middle age we find hysteria, epilepsy, eclampsia and tetanus. In still later years we find writing spasm and tremor. The female sex seems to be more disposed to spasms than the male. As Exciting Causes we may mention — 1. Mental emotions: fear, fright, anger, terror. Even the sight of con- vulsions has caused them in others. Epileptic fits have become epidemic in this way among the pupils of a whole asylum. 2. Diseases in the central organs and their membranes, like apoplexy, softening, encephalitis, tumors, tubercles, inflammation of the cerebral and spinal membranes, and morbid processes in the bones which encase the cen- tral organs. 3. Peripheric irritations of the nervous system, by strong light, tickling; also by wounds, blows and bruises of some organs, like the testicles or the uterus, or by irritation of large surfaces, like the mucous membranes — for example, the intestinal canal by indigestible food or worms, or the external skin by sudden taking cold, etc. 4. Various conditions of the blood, such as (according to Marshall Hall ) SPASMUS FACIALIS. 8oi great loss of blood or stagnation of blood within the brain; so, also, qualita- tive changes of the blood in exanthematic fevers, in pyaemia, uraemia and eholaemia. 5. Certain poisons: alcohol, narcotics, strychnine, secale, lead and mercury. The Prognosis of spasms depends entirely upon their causes. When they appear in consequence of organic lesions in the central organs, they are of a much graver nature than when in consequence of a mere peripheric irritation. * Spasms which appear during the beginning or during the course of other diseases, like exanthematic fevers, are a sign that the disease, with which they are combined, is of a violent character, but are not quite so bad a sign; when they occur in children as in grown persons. Spasms from blood poi- soning in uraemia and eholaemia are always a bad prognostic sign. I shall now speak of the different forms of Spasmodic Diseases. Spasmus Facialis, Mimic Spasm of the Face. It affects those muscles of the face which are supplied by the seventh pair of nerves, either on one or both sides. In its clonic form it causes the most awkward appearance of the face; whilst one side looks perfectly quiet and natural, the affected side is continu- ally in motion, cutting all sorts of capers and jerks. The will has not the slightest influence over these distortions. They come on unprovoked, and may last a shorter or longer time. In some cases they are brought on by a usual effort to talk, chew, etc., disturbing these natural muscular actions greatly. The tonic spasm is different. The face appears as though, during a dis- tortion, it had suddenly become rigid, stiffened, so that it does not partake of the motions of the sound side, which manifests itself especially in laughing or whistling. This rigidity might give occasion to confound it with paraly- sis of the face. However, chin, lips and nose are drawn towards the affected side; the corner of the mouth of the affected side is drawn downwards, whilst the eyebrow is drawn upwards. The eyelids of the affected side cannot be perfectly closed, and the mouth not perfectly opened, thus interfering with talking and chewing. The muscles of the affected side are hard to the touch, and the patient has a feeling as if they were stretched. As the most frequent Cause of this complaint, may be mentioned: sud- denly taking cold by exposure to a sharp, piercing wind, rain or snow driven into the face. Likewise external injuries, especially bruises of the bones of the face and skull, decayed teeth, etc. Violent mental emotions, like anger or terror, and hysteric conditions have also been observed as causes of this complaint. Therapeutic Hints. When caused by exposure to cold : compare Bellad. , Hyos. , Mercur. When caused by external injuries : Arnica, Hyper. 5i 802 MOGIGRAPHIA. When caused by diseasese of the bones, decayed teeth: Hepar, Mercur., Silic When caused by anger: Nux vom. When caused by fright and terror: Hyosc, /gnat., Opium. Constant winking of the eyelids: Anac, Bel/ad., Stramon. Risus sardonicus: compare Aeon., Alum., Anac, Asa/., Bellad., Bovista, Calc Carb., Cicuta, Conium, Crocus, Cuprum, Hyosc, Natr. mur., Nux mosc/i., Phosphor., Platina, Ra?i. seel., Sepia, Stramon., Veratr , Zincum. Mogigraphia, Graphospasmus, Writers' Cramp, Pianists' Cramp, etc. It commences first as a mere tired feeling of the hand, after long-con- tinued writing. By and by this feeling increases, and the writer has to make pauses frequently in order to rest the hand; lastly, it is quite impos- sible to hold the pen, and to write, because, ist, either a spasm of the ex- tensors draws the fingers asunder, or, 2d, a spasm of the flexors of the first three fingers, or of only one of them, makes it impossible to hold the pen. Such spasms may be clonic or tonic. Sometimes the thumb and fingers are only slightly drawn together, and writing might be possible, if it were not for the strong trembling which attacks the hand and the whole arm up to the shoulder, as soon as writing is attempted. If writing be attempted with the other hand, it is not long before the same spasms attack it also. It is quite remarkable that all other manual acts can be easily executed, although in some cases cramps and tremors attend them likewise. Similar spasmodic affections have been observed also in the habitual per- formances of shoemaking, milking, playing musical instruments, setting type, sewing, etc. Its causes seem to be overexertion in writing, or disturbance in the co-ordinating apparatus. It is increased by anxiety and constant think- ing of it. The most important remedies are Bellad., Caustic, Gelsem., Ignat., Nux vom., Ruta, Secale, Silic, Stannum, Siaphis., Zincum. Light and large pen- holders ought to be used. Chorea, St. Vitus' Dance Is defined now as a neurosis, the seat of which is supposed to be at times in the brain alone, at times in the entire nervous system; it is characterized by incessant inco-ordinate twitchings and jerkings of groups of muscles, either spontaneous in origin or excited by voluntary impulse, exclusively occurring in the waking state and accompanied by more or less developed psychical disturbance. (Von Ziemssen.) Dr. J. Lawrence Newton recognizes five forms: the true cerebral, the spinal, the uterine, the intestinal and rheumatic form. Chorea is prominently an affection of the period of bodily develop- ment, but is seen also: during pregnancy; in consequence of disturbances of THERAPEUTIC HINTS TO CHOREA. 803 menstruation and blood formation (chlorosis, anaemia), and is frequently con- nected with articular rheumatism. As Exciting Causes have frequently been observed: mental emotions, such as fright, or fear, etc. Symptoms. — 1 . Involuntary movements sometimes extend to all the mus- cles which obey the will; sometimes the) 7 are confined to certain groups of them, oftenest to the upper half of the bod} 7 ; sometimes only one side is agitated, and in exceptional cases we find a crosswise agitation — an arm of the one, and the leg of the other side. Again, involuntary movements some- times commence in a few muscles of the whole body. We then find the whole body in constant agitation, jerking, swinging, a ludicrous and some- times pitiful sight. There is no interruption of these irregular motions, ex- cept during sleep, which is generally restless and unrefreshing; and even then they recur, although in a less degree, when the patient dreams. On waking the same tumultuous scene commences again. 2. The regular voluntary movements of the body are thus greatly inter- fered with, and at last cannot be executed at all. Dressing, writing and playing instruments become impossible, talking difficult, and exertions to overcome the difficulty have always had the contrary effect — increase of spasmodic action. 3. The reflex motions, however, are not disturbed. If the patient itches somewhere, he can scratch himself without any trouble; so can he sneeze, cough and evacuate bladder and bowels, etc. 4. All other involuntary movements of the body are perfectly free in their action; there is no interference in breathing, in the pulsations of the heart, nor in the act of swallowing, and the peristaltic motions of the intestines are normal. 5. The sensibility is in most cases normal. ■ 6. The mental functions, however, suffer considerably from a long dura- tion of the disease. The patient at length shows a loss of memory, weak- ness of mental capacity, and in some severe cases even imbecility of mind; the disposition becomes fretful, irritable and peevish. Chorea is of a chronic nature and its duration extremely variable. It is apt to recur and relapses are especially frequent after mental excitement. Under judicial homoeopathic treatment it is in most cases easily cured. Therapeutic Hints. Agar. The spasmodic motions range from simple, involuntary motions and jerks of different muscles to a dancing-like turning of the whole body; or attack crosswise, an upper right and a lower left extremity, or vice versa; frequent nictitation of the eyelids; redness of the inner canthus of the eyes; flow of tears from the eyes; sensitiveness of the lumbar vertebrae; ravenous appetite, but difficult swallowing; cervical glands swollen; worse during the approach of a thunder-storm. A st. rub. Trembling jactitation of arms and legs; unable to feed her- 804 THERAPEUTIC HINTS TO CHOREA. self or to walk; frequent, clear, profuse urine; after fright and mental de- pression. Bel lad. Throwing the body forward and backward in lying, a kind of constant changing from emprosthotonus to opisthotonus; boring the head into the cushion; grating of the teeth; sore throat; numbness in the fingers; soreness of the last lumbar and the first dorsal vetebrse; after mental excite- ment; fright. Calc. carb. Sometimes only one-sided involuntary motions; sometimes amounting to falling down; exceedingly headstrong; period of second teeth- ing; worm symptoms; scrofulous habit; onanism. Cauloph. In young girls with menstrual irregularities. Caustic. Distortion, twisting and jerking of the limbs, even in the night, preventing sleep, paralysis of the tongue and the right side of the body; after suppressed eruption on head. Wm. Gross mentions a peculiar case of a young girl, who had the fol- lowing paroxysms: the child would lie down on her stomach, and inserting one of her knees into the hollow of the other knee, and drawing her feet upwards upon the buttocks, her body would commence jerking forward and backward, simulating the movements exercised during coitus; at the same time the muscles of her face became contorted, like risus sardonicus. After the attack the child was exhausted, but during the intervals she showed no particular symptoms; the spells were worst in the morning. Cimicif. Chiefly on the left side only; worse during the menstrual period; after suppression of the menses; from rheumatic irritation; frequent alternation of heat and cold in different parts of the body. Cina. The distortions often commence with a shriek, extend to the tongue, oesophagus and larynx, and continue even through the night; they are attended with frontal headache; enlarged pupils; dark rings around the eyes; itching of the nose; pale, yellowish, earthy face; ravenous appetite; pain around the umbilicus; hard stools; turbid urine; emaciation; all point- ing to irritation of the intestines hy worms. Coccul. Involuntary motions with the right arm and right leg ; they cease during sleep; face puffed, somewmat bluish; hands look as if frozen; paralytic symptoms. Crocus. Jerking in the muscles; spasmodic contractions of single sets of muscles; jumping, dancing, laughing, whistling; wants to kiss everybody; congestion of the head with bleeding of the nose; suppressed menses. Cuprum. Commences in one arm and spreads over the whole body, causing the most terrible contortions and awkward movements; inability to speak, or only imperfectly; after fright. Hyosc. Throwing about of the arms; misses what he reaches for; con- stant falling of the head from side to side; tottering gait; very talkative, or loss of speech; laugh at everything that is told to him; smiling, silly ex- pression of countenance; after typhus. THERAPEUTIC HINTS TO CHOREA. 805 Ignat. Especially when caused by fright or other mental excitement; worse after eating; better when lying on the back. La 11 roc. She tears her clothing; strikes at everything; spasmodic deglutition; indistinct articulation; she gets angry because she cannot be understood; idiotic expression of the face; cold clammy feet up to the knees; she can neither stand nor sit, nor lie down, on account of the incessant motion; wasting away; after fright. Lil. tigr. Convulsive contractions of almost all the muscles of the body, and a feeling as if she would go crazy if she did not hold tightly upon herself. My gale. Constant jerking of head to the right side, occasionally drops his head suddenly on his shoulder, sometimes he twists his head around to the right shoulder; twitching of the muscles of back and arms; pain in knees when walking; in attempting to control these involuntary motions, he' loses his breath, until he takes a deep inspiration Twitching of muscles of face and upper extremities; convulsive movements of the shoulders; lower extremities in constant motion; drags her legs when walking; mouth and eyes open and shut in rapid succession. (Howard.) Nat?\ mur. Chronic cases after fright or suppression of eruptions on the face; worse during full moon; paroxysms of jumping up high without taking notice of the things around him, thus hurting himself sometimes con- siderably; or mere jerkings of the right side and the head. Nux vom. When attended with a feeling of numbness in the affected parts; also after much drugging. Opium. Twitching and trembling of head and arms; throws limbs or stretches arms at right angles to body after fright. .Phosphor. He walks like one paralytic, without noticing it himself; twitching of the limbs; great exhaustion; after Calc. carb.\ during second dentition; in general, during the period in which the body is growing. Secale. The morbid contractions usually commence in some muscles of the face and spread thence over the whole body, and increase even to danc- ing and jumping motions. Sepia. Convulsive motions of the head and limbs; when talking (which is only a stammering), jerking of the muscles of the face; general muscular agitation; desire to constantly change position and place; ringworm-like eruptions on the skin every spring. Sticta. She cannot keep her feet to the ground; they jump and dance around in spite of her, unless held fast; when lying down, her limbs feel as though they were floating in the air as light as feathers. Stramon. The convulsive motions are often crosswise, or violent all over; preceded by formication in the limbs and a melancholy mood; worse during the equinoxes; inclination to pray; loss of memory; stammering; loss of speech; putting hands to the genitals. Sulphur. In chronic cases; after suppressed eruptions; weak, faint, hungry spells about 10 a. m. 806 HYSTERIA. Taj-ant. Trembling of the body; all the limbs are agitated; is in con- stant motion; can run better than walk; feels best in bed. Spasms subside on hearing the notes of a hornpipe; music lessens the symptoms. Ver. vir. Most violent distortions of the body, universal, unaffected by sleep; lips embossed with foam; waked up by a continual champing of the teeth; inability to swallow; intense sexual excitement. Viscum alb. Common mistletoe, is a popular remedy in England. Zinaim. Especially in those cases in which the general health suffers much from the disease, with great depression of spirits; worse after drinking wine. Hysteria. This hydra-headed complaint must be classed among the neuroses, in which at times part or the whole nervous system participates, without the presence of any apparent anatomical basis. Its most constant feature consists of an abnormal irritability, with neuralgic pains, and hallucinations in the sensor} 7 , and convulsions in the motor sphere; or the reverse, anaesthesia and paralysis. Although unmistakably a connection exists in many cases between the female genital organs and this complaint, it is nevertheless an erroneous assumption that hyseria is a disease exclusively peculiar to the female sex. However, the female sex does contribute the largest number of patients, especially during the ages between ten and thirtj* years; after the climacteric period its occurrence is rare. As important Etiological data must be mentioned: a peculiar psychi- cal constitution, liable to changing emotions and little strength of will; dis- orders of the female genital organs, menstrual disturbances, non-gratification of the sexual appetite, or over-irritation; persistent depressing mental emo- tions, such as the sense of failure in one of the objects of life (childless women and old maids), love-sickness and jealousy, injured vanity and wounded pride, self-reproach because of secret sins, grief and anxiety, etc. ; educational influences, such as too great indulgence, or too great demands upon the mental capacity, by overburdening with lessons and overstimulating the ambition. The Symptoms of hysteria are exceeding^ various and variable. We find in the sense of sight, photophobia, or dislike to particular colors, such as the red, or subjective light-phenomena, such as simple flashes, sparks, or more complicated figures, phantasms, and even visionary hallucinations; in the sense of hearing, oversensitiveness, or ringing, blowing, roaring, or hear- ing of voices; in the senses of smell and taste, various kinds of idiosyncrasies, such as aversions to different sorts of scent or taste which are not unpleasant to others, or a desire to smell asafcetida, or to devour chalk, coal and other such things; in other sentient nerves, all kinds of pain and abnormal sensa- tions, such as headache, tickling cough and pain in the larynx, soreness of the mouth and tongue, neuralgia of the mammary glands, heavy dull pain and oppression in the chest and about the heart, cardialgias and gone feeling in HYSTERIA. 807 pit of stomach, tightness in the epigastrium, pains in the hypochondria, in the bowels, in the ovaries, in the womb, in the external genitals, in the bladder and urethra, in the coccygeal region, in the back — spinal irritation, and in the extremities. Or we find anaesthesia of the sense of touch, or in some of the limbs, or in a portion of them, or on one-half of the body, especially the left, and but rarely, over the whole surface of the body. With the loss of cutaneous sensi- bility a similar loss of sensibility of the above detailed symptoms in the mus- cles, as well as in the hands and joints, may be united, and it may extend over the mucous membranes of eyes, nose, mouth, respiratory organs, genital organs and urinary passages. In the higher senses, amblyopia, amaurosis and deafness have been observed. We find also spasms of various descriptions, such as globus hystericus in the throat, or the rising of a ball from the region of the symphysis toward the stomach; spasmodic breathing, singultus, yawning, convulsive laughing or crying, or screaming; spasmodic retention of urine, spasm of the con- strictor ani; local spasms in all possible sections of the muscular system of the head, trunk and extremities, even general convulsions, or similar to chorea and epilepsy. Or we find paralytic conditions of the pharynx and oesophagus (hindering deglutition), of the bowels (preventing a spontaneous expulsion of gases and feces), of the vocal cords (producing aphonia), of the bladder (causing retention of urine), of the extremities, either in the hemi- plegic or paraplegic form, or crosswise, or of only one extremity, or of all four. In the palsied extremities a permanent contractioa not unfrequently develops itself. Both paralysis and contraction may last for years and ma}^ be cured by all kinds of moral influences, or resist them all. We also find changes in the circulation, powerful palpitation of the heart, or weakness of its action, pale and cold extremities, red face and hot head, with perspiration; also unilateral sweating — all alternating with normal con- ditions. In some cases haemorrhages have been observed from the nose, throat, stomach and lungs, and in rare cases from different portions of the skin (stigmatization), all mostly of a vicarious nature; salivation or its opposite, abnormal dryness of the mouth, occurs sometimes after hysteric fits; the hys- terical vomiting of large quantities of fluid seems to be in connection with a suppression or lessening of the renal secretion, and therefore likewise of a vicarious nature. The urine is often copious, clear, of low specific gravity (urina spastica) and frequently voided, especially after spasmodic attacks; at other times its secretion is diminished and coupled with spasmodic closure of the neck of the bladder, so that the small quantity which exists must be re- moved by the catheter. Iyeucorrhcea has often been found to increase after hysterical attacks. The hysterical attacks themselves vary greatly in their forms, according as more or less a similar loss of sensibility of the above detailed symptoms combine in greater or less intensity. One form has been styled the hystero- 808 THERAPEUTIC HINTS TO HYSTERIA. epileptic, on account of the similarity of its convulsions to epilepsy, another the cataleptic, another the hysterical trance, to which some have added som- nambulism, sleep-walking, magnetic sleep, hypnotism and ecstasy — an ex- hibition of elasticity of the term ' ' hysteria ' ' that leaves nothing to wish for and is truly marvelous. Therapeutic Hints. Being a functional disorder, hysteria is certainly amenable to treatment. Quite important here is the personal, psychic and moral influence of the physician upon his patient. The remedial agents are necessarily very numerous in a disease of so varied and variable a character. I shall, how-' ever, confine my remarks to but a few characteristic hints of the several remedies, and refer for fuller descriptions to the chapters on spinal irritation, neuralgia, spasms, paralysis and uterine disorders. Aeon. Fear to go into crowds; fear of death and predicting the hour of her death. Agar. Crosswise complaints. Anac. Forgetful, and irrestible desire to curse and swear. Arsen. Spasmodic dyspnoea, with fear of death. Asa/. Dryness of oesophagus; globus hystericus. Auru?n. Melancholy; longing for death; palpitation; alternate laugh- ing and crying. Bellad. Congestions to head; spasms; hallucinations. Calc. carb. Fears she will lose her reason; coldness in and on head; cold, damp feet; palpitation after eating; chorea-like and epileptiform spasms. Cazistic. Paresis of upper eylids. Chamom. Exceedingly irritable, peevish and impatient. Coccul. Tickling cough; choking in throat; oppression of chest; paralysis of tongue or pharynx. Coniu?n. Old maids; non-gratification of the sexual appetite; globus hystericus. Cuprum. Spasmodic affections. Gelsem. Paralytic symptoms in throat, in limbs; spasms from reflex irritation; cataleptic immobility, w T ith dilated pupils, closed e} 7 es, but con- sciousness. Hyosc. Illusions; silly expressions and silly actions; jealousy; disap- pointed love. Ignat. Choking in throat and constriction of chest, with sighing- breathing; tickling cough which may be suppressed by an effort of will; feeling of goneness and gnawing in pit of stomach; grief. Iodium. Rapid failing of strength and emaciation in spite of eating freely. Laches. Sensation of a lump in throat which descends on swallowing, THERAPEUTIC HINTS TO HYSTERIA. 809 but returns at once; suffocating sensation, with constant efforts to remove all external pressure from throat and chest; feels worse on walking; jealousy. Lil. tig?'. Hurried manner without accomplishing anything; weak, nervous; uterine; palpitation. Lycop. Full and satiated; rumbling in upper left side of abdomen; sandy or pale urine. Magn. mur. Fainting fits at dinner, nausea and trembling, relieved by eructations; spasmodic complaints. Merc. sol. Profuse saliva; perspiration without relief. Moschus. Anguish and fear of death; swooning; tetanic spasms. Natr, mur. Desire for salt; somnambulic states; pain in urethra after micturition. Nitr. ac. Longing for fat, herring, chalk, lime, earth; twitchings in various parts; trembling; great weakness. Nux mosch. Inclined to laughter; drowsy; great dryness of mouth ; leucorrhcea in place of menses. Nux vom. Pressure and pain in pit of stomach; belching; longing for chalk; tendency to faint; chronic spasms, with numbness. Pallad. Feels best in company and wants to be nattered; easily wounded pride. Phosphor. Alternation of laughing and weeping; sense of weakness in abdomen; dry, hard stools; increased sexual desire. Plati?ia. Pride, haughtiness; illusions; spasms alternating with cata- lepsy, or with dyspnoea; sexual erethism; physical symptoms alternate with mental symptoms. Pulsat. Mild, tearful, yielding, timid; peevish; changeable; loss of smell and taste; no appetite and no thirst; increased mucous secretion from orifices. Sabtna. Irritable in temper; abortion in third month. Sepia. Sensation of something twisting about stomach and rising to throat, with stiffness of tongue, speechlessness, and rigidity all over; spasms; fainting with profuse sweat; undisturbed consciousness and inability to move. Stannum. Feels fainty from going down stairs; cannot sit down slowly, drops down; rises without difficulty. Staphis. Great indignation on least occasion. Stramon. Hallucinations; desire for light; great sensitiveness; weep- ing and laughing alternately; sexual excitement. Sulphur. Flushes of heat; heat on top of head; cold feet; sensation of hunger in forenoon. Tarant. Choreic restlessness of limbs; music has a soothing influ- ence. Valer. Ecstasy; overexcitable, changeable disposition and ideas; jerk- ing, twitching, trembling. Verat? . alb. Cold sweat on forehead and elbows. Zincum. Fidgetiness of feet and lower extremities. 8lO NEURASTHENIA. Neurasthenia. Here we find an old acquaintance presenting itself in a new garb. Who is the physician that has not met nervousness in constantly varying forms, even up to nervous prostration, repeatedly in daily practice? Neurasthenia is a weakened condition of the nervous system (Nerven- schwaeche) with a resulting diminution of nerve-force. If we attempt to trace this weakness to a material cause, we will find ourselves disappointed, for this is a disease without a corresponding demonstrable tissue change. Neurasthenia is therefore not fatal unless some other destructive disease in- tervenes. The symptoms vary amazingly. From mere local disturbances in single parts, the entire nervous system may be involved, thus weakening the intel- lectual vigor and w 7 ill power by degrees, or result in depression of the emo- tional spheres. We find therefore loss of memory, inability to perform con- tinued mental work, and even great depression of spirits — melancholic and hypochondriacal states of the mind. Among the somatic symptoms sleeplessness is a most prominent one. Notwithstanding the greatest fatigue, weariness and exhaustion a continual mental irritation and erethism of the cortical portion of the brain does not allow the tired frame to settle into repose, but keeps it continually on the go in certain circles of consciousness, mostly of a troublesome nature, and thus increases the general exhaustion, and the broken-down feeling in mind and body. Neurasthenia shows itself in different forms. The cerebral form is characterized by physical and sensorial functional disturbances most fre- quently brought on by mental over-exertion and emotional excitement. The spinal form is characterized by neuralgic pains in the skin, muscles, joints and great exhaustion from least exertion, attended by palpitation of the heart, perspiration, oppression and anxiety, with jerking of limbs, hindering sleep; numbness and paretic inability to use the muscles. Its cause is most frequently severe illness, puerperal fevers, sexual excesses and emotional excitement. The cardiac form, neurasthenia cordis, is characterized by attacks of intermittent disturbances of the action of the heart, for instance, as if the heart were going to stand still with pain or pressure; vibration in the region of the heart; it is usually brought on in persons inclined to asthma by emo- tional excitement, from warm baths and excessive use of tobacco. The gastric form is characterized by stupefaction, pressure, feeling of intoxication, rush of blood to the head, flickering before the eyes, noise in the ears, nervous excitation, palpitation of the heart, alternating feelings of chilliness and heat, drowsiness, fullness in the stomach, pulsatio epigastrica, eructations, formation of gas, nausea, heart-burn. It is the result of defec- tive innervation and is often spoken of as nervous dyspepsia The sexual form in man is characterized by a timid and depressed dispo- THERAPEUTIC HINTS TO NEURASTHENIA. 8ll sition, little self-esteem, hypochondriacal mood, and relaxed posture. He is easily embarrassed, which is manifested by tremor, clumsiness and even ataxia, when being observed. The cause is usually sexual excesses, masturbation, or enforced absti- nence, with continuous sexual excitement, leading to pollutions and to^ early ejaculations during coitus. This has a depressing influence which leads to hypochondriasis and melancholia, and eventually a disturbance of the centre of erection, bringing about a psychic impotence. The patient believes him- self a victim of tabes dorsalis, being strengthened in this belief by the existence of neuralgic pains in the region of the plexus lumbo-sacralis. (Kraft-Ebing.) The sexual form in women is characterized in the beginning by symp- toms in the lumbar region, and especially effecting the regions which" stand in consensual connection with the sexual organs -(stomach, oesophagus, breasts, larynx, thyroid glands and trigeminus. The cause is similar to that in men: abusus veneris (especially mastur- bation, coitus reservatus et interruptus. The analogues to the pollutions in men are lascivious dreams with spastic contractions of the tubes and of the uterus and discharge of the secretion of the genital organs with volup- tuous excitement. The morbid development dates frequently from the time when puberty develops or climaxis begins' It is a remarkable fact that Neurasthenia has been spoken of so largely on this side of the water, and that it is almost considered a specific American disease. This does not denote that neurasthenia is confined alone to this country, but it seems to exist here to quite a conspicuous degree. As a reason for this has been given the preponderance of the nervous constitution and the undeniable hasty pursuit after gain and wealth, beside the ambitious striving to reach certain social or political positions, so characteristic of the American people. But even this does not seem to hit upon the precise cause, for mad chases after riches and influence exist everywhere. When we, however, find that people who cannot bear to indulge here in any kind of stimulation, whilst in England or on the Continent they loose this irrita- bility, it seems that the cause might be looked for in the different climates of these countries, and this difference is the apparently greater dryness of the atmosphere here, compared with Europe. Dr. Kraft-Ebing recommends for treatment a tonic diet, with as much protein and fat containing substances as possible, whilst stimulants should be avoided. Among the physical remedies are recommended a sojourn in the mountains; hydropathy; electricity as general Faraditzaion or electri- cal baths. Of medicinal substances are recommended: Iron, Arsenic, Strychnine^ Phosphor., Secale, Opium, Zinc, Cocaine, Damiana, Quinine, dif- ferent sedatives, and hypnotics. Therapeutic Hints. If the theory of climate be found correct it will certainly not be good 8l2 CATALEPSY. advice to send such patients into high altitudes, but rather, if they can afford it, to the moist climate of England. Special remedies for nervous weakness ( Nervenschwseche ) we already find mentioned by Jahr in his "Handbook," with the following indications. If caused by: Abuse of coffee: Cham., Ign., Merc, Nux vom., Sulph. Exertion of body: Am., Calc. c, China, Corr., Rhnstox. Exertion of mind, by reading, writing, etc.: Bell., Cale. c, Lack., Natr. mur., A T ux vom., Puis., Sulph. (Pic. ac., Sil.). Mercurial remedies: Hepar, Lack., Nitr. ac., Sulph. Narcotic substances: Carbo veg., Cham., Cqff., Lach., Merc, Nux vo?n., Puis., Sulph. Night waking: Bry., Carbo veg., China, Cocc, Natr. mur., Nux vom., Puis., Sclen., Sulph. Sedentary life: Lach., Nux vom., Sulph. Spirituous liquors: Aeon., Bell., Coffea, Lach., Nux vom., Puis., Sulph. Other useful remedies besides those given above, which will be found indicated, are: Ars. , Lye, Phos., Phos. ac, Picric ac, Sil., Staph., Sepia, Zinc Catalepsy- Is a sudden loss of all voluntary motory power, so quickly befalling all muscles that the different parts of the body remain precisely in the same po- sition in which the attack finds them, thus making the patient appear like a statue. At first the muscles are rather rigid; but the}' gradually grow more pliant, assume a waxy flexibility,. so that the limbs may be brought into any position, in which they continue to remain. The sensibility and conscious- ness of the patient is usually gone; he perceives nothing and recollects noth- ing; whilst in other cases some sensibility seems to remain; and in still others, sensibility and consciousness are entirely undisturbed. The patient sees, hears and knows everything that is going on around him, but is perfectly unable voluntarily to move a single muscle of his body; the link which makes the body an instrument of the soul seems broken. Such fits end, in simple forms of the disease, often quite as suddenly as they come on. The patient 'draws a long breath, sighs, yawns, and acts as though he were waking out of a deep sleep, and goes on with his interrupted work without even sus- pecting that anything had happened to him. Such attacks sometimes follow others at short intervals, and they ma)' last only a few minutes at a time. Graver attacks lasts hours and days. Skoda mentions one that lasted several months. Cataleptic spells are frequently combined with hysteria, melancholy, ecstasy, St. Vitus' dance, somnambulism and other nervous derangements. The disease is of rare occurrence and its real exciting causes seem to be mental agitation, anger, fright, sudden joy or fear, grief, disappointment, vexation, ecstasy or religious excitement, etc. Catalepsy is, by itself, not fatal. epilepsy. 813 Therapeutic Hints. If caused b}^ anger and vexation: Chamom., Bryon. If caused by fright: Aeon., Bellad., Ge/sem., Ignat., Opium. If caused by sudden joy: Coffea. If caused by grief: Ignat., Phosph. ac. If caused b}' jealousy : Hyosc., Laches. If caused by sexual erethism : Platina, Stramon. If caused by disappointed love : Ig?iat. , Laches. If caused by religious excitement: Stramon., Sulphur and Veratr. Epilepsy Is characterized by spells of sudden loss of consciousness and motor disturb- ances, under the form of more or less extensive convulsions. These spells recur at irregular periods in r :he beginning; the intervals are usually free from morbid symptoms; later, however, they are marked by various mental and bodily disturbances. The real seat of the disease has been sought in the pons and medulla oblongata, although a participation of other parts is not denied. Constant anatomical changes are thus far unknown, yet according to the latest investigations, certain histological changes in the bulb of the medulla seem to take the lead of all the others. One of its most prominent Causes is a hereditary disposition, develop- ing the disease usually before puberty, or not later than the twentieth year. Other occasional causes are: lesions of peripheral nerves, of the brain or the spinal cord ( "reflex- epilepsy "); psychial impressions and emotions, sexual irregularities, digestive disturbances, overexertion and great fatigue. In short the list of causes is a very large and varied one, and in many instances the cause may be as obscure as the nature of the disease itself. The epileptic seizures are in about one-half of the cases preceded for a day or two by one or the other, or several of the following Premonitory Symptoms: sadness and dejection of spirits, or excitement, loquacity, irri- tableness, quarrelsomeness or distrust; dizziness, headache and confusion of the head; dark coloration of the skin of the face and neck (rare); unusual deep sleep and general well-feeling, or restless sleep and leaden weight in limbs or slight trembling; voracious appetite, bad smell from the mouth. The immediate prodroma or so-called aura epileptica, which must not literally be taken only as a sensation of breath blowing upon the patient (scarcely ever recognized) . but in the wider sense as symptoms which pre- cede immediately the outbreak of the fit, and which last but a short time — these immediate prodroma are of great variet3 T . We have sensitive aura, consisting of tickling sensation., or dragging, tearing pain from the periphery (tips of toes or fingers) towards the head; one-sided headache; pains in epi- gastrium; or loss of feeling in one extremity, or one-half of the* face, taking a centrifugal direction. A vasomotor aura consisting of: paleness, coldness and numbness of one 8 14 EPILEPSY. extremity , commencing on the fingers and toes; or redness in spots in various parts of the body; a motor aura consisting of: spasms, trembling or shaking motion of different groups of muscles, rumbling in the bowels, straining at stool and on passing water, drawing up of the testicle, palpitation, etc. The aura of the special senses consists of: impressions of light and color, or seeing of corporeal figures; hearing of sounds and voices; sensations of disagreeable smell; sensations of a sweet taste. In isolated cases a profuse secretion of tears or perspiration, or an abundant flow of saliva has been observed. Of these various premonitory symptoms in the individual case, one or several, or none at all may be present; or the one or the other, or several of them may occur repeatedly, without being followed by an actual attack. The seizure itself is characterized by a loss of consciousness and general convulsions. The loss of consciousness is either sudden and complete, the patient being stricken down as if by lightning, without regard to attitude or surroundings; or a little more gradual, tarrying a second or tw T o, so that the patient can assume some recumbent position voluntarily, to save himself from injury by falling. The convulsions are, in rare cases, preceded by a short and sudden relax- ation of all the muscles; generally they commence with a tonic spasm, the extent of which is variable, attacking either the entire muscular frame, or one-half of the body (opisthotonus emprosthotonus) , or only some groups of muscles, those of face, throat and larynx — the unearthly shriek in some cases is caused by a laryngeal spasm — or the tonic spasm is wholly wanting, and the scene begins at once with clonic tw T itchings. During the stage of tonic spasm the color of the face is not in all cases alike; in some the attack begins with pallor, or in others with a dark redness of the face, or the color changes from pallor to redness. All this often lasts only a few seconds, sometimes from one-quarter of a minute to one minute. The clonic spasm now following, attacks almost all the voluntary muscles of the extremities, trunk and head, and its violence is often so great as to cause fractures, dislocations, breaking of teeth, deep lacerations of the tongue and rupture of muscles. This tumultuous state is at times interrupted by tonic spasms, so that the patient again becomes rigid. The face assumes a c3 7 anotic color, the eyeballs protrude, and respiration is forcibly quickened, and at times arrested. After the lapse of from half a minute to three min- utes, and only in very exceptional cases still longer, the convulsions either stop suddenly, or wear off by degrees until the patient lies quiet, with relaxed muscles, in a deep coma for some minutes longer, when the turgor diminishes and consciousness finally and gradually returns; or the paroxysm is immedi- ately followed by a deep sleep, varying from half an hour to several hours and longer. After consciousness is fully restored the patient feels tired, un- nerved, and as if bruised all over, or, in lighter cases, he may find himself wholly in his previous condition, and without recollection of what has hap- pened to him. The light form, Epilepsia mitior, is characterized by loss of conscious- EPILEPSY. 815 ness without any visible outward spasms, or at most accompanied only by fixation of the e} r eball. The transition forms of epileptic attacks consist of spells with loss of con- sciousness and local spasms. The irregular forms of epileptic attacks are characterized by spasmodic symptoms of a local character with no loss of consciousness and sensation, or at the utmost with only a slight confusion and obscuration of the senses. Sometimes the spasms are entirely wanting, and are replaced by motions of walking and running. At other times there are recurring attacks of mental disturbance, such as the delirium epilepticum during which an inclination sets in to wander about, or to use obscene language, or to act indecently or fool- ishly. Very serious cases amount to a furious mania, in which the patient is driven by an irresistible force to perform acts of violence, to annihilate every- thing in his reach, to commit the most shocking murders, etc. The sufferers often relate afterwards that they have had hallucinations of a repulsive and frightful character. The average duration of this maniacal condition may last from tw T o to four days; it may past off in a few hours. The epileptoid states show themselves like epilepsy, also paroxysmally, and constitute the principal feature of the disease, while the symptoms of the intervals are so little pronounced that no other nervous or mental affection could be recognized in them. Of such the epileptic vertigo is the most fre- quently occurring and the best known. The frequency of epileptic paroxysms varies within extremely wide limits; some patients have one seizure a year, others several in one day. In many patients the attacks occur principally during the night, with others during the day. So exists also a great variety in regard to the forms of the attacks. Some have only hard or grave attacks, others only the light ones, while still others have all the different forms mingled in alternation. The inter-paroxysmal condition is characterized most frequently by a weakened memory, by a depression of spirits, by gloominess, irritability, nervousness, distrust and a disposition to get easily angered. Patients de- cline into marked hypochondria or melancholy; the physiognomy and bear- ing are altered, the lips of the patients grow thick, their features coarse, finally assuming the expression of imbecility. In regard to Differential Diagnosis, I shall mention only its simula- tion. An interesting case was detected by Dr. MacDonald upon the follow- ing grounds: " First, Clegg was a convict, sentenced to hard labor, — this furnished a strong motive for feigning, and suggested suspicion; second, the occurrence of a paroxysm during my visit to the ward; third, the readiness with which he spoke of his complaint, and called attention to the cicatrices on his face and head; fourth, the marked change in his facial expression when he supposed he was unobserved; fifth, during the spasms the thumbs were not closed within the palms, the nails were not livid, muscular rigidity could readily be overcome, and the hands, after being forced open, immedi- ately closed; sixth, the sphincters were not relaxed; and, seventh, there 8l6 THERAPEUTIC HINTS TO EPILEPSY. were no ecchymoses, extravasations, or minute petechial spots observable upon forehead, throat, or chest. The presence or absence of pallor was not determined by observation in Clegg's case, nor was any value attached to the condition of the pupils." Prognosis. — As bad signs are to be reckoned: attacks which come in irregular groups; great frequency of the paroxysms; sudden attacks without any premonitory symptoms; vomiting, asphyxia, half-sided convulsions, with subsequent paralytic symptoms; long-continued coma, delirium, mania, stu- pidity after waking up. More favorable signs: short attacks and long intervals between; premon- itory symptoms before the attack; milder convulsions, with little embarrass- ment in respiration; brief or only partial loss of consciousness, and no dis- turbance of the health in the intervals. Still better is it, when the paroxysms become less frequent, shorter and milder. The outbreak of cutaneous erup- tions and ulcers is quite favorable. In regard to Causes, we find it unfavor- able when the disease is inherited, or is not cured during the age of puberty, or comes on in middle life, or is caused by disorganization of the brain or by continued peripheric irritations of the nervous system, like masturbation. More favorable are those cases which come on during the period of dentition, or are caused by disturbances in the nutritive functions, such as chlorosis, anaemia, lead or alcoholic poisoning; in fact, in all cases where it is possible to remove the cause. Therapeutic Hints. Agar. Nictitation of the eyelids; itching, burning and redness of the fingers and toes, as though they had been frozen; after fright; suppressed eruptions. Amy I niir. By inhalation. Arnica.™ "Sees eyes all around him sometime before and after the attack; feels sore and achy when sitting, especially when lying in bed; upper chest, head and face feel flushed and hot, while extremities are cold; anxious, wild expression of countenance; conscious during the whole paroxsym." (J. F. Edgar.) Arg. nitr. In boys with old-looking face; after chewing tobacco. Pupils dilated a day or two before the fit. Arsen. Preceded by a sense of warm air streaming up the spine into the head, vertigo; loss of consciousness and falling down. Afterwards con- fused and stunned. During the intervals, pressive pain in the occiput; burn- ing in the spine; sweet taste in the morning; after eating heavy food burning in the stomach and bowels; stool irregular, mostly diarrhceic, with burning in the anus; also burning in the glans penis during micturition; frequent cramps in the calves of the legs. Art. vulg. When there are a number of attacks soon after each other. Bellad. The convulsions commence in the arm; previously, and at the time, congestion of the head; throbbing in temples; during the attack " the THERAPEUTIC HINTS TO EPIEEPSY. 817 right hand clutches at the throat;" " during the intervals, peevish, angry, scolding, swearing; or fearful and full of anxiety; vertigo; growing dark before the eyes; ringing in the ears; headache, with twitching in the face; flushes of heat in the face; red face; enlarged pupils; jerking and starting in sleep. Bufo. After fright or onanism; attacks at night followed by some, hours of coma; loss of consciousness and falling down; tonic and clonic spasms; turgescence and distortion of face; livid face; convulsive agitation of mouth and eyes; bites tongue; bloody salivation; involuntary emission of urine; re- peated shocks through the whole body; the lower extremities are more in motion than the upper ones; copious perspiration running down the face. Calc. ars. Pain and oppression in the region of the heart before the fit. Calc. card. Before the attack; chewing motion with the mouth; stretch- ing of the limbs; great restlessness; palpitation of the heart; sense of some- thing running in the arm, or from the pit of the stomach down through the abdomen into the feet. After the attack; headache; dizziness; sweat on the head; great thirst; canine hunger; vomiting and diarrhoea. During the in- tervals ; stupid, peevish; anxious about getting well; vertigo; headache be- fore breakfast; pale, puffed face; perspires easily, especially on the head; hardness of hearing; eats a great deal and yet loses flesh; thick, swollen belty; too frequent and too profuse menses; swelling of the glands about the neck. Causes: fright; protracted intermittent; suppression of chronic erup- tion. Worse during the solstice and full moon; excited by chagrin or fear; by drinking cold water; by letting the legs swing when sitting. Frequently indicated after Sulphur. Cauloph. Epileptiform spasms during or near the menses. Caustic. Before the attack; imbecility of mind; heat of the head, fol- lowed by sweat all over; great pressure in the pit of the stomach, extending all over the chest and hindering breathing. During the spell: sometimes bleeding of the nose; very red face; biting the tongue; drawing the head to- wards one side; urine is passed involuntarily. Afterwards: soporous con- dition; headache; noise in the head; exhaustion. During the intervals: on the scalp and glabella small, round, soft lumps; sweats easily on the head; stoppage of the nose; tongue coated white on both sides ; sour or sweetish, badly-tasting eructation, like ink or rotten wood; pain in the small of the back, and constant coldness of the shoulders and joints of the feet; great restlessness, which urges him to run away. Causes : suppressed eruptions; protracted intermittent; softening of the brain. Worse during new moon; drinking cold water as soon as the pressure in the stomach commences prevents the attack. Chin. ars. After the attack cold perspiration, eructations and a feeling of such utter prostration, that the patient believes he cannot endure it long. (Payne.) Cicuta. Epileptiform spasms from venous congestion of the abdomen in 52 8l8 THERAPEUTIC HINTS TO EPILEPSY. children and women. Bluish, puffed face; eyes staring upon one point; electric shocks; trembling; difficulty of being roused from sleep; small, painful ulcers on the edges of the tongue. Cimicif. Epileptiform spasms at or near the menstrual period. Coccul. For women of great nervous and paralytic weakness, with suppressed or very painful menstruation; vertigo with nausea. Cuprum. Before the attack: nausea, retching and throwing up of phlegm; bloated abdomen; drawing sensation in the left arm; the arm is drawn involuntarily close to the body; formication and tearing in the right hand; shuddering; gooseflesh; palpitation of the heart; or sudden shriek and falling down, without any premonitory signs. During the spell: the fingers become dead; involuntary discharge of urine; bluish color of the pit of the stomach and chest; chest and head covered with perspiration. After the spell: weeping; headache; profuse discharge of a clear, watery urine; long trembling and shaking of the right hand; sleep. During the intervals: anxiety, tendency to be frightened; burning in the chest and abdomen, with chilliness of the remainder of the body; burning and tearing in the small of the back; numbness of the arms. In clearly idiopathic cases, with no or- ganic lesions; worse about new moon; after mental excitement; fright. Digit. When caused by excessive nightly emissions or onanism, with great weakness of the genital organs. Gelscm. Epileptiform convulsions after suppressed menses, with severe spasms of the glottis; epilepsy, with dull feeling in the forehead and vertex, and some pain and fullness in the region of the medulla oblongata before the attack. Glojioin. Great congestion of the head and right heart; during the spasms he spreads his fingers and toes asunder. Hyosc. Before the attack: vertigo; sparks before the eyes; ringing in the ears; gnawing and sensation of hunger in the pit of the stomach. Dur- ing the spell: purple, bluish face; projecting eyes; shrieks; grating of teeth; foaming; discharge of urine. After the spell: soporous condition, snoring. During the intervals: tearing and beating in the right eye, which weeps and seems protruded; constipation. Causes: jealousy; disappointed love; grief. The attempt to swallow fluids renews the attack. Hyper. Epileptiform spasms, always after striking the bod}* against anything. Ignat. Epilepsy caused by fright and suppressed grief; especially suit- able for children. Indigo. Before attacks : furious, excitable, easily angered; between the attacks: exceedingly melancholic and timid, or gloomy. (L,. M. Kenyon.) Ipcc. Epileptiform spasms, with shrieks; opisthotonus; pale, puffed face and gastric derangements. Laches. The patient goes to sleep before an attack, and then is seized with a spasm ; creeping sensation from nape of neck down the spinal column ; giddiness; headache; peculiar feeling in throat; bloated stomach and bowels; THERAPEUTIC HINTS TO EPIEEPSY. 819 cold feet. In those eases which are caused by onanism, or are in connection with morbid excitement of the sexual organs; fluor albus; frequent emis- sion of semen; also after jealousy. Nux vom. Painful spot in the abdomen in the region of the solar plexus; pressure upon this spot renews the attack; during interval, consti- pation; headache every morning; no appetite for breakfast and nausea after eating. CEnanth. croc. Recommended by Drs. Davidson and Oehme. Opium. Nightly attacks; combined with mental derangements; after the attack long, soporous sleep. Plumbum. Heaviness and numbness of the legs before the spell; swollen tongue; afterwards: long-continued stupid feeling in the head, and want of clear consciousness. Pul sat. Fits before menses; swelling of abdomen before menses; menses too light and scanty; headache principally over right eye; sensation of a lump rising in throat, which causes nausea while eating. (G. W. Cox.) Secale. Shows toxic-effects, which hint strongly to it, but its sphere of action has not yet been defined. Sepia. ' Fits every two, three weeks, usually in the morning; star- ing of eyes, turning of head towards left side, sense as of floating in the air, loss of consciousness. Several days before attack: noises in head and hardness of hearing and deep sleep. During pregnancy no attacks, but after confinement worse. During intervals flushes of heat, bodily restlessness, must move about. Sultry w T eather unbearable, also foggy. Before menses cutting pain in bowels, dryness of skin. Sepia* one dose, every seventh evening; better. Later, Pulsat*, Cup-turn*. Lastly, Sepia 200, better. From Oct. 26th, 1876, to Nov. 26th, 1877. (Kunkel.) (Allgem Horn. Zeitg., March 28th, 1882.) Silic. Before the attack : feeling of great coldness of the left side of the body; shaking of the left arm; slumber, with starting. The spasms spread, undulating from the solar plexus up towards the brain; violent screaming; groaning; tears drop out of the eyes; foam at the mouth. Afterwards: warm perspiration; slumber; paralysis of the right side; for scrofulo-rachitic indi- viduals; during sleep at night; worse about new moon. Stannum. Is recommended as one of the most important remedies, with- out particular indications; except that its sphere of action is said to have a strong bearing upon the genital organs of both sexes. Stramon. Epileptiform spasms; thrusting the head continually in quick succession to the right; continued rotary motion with the left arm; pain in the pit of the stomach; obstinate constipation; deep, snoring sleep; low-spirited; fear of death; desire to be alone. Sulphur, before the spell : Crawling and running as of a mouse down the back and arms; or a sudden feeling as if a mouse w T ere running from the right foot up the leg to the right side of the abdomen. After the attack, which consists of various convulsive motions, he wipes the tears from his 820 DIGEST TO EPILEPSY. eyes; soporous sleep; great exhaustion; jerkings in arms and about the mouth in cold air. Chronic cases always of psoric taint; suppressed eruptions. Tarant. During attack squinting of eyes which remain open; after- wards dejection and dizziness for twenty-four hours. Ver. vir. and Zizia are likewise recommended. Bromide of Ammonium (Kitchen), Bromide of Potassium (old school), Cya n ide of Potassiu m ( J . D uf ty ) . Digest of Epilepsy. BEFORE THE ATTACK. Loss of consciousness: Arsen. Imbecility of mind : Caustic. Furious, excitable, easily angered: In- digo. Some time before, sees eyes all around him: Arnica. Sense of floating in the air: Sepia. Vertigo: Arsen., Hyos., Laches. Headache: Laches. Dull feeling in forehead and vertex, pain and fullness in region of medulla : Gel- sem. Throbbing in temples, congestion: Bel- lad. Feeling of warm air streaming up the spine into head: Arsen. Heat of head, followed by sweat all over: Caustic. Several days before, noises in head: Sepia. Turning head towards left side: Sepia. Dilated pupils a day or two before: Arg. nitr. Staring eyes : Sepia. Sparks before eyes: Hyosc. Hardness of hearing several days be- fore: Sepia. Ringing in ears: Hyosc. Chewing motion with the mouth: Calc. card. Swollen tongue : Plumbum. Nausea, retching, throwing up of phlegm : Cuprum. Peculiar feeling in throat: Laches. Gnawing and sensation of hunger in pit of stomach: Hyosc. Pressure in pit of stomach, extending over chest and hindering breathing: Caustic. Bloated stomach and bowels: Cuprum, Laches. Pain and oppression in region of heart: Calc. ars. Palpitation of heart: Calc. card., Cup- Shaking of left arm : Silic. Drawing of left arm, which is drawn close to the body: Cuprum. Formication and tearing in right hand: Cuprum. Heaviness and numbness of legs: Plum- bum. Stretching of limbs: Calc. card. Sense of something running in the arm, or from the pit of the stomach down through the abdomen into the feet: Calc. carb. Crawling and running as of a mouse down the back and arms; or a sudden feeling as if a mouse were running from the right foot up the leg to the right side of the abdomen: Sulphur. Creeping sensation from nape of neck down to spinal column: Laches. Slumbering with starting: Silic. Deep sleep : Sepia. Goes to sleep and then is seized with a fit: Laches. Cold feeling of the left side of body: Silic. Cold feet: Laches. Shuddering, gooseflesh: Cuprum. Great restlessness : Calc. carb. DURING THE ATTACK. Conscious : Arnica. Loss of consciousness : Sepia. and falling down: Bufo. Shrieks: Hyosc, Ipec. Sudden shriek and falling, without pre- monitory signs: Cuprum. Groaning: Silic. DIGEST TO EPILEPSY 821 Congestion to head and heart: Glonoin. Drawing" head towards one side: Caustic. Thrusting" head in quick succession to the right: Stramon. Undulation from solar plexus up to brain: Silic. Head and chest covered with perspira- tion: Cuprum. Eyes projecting: Hyosc. staring upon one point: Cicuta. open and squinting: Tarant. and mouth convulsively moved: Bufo. , tears drop out of: Silic. Nose bleeding : Caustic. Face bluish, purple: Cicuta, Hyosc. distorted: Bufo. ■ livid: Bufo. pale: Ipec. ■ puffed: Cicuta, Ipec. very red: Caustic. turgescent: Bufo. Copious perspiration running down the face: Bufo. Mouth and eyes convulsed: Bufo. , foaming at the : Hyosc. , Silic. , bloody salivation: Bufo. Grating" of teeth: Hyosc. Biting tongue: Bufo., Caustic. Spasms of the glottis: Gelsem. Gastric derangements : Ipec. Bluish color of pit of stomach and chest: Cuprum. Urine, involuntary emission of: Bufo., Caustic, Cuprum, Hyosc. Left arm, rotatory motion with: Stramon. Bight hand clutches at the throat: Bel- lad. Fingers become dead: Cuprum. and toes are spread asunder: Glonoin. Convulsions commence in the arm: Bel- lad. Tonic and clonic spasms: Bufo. Lower extremities are more in motion than the upper: Bufo. Opisthotonus: Ipec Shocks through whole body: Bufo. Electric shocks ; trembling: Cicuta. AFTER THE ATTACK. Stupid and want of clear consciousness: Plumbum. Confused and stunned: Arsen. Sees eyes all around him: Arnica. Weeping: Cuprum. Dejected and dizzy for twenty -four hours: Tarant. Dizziness : Calc card. Headache: Calc card., Caustic, Cup- rum. Sweat on the head: Calc carb. Wipes tears from his eyes: Sulphur. Great thirst and canine hunger: Calc. carb. Eructations : Chin. ars. Vomiting and diarrhoea: Calc carb. Profuse discharge of clear, watery urine: Cuprum. Long trembling and shaking of right hand: Cuprum. Paralysis of right side: Silic Sleep : Cuprum. Slumber: Silic. Soporous sleep: Caustic, Opium, Sul- phur. and snoring: Hyosc Coma: Bufo. Cold perspiration : Chin. ars. Warm perspiration : Silic. Exhaustion: Caustic, Sulphur. Utter prostration : Chin. ars. DURING THE INTERVALS. Stupid, peevish: Calc carb. Desire to be alone: Stramon. Low-spirited: Stramon. Melancholy, timid, gloomy: Indigo. Anxious, wild expression: Arnica. about getting well: Calc. carb. Anxiety, easily frightened: Cuprum. , or fearful: Bellad. Fear of death : Stramon . Peevish, angry, scolding, swearing: Bel- lad. Mental derangements : Opium. carb. Vertigo : Bellad. , Calc carb. with nausea: Coccul. Headache before breakfast: Calc every morning: A r //.i- vom. over right eye: Pulsat. , occiput pressive: Arsen. , with twitching in the face: Bellad. 822 DIGEST TO EPILEPSY. Head, face, upper chest hot and flushed: Arnica. perspires easily: Calc. card., Caustic. On scalp and glabella, small, round, soft lumps: Caustic. Tearing and beating in right eye, which weeps and seems protruded: Hyosc. Pupils enlarged: Bel lad. Growing" dark before eyes: Bellad. Nictitation of lids: Agar. Ringing in ears: Bellad. Hardness of hearing: Calc. card. Stoppage of the nose: Caustic. Face flushed, hot, red: Bellad. pale, puffed: Calc. card. , in boys, old-looking: Arg. nitr. , jerkings about mouth and in arms in cold air: Sulphur. Tongue coated white on both sides: Caustic. , small painful ulcers on edges of: Cicuta. Taste, sweet in the morning: Arsen. Glands about neck swollen: Calc. card. Lump rising in throat, causing nausea while eating: Pulsat. No appetite for breakfast and nausea after eating: Nux vom. Eats a great deal and yet loses flesh : Calc. card. Eructations, sour or sweetish, badly tasting, like ink or rotten wood: Caustic. Pain in pit of stomach: Stramon. Burning in stomach and bowels after eating heavy food: Arsen. Constipation: Hyosc, Nux vom., Stra- mon. Irregular, mostly diarrhoeic stool, with burning in anus: Arsen. Painful spot in region of solar plexus; pressure on this spot renews the attack: Nux vom. Burning in abdomen and chest, with chilliness of remaining body: Cuprum. Thick, swollen bellv: Calc. card. Burning in the glans penis during mic- turition: Arsen. Frequent emissions of semen: Laches. Menses too light and scanty: Pulsat. too frequent and profuse: Calc. card. suppressed and painful: Coccul. Before menses, swelling of abdomen; Pulsat. , cutting pain in bowels: Sepia. Fluor albus : Laches. Spine, burning in: Arsen. Small of back, burning and tearing in; Cuprum. , pain in: Caustic. Arms, numbness of: Cuprum. Itching, burning and redness of fingers and toes, as though they had been fro- zen : Agar. Frequent cramps in calves: Arsen. Sore and achy when sitting or lying: Arnica. Chilliness of body, with burning in chest and abdomen: Cuprum. Coldness of shoulders and joints of feet; Caustic. of extremities: Arnica. Heat, flushes of, head, face and upper chest: Arnica. , in flushes: Sepia. Sweats easily about head: Calc. card. % Caustic. Dryness of skin: Sepia. Sleep, snoring: Stramon. , difficult of being aroused from: Ci* cuta. , jerking and starting in: Bellad. Restlessness, must move about: Sepia. , urges him to run away: Caustic. Sultry, foggy weather unbearable: Sepia . Paralytic weakness : Coccul. ATTACKS PREVENTED BY: Drinking cold water as soon as the pressure in the stomach commences; Caustic. Pregnancy: Sepia. ATTACKS WORSE OR EXCITED. Several right after each other: Art. vulg^ Every two or three weeks, usually in the morning: Sepia. In the night : Bufo., Opium. , during sleep: Si lie. During new moon: Caustic, Cuprum K Silic During solstice and full moon: Calc card. After mental excitement: Cuprum. ECLAMPSIA ACUTA. 823 Grief: Hyosc, Ignat. Jealousy: Hyosc, Laches. Disappointed love : Hyosc. fright: Cuprum. chagrin or fear: Calc. card. Drinking cold water: Calc. card. Attempt to swallow fluids: Hyosc. Softening of brain : Caustic. Pressure upon a painful spot in the re- Chewing tobacco : Arg. nitr. gion of the solar plexus: Nux vom. Venous congestion of abdomen in Striking the body against anything: women and children: Cicuta. Hyper. Onanism: Bicfo., Digit., Laches. Letting the legs swing when sitting: Symptoms of genital organs of both Calc. card. sexes: Stannum. At or near the menses: Cauloph., Suppressed menses : Coccul., Gelsem. Clinic. Protracted intermittent: Calc. card., After confinement : Sepia. Caustic. Suitable for children: Ignat. Suppressed eruptions: Agar. , Calc. card. , scrofulo-rachitic individuals: Caustic, Sulphur. Silic. psoric taint: Sulphur. ATTACKS CAUSED BY: Fright: Agar., Bufo., Calc. card., Iguat. Calc. Carb. is frequently indicated after Sulphur. Eclampsia Acuta. This is an affection entirely analogous in its external symptoms to epi- lepsy — sudden loss of consciousness, frequently setting in with a shriek; tonic and subsequently clonic convulsions, which are followed by a comatose sleep. But it is entirely different from epilepsy, in that it always accompanies some other morbid derangement, with the course of which it either ceases or ends fatally. Notlmagcl, on the contrary, confines Eclampsia to such cases of epilepti- form spasms, ' ' which, independently of positive organic diseases, present themselves as an independent acute malady, and in which the same processes arise, generally in the way of reflex excitement, and the same mechanism in the establishment of the paroxysms, comes into play as in the epileptic seizure itself." Eclampsia Gravidarum et Parturientium, Puerperal Convulsions. Its occurrence is rather rare — one in about five hundred pregnancies, and perhaps less than that. During pregnancy it is of a very rare occurrence, and even then is scarcely ever noticed before the sixth month. It occurs most frequently during the act of parturition, seldom during the lying-in period. Primiparse are most subjected to it, and it sets in mostty during the dilatation of the os uteri, or immediately after the expulsion of the child. According to Frerichs, it has been observed that such women suffer frequently with albuminuria during pregnancy, though this is not invariably the case. During the lying-in time these convulsions are generally the commencement of inflammation of the womb. The attack itself is characterized by the same convulsive features as are described under epilepsy. When setting in during pregnancy these convulsions generally cause contractions of the womb and 824 THERAPEUTIC HINTS TO ECLAMPSIA ACUTA. abortus; when at the beginning of labor-pains, they frequently retard the natural progress; but when towards the end of parturition, they are apt to hasten the expulsion of the foetus. After the birth of the child the contrac- tions of the womb generally cease; and this may give rise to haemorrhages, retention of the placenta and inflammatory processes of the womb. The convulsions themselves ma}* continue for hours afterwards, though they are mostly of less intensity. The influence upon the child is, according to Scan- zoni, not necessarily fatal; about one-half of them are said to die. The later the convulsions begin the greater is the chance for the child, and vice versa. The Prognosis is doubtful; the earlier they commence the more so. Therapeutic Hints. As albuminuria is frequently a forerunner of this terrible complaint, the patient ought to be carefully treated during pregnancy. Compare Albu- minuria. Atrop. sulph. (Szontagh.) Bellad. Deep red face; enlarged pupils; screaming; jerking and general convulsions; all of which are signs of cerebral congestion. Chin, sulph. Albuminuria; tetanic spasms with loss of consciousness during parturition and afterwards; swollen veins on the head and neck; pulse frequent, intermittent and weak. Cuprum. During the lying-in time; sour-smelling; sweat miliary erup- tion; anxiety; easily frightened; heaviness of the head; soreness of the abdomen to pressure; burning in the small of the back; numbness of the arms. " Spasms commence with cramps in fingers and toes; hands and feet turn outward." (Gw} T nn.) Gelsem. During pregnancy, and where there is an anaemic condition present; protracted labor; rigid os uteri. Hyosc. Cold perspiration; pale face; suffocating spells and convulsions during parturition; facial muscles greatly agitated. Ignat. Twitching of muscles of mouth and eyes; wild expression; eyes upturned; constantly attempting to pull her hair; laughing and crying; nervous, excitable. (I. D. Johnson.) Laches. The convulsions commence upon the left side of face, and con- tinue longer and are more severe about the neck and throat than elsewhere. (JVlinton. ) Opium. During parturition; cessation of labor- pains; coma; retention of stool and urine; after a fright. Platina. After parturition ; profuse haemorrhage; yawning; convulsions. Stratnon. Excited, scolding, striking, spitting, crying and laughing; face flushed, pupils dilated, in great terror. Spasms; writhing and floun- dering in manifold gyrations; every muscle in play. (O. P. Baer. ) Ver. vir. During parturition; also after blood-letting, during the puer- peral convulsions, causing furious delirium; cold, clammy perspiration, ECLAMPSIA INFANTUM. 825 turgid and livid face; hideous expression of countenance; great activity of arterial system. Also compare the hints under the head of Epileps} r . Eclampsia Infantum, Convulsions of Children. By this term is understood convulsions of children, during which they lose their consciousness more or less completely, which come on in spells, run an acute course and are generally connected with some other morbid process. There exists no stricter definition as yet. Eclampsia attacks by preference boys • during the first years — stout as well as sickly — especially during dentition. It often breaks forth at the com- mencement of exanthematic fevers, also instead of the chill in intermittent fever; succeeds a sudden fright of the mother in the event of her suckling the child immediately. It may be caused by fright, fear of punishment, strong light, tickling, or violent pain; intestinal irritations from worms, in- digestible food, such as raisins, cakes, the pulp of oranges, etc. These con- vulsions are characterized by loss of consciousness; spasms all over; con- gestion of the head; cyanotic appearance of the face, or, in anaemic children, paleness of the face; snoring; rattling breathing; sometimes vomiting or in- voluntary discharge of urine and feces. They sometimes follow each other in rapid succession, and may terminate life unexpectedly in consequence of asphyxia; as a rule, however, they yield readily to the appropriate homoeo- pathic remedy. Therapeutic Hints. Aeon. Great restlessness; high fever; dry skin, after fright; from irri- tation of seat worms; from taking cold; in consequence of inflammatory affections of the spine; during teething. Apis. Shrieking; boring the head into the pillows; inflammatory affec- tions of the brain. Arsen. Spasms, preceeded by burning heat of the whole body, with constant licking of the dry, cracked lips; wants to drink constantly, but little at a time; is hasty in all its motions; grasps the tumbler or anything it wants eagerly; is very restless, w r ith anxious expression of the face. Bellad. Glowing red, as well as a pale face, with enlarged pupils; great heat in the head; great vascular erethism; drowsiness, with inability to sleep; starting and jerking during sleep; grating of teeth; especially during den- tition; scrofulous diathesis. Calc. carb. The anterior fontanelle remains wide open ; glandular swell- ing about the neck; teething process is either very slow or else too rapid; much perspiration about the head; greatly inclined to take cold; hard, swol- len abdomen; rather inclined to looseness of the bowels; often indicated after Bellad.; one of the most important remedies during dentition; scrofu- lous diathesis. Camphora. Anaemic subjects; coldness of the whole body. 826 THERAPEUTIC HINTS TO ECLAMPSIA INFANTUM. Chamom. One cheek is red, the other pale; hot perspiration on the head, especially on the hairy portion; great thirst; bloated bowels; colicky pains; greenish discharges; sour vomiting; constant moaning and groaning; restlessness; the child wants to be carried about all the time. During sleep a suspicious working of the muscles of the face, as if smiling; during denti- tion; also, after nursing the breast of a woman laboring under the effects of a recent fit of passion. Cicuta. Especially when the child, without any premonitory signs, be- comes suddenly stiff, with his eyes fixed upon one point; also in violent spasms of the head and the upper portion of the body; with bluish and puffed face; also in convulsions from worms. Cuprum. In anaemic conditions; shrill cries during the attack; drowsy and stupid condition during the intervals, with nausea and vomiting of slime; bloated abdomen, with involuntary, thin discharges from the bowels; also when the child loses its breath from crying, and draws its feet spasmodi- cally upwards and backwards upon the nates. Cypripedium pub. In the premonitory stage, when there is a morbid irritability of the brain, in consequence of which the child is very excitable, laughs and plays at unwonted hours; is very wakeful and laughs even in sleep. Gelsem. During dentition, with sudden loud outcries; feverishness. Hyosc. Congestion of the head; bloated and dark face; protruding eyes; shrieks; foam at the mouth; involuntary discharges of urine; from fright or fear. Ignat. Violent convulsions; often tonic spasms predominant; nervous temperament; during dentition; during the commencement of exan thematic fevers; after fright, or when children have been punished. Fall asleep soon afterwards. Ipec. Pale face; nausea; vomiting; almost always when caused by eat- ing indigestible food; raisins, pound-cake, the pulp of an orange, etc.; or when the eruption of an exanthematic fever strikes in by taking cold. Mel Hot. During dentition with great congestion to the head. (Bowen. ) Opium. Trembling of the whole bod}', convulsive motions of the ex- tremities; soporous condition with snoring; retention of stool and urine; after a fright; or from nursing soon after a sudden fright of the mother. Platina. In anaemic subjects; tonic spasms without loss of conscious- ness; trismus; pale, sunken face; after the spell the child lies on its back, draws up its limbs and spreads its knees. Stannum. Renewal of convulsions with the cutting of every tooth; also in consequence of worms. Stramon. Congestion of the head; heat all over the body; red face; spasmodic thrusting of the head in all directions; profuse urine; deep, snoring sleep. Sulphur. Often when all other remedies fail; after suppression of erup- tions: diarrhoea in the morning; during the eruptive state of scarlatina. TREMOR. 827 / r er. vir. Convulsions with opisthotonus; anaemic subjects in conse- quence of diarrhoea. Zincum. Screaming and starting in sleep; anxious look when getting awake; heat of the body and nightly restlessness; twitching and jerking of different muscles, more on the right side than on the left; irritable mood; great appetite; bloated abdomen; involuntary discharge of urine. Accord- ing to Kafka, during dentition in children with anaemia. Tremor, Trembling. This affection is of very frequent occurrence, and of various forms. Sometimes the head trembles, while the motions of the arms go on normally. Some persons tremble during rest as well as when in motion; others, only during rest; a majority, however, during motion. During sleep all trembling ceases; also frequently when in a horizontal position, or in a position in which the trembling extremity rests firmly upon support elsewhere. Reflex motions are performed sometimes tremblingly, sometimes normally, while all automatic motions almost always remain undisturbed. Exertion of the will sometimes aggravates, sometimes masters the tremor; and during intense in- terest upon a subject it may cease entirely. Trembling may be partial, con- fined to the upper extremities, or extend over all the muscles, so that even the muscles of the face and jaws are involved. It is mostly of a transient character; sometimes part and parcel of a disease; sometimes, however, it becomes habitual, chronic, life-long. In children, it is found only occasion- ally, never of long duration. Old age is especially subject to it (tremor sen- ilis). We find it likewise more amongst women than men. Brain and spinal diseases (softening and atrophy) are mostly attended by it. It is brought on especially by the vapors of mercury; lead-poisoning; opium-eating, and abuse of alcoholic drinks and tobacco. It may be the result of typhus, and an effect of sexual excesses. Temporarily it may be caused by mental excitements, overexertions of the muscles, too much coffee or tea drinking, and too low a temperature. To the latter corresponds the trembling during the chilly stage of intermittents. Likewise we find trem- bling easily excited after being tired out, metally depressed, or exhausted in any way; and therefore it is frequently found during convalescence, after epileptic fits, catalepsy, neuralgia, and during the periods of menstruation and lactation. The mercurial tremor greatly resembles paralysis agitans (of which later), in its extent, its secondary paresis and the accompanying cerebral and psychical symptoms. The lead tremor is, as a rule, limited to the upper ex- tremities and some facial muscles (orbicularis, levator anguilioris), and is accompanied by numerous other symptoms of lead-poisoning. The alcohol tremor usually begins in the hands, from whence it may spread all over the body; it is worst in the morning during fasting, and alleviated by the use of spirits. The opium tremor is always associated with other opium symptoms, such as contracted pupils, constipation, etc.; and the nicotine tremor most 828 PARALYSIS AGITANS. frequently attacks only one side, or at least one side more than the other, and is generally accompanied with various nervous disturbances, such as muscular weakness, dizziness, neuralgia, myosis, etc. Therapeutic Hints. Compare multiple sclerosis, paralysis agitans. Mercurial tremor : Carb. veg.\ China, Hcpar, Laches., Nitr. ac, Sulphur, etc. Lead tremor: Alum., Bcllad., Hepar, Nux vom., Opium, Platina, Stra- in on., etc. Alcohol tremor : Arsen., /pec, Nux vom., etc. Opium tremor: Bel lad., Chamom., Ipec, Mercur., Nux vom., etc. Nicotine tremor: Arsen., Chamom., Coccul., Cuprum, Ignat., Nux vom., etc. Other tremors : Calc. carb., Cicuta, Mercur., Opium, Plumbum, Platina, Pulsat., Rhus tox., Stramon., Sulphur. The feeling of internal trembling: Calc. carb., Iodium, Rhus tox., Staphis. Paralysis Agitans, Shaking Palsy, Consists of a gradually increasing motor weakness and a trembling in the voluntary muscles of the body; the latter preceding the paralytic symptoms. In its external manifestation it appears as a tremor of high degree; but dif- fers from it by its constantly increasing intensity, and by its liabilty to ter- minate in paralysis and death. It commences lightly, as a feeling of weakness, with slight trembling of the upper extremities of the head. The patient is still able to execute all voluntary motions, and the trembling at first is not constant and may be mastered by the influence of the will. In some cases the tremor is limited to only one-half of the body, but in others it increases in intensity and becomes a perfect shaking of the whole body, by which even the bed upon which the patient rests is set in motion. In general the trembling is independent of voluntary or passive movements, and by this it is distinguished from chorea and from the trembling in disseminated sclerosis of the nervous centres. Sleep, and easy position, which at first will stop the shaking, eventually lose this effect, and the skin of the patient becomes sore in different places from the friction occasioned by the continued shaking, which the patient is unable to control. There are, however, more or less frequent spells of remis- sion. In some cases the patient has an irresistible desire to run, either for- wards or backwards, which at first he can resist to a certain degree, succeed- ing in making some uncertain steps on his toes; but at once he falls into a hasty run, until he regains control over these involuntary motions. At length, however, he cannot walk at all, but must be held back from these pitching forward or backward motions. To all this are gradually added: general exhaustion, great sensitiveness PARALYSIS; AKINESIS. 829 of the whole body, paralysis of the voluntary muscles, difficult deglutition, relaxation of the sphincters, with involuntary discharge of feces and urine, bed-sores, until, attended by the loss of mental capacity and delirium, death relieves the patient. Its Causes are obscure. It is said to have followed the taking of cold and after mental excitements; and its seat is supposed to be in the pons and upper part of the medulla oblongata, although most autopsies do not sustain this supposition; thus far its anatomical basis is undecided. The Prognosis is unfavorable. Therapeutic Hints. Compare Arsen., Bar. carl?., Caustic, Lycop., Mercui., Phosph. ac. y Rhustox.. Stramon., Tara?it., Zincum. Paralysis; Akinesis, Is an abolition of the faculty of exciting the normal function of the motor nervous apparatus and the muscles. A mere diminution of voluntary motion, attended with a sense of fatigue, is termed Paresis. The latter may gradually pass into paralysis. Paralysis may arise : 1. From destruction of functional capacity of those parts of the cere- brum, or of the ganglia at the base of the brain, or of the cerebellum, in which volitional impulses are probably converted into motor excitations (cen- tral paralyses). 2. From diminution or abolition of the conductivity of the motor nerves on any of their course, from their origin in the brain and spine to their ter- minations (paralysis ef conduction). 3. From abolition of excitability and contractibility of the muscles (myopathic paralyses). The Causes of paralysis are: wounds, occurring of course more fre- quently in the peripheral nerves than in the brain or spine (traumatic para- lyses); diseases of parts in the neighborhood of the nerves, such as exostoses, caries, aneurysms, echinococci, enlarged glands, herniae, tumors, etc. ; diseases of the nervous system, such as neuritis, myelitis, encephalitis, cerebral and spinal apoplexies, softenings, scleroses, tumors, etc. ; disturbances of the cir- culation, such as ischsemia, embolism, thrombosis, venous statis, etc.; poison- ing of the blood by vegetable alkaloids, such as woorare, ergotine, nicotine, saponine, hydrocyanic acid, camphor, etc., and metallic preparations, such as lead, etc.; acute diseases, such as acute exanthemata, erysipelas, typhoid fever, cholera, dysentery, acute articular rheumatism, diphtheritis; chronic infectious diseases and cachexias, such as syphilis and scrofulosis; catching cold ; exhaustion of the nervous system, by forced marches, excesses in venery, night watching, excessive mental exertion, etc.; reflex action from some primary disease, injury or irritation of the nerves at the periphery — reflex paralyses. 830 paralysis; akinesis. Paralysis may extend over a single muscle, or a group of muscles; over one-half of the body (hemiplegia), usually caused by a lesion in the brain on the opposite side, though it may also be of spinal origin; or over both halves of the body symmetrically, commencing usually in the lower extrem- ities and spreading to trunk and upper extremities (paraplegia). As concomitant and secondary symptoms of paralysis may be mentioned: relaxation or contraction of the affected muscles; want of all reflex and auto- matic movements, when there is interruption of the conduction in the peri- pheric motor nerves (or when the muscles are destroyed); an increase of re- flex activity so long as the reflex mechanism is not destroyed; associated movements in the paralyzed parts, in many cases where the paralysis is of centric origin above the centre of such associated movements; disturbances of automatic movements, especially of respiration in lesions of the lateral columns of the spinal cord in the dorsal and cervical regions; when the respiratory centre in the medulla oblongata is affected, asphyxia is soon pro- duced; in purely cerebral paralyses respiration continues undisturbed; reten- tion or involuntary passage of urine or of the contents of the bowels in various forms of paralyses; anaesthesia, if the disease affects a peripheric mixed nerve trunk, or when the cause of paralysis affects coincidently sen- sory nerves either in the brain or spine; hyperaesthesia of the parts and paraesthesia (formication, numbness, creeping, burning, etc.), inconsequence of irritations set up in the neighborhood of morbid processes, which cause paralysis; disturbances of the intellectual faculties are found only in paralysis of cerebral origin; coldness of the parts with passive hyper aeniia and cyanosis, especially in traumatic paralysis; atrophy of the skin, vulnerability of the skin, so that slight exposure to cold, pressure or irritation produces sores; deformity of the nails ; falling off of the hair on the paralyzed limb; atrophy of the muscles and bones ; cirrhosis of the muscles, and increase of the inter- stitial tissue; enlargement and hypertrophy of the lymphatic glands. All thesejtrophic changes are especially found in traumatic paralyses, less often in spinal, and still more rarely in cerebral paralysis. The Diagnosis between these three forms may be broadly stated as fol- lows: Peripheral paralyses are limited to the region supplied by one or a few nerve trunks; they are always associated with anaesthesia; reflex, automatic and associated movements are absent; spasms occasioned by central disease do not extend to the paralyzed muscles; trophic disturbances, especially atrophy of the muscles, are well marked at an early date; absence of all signs indicating spinal or cerebral disease. Spinal paralyses occur most frequently as paraplegia; attacking sym- metrical groups of muscles belonging to the lower exremities, trunk, belly, and upper extremities, progressively in accordance with the height which the disease has reached in the spinal cord (lumbar, dorsal or cervical regions); they are frequently accompanied by numbness, formication, etc., in the feet, by pain in the back, and a sensation of constriction around the body; they THERAPEUTIC HINTS TO PARALYSIS; AKINESIS. 83 1 are characterized by incontinence or retention of urine, by priapism, pollu- tions, spermatorrhoea and impotence; respiration is affected only when the corresponding part of the cord is involved: myosis in cervical lesions; con- vulsive movements proceeding from the brain do not extend to the paralyzed parts; trophic disturbances may or may not be present; psychical affections and affections of special senses are usually absent. Cerebral paralyses, from extravasation of blood, embolism, tumors, etc., are usually hemiplegia upon the opposite side of the body; sometimes, how- ever, it is limited to particular nerves and plexuses; reflex actions are almost always preserved and frequently increased in energy; associated and auto- matic movements are usually unaltered; motor irritation (contractures, twitchings and spasms) are not unfrequent in the affected parts; epileptic convulsions occur also in the paralyzed parts; atrophy of the muscles scarcely ever occurs, except in paralysis of the pons; psychical disturbances and dis- turbances of the higher senses are quite characteristic, and frequently aphasia (intellectual) or alabia (peripheric disturbance of speech) occur. Cerebral paraplegia is very rare, and generally occurs in the form of two separate hemiplegise, one side being more severely attacked than the other. Myopathic paralyses commence in particular muscles and gradually spread to others, frequently from one muscular fasciculus to another; they are preceded by atrophy; they are accompanied by fibrillar contractions and pain in the muscles, a diminution of the electrical excitability, and the pres- ence of a demonstrable local cause. Therapeutic Hints. Aeon. From congestion of spinal cord, attended with numbness of the parts. s£sc. glab. Is recommended for paralytic affections of the lower ex- tremities. Ai.sc. hipp. For paralysis of the upper extremities; back and legs weak. Agar. Paralysis of lower limbs with slight spasms of arms; pain in lumbar region and sacrum; crosswise affections. Alum. met. Paralysis from spinal diseases; loss of sensibility of the feet; inability to walk except with open eyes, and in the daytime. Anac. After apoplexy; loss of memory; imbecility of mind; loss of will. Apis. mel. One side paralyzed, the other twitching; cerebral origin. Arg. nitr. Paraplegia from exhaustion. Arnica. In consequence of exudations within the brain or spine; in consequence of apoplexy, of concussions, of weakening diseases of protracted intermittent fevers and ischias. Arse?i. When associated with great prostration and neuralgic pains; also in spinal affections with gressus gallinaceus, and as an antidote to lead- poisoning. 832 THERAPEUTIC HINTS TO PARALYSIS; AKIXESIS. Bar. carb. General paralysis of old age, with loss of memory and trembling of the limbs; also after apoplexy in old age, and especially in paralysis of the tongue. Bcllad. Apoplexy; congestion of the head; paralysis of the one and spasm of the other side of the body; paralysis of the face; locomotor ataxy. Cauloph. Paraplegia in consequence of retroversion and congestion of the womb after child-birth, with partial loss of sensation in the affected limbs; considerable emaciation, anaemia and general debilit}\ Caustic. Paralysis of the face or tongue or hemiplegia, with giddiness, weakness of sight, weeping mood; hopelessness; fear of death; drawing, lame feeling in the affected part; after exposure to severe, cold winds; catarrhal and rheumatic conditions; suppressed eczema or other chronic eruptions; apoplex}*. China. After great loss of blood. Cina. Paraplegia with unnatural hunger. ( Lounsbury. ) Coccul. Paralysis of face or tongue or pharynx; paraplegia; rheumatic lameness; in weakened and nervous subjects, who are inclined to fainting fits and palpitation of the heart; also when the paralytic affection originates in the small of the back after taking cold, with cold feeling of the extremities and oedema of the feet; likewise after apoplexy. Colchic. After a sudden suppression of general perspiration or of sweat of the feet by getting wet. Conium. Paralysis from periphery upwards; old women; humid tetters. Cuprum. After apoplexy, when there is congestion in the chest, strong palpitation of the heart, or slow, w T eak and small pulse; the eyelids keep closed and twitch; when opening the eyes, the eyeballs move about; paraly- sis after cholera and typhus; paralysis commencing at the periphery and progressing towards the centre. Curare. Nervous debility from loss of fluids or after exhausting illness Dulcam. After taking cold : and suppressed eruptions; paralysis of the upper and lower extremities, and the tongue; the paralyzed arm feels icy cold. Ferrum. After great loss of vital fluids. Gelsem. Loss of motion, but not sensation; paralysis of the organs of deglutition, and in aphonia, fallowing diphtheria; locomotor ataxy; para- plegia. Grapliit. Rheumatic, peripheric paralysis of the face. Hepar. After mercurial poisoning. Hyosc. After spasms. Ignat. After great mental emotions and night-watching in the sick- chamber; hysterical paraplegia. Kali carb. Trembling; paralytic weakness, with cramps in fingers and hands; also paralytic weakness in the hip-joint. Kali, phosph: After exhaustion of nerve power, after hysteria. THERAPEUTIC HINTS TO PARALYSIS; AKINESIS. 833 Laches. Especially left side; awkward, stumbling gait; gressus galli- riaceus; after apoplexy. Mercur. Rigidity and immobility of all the limbs, although they can be easil3 T moved by others; indescribable malaise of body and soul; trembling of limbs and bod}-; paralysis agitans. Natr. mur. Paralytic condition of the lower limbs; painful contraction of the ham-strings; after intermittent fevers, diphtheria, sexual excesses and violent fits of passion. Nax vom. Incomplete paralysis of the face, arms legs, with vertigo; weak memory; darkness before the eyes; ringing in the ears; loss of appetite; burning in the stomach; flatulence; vomiting after eating and drinking; con- stipation; especially in drunkards; after apoplexy, mental overexertion. Oleand. Painless stiffness and paralysis of the limbs; insensibility of the whole body; or hyperesthesia, skin sore from the ordinary friction of the clothing; trembling of the knees when standing, and of the hands when writing; preceded by spells of vertigo a long time before paralysis develops itself. Opium. Paralysis and insensibility after apoplexy; in drunkards; in old people; retention of stool and urine. Ox. ac. Paralysis from inflammation of spinal cord; limbs stiff; par- oxysms of dyspnoea. Phosphor. Paralysis in consequence of spinal affections; after sexual excesses; after confinement; tingling and tearing pain from the back down into the limbs; gressus vaccinus. Picric ac. After tonic and clonic spasms; on standing keeps legs wide apart, looks steadily at objects as if unable to make them out; limbs feel as if in an elastic bandage, particularly the legs; wasting palsy; progressive locomotor ataxy. Plumbum. Paralysis complete with atrophy of the affected parts, pre- ceded by trembling; mental derangement. Psorin. After debilitating acute diseases. Rhus tox. Rheumatic paralytic affections after getting wet, and after great or unwonted muscular exertions, strainings, etc. ; in consequence of typhoid processes; with painful stiffness, tearing, drawing and aching of the whole body; sometimes with tingling and numbness of the parts, or con- tinued cold feet for a long time; worse during rest, and when commencing to move, from washing in cold water, with every change of the weather; better from dry heat near the stove, from continued gentle moving about, and flex- ion of the limbs. Ruta. Facial paralysis after catching cold. Secale. Paralysis after spasms and apoplexy, with rapid emaciation of the affected parts, and involuntary discharges from bowels and bladder. Silic. Paralysis of the left hand, with atrophy and numbness in the fingers; paralysis of the legs, always worse in the morning, with heaviness of the head and ringing in the ears. 53 834 THERAPEUTIC HINTS TO PARALYSIS; AKIXESIS. Stannum. Hemiplegia, especially on the left side, with a feeling of a heavy load of the affected arm and corresponding side of the chest, and fre- quent night-sweats. Stramon. After convulsions; also paralysis of the one and spasms of the other side. Sulphur. After typhus, exanthematic fevers, suppressed itch or chronic eruptions and spasms; also when other remedies seem to fail. Tarant. Numbness and formication and loss of motor power. Terebhith. Paralysis of right arm and left leg. (Berridge. ) Zincum. Worse after drinking wine; great restlessness of feet; after suppressed foot-sweat. Besides, compare the following, which are partly taken from Jahr- for— Paralysis of the eyelids: Aniica, Arg. nitr.^ Bellad., Canthar., Coccul., Cupr. ac, Luphorb., Gclsem., Hyosc, Nitr. ac, Opium, PI lanbum, Rhus tox . , Sepia, Spigel., Stramon., Veratr., Ziyicum. Paralysis of the face: Bellad., Caustic, Coccul., Graphit., Nux vom., Opium. Paralysis of the tongue and organs of speech: Aeon., Arnica, Arse?i., Bar. card., Bellad., Caustic, Coccul., Cuprum., Dulcam., Hepar., Hydr. ac, Hyosc, Laches., Mur. ac, Opium, Plumbum, Stramon. Paralysis of the organs of deglutition ; Bellad., Canthar., Caustic, Coccul., Cup?'um, Gclsem., Laches., Silic, Stramon. Paralysis of the bladder: Arsen., Bellad., Canthar., Dulca?n., Gelsem., Hyosc, Laches., Lycop., Natr. mur., Opium. Paralysis of the rectum and sphincter ani : Caustic , Coloc , Hyosc. , Ly- cop., Opium, Phosphor., Ruta, Zinc sulph. Paralysis of all the limbs : Arnica, Arsen., Colchic, Dulcam., Gelsem., Meratr., Nux vom., Rhus tox., Sanguin. Paralysis of the upper extremities: Aeon., Alsc. hipp., Arnica, Bellad., Calc carb., Caustic, China, Coccul., Colchic, Dulcam., Lycop., Mercur., Nitrum, Nux vom., RJuis tox., Sepia, Tart, emet., Veratr. Paralysis of the right arm and left leg: Terebinith. Paralysis of the hands: Ambrd, Arsen., Caustic, Cuprum, Ferrum, Natr. mur., Rhus tox., Ruta, Silic Paralysis of the fingers: Ambra, Calc. carb.. Cuprum, Natr. mur., Se- cale, Silic Paralysis of the lower extremities: Alum., Arnica, Bellad., Bryon., China, Coccul., Colchic, Dulcam., Kali carb., Mercur., Nux vom., Phosphor., Plumbum, Rhus tox., Secale, Sulphur, Veratr. Paralysis of the feet: Arsen., China, Oleand., Plumbum. Hemiplegia: Alum., Anac, Arg. nitr., Arnica, Bellad., Caustic, China, Coccul., Dulcum., Graph it., Hyosc, Kali carb., Laches., Meratr. , Phosph. ac, Plumbum., Rhus tox.. Sepia, Stannum, Staphis., Stramon. THERAPEUTIC HINTS TO PARALYSIS; AKINESIS. 835 Left-sided hemiplegia: Arnica, A rse?i., Bellad., Caustic., Laches., Rhus tox. Right-sided hemiplegia: Arnica, Bellad., Caustic, Rhus tox. Paralysis of one and spasms of the other side : Bellad., Laches., Stramon. Paraplegia: Coccul., Lauroc, Nux vom., Secale and others. Paralysis in consequence of — Mental emotions: Arnica, Ig?iat., Natr. mur., Stannum. Bodily exertions : Arsen. , Arnica, Rhus tox. Spasms: Arsen., Caustic, Coccul., Cuprum, Hyosc, Lauroc, Nux vom., Plumbum, Rhus tox., Secale, Silic, Stannum, Stramon., Sulphur. Apoplexy: Arnica, Anac, Bar. carb., Caustic, Cuprum, Laches., Nux vom., Plumbum, Secale, Stannum, Stramon., Zincum. Taking cold: Arnica, Caustic, Colchic, Dulcam., Mercur., Rhus tox. Getting wet: Caustic, Nux vom., Rhus tox. Suppression of sweat : Colchic Onanism, sexual excesses: China, Coccul., Ferrum, Natr. mur., Nux vom., Sulphur. e Rheumatism: Arnica, Bar. carb., Bryon., Canthar., Caustic, China, Coccul., Ferrum., Gelsem., Lycop., Ruta, Sulphur, Tart. emet. Intermittent fevers: Arnica, Arsen., Laches., Natr. mur., Nux vom., Rhus tox. Typhus fever: Coccul., Cuprum, Nux vom., Rhus tox., Sulphur. Diphtheria: Arsen., Gelsem., Laches., Natr. mur. Cholera: Cuprum, Secale, Sulphur, Veratr. Suppressed eruptions: Caustic, Dulcam., Hepar, Sulphur. Poisoning by arsenicum : China, Ferrum, Graphit., Hepar, Nux vom. Poisoning by lead : Cuprum, Opium, Platina. Poisoning by mere: Hepar, Nitr. ac, Staphis., Stramon., Sulphur. THE BLOOD. The blood being the fluid which nourishes all parts of the system, which sustains respiration, which, in short, is the life of the body, must necessarily cause great disturbances of the body when it becomes in any way abnormally changed. The blood consists of corpuscles and serum. The corpuscles are of two kinds — red, and colorless or white. The serum contains water, fibrin, albumen, salts, fatty substances and extractive matters. Any of these constituents may be abnormally increased, decreased, or altered, causing an abnormal condition in the quality of the blood. The whole mass of the blood may be increased or decreased, causing an abnormal quantity. Obnoxious substances, like sugar, uric acid, oxalic acid, ammonia, sulphuretted hydrogen, urates, gall, pus, may be mixed with, and thus deteriorate the blood, causing a poisoned state of the whole fluid. Cyanosis. The blood-corpuscles absorb the oxygen, with which they come in con- tact during their course through the lungs. Any cause which prevents this absorption of oxygen by the blood-corpuscles hinders the transformation of the venous into arterial blood. This is the nature of cyanosis. It consists in a decreased absorption of oxygen by the blood corpuscles. Its Causes are numerous, and may be arranged under the following heads: i. Imperfect respiration, in consequence of spasms, or oedema, or croup- ous inflammation of the glottis and larynx; or in consequence of obstructions within the trachea and bronchial tubes, caused by spasms, mucus, blood, foreign bodies, false membranes; or in consequence of obstacles which pre- vent the air from entering the air-cells of the lungs, caused by infiltration, hepatization, exudation (emphysema, hydrothorax, pneumothorax); or in consequence of paralytic affections of the respiratory muscles and diseases of the abdomen, by which the lungs become compressed; enlargement of the abdominal organs, tympanites, ascites, etc. 2. Imperfect circulation, in consequence of heart disease, obstructions within the pulmonary vessels, obliteration of the pulmonary tissue and blood- vessels, immediate transmission of the venous blood into the left ventrical, in consequence of the non-closure at birth of the foramen ovale. 3. Inhalation of air, which contains too little oxygen, and is impreg- nated with irrespirable gases, like carbonic acid gas, etc. 4. Inability of the blood-corpuscles to absorb oxygen. This has been observed in some severe illnesses, such as typhus, pyaemia, and in the last stage of pulmonary tuberculosis; cholera. DISSOLUTION OF THE RKD BLOOD-CORPUSCLKS. 837 Symptoms. — Bluishness of the surface of the body, especially of the face and lips; coldness of the extremities and depression of the muscular and nervous system; sopor; in a still higher degree, asphyxia. Cyanosis is, therefore, not a disease in itself, but a mere consequence and symptom of other derangements; still as a symptom it has, nevertheless, some therapeutic value, suggesting Aeon., Amm. carb., Arnica, Arsen., Camphora, Carb. veg., Conium, Cuprum, Digit., Laches., Opium, Pulsat., Rhus tox., Sambuc, Secale, Veratr. In newborn children, where the foramen ovale has not closed, Laches. In consequence of persistence of the ductus Botalli, Lauroc Dissolution of the Red Blood-Corpuscles. Each blood-corpuscle lives a certain period of times, and after that it disintegrates and disappears and new ones form in its place. Thus a constant rotation between life and death goes on in these minute bodies in order to sustain the life of the whole body. In disease, however, this equilibrium is sometimes destroyed; more corpuscles die than are generated, and this causes a state of the blood which is called Oligocythemia. It is characterized by weakness of the muscular system, tired feeling all over; nervousness, palpi- tation of the heart, bellows-sounds of the heart and large arteries; murmur in the jugular veins. In still other cases the dissolution of the blood- corpuscles goes on so rapidly and to such an extent that the blood-serum becomes overloaded with the constituents of the destroyed corpuscles, and is thus discolored. Even the excretions of the body assume a bloody or dark appearance; and the exudations are of a brownish, or still darker hue. The skin and mucous membranes become tinctured with haematin (the coloring matter of the blood), and color it yellowish, which may be mistaken for jaundice. If such a profuse dissolution of blood-corpuscles is confined to a certain portion of the circulation, it constitutes an essential part in what is called Local Gangrene. A general septic dissolution through the whole system is General Gangrene, Septicaemia. We find such states of general dissolution in some forms of typhus, scurvy, puerperal fever, yellow fever, and various other forms of tropical and infectious fevers. Compare Alum, Arsen., Carb. veg., China, Kali phos., Laches., Nitr. ac, Secale. Leucocythaemia, Leukaemia. ' ' The number of the colorless cells is so much increased that the blood has a whitish color," that is, under the microscope. Virchow thought, by finding this state of the blood in some cases, he had discovered a new disease. And as, according to his observations, the predominance of the white cor- puscles appeared in connection with enlargement of the spleen and tumors of the lymphatic glands, he distinguished two forms of leukaemia, the splenic and the lymphatic. To this has recently been added a third form, Neumann's 838 HYDREMIA. myelogenous leukaemia, which is presumed to have its starting point in the bony marrow. The patients complain, long before any increase of the white cells in the blood can be discovered, of prostration, dislike to work, dull pains in the splenic region, headache, dizziness, ringing in ears, palpitation, shortness of breath, enlargement of the lymphatic glands in various parts of the body, but especially in the cervical, jugular, axillary and inguinal regions. How- ever, there are cases of considerable tumors of the spleen and lymphatic glands without leukaemia. This • ' new ' ' disease of Virchow has been well known and studied in all its features (except the accumulation of the white blood-corpuscles), by the older physicians, under the name of Sycosis, who considered it as the ef- fect of a contamination with gonorrhceal poison, while Virchow and his fol- lowers saw the cause in the surplus of white cells — without explaining the cause of this accumulation, which, as stated before, is often not present until a late period of the disease. Thus, instead of having discovered a new dis- ease, Virchow has found merely a new symptom of an old disease. Com- pare Von Grauvogl upon this subject in his great work, "Lehrbuch der Horn- ccopathie." Therapeutic Hints. Grauvogl recommends Natr. sulph. and Thuja as the main remedies. Other remedies, however, especially those of the hydrogenoid order, may likewise be indicated by special symptoms; such remedies are: Natr. nitr., A T atr. carb., Natr. acet., Kali, nitr., Calc. carb., Magn. carb. and phosph. y Silic.,Iodium, Broniium, Chlor., Nitr. ac, Natr. mur., Borax, Antimon., Alum., Carb. veg., Arnica, Aranea diad., Pulsat., Nux vom., Ipcc, Arsen. y Conium, Apis, Spigel., and animal food. Hydrsemia Consists in a decrease of albumen and an increase of water in the serum san- guinis. In consequence of this the serum is much more prone to exudation than in its normal state, and we therefore find this state of the blood fre- quently associated with dropsical effusions. Its CAUSES may be: — 1. Long-continued pathological secretions of clear albumen, or albumi- nous substances (mucus, milk, etc.); in consequence of albuminuria, serous diarrhoea, pus-formation, exudation, loss of blood, mucous discharges, too copious flow of milk, too long- continued nursing. 2. Insufficient supply of nutriment or disturbed nutrition, so that the re- ceived nourishment is not converted into albumen and assimilated. Hydre- mia is therefore found in connection with the most different morbid processes. We find it in combination with disease of the heart and lungs, especially tuberculosis, chronic indigestion, protracted intermitting fevers, Bright's disease, etc. plethora. 839 Therapeutic Hints Must be sought for under the above-named morbid conditions. Plethora. The quantity of the blood must always be estimated as a relative mass. We cannot say, so much is just enough, one ounce more is too much. And in fact during life we have no means for such estimation. The whole ple- thoric theory therefore rests upon a rather weak foundation. On the other hand, if we observe different individuals, it seems clear enough that some are richer in this vital fluid than others. And as objective signs, which indicate such repletion, are stated: 1. A higher degree of redness of the body — such higher color, however, may be often very fallacious; it is of any account only when it is perpetually so; and, 2. The greater fullness and repletion of the circulatory vessels, arteries and veins. This is plethora of olden times. More recent observers have split this theory into three branches. They divide plethora of old into — 1. Plethora vera, true plethora, which is said to characterize itself by fullness of the arteries and veins, repletion of single organs, florid complex- ion and increased temperature of the body. 2. Serous plethora, an increase of blood-serum, and decrease of cor- puscles, which characterizes itself by the fullness of the arteries and veins, paleness, or else quick change of color; and, 3. Plethora ad vasa, or false plethora, which is not too much blood in general, but too great an afflux of blood into the blood-vessels, as in fevers, in consequence of bodily and mental exertions, spirituous, irritating drugs, etc. All these distinctions are of little use for Homoeopathic practice, as the Homoeopathic physician will scarcely have occasion to trouble his brain with the question : Shall I bleed ? or shall I not ? Symptomatic Anaemia, Oligsemia. The first denotes a want, the latter a poorness of the blood; the exact pathological meaning is a diminution of plasmatic albuminates, of red cor- puscles and of water in the blood; changes in quality and quantity of other blood-constituents are of minor consideration. A sudden loss of blood by haemorrhage (internal or from wounds), al- though producing a state of anaemia, and in consequence thereof, perhaps general epileptiform convulsions, loss of consciousness, delirium, hiccough, retching, vomiting and death, does not exactly belong here. We here consider the subacute and chronic forms of anaemia, the Causes of which are exceedingly various. They may consist of: deficient supply of food, a want of light and air, too little or too much exercise, too high or too low tempera- ture, excessive losses of semen, too long-continued lactation, profuse men- struation, great care, or grief, or mental overwork, albuminuria, blennor- 840 PROGRESSIVE PERNICIOUS ANEMIA. rhoeas of the different mucous membranes, diarrhoea and dysentery, extensive suppuration, large effusions in the pericardial, pleural or peritoneal cavities, infiltration into the lung tissue, malignant growths, malarial infections, mineral poisonings (acids, phosphorus, etc.), animal parasites, especially the anchylostomum duodenale (compare the chapter on Intestinal Worms), in- digestion, diseases of the spleen, lymphatic glands, etc., and fever. The Symptoms of anaemia are: paleness of the skin and mucous mem- branes, dropsical effusions in consequence of the diminished albumen in the blood, emaciation, marasmus or general atrophy of the tissues, a tendency to degenerative processes and haemorrhages, and a decrease of the normal tem- perature, even down to 95 ° F. , and lower; muscular exhaustion, irritable weak- ness, anaemic murmurs over the region of the heart, and the " Nonnen- gerausch," or "bruit de diable," a continous humming sound over the internal jugular veins; dyspnoea. v The Duration and Prognosis of anaemia depends altogether upon the causes to which it owes its origin. Progressive Pernicious Anaemia, Idiopathic Anaemia, Also known under the names of essential malignant and essential febrile anaemia, includes those cases of extreme anaemia which tend uninterruptedly towards a fatal issue, and of which no adequate cause can be discovered, either in the patients' circumstances or in the previous state of their constitu- tion. Its parholog}* and causes are shrouded in utter obscurity. It attacks most frequently women from the age of twenty to that of forty, and the cases described and classed under this new term by Biermer and Gusserow have principally been observed in Switzerland. Most cases were those of preg- nant women. The Symptoms begin insidiously with a gradual paling of the skin and mucous membrane, increasing to a degree as found in acute anaemia from haemorrhage. A wasting of the tissues (marasmus) is usually not observed until fever sets in, but other symptoms of anaemia associate early w T ith the increasing paleness. Such are: Palpitation of the heart; a loud blowing, systolic murmur and purring tremor over the heart, and the venous hum in the jugular veins, characterized by great constancy and intensity; irritable weak- ness and great prostration with severe fainting fits from slightest exertion; dyspnoea, is hardly able to speak above her breath; effusion into the pericar- dium and pleura, and puffiness of the legs; haemorrhages from different parts of the body; the nose, gums, genital organs in women, and the skin in the form of petechiae and occasionally as large patches of ecchyinosis; haemor- rhages in the retina and other internal parts. The fever is of an irregular type, w T ith temporary exacerbations, when the temperature may run up to 104 F. As the end approaches it is prone to fall suddenly as low as 95 ° or even 93. 2 ° F. When occurring during pregnancy, it usually induces pre- mature labor, and this is the forerunner of death. With all these severe symptoms, Physical Examination shows no CHLOROSIS. 84I organic disease of the heart, nor of the kidneys (no albuminuria), nor of the spleen, liver or Emphatic glands, and microscopic examination reveals no disproportion in the relative number of red corpuscles and leucocytes, thus distinguishing this disease thoroughly from leukaemia. From chlorosis it differs by its dropsical symptoms and its haemorrhagic diathesis, and from other forms of anaemia by its fever. The duration of this disease is seldom less than six or eight weeks, and seldom more than the same number of months. - - Our present experience justifies us in regarding every case as tending inevitably to a lethal issue." (Immermann.) Therapeutic Hints. In any case of anaemia we must, above all things, determine its cause or causes, and remove such if possible. Nutritious diet, pure air, and rest, are important in the treatment of anaemia. As a mere symptom anaemia may hint to the one or the other of the following remedies: Arsen., Calc. carb., Card, veg., China, Cuprum, Ferrum, Helon., Hydrast., Kali carb., Natr. mur., Nux vom., Sulphur, Veratr. and many more. Chlorosis, Green Sickness. Chlorosis is a form of primary anaemia characterized by a marked diminution in the amount of haemoglobin in the blood, and a slight decrease in the number of red-corpuscles. In severe persistent cases there is often observed an imperfect development of the organs of circulation and reproduc- tion. The albuminates and leucocytes seem not to be affected, and this is an important pathological distinction between it and anaemia, in which latter there is always a decrease of the plasmatic albuminates. The disease is almost entirely limited to the female sex, between the fourteenth and twenty-fourth years of life; it is especially, therefore, a dis- ease of the age of female puberty, seems often to grow upon a hereditary disposition, a peculiar constitutional habit of the body, and may be excited by conditions incidental to modern social life, or atmospheric and telluric influences, or by emotional disturbances, such as terror, anxiety, disappointed love, homesickness and the like. Its Symptoms are manifold: 1. Color of the skin. A conspicuous paleness, sometimes clear, some- times yellowish, greenish, waxy. Even the lips and other mucous mem- branes appear pale; dark rings around the eyes. In some cases there is oedema of the feet, face and eyelids; temperature decreased; breath cool; lips, nose, ears, hands and feet cold. The patient is sensitive to cold, seeks a warm room. 2. Circulation. The pulse is usually small and compressible, varying in frequency, easily excited by any trifling cause. The heart's impulse varies likewise in frequency and intensity, amounting often to strong palpitations. 842 THERAPEUTIC HINTS TO CHLOROSIS. Sometimes the palpitation of the heart becomes habitual, and is one of the most prominent, and, at the same time, most annoying symptoms. Physical signs are those of anaemia: systolic murmurs over the apex of the heart, and humming sounds over the jugular veins. The latter are the most constant. 3. "Respiration is frequently dyspnceic, especially after any exertion; the patients sigh and cough occasionally 4. Muscular system. Great weakness; easily tired and exhausted. 5. Nervous system. Dizziness; headache; noise in the ears, especially in the right ear; pains in different parts of the body, especially in the stomach and back; even hysterical spasms; sadness; want of energy; frightful dreams; nightmare, melancholy, and even mania, and inclination to self-de- struction. 6. Digestion. Want of appetite; digestion slow; sour and foul eructa- tions; desire for sour things; morbid desire for chalk, paper, ashes, coals, even excrements. Often the most indigestible things — pork, beans, pastry, etc. — suit better than light soups, meat, etc. However, these digestive symptoms are, in some chlorotic persons, entirely wanting. 7. Genital sphere. There is generally amenorrhcea or irregular men- struation with pain; thin, watery leucorrhcea in place of the menses, or in some cases menorrhagia. Chlorosis is often combined with hysteria and chronic paroxysms; also Basedow's or Graves' disease stands in undoubted connection with it; and other neuroses, such as cardialgia, headache, toothache, backache, etc., are found as frequently in chlorosis as in anaemia. Its Duration is variable ; under proper treatment it may }deld in a com- paratively short time; otherwise it may last for years. Marriage sometimes relieves at once. Complications, such as acute febrile disease, phthisis, endocarditis, gastric ulcer, etc., of course, change its favorable prognosis. Therapeutic Hints. A?it. cnid. Menses commence at an early period, are profuse and cease afterwards; great deal of headache; peevishness; loss of appetite; irregular stool; excessive laziness and weakness, must lie down for hours; deep and unrefreshing sleep at night. Arsen. Trembling; frequent fainting; excessive debility; pernicious anaemia. Bellad. Laziness and indisposition to work or stir, great general de- bility, with 'weariness and a desire to sleep in the afternoon; shortness of breath; extreme paleness of the face changes instantaneously to redness, with cold cheeks and hot forehead. Bryon. All the symptoms worse from the slightest motion. Calc. card. Scrofulous diathesis; disposition to colds and diarrhoea; great weakness or curvature of the spine; vertigo, especially on going up stairs; disgust for meat; craving for sour and even indigestible things (chalk, coal, etc.); after eating, swelling of the stomach and palpitation of the heart; THERAPEUTIC HINTS TO CHEOROSIS. 843 menses sometimes too often and too profuse, or wanting; leucorrhoea; great weakness of breath; great weakness of the muscles; walking wearies and makes the heart palpitate; sitting causes severe backache and headache; therefore constant inclination to lie down; hands and feet are cold; the fingers sometimes appear dead. The mind is generally full of concern about imaginary things that might happen to her. Card. veg. When complicated with itch and fluor albus; the gums are swollen, scorbutic and receding from the teeth; the teeth are loose; feels wretched all over; can scarcely walk. China. In such cases as result from loss of vital fluids, menstrual or vicarious bleeding, suppurations, etc. ; or which set in after severe and pro- tracted illness, such as intermittent fevers, typhus, cholera, etc. ; showing in either case a tendency to dropsical effusions and oedematous swellings. Be- sides we observe sour belching, poor digestion, bloated abdomen. Cina. On drinking wine she shudders as though it were vinegar; spas- modic yawning; headache, pain in the chest and back, caused by fixing the eyes steadily upon some object, as, for example, when sewing; all these pains are aggravated by external pressure; spells of intermittent fever every after- noon at four o'clock, w T ith thirst and coldness of the hands and feet; colic and vomiting of ingesta; afterwards heat and sweat, followed by deep sleep. Conium. Menses wanting; genitals very sensitive; constant dry heat all over, without thirst; stitching pain in the region of the liver, and heavi- ness in the limbs; weeping mood; restlessness; great concern about any little thing that may happen; anxious dreams. Cuprum. Disposition to laryngeal and tracheal affections, to vomiting and purging; sweating of feet; torpid cases. (Von Grauvogl.) Cyclam. Suppressed menses; or scanty, painful menstruation; head- ache; vertigo; swollen eyelids; pale face, lips and gums; loss of appetite; no thirst; constipation; palpitation of the heart; constant chilliness; dread of fresh air; disinclination to move and to work; constant drowsiness; wants to be alone, and weeping does her good. Is very similiar to Pulsat. differing, however, from it, by its dread and disinclination for tresh air. Ferrum. Anaemia, characterized by great paleness of all the mucous membranes, especially that of the cavity of the mouth, by the bellows-sound of the heart and anaemic murmur of the arteries and veins; by great paleness of the face, which, however, is very apt to suddenly become fiery red, with vertigo; ringing in the ears; great palpitation of the heart and dyspnoea; thus showing a disposition to congestion and fluxion of the blood to these parts of the body. All the muscles are feeble and easily exhausted from slight exertion ; there is frequent vomiting of ingesta, especially after eating and frommotiom; cardialgia; the menses are either suppressed or watery; we observe general emaciation; oedematous swelling of the body; cool skin: constant chilliness and evening fever, simulating very closely hectic fever. — Florid cases, with disposition to phthisis, haemoptysis, menorrhoea, scrofulous inflammation of eyes, diarrhoea, ascarides, etc. (Von Grauvogl.) 844 THERAPEUTIC HINTS TO CHLOROSIS. Graphit. Scanty, pale, delaying menses, or they do not appear at all; cold vagina; aversion to coitus; oedema of the eyelids, external genital or- gans and abdominal parietes, leaving on pressure the imprint of the finger; face pale and yellowish. Ignat. Sensitive, nervous, hysteric women, who are inclined to spas- modic and intermitting complaints, and where the trouble is induced by mental emotions, such as fright, grief, disappointed love, etc. Ipcc. Headache, as though the brain were mashed, with nausea and vomiting; miliary eruptions on the forehead and cheeks by spells; pale face and pale mucous membranes; weak pulse; cold hands; morose, enjoys noth- ing. Natr. mur. In chronic cases and cachectic individuals, with dead, dirty, withered skin; frequent palpitation and fluttering of the heart; sup- pressed menstruation; leucorrhoea; diminished sexual desire; oppression and anxiety of the chest; sadness. Nux vom. Especially in those cases in which the functions of the stomach, intestines and liver are principally affected, and we may observe a train of symptoms like the following: irritable, angry disposition; great anxious concern about little things; headach, with bilious or sour vomiting, worse in the morning; pale, earthy face; feeling badly after eating bread or sour things; sour taste in the mouth; craving for chalk ; nausea and vomit- ing in the morning or after eating; cardialgia, with wind in the stomach, better from drinking something hot; obstinate constipation; running of the nose through the day, and stoppage of it at night; sore feeling all over in bed in the morning; dreads motion and fresh air; gets awake earty in the morning, then dozes again and wakes up finally, feeling much worse than at any other time. Phosphor. In deep-seated, chronic cases, with tubercular diathesis; brought on by depressing mental influences, such as grief, worriment, disap- pointed love, or by exhausting bodily causes, such as night- watching, loss of blood, diarrhoea, night-sweats, onanism, etc. We observe, in such cases, puffiness around the eyes, dry, hacking cough, great weakness in the sexual organs, consequent upon previous irritation of these parts; leucorrhoea of a whitish, watery, slime, especially profuse during the time of the menses, sometimes acrid and corroding; a total loss of energy in all the organic func- tions of the body. Plumbum. Want of breath and great oppression of the chest from motion; palpitation of the heart; obstinate constipation; oedema of the feet and anasarca; great muscular weakness. Pulsat. Great weakness and sluggishness in the circulation, manifest- ing itself in constant chilliness, coldness and paleness of the skin and face, with hot flashes and transitory redness of cheeks; soft, irregular pulse and palpitation of the heart, oppression of the chest and shortness of breath; disinclination to move and a sad and tearful disposition; the appetite is generally absent, and there is no thirst; the whole digestion is disturbed, DIGEST TO CHLOROSIS. 845 and consequently the assimilation of nutriments for the blood does not take place properly. We observe, therefore, signs of anaemia, such as dizziness especially when rising, and amenorrhcea, or scanty, slimy menses, which appear too late; in general the patient feels better in the open air. This distinguishes Pulsat. from Cyclam. It is frequently indicated after Calc. card. , Ignat. , Septa or Sulphur, and is followed well by Ferrum. Disposition to intermittents, melancholia, hysteria, heart and kidney diseases, discharge from ears, (von Grauvogl.) Sabina. Amenorrhcea; frontal headache, pressing down upon eyes, worse in morning on rising, better in fresh air; blue rings around eyes; nausea and qualmishness when in a crowd; burning in pit of stomach, with twisting and gurgling in bowels; bearing down; drawing pain in extremities; worse at night; lassitude and sleepiness. (Watzke.) Sepia. Bearing down as if everything would issue out of the genitals; prolapsus uteri and vagina; brown-reddish color of the vagina; diphtheritic ulcers in the vagina and on the labia; leucorrhcea, yellowish and passing away in starts; swelling of the external genital organs, with itching, burning and soreness; stitching pains in the ovarian region; palpitation of the heart, intermitting pulsation; occasionally a hard thump of the heart; frequent sickness at the stomach ; brought on even by the smell of cooking. Uneasi- ness in the presence of strangers; sudden flushes, starting at trifles; tongue coated most at root, clearing off in patches, leaving red surface; no menstruation. Sulphur. Heat of the head with cold feet; inclination to religious reve- ries; inflammation of the eyelids; frequent, unsuccessful desire for stool; leucorrhcea; oppression of the chest with palpitation of the heart; exhaustion even from talking; feels worse while standing; cutaneous eruptions; sleepy in the daytime, restless at night; perspires easily; feels faint before dinner. Is often necessary as 4 a foundation for the better action of other remedies. Besides compare: Alet. far., Alum., Helon., Senedo aur. Digest to Chlorosis. Inclination to religious reveries: Sul- phur. Wants to be alone: Cyclam. Inclination to lie down: Calc. carb. Indisposition to work or stir: Bellad., Calc. carb. to move: Pulsat. , and general debility: Bellad. Laziness: Ant. crud., Bellad. Uneasy in the presence of strangers: Sepia. Anxious about little things: Conium, Nux vorn. imaginary things : Calc. carb. Sadness: Natr. mur. Sad, tearful disposition: Pulsat. I Weeping mood and restlessness: Co- nium. Melancholy, hysterics: Pulsat. Irritable, angry: Nux vom. Morose, enjoys nothing: Ipec. Peevish: Ant. crud. Starting at trifles: Sepia. Vertigo: Cyclam. when rising: Pulsat. on going up stairs: Calc. carb. , with sudden redness of face: Fer- rum. Headache: Ant. crud., Cyclatn. , as though the brain were mashed, with nausea and vomiting: Ipcc. 846 DIGEST TO CHLOROSIS. , with bilious or sour vomiting, worse in the morning: Nux vom. , frontal, pressing down upon the eyes, worse in morning on rising, better in fresh air: Sabina. and pain in chest and back, caused by fixing the eyes steadily upon some object, when sewing; worse from exter- nal pressure: Cina. and backache from sitting: Calc. card. Heat of head, with cold feet: Sulphur. Disgust for meat: Calc. curb. No thirst: Cyclam. x Pulsat. Eyelids inflamed: Sulphur. swollen: Cyclam. cedematously: Graph it. Around the eyes, puffmess: Phosphor. , blue rings: Sabina. Ears, ringing in: Ferrum. , discharge from: Pulsat. Nose, running through day, stoppage at night: Nux vom. Face pale and earthy: Nux vom. and yellowish: Graphit. , and pale lips and gums: Cy- clam. , and pale mucous membranes: Ipec. , changing suddenly to fiery red, with vertigo: Ferrum. , , with cold cheeks and hot forehead: Bellad. , miliary eruptions on forehead and cheeks by spells: Ipec. Mucous membrane of mouth pale: Ferrum. Teeth loose, gums swollen, scorbutic and receding from teeth: Carb. veg. Tongue coated at root, clearing off in patches, leaving red surface: Sepia. Before dinner, feels faint: Sulphur. After eating, swelling of stomach and palpitation of heart: Calc. carb. bread or sour things, feels badly: Nux vom. On drinking wine she shudders as though it were vinegar: Cina. No appetite: Ant. crud., Cyclam., Pul- sat. Craving for chalk: Nux vom. for sour things and indigestible things (chalk, coal, etc.): Calc. carb. Belching: China. Nausea when in a crowd: Sabina. from the smell of cooking: Sepia. and vomiting after eating and from motion: Ferrum. , and in the morning: Nux vom . Vomiting of ingesta and colic: Cina. Burning in pit of stomach, with twisting and gurgling in bowels: Sabina. Cardialgia, with wind in stomach, worse from drinking something hot: Nux vom. Indigestion: Pulsat. and bloated abdomen: China. Stitching pain in liver region: Carb. veg. Constipation: Cyclam., Nux vom'., Plumbum. Irregular stool: Ant. crud. Frequent, unsuccessful urging: Sulphur. (Edema of abdominal parietes: Graphit. Ovarion region, stitching pain in the: Sepia. Prolapsus uteri and vaginae: Sepia. Bearing down: Sabina, Sepia. Sexual desire diminished: Natr. mur. Aversion to coitus: Graphit. Weakness of sexual organs after pre- vious irritation: Phosphor. Menses too early and too profuse: Calc. carb. commence at an early period, pro- fuse, but cease afterwards: Ant. crud. wanting or suppressed: Ant. crud., Calc. carb., Conium, Cyclam., Ferrum, Graphit,, Natr. mur., Pulsat., Sabina, Sepia. scanty, painful; Cyclam. , pale, delaying: Graphit. , slimy, too late: Pulsat. watery: Ferrum. Instead of the menses, whitish, watery, slimy, profuse, sometimes acrid and cor- roding leucorrhcea: Phosphor. Leucorrhcea: Calc. carb., Carb. veg., Natr. mur., Sulphur. yellowish and passing away in starts: Sepia. Vagina cold: Graphit. of a brown reddish color: Sepia. DIGEST TO CHLOROSIS. 8 47 , diphtheritic ulcers in: Sepia. External organs oedematously swollen: Graphit. , with itching, burning and sore- ness: Sepia. Genitals very sensitive: Conium. Dry, hacking cough: Phosphor. Oppression of chest and shortness of breath: Bel lad., Calc. carb., Pulsat. and want of breath from motion: Plumbum . and anxiety of chest: Natr. mur. and palpitation of heart: Ferritin, Sulphur. Palpitation of heart: Cyclam., Plum- bum, Pulsat., Sepia. and fluttering: Natr. mur. from walking: Calc. carb. Hard thump of heart, occasionally, and intermitting pulsation: Sepia. Bell0WS-S0nnd in heart and anaemic murmurs in arteries and veins: Fer- ?'um. Soft, irregular pulse : Pulsat. Weak pulse: Ipec. Curvature of spine: Calc. carb. Spasmodic yawning: Cina . Constant drowsiness: Cyclam. Sleepy and lassitude: Sabina. and weary in afternoon: Bellad. in daytime, restless at night: Sul- phur. Deep and unrefreshing sleep at night: Ant. crud. Wakes early in the morning, dozes again and feels worse afterwards: Nux vom. Anxious dreams: Conium. Cold hands: Ipec. , fingers sometimes appear dead: Calc. carb. and feet; feet damp: Calc. carb. Cool skin: Ipec. Constant chilliness: Cyclam. and evening fever, similar to hectic fever: Ferrum. Intermittent fever at 4 p. m., with thirst and coldness of hands and feet: Cina. Chilliness, coldness and paleness of skin and face, with hot flashes and transitory redness of cheeks: Pulsat. Sudden flushes: Sepia. Heat and sweat, followed by deep sleep : Cina. Dry heat all over, without thirst: Co- nium. Perspires easily: Sulphur. Drawing pain in extremities, worse at night: Sabina. Heaviness in limbs: Conium. Wretched all over, can scarcely walk: Carb. veg. Must lie down for hours: Ant. crud. Muscular weakness: Calc. carb., Plum- bum. , easily exhausted from slight exer- tion: Ferrum. Debility, trembling, fainting: Arsen. Exhausted from talking: Sulphur. Sulphur. and cedematous Cutaneous eruptions Dropsical effusions swellings: China. (Edematous swelling of body: Ferrum of feet and anasarca: Plumbum. Better in open air: Pulsat. from weeping: Cyclam. Worse from motion: Bryon. while standing: Sulphur. Dreads fresh air: Cyclam. and motion: Nux vom. Caused by mental emotions, fright, grief, disappointed love: Ig?iat., Phos- phor. loss of vital fluids: China. , night- watching: Phosphor. protracted illness: China. COMPLICATED WITH: A disposition to heart and kidney dis- eases: Pulsat. stomach, liver and intestinal affec- tions: Nux vom. laryngeal, tracheal and intestinal affections: Cuprum. phthisis, haemoptysis, menorrhcea, scrofulous inflammation of eyes, diar- rhoea, ascarides, etc.: Ferrum. tubercular diathesis: Phosphor. cold and diarrhoea: Calc. carb. itch and fluor albus: Carb. veg. 848 SCURVY, SCORBUTUS. intermittent affections: Ignat., Pul- sat. dead, dirty, withered skin: Natr. mur. sweating of feet: Cuprum. Total loss of energy in all the functions of the body: Phosphor. Pernicious anaemia: Arsen. Cyclam. is similar to Pulsat. , but distin- guished by its dread to fresh air. Pulsat. is frequently indicated after Calc. card., Ignat., Sepia, or Sulphur, and is followed well by Ferrum. Sulphur is often necessary as a founda- tion for the better action of other remedies. Scurvy, Scorbutus. This disease belongs to the general disorders of nutrition, and is charac- terized by an intense general cachexia in connection with various local erup- tions, and disorders of a hemorrhagic and haemorrhagico-inflammatory char- acter, most constantly observed in the gums. The occurrence of scurvy so extraordinarily frequent in the middle ages, has become much less frequent in our times; but it is still occasionally ob- served on the land in times of famine, in places undergoing siege, in poorly ventilated dwellings, and in cold and damp regions and seasons; on the sea during long voyages upon sailing vessels, and especially when a gloomy and anxious state of mind and poor food enter this combination of circumstances. As regards food there is no doubt, that a deficiency of fresh meat and vege- tables, especially potatoes and greens, induces the disease in many cases. And because these articles of diet contain a greater percentage of potash, than salt meat, dried beans and the like, some authors have unreservedly laid the cause of scurvy in a deficiency of potash in the food. This, however, is obviously wrong, since many outbreaks of scurvy are recorded where there was no lack of these articles. Hence, it can also be seen that a mere dietetic treatment will not always suffice for a cure. But there are still other con- ditions mentioned under which scurvy has been seen to develop, namely: convalescence from typhus and acute exanthemata, surgical diseases, especi- ally in military hospitals, and the dwelling together of old people in bene- ficiary hospitals. Its onset is usually insidious and its course lingering. We ob- serve at first a general debility, lassitude, sleepiness and depression of spirits; a sad-looking, pale, cachectic face, with blue rings around the eyes; loss of appetite, except perhaps in some cases a craving for fresh green or sour things; the stool is slow, the urine scanty and the skin dry. With all this there are aching pains, especially in the popliteal space, with circumscribed hardness and a light bluish color. After a few days the gums become swollen, spongy and bluish; they bleed at the slightest touch. There is a bad taste in the mouth and a fetid breath. The general debilit}' increases; ecchymosed spots appear on the skin; first on the legs, later all over the body from the size of a lentil to that of a half dollar and larger, at first looking purple, in severe cases black, later changing into all the different hues which extra vasted blood undergoes; frequent nosebleed. All these symptoms may reach a still higher degree; the weakness may augment to prostration, so that even the slightest exertion or motion causes fainting; the THEPAPEUTIC HINTS TO SCURVY, SCORBUTUS. 849 gums may issue a fetid, ichorous, bloody fluid; the ecchymosed spots may change into blisters, rilled with ichorous fluid and forming ulcers. The pain in the extremities may grow still more severe, and the joints and bones may swell; effusions of fibrin beneath the skin may harden the legs like boards. The hard stools may change into a thin, ichorous and bloody diarrhoea, with colicky pains. The spleen is usually enlarged. Epistaxis in- creases, and there are even bloody secretions from the conjunctiva, respira- tory organs, stomach (by vomiting), and from the urinary organs, in the form of blood}^ urine. If to all these symptoms be added extravasation of bloody serum into the pleura, the pericardium, the lungs, the brain or its membranes, the pa- tient generally dies, either suddenly or gradually in consequence of increas- ing prostration and hectic fever. Of course, all cases do not terminate thus. Its duration, however, is long, lasting months, and convalescence is very slow, if left to nature. Therapeutic Hints. The special cases which have been brought on by a deficiency of certain articles of food should certainly be supplied with these articles, as a matter of course, where it can be done. In other cases which owe their origin to other causes, the mere feeding with greens and acids will certainly be of no avail. We shall have to look again for help in the law of similars. Agave America?ia. Countenance pale and dejected; gums swollen and bleeding; left leg, from ankle to groin, covered with dark purple blotches; leg swollen, painful and of stony hardness; pulse small and feeble; appetite poor; bowels constipated. Amm. carb. Hectic fever, profuse haemorrhages from the intestines, nose and gums; falling out of the teeth; muscles soft and flabby; emaciation. Arsen. The gums bleed readily; fetid smell from the mouth; violent thirst, which obliges him to drink frequently, although but little at a time; offensive diarrhoea; excessive debility; stiffness and immobility of the knees and feet, with violent tearing pains, worse about midnight, better from ex- ternal warm applications; great despondency and restlessness. Canthar. Pains in the gums; coagulated blood in the mouth; early in the morning, in bed; bloody urine. Carb. veg. Swelling, receding, and bleeding of the gums; nosebleed; readily bleeding ulcers; general physical depression; attacks of sudden weak- ness, like fainting; after too much salty food. Cki?ia. Inertia; excessive debility ; haemorrhage from the mouth, nose and intestines; great desire for sour things; diarrhoea. Hydrast. Physical prostration; fainty, weak feeling; ulcers on the legs. Kali phosph. Easily bleeding gums; putrid decomposition; prostration. Mercur. Spongy, bleeding gums, of a sickly appearance; they look white along the upper border and recede from the teeth; bluish color of the 54 850 PURPURA HEMORRHAGICA. inner cheeks; fetid smell from the mouth. Sinking with an indescribable malaise of body and soul, obliging him to lie down; fetid ulcers on the legs, which speedidly become putrid; spongy, bluish, readily bleeding ulcers. Mur. ac. Swelling of the gums; scorbutic gums. Natr. mur. Scorbutic, putrid inflammation of the gums; bloody saliva; difficulty of talking, as if the organs of speech were weak. Nitr. ac. Swelling and bleeding of the gums; the teeth are loose; bloody saliva; putrid smell from the mouth; after abuse of Mercury. Nux vom. Putrid bleeding; swelling of the gums; putrid ulcers in the mouth; cadaverous smell from the mouth; bloody saliva; spitting of blackish, coagulated blood, and blowing blood from the nose; pain in the limbs; great weariness and languor. Phosphor. The gums bleed easily and stand off from the teeth; sore, excoriated spots on the skin; ecchymosed spots. Staphis. The gums are painful to touch and bleed easily on being touched; scrobutic ulcers. Sulphur. Swelling of the gums, with throbbing pain in them; bleeding; fetid smell from the mouth; sleeplessness at night; desire for brandy. Besides, compare Cistus can., Crotal., Hepar, Kreos., Sepia, Sulph. ac. y Terebinth. Purpura Haemorrhagica, Morbus Maculosus Werlhofii. This is a transitory haeaiorrhagic diathesis of sporadic occurrence and a relatively brief duration, the etiology of which is entirely unknown; its de- velopment appears spontaneous. In this apparent spontaneity of its occurrence, without regard to age, previous health, or inherited predisposition of the individual attacked, it dif- fers from haemophilia, scurvy, and symptomatic tendency to bleeding, which is frequently observed as a consecutive or accompanying symptom of certain severe and acute or chronic diseases, such as variola, typhus exanthematicus, phosphorus-rJoisoning, leukaemia, pernicious anaemia, protracted icterus, etc. It often begins suddenly, without prodromal warnings, with petechiae upon the skin or epistaxis; at other times its outbreak is preceded, for sev- eral days, by languor, headache, loss of appetite and even moderate fever. In still other cases it commences with rheumatic pains in the lower extremi- ties especially the knees and ankles, when it has been called Purpura rheu- matica or Peliosis rheumatica. (Schoenlein.) The haemorrhagic exanthem may extend over the entire body, and the individual spots vary greatly in size, from that of a pinhead to that of a len- til, a pea or a bean. The larger ecchymoses are rare, and assume every pos- sible shape. These maculae are often interspersed with more or less numerous vesicles, which are evidently produced by circumscribed haemorrhages into the rete Malpighi from capillary loops of the papillae of the skin. The color of the maculae, when fresh, is dark bluish-red; later it changes successively to greenish-blue, brown and yellow. Pressure does not alter the appearance. H^MOPHIUA. 851 It is exceedingly common for fresh crops to appear at varying intervals dur- ing the disease, which brings ab|^ut the various colors of the different ages of these maculae. As long as the disease manifests itself as a mere cutaneous eruption, it is called Purpura simplex ; when, however, it is attended by haemorrhages in other parts, it is called Purpura hemorrhagica. Such haemorrhages may ake place from the mucous membrane of the nose, mouth, stomach, intes- tines, urinary passages, genitals in women, and bronchi; they are much more common in morbus maculosus than even in severe cases of scurvy; but th bluish-red discoloration, the softening, swelling and spongy character of the gums, and the excessive sensitiveness of these parts, which is characteristic of scurvy, are entirely wanting. Haemorrhages occur exceptionally also within the serous cavities, in the meninges and in the substance of the brain. Simple cases pass over in a week or two; repeated and profuse haemorrhages may induce anaemic pallor, dropsical swellings, extreme weakness, fainting fits, etc. Therapeutic Hints. Compare, as the most important remedies, Crotal., Phosphor., Ledum, Bryon., Hamam., Secale, Arnica, Arsen., Ferr. p/wsp/i., Laches., Sidph. ac; and in cases of Epistaxis, Haematemesis, or Haematuria, the corresponding chapters. Heemophilia, Haemorrhophilia. By this name is meant a congenital haemorrhagic diathesis, in conse- quence of which even the slightest wounds, no matter where, always bleed very profusely. The cause is unexplainable; we only know that this ten- dency to bleed exists in certain families, and is propagated^ to three or four generations; sometimes leaping over one link and appearing again in the following. The female members of such families are generally, although not always, exempt, but they are very apt to propagate this tendency to their male children. There are no objective signs by which this diathesis could be recognized before the bleeding sets in. Such persons, however, are described as having blonde or reddish hair, a very fair skin, with tlie blood-vessels shining through, and blue eyes. In some cases it shows itself immediately after birth, as an uncontrollable bleeding of the navel; oftener during the first or second dentition, and in other cases still later. Then the blood oozes unin- terruptedly from the slightest wound, as out of a sponge, until the patient becomes exhausted from loss of blood. Mere bruises cause large effusions of blood into the cutaneous and subcutaneous tissues. Spontaneous bleedings from the nose, which are by far the most frequent, or from the lungs, stomach, intestines, or kidneys, do not take place until after several bleedings from external wounds. Such spontaneous internal haemorrhages are mostly 852 SCROFULOSIS. preceded by palpitation of the heart, oppression, congestion to the head, pain in the limbs, and, in some cases, by painful swellings of the knee and ankle- joints. Bleeders seldom reach an old age; in some cases, however, this ten- dency to bleed gradually diminishes with the advancing years, and ceases en- tirely at last. Therapeutic Hints. It seems that Phosphor, must be the main remedy. Compare likewise Secale, and for internal bleeding those chapters which treat of the correspond- ing haemorrhages. Eriger. is said to be very efficacious; also: Natr. sulph., Crocus. China, Arsen., Hamam. Scrofulosis. • We understand by this term a^ cachexia which manifests itself as a nutritive disturbance in the external skin, the mucous membranes, joints, bones, organs of sense, and, above all, in the lymphatic glands, insuch a manner that individuals thus affected betray the internal disorders by a peculiar habitus. According as the faulty nutrition leads either to an accu- mulation of fatty deposits in certain parts of the body, or to a deficiency in fat on account of too rapid growth, scrofulosis has been divided into a torpid and an erethic form. The habitus of the first Canstatt portraits in the fol- lowing manner: ' ' uncommonly large head; coarse features; thick, swollen nose and upper lip; broad cheek-bones; large belly; swollen glands on the neck; soft, nappy muscles." The erethic form he characterizes as follows: '*' conspicious white skin, which reddens easily, and through which the blood- vessels shine forth; red lips and cheeks; bluish color of the sclerotica, which gives to the eyes an expression of languor; the muscles of such individuals are thin and flabby; the w r eight of the body does not correspond with their size, showing a want of solidity of the bones; their teeth are fair, bluish, glisten- ing, long and narrow, and their hair is soft." The majority of cases, how- ever, lie between these two extremes, or represent a mixture of the charac- ters of both, as it happens with all such classifications. The special changes in the skin are eruptions, which usually have their seat in the face and on the scalp, and the} T consist of a superficial dermatitis, with exudation of lymph upon the free surface, constituting eczema or im- petigo, or as they are likewise called, tinea or porrigo, etc. Destructive processes, like forms of lupus, do not take place until sometimes at a much later period. The scrofulous affections of the mucous membranes involve most gen- erally by their secretion the adjacent parts of the exteral skin; thus we find that a scrofulous conjunctivitis, otitis or coryza is generally attended by an eczema either on the cheeks or about the entrance to the ear or on the upper lip. Bronchial and intestinal catarrhs, or catarrhal affections of the urinary or sexual organs of scrofulous individuals, are generally of an obstinate char- acter. SCROFULOSIS. • 853 The scrofulous affections of the joints manifest themselves either as dropsical effusions, or as the so-called white swellings, or even as suppurat- ing processes, constituting caries of the bone-ends and destruction of the capsular ligaments, as found in coxitis, gonarthrocace, etc. The bones themselves are attacked by inflammation of their texture or lining, constituting either osteitis or periostitis, or caries, or necrosis, or all combined. Scrofulous affections of the organs of sense manifest themselves in the eyes, either as inflammation of the Meibomian glands, or as conjunctivitis or corneitis, which latter not unfrequentfy leaves behind spots and cicatrices upon that organ; in the nose, as obstinate coryza, or, although only in quite rare cases, as lupus; in the ears, as otitis, which may terminate even in de- struction of the petrous portion of the temporal bone. The greatest nutritive disturbances are sustained by the lymphatic glands of scrofulous individuals. Everywhere, where there is an inflammatory pro- cess of the skin or in the mucous membranes, we find the adjacent lymphatic vessels and glands participating in that process. The glands swell and in- flame, and the inflammation spreads from the parenchyma of the glands to the surrounding cellular tissue, causing suppuration and abscesses, which are of slow growth and great obstinacy, leaving on healing almost always ugly cicatrices. We find these glandular abscesses most frequently in the cervical region. But the lymphatic glands of scrofulous individuals swell also with- out any inflammation of neighboring organs. This is almost a pathognomonic sign of scrofulosis. We sometimes find whole convolutes of these glands enormously enlarged. The Exciting Cause of these pathological changes in the lymphatic glands is now generally conceded to be the bacillus tuberculosis of Koch , and, in fact, scrofulosis has been called chronic tuberculosis of the lymphatics, When the}- inflame and suppurate, they form, as above stated, abscesses, which break; in other cases, the puriform matter becomes desiccated into a cheesy mass, and may be finally transformed into chalky substance, when it appears under the skin as a hard, uneven protuberance. Such chanVy masses not unfrequently irritate the adjacent parts, and give rise to troublesome inflammation and suppuration of the glands. The main seat of these glandu- lar swellings is the cervical region, especially behind the ears and under the lower jaws, extending sometimes as far down as the shoulders. But the bronchial and mesenteric glands also are not unfrequently the seat of this nu- tritive derangement. The scrofulous diathesis can be inherited from scrofulous or tuberculous parents, although children from such parents may be entirely free from any scrofulous taint. It has also been attributed to parental tertiary syphilis, carcinoma, advanced age, or when parents have been near relatives. Acquired it may be by podr or faulty diet, or by the want of exercise and fresh air; frequently by the joint action of different unhealthy influences. Its course is always chronic; sometimes periodically improving, and then 854 THERAPEUTIC HINTS TO SCROFULOSIS. growing worse again. Its worst feature is its tendency to make children prone to the worst forms of illness of childhood, such as croup, hydrocephalus and tuberculosis, with which they combine and which they aggravate. Statistics show that most of the victims of these diseases are scrofulous chil- dren. Therapeutic Hints. Compare in general, as the most important remedies, Aln. rub., Asa/., Aurum, Badiaga, Baryt. card., Bellad., Calc. card., Calc. phosph., Cistus, Conium, Hepar, Iodium, Lycop., Mercur., Natr. mur., Rims tox., Sepia, Silic, Sulphur. Theridion "I always interpolate, when the best chosen remedies fail, and allow it to act for at least eight days." (Baruch.) For special hints, reference is made to the special ailments under their respective heads, and to Goullon's Scrofulous Affections, translated by E. Tietze, M. D. ACUTE INFECTIOUS DISEASES. The acute infectious diseases form a group which are caused by specific pathogenic micro-organisms, be they bacteria as in typhoid fever, protozoa as in malaria, or fungi as in actinomycosis. Many are epidemic and contagious. Infectious is now applied to those diseases caused by specific pathogenic micro-organisms, -the term contagious on the other hand is applied in refer- ence to the manner of transmission of a disease, and not in reference to its causative agent. Fever. Fever is characterized by an increase of temperature of the body, and a rapid consumption of the tissues. # Without an increase in the natural heat of the body, there is no fever. It is necessary, therefore, to know something about — Clinical Thermometry. The normal temperature in the axilla of a healthy person ranges between 97.25 and 99. 5 F.; the mean is 98.6° F. or 37 ° C. This temperature is nearly the same in all climates and keeps its standard alike in summer and winter. Its daily oscillations are most marked after meal-times, when there is a slight rise The mean temperature we find a short time before the main meal, its maximum about four hours after the main meal, and its minimum in the night hours. In order to ascertain the degree of temperature of a person it is sufficient that the bulb of the instrument be held for five or ten minutes firmly in the hand, or, what is much more preferable with patients, to insert the bulb into the axilla, taking care that it be entirely surrounded by the adjacent parts. This is easily secured by slightly pressing the upper arm against the chest. In this way the instrument is kept in a firm position, and after the lapse of five or ten minutes the quicksilver partakes of the same degree of warmth as the surrounding parts, and its expansion can easily be read on the scale of the instrument. However the self-registering clinical thermometer for use in the mouth or rectum is the most satisfactory for general use. "A normal temperature does not necessarily indicate health; but all those whose temperature either exceeds or falls short of the normal range are unhealthy." "The range of temperature in severe diseases is between 95 ° F. and 856 CLINICAL THERMOMETRY. 108. 5 F., and very seldom falls below 91. 4 F., or rises to 109. 4 F., though in rare cases it has reached 112.55 F." " Alterations of temperature may be confined to special regions, whilst the rest of the body remains almost normal; they seldom exceed i.8° to 2 F." "A rapid increase in the heat of the body, and decrease of the heat of the extremities, is associated with 1 cold shivers, rigors, fever-frost.' " ' ' A protracted temperature of 101.3 F. , or more, is usually accompanied with heat, lassitude, thirst, headache, frequency of pulse; if persisting, with diminution of body- weight, ' pyrexia,' fever, fever-heat." ''Any consider- able diminution of warmth in the extremities, with very high, or very low central temperature, is expressed by a small pulse, sunken features, weak- ness, nausea, cold sweating, collapse." 11 Temperatures much below 96. 8° F. are ' collapse ' temperatures. Below 92. 13 F. deep, fatal algide collapse. 92. 3 to 95 F. algide collapse with great danger, still with possibility of recovery. 95 to 96. 8° F., moderate collapse, in itself without danger. 99. 5 to 1 00. 4 F., sub-febrile temperature. 100. 4 to 101.12 F., slight febrile action. 101.3 to 102. 2 F. in morning, rising to 103. i° F. in evening, moderate fever. 103. 1 ° F. in morning and about 104 F. in evening, considerable fever. 103. 1 ° F. in morning and above 104.09 F. in evening, high fever. 107. 6° F. and above indicates a fatal termination, except in relapsing fever; hyperpyretic temperatures." 1 ' There is often a contrast between the temperature and the frequency of the pulse ; though, as a rule, slight febrile heat coincides with a pulse of 80 to 90; moderate fever with 90 to 108; considerable fever with 108 to 120; extreme heat with 120 and upward per minute." ' ' A pulse rather slow in proportion to the temperature is favorable as in- dicating a tranquil nervous system. A low pulse with high temperature in- vites us to look for spinal cause, as pressure on the brain, depressing action of drugs, etc." ' ' A low temperature and frequent pulse points to local complications in the thorax or pelvis. Not forgetting, however, that moving accelerates the pulse. ' ' ' ' The number of respirations per minute does not correspond so closely to the temperature as the frequency of the pulse. In collapse there is often (not always) a frequency of respiration, and in slight fever of childhood also; in moderate fever the respirations amount to 20 or so per minute; in children to 40 or 50. In considerable or extreme degrees of fever they are higher yet, 60 in many cases; movement also increases their frequency. In other cases a quickened respiration indicates local causes." {Medical Thermometry and Hu7)ian Temperature, by Wunderlich and Seguin.) CRISIS AND CRITICAL DAYS. 857 The temperature in special diseases is stated in the corresponding chapters. Crisis and Critical Days. Already Hippocrates, in the twenty-fourth aphorism of the second book, teaches in regard to critical da}^s as follows: " Of seven days, it is the fourth that is indicative. With the eighth day begins the second week. The eleventh again must be observed, because it is the fourth day of the second week. So also must be noticed the seventeenth day, as it is the fourth from the fourteenth and the seventh day from the eleventh." And in aphorism thirty-six, in the fourth book, he says: "Such sweats which occur in fever- patients on the 3d, 5th, 7th, 9th, nth, 14th, 17th, 21st, 27th, 31st or 34th day, are salutar}-, because they bring on a favorite turn in the disease. If sweats, however, occur on other days, they denote exhaustion, obstinacy and relapse of the disease. ' ' These remarks are no doubt the result of a large amount of observation on fever- patients, which, having been left to nature, afforded a clear basis for observation. As such they have been verified up to this day. As the most important of these critical days are acknowledged, according to von Grauvogl, the 3d, 5th, 7th, 13th and 21st. Why is it that these days should have more importance in the course of a disease than others? Is there any natural connection between these odd numbers and the diseased states of the body? The old school has acknowledged the Hippocratic facts, but has never succeeded in solving the perplexed question. Just as many other things, which belong to the interior vital workings, could not be solved until the higher light of Homoeopathy had been made to shine upon the organism, so also had this problem to wait until Dr. von Grauvogl caught the seemingly loose and unconnected threads between odd days and certain developments in disease, and showed their legitimate connection by nature's own laws. I shall try to condense his views on this subject as he has set them forth elab- orately in his Lehrbuch der Homceopathie . According to physiological experiments it appears that a living organis- mus, when it is subjected to a starving process, does not lose its bodily sub- stance evenly, but rather periodically, so that its greatest losses always fall upon the 5th, 8th and 13th day. Thus the operations in a living organism differ essentially from mere mechanical or chemical operation. If you, for example, expose a vessel with water to an equally dry atmosphere, it will lose its contents by evaporation evenly, just so much an hour. The living organism does not. It regulates its expenditures, or its losses, according to its own laws, which allows its receipts and expenditures to oscillate between a certain boundary, and make its operations to go 011 in regular periods. These periodical fluctuations are, therefore, the law of normal life, part and portion of all its evolutions in health and disease, and are not peculiar to states of disease. When, therefore, in diseases on the 3d, 5th, 7th, 13th, 21st and 35th day, a greater amount of losses sets in in the form of excretions, 858 INTERMITTENT FEVER. such as sweat, flow of urine, diarrhoea, etc., which is called the crisis, it is nothing more nor less than the same periodic oscillation which is going on continually in the living organism, and which becomes only more conspicuous in disease, because it is frequently followed by a decided improvement or death. It necessarily must become more conspicuous, because this periodical loss is added to the extra consumption, which is a condition of the acute dis- ease. If the physical state of the patient be such as to endure both, he, of course, must feel better the next day, when the periodical acme ceases; and he dies, if his physical power cannot endure the united action of both. Thus the critical days of the disease are nothing more nor less than the normal, periodical fluctuations of the living organism, with which they cor- respond; and the crisis is that critical day with its normally increased ex- cretions, which falls together with the height of the disease. These obser- vations are corroborated by the following facts: that the so-callled crisis does not appear, when, during the course of a disease, the organism is weakened by improper medication, because then the natural periodic fluctuation is dis- turbed and destroyed; and it does not appear when, by the application of the proper remedy, health is restored; because the periodic fluctuation alone is not conspicuous enough to be observed. It is, however, never wanting when the disease runs an undisturbed c ourse; and, in so far, it is an important means to distinguish between a suc- cessful and an unsuccessful treatment. This is the theory of Grauvogl. It may be proper to add some further conclusions as to the importance of watching the critical days during homoeopathic treatment. 1. The right remedy cures a disease without a crisis; and thus we have an indisputable proof that the selected remedy was the remedy. 2. Aggravations after a remedy, when they occur on critical days, need not be the result of the remedy, as the conjoined action of the disease and the periodical oscillation alone will cause them naturally. 3. When, after the administration of a homoeopathic remedy, a crisis takes place notwithstanding, we may be sure that we did not "hit" the case, and that the patient got well without our aid. 4. When no crisis appears, and the patient gets worse and worse, it is clear that we did not find the right remedy, and w T e may even have spoiled the case by wrong means. Lastly, it seems to explain the observation that in most chronic cases the well selected remedy develops its action visibly not before the eighth day, and that we then ought not to disturb its action, either by repetition or change, before the thirty-fifth day. Intermittent Fever, Fever and Ague. This fever is caused by a poison, which, under certain conditions, origi- nates in marshy lands, swamps, in low regions near rivers, in newly settled places which just came under the hand of cultivation; in the neighborhood INTERMITTENT FEVER. 859 of canals when first dug; in regions which seemingly lie dry, but contain a great deal of underground water; the dryer the surface the greater the effluvia from underneath the porous and cracked crust. This poison is called swamp-miasma, or malaria. Its nature is entirely unknown, but differs totally from typhus, smallpox, scarlatina and measles virus, as it never is propa- gated or carried from one person or place to another. Although swamps, damp, low regions, etc., are necessary for its development, yet they seem not the only conditions under which malaria is generated. Neither does the heat of the sun, the decay of vegetable substances, explain fully its presence here and its absence there; because there are large tracts of land where all these conditions exist without any sign of miasma; whilst, on the other hand, we find small, confined districts in which ague prevails every spring and summer. Another peculiarity of the poison is, that it seems to spread hori- zontally, so that it is often prevented from spreading further by a wall, a hedge, unless carried over these obstacles by a blast of wind. In those places where the miasma develops itself, ague prevails endemic ; but how widely spread epidemics of intermittent fever originate is wholly unexplain- able. So, also, have great ague epidemics been the forerunner of the Asiatic cholera; in hot climates both are often found together, and still more fre- quently go hand-in-hand, typhus fever, dysentery, influenza and ague; all which facts we cannot explain. Quite inexplicable is also the occurrence of sporadic cases in places where the miasma never prevails, and the attacked person had never been in a malarial region. Late researches point to the Plasmodium malarise (Hsematozoon of Laveran), as the probable micro-organism causing malaria. It is aproto- zoon found in the blood particularly during a paroxysm, attached most frequently to the red blood corpuscles, which it destroys. It exhibits amoe- boid movements. The liability to invasion by the miasma is a very general one; no age or sex being exempted. Unlike smallpox, scarlatina, etc., the liability to repeated attacks increase after the first invasion. Persons thoroughly satu- rated with the poison may not suffer any more with acute outbreaks of chills and fever, but are more subject to a chronic enlargement of the spleen and a malaria cachexia. The time of incubation is not known with certainty; in some cases the poison seems to develop its consequences at once, and in others it seems to linger in the system from six to twenty days, in still others three, six and even nine months. Before, however, it produces its own characteristic type of paroxysms of chills and fever, with intervals of immunity — apyrexia — it often manifests itself for a while only as a general indisposition — a general malaise and disturbance of different functions. The real paroxysm of an intermittent fever consists of three stages — the chill, the heat and the sweat. The chilly stage may last from a few minutes to fully three hours. Dur- ing this stage the appearance of the patient is remarkably altered; his whole 86o INTERMITTENT FEVER. volume seems to shrink; his face appears sunken, his nose pinched, and the rings on his fingers (if he wears any) become quite loose. The arterial blood is prevented from reaching the surface, while the venous blood is stagnated in the capillaries; this makes the skin pale and the lips and nails blue. The whole surface is cold, and covered with the well-known appearance of goose-skin (cutis anserina). The internal temperature, however, increases rapidly from two to three, even to five and seven degrees above the normal standard. The attending symptoms of this stage are numerous and various — headache, thirst, colic, cough, oppression, backache, etc., etc.; either one, or all, or still others, may exist in a lighter or graver degree or not at all at that stage. The stage of heat creeps on slowly, still intermingled with chill}'' sensa- tions. Finally, the whole body is in a perfect blaze; the temperature rises still higher and remains so until near the end of this stage. There have been cases observed where the thermometer rose to 108.5 and 109. 4 F. Physical examinations may also detect a swelling of the spleen which, having com- menced during the chill, reaches its height during this stage. The heat generally lasts from a few to eight, or even twelve hours. Here, too, as in the chill y stage, the attending sj^mptoms vary in number and character in each individual case. The third stage, that of sweat, finally closes the paroxysms, and, in most cases, greatly relieves the sufferings of the patient. The temperature sinks step by step till at last the patient feels more or less completely well again. There are, however, enough cases in which this last stage is likewise attended by a number of various symptoms, which, indeed, are important, like those of the first and second stage, in regard to the selection of the remedy, but have no particular bearing on the diagnosis of the case. The apyrexia which now follows is very seldom entirely free of all mor- bid manifestations, and these are likewise numerous and various, and for the observant homoeopathic physician of the highest importance. Just these manifestations may present to him the hints which will lead him to the dis- co very of the required remedy for the case. When an intermittent fever develops its paroxysms in these three stages, and in this order, it is called intermittens completa ; when, however, one or the other of the stages is wanting, it is called intermittens incompleta ; and when the order of its stages is reversed, so that, for example, the paroxysm commences with sweat and ends with the chill, it is calle'd intermittens inversa. The apyrexia is, in different cases, of variable duration. It may last only six, eight, or twelve hours, so that the new paroxysm sets in after twenty-four hours from the one preceding, then it is called a daily or quo- tidian fever ; if twice twenty-four hours elapse between the paroxysms, it is called a tertian fever; and if three times twenty-four hours intervene, it is called a quartan fever. Sometimes it recurs only ever) 7 seventh day — inter- mittens septiana. THERAPEUTIC HINTS TO INTERMITTENT FEVER. 86 1 The most frequent forms are the quotidian and tertian. Sometimes it happens that the paroxysms keep no regular time; they either set in each time earlier (anticipating), or later (postponing). In such cases it may come to pass that the original type is altogether changed into another; for example, a quotidian by postponing into a tertian, or tertian by anteponing into a quotidian. When a fever-paroxysm lasts so long that its end reaches to the beginning of a new paroxysm, it is called a febris intermittens sub- intrans. When, however, the intervals of a quotidian, tertian, or quartan fever are again interrupted by another paroxysm, then it is called a febris intermittens duplicata. The double quotidian consists of two paroxysms within twenty-four hours, the intervening being generally lighter than the original. The double tertian has one paroxysm every day, mostly at differ- ent hours, and again the intervening lighter than the original; while the double quartan has two paroxysms in three days, and in this way, that two successive days are fever days, and the third day is free. Masked intermittents show themselves usually as typical neuralgias, in the course of one or another nerve-trunk, which, however, cannot be dis- tinguished from other neuralgias, except by their typical recurrence; they manifest themselves also in the form of intermittent hyperemia, haemorrhage, oedema, coryza, bronchial catarrh, etc., as typical skin affections, such as erysipelas, purpura, urticaria, pemphigus, and in many other typical forms of disease. A long-continued, oftentimes suppressed intermittent fever frequently terminates in dropsy in consequence of existing functional disturbances of the spleen, which gradually become an organic lesion, or in chronic paren- chymatous nephritis, or scorbutic affections and general ague cachexia. Therapeutic Hints. Aeon. In recent cases of young individuals of a full habit; all the stages must be sharply marked, with a prominent congested state of the head and chest. The pulse is full, hard and frequent. During the chill internal heat, with great anxiety, sensitiveness and restlessness; the pupils are con- tracted. The heat is confined mostly to the head and face; great thirst for cold water and inclination to uncover. The sweat is most prominent on the parts covered, and is attended with earache and profuse micturition. Ant. crud. Predominant gastric symptoms: thick-coated tongue; bitter taste; nausea; belching; vomiting; loss of appetite; little or no thirst; pain in the bowels, diarrhoea or constipation. Sweat breaks out after the chill with the heat but soon disappears, dry heat continuing. Apis. According to Wolf, is one of the most important remedies in all kinds of intermittent fevers, and indeed has been used everywhere with great success. Chill with thirst about three or four o'clock p.m. ; worse in a warm room or near the stove; renewed chilliness from slightest motion, with heat of the face and hands. Heat, especially in the chest, pit of the stomach, bowels, female organs and hands, with muttering and unconsciousness; 862 THERAPEUTIC HINTS TO INTERMITTENT FEVER. diarrhoea; shortness of breath; drowsiness or sleeplessness; rarely thirst. Sweat alternates with dryness of the skin; no thirst. Nettle-rash during sweat or apyrexia. During the a pyrexia, pain under the short ribs, worse on the left side; great soreness of all the limbs and joints, great debility; en- largement of the abdomen; swollen feet and scanty urine. Apis is therefore indicated not only in recent but also in protracted and badly-treated cases. After it Natr. mar. follows well. Ar?iica. Before and during the chill great thirst; drinks a great deal, and vomits afterwards; yawning and stretching; pain in all the bones; bed and sofa feel too hard; the chill is felt worst in the pit of the stomach; cold hands and feet, with heat in the head and face, and redness of one cheek; heat, with indifference, stupor; drinks less; the sweat smells sour; during the apyrexia stitching pain in the region of the spleen; soreness of the spleen on pressure; aching in all the limbs as though beaten. A?'se?i. Intermittens incompleta. Before the attack: vertigo; head- ache; yawning; stretching; general discomfort; weakness; pain in the pit of the stomach and empty eructations; cutting pain in the bowels. The chill is frequently intermixed with heat; or heat and chilliness follow each other in rapid succession; or the patient feels cold inside and burning hot outside. During the chill: generally no thinst; if there be any, drinking increases the chill and causes vomiting; oppression and spasms in the chest, with hack- ing cough; bloating of the pit of the stomach; pain in the pit of the stomach; anxiety, restlessness; blue nails. The heat is either wanting, or mixed up with the chill, or is very great, with delirium, unconsciousness and headache; restlessness; anxiety, pulsation through the whole body; tension and press- ure in the left rrypochondrium ; burning in the stomach; generally great thirst, but drinking little at a time; also drinking a great deal at a time; oppression and short breathing; palpitation of the heart. The sweat sets in some time after the heat, or does not appear at all; during the sweat the thirst is often the greatest, and the patient drinks large quantities of water; the symptoms of the former stages become ameliorated. The apyrexia is never clear. The face is pale, sunken, earthy, sallow, bloated; the lips are pale, cracked, swollen and crusty; the tongue is white and dry, or coated yellowish; the taste is gone, without bad taste, only after eating, bitter taste; the appetite is sometimes increased for a while, satisfying it causes heat and nausea, and not satisfying it causes an unpleasant sensation of discomfort; the hypochondriac regions are swollen, especially the left, the abdomen is bloated; the stools are diarrhceic, fetid; the urine is rather scanty and turbid; the feet are cedematous; the skin is pale, often covered with cold perspiration; there is sleeplessness, especially the night before a new paroxysm, and great sinking of general strength. Bellad. The heat predominates, with vertigo, hallucinations, delirium, restlessness, anxiety; drowsiness with inabilily to go to sleep, or sopor; head- ache, throbbing in right temple, injected eyes, and sensitiveness to light; red cheeks; throbbing of the carotid arteries; choking sensation in the throat; THERAPEUTIC HINTS TO INTERMITTENT FEVER. 863 great thirst and dryness of the mouth and throat; palpitation of the heart; painful swelling of the spleen; constipation; great irritability of temper, or else tearful mood. Bryon. The chill predominates, only exceptionally the heat; great thirst during the chill, still greater during the heat; the sweat lasts long. There are, as the most important leading symptoms: stitching pains in the sides of the chest, with hard cough; stitching pain in the hypochondriac regions and in the abdomen; rheumatic pains in the limbs; all worse from motion. Cad. grand. Regular paroxysms at 1 1 o'clock a. m, or p. m. ; first chill, then burning heat, with headache, coma, stupefaction, insensibility; thirst, shortness of breath, inability to remain lying. The sweat is profuse and at- tended with inextinguishable thirst. The apyrexia is complete. Calc. carb. Chronic cases; chill commences in pit of stomach; thirst during the chill. General indications: hardness of hearing; pot-belliedness; hard, bloated stomach, enlarged spleen ; diarrhoea white; undigested; monthly period too early and too profuse; glandular swellings about the neck; alto- gether scrofulous diathesis. Capsic. Chill, mostly with thirst, and worse after drinking; the chill commences in the back and spreads all over, and is relieved by hot irons or jugs of hot water; after the chill sweat ; or heat, with sweat and thirst at the same time. During the chill: giddiness and excruciating, tearing pains in the back and limbs, extorting cries and causing the patient to bend together like a hedgehog. During the heat: cutting pains in the bowels, and slimy, burning stools, with much pressing and bearing down; headache. Carb. veg. Irregular paroxysms, sometimes commencing with sweat, followed \>y chill. Before the attack toothache, headache and pain in the limbs. During the chill great thirst. Heat and sweat frequently mixed together, with evening hoarseness, dizziness, red face, nausea, but no thirst. The sweat is sour and sometimes very profuse. Afterwards long-continued headache; heat and burning in the eyes; yellow complexion; liver-spots in the face; belching; bad smell from the mouth; stomach bloated; spleen swollen and painful; abuse of quinine. Cedron. Chill at 3 A. m. or 3 p. m., is preceded by mental depression, or excitement; during chill no thirst; chill predominates; during heat thirst for warm drinks; numb, dead feeling in legs; sweat profuse, with thirst and tearing pains in extremities. During apyrexia general malaise and great debility. Ckamom. Heat and sweat predominate, and are often together; red face, or only one cheek red and the other pale; sweat especially about the head, and mostly hot. The tongue is red in the middle and white on the sides, or white in the middle and red on the edges; bitter taste; bitter vom- iting; great oppression about the heart; diarrhoea. The patient is very irri- table, excited, complaining, with great restlessness and anxiety. China. The paroxysms come most at irregular hours, with thirst before 864 THERAPEUTIC HINTS TO INTERMITTENT FEVER. (not during) chill or heat and during the sweat; they are mostly preceded by palpitation of the heart with anxiety; sneezing; nausea; hunger; pressure in the stomach; pain in the bowels and jerking, tearing headache; pain in the limbs and great debility. During the fever the veins appear greatly en- larged, and there is great congestion to the head, with redness and heat of the face, even with chilliness and coldness of other parts of the body. The sweat is sometimes only partial and cold, for example, on the forehead; at other times it is profuse, and almost always attended with thirst. In general the patient sweats easily, especially at night, during sleep; there is swelling of the liver and spleen, painful to motion and pressure; a characteristic weakness, exhaustion and cachectic appearance, a sallow yellowishness of the skin, not only in the face but also on the chest and region of the stomach, and different anaemic and dropsical symptoms. The urine is scanty and turbid, with a thick yellowish or brick-dust sediment, or a sediment of little crystals. The presence of swamp miasma is another indication. Chin, sulph. Regular paroxysms at the same hour, and clear intermis- sions; real thirst mostly only during the sweat. During the paroxysm pain in the dorsal vertebrae on pressure ; pain in the region of the liver and spleen on bending, taking a deep breath, coughing; the urine gives a voluminous, brick-dust-like or fatty sediment, or contains crystals of urates; ringing in the ears, with dizziness and enlarged feeling of the head. Cimex. Before the chill thirst and heaviness in the legs. The chill commences with clenching of the hands and violent raging; it is attended with pains in all the joints; sensation as if the tendons were too short; the knee- joints are usually contracted, so that the legs cannot be stretched; the chest feels oppressed, obliging one to frequently take a long breath; irresistible sleepiness; it ends with a tired feeling in the legs, obliging one to change po- sition constantly ; with thirst; drinking, however, causes violent headache; continuous dry cough; oppression of breathing; heaviness in the middle of the chest; anxiety. Abstaining from drinking ameliorates all this. The heat is attended with gagging; the oesophagus feels constricted, and the water drank goes down only at intervals; no thirst. The sweat is mostly on the head and chest, accompanied by hunger. Cina. Thirst only during the chill, or only during the heat. Nausea, vomiting, diarrhoea, pain in the stomach and abdomen may set in at any time, and soon be followed by a clean tongue and ravenous appetite. The face is puffed and pale even during the heat, or glowing red; the pupils are much enlarged, and the child picks often at the nose. Diadema. Paroxysms every day or every other day at precisely the same hour; chill predominating; constant chilly feeling; always worse on rainy, cold days; menses too early and too profuse; enlargement of the spleen. Eupat. per/. Long before the chill great thirst, which continues through chill and heat; after drinking, vomiting; the paroxysms usually occur in the morning, about seven or nine o'clock; they are attended with intense itching THERAPEUTIC HINTS TO INTERMITTENT FEVER. 865 in the back and limbs, as if the bones were broken, and with a number of gastric or so-called bilious symptoms; the sweat is generally not very promi- ment, or even wanting, but sometimes drenching, and the intermission is sometimes marked by a loose cough. Eupat. purp. The paroxysm comes at different times in the day, every other day; chill commences in the small of the back and then spreads over the body; violent shaking, with comparatively little coldness; thirst during chill and heat; vomiting between chill and heat; violent bone-pains during chill and heat. Ferrum. Similar to Arsen. and China, it will frequently be of service in protracted and cases badly-treated by Quinine, which are characterized by anaemia and total prostration of the reproductive sphere of the system. We observe great paleness of the face, which, however, may flush up from any excitement to a fiery redness of short duration; paleness, whiteness of the inner surface of the mouth; vomiting of everything that is eaten without be- ing digested; swelling and hardness in the hypochondriac regions; great weakness and emaciation; dropsical swelling of the feet; frequent conges- tion of the lungs; continued shortness of breath; nun's murmur in the veins. Gelsem. Chill in afternoon or evening, commencing in hands and feet, or running up back from sacrum to occiput, without thirst; or only fever at 10 a.m., without chill and without thirst. The heat is attended with red face and sleep, or with nervous restlessness, delirium, mental anxiety or agi- tation, vertigo; a curious sensation of falling, sensitiveness to light and sound, partial blindness or deafness. Where there is a want of distinctness in its several stages; the whole presents an adynamic condition of the system. Hepar. Bitter taste in the mouth; bilious vomiting; diarrhoea; itching, stinging, nettle-rash before and during the chill; fever-blisters around the mouth; tettery eruption on the chest; previous abuse of Mercury. During the sweat keeps himself closely covered. Ignat. Thirst only during the chill, or in short spells, independent of any stage. The chilliness is relieved by the external application of warm' things; external heat, or heat in some, and coldness of other parts of the body; sometimes with pain in the bowels; afterwards sleep and sweat. The paroxysms are sometimes accompanied with spasmodic symptoms; heaviness of the head; aching pain in the occiput; vomiting and pressive pain in the pit of the stomach; urticaria over the whole body. The paroxysms are apt to postpone or antepone. Ipec. Predominance of gastric symptoms during the paroxysm as well as during the apyrexia. It begins chiefly with yawning, stretching and a collection of saliva in the mouth; then follows the chill, aggravated by ex- ternal warmth, with or without nausea, vomiting, diarrhoea, or great oppres- sion of the chest, with heaving. The three stages may be very strongly marked or very light; the thirst is generally quite inconsiderable in all of them. The ap}^rexia has the same gastric symptoms, especially a marked 55 866 THERAPEUTIC HINTS TO INTERMITTENT FEVER. sensation of relaxation of the stomach, as though it were hanging down; entire loss of appetite. The spleen is little, if any, swollen. Miasma; after the abuse of Quini?ie and Arsenicum; after faults in diet. Laches. One of the most important remedies after the abuse of Qui?iine. The paroxysms are mostly in the afternoon, with pain in the small of the back and limbs; restlessness; oppression of the chest; jerking; headache; red face; talkativeness. During the chill wants to lie near the fire, or be held tightly to relieve the pain in head and chest, and prevent shaking. Lycop. Where there are other chronic symptoms — cough, with thick, yellow, salty expectoration; oppression of the chest; pain in the left side; palpitation of the heart ; pale face, often with circumscribed redness of the cheeks; sour vomiting between chill and fever; bloatedness of the stomach; rumbling in the bowels; great debility; the sweat is often sour and profuse, sometimes following immediately upon the chill, and at other times not until some time after the heat; after the sweat, thirst. Fever paroxysms often from 4 to 8 p.m. Mangan. Incomplete intermittent, consisting of only heat and sweat, with moderate thirst. Mejiyanth. Irregular time and type; chill predominating without thirst; especially coldness of fingers, toes and legs, not relieved by external warmth of abdomen. Mezer. Incomplete intermittent, consisting of chill with thirst, and sweat with sleep. Natr. mtir. One of the most important of all in recent as well as in inveterate and badly treated cases. Hard chill very often at ioor n o'clock A. m. , with great thirst which continues through all stages. The heat is characterized by the most violent headache, relieved by perspiration. There soon appears an eruption of hydroa or fever- blisters, which cover the upper and lower lip like pearls. During the apyrexia sallow complexion, dry, white coated tongue; bitter taste; water tastes bad; loss of appetite; after eating, sour belching and vomiting; pressure in the stomach; swollen stom- ach; pain in the region of the kidneys; cutting pain in the urethra after micturition. Nux vom. Is characterized by great prostration and paralytic weak- ness from the beginning. Hard chill with bluish face and blue nails; stitch- ing pain in the abdomen; spasmodic drawing and stiffness or the lower ex- tremities; great thirst; the heat is great, and notwithstanding this the patient covers himself all over, because uncovering or the slightest motion makes him feel chilly; headache; great thirst, especially for beer. Both chill and heat are accompanied by gastric and bilious symptoms. During the sweat the painful symptoms gradually subside. During the apyrexia, headache; yellowish complexion; belching; loss of appetite; nausea; vomiting; consti- pation; liver and spleen swollen; cough; debility; soreness of the spine. Opium. Sleep, during chill, heat and sweat; during sweat he still feels burning hot; children and old people. THERAPEUTIC HINTS TO INTERMITTENT FEVER. 867 Podoph. Chill at 7 A. m., without thirst; heat with thirst; loquacity during chill and heat; sweat with sleep; besides, pain or uncomfortable feeling in region of liver which makes him rub and stroke this part; diar- rhoea during forenoon, frequently changing in color. Pulsat. The several stages are in general not very violent, and mostly unattended by thirst: or thirst only during the heat; or the several stages are mixed up; one-sided sweat. The paroxysms set in frequently (though not always) in the evening, and last through the night. Characteristic feat- ures: tearful and peevish; headache during the intermission; face pale or greenish-yellow; tongue moist, coated, with bad taste; loss of appetite and thirst; nausea; vomiting of slime and bile; spleen enlarged; stools diarrhceic, slimy, watery, at night; profuse, watery urine; suppressed or scanty menses; pain in the chest and cough, with pain in the head and pit of the stomach; frequent palpitation of the heart; murmur in the jugular veins; constant chilliness and drowsiness; chlorotic state of the system. Rhus fox. Before the chill: stretching of the limbs; yawning with a feeling in the maxillary joint as if sprained; thirst; dry, teasing cough, with sweetish, foul expectoration. Chill, in some parts, and in others heat; or hard chill, with aching in the small of the back, drawing in the limbs and formication in the fingers; with restlessness and constant change of position. The heat is sometimes before and sometimes after the chill, and often at- tended with nettle-rash; pain in the bowels and diarrhoea. The following sweat is often profuse and sour. The paroxysms set in most frequently in the evening and last through the night; they generally return every day, but seem altered every other day. Sabad. Intermittens incompleta, consisting of chills only; or intermit- tents with predominating chill, and thirst between chill and heat; the paroxysms occur precisely at the same hour; sometimes they are accom- panied by morbid hunger in alternation with loathing of food; during the apyrexia there is constant chilliness; sometimes cough with heavy breathing and pain in the chest. Sambuc. Profuse, debilitating sweat lasts through the apyrexia, com- mences in the face, is worse while the patient is awake, disappears and changes to a dry heat when he is falling asleep. Sepia. Chronic cases, with one or the other of the following symptoms: frequent flushes of heat; paralytic sinking down of one of the upper eyelids; yellowishness of the white of the eyes; brownish-yellow saddle across the bridge of the nose; yellowishness around the mouth; loathing of meat and milk; diarrhoea after drinking milk; pain in the liver on moving; bearing down towards the genitals; palpitation of the heart; tettery eruptions; the coldness begins in the feet and rises upwards. Silic, In scrofulous subjects. Stramon. Chill, with icy-cold skin, covered with cold sweat; hands and feet livid, head and face hot, vertigo; delirium; epileptiform; convul- sions. Wants to be covered during all stages. 868 DIGEST TO INTERMITTENT FEVER. Sulphur. Like Sepia, in chronic cases; especially when rooting in the soil of suppressed eczema or other cutaneous eruptions, with one or the other of the following symptoms: heat on the top of the head with cold extremities; red lips; red tip of the tongue; always worse after eating; sudden attacks of faintness, with hunger in the forenoon; costiveness, or else looseness of the bowels early in the morning, driving out of bed; hemorrhoidal complaints; leucorrhcea; cough when lying down in the evening; feverishness through the night: complete sleeplessness; itchiness of the skin. Tart. emet. Thirstlessness during chill and fever, shuddering with sleepiness; heat with sopor; sweat with sleepiness; fainting; anxiety; and pain in the lower extremities. Thuja. According to Wolf, if Apis is not sufficient, and the complaint originates in a chronic gonorrhceal contamination of the system; only the uncovered portions of the body perspire; those which are covered are dry and hot. Veratr. Chill at 6 a.m.; chill and coldness predominate, with sticky, cold perspiration and thirst; heat not so marked; sweat profuse, often cold and long-continuing. Attending symptoms: great exhaustion; sinking of strength; nausea; vomiting; diarrhoea, or obstinate constipation; cramps in the limbs. It is indicated, therefore, in the most pernicious kinds of inter- mittent fevers, and those which occur during the prevalence of cholera. For still further particulars I refer to H. C. Allen's and T. P. Wilson's Treatise on Intermittent Fever, and Wm. A. Allen's Repertory. Digest to Intermittent Fever. BEFORE CHILL. , general discomfort, weakness Mental depression or excitement: Ce- Arsen. dron. Itching", stinging nettle-rash: Hepar. VertiffO : Arsen. Sleeplessness the night before, and great Headache: Arsen., Card, veg., China. sinking of general strength: At sen. Toothache and pain in limbs: Card. veg. CHILL BEGINS WITH: Bitter taste, bilious vomiting, diarrhoea: Yawning, stretching and a collection of Hepar. saliva: Ipec Thirst, drinks a great deal and vomits Clenching of hands and violent raging: afterwards: Arnica, Eup. perj. Cimex , palpitation with anxiety, sneezing, nausea; hunger, pressure in stomach, TIME OE OCCURRENCE. pain in bowels, pain in limbs, and great Midnight, after: Arsen. debility: China. 3 o'clock A. M. or P. M.: Cedron. , dry, teasing cough, with sweetish, 6 o'clock A. M.: Veratr. foul expectoration: Rhus tox. 7 o'clock A. M.: Podoph. , and heaviness in legs: Cimex. 7-9 o'clock A. M.: Eup. per/. Yawning and stretching, pain in pit of 10 o'clock A. M.: Stannum. stomach and eructations; cutting pain 10-11 o'clock A. M.: Natr. mur., Sulphur. in bowels: Arsen. 11 o'clock A. M.: Nux vom. , pain in bones; bed or sofa feel or p. M.: Cact. gaand. too hard: Arnica. Noon, about: Nux vom. , Sulphur. , maxillary joint feels as if 1-2 P. M.: Arsen. sprained: Rhus tox. 2-3 P. M.: Laches. DIGEST TO INTERMITTENT FEVER. 869 3 P.M.: Apis, Bel I ad. Afternoon and evening: Gelsem. Evening: Nux vom., Pit /sat., Rhus tox. Any time: Arsen., China, Eup. per/., Eup, pur p., I pee., Natr. mur., Nux vom., Pulsat., Sulphur. Irregular time: China, Menyanth., Sepia. At precisely the same hour: Cedron., Diad., Sabina. Postponing: China, Cina, Ignat., Ipec. Anticipating: Arsen., Bryon., China, Ignat., Natr. mur., Nux vom. Quotidian: Arsen., Card, veg., China, Cina, Diad., Gelsem., Ignat., Ipec., Natr. mur., Nux vom., Pulsat., Rhus tox., Sulphur. , double: Ant. crud., Apis, Bellad., China, Elater., Stramon., Sulphur. Tertain: Arsen., Bellad., Bryon., Card. veg., China, Cina, Diad., Eup. per/., Ignat., Ipec., Natr. mur.. Nux vom., Pulsat., Rhus tox. , double: Arsen., China, Eup. purp., Lycop., Rhus tox. Quartan: Arsen., Card veg., China, Menyanth, , Natr. mur., Nux vom., Pulsat., Rhus tox., Sabina, Veratr. , double: Arsen., China, Eup. purp., Rhus tox. LOCATION AND DIRECTION. Pit of stomach, commences in: Calc. carb. , is felt most in: Arnica. Back, between shoulders, commences in, and spreads all over, worse by external heat: Bryon., Capsic. Small of back, commences in, and spreads all over: Eup. purp. Hands and feet, commences in, or run- ning up back from sacrum to occiput: Gelsem. , coldness of, with heat in head and face, and redness of one cheek: Arnica. Feet, begins in, and rises upwards: La- ches., Sepia. Fingers, toes and legs, abdomen, cold- ness of, not relieved by external warmth: Menyanth. In some parts, in others heat: Rhus tox. Left hand cold, right one warm: China. Icy-COld skin, covered with cold sweat: Stramon. ACCOMPANIED BY: Delirium: Stramon. Loquacity: Podoph. Anxiety, sensitiveness and restlessness: Aeon., Arsen. Vertigo: Capsic, Stramon. Pupils contracted: Aeon. Face bluish and nails bluish: Nux vom. and head hot: Stramon. Thirst during chill only: Apis, Calc. carb., Capsic, Carb. veg., Cimex, Cina, Ignat., Mezer., Nux vom., Veratr. Thirst during chill and during heat: Eup. per/. , Eup. purp. and more during heat: Bryon. between chill and heat: Sabad. during chill and all stages: Natr. mur. , or in short spells, independent of any stage: Ignat. , or only during heat: Cina. , chill worse after drinking: Arsen., Capsic , chill with; but drinking causes headache, dry cough, oppression of breathing, heaviness in middle of chest, anxiety: Cimex. , without: Arsen., Cedron., Gelsem., Menyanth., Podoph. , , during chill and fever: Tart. emet. Morbid hunger or loathing of food; Sa- bad. Gastric and bilious symptoms: Eup. per/., Nux vom. With Or without nausea, vomiting and diarrhoea: Ipec. Vomiting after drinking: Arsen. between chill and heat: Eup. purp. Bloating and pain in pit of stomach: Arsen. Stitching pain in abdomen: Nux vom. and hypochondriac regions: Bryon. Chest, oppression of, and heaving: Ipec. , , must take long breaths: Cimex. , , and spasms in chest, with hacking cough: Arsen. 870 DIGEST TO INTERMITTENT FEVER. , stitching pain in sides of, with hard cough: Bryon. Aching in back and limbs, as if the bones were broken: Eup. Perf. in small of back, drawing in limbs, formication in fingers, with restlessness: Rhus tox. Tearing pains in back and limbs, ex- torting cries and causing the patient to bend together like a hedgehog: Capsic. Drawing and stiffness in lower extremi- ties: Nux vom. Pains in all the joints, as if the tendons were too short; knee-joints contracted; Cimex. Rheumatic pains in the limbs, worse from motion: Bryon. Pain in all the bones, couch feels too hard: Arnica. Violent bone-pains: Eup. per/., Eup. purp. Livid feet and hands: Stramon. Blue nails: Arsen. Chill ends with a tired feeling in legs, must change position: Cimex. Sleepiness: Cimex. , with shuddering: Tart. emet. Sleep during chill, heat and sweat: Opium. Itching, stinging nettle-rash: Hepar. Sticky, cold perspiration: Ver. alb. CHILL IS AGGRAVATED : After drinking: Capsic. In a warm room or near the stove, and motion: Apis. By external warmth: Ipec. CHILL IS RELIEVED : By external warmth: Ignat. and being held tightly: Laches. Wants to be covered during all stages: Stramon. Chill predominates: Bryon., Cedron, Diad., Hfenyanth., Sabad. , Ver. alb. , only exceptionally the heat predominates: Bryon. Chill and internal heat: Aeon. intermixed with heat, or cold inside and burning hot outside: Arsen. AFTER CHILL : Vomiting: Eup. purp. Vomiting, sour: Lycop. Sweat: Capsic. and heat; sweat soon disappears, dry heat continues: Ant. crud. HEAT. At 10 A. M., without chill or thirst: Gelsem. From 4-8 P. M.: Lycop. Sometimes before the chill: Rhus tox. Mixed up with chillness: Aeon., Apis, Arnica, A) sen., Bellad., Chamom., China, Eup. purp., Gelsem., Laches., Nux vom., Podoph., Pulsat., Rhus tox., Sulphur. with sweat: Capsic, Card veg., Eup. perf., Ipec, Opium, Podoph., Pulsat., Rhus tox., Sabad., Sepia, Stramon., Veratr. External heat ; or heat in some, and coldness of other parts: Ignat. ACCOMPANIED BY: Coma, stupefaction, insensibility: Cact. grand. Unconsciousness: Arsen., Natr. mur. , with muttering: Apis. Delirium: Arnica, Arsen., Bellad., Chin. sulph., Gelsem., Ignat., Laches., Natr. mur., Nux vom., Opium, Podoph., St ram 07i. Loquacity: Podoph. Indifference, stupor: Arnica. Anxiety, or agitation: Arsen., Bellad., Gelsem. Vertigo: Arsen., Bellad., Bryon., Carb. veg., Gelsem., Ignat., Ipec, Natr. mur., Nux vom., Pulsat., Sepia, Stra- mon., Veratr. , curious sensation of falling: Gelsem. Headache: Aeon., Arnica, Arsen., Bellad., Bryon., Capsic, Carb. veg., China, Eup. perf., Ignat., Laches., Natr. mur., Nux vom., Opium, Po- doph., Pulsat. , Rhus tox. , Sabad. , Sepia, Sulphur. , relieved during sweat: Natr. mur. Sensitiveness to light and sound, or partial blindness and deafness: Gelsem. Eyes injected: Bellad. Pupils enlarged: Cina. DIGEST TO INTERMITTENT FEVER. 8 7 I Ears cold: Ipcc Nose cold: Ignat. Picks at nose: Cina, Face cold: Ipec, Pulsat. pale: Arsen., Bryon., Capsic, Cina, I pec, Rhus tox., Sepia. and red alternately : Aeon., Bel- lad., Capsie., Ipec, Nux vom., Opium, Pulsat. One cheek pale, the other red: Chamom. Cheeks puffed: Cina. Lips, burning of: China. , dryness of: Rhus tox. , fever-blisters on: Hepar, Ignat., Natr. mur., Nux vom. Tongue red in middle and white on edges, or white in middle and red on edges: Chamom. Mouth and throat dry; choking sensa- tion in throat: Bel I ad. (Esophagus constricted: Cimex. Thirst: Aeon., Arsen., Bellad., Bryon., Cact. grand., Capsie., Chamom., China, Chin, sulph., Eup. purp., Hepar, Ipec., Laehes., Natr. mur., Nux vom., Podoph., Pulsat., Rhus tox., Sulphur. for beer: Nux vom. , drinks but small quantities at a time: Arsen., China, Pulsat. , drinks large quantities: Aeon., Ar- sen., Bryon., Natr. mur. , drinks less during fever: Arnica. - , only during heat: Cina, Pulsat. for warm drinks: Cedron. for cold water: Aeon. When drinking, the water goes down only at intervals: Cimex. No thirst: Ant. tart., Apis, Calc. card., Camphora, Capsie., Card, veg., China, Cimex, Ignat., Pulsat., Sepia. Hunger: China, Cina, Phosphor. Nausea: Ant. tart., Arsen., Bryon., Card, veg., Eup. per/., Ipec., Natr. mur., Nux vom. Gagging: Cimex. Vomiting of bile : Chamom., Cina, Eup. perf., Natr. mur. after drinking: Arsen. after cold drinks: Lycop. Vomiting of ingesta: Cina, Eup. per/., Eerrum, Ignat., Nux vom. , sour: Lycop. Gastric and bilious symptoms: Nux vom. Cina, Stomach, burning in: Arsen. , heat in: Apis, Laches. , pain in: Arsen., Card. veg. Rh us tox. , Sep ia . Hypochondrium, left, tension and press- ure: Arsen. , stitching pain: Bryon. Bowels, pain in: Arsen., Card, veg., Cina, Ignat., Nux vom., Rhus tox. , cutting pain in : Capsie. , stitching pain in: Bryon. , heat in: Apis, Cact. grand., China, Laches. Diarrhoea: Cina, Pulsat., Rhus tox. , slimy, burning, with much pressing and bearing down : Capsic. Female organs, heat in: Apis. Hoarseness in evening: Card. veg. Chest, heat in: Apis. , stitching pain in sides of: Bryon. , oppression and short breathing: Apis, Arsen., Cact. grand., Card, veg., Cimex, Ipec. Palpitation of heart: Aeon., Arsen., Bellad., Calc. card., Sepia, Sulphur. Pulsation through whole body: Arsen- Limbs, pain in: Arsen., Bryon., Calc. card., Capsic, Card, veg., China, Eup. perf. Eup. purp., Laches., Pulsat., Rhus tox., Sepia, Sulphur. numb, dead feeling in legs: Cedron. Veins distended: Bellad., Camphora, China, Pulsat. Nettle-rash: Apis, Ignat., Rhus tox. Sleep: Apis, Gelsem., Ignat., Natr. mur., Opium. Sopor: Ant. tart., Bellad., Opium. Sleeplessness : Aeon. , Arsen. , Nux vom. , Pulsat. , with sleepiness: Bellad. Restlessness: Acoti., Arsen., Bellad., Capsic, Chamom., Gelsem., Pulsat., Rhus tox. Inability to remain lying: Cact. grand. Wants to uncover: Acoti., Arnica, Arsen., China, Eup. perf., Laches., Natr. mur., Pulsat. Averse to uncover: Apis., Bellad., Hepar, Ignat., Nux vom., Rhus tox., Stramon. Feels chilly when uncovering: Arnica, China, A r ux vom., Pulsat. &72 DIGEST TO INTERMITTENT FEVER. SWEAT. Profuse: Bryon., Cact. grand.. Car/). veg. % Cedron, Hepar, Mcrcur., Natr. mur., Rhus tox., Sambuc, Veratr. and sour: Bryon., Carb. veg., Cha- mon., Hepar, Ipec, Lycop., Rhus tox., Sepia, Sulphur. Drenching', sometimes, generally not prominent, even wanting: Eup. pcrf. Cold: Arsen., Camphora, China, Cina, /per., Lycop., Sepia., Strain on, Veratr. Hot: Chamom., Opium. Long-continuing": Bryon., Ferrum, Ver- atr. , lasts through apyrexia, worse dur- ing waking; dry heat during sleep: Sambuc. About head: Chamom., Eup. purp., Opium. On forehead: China, Cina, Stramon., Veratr. On head and chest: Cimex. On one side only: Acon. % Bryon., Cha- mom., China, Lycop., Nux vom., Put- sat., Rhus tox., Sulphur. On covered parts : Aeon. On uncovered parts, exceptface: Thuja. Sets in some time after the heat: Arsen. , or immediately after the chill: Lycop. Sweat alternates with dryness of skin: Apis. ACCOMPANIED BY: Thirst: Arsen., Cact. grand,, Capsic, Cedron, China, Chin, sulph., Natr. mur. after the sweat: Lycop. No thirst: Apis, Calc. carb Cina, /gnat., Nux vom., Veratr. Hunger '• Cimex, Cina. Tearing pains in extremities: Nettle-rash : Apis, Rhus tox. Sleep: Arnica, Arsen., /gnat., J/ezer Opium, Podoph., Pulsat., Rhus tox Sulphur. Wants to uncover: Aeon., Calc. carb Eup. per/., Eerrum, Natr. mur, Opium, Veratr. Covers tightly : Hepar. Uncovering causes pain: Stramon. Cimex, Sambuc, Cedron. Painful symptoms gradually subside: Arsen., Nux vom. AFTER THE SWEAT. Long-continued headache : Carb. veg. Thirst: Bel I ad., Lycop., Nux vom., Sa- bina. Hunger: Cina. Diarrhoea: Pulsat. Cough: Eup. per/. Weakness: Arsen. Chill : Carb. veg. PAROXYSMS IN GENERAL. Regular at the same hour with clear in- termissions, though not always: Chin, sulph : All Stages strongly marked, or very light; no great thirst: /pec. in general not very violent, and mostly unattended by thirst: Pulsat. Return every da3 T , but seem altered every other day: Rhus tox. Incomplete: Arsen., J/augan., Mezer. , Sabad. (Compare: no chill, or no heat, or no sweat. ) Irregular, commencing with sweat, fol- lowed by chill: Carb. veg. , sweat after chill: Lycop. , several stages mixed up: Pulsat. Chill predominating: Bryon., Cam- phora, Cedron, Diad., J/enyanth., Sabad., Ver. alb. Heat predominating: Bell ad., Bryon. , Cact. grand., Chamom., Hepar, /pec, Rhus tox. Sweat wanting: Apis, Arsen., Bellad., Diad., Eup. per/., Gelsem., Lycop., Pulsat., Rhus tox., Sulphur. Headache is better: Natr. mur. Gastric symptoms : /pec Bitter taste and vomiting; oppression about the heart; diarrhoea; irritable, excited, complaining, restless, anxious: Chamom. During afternoon, talkative, headache, red face, oppression of chest, pain in small of back and limbs, restless: La- ches. Pain in dorsal vertebrae on pressure, in liver and spleen on bending, breathing and coughing; brick-dust or fatty sedi- ment in urine; ringing in ears with diz- DIGEST TO INTERMITTENT FEVER. 873 ziness, and enlarged feeling of head; Chin, sulph. Spasmodic Symptoms ; heaviness of head; aching in occiput; vomiting and pressi ve pain in pit of stomach ; urticaria over whole body: Ignat. Anaemia, and total prostration of the re- productive sphere of system: Arsen., China, Ferrum. Recent cases of young individuals of a full habit: Aeon. Children and old people: Opium. Chronic cases : Calc. card., Card, veg., Sepia, Sulphur.. After abuse of quinine: Arsen., Fer- rum, /pec., Laches., Natr. mur., Nux vom., Pulsat. Swamp miasma : Cedron., China, Ipec, Nux vom., Natr. mur. DURING APYREXIA. Cina, Nux 'om. Tearful: Bellad. Pulsat. — — and peevish: Pulsat. Irritable: Aeon., Bellad., Bryon., Cha- mom., Nux vom., Pulsat. Anxiety: Aeon., Camphor a., Tart. emet. Fear of being left alone: Lycop. Wants to be alone: China. Headache: Arnica, Arsen., Bellad., Bryon., China, Gelsem., Ignat., Natr. . mur., Nux vom., Opium, Pulsat., Rhus tox., Sepia. Heat on top of head, with cold extremi- ties: Sulphur. and burning in eyes: Card. veg. Yellowishness of white of eyes: Sepia. Swelling of lids: Apis. Sinking 1 down of one of upper lids: Sepia. Hardness of hearing: Calc. card. Ringing in ears: China. Face bloated: Arsen., Ferrum. pale: Arsen., Camphora, Card, China, Ferrum, Ignat., Lycop., vom., Pulsat., Sulphur. , and flushing up easily any excitement: Ferrum. , with circumscribed redness of cheeks: Lycop. — , sunken, earthy, sallow: Arsen. yellow: Arnica, Arsen., China, veg., Nux from Fup. perf., Ferrum, A r atr. mur., Nux vom., Rhus tox., Sepia. , and also chest and region of stomach: China. greenish yellow: Pulsat. , brownish. yellow saddle across bridge of nose: Sepia. yellowish around mouth: Nux vom., Sepia. Around mouth and corners of mouth, fever-blisters and eruption at: Hepar, Ignat., Natr. mur., Rhus tox. Lips pale, cracked, swollen and crusty: Arsen. red: Sulphur. About neck, glandular swellings: Calc. card. Pain in back of neck: Fen um. Mouth, bad smell from: Card. veg. , taste bad: Pulsat. , of water: Natr. mur. , bitter: Ant. crud., Arnica, Arsen., Bryon., Chamom., China, Nux vom., Pulsat., Rhus tox., Sul- phur. , lost: Arsen., Pulsat. , foul: Arnica, Bellad., Fer- rum., Natr. mur. . Nux vom. , Podoph. , Pulsat. , Rhus tox. Mouth, taste sour: Lycop., Nux vom., Sepia. Tongue blistered: Natr. mur. broad and indented: Podoph., Rhus tox. , brown streak down the middle: Ar- nica, Fup. purp., Laches. — — dry: Arsen., Bellad., Natr. mur., Pulsat., Stramon. on tip: Rhus tox., Sulphur. pale: E up. perf., Ferrum, Ipec. , red papillae: Aeon., Apis, Bellad., Nu x vom., Sir a mon . , red: Apis, Bellad, Lycop., Sulphur, Tart. emet. on tip: Arsen., Laches., Nux vom., Rhus tox., Veratr. white: Ant. crud., Arsen., Natr. mur., Nux vom.. Pulsat., Sulphur. yellow: Arsen., Bryon., China, Fup. perf., Ipec, Nux vom., Podoph., Pul- sat., Sulphur. Inner mouth pale: Ferrum. Appetite, loss of : Ant. crud., Arnica, Arsen., Bryon., Card, veg., China, 8 7 4 DIGEST TO INTERMITTENT FEVER. Ant. crud. Card, veg., Nux Ignat., I pec, Natr. mur., Nux vom , Podoph., Pulsat., Rhus tox. for beer: Nux vom., Pulsat. sometimes increased, with heat and nausea when satisfied: Arsen. Loathing" of milk and meat: Sepia. Hunger: A?it. crud., Arnica, Card. vcg., China, Cina., Jlenyanth., Nux vom., Rhus tox., Sepia, Sulphur, Veratr. , with faintness in forenoon: Sul- phur. Thirst: China, Cimex., Sulphur, Veratr. , loss of: Pulsat. , little or no thirst: Belching .* Ant. crud., vom. , sour, after eating: Natr. mur. Nausea: Ant. crud., Ar?iica, Arsen., Cina, Eup. per/., Ipec, Nux vom , Pulsat., Rhus tox., Tart, emet., Veratr. Vomiting: Ant. crud., China, Cina., Eup. per/., Ferrum, Ipec, Lycop., Nux vom., Sepia, Veratr. of bile: Arsen., Eup. per/., Ipec , Nux vom., Pulsat., \ T eratr. Vomiting after eating: Natr. mur. of ingesta: Arsen., Eup. perf., rum, Ipec, Nux vom., Pulsat. of slime: Nux vom., Pulsat. , followed by a clean tongue ravenous appetite: Cina. Stomach bloated: Calc card., Card. veg., Lycop., Natr. mur., Nux vom. , pressure in: Ant. crud., Natr. mur., Rhus tox. , sense of relaxation, as though it were hanging down: Ipec. Bowels bloated: Apis, Arsen., Calc card., China, Natr. mut . , pain in: Ant. crud., Cina, Sulphur, Tart. emet. , rumbling in: Lycop. Constipation: Ant. crud., Bellad., Bry- on., Natr. mur., Opium, Sulphur, Ver- atr. or diarrhoea: Ant. crud., Sulphur., Veratr. Diarrhoea: Ant. crud., Arsen., Calc. card., Gelsem., Podoph., Pulsat., Rhus tox., Sepia, Sulphur, Veratr. — — after drinking milk: Sepia. Haemorrhoidal complaints: Sulphur. Liver, pain in: Arsen., Bellad., Bryon., Fer- and Ch ina , Lycop. , Natr. mur. , Nux vom. , Pulsat. , , with inclination to rub and stroke this part: Podoph. , , worse on moving: Bryon., China, Sepia. , , and spleen: China, Nux vom . , swollen: China, Nux vom. Spleen enlarged: Arsen., Bellad., Calc card., Card, veg., China, Diad., Fer- rum., Pulsat. , pain in: Apis., Arnica, Arsen, Bel- lad., Card, veg., China, Ferrum., Natr. mur., Nux vom. Hypochondriac regions, worse left, pain in: Apis. , right side: Eup. per/., Nux vom. , swollen: Arsen. , ■ and hard: Ferrum. Kidney region painful: Natr. mur. Urine scanty: Apis, Arsen., Bryon., China, Natr. mur. , turbid: Arsen., China, Cina, Lycop,, Natr. mur. profuse: Eup. perf., Pulsat. Micturition, cutting in urethra after: Natr. mur. Menses suppressed: Arsen., Calc card., Ferrum, Lycop., Nux vom., Pulsat., Sepia, Sulphur. scanty: Lycop., Natr. mur. Pulsat., Sulphur. profuse; Calc. card., Diad., Nux vom. Leucorrhcea, Sulphur. Cough: Apis, Arsen., Bellad., Bryon., China, Cina, Eup. perf., Ipec, Nux vom., Pulsat., Sulphur. in evening on lying down: Sulphur. , loose: Eup. perf. , thick, yellow, salty expectoration: Lycop. , with heavy breathing and pain in chest: Sadad. , with oppression; pain in left side: Lycop. , with pain in chest, head and pit of stomach: Pulsat. Congestion of lungs; shortness of breath: Ferrum. PERNICIOUS INTERMITTENT FEVER. 875 Palpitation of heart: Aeon., China, Lgnat., Laches., Lycop., Natr. mur., Pulsat., Sepia, Sulphur. Nun's murmur in veins: Ferrum, Pul- sat . Fainting : Tart. emet„ Spine, soreness of: Nux von. , , between shoulder-blades: Chin. sulph. Limbs, aching as though beaten: Arnica. , cramps in: Veratr. Limbs, soreness in: Apis. Pain in lower extremities: Tart. emet. Feet swollen: Apis, Arsen., Bryon., China, Ferrum, Nux vom., Pulsat., Sepia. Sleepy, drowsy: Bellad., Bryon., Calc. card., Opium, Pulsat., Tart. emet. Sleepless: Arsen., Bellad., China, Cina, Ipec, Natr. mur., Rhus tox., Sulphur. C hilline s S : A rsen . , Bryon . , Hepar. , Pulsat., Sabad., Veratr. Feverish through the night: Sulphur. Flushes of heat: Sepia. Sweating: China, Sambuc, Veratr. , one side: Pulsat. Skin pale, covered with cold sweat: Ar- sen. itchy: Hepar, Ignat., Rhus tox., Sulphur. , tettery eruptions: Sepia, Sulphur. , on chest: Hepar. , nettle-rash: Apis. Debility, prostration: Apis, Arsen., China, Ferrum, Gelsem., Lycop., Natr. mur., Nux vom., Sulphur, Veratr. Diathesis, scrofulous: Calc. card., Silic, Sulphur. , psoric: Calc. card., Card, veg., Cina, Sepia, Sulphur. , gonorrhceic: Thuja. Arsenic poison: Hepar., Lpec, Nux vom. Mercury poison : Hepar. Quinine poison: Arnica, Arsen., Bel- lad., Card, veg., Ferrum, Lgnat., Laches., Natr. mur., Nux vom., Pul- sat., Sulphur, Veratr. Apis follows well after Natr. mur., Thuja. Pernicious Intermittent; Remittent and Continuous Malarial Fevers; Congestive Fevers. 1. Pernicious fevers are characterized by special dangerous, local affec- tions of important organs; they often appear in the form of an epidemic; their paroxysms are usually of the same duration as those of a simple inter- mittent; sometimes they last longer; their separate stage, may be distinct or ill-defined, with complete or incomplete intermittance of various types. When there are severe disturbances of the nervous system, the most common forms are the comatose, or the intermittens apoplectica, with unconsciousness, stertorous breathing, etc.; the eclamptic form, mostly found among children and puerperal women, with convulsions and unconsciousness; the tetanic form, the severest of all pernicious forms, with tetanic spasms; the hydro- phobic form, with symptoms of hydrophobia. When the alimentary canal is especially affected, we have the choleraic form, especially found in hot climates, which may increase to an algid intermittent; the cardialgic form, with great pains in the region of the stomach; the dysenteric form, with all the symptoms of dysentery; the hemorrhagic form, with haemorrhages from the stomach or bowels. The pneumonic and pleuritic forms show serious affections of the lungs and pleura, and the icteric form especially attacks the liver. 876 PERNICIOUS INTERMITTENT FEVER. 2. Remittent and continuous malarial fevers are frequently met with in the south and southwest of the United States, and in the tropical countries. They are all of a malarial origin, which is proved by the fact that they occur exclusively in regions where ague prevails, in regions, therefore, which, bv their conformation of soil and climate, constitute the necessary conditions for the development of the miasma: and it is further proved by the fact, that remittent fevers, when improving, gradually change into the intermittent type. Hence remittent fevers are only graver forms of the effects of the same unknown virus, called miasma, that causes the ague, and this cor- responds again with the fact, that we find remittent fevers oftener in such regions in which the common intermittent cases are likewise much more severe than in other regions. Remittent fever has no apyrexia, but in place of it there is merely a slack- ing off of the fever, which is again succeeded by another exacerbation. If it be of a severe type there is not even such a remission of its violence. These remittent fevers may be divided into three forms: 1 . The bilious or gastric remittent, characterized by commencing with a chill, which is followed by a violent fever and many gastric symptoms; the spleen is swollen; there is slight icterus; irregular and whitish stools; herpes labialis; headache; pain in the limbs; dizziness; ringing in the ears; epis- taxis; bronchial irritation; great debility. It might be confounded with the beginning of typhus if it were not for the fever blisters around the mouth and the exacerbations, recurring at first irregularly, but later, regularly, as- suming a regular remittent type. It ma}' last from several days to three weeks, and corresponds to the febris intermittens subintrans. 2. The typhoid form gradual^ loses the remissions and becomes con- tinuous. The patient is delirious or lies in a stupor; his tongue is dry and his spleen swollen. In addition to all this there may be icterus, or symp- toms of pneumonia, dysentery, etc. This form lasts from eight to fourteen days, and, on getting better, works over into an intermittent type; if fatal, the patient dies in a comatose condition, corresponding thus to the comatose form of a pernicious intermittent. 3. The gravest form is characterized by a high degree of adynamia and a tendency to rapid collapse. Such patients are deeply apathetic from the very beginning, and exhibit functional disturbances in almost all organs. Many patients are icteric; others bleed from the nose, stomach or kidneys; others show albuminuria, or suppressio urinae; and still others have cholera- like or dysenteric discharges from the bowels. Liver and spleen are swollen, terminating sometimes in inflammation and suppuration. The serous mem- branes show exudates, and the external skin is covered with petechias, or destroyed by decubitus and gangrene. Congestive fever, malignant bilious fever, typho-malarial fever, etc., are only other names for the above-described different forms of remittent mala- rial fevers. yellow fever. 877 Therapeutic Hints. Compare Intermittent Fever. The comatose form requires principally Bellad. y Hyosc, Laches., Opium, Stramon., Tart. emct. The adynamic form especially Arnica, Arsen., Bryon., Camphora, Carb. veg., Chin, sulph., Ferrum, Hydr. ac, Laches., Phos. ac, Rhus tox., Veratr. Yellow Fever. The following is from the special report of the Homoeopathic Yellow Fever Commission: " Yellow fever is a specific disease, entirely independent of malaria, oc- curring rarely a second time in the same person, infectious and capable of transmission to any distance by means of fomites or infected material. 11 The yellow fever germs, for we accept provisionally the germ-theory of the disease, are indigenous to the West Indies and perhaps to the west coast of Africa, and have been thoroughly naturalized in many localities in the southern portion of the United States. They were imported into New Orleans during the last quarter of the eighteenth century, and have existed in the soil or atmosphere of that place ever since, either in a latent or an active condition. They may lie dormant for many years consecutively, and they require a concurrence of causes to develop them into a state of disease- producing activity. 4 ' Some of the factors which seem to be favorable to the excitation of the yellow fever germ are the following: ''Low, swampy ground near the level of a tropical sea. Long contin- uance of a very high temperature, following heavy rains. Long continuance of south and east winds. Aggregations of human beings with the excreta of their bodies in small spaces. A crowded and dirty ship may be a nidus for yellow fever, as well as a crowded and dirty city. Long continuance of calm weather, unbroken by thunder-storms. Exposure of decaying vege- table and animal matter to a burning sun. Inefficient drainage and the gen- eral accumulation of filth, especially the city garbage. Deficiency of ozone in the atmosphere. Pestilential exhalations from an upturned soil. ' ' When the yellow fever germ has been waked into activity by these causes, it may be transported to places where none of them exist. It seems that a certain concurrence of several of the above factors is necessary to the generation of yellow fever. There is probably one combination in one epi- demic, and a somewhat different combination in the next epidemic. An epidemic may be mild or severe, according to the number and force of the concurring causes. There may also be other unknown but discoverable factors, which may be necessary at one time to produce an epidemic, and not necessary at another. No one of the above suggested causes could ex- cite an epidemic by itself, and it is not probable that they all ever concurred 878 YELLOW FEVER. equally to the formation of the disease. The most extensive collections and comparison of facts are necessary to illumine the very great darkness which lies upon these complex questions. ' ' The naturalized yellow fever germs may receive so slight a stimulus as to produce only a few sporadic cases. Or they may be vitalized in certain localities to such a degree as to occasion quite an outbreak in those localities, not easily communicated to other quarters. Or thirdly, the dis- seminated germs may be vivified in all directions, and a general epidemic excited. Or lastly the naturalized germs may lie entirely quiescent, until fresh and active germs are brought in from foreign ports, which then act as sparks to ignite the inflammable material already existing. We thus have four shades or degrees of yellow fever visitation: sporadic cases; local and limited outbursts; epidemics from naturalized germs, and epidemics from importation. In sporadic cases and limited outbreaks the specific nature of the fever is not clearly brought to light, and it is sometimes difficult to diagnose it from the dominant malarial or bilious diseases. The imported epidemic, whether from Havana to New Orleans or from New Orleans to Memphis, etc. , etc. , is always a more quick-spreading and malignant disease than that arising from our naturalized germs. The comparative mildness of the late epidemic in New Orleans, is one out of several reasons for believing that the disease was of local origin. 1 ' The yellow fever of domestic origin can only be prevented by local sanitary measures. So long as the public authorities ignore the crying evils at home, and watch only for the enemy at the seaside, we shall continue to be scourged with repeated epidemics of yellow fever. Quarantine may or may not keep out the tropical foe, but our utmost energies should be con- centrated against the enemy which has been domiciliated in our households for nearly a century. ' ' The incubation is short, frequentty not longer than a day or two; in some cases fourteen days. Its course is an acute one, lasting from three to ten days, and consists of three distinct stages. 1. The febrile stage. — ''Very high fever, preceded or not by a chill, with extremely severe pains in the head (occipital region predominantly), back and limbs. Temperature from 103 to 107 F.; great restlessness and malaise, accompanied sometimes with mental anxiety and fear of death; vomiting of ingested bile; red, watery eyes; suffused countenance; sleepless- ness or stupor with intense heat; delirium, sometimes violent, sometimes muttering; skin very hot and dry, but very easily excited to perspiration." 2. The stage of exhaustion. — "Passing in most cases by insensible gradations from a state of great apparent, but of really little danger, the patient enters the second stage of yellow fever, in which he may seem to be doing very well to an inexperienced eye, while in fact he may be in an alarming and even hopeless condition. The pulse becomes natural again, or SPECIAL HINTS TO YELLOW FEVER. 879 weak and irregular, or in some cases very slow, forty or even thirty to the minute. The patient expresses himself as well, wants to eat or drink, would commit great imprudence in diet, or talking, or throwing off cover, or get- ting out of bed, if permitted; apathy, indifference, no realization of danger; at night sleeplessness, sometimes a terrible pervigilium, restlessness, great nervousness; sour or acid eructations; epigastric pains; tenderness on press- ure over the liver and spleen; vomiting of ingesta, of a claret-colored water, of mucous substances specked with blood, of pure blood, of floating shreds like bees' wings, of brown vomit, of genuine coffee-grounds, black vomit; excesssive irritability of stomach; black stools; hiccough. Sudden and un- accountable changes of color; alternate flushing and paleness; yellow tint of the sclerotica; increasing yellowness of the surface, even in some cases to the deepest jaundice, and haemorrhages; oozing of dark blood from gums, nose, eyes, ears; haemorrhage from the uterus, bowels, or kidneys; petechiae; decided albuminuria; scanty or suppressed urine, followed by coma or con- vulsions; secondary fever, from local congestions or inflammations." 3. The stage of collapse. — "Skin of a dirty yellow or almost bronze color; large petechial spots; slow oozing of blood from every orifice of the body; black vomit; bloody, black, or totally suppressed urine; extreme jactitation; total apathy or muttering delirium; hiccough; cold extremities; feeble and flickering pulse; convulsions; involuntary discharges of black matter, and utter prostration, sometimes with precordial anguish and undy- ing irritability of the stomach." {Report of Homoeopathic Yellow Fever Com- mission.} Therapeutic Hints. In the first stage most physicians have used Aeon., Bellad., Bryon.; some have recommended Gelsem. and Ver. vir.; one has called attention to Eupat. per/., Cimicif., Baptis. In the second stage all used Arsen., many also Laches., or Crolal., and on failure of these remedies, Card. veg. Phos- phor, is barely mentioned by two physicians. In the third stage the choice lay between Arsen., Crotal., Carb. veg., Hydr. ac, Secale and Tincture of Aeon. Special Hints. Aeon. First stage; burning heat and dry skin; full, hard, quick pulse; desire to be uncovered; great restlessness and anxiety; fear of death; dizzi- ness on rising; pain in the forehead and temples; face dark red; eyes in- jected, sometimes sensitive to light; lips and mouth dry; great thirst; nausea, vomiting; heat in the stomach; short, anxious respiration; distress in car- diac region; pain in the back and extremities. Useful only for a short time; is followed well by Bellad. (Taft, Hardenstein.) Apis. Pain in forehead and temples, relieved by pressure; burning, stinging heat in face with purple color; dry, swollen and inflamed tongue with difficulty of swallowing; strangury, or urine scanty and high colored; sleep disturbed by many dreams; restlessness and delirium. (Angell.) 88o SPECIAL HINTS TO YELLOW FEVER. Arg. nitr. Second stage; vomiting of a brownish mass, mixed with coffee-ground-like flakes. (Holcombe.) Meningeal symptoms. (Harden- stein.) Arscn. Second and third stage; dull, heavy or throbbing pain in the head; face yellowish and livid, or deep, dull red; eyes dull and sunken, with dark rings around and yellow sclerotica; nose pointed; nosebleed; lips and tongue brown or black; vomiting, especially after drinking; black vomit; burning or stitching pain in the epigastrium and region of the liver; great pressure in the pit of the stomach; cramp-pains in the bowels; diarrhoea, with tenesmus, or painless and involuntary; bloody discharges; retention of urine; bloody urine; oppression of the chest, with short, anxious breathing; pulse irregular, frequent, small, trembling; internal heat and external cold- ness of the body, and cold, sticky perspiration; stiffness and lameness of the limbs; rapid sinking of strength; anxiety and restlessness; wants to go from one bed to another; delirium with desire to escape. (Taft, Holcombe.) Baptis. Stupid stare and bewildered look; cannot collect himself; face dull red, listless, besotted; dry, red tongue, or with a dark yellow coating; difficulty of protruding the tongue; fetid breath; urine scanty and high colored; all symptoms worse from evening till one o'clock A. m. (Angell.) Bellad. First and second stage; dry, burning heat, with changing pulse; sharp, stitching, shooting and throbbing pains in the head and ears; face scarlet red, shining and swollen; eyes red, glistening, staring, dilated and oscillating pupils; carotid arteries pulsating; dry, hot tongue and throat; nausea and violent vomiting; cramp-like pain in the stomach; burning and throbbing in the pit of the stomach; urine red or brown; painful heaviness and cramp-like pain in the back, loins and legs; head and body hot, feet cold; delirium, afraid of creeping things. (Hardenstein, Taft.) Bryon. First and second stage; headache in back of head down to neck and shoulders, worse from motion; pain in the eyes when moving them; the eyes are red or dull and glassy, or glistening and watery; tongue dry and coated white, or dirty-yellowish, or brownish; burning thirst; vomiting worse after drinking; fullness and oppression in the pit of the stomach and bowels; pleuritic pains in the chest with or without cough; pain in the back and limbs; yellow skin; anxiety and fear about the future; loss of memory; de- lirium. (Taft, Hardenstein, Angell.) Cadm. sulph. When nausea is not relieved by Ipec. or Arsen., in first stage. Taste like pitch in the mouth; salty, rancid belching; nausea in mouth, chest and abdomen, often with pain and cold sweat in face, pain in abdomen; vomiting of sour, yellow and black matter; burning and cutting in stomach; vertigo, room and bed seem to spin around. (Hardenstein.) Camp/wra. When there is a severe and long-lasting chill at the com- mencement. (Holcombe.) Trembling of the internal parts; coldness of limbs. ( Hardenstein. ) Canthar. Second and third stage; complete insensibility; cramps in the abdominal muscles and legs; suppression or retention of urine; haemor- SPECIAL HINTS TO YELLOW FEVER. 88 1 rhages from the stomach and intestines; cold sweat on the hands and feet. (Taft.) Strangury. (Holeombe.) Chamom. Suitable especially for women and children with gastric irritations. (Holeombe.) An intercurrent remedy for colic. (Harden- stein.) Card. veg. Like sulphur in cholera, so is, according to Hering, Card. veg., that medicine which, more than any other, corresponds in the totality of its action, to yellow fever. Taft recommends j.t, especially for the third stage, and Howard gives the following indications: haemorrhages with great paleness of the face, violent headache, great heaviness in the limbs and trem- bling of the body. — The report of the Yellow Fever Commission gives the following indication: pupiis do not respond to the light; haemorrhage from the eyes; repeated nosebleed, with small, intermittent pulse; hippocratic face; grayish -yellow; red cheeks, covered with cold sweat; bloody saliva; rancid eructations; enormous flatulence; burning in the stomach, with vomiting of blood; all discharges fetid and offensive; menorrhoea; capillary stagnation; cyanosis; thread-like pulse, sleepless, intensely restless, from suffocating sen- sations; icy coldness of the body; ecchymoses. Cepa. Is said to have cured a case of yellow fever when raging in Philadelphia; there are a good many symptoms in its pathogenesis which might suggest its further application. Cimicif. Delirium with excessive restlessness; subsultus tendinum; wak- ing from sleep with start; dreams and delirium about negroes, devils, etc. (Angell.) Violent pains in small of back; stiff neck; soreness of all mus- cles; pains like electric shocks here and there; sharp pains from neck to vertex. Melancholy, indifferent, taciturn. (Report of H. Y. F. Commis- sion.) Coloc. For colic and colicky pains. Crotal. Is indicated especially by the haemorrhages from the eyes, nose, mouth, stomach and intestines. (Bute.) The report of the Commission, and Hardenstein, give the following indications: delirium with open eyes; utter apathy; confused speech; disconnected answers, with coldness of the skin and rapid pulse; terrible headache, with red, puffed face; face yellow, or sometimes of a leaden color; blood flows from the eyes, ears and nose, in- deed from all the orifices of the body, even bloody sweat; thirst; sour, acrid eructations; scraping, rancid sensation down the oesophagus to the stomach; extreme nausea and vomiting on least exertion; vomiting of bile, of blood; swelling of the whole abdomen; enlargement of the inguinal glands; bloody stool, sometime involuntary; haemorrhage from the urethra; painful reten- tion of urine; menses anticipate; hoarse, weak, rough voice; pains in chest; pulse slower than natural (sixty beats), or intermitting and scarcely per- ceptible; pains in bones; deep yellow color of the whole body; purple spots; extreme depression of the vital powers; spasms; death by syncope; acts more on right side. . 56 882 SPECIAL HINTS TO YELLOW FEVER. Crot. tig/. Recommended by Haekett, an allopath; he saw from his doses aggravations, but afterwards rapid improvement. Cuprum. When Arsen. does not relieve the vomiting of blood. ( Kiistner. ) Eupat. perf. Valuable in first stage as an intercurrent remedy in cases where the bones ache as if broken, with headache and backache, thirst and vomiting. (Angell.) Gelsem. Unconnected ideas, cannot follow any idea for any length of time; if he attempts to think consecutively, he is attacked by a painful vacant feeling of the mind; giddiness with loss of sight; indistinctness of vision, or double vision; fullness of head, with heat in face, and cold feet; pain in back of neck; heavy, dull expression of countenance and yellow face, or nausea and paleness. Sticky feeling in mouth; fetid breath; tongue coated whitish or yellowish; dryness and burning in throat; sour eructations; pulse frequent, full, but soft. As soon as he goes to sleep, he is delirious. (Angell.) Ipec. In the first stage; dizziness, chilliness, pain in the back and limbs, uncomfortable feeling in the epigastrium, with nausea, vomiting and great weakness. (Taft. ) To be followed by Cadmium sulph . if relief is not soon attained. (Hardenstein.) Laches. Quite important in any of the stages. Kiistner gave it also after previous abuse of mercury or quinine. The report of the Commission, and Hardenstein, gave the following indications: delirium at night; loqua- cious, disposed to quarrel; slow, difficult speech; drowsy; rush of blood to the head; red face; yellow conjunctiva; yellow or purplish tint of skin; blood dark; non-coagulable; small wounds bleed much; perspiration stains yellow; lips dry, cracked and bleeding; tongue heavy, trembling, dry and red, cracked at tip; tip red, centre brown; difficult speech; sour eructations; heartburn; nausea after drinking; vomiting, with palpitation; dyspnoea; anxiety about the heart; cannot lie on left side; irregular, weak pulse; urine almost black; persistent sleeplessness; fainting; trembling all over; sudden flushes of heat; sensitiveness about the neck and pit of stomach against any pressure; worse when waking; better after nourishment. Acts more on left side. Mercur. Yellow skin; red, injected eyes, sensitive to light; paralysis of one or the other limb; tongue moist, coated, thick and white, or dry with brown slime; pulse irregular, quick, strong and intermitting, or soft and trembling. Drowsy or sleepless from nervous irritation; tired and weak; rapid sinking of strength; dizziness and violent headache; violent convulsive vomiting of slime and bilious matter; burning pain and sensitive- ness of the stomach; constipation or diarrhoea of slime, bile or blood; cold- ness of the extremities with cramps. Great irritability of all the organs; anxiety and restlessness; weak memory; fears; discouragement; crossness. (Taft.) Nux vom. After allopathic drugging, or in persons accustomed to SPECIAL HINTS TO YELLOW FEVER. 883 drinking strong liquors. According to Taft: yellow skin, pale or yellowish face, especially around the nose and mouth; eyes injected, yellow and watery; dark rings around the eyes; tongue slimy or dry, cracked and red on the edges; thirst for beer or stimulating drinks; burning in the stomach; press- ure or cramp-pain in the stomach; vomiting of sour, bilious, or slimy sub- stances; hiccough; dizziness or headache; trembling of the limbs; cramps in different parts of the body; contractions of the abdominal muscles; thin, slimy, bilious or bloody stools; burning pain in the neck of the bladder, with difficult urination; coldness, lameness and cramps in the legs; cold feet. Excessive anxiety; fear of death; despondency or loss of consciousness and delirium, with moaning and groaning. Phosphor. Hemorrhagic form, with petechial spots, or with menin- gitis, or especially pleuritic pains after Bryon. (Hardenstein.) " Its power of producing acute yellow atrophy of the liver, fatty degeneration, malignant jaundice, albuminous urine, the haemorrhagic diathesis, and many of the symptoms of Arsen. and Crotal. shows that is a remedy of great homoeo- pathic applicability to yellow fever." (Report of Commission.) Rhus tox. According to Taft: dirty yellow color of the body; glassy, sunken eyes; dry, black tongue; talkative delirium, or coma with rattling respiration; constant groaning; torturing pain and burning in the stomach; nausea; vomiting; paralysis of the lower extremities; cramps in the abdomen; colic; diarrhoea; difficult}' in swallowing; constant restlessness and tossing about. According to Angell: bright redness of face (in first stage), or pale and sunken face, with pointed nose; epistaxis; dryness of mouth and throat; dry cough and red. tongue, or dark brown (mahogany) or black; cracked tongue, unable to protrude it; eructation and rumbling in abdomen, causing great distress; diminished urine; sleeplessness. Sulphur. Melancholic; fearful; undecided; sad; absent-minded; dizzi- ness; headache; face pale or yellowish; eyes red or yellowish; itching and burning in the eyes; noises in the ears; tongue dry, red, or with white or brown coating; aphthae in the mouth; nausea with trembling and weakness; vomiting of sour, or bilious, or bloody and black masses; pressure in the stomach; pain in the back and loins. (Taft.) Tart. emet. Continuous nausea with vomiting, or vomiturition with perspiration on forehead; shuddering; attacks of fainting and trembling; great prostration. (Angell.) Verbena Jam. The juice of the leaves of this plant, the species of which is not properly given, is said to have cured a number of the most des- perate cases. Veratr. According to Taft: yellowish or bluish face, cold and covered with a cold perspiration; eyes dull, yellowish, watery; deafness; lips and tongue dry, brown, cracked; difficult swallowing; hiccough; great thirst; vomiting of bile or blood; burning in the stomach; coldness of the hands and feet; trembling and cramps of the hands, feet, legs and abdomen; diarrhoea, thin, blackish or yellowish; pulse small, scarcely perceptible, intermitting. 884 DIGEST TO YELLOW FEVER. Great exhaustion; vertigo; fear; despondency; restlessness; loss of con- sciousness; coma or delirium. According to Angell: after purging from castor oil; vomiting of slime and diarrhoea, sometimes involuntary stools; hopelessness of life. According to Hardenstein: in first stage trembling and jerking of external parts; coldness all over the body. Ver. vir. Intense fever with occipital pains, and vascular and nervous erethism, threatening convulsions, especially in children; developments of local inflammations; precordial distress; vomiting with cold sweat on the face; great and sudden changes in the pulse. (Report of Commission.) Aside from these remedies we find recommended: For nausea: Apomorph., Kreos., Hydr. ac, Lobel. inji. For nervousness and sleeplessness: Coffea or Bellad., Opium, Daphne hid., Sepia. For haemorrhages : Plumb, ae., -£$ of a grain (Angell), Sulph. ae., Tereb., Millef., Eiiger., Pycop., Arnica, Sabina, Secale, Hamam., Thlaspi bursa pastoris. For albuminuria: Euonymin , He/on., Cuprum, Merc. corr. For retention of urine, with delirium and convulsions: Hyosc, Opium, Stra m mon . , Plu m b u 771 . For difficult urination and tenesmus : Lycop., Te7eb., Chimaph., Apis, Apocy7i., Primus spi7iosa, Ca7in. Ind., Sulphur, Citric ac. For cerebro-spinal symptoms: Glo7ioin., Cor all., Cicuta, Zincum. During convalescence : Calc. carb., China, Hepar. (Report of Commis- sion, Hardenstein/) Digest to Yellow Fever. Consciousness, loss of : Nux vom., Ver. alb. Insensibility : Canthar. Memory, weak: Mercur. , loss of: Bryon. Absent-minded : Sulphur. Cannot collect himself: Baptis. Unconnected ideas ; cannot follow any idea for any length of time; if he at- tempts it, he is attacked by a painful vacant feeling of the mind: Gelsem. Disconnected answers, with coldness of skin and rapid pulse: Crotal. Confused speech : Crotal. Stupid stare and bewildered look: Bap- tis. Delirium : Bryon. with open eyes: Crotal. at night: Laches. as soon as he goes to sleep: Gelsem. Delirium and coma: Rhus tax., Ver. alb. about negroes, devils, etc.: Cimie. , afraid of creeping things: Bel lad. , talkative: Rhus tox. , with moaning and groaning: vom. , with desire to escape: Arsen. , restlessness: Apis, Cimie. Nux Loquacious : Laches. Moaning and groaning: Nux vom., Rhus tox. Taciturn : Cimie. alb. Indifferent: Cimie. Apathy: Crotal. Fears: Mercur., Sulphur., Ver. about the future: Bryon. of death: Aeon., Nux vom. Anxiety : Arsen., Bryon., Nux vom. Anxiety and restlessness: Aeon., Arsen. Mercur. Sad: Sulphur. Melancholy: Cimie, Sulphur. Despondency: Nux vom., Ver. alb. Hopelessness : Ver. alb. DIGEvST TO YEI^OW FEVER. 885 Discouragement : Mercur. Undecided: Sulphur. Crossness : Mercur. Quarrel, disposed to: Laches. Vertigo : Sulphur, Ver. alb. , room and bed seem to spin around: Cadm. sulph. on rising: Aeon. and headache: Mercur. or headache: Nux vom. • , with loss of sight: Gel son. and chilliness: Ipec. Headache: Card, veg., Sulphur. , dull, heavy, throbbing pain: Arsen. , with red, puffed face: Crotal. Pain, forehead and temples: Aeon. , , relieved by pressure: Apis. , back of head down to neck and shoulders, worse from motion: Bryon. , sharp, from neck to vertex: Cimic. , ,stitching and throbbing in head and ears: Bell ad. ■ in occupit, with intense fever: Ver. vir. Head and body hot, feet cold: Bellad. , rush of blood to the: Laches. , fullness of, with heat in face and cold feet: Gelsem. Meningeal symptoms: Arg. nitr., Phosphor. Eyes itching and burning: Sulphur. • painful when moving them: Bryon. red, injected : Aeon. , Bellad. , Bryon. , Mercur., Nux vom., Sulphur. , , sensitive to light: Aeon., Mercur. glistening, staring: Bellad., Bryon., glassy, sunken: Rhus tox. , dull and watery: Bryon. dull and sunken: Arsen., Card. veg. and watery: Ver. alb. yellowish: Laches., Sulphur, Ver. alb. and watery; dark rings around eyes: Arsen., Nux vom. Pupils dilated and oscillating: Bellad. do not respond to the light: Carb. veg. Sight indistinct, or double vision: Gel- sem. Haemorrhage from eyes: Carb. veg. and all orifices of body: Crotal. Ears, noises in: Sulphur. , deafness: Ver. alb. , haemorrhage from: Crotal. Nosebleed: Arsen., Crotal., Rhus tox. , with small, intermittent pulse: Carb. veg. Nose pointed: Arsen., Carb. veg., Rhus tox., Ver. alb. Face, dull, heavy expression: Gelsem. , listless, besotted expression : Baptis. pale, with nausea: Gelsem. , with haemorrhages: Carb. veg. and sunken, with pointed nose: Rhus tox. — or yellowish: Nux vom., Sul- phur. red: Laches. bright red: Rhus tox. dark red: Aeon. dull red: Arsen., Baptis. scarlet red, shining and swollen: Bellad. purplish, with burning, stinging heat: Apis, yellowish or bluish, with cold sweat: Ver. alb. yellowish, grayish, hippocratic: Carb. veg. , or of a leaden color: Crotal. and livid: Arsen. , especially around nose and mouth: Nux vom. , cold sweat on : Carb. veg. , , during vomiting: Ver. vir. , cold sweat on forehead during per- spiration: Tart. emet. Lips dry, cracked and bleeding: Laches. and mouth dry: Aeon. and tongue dry, brown, cracked: Ver. alb, brown or black: Arsen. Tongue dry and cracked: Laches., Nux vom., Rhus tox., Ver. alb. , black: Rhus tox. , brown: Ver. alb. , red at tip: Laches. , on edges: Nux vom. 886 DIGEST TO YELLOW FEVER. and red: Baptis., Laches., Sul- phur and hot, and throat: Bellad. and brown: Ver. alb. and black: Rhus tox. and brown or black: Arsen. or red: Rhus lo.v. and coated white, or dirty-yel- lowish, or brownish; Bryon. dark yellow: Baptis. ' white or brown: Sulphur. with brown slime: Mercur. ; swollen and inflamed, with dif- ficulty of swallowing: Apis. , tip red and centre brown: Laches. , red streak in centre: Ver. vir. moist and coated thick and white: Mercur. coated whitish or j-ellowish: Gel son. heavy, trembling: Laches. difficult of protruding: Baptis., Loa- ches., Rhus tax. Mouth, and throat dry: Rhus lo.v. , aphthae in: Sulphur. , haemorrhage from: Crotal. , bloody saliva: Garb. veg. , sticky feeling in: Gelsem. , taste like pitch: Cadm. sulph. , fetid breath: Baptis., Gelsem. Thirst: Aeon., Arsen., Bryon., Grotal., Eup. per/. , Ver. alb. for beer or stimulating drinks: Nux vom. Swallowing difficult: Rhus tax., Ver. alb. Speech slow, difficult: Laches. Throat dry and burning: Gelsem. , scraping, rancid sensation to stom- ach: Grotal. Eructations, rancid: Cadm. sulph., Garb, veg. , salty: Cadm. sulph. , sour: Crotal., Gelsem., Loaches. and distressing rumblings in bowels: Rhus tox. Heartburn: loaches. Hiccough: Nux vom., Ver. alb. Nausea in mouth, chest and abdomen, with pain, and cold sweat in face; Cadm. sulph. and paleness: Gelsem. and trembling and weakness: Sul- phur. and drinking: Laches. and vomiting: Aeon., Be/lad., Nux vom., Tart. emet. , with great weakness: /pec. Vomiting, with sweat on forehead: Tart, emet. , with cold sweat on face: Ver. vii\ , with burning in the stomach: Carb, veg. , with palpitation: Laches. , with thirst: Eup. per/. after drinking: Arsen., Bryon. , when the water gets warm in the stomach: Phosphor. of black stuff : Arsen., Cadm. sulph. , Sulphur. of a brownish mass, mixed with cof- fee-ground-like flakes: Arg. nitr. of bl( od: Arsen., Garb, veg., Crotal.^ Cuprum., Sulphur., Ver. alb. sour, bilious: Cadm. sulph., Crotal. , Mercur., Nux vom., Sulphur, Ver. alb. — — slime: Mercur., Nux vom., Ver alb. and diarrhoea, sometimes involun tary: Ver. alb. Gastric irritations: Chamom. Stomach, burning in: Card, veg., Vet\ alb. , and cramp-pain in: Nux vom. , and cutting in; Cadm. sulph. — •-, burning and sensitiveness in: Mer- cur. , and throbbing in: Bellad. , and torturing pain in: Rhus tox . , in, and coldness of hands and feet: Ver. alb. , or stitching pain in, and region of liver: Arsen. , heat in: Aeon. , pressure in: Arsen., Sulphur. , fullness and oppression in: Bryon. , sensitive to pressure in, and about the neck: Laches. , distress in: Ver. vir. , cramp-like pain in: Bellad. , haemorrhage from, and bowels: Canthar. , Crotal. Abdomen, flatulence: Garb. veg. DIGEST TO YELLOW FEVER, 887 , swelling: Crotal. , cramps in: Arsen., Rhus tox. . , and in extremities: Ver. alb. , in abdominal muscles and legs: Canthar. , contraction of abdominal muscles: Nux vom. , colic in: Cadm. sulph., Coloc, Rhus to.v. Enlargement of inguinal glands: Crotal. Diarrhoea: Rhus to.v. , sometimes involuntary: Ver. alb. , bilious, slimy: Mercur. Nux vom. , thin, blackish, or yellowish: Ver. alb. , bloody: Canthar. , Crotal., Mercur., Nux vom. , , sometimes involuntary: Cro- tal. , with tenesmus, or painless and in- voluntary: Arsen. or constipation: Mercur. Neck of bladder, pain in, with difficult urination: Nux vom. Strangury: Apis, Canthar. Retention of urine: Arsen., Canthar., Crotal. Urine diminished: Rhus tox. scanty and high colored: Apis, Bap- tis. red or brown : Bellad. almost black: Laches. blood)-: Arsen., Crotal. Menses anticipate: Crotal. Menorrhagia : Cat -b. veg. Voice hoarse and weak : Crotal. Chest, pain in: Crotal. , pleuritic pains in: Phosphor. , , w T ith or without cough: Bryon. Respiration rattling, with coma: Rhus tox. Oppression, with short, anxious breath- ing: Aeon., Arsen. , anxiety about the heart: Laches. Distress in cardiac region: Aeon. Palpitation, with vomiting: Laches. Pulse frequent, full, but soft: Gelsem. , small, trembling: Arsen. full, hard, quick: Aeon. intermitting: Card, veg., Crotal.? Mercur., Ver. alb. irregular, quick and strong: Mercur. , great and sudden changes: Ver. vir. and weak: Laches. slower than normal : Crotal. small, scarcely perceptible: Carb. veg., Crotal., Ver. alb. soft and trembling: Mercur. thread-like: Carb. veg. Carotid arteries pulsating: Bellad. Neck, pain in back of: Gelsem. , stiff, and soreness of all muscles: Cimic. Back, small of, pains in: Cimic. and loins, pain in: Sulphur. and limbs, pain in: Aeon., Bryon, Lpec. , loins and legs, heaviness and cramp- like pain in: Bellad. — — and headache, and as if all the bones were broken: Eup. perf. Bones, pain in; Crotal. Different parts of body, cramps in: Nux vom. Limbs, stiffness and lameness of: Arsen. , paralysis of one or the other of the: Mercur. , heaviness of: Carb. veg. , coldness of: Camphor a, Ver. alb. , , with cramps of: Mercur. Legs, coldness, lameness and cramps in: Nux vom. Feet cold: Nux vom. Blood dark, non-coagulable: Laches. flows from all orifices: Crotal. , discharges of : Arsen., Carb. veg. , capillary stagnation, cyanosis; all discharges fetid and offensive: Carb. veg. Small wounds bleed much: Laches., Phosphor. Trembling all over: Carb. veg., Laches. of internal parts: Camphora. of the limbs: Nux vom. and attacks of fainting: Tart. emet. and jerking of external parts: Ver. alb. Subsultus tendinum: Cimic. 888 DENGUE. S^pasms : Crotal. Paralysis of left side: Laches. of lower extremities: Rhus tox. Pains like electric shocks here and there: Citnic. Irritability of all organs: Mercur. , vascular and nervous, threatening convulsions, especially in children: Ver. Coldness all over: Ver. alb. , icy, all over: Camphora, Card. veg. , external, with internal heat: Arsen. Chill, severe and long-lasting, at the commencement: Camphora. Shuddering : Tart. emet. Heat, dry burning: Aeon. , , , with changing pulse: Bellad. , sudden flushes of: Laches. , internal, with external coldness, and cold, sticky perspiration: Arsen. Fever, intense, with occipital pains: Ver. vir. Local inflammations: Ver. vir. Sweat bloody: Crotal. cold, sticky: Arsen. , on face: Card. veg. , on hands and feet: Canthar. stains yellow: Laches. Coma, with rattling respiration: Rhus tox. Drowsy : Laches. or sleepless from nervous irritation: Mercur. Sleeplessness : Laches., Rhus tox. and restlessness from suffocating sen- sations: Card. veg. Sleep disturbed by many dreams: Apis. Waking with a start from sleep: Cimic. Restlessness: Ver. alb. and tossing: Rhus tox. , w r ants to go from one bed to another: Arsen. Sinking of strength: Arsen., Mercur Exhaustion: Ver. alb. Prostration: Tart. emet. Depression of vital powers: Crotal. Fainting: Laches. Death by syncope: Crotal. Skin yellow: Bryon., Mercur. or purplish: Laches. deep yellow: Crotal. dirty yellow: Rhus tox. , purplish spots: Crotal. , ecchymoses: Card. veg. , petechial spots: Phosphor. Worse on right side: Crotal. on left side: Laches. lying on left side: Laches. from evening till i o'clock . Baptis. when waking: Laches. Desire to be uncovered: Aeon. Better after nourishment: Laches. Aeon, is followed well by Bellad. Cadm. sulph., when nausea is not re- lieved by Arsen. or Lpec. Carb. veg. is, according to Hering, the fundamental remedy in yellow fever, like Sulphur in cholera. Cepa is said to have cured a case of yel- low fever. Chamom., as intercurrent remedy for colic in children. Crot. tigl., in allopathic doses, was fol- lowed by aggravation and final rapid improvement. Cuprum, when Arsen. does not relieve the vomiting of blood. Laches., after previous abuse of mercury or quinine. NllX VOm., after allopathic drugging. Phosphor, is similar to Arsen. and Cro- tal. , and produces acute yellow atrophy of liver, fatty degeneration, malignant jaundice, albuminous urine andhaemor- rhagic diathesis. Ver. alb., after purging with castor oil. Verbena Jam. is said to have cured a number of the most desperate cases. Dengue, or Break-bone Fever. Dengue is an epidemic infectious disease*, which occurs mostly in this country, in the Southern States. Zuelzer in Ziemssen's Encyclopedia, says: " The name dengue is applied to an acute disease, which mostly occurs as an TYPHUS. 889 epidemic iu hot climates, seldom sporadically, and the course of which, after a sudden onset or after slight prodromata lasting several days, consists of two paroxysms accompanied by fever, either following immediately one upon the other, or after intermission of one, two or three days. But the parox- ysms are essentially different one from the other; the first is characterized by continuous high fever, reaching its height within the first 12 to 24 hours (temperature 106. 7 and 107. 6° F. , and pulse from 120 to 140 per minute), and numerous exceedingly painful swellings of the joints, which interfere with motion, also, more rarely, by an exanthem. These symptoms subside after two or three days, simultaneously with the sudden outbreaks of a sweat, or epistaxis, or a diarrhoea, which is often critical. 11 The second febrile stage, which lasts from two to three days, is marked by a remitting fever, and a more or less extensive blotchy or uniform, non- elevated, rose-red eruption and great itching of the skin, also less frequently by swelling of the joints. ' ' The subsequent recovery is gradual, and accompanied by decided des- quamation. Its course is generally accompanied by great loss of appetite, restlessness and sleeplessness. More serious brain-symptoms are absent. 1 ' The disease attacks all ages and both sexes; with adults it terminates in recovery, with children it is occasionally dangerous. It sometimes leaves be- hind long continued and painful swellings of the joints, diarrhoea, emaciation and great debility. Relapses also occur. It is not yet determined whether the disease is contagious or occasioned by miasmatic influence. ' ' Typhus. Typhus means literally, smoke, stupefaction. In the course of time this word has been used to signify different pathological affections, all of which, however, were characterized by a dry tongue, stupor, delirium and great prostration. Nowadays it has become usus to designate only three forms of low fever by the term typhus, namely: the typhus exantheniatieus, or pete- chial typhus, which is characterized by a peculiar eruption; the typhus abdo- minalis, or ileo-typhus. which is characterized by a peculiar diseased state of the small intestines, in this country best known under the name of typhoid fever ; and the relapsing fever. Typhus Exanthematicus, Petechial Typhus. This form is also known under the name of Jail-fever, Ship-fever, or Camp-fever. Its immediate Cause is unknown; recent observers, however, agree that it is spread by a typhus-germ which has not yet been discovered. Its contagiousness is great, and increases with the duration of closer contact with typhus patients, therefore assistants and nurses in hospitals are much more frequently attacked than the visiting physicians and students; and where many persons are confined to a limited space, e. g., in prisons, on shipboard, in camps, etc., the pestilence spreads rapidly to those thus con- 890 TYPHIS BXANTHEMATICUS. fined. The disease germ is carried by every article which has been in contact with diseased persons, by water, if polluted with excrements from patients. by air, if contaminated with diseased exhalations, etc. Famine, atmospheric and telluric conditions, damp, marshy soil. etc. , favor its development. It at- tacks rich and poor of both sexes and of all ages, but most frequently those between the ages of 20 and 40 years. Ordinarily, it occurs but once in a life- time. Epidemics have most frequently raged in Ireland, but other parts of the globe have also suffered from epidemics. The time of incubation varies from a few days to a week and longer, and is attended with various disturbances, none in any way characteristic of the complaint. The stadium invasionis commences in many cases with a severe chill, or with several slight chills, sometimes repeated at intervals during the first day, which are followed by a continuous great heat, amounting already on the third or fourth day to 103 or 104 F. in the morning; and to 104 or 105.8 , rarely to 107. 6° F. in the evening. The patient is at once stricken down by a sense of great weakness and debility, and complains of heaviness or pain in the head, which at times is somewhat ameliorated by a spontane- ous bleeding from the nose; of vertigo, flickering before the eyes and ring- ing in the ears. His hearing becomes impaired; his muscles are sore and pain- ful, and on motion his limbs tremble. He lies apathetic on his back, talks deliriously while awake, or mutters in his sleep. Others, however, are intensely excited, almost wildly, scarcely to be held in bed. With all this we observe various catarrhal affections, of the eyes, nose, throat and chest, which latter is the most constantly affected part, manifesting itself by a harrassing, rough cough, with a scanty, tough, sometimes bloody expec- toration. Auscultation reveals numerous rhonchi. The tongue looks, at this stage, white; with a pappy taste; there is, at times, nausea, vomiting and diarrhoea. This state of things lasts about half a week, when between the third and fifth days, scarcely later than the seventh da}*, the second stage, the stadium eruptionis et florescentiae, commences. We now observe the breaking forth of a rash — roseola spots, greatly resembling that of measles — first on the trunk and gradually spreading over the entire body. During the first few days these spots disappear on pressure, later, when exudation of blood-corpuscles or coloring matter has taken place, they fade no longer under pressure; they remain till toward the end of the second week. True petechiae, on the contrary, are spotted extravasations of blood from the be- ginning; they remain longer and disappear more slowly, and may re-appear after the roseola has gone. The appearance of this eruption does not in the least ameliorate the condition of the patient; on the contrary, he grows worse all the time; his sensorium becomes more clouded; he is unable to think, gives slow, incoherent answers, is in constant delirium, either of a mild or raving nature, with constant attempts to jump out of bed and run away. After recovery the patient scarcely ever remembers anything of this stage. The difficult}* of hearing increases; the tongue grows dry and is covered TYPHUS KX ANTHEM ATICUS. 89 1 with a brownish coating, and the respiration, although the cough has lessened materially, is quick and superficial, with increased rhonchi and a dull per- cussion sound on the dependent parts of the thorax. There is almost always constipation at this stage, with involuntary discharge of urine. The heat retains its height to the latter part of the first week, when in light cases it generally slackens off a little, and by the seventh day shows an appreciable remission for the first time. In severe cases, however, the temperature of the body increases during the second part of the first week , and shows no re- mission on the seventh day. The spleen is considerably enlarged toward the end of the first week, and the eruption commences to grow more livid with the commencement of the second week. Now the patient lies flat on his back, with his eyes half closed, and his hands on his genitals; in deep stupor, out of which he can scarcely be roused; he mutters single, unintelligible words, draws faces according to the nature of his ever- working imagination, gesticulates, catches at something in the air, or picks the bedclothes, tries to rise or to put his feet out of bed, in fact, his mind seems to be constantly busj~ at something, although entirely disconnected with the world around him. He manifests no desire for drink, which, however, is taken when of- fered, though sometimes with great difficulty, as the tongue is parched and trembling and the swallowing difficult. The teeth and gums are covered with sordes, the nostrils appear blackened as by soot, and the breath exhaled has a terrible smell. By this time the petechial eruption is joined by the breaking forth of a miliary eruption; the bronchial catarrh may increase to pneumonia or collapse of the lungs, and a number of cases, even light once, are complicated with parotitis. The fever increases in all cases with the beginning of the second, may there have been a remission on the seventh day or not. In light cases, however, this aggravation is not very severe, nor does it last more than a few days, while in severe cases it reaches up to 106. 8° or even 107. 8° F., lasting to the end of the second week, -even to the sixteenth and seventeenth day of the disease. The third stage, or the stadium criticum, commences almost always in the latter part or the second week, or, in severe cases, in the first days of the third week. The change sets in remarkably quick, often in one single night, in which the patient at once, after so many sleepless nights, enjoys a deep, quiet sleep, out of which he awakes for the first time conscious again, but without remembrance of what has passed. The temperature has sunk, perhaps, two degrees and the frequency of the pulse, perhaps, twenty to thirty beats per minute; instead of the pungent heat, the body is in a gentle perspiration and the roseola spots appear much paler. Now convalescence commences, which goes on, however, quite slowly. The crisis is accom- panied by the formation of sediments in the urine, an increase in its quantity, a disappearance of the albumen, and a normal amount of urea and chlorides, though these changes occur slowly. Often recovery is delayed or even frus- trated by a renewance of a slow fever, which takes away the last strength of the patient, or other sequelae retard its progress, among which the most 892 TYPHOID FEVER. frequent are inflammation and suppuration of the parotid glands, pneumonia, pleurisy, diphtheritic or follicular inflammation of the intestines, numerous furuncles, ecthyma pustules or large abscesses in the subcutaneous or inter- muscular cellular tissue; even thrombi in the veins of the legs, and their consequences. There have been observed light, abortive cases of exanthematic typhus, in which it did not even come to an eruption or to an enlargement of the spleen, and where the whole morbid process was finished in two weeks. Loss of hair is not uncommon after an attack of typhus. Therapeutic Hints. See the following chapter. Typhoid Fever, Typhus Abdominalis, Enteric Fever. Typhoid fever is an acute infectious disease the exciting cause of which is probably a specific pathogenic bacterium known as the typhoid bacillus (bacillus of Eberth ). Owing to the frequency of its occurrence it is one of the most important of all the fevers. The water we drink is undoubtedly the chief vehicle by which the germs gain access to the system, although other articles of food contaminated with the virus may be the source of in- fection. Once having entered the alimentary tract the germs attach themselves to the intestinal walls. Here they penetrate the solitary follicles and Peyer's patches, which become infiltrated and swollen, finally undergoing necrotic changes and leaving large ulcers. The}* then pass into the mesenteric glands through the lymphatic vessels and thence into the blood, being thus carried to the spleen and liver. The faeces ol typhoid fever patients containing as they do millions of the bacteria are especially dangerous, affording a ready means for the propaga- tion of the disease. It is therefore imperative that they be disinfected, as well as all linens and clothing that have been contaminated by the patient. Poisoned water can be disinfected by boiling. It was formerly held that infection took place through the respiratory tract, the atmosphere being the carrier of the contagion, but since the dis- cover}' of the bacillus and a thorough study of its life history this seems un- tenable. (Fraenkel.) The period of incubation is generally about two weeks; it may, however, be from three to four weeks in exceptional cases. In large cities sporadic cases happen at any season ; epidemics of typhoid fever occur most frequently from August to November. The greatest individual disposition to take the disease seems to prevail between the ages of fifteen and thirty years. Children less than one year old are very seldom attacked; after this up to fifteen years the predisposition steadily increases, while after the age of thirty years it steadily decreases. On the whole the disease attacks by preference the strong and healthy; it TYPHOID FEVER. 893 avoids those already suffering with chronic ailments, and also pregnant and puerperal women, and those who are nursing infants, although exceptions exist. Persons who have passed through the disease once before are not al- ways exempt from another attack, and "real recurrences, that is a new attack coining on soon after the first has run its course, and relapses before the completion of the disease are often seen." (Liebermeister.) The principal anatomical changes which typhoid fever produces, are: catarrh in the chest, even in the finest bronchial tubes; enlargement of the spleen to double and even six times its natural size; and ulceration of the small intestines. These last, more or less constant, anatomical changes have given rise to the appellation of ileo-typhus. Rokitansky distinguishes four stages of this typhoid process upon the mucous membrane of the small in- testines: 1. The congestive state, by which the whole membrane appears swollen, injected and covered with slime, worse so, however, on its lower portion in the neighborhood of valvula Bauhini. 2. The state of infiltration, by which the general redness and swelling gradually disappear and become concentrated to the solitary and Peyer's glands in the lower part of the ilium. 3. The state of softening, by which the swelling of the glands is ab- sorbed, or the glands burst and become covered with a dry, crumbly crust, or they burst and discharge their contents without getting covered with a crust. 4. The state of ulceration, by which the affected glands suppurate and form the typhoid ulcer. These ulcers are round when originating out of a solitary foliicle and elliptic when originating out of Peyer's plaques; their size varies from that of a hemp-seed or pea to the size of half a dollar. Their basis is the submucous cellular tissue which lines the muscularis of the gut. The Symptoms and Course of typhoid fever are the following: The patient has generally several days previous to the attack a sense of general indisposition, weakness and debility, with headache, dizziness of soreness of the limbs, and sometimes repeated attacks of bleeding from the nose, or none at all. The attack itself begins almost always with a more or less violent chill, or repeated chilly sensations, but sometimes without a chill. It is, therefore, not always possible to fix accurately the time of the disease. The chill is followed by heat, which keeps a regular, quite characteristic, typical rise and fall every day for the first three or four days. " rising about i.8° to 2. 7 F. from morning till evening, and falling from every evening till next morning about .9° to 1.3 P., so that on the third or fourth evening a tem- perature of 104 F. is reached, or a little exceeded. The formula of this ascent is nearly as follows: First day, morning: 98. 6° F., Second day, " 100.2 1 ° F., Third day, " 101.66 F., Fourth day, " 102. 56 F., evening: 101.8 F. (< 102. 56 F. ' ' 103.64 F. 1 . 104.54 F. 994 TYPHOID FEVER. This pyrogenic course in the initial stage of typhoid fever is so decisive a test for its diagnosis that Wunderlich further says: " If the temperature of the second, third and fourth evenings is only approximately normal; if the temperature of the first three evenings, or of two of them, is of the same height; if the temperature of two out of the first three mornings is alike; if the temperature of the first two days rises to 104 F. or more; if the temper- ature retrogrades only once on any of the first four mornings and evenings: in ever}- one of these cases w r e may or must exclude typhoid fever from our diagnosis; and contrarily, said diagnosis is the more certain as the course of the temperature of the first four days comes nearer to the above formula." " Meanwhile, exceptions must not be overlooked. The rise ma} T be com- pleted in two days, or protracted to five; both foreboding a severe course, the latter a delay in the favorable turn (crisis or lysis) till the middle of the third week; the temperature may return to normal the second morning, and be succeeded by a greater rise the second evening; the rise of the first and sec- ond day being less, that of the third and fourth will be much more; the height reached the third and fourth day is not always 104 F., but may be a few tenths less or more by a whole degree, 105. 8° F. When the typhoid fever is secondary to another disease its initial is obscure, often unrecog- nizable. ' ' ' ' In the second half of the first week, and the first half of the second, the course of the temperature is quite uniform, but cannot help the diagnosis. At this time the maximal height, 104 to 106. 7 F., is rarely reached more than once between noon and evening of the fourth or fifth day, meantime the morning temperature is .9° to 2.7 F., lower than the evening's — one remission may be accidentally even lower." (Wunderlich' s Thermometry, by Seguin, page 123.) The course of the temperature during a whole attack may be character- ized in this way, that in the first week it rises steadily, in the second week it is continuous, having the same maximum and minimum even- day, in the third week it becomes remittent, showing greater remissions in the morning although the exacerbations in the evening keep still the same height, while in the fourth week the remissions become more marked and the exacerbations gradually lower. (Liebermeister.) With the temperature rises also the pulse, amounting generally during the first week fiom ninety to one hundred beats per minute; sitting up, bodily exertion, or mental excitement, is apt to accelerate it considerably, even to twenty or thirty beats. With all this the patient complains of great weakness and prostration, severe headache, dizziness, flickering before the eyes, and ringing in the ears; his sleep is restless and disturbed by tiresome dreams, sometimes of the same thing over and over again; he calls out in sleep or talks incoherently. When awake he is full}' conscious but indifferent, answers questions slowly and reluctantly. His thirst is great, his appetite gone, and his taste pappy, disagreeable. The bowels are during the first days frequently constipated, TYPHOID FEVER, 895 but change towards the end of the first week to diarrhoea. There is in many cases repeated bleeding from the nose, and already at this time a catarrhal irritation in the chest. The face is flushed, especially the cheeks look dark red as long as the patient lies quietly on his back, but it turns pale and sunken when he sits up a while. The tongue is soft, flabby, showing the im- prints of the teeth, and is covered by a slight whitish fur, which gradually is thrown off, leaving the tongue moist, smooth and red, as though it were cov- ered with a fine gold-beater's skin; it soon, however, grows dry. In cases where the tongue is thickly coated, this covering commences to disappear either on the tip and edges, whereby the yellowish-white coating becomes encircled by a gradually broader-growing, deep, red belt, or it disappears at first in the centre, and constitutes that well-known, dry, red streak in the middle of the tongue, which is frequently broader at the point of the tongue, and forms, in this wa} T , a kind of triangle, with its base down at the tip. The abdomen at this time appears somewhat bloated and is sensitive to strong pressure. A deep pressure upon the ileo-caecal region may cause a gurgling noise in that region, especially if there be already diarrhoea present. The spleen is swollen, which can be detected by percussing the patient when he lies upon his right side. Finally, there appear toward the end of the first week, single, pale, reddish, lentil-sized roseola spots upon the epigastrinm and adjacent parts of the chest and abdomen. In the second week the temperature of the body ranges between 104° F. and more; towards morning there is only a slight remission, and the pulse grows softer, weaker, and more frequent, from no to 120 beats, revealing more or less weakness of the heart. The dizziness increases, the ringing in the ears changes to hardness of hearing, which is generally dependent upon a catarrhal affection of the Eustachian tubes and tympanum. The expres- sion of the face becomes more and more stupid, and the indifference of mind increases. By and by the consciousness of the patient becomes clouded and he sinks gradually in a state of somnolence and stupor. Although the tongue is as dry as " chip," yet he utters no desire for drink; takes it, however, when offered, very greedily. When asked to show his tongue, he does not seem to comprehend at first, but finally, with great effort, he brings it forth, pointed and trembling. Stool and urine pass off involuntarily. The patient lies always on his back, and having lost consciousness of all muscular power, the body follows its own weight and the patient slides gradually down in bed, without any effort of his own to change this position. The mental opera- tions are still going on; we see it on the now and then trembling lips, as efforts to speak, and in the low murmuring of unintelligible words now and then. This is febris nervosa stupida. Other patients, although likewise mentally disconnected with the ex- terior world, neither knowing nor understanding what is going on about them, manifest a vivid, dreamful perturbation of the mind. They are in constant agitation, throw off the covers, try to get out of bed and to escape, talk loud or lisp some unintelligible words, gesticulate 896 TYPHOID FEVER. and become angry when interfered with. Their obstinacy in gaining their imaginary ends is sometimes astonishing; when all at once it changes to some other object. In other cases there seems to be no intelligible connection be- tween the constantly-changing phantasmata, with which they seem to be haunted. This agitation of the mind is generally greatest during the night. This is febris nervosa versatilis. There are again cases where both of these states make a regular turn; the febris stupida prevailing through the day, and the febris versatilis through the night. During this w T eek the bowels are almost always loose, owing to the catarrhal affections of the intestines; the cheeks have a brownish-red or bluish color; the eyelids are half closed; the conjunctiva is injected; the nose is thoroughly dry, and the nostrils are blackened as by soot. On the gums and teeth we observe sordes; the tongue is covered with a brownish crust, which gradually grows black from the mixture of blood; it is stiff, making swallowing quite difficult. The abdomen is inflated like a drum; the spleen has grown still larger, and the roseola-spots have, in some cases, likewise increased, and are joined b3^ numerous sudamina. On the chest, physical examination reveals solidification of the dependent parts of the lungs and far-spread catarrhal affections. There is a less full percussion sound, weak vesicular breathing, fine, bubbling rattles in the dependent parts anH loud rhonchi ever} T where else. The third week does not bring any amelioration as yet. The tempera- ture of the body is still on the increase, and the morning remissions are quite indistinct. Only where the case turns favorably, there is in the second half of the third week a decided improvement in this respect. While the even- ing temperature still rises to 104 or over, the morning temperature shows greater remissions. The prostration reaches, in this week, its climax; the patient slides down in bed; there is a constant jerking of the tendons; somnolence and stupor are complete, and stools and urine are passed unconsciously, or the urine is retained in consequence of a paralysis of the detrusor vesicae; the roseola-spots commence to get paler, the sudamina increase more and more, and in some cases there appear petechias. To all this associates an erythema in the region of the sacrum, which, by throwing off the epidermis, is soon converted into a bed-sore — decubitus. This is, indeed, the week when the mortality of typhoid patients is the greatest, while in favorable cases its latter part is the turning point. We observe then a gradual abatement of all the above-detailed symptoms. The stupor changes into a natural sleep, consciousness gradually returns: diarrhoea, respiration, pulse, countenance, all improve. This improvement continues in the fourth week, or in some instances commences then, and finally passes over into the state of convalescence. During this time nearly all the patients lose their hair, which, however, is soon followed by a new crop. This is about the course which a majority of typhoid fever cases run. TYPHOID FEVER. 897 Besides this, however, there are a number of variations, of which the follow- ing are the most important: The Abortive typhoid fever is, in every respect, much lighter, and cor- responds to the "gastric fever, or nervous fever" of older writers. Although it shows all the symptoms of a regular tyhoid fever, yet they are all much milder; the temperature of the body never reaches such an intensity, and already on the eighth or ninth day there is a considerable morning remission, which sinks at the end of the second or during the third week to a normal state, with only slight aggravations in the evening. Still the patients gain their usual strength quite, slowly. The Typhus ambulatorius is a peculiar form, corresponding to the "walk- ing cases' ' of yellow fever, in which the patient complains only of general debility and exhaustion, but still attends to his business, until suddenly he sinks under the signs of perforation of the intestines or intestinal haemor- rhage. In such cases it seems that the poison has localized exclusively in the intestines, without affecting the general circulation. The Typhus tumultuarius, on the other hand, sets in at once so violently that the temperature of the body rises already in the first week to 106 F. and above, and the pulse to 120 and 130; all other symptoms are correspond- ingly severe, so that the disease reaches its climax towards the end of the first or the beginning of the second week. Such cases are mostly fatal at this early period, or the symptoms grow milder again in the second week, and take then the usual course. The Pneumo-typhus and Broncho-typhus are forms in which the poison seems to affect principally the chest, causing hypostasis of the lungs, pneu- monia, or violent bronchitis, while the characteristic affections of the small intestines are comparatively light, or even wanting. Pneumo-typhus must not be confounded with Typhoid-Pneumonia. Cardiac weakness, the result of degeneration of the muscular tissue of the heart, is responsible in part for the tendency to disintegration which is found in all tissues of the body, and is the most frequent immediate cause of death, and consequently "the observation of the pulse is of even greater sig- nificance than the observation of the temperature for the prognosis of some cases. So long as the pulse is, in a measure, strong, and its frequency only moderately increased, no immediate danger exists on the side, even when the constant elevation of temperature is very considerable. ' ' ( Liebermeister. ) This degeneration of the heart-muscle exists, to a greater or less degree, in all severe cases without exception. Parenchymatous degeaeration. of the Liver is also found in every severe, prolonged and fatal cases of typhoid fever, and may reach so high a grade as to present a distinct complication, a group of symptoms characteristic of icterus gravis or acute yellow atrophy of the liver. Still, jaundice occurs less frequently during typhoid fever than in pneumonia. Parotitis begins most frequently during the third or fourth week, is always confined to the most severe cases only and is a bad prognostic sign. 57 898 THERAPEUTIC HINTS TO TYPHOID FEVER. In still other cases the normal progress of the disease is interrupted by an intercurring perforation of the intestines, when the typhoid ulcers eat through the muscularis and serosa of the gut or by the imprudent use of solid food during early convalescence, which, acting mechanically, ruptures the gut at the weakest spot. This is always followed either by a partial or diffuse peritonitis, the symptoms of which compare under the corresponding chapter. The most reliable sign, however, of perforation, during typhus, is tympanites, or the sudden escape of gas into the peritoneal sac, which presses the liver back from off the thoracic wall, and causes, on percussion, in place of the dull liver sound, a clear tympanitic sound. Or the natural progress of the disease is interrupted by an intercurring haemorrhage from the bowels, This takes place either in consequence of er- rosions of blood-vessels near the ulcers, or in consequence of the bursting of overfilled capillaries. It causes bloody stools, and, if profuse, collapse and a sudden sinking of the temperature, which sometimes restores consciousness for a while, but generally ends fatally, in consequence of the exhaustion which it produces. Less dangerous are the intercurring profuse haemorrhages from the nose, which take place sometimes in the second or third week of typhus, and the haemorrhages from the womb in female patients. But as both are the consequence of a highly debilitated state of the system, none of them can be considered as a favorable sign. Or the whole course of the disease is protracted by the slow healing pro- cess of the intestinal ulcers. In such cases we find the typhus followed by a low, asthenic fever for weeks afterwards, or in fact there is no cessation of the fever; the sensorium remains clouded; the weakness increases; the emacia- tion grows excessive; the bed-sores enlarge; any part of the body, wherever its own weight rests upon, shows the signs of decubitus. Man)" of these patients die about the fifth or sixth week, as such afar-spread decubitus alone seems to be sufficient to consume the little strength that is left. As Sequels of typhus may be mentioned: neuralgia, partial paralysis, partial anaesthesia, mental disturbances, tabes, anaemia and hydrsernia. It is not unfrequent that, during the period of reconvalescence, phthisis pulmonalis is developed. Therapeutic Hints. As long as there is fever it will be necessasy to enforce a strict liquid diet, which may consist, of milk (2-4 pints per day, administered in suitable quantities about every 2 hrs.). meat broths, albumen, koumiss, etc. After the subsidence of the fever it is well to return cautiously and slowly tosolid food, beginning with semi-solid and easily digested substances. Retention of urine should be anticipated; obstinate constipation of the lower bowel should be relieved by a gentle enema. Agar. muse. Constant delirium, attended with attempts to get out of bed, with a tremulous propulsion of the tongue and a general tremor of the whole body. (G. C. Hibbard.) Desire for alcoholic drinks, which are easily borne. It suits well typhoid fever in drunkards. (A. Charge.) THERAPEUTIC HINTS TO TYPHOID FEVER. 899 Alumen. Great masses of coagulated black blood pass from the anus in the third week of typhus, with signs of the greatest exhaustion. (Hering.) Alumina. Is often indicated when Bryon. , though indicated, does not act deep enough. (Gosewitsch.) Apis. According to Wolf, in the presence of: apathic conditions, uncon- sciousness, stupor, with murmuring delirium, hardness of hearing, inability to talk and put out the tongue, which is cracked, sore, ulcerated or covered with vesicles; difficulty in swallowing, great soreness and bloatedness of the abdomen; constipation, or frequent, painful, foul, bloody and involuntary discharges from the bowels; unconscious flow of urine; dry, burning skin, or partial, clammy sweats; trembling and jerking of the limbs; white miliary eruption on the chest and abdomen, greatest weakness and sliding down in bed; frequently changing, weak and intermitting pulse. Arnica. Stupefied condition; sits as if in thought, yet thinks of noth- ing, like a waking dream; forgets the word while speaking; confusion of the head; loss of consciousness; delirium; great weakness, weariness and bruised soreness, which compels to lie down, and yet every position feels too hard; unrefreshing sleep, with anxious dreams, talking, and loud blowing during expirations; bleeding from the nose; trembling of the lower lip; dry tongue; with a brown streak in the middle; putrid smell from the mouth; distention of the abdomen; involuntary discharges of feces and urine; pleuritic stitches at every inspiration; great sinking of strength. A? sen. Especially for weak or debilitated individuals, old age and children; in slow, protracted cases, with mild delirium ; loss of consciousness; great restlessness and anxiety, manifesting itself in constantly moving head and limbs, while the trunk lies still, on account of too great weakness; pick- ing of the bedclothes; sopor; face distorted, sunken, anxious, hippocratic; lower jaw hanging down; cheeks burning hot, with circumscribed redness; eyes staring, glistening or sunken, dull and watery, or closed with sticky matter; hardness of hearing; lips dry and cracked; lips, gums and teeth covered with brown or black slime; tongue red and dry, cracked; stiff, like a piece of wood; black tongue; speech unintelligible, lisping, stammering, as though the tongue were too heavy; excessive thirst, but little drinking at a time; the fluid rolls audibly down into the stomach; vomiting and retching; burning in the stomach and bowels, sensitive to pressure; meteoristic disten- tion of the abdomen; constipation or looseness of the bowels; brownish or watery, bloody, foul, involuntary discharges; involuntary discharge of urine or retention of urine. "Frequent urging to urinate, with burning and scanty discharge." (W. J. Martin.) Voice weak and trembling, or hoarse, coarse or crowing; breathing short and anxious, oppressed, rattling; dry cough; fetid breath. On chest and abdomen roseola spots; white miliary eruption, even petechia; decubitus; excessive prostration and rapid emaciation; pun- gent, hot, dry skin, like parchment; cold, clammy perspiration, pulse frequent, small, trembling, intermittent. A cadaverous smell scents the whole atmos- phere. All symptoms worse about and soon after midnight or noon. 900 THERAPEUTIC HINTS TO TYPHOID FEVER. Arum. trip. Lips and corners of mouth sore and cracked; excessive salivation; saliva acrid; breath very fetid; picking the ends of the fingers with the nails; picking the lips until they bleed; boring with the fingers in the nose; great restlessness, tossing over the bed, wants to escape while per- fectly unconscious of what he is doing, or what is said to him; urine generally suppressed. ( Lippe. ) Baptis. "She cannot go to sleep, because she cannot get herself to- gether. Her head feels as though scattered about, and she tosses about the bed to get the pieces together." (Dr. Bell.) Dull, stupefying headache, confusion of ideas; delirious stupor; heavy sleep, can scarcely be aroused long enough to answer a question, falling asleep in the middle of the sen- tence; dark red face, with a besotted expression; injected eyes; coated tongue, brown and dry, particularly in the centre, or dry and red; sordes on the teeth; fetid breath; fetid sweat; fetid discharges from the bowels; fetid urine; great debility and nervous prostration; ulcerations; chilliness all day; heat at night; chilliness, with soreness of the whole body. Sensation as though there were a second self beside the patient in bed. Bellad. During the early stage, especially of tumultuous cases, when there is great congestion to the brain, with great drowsiness, and an inability to go to sleep, and frequent starting during sleep; violent delirium, with attempts to run away, to strike, bite, or spit at his attendants; sparkling, staring eyes; throbbing of the carotid and temporal arteries, and also in the forehead; deafness; burning heat and redness of the face; distortions of the mouth; dryness of nose, mouth and throat; tongue with red margin and white centre; trembling and heaviness of the tongue, with stammering as if drunk; sore throat and dry cough from bronchial irritation. Bryon. In any stage when there is delirium, especially at night, about the affairs of the previous day or business matters; visions, especially when shutting the eyes; irritableness ; peevishness; easily offended; hasty speech; headache; dull, pressive, or stitching, tearing pains, worse from motion and opening the ey T es; eyes dull, watery; hardness of hearing; dryness of nose; lips dry, brown, cracked; tongue coated thick, white, or yellowish, later brown and dry; dry feeling in the mouth, without any thirst, or else great thirst, with drinking large quantities at a time; bitter taste in the mouth; nausea; retching; great soreness in the pit of the stomach to touch or motion; bowels constipated; hard cough, with stitching pain in the chest and region of the liver; bronchitis; great lassitude and weakness; wants to lie quiet; pain in all the limbs when moving; restless sleep, with groaning and moaning, and frequent movements of the mouth, like chewing; eruption of white mil- iary rash, with anxiety in the region of the heart; sighing, groaning and moaning, and a peculiar sour smell of the body, with or without sweat. Calc. carb. According to Goullon, during the aggravations, which pre- cede the outbreak of the miliary rash, about the fourteenth day of the disease; palpitation of the heart, tremulous pulse, anxiety, restlessness, redness of the face, delirium, jerkings, especially in children; short, hacking cough: THERAPEUTIC HINTS TO TYPHOID EEVER. 901 excessive diarrhoea. Also when a pneumonia develops, tending to gray hepatization with its characteristic sputa; great soreness of the soles of the feet. Beside this, it may be indicated at the very onset, and then cut off all further progress, in persons inclined to grow fat; after great anxiety and worriment of mind; utter sleeplessness from overactivity of the mind; it is the same disagreeable idea which always rouses toe patient as often as he falls into a light slumber; constant tickling under the middle of the sternum, causing a hacking cough, worse from talking or moving; during coughing, painful shocks in the head; the brain feels hot and burning. (Lippe.) Urine very dark, but clear. Camphora. In extreme cases like Card, veg., only that the symptoms set in much more rapidly. Greatest weakness; cold sweat all over; quickly decreasing temperature, especially of the extremities; small, very frequent, scarcely perceptible pulse; great nervous restlessness of body and limbs; collapse in face; cold, pointed nose and cold mouth; automatic motions of the muscles; delirium; syncope; snatches of sleep; great thirst, with red, dry tongue; frequent involuntary stools, after much rolling and rumbling in the bowels. (Trinks. ) Ca7ithar. May be indicated by its characteristic urinary symptoms. Card. veg. Often at the brink of death a saviour, in those states of collapse, dissolution of blood, and paralytic conditions, which seem rapidly to invade the whole organism. All this is indicated by stupor, out of which the patient can scarcely be roused for moments; the eyes are dull, without lustre, and the pupils without reaction against light; the hearing is gone; the face is pale, sunken, hippocratic, cold; there are haemorrhages from mouth and nose; the tongue is sometimes moist and sticky; other times parched and cracked, heavy, scarcely movable, bluish or pale; the pit of the stomach is bloated; the abdomen meteoristic, with loud rumbling and gurgling of wind in the intestines; there is colliquative diarrhoea, brownish, grayish, or bloody, of a cadaverous smell, and involuntary. The cough has ceased, and the col- lecting secretions cause loud, rattling breathing, a sign of beginning paralysis of the lungs; the circulation is without energy; the blood stagnates in the capillaries and causes cyanotic blueness of face, lips and tongue; ecchymotic spots here and there; decubitus; the pulse is extremely weak, frequent, small, scarcely perceptible; face and extremities grow cold and become covered with cold perspiration — all signs of beginning paralysis of the heart; in short, the patient offers a picture of complete torpor of all vital functions, thus differing entirely from that of Arsenicum, which is always more or less associated with erethism of the system. Chma. Especially where there is painless diarrhoea, bloatedness of the abdomen, haemorrhages, and slowly progressing convalescence after such weakening influences. Coccul. In cases which are mainly characterized by a deprimation of the nervous system, showing little or no disturbance in the vegetative sphere of the system, except enlargement of the spleen. There is a slowness 902 THERAPEUTIC HINTS TO TYPHOID FEVER. of comprehension; he does not find the right expressions for his ideas, what has passed he cannot remember; he talks muttering, mumbling; it costs him a great deal of effort to speak the words plainly; and then again for a short while he is very irritable, cannot endure either noise or contradiction, and speaks hastily. Most of the time, however, he sits in silence or feels an un- conquerable inclination to sleep; his eyelids are heavy, fall shut, as if para-' lyzed; the drowsiness may increase to coma. There is dizziness in the head, especially when rising up in bed, with nausea, compelling to lie down again; ringing in the ears; heat in the head and chilliness elsewhere in the body; pappy taste in the mouth; belching; nausea; distention and rumbling in the abdomen; great general weakness and weariness; great heaviness in the feet; attacks of trembling and jerking of the eyelids, muscles of the face and limbs; and fits of fainting from bodily movement, with spasmodic distortion of the facial muscles. Especially indicated after mental and bodily overexertion. Cholchic. According to Wells, great weakness, as if after exertion. If the patient be raised up the head falls constantly backwards, and the mouth opens to the widest extent. Sudden sinking of the forces, so that in ten hours he can hardly speak or walk; cadaverous aspect and extreme prostra- tion; emaciation; lying on the back; comatose; eyes half open; respiration audible and accelerated'; hands and feet cold; trunk hot and extremities cold; skin dry; sweating; suppressed, cutaneous transpiration; forehead covered with cold sweat; pulse small and contracted, quick and hardly per- ceptible, small and frequent, quick and thready; pulseless; delirium, with cephalalgia; intellect beclouded, though he gives correct answers to ques- tions; unless questioned he says nothing of his condition, which does not seem to him dangerous; perception entirely lost; he is unconscious; eyes hollow, staring and sunken; pupils much dilated and little sensitive to light, or immovable, and but slightly dilated; nostrils dry and black; face sunken and hippocratic; risus sardonicus; lips, teeth and tongue covered with a thick, brown coating; lips cracked; face covered with perspiration; grinding of teeth; tongue protruded with difficulty; tongue bright red; tongue heavy, stiff and numb; loss of speech; inextinguishable thirst; epigastrium and stomach extremly sensitive to pressure; abdomen distended, tense and hard; surface of the abdomen hotter than the rest of the body; tympanites with pain in the back; watery diarrhoea; the stools are passed insensibly; stools fluid, offensive, with white flakes; involuntary stools; numerous, liquid, dark, offensive stools, with severe pain; secretion of urine suppressed; urine copious; involuntary urination; respiration irregular and intermittent. Cuprum. According to Baehr, in typhus without high fever, but with excessive weakness, which increases rapidly under the signs of dissolution of blood (nosebleed and petechia), until under general paralytic symptoms death ensues. Fluor, ac. Recommended by Hering when there is decubitus. Gelsem. Stage of invasion with sense of extreme prostration; trem- bling from weakness; muscles refuse to obey the will; pulse slow, but greatly THERAPEUTIC HINTS TO TYPHOID FEVER. 903 accelerated by lifting or turning the patient; severe pains in head, back and limbs; chilliness, cold hands and feet; crimson flush of face; thick, brown, coated tongue; occasional moisture here and there; sleeps frequently half waking and talking incoherently; head feels "big as a bushel;" vertigo; blind spells; epistaxis; iliac tenderness. (J. C. Morgan.) Ginseng. Loud gurgling noise in the ileo-caecal tract, dry tongue, heat, delirium on going to sleep. (Liedbeck.) Hamam. Haemorrhage from the bowels of fluid, dark, fetid blood; great soreness of the abdomen. Helleb. nig. Facies quatrata; stupid expression, though the face is not collapsed; vacant look of the eyes with dilated pupils; constant som- nolence, out of which the patient may be roused, but does not gain full con- sciousness; he stares at the physician, is slow in comprehending and answer- ing his questions; all perceptions by the senses grow only slowly or not at all conscious. The patient utters no desire; when left alone sinks in slum- ber; he lies upon his back with limbs drawn up; sliding down in bed. Mucous membranes but little or not at all affected; abdomen not bloated, unpainful; no diarrhoea; sometimes unconscious discharge of urine; slow action of the heart; pulse only 80 per minute; respiration slow; temperature of skin nearly normal; no miliary eruption; no sign of putrid dissolution of the blood; loss of flesh trifling; only the brain seems to be the invaded part of the body. (Trinks.) Hydr. ac. When the drink which is swallowed rolls audibly down the throat, as though it were poured into an empty barrel. (Heynel.) Hyosc. Entire loss of consciousness, and of the functions of the organs of the senses; does not recognize relatives or friends; illusions of the imagina- tion and senses. Delirium which is continued while awake, and which sees persons who are not and have not been present. Indistinct and muttering loquacity; muttering with picking of the bedclothes; inability to think, the thoughts cannot be directed or controlled; constant staring at surrounding objects, with apparent entire self-forgetfulness; or else great agitation; rest- lessness; jumping out of bed; attempts to run away, etc. Byes red and sparkling, staring, rolling about in their orbits; squinting; deafness; dis- torted face, stupid expression; tongue red or brown, dry and cracked; para- lyzed; loss of speech, or indistinct speech; cadaverous smell from the mouth; involuntary or unnoticed stools in bed; suppressed secretion or retention of urine; involuntary discharge of urine, leaving streaks of red sand on the sheet. Paralysis of sphincter ani and vesicae. Convulsive motions; grating of teeth; jerkings; subsultus tendinum; trembling; sleeplessness, or constant sleep with muttering; coma vigil. Roseola spots on chest and abdomen; cold extremities. Ignat. Great impatience and despair about pains and bad feelings, which he cannot describe; gets easily frightened, and feels as though he were swung to and fro in a cradle or in a swing. Attacks of yawning, stretching, followed by pain in the front of the head, which does not allow opening the 904 THERAPEUTIC HINTS TO TYPHOID FEVER.' eyes; choking sensation from the stomach up into the throat, with oppression in the chest, better from belching; palpitation of the heart; sinking, weak feeling in the pit of the stomach; convulsive motions of the limbs; jerking of the tendons. Sleeplessness on account of various visions as soon as he falls into a doze; troublesome dreams. Kali card. Intermitting pulse, vomiting, headache, nervous, easily frightened, pale, sickly complexion. (Goullon, Jr.) Kreos. Typhoid haemorrhages, with fetid stools, followed by great prostration. (Trinks. ) Laches. Fever worse in the afternoon; sweat without alleviation; sleep with following aggravation of all the symptoms; loss of consciousness; mut- tering; stupor; sunken countenance; dropping of lower jaw; dry, red or black tongue, cracked on the tip and bleeding; in the attempt of protruding it, it trembles; or the tip remains under the lower teeth, and does not come out; dry lips, cracked and bleeding; stools very offensive, whether formed or loose; haemorrhage from bowels, with flakes of decomposed blood, having the form and appearance of charred straw, in longer or shorter pieces, to- gether with portions more or less ground up; sore throat with deafness; nasal, indistinct speech; dyspnoea; cough, with slimy, bloody expectoration; after sleeping a short time, terribly restless, tossing about and throwing the bed- covers off. Lauroc. Clonic spasms of the upper and lower extremities with para- lytic weakness of the limbs; no loss of consciousness. (Trinks.) Lycop. Sopor; delirium; uses wrong words for correct ideas, which he intends to express; fear to be left alone; restless sleep, with outcries and loud laughing; when awaking, exceedingly cross, irritable, scolding, scream- ing, behaving disagreeably; violent jerkings of the limbs, shaking the whole body, awake or asleep; subsultus tendinum ; catching at flocks; sunken face, yellowish, or with circumscribed redness in the afternoon; tongue red and dry; sometimes it is spasmodically thrust to and fro between the teeth; lower jaw sunken; bowels much distended, with rumbling and constipation; urine leaves, if voided in bed, a red, sandy stain; cold hands and cold feet; one foot hot and the other cold; wants to be uncovered during heat. Mercur. May be indicated at the beginning of the disease, when there is; swollen and bleeding gums; fetor from the mouth; pain in the liver; yellow-green stools; dark urine; bronchitis; icteroid color of the skin. 11 Obtuseness of mental operations, with great inclination to sleep; heaviness and muddledness of the head; thick and dirty-whitish coating of tongue; in- sipid, pappy, slimy, foul taste, with desire for refreshing things; thirst; pain- ful sensitiveness of precordial, hepatic, umbilical and ileo-caecal region; bilious, slimy or watery diarrhoea, which, however, may be absent altogether; prostration; sometimes copious, debilitating perspiration; pale and sunken face and eyes; also dirty-yellowish color of face." (Trinks.) Moschus. In cases of impending paralysis of the lungs, where the cough ceases and the collected mucus cannot be expectorated; where respira- THERAPEUTIC HINTS TO TYPHOID FEVER. 905 tion and pulsation of the heart grow weaker and weaker; where in swallow- ing, the fluid rolls audibly down the throat, and stool and urine pass off in- voluntarily. Mur. ac. Febris stupida; constant sliding down in bed, with groaning and moaning in sleep, and muttering and unconsciousness while awake; ex- cessive dryness of mouth and tongue; the tongue is heavy, paralyzed; the patient cannot move it at will, even if conscious; the pulse intermits every third beat; profuse discharge of watery urine; watery diarrhoea; stools and urine in vol untary. "Febris nervosa versatilis after Bryon., if the disease still grows in intensity. Continuous delirium, hindering sleep and rest; the patient is all the time occupied with things past and present; he forgets time, place and all he has said. Vivid hallucinations; the eyes shun the light; the ears are sensitive to slightest noises and hear sounds — the falling of rain, or music — which do not exist; smell and taste very acute. The eyes glisten; the pupils are contracted; the cheeks reddened; nose, lips and tongue are dry; the tongue is not or only slightly coated; great thirst; little or no affec- tion of the mucous membrane of the intestines; discharges from the bowels none, or but seldom; urine clear, of acid reaction; pulse very frequent, irri- tated, without energy, no to 130; respiration accelerated; skin mostly dry, hot. Great desire to sleep, without ability to go to sleep; muscular power not very much decreased; slight feeling of weakness and weariness." (Trinks.) Nitr. ac. In cases of typhoid haemorrhages; great sensitiveness of the abdomen; green, slimy, acrid diarrhoea; tenesmus; white, coated tongue, with sore spots; inflammatory affection of the lungs, with rattling cough and breathing; brownish, bloody expectoration and irregular pulse; after calomel. Nuphar. Liquid, yellow, fetid stools most frequent between four and seven in the morning. Nux mosc/i. Profound coma; lying silent, immovable; insensible; dif- ficult comprehension; slowness of ideas; dwells long on her answer, or does not answer at all; very deaf; putrid, colliquative diarrhoea; rolling, rum- bling and gurgling in bowels; dreamy state, with drowsiness and drooping of eyelids; dryness of mouth, tongue and throat, with fullness of stomach and loss of appetite; in the evening the dryness is so great that the tongue sticks to the roof of the mouth, yet there is no thirst. (Hering, confirmed by Nash.) Nux vom. " In the early stage; if there be chilliness on slightest move- ment; dryness of the front of the mouth and tip of the tongue; intolerance of impressions on the external senses, all of which seem much exaggerated; great sensitiveness to the open air; thirst, with aversion to water; strong de- sire to lie down, and considerable relief on doing so." (Wells.) Opium. Febris nervosa stupida; the stupor is complete; he cannot be roused or only with great difficulty; lies speechless, with open eyes and stiff limbs; delirium, mild or furibund, with loud talking, laughing or singing; 906 THERAPEUTIC HINTS TO TYPHOID FEVER. attempts to escape; congestion to the head; face dark red and bloated; res- piration slow, deep drawn and sighing, stertorous, rattling; constipation or offensive watery diarrhoea; involuntary stools; retention of urine. Phosphor. Pneumo-typhus; violent bronchitis and even hepatization; hard, dry cough with tightness in the chest; or loose, rattling cough, with tough, transparent, or thick, yellowish, or reddish expectoration; cough worse from evening until midnight; vomiting of watery, bilious and slimy masses with great pain; frequent, unpainful diarrhoea, with meteorism and loud rumbling; the discharges are watery, greenish, grayish, or black from decomposed blood; great weakness after each discharge; numerous roseola spots, ecchymosis and miliary eruption on the trunk; great heat of the trunk, with cold perspiration on head and extremities. "Rapid sinking of strength; very quick, small, thread-like pulse; stupor; unconsciousness; sopor and stupefaction; delirium and flaccilegium ; hardness of hearing; dull, half-shut eyes; hippocratic face; lying on back; dry, immovable tongue, covered with black crusts; very sensitive abdomen, painful to touch; rolling and rumbling in abdomen during and after drinking; rattling in windpipe; impending paralysis of brain and collapse; burning pain in the brain." (Trinks.) Phosph. ac. Complete apathy and indifference; don't want to talk; answers slowly and reluctantly, or short, incorrectly; stupid sleep from which he may be roused, when he answ T ers correctly; but soon falls asleep again; stupor; stupid and indifferent expression of the face; bleeding from the nose; meteroristic distention of the abdomen, with a great deal of rumbling and gurgling, and unpainful, watery, grayish diarrhoea, also involuntary stools; great debility; relaxed pale skin; ecchymosis; bluish-red spots on the parts which the patient lies upon; decubitus; temperature of the body not high; constant, sticky or profuse sweat; pulse weak and small, frequent and intermitting. " Dryness of the mouth and throat; gray- whitish coating of the tongue; the patient slumbers even in daytime, with murmuring de- lirium; the eyes are dim, sleepy; the skin remains dry or clammy; a miliary rash appears first about the neck, then upon the back, then on the chest, etc., at last upon the feet." (Trinks.) Psorin. Retarded convalescence from profuse perspiration; patient hopeless and despairing of recovery; extreme prostration. (Hering. ) Pulsat. At the early stage where external heat is intolerable, causing a sense of heat with distress; uncovering, however, is followed immediately by a chill; or there is heat only of one side, or heat of one side with coldness of the other, or sweat of one side; there may be great drowsiness; delirium; frightful visions; try tongue, as if burnt, and yet no thirst; rumbling in the bowels and diarrhoea, with pinching pain, worse at night; pulsating in the epigastrium. Rhus fox. Mental operations are slow and difficult; he answers cor- rectly but slowly, sometimes hasty; delirium; talks much to himself, or talks incoherently, without any seeming connection of ideas; headache; worse THERAPEUTIC HINTS TO TYPHOID FEVER. 9°7 from opening and moving the eyes; bleeding from the nose, especially after midnight; the lips are dry and covered with brown crusts; the tongue is red at the tip, in the shape of a triangle; the bowels are loose, worse at night; involuntary alvine discharges during sleep. There is often severe cough, with tough, bloody expectoration; bronchitis; pneumonic infiltration of the lower lobes of the lungs; severe rheumatic pains in the limbs, worse in rest; somewhat ameliorated by moving and changing position; constant restless- ness; tossing about; restless sleep, with frightful dreams, and frequent wak- ing, and never that state of quiet, profound coma; dry heat or sweat, during which the patient desires to be covered; roseola spots; miliary eruption; great exhaustion. Secale. Large purple spots on the body, particularly on the feet; body cold, especially hands and feet, and would not be covered; cold perspiration, mostly on face and forehead; copious vomiting of thick, black bile, mixed with mucus. (Lippe. ) Silic. Sometimes in the very worst cases, with excessive debility, pro- fuse perspiration and a strong desire to be magnetized: magnetizing relieves the great weakness, and Silicea promotes the forming of abscesses, boils, etc., thus throwing the poison to the surface, and securing a gradual though slow recovery. S tram o?i. Loss of consciousness; imbecility; stupefaction of the senses; delirium; hallucinations; singing; laughing; whistling; screaming; constant, involuntary, odd motions of the limbs and body; spasmodic distortions of the face; staring look; wrinkled skin on forehead; loss of sight, hearing and speech; all objects appear oblique to him; inner mouth feels raw and sore, or is ulcerated; red rash upon the chest; blackish diarrhoea every hour; stools smell like carrion; suppressed secretion of urine; retention of urine; copious, involuntary discharge of urine. Febris nervosa versatilis. Sulphur. When in psoric individuals the well-selected remedy has no or onry a superficial effect; besides, if there be sleepless nights; slow com- prehension when being asked; heat and fullness in the head; chronic sore and inflamed eyelids; great dryness of the ears; pale, sickly aspect; bright red lips; undefined redness on the tip of the tongue; bleeding from the nose, teeth and gums; offensive smell from the mouth; diarrhoea, worse early in the morning, unpainful or with tenesmus; great prostration after stool; offensive urine; catarrh and inflammation of the lungs, especially during commencement of infiltration, recognizable by the crepitation sound. Tarax. During rest intolerable tearing pains only in the lower extremi- ties {Rhus tox. has such pains in all the limbs) ; constant muttering to him- self, similar to that of Hyos.; violent, tearing pain in the occiput; great chilliness after taking anything to eat or drink. (Von Boenninghausen.) Map-tongue. Tart. emet. In pnemo-typhus, with great rattling in the chest, d5 T spnoea, etc. ; symptoms of oedema pulmonis. Tereb. Bloody urine. 908 GENERAL HINTS TO TYPHOID FEVER. Veratr. During cholera epidemics; great prostration; cold sweating; coma; vomiting and watery diarrhoea; bluish face; pointed nose; wrinkled skin. Ver. vir. Constant talking and muttering unintelligibly, with open eyes; squinting; ocular conjunctiva injected, secretion of yellow mucus at inner canthus; nightly agglutination; face pale, with cold sweat; boring occiput into pillow, jerking head backward, sometimes forward. Pupils dilated; dropping of lower jaw; corner of mouth drawn down on left side- champing teeth; tongue coated white; red streak down the centre; beating of heart when turning over in bed, shaking left side of thorax; pulse irregu- lar; urine dark and turbid, fetid, involuntary; great restlessness; constant moving, thrusting out one leg, then drawing it up; position on back with thighs flexed on pelvis; carphologia; picking at bedclothes; subsultus ten- dinum, like galvanic shocks; twitching of facial muscles (G. W. Sherbino.) Zincum. Staring eyes; delirium with attempts to get out of bed; com- plete unconsciousness; lying on the back and sliding down in bed; grasping at flocks; subsultus tendinum; constant trembling of the hands and coldness of the extremities; relaxation of the muscles of the face; hippocratic face; pale, waxy complexion of the face; decubitus on the sacrum and trochanter; frequent, involuntary discharges from the bowels; frequent, small, intermit- ting, scarcely perceptible pulse; impending paralysis of the brain. .General Hints. In predominant cerebral symptoms compare: Apis, Bel/ad., Bryon., Cuprum, Hyosc, Laches., Mur. ac, Opium, Stramon., Zincum. In predominant abdominal affections: Apis, Arsen., Bryon., Card. veg. } China, Colchic, Ginseng., Mercur., Nux vom., Phosph. ac, Rhus fox., Secale, Sulphur, Veratr. In pneumo-typhus : Apis, Bellad., Bryon., Calc. carb., Hyosc, Mercur., Phosphor. , Pulsat. , Rhus fox. , Sulphur, Tart. emet. In febris nervosa stupida : Arnica, Arsen., Carb. veg., Coccul., Hyosc, Laches. , Mur. ac. , Phos. ac. , Rhus tox. , Secale. During convalescence, when there is too great hunger: Pulsat. Diarrhoea, with cutting in the bowels after sour things: Ipec Overexertion of the body: Rhus tox. Fright: Ignat. Chagrin: Nux vom. L Tacamahac (Ind.), which secretes a kind of resinous substance on the pedicles of its leaves and around its twigs. But as it is an undoubted fact that itch never heals spontaneously, and as we have likewise undoubted facts that it has been cured solely by the internal appli- cation of homoeopathic remedies, it seems that those who contend that even acarus-itch in the course of time is not altogether a mere local, cutaneous trouble, are after all deserving some credit. All parasites, no matter whether animal or vegetable, can grow only upon a suitable soil; if this soil be made insupportable to them, they die or leave, and this is as good as killing, re- garding the riddance of the intruders, but it is infinitely better for the pa- tient, as by this means the organism is not injured, but brought into a healthy state. 1020 special hints. Special Hints. Arsen. Inveterate cases; eruption in the bends of the knees; pustulous eruption; burning and itching; better from external warmth. Card. veg. Eruption dry and fine, almost over the whole body, worse on the extremities; itching worse after undressing; dyspeptic symptoms; belching of wind and passing flatus; after the abuse of mercurial salves. Caustic. After the abuse of Sulphur and Mercury; yellow color of the face; warts on the face; involuntary discharge of urine when coughing, sneezing or walking; sensitiveness to the cold air. Hcpar. Fat, pustulous and crust} 7 itch; also after previous abuse of mercury. Mercur. Fat itch, especially in the bends of the elbows. Psorin. Inveterate cases; with symptoms of tuberculosis; also in recent cases; eruption in the bends of the elbows and around the wrists; repeated outbreaks of single pustules, after the main eruption seems all gone. Sepia. After previous abuse of Sulphur; itching worse in the evening; especially in females. Sulphur. Main remedy; voluptuous tingling-itching, with burning and soreness after scratching. Sulph. ac. When itchiness of the skin and single pustules appear every spring, after an imperfectly cured itch. Prairie Itch, Prurigo Contagiosa. " Is an acute inflammation of the skin, appearing in new districts, where it may be for a time endemic. It may be preceded by the premonitory sy mp- toms of malaise, headache and slight febrile disturbance; or its onset may be first marked by the appearance of erythematous points, covered with small transparent vesicles, varying in size from a pin's head to a mustard-seed, and situated for the most part on the neck, shoulders, back and outer surface of the limbs. An intolerable nightly itching accompanies the eruption, creating an almost irresistible desire to scratch the parts. The scratching obliterates the vesicles, and gives rises to scratch-marks, and to the secretion of an ex- ceedingly acrid, irritating fluid, which oftentimes indefinitely prolongs the disease. Large blackish crusts covering suppurating ulcers are an occasional result. Furuncles quite frequently complicate the trouble." (Kippax.) Therapeutic Hints. Rumex crisp. Principal remedy. (Searle.) Diluted lye-of- wood ashes locally. Rhus tox. and Ledum may be studied. (Kippax.) Burns and Scalds. Injuries to the skin or flesh caused b3* the action of fire or heated solid bodies are called Burns; injuries by the action of some hot fluid or steam, are called Scalds. Both may vary greatly in degrees of intensity and danger, from a mere superficial dermatitis to a complete destruction of the parts in- THERAPEUTIC HINTS TO BURNS AND SCALDS. 1021 volved; they may be confined to only a small spot, or extend over large surfaces, or may reach the internal mucous membrances by inhalation or deglutition, or may involve particular sensitive parts of the body, such as the genitals, or places where large trunks of nerves or blood-vessels lie close to the surface, for instance in the region of throat and neck. Upon all these different possibilities depends the more or less pronounced constitutional effect of the injury and its danger. The shock is sometimes terrible, manifesting itself in a sudden sinking of vital power, cold extremi- ties, vomiting and anxiety. In superficial and not widely extended injuries these symptoms are wanting, and it is more the intense burning pain in the parts involved, that cause distress; but even in lighter cases fever and sleep- lessness may be a speedy consequence. Severer burns are followed by sup- puration, ulceration, sloughing, attended by fever, and sympathetic affections of the bowels, such as colic, diarrhoea, intestinal haemorrhage. The destruc- tion of two-thirds of the entire cutaneous surface is considered as fatal; but death ma} r also ensue from the shock, or subsequent ulceration, sloughing and hectic fever, or haemorrhage. Therapeutic Hints. Blisters must be emptied by pricking with a fine needle, or sewing a thread through them, so that the epidermis may remain intact. To "draw the fire out," several applications have proved efficacious. Pure alcohol will do it in many cases. An alcoholic solution of Cantharides, 3d dilution, acts frequently like a charm; so does a like solution of Causticum, or Urtica urens. If there be bicarbonate of soda, the common baking powder, close at hand, a paste made of it and applied quickly, has also been found of excellent use. But castile soap, or any other common soap, made into a paste by scraping and mixing with warm water, is indeed one of the best external applications, because it is most always at hand. So may sweet oil, either alone or mixed with a few drops of the 3d dilution of Cantharides, or with equal parts of lime water, act very beneficial. Sometimes a mixture of sweet oil and chloride of lime made to a salve has relieved where Cantharides and soap were of no use. It is of great importance that the air should be excluded from the parts involved. Raw cotton, not glazed, and free from seeds, is excellent for this purpose, as it is light, soft and pliable, easily adapting itself to an} T part. Some physicians moisten its surface which is intended to come in contact with the burn or scald with the tincture of Calendula, or of Cantharides or of another of the articles mentioned, before applying it. Special Hints. Aeon. Shock, fever, restlessness, sleeplessness. Arnica. Stays abundant suppuration. • Arsen. Great restlessness, sinking of strength; colic and diarrhoea. Internal burns. 1022 CHILBLAINS. Ca?ithar. Internal burns. Card. veg. Shock, with symptoms of collapse. Caustic. Internal burns. Chamom. Colic; convulsions. Chi?ia. Profuse suppuration, weakness, hectic fever. Coffea. Nervous excitability and sleeplessness. Kreos. Discharge fetid and wound bluish. Laches. Wounds do not heal, take a purplish aspect. Opitim. Shock, tendency to convulsions, especially in children; sleep- lessness. Sapo. Internal burns, most important. Urtica urens. Chilblains, Frostbites. Like heat, so does intense cold produce inflammatory affections, most frequently on the least protected parts of the body, the ears, nose, fingers and toes. But this inflammation is of a secondary nature, and sets in when heat and circulation of the frosted parts have been restored too hastily by the application of external warmth, and is called Chilblains or Frostbites. Here, too, as in burns, the injury may be superficial or involve deeper structures. The parts become swollen, look dark red and have a sensation of tingling, burning and itching; there form vesicles upon the outside, which burst and produce unhealthy looking sores, and gradually a more or less deeply ulce- rated surface. Even gangrene may result from this cause. A peculiarity of frostbites is, that, after healing or spontaneously disappearing, they frequently return again at the next cold season, or become troublesome again during the hot weather. Therapeutic Hints. A frozen part of the body must not be exposed to external heat. Cov- ering or gentle rubbing with snow, or immersion into cold water in a cold room are the first best things to be done for its restoration. Hering has recommended as a preventive the rubbing with Camphor spiritus of the least protected parts before the exposure to intense cold; the same remedy may be applied as a restorative when snow or cold water have ' ' drawn out the frost " as far as they can. Special Hints. Agaricus muse. Toes or fingers are red and swollen and burn and itch intensely. Arnica. Parts are blue, red, swollen. Arse?i. After handling of ice, the pain is relieved by external warmth; bluish-redness of the sides of the feet; vesicles turn blackish; tendency to gangrene. ANOMALIES IN THE SECRETIONS OF THE SKIN. IO23 Bellad. Bluish-red inflammation; pain burning, or stinging, or creep- ing, tingling, worse at night and on moving. Canthar. Externally, if Ca?nphor does not relieve. Card. veg. If Arsen. is not sufficient. Frag aria vesca. Pain from chilblains during hot weather. Hepar. Very painful and suppurating. Kali card. Inflammation with aching, cutting pain; bluish appearance. Laches. Parts swollen become bine and black. Natr. mur. " Intense burning and tenderness of the soles of the feet, painful when walking, with stinging vesicle on the tip of the tongue and sen- sation as if a hair were lying on the tongue. ' ' (Gilchrist. ) Nitr. ac. Parts swollen, itching and painful; worse during any slight increase of cold weather; fetid sweat of feet. Nux vom. " Superficial inflammation, with bright red swelling, burn- ing and itching, or when the tumefied part cracks and bleeds easily." (Helmuth.) Petrol. "Burning and itching like fire; heel painfully swollen and red; feet tender and bathed in foul moisture. ' ' (Lilienthal. ) Popular reme- dies of the same nature are: Cosmoline, Vasaline and Coal-oil. Phosphor. When the pain is very intense. Pulsat. Swollen, red and bluish; worse in warm weather and better from cold applications. Rhus tox. Burning, itching pain, worse in afternoon and during rest. Ruta. Burning pains in the bones after frostbites. (Hering.) Secale. When the pain is worse in the warmth and better in the cold; gangrene. Sulphur. ' ' Thick, red chilblains on the fingers. ' ' (Hering. ) Zincum. " Chilblains itch and smell. " (Hering.) V. ANOMALIES IN THE SECRETIONS OF THE SKIN. The secretion of gaseous substances is either augmented, for example, in fevers, when the temperature of the body is considerably raised, and in a hot atmosphere; or it is diminished, when the air is damp and its temperature low. In disease, a diminution of gaseous secretion has been ascertained by actual measurement only in diabetes mellitus. The secretion of watery substances, which is called perspiration or sweat, may be promoted in any healthy person by drinking large quantities ot water, and covering with a thick blanket, by strong exercise of the body, by the heat of the weather, etc. In diseases it is sometimes entirely wanting, at other times, a very prominent symptom, for example, in pneumonia, in some forms of rheumatismus acutus, etc. Some persons are much more in- clined to sweat than others; an excessive inclination to sweat is called Hyper idrosis. It seems that repeated sweatings increase the inclination to it. When the fluid which is secreted in the sudorific glands cannot pass freely 1024 SUDAMINA. upon the surface, either because the sudorific ducts are stopped up, or be- cause they are too narrow to give vent to all the fluid which is produced within the glands, we observe the fluid to collect under the epidermis, and *o raise it into numerous little vesicles, which contain a perfectly trans- parent fluid of an acrid reaction. This eruption is called Sudamina, or Miliary Rash. The stoppage of the outlets of the sudorific glands occurs most frequently in diseases in which there has been great dryness of the skin previous to the outbreak of the sweat, as, for example, in the first weeks of typhus. The appearance of the eruption has no influence upon the course of the disease; it is observed as well in critical sweats as in those which break out sometimes when the disease takes a bad turn, and may even appear during the last struggles of agony. When the transparent, minute vesicles appear upon a naturally colored skin, it is called miliaria alba, when upon a skin which is reddened by hyperemia or hseinorrhagic effusions, it is called miliaria rubra, As a symptom it may indicate Arsen., Bryon., Calc. carb., or Ipec. Prickley heat is likewise a miliary rash, consisting of numerous pin- head-sized, reddened papules, or vesico-papules, in consequence of a disordered action of the sweat-glands, covering the trunk, arms, neck and even, at times, the face. It occurs during the hot weather, and is often very annoying on account of its stinging-itching, but usually disappears when cooler weather sets in. Quite frequently do we find partial hyperidrosis on the palms of the hands, on the soles of the feet, under the arm-pits and on the genitals. The sweat of the feet, in the axillae and on the genitals, is often excessively offen- sive, which seems to have its cause in a decomposition which the sweat, the sebaceous secretion and the softened and loosened epidermis undergo. The suppression of these partial sweats has been considered from olden times as very detrimental to health, causing spinal affections and different other com- plaints. In later times this has been reversed; now they sa5 7 : intercurring diseases stop this partial sweating. Ma} 7 be; may be not. So much is cer- tain, and I have observed many a time that the cessation of partial sweats stands in closest relation with various general complaints, and that the patient does not get better until the foot-sweat or axilla-sweat, etc., is re-es- tablished. Foot-Sweats. "Bar. carb. Fetid foot-sweat, with callosities on the soles which are painful on walking; soles feel bruised at night, keeping one awake, after ris- ing and walking. Calc. ost. Foot-sweat which makes the feet sore; feet feel cold and damp, as if she had wet stockings: burning in the soles. Canthar. Temperary cold sweat on feet; smells like urine. Carb. veg. Foot-sweat excoriating toes; toes red, swollen; stinging, as if frosted; tip of toes ulcerated. FOOT-SWEATS. IO25 Graphit. Profuse foot-sweat, not fetid as in Sepia or Silic. , but the most moderate walking causes soreness between the toes, so that the parts become raw; spreading blisters on the toes, thick and crippled toe-nails. (Jahr gives fetid feet under Graphit. ) Helleb. Humid, painless vesicles between the toes. Iodnm. Acrid, corrosive foot-sweat ; cedematous swelling of the feet. Kali carb. Profuse fetid foot-sweat ; swelling and redness of the soles; chilblains; stitches in the painful and sensitive corns. Lac. ac. Profuse foot-sweat, but not fetid {Graphit.) Lycop. Profuse and fetid foot-sweat, with burning in the soles; one foo} hot, the other cold, or both cold and sweaty; swelling of the soles; they pain when walking; fissures on the heels. Mur. ac. Cold sweat on the feet, evening in bed; swelling, redness and burning of tips of toes; chilblains. Nitr. ac. Foul-smelling foot-sweat ; chilblains on the toes. Petrol. Feet tender and bathed in a foul moisture ; feet swollen and cold; hot swelling of the soles, with burning; heel painfully swollen and red; chilblain; tendency of skin to fester and ulcerate. Plumbum. Fetid foot-sweat; swelling of the feet. Podoph. Foot-sweat evenings. Sepia. Profuse foot-sweat or very fetid, causing soreness of toes; burn- ing, or heat of the feet at night; crippled nails. Silic. Offensive foot-sweat with rawness between the toes; itching of soles, driving to despair. Squilla. Cold, foot-sweat; sweat only on toes; soles red and sore when walking. Sulphur. Sweating and coldness of the soles; burning soles, wants them uncovered. Thuja. Fetid sweat on toes, with redness and swelling of the tips; nets of veins, as if marbled, on the soles of the feet; suppressed foot-sweat; nails crippled, brittle or soft. Zincum. The feet are sweaty and sore about toes; also fetid; chilblains from cratching and friction ; the suppression of sweat causes paralysis of the feet. Jahr gives the following: Foot-sweat. — Aeon., Amnion., Baryta, °Calcar., Carb. veg., Coccul., Cuprum, Cyclam., Droser., Graphit., Ioduin, °Kali. Kreos., Laches., °Lycop., Magn. mur., Mercur., Natr. mur., Nitr. ac, Nux jug., Petrol., Phosphor., Phosph. ac, Plumbum, Pulsat., Sabad., Sabi?ia, °Sepia, °Silic., Squilla* Staphis., °Sulphur, Thuja, Zincum. corrosive, Iodum, Lycop., Nitr. ac, Silic, Zincum. {Carb. veg.) , fetid. Amnion., Baryta, Cyclam., Graphit., Kali, °Nitr. ac, Nux jug., Phosphor., Plumbum, Sepia, Silic., Zincum. cold, Coccul., Droser., Ipec, Lycop., Afercur., Squilla, Staphis., Sul- phur. (Canthar.) 65 1026 FOOT-SWEATS. night (at), Coloc. (Evening, Mur. ac, Podoph.) suppressed, ° Cuprum, Kali, °Natr. mur., °Nitr. ac, ° Sepia, °Silic. {Apis, Pulsai., Rhustox., Thuja, Zl?icu??i.) soles of feet (on), Aeon., Arnica, Kali, Natr. mur., Nitr. ac., Petrol., Plumbum, Saba a 1 ., Si lie, Sulphur. toes (between the), Aeon., Arnica, Clemal., Cyclam., Ferru?n, Kali, Sepia, Silic., Squill a, Tar ax., Thuja. To this we may add: profuse. Carb. veg., Graphit., Kali carb., Lac. ac, Lycop., Sepia. With much itching of soles, Silic, Sulphur. With burning, Calc ostr., Lycop., Mur. ac, Petrol., Sepia, Sulphur. With rawness, Graphit., Silic (Carb. veg.) With soreness. Bar. carb., Calcar., Carb. veg., Graphit., Iodu??i, Pet- rol., Sepia, Squilla, Zincum. With redness and swelling in the soles. Iodum., Kali carb., Lycop., Petrol., Squilla; in the feet, Plumbum ; in the tips, Mur. ac, Thuja; in the toes, Carb. veg. With pain on walking. Bar. carb., Graphit., Lycop., Squilla; at rest, Carb. veg. (stinging), Petrol, (pain in the heel of foot). With crippled nails. Graphit., Sepia, Thuja. moisture (rather than sweat), fetid, Petrol; cold, Calcar." (Dr. E. Fornias. ) A diminution of fluid secretion, causing great dryness of the skin, often attends marasmus senilis. Sometimes it is a disturbed innervation, and sometimes the consequence of skin diseases. Besides, there are cases of Anidrosis and even of half-sided Anidrosis, for which there is no explanation. A qualitative change in the secretion of sweat takes place in icterus, which colors the linen yellow, and in suppressed urinary secretions, when the sweat contains urinary ingredients. The secretion of sebaceous substances, if diminished, causes great dry- ness and brittleness of the skin, if augmented (seborrhea), it forms crusts upon the scalp, especially in children, or on the cheeks, nose, eyelids, ears and nipples, especially in females who menstruate irregularly. A thicken- ing of it with the excretory ducts causes comedones, milium and atheromata. A Comedo has a dark surface from the dust and dirt outside, which has been mixed with it. A Milium is a collection of hardened sebum with the extended follicle; being covered by the epidermis it shows no dark, dirty point. A Molluscum is a greatly enlarged sebaceous gland, which is filled by thickened sebum. Being always united with a hair-follicle, with which it has a common outlet, the swelling or tumor generally shows a dark point and umbilical depression on its summit. The color of the skin over it is either normal in color or pinkish. It attacks mostly the face, but it may appear on other parts. Its contents can often be squeezed out. Internal remedies are: Silic, Calc. ars., Bryo?i., Kali hydr., Lycop., Natr. mur. INDEX. A Abdomen, 420 Abdominal Disorders, Special Forms of, . 422 Abscess of the Ankle Joint, .... 767 Abscess of the Brain, 105 Abscess of Cornea, 153 Abscess, Peritonsillar 261 Abscess, Retrotonsillar, 261 Abnormal Collection of Gas in In- testinal Canal, 498 Abnormal Largeness of the Head, . 123 Abnormal Smallness of the Head, . 124 Acarus Scabiei, 1018 Accommodation and Refraction, . . 169 Accommodative Asthenopia, . . . .173 Acne Punctata, 253 Acne Rosacea, 253 Acne Syphilitica, 641 Activity, 51 Acute Infectious Diseases, 855 Acute Miliary Tuberculosis, .... 948 Acute Spinal Paralysis of Adults, . 735 Acute Yellow Atrophy of Liver, . . 541 Adaptation, . . 170 Affections of Bronchial Tubes, . . . 327 Affections of the Pulmonary Paren- chyma, 344 Agenesia, 120 Agraphia, 115 Ague, 858 Akinesis, 829 Albuminuria, 587 Alcoholism, Chronic, 62 Alopecia, 131 Alopecia Syphilitica, 642 Alveolar Cancer of Liver, 545 Amaurosis, 165 Amblyopia, 165 Amenorrhcea, 700 Amnesic Aphasia, 115 Amygdalitis, . 261 Amyloid Degeneration of the Kid- neys, ... 600 Amvloid Degeneration of Liver, . . 544 Anaemia of Brain, 67 * Anaemia, Progressive Pernicious, . . 840 Anaemia of the Skin, 1004 Anaemia (Symptomatic), 839 Anaesthesia, 773, 798 Anaesthesia of Larynx, 301 Anaesthesia of the Trigeminus, . . . 977 Analogy Between Bar and Eye, , . 182 Anchylops, 134 Anchylostomum Duodenale, . . . . 519 Aneurisms of Brain, 121 Aneurism of Thoracic Aorta, . . . 415 Anidrosis, 1026 Angina Catarrhalis, 263 Angina Faucium, 263 Angina Follicularis, 265 Angina Granulosa, 265 Angina Ludovici, 271 Angina Pectoris, 412 Angina Tonsillaris, 261 Anteflexion, 676 Anterior Nasal Cavity, 211 Anteversion, 676 Anthrax, 950 Aorta, 415 Aortic Opening, Constricted, .... 403 Aortic Valves, Insufficient, 402 Apathic Idioc}^, 50 Aphasia, 115 Aphthse '. . . 274 Appendicitis, ...... ... 455 Apoplexy, Pulmonary, 372 Apoplexia Sanguinea, 109 Apoplexia Sanguinsa, 104 Apoplexia Serosa, 103 Arthritis, 753 Arthritis Deformans, 755 Arthritis Sicca, 755 Ascaris Lumbricoides, 515 Ascites,' 529, 553 Aspermatism, 656 Astigmatism, 172 Asthenopia, 173 Asthma, Bronchial, 340 Asthma Thymicum Koppi, 303 Asthma Millari, 303 I02i INDEX. Asylums for the Insane, 54 1 Atony of the Bladder, 614 Atrophy of the Brain, 120 Atrophy of Liver, (Acute Yellow), . 541 Atrophy of the Nerves, 772 Atrophy of the Skin, 1003 Atrophy of the Skull, 125 Auditory Canal, 184 Auditory Vertigo, 207 Auricle, 184 Auscultation, 284 Auscultation of Chest, 315 Auscultation of Cough, 326 Auscultation of Heart, 387 Auscultation of Voice, 323 Azoosperniism, 656 B Bacillus, Comma, 959 Bacillus Diphtherias, 926 Bacillus of Eberth, 892 Bacillus, Klebs-Lceffler, 926 Bacillus of Tetanus, 956 Bacillus Tuberculosis, 948 Bacteria, 855 Balanitis, 626 Baldness, 131 Barrel Chest, ... 307 Basedow's Disease, 178 Basilar Meningitis, 91 Bicuspid Insufficiency, 401 Bilious Fever, 426 Bladder, Diseases of, 607 Blenorrhcea of the Bronchi, .... 329 Blenorrhcea of the Lachrymal Sac, . 139 Blepharitis Marginalis, 134 Blepharospasm, 177 Blood Icterus, 555 Boil, ....'... 1014 Brain and its Membranes, 67 Break Bone Fever, 888 Bright's Disease, 589 Bronchial Asthma, 340 Bronchial Catarrh, 327 Bronchial Hemorrhages, 372 Bronchial Tubes, 327 Bronchiectasia, 329 Bronchitis, 327 Bronchocele, 279 Bronchorrhcea, 329 Broncho-Typhus, 897 Bruised Head of a Child After Birth, 123 Buboes, 625, 638 Bunion, 771 Burns, 1020 Bursitis, 767 C Calculi Vesicae, 612 Camp Fever, 889 Cancer of the Breast, 715 Cancer of the Intestines, 509 Cancer of the Larynx, 301 Cancer of the Liver, 545 Cancer of the Pancreas, 569 Cancer of the Rectum, 510 Cancer of the Spleen, 567 Cancer of the Stomach, 439 Cancer of Tongue, 258 Cancer of the Womb, 687 Cankers of the Mouth, 274 Caput Succedaneum, • . . . 123 Carbuncle, 1014 Carbunculus Contagiosus, 950 Carcinoma of Brain, 121, 122 Carcinoma Fasciculatum, 545 Carcinoma Hepatis, 545 Carcinoma of Larynx, 301 Carcinoma Testis, 648 Carcinoma Ventriculi, 439 Cardialgia Nervosa, 430 Carditis, 407 Caries, 760 Catalepsy, 812 Cataract, 167 Catarrh, Biliary, 548 Catarrh, Bronchial, 327 Catarrh, Chronic Intestinal, .... 449 Catarrh, Intestinal, 447, 469 Catarrh, Laryngeal, 286 Catarrh, Nasal, 213, 217 Catarrh of Stomach, 425, 428 Catarrhal Urethritis, 621 Catarrh of the Uterus, 663 Catarrhal Inflammation of the Rec- tum, 458 Catarrhal Opthalmia, 140 Catarrhal Nephritis, 589 Catheterism of Middle Ear, .... 190 Cephalalgia, 775 Cephalalgia Rheumatica, 741 Cellulitis, Orbital, 178 Cerebro-Spinal Meningitis, 943 Cervico-Occipital Neuralgia, .... 790 Chalazion, 138 Chancre, 626 Checked Evolution of Psychical Development, 49 INDEX. IO29 Chemosis, 142 Chicken-pox, 1001 Chilblains, 1022 Chiragra, 753 Chloasmata, 554 Chloasmata Uterina, 1003 Chlorosis 841 Cholsemia, 554 Cholelithiasis, 549 Cholera Asiatica, 959 Cholera Infantum, 469 Cholera Europcea, 468 Cholera Morbus, 468 Cholera Nostras, 468 Cholera-Typhoid, 962 Cholesteatoma, 12 1 Chorea, 802 Choroidea, 160 Choroiditis, 160 Chromotopsy 164 Chronic (Edema, 370 Chronic Myelitis of Erb, 730 Chronic Rheumatism of the Joints, . 740 Chronic Sore Throat, 265 Cirrhosis, 539 Clinical Thermometry, 855 Coccyodynia, 737 Cold in Head, 213 Colica, 500 Colica Renalis, 601 Colloid Liver, 544 Comedo, 253, 1026 Conation, 51 Condylomata, 637 Condylomata in Larynx, 300 Congestion of Brain, 69 Congestion of Liver, 533 Congestion of Lungs, 370 Congestive Fever, 875 Conjunctiva, 140 Conjunctivitis Croupous, 151 Conjunctivitis Diphtheritica, .... 150 Constipation, .... 478 Constriction of Left Auriculo-ventri- cular Opening, 402 Consumption, 354 Consumption of the Bowels, .... 509 Convulsions, 800 Convulsions of Children, 825 Cornea, 152 Corneitis, 152 Coryza, . . 213 Coxalgia, 763 Coxarthrocace, 763 Cramp, 800 Cramp of the Stomach 430 Craniotabes, . 124 Cranium and Its Integuments, . .123 Cretinism, 34, 49 Crisis, 857 Critical Days, 857 Croup 292 Croupous Conjunctivitis, 151 Croupous Pneumonia, 345 Crusta Lactea, . . 231 Curvature of the Spine, 768 Cyanosis, 836 Cyclitis, 161 Cystitis, 607 D Dacryocystitis, 128 Dandruff, 128, 1009 Deafness, Nervous, 207 Decubitus, 1004 Delirium Tremens, 60 Delusive Ideas, 34 Dementia, 34 Dementia Paralytica, 40 Dementia Senilis, ......... 41 Dengue, 888 Dermatitis, 1004 Diabetes Insipidus, 583 Diabetes Mellitus, 576 Diaphragm, Neuralgia of the, . . . 418 Diaphragmitis, 416 Diffuse Corneitis, 153 Diffuse Nephritis, 589, 593 Dilatation of Heart, 407 Dilatation of (Esophagus, 282 Diplococcus Pneumoniae, 943 Dipsomania, 62 Diphtheria, 925 Diphtheria, Catarrhal, 927 Diphtheria, Croupous, 927 Diphtheria, Gangrenous, 927 Diphtheritic Conjunctivitis, .... 150 Diseases of the Prostata, 649 Diseases of the Testes, 646 Diseases of the Vesiculae Seminales, 651 Dislocation of the Lens, ..... 169 Displacement of the Womb, .... 676 Distiachis, ... 134 Diverticula, (Esophagus 283 Diverticula of the Bladder, 608 Dizziness, 74 Dropsy of the Chest, 383 Dropsy of the Pericardium, .... 397 IO^O INDEX. Drops}' of the Peritoneum, 529 Dropsy of the Scalp, 123 Dry Catarrh, 3 2 9 Drumhead, 184 Dysentery, 460 Dysmenorrhcea, 7°3 Dyspepsia, 4 2 3 Dysphagia Inflammatoria, . . . . 280 Dyspncea, Laryngeal, 297 JEar, The, Ear Wax Diminished or Increased, . Echinococcus-Cysts, Echinococcus-Cysts of the Spleen, Eclampsia Acuta, Eclampsia Gravidarum, Eclampsia Infantum, Ecthyma, Ecthyma Syphiliticum, Ectropium, Eczema, Eczema of Auricle, Eczema Capitis, Eczema of Face, Eczema Syphilitica, Embolism and Thrombosis, . . . . Embolism of Brain, Emotions, Empyema, 375 Emphysema Pulmonum, Emphysematic Chest, Encephalitis, Encysted Tumor of Lids, Endocarditis, Endometritis, Enteralgia, Enteric Fever, Enteritis, Enteritis Catarrhalis, Entero-colitis, Entozoa, Entropium, Enuresis Nocturna, Epidemic Parotitis, Epididymitis, Epilepsy, Epistaxis, Epithelioma of Face, Epithelioma of Lids, Epulis, Erosions, Catarrhal, Erysipelas, 182 186 547 567 823 823 825 1012 642 134 1008 184 125 231 641 113 113 56 378 366 308 105 138 398 663 500 892 447 447 470 514 134 616 923 624 813 225 234 138 236 274 969 Erysipelas Bullosum, 969 Erysipelas, Habitual, 970 Erythema, 1004 Eustachian Tubes, 212 Examination of the Abdomen, . . . 420 Examination of Ear, 184, 1S0 Examination of Liver, 533 Examination of Nasal Cavity, . . . 211 Examination of Thorax, 306 Exanthemata, 973 Exophthalmic Goitre, 178 Exostosis, 760 Exultatio Furiosa, 52 Eyes, 133 Eyeball, Fixed State of the, .... 177 Eyeballs, Trembling of the, ... 177 Eyeballs, Twitching or Quivering, . 178 Eyelid, Tumors of, 138 F Face 228 Fatty Heart, 409 Fatty Liver, 543 Favus, 129 Felon, 769 Febrile Albuminuria, 587 Fever, 855 Fever, Break-bone, . 888 Fever, Cerebro-spiual, 943 Fever, Congestive, 875 Fever, Enteric, 892 Fever, Hay 224 Fever, Intermittent, 858 Fever, Gastric, 897, 426 Fever, Nervous, 897 Fever, Pernicious,' Intermittent, . . 875 Fever, Pneumonic, 345 Fever, Relapsing, 919 Fever, Remittent, 875 Fever (Rheumatic), 73*9 Fever, Scarlet, 978 Fever, Typhoid, 892 Fever, Typho-malarial, 876 Fever, Yellow, 877 Fibroid Phthisis, 354 Fibroma, Papillare of Larynx, . 300, 301 Fig-warts, 637 Fish-skin, 1003 Fissura Ani, 511 Fistula Lachrymalis, 139 Fistula Recti, 460,512 Fistula of the Teeth, 236 Fixed Ideas, 34 INDEX. 1 03 I Flatulency 49S Folie Circulaire, . . . 54 Follicular Inflammation, 274 Fontanelles, 124 Foot-sweats, 1024 Fornix Pharyngis, -. . - 212 Freckles, , 1003 Frostbite, 1022 Fremitus in Chest, 310 Frenzy, 52, 53 Frog, •. 260 Fungi, 855 Fungoid Growth on the Gums, . . . 236 Furious Mania, 51 Furuncles, ■••... 1014 Furuncles of External Ear, .... 188 G Gall-stones, - 549 Gall-stone Colic, 550 Gangraena Pulmonum, 371 Gangrene of the Cheeks, 275 Gastralgia, 430 Gastric Fever, 426, 897 Gastritis, 425 Gastritis Caustica, 429 Gastritis Toxica, 429 Gastromalacia, 445 Giddiness, 74 Gin-drinker's Liver, 539 Glaucoma, 162 Gleet, 620 Glioma, 121 Glioma of the Brain, 122 Glossitis, 257 Glycosuria, 576 Goitre, 279 Goitre, Exophthalmic, 178 Gonagra, 753 Gonarthrocace, 765 Gonococcus of Neisser, 619 Gonorrhoea, 619 Gonorrhoea of the Rectum, .... 625 Gonorrhoea Spuria, . . : 626 Gonorrhoea Vesicae, 625 Gonorrhosal Ophthalmia, 142 Gonorrhoeal Rheumatism, 625 Gout, 753 Granular Atrophy of the Kidney, . . 597 Granular Ophthalmia, 144 Granulated Liver, 539 Graphospasmus, 802 Gravedo, Nasal, 213 Green-sickness, . 841 Graves's Disease, 178 Gumboil, 236 Gummata, 644 Gums, 235 H Haematemesis, 443 Haematogenous Cholaetnia, .... 555 Haematoma Durae Matris, 104 Haemato-pneumothorax, 386 Haematothorax, 381 Haematozoon of Laveran, 859 Haematuria 584 Haemometra, 675 Haemophilia, 851 Haemoptee, 372 Haemoptysis, 372 Haemorrhage, Choroid, 162 Haemorrhage from the Stomach, . . 443 Haemorrhage, Pulmonary, 372 Haemorrhagia Intestinalis, 490 Haemorrhage, Uterine, 691 Haemorrhagic Infarctions, 372 Haemorrhagic Infarction of the Spleen, 564 Haemorrhagic Nephritis, 589 Haemorrhoids, 490 Haemorrhophilia, ... 851 Hair, , 131 Hair, Color of, 131 Hay Fever, 224 Head, 67 Heart, 387 Heart Clots, 406 Heart, Fatty Degeneration, .... 409 Heart Muscle, 407 Heart, Nervous Affections, 410 Helminthis, 514 Hemicrania, 775 Hemcratopia, , 166 Hemiopia, 166 Hepatitis Suppurativa, . . ... 536 Hepar Adiposum, 543 Hepatogenous Cholamiia, 554 Hepatitis Vera Circumscripta, . . . 536 Hernia, 4S4 Herpes, 1005 Herpes, Labial, 274 Herpes Preputialis, 1005 Herpes Tonsurans, . . 130 Herpes Syphilitica, 641 Herpes Zoster, 1005 1032 INDEX. Hiccough, 418 Hip Disease, 763 Hobnail Liver, 539 Homoeopathic Asylums for the In- sane, 54 Hordelum, 137 Honey-comb Ringworm, 129 House-maid's Knee, 767 Hydatids of the Liver, 547 Hydraemia, 838 Hydroa 274 Hydrocele, ... 646 Hydrocephaloid, 68, 469 Hydrocephalus Acutus, 91 Hydrocephalus Acquisitus, .... 101 Hydrocephalus Congenitus, .... ior Hydrocephalus Ex VacUs, 103 Hydrocephalus Senilis, 103 Hydrocephalus Acutus Sine Tuber- culis, 63 Hydrometra, • 675 Hydronephrosis, . 603 H3 T dropericardium, "397 Hydrophobia, 951 Hydrops Cystidis Fellese, 551 Hydrops Ovarii, 661 Hydrorrhachis Congenita, 723 Hydrosarcocele, 647 Hydrothorax, 383 Hyperaemia of Brain, . . ... 69 Hypersemia of Liver, 533 Hyperaemia of Lungs, 370 Hyperaemia of the Spleen, 564 Hyperaemia of the Skin, 1004 Hyperaesthesia, 773 Hyperaesthesia of Larynx, 302 Hyperaesthesia of Retinae 167 Hyperidrosis, . . 1023 Hyperplasia of the Pineal Gland, . . 121 Hypermetropia, 171 Hypertrophy of the Brain, .... 119 Hypertrophy of Heart, 407 Hypertrophy of the Nerves, .... 772 Hypertrophy of the Prostata, . . . 649 Hypertrophy of the Skull, 123 Hypertrophy of the Skin, 1002 Hypertrophy of the Spleen, .... 566 Hyperkinesis, 800 Hyperuresis, 583 Hypopion 153 Hysteralgia, 690 Hysteria, 806 Ichthyosis, . 1003 Icterus, 554 Icterus Gravidarum, 556 Icterus Menstrualis, 556 Icterus Neonatorum, 556 Idiocy, 34 Idiocy, Apathic, 50 Idiocy, Intellectual, 49 Ileus, .... 488 Imbecility, 34 Impaired Hearing, 198 Impetigo, ion Impetigo Contagiosa, 1011 Impetigo of the Scalp, 125 Impotence, 655 Incontinentia Urinse, ....... 615 Indigestion, 423 Infantile Spinal Paralysis, 735 Infectious Diseases, 855 Inflammation of the Anterior Spinal Columns (Acute), 735 Inflammation of the Auditor}* Canal, 188 Inflammation of the Bowels, .... 447 Inflammation of the Bladder, . . . 607 Inflammation of the Breasts, . . . . 713 Inflammation, Catarrhal, of Rectum, 458 Inflammation of Diaphragm, . . . 416 Inflammation of Dura Mater, . . . 104 Inflammation of Heart- Muscle, . . 407 Inflammation, Interstitial of Liver, 539 Inflammation of Liver Capsule, . 536 Inflammation, Follicular in Mouth, 274 Inflammation of the Gums, .... 236 Inflammation of the Nerves, .... 772 Inflammation of Arm, 227 Inflammation of the Orbit, .... 178 Inflammation of the Pancreas, . . . 569 Inflammation of the Pericardium, . 394 Inflammation of Pleura, 374 Inflammation of the Prostate, . . . 624 Inflammation of the Renal Capsule, 605 Inflammation of the Renal Pelvis, . 604 Inflammation of the Spinal Marrow, 726 Inflammation of the Spleen, .... 564 Inflammation of the Stomach, Toxic, 429 Inflammation, Syphilitic, of Liver, . 541 Inflammation of the Throat, .... 271 Inflammation of Tongue 257 Inflammation of Tonsils 561 Influenza, 922 Ingrowing Toe Nails, 771 Insanity, 34 INDKX. I033 Inspection of Larynx, 284 Insolatio, 106 Insomnia, 86, 90 Insufficiency of Aortic Valves, . . . 402 Insufficiency of Tricuspid Valve, . . 401 Insufficiency of Mitral Valves, . . . 401 Insufficiency of Pulmonary Valves, 401 Insufficiency of Tricuspid Valve, . . 404 Intellectual Idiocy, 49 Intellectual Sphere, 34 Interlobular Bmphysema, 366 Intercostal Neuralgia^ 791 Intermittent Fever, 858 Interstitial Inflammation of Liver, . 539 Interstitial Nephritis, 597 Intertrigo, 1004 Intestinal Canal, 447 Intestinal Catarrh, 447 Intestinal Catarrh of Infants, . . . 470 Intestinal Haemorrhages, 490 Intussusception, 487 Invagination, 487 Inversion of the Womb, 678 Iris, 158 Iritis, 158 Irritability of the Bladder, 613 Ischias Postica, 793 Ischuria Vesicalis, 617 Itch, 1018 J Jail Fever, 889 Jaundice, 549, 554 Joints (Tuberclosis of the), 762 K Keratitis , . . . 152 Kidneys, diseases of, 569 Kleptomania, 41 Kraft-Ebling 35 Kyphosis, 768 L Labial Herpes, 274 La Grippe, 922 Lardaceous Kidney, 600 Lardaceous Liver, 544 Large White Kidney, 593 Laryngeal Dyspnoea, 297 Laryngeal Phthisis, 299 Laryngitis, 303 Laryngitis, Acute Catarrhal, . . 286, 292 Laryngitis Chronica, 288 Laryngoscopy, 284 Larynx, . . . . , 284 Left Auriculo- Ventricular Stenosis, . 402 Lehrbuch der Psychiatie, 35 Lens, 167 Lentigines 1003 Leptomeningitis, 93 Leptomeningitis Infantum, ... 93 Leptomeningitis Spinalis, 724 Leucocythasmia, 837 Leucoma Corneae, 154 Leucorrhcea, 663 Leukaemia, 837 Leukomyelitis Posterior Chronica, . 730 Lichen, 1016 Liver, 533 Liver Spots, 1003 Lichen Syphiliticus, 641 Lienitis, 564 Lobar Pneumonia, 345 Local Abnormalties of Chest, . . . 308 Lockjaw, 956 Locomotor Ataxia, 730 Lumbago Rheumatica, 742 Lumbo-Abdominal Neuralgia; . . . 792 Lung Fever, 345 Lupus, 233 Lupus Syphiliticus, 642 Lyssa, 951 M Macula Corneae, 154 Maculae Hepaticae, 554 Macular Syphilide, 640 Malacosteon, 758 Malaena, 490 Malaria, 859 Malignant Pustule, 950 Malum Cotunnii, 793 Malum Pottii, 768 Malum Senile, 755 Mania, 51, 52 Mania Furiosa, 51 Mania Periodical, 54 Marantic Thrombosis, 118 Mastitis, 713 Mastodynia, 792 Measles, 974 Medullary Cancer of Liver, .... 545 Melanaemic Liver, Malarial, .... 533 Melanoma, 121 Melancholia, 56 1034 INDEX Mellituria, 576 Membrana Tympani, 184 Meniere's Disease, 207 Meningitis Cerebro Spinalis Epi- demica, 943 Meningitis of the Convexity, . 93 Meningitis Tuberculosa, 91 Menorrhagia, 694 Menstrual Anomalies, 694 Menstruatio Difficilis, 703 Mental Diseases, 33 Meteorism of Abdomen, 498 Metritis, 672 Metrorrhagia, 691 Micrococcus Erysipelatis, 969 Middle Ear, 189 Migrsena, 775 Miliary Tuberculosis, Acute, .... 948 Milium, 1026 Milk Crust, 231 Mimic Facial Spasm, 801 Mind, 33 Miserere, 488 Mitral Insufficiency, ■ . 401 Moist Catarrh of Middle Ear, ... 197 Mogigraphia, 802 Mollities Ossiurn, 758 Molloscum, 1026 Monomaniacs, 52 Morbid Growths, Uterine, 686 Morbilli, 974 Morbid Winking, 177 Morbus Addisonii, 605 Morbus Anglicus, 756 Morbus Maculosus Werlhofii, . . 850 Morrhinismus, 65 Mother's Marks, 130, 1002 Mouth, 235 Multiple Sclerosis, 728 Mumps, 923 Muscular Asthenopia, 173 Muscular Rheumatism, 741 Myalgia Cervicalis, 741 Myalgia Lumbalis, 742 Myalgia Pectoralis et Inter-Costalis, 741 Myalgia Rheumatica, 741 Myalgia Scapularis, 742 Myelitis, 726 Myelomalacia, 728 Myocarditis, 407 Myopathia, 741 Myopia, 171 Mydriasis, 175 Myosis, 175 Myxoma of the Brain, 122 N Nsevi Spili, • • • . . 1002 Nasal Blennorrhcea, 213 Nasal Catarrh, Chronic, 217 Necrosis, 760 Nephritis, 589 Neoplasms of the Larynx, 300 Neoplastic Formations in the Nerves, 772 Nephralgia, . . ¥ 601 Nephrolithiasis, 601 Nerves, Inflammation of the, . . - 772 Nervous Deafness, 207 Nervous Fever, S97 Nervous Sick Headache, 775 Nervousness, 773 Nettle-rash, 1007 Neuralgia, 774 Neuralgia, Cervico-brachial, .... 791 Neuralgia, Cervico-occipital, .... 790 Neuralgia of the Diaphragm, . . . 418 Neuralgia of the Eye, 178 Neuralgia Facialis, 784 Neuralgia, Intercostal, ...... 791 Neuralgia Ischiadica, 793 Neuralgia of Larynx, 302 Neuralgia, Lumbo-abdominal, . . . 792 Neuralgia of the Mammae, .... 792 Neuralgia Uteri, 690 Neurasthenia, 810 Neuritis, 772 Neuromata, 121, 772 Neurosis of Larynx, 301 Neuro- etinitis, 164 Night-blindness, 166 Noma, 275 Non-desquamative Nephritis, . . . 593 Normal Sounds of Respiration, . . . 316 Nose, 210 Nosebleed, 225 Nutmeg Liver, 534 Nystagnus, 177 Nymphomania, 53 o Occlusion of Cerebral Arteries, . . 113 Occlusion of Intestines, ...... 487 Odontalgia, 238 CEdema, Chronic, 370 CEdema Glottidis, 296 Oedema Laryngis, 296 Oedema of Lungs, 370 INDEX. I035 Oesophagus, 2S0 CEsopaphagitis, 280 Old Sight, 170 Oligemia, 839 Oligocythemia, 837 Omagra, 753 Omodynia Rheumatica, 742 Onyx 153 Oophoritis, 658 Opisthotonus, . . 957 Opacity of Cornea, 154 Opium Poisoning, 65 Ophthalmia Catarrhalis, 140 Ophthalmia Gonorrhceica, . . . 142, 625 Ophthalmia Granulans, 144 Ophthalmia Neonatorum, 143 Ophthalmia Phlyctenularis, .... 146 Ophthalmia, Purulent, 142 Ophthalmia Tarsi, ........ 134 Oplic Nerve, 164 Orbit, 178 Orchitis, 624, 647 Osteitis, 760 Osteomalacia, 758 Otalgia Nervosa, 209 Otitis Media, 193 Otitis Externa, 188 Otitis Media, Chronic, 197, 198 Ovarian Cysts, 66 r Ovarian Dropsy, 661 Ovaritis, 658 Oxaris Vonnicularis, 514 Ozena, 217 Pachymeningitis, 104 Pachymeningitis Externa, 104 Pachymeningitis Interna, '104 Palpation of Chest, 308 Palpitation of Heart, 410 Panaritium, 769 Pancreas, Diseases of, 568 Pancreatitis, 569 Pannus, 144, 153 Panophthalmitis, 160 Papilloma of Larynx, 300, 301 Papular Syphilide, 640 Paracystitis, 607 Paragraphia, 116 Paranephritis, 605 Paranoia, 34 Paranoia Inventoria, 36 Paranoia Reformativa 36 Paranoia Religiosa, 36 Paranoia Sexualis, 35 Paraphrenias, 378 Paralysis, 829 Paralysis Agitans, 828 Paralysis of the Bladder, 614 Paralysis of L,arynx, 301,302 Paralytic Chest, 3o7 Paraphasia, , 116 Paraphimosis, 620 Parenchymatous Corneitis, .... 153 Parenchymatous Metritis, 672 Parenchymatous Nephritis, Acute, . 589 Parenchymatous Nephritis, Chronic, 593 Paronychia, 769 Paresis of the Bladder, 614 Parotitis, 923 Parotitic, Epidemic, 923 Parotitis, Metastatic, 923 Parulis, 236 Peliosis Rheumatica, 850 Pemphigus, ior2 Pemphigus Syphiliticus, 642 Percussion, 311 Pericardium, . . 394 Pericarditis, 394 Pericystitis, 607 Perichondritis Laryngea, 298 Peri-Hepatitis, 536 Perinephritis . 605 Perioophoritis 658 Percarditis, 459 Peritonitis, 526 Peritonsillar Abscess, 261 Perityphlitis, 455 Perforation of the Diaphragm, . . . 418 Pernicious Intermittent, 875 Persecution, 34 Personalities, Grand or Rich, ... 34 Pertussis, 939 Pestilentia, 972 Petechial Typhus, 8S9 Phimosis, 620 Photosia, 164 Phlebitic Thrombosis, . . , . . . 11S Phlegmonous Inflammation of lids, 133 Phlyctenular Ophttalmia, . . . . . 146 Phthisis Daryngis, 29S Phthisis Pulmonum, 354 Pianists Cramp, S02 Pigment Diver 533 Piles, 490 Pin Worm . . 514 Plague, the, 972 1036 INDEX. Plasmodium Malariae, 859 Plastic Iritis, 158 Plethora, 839 Pleura, 374 Pleurisy, 374 Pleuritis, 374 Pleuritis Sicca, 376 Plica Polonica, 132 Pleurodynia Rheumatica, 741 Pneumonia, Lobar, . 345 Pneumonia, Catarrhal, 344 Pneumonia, Croupous, 345 Pneumonia from Embolism, .... 344 Pneumonia, Lobular, 344 Pneumonia, Serous, 344 Pneumo-haemothorax, 381 Pneumo-pyo-haemothorax, 381 Pneumothorax, 381 Pneumo-typhus, 897 Podagra, 753 Podarthrocace, 767 Pollutions, Nocturnae et Diurnae, . . 652 Polyarthritis Rheumatica, Acuta, . 739 Polydipsia, 583 Polyomyelitis Anterior, Acuta, . . . 735 Polyomyelitis Anterior, Subacuta et Chronica, 736 Polypanarthritis, 755 Polypi of Ear, 206 Polypi of Nose, 227 Polypus of Rectum, 510 Polyuria, 583, 598 Pompholyx, 1012 Porencephaly, 50 Porrigo Devalcans, 131 Porrigo Favosa or Lupinosa, .... 129 Posterior Staphyloma, . .... 161 Prairie Itch, 1020 Preacher's Sore Throat, 265 Presbyopia, 170 Pressure Diverticula, 283 Prickley Heat, 1024 Procidentia, 677 Proctitis, 458 Prolapsus of the Uterus, 677 Prostatitis, 649 Prostatitis Gonorrhoica, 624 Progressive Muscular Atrophy, . . . 758 Progressive Pernicious Anaemia, . . 840 Prolapsus Recti, 513 Prosopalgia, . 784 Proctalgia, 514 Prurigo, 1017 Pruritus, 1017 Pruritus Vulvar, 712 Prurigo Contagiosa, 1020 Psammona, 121 Pseudo-Croup, ... 286 Psoriasis, 1015 Psoriasis Palmaris and Plantaris, 604 Psychiatrie, 35 Pterigiutn, 152 Ptosis, 175 Ptyalism, 259 Puerperal Convulsions, 823 Pulmonary Affections, 344 Pulmonary Apoplexy, 372 Pulmonary Consumption, 354 Pulmonary Tuberculosis, 354 Pulsation of the Heart, 311 Purpura Haemorrhagica, 850 Purpura Rheumatica, 850 Purpura Simplex, 851 Purulent Inflammation of the Portal Vein, 553 Purulent Nasal Catarrh, 213 Purulent Ophthalmia, 142 Pustular Syphilide, 641 Pyelitis, 604 Pyelonephritis, 604 Pylephlebitis Adhaesiva Chronica, . 552 Pylephlebitis Suppurativa, 553 Pylethrombosis, 552 Pyo-Pneumothorax, 381 Pyothorax, 375, 376 Q Quinsy, . 261 Quivering of the Eyelids, 177 R Rabies, 951 Rachitic Chest, 307 Rachitis, 756 Ranula, 260 Recessus Pharyngia, 212 Red Softening of Brain, 113 Refraction and Accommodation, . . 169 Relapsing Fever, 919 Remittent Fever, 875 Renal Abscess, 601 Renal Calculi, 601 Renal Cirrhosis, 597 Renal Colic, 602 Renal Gravel, 601 Renal Sclerosis, 597 Retention of Urine, 617 INDEX. IO37 Retina, 164 Retinitis Albuminuria, 597 Retroflexion, 677 Retro- Pharyngeal Abscess, . . ■ . 270 Retro-Tonsillar Abscess, .261 Retroversion, 677 Rheumatic Iritis, 158 Rheumatic Fever, ■ . . 739 Rheumatismus Articulorum Acutus, 739 Rheumatismus Articulorum Chroni- cus, 740 Rheumatismus Muscularis, .... 741 Rheumatismus Nodosus, 755 Rickets, 756 Ringworm, 1007 Ringworm of the Scalp, 130 Rcetheln, 994 Rodent Ulcer, 234 Rose Cold, 224 Roundworm, 515 Rubella, 994 Rubeola, 974 Round, Perforating Ulcer of Stom- ach, 435 Rupia, 1013 Rupia Syphilitica, 642 Rupture, 4§4 Rupture of the Diaphragm, .... 418 Rupture of the Spleen, 567 Sago-Spleen, 566 Saliva, 259 Salivation, 259 Sand Tumor of the Brain, 121 Sarcocele, 647 Sarcoma of the Brain, 122 Satyriasis, 53 Scabies, 1018 Scalds, 1020 Scarlatina, 978 Scarlatina Maligna Typhosa, . . . 981 Scarlet Fever, 978 Sciatica, 793 Scirrhus seu Carcinoma Mammae, . . 715 Scotomata, 166 Scirrhus Ventricali, 439 Scleritis, 157 Sclerosis of Middle Ear, 197 Sclerosis of the Posterior Spinal Columns, 730 Sclerotica, 157 Sclerotica-choroiditis Posteria, . . . 161 Sclerotitis 157 Scorbutus, 848 Scrofulosis, 852 Scrofulous Ophthalmia, 153 Scurvy, 848 Seasickness, 86 Sebaceous Tumors, 138 Seborrhcea Capillitii, 128 Senile Dementia, 41 Serous Iritis, 158 Sight, 169 Singultus, 418 Shaking Palsy, 828 Ship Fever, 889 Skin, Diseases of, 1002 Sleep, 86 Small-pox, 995 Softening of the Bones, 758 Softening of Brain, 105, 113 Softening of the Spinal Marrow, . . 728 Softening of the Stomach, 445 Soft Palate, 263 Sore Throat, 263, 270 Spasm, 800 Spasm of the Bladder, 613 Spasm of Glottis, 303 Spasmodic Spinal Paralysis, .... 734 Spasmus Facialis, 801 Spastic Stenosis CEsophagi, .... 281 Spermatocele, 648 Spermatorrhoea, 652 Sphere of Conation and Activity, . 51 Sphere of Feelings or Emotions, . . 56 Sphere of the Intellect, 34 Spina Bifida, 723 Spinal Anaemia, 718 Spinal Apoplexy, 719 Spinal Hypersemia, 718 Spinal Irritation, 721 Spinal Paralysis (Acute Atrophic), . 735 Spinal Paralysis (Chronic Atrophic), 736 Spinal Paralysis (Spasmodic), . . . 734 Spirillium of Obermeier, 919 Spleen, Diseases of, 563 Splenitis, 564 Spotted Fever, 943 Squamous Syphilide, 641 Squint, 176 Stagnation Aktesiae, . 283 Stagnation of Blood in the Brain, . 69, 71 Staphyloma Cicatricial of Cornea, . 154 Staphyloma Posterioris, 161 Staphyloma Ulcerative of Cornea, . 154 Stenocardia, 412 io*8 INDEX. Stenosis of Left Ariculo-ventricular Opening Stenosis (Esophagi, Stenosis of the Pulmonary Opening, Stenosis of Right Auriculo-ventricu- lar Opening, Sterility in the Male, Stomacace, Stomach, Stomatitis, Stomatitis, Catarrhal, Stomatitis Parasitic Stomatitis Ulcerosa, Stones in the Bladder, Strabismus, Stricture of the Oesophagus, .... Strictures of the Urethra, ... Struema, Strongylus Duodenalis, Stupidity, Stupor, St. Vitus' Dance, Stye, Spondylarthrocace, Subacute aad Chronic Inflammation of the Gray Anterior Spinal Horns, Sudamina, Summer-complaint, .... 68, 469, Sunstroke, Suppurative Catarrh of Middle Bar, Suppurative Iritis, Suppurative Nephritis, Supra-renal Capsules, Disease of, . . Sycosis, Syphilides, Syphilis, Syphilis Congenita sive Hereditaria, Syphilis Laryngis, Syphilitic Affections of the Bones, . Syphilitic Affections of the Mucous Membranes, Syphilitic Contractions of the Mus- cles and Tendons, Syphilitic Inflammation of Liver, . Syphilis of the Internal Organs, . . Syphilitic Iritis, Syphilitic Skin Diseases Syphilitic Tumors of the Brain, . . Syphilomata in Larynx, 402 281 404 404 655 2/5 422 272 272 272 274 612 176 281 625 279 519 34 86 802 137 768 736 1024 470 106 198 153 60 r 605 637 640 629 645 300 643 643 644 54i 644 153 640 122 300 Tabes Dorsalis, 730 Tape Worms, 516 Teleangiectasis, 130 Temperature, Normal, 855 Tetanus, 956 Tetanus Neonatorum, 957 Tetter or Scald of Scalp, 125 Teeth 237 Thermic Fever, 106 Thorax, , 306 Thrombosis, 113 Thrombus Neonatorum 123 Thrombosis of Portal Vein, . . . 552 Thread Worm, 514 Thrush, 272 Thrombosis of the Cerebral Sinuses, 117 Thyroidal Perichondritis, 298 Tic Doloreaux, 784 Tinea, 130 Tinea Favosa, 129 Tinea Tarsi, ....'. 134 Tinnitus Aurium, 208 Tobsucht, 52, 53 Tongue, 253 Tonsils, 260 Tonsilla Pharyngea, 212 Tonsillitis, 261 Torticollis Rheumaticus, 741 Tootache, 238 Torsion of the Bowels, 487 Trachea, 284 Traction Diverticula, 283 Traumatic Iritis, 158 Traumatic Pylephlebitis, 553 Trembling, 827 Trembling of the Eyeballs, .... 177 Tremor, 827 Tricuspid Valves Insufficient, . . . 404 Trichiasis, 134 Trichinosis, 522 Trichina Spiralis, 520 Tricocephalus Dispair, 519 Trismus, 956, 957 Tubercles of Brain, 121 Tubercular Syphilide, 642 Tubercular Tumors of the Brain, . . 122 Tubercular Ulceration of Larynx, . 298 Tuberclosis, Acute Miliary, .... 948 Tuberclosis of the Joints, 762 Tuberculosis Intestinalis, 509 Tuberculosis, Pulmonary, 354 Tumor Albus Genu, 765 Tumors of the Brain, 120 Tumors, Gnawing in Larynx, . . . 300 TussisConvulsiva, 939 Twitching of the Eyelids, 177 INDEX. IO39 Tympanitis Abdominals, 532 Typhlitis, 455 Typhoid Fever, S92 Typhoid Fever, Abortive, 897 Typho Malarial Fever, S76 Typhus, 889 Typhus Abdominalis, 892 Typhus Ambulatorius, . Typhus Biliosus, . . . Typhus Exanthematicus Typhus Recurrens, . . Typhus Tumultuarius, . Tylosis, U Ulcerated Sore Throat, Ulceration of Cornea, Ulcers in Fauces, Ulcers in the Mouth, 274, Ulcus Rodens, Ulcus Varicosum, Ulcus Ventriculi Perforans Chron- icum, Uraemia, Urea Urinae Profluxia, Urinalysis, Urinary Casts, Urine, Examination of, Urticaria, Uterine Polypi, Uvula 897 920 889 919 897 134 270 154 270 275 234 ion 435 588 57i 583 569 574 569 1007 686 163 V Vaccination, . Vaginismus, Vaginitis, . . Varicocele, . . Varicella, . . Varicose Ulcers, Variola, . . . 998 711 711 648 1001 ion 995 Varioloid, 995 Variolois, 995 Valsalva's Method, ... .... 190 Vascular Naevus, 130 Veneral Diseases, 619 Verrucktheit, 34 Vesicular Emphysema, 366 Vertigo, 74 Vibration of Voice, 310 Vicarious Menstruation, 700 Vomiting, 424 w Warts on Lids, 138 Water on the Brain, 93 Waxy Kidney, 600 Waxy Liver, 544 Weak-mindedness, 50 Wens, 130, 138 White Softening of Brain, 113 White Swelling, 762 White Swelling of the Knee. . . . 765 Whitlow, 769 Whooping-cough, ....••.. 939 Winking, Morbid, 177 Word Blindness, 115 Word Deafness, 115 Worms, Intestinal, 514 Worms, Tape, 516 Writers' Cramp, 802 Wry Neck, 741 Yearly Cold, . . 224 Yellow Atrophy (Acute) of Liver, . 541 Yellow Fever, 877 Yellow Softening of Brain, 113 Zona, 1005 1*1 I*