A COMPENDIUM Principles and Practice of Medicine, USE OF STUDENTS AND PRACTITIONERS. STEPHEN H. POTTER, M. D., r EMERITUS PROFESSOR OF CLINICAL MEDICINE IN THE AMERICAN MEDICAL COLLEGE, ST. LOUIS, MO., ETC. SECOND EDITION- — REVISED AND ENLARGED. dj J..W HAMILTON, OHIO: BUTLER COUNTY DEMOCRAT PRINT. 1879. Entered according to the Act of Congress, in the year 1878, BY STEPHEN T£ . POTTER, M. D., In the office of the Librarian of Congress. All rights reserved. 1 J Preface to the Second Edition, Long personal experience, as to the wants of the busy practitioner, and the devoted student, convinces the author that a work of reference is indispensable. A compend, in a compact and tangible form containing the proper knowledge of a purely practical nature, is a desirable addition to any medical library. The active physician is often at a loss to know in what direction to look for such facts and suggestions as are here collected. Some are scattered through voluminous treatises, or in many instances are found only in the — to him — inaccessible pages of medical periodicals. The precepts and hints offered for guidance will, it is believed, supply often and urgent need. Students, in attempting to take notes, as all should, are hurried along the current of lectures, and often seize upon unimportant remarks, instead of the essential facts to be retained. Notes taken by different students often compare strangely; to them this compend will prove invaluable. The cordial endorsement of the first edition, the frequent, and urgent demand for a second one, by leading and active members of the profession — with which the author has been favored — inspire the hope that the present volume, in its revised and enlarged form, may become an indis- pensable companion to students and practitioners. In compiling this compend, the author takes great pleasure in gratefully acknowledging his obligations to the able and voluminous writings o f Tanner, King, Mint, Howe, Roberts, Scudder, Memeyer, Newton, Wood, Hartshorn, Dunglison, Ziemssen's Cyclopaedia of the Practice of Medi- cine, and the files of many different medical periodicals, etc. (This unpre- tentious volume is not intended to take the place of, or supersede any other. It is offered as a ready helper, when want of time will not permit a more extensive research. There is no easy road or short cut to sound medical attainments. S. H. POTTER. CONTENTS CHAPTER I. Preface to second edition Introductory explanations 5 CHAPTER n. Causation of Disease. — Etioloy — General and Special 9 CHAPTER HI. Anatomical Changes. — Congenital Malformations — Hypertrophy — Atro- phy — Induration — Softening 16 CHAPTER IV. Symptomatology or Semeiology 22 What We Must Know of a Patient 22 How to Examine a Patient 23 Rules for Practitioners 31 SECTION II.— CHAPTER I. Hypersemia — Congestion. — Forms of— Post Mortem Appearances 33 CHAPTER II. Dropsy — Hydropsy. — Varieties — Causes — General Treatment 37 CHAPTER III. Hemorrhage. — Varieties — Sources — Prognosis — Hemorrhagic Diathesis — General Treatment 39 CHAPTER IV. Inflammation. — Changes Observed — Varieties — Nature and Origin — Results and Products — Suppuration and kinds of Pus — Ulcera- tion — Gangrene or Mortification — Effects on Different Structures — Symptoms — Results— Treatment 41 CONTENTS. CHAPTER V. Degenerations. — Fatty Metamorphosis. — Caseation or Cheesy Degenera- tion. — Causes and Effects. — Fatty Infiltration. — Mineral, Calcare- ous Degeneration. — Petrification. — Fibroid, Pigmentary, Mucoid, and Colloid Degenerations. — Lardaceous Disease. — Albuminoid Infiltrations. — Amyloid Degeneration. — Waxy Disease 54 CHAPTER VI. Fever or Pyrexia. — Type due to the Course and Mode of Progress — Due to Combination and Severity of Symptoms. — Low Types of Fever. — Pathology — Increase of Temperature, Excessive Excretory Elimination, Deficient Elimination, Emaciation, Debility, and Prostration — General Treatment 64 SECTION III. Classification of Diseases 75 CHAPTER I. Contagion . — Origin — Source. — Conditions and Modes of Propagation. — How Transmitted. — How it Gains Access. — What Constitutes Infection. — Degree of Contagiousness. — Nature of Contagion — Chief Theories of. 77 Epidemics. — Varieties: — Sporadic, Endemic, and Epidemic. — Prevention, and Limitation of Epidemics 82 CHAPTER II. Clinical Investigation of Acute Febrile Diseases. — The Use of the Ther- mometer 88 " PART II. — Individual Diseases. CHAPTER I. Zymotic Diseases. — Variola — Small -pox — Varieties. — Varioloid.— Vac- cination. — Varicella. — Scarlatina — Varieties. — Diphtheria — Etiolo- gy, etc. — Measles. — Morbilli — Rubeola. — Mumps. — Parotitis Conta- giosa. — Whooping-cough. — Pertussus. — Influenza. — Epidemic Catarrh. — Dengue— -Break-bone Fever. — Malarial Fever. — Inter- mittent — Remittent — Typho-Malarial — Yellow— Cerebro-Spinal — Relapsing — Typhus — Typhoid Fever. — Cholera. — Epidemic — Asi- atic — etc 93 CHAPTER II. Constitutional Diseases — Diathesis. — Rheumatism. — Varieties. — Gout. — Scurvy .—Constitutional Syphilis — Secondary — Syphiliza- tion — Infantile Syphilis. — Scrofula. — Rickets. — Anaemia. — Leu- cothyaemia — Pyaemia. — Embolism — Thrombosis. — Melasma — Supra-Renalis— Addison's Disease. , 169 CONTENTS. Ill CHAPTER III. Diseases of the Digestive Organs. — Stomatitis. — Tonsillitis— Pharyn- gitis.— Retro-Pharyngeal— Abscess.— Stricture of the (Esophagus.— Gastritis.— Gastro-Hepatic Catarrh.— Chronic Gastritis.— Gastric Ulcer.— Induration of the Pylorus.— Dyspepsia.— Enteritis.— Peri- tonitis.— Colic— Varieties.— Obstruction of the Bowels.— Cholera Morbus.— Constipation.— Diarrhoea— Varieties.— Malsena.— Cholera Infantum.— Dysentery.— Diseases of the Caecum and Appendix Vermiforrnis 202 CHAPTER IV. Diseases or the Liver and Its Appendages.— Jaundice. — Congestion. — Suppurative Inflammation.— Abscess.— Inflammation of the Bile- Ducts. — Chronic Diseases of the Liver 245 CHAPTER V. Diseases of the Gall Bladder. — Gallstones. — General Diagnosis — Prognosis and Treatment of Chronic Diseases of the Liver 280 CHAPTER VI. Diseases of the Spleen.— Pancreas.— Suprarenal Capsules. — Abdom- inal Aneurism 292 CHAPTER VII. Diseases of the Urinary Organs. — Uraemia. — Nephritis. — Bright 's Disease. — Diabetes. — Cystitis... 309 CHAPTER VIII. Diseases of the Respiratory Organs. — Pneumonia. — Pleurisy. — Ab- scess of the Lung. — Pulmonary Gangrene. — Emphysema of the Lung.— Collapse of.— Bronchitis.— Asthma —Bronchial Dilatation.— Laryngitis. — Laryngoscope. — Laryngismus. — Croup — Varieties. — Pleurodynia, — Phthisis Pulmonalis.— Cancer.— Rare Formations. — Haemoptysis 319 CHAPTER IX. Diseases of the Circulatory Organs. — Angina Pectoris. — Syncope. — Palpitation.— Acute Pericarditis.— Endocarditis.— Acute Myocardi- tis. — Valvular Disease. — Hypertrophy. — Atrophy.— Fatty Degener- ation. — Modes of Sudden Death in Heart Disease. — Thyro-Cardiac Disease. — General Diagnosis — Prognosis and Treatment of Chronic Cardiac Diseases. — Rare Cardiac Diseases. — Malformations of the Heart and Great Vessels 355 CHAPTER X. Diseases of the Bloodvessels. — Arteritis. — Thoracic Aneurisms.— Mediastinal Tumors 388 CHAPTER XL Diseases of the Brain and Nervous System.— Inflammation of the IV CONTENTS. Brain — Varieties. — Tuberculous Meningitis. —Hydrocephalus.— Softening of the Brain. — Inflammation of the Spinal Marrow. — Apoplexy. — Aphasia. — Paralysis — Varieties.— Locomotor Ataxia. — Epilepsy.— Catalepsy.— Convulsions— Varieties.— Chorea. — Tetanus. — Hydrophobia. — Neuralgia — Varieties. — Delirium Tremens. — Hysteria. — Hypochondriasis 396 CHAPTER XII. Diseases of the Skin. — Exanthemata — Erythema — Urticaria — Roseola Papulae — Lichen — Strophulus — Vesiculae — Eczema — Herpes — Bullae — Pemphigus — Rupia — Pustulae — Ecthyma — Impetigo — Squamae — Lepra — Psoriasis — Pityriasis — Icthyosis — Maculae — Ephelis — Vitiligo— Chloasma — Alopecia— Hypertrophic— Naevus — Clavus — Veryuca — El ephantiasis — Condylomata — Tubercula — Acne— Molluscum— Lupus— Frambaesia— Keloid— Haemorrhagiae — Neuroses — Prurigo — Anaesthesia — Neuralgia Cutis — Parasitica — Scabies — Army-Itch — Favus — Sycosis — Tinea — Chloasma — Plica Polonica — Syphilida 440 CHAPTER Xni. Hemorrhages. — Varieties : — Active — Passive — Traumatic — Sympto- matic — Critical— Vicarious — Epistaxis — Haemoptysis — Pulmonary Haematemesis — Haematuria — Intestinal — Uterine 468 CHAPTER XTV. Dropsical Affections. — Varieties : — (Edema — Anasarca — Hydroceph- alus— Hydrothorax— Hydropericardium— Ascites— Ovarian — Hy- dronephrosis—Hydrocele 474 CHAPTER XV. Entozoa— Intestinal Worms.— Cestoid— Taenia Solium— Mediocanel- lata — Echinococcus — Bothriocephalus Latus — Cysticercus cellulosa — Echinococcus Hominis — Cysticercus — Trematode — Distoma Hepaticum— Ophthalmobium— Bilharzia Haematobia— Tetrastoma Renale — Nematoid — Acaris Lumbricoides — Tricocephalus Dis- par — Oxyuris Vermicularis — Sclerostoma Duodenale — Filaria Medinensis— Strongylus Gigas— Trichina Spiralis 478 CHAPTER XVI. Pestts Bubonica— Bubo Plague— "Black Death." 486 CHAPTER XVII. Inhalation and Atomization 490 CHAPTER XVin. Hypodermic Medication 493 CHAPTER XIX. Natural Therapeutics....,,. , , 495 INTRODUCTION Medicine, in the broadest sense of the term, comprises all per- taining to the knowledge, prevention and cure of disease; properly including the conduct of physicians in treating disease. The Medical profession includes all who devote themselves to the study and practice of medicine, surgery, and obstetrics, either separately, or combined. In our Country most physicians are, of necessity, general practitioners. Surgery, and obstetrics, as separate branches, can be practiced only in large cities. The distinction of physician, surgeon, and obstetrician is purely conventional. The only license given, or degree conferred by our medical colleges and universities is that of Doctor of Medicine. Medicine, divided into the three departments named is natural, and has enhanced the knowledge and efficiency in each department. Further subdivisions have been found useful and convenient. These are known as Specialties. It is obviously difficult for one mind to grasp and retain the vast and increasing accumulation of medical knowledge. It is as obvious that the great principles of medicine should be understood by the specialist, or undue relative promi- nence will be given to what is not of paramount importance. Pathology is the study of disease as a province of scientific medi- cal knowledge. It has two important divisions termed Special and General Pathology . Diseases manifest particular forms, or species — individual diseases. The study of these constitute special pathol- ogy, A morbid condition which enters into a number of individu-. al diseases is termed fever. In this sense the study of fever, be- longs to general pathology; but the study of each form of fever is special pathology. Thus, the relation of General and Special pa- thology is analogous to the relation between general and special anatomy; the first describes the various tissues which compose the different bodily organs, and the other describes the particular organs formed of those tissues. The number of tissues is small compared with the number of organs, so the morbid conditions in- cluded in general pathology are few when compared with the large number of diseases belonging to special pathology. General and INTRODUCTION. special pathology bear similar relation to each other, as the terms Science and Art. The former treats of principles, the latter ap- plies those principles to the practical developement of art. "Science is knowledge reduced to principles ; art is knowledge reduced to practice" General Pathology admits of several subdivisions. 1. Nomen- clature, or naming diseases. The name of each disease should ex- press the morbid condition and its situation. This desideratum is not yet attained because the character of some is not fully known, and long use renders it difficult to change some others. Inflamma- tion, which enters into a large number of individual diseases, is ex- pressed by the suffix itis added to the anatomical name of the part affected. Thus, pneumonitis, bronchitis, pleuritis, peritonitis, etc. are names denoting the character of each 'disease referred to, and the particular structure inflamed. The suffix cea a transudation, or flux, occuring in a part where the transuded liquid escapes upon a mucous surface. Examples are bronchorrhoea, gastrorrhoea, cys- torrhcea, entorrhoea, etc. terms not yet sufficiently in vogue. The suffix rhagia expresses a flow of blood, or hemorrhage from a mucous surface, as metrorrhagia, gastrorrhagia (haemateinesis, en- terorrhagia (melaena,) bronchorrhagia (hemoptysis, in like manner terms which have not displaced others in common use. The suffix algia signifies a morbid condition, causing pain without inflamma- tion. Thus, neuralgia is a general term, expressing an affection of a nerve or nerves ; as gastralgia, enteralgia, pleuralgia, etc. express the character and seat of the affection. Words ending in cemia apply to morbid conditions of the blood as anaemia (impoverishment), uraemia (morbid accumulation of urea in the blood), septicaemia (putrid infection of the blood). Words ending in uria are applied to certain morbid conditions of the urine ; as albuminuria, and oxaluria. The prefix hydro denotes a dropsical disease of a part named ; hydrothorax, hydrocephalus, hydro-peritoneum, hydropericardium. And the prefix pneumo de- notes the presence of air in a part ; as pneumothorax, pneumoperi- cardium. Modern efforts to introduce names expressive of the character and seat of morbid conditionsjiave measurably succeeded- As our pathological knowledge increases our nomenclature can be perfected. INTKODUCTION. i Another subdivision of General Pathology relates to the appre. ciable morbid changes in the solids and fluids of the body ; termed morbid anatomy. Morbid changes not visable, or not yet ascer- tained by our present means of observation are termed functional, and are also called dynamic. Appreciable anatomical changes, either permanent or persisting are known as lesions. The study of the minute anatomy of the tissues by the aid of the microscope is called Histology ; and the term Morbid, or Pathological Histology is some- times used to designate that portion of morbid anatomy relating to abnormal changes which the microscope reveals. Anatomical changes, or lesions belong to general pathology, so far as they are common to a number of diseases. Lesions do not constitute, but are the result of disease. They are always due to previous morbid actions in which consist the local affection. Lesions are serious or otherwise in proportion to their character, their situation, and the extent of structural change in- volved. Etiology, another branch of general pathology, treats of the causes of disease. These are numerous and their character and mode of action, so far as known, are of great importance in treat- ing disease. Symptomatology or Semeiology , is the study of the great number and variety of phenomina or events called symptoms, which disease occasions, and is included in general pathology. Diagnosis is the discrimination of diseases from each other, and is only second in importance to their treatment. Prognosis is the prediction of the probable course and termina- tion of diseases. Both diagnosis and prognosis also belong to gen- eral- pathology. Hygeine or Prophalaxis is the study of the prevention of disease ; and is a branch of medical knowledge of the first importance. This belongs to both special and general pathology. General Therapeutics includes the general principles involved in the means and measures of treating maladies. Special Therapeutics, is the special means employed in the treat- ment of individual diseases. In a practical view, this is the most important, being, in fact, the great object, aim and end of both the principles and practice of medicine, Pathology has been aptly termed morbid physiology. Both are 8 INTRODUCTION. parts of the science of life, or biology. Both are occupied with vital processes, action and properties. The only difference being that physiology investigates them in health, and pathology in con- dition of disease. This division is obviously arbitrary, but suffici- ently marked and appropriate. Every physiological discovery sheds new light upon pathology. Disease is a term very difficult to define. ChomePs defines dis- ease : "A notable disorder affecting more or less of the constituent parts of the living organism, as regards either their material constitu- tion or the exercise of 'their functions ." This definition is, perhaps as good as any other. It is easier to say what it is not than to tell what it really is. Probably no individual can be found who enjoys perfect health of every organ and function. The medical man is never called before the boundary is passed between health and disease. In presenting this Compend of Medicine the aim of the author is to give a truthful statement of pathological knowledge as it exists at the present time. The progress of pathalogical knowledge has produced within the past few years, a great change in the principles and practice of medicine. Of future progress no one can predict. When physiologists have succeeded in elucidating more fully the phenomena of life, then pathologist, following closely up will be better able to explain the phenomena of disease. CAUSES OF DISEASE, OR ETIOLOGY. CHAPTER II. CAUSATION OF DISEASE, OB ETIOLOGY. This subject is very important, and demands careful investiga- tion. Every effort must be made to ascertain what influences have contributed to produce the morbid condition present, in every case of disease. Different terms are employed to classify the causes of disease. The proximate or pathological cause is the actual condition of any part or organ which develops the symptoms present. Remote causes are divided into predisposing and exciting, some of the latter are called determining causes. Predisposing causes include those which render the system, an organ, or a part more liable to be affected by the exciting causes ; these are the immediate agents in the production of some morbid deviation of function or structure, which constitutes disease, Pre- disposition is a state favorable to the action of an exciting cause, and the individual in whom it exists is said to be predisposed. What may predispose at one time may excite at another, especially when there are several injurious influences, acting together, for a long time. A predisposing cause may render one organ more liable to disease than another, as the influence of age upon the seat of tubercle or cancer. The causes of disease given more in detail are conveniently classified into : 1. Intrinsic, which depends upon the person, in whom they are inherent, or acquired. 2. Extrinsic, are chiefly external influences, and accidental. 1. Intrinsic, a. Age. — Many diseases are more likely to oc- cur at certain periods in life than at others ; some tend to attack various organs at different ages, or certain tissues of the same part. The nutrative and functional activity of the general system, or of special organs, are greater at one period of life than at another, 2* 10 CAUSES OF DISEASE OR ETIOLOGY. hence, the liability to local or general disease is greater. Changes of structure towards decay, often account for the predisposition due to age, as degeneration of, and a brittle state of the blood vessels? tending to apoplexy. The young and old are very liable to mala- dies incident to those extremes in life. b. Sex. — An average larger number of males die than females. Females are more prone to some disorders than males, and vice versa. Other affections are limited to either sex. This is due to the different conditions of special organs in the two sexes and on the functions peculiar to each sex ; on dissimilarity of occupation , habits and constitutional vigor ; also, on peculiarities of the nerv- ous system. Women are more sensitive and excitable than men, and hence, are more prone to nervous disorders, &c. c. Constitutional Condition. — State of Health, &c. — A Con- genital or an acquired state of debility predisposes to numerous diseases. The opposite condition of vigor and robustness increases the lia- bility to acute attacks. The state of the blood has great influence in producing disorders due to its watery state (anemic) ; or the opposite, too rich in quality (plethoric). Prior Diseases, especially of an acute form predispose to excite others, as various fevers, pertussus, lung troubles, syphilis, rheu- matism, &c. A neglected symptom, as cough may lead to involving the whole lung.' Habitual neglect in attending to certain functions, as daily defeca- tion disposes to serious results. The existence of structural changes, of a morbid nature often predispose to further lesions, and may ex- cite disease in other parts, as a calcified condition of arteries rend- ers them liable to rupture ; lung affections often excite diseases of the heart, and vice versa, or one disease of the heart or lung may excite another. Direct loss of blood ; excessive, or chronic dis- charges ; the sudden suppression of an habitual discharge, or of a chronic skin disease, and some local expression of a constitutional disease, as gout, &c. all these may predispose to injurious results. d. Temperament. — Some pathologists urge that temperaments predispose to special diseases respectively. Others oppose this view as of not much practical value. Few individuals can be found whose physical functions and organs are so nicely balanced, as not to be inclined to some special form of disease. Four temperaments CAUSES OF DISEASE, OR ETIOLOGY. 11 are described, the sanguineous, lymphatic, billions, and nervous. Cer- tain constitutional peculiarities are termed temperaments. Space will not admit of a proper discussion of this question here. e. Idiosyncrasy. — Certain things affect some persons injurious- ly which do not influence others similarly, or at all-; such is the case with articles of food, as honey, fish, butter, mushrooms, &c, or remedies, as quinine, ipicac, iodide of potassium, &c. This indi- vidual peculiarity is called " Idiosyncrasy." This may predispose to some diseases. Practical importance attaches to this, and it should be specially regarded in directing the diet, and in prescrib- ing medicines. /. Hereditary Predispositions. — Those diseases which are transmissable from parent to offspring, as conceded, are : (i.) Certain blood, or constitutional diseases, as syphilis, Cancer, scrofula, tuberculosis, diabetes, gout, rheumatism. (».) Some diseases of the nervous system, as insanity, neuralgia, epilepsy, apoplexy, chorea, paralysis, and hypochondria, (iii.) Physical Deformities, as well as deficiencies in connection with special senses, as deafness, blindness, &c. (iv.) Early degenerations, either general or local, and which ap- pear in degeneration of the vessels, fatty changes of organs, premature grayness or baldness, loss of the elasticity of the skin, loss of teeth, &c. These may not be identical in dif- ferent generations. (v.) Some cutaneous affections, as lepra, psoriasis, etc. (w.) Asthma and emphysema. (vii.) Urinary calculus and gravel, (viii.) Haemorrhoids (?). The conditions in the parent and child may be dissimilar, merely related, as epilepsy in one, and insanity in the other. A vicious habit in the parent may lead to disease in the child, as intemper- ance may originate special nervous . maladies. Constitutional dis- ease in a parent may sometimes cause a delicate and feeble child. Transmitted disease may be congenital and develop in the foetus in utero, or it may be delayed until after birth, at some period, or lie dormant until developed by some "exciting cause' 1 . In some instances, it may pass one generation and appear in the succeeding one. This is termed "Atavism?'. Intermarriage intensifies hereditary maladies of the same char- 12 CAUSES OF DISEASE, OR ETIOLOGY* acter, as consumption, also of those very young, or of unequal ages, and those of close blood relations. Gout and perhaps asthma, when inherited, sometimes develop at an unusual early age. Some whole families are prone to certain disorders, and to have them severely, as infectious fevers, &c. The family history is thus shown to be of vast importance. In- quiry must be made as to parents, brothers, sisters and children, grand parents, uncles, aunts and cousins. Direct inquiry into habitual state of health, particular diseases, at what ages death occured ; and other points which any case may suggest. g. Race. — The influence of race increases the liability to special maladies and greater immunity from others. The prevalence of some diseases among particular races may be accounted for by their places of abode, mode of living, and their habits. 2. Extrinsic Causes. — Depending on Surrounding Meteor- ological AND OTHER CONDITIONS. (i.) Atmosphere. — The air we breathe influences the condition of health in numerous modes. It may be impure. Improper ventilation, the air containing a large amount of the products of respiration combustion, &c. "The air has suspended in it a large amount of atmospheric and aqueous, microscopic germs — living organisms. Gases may be mixed with it, such as emanations from decomposing vegetable and animal matters, in sewers, ces- pools, and from various factories. Suspended impurities, as dust? hair, wool, cotton, minute fragments of metals, unconsumed car- bon, arsenic, &c. Specific poisons are often transmitted through this vehicle. A due proportion of moisture, whether deficient or excessive, is vastly important. The electrical condition of, or the quantity of ozone in it has influence. Lastly, the degree of at- mospheric pressure affects the health, as is shown in the ascent of high mountains, or the result. Atmospheric influences act either as exciting or predisposing causes, and are prolific sources of nu- merous diseases. (it.) Temperature. — Excessive or long continued cold or heat, •general or local, tend to disease, as sunstroke, and the effects of in- tense Arctic cold. Sudden atmospheric extremes, and exposure to cold winds are often very injurious. Exposure to a draft of air when heated and perspiring, inducing a ''chill", changing wet clothes ; going from a warm atmosphere into a cold, damp cellar, or ice-house, &c, excite disease. CAUSES OF DISEASE, OK ETIOLOGY. 13 (iii.) Amount of Light and Isolation. — When this is persist- ently deficient great injury results, as imprisonment in dungeons, working in mines, &c. The kind and amount of artificial light used may have important influence. (u\) Soil. — The breaking up of soil often gives bad results. The chief modes, in which soil exercises its influence, are : the amount of matters contained, subject to decomposition; by its degree of permeability to moisture ; its effect on the light and heat of the sun, whether reflective or absorptive ; its chemical composi- tion, affecting the composition of contiguous air and water. Marshy soil, at a certain temperature, is prolific of malaria. Clayey soils are moist and cold. Gravelly and sandy soils are healthy, except when they contain vegetable matter. Soils containing magnesia and lime are reputed to induce renal calculus and goiter. (r.) Sewerage. — Deleterious gases emanating from sewers ; de- composing organic matter, and certain specific agents they contain, are fruitful causes of disease. Drinking water often becomes con- taminated with leakage from sewers and becomes the exciting cause of certain maladies, as typhoid fever, &c. (6.) Causes due to Social Condition and individual Habits, and special accidental influences. (?".) Food. — This may be of improper quality, scant in quantity, either habitually or temporarily, inducing or enhancing disease in children, or at any age. Excessive food, or too rich, or indiges- tible. Irregularities in time of eating ; bolting food, and imperfect mastication, from whatever cause, entail great organic and func- tional evil. (u.) Dkink. — Intemperance in alcoholic stimulants is a pro- lific cause of disease, which demands special attention in investi- gating the cause of maladies. Spirits frequently taken, strong, or slightly diluted, on an empty stomach, is the worst. Compounds — much sold as spirits, beer, etc., contain very noxious adulterations- Water, as often drank, or the want of it is a fruitful source of dis- ease. Insufficient supplies for purposes of cleanliness, etc., entail serious results. Too much fluid taken with meals do great injury. Water often conveys morbific agents into the system, as poisonous metals, certain salts, noxious gases, the ova of worms, and other living organisms, organic matters, especially the excretions, decom- posing vegetable matters, and specific poisons. Excessive tea- II • CAUSES OF DISEASE, OR ETIOLOGY. drinking is injurious, as is often manifest. Adulterated or de- composed milk has often been proved to be the medium of convey- ing specific poisons into the system. (Hi.) Other habits, as excessive smoking; snuff-taking ; the use of narcotics, opium, etc., or excessive indulgence in hot condi- ments, are usually very injurious. (iv.) Clothing. — Insufficient clothing, or overclad, either only from time to time or habitually ; leaving the bosom and limbs too slightly clad; the chest too little protected, or the reverse, over- weighted with clothing, too tight, interrupting circulation — all these exert baneful influences. It is dangerous to allow wet clothes to dry upon the body, for obvious reasons. (v.) Want of cleanliness, personal or domestic, often excite dis- ease. So, also, with certain fabrics which irritate the skin ; or when dyed with poisonous ingredients, may injure the system. (vf) Amount of Labor and Exercise.' — Excessive, prolonged labor, or only at intervals, or the reverse — too little exercise, or none — a sedentary life, give bad results. Various occupations illustrate ins tances of hygenic errors. Sudden, severe effort may prove dangerous to chronic structural disease. (yii.) Mental Causes. — Excessive intellectual study and effort combined with deficient rest and sleep ; anxiety, worry ; all violent and depressing emotions, as sudden joy, grief, deep anxiety, or severe sudden fright. All these either predispose to or excite dis- eases, especially of the nervous system. (viii.) Mechanical Causes. — These comprise a very important class, especially exciting or determining some morbid state, due to the direct irritation or injury which they produce. They are ex- ternal violence, chronic pressure, straining and over-exertion, the irritation of foreign bodies, and the long maintainance of a certain position, as accumulations of foeces, calculi, parasitic, animals and plants, and small particles of substances inhaled into the respira- tory organs. Occupations often prove injurious in some of these ways. A mechanical cause often excites a local expression of a constitutional malady ; as pressure, or injury, may develop cancer in an organ or part. (ix.) Venereal excesses, masturbation, too early, or frequent sensual excitement, are prolific causes of both functional and con- stitutional evil. CAUSES OF DISEASE, OR ETIOLOGY* 15 The causes which have been noticed are generally more or less combined in any individual case. To ascertain which of them are acting, we inquire of a patient as to his residence, occupation, social condition, habits, previous health, and that of his family. 4. Some diseased conditions are caused by the presence of poison in the blood which is generated in the body, resulting from perversion of digestion, assimulation and nutrition. Gout and other maladies, when once developed, may be transmitted. SPECIAL CA USES OF DISEASE. There are certain agents which cause it, yet to be considered, re- quiring special notice. They are mostly of the nature of various kinds of poisons, and give results which are more or less constant and definite. 1. Chemical Poisonous Substances, Especially Metals. — Some of these act injuriously upon the system as the result of occupation, such as lead, mercury, arsenic, phosphorus, copper, gold, and other substances. Arsenic may be given off in the form of a fine powder^ from certain green papers used in papering rooms, and then be taken from the atmosphere by individuals. There are many other ways these metals may affect the system without being directly ad- ministered as poisons or medicines. 2. Causes Originating in the Vegetable Kingdom. — Many com- mon poisons are derived from this source, such as opium, etc. Parasitic plants, growing in various structures of the body, are fre- quent causes of disease. This is marked in skin affections. The presence of certain fungi in the stomach is said to excite emesis etc. Decomposing vegetable matter often does great harm, causing malarial or miasmatic fevers, as ague, yellow fever, etc., and also some nervous and other complaints. Contagion is believed by many to be due to low vegetable organisms. 3. Causes Originating in the Animal Kingdom. — Certain ani- mals are venomous and can inflict poisoned wounds, as serpents, etc. Some are poisonous when taken, as cantharides. Animal parasites set up morbid conditions, as worms, and those which infest the skin. Specific contagious poisons, as those inducing small-pox, scarlatina, etc. Casuality represents the last and essential point to be reached. The scientific rule for the classification of diseases must refer to 16 the cause, i. e., must be etiological. Then shall we learn how to deal with the root of maladies. The indicatio casualis will assume a high position in therapeutics, and we shall find efficient remedies with which to answer it. In many diseases a successful prdphalaxis will narrow therapeutics rendering much of the present superflu- ous. The science of public hygiene is based upon the etilogical principle, and is so firmly rooted in it that they cannot be separated- We are very far from having a complete etilogical classification^ because our present knowledge of the causes of disease, which have only very recently been subjected to a systematic investigation, is yet confined to the first rudiments. The unities of disease are yet mostly anatomical ; in fact, in many departments, we have not even reached this point, but are still obliged to recognize symptom- atic unities. Hence, we yet have such diseases as epilepsy, dia- betes, neuralgia, mental diseases, etc., expressive of neither the morbid condition nor the situation of many diseases in our present nomenclature. CHAPTER III. Anatomical Changes — Hypertrophy — Atrophy. Congenital Malformations consist of the malposition, the incom- pleteness, or absence of organs, either in redundency or deficiency of size ; deviations in form, supernumerary parts, want of proper connection of parts, etc. These may be caused by intrinsic defects of the ovum, to arrested or obstructed development, or by ex- trinsic causes and in some cases by diseases to which the foetus is liable. This subject more properly belongs to obstetrics, and will be considered no further here. Anatomical changes in solid parts are known by morbid appear- ances, some are obvious to the unaided eye, others require the aid of the microscope to detect them. Changes in color, form, etc seen by the naked eye are termed the gross appearances of disease. Those developed by the microscope are called microscopical charac HYPERTPOPHY — ATROPHY. 17 ters. The touch determines certain changes, as density, roughness, smoothness, altered form, etc. Diminution and increase in weight must be noticed. The student must first become familiar with the normal appearances, gross and microscopal of the various organs and structures before he can be qualified to appreciate the changes re- sulting from disease. Anatomical lesions are : 1st. Lesions of quantity ; 2d. Lesions of consistence ; 3d. Lesions of composition. Those of quantity are first, a morbid increase, second, a morbid diminution of substances proper to the affected part. The abnormal change in this class is purely quantitative, not qualitative. A morbid increase of sub- stance is termed hypertrophy, while a morbid diminution of sub- stance is named atrophy. HYPERTROPHY. Hypertrophy — Hyperplasia — is an abnormal activity of nutri- tion, and enlargement by increase of the normal materials of the parts, without other change. It consists in an excess of appropria- tion. When a part enlarges from a deposit of material foreign to its normal composition, or from a disproportionate excess of certain of its normal constituents, the term false hypertrophy is applied. True hypertrophy simply consists in excess of nutrition. False hypertrophy is a perversion of this process, as when the liver is augmented by fatty deposit, carcinoma, etc. Hyper-nutrition is not always the cause of the enlargement of an organ. The hollow viscera as heart, stomach, bladder, etc., may increase in volume from dilatation, not by incrtase of substance, which perhaps is less than normal ; such is not hypertrophy. A physiological mystery yet exists as to why the body gradually de- velops to manhood, the inherent limit of size, preserving that definite size and form, during molecular changes incident to nutrition. True hypertrophy proceeds from prolonged excessive increase of the function/of a part. The heart is most liable to this lesion. The enlargement is generally due to valvular lesions, which, inter- fering with the passage of blood through the heart, induce perma- nently an increase of its muscular motion. This process increases the muscular walls in bulk, by growth, precisely as the voluntary muscles enlarge w T hen constantly exercised. The heart may en- large to six times its normal size, yet there is a limit to this pro- 3* IS HYPERTROPHY — ATROPHY. cess. The necessity ceases after reaching a certain point, which varies in different individuals. Hypertrophy of the muscular tunic of the bladder, due to chronic urethral obstruction, illustrates this lesion, resulting from prolonged increase of function. Hyper- trophy of involuntary muscular structure involves the production of new fibres, as, during gestation, there is a development of the muscular uterine walls. If the function of one kidney is impaired, lost, or the kidney removed, hypertrophy of the other usually ensues. This is caused by doubling the functional activity and capacity of the other kid- ney. This is a conservative lesion of increased capacity for the bodily welfare. This is true of most lesions of hypertrophy in the muscular and glandular structure. Either undue determination of blood to a part, or inflammation may produce hypertrophy of fibrous and areoler tissues. Corpulence, or hypertrophy of the adipose tissue is a general diathesis of which the undue growth of the tissue is the expression. Hyperplasia is a term applied when new anatomical elements are generated, without other change than number, as in* increase of fibrilla in a muscle. ATROPHY. Atrophy — This is the reverse of hypertrophy ; the destructive assimulation continues, while fresh supplies are diminished, or sus- pended ; hence, loss of the proper substance being appropriated to a part, it undergoes waste. Atrophy may be general, in- volving all the tissues and fluids, but some more than others, as in old age, phthisis, cancer, etc. It may be limited to the muscular or glandular structures, only one organ, a special tis- sue in it, as the heart, liver, or kidney ; while other tissues may increase. Effects. — The weight diminishes, unless obscured by conges- tion, or in some other manner. Usually there is a lessening in size, not invariably ; sometimes there may be apparent en- largement. Atrophied parts are generally paler, and either dryer and firmer, or softer than normal. Their functions are impaired. Causes. — 1, Interference with the nutrative qualities of the blood causes general wasting ; deficiency in the quantity or quality of food ; diseases which disturb digestion and absorp- HYPERTROPHY ATROPHY. 19 tion, also a direct loss of blood, and affections which remove the nutrative 'elements of the blood, as Bright's disease, pro- longed suppuration, or phthisis, cancer, etc., often involving the internal organs. 2. Combined with the above causes, or alone, there is often an increased icaste of tissue, which cannot be repaired, as in fevers and other diseases. In some cases this is limited to a single organ, without apparent cause, as acute atrophy of the liver, etc. 3. The general vitality and nutrative activity of the tissues may be impaired, or that of a special part or organ, and general or local atrophy result, as in u senile atrophy" and in the wasting of organs and structures at a period in life when functional activity ends, as in the thymus gland, spleen and lymphatic glands at different ages, and the rapid diminution of the uterus after delivery. Some previous disease may impair vitality, as inflammation, overuse, or deficient exercise have similar results, a s the brain or testicle. Opposite examples are common, as wasting of the muscles of paralyzed limbs, of bone after ampu- tation, or nerves after severing their connection with the cere- brospinal axis. 4. A deficient supply of arterial blood will cause atrophy, whether interference with its passage to a part, or overload- ing the veins in continued mechanical congestion, producing mainly '-local atrophy." It may affect any part when the supply of blood is inadequate. If entirely stopped, gangrene results. 5. Direct pressure upon an organ, as by pericardal thicken- ing on the heart leads to atrophy, the wasting of bone and other tissues, by the pressure of a tumor or aneurism, partly, not wholly, interfering with the supply of blood. 6. Nerves influence nutrition ; when any nerve is paralyzed, atrophy is liable to occur in any part supplied with it. This is attributable to cessation of function, want of supply of blood, and the control of nerves over nutrition. 7. Certain medicines, long continued, have power to cause the absorption of organs or tissues and atrophy, as mercury, iodide or bromide of potassium, alkalies, etc. This power is made use of to promote the removal of morbid products. 20 INDURATION. 8. Lastly, To account for "progressive muscular atrophy, 1 ' no adequate explanation has been reached. INDURATION. Induration — Expresses the condition of a part when its dens- ity and firmness is abnormally increased. In cirrhosis of the liver, the morbid production of fibroid material in the interlob- ular spaces gives to the liver an abnormal density and firm- ness. It is a change of the composition of the structure in- volving morbid products in the parts affected. Of that vari- ety of degeneration of the kidney characterized by contraction and hardness, the same is true. Induration occurs when parts are condensed by pressure, and when deprived of their normal quantity of liquid, as in pleuritis with large effusion In these cases the carnified lung is compressed into a small, compact mass resembling flesh, more than lung tissue, hence it is said to be carnified, though the composition and structure are not essentially altered. Insufflation after death restores the con- densed lung to its normal state, and this may be done in life if the liquid effusion is absorbed, or evacuated, and the pres- sure relieved. In lobular pneumonia a similar condensation of the pulmonary lobules occurs from collapse. Induration from deficiency of liquid is seen by the abnor- mal density and firmness of the brain, and other organs ; and after death from cholera, caused by intestinal transudation. Indur- ation of the substance of the brain has been observed in cases of acute and chronic lead poisoning ; and the brain in these cases has been known to contain sulphate of lead. Sclerosis (hard) is a term often used to denote induration. SOFTENING. Softening applies to a part when its density and firmness are abnormally diminished in a less or greater degree. Soft- ening is incidental to. some manifest change of composition or structure, or an element of certain morbid action, as inflamma- tion and gangrene; as an inflammatory deposit in pneumonitis, in the second stage. The affected part of the lung, though solidified (hepatized), has less firmness than normal, is said to be friable. This friability is marked in the stage of purulent nfiltration, the substance gives way under slight pressure. Softening constitutes a lesion of itself in cases in which por- SOFTENING. 21 tions of the brain and spinal cord, have been found softened without previous inflammation. Non inflammatory softening of the brain is associated with degenerative changes of the coats of the cerebral arteries; the circulation is impeded and nutri- tion impaired ; it occurs from arterial obstruction, caused by a mass of fibrin or a vegetation derived from the left side of the heart, constituting an embolus or plug, as in certain cases of apoplexy. Softening is incidental to inflammation affecting any of the tissues. This is marked in inflammation of the mucous mem branes; they are often disorganized and reduced to a pulp, and removed by substances passing over them, as in dysentary, etc. Softening of the brain and spinal cord results from in- flammation extending from the meninges, developed around a clot of blood, or a tumor of some kind, or originating spon- taneously within the nerve centres. This subject will be more fully discussed in connection with some individual diseases. Softening which is non-inflammatory, independent of other palpable changes, is generally due to defective nutrition in the affected parts, as when cerebral softening is caused by arterial obstruction. It may be due to a deficiency of nutrative sup- plies in the blood, as softening of the heart in typhus or typhoid fever. Softening, consisting in merely a diminished coherence of the elements of the parts, without disorganization, is not a grave lesion. Softening of the brain, due to a temporary defect in the arterial supply, may lecover after the circulation is re-established. When softening involves disorganization, due to mortification and death of the affected parts, this has been called necrobiosis. This subject will be continued in con- nection with other topics, so far as it legitimately belongs to the practice of medicine, as distinguished from surgery. Per- versions of structure, abnormal products, infiltrations, exuda- tions, formations of tubercle, scrofula, carcinoma, etc., will be carefully considered hereafter. 22 CHAPTER IV. Symptomatology, or Semeiology. Symptoms express all the evidence of diseased condition in the living body. The name " symptom " signifies to fall together, and means concurrence of events. The terms associated with symptoms are : 1. General or constitutional, and local, as either expressed by the whole body, or any special part of it. 2. Objective and Subjective. — The first embraces all symptoms obvious to the senses of the examiner; the last those felt only by the patient. 3. Direct, or Idiopathic, and Indirect. — The former denotes symptoms expressed by the diseased part ; the latter by some part remote, sometimes called sympathetic, as vomiting, occuring during pregnancy. 4. Premonitory, or Precursory — Are symptoms indicating what is likely to occur, or giving warning of a disease. 5. Diagnostic, Prognostic, and Therapeutic symptoms respective- ly indicate the kind of a disease, the prospect and the proper treatment. 6. Pathognomic symptoms are the expressions of special dis- eases, and no other — absolutely belong to it. "i Sign'' 3 is a term which is expressive of the nature of the disease ; it is a diagnostic or pathognomic symptom. Physical signs are merely objective symptoms, only elicited by special modes of " physical examination." WHAT WE MUST KNOW OF A PATIENT How to Examine a Patient. — This should be conducted in a careful and systematic inquiry as to the condition of each organ so far as possible. In ordinary practice this is often impractic- able, and although desirable, the rule is not enforced. The following suggestions may give a plain and practical mode of examination : SYMPTOMATOLOGY, OR SEMEIOLOGY. 2$ The young practitioner will find it useful to him to take notes of his cases. These should be based upon a general sys- tem of inquiry, and comprise an outline sketch of each case from its inception to the termination, whether favorable or otherwise. This sketch can be filled up afterward when leisure affords the time. Such a table will prove useful to the most systematic of long experience. Dr. H. W. Acland's table is valuable for present and future reference, and it is here given. History. — When were you last well ? How did you first feel unvrell? Your supposed cause, mode of becoming sick, and have you had any treatment? Of what do you now complain ? Have you been sick before, and with what? If the foregoing, suggests it, inquire as to residence, occupation, past life, any change of habits, history of family, hereditary predisposition, etc. I. Present State. — General Aspect. — Manner, posture, color, shape, temperature, weight, eruption, oedma. Notice generally the head, neck, chest, abdomen, limbs. II. Organs of Digestion. — Taste, thirst, hunger. Lips : their color and texture. Teeth : Loose or diseased. Gums : Size, color, position, and texture. Tongue: Form, volume, color, surface, dryness, coating and protrusion. Stomach : Nausea, vomiting, eructations, pyrosis, pain while or before, or after eating, and how soon. III. Organs of Absorption. — Lymphatics : Tender, red, hard. Glands : Tender, swollen ; if so how long ? The patient must either be in bed, or undressed, for a further thorough inquiry into Nos. IV., V., and VI. IY. Examination of Abdomen- — Percussions, palpitation, measurement. Size of spleen and liver. Existence of pain, diminished or increased by pressure ; circumscribed or general ; under the hand or elsewhere. Existeuce of tumors, fluids, flatus, feces ; of hernia ; ot tumors in groin ; of hemorrhoids ; of feces in rectum. Y. Organs of Circulation. --Heart— Position, dimensions, force, rhythm, sound — its character, situation and distance. Arteries — Pulse at the wrist; rate, volume, hardness, laboring, egularity, intermission, dicrotism, etc ; murmurs. VI. Organs of Eespiration. — Respiration Generally : Fre- 24 SYMPTOMATOLOGY, OK SEMeIOLOGY. quency, regularity, difficulty, odor of breath. Nares : Discharges, odor, action. Epiglottis; Larynx: Tenderness, alteration of voice. Cough : Its character and supposed cause. Expectoration : Color ? odor, tenacity, chemical, microscopical properties. Examination of Thorax - -Form flattened, round, symmetrical: supra- and infra-clavicular spaces, etc Movements: Vocal frem- ities ; intercostal spaces. Resonance on Percussion: Changed by posture. Sounds on inspiration, expiration, speaking, coughing succussion. VII. Organs of Secretion and Excretion. — Shin : Erup- tion ; sweat: quantity, chemical quality; locality. Kidneys: Pain in micturition ; its seat and direction ; pain in the loins. Urine : Frequency (night or day), .quantity, examination — acidity, spe- cific gravity, albun^en, sugar, bile, excess of urea, etc. Bladder: Tumors, irritability, etc., calculus. Bowels : Frequency of action, character of evacuations. VIII. Organs of Generation. — (Male,) penis, scrotum, tes- tes, cord. (Female,) Catamenia : Color, quantity, frequency, duration. Leucorrhcea, or other discharges. Pain : Its seat, duration, causes, periodicity. Uterine: Pelvic, ovarian enlargement, tenderness, ulcerations. External Sores: Eczema, pruitirs. IX. Nervous System. — Brain : General intelligence, mem- ory, speech, slowness of manner, headache (where), giddiness, sleep, dreams, fits, (one kind or more). Spinal Cord and Nerves : Pain, alterations, in kind or degree of sensibility, in sight ( pupils ), hearing, smell, taste, touch, numbness ; tremors, rigidity, rigors, paralysis. X. Organs of Motion. — Pain, stiffness, swellings, nodes, abscesses. The foregoing is what we should know of the patient aided by inquiry of friends, etc. A skillful and experienced practitioner can learn the truth of any case in order, or in no particular order The table is more especially given to train students and beginners, in the diseases to which each system of or- gans is liable, and to indicate the various symptoms peculiar to each disease, respectively Physical examination includes all modes of investigation by SYMPTOMATOLOGY, OR SIJMEIOLOGt. 25 which objective symptoms can be made apparent. Special meth- ods of examination are limited, by many, to particular portions of the body, as the chest or abdomen. A general survey of the entire system is often required to make out the real nature of the disease. We must employ our external senses, aided by the use of various instruments, and by chemical and micro- scopic investigation. The symptoms which are connected with each individual or- gan or part, will be enumerated in describing each particular disease. It may be well to state here that pain is quite common to all maladies. This symptom is very liable to exaggeration, and may be merely sympathetic. The inquiries about the character of pain are : a. Is it acute, or chronic ? b. Its precise situation and extent, and structure in which it appar- ently exists? c. Its intensity and special character? d. Wheth- er it is constant or occasional, remittent, intermittent, or par- oxysmal? e. The effects of pressure upon it, whether showing tenderness or aflording relief, f. How it is affected by move- ment, as coughing, vomiting, eating, etc.; these vary with the structure in which the pain originates, and is often valuable in diagnosis. Mode of Invasion, Course and Duration of a Disease. — These are very important. The various points are: 1. The attack may be sudden, as apoplexy, syncope, many hemmorrhages, etc. The after course differing essentially according to its nature, often rapidly fatal. 2. Frequently it is acute, coming rapidly though often preceded by premonitory symptoms; being severe in its character, and brief in duration. Many acute maladies run a pretty definite course, as a rule, as pneumonia, or the eruptive fevers, and an acquaintance with their natural history is important. Irregularities are quite common, due to disturbing influences. In many diseases there are distinct varieties. When the onset is less rapid, and the symptoms milder, the case is termed sub-acute. 3. The majority of diseases are chronic, the symptoms milder and gradual, not severe, the progress slow and protracted. A chronic disease may be the sequel of an acute one, or acute may terminate in chronic. 4. Some diseases have periodical exacerbations, coming on at regular or irregular intervals, the patient being compara- 4* 26 SYMPTOMATOLOGY, OH SEMEIOLOGY* lively, or quite, well, in the intervals. Such maladies are chronic in their progress, but acute in onset and intensity ? having an intermittent course, as ague, epilepsy, asthma, etc. Complications and Sequelae. — These are the advents of other affections, either during the course of the primary diseases or subsequent to their termination, or resulting from them. They are quite common in acute diseases, as fevers, etc. Compara_ tively, few primary acute diseases have a fatal termination. The setting in or development of some other disease during their course, or resulting from them, constitute the chief danger. The skillful practitioner guards carefully against complications and sequelw. Terminations. — Clinically considered, a case may terminate : 1. In complete recovery, which may be .rapid and sudden ; usually gradual, the patient passing a period of convalescence, of less or greater duration. 2. Incomplete Recovery. — Either general ill health remaining, or some part or organ being permanently altered in function or structure ; a more or less chronic state of disease remaining. 3. Death. — This may occur suddenly, rapidly, or gradually. Death is a complex process, all the functions of the vital or- gans being more or less involved; often the heart, respiratory or- gans, or brain give signs of approaching dissolution. Death beginning at the heart is said to be by syncope, due either to a want of a proper supply of blood, produced rapidly or grad- ually (ancemia) or to a loss of contractile force due to me- chanical interference, structural changes, or disturbance of nerve function (cesthenia). In starvation these two modes of death are combined. Death, beginning at the lungs occurs by suffocation, or asphixia. This may be due to the inspired air being unfit to areate the blood, or not entering the lungs in sufficient quantity (apnoea), or a stoppage of the flow through them, as a clot suddenly obstructing the pulmonary arteries. Death, beginning at the brain, is said to be by coma, indi- cated by stupor or insensibility, soon followed by interference with the functions of respiration. The symptoms which indi- cate approaching death will be given when treating of the indi- vidual diseases of the various organs. SYMPTOMATOLOGY, OR SEMEIOLOGY- 27 Diagnosis. — It is a primary object to arrive at a correct diagnosis in every case ; otherwise no rational treatment can be pursued* and it will be impossible to give correct prognosis. In making a diagnosis it is necessary to consider : 1. Is there any disease in the patient ? Not a few call a physician and complain without cause, especially among the class of "malingerers.'' Others feign sickness to avoid, to them, unpleasant duties, etc. 2. If there is any morbid condition present, is it of an acute or chronic character? 3. Does it affect the general system, or is it localized in any special organ or organs ? 4. If general* what is its nature? 5. If seated in some organ, is this merely disturbed in its functions, or is there organic and structural changes ? 6. If the latter, it is necessary to ascertain the nature of the structural alteration, the part and extent of the organ involved, and the stage of the disease, as in phthisis, whether tubercular or not ; how much of the lung or lungs are involved ; or, if there is merely consolidation, or if this has broken down into cavities ? The available points in aid of a correct diagnosis are : 1 Patient's previous history, and his family history. 2. History of existing illness, duration, cause, and manner of attack. 3. The actual symptoms present, especially objective ones. 4. The progress, duration, and termination of the case 5. The result s of treatment. A Diagnosis is a process of reasoning, and the degree of difficulty varies much in different cases. In some cases a correct conclusion is readily reached from one or more "pathog- nomonic " symptoms ; in others every point must be carefully weighed, especially when diseases are similar, even then we may hesitate until after carefully watching the course of the case, and the effects of treatment until doubts and difficulties clear away. In some cases a diagnosis can only be made by exclusion, and occasionally it can not be made at all. One symptom is sometimes so marked, that the diagnosis consists in finding out the cause of it, as jaundice or ascites, etc. Usually if one organ is affected others may be also, and 28 Symptomatology, or Semeiology. that diseases present several varieties; all these facts must be observed in making out the entire diagnosis. Prognosis. — To "give a prognosis" implies a knowledge of the nature, natural history, course, duration, complications, and termination of the disease considered; and an acquaint- ance which the influence of age, constitution, etc., have upon it; also those due to external influences. A positive opinion may be readily formed in many cases; if enshrouded in doubt, great care is requisite. Friends should be informed as to pos- sible danger, and probable favorable results. If uncertain, it is wiser to encourage, and persevere in treatment. Should both patient and friends lose hope, that would be the end of effort. The points at issue in regard to prognosis are : 1. Is the case likely to recover, or terminate in death? 2. Its proba- ble duration, in either event, and whether it may be sudden- 3. If recovery: will it be complete, or will a morbid condition remain, especially organic? 4. When certain slight symptoms xist, are there signs of something more serious about to occur, as numbness or limited paralysis? These are often premonitory of organic disease of the brain. Treatment. — There is a tendency to disparage treatment, especially as to impressing the system with medicines. Exper- ience has proved the great benefit which generally results from properly conducted treatment, and that it is often essen" tial to the continuance of life. It should be kept in mind that there is generally a tendency to recover. The objects of treatment are : 1. To cure a patient as soon as possible, restoring the functions and organs to their normal state, without entailing any structural change. This is called " curative treatment" and is a reality. 2. Some cases require a sustaining treatment until they run a certain course, without expecting to effect an immediate cure; only actively interfering when untoward symptoms arise, the object being to prevent death and permanent injury. Some kind of fevers furnish exam- ples. 3. Unfortunately in some cases death is inevitable ; then the aim of treatment is to contribute to the comfort of the patient in every way possible, and to prolong life. 4. Symp . 8YMPT0MAT0LGY, OR SEMEIOLOGY. 29 toms are frequently present which it is the chief object to re- lieve, or remove. This may be paliative, or occasionally cura- tive, as the removal of ascites and other forms of dropsy may give a long period of immunity from affliction, although the organic lesion which leads to dropsy may remain. A symptom should not be suppressed, at the risk of the disease, as a cough is often a necessity for expectoration ; it must not be stopped . 5. Preventive treatment includes : to obviate the tendency to disease ; the prevention or the extension of disease ; the warding off of habitual attacks, as epilepsy, asthma, acute dyspepsia, etc.? the avoidance of complications; the rooting out of various con- stitutional disorders ; and of contagious diseases from commun- ities, etc. 6. Instances often occur when the chief treatment consists in warning the patient to carefully avoid doing things that may result in bodily harm, as in certain cases of cardiac disease ; those subject to gout, rheumatism, predisposed to phthisis, etc. To pre" vent maladies is a higher function than dispensing drugs. Indications. — In treating an individual case a definite object should be deduced from the symptoms present. The indications may be derived from : 1. The seat, nature and stage of the disease. 2. The causes of it. 3. The condition of the patient as to age, constitution, etc., as well as surrounding circumstances. 4. The symptoms present, which may either point to measures to be used, or contra-indicate a particular treatment which should be otherwise pursued. 2. The condition of the principal bodily organs, as the heart, lungs, kidneys, etc. It should be the rule to ascertain their condition. This often controls the indications. Treatment consists of three kinds, therapeutic, diatetic and hygeinic, each requires careful observance. Therapeutic treatment means the use of medicines. Their proper employment will do much good, and they are often indispensable. When special remedies which have a curative action upon certain diseases are unknown, then we have to use them in various combinations, according to certain principles, thereby obtaining great benefit- Dietetic Tkeatment. — This is indespenable. The body must be sustained by nourishment. It can not be on medicines, cer- tainly. Often a patient needs only proper advice as to diet- 30 SYMPTOMATOLOGY, OR SEMEIOLOGY. Directions must include the nature of the food ; the quantity, at what intervals, etc. Personal examination of the food of a patient is often important, and special directions may be needed as to how to prepare it, as beef tea, etc. Alcoholic stimulants re- quire great care in their administration. Hygeinic Treatment. — This includes attention as to place of residence, its hygeinic conditions, ventillation, etc., habits of life, exercise, clothing, change of air and climate, etc. In treating acute cases, especially all forms of fevers, it is imperative on the physician to personally inspect the sick-room, regulate the ventillation, its cleansing, the condition of the bed, the removal of excessive curtains, or carpets, and everything, even of minor importance. A competent and faithful nurse, who understands, or can be readily instructed in correct hygeine, is vastly import- ant in every grave case. Ordinarily a nurse should merit and receive credit for a cure, second only, to the attending physician* Every available attention should be given to the comfort and well-being of a patient. Topics. — External applications are available and very useful in treatment. These will be fully described in treating individ- ual diseases. Common sense is an essential factor in managing cases of dis- ease. Difficulties, ever varying, often formidable and perplexing, require the exercise of much thought, patience and sound discre- tion. Every case should be studied upon its own merits ; deduce the rational indications and fulfill them. It is better to pursue a well known and often proved course of treatment, than to hazard experiments with new, and, to us, untested remedies, however re- commended. Medicines impress the system, either favorably or otherwise. It is not enough to follow authorities. The practi- tioner who assumes the responsibility to treat disease, must be authority to himself. New remedies (to us,) should be first tested upon our own persons, as a rule. RULES FOR THE PRACTITIONER. 81 MULES FOR TEE PRACTITIONER. Physicians will find the following, or similar simple rules, very useful in the daily routine of professional duties : 1. The object of treatment is to restore health as speedily, pleasantly and safely as possible. TV hen the spontaneous efforts at cure are progressing favorably toward recovery, it is unwise to interfere with drugs. 2. When a remedy is indicated, and a choice is possible, select the one which is most agreeable in its action, and without injurious results upon the body. 3. Prescribe medicines in the forms which are most accepta- •ble. Conceal, if possible, offensive odors and tastes, especially with " sensitive patients " and children. 4. When there is an idiosyncracy as to any special medicine? or form of it; or as regards any particular diet, avoid prescribing them. Extreme susceptibility to the influence of certain drugs, odors, tastes, and food, sometimes exist, and it is unwise and un- safe to combat known peculiarities. 5. The condition of the patient when the medicine will act must be regarded, as a sudorific, when the patient must be exposed to the open air, would prove worse than useless. 6. Incompatible medicines in a prescription, or in two which alternate each other, must be carefully avoided, unless intended to form a new compound. When alkalies are indicated and used lemon or other acid drinks are obviously improper. And vice versa. 7. Incurable diseases require alleviation. Giving no undue en- couragement, it is a humane duty to render waning life as com- fortable as possible, and extend it to the utmost limit. 8. Do not prescribe or allow the use of quack medicines, or 32 RULES EOR THE PRACTITIONER. Secret remedies, and none whose composition is not understood. 9. Good advice must be given from time to time, and pains taken to impress the patient and attendants with the importance of thoroughly carrying out the directions. Superstitions and pre- judices must be kindly met and overcome without giving offense- Hope and confidence are indispensable factors, in chronic cases, at least. The patient who has faith in the doctor will recover much sooner ceteris 'paribus than one who is shy or incredulous. 10. Prescribing medicines without the proper diet or manage ment, is only half doing duty. Directions must be given in plain detail — as to proper places for the bed, ventillation, amount of light, position in the bed, degree of quiet, exclusion of callers, cleanliness of the patient, and the nature, quantity and interims of food. No cooking in the sick-room. In protracted cases, one bed for the day and another for the night is desirable. The spread of infectious disorders must be timely and carefully prevented Soiled clothing, dirty water, etc., must be removed, A bed-pan containing a disinfectant, ought to be used to receive the evacua. tions, and promptly carried out. 11. Formula should not be prescribed with servile exactness. All medicines of any power have to be adapted to the condition of each case. "A bundle of ready-made receipts, in the hands of the routine practitioner, is but a well-equipped quiver on the back of an unskilful archer.*' 12. All cures are not our cures. The medicines given may not have been taken, or may not have been absorbed, or its properties may have been destroyed by adulteration, or it may have worked injury, even — a recovery in spite of the disease, medicine and the physician. 13. " The poor you have always with you," is a humane appeal which cannot fail of the proper and ready response by a profession which fully appreciates the sufferings and necessities, often aggra- vated, prolonged and more fatal among the poorer classes of our common humanity. ItYPER^MfA, OR CONGESTION. 83 SECTION II. It is now proper to consider certain morbid conditions which are included in "general pathology," and acquire a comprehensive knowledge before considering them in connection with special diseases. CHAPTER I. Hyperemia, or Congestion. These signify excess of blood in a part. The cause, and the vessels in which accumulation chiefly occurs, give character to the hyperemia, as active or arterial ; mechanical, or venous ; passive, or capillary. I. Active, or Arterial. — " Determination of blood." The arteries are mainly aifected, an increased afflux of blood passing through them ; usually too much blood also passes out through the veins; the circulation is accelerated, the arteries are dilated, either because the pressure becomes extraordinary, or they can not resist it. Symptoms and Effects.- -More or less bright redness, with turgescence and increased temperature, are the objective signs of "active congestion." Visible pulsation and increased or altered secretion may be apparent. The vessels may become ultimately distended to a degree to exude serum, or even to rupture and cause hemorrhage. Heat, fullness, and throbbing are the subjec- tive symptoms ; or the functions of a part or organ may be mater. . iaily affected, as observed in the lungs or nerve centers, producing severe symptoms. If this congestion continues a long period, it may terminate in hypertrophy, or induration ; the arteries becom- ing permanently thickened and dilated. Causes. — 1. Paralysis of the muscular coat of the arteries, yielding to the normal pressure of the blood. This paralysis may be due to direct injury to the spinal cord, or to the sympathetic 5* 34 HYPEREMIA, OR CONGESTION. trunk, as the pressure upon the sympathetic trunk by an aneurism in the neck, congestion results ; by reflex irritation through the sensatory nerves, as congestion from a sinapism ; heat or cold, or due to excessive use or increased activity, as in the eye or mam- mary gland, or accruing from severe neuralgia. Many internal congestions are probably due to this cause Causes acting through the brain are apparent, as emotional blushing and the effect of certain poisons. 2. The rapid withdrawal from arteries of external support, cause their dilation and congestion : the result of applying a cupping-glass to the skin, thus removing the common pressure of the atmosphere. 3. The pressure on internal vessels may be increased by the augmented force of the heart, or because some vessels being oblit- erated, and others compelled to do increased work, unduly distend- ing them ; as, when a main artery is tied, the " collateral circula- tion " is rapidly increased ; or, when otherwise suddenly blocked. Internal congestions are often due to this cause, following exposure to cold, due to constriction of the skin, thus driving the blood inwardly. II. Mechanical, or Venous. --No excess of blood enters a part in this form of congestion. It consists in obstruction to its passage, hence the veins and capillaries are languid in action, become overfilled with dark blood. This is an important form of congestion, often calling for the special attention of the practitioner. Symptoms and Effects. — If superficial, the objective signs are : Redness of a dull, dusky, purplish, or livid hue ; distension and often knotted condition of the capillaries and veins ; increase of bulk, and frequent lowering of temperature. At length serum exudes containing some solid constituents of the blood, causing " dropsy, 1 ' and greater enlargement, with softness, pitting on pres- sure. Sometimes there is a fibrinous exudation, giving a brawny and firm feel, as after obstructions in the veins of the leg in phlegmasia dolens. In congestion of the kidneys albumen may be found in the urine. Congestion of mucuous surfaces leads to watery flux. In more intense congestion the coloring matter of the blood exudes, or the red corpuscles migrate through the walls of the vessels into contiguous tissues ; or finally the vessels may rupture and hemorrhage result, as in varicose veins; as the bJeeding in HYPEE^EMIA, OR CONGESTION. 35 the stomach, or intestines, which results from obstruction of the portal vein. If the vessels are weakened the same may occur in the structure of organs, as well as on free surfaces. When the congestion is excessive, rapidly produced or long continued, nutrition ceases and ulceration or gangrene may result. A u thrombus " occasionally forms in a congested vein, as in the portal vein in cirrhosis of the liver. Mech anical congestion of the organs or tissues will lead to permanent thickening or enlargement, forming a fibroid material, causing stiffness, induration and loss of contractility. The subjective symptoms vary with the parts con- gested. Usually there is sense of weight, or dull, heavy uneasiness. The functions of the' affected parts are more or less impaired. The external parts often feel numb and cold when the seat of venous congestion. Causes. — 1. A mechanical interference with the venous circula- tion through parts is the usual cause. If seated in the heart, it affects the entire systemic, or pulmonary circulation, or both, due to the precise locality of the obstruction. Only some special veins, or system of veins, may be affected, such as the portal, or those of a limb, it being a local impediment. The obstruction may be within the vessels, as a thrombus; external pressure ; or con- striction, as from a ligature, cirrhosis of the liver, etc. 2. Dependent parts are quite liable to congestion from the force of gravitation, especially if the tissues are relaxed and yield- ing, or the " vis atergo'' is deficient; as in the congestion of the veins ot the legs, after long standing, and in hemorrhoids, resulting from sedentary habits. 3. Deficient vis a tergo frequently occasions this form of hyperemia, or predisposes to the action of other agencies in its development. The heart, or arteries, may be weakened in their action, contractility and elasticity due to degen- eration, impairing the forces of circulation, and devoid of force to drive the blood through the veins, as is quite common in very old age. III. Passive or Capillary. — There is a distinction between mechanical and passive congestion, though many authors associate them. The circulation is very languid through the capillaries, due to disturbance in the vital and nutrative relation between the blood and elementary tissues. The state of the part is similar to that existing in mechanical hyperaemia. Atrophy of, and degener- 36 HYPEREMIA, OR CONGESTION. ative changes in, the tissues are likely to result, and there is a liability to low, asthenic forms of inflammation, with a chronic tendency. Causes. — A debilitated condition of the body induces passive congestion; due to feeble circulation, deficient nutrition, and an atonic state of the tissues. Dependent parts, and those distant from the heart, are especially prone to it, as coldness and blueness of the extremities, ears, nose, etc. The hypostatic congestions in various low fevers and prostrating diseases, are partially of this class. 2. Passive congestion may be due to morbid conditions of the blood, as when it is insufficiently areated, and deficiency of fibrin also favors its advent. 3. Anything which locally debilitates or impairs any organ or part and the functions of its tissues, render them liable to become the seat of passive congestion ; as in paralized limbs, and what follows functional activity of an organ exhausting it. It may be the result of active congestion or inflammation, due to tne per- verted relations between the blood and tissues, as is frequent after tonsilitis, etc. Post Mortem Appearances. — The essential character of this morbid state is redness, varying in tint and form according to the nature of the congestion. Bright red denotes active congestion, in the form of minute net- work, or it may appear uniform, or in points when certain special structures are affected. There may have been active congestion in life, yet no postmortem redness apparent, due to arterial contraction expelling the blood into the veins ; minute extravisations of blood sometimes render red points apparent. Yenous congestion is more or less dark red, or it may be bluish, or purple ; the veins are visible and distended in net work form. The post-mortem gravitation of the blood into the dependent parts often gives the appearance of congestion where none had existed. Post-mortem staining by the coloring matter of the blood may simulate congestion. The results of congestion, as described, may be apparent after death ; as dropsy, etc., and where it bad long continued, considerable changes in appearance and structure] are readily seen. The pigment derived from the coloring matter of the blood often gives a gray or dark hue to the parts. DROPSY. 37 CHAPTER II. DROPSY. Dropsy, formerly correctly called hydropsy, signifying water appearance, is often described as a disease, while in reality it is only a prominent symptom due to some local or general morbid condition. An accumulation of water, or serous liquid in some one or more of the natural serous cavities of the body, or in the meshes of the areoler tissue, or in both, often appearing independently of in- flammation. Causes. — 1. Obstruction to the return of venous blood, over- distending the veins and their capillaries, due to various different conditions. The most common of these are : Valvular or other disease of the heart. Ketarded circulation and increased fullness of the veins, as in pulmonary emphysema, bronchitis, etc. Struc- tural disease of the liver, or impeding the return of blood through the portal system of veins. The pressure of tumors, enlarged glands, and the gravid uterus, etc., on veins. 2. It may be caused by kidney disease, due to imperfect elim- ination of uiea, and water also accumulates in the blood. 3. It may be also due to anaemic or watery blood. 4. Inflammatory hyperemia leads to it, as is seen in pleuritic effusion, strumous hydrocele, etc. The various forms of dropsy are : Anasarca ; ascites ; hydrocephalus ; hydrothorax ; hydropericardium ; hydrocele, etc. The dropsical affections will be separately considered in detail with other indi- vidual diseases. General Treatment. — The indications are : 1. To remove when possible, or when not, to relieve the diseased condition of which dropsy is a symptom or expression. 2. To carry off the liquid and restore the normal state. These indications point to the use of purgatives, diuretics, emetics, diaph- oretics, and topics. To alteratives, tonics, etc., as restoratives. When the accumulation of liquid cannot be carried off through the 38 DROPSY. natural channels, which ought to be the first effort, as a rule, then resort must be had to tapping ; incisions, or accupuncture and issues. Purgatives. — Among those which have been found most efficient are : Apocynum, Compound powder of jalap and Cream of tartar, equal parts. Compound podophyllin pills. Elaterium. Black hellabore. Turpentine emulsion. Khubarb. Colocynth, etc., termed hydragogue cathartics. Diuretics. — Digitalis. Dwarf Elder. Infusion of Buchu and Uva ursa. Copaiba, or its resin. Nitrate of potam. Spirits of nitrous ether. Acetate of potash. Compound spirits of horse- radish. Oil or spirits of juniper. Benzoate of amonia and digit- alis. Liquor potassae. Fomentations over the loins Cupping the loins. Dry cupping over the kidneys, etc. Emetics. — Ipecacuanha. Mustard. Compound emetic powder, or acid emetic tincture, etc. Alteratives. — Iodide of potassium. Alterative syrup. Syrup of corydallis eompositus. Chlorate of potash. Colchicum. Arsenite of potassa, etc. Tonics. — Citrate of iron and amonia. Tartarated iron. Pyro- phosphate of iron. Nitro-hydrochloric acid. Citrate of iron and quinine. Hydrastus canedensis, and other vegetable tonics. Cod- liver oil. Tincture of perchloride of iron, etc. Topics. — Fomentations. Hot-water baths. Hot-vapor baths. Hand baths Frictions, and sometimes unguents, etc. Treatment must be directed to build up the general system ; especially to improve the state of the blood. The digestive and nutrative functions claim the first attention. G-ood, nourishing and digestable diet is indispensable, and that which is apetizing In short, everything must be done to improve the blood and the gen- eral system. Cleanliness of dropsical parts is necessary, and to avoid pressure upon them. HEMORRHAGE. 39 CHAPTER III. HEMORRHAGE. Hemorrhage signifies the escape of blood from the natural chan- nels or vessels of circulation. The heart may rupture, or the blood may escape from either the arteries, veins, or capillaries. Capil- lary hemorrhage is most frequent in medical practice. As a rule the vessels are ruptured, but the bleeding may occur without actual rupture. Often no lesion can be detected by the most care- ful scrutiny, and it is known that both the red and white cor- puscles can escape through the coats of the blood vessels. The blood may be poured out on a free surface, as that of the skin, or on a muco us or serous membrane, or into the interstices of tissues, into the substance of organs, or into morbid growths. Varieties. — 1. Traumatic — When a vessel has been directly divided; and spontaneous, when the bleeding is due to some consti- tutional condition. 2. Symptomatic, when clearly the result of disease, as in tubercle, cancer, etc., and idiopathic, or essential, when no such cause exists. 3. Active hemorrhage is that resulting from active congestion, or active inflammation, and it is termed passive when debility of the system and poverty of the blood exist. Hemorrhages occurring at intervals are called constitutional, and seem to promote the general health, as bleeding from piles in plethoric people. Vicarious hemorrhage is supplemental to some other, as a woman having periodical bleeding from the nose in place of the usual cata- menial flow. Critical hemorrhage is one occurring during the progress of dis- ease, producing a marked injurious effect. The foregoing classification is of no great practical importance. The seat of hemorrhage generally varies with the age of the patient. Bleeding from the nose is more frequent in youth ; from the lungs, bronchi, stomach, urinary passages, and uterus in 40 HEMOREHAG& adults ; and from the cerebral vessels, and rectum late in life. Special terms are used to indicate the source from which the blood escapes, as epistaxis, bleeding from the nose ; haemoptysis, from the air-passages or lungs ; hcematemesis, from the stomach ; malaena, from the bowels ; hcematuria, from the urinary organs ; and Menor- rhagia, from the female genital organs. The pathological conditions to which these hemorrhages are due will be explained more fully hereafter, in connection with individ- ual maladies. Prognosis. — This will depend upon : 1. The quantity of blood lost. 2. The seat of the hemorrhage. 3. The condition of the patient, and the immediate obvious effects of the bleeding. 4. ^Whether it is possible to stop the hemorrhage, or whether it is likely to recur. General Treatment. — 1. Perfect quiet, in a cool apartment. Sim- ple unstimulating food and drink. Position, such as to prevent afflux of blood to bleeding organs. Turpertine stupes. Ligatures. 2. Remedies. — These vary in different cases, with the various causes to which they are due. The available general means are : Cold applications, as ice and cold water. G-alic acid. Tannin. Mineral acids. Amonio sulphate of iron. Tincture of perchloride of iron. Creosote. Ipecacuanha. Oil of turpentine, titrate of silver. Alum, salt, kino. Matico. Ehatany. Ergot of rye Opium. Digitalis. Aperients. Transfussion, etc Hemorrhagic Diathesis. — r Ihis is usually congenital or may be due to insufficient nourishment ; or sometimes caused by a diseased spleen. In this there is absence of coagulable constituent of the blood. Symptoms. — Echymosis. Dropsy. Painful swelling around joints. Bleeding from umbilicus after birth ; from the nose or gums in youth ;from the urinary passages and rectum in age. Fatal loss of blood after leech-bites ; extraction of teeth, rupture of hymen, etc. Treatment— Avoid surgical operations. Caution after accidents Nourishing food, etc. Eemedies are those indicated in passive hemorrhages. INFLAMMATION. 41 CHAPTER IV INFLAMMA TION. This is a morbid action of vast importance. Inflammatory affec- tions are so common and numerous, that the student and practi- tioner require a thorough acquaintance with the subject in order to become qualified to perform their daily functions with the proper skill and success. The medical man is not interested so much in the various profound theories upon the pathological changes involved, as in a plain statement of all Xh.Q essential points pertaining to this subject. There are questions connected with inflammation, the full discussion of which does not properly come within the province of this work. Inflammation. — From inflammo, to burn. Synon. Phlogosis ; Phlegmasia; Hyperhcematosis.- -Sometimes a destructive, sometimes a formative, process; consisting essentially of local congestion, and stagnation ( stasis ) of the blood, with exudation of liquor sanguinis, emigration of white corpuscles, and proliferation of these and cell elements of the affected part. I. Changes Observed by the Microscope in Inflamed Tissues. These may be studied by irritating the transparent vascular tissues of animals, and watching the effects. The web of a frog's foot, its tongue or mensentery, and the wing of a bat, are most commonly used for this purpose, and the following phenomena are apparent: Changes in the Blood-vessels and Circulation. 1. The Blood-vessels become Altered. — In almost all cases there is an immediate dilatation of the small arteries with elongation and tortuosity, which increases ten or twelve hours, and then remains stationary. A primary contraction rarely occurs, of short duration. 7* 42 INFLAMMATION. After a time the veins enlarge, their shape becomes changed into little bulgings and contractions, giving rise to a variocose or aneurismal appearance. Structural changes in the capillary walls occur in the course of time, becoming the seat of fat-granules, especially around the nuclei, and they send out processes by bud- ding, which finally unite together. 2. The Circulation is Disturbed. — First an increased rapidity in the flow of blood! except when contraction occurs. This is soon followed by a rather sudden change to the normal rate of move- ment, then becomes slower, which begins in the veins. A to-and- fro oscillation is then often seen, and finally complete stasis, or stagnation occurs, the vessels appear crowded with red corpuscles. Neighboring vessels often present all these various conditions as to movements, and around the center of stasis, the vessels are usually overloaded, the circulation slow ; while beyond this still, the flow is increased in activity. 3. Important Phenomena Occur in the Blood Corpuscles. — The white corpuscles accumulate in the vessels, especially in the veins adhering to their walls, forming a continuous motionless layer, the current continuing until stasis occurs. After a time the corpuscles pene- trate the walls of the capillaries, and may be seen in various stages of their transit, forming button-shaped elevations, then hemispher- ical prominences, then pear-shaped bodies, and finally separating altogether. This process is due to the power which these corpus- cles possess of spontaneous movement, of altering in shape, and of digesting the protoplasm of the vascular walls, by virtue of their amaboid nature, so that no actual opening is left, showing where they have escaped. The name of " leucocytes " is now given to these escaped white corpuscles. After they leave the vessels they send out processes, assuming peculiar shapes, and ' ; migrate " far and wide into the adjacent tissues; at the same time, often under- going a process of division, and becoming increased in number. The red corpuscles show the same tendency to aggregation and stasis, and they may so adhere that their outlines are quite ob- scured. They often also " migrate " through the walls of the vessels, but not nearly to the same extent as the white blood-cells. Dr. Lionel Beale states that, in an inflammation, little particles of bioplasm, or germinal matter, of the blood, pass through small rents INFLAMMATION. 43 or fissures in the capillary walls, and afterwards grow and multiply by division. Some of these are detached from white corpuscles. He assumes that most of the particles seen outside of the vessels originate in this way, not from the direct transit of white corpuscles. 4. An Exudation of Liquid More or Less Approaching to "Liquor Sanguinis'' Generally Occurs, Not Invariably. — There is [always a tendency to the escape of fluid from the vessels of inflamed tissues, which, though usually called " liquor sanguinis," is rarely iden- tical with it in composition. It may be mere serum, but as a rule it contains fibrin albumen, also a considerable proportion of phos- phates, chlorides, and carbonates. Its nature and quantity will vary according to the seat and intensity of the inflammation. In parts which have no vessels, the alterations which have been described can be seen in contiguous tissues, from which the nutri- ment for the non-vascular structures is derived. Changes in the Affected Tissue. The nutrative processes are rapidly disturbed when inflamma- tion sets in, and in some structures this is the only perceptible deviation from health, there being no appreciable amount of exuda- tion. Such inflammations are termed u parenchymatous,'' and are noticed in cartilages, and certain organs, such as the kidneys. The first tendency is to the active formation of cells, or cell-prolifer- ation, or germination, which is due to the increase in size of those already existing, and of their nuclei, and the division of the latter along with the protoplasm of the cell contents, so as to form new cells (endogenous) formation. They also undergo many changes in form, and exhibit amgeboid movements. This cell-proliferation is in proportion to the intensity of the inflammation, but greatly varies in the different tissues. In epithelial structures it is very rapid ; less so in connective tissue, cartilage, bone, and the cells of organs, and does not occur at all in the higher tissues, such as nerve. These new cells are prone to decay, especially when they are quickly formed, and the inflammation has been very active; yet they may develop into a permanent tissue, which tends to be of a lower organization than the original one. When intercellular substance exists, it often softens and breaks down, and the entire structure may be com- pletely destroyed at last, the histological elements be involved in 44 INFLAMMATION. the degeneration. Dr. Beale describes the " bioplasm" of inflamed tissues, as increasing greatly in amount. II. Nature and Origin of Inflammation, with the Explan- ation of the Phenomena Observed. The present views of the phenomena of inflammation are that they are due to disturbance in the mutual vital relations of tissues, blood-vessels and blood. This pathological process, affecting the nutrative conditions, results from some injury to, or irritation of, a tissue, direct or indirect. An impression is thus produced on the centripetal or sensory nerves, which is communicated to the vaso-motor centre, there reflected to the centrifrugal or vaso-motor nerves, and conveyed by them to the vessels, which consequently dilate, because of a paralyssis of the muscular coat. The primary acceleration of the flow of blood may be due to dilatation, the subsequent phenomena are the result of some alteration in the vital properties of the living tissues, including the coats of the vessels and the adjacent structural elements. The former are so deranged as to lead to stasis, and to allow of the free passage of liquid and leucocytes, having lost their resisting power. The cell- proliferation, and increase of bioplasm are due to the direct influence of the abundant supply and frequent change of the nutrative fluid, the "liquor sanguinis," in stimulating growth and development. The primary irritation may immediately set up this overgrowth, or it may be originated through the nerves directly, and may itself tend to promote a free escape of fluid from the vessels, because it causes a greater demand for nutriment It is the opinion of able pathologists, that the whole process of inflammation is due to a direct change in the vessels or blood, set up by the molecular tissues of the part affected, and that it is not produced through the medium of the nerves. III. Eesults and Products. 1. Resolution. — The changes already described having occurred, to a greater or less extent, what is termed resolution may occur, which means a subsidence of the vascular disturbances, and the absorption of any exudation, leaving the tissue normal. Any leucocytes which are present either undergo fatty degeneration before absorption, or re-enter the blood-vessels or lymphatics. INFLAMMATION. 45 Resolution may take place very rapidly, and it is then named deli- tescence ; or metastasis may occur, — the disappearance of inflammation from the part, with its simultaneous development in another. 2. Exudation and Effusion. — There is an escape of fluid from the vessels in inflammation, varying much in quantity and composition. These effusions include serwn, fibrinous exudation or lymph, blood, and mucin. Serum. — This effusion is seen in connection with serous mem- branes, or in the sub-mucous tissue in certain parts. It is not uniform in its composition and characters, but contains a variable amount of albumen, and generally fibrin also, with considerable phosphates and chlorides. It may continue for a long time unal- tered, or is absorbed, if the inflammation subsides or may become changed into pus. Fibrinous Exudation, Lymph, Coagulable Lymph, Inflammatory Exu- dation. — In some forms of inflammation an exudation escapes from the vessels which is coagulable, containing much fibrin, the above names are applied to it. There is really no line of distinction between this exudation and the serous effusion resulting from inflammation. It has a number of leucocytes in it, as well as cells, resulting from proliferation, and Dr. Beale describes it as containing more or less of the particles of " bioplasm." Often organization tends to occur in it, but others think that only the cells and bioplasm become developed, the lymph nourishing these ; while some are of the opinion that the fibrin coagulates and fibrilates, and itself contrib- utes to the formation of new tissues. There are two kinds of lymph — the plastic, or fibrinous, which contains abundant fibrin-forming ingredients, tends to coagulate and develop tissues; and the aplastic corpuscular, or croupous, in which there are a large number of cells, with slight tendency to organization, but rather a proneness to degeneration and to the formation of pus or other low products. The condition of the patient, the seat and intensity of the inflammation, and other causes, influence the nature of the exudation materially. After the subsidence of the inflammation, the cells which are derived from leucocytes, or from proliferation in the affected tissue, as also the masses of germinal matter, may become developed and organized. Some form of connective or fibrous tissue is generally 46 INFLAMMATION. produced, but bone, elastic tissue, epithelium, or fat, may be ulti- mately formed. Certain of the higher tissues are never developed under these conditions. The organization into new tissue is well seen in the changes which occur in the granulation-tissue by which wounds cicatrize, and in the adhesions and thickenings formed in connection with inflamed serous membranes Very serious conse- quences often attend these changes, structures become thickened, hardened, contracted, or bound together, and transparent tissues rendered opaque. A process of degeneration sets in after organization, as wasting or withering, the substance becomes dry, yellow, horny, and stiff, by a fatty or liquafactive change, which leads to its absorption, or by the formation of black pigment. Changes similar may occur in the products of corpuscular lymph. In a majority of tissues the cells which undergo development are at first derived from leucocytes, afterwards others are formed by cell-proliferation. Blood is sometimes present in inflammatory exudations. It is partly the result of migration of the red corpuscles, but may be due to the actual rupture of vessels, especially recently formed ones. Mucin — In some inflammations of mucous membranes this substance is found, and it gives a tenacious, stringy character to the fluid discharged from the surface. 3. Suppuration, or Formation of Pus. — The tendency to this process varies according to the tissue affected, and the constitu- tional condition, and it generally is more liable to occur if the inflammation is very severe and concentrated. Pus may form on a free surface, and be discharged, and often mixed more or less with other material; it may accumulate in cavities, such as those lined with serous membranes ; or it may involve the substance of organs and tissues, in the form of a circumscribed abscess, or as a diffuse purulent infiltration. Physical Character of Pus. — Thick, viscid, pale yellow liquid, odorless, alkaline in reaction, with a specific gravity of about 1030. It consists of a fluid, " liquor puris," in which float pus-corpuscles, and other microscopic particles. Liquor puris is an albuminous fluid, but also contains salts, pyin, chondrin, and fat. The cor- puscles closely resemble pale blood-corpuscles in size and appear- INFLAMMATION. 47 ance, being more or less round, or sometimes irregular, granular, and having one or more nuclei, which are made more apparent by acetic acid, and often break up when acted upon by this re-agent. They have the power of spontaneous movement and migration, and they can alter in form, and increase in number, by fusion. Dr Beale describes pus-corpuscles in the living state, as masses of bioplasm, without cell wall, which assume a variety of forms, but never spherical, send out protrusions in every direction, these becoming detached and forming new corpuscles, and which are capable of spontaneous movement. When dead, they assume the spherical form, their movements cease, a kind of cell wall forms, they become more granular, and bacteria are developed in them. In this condition they are usually seen under the microscope. It is now generally considered that the most of these cells, especially in the earlier stages of inflammation, are merely white blood-corpuscles which have migrated, — leucocytes. Beale be- lieves they are derived from the particles of bioplasm which escape. Afterwards others are formed by proliferation of the other cells and germinal matter of the tissue affected, and they increase in number by cleaverage and endogenous formation. These " leuco- cytes " possess the power of destroying the tissues with which they come in contact, and it is partly in this manner that an abscess makes its way to, and opens on the surface. Various Kinds of Pus. — " Healthy or laudable, ' " ichorous or watery," " serous," " sanious,'' etc. For further knowledge of these, the reader is referred to surgical works, to which it properly belongs. Pus may decompose and form noxious gases, and it sometimes undergoes physical and vital changes, if not discharged, its fluid portion being absorbed, its cells becoming withered, and undergoing fatty degeneration, so that it is converted into a cheesy mass, containing fat-granules, shriveled cells, and neuclei. | 4. Softening of tissue is not an uncommon result of inflammation, and it may proceed to such a degree as to cause the complete breaking up of the affected structures. This is illustrated by the softening resulting from inflammation of the brain. 5. Induration is another consequence of inflammation, especially when chronic, or due to the substitution of an imperfect fibrous tissue for the normal structure. 48 INFLAMMATION. 6. Interstitial absorption is sometimes observed, as in the case of osseous inflammation. 7. Ulceration. — An ulcer is the result of the destruction of the tissues on the surface by inflammation. If this is quite superficial only the epithelium being removed, it is called excoriation, or " abrasion." Ulcers frequently come under the notice of the physician in connection with mucous surfaces, and they present many differences in form, size, and appearance. A discharge of pus usually occurs from the surface after the inflammation process subsides. An ulcer tends to cicatrize, by the development of granulation-tissue into fibrous tissue, which afterwards is prone to contract, leading to serious results. Ultimately the original struct- ures may be developed anew, but a 1 ong time passes before this is attained, and some tissues are never reproduced. 8. Gangrene, or Mortification.— Rapid death of the involved parts may result from very severe inflammation, under certain conditions^ and a slough forms, becomes isolated from the living textures, and undergoes a process of separation, leaving an ulcerated surface. This is the result of direct injury to the vitality of the structure," of the stagnation of blood, and of the injurious effects produced by the exudations. Almost any tissue may mortify from this cause, but it is specially common in the subcutaneous areolar tissue, and in the mucous membrane of the alimentary canal. Gangrene is rarely seen in organs. The gangrene is of the " moist" kind, and therefore the slough is prone to decomposition. Different tissues are liable to different kinds of inflammation as to products and terminations. This is readily seen by the results of inflammation affecting serous and mucous membranes respectively. Serous inflammation is at first marked with redness, loss of polish, opacity and thickening of the membrane. Then a fibrinous exudation is deposited on the surface, varying in amount, charac- ter, and arrangement, which contains abundant cells, chiefly leucocytes, but partly derived from cell-proliferation in connection with the epithelium-particles. Simultaneously an affusion of fluid occurs, into the serous cavity, turbid, and containing coagula, and abundant cells, similar to those in fibrinous layer. The furthef tendency is to the absorption of this fluid and forming of thicken- ings, adhesions, or agglutinations in connection with the serous INFLAMMATION. 49 membrane. Pathologists now incline to the opinion that the fibrinous layer is not organized but undergoes fatty degeneration, becomes absorbed, and that the adhesions are produced by the development of minute vascular papilla?, or granulations, which form on the surface of the membrane under the epithelium. If the inflammation is intense, or long continued, the fluid may become purulent, and this is apt to occur in certain constitutional conditions. r £he general tendency of serous inflammation is to produce material capable of organization. Mucous membranes are subject to three varieties of inflammation : Catarrhal; croupous; membranous, plastic or fibrous; and diph- theritic. Catarrhal. — This is the common form. It begins with conges- tion and swelling of the membrane, at first abnormally dry. Soon there is an increased secretion of viscid mucous, containing abundant cells, derived from the proliferation of the epithelium and from leucocytes, and if inflammation continues, the discharge assumes a purulent appearance, due to the large number of cells mixed with it, many of the precise character of pus-cells. The follicles and glands enlarge and fill with cells. Sometimes the sub-mucous tissue becomes infiltrated, and if loose, considerable serum may collect in it. Abrasion or ulcers are frequently pro- duced If infiltrations become chronic, considerable changes in the structure of the glands and membrane. Croupous. — This differs from catarrhal in that a layer of "false membane " is deposited on the surface, varying in consistence and thickness. This consists of coagulated fibrin, either amor- phous or fibrillated, including epithelium and pus-cells. It has recently been described as being constituted of altered epithelium- cells without any fibrin. It is, however, distinctly fibrilated in some cases, but evinces no tendency to organize. Dipatheritic. — This is characterized by a fibrous exudation not only upon, but into and beneath the mucous membrane, which is destroyed and converted into a slough, and an ulcerated surface is left. The difference between inflammations of mucous and serous membranes is thus made apparent. In that of mucous membranes the products have no tendency to organize, owing to the abundance of cellular elements being 50 INFLAMMATION. discharged with the secretion, while those of serous membranes are retained for organization. IV. Symptoms and Signs. 1. Local; Objective. — In visible parts, it generally presents three well-recognized objective signs of change : Redness, swell- ing and heat. Redness varies in degree and hue, generally tending to be bright. Toward the centre of inflammation this is more marked, gradually fading, until lost at the circumference, disap- pearing more or less on pressure. This is due chiefly to overload- ing of the vessels and blood stasis, but partly the result of migration of red corpuscles, or rupture of vessels, and extravasa- tion. Non-vascular tissue cannot have redness, but the neighbor- ing structures which nourish it exhibit the redness. Owing to the contraction of arteries, redness may disappear after death. Swelling. — This varies greatly, accompanied by hard or soft feeling, due to the increased amount of blood in a part, and the various exudations and effusions poured out, also the proliferation of tissue, these explain the enlargement wnich is often troublesome. Increased local heat is frequently quite apparent to the touch, or at times it can only be detected by the thermometer. This is mostly due to the great activity of nutrative and chemical changes in the part, but to some extent to the increased flow of blood through it. Dr. Beale attributes the increased heat to the rapid growth of bioplasm. The same objective changes obtain in internal inflammation, but cannot be observed in life ; careful physical examination, hereafter to be explained, will often enable us to determine the physical condition as to the presence of exudations and effusions internally. Subjective, — Pain is commonly present in inflammation, though it may be absent, and it varies in intensity and kind, in different tissues. Tenderness is usually present and may exist alone. Functions of structure and organs are always disturbed, and often those of adjacent parts are implicated. Secretions are always changed in quantity and cornpositon. General or Constitutional. — Acute fever, usually of the inflam- matory type, at first, varying much in degree, due to the tissues affected. It is " symptomatic " or '•sympathetic/' When sup- puration begins, a shivering usually occurs, and the fever is ap INFLAMMATION. 51 to become hectic. If gangrene supervenes, typhoid fever is present. The state of the blood is hyperinotic, having an excess of fibrin, coagulating firmly, often presenting the " buffy '' coat Water is excessive, but salt and albumen are deficient. The red corpuscles run together, and form " rouleaux, " under the microscope. The fever is due either to paralysis of the vaso-motor nerves, or the whole blood is raised in temperature by the local production of heat. Y. Causes. Predisposing causes not only influence the occurrence, but also the part inflammation affects, and the variety it assumes. 1. The general condition of the system and the blood power- fully predispose to inflammation Weakness, impoverished blood, due to deficient food, disease, vicious habits, bad hygiene, etc. The reverse condition : plethoric, over feeding, stimulating, lux- urious life, render persons exceeding prone to attacks. Poison in the blood is the most important general condition, often of special kind, and affects particular tissues, as eruptive fevers, syphilis, diabetis, gout, rheumatism, etc. Old people and children are most liable, but not of all structures. Persons of sanguine temperament are most liable to inflammation. 2. Local. — Mechanical or passive congestion, defective nutrition of a part, vessels in a state of degeneration, as in old age, etc. Exciting causes are mechanical injury or irritation from without or within, as wounds, bruises, worms, tumors, extravasated blood, retained excretives, concretions, deposits, etc. 3. Chemical Irritants. — Great heat or cold. A specific inflam- mation from croton oil, tartar emetic, a blister, etc. Contact of air to irritated or ulcerated surfaces, or pus, or gangrenous fluids, come under this head. 4. Introduction of specific poisons induces inflammation, small- pox, vaccination/glanders, syphilis, gonorrhse, etc. 5. The cause may exist in the blood itself, by the introduction from without of a chemical or organic poison, as arsenic, canthari- des, etc , or a contagious poison, and produce special results. One inflames the stomach and the other the kidneys, while various acute fevers show special inflammatory eruptions, and peculiar disorders of organs and structures. Irritants may be generated within the body, as in gout, rheumatism, or in successive destruc- 52 INFLAMMATION. tion of tissues, the materials thus formed act as exciting and pre- disposing causes of inflammation, which are called secondary. 6. Cold and wet, acting on the skin, while the body is per- spiring, produce a "chill," which is followed by internal congestion and inflammation. The small cutaneous vessels contract and drive the blood inwardly, and also interfere with cutaneous excretion, causing noxious accumulations in the blood. These are termed idiopathic or primary inflammations. VI. Varieties. It is acute or chronic according to intensity and rate of progress. Sthemic or asthenic according to symptoms present. Plastic, ad- hesive, suppurative, or gangrenous according to the products and terminations of inflammation. Circumscribed or diffuse. Healthy, or phlegmonous, or unhealthy. Non-specific, or specific, the latter includ- ing syphilitic, gouty, strumous, tubercular and other specific forms of inflammation. Symptoms of Inflammation. — For clearness these may be aggregated and summed up : Pain. Swelling. Heat. Eedness. Blood, when tested, is buffed and cupped. Diminution of red corpuscles, and increase of fibrin : Perhaps an increase of color- less corpuscles, and increase of the blood. Symptomatic fever. Depression. Eigors. Frequency of the pulse. Headache. Thirst. Loss of appetite. Furred tongue. Diminution of chlorides in the urine. Increased excretion of urea. Sweating. Hectic fever. Excessive wasting. Prostration. Varieties and Results. — Adhesions. Suppurations. Ulcerations. Hemorrhage. Sloughing. Gangrene. VII. Treatment. Only a general treatment is proper here, and it is very difficult to give even an outline of it, because inflammation varies so much j under different circumstances and conditions. In giving individ- ual inflammatory diseases the proper treatment will be carefully set forth in detail. For the present, only the main details wiU be given. 1. If conditions exist likely to give rise to inflammation, take measures to prevent it. After an injury the part should be kept at rest, and appropriate means applied. The condition of the blood INFLAMMATION. 53 which tends to secondary inflammation should be corrected If paralysis of a nerve exists all sources of irritation must be avoided. 2. Subdue the inflammation as soon as possible, and thus prevent unfavorable results. If any exudations and effusions have been poured out, limit them, or procure absorption, or remove them in some other way as soon as possible, and restore to the normal state. Guard against suppuration, ulceration and gangrene, and treat them promptly when they occur. Treat the general condition — fever, constitutional disorder, etc. Attend to local symptoms and the special character of the inflammation. Remove the cause if possible ; enjoin perfect rest. Position must be such as to prevent accumulation of blood. Antiphogistic remedial measures must be employed to lessen vascular action, both in the quantity of blood present and its rate of movement Modern practice has substituted for venesection, aconite, veratrum, digitalis, etc., as sedatives in inflammation. An important class of remedies in some cases, if prudently employed, are those which increase the various excretions, and thus relieve the blood-vessels, as purgatives, diuretics and diaphor- etics. It is very important to restore and keep the secretions, the bowels open and the liver in proper action. Purgatives, to a due extent, are important in inflammation of the liver. Local Measures. — Applications of cold in the form of evaporating lotions ; cold water, cold irrigations, ice, etc. Only in the early stage these remedies are mostly useful, and when the inflammation is superficial, or near the surface. Seat and moisture, in the form of hot water dressings ; poultices and hot fomentations act very beneficially in many cases. In other instances sinipisms and even blisters may be required. All these determine the blood to the surface, a necessity in all forms of internal inflammation. Yarious forms of counter-irritation are recommended, as painting with a solution of iodine, irritating liniments, unguents, etc., as also various baths, which often prove efficient means in getting rid of various effusions. Operations for the removal of the products of inflammation may be required when they cannot be otherwise disposed of. Certain acts may be requisite in other cases to promote the discharge of certain products, as coughing in bronchitis, etc. 54 DEGENERATION. The various forms of fever present must be treated by the prin- ciples laid down on each subject respectively. If any specific inflammation exists, particular constitutional reme- dies are indicated, as alkalies in rheumatism, colchicum in gout; tincture of iron in erysipelas, chlorate of potash in inflammation of the mouth and throat, etc. Diet is very important, and must vary according to circum- stances. In depression, it may be sustaining, and stimulation may be also required. In suppuration and gangrene, tonics are neces- sary, as mineral acids, steel, cod-liver oil, cream, etc. The hygienic conditions must receive careful attention. Pain is a prominent local symptom, which requires careful at- tention. Opium has been much employed in various forms to allay irritability ; to quiet the peristalic action of muscular tissues ; to induce sleep, and to directly influence the inflammatory process. . It is proper here to warn practitioners against its use when the respiratory organs, the kidneys, or the brain and the spinal cord are involved. Hydrate of chloral and other sedatives are often better and more appropriate to secure rest and relieve pain. CHAPTER V. DE GENERA TIONS. Degeneration implies the conversion of one tissue into another, less organized, and which is incapable to suitably perform the necessary functions. It is a retrograde metamorphosis. This is due either to a change of albuminoid compounds, or to molecular absorption of the structural elements, and their replacement by others, lower in the scale. This term is also applied to certain morbid processes when new material is deposited among the normal elements of a tissue ; it being derived from the blood, may not be absorbed, or entirely replace them. Metamorphosis is the term DEGENERATION. 56 applied to the former, and infiltration to the latter of these"two kinds of degeneration. 1. These pathological changes interfere with the functions of organs or tissues. 2. They produce conditions which predispose to the occurrence of dangerous lesions. A fatty heart is liable to rupture, and a fatty or calcified condition of the :E blood-vessels very often result in their laceration, and extravasation of blood, as well as aneurism. Hence this subject assumes great practical importance. I. Fatty Degeneration. This comprises fatty metamorphosis and infiltration, each requir- ing distinct consideration. 1. Fatty Metamorphosis. — The direct conversion of albuminoid constituents of tissues into fat is common to decay in old age, and is fraught with serious results. It may occur with the cells or fibres. The fat usually deposits in a granular form, but finally accumulates in masses or drops of oil. These granules are recog- nized by their distinct and dark outline, their solubility in ether, and their refractive power upon light. Muscular Tissue. — The voluntary or other muscles may become the seat of fatty change. The whole muscles may be converted into fat, without any alteration in their general size or shape, or in the arrangement of their fibres. This most frequently occurs in the fibres of the heart. Under the microscope the fibres are seen somewhat dim at first in their transverse striae, due to the presence of a few minute fat-granules, arranged in longitudinal or trans- verse lines, or usually in an irregular form. Ether renders the striae apparent. Increase in the size and number of these granules obscure them more and more until all trace of muscular fibre disappears, leaving nothing seen except fat-molecules and oil-drops occupying its course. When the sheath surrounding the fibre (sarcolemma) exists, it may finally rupture, and the fat be scat- tered. The conversion of muscle into adipocere after death, is a fatty degeneration. Blood-vessels — As age advances, the arteries are quite prone to fatty degeneration. This may originate .in the cells of the inner coat, or in the muscular coat, or associated with " atheroma,"' which will be described. At length the tissues may be destroyed and carried away 3 with the blood, leaving uneven erosions on the 56 DEGENERATION. inner surface of the vessels. The capillaries are also apt to under- go a fatty change. The nerve tissues, fibres and cells are liable to fatty degeneration, become the seat of molecular fat and ultimately break up. The varieties of softening of the brain and spinal cord, exhibit striking specimens of fatty degeneration. The so-called " compound inflammatory globules," or " exuda- tion-corpuscles," as also " pus-corpuscles," are merely due to the conversion of the contents of cells, either normal to the part or migrated from the blood into fat. Many of these have their origin in cellular-tissue corpuscles. Fatty degeneration also occurs in the cells of the liver, lymphatic glands, epithelium of the renal- tubes, supranal capsules. " Arcus seniles " is due to the same process in the conea. In their natuial decay most organs undergo this change, which is also manifest in various secretions, as well in the production of the corpus leutenum in the ovary ; the degen- erative changes in the placenta approaching the full period of utero-gestation Various tumors, tubercles, cancer and other morbid growths are capable of fatty change. Cells enlarge, are more spheroidal and distended when they become fatty. The granules first appear distant from the nucleus, irregularly scattered; then become larger and more numerous, obscure the nucleus, and finally obliterate it. The cell-wall is often ruptured or absorbed, followed by accumulation of granular fat, which often separates its constituent particles from interme- diate liquafaction. Caseation, Caseous or Cheesy Degeneration. — Lately these terms have become quite prominent to designate the conversion of differ- ent structures into a kind of soft, dryish, cheesy-appearing sub- stance of yellowish color. This material consists of withered cells, fat-granules, partially saponified fat, and chrystals of chloresterin. It mostly occurs where there is a large accumulation of cells, crowding together, especially where vessels are sparse, and the tissues dry. Pulmonary phthisis affords frequent examples of this process of partial fatty degeneration, but of necessity associated with tubercle. It is often seen in chronic abscess, as scrofulous lymphatic glands, diseased bones, cancer, etc. Ultimately a creamy or puriform, or a fatty emulsion may be'produced. It may be ex- pectorated, or qtherwise discharged, and thus caseous matter may DEGENERATION. 57 escape. It may be incapsulated by some dense tissues, and finally calcify. Effects. — The immediate effects of fatty degeneration may be obvious; in the earlier changes, the microscope alone reveals the change. The affected tissues become paler, with a reddish or brown tint ; well seen in muscles ; and in the brain. It varies from white to red. There is a tendency to opacity. The most marked alteration is the tendency to softening of structure until it breaks down under pressure, into almost a fluid pulp. Vital properties, as elasticity, or contractility, are impaired or lost. In the advanced stage the tissues have an oily feel, and ether dissolves out consid- erable fat. Great importance attaches to the remote consequences. The functions of organs are impaired, or lost. Structures are liable to yield or rupture, as in the heart or vessels. Arteries thus affected are liable to aneurism, etc. Causes. — Interference with nutrition. The causes are : 1. Sen- ile decay, in which most tissues degenerate. 2. Deficient supply of arterial blood to a part from obstruction, external pressure, changes in the vessels. 3. Some constitutional disease, lowering vitality. 4. Congestion, inflammation, rapid development of tis- sue, excessive use of functions, which disturbs vitality. 5. Excess of fat in the blood may possibly aid this degeneration. 2. Fatty Infiltration. — This process is essentially distinct from " fatty degeneration." No change in the tissues, but merely ex- cess of deposit of fat from the blood within the cells of the affected part, infiltrating the structure : a hypertrophy of fat. It occurs, in oil-drops, running together, obscuring the contents of the cells without destroying them. The best examples of this infiltration are seen in the increase of adipose tissue in some persons, subcu- taneous and around the internal organs; also in the muscular tissue, especially that of the heart ; and in the hepatic cells. In the first two the connective tissue cells become filled with fat. The degree of change in the heart is from a slight increase, to be- come converted into adipose tissue, no trace of muscular fibre, or only few scattered ones, the most of them having undergone real fatty degeneration from pressure, and then removed. This process may also occur in paralyzed voluntary muscles, and those rendered otherwise inactive. The cells of the liver become pitted with oil- 58 DEGENERATION. drops, enlarge, become more spherical, and hide their contents. Effects. — Fatty infiltration enlarges organs, alter them in form, tending to roundness in margin and outline. The color becomes paler, and may be even to that of adipose tissue. Softening, with a doughy feel, like ordinary fat, much oil present as seen on the knife, the fingers, blotting-paper, or by ether, are the chief changes observed. This process interferes with the functions of tissue, but not to the extent as in fatty degeneration unless they have suffered from pressure. Causes. — 1. Excess of fat in the blood is a common cause of this morbid change, and is attended with obesity. This is due to ali- ments which contribute to its formation, and want of proper exer- cise, and general luxurious habits combined. There is also less than the common waste of fat under such conditions. 2. It is a singular fact that in some diseases, attended with great emaciation, some organs are prone to fatty infiltration, especially the liver. This is manifest in phthisis, due to the general absorp- tion of fat, its consequent accumulation in the blood from which it is deposited in the liver. 3. Interference with respiration may lead to fatty infiltration, be- cause the fat is not properly consumed, hence, the occurrence of such heart and lung degenerations are explained in part, at least. 4. Local inactivity may induce fatty infiltration, as has already been explained, for want of muscular inactivity, etc. II. Mineral or Calcareous Degeneration. — Calcification. — Petrification. This degeneration must be distinguished from ossification, there being no conversion into bone, but merely an infiltration of the tissue with particles of calcareous matter. These are in the form of minute molecules, irregularly deposited between the histological elements. Microscopically they appear like dark, opaque, irregu- lar particles by transmitted light, and have a glittering look in mass- They resemble fat, but are soluble in dilute mineral acid, attended with effervescence, giving off bubbles of gas, due to the decomposition of carbonates. This deposit occurs around small vessels first, then may extend and form irregular concretions of various sizes. This chiefly consists of calcic and magnesic phos- DEGENERATION. 59 phates and carbonates, other salts being present, the chemical composition differs in the different structures. Calcification occurs in parts which have lost their vitality by undergoing other changes of degeneration, especially fatty. It is in fact the last degeneration possible. The auricles, valves, and orifices of the heart are most commonly affected by it, and where the worst effects are produced It may occur in fibrous, or fibro- serous membranes as the dura-mater, the pericardium, tumica albuginea, etc., also in the walls of hollow organs, as the stomach, gall-bladder ; the pia-mater and choroid plexuses of the brain, constituting ( " brain-sand " ; in muscle, cartilage, nerve tissues ; in various glands and organs, as kidneys, lungs, absorbent glands, prostate, thyroid and pineal glands ; in withered tubercle, cancer, inflammatory exudations, fibrinous deposits from the blood, tumors of all kinds, and chronic abscesses. Effects. — Calcareous deposit produces hardness, roughness, stiff- ness, rigidity and brittleness. There is a gritty sensation, and in membranes they are easily broken. Stoney masses of some size are sometimes formed; occasionally a chalky fluid is produced, similar to cement. The change in shape and size of structures, the roughness, brittleness, interference with movement and functions, elasticity and contractility are serious results. It narrows arter- ies, renders them rough and rigid and easily ruptured, hence the supply of blood is deficient, and consequent atrophy or gangrene results ; also the formation of internal clots, or extravasation of blood and hemorrhages. It causes serious cardiac obstruction and interference with its functions. In some cases calcification is a most favorable process, as in phthisical deposits, and in lymphatic glands. A cure is sometimes thus effected, and may remain for years inert, causing no disturbance. A mass may form in the abdomen of the scrofulous, and give little inconvenience, and the patient may die of quite a different disease, or some acute one. Causes. — 1. Deficient vitality and lowering of nutrative activity in general, and advanced age, or local as morbid products, and is due to insufficient supply of blood, with tardy circulation. It is often the termination of atrophic and degenerative processes. 2. Due to excessive salts in the blood. This may be due to dis- eases of the bones, mollities ossium, necrosis, or extensive caries, 60 DEGENEKATION. in which their salts are actively absorbed, and " metastatic depos- its " take place in other tissues, often involving many organs and structures. Deranged urinary secretion may lead to this condi- tion, the salts being retained, the kidneys are prone to become the seat of deposit. III. Fibroid Degeneration. Structures are sometimes changed into inelastic, tough, imperfect fibres, similar to fibrous tissue. A hyperplasia of cellular elements occur without much exudation. The part is opaque, whitish, stiff, and thickened, occasionally rough and hard. The serous andfibro- serous membranes often show this change in thickened patches like those seen in the pericardium. The covering of the liver, spleen, and sheaths of vessels are frequently affected by it. Also the cardiac valves, tendinous cords and muscular tissue, interfering with their functions, and may end in calcification. It is due to friction, pressure, repeated traction, and sometimes to long- continued congestion. To define the line between this process and chronic inflammation is often difficult. Some pathologists hold that fibroid degeneration is always the result of chronic inflam- mation. IV. Pigmentary Degeneration. Pigmentation. Various causes may change the color of tissues, as in jaundice, local staining with bile, the bronzed skin in suprarenal disease, color due to gases, or matters set free in mortifying parts, and that in- duced by the long use of nitrate of silver. The deposit of actual pigment in various tissues ; its origin, nature, and the character of the difterent kinds are to be considered here. 1. It exists in the coloring matter of the blood; it undergoing certain changes, either from transudation, migration of red corpus- cles, hemorrhage, or of capillary stagnation, it may be present in a part. It is at first diffused, staining the tissues, especially the cells, leaving the envelope and nucleus unstained. At length it shows various tints, as yellow, yellowish-brown, brown, dark brown, reddish -brown, gray, or black ; depending upon the duration of the existing pigmentation ; separating into molecules or chrys- tals, or both, within and outside the cells. The chrystals may aggregate in large granules, round or irregular, well-defined, DEGENERATION. 61 opaque, or sometimes glistening. These resist acids, and are inde- structible, except by strong alkalies, forming a red solution. It is supposed to consist of " hseniatoidin," but when black it is termed neianin. These are found in cerebral apoplexy, in pulmonary congestions or hemorrhage, extravasated blood in " corpus luteum '' in the ovary ; " in rusty expectoration " of pneumonia in its pro- gress ; and in certain diseases of the blood itself contains particles of black pigment, as in the rare disease named melancemia, in pro- tracted ague, seen in enlarged spleen, supposed to be absorbed from the blood. This condition also obtains in melanotic tumors, and sometimes black pigment fills the portal vessels of the liver. It occurs in growths connected with the tissues which normally contain much pigment, as the choroid coat of the eye. 5. Pigmentation in the bronchial glands and lungs is often due to the inhalation of certain matters with the air, as particles of carbon, owing to imperfect combustion. From this cause the lungs become darker as age advances, or owing to certain occupa- tions, as colliers, miners, stone-masons, etc. Minute granules of carbon, resisting chemical change, after entering the small bron- chi and air-cells penetrate the epithelium cells and tissues, between the lobules and around the bronchi, lying there free, or inclosed in the connective tissue corpuscles. Being taken up by the lymphatics and conveyed to the bronchial glands, which be- come black. Abundant pigment is seen in the black expectora- tions, due to abundant deposit of foreign matter and the irritation and inflammatory process, and stagnation of blood thus occasioned. V. Mucoid Degeneration. Certain tissues occasionally undergo a process of liquefaction, to which the term mucoid is applied. They are changed into a homo- geneous mucillaginous, colorless mass, which yields mucin. They seem to return to a foetal condition. This change may be limited to spots, or may become extensive. When the former, they are surrounded with normal tissue, and show the appearance of cysts. The intercellular tissue is most involved, sometimes the cellular elements are drawn into this degeneration. Cartilages, bone, ser- ous membranes, and the choroid plexes of the brain become the seats of this process. Certain tumors are of a " mucoid ' character 62 DEGENERATION. from their origin, and many others, to a greater or less extent, undergo this form of degeneration. VI. Colloid Degeneration. This substance is of glue-Jike or of a jelly consistency, devoid of color, glistening and transparent. Derived from the albuminoid tissues, it differs from mucin by including sulphur in its composi- tion, and acetic acid will not precipitate it It involves the con- tents of cells, not the intercellular structure. Finally it may embrace considerable masses, which appear to be in cystic cavities. " Col- loid tumors " sometimes start as new growths, and certain other tumors are prone to this change. Now " Colloid tumors " are not recognized as cancers, as heretofore, and it is at present considered that non-malignant tumors may become the seat of this degenera- tion. Enlarged lymphatic and thyroid glands contain this material occasionally. VII. Lardacious Disease. — Albuminoid Infiltrations. — Amy- loid Degeneration. — "Waxy Disease. A very important morbid condition of organs and tissues have recently been described under the above names. Much is yet to be ascertained about this morbid process. The present state of knowledge in this regard may give a tolerably fair comprehension of the subject. 1. Characters of the Substance and Objective in the Diseased Tissues m — Infiltration of an apparently quite structureless and homogen- ous, and, at first, nearly transparent material constitutes this dis- ease. Said to give certain characteristic chemical reactions. An aqueous solution of iodine applied to the affected part sometimes produces a deep reddish-brown color, but chiefly useful to indicate slight infiltration, especially in microscopic sections. If an organ or tissue is much affected it enlarges, sometimes to a great degree, without irregularity, surface smooth, margins rounded ; weight is proportionately increased, specific gravity is high, and the organ feels solid, firm and heavy. It is a combination of toughness, re- sistance and elasticity, somewhat resembling wax and lard corn- combined ; hence the names "waxy" and " lardaceous." A sec- tion shows a glistening, translucent appearance ; dryish, pale, compact, quite smooth and uniform. It maybe limited to certain DEGENEKATION. 63 spots or to vessels, and is well seen in sago-spleen, confined to the malpighian corpuscles. It generally most affects minute capillar- ies and arteries, the infiltration originating in the muscular coat- The walls thicken, the channel narrows, and -in section the vessel remains open, assuming a compact, shining translucent aspect like silvery threads or cords. In due time the material extends to the cells, enlarging and making more spherical, displacing the normal contents and destroying the nucleus. Then they coalesce giving the whole structure a peculiar glistening aspect. 2. Nature and Origin. — Many attribute to this substance some- thing allied to starch and cellulose, hence the term " amyloid " ; in others a form of chloresterim. It is now generally conceded to be albuminoid, a nitrogeneous compound. Dr. Dickinson holds it to be deallcalized fibrin. Most pathologists consider it a direct deposit from the blood, due to some alteration in that fluid, occurring under certain conditions. Nothing of this albuminoid nature has ever been detected in the blood, and most likely it is modified after its escape from the vessels. In local lesions this is a general disease. 3. Organs and Tissues Affected. — It may involve any part or struc- ture, usually several organs are involved in this morbid process, The kidneys, liver, spleen and absorbent glands are most prone to it. Other structures, as the stomach, intestines, bones, suprarenal capsules, muscles, brain, cord and their membranes, the tonsils, serous membranes, the bladder, etc Morbid deposits in connec- tion with inflammation, cancer and tubercle, it also affects. It originates in the lymphatic glands, when it follows disease of the bones, and some, therefore, favor the local origin of this degen- eration. 4. Causes and Diseases with which it is Associated. — Some previous disease almost always produces it, in which there has been a chronic and excessive suppuration, but not indispensible, as some very grave cases of the kind have occurred without previous suppuration. Separate conditions under which it may occur are caries, necrosis, and rickets ; after syphilis, especially if attended with suppuration and affection of bones ; or if much mercury had been employed. Albuminoid disease affects children who are congenitally syphilitic. Also chronic pulmonary phthisis, and other lung maladies, attend- 64 DEGENERATION. ed with large purulent expectoration. In chronic empyaemia ; ex- tensive intestinal ulcerations ; after long malarial influence or ague ; in kidney disease and pyelitis. 5. Clinical History and Symptoms. — Only a general history is necessary here, as the symptoms will be given in connection with this disease in individual organs. In albuminoid disease we have impaired nutrition ; emaciation, pale and anaemic, with transpar- ency of tissues, and a waxy appearance. Often great debility, and proDeness to syncope. The legs are oedematous, due to weakness and an aemia. Various organs are enlarged, and their functions greatly impaired. 6. Treatment. — The general indications are to counteract the cause and suppress the suppuration, etc. The general health must be improved by proper nourishment, hygienic measures, tonics, iron, and other remedies, as indicated in different cases. Syrup of iodide of iron, when persevered with often gives good results. CHAPTER VI. FEVER, OR PYREXIA. A correct knowledge of "fever" as a general condition is es- sential to proper appreciation of it as symptomatic, or resulting from special disease. The symptoms indicating " pyrexia " are so com- mon that it is very important to acquire clear views of the nature and effects of fever on the general system. Fever may naturally be divided into two distinct classes : 1. When the symptoms of fever constitute the primary devia- tion from health, not due to any local cause, it is termed idiopathic, primary, essential or specific, or it is simply called a fever. Some morbid poison in the blood, introduced from the outside, or pro- duced within the body, is the cause. Rheumatic fever affords a specimen of this class. FEVER, OR PYREXIA. 65 For convenience the general characters of fever will be first con- sidered, and then pointed out individual forms which occur. 2. It may be due to some local lesion or disease in some organ or tissue,as an inflammation. This is called the " pyrexial state," or secondary, symptomatic, or merely pyrexial fever. The fever attend- ing pneumonia illustrates this class. Essential Phenomena and Symptoms. — 1. Elevation in temperature is considered the only essential sign of fever. If excessive heat obtains, a febrile condition exists. The patient feels a sense of abnormal heat, or the skin feels hot to the touch. These methods of knowledge are unreliable; the thermometer is the only positive test, if fever is thought to exist. The tempera- ture may be only slightly above normal and does not usually exceed 105° or 106°, but may rise to 108°, 110°, or even 112° Fahr. In certain cases it may continue to rise a considerable time after death, as in puerperal peritonitis. 2. Alterations in the Secretions. — They are diminished in quantity as a rule, due to deficient elimination of water, it being retained in the body. Hence some prominent symptoms result ; as dryness and roughness* of the skin ; although occasionally there are cases of profuse perspiration. Derangement of the alimentary canal. The salivary, gastric, and enteric secretions are deficient; hence a furred tongue ; a clammy mouth ; thirst, but no appetite ; the bow- els are usually constipated; nausea and vomiting often occur. Urine is scanty and high-colored, very acid, with a high specific gravity and a strong odor. It is altered, containing an excess of its organized nitrogenized elements, such as uric acid and urea. There is also an increase of hippuric acid, sulphates, phosphates, and often, not always, coloring matter. The alkaline chlorides may be absent, and always deficient. 3. Changes in the Circulation and Respiration. — The pulse usually bears almost an exact proportion. to the temperature, as a rule. It is increased in frequency, and may increase from normal to 120, 140, or even 160, beyond which it cannot be accurately counted. In other respects it greatly varies in different cases. It may be- come very weak in long-continued or severe cases, irregular or intermittent, due to feeble action of the heart. The use of the sphygmograph indicates the state of the circulation in lever cases. 66 FEVER, Alterations in the Blood. — The alkalies are diminished, and the alkalinety of the serum ; in a brief period the red corpuscles and albumen diminish, while the white corpuscles increase. The fibrin is much above the normal quantity in some forms of fever, in others it is much reduced. Change in Respirations. — These are usually quickened in propor- tion to the pulse ; its ratio is always disturbed, mostly in excess. The elimination of carbonic acid increased on the whole, due to increased frequency of respiration. 4. Disturbance of the Nervous System — In the early stage, rigors or chills ; general soreness or pains ; a general feeling of languor, exhaustion, and disinclination to effort. Special local pains and headache are frequent in some fevers. Restlessness, insomnia, and nocturnal delirium are quite common. In certain cases great nervous derangement, indicated by great prostration ; delirium, either muttering or violent; stupor or somnolence, tending to coma ; muscular disturbance, as tremors, subsultus teudinum ; picking at the bedding, or at imaginary objects, convulsions, show the great disturbance in the nervous system, incident to fever. 5. Modes of Termination. — These symptoms, which are varied greatly in different conditions of fever, lead to an inquiry as to how it may be terminated, or how defervescence may be attained. 1. By Crisis. — This is indicated by a fall in temperature of the body, becoming normal in a few hours ; an increase in the various excretions, indicated by copious perspiration, a free flow of urine containing much solid constituents, or watery dia.rrhoea. A hem- orrhage sometimes occurs, as epistaxis, etc. 2. Lysis. — This term signifies a gradual defervescence, the temperature subsiding regularly and slowly, several days, to the normal standard, without critical discharges. 3. By a Combination of Crisis and Lysis. — In such a case there is a rapid fall to a certain point, then a gradual lowering of the temperature, or there may be, ( for days, a regular alteration of high and low, until the fever subsides. 4. Defervescence is occasionally very irregular in its course and progress, and during convalescence the temperature and the amount of excretion are often lower than normal. FEVEE, OR PYEEXIA. 67 III. Type of Fever. — The symptoms of fever, as described, are very variously associated with it, and present a large range in their severity and course, which gives recognition of certain types. Types Depending Upon the Course and Mode of Progress of the Symptoms. 1. Continued. — This includes all fevers without any marked variation in temperature at different periods of the day. Acute specific fevers, as small -pox, scarlet fever, etc., and those accom- panied with inflammation belong to this type. In these the tem- perature rises more or less rapidly, up to a certain degree, remain- ing stationary for a time ; finally defervescence occurs in one of the modes mentioned. 2. Remittent. — This has marked remissions in temperature and other symptoms, succeeded by exacerbations This variety is quite common in a warm climate. " Hectic " fever is also charac- teristically remittent. 3. Intermittent. — In this type, intervals, with stated periods, run a regular course, and it has a cessation of all fabrile symp- toms, which return at certain regular periods, and run through a definite course, the temperature in intermission remaining quite normal. Examples are found in the various forms of ague. 4. Relapsing. — As the name indicates, after the continued type of some forms of fever, defervescence and apparent recovery occurs, then, after some days, a relapse takes place, which may occur more than once. Within a few years past, epidemics of this type have occurred. Types Depending Upon the Combination and Severity of Symptoms. 1. Simple. — Ordinary " febricula " is a good example of this* A simple expression of fever, with all the characteristics, without any degree of severity. 2. Inflammatory. — This type is always associated with local acute inflammations, at first, as the name indicates. It does not invariably bear a proportion to the intensity and extent of the inflammation. The young, and plethoric, and those of a sanguine temperament are most subject to it. 68 FEVER; OR PYERXIA. The symptoms are marked, varying in severity and of a sthenic character. At first there are distinct rigors or shivering, followed by a good deal of reaction ; the temperature is high, the skin is dry and hot. There is headache, and pains in the limbs. The frequent, strong and full pulse shows that the vascular excitement is high. The blood contains an excess of fibrin. The tongue is thick-furred, but moist, and the breath is offensive ; great thirst, with total loss of appetite, and constipation. The urine is scanty and very febrile. The patient is restless and sleepless, with noc- turnal delirium ; occasionally great nervousness exists at first, especially in children, such as delirium and convulsions. 3. Hyperpyrexia!. — In this the temperature rises very high, varying from 107° to 112°, or above ; ascending rapidly, and attended with serious symptoms, which are referable to the nerv- ous system and organs of respiration, and tending to an early and fatal termination. Sunstroke, acute rheumatism, and pneumonia are the most frequent examples of this type of fever. Low Types of Fever. Asthenic, Adynamic — The temperature only slightly above normal ; patient very weak ; pulse is feeble and small, though frequent, and there is prominent febrile reaction. There is little thirst, and the tongue continues moist. There is usually nocturnal delirium, without much other brain symptoms. Typhoid, or Ataxic. — " The typhoid state " presents some im- portant distinctions from the Asthenic. The tongue is dry, and covered with a brown crust ; " sordes " covers the gums and teeth ; the heart's action is impaired ; the pulse is weak and compressible and often intermittent ; there is a tendency to capillary conges- tion in depending parts ; the brain symptoms are marked, such as low, muttering delirium, muscular tremblings, stupor, closing in coma. Malignant. — This is of low type, and prone to hemorrhages and petechse, hence it is malignant. The terms " septic "' or " putrid '' are applied to this type of fever. There is another malignant form in which some poison seems to act so violently as to knock down the subject of it without local lesion or reaction. Hectic. — This attends great drains from the system, as in phthisis, FEVEK, OK PYKEXIA. 69 and is distinctly an intermittent or remittent type, the exacerba- tions usually occur once, occasionally twice, in twenty-four hours. At first there is only a slight eveDing rise in temperature, and quickening of the pulse ; at length it increases, beginning with chilliness or rigors, succeeded with much heat toward evening,, increasing to or beyond midnight, and is followed with a profuse sweat, until the clothes are saturated. The heat is great, with burning in the palms of the hands and soles of the feet. There is a circumscribed, bright red spot on the cheek, a hectic flush. The pulse is easily excited, usually above 100 per minute and may rise during the paroxysm to 120 or 130. It is generally jerky, soft and compressible. The respirations are short and hurried. Eapid emaciation attends this fever and the patient finally is ex- ceedingly exhausted. The mind is unaffected until late in the case, it is often lively and brilliant. Pathology. — This includes the cause, nature, and events in the course of fever. Some local irritation, or poison in the blood, may originate it, by acting on the nervous system, producing meta- morphosis of the bodily structures, and rapid wasting of fat and nitrogenized tissues, hence the muscles waste ; also there is atro- phy of the nerve centres, ganglia and nerves ; the bones become lighter, and the red blood-globules are diminished in number. The glandular organs are often enlarged and congested, especially in healthy and young subjects. The cells of the spleen, liver, and lymphatic glands enlarge and become granular. There is an excess of substances produced, which the normal processes form, such as carbonic acid, urea, uric acid, etc. Inter- mediate products of decomposition are prone to form. There is no certainty as to the place where the change occurs. The results of this destruction are very important, and are next considered. 1- Increase of Temperature. — This is caused by the chemical and vital changes in the blood and tissues, while the various sub- jects undergo oxidation, or combustion, to an abnormal degree . The febrile temperature is in proportion to these destructive pro- cesses, as evinced by the quantity of material eliminated in the various excretions, and otherwise. The amount of perspiration, which is usually suppressed in fever, adds to the increase of tem- perature, Dr. Beale holds that there is great increase in the bio- 70 FEVER, OR PYREXIA. plasm of the blood, vessels, and tissues : and that insufficient oxida- tion loads the blood with noxious materials, which the excretory organs are unable to remove. This condition of the blood favors the growth of bioplasm. He thus accounts for the increase of temperature. Excessive Excretory Elimination. — There is, as a rule, a propor- tion between temperature and the amount of excretion. To this there are exceptions. The usual metamorphosis of tissues forms an abnormal quantity of the solid constituents of the urine dis- charged, especially urea and uric acid, and an increase in the quantity of carbonic acid exhaled. In the progress of some fevers there is little or no elimination, and the products of metamorphosis are retained in the blood in great excess. Substances are pro- duced which the kidneys cannot remove, hence critical discharges are more common at the termination of fever, or this favorable event may be due to these discharges. 3. Results of Deficient Elimination. — Typhoid fever results from the poison of retained products of metamorphosis. The cir- culation of these through the nerve-centres and tissues produce the low symptoms, The nervous symptoms have been referred to excessive temperature ; or to the plugging of minute vessels of the gray matter with white corpuscles. Secondary Inflammations. — These are caused by the irritative action of the products of destruction of tissue circulating through the various organs and tissues. Emaciation, Debility and Prostration. — These conditions natur- ally result from waste of tissues, and are in proportion to the activity of their destruction. Very little food is taken or assim- ilated to supply this vast waste. Effects on the Circulatory System. — The heart is early excited, and finally becomes greatly disturbed and impaired, for obvious reasons : Degeneration of the muscular fibres and their impair- ment ; it is supplied with impure blood and imperfect nerve stim- ulants. Changes in the pulse ; tendency to hypostatic congestions and abnormal state of the blood-vessls and tissues , the excessive growth of bioplasm, and blocking up of the capillaries are the resulting events. These are the main or general points in the pathology of fever, to which may be added : The retention of water FEVER, OR PYREXIA. 71 in the body, G-elatin, which has affinity for water, has been said to form in the blood. There is no proof of this theory. Prognosis. — There are certain conditions which always enhance the prognosis of fever ; 1. Its Intensity. — Danger is in proportion to its intensity. Ke- coveries are very rare after the temperature has risen above 107°. Eecent cases treated upon a new and vigorous plan go to show recoveries after that temperature has been exceeded. 2. Its Type. — Most forms of fever are grave maladies, and any tendency to seriously affect the nervous system, as typhoid or ady- namic symptoms, excite anxiety. 3. Defective Elimination places, a patient in great peril, especi- ally if associated with very high temperature. 5. The Previous State of Health of the Patient. — Kobust, plethoric young persons are generally more serously affected than those of opposite condition. Some diseases increase in danger, such as gout ; the presence of diseased organs, especially the heart and kidneys, complicate cases very much. General Treatment. — This will depend upon the cause and nature of the fever, and whether it is primary or secondary, Every case must be treated on its own merits. 1. Diminish the Temperature, if Excessive. — One of the most efficient means for this purpose is the external application of cold. This acts by increasing elimination by the skin, and moderating the destruction of tissues. Dr. Beale thinks it is by diminishing the growth of bioplasm. There are various other modes of applica- tion, such as sponging the surface, of the body with water, either tepid or cold, as best adapted to the case; by cold affusion or douching, which may be done while the patient is in a warm bath ; by a wet-packing in a sheet ; by placing the patient in a warm or tepid bath, then gradually reducing the temperature, by gradually removing the warm and adding of cold water ; by the proper use of cold baths; by injecting tepid or iced water into the rectum ;. by pulverized ice in bags, which are sometimes applied to the head, spine, chest and abdomen, separately, or at the same time. After being kept in the bath for a variably time, according to necessity, the patient should be wiped dry, followed with brisk 72 FEVER, OR PYREXIA. frictions, and removed to bed, and hot applications to the feet. Eepeat the bath several times, if necessary, and apply ice at intervals. Ordinary cases require only frequent sponging of the surface, which is often decidedly beneficial, giving great relief. Cold is extremely valuable in cases of high temperature, or shows a ten- dency to high elevation. This is sometimes indispensible to recovery. The more appropriate medicinal agents to lower the temperature are* aconite, veratrum virida," and digitalis. These reduce the pulse, and thus the temperature, and act, more or less, upon the organs of secretion. Quinine is used to check the ascent, and lower the temperature, and is useful when properly employed. Dilute sulphurious acid has been much extolled for this purpose. 2. Watch the Excretions and observe whether there is the proper elimination. Heroic eliminatory treatment^in fever is not judicious. The use of aperients, or mild purgatives,, diuretics and diaphoretics, are the better means to employ. Examine the excretions daily, especially the~ urine. If symp- toms indicate the accumulation of urea in the blood, appropriate energetic eliminatory measures are required, suclr as free action of the bowels and kidneys. Diaphoretics and diuretics, such as saline mixtures containing citrate of potash or amonia, or liquor amonia] acetatis, with the free use of diluent drinks. The use of baths to increase the action of the skin ; hot poultices or fomentations over the loins; simpisms or dry cupping may be required in grave cases of poisoning by urea in the blood, due to want of renal excretion. Great caution is requisite not to weaken the patient. Employ supporting measures. Saline aperients are better than purgatives. Diarrhoea may be the " natural mode of eliminating a poison," but if excessive, it must be diminished (not suddenly checked) by appropriate remedies. 3. Proper Food and Stimulants — This is one of the most difficult and essential parts of the treatment of fever. The food must be nutritrious and capable of assimilation. Good milk, cream, beef tea, eggs, etc..|are valuable articles of diet. The food should be given frequently and at regular intervals; in definite and moder- FEVER, OR PYREXIA. 73 ate quantities ; the patient must not sleep too long, without nutri- tion. Definite rules are impracticable, as every case must be treated as circumstances require. Large quantities of nutriment are indispensible in treating low forms of fever. Alcoholic stimulants are not always required. Their indiscrim- inate use does great harm. In a large number of cases and in certain conditions these are indispensible. It requires great caution and much experience to suitably administer alcoholic stimulants ; the proper amount, etc. Great caution is necessary to obtain pure spirits. Wine, brandy, or whisky generally answers best. These should be given either diluted, or in the form of milk-punch, egg-nogg, etc.; in definite doses and at proper intervals. The conditions when its use is indicated may be under- stood by the nature of its action. 1. Its direct action on the nerves of the stomach. It immediately stimulates the heart's action, and thus promotes the capillary circulation. 2. After absorption in the blood, it alters the constituents and chemical properties of the fluids and solids, and cuts short the life of rapidly growing bioplasm, or causes it to live more slowly. 3. It reduces the permeating influence of the blood serum ; renders the walls of the vessels less permeable to fluids ; checks the disintegration of blood corpuscles, and has a direct action upon the particles of naked and living bioplasm. These are the good results of alcohol in cases of fever and inflammations, but only when indicated and wisely employed. 4. Hygienic Conditions. — Attention to these is of vast import- ance in connection with fever. Free ventilation is essential, to obtain plenty of pure, fresh air, and to drive out that which has become vitiated. Cleanliness must be carefully observed. Rest and quiet of mind and body must be required. 5. Special symptoms appear in the course of fever, demanding special treatment. Those indicating adynamia, or typhus, invite free stimulation ; ammonia, ether, camphor, quinine, nux vomica, hydrastin, belladona, mineral acids, etc. Stimulants and tonics, prudently given, and the application of sinipisms over the heart. Compounds of phosphorous and strong coffee are recommended as restoratives. 74 FEVEE ; OH PYEEXIA. Symptoms of exalted nervous excitement are often very trouble- some. Hypnotics, to procure quiet and sleep, may become. neces- sary, and may be usefully combined with stimulants. If delirium or tendency to coma be present, free douching of the head with cold or tepid water may be beneficial. Ice-bags may be required ; often the application of sinipisms, or a blister to the nape of the neck, or sinipisms to the legs and feet are indicated, and often re- sult beneficially. If nervous symptoms are connected with the retention of excre- tions, efficient means must be employed to alleviate them. Symp- toms referable to the digestive organs also often call for special attention- Nausea and urgent thirst are best relieved by the fre- quent taking of small pieces of ice in the mouth, and they are precious to suffering fever patients. Vomiting and diarrhsea often occur, and must be controlled by remedies to be mentioned when considering those symptoms. 6. Local complications such as hypostatic congestion, and in- flammation of the lungs, must be carefully watched for and guard- ed against. Position of the patient will have influence against these, as elevating the head and chest, and by frequent change of posture. Cough and expectoration must be promoted so as to dis- charge the bronchial mucous accumulations. Bed sores are liable to form, and great care is required to prevent such an additional iction. 7. Convalescence requires watchful care. The practitioner's duty is not completed when a severe fever has run its course and subsided. Special directions as to diet, hygiene, habits and rest or a ■ tives are necessary. ISTormal appetite, digestion and assimilation may be secured, by tonics, etc. Excessive muscular exertions and fatigue must be avoided until the return of normal strength will fully warrant such a venture. A relapse from any cause is a great misfortune. CLASSIFICATION OF DISEASES. 75 SECTION III. It is now in order to consider individual diseases, and their clinical character. Every abnormal condition of the body, or any part of it, either in function or structure, are included in the term disease. The Nomenclature and Classification of diseases have been sub- jects of much controversy. They are variously arranged by differ- ent able authors and by distinguished bodies of medical instructors. As a source of information it is proper here to record some of the principal ones. CLASSIFICATION OF DISEASES. The following classification by Dr. Farre has received quite exten- sive approbation : CLASS I. Zymotic Diseases. — Zymotici. Diseases that are epidemic, endemic or contagious ; induced by some specific matter, or the want of food, or by its quality. In this class are four orders. Order 1. — Miasmotici. Examples: Small-pox, Hospital Gangrene, 2. Enthetici (implanted diseases). Ex.: Syphilis, Hydro- phobia. 3. Dietici. Ex. : Scurvy, Alcoholismus. 4. Parasitici. Ex : Scabies, Tapeworm. CLASS II. Constitutional Diseases. — Cachectici ; sporadic diseases, affect- ing several of the organs of the body. Order 1. Diathetici. Ex.: Ansemia, Cancer. 2. Phthisici. Ex.: Scrofula, Phthisis. 76 CLASSIFICATION OF DISEASE. CLASS III. Local Diseases. — Monorganici (affections of one organ). Order 1. Brain Diseases. Cephalici. 2. Heart Diseases. Cardiaci. 3. Lung Diseases. Pneumonici. 4. Bowel Diseases. Enterici. 5. Kidney Diseases. Nephritici. 6. Genetic Diseases. Genetici (or organs of repro- duction). 7. Bone and Muscle Diseases. Myostici. 8. Skin Diseases. Chrotici. CLASS IV. Developmental Diseases: — Metamorphici. Order 1. Of Children. Paidici. 2. Of "Women. Gyniaci. 3. Of the Aged. Geratici. 4. Of Nutrition. Atrophici. CLASSIFICATION BY THE COLLEGE OF PHYSICIANS AND SURGEONS. GEOUP I. 1. General Diseases. — These affect more or less the entire system, and though local morbid conditions are often present, they arise secondarily, or as the necessary or accidental consequences of the general disorder. Under this class are included : (a ) The various idiopathic fevers and certain other affections, which are due to the action of a specific poison on the system, introduced from without. Ex : Scarlatina, Small pox, Ague, etc. (6.) Constitutional Diseases. — These depend upon some unhealthy condition of the blood, or cachexia, which is usually revealed by local lesions, occurring in several parts of the body at the same time, or in succession. Many of them are produced by a morbid poison, either entering from without, or more commonly generated within the system, or handed down by hereditary transmission. In some of these diseases no such poison can be detected. Ex. Kheumatism, Scurvy, Cancer, etc. : CLASSIFICATION OF DISEASES. 77 GROUP II. II. Local Diseases. — Under this group are described the various affections of the different organs and tissues in succession, and certain local manifestations of constitutional maladies. The foregoing classifications of diseases are among the chief ones now followed by authors on the Practice of Medicine The chief character of this work is intended to be essentially and thoroughly practical Not for a moment is it intended to allow this utillitarian end to escape the mental view. It is the aim to point out how to recognize and how to cure disease. Therefore a servile adherence to any particular form of classification is not important, when a more direct method can be employed. 1. General Diseases. There are certain subjects which bear upon diseases, in general, which require consideration, and the methods to be adopted for their clinical investigation, before introducing the important sub- ject of individual diseases. CHAPTER I. ON CONTAGION. This is a momentous question. It is connected with various other maladies, but its chief interest is associated with acute specific fevers. Contagion strictly signifies the propagation of disease by contact. In a general sense a contagious disease is a disease capa- ble of being 'transmitted from one animal, or person, to another, either of the same or different species. The agent by which it is so transmitted is the " contagion." 1. Origin and Source of Contagion. — What was the origin of the various contagious poisons, and whether they can be produced de novo, are questions of no practical importance. Possibly a few contagious diseases are thus generated. The mass of these mala- dies which claim our careful investigation are transmitted from one human being to another. Some are transferred from some animal 78 CONTAGION. to man, as vaccina, glanders, hydrophobia, malignant pustule, etc. These can be retransmitted to the same or another animal, in a modified form, in some cases. Conditions under which it Exists, and Modes of Propagation.. — It exists under various forms, and is eliminated in different ways That one distinct class of these affections are due to animals or plants and their germs, is obvious, as in the various forms of tinea, and scabies, etc. It is believed to be associated with various kinds of organized cells in other cases, such as those of tubercle, cancer? etc. Pus, or other material, is often the agent for conveying the poison derived from pustules, or an inflamed or ulcerated surface, as in gonorrhoea, syphilis ; glanders, small-pox, and puerperal peri- tonitis. It may be contained in vessels, scabs, etc. Many conta- gious poisons are exhaled and excreted from the body, especially from the skin and lungs without palpable existence ; the breath alone is supposed to convey whooping-cough, while others seem to exist in all the exhalations and secretions, as small-pox. The shedding epithelium furnishes abundant poison in scarlatina. Cholera is believed to be conveyed only by the fceces, and typhoid fever through drinking water. A special secretion in the saliva only can transmit hydrophobia. A contagious poison may be con- veyed directly by the blood, and the emanations from the dead body of an affected person may produce it in another person, and continue to do so some time after death. How Transmitted, and how it Gains Access. — Contact of the poison with punctured or abrased tissue is sometimes required, so as to insure absorption, as in inoculated vaccini. It may occur on an ulcer or abrasion, as in hydrophia, syphilis, etc., or without abra- sion on a mucous surface, as in purulent opthalmia, and gonor- rhoea. Parasitic diseases are propagated by contact, as scabies; and malignant pustule by the fluid soaking through the skin. What constitutes Infection.-- Many contagious diseases give off their poisons into the surrounding atmosphere. These inhaled, swallowed, or absorbed by other persons constitute infection. It may get into food and drink, as milk, water, etc., and thus infect and spread. It may attach to clothes and various fabrics, which are termed " fomites,"' and are capable of retaining the poison in great activity, for a long period, and thus convey their several dis- CONTAGION. 79 eases to distant places, the poison tends to weaken with the lapse of time. Persons passing from the sick often convey disease to the healthy. Clothes sent to be washed, or sent from an infected school ; or by letters, cabs, and numerous other agencies. Furniture, walls, floors, curtains, etc., act as " fomites," may infect, often after a long interval, when not carefully disinfected. Flies and other insects are believed to convey contagion. Drinking-water is thought often to contain drainings from excreta and to become a dangerous agency for cholera and typhoid fever. After contagious poison has reached a person it attaches to the skin, mucous membrane of the nose, throat, respiratory, and ali- mentary passages, etc., and may penetrate into the air-cells of the lungs. It passes through B the thin membranes and imbeds in the thick mucous tissue, through which it gradually finds its way into the minute interstices between the epthelium cells of the skin. In this manner it penetrates the minute capillaries and lymphatics, entering them and is conveyed throughout the body. Absorption is facilitated by a moist, soft, and swollen skin, or by distended and weak capillaries ; by wounds or abrasions, and a relaxed condition of tissue, such as the uterus after delivery. 2. Degree of Contagiousness of Different Diseases. — There are var- ious degrees of contagiousness in different diseases. Small-pox and others readily communicate typhoid fever ; and others are uncer- tain; many modifying influences always attend The contagiousness of a disease is in proportion to the quantity and intensity of the poison ; a very minute quantity is sufficient in some cases. The violence of contagion varies at difterent periods in a disease, or an epidemic. The mode of application modifies it ; inoculation is obviouslv most certain, it being weakened by transmission through successive persons; and if largely diluted, it is correspondingly less likely to take effect If certain liquids, containing contagious particles stand some time, the poison subsides, so that the upper portion loses its effect, and the particles may also be separated by thorough filtration. The temperament, constitution, state of health, and previous habits modify the effect. A previous attack sometimes, not invariably, protect against, a second attack, and a second is 80 CONTAGION. usually mild. Two of these affections seldom occur at the same time in the same person, and if so, they modify each other ; and in some instances, one protects against another, either temporarily or permanently, or greatly modifies, as in cow-pox and small-pox. Without apparent reason some persons seem quite insusceptible to certain infections, possibly having occurred during intra-uterine life. Unfavorable Irygienic conditions increase the virulence of con- tagion. Water is said to intensify the contagion of cholera and typhoid fever. Seasons and climates considerably modify some diseases requiring a high temperature to develop them, and others are checked by great heat. The direct application of great heat or extreme cold, and certain chemical agents, are potential in destroying contagious poisons, or neutralizing them. Upon these we depend, to a great degree, to check the spread of contagious diseases. Chlorine, hypochlorite of lime, sulphuric acid, sulphites , carbolic and cresylic acids, chloralum, and Condy's fluid, are among the best active substances as disinfectants. 3. Nature of Contagion. — Those diseases due to parasites, the special animal or plant is the contagion. As to ordinary infection, it is pretty well settled that it is quite distinct from pus, or any material with which it may be associated, and which only forms a vehicle for the poison. In each disease there is a specific poison, capable of producing this one and no other, and without its action upon the system it cannot occur. This is named a " contagium," "virus," " zyme," or "ferment." The chief theories as to the nature of this poison are : 1. It is a " suttle entity " impossible to detect. 2. It is a chemical substance, most commonly supposed to be in the form of a volatile gas, and as knowledge improves, may be isolated. 3. That it is some "albuminoid matter, in a state of rapid change " causing a fermentative or zymotic action in the blood and tissues (hence the name "zyme 1 '). 4. The "germ theory" is now most gener- ally held, that every contagious disease is due to living germs, each specifically distinct from all others. As to the precise nature of these germs, opinions are divided into two theories. 1. The majority believe that they are really microscopic para- CONTAGION. 81 sites. Some holding that they belong to the vegetable, and others to the animal kingdom, such as minute fungi, vibriones, bacteria, etc., or their germs. Bodies of this nature have been noticed in- the contents of vesicles, pustules, blood, secretions, excretions, etc, in some of the infectious diseases, as vaccini, small-pox, cholera, and typhoid fever. These have been termed micrococi, micro- zymes, microphytes, microzoaires, etc. 2. Dr. Lionel Beale argues that the germs are not parasitic, but are extremely minute particles of living germinal matter, or bio- plasm, which present no differences in appearance in different diseases, even under the highest powers of the microscope, but have an essential difference in vital power.* 4. The effects of the action of the " contagion " upon the system and the change it undergoes — The results may be local and super- ficial, as scabies, and gonorrheoea, or at first local, and subse- quently become constitutional, as syphilis. As a rule the first action of the poison is upon the general spstem, usually followed by local lesions. Attention here will only be called to this last course of events as connected with specific fevers When the poison of a " specific fever " enters the body, it either produces some primary change in the blood, or acts upon the nerves, or both. The blood loses fibrin, changes its chemical ele- ments; a fermentative or zymotic action begins; the germs rapidly multiply at the loss of albuminous elements of the blood, walls of the vessels, and tissues. At first there is a period of incubation, tolerably definite for each disease, during which there are either no s3Tnptoms, or none of any definite character. In hydrophobia this incubation may last for months, and that of others is often indefinite, but whether long or short, at its close there appears mn-e or less severe general symptoms, the onset of which is usually well marked by rigors or chills, etc., of a febriale nature, and there are often some local symptoms. If the poison is intense, and its increase rapid, death may occur without structural lesion. If this event does not occur, the local disease is manifest after a certain time, which may be limited to *Only a mere outline of this subject can be given in this part of the subject. Those wishing to pursue this interesting topic are referred to the writings of Burdon, Sanderson, Beale, Simon, Guy, and others. 82 CONTAGION. one tissue or organ, or several parts, constituting its anatomical characters. The various eruptions in contagious fevers, are im- portant local signs of these affections. The symptoms subside after a certain period, and if fever existed defervescence occurs, the poison ceases to increase and is finally expelled, and structural changes may or may not result. There is considerable uniformity in the course of the various stages and duration, and in the entire affection from the beginning to the end. An acquaintance with the " natural history " of each malady is important. Complications and sequelae are frequent, which interfere with the natural course- Intensity is very various ; some are mild ; others assume a typhoid or malignant type, proving very fatal. Epidemics sometimes show these peculiar types. Elimination of Contagious Poisons. — The various theories are : 1. The living particles make their way out of the vessels, and through the tissues to the surface. 2. They are conveyed out- ward, suspended in the fluid which transudes from the small vessels. 3. The poison is directly eliminated by the epithelial and secreting cells especially those of the skin, kidneys, and intes- tines. By this theory the cells attract and separate the virus, and are then cast off, and replaced by new cells. The adherents of this idea regard the eruptions epithelial desquammation, diarrhoea, etc., efforts of nature to eliminate the poison. They base a special treat- ment on this idea to assist nature in this " eliminatory " process These views are very strongly opposed. Dr Beale argues that the cells possess no eliminatory power, but that the poison actually de- stroys them, and this is the cause of the shedding of epithelium, as observed after scarlet fever. On Epidemics. The manner in which most diseases are disseminated among mankind is naturally divided into three classes, viz : 1. Sporadic, those which occur in an isolated and scattered manner, and do not affect a large number of people at the same time, as bronchitis, etc. 2. Endemic, those which are peculiar to some districts, or constant- ly prevalent in such districts, more or less, as ague, etc. 3. Epi- demics, those which suddenly attack large numbers of people, and spread rapidly among them, often producing terrible devastation and dismay ; this occurring at regular intervals, as cholera, etc. EPIDEMICS. 83 The term Zymotic now includes all epidemic, endemic, and con- tagions diseases which can be prevented by proper attention to hygienic and other conditions. Miasmatic is a term applied to specific fevers, caused by malarial influences. Epidemics are supposed to be produced by some influence, the nature of which is, in most cases, quite unknown. An epidemic may occasionally be distinctly traced to the influence of contagion, aided by unfavorable hygienic conditions, or some obvious cause, as famine. Its origin cannot be thus definitely fixed, as a rule ; certain maladies occur as epidemics, which are probably not in- fectious, as influenza, &c. The facts observed relating to epidemics may be briefly stated : 1. Epidemic influence chiefly affects those diseases which are infectious, rendering them more prevalent and dangerous ; or ma- larial affections, as those caused by poison due to the decomposition of vegetable matter. Only one of these is epidemic at the same time, as a rule; sometimes there seems to be a tendency to the prevalence of several acute specific diseases together. Sometimes other maladies appear to assume an epidemic form, and occasionally a new disease appears in this manner. Ordinary diseases, only, are sometimes thus influenced, or have a tendency to influence special organs. 2. A prevailing epidemic affects more or less the type of other diseases ; thus, choleraic diarrhea is prevalent when cholera pre- vails, and catarrhal affections are common during the prevalence of influenza. 3. The extent of an epidemic varies widely. If it is very severe, it usually appears in different places in succession, abating in one region as it invades another. It may confine itself to a certain district, being then usually due to some palpable local cause. 4. The progress is subject to variations. Generally it is regu- larly onward in a certain direction, and in this manner an epidemic may make a circuit of the globe. It may make a very rapid stride, or proceed very slow and gradual. Epidemics sometimes leave a place and then return ; or pass over special regions ; or go out of their direct course in a lateral direetion, affecting parts out of their proper line of progress. They frequently advance directly against the current of winds. 9* 84 EPIDEMICS. 5. The mode of invasion of epidemics may be sudden or less grad- ual, usually the latter. An epidemic usually gives indications of its approach by some mild form of symptoms, as cholera is usually preceded by diarrhea ; or a few sporadic cases may first occur, giving warning of its approach. 6. The. intensity of an epidemic is very various, sometimes ex- cessivety fatal, and other times comparatively mild. As a rule, it proves most fatal in its early period, and gradually becomes milder until it ceases altogether. This may be explained in part by the fact that those who first suffer are those most predisposed to it, and by the gradual exhaustion of the cause of the epidemic. 7. The duration of an epidemic is very irregular. It may per- sist with remissions, or intermissions, for several years, as has cholera sometimes. 8. Cycles of epidemics have been frequently observed, one disease after a certain period being followed by another, and this by a third, and so on. Eecently a theory has been put forth to explain epidemics ; that there exists what is termed a 'pandemic wave, under the influence of which a series of oscillations of febrile diseases occur, these following each other regularly over the globe. 9. The most interesting and important fact is that epidemics are largely under human control, both in prevention, and in rendering them less severe, by due attention to known hygienic measures, which wall next be explained. The advance of civilization has already extinguished some epidemics from countries and districts where formerly they were excessively rife and destructive In- creasing knowledge of the causes and of the proper sanitary anti- dotes indicate that many epidemics yet existing will also become extinct. 10. Epidemic influences affect animals, as well as human beings, often to a great extent and to a destructive degree. It is not at all improbable that j>lants suffer extensive blight from similar influ- ences, hence the occasional complete or partial failure of crops in wide districts not explainable by the ordinary known causes. Hygienic Treatment of Contagious Fevers. — When treating a patient suffering with an infectious fever, it is very important to prevent its extension to others. This is also highly useful to the welfare of the patient. The physician now becomes more an edu- HYGIEINE IN CONTAGIOUS FEVERS. 85 cator than a dispenser of drugs. The chief instructions and requisite measures are : 1. Separation from other persons as far as possible is a necessity, and in some cases almost complete isolation. Crowding must be prohibited, and only those persons who are required to be in the sick-room should be admitted at all. These should wear clothes to which contagion cannot easily adhere, and go as little as possi- ble among healthy people. Practitioners ought to observe due precautions against conveying any contagion themselves, or allow- ing others to do so. 2. Adequate ventilation is indispensible, by opening the windows freely, even at night, care being taken to protect the patient from draughts. It will not suffice to merely give orders, but show how this should be done. 3. All surplus curtains, bed-clothes, carpets, and other materials which can act as "fomites," must be removed. Ventilation is also promoted in this manner. Nothing should interrupt the circula- tion of pure fresh air. 4. Cleanliness must be observed in the most scrupulous manner, as to the patient, bed, clothing, rooms, &c. 5. Persons who come close to the patient should avoid inhaling the breath, or exhalations, and not afterwards swallow their own saliva, but clean out the mouth and nostrils. Thus may the disease sometimes be prevented from being taken by visitors. 6. Disinfection or destruction of everything which may convey the contagion. All exhalations and discharges should be immedi- ately disinfected. Anything coming off from the skin can be best destroyed by frequent sponging with a disinfectant. The room should be perceptibly impregnated with a volatile disinfectant, such as chlorine, carbolic acid, sulphurous acid, or chloralum, &c. A good safeguard is to hang across the doorway a sheet, kept moistened with dilute carbolic acid, Condy's fluid, Burnett's fluid , or chloralum, Secretions of the mouth and nose ought to be re- moved with disinfected rags, and those immediately burned. Ex- cretions should be received into vessels containing a disinfectant, and mixed thoroughly with it before conveying them from the sick- room. This is indispensible when treating cases which are known to be propagated by the evacuations, as typhoid fever, cholera, &c, 86 LIMITATION OF EPIDEMICS. and, if possible, convey the stools to a separate closet, and fre- quently flood it by a disinfectant, as powder and carbolic acid, chloride, or sulphate of zinc, chloride of lime, or chloralum. All bed-clothes, clothing, &c, must be put into a vessel containing a disinfecting fluid before leaving the room to go to be washed. Clothes previously worn by the sufferer must be also disinfected. The windows, floor, door, walls, &c , ought to be frequently spong- ed with a material to disinfect them. 7. Any food must not be allowed to remain long in the sick- room, and should not be taken in by any one who is not habitually in the room. 8. After the patient has left the room it must be thoroughly cleaned and disinfected in every nook and corner, then white-washed, or re-papered and painted. Carbolic acid, sulphurous acid, chlor- alum, or chlorine, are most efficient for disinfecting unoccupied apartments. Heat is very valuable for disinfecting bedding, &c. The Prevention and Limitation of Epidemics. When an epidemic threatens to invade any place or district, or already exists, additional precautions are required in proper hygi- enic conditions, and in other measures as well. The uninstructed in this regard must be taught what to do, and '-'compulsory educa- tion" should be enforced, if need be. Competent persons must be appointed to visit every house and see that the proper measures are carried out, especially in crowded and uncleanly places The chief practical instructions and duties are: 1. Cleanliness in every particular is indispensible. Premises must be frequently washed and white -washed. Prevent all over- crowding, and insist upon free ventilation. Look in among the poor, and in common lodging houses, and crowded alleys, &c. 2. Persons who are likely to spread infection must be prohibited from mingling with other people, in private or in public, and from traveling to other parts. 3. Decomposing organic matter, especially, house refuse, should be promptly removed after having been disinfected, or if this cannot be got rid of, mix in it an abundance of disinfectant material. House drains and sinks, street drains and sewers, water-closets, cesspools, privies, ditches, gutters, &c , require careful inspection, and to be kept in good condition. The earth around dwellings is PREVENTION OF EPIDEMICS. 87 often saturated with organic matter, and requires special attention. In removing such from around dwellings, it is better for the dwell- ers to be away if possible, and thus avoid poisonous emenations. Disinfectants must be freely used around houses, and especially in filthy localities. 4. Examine with great care the source of water supply, especially that which is used for drinking, and be sure that no organic matter gets into it from sewers, drains, cesspools, polluted grounds, &c. Waste-pipes from cisterns, opening into drains, must be examined to see whether organic matter finds its way into the water. This is especially necessary when cholera or typhoid fever prevail. Water should always be filtered as a wise precaution. 5. Healthy people may be removed to a locality out of danger of the infection when practicable. It may become necessary to carry out a principle of "quarantine" sometimes to stop an epidemic. 6. When there is any known preventive of an epidemic disease, this must be resorted to at once and generally, as vaccination, when small-pox prevails. 7. The general health of the people should be fostered and pro- moted by every possible means, and all causes that lower the sys- tem, as intemperance, or bad habits and ill living, must be avoided. Those who attend upon the sick should use every precaution. They should dismiss fear, be cheerful, and live upon good nourishing and digestible food, without much stimulants. They require daily exer- cise in the open air and bright sunlight. They also need sufficient sleep, and at proper intervals, observing the most scrupulous care and attention to personal cleanliness. 8. Any one giving the slightest symptoms of the prevailing disease should be without delay brought under the proper treatment. 9. Allow no person who is suffering from an epidemic disease to be brought into a locality of healthy people, if it is possible to avoid such a calamity. The conveyance of such persons by public vehicles is a heinous crime, now punishable by law, in every civil- ized land. Special conveyances are provided, when needed, to remove them to a pest-house or hospital. When such patients are sick at home, isolate them, and in upper rooms, if it is possible to do so. CHAPTER II CLINICAL INVESTIGATION OF ACUTE FEBRILE DISEASES. The largest number of diseases which practitioners are called upon to treat belong to the class of acute febrile diseases. It is essential to have a clear conception of the proper manner of inves- tigating the nature and extent of morbid action in each case, and that a correct diagnosis be ascertained as soon as possible. The special inquiries of the patient and attendants are : 1. Has the patient been exposed to any infectious disease ? Has there been any other obvious cause likely to occasion a febrile con- dition, as a cold, exposure to malaria, &c? 2. Ascertain the exact date, even the hour, when febrile symp- toms began ; the nature of them must be ascertained and noted with care. 3. The subsequent symptoms, in detail, must be inquired about, and the times when they occurred, and those which now obtain. The premonitory symptoms or forming stage of acute specific fevers. Certain local symptoms are usually manifested, differing in each case, and more or less characteristic. Those which require notice are: the existence and severity of general and local pains, as the back, or epigastrium, catarrhal, throat, stomach, intestinal, and head symptoms. Of course, if the fever is caused by inflammation of some organ or tissue, local symptoms will indicate the seat of the mischief. 4. The degree the fever,- or height the abnormal heat has attained, is the most important, because it is conceded that the danger in acute fevers usually bears exact proportion to the temperature above the normal one, also, its course and its mode of progress. To determine the temperature the sense of touch is not reliable, as this at best cannot be more than approximate, or relative. The careful and systematic employment of the thermometer gives pre- cision, and materially aids in determining a diagnosis at an early period. In the exanthemata the fever is of the "continued" type. THE USE OF THE THERMOMETER. 89 The degree of intensity, and rapidity of onset, foretell the nature of the exantheni in many cases, and at an early period. Each is understood to have a definite course of temperature, though ex- ceptions are observed. 5. A skin eruption usually constitutes the anatomical characters (f special fevers. This rule is not without exceptions. There is no cbubt that scarlatina, measles, small-pox, &c, may occur without aiy eruption. When due to inoculation, eruption may be confined to the spot of introduction. As to the eruption, the points to be observed are: 1. the exact time of its appearance; 2. its primary sect., and the mode and rapidity of its extension over the body, if this occurs ; 3. its amount; 4. its precise characters, and the changes it undergoes during its progress and decline ; 5. its duration and seqtel. 6. Careful physical examination of the chief organs of the body, and including the urine, is imperative in all febrile diseases. This may reveal the cause of the fever even where no symptoms point to any particular organ In specific fevers complications are prone to arise, )r some organ or organs are primarily affected ; an early de- tection of such untoward derangement is very important. Hence daily examinations, at least, are requisite, and the principal organs more frequently. The sphygmograph is valuable in indicating the condition of the circulation of the blood. The Use of the Thermometer. There is now a generally recognized value of the thermometer in the investigation of disease, and it becomes necessary to em- phasize the importance of employing it in daily practice, because many omh its use to the desirable extent. ' The instrument used should be sensitive and accurate, of a suffici- % ent range, self -registering, and of a convenient size for carrying in the pocket, or what is now generally called a "Clinical Thermome- ter,-' and is generally furnished by respectable instrument makers. Directions* for Use.' — 1. The Curved Thermometer. — Its bulb must be well fitted into the armpit, being introduced below the fold of the skin covering the edge of the pectoralis major muscle, and so kept in close contact with the skin, completely covered and firmly surrounded by the soft parts. In very thin or very old per- sons this adjustment requires special care. The instrument must 90 THE USE OF THE THERMOMETER. be retained in situ during a period of not less than four minutes; and the height of the mercury in the graduated stem must be read while the thermometer is still undisturbed in the axilla, care being taken that the axis of vision falls perpendicularly on the column of mer- cury in the tube. II. The Straight Thermometer, which is self-registering, must hav* its index set before commencing to take an observation. [N. B — The index is the bit of mercury detached from the colunn in the stem of the instrument.'} 1. This index is to be set by bringing the bit of detached mer- cury down into the clear part of the stem, just below the lhes which indicate the degrees. This is done by taking the bulb tnd stem of the instrument firmly in the hand, and then by a single rapid swing of the arm the index will come down the stem ; and this swing of the arm must be repeated till the top of the incbx is at least below the lines which indicate the degrees. 2. After the index has thus been set, the bulb of the instranent may then be applied to the axilla, or between the thighs, under the tongue, or any part which is completely covered ; and being re- tained in close apposition (by strapping, if necessary) with tie sur- rounding soft parts for a sufficient length of time, the instrument is to be carefully and gently removed, when the top of the index — i. e., the end farthest from the bulb — will denote the miximum temperature during the period the instrument has been in perfect contact with the parts. The patient should have been at perfect rest in bed for at least one hour before observations on tempera- ture are made, and he ought to lie on the side, so as to completely close the axillary space, which is the seat of the thermometer, con- verting it into a close cavity. III. The observations ought to be continued daily, and regular- ly taken at the same hour every day, throughout the whole period of sickness. The most useful periods for observation are : 1. Be- tween 7 and 9 o'clock in the morning. 2. At noon.' 3. Between 5 and 7 o'clock in the evening. 4. At midnight. For most prac- tical purposes, it is sufficient to note the temperature twice daily — morning and evening — with an occasional observation at midnight. IV. In all observations of temperature the pulse and the respi- ration should be noted at the same time. CORELATION OF PULSE AND TEMPERATURE. 91 As a general rule the correlation of pulse and temperature may be stated as follows, namely : An increase of temperature of one degree above ninety-eight degrees Fahr. corresponds with an in- crease of about eight beats of the pulse per minute, as in the fol- lowing table: A temperature of 98 deg Corresponding with a pulse of 72 (Health.) " 99 " Ought to correspond with a pulse of 80 100 " " " " 88 101 " " " " 96 102 " M " " 108 103 " " " " 112 104 " " " " 120 105 " " " " 128 106 " " " " 136 This statement is, however, in some respects arbitrary, and is given for the convenience of comparing different diseases with some standard. In some diseases a high temperature is found with a low pulse, and a low temperature with a high or rising pulse. The pulse, too, sometimes rises in rapidity when the temperature falls, or falls when the temperature rises. In children the records are contradictory. For example : Ac- cording to the observations of M. Roger, and Dr. Holland, the temperature of children is somewhat higher than adults, when placed in conditions favorable to sustenance. At birth the tem- perature of the infant is the same as that of the mother, but quickly falls to 93.4 degrees, or 95.5 degrees, rising in the course of twenty-four hours to 97.7 degrees — i. e., more than half a degree below adult heat (Maclag&n). Between four and six years of age, M. Roger found the temperature to be 98 9 degrees Fahr.; and be- tween six and fourteen years, 99.16 degrees (Carpenter). Dr. Ben- nett states generally, that in children the heat of the body is about two degrees higher than in adults. Having satisfied ourselves as to the delicacy and accuracy of the thermometer, and obtained a standard for comparison, we are pre- pared to appreciate the ranges of temperature in febrile diseases as measured by such an accurate instrument. The maintenance of a normal temperature, within the limited fluctuations just noticed, under all these varying influences, gives a complete assurance of the absence of anything beyond local and unimportant disturbances; and, long before the subject was work- ed out so thoroughly as it has been, it was often casually observed 92 acute febeilejmseases. that any acute disease, however slight, elevates abnormally the temperature or animal heat ; mia and secondary abscesses : in fatal exhaus- tion. After healing of ulcerations in favorable cases there may be troublesome constipation from contraction of cicatrices. Severe and protracted cases may be considered as going through, 1st, the inflammatory, and 2d, the ulcerative stages. Simple acute dysentery is commonly sthenic or active, and inflammatory, without early or great tendeney to prostration. En- demic or epidemic dysentery (the first name is the more correct) is generally asthenic. In this form fever may be absent, or brief, or of a typhoid character. Vomiting is not rare in this, as it is in the ordinary acute form. Coldness and debility come early. Sometimes, in malarial districts, dysentery, like all other mala- dies, may be intermittent ; with daily or tertian exacerbations and intervals. 240 BLOODY-FLUX— TREATMENT. Morbid Anatomy. — Redness, turgescence, thickening, softening, ulceration, suppuration, and occasionally pseudomembranous de- posits, are, after death from dysenter}^ found, in various degrees, in the rectum, colon, and caecum ; chiefly in the lower bowel. The hemorrhage which makes the typical bloody stools, is due to the congested and inflamed mucous membrane being constricted, in the tenesmus, by spasmodic and irregular contractions of the mus- cular coat. Chronic variety : — Most intractable. Often causes atrophy of mu- cous membrane with degeneration of intestinal glands ; or imper- fectly cicatrized ulcers remain in tissues of caecum, colon, or rec- tum. Most cases recover. Sometimes, however, patient gradually wastes : skin gets dry and scaly: improvement one day with relapse the next : discharges of fecal matter, mixed with thin pus and blood, most offensive: the exhaustion, pains, tenesmus, etc., ren- der death welcome. Chronic dysentery presents nearly always ulceration of the rectum or colon, or both. The discharges in this may become almost en- tirely muco-purulent. Causes. — Predisposition to dysentery is common in the latter part of summer ; in cities and neighborhoods from the middle of July to the end of October. Relaxing heat ; cold and wet ; indigestible food: bad water; malaria, etc. TreaTxMENT. — In simple acute form there is always constipation, or obstruction at the place or part inflamed, hence the plain indi- cation is to clear the bowels of all faecal and other matters, and maintain aperient action until the local inflammation subsides, in any form of dysentery, either acute or chronic. This is the essen- tial pathological condition and must be observed throughout the the treatment in every case. A proper cathartic is important, one that will allay, not increase inflamatory action ; such as a full dose of castor oil ; or a compound of senna, jalap and cream of tartar, in proportion of one part of each of first two, and two of the latter. Aid free catharsis by cold mucillaginous enema, also promote sub- sequent aperient action with same. Enamata are very important in this disease throughout. If there be great pain, add fluid ext. of hyoscyamus 3ss to each injection. When there is nausea and vomiting, an emetic is often indicated, as syrup or powder of ipecac. BLOODY-FLUX — TREATMENT. 241 In treating acute dysentery, early attention is as important as in cholera. The patient should immediately take to bed, remain quiet, hopeful and cheerful. The remedy, and which has almost specific action, is ipecacuanha in full doses. Give grs. 25 to 30 of the powder in a small quantity of fluid, with a little syrup of orange-peel, the patient keeping quiet in bed and taking no fluid for three hours ; if thirsty, allovv him to suck small pieces of ice. In from six to eight hours a smaller dose may be given, this depending upon the effect of the first, and the urgency of the symptoms, by which also the subsequent repetition of the drug must be guided, and it may be required for several days. It is proper to give 10 to 12 grains at bedtime for two or three nights after the stools appear healthy to prevent a relapse. If vomiting persists after ipecacuanha has been judiciously tried, hepatic complication or overcharging of the system with malaria may be suspected. Topics. — Local applications over the abdomen are very im- portant and useful, especially warm poultices, fomentations sprinkled with turpentine, laudanum, or chloroform, and sinapisms. Symptomatic treatment is generally required, such as emollient and anodyne enemata, if tenesmus is very severe. Apropriate diet requires the most scrupulous care. The best I have employed is prepared thus: Lukewarm water and new milk, of each one pint; place over a fire in a suitable vessel, add a little salt and break a hen's egg into same; keep stirring until it nearly boils, then set off and stir until luke- warm again, grate a little nutmeg over it. This is palatable and nourishing, may be freely taken, and will generally be retained, when all else is ejected in most cases of persistent vomiting. In the progress of the case beef tea, plain soups, arrow root, sago, raw white of eggs, jellies, &c, may be allowed in small quantities between the periods of doses of ipecacuanha. Stimulants must be avoided, except in typhoid cases, when they may be required to a proper extent. As the patient improves the food may be cautiously changed. 19* 242 BILIOUS DYSENTERY There are two forms of dysentery which require a modifica- tion of the treatment — the malarious, and the scorbutic. The former calls for full doses of quinine, or other antiperiodics, alternating with the ipecacuanha; the latter for fresh fruits and other antiscorbutics. Hygienic measures demand every care, as due ventilation, disinfection, immediate removed of the evacuations and their destruction. As a means of sound discretion these measures are very important, more especially in scorbutic and typhoid cases, for obvious reasons. In Chronic dysentery, the management most essential is to regulate the diet, and attend to sanitary measures for improv- ing the general health. Rest of the bowels and body; wearing a bandage over the abdomen, or a water belt ; frictions over the abdomen with anodyne and irritant liniments ; water com- press over the anus, or gentle douching the same ; tincture of iodine over the left iliac fossa ; anodyne enemata. Tincture of steel in full doses three or four times a day, with 3 to 5 grains of Dover's powder at bedtime, often give excellent results. Any acute or sub-acute exacerbation calls for perfect rest and immediate use of ipecacuanha. Hygienic measures are change of air; removal from a malarial district, or from a tropical region to a salubrious or temperate one ; the wearing of warm clothing ; the use of tepid baths, followed by frictions. Great prudence is required to prevent relapse during recovery. Bilious Dysentery. — This is a distinct form and is quite common in some places, in summer and autumn. If this variety of the malady is allowed to continue more than ten days, the inflammation is prone to extend and involve much of the colon with ulcerations, and the system in a typhoid con- dition of great danger. Treatment.— The disposition to vomit bilious matters, the morbid excitement of the liver, and derangement' of the secre- tions generally, indicate that the treatment should begin with thorough emesis. Ipecacuanha is best for this purpose and should be continued until- the secretory functions are well im- DISEASES OF THE CiECUM, ETC. 243 proved and revolutionized. Then follow with free catharsis of an unirritating character, as named in the common form of the disease to clear the primae viae of bilious and other irrita- ting matters. When this is accomplished the case is usually modified to a simpler character and may be treated accord- ingly. If the case is neglected, or wrongly treated, until it assumes a grave nature as above named, a supporting and soothing treatment will be required as in a severe form of typhoid fever. Diseases of the Cecum and its Appendix Yeemiformis. The derangement of the caecum and its appendix are natur- ally divisible into 1. Functional disturbances; 2. Inflamma- tion of its walls, as cmcitis or typhlitis; 3. Perforating ulcer of the caecum ; perforation of the caecum and its appendix, due to the presence of foreign bodies in it; and 4. Perityphlitis. The size, position, connections, arrangement, and functions of the caecum render this organ one of peculiar interest and importance; its anatomy and physiology should be carefully studied and well understood. The exact functions the caecum does perform are not yet settled or distinctly understood. Its structure and relations imply that its contents must necessarily pass slowly through this viscus. Tiedmann, Cymelin and others hold that its secretions and that of the vermiformis are alkaline in reaction, having for its office the conversion of starch into sugar, the semi-liquefaction of faeces, and the lubrication of the colon. The butyric and lactic acids uniformly present are due to the decomposition of the saccharine materials. The caecal con- tents soon assume a foecal odor, due to the secretion of a volatile oleaginous material. Sulphuretted hydrogen is also generated here. The caecum sometimes bcamcs (nomcusfy disUrdcd, due to various causes. 1 . Dcjcr d( l! i } <. n a ici j: 'c nd t x p r ded 244 C^ECTIS OK TYPHLITIS. colon. 2. Upon a paucity of the caecal alkaline secretion. 3. Upon a weak state of the caecum itself. These abnormal difficulties and distention may be greatly enhanced by the presence of calculi, entozoa and foreign bodies. Ordinarily, from the impaction of faeces and the accumula- tion of gas, pain in the right iliac fossa, more or less paroxysmal is complained of, vomiting is of frequent occur- rence, numbness and pain in the right thigh, retraction of the testicle, and frequent micturition are sometimes observed, due to irritation of the last dorsal and genito-crural nerves. Cjecitis or Typhlitis. — From ccecus, blind; terminal itis. Synon. Typhlitis; Tuphlo-enteritis. — Inflammation of the caecum or its appendix may be caused by accumulation of hard faecal matter, stones, rinds or skins of fruit, biliary and intestinal concretions, balls of lumbrici and oxyurides, etc. The mucous membrane of the intestines is more susceptible to irritation and inflammation during childhood and adolescence than later in life. Symptoms. — In acute form. — Fever, nausea, constipation, fullness and tenderness over and about the right iliac fossa, and pain, made exquisite by pressure. Position of patient on the right side, with trunk bent and knees drawn up to relax painful parts. If the peritoneal coat gets involved, evidence of general peritonitis will become apparent. The areolar tissue around the caecum may also become inflamed (perity- phlitis) and cases may go on to suppuration and abscess. Inflammation of the veriform appendix due to constitutional causes or escape of morbid matter into this part, the symptoms are very acute : such as excruciating tormina, tympanitis, hiccough and vomiting, obstruction of the bowels, great pain extending to the right ovary, or testicle, shooting down inside of the thigh. Gangrene and general peritonitis may follow and cause death, or a portion of large intestine and caecum with appendix may slough off, be passed with stool, and yet, strange to know, recovery may ensue. In cases of tubercular typhlitis ulceration occurs more frequently in the appendix than in the caecum itself. ' DISEASES OF THE LIVER. 245 Chronic Ccecitis. — The symptoms in this malady come on slowly and insidiously. It is characterized by failing health; weakness; loss of flesh; colicky pains in the right iliac region; flatulence; loss of appetite; indigestion; diarrhoea alternating with constipation. If the mucous coat ulcerates, mucous dis- charges occur, and attacks of hemorrhage. Ultimate exhaus- tion usually causes death. Perforation is comparatively rare. Treatment. — In the acute form, saline laxatives; copious warm enemata, using a long rectal tube ; admister anodynes hypodermically; apply hot fomentations assiduously and tur- pentine stupes to the abdomen; stimulants, as Champagne, may be required if the patient becomes much prostrated. Gener- ally, this or similar procedure will fulfill the indications and afford relief. Ice-water to allay thirst and vomiting is often required, and absolute rest. If symptoms of ulceration become manifest, ammonia and bark or quinine and ammonia; egg- nog, milk, cream, raw eggs, beef tea and similar nourishment is required. CHAPTER IY. DISEASES OF THE LIVER AND ITS APPENDAGES. Clinical Characters. — 1. Morbid sensations connected with the liver are referred mainly to the right hypochondrium. They may extend across the epigastrium to the left side, or shoot in various directions. These include different kinds of pain, with or without tenderness, or merely a sense of uneasi- ness, fullness, weight and heaviness. Sympathetic pains in the right shoulder are very common. 2. Some important symptoms result from disturbance of the biliary functions, the chief being those associated with jaundice, 246 DISEASES OF THE LIVEIL with which they will be discussed. Bile may be secreted in excess, or be of bad quality, acting as an irritant, causing bilious diarrhoea and vomiting. 3. Obstruction of the portal circulation leads to mechanical congestion of its tributary veins. The obvious clinical phenomena resulting from this are those indicating gastro- intestinal disturbance, with catarrh and its consequences; hemorrhage into the alimentary canal; distention of the super- ficial abdominal veins; ascites; enlargement of the spleen; and haemorrhoids. After death the veins within the abdomen are often found much enlarged and varicose, and the organs pre- senting the usual morbid changes which follow long-continued venous congestion. 4. If the liver is enlarged, it sometimes gives rise to symptoms by pressing upon neighboring structures, such as the diaphragm, vena cava, or duodenum. 5. Physical examination of the liver may demonstrate either displacement, alteration in shape, enlargement, contraction, or alteration in its characters on palpation. The general char- acters of hepatic tumor are as follows : First. Its seat corres- ponds mainly to that of the liver, or there is a history of its having grown from this direction; it does not descend into the pelvis, but can be traced within the margin of the thorax, and appears superficial; sometimes it is distinctly visible, or bulges out the lower part of the chest. Second. Though the dimen- sions may be very great, yet, as a rule, the normal general outline of the liver can be traced more or less distinctly; while the sensations on palpation are often sufficiently character- istic. Third. The organ is somewhat movable on manipula- tion, but not to any marked extent. Fourth. On percussion there is absolute dullness, with considerable sense of resistance generally; the dullness can be traced upwards towards the chest, and may have the curved outline characteristic of the liver; it is, however, influenced by different degrees of distention of the stomach and bowels. Fifth. The move- ments of the diaphragm are often interfered with, especially DISEASES OF THE LIVER. 247 on the right side, but the liver is generally altered in position by deep breathing. Sixth. Posture may influence the organ also, it being more prominent and lower in the abdomen in the standing posture. 6. Occasionally the gall-bladder presents an enlargement, with the following characters : First. It occupies generally the right hypochondrium, and can be felt coming from under the margin of the liver, appearing to be superficial; occasion- ally, however, it is so much enlarged as to extend down to the crest of the ilium. Second. As a rule the shape is pyriform, with the base towards the surface. Third. The surface is generally smooth, and has an elastic or fluctuating feel. Fourth. Almost always the tumor is very movable from side to side, turning on a fixed point, which is under the liver; even a change of posture may alter its position considerably. Now and then it is fixed by adhesions. Hepatalgia. The occurrence of intermittent attacks of severe pain in connection with the liver has been attributed, especially by Dr. Anstie, to a simple neuralgia in some instances. This affection is but a part of a general nervous condition, attended with similar pains in other parts, and deep mental depression. The attacks are not accompanied with vomiting, but there may be jaundice. The main difficulty in diagnosis is to separate this pain from that due to the passage of a gallstone. Jaundice — Tcterus. Jaundice is another of those symptoms which has been dignified by being described as a special disease. Essentially it merely means the peculiar discoloration of skin and other structures, which is observed when the bile-pigments accumu- late in the blood. Etiology and Pathology. — Cases of jaundice have long been divided into : First Those in which there is a mechanical obstruction to the escape of the bile through the ducts. Second. Those in which there is no obstruction. 248 DISEASES OF THE LIVEIt. 1, Jaundice from Obstruction. — This may be due to: First, Impaction oj some, foreign body in the hepatic or common bile- duct, viz., gallstones, thickened or gritty bile, rarely parasites, either formed in the liver or its duct (distoma hepaticum* and hydatids), or having entered from the intestines (roundworm), very rarely fruit-stones or other bodies which have passed into the duct from the bowels. Second. Catarrh of the mucous membrane of the ducts, or of the duodenum about the orifice, causing narrowing of the calibre. Third. Organic changes in the walls of the duct or at the orifice, leading to more or less stricture, even to complete obliteration, viz., congenital con- striction or closure, thickening of the walls from inflammatory changes, perihepatitis, cicatrization of an ulcer either in the duct or duodenum. Fourth. Pressure upon the duct, invasion of its canal, or closure of its opening by tumors, &c, especially by projecting growths from the liver, enlarged glands in the portal fissure, and pancreatic disease involving the duodenum; rarely by pyloric tumor, growths in or behind the peritoneum, hepatic aneurism, fecal accumulation in the colon, uterine and ovarian enlargements including pregnancy and renal tumors. Fifth. Functional disturbance of the muscular coat of the duct, in the way of spasm or paralysis. Physiologists differ as to how the bile is secreted. This influences opinions as to the pathology of jaundice in cases of obstruction. It is generally maintained that both the bile- acids and pigments are formed in the liver; some believe, how- ever, that the latter are produced, either partly or entirely, in the blood, and merely separated by the liver. Hence arise the two theories : 1. That the discoloration of jaundice is due to excessive absorption of the bile by the veins and lymphatics after its formation. 2. That it results from suppression of its secre- tion, and hence retention of the pigment in the blood. The *The distoma hepaticum, or liver-fluke, is a small trematode worm, often found in sheep, very rarely in the human being, occupying either the gall- bladder or bile-ducts. It is of a flattened, elongated, oval form, soft, and brownish or yellowish in color. • DISEASES OF THE LIVER. 249 former is probably the correct view, and the intensity of the jaundice will be in proportion to the rapidity with which the secretion of bile is going on, and to the slowness of its decom- position in the blood. Absorption is always proceeding during health, but the bile thus taken up is speedily changed, in the process of digestion and nutrition. 2. Jaundice without Obstruction. — The conditions under which this variety is supposed to occur are : First. In certain specific fevers, viz., yellow, remittent, intermittent, and relaps- ing fevers; very rarely in typhus, typhoid, or scarlatina. Second. When certain poisons are present in the blood, especially in connection with pyaemia, snake-bites, poisoning by phosphorus, mercury, copper or antimony, inhalation of chloroform or ether. Third. In acute or chronic atrophy of the liver, or destruction of its tissue from any cause. Fourth In Congestion of the liver. Fifth. From disturbed innervation especially after sudden intense mental emotion. Sixth. When the blood is insufficiently aerated, as in pneumonia, new-born infants, or as the result of overcrowding and bad ventilation. Seventh. Where bile is formed in much excess. Eighth. In cases of habitual or long-continued constipation. Ninth. In certain states of the portal system of veins, as when they con- tain abundant pigment granules, or are unusually empty after profuse hemorrhage from the alimentary canal. Tenth. As an epidemic. The views of different writers as to the pathology of the various forms of the non-obstructive jaundice are, that it is due 1. To suppression of secretion. 2. Increased absorption, so that more bile enters the blood than can undergo decompo- sition, either from excessive secretion, undue retention of bile in the intestines owing to constipation, or diminution of pres- sure in the portal vessels. 3. Impaired and delayed meta- morphosis of the bile elements in the blood, and some think that the bile-acids are converted in this fluid into bile-pig- ments, owing to imperfect oxidation. 4. Conversion of the haematine of the blood into bile-pigments. Nervous disturb- 250 DISEASES OF THE LIVER. ance in producing jaundice may affect the activity of the secretion, the state of the portal veins, or the rapidity of the changes in the blood. \ Jaundice is not a necessary accompaniment of even grave organic disease of the liver itself, and, in such cases, when it is very marked it generally results from some projection from the organ interfering with the main ducts, or from the glands in the fissure being iuvolved. It may be due to destruction of the liver tissue, or to the ducts or the circulation in the interior of the organ being interrupted. Anatomical Characters. — In jaundice not only are the skin and conjunctiva more or less stained with bile-pigment, but also most of the other tissues, organs, and fluids of the body, as well as morbid exudations and effusions. In the skin the pigment exists chiefly in the rete mucosum, also involving the sweat-glands considerably. The nerve-tissues are but slightly affected, and the general mucous membranes with their secretion still less. The bile-pigments are found in the clot and serum of the blood, but not the acids; in pro- longed cases coagulation is imperfect, and the corpuscles are altered in their characters, while not uncommonly there are extravasations of blood. In cases of obstructive jaundice the liver itself becomes at first enlarged uniformly, without any alteration in shape, and mottled of a more or less deep yellow tint, in some cases being olive green ; its ducts are distended, and in time numerous particles of pigment are seen in the cells. Should the obstruction be in the common duct, the gall-bladder will be enlarged. If the obstruction is persistent, the liver undergoes degeneration, becoming atrophied, very dark, sometimes almost black, and softened, many of its cells being destroyed, leaving only a granular detritus under the microscope. The kidneys also are much changed in prolonged cases, being deeply colored, their tubules containing a black or brown deposit, and their secreting cells presenting granules of pigment, or ultimately breaking down. Symptoms. — Usually the first signs are afforded by the DISEASES OF THE LIVER. 25l urine, next by the conjunctivae, and then by the skin. The conjunctivae are more or less deeply tinged yellow. The skin may present a variety of tints, from a faint yellow to a brown- ish or blackish-green. The color is deepest where the epi- dermis is thin, and varies with age, complexion, amount of fat, etc. If the lips or gums are compressed, so as to expel the blood, a yellowish hue is often observed. The urine has a color ranging from a light saffron-yellow to one resembling mahogany or porter; on standing it usually becomes greenish. Its froth is yellow, and it will tinge white linen or blotting- paper dipped into it, often staining the underclothing. Chem- ical examination is most important, as indicating the presence of bile-pigments, and, as many believe, of bile acids. The former is tested for by nitric acid. Either a few drops of urine and acid may be placed on a white porcelain surface, and allowed to come into contact; or a little urine may be poured into a test-glass, and the acid allowed gently to run down its interior, so as to sink to the bottom. A play of colors is observed, to violet, green, blue and red, these soon disappearing. The bile-acids are detected by adding a frag- ment of lump-sugar to a little urine in a test-glass, and then pouring in a small quantity of strong sulphuric acid, drop by drop, alowing it to trickle down the side of the tube. A deep purple color is produced where the acid and urine meet. Another important character is, that the urine often contains leucin and tyrosin, crystals of which may be seen under the microscope after careful evaporation of some of the excretion to a syrupy consistence. In some cases the quantity of urine is deficient at first ; the reaction is acid ; the proportion of urea and uric acid varies, and they may be in excess. In advanced cases sugar sometimes appears. Renal epithelium or casts tinged with biliary coloring matters are occasionally observed. When the bile does not reach the intestines, the consequences are constipation, with unhealthy stools, these being deficient in coloring matters, often pale drab or slate-colored, dry, often- 252 DISEASES OF THE LIVEB. sive, and containing excess of fat ; formation of much foul gas from decomposition, with, consequent flatulence, and passage of fetid flatus. Occasionally diarrhoea is observed from time to time, or dysenteric symptoms. There is usually a disin- clination for food, especially for fatty matters, and eructations are common, which may have a bitter taste. Evidence of the presence of bile is often afforded by the sweat, milk, saliva, and tears. From the accumulation of bile-acids in the blood result not uncommonly cutaneous itching, which may be very distressing; slowness of the heart's action and pulse, which may fall to 50, 40, or even 20 per minute ; also a feeling of languor, depression, and debility, lowness of spirits, with incapacity for exertion, irritability, and drowsiness. The symptoms last mentioned are also partly due to the emaciation and impaired nutrition, which usually become soon apparent, in prolonged cases being very marked. In some instances urticaria, lichen, boils, carbuncles, or petechia? are observed. Yellow vision ( xanthopsy ) is an extremely rare phenomenon and its cause is very uncertain. Jaundice, especially the non-obstructive variety, may be accompanied with symptoms indicative of the " typhoid state," low, nervous symptoms, or dangerous hemorrhages, particularly from the stomach and bowels, ending speedily in death. It is important to observe that these phenomena are out of proportion to the intensity of the jaundice. They have been attributed to the accumulation in the blood of bile-acids or their formative elements, or of some noxious substance formed in the cells of the liver ; or to the metamorphosis of materials in the process of preparation for excretion by the urine being checked or modified, owing to a deficiency of bile, which is required for these changes ; so that instead of urea and such compounds, intermediate products are formed, which collect in the blood and act as poisons. In some of these cases the above symptoms are independent of the jaundice, and result from some general morbid state, or some condition of the kidneys, which leads to blood-poisoning. DISEASES OF THE EIVEE. 253 Physical examination in cases of obstructive jaundice reveals enlargement of the liver, not great, and quite regular. If the common duct is obstructed, the gall-bladder may also present a fluctuating enlargement. Im prolonged cases the liver may show the physical signs of atrophy. The course, duration, and intensity of jaundice vary greatly, according to its cause. It may be merely a slight temporary disturbance, or permanent and extreme in degree. Diagnosis. — The first matter is to be certain that there is jaundice. The discoloration of the skin might possibly be simulated by a chlorotic tint, the cachexia of chronic lead- poisoning, malaria, or cancer, the color associated with suprarenal disease, or bronzing from exposure to the sun. The conjunctivae and urine should always be particularly examined. It must be remembered, however, that the yel- lowness due to the collection of fat under the conjunctivae may be mistaken for that of jaundice. Also pigments form in the urine sometimes, which render it very dark ; and now and then malingeres purposely stain the skin and add color- ing matters to the urine. It may be difficult to determine whether jaundice is of the obstructive or non-obstructive variety, but the latter, as well as its particular cause, may be generally recognized : 1. By the circumstances under which it occurs, and the other symp- toms which accompany it. 2. By the discoloration being less marked. 3. By the presence of more or less bile in the stools. 4. By examination of the urine, as already stated, giving^ indi- cations of the presence of bile-acids only in the obstructive form of jaundice, though many deny this, and which in the non-obstructive variety yields leucin and ty rosin. The precise cause of obstructive jaundice is determined by: 1. The age, sex, habits, and general past history of the patient. 2. The preceding and accompanying symptoms, both local and general. 3. The rapidity with which the jaundice has set in and its intensity. 4. Careful physical examination of the abdomen. 5. The course and progress of 254 DISEASES OF THE LIVER. the case and the effects of treatment. The gall-bladder being enlarged or not, will show whether anv obstruction exists with the hepatic or common bile-duct. Prognosis. — As a rule, it may be stated that non-obstruc- tive jaundice is much the more grave. Typhoid and low nervous symptoms are highly dangerous, as are also hemor- rhages, and signs of interference with the renal secretion. In obstructive cases not only will the prognosis vary with the cause of jaundice, but also with the rapidity with which it comes on, its intensity and mode of progress. In every case a cautious prognosis should he given, as it is never certain how it may turn out, and this is particularly true if jaundice sets in rapidly and becomes speedily intense. Catarrhal jaundice generally soon disappears. Of course when it is due to obstructive organic disease, especially cancer, there is no hope of recovery, but it is astonishing what an extreme degree the discoloration may attain in some instan- ces, without any proportionate general disturbance to lead to the idea that bile acts as poison. Jaundice in pregnancy is considered highly dangerous. Treatment. — 1. Treat the condition upon which it de- pends, and remove any obstruction to the flow of the bile, if practicable. 2. Promote secretion of bile, if necessary, by remedies to be considered; or on the other hand to limit its formation. 3. Attend carefully to the diet, especially avoid- ing fatty and oily substances, as well as much starch, sugar, or alcoholic stimulants. 4. Treat the symptoms due to the absence of bile from the alimentary canal, especially constipa- tion and flatulence ; or supply a substitute for this secretion in the way of artificially-prepared inspissated ox-gall, in from 5 to 10 grain doses, given 2 or 3 hours after meals. 5. Pro- mote the renal and cutaneous secretions. 6. Attend to the general condition, giving quinine, iron, and other tonics, and always adopt hygienic measures tor improving the health, in chronic cases; treating adynamic symptoms by stimulants; low nervous symptoms by encouraging free elimination by DISEASES OF THE LIVER. 255 the bowels, kidneys, and skin ; hemorrhages by astringents. In cases of permanent obstruction, it has been proposed to make an artificial fistula in the gall-bladder, having first excited adhesion with the abdominal wall by means of escha- rotics. The irritation of the skin may demand measures for its relief; alkalies and opiates or morphia internally, or the latter hypodermically, and warm and alkaline baths are most serviceable for this purpose. It must not be forgotten that the color of jaundice remains for a time after any cause of obstruction has been removed ; and if this has been effected, it is not necessary to continue further active measures. The removal of the bile from the system may be promoted by occasional alkaline baths, aperients, and mineral waters, while convalescence is promoted by hygienic and other measures for iniDroving the health. J. o CONGESTION OF THE LIVER— HYPEREMIA. Etiology. — Active hepatic congestion occurs to some de- gree during every period of digestion. As a morbid condition it is met with : 1. After errors in diet, especially habitual excess in eating or indulgence in too rich articles, abuse of alcohol or hot condiments, particularly in those who take lit- tle exercise. 2. As the result of continued exposure to exces- sive heat in tropical climates, or of a sudden chill while heated. 3. In connection with malarial, yellow, relapsing, and other fevers. 4. Vicarious menstruation, or other habitual discharges, as bleeding from piles. 5. As the result of injury. 6. Associated with morbid deposits in the liver and the early stage of inflammation. Mechaniccd congestion is generally due to some condition of of the heart or lungs, which interferes with the general venous circulation; very rarely to local obstruction of the hepatic vein or inferior vena cava. Passive congestion follows habitual constipation, or re- sults from a torpid state of the portal system, from paralysis of the coats of the vessel, or any other cause. 256 DISEASES OF THE LIVER. Anatomical Characters. — It is only the mechanical form of congestion that is generally seen after death. The liver is enlarged more or less, quite uniformly, its surface being smooth, and the capsule stretched. It often feels unusually firm. On section an excessive quantity of blood flows, the color of the surface is dark, sometimes even pur- ple, and the vessels appear abnormally filled, being in time dilated. The dark color is rarely uniform, but appears chiefly in connection with the intralobular branches of the hepatic veins, constituting the so-called hepatic congestion. Portal congestion is the term applied when the vessels at the circumference of and between the lobules are most dis- tended, but it is rarely seen. Nutmeg Liver. — It is named from a section presenting a variegated appearance, resembling that of a nutmeg, being a mixture of red, white, and yellow tints. The condition is observed after congestion from cardiac obstruction has lasted for some time, and it depends on the following pathological changes. The branches of the hepatic vein are distended and overloaded, deep red and well defined ; the circumference of the lobules corresponding to the portal branches is anaemic, and has undergone degenerative fatty changes, hence being pale and opaque ; while the bile is stagnant in many of the smaller bile-ducts, by which the yellow tint is produced. Symptoms. — Local congestion produces a sense of uncom- fortable tension, fullness, and weight, especially after meals and when lying on the left side; sometimes there is slight tenderness. There may be pain in the right shoulder. Slight jaundice is often present, but the stools contain bile. The spleen becomes enlarged iu time. The alimentary canal is deranged as impaired appetite, foul tongue, constipation or diarrhoea, and flatulence ; often the result of the same cause which produces the hepatic congestion, it may be partly due to deficient or unhealthy bile. Some general disturbance often accompanies the congestion. The urine is frequently ABSCESS OF THE LIVEE. 257 deficient and concentrated, depositing abundant urates; it also may contain biliary coloring matter. The physical signs of congested liver are moderate enlarge- ment, liable to some variation ; regularity and uniformity in shape, in surface and margins ; with somewhat increased firmness. Treatment. — For active congestion the measures to be adopted are — to remove its exciting cause, an emetic being useful if it is due to irritating articles of food; to restrict the diet to small quantities of beef-tea, milk, and such articles ; to apply warm poultices, fomentations, or sinapisms over the hepatic region, dry-cup freely ; give a dose of podphillin followed by saline aperients, such as citrate of magnesia, sulphate with carbonate of magnesia, sulphate of soda, or cream of tartar. After the acute symptoms have subsided, alkalies with bitter tonics are useful, as well as alkaline and saline minerarwaters ; and subseqently the principles of treat- ment must be similar to those described hereafter in connec- tion with chronic hepatic diseases. These will also apply to cases of mechanical congestion. Circumscribed or Suppurative Inflammation — He- patic Abscess. Etiology and Pathology. — The usual form of acute inflammation of the liver-tissue ends in suppuration, which is rare, except in tropical climates. The cases in this country are principally among sailors and others who have come from these regions. We have two forms of hepatic abscess, the tropical and pycemic, the latter occurring in temperate climates. Causes. — 1. Direct injury to the liver, or over the hepatic region. 2. Convection of septic matters from various parts of the body, either internal or external, the products of wounds, operations, abscesses, ulcerations, gangrene, &c. The deleteri- ous substances may come from any part, but hepatic abscess is especially frequent after ulceration or gangrene of the stomach or bowels, as the result of operations affecting the 20* 258 ABSCESS OF THE LIVER. alimentary canal, and in connection with ulceration or sup- purative inflammation about the bile-ducts or gall-bladder, because then the materials are immediately taken up by the portal system of vessels. These cases may originate in phlebitis, extending along the portal vessels to the liver. 3. An embolus or thrombus in the portal vein softens and breaks down (suppurative pylephlebitis), and the particles may be conveyed into the liver and originate an abscess there. 4. Rarely some direct irritation in the substance of the liver, as a suppurating hydatid cyst, gallstones, roundworms which have entered through the ducts, or foreign bodies. 5. The etiology of tropical abscess requires special comment. There are two views as to the exciting causes of the inflammation in these cases: 1. That it is the direct result of continued intense heat combined with malarial influence. 2. That in addition to these influences, which induce a predisposing depraved condi- tion of system, there must be a sudden chill. Intemperance, excessive eating, indolent and luxurious habits generally, act as powerful predisposing causes. Anatomical Characters. — The post-mortem examina- tion in acute hepatitis generally reveals suppuration. It is supposed to commence with active hyperemia, followed by effusion of lymph and degeneration of the hepatic cells, caus- ing the affected part to become swollen or prominent, paler, yellowish and softened; then suppuration begins in points in the centre of the lobules, which gradually coalesce, forming abscesses of various sizes. The pus-cells are probably partly leucocytes, partly the products of endogenous multiplication of the liver-cells. The situation, number, size, and exact shape of the abscesses vary widely, as well as the nature and amount of their contents, and the condition of the surround- ing tissue. The right lobe is much more frequently affected than the left. Important differences as. to number and size are observed between tropical and pycemic abscesses. In the for- mer case there is generally one large abscess, and rarely is the number above three; in the latter the separate accumulations ABSCESS OF THE LIVER. 259 of pus are very numerous and small, not often being above a hen's egg in size. The progress and termination of these abscesses are variable. AVhen large, and especially of the tropical variety, they tend toward the surface or in some other direction, finally bursting externally, or into the peritoneum, intestines, stomach, gall- bladder, hepatic duct, hepatic or portal vein, inferior vena cava, pelvis of right kidney, or, rarely, through the diaphragm into the pleura, lung, or pericardium. After the discharge of the pus, cicatrization may take place, causing contraction and depression of the surface of the liver. In some cases an abscess remains dormant for a considerable period, and then rapidly increases. The fluid portion of the pus may be absorbed, the contents becoming caseous, then putty-like, and finally calcareous, the tissue around forming a dense cicatrix. The gall-bladder is sometimes inflamed. The bile in it is frequently unhealthy, but presents no special characters. The consequences of the rupture of an abscess into various struc- tures are elsewhere described. Symptoms. — Local. — Pain and tenderness are complained of over the hepatic region, often preceded by uneasiness. The pain differs much in its severity and characters; in most cases it is dull, aching, and tense, but usually increases as suppura- tion occurs, and may then become throbbing; it is more marked when the inflammation is near the surface. Sympa- thetic pains about the right shoulder and scapula are occasion- ally present, but only when the upper surface of the right lobe is affected. Then also a deep breath or cough aggravates the pain, and the breathing is hurried, short, chiefly upper costal, while there is some sense of dyspnoea, with often a short, dry cough. Jaundice is very uncommon in connection with tropical abscess, but some degree of it is observed in pysemic cases. Ascites is extremely rare, unless the inflam- mation depends on pylephlebitis, when signs of obstruction of the portal vein are prominent. More or less disturbance of the alimentary canal is almost always observed, such as loss 260 ABSCESS OF THE LIVEB. of appetite, furred and irritable tongue ; thirst, nausea or vomiting, constipation or diarrhoea. The urine is at first very markedly febrile; after suppuration it often becomes pale, copious, and deficient in urea. Physical Characters. — The liver is at first uniformly and moderately enlarged. Should the abscesses formed be small and deeply seatecL as in pyemic cases, nothing further can be observed; but if one or more of them become large and super- ficial, then the following characters are presented: 1. The general enlargement increases considerably, and a bulging prominence presents in some direction, or occasionally more than one. This is generally observed in the epigastrium or right hypochondrium ; sometimes it causes distension of the lower part of the chest, with flattening of the spaces. 2. The general surface and margins of the liver, as a rule, feel smooth and regular, but occasionally from the projection of several small abscesses, or on account of perihepatitis, they are undu- lated and irregular. 3. The local bulging soon affords a sensation of elasticity, and then of fluctuation, gradually extending and becoming more perceptible, surrounded by a ring of inflammatory induration. There is no "hydatid fremitus." 4. The hepatic dullness is altered in outline as well as in area, and when the abscess tends towards the thorax, this is often one of the chief* signs noticed. 5. Auscultation may reveal friction-sound over an abscess, due to peritonitis. It may also indicate invasion of the qhest, and interference with the expansion of the lung. 6. By means of the exploratory trocar pus may be obtained, and this is important for diagnosis in doubtful cases. Harked pulsation may be observed in connection with an abscess presenting in the epigastrium, conducted from the aorta, and simulating aneurism. The spleen may be enlarged, but chiefly in pyemic cases, and not as the direct result of the hepatic disease. General Symptoms. — Chills or rigors often usher in an attack of acute hepatitis, followed by more or less pyrexia and considerable constitutional disturbance. Suppuration is indi- PERIHEPATITIS. 261 cated by repeated rigors, fever of a hectic type, remittent or intermittent, with sweats, prostration and wasting. Ultimate- ly typhoid symptoms may occur, ending in low nervous disturbance and death. The ultimate course of events will depend upon the progress of the disease. The symptoms may subside, and the abscess undergo retrograde changes, ending in cure. Almost always, however, it tends to open in some of the directions already mentioned, and the corresponding symptoms will be readily understood. When it approaches the surface, it produces redness, oedema, and other signs of superficial suppuration, before it bursts. Most cases of hepatic abscess are rapid in their progress, but tropical cases may last six months or more; pysemic forms are much the more fatal and speedy in their termination. Some cases go on for a long period, and ulti- mately recover, the abscess discharging its contents and cicatrizing. II. Perihepatitis. This term is applied to inflammation of the covering of the liver and Glisson's capsule, which is not uncommon as an acute affection, associated with peritonitis, or organic diseases of the liver, or resulting from injury or extension of inflam- mation from neighboring parts. It may arise from a chill. It tends to exudation, with thickening, opacity, and adhesions; occasionally pus is formed. The symptoms are pain, some- times sharp, increased by cough and deep breathing, with superficial tenderness, but no particular derangement of the hepatic functions, or alterations in the physical characters of the liver. There is usually more or less fever. If it is chronic, or if there are repeated attacks, as not uncommonly happens in syphilis or chronic heart diseases, there may be signs of obstruction of the portal vein or bile-duct, with atrophy of the liver. III. Inflammation of the Bile-Ducts. Catarrh of the bile-ducts is a common' affection, especially 262 INFLAMMATION OF THE BILE-DUCTS. r in children and old gouty persons. Its chief causes are extension of catarrh from the duodenum; hepatic congestion ; irritation of the mucous membrane by gallstones, parasites, foreign bodies, unhealthy bile, causing considerable inflam- mation ; and blood-poisoning in fevers and other affections. The morbid appearances are similar to those of other catarrhs. Occasionally croupous or diphtheritic inflammation is observed. The symptoms of simple catarrh indicate partial obstruction of the bile-ducts, with jaundice, enlargement of the liver and gall-bladder, preceded by signs of gastro- duodenal catarrh. Often local pain and tenderness, with some fever. The duration and course of these cases vary much. Diagnosis. — At first there may be considerable difficulty in distinguishing inflammation from mere active congestion, and also in separating the different kinds of inflammation from each other, especially suppurative hepatitis and peri- hepatitis. When pus forms, this is generally revealed by evident physical signs and increased constitutional disturb- ance. Commonly, however, distinct objective indications of pysemic abscesses are wanting; the differences between these and tropical abscess have been mentioned. The conditions which, may be mistaken for abscess in the liver are inflamma- tion and suppuration in the gall-bladder, a suppurating hydatid cyst, and abscess in the abdominal parietes. Prognosis. — In the milder forms of hepatic inflammation the prognosis is favorable, but when suppuration occurs it is very serious. It will then depend mainly on the size and probable number of the abscesses ; the direction in which they open (Maclean stating as his experience that the largest num- ber of recoveries follows bursting into the lung, and then into the intestine ; and that the prognosis is much more favorable when the abscess points at the ensiform cartilage than in an intercostal space); the general condition of the patient; and whether the liver-affection is associated with other morbid states, such as dysentery. Pyemic abscesses are very fatal. ABSCESS OF THE LIVER. 263 Treatment. — The slighter forms may be treated in the manner described under congestion. Much difference of opinion is held as to the management of tropical abscess in its early stage. The usual measures are emetics; cupping; con- stant poulticing or fomentations; saline purgatives; and the administration of ipecacuanha, as in dysentery. In pysemic abscess, lowering measures are injurious. When suppuration occurs, poultices and fomentations must be assiduously applied. The question of opening abscesses is much discussed. Most authorities seem to favor operating; some prefer leaving the abscess to take its own course, on account of the dangers of peritonitis, decomposition from entrance of air, hemorrhage, or gangrene. If there is satisfactory evidence of the existence of a single" abscess, it appears advisable to let the matter out, and even in doubtful cases a small exploratory trocar may be employed. When there are several collections of pus, as in pyaemia, operative interference is contraindicated. The differ- ent modes of evacuation are by puncture with a small trocar and canula ; free incision ; or application of caustic potash so as to produce a slough, this last being also used to excite adhesions to the abdominal wall. The air must be excluded and carbolic acid freely used. In the case of a moderate- sized abscess, it seems best to let out all the pus at once, and leave a drainage-tube in ; when very large, it may be emptied gradually by successive operations. Large poultices should be afterwards applied, frequently changed, and disinfectants freely used, the patient lying as much as possible in that position most favorable for the escape of the pus. It is use- ful in some cases to wash out the abscess with weak carbolic acid. In the early period of the disease the diet should con- sist of milk, beef tea, &c; when suppuration is set up it should be as nourishing as possible, while stimulants are called for at this time, as also quinine, mineral acids, or tincture of steel. Narcotics are often required, and various symptoms demand attention in many cases. The general treatment for pyaemia is indicated in pysemic cases. 264 Atftfffi YELL6W ATROPHY. Acute Yellow Atrophy. Etiology and Pathology. — The causation of this rare disease is very uncertain. Most cases occur in connection with pregnancy, but it has also been attributed to severe nervous disturbance due to depressing emotions ; blood-poison- ing in typhus, scarlatina, &c. ; malarial influence ; or to the production within the body of some special poison as the result of faulty digestion or assimilation. The chief predisposing causes mentioned are age, the disease almost always being observed before 40, but never in childhood ; the female sex ; intemperance ; venereal excesses ; and syphilis. Most authorities consider acute atrophy as being the result of diffuse parenchymatous inflammation excited by some poison. It has also been attributed to obstruction of the smaller bile- ducts, or to excessive collection of bile in them, by pressure upon the surrounding structures. Anatomical Characters. — Diminution in size and weight of the liver, relaxation of tissue and softening, change in color to a dull yellow, and disappearance of any lobular divisions. It may be reduced to half its ordinary bulk, or less, being especially diminished in thickness, and it lies back out of sight, shrunken and flaccid, while the peritoneum covering it is lax and often in folds. In parts where the disease is less advanced hyperemia and a grayish exudation have been described. Microscopic examination reveals fatty degenera- tion and destruction of the gland-cells, until nothing remains but a granular detritis, oil-globules, and pigment. There is only a little mucus in the gall-bladder and ducts as a rule. Extravasations of blood in the alimentary canal and other parts, with ecchymoses, are common. The spleen is generally enlarged. The kidneys exhibit degeneration of, and deposits of pigment in, the epithelium cells. Leucin and tyrosin are found in the blood and tissues of the liver, spleen, and kidneys. Symptoms. — Slight jaundice is usually observed soon. It afterwards increases, but seldom becomes intense, and it may ACtfTE YELLOW ATROPHY. 266 be iimited to the upper part of the body. This has been attri- buted to blocking-up of the smaller ducts by the debris of the cells. Among the usual symptoms are pain over the epigas- trium and hypochondriuni, with tenderness, vomiting, and constipation. There is not much pyrexia, but the pulse is often hurried and is liable to much variation, while the tem- perature is raised in some cases considerably towards the close. The striking clinical phenomina are those of the " typhoid state," with prominent nervous symptoms ; great diminution or complete disappearance of the hepatic dullness ; generally enlargement of the spleen ; peculiar changes in the urine; and hemorrhages. The nervous symptoms are at first headache, great depression, languor, irritability, and restlessness, speedily followed by low delirium, stupor, coma, twitchings, convul- sions, with involuntary discharge of faeces and urine. The tongue becomes brown and dry, with sordes on the teeth. The urine yields considerable quantities of leucin and tyrosin, w T hile the urea, uric acid, and salts are much diminished, some- times almost entirely absent; some bile-pigment is usually present, and often a little albumen or blood. Hemorrhage most frequently takes place into the stomach and bowels; cutaneous petechia? and vibices are not uncommon, and, in rare instances, uterine hemorrhage or epistaxis occurs. The course of the disease is generally very rapid, and the termina- tion fatal. When it arises in the course of pregnancy, it leads to miscarriage or abortion. Diagnosis. — At first it is difficult to diagnose acute atrophy, but once the symptoms are fully developed, with the physical signs of diminution in the size of the liver, the nature of the case becomes evident. Prognosis is very grave, the disease almost always ending fatally. Treatment. — Free purgation, promotion of the action of the skin by hot air or vapor baths, diuretics, cold douches to the head, have been the chief measures recommended, but 266 HYPERTROPHY AND ATROPHY. they are of little service when the disease is established. Hemorrhages and other symptoms must be treated as they arise, with supporting and soothing measures generally. CHRONIC DISEASES OF THE LIVER. HYPERTROPHY AND ATROPHY. A simple hypertrophy of the hepatic tissue is observed in some cases of leucocythaBmia, very rarely in diabetes, and as the result of residence in hot climates. Clinically it is'indi- cated by a slow^ moderate, and uniform enlargement of the liver, without any evident symptoms. Atrophy generally occurs in old age, and may result from starvation, or pressure upon the surface of the organ by tight stays, peritoneal adhesions, &c. Fatty Liver — Hepar Adiposum. Etiology. — This belongs to the fatty infiltrations, the secreting cells becoming filled with oil. The conditions are : 1. In phthisis and other wasting diseases, such as ^cancer, gastric ulcer, chronic dysentery. 2. In chronic lung and heart affections, leading to imperfect aeration of blood. 3. As the result of over-feeding, especially excessive consumption of hydrocarbonaceous substances, and abuse of alcohol in the form of ardent spirits. Deficient exercise and indolent habits aid the development of the disease. Some individuals are more predisposed than others. Fatty degeneration may be set up in connection with other morbid conditions of the liver, as albuminoid infiltration or cirrhosis. Anatomical Characters. — Enlargement and increase in weight, though the specific gravity is diminished, the margins thickened and rounded, and the surface quite smooth ; yellow- ish color with opacity, both externally and on section, mottled with red softening of the tissue, has a doughy, inelastic feel, FATTY LIVER — ALBUMINOID LIVER. 267 pits on pressure, and readily breaks down or tears ; ansemia, but little blood escaping from the cut surface ; loss of distinct- ness of outline of the lobules ; and evidence of the presence of much fat to the knife, blotting-paper, or ether. The liver may yield as much as 43 or 45 per cent, of oily matters, which consist of olein and margarin, with traces of cholesterin. Microscopic examination shows enlargement of the cells, which are spherical, and loaded with fat. In the less advanced cases this reveals the change. The morbid process extends from the circumference of the lobules towards the centre. Symptoms. — Dyspeptic disturbances are common. Physi- cal examination is the only positive means of diagnosing fatty liver: 1. There is enlargement in a downward direction, slow in its progress, and usually moderate in degree, the organ never attaining any great size. 2. The shape is quite normal, and the surface and margins are smooth and regular, the latter feeling rounded. 3. Palpation' often reveals a soft, doughy consistence of the tissue. The general symptoms are those associated with fatty changes, viz., want of tone, inaptitude for exertion, pallor and pastiness of the skin, &c. Signs of fatty changes in other organs and tissues, as the heart, vessels, and kidneys, may be observed. Albuminoid, Lardaceous, or Waxy Liver. For the etiology and pathology of this morbid condition the reader is referred to the chapter which treats of it generally. The liver is one of the most common seats of albuminoid deposit. Anatomical Characters. — The size and weight are con- siderably increased, and the specific gravity. The liver is somewhat flattened, with rounded edges. The surface and margins are quite smooth, the peritoneum stretched, and the tissue feels very firm and resistant. On section the usual pale, anaemic, dry, grayish, and glistening aspect of larda- ceous disease is observed; the surface is quite homogeneous, 26S HYDATID TUMOK OF THE LIVER. without any trace of lobules, or these may appear enlarged. The ordinary chemical tests are yielded, and microscopic examination reveals the presence of the deposit in connec- tion with the vessels and cells. It is first observed in the middle zone of the lobules, where the branches of the hepatic artery are distributed. The exact appearances may be varied by the association of other morbid conditions, such as fatty degeneration, cirrhosis, or syphilitic cicatrices. The disease commonly involves other organs. Symptoms. — A feeling of weight, tension, and discomfort. Jaundice and signs of obstruction of the circulation when present are due to pressure by enlarged glands in the portal fissure, or thickenings with local inflammatory changes; or, ascites, to chronic peritonitis or constitutional debiiity and ansemia. The physical signs are : 1. Enlarge- ment in a downward direction, gradual in its progress, fre- quently very great at last, so as to present a visible, prom- inent tumor. 2. No alteration in form, the surface smooth and uniform, with rounding of the margin. 3. Consist- ence dense and resistant, often hard. These are the usual general symptoms indicative of albuminoid disease, with signs of implication of other organs, and the existence of some constitutional condition associated with it. Hydatid Tumor of the Liver— Echinococcus Homlnis acephalocyst. Etiology and Pathology. — The morbid condition, re- sulting from the development of the embryo of a tape- worm in the human body, is afforded by this complaint, though the parasite may be found in almost every organ and tissue in the body, yet the liver is its most frequent seat, the subject may be treated once for all in the present chapter. A hydatid tumor is due to the development of embryos of the tcenia echinococcus, each of which produces a scolex, named echinocoecus hominis, and then they become inclosed in cysts. This tapeworm infests dogs and wolves, fragments are evacu- ated in the excreta, their ova are set free, become mixed with HYDATID TUMOR OF THE LIVER. 269 water or food, and are thus introduced into the alimentary canal of a human being. When the embryos are liberated they bore the walls with their hooks, and then migrate, usually settling in the liver, there developing into scolices. The echinococcus also infest sheep, and mutton-eating dogs become the seat of the tapeworm. In Iceland this disease is especially prevalent. In this part of the world it is exceptionally met with, usually those who have been abroad. Most cases occur during middle life, and among the poorer classes. Anatomical Characte&s. — The structures which ordi- narily form a typical hydatid tumor, are: 1. Externally a firm, whitish or yellowish, fibrous vascular capsule adherent to the surrounding tissues. 2. Within this, moulded to its interior but easily separated from it, is a delicate cyst or bladder, elastic, grayish, semi-transparent or gelatinous in aspect, and compared to boiled white of egg ; under the micro- scope it is seen to consist of several hyaline, concentric layers, a section presenting a characteristic laminated appearance. The most internal layer is extremly delicate and studded with minute transparent cells. The term " mother-sac or vesicle," is usually applied to this structure as a whole ; but it has also been limited to the internal lamina just mentioned, which has been termed the " germinal membrane." 3. A quantity of fluid is contained within this cyst, usually completely filling it, colorless and transparent ; of low specific gravity ( 1007 to 1009); generally alkaline or neutral, but may be acid ; and consisting mainly of a strong solution of chloride of sodium, without any albumen or other organic substance. 4. Floating in this fluid, or attached to the inner surface of this mother- cyst when small, are numerous secondary or "daughter cysts," in some instances amounting to hundreds or thousands, completely filling the space so that there is little or no fluid, and becoming flattened by mutual pressure, having precisely the same structure as the mother-sac ; within the larger of these there may be a third generation, and rarely a fourth. 270 HYDATID TUMOR OF THE LIVER. 5. When the walls of the sacs are examined carefully, little whitish, opaque spots are visible on the inner surface, which are the scolices of the echinococcus in various stages of devel- opment, usually in groups or clusters, occasionally single. These may also be free in the fluid, making it somewhat opaque. Each scolex is very minute, measuring from l-20th to l-6th of a line in length, but this and the form vary according as the head is retracted into the body or extended. The head presents a proboscis, four suckers, with a double circle of characteristic, curved hooks, movable, of unequal length ; a constriction separates it from the body, the latter being striated longitudinally and transversely, presenting behind a depression with a pedicle, by which the animal is fixed to the sac in its early condition. Numerous round and oval calcareous particles are imbedded in the tissue. In most cases there is but one tumor, sometimes two, three, or more, one predominating over the others. The size varies extremely; the hydatid may attain dimensions to fill the abdomen and invade the chest. The daughter-cysts, range from a millet-seed to an egg in size; subsequent gen- erations are very minute. The right lobe is the most frequent seat, but the cyst may be in any part, deep or superficial. Necessarily if the hydatids are numerous, large, or super- ficial, they alter the dimensions and form of the liver. The surrounding hepatic tissue is atrophied; sometimes hypertrophy of the healthy portion. Peritonitis may be excited over the tumor, causing thickening and adhesions. In the course of hydatid disease, 1. The tumor enlarges, displacing adjoining structures and interfering with their functions, until it bursts in some direction, or is ruptured by violence or in some other way. The opening may occur externally through the abdominal or lower thoracic walls ; into the pleura or lung, especially the right, which is the most common direction ; pericardium rarely, peritoneum, stomach or intestines," gall-bladder or bile-duets, hepatic vein or inferior vena cava. 2. Inflammation and suppura- HYDATID TUMOR OF THE LIVER. 271 :ion sometimes occur, either spontaneously from rapid growth, Torn injury or operation, or from the entrance of bile. 3. [f the hydatid is slow in its progress, it not uncommonly mdergoes degenerative processes as it gets older, and this nay ultimately bring about a spontaneous cure. The en- rance of bile is supposed sometimes to induce this. The niter capsule becomes much ' thickened, firm, irregular, >paque, and ultimately calcined partially or completely. This mpedes further growth, and the contained hydatids com- )ress each other, shrivel, and die. The fluid thickens, atty and calcareous degeneration takes place, until there >nly remains a putty-like debris, in which shreds of the resides and hooklets of the echinococci are embedded, re- pealing the nature of the mass. A cicatrix-like depression nay finally be left. 4. Occasionally cysts are found in vhich there are no echinococci. The name " acephalocyst " las been applied to this condition, and it has been regarded & an abortive or sterile form of the parasite, in which he development is arrested. A very rare form of this disease is named " Multilocular lydatid cyst." The liver is occupied by a mass, in some :ases as large as a child's head, or larger, consisting of a troma of cellular tissue, usually altered by fatty degeneration, n which are imbedded cells or alveoli of various sizes, inclos- ng a gelatinous substance, in which microscopic examination eveals fragments of the laminated membrane of hydatids, looklets, or even perfect scolices and calcareous particles. Che centre of this mass is liable to undergo suppuration, alter- ng its characters. This has been attributed to the embryos laving been deposited in the lymphatics, bloodvessels, or lucts of the liver; or to the absence of early rupture of the xternal fibrous cyst, so that the parasites grow and migrate n various directions, and thus enter the different vessels. Symptoms. — It may be latent from first to last. Should it ,ttain a great size, there is a sense of fullness and tension, in are cases jaundice, or signs of portal obstruction, in oonse- 272 HYDATID TUMOR OF THE LIVER. quence of pressure upon the ducts or veins, or their being blocked up by hydatids. Surrounding structures may also be interfered with, especially the diaphragm and respiratory organs. Should the cyst rupture, the symptoms depend on the direction in which this occurs, being in many instances very grave. If the opening is external, characteristic struc- tures may be discharged. The occurrence of suppuration is indicated by the ordinary local and constitutional signs of hepatic abscess. The physical characters of hydatid tumors demand particular attention. 1. The liver is enlarged, and this is the first to attract notice. The growth is chronic and imperceptible, but it may attain enormous dimensions, so as to give rise to a general enlargement of the abdomen, or it may invade the whole of the chest, causing it to bulge. 2. The form of the liver is altered, as evidenced by palpation and percussion; there is an evident tumor in some part, especially the epigas- trium or hypochondrium. Smaller prominences are some- times felt along the margins or surface, causing lobulation and irregularity. 3. Any prominent hydatid tumor is gener- ally quite smooth, and more or less elastic or fluctuating. 4. " Hydatid fremitus" is often elicited very clearly. 5. In any doubtful case it is justifiable to make an exploratory puncture with a small trocar and remove some of the fluid, the physical and chemical characters of which are quite characteristic. Perhaps some of the microscopic structures may come away. The signs described are modified by the degenerative and other changes which occur in the cyst. The outer wall mav feel hard and bony. If the case comes under observation when the abdomen presents a general enlargement, it is not easy, except by the history, to make out where the growth originated. The mutilocular cyst is said to be distinguished by being nodulated, hard and tender; by jaundice, ascites, and enlarge- ment of the spleen being usually present ; and by its tendency to inflame and suppurate. This may run a rapid course. cancerous and other growths. 273 Cancerous and Other Growths of the Liver. Etiology. — The liver is a frequent seat of internal cancer, either primary or secondary, the latter occurring after cancer of the stomach. It has been attributed to injury. Most cases are between 50 and 70 years of age, the disease being extremely rare before adult life. In some there is an hereditary taint. It is more common among males. Anatomical Characters. — Hepatic cancer occurs in the form of tuberous masses, intermediate between those of scirrhus and encephaloid, approaching more to one variety or the other in different instances. There is a wide difference in size and number, the nodules being small at first, and gradu- ally enlarging, until they may reach the dimensions of a child's head or more. Several are found, unequal in size, and by their coalescence considerable tracts of the organ are some- times involved. Originally the shape is spherical, but when the masses reach the surface they become flattened, or depressed in the centre, so as to present shallow concavities or umbilications. They are not separated from the surrounding tissue by any definite structure, but occasionally there is a distinct cyst around a mass. The consistence is moderately firm, but it may range from that of a soft, brain-like, semi- fluctuating substance to that of a hard, cartilaginous tissue, and the amount of cancer-juice which can be expressed will vary accordingly. The color of a section is mostly white or yellowish-white, dotted and streaked with red, from vessels, but may be extremely vascular and dark-red, resembling "fungus nematodes." The proportion of cancer-cells and fibrous stroma in any mass, as observed under the microscope, depends on the variety. The liver is enlarged in proportion to the number and size of the growths, being often large and heavy and irregular. Its tissues are more or less destroyed and compressed, the ves- sels and ducts are invaded or obliterated, jaundice and signs of obstructed circulation are often the result present. New vessels form from the hepatic artery. The cancer begins in 21* 274 CANCEROUS AND OTHER GROWTHS. the centre of the lobules or the interlobular tissue. When a mass reaches the surface it produces limited peritonitis, with thickening and adhesions. Neighboring tissues are involved by extension, and the Lymphatic glands in the portal fissure. The growth is rapid when the cancer is soft. Certain changes are liable to occur. The vessels of encephaloid cancer often give way, leading to extravasations of blood into tne in- terior, which afterward change, and cause unusual appearances. Very soft accumulations have burst into the peritoneum in rare instances. Degenerative changes frequently occur in the less rapid forms, in the way of caseation, or atrophy with con- traction, induration, and the formation of a firm cicatrix. A section often presents a reticulated appearance from fatty degeneration. Exceptionally hepatic cancer is infiltrated. Melanosis, cystic cancer, and colloid have been rarely met with. Recent careful observation has shown that some of the morbid growths, described as cancer, are composed of spindle-celled sarcoma ; cysts, resulting from obstructed ducts, and erectile tumors have been described. Symptoms. — Hepatic cancer is characterized by marked local disturbances; it may be latent. At first, a sense of dis- comfort and weight soon increasing to distinct pain and tenderness, often very severe, especially if the growth of the cancer is rapid, or if peritonitis is excited. The pain is often lancinating, shooting to the back, shoulders, over the abdomen, &c. Jaundice and ascites are common symptoms, the result of obstruction of the main ducts and vessels by projections from the liver or glands in the fissure; ascites may be associated with chronic peritonitis. Once the jaundice begins it is per- sistent, often intense; it may be temporary from catarrh of the ducts. The spleen is rarely enlarged. The superficial abdominal veins are sometimes distended. Physical Signs. — The liver signs indicative of cancer are : 1. Enlargement, often great, rapid in its progress, and chiefly in a downward direction. 2. Alteration in shape and irregu- CIRRHOSIS OF THE LIVER — CHRONIC ATROPHY. 275 larity of outline, nodules or larger masses being felt, some- times seen along the surface and margins, which are common- ly u nib Weeded. 3. Firmness and resistance of the projections, occasionally a soft elastic feel, or a sense of obscure fluctuation. 4. Occasionally, friction-fremitus and sound during breathing, these being due to peritonitis. Digestive derangements are present in most cases, and first attract attention. The cancerous cachexia is well-marked, with rapid wasting, debility, and anseinia. The pyrexia is sometimes considerable when the progress of the disease is rapid. Cancer often occurs in other organs, either primary or secondary. The progress of hepatic cancer is generally rapid, and rarely extends beyond a year. Cirrhosis of the Liver — Chronic Atrophy. Etiology and Pathology. — Several distinct morbid conditions have been included under the term " cirrhosis," which have different modes of origin. The genuine disease results from a chronic interstitial inflammation, extending into the minutest portal canals, and leading to proliferation of cellular tissue between the lobules, or to an exudation, which organizes and then contracts, with pressure upon and obliteration of the vessels, and atrophy of the secreting elements. Some attribute it to a constitutional diathesis characterized by the formation of a fibroid tissue in different structures of the body, of which the morbid state of the liver is a local development. Others regard the disease as commencing in degeneration and destruction of the secreting cells, the ducts, vessels, and areolar tissue remaining, fol- lowed or not by proliferation of the latter. The important exciting cause of these changes is abuse of alcohol, especially indulgence in ardent spirits on an empty stomach. Hence, the common name " gin-drinker's liver." The alcohol being absorbed and circulating through the liver either sets up inflammation or leads to degeneration of the cells. Cirrho- 276 CIEEHOSIS OF THE LIVES — CHEOXIC ATEOPHY. sis occurs without intemperance, and is then attributed to malaria or prolonged heat, abuse of hot condiments and various articles of diet, the circulation of products of faulty digestion, or to the extension of a localized peritoneal inflammation. It occurs between 30 and 50 years of age, being rare in youth, and not common in advanced age. Males suffer more than females, and those whose occupation exposes them to the exciting cause. Anatomical Chaeacters. — In the advanced stage of cirrhosis the liver is wasted, and diminished in weight, some- times even § or J-, especially the left lobe and edges, the latter being often reduced to a thin fibrous rim. The form is rounded. The surface is pale and covered with roundish prominences, varying in size from minute granules to pro- jections or knobs J or \ an inch in diameter, or larger, like hobnails (hence the names " granular or hobnailed liver "). They may be uniform in size, but are commonly unequal. Local depressions are frequent. The capsule is thickened, inseparable; local peritoneal adhesions and thickenings are constant. The consistence is dense, firm, tough, and leathery. The color is a mixture of grayish and yellow ; the former arranged in bands of different widths, sometimes extending over considerable tracts; the latter varies in tint, in some specimens bright-yellow, in others almost brownish, corresponding to the granulations. The name "cirrhosis " is derived from its yellow appearance. The effects of cirrhosis outside the liver are important, visi- ble on post-mortem, being mainly those from obstruction of the portal circulation. Most important as to treatment is the fact that considerable anastomoses form between the hemor- rhoidal veins, and the superficial branches of the portal vein in the liver and the veins of the diaphragm and abdominal walls; through the peritoneal adhesions and along the sus- pensory ligament. Similar changes to those observed in cirrhosis are not un- frequent in other organs and tissues at the same time. CIRRHOSIS OF THE LIVER — CHROMIC ATROPHY. 277 Other forms of chronic atrophy : 1. The result of long- continued mechanical congestion from heart disease, the liver contracts and presents characters much resembling those -of true cirrhosis, with an important difference, and the atrophy is rarely so marked as in the latter. It is produced by the pressure of the distended tributaries of the hepatic vein upon the contiguous cells, causing their degeneration ; hence the centre of the lobules becomes first wasted and depressed; the circumference remains and forms granulations. Ultimately extensive depressions are produced, and proliferation of con- nective tissue occurs. Attacks of chronic perihepatitis are common, increasing the tendency to atrophy. 2. A form of granular atrophy, independent of intemper- ance; the fibrous tissue is not increased, and the liver is softer than in health. 3. Atrophy may result from adhesive pylephelbitis : the trunk or some of the branches of the portal vein are obliter- ated. Cicatricial retractions are observed on the surface, with corresponding indurations. 4. A form due to chronic attacks of perihepatitis : thick- ening of the capsule or pressure upon the vessels ; fibrous bands pass into the interior, but no granulated appearance. 5. Syphilis commonly leads to atrophy, by exciting peri- hepatitis or simple interstitial hepatitis, or as the result of changes in gummatous deposits. 6. The last variety is named "red or chronic atrophy." It may be associated with the deposit of pigment in the minute vessels, especially after prolonged and repeated attacks of malarial fever; it sometimes follows ulceration in the alimentary canal. The entire organ is wasted, but it differs from true cirrhosis, there being no granulation of the surface ; in a section being dark-brown or bluish-red and homogeneous, being little indication of lobules ; the consist- ence being less firm. The cells are diminished, filled with brown pigment-granules. The ramifications of the portal a gallstone, but to its angular shape. It usually diminishes when 278 CHROKIC ATROPHY. vein are destroyed, its branches ending in csecal, club-shaped extremities. Symptoms. — In all these forms of contracted liver, the diagnostic clinical indications are derived from the evidences of interference with the 'portal circulation, and the signs afforded by physical examination. There are additional symptoms due to derangement of the secreting functions, and others evidencing marked constitutional disturbance. In the early stage of true cirrhosis it is customary to find a train of symptoms merely of congestion of the liver with gastroenteric catarrh, due to abuse of alcohol; there is nothing characteristic about them. Occasionally the disease begins with severe local symptoms, indicating acute hepatic conges- tion, catarrh of the ducts, and gastroenteritis, accompanied with fever. For a time there are evidences of enlargement of the liver. As the case advances the results of portal obstruc- tion are observed; ascites, often extreme ; enlargement of the superficial veins of the abdomen, especially on the right side ; gastroenteric catarrh ; hemorrhage from the stomach or intestines ; hemorrhoids ; and enlargement of the spleen. Digestive disturbances are prominent. Painful sensations about the hepatic region are present in the early stages; when the disease is advanced there is rarely uneasiness, if any ; there may be tenderness, due to peritonitis or perihepatitis. Jaundice is but rarely prominent; it is observed at the early period, mainly due to congestion, catarrh of the ducts, or pressure of enlarged glands. Extreme jaundice may result from perihepatitis, or it appears toward the termination of a case, independently of any obstruction. The stools usually contain bile. Physical Signs. — These are : 1. Diminution in hepatic dullness in proportion to the contraction. 2. Granulation or nodulation of the surface, with hardness. Sometimes the edge of the liver can be grasped between the thumb and fingers. 3. Occasionally friction-sound. Ascites obscures the examina- tion, but the organ can be easily felt after paracentesis. In TUBERCULOSIS — SYPHILITIC DISEASE. 279 some instances there is great enlargement of the liver, but the nodulated surface can be recognized. The constitutional disturbance is marked at last by emacia- tion and weakness, with a peculiar, sallow, earthy complexion, dry, harsh skim and flabby tissues. Purpuric spots and blotches on the skin may be visible, and there may be exten- sive ecchymoses or hemorrhages from mucous surfaces. The progress of cirrhosis is chronic, but may run a rapid course from its first appearance. The modes of death are gradual asthenia and exhaustion ; jaundice with typhoid symptoms ; lung complications ; acute peritonitis ; or hemor- rhage from the alimentary canal. Tuberculosis. Tubercle is observed in the liver in connection with general acute miliary tuberculosis. Occasionally it is secondary to chronic tubercle in other parts. It may break down and form small cavities. Clinically it cannot be recognized with any certainty. The organ is usually enlarged, it may be enormously. In post-mortem of J. Going, D. D., of Gran- ville, Ohio, I found his liver weighed fifteen pounds. Syphilitic Disease. The morbid conditions of the liver which may result from syphilis are : 1. Lardaceous disease. 2. Perihepatitis. 3. Simple interstitial hepatitis, leading to general atrophy and induration. 4. Gummous hepatitis, in which gummata are deposited extensively, undergoing degenerative changes and becoming surrounded by a dense fibroid tissue, from which processes extend toward the surface in various directions The liver tissue is destroyed, and deep cicatricial depressions or furrows are seen on the surface, producing a lobulated appearance. During life the characters of the liver may be determined by physical examination, in the gummatous form it is enlarged. There is pain, with tenderness, and signs of 280 ' DISEASES OF THE GALL-BLADDER. obstruction of the bile-ducts and portal vein. The progress is usually chronic. CHAPTER Y. DISEASES OF THE GALL-BLADDER. The morbid conditions of the gall-bladder may be briefly stated. Most of them cause enlargement, and it is impor- tant to be able to recognize the distinctive clinical charac- ters of each form of enlargement. 1. Distention with Bile. — When anything obstructs the commom bile-duct, as a gallstone, the gall-bladder becomes filled with bile and may attain enormous dimensions There will be the usual signs of obstructive jaundice, with enlarge- ment of the liver ; the gall-bladder is perceptible as a fluct- uating tumor, sometimes reaching nearly to the iliac crest, and somewhat tender. 2. Acute Inflammation and Suppuration. — The mucous membrane is liable to catarrh, croupous or diphtheritic in- flammation; the important form of acute inflammation is that which is attended with pus in its interior, which re- sults from irritation of gallstones, or from obstruction of the cystic duct by these. It is indicated by a painful and tender fluctuating enlargement of the gall-bladder, which may assume the characters of an abscess, or even burst, accompanied with rigors and fever, the latter tending to a hectic type. It is preceded by signs of gallstones, but there in no jaundice or hepatic enlargement. 3. Chronic Inflammation. Hydrops Vesicce Felleoz. Dropsy of the Gall-Bladder. — If the cystic duct is obstructed for a long period, the gall-bladder may gradually dilate by the DISEASES OF THE GALL-BLADDER. 281 accumulation of a clear, serous, or synovial-like fluid; the walls become thinned and atrophied. The organ is dis- tended; often to an extreme degree; there is little pain or fever, jaundice is absent and the liver is not enlarged. Occasionally the result is different. The liquid portions of the contents of the gall-bladder are absorbed, an inspissated substance remains, in which calcareous salts are deposited ; the walls thicken and contract from chronic inflammation, and ultimately a firm, puckered mass is left, inclosing a chalky pulp. 4. Accumulation of Gallstones. — Gallstones are otten pres- ent in the gall-bladder, without affording any evidence of their existence. In some instances, however, especially when they are very numerous and large, they cause local uneasy or painful sensations, increased after food or after exertion or jolting ; as well as reflex disturbance of the stomach and other parts, and with constitutional discomfort and depres- sion. Occasionally they give temporary severe symptoms by attempting to enter the cystic duct, then falling back into the gall-bladder. They may excite inflammation or ulceration of the mucous surface, the latter ending in perfo- ration or pyaemia. In rare instances such a number of calculi collect as to form a tumor of considerable size, having the general Characters of enlargement of the gall-bladder with the differences : 1. It feels hard and sometimes nodu- lated. 2. On palpation a peculiar sensation is experienced, of rubbing together of the calculi, compared to that of grasping nuts or pebbles. 3. Ajsimilar sound may be heard on auscultation, and occasionally loud rattling is perceptible on shaking or moving the patient. Occasionally local peritonitis is excited by this enlargement, becomes adherent. When such a tumor exists there are sensations of weight and uneasiness on moving from side to side. The course of these cases is very slow. 5. Cancer. — The signs of this rare disease are : 1. Lanci- nating pains with tenderness in the region of the gall-bladder. 282 2. A tumor 7 having the characters of enlarged gall-bladder, feeling firm, resistant, irregular, and nodulated, without pe- culiar sensation of gallstones ; adherent and fixed ; growing rapidly. There are evidences of cancer in other parts, with marked cancerous cachexia. A fistulous communication with the intestines is often formed. Gallstones are present. Jaun- dice and vomiting are common. Gallstones — Biliary Calculi — Cholelithiasis. Etiology and Pathology. — There is uncertainty as to the mode of origin of gallstones. The chief views may be stated : 1. They are the result of inspissation and concentra- tion of bile. 2. They depend upon certain biliary ingredients being in excess, as cholesterin and coloring matters. 3. The bile has some abnormal composition, either when first formed, or as the result of subsequent chemical changes, which pre- vents it from holding certain elements in solution, and hence the deposit. Calculi has been attributed to deficiency of soda, with excessive acidity ; excess of lime, causing a separation of pigment ; decomposition of the salts of soda with biliary acids, or decomposition of the latter, with precipitation of choles- terin and pigment. 4. They originate in plugs of mucus, epithelium, or foreign bodies (worms, fruit-stones, &c), upon which the ingredients of the bile are afterwards deposited. It is probable that each of these views is correct in different cases, and when once the formation of a gallstone has com- menced, its increase may be due to some other cause than that which originated it. A catarrhal state of the gall-bladder and ducts favors the production of calculi, either by inducing stag- nation, or by the mucus then formed favoring decomposition of bile, or adding carbonate of lime to it. This decomposition has been attributed to the absorption of ferment from the intestines. Predisposing causes of gallstones are: advanced age; the female sex; sedentary habits; habitual constipation; over- indulgence in animal food and stimulants; organic diseases of 283 the liver, gall-bladder, or ducts, interfering with the escape of bile; drinking water containing excess of lime. Anatomical Characters.—- The most frequent original seat of biliary calculi is the gall-bladder; they may be found in any portion of the ducts or in the liver. The number varies from one to hundreds or thousands; usually several are found. There is a wide range in size, in an inverse ratio to the number; several may be cemented together, forming a large concretion. Originally most of the calculi are round or oval, but when numerous, by rubbing together they become worn and angular, presenting flat or concave facets, occasion- ally actual articulations. In the ducts they exhibit curious shapes, branched, coral-like, &c. They present an endless variety of tints, from white to black, blue, green, red, &c, according to their composition; may be translucent. They have a greasy or saponaceous feel, with a waxy, brittle consist- ence, being readily cut or crushed; sometimes very firm. Most lie in water when recent; some float, and most will after having been dried. The structure is rarely homogeneous and uniform. After a calculus has existed some time, a section shows three parts, named from within out, — the nucleus, of which there may be more than one ; the body, which is often in concentric layers, or presents a radiated appearance; and the crust, this being usually smooth externally, but occasion- ally wrinkled, rough, or tuberculated and warty. The layers become lighter in color from the centre towards the circum- ference; not always. The chemical composition is very variable, but the most common ingredients are cholesterin and bile-pig- ments, with a little lime or magnesia. To these may be added biliary and fatty acids, generally combined with lime; modified bile-pigments; phosphates, carbonates, salts of soda or potash in small proportions, and metals, (iron, copper, and manganese). The nucleus is often made up of mucus and epithelium, and the former may unite the different parts. The morbid conditions produced by gallstones are : 1. Irritation, inflammation, suppuration, ulceration, pyaemia or 284 GALLSTONES, ETC. perforation, of the gall-bladder or ducts, the last in different directions, into the stomach, duodenum, peritoneum, or externally through the abdominal wall, rarely into the colon, portal vein, pleura, pelvis of the right kidney, or vagina. Fistulas may be left. 2. Inflammation and abscesses in the liver, if lodged there ; or formation of a cyst around the calculi. 3. Obstruction of some of the ducts in the liver, or of the hepatic, cystic, or common duct. 4. Obstruction of the intestines by a large calculus, this having entered through a fistulous communication of the gall-bladder. 5. Inflamma- tion, ulceration, or gangrene of the bowel, with perforation. Symptoms. — The passage of a gallstone along the duct to the intestine — biliary or hepatic, colic — usually severe; not always. A sudden, intense pain in the right hypochondrium, often coming on just after a meal or after effort ; constricting, griping, tearing, burning, boring, etc.; it shoots over the abdo- men, round the side, to the back, or toward the right shoulder. The patient doubles up, rolls about, as in ordinary colic, groaning and pressing upon the abdomen, which gives some relief, there being generally no tenderness at first. The pain may subside, leaving a dull aching ; urgent paroxysms return at intervals. The attacks occasion exhaustion, signs of col- lapse, an anxious countenance, faintness which may end in syncope, and cramps of the abdominal muscles, but no fever. Sympathetic vomiting is frequent; sometimes hiccough. Occasional symptoms are spasmodic tremors or convulsions, and rigors. In a day or two, if the gallstone reach the com- mon duct, there are the usual signs of obstructive jaundice. When the calculus reaches the duodenum the suffering sub- sides with relief, and the jaundice disappears. In the majority of cases calculi pass by the bowels and are discharged, some- times in great numbers, without any further mischief. They may be detected by washing the stools through a sieve. Rarely they pass into the stomach and are vomited. The intensity of the pain is not in proportion to the size of DIAGNOSIS OF CHRONIC LIVER DISEASES. 285 the concretion reaches the common duct ; this is larger than the cystic duct ; it increases again as the orifice is approached. Jaundice may be slight, when the calculus is angular it leaves room for the bile to flow, or its passage is sometimes too rapid for the appearance of jaundice ; this may be permanent and extreme, owing to the impaction of a stone. It is important to look for the calculi in the stools, by their shape, number, &c, an opinion can be formed whether any remain, and their characters. When one large gallstone has escaped other smaller ones often follow without causing any particular dis- turbance. Sometimes the pain subsides, but no calculus is passed, because it returns to the gall-bladder. Sometimes pain and soreness remain after the escape of a concretion into the duodenum, owing to nervous irritability or to local irritation of the nerves; inflammation may be excited indi- cated by pain and tenderness with fever. The symptoms of hepatic colic are due to the passage of grit or inspissated bile. An attack may end fatally, from its intensity and collapse, irrespective of the serious morbid changes a gallstone is liable to set up, any one of which may cause death. General Diagnosis of Chronic Liver Diseases. The main elements in the diagnosis of chronic hepatic diseases, from other affections and from each other, are : 1. The general history of the patient may show some known cause of certain liver complaints, especially abuse of alcohol; over- eating, deficient exercise, and luxurious habits; residence in tropical climates or malarial districts; the previous occurrence of dysentery or ague; or syphilitic infection. Family history may aid in diagnosis, if indicating a cancerous taint ; the age and sex deserve consideration. 2. The constitutional condition is important. Some state in which lardaceous or fatty liver is likely; signs of the cancerous cachexia, syphilis, or cirrhosis. The absence of constitutional disturbance is sometimes service- able in diagnosis. 3. The presence or absence of symptoms referable to the liver, their nature, intensity, and the history of 286 DIAGNOSIS OF CHEONIC LIVEE DISEASES. their progress, deserve careful attention, as pain and tender- ness ; jaundice ; ascites and other evidences of portal obstruc- tion. 4. Physical examination is valuable. 5. The state of other organs may afford aid, by revealing local manifestation of some constitutional disease, as cancer in the stomach, waxy kidney ; or some condition with which hepatic derangement is associated, any ulceration in the alimentary canal, gastro- enteric catarrh, or a state of the heart which obstructs the circulation. 6. The rapidity of the progress of a case to the time seen, its subsequent course, and the results of treatment, are important in difficult cases. Physical examination requires special attention in detecting the characters of enlargements or contractions of the liver and enlargements of the gall-bladder. 1. Enlargements. The ex- tent, direction, and rapidity of growth. 2. Whether the liver is normal shape and outline, or presents outgrowths or irregu- larities. 3. The condition of the surface and margins as to smoothness, nodulations, &c. 4. The consistence and other sensations generally, any special prominences, including fluctuation, hydatid fremitus, &c. 5. Whether there is any evidence of local peritonitis as friction-fremitus sound, or adhesions to the abdominal Avail. 6. Occasionally it is requisite to use the exploratory trocar. The gall-bladder should be noticed whether it is altered alone, or with the liver, and vice versa. The Causes of enlarged liver are: 1. Congestion, especially mechanical. 2. Accumulation of bile from obstruction in the ducts. 3. Albuminoid disease. 4. Fatty infiltration. 5. Hydatid cysts. 6. Cancerous and other growths. 7. Hepa- titis, when ending in suppuration. 8. Cirrhosis in its early stage, and exceptional instances, when advanced. As rare causes may be mentioned. 9. Simple hypertrophy. 10. Syphilitic gummous hepatitis. 11. Tubercle. 12. Lym- phatic growths. 13. A peculiar enlargement with vitiligoidea. The chief practical difficulties in diagnosis are : 1. Hepatic enlargement, sometimes changes in shape and other characters, DIAGNOSIS OF CHRONIC LIVER DISEASES 287 I may be simulated by the normally large size of the organ in children ; congenital malformation ; pressure by a rickety or otherwise deformed thorax ; the result of tight-lacing ; depres- sion by various morbid conditions in the chest, pleuritic effusion and tumors ; elevation towards the chest by abnormal conditions in the abdomen. Distension of the colon w T ith gas may give signs simulating atrophy. 2. Morbid states of other structures often give signs of hepatic derangement; or they may put these in the background. Enlargement may be simulated by a contracted state of the right rectus muscle; inflammation and suppuration in the abdominal walls ; accumulation of fseces in the colon ; tumor in connection w r ith the right kidney, suprarenal capsule, or peritoneum. Scirrhus of the head of the pancreas interferes with the escape of bile from the liver, and causes its enlargement, with jaundice. The coexistence of ascites, chronic peritonitis with effusion, renders physical examination unsatisfactory. The use of the trocar is then most serviceable, to remove the fluid. Liver disease is obscured by symptoms referable to a morbid state of some other organ, as cancer of the stomach, etc. Sometimes the liver becomes so enormous in hydatid disease as to fill the abdomen, and it becomes impossible to tell exactly where the enlargement commenced. The history as to where it started, and its greater prominence about the hepatic region may clear up the difficulty. 4. In instances the liver is affected with two or more morbid conditions, as cirrhosis with fatty or albuminoid disease. Hydatid tumor may be con- founded with distended gall-bladder; soft cancer; right pleu- ritic effusion; abscess which has become chronic; aneurism; cystic disease of the kidney; or hydatids outside the liver. Cancer may be simulated by syphilitic disease ; waxy liver, if combined with cirrhosis, or if some parts of the liver are more affected than others, causing local projections; other forms of cirrhosis with enlargement ; multilocular hydatid disease. Pain referred to the hepatic organs may be simulated b\ painful affections of the superficial structures, either muscular 288 GENERAL PROGNOSIS. or neuralgic ; gastric and duodenal disorders, either functional or organic; intestinal colic; accumulation of faeces in the colon ; aneurisinal, pancreatic, and other tumors pressing on the nerves ;' passage of a renal calculus ; pleurisy ; the pain in hypochondriasis; local peritonitis. The passage of a gall- stone is indicated by the individual in whom it occurs, the past history, and the symptoms present, by jaundice and the escape of calculi in the stools. Gallstones are commonly formed in organic disease of the liver or gall-bladder. Simple hepatalgia is difficult to make out. General Prognosis. The prognosis of a chronic hepatic disease depends upon its nature ; the degree; the escape of its secretion prevented, and its circulation impeded; the constitutional condition; the state of other organs ; and the possibility of removing any causes of the disease ; the results of treatment. Fatty and lardaceous disease are very slow in their progress; do not seem to hasten a fatal issue, though they are little amenable to treat- ment. Cancer is fatal and rapid in its course, if of the softer kind. Hydatid disease is chronic and unattended with dan- ger ; it may be cured in many cases by appropriate treatment. It may prove dangerous by rupturing, becoming inflamed and suppurating, or some of its contents being discharged into the bile-ducts, blocking them up. Syphilitic liver can be much improved by early and proper treatment. The different forms of atrophy are serious in their prognosis, though slow in progress. In cases of cirrhosis, if the ascites can be got rid of, a result which may be attained, the patient may be restored to comparatively good health and live many years. Serious hemorrhage from the alimentary canal is liable to occur in cirrhosis. Gallstones have many dangers attending them. Examination of calculi passed, size, number, and shape, will aid in determining whether any remain, and whether the attacks of hepatic colic are likely to roccur. GENERAL TREATMENT. 289 General Treatment. The treatment of hepatic disease should be conducted on simple principles. 1. The diet needs careful supervision, adapted to the consti- tutional condition, nutritious, containing abundant protein elements; simple and easily digestible, caution in the use of alcohol, hot condiments, fatty, amylaceous, saccharine sub- stances, and rich articles of diet generally. In many cases it is important to forbid stimulants, or allow light wines; if spirits are needed, they should be given much diluted and in restricted quantities. The patient may take much salt with food. 2. Hygienic management is in some cases important. The ordinary measures for improving the general health; remove from a tropical climate or malarial district; cessation of seden- tary and luxurious habits generally, a sufficient amount of exercise in the open air taken daily ; and maintain free excre- tion of the skin by the aid of baths. 3. Treatment against some constitutional morbid condition proves serviceable, and may have a direct influence on the liver, which applies particularly to fatty, lardaceous, and syph- ilitic disease. General tonic treatment and remedies for improving the blood are beneficial, as the various preparations of iron, strychnine or nux vomica, iodide of potassium or iron, muriate or corbonate of ammonia, have been- found to influence the size of lardaceous liver. Iodide of potassium is the remedy for syphilitic disease. 4. The medicines which are believed to act immediately on the liver, influencing its secretory functions, named cholagogues, are podophyllin; leptandrine; nitric and muriatic acids, either externally or in the form of bath ; taraxacum and caseara sagrado. Clinical observation affords evidence that in certain morbid conditions, when the bile is deficient, these remedies decidedly increase it. This is due to their aiding in removing 22* 290 GENERAL TREATMENT. some state which impedes the formation of bile, or in promot- ing its discharge. It is certainly injurious to get into the habit of constantly taking podophyllin, etc. A dose of podo- phyllin now and then is serviceable. A mixture containing nitro -muriatic acid with extract of taraxacum enjoys consider- able repute, in congestion of the liver and the earlier stages of cirrhosis ; probably these medicines act mainly through their direct action upon the alimentary mucous membrane. Nitro- muriatic acid bath (Si of nitric and 5ij of hydrochloric to a gallon of water at 90° to 98° F.), in which the feet are placed, and then the inside of the upper and lower extremities and the abdomen are sponged over freely. This bath benefits those suffering from disordered liver. 5. Symptoms referable to the ailmentary canal call for treatment in liver diseases, as gastric or enteric catarrh, con- stipation, flatulence, hemorrhage, &c; or there may be organic disease in the stomach or intestines. These conditions must be treated by alkalies and their carbonates, citrates, tartrates, and other vegetable salts; different bitter infusions or tinc- tures ; saline aperients and mineral waters. Keep the bowels regular without strong purgatives. 6. Jaundice and ascites have been considered. Early and repeated, removal of fluid by paracentesis in ascites from cirrhosis as a means of cure, a treatment which has of late received support from our best authors, and from communications in the medical periodicals. 7. Local applications aid to relieve pain and congestion, such as dry heat, poultices and fomentations, to which ano- dynes may be added, sinapisms, anodyne plasters, dry cupping, etc. 8. Look to other organs, and treat them, if required, par- ticularly the heart, a diseased condition of which may be the immediate cause of hepatic symptoms. The kidneys must also receive careful attention. A hydatid tumor requires operative interference. No known drug has any influeuce upon the parasite, a spontaneous cure GENERAL TREATMENT. 291 being rare. When the growth attains some size and becomes a source of trouble, this course of treatment should be adopted, it should not be delayed too long. There is much difference of opinion as to the best plan of operation. The principal methods are : 1. Puncture with a trocar and canula, and evacuation of the fluid through the latter. 2. Puncture and subsequent injection of the cyst with some irritating liquid, to excite inflammation, such as bile or tincture of iodine. 3. Re- moval of the contents through a large incision. 4. Gradual opening of the cyst by the repeated application of caustic potash to the abdomen over the most prominent part of the tumor. 5. Puncture of the tumor with needles and transmis- sion of electric shocks through it. Some assert that all that is necessary is to evacuate the fluid, and that then the parasite will die. Others, that it is necessary to excite inflammation. The evidence is in favor of the simple use of the trocar. Some recommend a very small one, others a very large one; there is a difference of opinion as to whether it is requisite to remove the whole of the fluid, some using an exhausting syringe to draw it off. Dr. Murchison advocates the use of a fine trocar. The canula should be removed before the whole fluid has been drawn, as it ceases to flow in a full stream ; pass a wire through the tube to see that it is not stopped up by a hydatid vesicle. The object is to prevent the entrance of air, one of the main dangers; it tends to supperation. Another danger is the escape of fluid into the peritoneum ; to prevent this pressure should be made over the punctured portion of the abdomen during the removal of the canula. The opening should be made over the most prominent part of the tumor. Local ansethesia may be induced. After the operation close the opening with lint steeped in collodion; apply a compress and bandage to it. Absolute rest three days, an opiate given at once and repeated if necessary. If the fluid collects again, repeat the operation, not too soon, as the enlargement may be due to inflammatory effusion. In cases which are successful considerable fullness may remain some months. Should the 292 DISEASES OF THE SPLEEN. tumor be large its walls are thicker and less elastic, use a large trocar. A free incision is admissible when suppuration has occurred, or a large trocar may be used and an elastic tube left in, the cyst washed out with carbolic acid solution. The events which may occur with hydatid tumor must be treated on ordinary principles. During the passage of a gallstone the measures are : 1. Anodynes; opium or morphia in full dose, subcutaneous in- jection of the latter; belladonna, hyoscyarnus, chloroform and ether, by inhalation. 2. To treat certain symptoms, especially vomiting and collapse. Apply fomentations, poul- tices, or anodyne applications constantly over the hepatic region, or put the patient in a warm bath. Drink a warm solution of bicarbonate of soda (5i or Sii to Oj). Large warm enemata may be beneficial. For the prevention of gallstones attention to diet and hygiene is essential, and the use of remedies which improve the state of the alimen- tary canal, or those which act on the liver. It has been supposed that they can be dissolved after their formation, by means of a mixture of turpentine and ether, chloroform, alkalies, Or [alkaline mineral waters.' It is very doubtful whether either of these has any such effect, but alkalies and mineral waters often do a great deal of good in these cases. The results from gallstones must be treated as they occur. Inflammation about the gall-bladder requires poultices and fomentations. . If pus forms, or if much fluid collects, it is sometimes requisite to puncture the cyst and let it out, leavinga fistula. CHAPTEK VI. DISEASES OF THE SPLEEN. Clinical Characters. — 1. The spleen may be diseased without local morbid sensations. When enlarged, it causes DISEASES OF THE SPLEEN. 293 a sense of fullness and tension about the left hypochon- drium, with pain and tenderness. 2. The constitutional condition. In prolonged cases a state known as " splenic cachexia" is induced, characterized by extreme anaemia, the mucous membranes being pale and bloodless, and the face presenting a waxy, or sometimes an earthy, sallow appearance ; great debility ; wasting, not usually rapid ; sense of prostration aDd dullness ; shortness of breath on any exertion, with hurried breathing, chiefly due to the anaemia; tendency to hemorrhages, in the form of epistaxis, bleeding from the gums, and petechia? under the skin; oedema of the legs and eyelids, or general dropsy. 3. Symptoms from pressure of an enlarged spleen on sur- rounding parts, the diaphragm, the dyspnoea thus increased, bronchial catarrh, vomiting, excited by pressure on the stomach. Physical examination of a splenic tumor shows : 1. It- is extra-pelvic, occupies mainly the left hypochondrium, being felt to come from beneath the margin of the thorax. In its growth it tends toward the front of the abdomen, down- wards and to the right; ultimately it extends to other regions, and appears superficial, can be separated posteriorly from the mass of the dorsal muscles. Percussion shows increase in area of splenic dullness, upwards or backwards; it rarely reaches above the fifth rib, and does not extend to the spine. There is a sense of resistance, deficient elasticity of the ribs. 2. The form is that of the spleen exaggerated. The anterior border can be felt obliquely down and to the right, sharp and thin, presenting notches or shallow exca- vations. The lower end is rounded. The outline of the spleen may be visible. 3. The tumor feels firm and solid ; may give a sensation of elasticity; fluctuation extremely rare. The surface smooth, may be irregular. 4. An im- portant character of splenic tumor is a great mobility. Generally more readily moved in all directions by manipu- lation and respiration than any other tumor; often felt below 294 CONGESTION OR HYPEREMIA OF THE SPLEEN. the ribs after a deep inspiration, when otherwise imper- ceptible. Posture also affects it markedly. 5. A splenic murmur may be heard. Difficulties in recognizing enlargement of the spleen are: 1. Not sufficiently large to come below the margin of the thorax; then can only be made out by percussion. 2. When large, it may be kept up by the costo-colic fold of peritoneum, or adhe- sions at its upper end. 3. Adhesions may prevent any mobility and the tumor become fixed. 4. The enlargement may be so great as to obscure the outline of the spleen, the latter assum- ing a vertical direction. 5. Enlargement of other organs may conceal splenic tumors. 6. Accumulation of flatus in the colon may obscure its detection. The morbid conditions for which enlarged spleen is liable to be mistaken, or vice versa r are cancer about the cardiac end of the stomach; enlarged left lobe of the liver ; tumor of the omentum ; and tumor in con- nection with the left kidney or suprarenal capsule. Congestion or Hyperemia of the Spleen. Etiology. — The spleen becomes congested because of its great vascularity and yielding nature of its capsule. After every meal it is in this condition. Active hyperemia is com- mon in acute febrile diseases, in typhoid and intermittent fevers, in typhus, erysipelas, pyaemia, puerperal fever, acute tuberculosis, in vicarious menstruation, injury and morbid deposits. Mechanical congestion follows obstruction to the portal circulation, direct or secondary, to chronic heart and lung-affections. Anatomical Characters. — The characters of a recently congested spleen are enlargement, the capsule stretched and smooth ; increase in weight ; redness of a dark hue ; and diminution in consistence, the substance of the organ some- times quite pulpy or almost liquid. The blood is much increased, red blood-cells are abundant, and the splenic tissue increased. After long-continued or repeated hypersemia, it HEMOEEHAGIC INFAECTION — SPLENITIS. 295 becomes permanently enlarged, hardened and hypertrophied. Symptoms. — The clinical sign of congested spleen is, the organ is enlarged to a great degree, and liable to vary con- siderably. Occasionally soft, but generally firm. Tenderness is common, and may be marked in acute congestion. Hemoeehagic Infaection — Splenitis. Etiology and Pathology. — The spleen is one organ in which emboli frequently lodge, causing hemorrhagic infarc- tions. May also arise from the formation of local thrombi in the organ. Inflammatory action is excited, when the emboli have septic properties, as in typhus or pyaemia, and this is frequent cause of splenitis. Inflammation results from injury; and it may occur in malarial districts, in tropical climates, or idiopathically. Anatomical Chaeactees. — Infarctions in the spleen are seen on a section in wedge-shaped masses, base towards the surface, projecting somewhat ; when deeper they are rounded. They vary in number and size. Originally each infarction is dark and firm, and surrounded by congestion ; in time changes take place, the coloring matter is absorbed; the mass is yellow- ish-white. Caseous degeneration with ultimate absorption may occur, a depressed cicatrix remaining ; or it may end in cal- cification. In pyaemia and similar affections, the infarctions rapidly break down, form a purulent fluid, and the spleen is in- flamed and congested. One or more abscesses form, sometimes finally involving the entire organ, being converted into a mere bag of pus. An abscess occasionally bursts externally or into the peritoneum, stomach, thorax, etc. Rarely it be- comes encapsuled, and undergoes curative changes, its fluid portion being absorbed, so that finally only a caseous mass remains, which may calcify. The peritoneum is often inflamed over the affected part. Symptoms. — Very rarely can embolism in the spleen and its results be recognized during life, but it may be suspected if, with some source of embolism, there should be rigors and 296 HYPEETEOPHY LEUCOCYTH^MIA. fever, with local signs indicating inflammation of the spleen, as pain and tenderness in the left hypochondrinm ; enlarge- ment and vomiting. An abscess is scarcely ever diagnosed ; it may cause a fluctuating enlargement, or burst externally.' It is attended with hectic fever and rapid wasting. Should it rupture internally, there are the usual signs of perforation. Hypeeteophy. — Leucocythjemia. Etiology and Patholgy. — The most important form of enlarged spleen is that which is hypertrophy of its tissues. It may follow long-continued or repeated congestion, but par- ticularly after ague, or after residence in malarial districts, and the result of portal obstruction. If this hypertrophy is due to interference with the escape of the cells out of the spleen, not to excessive formation. It is most important in the disease named leucocythcemia or leukcemia, characterized by the presence of a great excess of white corpuscles in the blood, an increase in the lymphatic tissues in certain organs and structures, in the spleen and lymphatic glands, occasion- ally in the liver, kidneys, lungs, heart, thyroid gland, supra- renal capsules, in serous and mucous membranes. Virchow has described two forms : in one the spleen is enlarged; this is sometimes more common ; in the other it and the lymphatic glands. The increase in white blood-cells is mainly due to excessive format ion in the spleen or lymphatic glands; it has been attributed to diminished metamorphosis of these into red corpuscles, to their proliferation in the blood, and a new formation by the walls of the vessels. Anatomical Chaeactees. — In hypertrophy from hyper- emia, the spleen is increased in size and weight, sometimes great, but retains its normal form ; its consistence is increased, a section appears pale and dry, sometimes gray, or black spots or patches due to pigment. The tissue is quite normal, but increased and condensed, the trabecule being also thickened and firm, appearing as white lines. When the spleen is affect- HYPEETEOPHY — LETJCOCYTH.EMIA. 297 ed in leucocythseima it is first congested, the cellular elements increasing. Ultimately it may attain enormous dimensions. It is not invariably firm. The increase of tissue, particularly in the Malpighian corpuscles, becomes enlarged; the vessels increasing in number, they are seen on section firm, whitish, irregular, scattered nodules, the surrounding pulp atrophied as they extend, often much pigmented. The trabecular are thickened. The capsule is thickened, opaque, and adhesions form with neighboring structures. Hemorrhagic infarctions or their remains are common. When the lymphatic glands are affected they enlarge, in cases forming tumors by their aggregation. They resemble ordinary glands, soft, smooth, uniform surface, from which a turbid fluid can be expressed. The cortical portion is much thickened. In the liver, the changes associated with leucocythsemia are in the form of little whitish spots, consisting of a soft adenoid tissue, composed of small cells and nuclei. The liver may be occupied by considerable masses of this substance, causing its enlargement. The deposits are mainly derived from infiltra- tion by elements conveyed by the blood from the spleen and glands, in part due to local hyperplasia of the adenoid tissue normally present. The changes in the blood, in the splenic variety of the dis- ease it contains an enormous number of white corpuscles ; in the lymphatic variety, there are abundant small cells and free nuclei, like those in the glands ; and in mixed cases as the disease apprpaches more one type or the other, does the rela- tive proportion of these elements vary. Other characters of the blood are marked, lowering of its specific gravity ; great diminution of red corpuscles, and iron ; increase of water ; and in some instances, the presence of abnormal ingredients, such as are usually found in the spleen, viz. : hypoxanthin, lactic, formic, and acetic acids. The proportion of white cor- puscles differs in blood taken from different parts of the body, being highest in that of the splenic vein. After death soft, 298 DISEASES OF THE SPLEEN. yellow clots are found in the heart and great vessels, some- times almost purulent. Symptoms. — Hypertrophy of the spleen may long exist to a marked degree without producing any evident disturbance. In some advanced cases there are signs of marked splenic cachexia. Physical examination usually reveals the enlarged spleen. In leucocythcemia the essential clinical phenomena are: 1. Splenic cachexia, often attaining a high grade. 2. The phys- ical signs of enlarged spleen, in some instances this organ "being so hypertrophied as to cause general enlargement of the abdomen. 3. In a few cases enlarged masses of lymphatic glands, either externally, internally, or both ; occasionally signs of enlarged liver. 4. Sometimes evidences of pressure by the spleen on surrounding structures, especially the dia- phragm. 5. Peculiar changes in the blood. Prick the finger so as to get a drop, and examine this microscopically, when the increase in white corpuscles is perceptible. Subjective sensations in the abdomen are a sense of weight, fullness, and transitory pains. There are digestive derangements, and vomiting and diarrhoea. The disease is very chronic ; there is no pyrexia in the earlier periods, may be some irregular febrile disturbance, towards the close the temperature is raised persistently. Death may take place gradually from asthenia and exhaustion, preceded by delirium, stupor, and coma; or more speedily from hemorrhage, diarrhoea, and other complications. Other Morbid Conditions of the Spleen. 1. Labdaceous Disease. — For the etiology, morbid anat- omy, and constitutional symptoms of this condition, the general account is already given. The deposit is in some cases limit- ed to the Malpighian corpuscles, producing the appearance known as the "sago-spleen," in which translucent granules are observed, like boiled sago. Clinically the enlargement of the spleen is recognized by its very hard and dense consist- MORBID CONDITIONS OF THE SPLEEN. 299 ence, and by its steady growth, finally reaching extreme dimensions in some cases. Other organs are involved; there is a constitutional condition with which albuminoid disease is associated. Diagnosis. — Physical examination is requisite to positively recognize diseases of the spleen. The main difficulties have been indicated already. Leucocythseniia requires an examin- ation of the blood. History of cases help, if they show ex- posure to malarial influences, or previous attacks of ague. If there is obstructed portal circulation, enlarged spleen results. Prognosis. — Acute diseases of the spleen are rarely dan- gerous; chronic ones are slow in progress, except malignant ; if only hypertrophy the health remains good for a long time, and it is next to impossible to reduce it. Leucocythsemia is in- curable, it lasts a variable time, an average of from 12 to 15 months. Treatment. — This is indicated by the descriptions of the various affections already given. No remedies are known to have special effect in reducing enlargement of the spleen, other than treating it on general principles. Acute inflammation {splenitis), a rare disease, require similar management to that of acute hepatitis; an emetic, followed with catharsis, and a febrifuge. Fomentations over the left side, or sinapism, pediluvium, etc. Chronic forms require supporting measures throughout. An abscess, which may be enormous, may be evacuated in various directions, as described in hepatic abscess, and must be similarly treated. Its discrimination from sup- purations in its vicinity is very difficult. The prognosis is unfavorable. Our present knowledge does not enable us to understand fully the consequences of the impairment or loss of the func- tions of the spleen. It is well known that this organ may be removed from inferior animals without the destruction of life or serious injury to health. This fact goes to show that what- ever may be its functions they are adequately performed by 300 MORBID CONDITIONS OF THE SPLEEN. other organs in its absence. There is reason to believe that this statement is applicable to man as well as to inferior animals. A case of much interest, as bearing on this point, is communicated by Dr. John L. Alston, of Texas, who, during the late civil war, served in the army of the rebellion. His account of the case is: "¥m. H. Worden, aged about eighteen years, in fine health, was wounded on the 8th of October, 1861. The ball entered the integument one inch to the left of the spinous process of the fourth lumbar vertebra, and pursued a diagonal course upward, coming but between the ninth and tenth ribs half-way between the sternum and spine. The ball must have entered the cavity of the abdomen, for at the orifice where it made its exit nearly the whole of the spleen protruded. The organ was not wounded, and it had a fresh and florid appearance as if it were not much strangulat- ed. The protruding portion measured three and a half inches in length and two and a half inches in width. He came under my observation on the third day after the wound was received. Surgeon Rice, of Gen. Cheatham's staff, agreed with me that the protruding substance was the spleen. I threw a strong ligature around it, and each day tightened the ligature. It dropped off on the fourth day. The stump which remained plugged up the bullet-hole. No suppuration ensued, and he got well without a bad symptom. On the day after the ligature came off he was sitting up, and was walking about in five or six days afterward. He said that he had lost a great deal of blood when he received the wound. When he left the hospital he was entirely well, not seeming to suffer at all from the loss of his spleen." It would be interesting to know whether the effects followed in this case which are sometimes observed after the removal of the spleen from the dog or cat, viz., a ravenous appetite and ferocity of disposition. The spleen was removed forenlargement, by Spencer Wells, of London. The organ weighed, after nine ounces of blood had drained out of it, 5 lbs. 11 ounces. The patient, a REMOVAL OF OF THE SPLEEN. 301 married woman, aged 34 years, survived the operation a little over six days. The annals of medical literature contain additional cases in which this organ has been removed for enlargement. The first case was in Naples, in 1549; the operation was performed by a surgeon named Zaccarelli. The patient recovered. The authenticity of this case is perhaps open to distrust. The second case was in Germany, in 1826. The name of 'the operator was Quittenbaum. The organ weighed nine pounds. Death followed in six hours. The third case was also in Germany, in 1855; the name of the operator, Kuckler ; the weight of the organ was three pounds, and death followed in two hours. Four additional cases of spleenotomy have been reported. In one of these cases the operation was entered upon with the expectation of finding an ovarian tumor. A large cyst was attached to the organ. A speedy recovery followed. The operator was M. Pean, and the case was reported for V Union Medicale, Nov. 1867. The operation in the second case was performed by M. E. Kceberle, and is reported in the Gazette Hebdomadaire, October and November, 1867. The patient was a woman aged 42. The patient did not recover conscious- ness after the operation, and died evidently from hemorrhage. In the third case, the patient was a groom, aged 20. The operation was performed by Thomas Bryant, and the case is reported in Guy's Hospital Reports, vol. xii, third series. The operation was begun at 2.30 p. m., and at 4.50 p. m. the patient died. The operation in the fourth case was performed by Thomas Bryant — patient a female aged 40. Death took place from hemorrhage, within a few minutes after the com- pletion of the operation. M. Kceberle, in the report of this case, cites three cases in addition to those which have been referred to, the operation being successful in each of the cases. One of these cases was in 1549. The patient recovered in 24 days. In another the spleen escaped through a wound from a sword. The patient six years afterward was in perfect health. This was in 1678. In the remaining case the spleen made a 302 DISEASES OF THE PANCREAS. hernia through'an opening of an abscess below the umbilicus. The patient lived five years after the removal. In the last two cases, it will be observed, there was no hypertrophy. These do not encourage the removal of the spleen. Diseases of the Pancreas. Owing to the infrequency, and their obscurity as regards diagnosis, affections of the pancreas require but a passing notice. This gland may be the seat of inflammation, acute or chronic. Of all the glandular organs — liver, ovaries, testes, kidneys, etc. — the pancreas is perhaps the least liable to become inflamed. Acute pancreatitis has been found, on ex- amination after death, to occur in cases of continued fever, of puerperal fever, of pyseniia, and apparently as a result of the employment of mercury. The morbid appearances denoting acute inflammation are engorgement, softening, enlargement, and suppuration. Gangrene has been observed. The symp- toms which have been observed are, pain referable to the epigastrium, vomiting, diarrhoea, chills, and more or less febrile movement. The data for determining the clinical history of the affection are insufficient. A discharge, by vomiting and stool, of a liquid resembling saliva, supposed to be the pancreatic secretion, has been thought to be a diagnos- tic symptom, but there is no reliable evidence of the correct- ness of this opinion. It remains to be ascertained whether the presence of fat in the stools is a diagnostic symptom. The diagnosis, with our present knowledge, is impracticable. Were it practicable to ascertain the existence of the affection before death, the indications for treatment would be the same as in other parenchymatous inflammations. An abscess of the pancreas has been known to open into the stomach. Chronic pancreatitis is, if- possible, even more obscure as to diagnosis, than the acute form of the disease. In a case observed by "Wilks, death followed extreme emaciation without any symp- toms pointing to the seat of the disease. From what has been stated with regard to the diagnosis, it follows that is impossible DISEASES OF THE PANCKEAS. 303 to form ail opinion as to the proportion of cases in which, either acute or chronic pancreatitis ends in recovery. The pancreas is sometimes the seat of cancer, which is generally secondary to cancerous deposits in adjacent parts. In certain cases regarded as cases of scirrhus, the affection is chronic inflammation of the areolar tissue which enters into the composition of this organ, constituting an affection analo- gous to cirrhosis of the liver, and the two affections are apt to be associated. Enlargement of the head of the pancreas from chronic inflammation, cancerous disease, or the formation of cysts, may constitute a tumor discoverable by manual explor- ation. The diagnosis involves its discrimination from other tumors in the same situation. It is most likely to be con- founded with aneurism of the aorta and cancer of the pylorus. A pulsation may be communicated to the tumor from the aorta, and this will suggest the idea of aneurism. The diag- nostic symptoms and signs of aneurism of the abdominal aorta are to be sought for, and this affection excluded by their absence. Cancer of the pylorus is to be excluded by the absence of the gastric symptoms which usually accompany this affection. The connection of structural disease of the pancreas and fatty diarrhoea has been considered in treating of the latter. The presence of free fat in the alvine dejections, taken in connection with a tumor supposed to be an enlarged pan- creas, is a point of weight in the diagnosis. The absence of fatty dejections is not proof against, but their existence is strong evidence for, the supposition that the tumor is pancreatic. Enlargement of the head of the pancreas may give rise to serious results from pressure upon adjacent parts. The duct leading from the pancreas is sometimes compressed, and dilata- tion of its branches within the organ ensues. Pressure upon the ductus communis, involving obstruction to the flow of bile, is followed by the retention of this secretion, causing persis- tent jaundice, dilatation of the bile-ducts, and, at length, dis- organization of the liver. Cases of jaundice with enlargement of the head of the pancreas, the obstruction and retention oi 304 DISEASE OF THE SUPRARENAL CAPSULES. bile have been due, not to the pressure of the pancreatic tumor on the common duct, but to disease of Glisson's capsule or cirrhosis of the liver. An enlarged pancreas may cause obstruction of the pylorus or duodenum, and this renders it difficult to differentiate the affection from cancer of the pylo- rus. Pressure upon the portal vein may exist to an extent to give rise to hydro-peritoneum. Calculi may form in the pancreatic ducts,, varying in size from that of a pea to an almond. These have been found in con- siderable number. In their journey along the excretory passage to the duodenum, they may /occasion severe pain, resembling that caused by biliary calculi. Paroxysms of pain due to the passage of pancreatic calculi, or attacks of pancre- atic colic, are sometimes attributed to gallstones, nor is it practicable, with our present knowledge, to make the differ- ential diagnosis. It is not very important since the indications for treatment are the same in either case. Clinical observa- tion with reference to the presence of free fat in the dejections, may show this symptom to be present in cases in which, with- out special attention, it is overlooked, and it may be found that this symptom is of much value in the diagnosis of affec- tions of the pancreas. DISEASE OF THE SUPRARENAL CAPSULES.— ADDISON'S DISEASE. Clinical History. — Dr. Addison first called attention to a series of symptoms associated with disease of the suprarenal bodies. One prominent phenomenon consists in a peculiar cachexia, which sets in gradually without obvious cause, characterized by increasing debility, languor, indisposition for bodily or mental effort, at last extreme prostration ; marked anaemia, the sclerotics being pearly- white; wasting, not to any degree, nor always observed; feebleness of the heart's action; the pulse very soft, weak, and compressible, and a tendency to faintness, sometimes prolonged attacks of syncope. Another DISEASES OF THE SUPRARENAL CAPSULES. 305 feature is a discoloration of the skin, the so-called bronzed appearance, due to the presence of pigment-granules in the rete mucosum; occasionally pigment-cells. The hue varies, and becomes darker by degrees; may resemble a mulatto, or simple dingy or smoky, or brown, yellowish, grayish- black, etc., all over the body, usually commences over ex- posed parts, as the face and neck, also on the upper extrem- ities, in the axillae, and about the penis, scrotum, and navel. The palms and soles sometimes present spots of pigment. The mucous membranes are discolored, the lips assuming a mulberry hue, or spots of pigment being observed on them and on the inside of the cheeks, with dark streaks opposite the angles of the mouth. In addition there is pain in the epi- gastrium, sometimes severe, with vomiting, may be urgent. Other digestive disorders are common, and obstinate diar- rhoea. The course of the disease is slow, chronic ; death takes place by a gradual asthenia, occasionally preceded by nervous disturbances. Exceptionally the progress is acute and rapid. Pathology.— There are several points in the symptoms about which there is difference of opinion. The bronzing of the skin is a question what relation it bears to suprarenal disease. A complete destruction of these bodies may occur without such discoloration ; this has been observed where there was no suprarenal mischief. Hence, some pathologists refuse to acknowledge any relationship between the two. Again, a difference of opinion as to whether the bronzing is associ- ated with all forms of suprarenel disease, or one special variety. The morbid changes are : 1. Acute inflammation ending in suppuration. 2. Tubercle. 3. Cancer, always secondary, and of the encephaloid variety. 4. Amyloid disease. 5. Fibroid degeneration with hardening. 6. Fatty degeneration. 7. Atrophy. 8. Hemorrhage. 9. Peculiar alterations associated with bronzed skin. Besides the changes, alterations in the solar plexus and semilunar ganglia, atrophy of the mucous coat of the ali- 306 ABDOMINAL, ANEURISM. nientary canal, with degeneration of the glands. These have an important influence in the pathology, the changes in the sympathetic nerve, branches of which are very abundant in the suprarenal bodies. The blood contains an excess of white corpuscles. Diagnosis.— If symptoms of failing health and cachexia appear, without any evident organic mischief, Addison's disease may be suspected. When the bronzing appears, there is no doubt about the nature of the case. Prognosis is very grave, the disease always ends fatally; a case may go on for a long time. Treatment. — All that can be done is to promote health and strength by a highly nutritious diet ; tonics, quinine. Abdominal Aneurism. The most important form of abdominal aneurism is that of the aorta. One may be found on the cseliac axis or its branches, the hepatic, on the mesenteric, or renal arteries, or iliac arteries. Symptoms. — The detection of a tumor, having the usual characters of an aneurism. Often there are signs of pressure on surrounding structures, and evidences of constitutional disturbance. The 'physical characters of an aneurismal tumor are: 1. It is usually seated in some part of the course of the aorta, but projects more to one side than the other, especially towards the left. It may be in other parts. 2. The shape is rounded, surface smooth, tumor yields on being compressed. 3. It is quite immovable, unaffected by respiratory movements; if very large it may interfere with these movements. 4. A variable degree of pulsation, synchronous with the cardiac systole usually, but sometimes also diastolic, distinctly expan- sile, tending laterally and forwards, commonly more to one side, occasionally attended with a thrill. 5. Percussion reveals dullness, with a sense of much resistance. 6. Often a systolic murmur, sometimes very loud and harsh, but not always ABDOMINAL ANUERISM. 307 heard, or slight, may be seated beyond the aneurism. ~No diastolic murmur. The murmur is influenced by posture and pressure. The points of practical importance are : 1. The signs may be in the back; it is essential to make examination here. Sometimes no sign except a murmur in this region. 2. There is no relation between the size of an aneurism and the pulsa- tion or murmur. 3. Occasionally the tumor is movable, and not uncommonly both pulsation and murmur are considerably influenced by posture, hence examine in different positions. Observe that the impulse does not disappear when the patient is in a kneeling attitude supported on the hands. 4. The signs may change in the progress of the case. The pressure-symptoms will vary with the situation of the tumor. The most couimon are neuralgic pains, sometimes severe, shooting in different directions, from pressure on nerves, causing permanent contraction of the flexors of the hip-joint ; deep gnawing pain, from erosion of the vertebrae ; anasarca of one or both legs, with distention of the superficial veins, due to pressure on the vena cava, or one of the iliacs. Micturition is affected at times, and albuminuria may occur from pressure on the renal veins. Wasting of the testis from obliteration of the spermatic artery. Aneurism of the hepatic artery is a possible cause of jaundice and ascites, by pressing on the neighboring duct and portal vein. Patients have a feeling of pulsation. The alimentary canal is out of order, may be obstinate constipation. Patients fre- quently look well, but may present a very peculiar aspect indicating profound illness, with anaemia, without physical signs of aneurism. Diagnosis. — The chief conditions which may simulate aneurism are: 1. Simple aortic pulsation. 2. The pancreas or a solid tumor transmitting an impulse from the aorta, or giving rise to a murmur by pressure. 3. A fluid accumula- tion, such as hepatic abscess or hydatid tumor, receiving an impulse from the aorta. The diagnosis from mere aortic 308 ABDOMINL AANETJRISM. pulsation requires special comment. The chief facts in favor of this condition are: 1. It is genarally seated in the epigas- trium. 2. It is observed in highly . nervous and anaemic persons, in women, in very thin individuals, or dyspeptics. 3. There are no signs of pressure, nor any pain or tenderness. 4. The impulse is scarcely ever expansile and lateral, tends in a forward direction, is never attended with a thrill; no in- crease in dullness, or evident tumor, if a murmur is present, it is soft and blowing or whiffing, never harsh or loud. Some cases are difficult to diagnose, the progress must be watched, and the effects of treatment observed. An aneurism may exist without physical signs. Occasion- ally it presents the characters of a solid tumor without any pulsation or bruit. If deep pain near the spine, and if the constitution shows signs of being gravely disturbed, aneurism should be suspected and examination made repeatedly, behind as well as in front. Treatment. — The rapid-pressure treatment, employed by Dr. W. Murray, of ISewcastle-on-Tyne. The plan is to keep the patient under chloroform, and apply a tourniquet over the aorta above the tumor, maintaining steady and constant pres- sure until all pulsation has ceased in the aneurism on remov- ing the tourniquet. The blood coagulates in the sac, and afterwards collateral circulation is set up. The results of this treatment are certainly such as to recommend its adoption in appropriate cases^ if other measures do not appear to be pro- ducing good effects. If the aneurism is high up, distal pres- sure may possibly be of service. Pain is a symptom often calling for interference, and is best relieved by chloral, or subcutaneous injection of morphia. Posture may influence it considerably. It is important to attend to the state of the digestive organs. A belladonna plaster should be worn con- stantly over the aneurism. For the pathology, etc., of this kind the reader is referred to aneurism of the thoracic aorta. DISEASES OF THE URINARY ORGANS. 309 CHAPTER VII. DISEASES OF THE URINARY ORGANS. . Congestion. Etiology. — The causes are : Sudden exposure and check of perspiration ; overdose of cantharides, turpentine and other irritants; active renal congestion or disturbance in connection with, febrile and inflammatory diseases, etc. Passive congestion is incident to heart-disease, pulmonary ob- struction, as in emphysema or pleuritic effusion; when pressure impedes the circulation in the vena cava, or renal veins, as in abdominal tumors or pregnancy. Symptoms. — Pain in the lumbar region, increased on pressure, with tenderness ; urine scanty, highly colored, sometimes bloody ; may contain albumen, and give fib- rinous casts. Often voided with difficulty, attended with burning pain, etc. Diagnosis. — Active congestion has a known cause : be- gins suddenly. Passive congestion is due to some other organic disease, is variable, not progressive. Occasionally it is difficult to distinguish this from Bright's disease. This distinguishes them from permanent diseases of the kidneys. Treatment. — Active congestion requires cooling saline purgatives and diuretics. Fomentations over the lumbar region ; warm pediluvium ; hip-baths, and emollient drinks. These measures should be used industriously until relief is reached. URiEMIA. Uremia takes its name^from supposed excess of urea which the kidneys secret, being retained in the blood. The ques- tion remains unsettled, whether it is urea, or] an ammoniacal educt from its decomposition in the blood. Without demon- strating the latter, the former is considered most probable. 310 NEPHRITIS. Uraemia may occur in the progress of diphtheria, scarlatina, etc. Symptoms. — Headache, often fixed behind the orbits or neck; pressure over the forehead or vertex; dimness of vision; irritability of voluntary muscles and twitching; nausea and vomiting; diarrhoea; epileptiform convulsions; face pale and pupils dilated; stupor ending in fatal coma and death. Treatment. — Use measures to promote the excretion of urine. Apply heat and moisture to the loins, or dry cupping. Promote action by the skin with hot air or warm vapor baths, and treat other symptoms as they arise. For epileptiform attacks, inhale ether or chloroform. Sinapisms to the back of the neck and limbs. Use saline cathartics; diuretics and diaphoretics. Nephritis. In the present state of urinary pathology, it is common to merge the topic of inflammation of the kidney (except suppura- tive pyelitis) as distinct from active renal congestion — in Bright's disease. If this be questionable as a matter of patho- logical system, it has at least practically no disadvantage ; as the symptoms of nephritis are included in one or other of the affections named; and so is its treatment. We may submit, therefore, to the usage of authority upon this point, without hesitation. The symptoms of acute pyelitis (inflammation of the pelvis of the kidney) are essentially those of renal conges- tion, intensified; with tenderness on pressure over the kidney, and fever, until suppuration is established ; then, purulent discharge for a variable time from the kidneys. Before pus appears, blood, in small quantity, mucus, and renal epithelial cells may be found in the urine. A tumor in one of the lumbar regions may precede for a while the escape of the pus. To such a state of things the term pyonephrosis is sometimes (though not desirably) applied. Hydronepohosis is a dropsical accumulation of water in the kidney. Treatment. — Active catharsis; diuretics; diaphoretics; 311 sinapisms, fomentations, and poultices over the lumbar region. Drink flaxseed tea with lemon-juice in it. Bright's Disease. Definition. — Albuminuria, due to structural change in the kidneys ; disease of the kidney, characterized by albumi- nuria and dropsy. Varieties or Stages — Authorities differ as to these. Bright believed there were three varieties. Dr. G. Johnson asserts two, the desquamative and non-desqaumative nephritis. Frerichs considers them to be stages of the same affection, and admits three stages, essentially, of hyperemia, exudation, and degeneration. Anatomically, we have the large, smooth, white kidney, the small, smooth kidney, the granular uncontract- ed kidney, and the granular contracted kidney. We may safely follow Roberts, in dividing Bright's disease, first into acute and chronic. The latter is then divided into, 1. Cases which have lapsed from the acute state (smooth, white, generally large kidney); 2. Cases chronic from the beginning (granular, red, contracted kidney); 3. Cases associated with waxy or amyloid degeneration of the kidneys. Causation. — Bright's disease is one-third more common in males than in females. The greater number of cases occurs between the ages of 45 and 65. Acute Bright's disease is most often produced by cold and dampness; next by scarlet fever, pregnancy, or violent intemperance. The acute form is most common in early life. Chronic Bright's disease is promoted by exposure to cold and wet; is caused by abuse of spirituous liquors, very often. Other predisposing causes are gout, constitutional syphilis, and affections of the bladder and urethra. Symptoms. — Acute Bright's Disease. — After exposure to cold, or a drnnken fit, or scarlet fever, the patient is seized with chilliness, headache, nausea, vomiting, paiu in the back and limbs, checking of perspiration, and oppression' in breath- ing. Fever follows; and the face, trunk and limbs become 312 bright's disease. puffy with anasarca. Effusion may also occur into the pleura or peritoneum. The urine is scanty, heavy, and dark in color, from the presence of blood; and very albuminous. The disposition to void it occurs more frequently than during health. The deposit from it, under the microscope, shows blood-corpuscles, loose renal epithelium, free nuclei, tube-casts, and shapeless masses of fibrin and debris. After one, two, or three weeks, or even a longer period, the attack proceeds to one of three terminations : recovery, death, or lapse into the chronic state. Death results through ursemia, or from secondary pneumonia, pleurisy, peritonitis, pericarditis — or hydrothorax, oedema of the glitois, hydroce- phalus, or ascites. Probably two-thirds or more of the cases of acute Bright's disease recover. Treatment. — Cupping the loins, hot water 'or hot air or "blanket" bath, active purging, as with cream of tartar and jalap, or citrate of magnesium, and diaphoretics, as citrate of potassium or liquor amnion, acetat. The diet should be liquid and simply nutritious. Flaxseed tea with lemon juice in it, drank freely, is an excellent and much relished diuretic. Chronic Bright's disease comes on slowly, it is seldom detected until after the lapse of months or years. Gradual loss of strength, pallor or puffiness of the face, shortness of breath, and frequent disposition to urinate, are early signs of it. But they are not always present ; the denouement of the disease may be by a convulsion, oedema of the lungs, amauro- sis, or some violent local inflammation. Symptoms of a well-marked case (not all present in every instance) are : albuminous urine, deposits of tube-casts and renal epithelium, dryness of skin, frequent micturition, es- pecially at night, general dropsy, or local effusions into the cavities, indigestion, anaemia, uraemic effects, (headache, diz- ziness of sight, convulsions, coma, vomiting, diarrhoea), en- largement of the heart, and secondary inflammation. Bron- chitis is especially common. 313 The progress of the case is usually interrupted by ex- acerbations and intervals ; each fresh attack leaving the patient manifestly worse than before. Such attacks much resemble acute Bright's disease ; they are sometimes referred to known causes ; the intervals may last weeks, months, or even years. In prognosis, the tendency is always toward a fatal re- sult. About one-third die of uraemic poisoning. A con- siderable number die of local dropsical effusions. One-fifth from secondary pneumonia, pericarditis, or pleurisy. The rest, by exhaustion from anaemia, indigestion, and anasarca, or the complications of apoplexy, cirrhosis, phthisis, in- testnal ulcerations, etc. Diagnosis. — The presence of albumen in the urine, with dropsy, not of sudden origin or brief duration, is pathog- nomonic of this affection. The tests for albumen, by heat and nitric acid, are readily applied. The microscope will show also free renal epithelium and tubular casts in the urine ; in advanced cases, the casts are sprinkled with oil- dots. The solids of the urine, especially the urea, are re- duced below the normal amount. Pathology. — Degeneration of the structure of the kid- ney induces albuminuria, by allowing the serum of the blood to pass almost unchanged through the cortical sub- stance into the tubuli uriniferi. The deficiency of urea is due to the same impairment of secreting power. The con- sideration of the different varieties of renal degeneration would be too complex a subject for these pages. The reader is referred for it to the standard treatises on the subject. Treatment. — The indications in every case of Bright's disease are : 1. To hinder the progress of structural change in the kidney. 2. To prevent uraemia and secondary in- flammation. 3. To palliate concomitant symptoms or states, as anaemia, dropsy, dyspepsia, etc. Regimen or hygienic management is of the utmost im- 314 bbight's disease. portance for the first of these ends. Avoidance of exposure to cold, wet, or great fatigue ; the reform of intemperance, if it has existed, or of other excesses — will be indispensable. Clothing should be sufficiently warm, with flannel next to the skin. Bathing frequently, at such temperature as is borne without either chill or relaxation, is to be recom- mended. The bowels should be kept regularly open. Nourishing diet, of which milk may generally be part, is of consequence. Iron will do more good than any other medicine, unless it be cod-liver oil in persons of strong stomach. They may be very well combined. The tincture of the chloride of iron is as good as any other chalybeate, as a general rule. With some, the citrate of iron in solution, or a carbonate of the iodide, will agree more readily. It is very doubtful whether astringents ever check to ad- vantage the waste of albumen through the kidneys. If any be worth the trial, it is ammonio-ferric alum. Counter-irritants over the kidneys, unless of the mildest character (tinct. iodin., emplastr. picis, etc.), will not do any important good in chronic Bright' s disease. For the dropsy, warm baths and hydragogue cathartics are advised. Of the latter, cream of tartar and jalap, together, are the favorites : 2 to -3 drachms of the bitartrate with 10 to 20 grains of jalap two or three times a week. If serious dropsical accumulation threaten life, elaterium (gr. | or $ every four hours, in pill, till it acts) may be given. But it is a decided mistake to harass the patient constantly with exhausting purgation. It is to be remembered that it can act only as a palliative, removing part of the effects of the malady, not the disease itself. If the warm bath do not agree, or fail to produce diaphore- sis, those who have access to it should try the hot air bath at 130° to 150° Fah. This rarely fails to produce/free perspira- tion. For weaker invalids, the vapor bath is available. Of diuretics, acetate of potassium, spirit of nitrous ether, DIABETES MELLITUS 315 and infusion or compound spirit of juniper will be least likely to disappoint. But all will not unfrequently fail. Then we have as a resource (where tapping for ascites is not demanded) for the relief of great oedema, the use of incis- ions with a lancet, or needle, in the swollen legs and feet. Some prefer a number of small incisions with an abscess lancet plunged through the skin of the calf and dorsum of the foot. It is possible that erysipelas may follow ; but this danger will be lessened by repeated warm sponging of the limbs, washing them with diluted glycerine, inunction with lard, cold cream or vasoline, which is best. The complications of Bright's disease must be treated according to their own indications, on general principles — bearing in mind always the degenerative and asthenic tendencies belonging to the malady. Diabetes Mellitus. Synonym. — Glycosuria. Definition. — Excessive urination, with the presence of sugar in the urine. Causation. — Twice as many men as women have this disease. It is most frequent among young and middle-aged adults; the mortality from it being greatest from fifteen to fifty-five. It is more common in cities and manufacturing districts than in the open country. Occasionally it is heredi- tary. Exciting causes appear to be, exposure to cold and wet ; drinking cold water largely when heated; excessive use of saccharine food ; intemperance ; violent emotion ; febrile diseases ; and organic affections and injuries of the brain and spinal cord. Symptoms and Course. — Beginning insidiously, with malaise and slight loss of flesh, urination becomes excessive, with corresponding thirst, and very often bulimia or excessive appetite ; emaciation is progressive ; the skin harsh and dry ; the tongue, glazed and furrowed, the mouth clammy; the 316 DIABETES MELLITUS. sexual and mental powers fail by degrees. Lastly, hectic fever, oedema of the limbs, diarrhoea, and often all the symp- toms of pulmonary consumption terminate the case. Complications. — Tuberculization of the lungs occurs in nearly half the cases of diabetes mellitus which last over a year or two. Inflammations of an asthenic type are common in all the organs. Boils and carbuncles are very frequent. Gangrene of the lower extremities has been several times observed. Amblyopia (obscure vision) is present in about one-fifth of the cases. Cataract generally forms in cases of long standing ; but may be absent altogether in those of less than two years' duration. Diagnosis. — The detection of sugar in the urine, not tem- porarily, but for a considerable time, is of itself sufficient to make out the case. (See Chemistry.) Prognosis. — Recovery is not impossible in diabetes ; but a large majority of cases end in death. Amelioration — keeping the disease in abeyance — is often an attainable end. The younger the patient in whom the disorder begins, the less ultimate hope. In old persons glycosuria seems more often compatible with tolerable health for a long time. Cases traced to mental emotion or to injuries are somewhat more hopeful than those of indistinct origin. Amblyopia, cataract, and albuminuria, as well as phthisical symptoms, mark the case as incurable. Considerable diminu- tion of the sugar, or of the water, passed, is always a favorable prognostic. But the diabetic patient is much more liable than others to those inflammatory complications which, on -slight exposure, may hasten the termination of life. Treatment. — No direct control over the sugar-forming process in the body has yet been obtained by medicine. But, although it would seem that simply diminishing the formation of sugar by withholding material for it ought not to be expected to do much good, it does prove beneficial. The most important measure yet devised in the management of CYSTITIS. 317 diabetes is, the prohibition of sugar and starch, and of every- thing which can yield them, as food. Bread, except bran bread, which is almost free from starch, potatoes, and nearly all vegetables and fruits must be excluded. The safe excep- tions are, the cabbage, broccoli, onions, spinach, celery, and lettuce. Of animal diet, milk and liver are forbidden articles. All meats, eggs and butter, and jellies are allowable. Gluten bread may be made on Bonchardat's plan, without starch, in- flated by machinery with carbonic acid or compressed air. Tea or coffee may be sweetened with glycerine (chemically pure, as Bower's or Price's. Spirits, wines, and beer should be avoided unless called for by positive weakness; if that exist, the least saccharine should be preferred, as sherry, claret, or whisky, in minimum quantities. There is no advantage in restricting the amount of water taken to quench thirst. Variety of diet, of course, within the prescribed limits, is important, to prevent disgust and loss of appetite. Of medicines, none have been yet shown to do much service in checking the disease. The most positive influence in di- minishing the diuresis belongs to opium ; but this does not appear to interfere with the progress of the disease. Various drugs have been tried, and lauded greatly by different users ; but their effects will not bear scrutiny without disappoint- ment. Among them the most prominent are alkalies, yeast, rennet, pepsin, iron, quinine, creasote, alum, iodine, nitric acid, turpentine, and the inhalation of oxygen. The free ingestion of sugar has been freely experimented with, but in vain. A therapeutic remedy for diabetes remains to be discovered. Cystitis. Definition. — Inflammation of the bladder. Varieties. — Acute and chronic ; idiopathic, traumatic, secondary. Causation. — Wounds, bruises, or other injuries; the presence of gravel, or a calculus, or hydatid vesicles from the 318 CYSTITIS. kidney; irritating diuretics; or decomposing urine retained by stricture, may induce acute cystitis. The continuation or frequent repetition of the same causes produces " chronic inflammation." Symptoms: Acute Cystitis. — Pain in the vesical region; frequent desire to pass water, with burning in the urethra, and tenesmus, or disposition to bear down or strain. There is fever, alternating with chills. The bladder may sometimes be felt as a small round swelling, sensitive upon pressure. In bad cases, there arenausea, anxiety, delirium, and cold perspiration; the scantily passed urine becomes purulent and bloody, alkaline and fetid. Chronic Cystitis has usually much less severity of symptoms; but it may be very distressing from the tenderness and irritability of the bladder, and the frequent disposition to urinate, with dysuria. The urine is either mucous or muco- purulent. Teeamext. — Acute cystitis, perfect rest and a saline laxative or castor oil is apt to be the best. Warm hip baths will ■ be very soothing. Flaxseed tea may be taken freely. Opium, hyoscyamus, chloral, or belladonna may be called for by great pain or nervous irritability. Opium or belladonna suppositories or laudanum enemata, will answer best if anodynes have to be repeated often. In chronic cystitis, the other measures named may be suit- able from time to time ; also injections of lime-water and glycerine, or weak solution of nitrate of silver, or of sul- phate of copper, or acetate of lead, in water or glycerine, may be serviceable. Catheterism may at times be .indispen- sable, both in acute and chronic cystitis; but it should be avoided if possible, on account of the mechanical irritation of the instrument. A soft catheter is the best. DISEASES OF THE RESPIRATORY ORGANS. 319 CHAPTER VIII. DISEASES OF THE RESPIRATORY ORGANS. Pneumonia. Definition. — Inflammation of the substance of the lung. Varieties. — According to its seat; single, double, lob- ular. According to causation; idiopathic, from cold and wet; traumatic, from injury; tuberculous, in phthisis; and typhoid pneumonia. Symptoms and Course. — A chill or stage of depression, followed soon by fever, with oppression in breathing, dull pain (not always present) in the chest, and sometimes short cough. Delirium is common. Temperature of the body high, especially on "the fourth or fifth day ; sometimes, in the evening, reaching 104° or 105° Fahr. in the axilla. Secretions scant, as in other febrile states. Urine containing an excess of urea, but deficient especially in the chlorides, in the middle period of the attack. Expectoration commences about the third day usually, the sputa being composed of mucus, lymph, and blood mixed together, making the rusty sputum of pneumonia. The height of the attack is generally reached between the fifth and seventh day ; after which the temperature declines, and, in favorable cases, all the symptoms subside. In others, oppression in breathing, and prostration increase ; cough deepens, and expectoration becomes more abundant, at last purulent. Death seldom occurs before the sixth, and may be as late as the twentieth day. Stages. — 1. That of congestion or engorgement, and the commencement of exudation. 2. That of exudation and red hepatization. 3. That of gray hepatization, softening or purulent infiltration. Physical Signs. — These differ in the three stages. In the first they are, moderate dullness of resonance on per- 320 PNEUMONIA. cussion over the affected lung, and, on auscultation, after the first day or two, the fine crepitant rale. In the second stage, decided dullness on percussion, no rale, but, instead, bronchial respiration and bronchophony; with increased vocal fremitus. In the stage of softening or suppurative infiltration (gray hepatization), dullness on per- cussion, and coarse crepitant or mucous rale. "When resolution follows the second stage, as in most cases of recovery, the bronchial respiration gives way to returning fine crepitation (crepitus redux) ; and then the dullness of resonance on percussion also generally disappears. Terminations. — Resolution; death in the second stage from asphyxia; death from exhaustion in the third stage; recovery after the third stage (uncommon); abscess ; gangrene of the lung. Morbid Anatomy. — The lower or iddme lobe is almost always the seat of the disease. Should death take place (as it rarely does) in the first stage, the lung would be found some- what sw T ollen, dark-red, inelastic (splenization), and filled with blood or bloody serum. It will still float in water, though heavier than healthy lung. It is easily torn. In the second stage, of hepatization, the lung is no longer spongy, but presents considerable resemblance to the liver; although a finger may be easily thrust through it. When entirely hepatized, it will not float in water, the air being displaced from the cells by the exudation of coagulable lymph. The third stage consists in the degeneration (in the absence of more favorable resolution by absorption) of the exudation. This occurs by granulation, softening and suppuration. Mostly the latter is infiltrated; occasionally an abscess forms. In gray hepatization, the lung is solid, impermeable to air, with a granite-like appearance of red and white points on section. It sinks in water, but is more easily torn or crushed into a pulp than in the second stage. Diagnosis. — The only affections with which pneumonia is PNEUMONIA. 321 likely to be confounded are pleurisy, bronchitis, and phthisis. In children, collapse of the lung has been mistaken for lobu- lar pneumonia. From pleurisy, it is known by the absence of the sharp pain belonging to the latter, and by the crepitant rale and rusty sputa. From bronchitis, by the dullness on percussion, rale, bronchial respiration, and bronchophony. From phthisis, by its sudden onset, fine crepitation, and sputa, as well as by the acute violence of the attack. Latent pneumonia some- times complicates fevers, etc. Prognosis. — Simple pneumonia, of one lung, in a young and previously healthy person, ought, under favorable circum- stances and judicious treatment, always to be recovered from. In the aged, it is dangerous ; and double pneumonia is so at all periods of life, though good recoveries do occur. It is double in about one case in eight. Among the unfavorable signs — most of which are obvious — are expectoration of pure blood in the first stage, and albuminuria in the second. Treatment. — An emetic, followed by a cathartic, is usu- ally proper to begin with. The early administration of a purgative, as Epsom salts or citrate of magnesium, is proper, in the absence of any special contraindication. A water pack on the chest or hot fomenta- tions do good. The hot skin, hard or oppressed pulse, pain and dyspnoea, and more or less darkly flushed face, require small doses of aconite or veratrum, followed by ipecacuanha or nitrate of potassium, gr. x, every two hours. Some prefer acetate of potassium. Asthenic pneumonia requires a different treatment; and the same will apply to the third or suppurative stage of all cases. Support may be required, in a few cases, even from the first; by beef-tea, wine, or spirits (best with nourishment, as in punch), quinine or ammonia. In hospital, some cases 24* 322 PLEURISY. may recover under this plan alone; but they are the exceptions. Beef-tea in the second stage, and quinine later. A large blister over the affected part is generally useful about the fifth, sixth, or seventh day of the attack. Typhoid pneumonia is a term not always uniformly applied „ It means, sometimes, or with some authors, inflammation of the lungs complicating typhoid fever ; others include under it all cases of asthenic pneumonia. More generally, however, it designates that form of the disease in which epidemic or endemic influence has impressed a peculiar character. Malarial regions especially exhibit this, in the "winter fever" or typhoid pneumonia of our Southern States. Early and great debility, out of proportion to the local symptoms, with a ten- dency to low delirium, and to remittence, mark this disorder. In treatment, it bears- no depletion, hardly the reduction of excitement by a sedative. Diaphoretics first, as ipecac, one grain, alternated with five or ten grains of nitrate of potassi- um, every three hours; or liquor ammonii acetatis, or solu- tion of acetate of potassium ; then quinine, when the need of a tonic is apparent, which may be very early ; with strong liquid nourishment, and moderate counter-irritation; these are the measures usually proper in typhoid pneumonia. Pleurisy — Inflammation of the Pleura. Varieties. — Single or unilateral, and bilateral or double ; idiopathic, traumatic, and secondary, as tuberculous, cancerous*. Symptoms and Course. — Generally, after a chill or cold stage, sharp pain in the side, impeded and accelerated respira- tion, short, sharp cough, and fever. The pain centres in the- infra-mammary or lower axillary region ; it is often intense, and is increased by a long breath, by coughing, pressure, or lying on the affected side. The pain and fever lessen after effusion has occurred ; but the dyspnoea may then be increased. It is, after that period, most comfortable to lie on the diseased side, so as to allow of free breathing by the other lung. Acute pleurisy is often recovered from without anv PLEURISY. 323 considerable effusion. When the latter does occur, absorp- tion mostly follows. If not, life is endangered by interference with respiration. At first serous, constituting one form of hydrothorax, the fluid may become purulent; this is empyema. The term false empyema is sometimes given to a collection of pus in the pleural cavity from the rupture of an abscess in the lung. Pneumothorax is the accumulation of air in the cavity of the pleura ; hydro-pneumothorax, of water and air together. Both of these are most common in tuberculous pleurisy, i. e., in the course of a case of pulmonary phthisis. Stages. — In severe pleuritis there may be, 1, the adhesive; 2, the effusive; 3, the suppurative stage. In more favorable cases the 3d stage is that of absorption. Physical Sigxs. — Of the 1st stage, deficient elevation of the ribs in breathing, feeble respiratory murmur on the affected side, and friction sound. 2d stage, dullness of reso- nance on percussion, bronchial respiration, bronchophony, sometimes wgophony. When the effusion becomes very copi- ous, bulging of the side occurs, suppression of respiratory sound and of vocal resonance and vibration, with exaggerated or puerile respiration on the sound side. Displacement of the heart may^take place if it is on the left side; of the liver if on the right. There is no physical sign by Avhich empyema can be distinguished from serous effusion; but irritative fever usually accompanies empyema. Absorption following extensive effusion allows retraction and depression of the chest on that side, from the slow or imperfect expansion of the lung. Then return, first, bronchial respiration and voice, or segophony, and gradually the normal respiratory murmur. Sometimes, from adhesions of false membrane over the lung, permanent depression of the thorax on that side is left. During effusion, its fluid character as well as extent may be shown by percussion in different positions. Sitting up, it falls forward, and rises to a higher line in front; lying on the back, the dullness, from gravitation, may fill much lower in the 324 PLEURISY. anterior region. Sometimes adhesions prevent this. Succus- sion, or sudden shaking of the chest of the patient, may produce an audible splashing, if the ear be over or near the affected side. By ocular inspection and measurement, the changes in the amount of the effusion may be estimated from time to time. Morbid Anatomy. — In the early period, general redness and vascular injection of the pleura, with bands of whitish and more or less translucent or opaque coagulable lymph, causing adhesions of the pulmonary and costal pleura. Later, serous, sanguinolent or purulent effusion, in variable quantity, and sometimes displacement of the heart, lungs, and liver, and bulging of the ribs and intercostal spaces. Diagnosis. — From pneumonia, pleurisy is known in the height of the acute attack by the sharpness of the pain, the friction sound, and absence of crepitant rale and of dullness on percussion. After effusion, especially by the change of the line of dullness with change of position, sitting and recumbent ; by the bulging ; and the degree of diminution of vibration of the walls of the chest when speaking. From intercostal neuralgia, pleurisy is distinguished by the absence of fever and friction sounds in the former, and the non-increase of the neuralgic pain upon inspiration. Conges- tion, in some rare cases, attends neuralgia; the diagnosis is then more difficult. In intercostal muscular rheumatism, there is slight increase of pain in breathing deeply, but as much in moving the arms ; and the pain is much less acute, and generally without fever. Prognosis. — Pleurisy is rarely fatal; though death may occur, from very abundant effusion in bilateral pleuritis, or, with empyema in the unilateral, through gradual exhaustion. Causation. — Exposure to cold and damp is the ordinary exciting cause of "idiopathic" pleurisy. Fracture of the rib, punctured wounds, etc., may cause traumatic pleurisy. In the course of phthisis, it not uncommonly occurs by extension ABSCESS OF THE LUNG. 325 of the disease from the lung. Cancer of the chest may pro- duce it in an analogous manner. Treatment. — An emetic, followed with a free purge. Then give ipecac 2 J grs. to 1 gr. of opium every two or three hours till the pain subsides, which will suffice in most cases, if sinapisms or hot fomentations are industriously applied to the chest at the same time; also, hot and moist appliances to the feet, to induce free general perspiration. This antidotes the cause— a sudden cold. Carefully avoid narcotism, and if the pain continues, a large blister should be applied over the part affected, which usually brings entire relief. For the effusion, diuretics, as squill, juniper berry infusion or compound spirit, acetate or bitartrate of potassium, etc., may be used. Iodine, in LugoPs solution, and iodide of potassium alone, are often advised. Repeated blistering some- times has excellent effect. When life seems to be threatened by exhaustion from dyspnoea, owing to large effusion not becoming absorbed, paracentesis, or puncture of the chest, is proper. Dr. Bow- ditch's plan is the best for this. He uses Dr. Wyman's apparatus, which is a trocar, with a silver canula having a stopcock, and capable of being connected with a syringe by an intermediate piece, also haviug a stopcock, both cocks acting the same way. The operation is performed while the patient is sitting up, if able, or lying over the edge of the bed. The puncture is made somewhere between the seventh and tenth ribs, just behind their angles; making sure first of the posi- tion of the liver and spleen, so as to avoid them. Dieulafoy's pneumatic aspiration has been recently found to be an avail- able method in thoracentesis. In chronic cases of pleuritic effusion or empyema, the strength of the patient requires to be supported by good diet, and sometimes by tonics. This, in empyema, is often the most important part of the treatment. Abscess of the Lung. In rare instances, inflammation of the lung, active or 326 PULMONARY GANGRENE. latent may terminate in abscess. Before rupture, dullness on percussion, bronchial respiration, and dyspnoea proportioned to the size of the abscess, are present. When an opening occurs, allowing the matter to escape into the bronchial tubes, the rather sudden commencement of purulent expec- toration should attract attention. Then the physical signs of a cavity are discovered by percussion and auscultation ; amphoric or tympanitic resonance on percussion, cavernous respiration, metallic tinkling, etc., varying with circum- stances. As is the case with pleuritic empyema, pulmonary abscesses may communicate externally by a spontaneous opening. The principal importance of abscess of the lung consists in the possibility of mistaking it for phthisis. The points of difference will be alluded to in connection with that disease. Pulmonary Gangrene. This may occur in pneumonia from extreme violence of the inflammation, or from a depressed state of the system ; also, from cancer within the chest, pyaemia, etc. It is rare, but more common than circumscribed abscess of the lung. Unless very narrowly limited, pulmonary gangrene is always fetal. Its signs are, coarse mucous rale, taking the place of the vesicular murmur in the lower part of the lung, with copious brownish and offensively fetid expectoration, dysp- noea, and great prostration. In bronchitis, occasionally, temporary fetor of the expec- toration and breath may simulate gangrene; but transiently, and without the above symptoms. The treatment of pulmonary gangrene must be, of course, supporting and antiseptic. Alcoholic stimulants, rather freely given, will be proper, with concentrated liquid food, as beef-tea. Sulphite ' of sodium (ten grains in solution every three hours) may be tried; or chlorine water, a tea- spoonful or two every two or three hours. emphysema of the lung, etc. 327 Emphysema of the Lung. This is dilatation of the pulmonary air-cells of one or both lungs. It may accompany prolonged asthma, or may follow chronic bronchitis. Its symptoms are, dyspnoea, and, when extensive, blueness of the lips, cyanosis, from interference with the circulation through the lungs ; in many cases wheezing respiration. The physical signs are bulging of the chest, increased clearness of resonance on percussion, and feeble inspiratory murmur with prolonged expiratory sound; some- times displacement of the heart or liver. It is most easily mistaken for pneumothorax. But, in the latter, the reso- nance on percussion is more tympanitic, the inspiratory mur- mur still feebler, or quite absent, and there is no prolonged expiratory sound ; besides which, the concomitants of pneu- mothorax are usually too severe to distinguish it. Collapse of thg Lung. In whooping-cough or in severe bronchitis, especially in children, obstruction of a considerable air-tube may lead to an exhaustion of air from the cells supplied by it, and a return of that portion of the lung to the unexpanded con- dition (atelectasis) of foetal life. The same state may accur in other conditions, from debility. It was formerly always mistaken for lobular pneumonia. It is usually fatal, unless very limited. Bronchitis. Varieties. — Acute and chronic ; general, capillary ; plas- tic, rheumatic, and syphilitic bronchitis. Symptoms and Course. — Systemic depression, followed by fever ; tightness and soreness of the upper and anterior part of the chest ; cough, at first short, dry, and tight ; later, deeper and looser, with expectoration ; the latter being at first mucous, in rare instances pseudo-membranous, in severe cases at a' late stage purulent. Capillary bronchitis is ^marked by great dyspnoea and tendency to early depression and prostration. 328 BRONCHITIS. Chronic bronchitis is often free from febrile symptoms, the cough and expectoration, with slight dyspnoea, character- izing it. Physical Signs. — JSTo dullness on percussion, except in case of collapse of part of a lung from obstruction; sonorous rhonchus and sibilus, generally, though not quite always, on both sides of the chest; varying from time to time, in seat, character, and loudness. In capillary bronchitis, extended mucous, crepitant, or subcrepitant rales, closely resembling the fine crepitation of pneumonia. Diagnosis. — No difficulty exists except in distinguishing chronic bronchitis from phthisis. Absence of dullness on percussion and of the signs of excavation, are most important ; the expectoration also is whiter and of less weight in bron- chitis ; and there is no hectic fever. Prognosis. — Acute bronchitis is dangerous in old persons and young children; seldom fatal in vigorous middle life. The capillary form is always most serious, death taking place sometimes from the 10th to the 12th day. Chronic bronchitis is not often fatal, even by exhaustion; but it may last an indefinite time, even many months. Treatment. — Abortive treatment of a " cold on the chest " may sometimes be effected within the first twenty-four hours, by taking, at bedtime,. a glass of hot lemonade or ten grains of Dover's powder after a warm mustard foot-bath. Should this fail or be omitted, a brisk saline purgative should be given, of Epsom or Pochelle salts, or citrate of magnesium. Then, when the fever is high, cough very tight, and breast sore, the ipecacuanha in nauseating doses given every two or three hours, with frequent draughts of flaxseed tea or some similar demulcent. A large sinapism over the upper sternal region will aid in giving relief; and so will friction with oil of turpentine, and hot fomentations. - In milder cases, or where the strength of the stomach is doubtful, syrup of ipecacuanha, i to J drachm every two or three hours, will answer ; and it should be continued until the ASTHMA. 329 cough softens and the breathing becomes easier. Then syrup of squills may follow, in fliiidrachm doses, every three or four hours. When the cough is troublesome at night J to 1 fluidrachm of paregoric may be added at bedtime ; or through the day, occasionally, if coughing be very violent or frequent. Opiates do the most good, however, after some loosening of the cough with free expectoration. When the fever has abated, and especially if dyspnoea continue, a blister may be applied over the sternum. In capillary bronchitis, or in the ordinary form in the aged and feeble, the more stimulating expectorants maybe required, as senega, in decotion or syrup, chloride or carbonate of am- monium, with quinine and beef-tea, wine-whey, or whisky- punch. Inhalation of steam, alone, or from infusion of hops, sometimes soothes the air-tubes advantageously. Chronic bronchitis requires persevering use of counter- irritation over the chest, painting with tincture of iodine, plaster of Burgundy pitch, hemlock, etc., an alternation of stimulating and alterative expectorants, and tonics. Besides squill and senega, ammoniacum, copaiba, and chloride of ammonium are most frequently useful. If the system be below par, quinine, iron, and cod-liver oil are important. When secretion is very copious, inhalation of tar-vapor or of creasote should be tried. The former may be used by putting an ounce or two of tar in a cup over boiling water, so as to diffuse the tar-vapor through the chamber. Creasote, 20 or 30 drops, may be put into half a pint of boiling water, to be breathed by means of an ordinary inhaler. When medicine fails, change of air will sometimes entirely cure. Asthma. Definition.— Paroxysmal and spasmodic dyspnoea. Varieties — Idiopathic and symptomatic ; dyspeptic asthma ; hay asthma. Symptoms and Course. — Every night, or once a week, month or year, or at irregular intervals, the attack comes on. 330 ASTHMA. Most frequently it is between 1 and 3 o'clock in the morning. Premonitory symptoms often are great drowsiness, or wakeful- ness, headache, flatulence, itching under the chin. Dyspnoea is then the characteristic symptom. The sufferer sits or stands up, leaning forward, and labors to breathe. The chest is expanded to its utmost, by the accessory as well as principal inspiratory muscles. The countenance is anxious, with pallor, coldness, and in severe cases lividness, of the face and hands. Perspi- ration is often copious. A wheezing sound accompanies respiration ; giving way finally, with relief, upon the expector- ation of mucus, usually rather thick, and in pellets. The attack may pass over in a few minutes, or may last for hours, or, with some remission, days or weeks. Where asthmatic symptoms are persistent, as is not very uncommon, for years, some structural change in the organs of the chest exists; it is then symptomatic asthma. Physical Signs. — Inspection shows unusual elevation of the ribs and shoulders. Placing the ear on the chest, sonorous and sibilant sounds, loud but mostly small in calibre, are found to take the place of the respiratory murmur. These sounds change their locality frequently. As the attack gives way, with expectoration, some mucous rale is heard. Special exploration is necessary in each case to determine the presence of pulmonary or cardiac complications. Prognosis. — Death almost never occurs during the fit of asthma. Those subject to it often live to old age. But dilatation of the pulmonary air-cells, and enlargement of the heart, may follow in protracted cases, breaking down the health. Pathology and Nature. — It has been made certain that asthmatic dyspnoea is owing to a spasmodic constriction of the smaller bronchial tubes, by tonic contraction, mostly reflex, of their involuntary muscular fibres. Causation. — Asthma is hereditary in a majority of cases. Males have it more often than females. It may occur at any age. ASTHMA. 331 Treatment. — During the attack, our aim must be to give relief, by relaxing spasm. An emetic, then ipecacuanha wine, with tincture of lobelia, one-quarter to one-half fluiclrachm of each every half-hour until nausea or expectoration is pro- duced, I have known often to act well. Hoffmann's anodyne, in one-half drachm or drachm doses, will sometimes do great good ; and so may hydrate of chloral, in doses of from twenty to forty grains. Some practitioners advise hyoscyamus, musk and hydrocyanic acid. Smoking tobacco is relieving in some instances ; smoking cigarettes of stramonium leaves, in others. More still find comfort in breathing the air in which are burned papers which have been soaked in a saturated solution of nitrate of potassium. Inhalation of ether or nitrous oxide may be carefully used in extreme cases. As an adjuvant, the warm mustard foot-bath may be employed, as well as sina- pisms or dry cupping between the shoulders. Between the attacks, endeavor should be made to rectify digestion and its tributary processes, and to invigorate the nervous system. Some cases will require podophyllin, nitro- muriatic acid, or taraxacum, bitter tonics and mild laxatives, such as rhubarb, etc. Others need iron and quinine. Iodide of potassium is highly recommended by some; conium, canna- bis indica, and arsenic in small doses by others. There is reason for giving trial to the bromide of potassium in obstinate cases; most patients will bear from 10 to 20 grains of this twice or thrice daily for weeks together without inconvenience. Prophylaxis. — No disease is more curiously capricious in its causation than asthma. Some always have a paroxysm if they visit the sea-shore; others are more secure there than elsewhere. One cannot sleep on the first floor ; another does better there than higher up. Each must learn his own peculiarities, and be governed accordingly. Most remarkable are the annual attacks of hay asthma, summer catarrh, or asthmatic bronchitis, to which a few individuals are subject. 332 BRONCHIAL DILATATION — LARYNGITIS. In asthmatic persons generally, nothing is more important thag prudence and regularity in diet, regimen and habits. Bronchial Dilatation. In this, extreme degrees are not common; it is of interest chiefly because it is possible for it to be mistaken for phthisis. There are two forms; the tubular and the saccular enlarge- ment. In either, slight dullness on percussion may occur, from condensation of the lung around the expanded part. Sonorous rhonchus and coarse mucous rale exist, the latter especially in the saccular form. In this, the signs are almost identical with those of tubercular excavation; but they occur usually at the middle or lower part of the lung, and are stationary, as they are not in tuberculization. The cough is very troublesome, and attended by copious mucous or slightly purulent expectoration, is common in bronchial dilatation. The palliation of this symptom, with care of the general condition of the patient, is all that can be accomplished for it in treatment. Laryngitis. Slight inflammation or congestion of the mucous membrane of the larynx is very common as the result of cold ; its signs being hoarseness, with a dry, short, harsh cough, and some soreness in drawing a breath. But simple acute laryngitis of severe grade is quite a rare affection. When it occurs, there is fever, with hoarseness, "brassy" cough, distressing dyspnoea, and difficulty of swallowing. (Edema glottidis, or submucous effusion of serum, constitutes the greatest danger in laryngitis; the swelling, obstructing respiration to a degree often fatal. This disorder is almost exclusively met with in adults. Early purging, counter-irritation, the internal use of ipecac, in doses just short of nausea, with moderate quantities of opium, and the frequent inhalation of the steam of boiling water, constitute the best treatment. If dyspnoea becomes THE LAKYNGOSCOPE. 333 decidedly serious, threatening asphyxia, tracheotomy is advised. Some account of this operation will be given in connection with Croup. (Edema of the glottis may be produced immediately by the ingestion of boiling water, or of sulphuric or nitric acid. This has often accidentally happened. Chronic laryngitis, with ulceration, is a not infrequent attendant of phthisis. Some cases of the latter begin with it; in others it occurs somewhat late in the course of the disease. Syphilitic ulceration of the larynx is tolerably common, as a secondary symptom. This, as well as polypi or other tumors of the larynx, may be discovered, and treated by operation for removal, or with solutions of nitrate of silver, etc., with the aid of the laryngoscope. The confidence of many physicians in the utility of very strong solutions of nitrate of silver in chronic inflammations of the mucous membranes, of the throat or elsewhere, has not increased, in fact has not been sustained, by what has been seen in practice. Dr. Horace Green and others have made frequent use of it of the strength of sixty grains to an ounce. Except for ulceration, which may benefit even by the solid caustic, from four to ten grains in the ounce of water will do more good, in almost all cases, than the stronger proportions. The application of nebulized liquids, by apparatus for atomization, is now much in vogue in both acute and chronic laryngitis. Some remarks upon this will be made hereafter. The Lakyngoscope. The apparatus required for laryngoscopy consists of a laryngeal mirror, an illuminating mirror, and a tongue- depressor. Glass or polished metal may do for the mirrors. The laryngeal mirror may be round or square, preferably the former ; and about an inch or less in diameter. It should be attached at an obtuse angle (120° to 125°) to a stem, which may be fastened into a slender handle so as to be drawn out or pushed in. 334 APHONIA LOSS OF VOICE. The illuminating mirror is larger (from 3 to 12 inehes in diameter) and concave, to concentrate reflected light. It may be held by a handle in the operator's mouth, or fixed by a band to his forehead, or, best, as used by Semeleder, perforated in the middle and fastened so the bridge of a pair of spectacles (with or without the glasses) so as to rest before one of the eyes and be looked through. The laryngeal mirror is introduced (after being warmed to prevent condensation of moisture) so that its back pushes the uvula upwards and backwards, its lower edge presses upon the posterior wall of the pharynx, and its stem rests in the angle of the mouth. Sunlight, horizontal (morning or evening), is the best for laryngoscopy, but artificial light, as of a good lamp, may suffice. The diffHeulty of the operation is produced by the irritabil- ity of the fauces and larynx. Few can allow of a successful examination on the first attempt; practice makes tolerance. To hasten this, bromide of potassium has been given by some. The frequent insertion and retention for a while of the finger of the patient, or of an instrument, in the fauces, accustoms the parts to pressure. Holding ice in the throat just before the examination also lulls sensibility. By laryngoscopy, tumors, ulcerations, inflammatory changes, etc., in the larynx may be inspected, topical applica- tions, as of nitrate of silver, made, and surgical operations performed, with a precision not otherwise possible. Khinoscopy is the examination, in a similar manner, of the posterior nares. It requires merely a smaller mirror (less than three-fourths of an inch in diameter) than for laryn- goscopy, and at about a right angle to its handle. Aphonia — Loss of Voice. Loss of voice may be transient or permanent; and either functional or structural in its origin. Especially in hysterical females, a nervous shock may produce a paresis or enfeeble- ment of the vocal power, lasting often for days together. LARYNGISMUS STRIDULUS. 335 Faradization, i. e., the use of induced electrical currents (as magneto-electricity) , carefully applied, has sometimes cured nervous or hysterical aphonia. Vesication of the back of the neck may be useful ; improve the general health. Congenital dumbness, except in idiots, is due to deafness, making the learning of speech impossible, unless by a recently invented system of instruction by sight. Organic or structural aphonia is caused by lesions of the larynx, such as ulcerative destruction of the vocal cords, tumors, etc., which are to be diagnosticated by laryngoscopy. The term dysphonia clericorum has been applied to an affec- tion of the throat not uncommon among clergyman and other public speakers, " follicular disease of the pharyngo-laryngeal membrane." A conventional treatment for this affection has been the application every day or two of a solution of nitrate of silver, with a brush or probang. Saturated solution of tannin is also used for it. If these local remedies do not relieve in a week or two, the frequent swallowing of small pieces of ice, or gen- tle gargling several times a day with ice-water, may be sub- stituted with advantage. Counter-irritation of the throat should, if necessary, b© persevered in for a considerable time. Three drops of croton oil (diluted with as much sweet oil for a delicate skin) may be rubbed over a limited space in front of the throat every night until a papular eruption comes out.* Many cases of this complaint are as much constitutional as local in origin. Where real dysphonia (difficulty or imperfec- tion of vocalization) exists, public speaking or singing must be avoided to allow the organs repose. Tonics and change of air may often prove the best measures of treatment ; every means to improve the general health. Laryngismus Stridulus. This is an infantile affection, consisting in spasmodic *Patients should be cautioned, of course, against allowing the oil to come near the eyes. I have known a severe ophthalmia to result from neglect of this. 336 ceoup. closure of the glottis, causing a stridulous or shrill ' whistling respiration. It is more apt to occur during dentition, but is not very common. Its onset is sudden, and duration brief. Though exceedingly alarming, it is seldom fatal. The treatment must be prompt ; applying a sponge wrung out of hot water to the throat, and putting the feet into hot water, to produce derivation and diffusive stimulation. In severe cases mustard plasters (diluted with flour) may be applied to the chest and back. Some advise the momentary inhalation of ether or chloroform. When life is really in great danger from prolongation of the spasm, tracheotomy may be justifiable. Children who have laryngismus are generally anaemic ; requiring iron and salt baths, etc., to invigorate their constitutions. Ceoup. Croup is an acute cynanche or angina, whose signs are, a hoarse cough, difficult and audible respiration, and aphonia ; the seat of this disorder being the upper portion of the air passages. Its place in nosology has been empirically or con- ventionally (rather than systematically) established. For brevity's sake, the following propositions may be submitted : 1. The pathological elements of croup are spasm; hyper- emia or congestion; inflammation, either ordinary or diphtheritic. The spasm affects the muscles whose action tends to close the rima glottidis ; but may involve also the muscular coat of the trachea itself. The hyperemia commences in the mucous membrane of the larynx or trachea, but often extends throughout the whole anterior cervical region. The inflammation may be located in a small portion of the same mucous membrane, or, it may extend downwards indefinitely into the bronchial tubes. 2. We may mentally distinguish between cases in which the croupal dyspnoea results from simple spasm, from simple ceoup. 337 tumefaction, or from inflammation without any spasmodic constriction of the glottis. In practice the pathognomonic cough and breathing rarely attend such an isolation of one o these conditions. A certain number of cases, however, occur, of purely spasmodic or nervous croup ; now and then substi- tuting more general convulsions; as when worms have been an exciting cause. A purely inflammatory case is equally rare. In fatal pseudo-membranous cases, autopsic examina- tion has shown that the amount of false membrane was by no means sufficient, alone, to have occluded the larynx or trachea; the result being due to the additional spasmodic contraction. 3. The most frequent form of the disease, common night croup, is pathologically characterized by spasm of the glot- tidean apparatus, with congestion and tumefaction (transient in character), of the laryngotracheal mucous membrane. It is in these respects precisely analogous in nature to the asth- matic attack, whose seat is in the smaller bronchia?. There is no strongly-marked line of separation between this form and the catarrhal croup, or croupal catarrh, in which more or less active inflammation occurs, prolonging the existence of the symptoms. 4. Viewing the hypersemic state as simply intermediate, we may classify cases of croup, as they ordinarily occur, clinically, as, 1, those in which spasm predominates; and 2, those in which inflammation is the dominant condition ; or into spas- modic and inflammatory cases. 5. Pseudo-membranous, or "true croup," does not generic- ally differ from inflammatory croup; of which it is only a grade or termination, as any case of inflammatory or catarrhal croup may end in the exudation of coagulablc lymph within the air tubes. 6. Whether this shall occur or not, in any given case, depends, 1, on the degree of the inflammation; 2, on the state of the blood of the patient; 3, on the treatment, 338 croup. 7. It cannot be predicated by experience, that either vigorous and plethoric, or feeble and ansemic children, are especially prone to the membranous form or termination of inflammatory croup. It may and does occur frequently in both. 8. The ordinarily recognized signs for the diagnosis of inflammatory, from non-inflammatory croup, are sufficient as the persistent duration of the croupal cough and voice — the (generally) slow onset— the febrile symptoms — and the stridu- lous inspiration, as the dyspnoea increases. 9. Inflammatory or true croup is, with the above inclusion (as always potentially membranous), not at all .necessarily fatal, although highly dangerous. The presence of the false membrane itself does not inevitably determine a fatal result. 10. In no disease does more depend on early treatment, which is often prevented by the insidious approach of the attack, deluding the parents. The mortality of the disease may thus in part be accounted for. 11. In the treatment of all forms of croup, relaxation and proper secretion are the two great indications. 12. In the spasmodic cases, emetics and antispasmodics (as ipecacuanha, onion, assafoetida, lobelia, etc.,) will effect these objects, especially if aided by the warm bath or foot bath or both. 13. In mild inflammatory cases, saline purging, gentle vomiting, and the use of demulcents, counter-irritation, pediluvia and inhalation of vapor will relieve. 14. The most satisfactory emetic for employment in severe cases is a combination of ipecac and alum, the latter being used in half teaspoonful doses in urgent cases, until emesis is pro- duced. Nor should the practitioner hesitate to compel repeated vomiting at intervals, in desperate cases. 15. Nitrate of potassium has experience and reason in its favor. Being a solvent of fibrin, it should tend to prevent the excessive coagulability or the exudation. According to late theories, ammonia might do the same thing ; but the clinical or therapeutic antecedents of ammonia point otherwise. croup. 339 16. The great evil in membranous croup is the solidifying tendency of the exudation ; why should not, therefore, an abundant imbibition of fluids, even of water, do much toward the counteracting of this? Inhalation of steam, from hot water poured upon unslaked lime, is eulogized by recent writers. Glycerine and water aa in teaspoonful doses is recommended by others. 17. No clear indication exists for the use of opium in the majority of cases of inflammatory or membranous croup ; although it may become useful, in cases which are protracted, or which are attended by a more than usual disposition to spasmodic symptoms. Blisters are decidedly useful ; but they should not be left on long in croup, a superficial vesication only being desired. The application of a strong solution of nitrate of silver to the fauces (and larynx, if possible) does good in many cases ; in the pre-exudative stage, as a medicament ; in the exudative as a mechanical operation aiding to dislodge the membrane. Iodide of potassium is too slow in its systemic action to be relied on ; and the same may be anticipated of the bromide, al- though nothing should forbid their fair trial. Tracheotomy or laryngotomy will, when performed early, succeed in a fair number of cases ; but in those very cases it is impossible to know that they (as well as those in which it fails) might not have recovered without it. Few practitioners, therefore, in this country, can demand the operation early ; and in the moribund state, the vascular congestion, from asphyxia about the throat, renders success extremely difficult, sometimes impossible. Dr. C. West, who has had but one recovery in sixteen cases, was obliged to admit its success, in some otherwise hopeless instances ; especially in France, where Trosseau and others operate earlier than in England or here. It is most generally fatal in children under three years of age. Where there is reason to suppose the membrane extends into the 340 PLEURODYNIA. bronchial tubes, it is of course in vain. The danger of hem- orrhage is least if the operation is early. If performed, it should be deliberate, making a considerable opening of the trachea, and inserting a tube or canula of good size. Then the patient should be surrounded with a warm r moist atmosphere. The canula should be withdrawn in as few days as possible, upon the return of permeability to the larynx. The wound may then be treated with ordinary mild dressings to exclude the air and heal it up. Lately, the fact that lime will dissolve false membranes has been applied to the treatment of croup ; by making the patient breathe the steam from boiling water poured over unslaked lime. Although the lime is not volatile, some of its minute particles will be raised mechanically by agitation. Successful cases of its use are reported. Pleurodynia — Intercostal Eheumatism. Symptoms — Pain, generally rather dull, sometimes quite severe, of one or both sides, oftenest on the left. It is increased by deep breathing or coughing, moving the arms or trunk. Diagnosis. — From pleurisy, it is known by the absence of fever, and of all modifications of the sounds heard upon per- cussion and auscultation. Treatment. — A large mustard plaster over the part; friction with soap or volatile liniment; dry cups; a blister, or the hypodermic injection of morphia, if obstinate as well as> severe; relaxing nauseants and alkalies internally. Phthisis Pulmonalis — Consumption. Definition. — Caseous or tuberculous consumption of the lungs. Varieties. — Acute, chronic, and latent phthisis. Symptoms and Course. — Consumption may begin after a severe acute bronchitis or broncho-pneumonia; or, more gradually, with an apparently slight hacking cough; or with a PHTHISIS PULMONALIS. 341 hemorrhage; or with dyspepsia and general debility; or with chronic laryngitis. Increasing, in most cases slowly, the pectoral and constitutional disorder becomes developed. We have then pains in the chest, frequent and severe cough, hemorrhage occasionally (in about two-thirds of the cases) and pallor, acceleration of the pulse and elevation of the tempera- ture, with the paroxysms of hectic fever, as chills followed by fever with bright flush of cheek but without headache; emacia- tion, arrest of menstruation in the female, night-sweats, col- liquative diarrhoea; finally, often, though not always, delirium; and death, mostly by exhaustion, but sometimes by suffoca- tion. The spirits of the patient are apt to be cheerful, even hopeful of life almost to the last. Appetite is variable, digestion usually not vigorous; but to this there are exceptions. The expectoration in phthisis is at first mucous or bloody; later, muco-purulent and bloody, or else nummular; as in roundish masses like coins, not floating perfectly in water; or, abundant and purulent. Stages. — 1. Incipient phthisis; 2. The stage of consolida- tion of the lung; 3. That of excavation or vomicae; 4. Advanced or confirmed consumption. Physical Signs. — Is there a pre-tubercular stage of phthisis? If so, it cannot be certainly pronounced upon. The earliest indications upon physical exploration are, a sink- ing in under the clavicle upon the left side, with prolonged expiratory sound. Not long after, the evidence of consolida- tion is, increased dullness over the apex of the lung upon percussion (not invariably but generally upon the left side) with blowing or bronchial respiration, or interrupted jerking respiratory murmur, and increased vocal resonance and vibra- tion. Dry crackling follows, with mucous or coarse crepitant rale. When softening of the tubercular deposits occurs, moist crackling and gurgling become very distinctive signs. The pressure of a vomica is shown by cavernous respiration and bronchophony or pectoriloquy. Percussion resonance over 342 PHTHISIS PTJLMOSALIS. the cavity will be dull if its walls be thick, and amphoric if they are thin and tense; if thin and relaxed, the bruit depot fele, or cracked-pot sound. On percussion over a cavity when the patient's mouth is shut, the sound produced will be of a lower pitch than when the mouth is open. Pneumothorax and hydro-pneumothorax, i. e., dilatation of the pleural cavity and compression of the lung, by air, or air and liquid together with perforation of tne lung, are not uncommon results of tuberculization, although possible with- out it. Of pneumothorax, the percussion resonance is tym- panitic ; respiratory murmur lost. Hydro-pneumothorax may give tympanitic resonance above, with metallic tinkling on auscultation, and dullness below. Physical and Microscopical Peculiarities. — Tem- perature has of late been found to be a diagnostic aid in phthisis. It is asserted that there is a continued elevation of the heat of the body in all cases in which tubercle is being deposited; that this may occur four weeks before any local physical sign is discoverable; and that the rise in the heat of the body varies, during the progress of the case, with the greater or less activity of tuberculization. Exceptions occur, however, to the truth of this statement. When expectoration is copious, some necrologists aver that the diagnosis may be aided by its minute characters; arched and anastomosing fragments of pulmonary fibrous tissue, and tubercular corpuscles, being discerned. But it is not certain that the former are only thrown off in phthisis ; and the latter may be absent or obscure in character in an otherwise clear ca^e of consumption. Dr. Fenwick, of London, detects minute portions of lung-tissue by boiling the expectoration a few minutes with its bulk of solution of caustic soda (gr. xv in fBj of distilled water), and then adding cold water in a conical vessel. The sediment is then examined with the microscope. Terminations. — The cicatrization of vomica?, and the ces- sation of tubercular deposition, have, although exceptional, ■ PHTHISIS PULMONALIS. 343 been often found to occur; and so have the cornification and calcification of unsoftened tubercle. Recovery from phthisis may in such cases be expected to take place, as the arrest of the local disease only attends the presence of a favorable con- stitutional state. Death from consumption may come by asthenia or by apnoea. The first is most common. Suffocation or apncea may follow, 1, from hemorrhage; 2, rupture of a large vomica; 3, pulmonary oedema or hydrothorax; 4, excessive secretion or bronchorrhcea, beyond the power of expectoration. Prognosis. — Phthisis is certainly one of the most destruc- tive of diseases. In no case can recovery be anticipated; but it does occur, as every physician must have witnessed. I have seen many of such recoveries; generally from the incipient stage, but even where vomica, emaciation, and night-sweats had occurred. Dr. A. Flint has recorded the history of sixty-two cases of restoration from consumption. I have witnessed as many cases of recovery. Under improved hygiene and medical treatment, the mortality from phthisis appears to be declining. The duration of phthisis varies greatly, being least, as a general rule, in the youngest subjects. Eighteen months to two years is the most frequent period. But in some instances life is prolonged under it for twenty, thirty, or even forty years. Acute phthisis, or galloping consumption, may end life in from six weeks to three months. This sometimes follows pneumonia. Its symptoms differ from those of ordinary con- sumption chiefly in their rate of progress. Softening of tubercle and the formation of cavities do not always occur to any extent, apnoea being caused by extensive diffusion or infiltration of the caseous or tuberculous deposit through the lungs. Causation. — Hereditary taint of constitution is general; independent origination of phthisis the exception. From 18 to 35 years is the time of life most subject to it; but it is now 344 PHTHISIS PULMONALIS. and then met with even in children, and frequently in the aged. Statistics in Europe and this country show some pro- portion between the mortality from consumption and nearness to the sea level; the lowest lands having the greatest total amount of it. High, dry, and equable climates and situations, even though cold, are most exempt from it. It is not a disease of the Arctic regions, and there is more of it in special areas of country. Individually, and in families, all causes that depress vitality promote it ; but most of all impure atmosphere and dampness of locality. Sedentary employments and exhausting excesses, with foul air, make large cities most of all productive of it. In constitutions having the proclivity towards it, tuberculiza- tion may be brought on by any reducing disease, especially such as involves the breathing organs: as measles, bronchitis, pneumonia, etc. Pathology. — It has, until recently, been the accepted doctrine that true phthisis was always a tubercular disease, whatever inflammatory and hemorrhagic symptoms occur in it being results of the deposition and changes of tubercles, either yellow or gray, in the lungs or elsewhere. Within a few years, however, a different view has met with much favor in the profession, under the teaching of Yirchow, Oppolzer, Niemeyer, and others. According to these authors, catarrhal or caseous pneumonia may be, or may become, when prolonged, phthisis pulmonalis, without any tubercular deposit. Second- ary deposition of tubercle may occur ; it is sometimes asserted (Buhl) that true tubercle is always secondary, depending on the absorption (resorption) of the caseous product of inflam- mation. Under the class of new growths, rare cases of destruction of lung are due to the breaking down with syph- ilitic gummata. Many pathologists now deny the tubercular nature of the yellow infiltration, insisting that only the miliary transparent and opaque granular matter are really tubercles. This subject is now undergoing special investigation. The production of tubercle in animals by inoculation is asserted by PHTHISIS PULMONALIS. 345 authors. Tuberculosis of the lungs has, in some experiments, followed inoculation with pus, and other morbid products, as well as with tubercle, showing that it is not precisely a specific pathogenetic process. Anatomical Characters, — Earely the post-mortem merely shows the remains of an acute croupus pneumonia, which has ended in the destruction of the lung-tissue, usually much more. Treatment. — By general consent, hygienic management stands first in importance, while medicine is secondary in the treatment of pulmonary consumption; the latter* is indispensa- ble of course. Medication must meet indications as they occur. The objects to be kept in view in the treatment of phthisis are three: 1st, prevention and arrest; 2d, cure ; or, failing these, 3d, palliation of symptoms, and prolongation of life. Every case requires thoughtful consideration, and it must not be imagined that this is a disease capable of being controlled by any one remedy or class of remedies. An essential part of the treatment is the maintenance and promotion of a state of general good health and constitutional vigor as possible. 1. General Hygienic and Dietectic Treatment. — This is of the utmost importance, both for prevention and cure, and without all other measures are unavailing. The chief are, a healthy residence, on a dry soil, in a suitable climate, elevated, but well protected from cold winds, with pleasant scenery and sufficient vegetation ; free ventilation, especially the sleeping apartments ; fresh air and exercise, as the powers of the system will permit ; the avoidance of crowded places at night, and of all causes which are likely to excite pulmonary affections ; the use of warm clothing, with flannel next the skin; the employment of baths, as they can be borne, with friction afterwards ; the administration of as nutritious a diet as can be assimilated, which should contain a good proportion of fatty elements; and the avoidance of all injurious habits, such as intemperance, excessive venery, &c. It is requisite to 346 PHTHISIS PULMOXAL1S. inquire into the occupation, and to change this, should it entail long, daily confinement in a close room, with deficient exercise, or exposure to the exciting causes of lung diseases. The patient should be releived from severe mental labor or anxiety. The amount and character of the exercise must vary in different cases, such as aids in the expansion of the chest, especially in young patients, though kept within proper limits. Walking and riding are useful, and if these cannot be endured passive exercise must be enjoined, the patient being driven out daily when weather permits, so that a proper supply of fresh air may be obtained. Overfatigue must be avoided. Certain acts which call into exercise the muscles of respiration are useful, if duly regulated, such as deep inspirations, reading aloud, or moderate singing. Anything that interferes with the freedom of the respiratory movements, as the pressure of tight stays, or a bent position, ought to be forbidden. Milk and cream are valuable articles of diet ; also concentrated and digestible food. 2. Where there is fear of phthisis setting in, attention should be paid to the least sign of pulmonary disorder. Tf acute, and of an inflammatory nature, the measures already mentioned when treating of the various inflammations must be employed. Acute exacerbations should receive attention ; it is very important to avoid lowering measures, and to pre- serve the strength. Everything which produces irritation of the lungs must be strictly avoided. 3. Look to the state of the digestive organs. Unless digestion is carried on properly, all other measures are unavailing ; reg- ularity of meals and. other matters, upon which healthy digestion depends, should receive due consideration. If any form of dyspepsia is present, the appropriate remedies must be administered. Should there be evidences of gastric irritation, a combination of bismuth with an alkaline carbonate and hydrocyanic acid is beneficial. In the early period the bowels are often confined; some mild aperient must be given, so that they may be daily opened. PHTHISIS PULMONALIS. 347 4. Various tonics and other medicines, which improve the state of the health generally, and of the blood, are very serviceable in phthisis. Of these the principal are the diluted mineral acids — nitric, hydrochloric, sulphuric, or phosphoric ; quinine ; different preparations of iron, especially if there is ansemia ; salicine ; strychnia ; and vegetable bitter infusions or tinctures, such as those of gentian, calumba, chiretta, quassia, cascarilla, etc. These and others may be given in various combinations so as to render them palatable. 5. Among the special therapeutic agents recommended for phthisis cod-liver oil holds a good position. Experience has testified to its good effects in this disease. Only a small dose should be given at first, not too often repeated. A teaspoon- ful once or twice a day is sufficient at first, the dose being in- creased by degrees to a tablespoonful three times daily ; seldom desirable to exceed this quantity. Most patients take the oil best immediately or soon after meals ; lying down for a short time after taking it will prevent any ill effects. Some can take it best when going to bed at night. Use some vehicle for administering the oil, but the quantity of this should not be large. It may be given with the medicine, if this is of a bitter or acid nature or with steel wine. Milk, orange wine, stout, or a little cold brandy and water, are among the most useful vehicles. "When the oil causes sickness, it is well borne with lime-water and milk in equal parts, some of which may also be drunk after it. Small doses of strychnine have been found very useful in preventing the nauseating effects of the oil. It is important to see to the quality of the oil at first, otherwise a patient may get an antipathy to it. A good pale oil seems to answer best generally. Regularity and persever- ance in the use of the remedy are essential in order to realize the effects it is capable of producing. During its administra- tion the diet must be carefully attended to, and should not be of too rich a character. If it appears to disagree with the digestive organs it may be temporarily omitted during the warmer months. Some recommend cod-liver oil by inunction 348 PHTHISIS PULMONALIS. or enema ; though necessary under some circumstances, these modes of administration are objectionable as a rule. Inunc- tion is often good in children. Special preparations have been made, as the "etherized oil," or a combination with quinine, hypophosphite of lime, etc. Substances are advocated as substitutes for cod-liver oil, but are less efficacious. Among these are olive, skate, shark or dugong oils, cocoanut oil, dog's fat, glycerine, and cream. The last two certainly produce good results in many cases. Pancreatic emulsion, introduced by Dr. Dobell, who also gives it with cod-liver oil; hypophosphites of lime, soda, iron etc.; phosphate of lime ; extract of malt ; maltin ; iodide of potassium ; sulphurous acid and sulphites ; arsenic ; koumiss, etc. These have been variously reported upon by different observers ; most of them are useful in certain cases, but can scarcely be considered specific remedies. 6. Local Treatment. — Applications to the chest are useful in most cases, for the relief of symptoms, the subdual of in- flammatory processes; possibly, they may have an immediate effect on some forms of phthisis. The most useful are small or flying blisters ; applications of iodine, and liniments, tur- pentine, or acetic acid. In acute exacerbations, fomentations and poultices are required. 7. Treatment of Symptoms and Complications. — Various symptoms call for attention during the course of a case of phthisis. Pyrexia must be subdued, if it is inclined to be high. Quinine in full doses, with digitalis may be given. Debility and wasting must be counteracted by the general treatment and by subduing the fever. When there is much exhaustion, considerable quantities of stimulants are required. Night sioeats are controlled by a pill at night, containing 2 or 3 grains of oxide of zinc, or by a full dose of quinine, or gallic acid, or the administration a few days of a mixture of quinine, alum, and dilute sulphuric acid. Sponging the upper part of the body with vinegar and water or bay rum is useful. Pains about the chest may be relieved by the local applications men- PHTHISIS PULMONALIS. 349 tioned, or by wearing some anodyne or warm plaster; cases with pain in the side, either muscular or pleuritic, may be relieved by strapping the side properly. Cough is often a troublesome symptom. It is not desirable to stop it; this must be influenced by the amount of expectoration;"' the discharge is to be encouraged, or its amount diminished by proper remedies. In most cases it should be relieved. The state of the throat and larynx may cause the cough. Local applications of tannin, chlorate of potash, or astringent gargles or lozenges, are beneficial. If the cough is irritable, various anodynes are valuable, as codeia, hydrate of chloral, bromide of ammonium, conium, belladonna, chlorodyne, etc., some of which may be combined. These may be given in the form of lozenges, syrups, etc.; give all cough-mixtures in small doses. Ano- dyne and other inhalations are serviceable, but not for any curative effect in phthisis. They are particularly useful if the larynx is affected. If the expectoration is fetid, disinfectant inhalations are beneficial. Dyspnoea and haemoptysis must be treated according to the ordinary principles. Vomiting is sometimes a very distressing symptom; if the ordinary reme- dies fail, small doses of strychnia often give satisfactory results. Diarrhoea, if due to ulceration of the bowels, is fre- quently very difficult to check. Powders containing 10 grains of carbonate of bismuth, with 5 grains of Dover's powder, commonly stop it, but enemata of starch and lauda- num are most relied upon. Other complications must be attended to as they arise. 8. Change of Climate and Sea-voyages. — This is an import- ant subject in the treatment of phthisis only the main principles can be indicated. As to climate the chief points are — that there is neither extreme of temperature; the air is pure, not too moist; the soil healthy; no likelihood of sudden changes, exposure to cold winds, or continued unfavorable weather. Choose a place where there is bright sunshine, attractive scenery, and pleasant company. One most import- ant object in selecting a climate is — that the patient may be 350 CANCER OF THE LUNGS. out in the open air much. The salutary influence of high altitudes upon phthisis has been well established; patients should reside in warm and sheltered places during the colder months, and go to a high and dry region during the warm season. The exact qualities of the climate which are suitable for any individual case will depend upon its mode of origin, and the condition of the bronchial mucous membrane, as to its degree of irritability. Cases of constitutional origin are benefited by a sojourn in lofty regions. The seaside places suitable for phthisical invalids are the Isle of Wight, Madeira, West Indies, and the Azores, where both temperature and moisture are considerable. Among inland regions, Pau, Pisa, Upper Egypt, Syria, Australia, certain parts of South America, and California; or, if elevated districts are desired, the Alps, Andes, Himalayas, or American mountain ranges afford the requisite conditions. Long voyages, to Australia, or up the Mediterranean, are useful in cases, but should not be recommended if the disease is far advanced. A large number of patients are unable to avail themselves of the benefits of a suitable climate. Various hospitals established in seaside places afford these advantages more widely than formerly. If, during the winter months, patients are unable to get to a proper climate, they should keep indoors as much as possible in bad weather, avoid every cause of cold, and wear a respirator. Men should allow the beard and mustache to grow. CANCER OF THE LUNGS. Etiology. — This disease is rare; is most common from 40 to 60 years of age, and more males are affected than females. It is supposed to be infectious, or inherited. It is generally secondary to cancer of the bones or testicles; may result from direct extention, or be primary in its origin. It generally extends, to involve neighboring parts, but rarely followed by econdary cancerous formations in other internal organs. CANCER OF THE LUNGS. 351 Anatomical Characters. — Encephaloid is the variety of cancer usually in the lungs, and is often extremely soft, pulpy, and vascular. Other forms are occasionally seen alone or in combination, and deposit of black pigment, constituting melanotic cancer. Secondary cancer is generally in the nodular form, and affects both lungs; the nodules vary in size, and when at the surface tend to be depressed; by their union a lung may be involved throughout. Primary cancer involves only one lung, the right, and is infiltrated. After a time the cancerous matter undergoes fatty degeneration and softening, cavities being produced ; extravasations of blood are common. The vessels and bronchi are involved in the disease or obliterated by pressure. The unaffected part of the lung-texture may be normal, or various morbid changes are set up. A cancerous lung feels heavy. Extensive pleuritic adhesions usually occur. Symptoms. — Secondary cancer comes on insidiously, with- out subjective symptoms. In primary cancer, there is pain in the chest, may be severe, lancinating, with tenderness. Cough, with a peculiar expectoration, in the form of a substance resembling currant jelly, or cancer elements. Hcemoptysis is common. Dyspnoea is severe if there are projecting nodules, pressing on the nerves, or if the cancer is associated with a mediastinal tumor, when there are other signs of pressure on neighboring structures. The general symptoms are not as severe as might be expected. The cancerous cachexia may or may not be evident; emaciation, fever, night-sweats, with failure of strength, more or less, may be comparatively slight, in the secondary form. Wasting is rapid in its progress when once established. Physical Signs. — These vary according to the form, seat, and cancerous accumulation, and whether it is accompanied with a mediastinal tumor. Scattered nodules, the percussion and respiratory sounds may be altered. If a lung is exten- sively involved with nodular cancer, converted into a mass of 352 RARE FORMATIONS IN THE LUNGS. encephaloid, the signs are: enlargement of the side, with widened and flattened spaces, the surface smooth without sense of fluctuation ; deficiency or absence of movement ; weakened vocal fremitus ; dullness, unaltered by position with sense of resistance ; breath-sounds weak or absent over a variable area ; vocal resonance deficient ; displacement of heart or diaphragm; the cardiac sounds to an unusual degree. In the infiltrated form, the lung is contracted; physical examination shows: retraction of the side, depression of spaces ; deficient move- ment, but the spaces still act ; vocal fremitus, increased, lessened, or absent, according to the amount of consolidation; hard, wooden, high-pitched or tubular percussion, which may extend across the middle line-, bronchial, blowing, or feeble respiratory sounds ; vocal resonance intensified ; displacement of the heart, with intensification of the sounds, and drawing up of the diaphragm. Ultimately there may be signs of cavities. In the non-cancerous parts, signs of hypertrophy, bronchitis and emphysema, are present. Prognosis is necessarily fatal, death occurring either from local or general causes. Treatment can only be palliative, and the usual remedies must be employed for symptoms as they present themselves. Bare Formations in the Lungs. It will necessary to enumerate these to indicate their possible occurrence. Those that require recognition include hydatids ; albuminoid degeneration ; sarcomatous enchondroma- tous, osteoid, or myeloid tumors, and hematoma. Haemoptysis — Pulmonary Hemorrhage. Haemoptysis, or " spitting of blood," signifies the discharge of blood through the mouth, from any part of the air-passages below the upper opening of the larynx. It may occur with- out warning, or preceded by premonitory symptoms, as weight, HEMOPTYSIS — PULMONARY HEMORRHAGE. 353 fullness about the chest, dyspnoea, a sense of heat, tickling in the throat, or a saltish taste. Usually the blood is brought up by coughing, but it may arise in gulps without effort, or a sudden gush, when it may also escape through the nose; vomiting may occur. Quantity varies from a few streaks in the sputa to an amount sufficient to cause death. The blood is florid and frothy, occasionally dark, non- aerated, when abundant and suddenly discharged. Clots may be observed, but the greater portion is liquid. There is no change in the blood. The duration of haemoptysis varies; after the urgent symptoms have subsided, the sputa are tinged some time. Recurrence happens, in some cases periodical. If from the lungs in quantity, moist rales are heard over part of the chest. The effects on the system depend on the amount of blood lost, and the rapidity and duration of its discharge. Death does not often result immediately, but may occur from the loss of blood, or its causing suffocation. Frequently some febrile excitement is associated with haemoptysis, the pulse full, bounding, but soft. Should blood remain in the lungs, it may set up inflammation, and thus originate phthisis. Etiology. — 1. In some cases there is no obvious local disease. In this group may be included haemoptysis from going up a height, severe straining, coughing, blowing wind instruments, etc., which is apt to occur in those whose tissues are weak; vicarious haemoptysis; that due to the inhalation of irritating substances, or to injury; and that dependent upon an unhealthy state of the blood, as scurvy or purpura. 2. Diseases of the larynx, trachea or bronchi, as congestion, inflam- mation, ulceration, morbid growths, cancer. 3. Diseases of the lungs, as congestion, acute or chronic pneumonia, abscess, gangrene, hydatids, phthisis, cancer. 4. Mediastinal tumors, tubercular and cancerous glands, opening into the air-passages. -5. Cardiac diseases, as mitral disease, hypertrophy of the right ventricle, or a weak dilated left ventricle. 6. Disease 26* 354 HAEMOPTYSIS — PULMONARY HEMORRHAGE. of the pulmonary vessels. 7. Aneurism opening into the air- passages. 8. Blood sometimes gets into the windpipe from the throat or nose, and is expectorated. Haemoptysis generally comes from the capillaries; a branch of the pulmonary artery may give way, or is perforated by erosion. In phthisis minute aneurisms have been found upon the branches of this vessel, which have ruptured, and thus caused large hemorrhages. Diagnosis. — Haemoptysis may be simulated by bleeding from the mouth or throat, or by epistaxis. The quantity and characters; the mode of ejection; and, thorough examination of the nose, mouth, fauces, and chest, will indicate the source of the bleeding. The part of the organs from which the blood escapes is ascertained by physical examination, and the local symptoms. Erosion of a branch of the pulmonary artery is characterized by coughing up of dark blood. Treatment. — Haemoptysis must be treated on the princi- ples of hemorrhages in general, varying according to its cause. Keep the patient at rest in a cool room, a recumbent posture, with the head rather high; subdue cough; give ice to suck freely; and administer astringents with vascular seda- tives. Gallic acid in full doses with opium every two or three hours, dilute sulphuric acid and alum, turpentine, and ergot of rye. Ipecacuanha given to simply nauseate is often sufficient alone. The subcutaneous injection of ergotine is advocated. Digitalis is valuable, if the heart is acting excitedly. Saline aperients are useful if there is plethora. The application of ice to the chest is often beneficial; it must be done carefully, the ice being removed by degrees. Dry cupping over the chest is serviceable in some cases. Hot foot-baths, or a Junod's boot, or apply ligatures around the limbs. In all cases of haemoptysis of any moment, it is important to keep the patient under observa- tion until all irritation has subsided. Everything likely to bring on an attack must be avoided, while the; DISEASES OF THE CIRCULATORY ORGANS. 355 condition of the blood is improved by proper diet and the administration of tincture of steel, etc. CHAPTEE IX. DISEASES OF THE CIRCULATORY ORGANS. The evidences of disease in the central organ for the circula- tion of the blood are not confined to this part but must be apparent throughout the system. Grave organic heart disease may exist without there being any evident symptoms to indi- cate it; and serious disturbance may exist about the heart, which is entirely functional. Other diseases are associated with cardiac affections, especially renal and pulmonary, which modify the symptoms much. Angina Pectoris — Suffocative Breast-pang. This is the only affection belonging to the subjective sensa- tions about the heart, which requires special notice. It is characterized by extremely painful sensations, with a sense of impending suffocation. Etiology. — Angina pectoris is a nervous affection associated with the cardiac plexus, accompanied with spasm or paralysis of the muscular tissue of the heart. It supervenes upon some organic disease of the heart or pericardium, not invariably; it is not confined to any particular morbid condition, most com- mon in extensive atheroma or calcification of the coronary arteries; fatty degeneration of the heart; and flabby dilatation. The exciting cause may be centric, as emotion; reflex, as from dyspepsia, cold, straining; or, some intrinsic disturbance of the cardiac ganglia. Certain distinct predisposing causes, as the 356 ANGINA PECTORIS. male sex; advanced age, the complaint rare under 40 or 50; and a high social position. Symptoms. — An attack comes on with abrupt suddenness, but warnings of curious sensations or slight pain about the cardiac region. The first paroxysm occurs while the patient is walking up a hill, against the wind after a meal. The symptoms are intense pain in some part of the pre- cordial region, which may be excruciating. It may be shoot- ing, plunging, tearing, aching, gnawing, sickening, burning, often indescribable. A sense of oppression or constriction is felt across the chest, as if forcibly compressed and could not expand ; a sense of suffocation and inability to breathe, though this act is not interfered with, and there is no indication of cyanosis. If a deep breath can be taken and held, this may relieve the pain. Usually no tenderness, but relief from press- ure ; occasionally tenderness over the sternum and adjoining spaces. Painful sensations shoot from the heart, as down the left arm, even to the fingers ; sometimes the right, up the left side of the neck, backwards, or round the side. There is grave disturbance of the system. The face pale covered with cold sweat, and the expression is intense anxiety, alarm, and dread of impending death. The pulse feeble, fluttering or irregular if the attack is prolonged. Much de- pends on the condition of the heart in angina ; this is also true of the physical signs. Occasionally vomiting and eructations accompany the attack. The patient is quite conscious at first ; in prolonged or fatal cases may fall into a state of syncope, and spasmodic movements or general convulsions. Usually an attack consists of several brief paroxysms, with intermissions; there may be only one; the morbid sensations generally cease suddenly, this being attended with relief, a feeling of exhaustion afterwards, which may last some time. Rarely does the first attack prove fatal ; it may, suddenly or gradually. Some cases of sudden death are due to angina. A marked character of the complaint is its tendency to recur from slight causes. ANGINA PECTORIS. 357 A form of angina pectoris is described, not attended with pain — Angina sine dolor e ; also an affection named pseudo angina pectoris, common among young persons, and attended' with sudden pain and unpleasant sensations about the heart, palpitation, disturbance of breathing, faintness and giddiness, pallor of the face, and feeble pulse. The condition of the patient may appear to be really serious, but very rarely does a fatal termination occur. This complaint occurs in ansemia, various nervous disorders, as hysteria, or blood-disease, as gout, etc. Prognosis. — True angina pectoris is very dangerous; that which simulates it is not; it is important to distinguish between them. The presence and nature of organic cardiac disease must necessarily influence the prognosis. Treatment. — 1. To prevent attacks, avoid exciting cause, and carry some remedy in the pocket to use immediately if there is the least indication of the approach of a paroxysm. 2. During an attack any obvious source of reflex disturbance, as indigestible food, must be removed. The internal remedies are sedatives, antispasmodics, and stimulants, full doses of hydrate of chloral, various ethers, chloroform, ammonia, musk, camphor, hot brandy and water, etc. Digitalis and bella- donna are recommended. Inhalations of chloroform, ether, or nitrite of amyl may be tried carefully in bad cases. The last has been well spoken of. Local applications of dry heat, ivith friction, sinapisms or friction with chloroform or belladonna liniment are useful. Gentle galvanism is recommended. In a gouty person the joints of the feet should be irritated. 3. During the intervals the treatment applies to cardiac affections in general, in the way of attending to the digestive organs, to the general and constitutional condition, and that of the blood and hygiene. Tepid 'or cold baths followed by friction, change of air and scene are beneficial. Also a belladonna plaster worn over the cardiac region. For pseudo-angina similar remedies are indicated during a 358 I SYNCOPE. paroxysm, but they need not be so powerful. At other times the treatment must be directed to the state of the patient. Syncope. The phenomena are due to a failure of the heart action, speedily followed by disturbance of the nervous centres, due to anaemia, and this by failing pulmonary functions. Etiology. — The predisposing causes of syncope are early adult age; the female sex; a nervous temperament; and a state of weakness, with poor quality of the blood. Exciting causes. A condition allied to "shock," in which the three chief systems are simultaneously affected, the nervous centres are first. It is not easy to determine whether a case should be classed as one of syncope or shock. The causes are: 1. Want of blood in the heart; obstruction in the principal veins; or sudden removal of pressure from the great vessels, as when syncope follows paracentesis abdominis for ascites. 2. Inade- quate supply of blood to the cardiac walls, as obstruction of the coronary arteries; or a supply of impure blood, as in low fevers, or when syncope comes on in a hot and crowded room. 3. Partial or complete paralysis of the muscular tissue of the heart, from organic change, or nervous disturbance, centric, reflex, or intrinsic. Numerous causes act in this way, as fatty and other degenerations of the heart, flabby dilatation, or a weak state of this organ in chronic diseases, as cancer, phthisis, etc., sudden reflux of blood in aortic regurgitation; various poison- ous substances (aconite, tobacco, prussic acid, antimony, etc.); strong emotion and severe cerebral lesions; long continuance in a warm bath; reflex disturbance from bad smells, or un- pleasant sounds; pain of any kind; extensive burns; passage of a catheter ; a shock to the sympathetic, as from a blow in the epigastrium; drinking cold water when heated; taking indigestible food, or overeating after fasting, etc. Lightning sometimes produces death in -this way. 4. Continued spas- modic contraction of the heart, as in angina pectoris. 5. SYNCOPE. 359 Mechanical pressure outside the heart, as great pericardial effusion. Anatomical Characters. — The state of the heart varies according to the cause. After great loss of blood, it is usually contracted and empty. When the walls are paralyzed, the cavities are dilated and contain blood, fluid or coagulated. The lungs are anaemic, and the nervous centres markedly so. Symptoms. — Syncope may come on suddenly, or cause instantaneous death. In many cases it is gradual, being premonitory symptoms before actual insensibility, as faintness, giddiness, trembling, with sinking in the epigastrium, nausea, and sometimes vomiting; pallor of the face, drawn features; chilliness and shivering, or a sense of heat, but cold, clammy perspirations; a rapid, small, and weak pulse, irregular and slow, the large arteries may throb; hurried, irregular breath- ing or gasping, sighing; restlessness; slight convulsive move- ments; mental confusion; disturbance of the senses of sight and hearing; dim vision; sensibility to light, and noises in the ears. When the syncopal state is complete, absolute insensi- bility, with dilatation of the pupils; deathlike pallor, cold and clammy sweats; a slow and extremely weak, irregular, or imperceptible pulse; infrequent, irregular respiration, which may ultimately cease altogether. Convulsive movements; the sphincters may relax, involuntary discharge of faeces and urine. Examination of the heart sIioavs feebleness or absence of impulse and sounds. This condition lasts a variable time, and ends in death or recovery. In the latter, uncomfortable sensations are experi- enced as the patient returns to consciousness, as palpitation, vomiting, or convulsive movements. Treatment. — Any reflex cause of syncope should be removed. The posture of the patient should be horizontal, wiih the head low. Fainting may be prevented by bending for- wards, hanging the head down between the knees. Clothes should be loosened, and plenty of fresh air admitted. Ammo- nia to the nostrils; dashing cold water in the face; or friction 360 PALPITATION. with the hand or with stimulating liniments, along the limbs and over the heart, may restore vitality. The internal admin- istration of stimulants, as brandy, wine, ammonia, ether, musk, is useful, and if they cannot be swallowed, and there is danger, enemata should be employed. Attempt to confine the blood to the central organs by pressure on the arteries of the limbs, by the fingers or tourniquets, warmth being maintained by hot bottles and friction. Sinapisms, or turpentine stupes over the heart if necessary; in dangerous cases, regulated gal- vanism along the pneumogastric nerves, artificial respiration and transfusion, if there has been great loss of blood. Palpitation. Etiology. — A want of power; a laborious effort of the heart, being taxed beyond its powers. The individuals in whom it is most frequently seen are young adults and persons beyond middle age, females, nervous persons, and fat flabby people, who live highly, take but little exercise, and suffer habitually from dyspepsia. Exciting Causes. — 1. Acute or chronic organic disease of the heart or pericardium. This results from some obstruction to the circulation which the heart can not overcome. 2. Mechan- ical interference ivith the cardiac action is accompanied with palpitation, as tight lacing, distorted chest, displacement by pleuritic effusion, abdominal enlargements and flatulent dis- tension of the stomach. 3. Obstruction due to disease in the vessels ; if there is not adequate compensatory hypertrophy, palpitation is induced. Hence it occurs in atheroma, calcifica- tion, or hypertrophy of the arterial coats in Bright's disease. 4. Chronic affections of the lungs, as bronchitis and emphy- sema, which interfere with the circulation, induce palpitation. It may depend upon the blood, either in quantity or quality, as plethora, anaemia, gout, renal disease, fevers, and admixture of materials taken into the system from without. There is a difficulty in driving on the blood, and the heart is disturbed PALPITATION. 361 and supplied with impure blood. 6. Numerous causes act through the nervous system, directly from the centres, or reflex irritation, as continued cerebral excitement or mental labor ; emotion ; functional nervous disorders (hysteria, epilepsy, chorea, neuralgia) j the abuse of tea, alcohol, or tobacco ; reflex disturbance in the alimentary canal (as indigestible food), or in the genital organs. This nervous palpitation is due to spasmodic contraction of the arterioles, a difficulty in the passage of the blood, or innervation of the heart itself, its action less efficient. In some cases palpitation is always present, more or less increased by anything which throws extra effort upon the heart, as slight exertion. In other cases it is paroxysmal, brought on by some evident exciting cause, or independently of this. Irregularity is a form of cardiac disturbance alone or accom- panying palpitation, an indication of want of power. It may affect the rhythm, the force, or both. Rhythmical irregularity is due to a halting, hesitation, or partial arrest of the ventric- ular contraction, which may be brought on by disturbance of the balance of power between the vagus and cardiac ganglia, or between the opposition offered to the blood to be driven and the power to drive it. It is not necessarily associated with grave organic disease, dilatation, or low conditions of the system, as malignant fevers. The irregularity may be of a hesitating character ; sometimes it passes through regular cycles ; in other cases the cardiac action is confused. Intermittency is evidence of cardiac failure, a complete arrest in the ventricular contractions, until two or more auricular contractions occur before sufficient blood is sent into the ventricle to rouse it into activity. The conditions are fatty degeneration of the heart • aortic obstruction ; hyper- trophy and dilatation ; irritation of the vagus nerve, at its root from cerebral disease, or in its course from pressure of a tumor ; the advanced stages of severe fevers ; diseases of the lungs causing great obstruction, the left ventricle being dis- 362 PALPITATION. turbed with the right; or mere nervous disturbance of the heart. It may be induced voluntarily, by holding the breath. Symptoms. — Palpitation, frequency and quickness of the heart's beats, when a severe paroxysm comes on. The action may be regular, irregular, or intermittent. There is also in- equality in force. Subjective sensations over the cardiac region, the patient conscious that the heart is acting, with a sense of rolling, jogging, falling back, jumping into the throat, and other indefinable feelings (precordial distress or anxiety). There may be pain, almost anginal, relieved in some cases by pressure. Daring severe paroxysms, faintness ending in syncope ; dyspnoea, with hurried breathing, and in- ability to a catch the breath ;" flushing of the face, headache, heat, giddiness, disturbed vision, and noises in the ears ; cold extremities. Sometimes anxiety and fear of death. The radial pulse corresponds to the heart's beats, though not always ; small and weak, though the heart is acting violently ; the large arteries throb quick and sharp. The duration and severity of palpitation vary much, the symptoms more severe where there is irregularity. It often terminates by profuse diuresis of light-colored urine, or a sense of exhaustion, calling for prolonged sleep. The palpita- tion due to drinking strong tea is sometimes of a distressing character. Occasionally it is constant in intensity, without organic disease ; some marked cases occur in young women. Physical signs due to mere palpitation are: 1. Impulse too extensive ; often strong, but not heaving ; may be irregular in rhythm and force, jogging, fluttering, etc. 2. Dullness, in- creased to the right in prolonged cases, from overdistension of the right cavities with blood. 3. Sounds louder than natural, with tendency to reduplication. 4. Occasionally a temporary systolic murmur at the base of the heart or left apex. Intermittent action of the heart, sometimes with distressing and horrible sensations, an intense dread of death. PALPITATION. 363 Diagnosis. — Determine whether the disturbances of the heart's action are due to organic disease; this can only be done by physical examination, and by consideration of the circumstances of the case. The impulse of palpitation differs from that of hypertrophy, in not being heaving. Prognosis. — This will vary greatly, according to the cause, the presence and nature of any organic disease ; simple palpita- tion is not harmless; it may be a serious matter. Irregularity or intermittency is not a certain sign of organic disease; both conditions may be associated with mere functional disorder. Treatment. — 1. During a paroxysm of palpitation, the chief measures are, to get rid of every source of reflex irrita- tion ; to give antispasmodics, sedatives and stimulants, as brandy, ethers, ammonia, morphia, hydrocyanic acid, henbane, musk, tincture of lavender, galbanum, assafoetida, etc., as well as medicines which act upon the heart directly, as digitalis ; to apply dry heat or sinapsims over the precordial region and the extremities. 2. During the intervals, or in chronic cases, look to the state of the heart ; digitalis improves its action ; avert every cause of -fits, by removing mechanical pressure, attending to diet, diges- tive organs, and habits; avoid excess in the use of alcohol, tobacco, or tea, overstudy, mental excitement, and veneeral excess ; treat constitutional diathesis as gout, and improve the nervous system and blood., with mineral tonics, acids, quinine, strychnine, or tincture of nux vomica, various preparations of iron, cold baths, with douches and frictions, proper exercise, change of air and scene into a pleasant climate. A mixture containing tincture of steel, nux vomica and digitalis, is benefi- cial. A belladonna plaster over the cardiac region. Similar treatment applies to the other forms of cardiac disturbance. 364 ACUTE PERICARDITIS. ACUTE INFLAMMATION OF THE HEART AND PERICARDIUM. I. Acute Pericarditis. Causes. — Certain blood diseases, rheumatic fever and Bright' s disease, and occasionally in pysemia, typhoid, typhus, variola, scarlatina, puerperal fever, gout, scurvy, purpura, in cyanosis, or after the cure of chronic cutaneous diseases. 2. From injury, as a wound of the pericardium, or laceration by fractured ribs (traumatic). 3. From perforation, as asbcess opening into the pericardium (perforative) . Extension of in- flammation, or irritation by neighboring disease, as pleurisy, pneumonia, chronic cardiac disease, aneurism of the aorta, abscesses in the vicinity, carious ribs, tumors. 5. From the irritation of some new formation in the pericardium, as cancer or tubercle. Anatomical Characters. — They are similar to those in other serous inflammations, and run a similar course. The exudation is deposited on both surfaces, more on the visceral; rarely over the whole extent ; usually in patches ; may be confined to a small area about the great vessels. The thick- ness and mode of deposit are variable, the lymph being stratified, or little elevations, ridges, bands, masses, and other arrangements. Usually tolerably consistent, sometimes quite tough, adhering to the surface. In low conditions it may be soft and granular. The effusion is sero-fibrinous, containing flocculi; in exceptional cases it may have blood or pus mixed with it, rarely purulent. The quantity, from eight to twelve ounces, may range from an ounce to two or three pints. Gas is sometimes present, from decomposition. Definition. — Inflammation of the covering membrane of the heart. Varieties. — Simple or idiopathic, and rheumatic pericar- ditis. The latter is very much the more common. Symptoms. — Fever; pain (occasionally absent) at andradiat- ACUTE PERICARDITIS. 365 ing from the heart; tenderness on pressure in the cardiac region; accelerated, irregular, or oppressed, rapid and feeble pulse; anxiety or delirium; nausea and vomiting in some cases; short hacking cough; towards the end, coldness and pallor or lividity, cedema of the face and extremities, loss of pulse. Stages. — 1. Acute inflammation; 2. Adhesion; 3. Effu- sion. Physical Signs. — Before adhesion or effusion, usually, exaggeration of the heart's impulse. Then, pericardial friction- sounds (to and fro), the vibration of which is sometimes felt by the hand. After effusion, dullness on percussion, with muffling of the heart's sounds to the ear on auscultation. The friction-sounds disappear during this period, sometimes to return as the effusion is absorbed. Diagnosis. — From endocarditis and from pleurisy it is sometimes not easy to distinguish pericarditis. The symptoms of the latter and those of endocarditis are the same; and the friction-sounds occur in both. The heart's impulse is more apt to be sustained in strength in endocarditis; and, in the latter, no dullness on percussion occurs, nor are the heart- sounds muffled at any stage; while valvular murmurs follow endo- and not pericarditis. Friction-sounds which are outside of the heart (pericardial) have a nearer character to the ear than endocardial sounds; they are more narrowly limited, not passing along the vessels; they do not keep exact time with the cardiac sounds, and may vary from day to day; and sometimes the vibration may be felt externally. Pleurisy causes friction sounds, and afterwards dullness on percussion. But the former sounds are more diffused, are generally single, not "to and fro" or double; and the dullness extends further over and around the side. Latent pericarditis may possibly, from some symptoms, be taken for inflamma- tion of the brain or of the stomach. Physical exploration should prevent such errors. 366 ENDOCARDITIS. Prognosis. — There is great danger to life in pericarditis; and its course is sometimes terminated by death in a few days. In other cases resolution may take place promptly; but more often the heart is clogged for a considerable time (weeks or months) with effusion, or a more protracted interference occurs from adhesion of the pericardial surfaces. This latter is some- times shown by a dimpling, or sinking in, with each beat of the heart, of the intercostal spaces above and below TREATMENT.-^-In some cases, where fever is high and pain intense, heart sedatives, a brisk saline cathartic, as Epsom or Rochelle salts, or citrate of magnesium, should commence the medication. Fomentations over the chest, etc. Where the rheumatic diathesis is marked, alkalies will be indicated. Carbonate or bicarbonate of potassium, or bicar- bonate of sodium may be given, in scruple or half scruple doses, with as much of Rochelle salts, three or four times a day. A blister over the heart, as the fever lowers, will often have a good effect. If effusion occur, blistering may be repeated. A Dover's powder at night. For the stage of effusion, or "chronic pericarditis," the usual treatment consists of diuretics, as squills, juniper, sp. seth. nit. etc., varied and continued until absorption occurs. Tonics will often promote the same end. A rapidly depressing case of pericarditis, with cold, blue skin, and feeble, irregular pulse, will require, instead, a sup- porting or stimulating treatment from the first; with dry cups and blisters; and quinine, ammonia, and whisky, instead of sudorifics or laxatives. Myocarditis is inflammation of the muscular substance of the heart. It can hardly have other than a nominal existence. II. Endocarditis. Definition. — -Inflammation of the lining membrane of the heart. Symptoms and Physical Signs; Diagnosis. — These ENDOCARDITIS. 367 have been sufficiently stated in the account just given of pericarditis, and need not be repeated. Like that disease, it is most often of rheumatic origin; but may occur in Bright' s disease or in pyaemia. Valvular derangement and its signs give great interest to endocarditis and its resulting changes. Mostly it is the left side of the heart that is chiefly affected. The simplest and most common sign of this is a blowing sound, heard on auscultation. But a bellows murmur is heard also in cases of anaemia, and a blowing sound occurs not rarely in fevers; or it may belong to an organic heart-affection of long standing. This last fact should be ascertained by the history of the patient, as well as by the aid of symptoms; but the old murmur is generally rougher and more fixed in its seat. It is possible, though rare, for endocardial inflammation to be located so far from the valves as to cause no blowing sound. Clots sometimes form in the heart in endocarditis (as well as in some other diseases attended by prostration), obstructing the circulation, even to a fatal extent. Although most clots are post-mortem in origin, there is no doubt that sometimes firm fibrinous masses do occlude the valves for some time before death. The symptoms produced are, blueness and coldness of the skin, indistinctness of the heart-sounds, feebleness and irregularity of the pulse, nausea and vomiting, anxiety of expression and fainting. Much more often, vegetations or fibrinous deposits of exuda- tion on the valves of the heart are carried in fragments therefrom by the blood into the arteries. Being arrested, as in a vessel of the brain, or a limb, etc., the condition of obstruction designated as embolism results ; which receives attention in another part of this book. Old valvular vegeta- tions, as well as the recent ones of endocarditis, may give rise to emboli ; which, also, arise from coagulation in a vein, or thrombosis. Endocarditis produces valvular derangement in the mitral valve most frequently in the young ; in the old (from this 368 ACUTE MYOCARDITIS. cause as well as from degeneration), disease is rather more common in the aortic valve. The forms of disorder, indicated by murmurs, occur in the following order of frequency; 1st. Aortic obstructive ; 2. Mitral regurgitant ; 3. Aortic regur- gitant ; 4. Aortic obstructive and mitral regurgitant together. Enlargement of the heart, either with muscular thickening (hypertrophy) or with attenuation (dilatation) is a common consequence of endocarditis with valvular lesion. In every case the important question is, less the state of the particular valves, than the amount of interference with the functional action of the heart. In young persons, remarkable recoveries sometimes take place from very considerable lesion of the valves. In other instances adaptation of the heart itself, and of the general system, by degrees, is effected, so that quite good health, and even capacity for exercise, may be attained, while the physical signs of the local organic change remain. Sudden death is less common in heart-disease than is popularly supposed. Some persons having it have lived twenty or thirty years. Dr. Black has shown the great importance of breathing pure air to persons who have symptoms of heart- disease after middle life. Treatment. — Nothing can be done directly for endocar- ditis, and the treatment is mainly that of the disease in the course of which it occurs. In rheumatism alkalies should be given freely, so as to render the blood less irritable. As a rule stimulants are required in endocarditis, in some cases in large quantity, with abundant nutriment. Digitalis is indi- cated if the heart is failing. Should there be signs of obstruction from coagulation, it is recommended to give alkalies and carbonate of ammonia freely, with alcoholic and other stimulants. III. Acute Myocarditis. A brief consideration must suffice for inflammation of the heart-substance. It is frequently set up inthe layers contig- VALVULAK DISEASE. 369 nous to an inflamed endocardium or pericardium. It may occur independently in a few instances, either as a diffuse inflammation or localized, the latter terminating in abscess. Pyaemia and septicaemia lead to myocarditis, and formation of abscesses. Myocarditis is attended with discoloration, softening, infil- tration with a sero-sanguineous fluid, exudation, sometimes pus, may collect in abscesses. May lead to the formation of cardiac aneurism or rupture of the heart. If recovery takes place, depressed scars may be left. The symptoms and signs are very obscure. It tends to make the cardiac action weak and irregular; when this is a promi- nent feature in the course of peri- or endocardatis, implication of the heart may be suspected. The general symptoms are pyrexia of an adynamic type, with signs of blood-poisoning and collapse. The only treatment affording any hope is free stimulation. Yalvulae Disease. The valves of the heart may be impaired either by inflam- mation or by degeneration (as calcareous deposit or "ossifica- tion"). The latter, degenerative valvular changes, occur gradually; and mostly late in life. Either form of valve- disease, or at least of valvular alteration, is generally perma- nent; the degenerative form almost invariably so. Changes may occur, by simple thickening, or by deposits of fibroid, fatty, or calcareous material; or by atrophy, contrac- tion, adhesion, or ulceration of the valves; or gouty deposits of urates and carbonates of sodium and calcium. The valve (mitral or aortic primarily, or tricuspid or pulmonary second- arily) may be thus rendered incapable either of perfect closure, or of full opening; in most instances at least, a permanently lialf-open state results. A considerable variety of pathological conditions may exist *27 370 VALVULAR DISEASE. in organic disease of the heart; while the number of cases in which an exact and unequivocal diagnosis can be made is comparatively small. We must not confine' attention at all to the physical signs alone, but compare also with these the pulse,, the force of the heart, other general symptoms, and the entire history of the case. Certainty can hardly ever be obtained, unless it be (Stokes) in the diagnosis of one of the following three conditions : 1. Uncomplicated disease of the mitral valve. Signs of this are — a permanent murmur, with the first sound, loudest towards the apex and left side, and not heard over the aorta; the second sound natural. The heart's action natural; the- impulse not excited, the pulse natural. 2. Disease of the aortic valves, with permanent openness. With this, there is no murmur with the first sound; the second sound is replaced by a double murmur, loudest at the base of the heart, and heard along the aorta. In an advanced stage of this condition, the arteries give to the finger, or even to the eye, an impression of bounding pulsation; with a jerking, or abruptly ending pulse at the wrist. 3. Disease of the aortic valve, without permanent openness. Here, the action of the heart is slow and feeble, generally regular, or only occasionally intermitting. A murmur is heard with the first sound, the second being healthy ; but a murmur may be heard with the second sound, in the aorta and carotids. It must be noticed that in anaemia, without heart-disease, a bellows murmur is often heard, extending into the arteries. Chiefly by the concurrent signs and symptoms this is distinguished from organic disease of the heart. Anaemic murmurs are more variable, and are not much increased by moderate exercise. When the aortic valvular orifice is greatly contracted, the pulse at the wrist may become very feeble, almost absent, while the heart's impulse is strong. Advanced mitral or aortic disease is accompanied usually by ENLARGEMENT OF THE HEART. 371 derangement, sympathetic or obstruct] ye, of the lungs, liver, and other organs; with haemoptysis, anasarca, cyanosis, irreg- ularity of the pulse, syncope, etc. Pulsation of the jugular veins indicates mostly secondary disorder upon the right side of the heart, with regurgitation into the venae cava?. Pseudo- apoplectic syncope may occur in permanent patency of the mitral valve; or in fatty degeneration of the heart, with or without valvular disease. Enlargement of the Heart — Hypertrophy. Uncomplicated dilatation of the whole heart, or of either pair of corresponding cavities, or of any one cavity, is very uncommon. Complicated dilatation is frequent. It may depend — 1, on a debilitated state of the cardiac muscle; 2, on valvular disease; 3, on obstruction beginning in organs remote from the heart. The commonest form of dilatation makes part of a triple affection, in which the heart, lungs, and liver are together involved. All this may come, in the first place, from a cachexia, such as gout or scurvy, or from simple anaemia. Exacerbations in the disorder may occur; as, of pulmonary congestion, enlargement of the liver, cardiac asthma, bron- chitis, or dropsy. The prognosis cannot be very favorable in such a case; and only palliative, or recuperative, treatment avails, along with hygienic management, to economize the powers of nature. Dilatation of the heart is indicated, upon physical explora- tion, when, with extended impulse of the heart, we have dullness on percussion beyond the usual limits. If true hyper- trophy, or muscular thickening, be present, the impulse is very forcible as well as extended. The heart-sounds are apt to be clear, though not loud, in attenuated dilatation; rather loud, but dull toned, in enlargement with thickening of the walls. But these differences are hardly to be relied upon. Hypertrophy of the muscular tissue of the heart is most 372 ATEOPHY OF THE HEART. often induced by valvular obstruction or regurgitation, com- pelling unusual and continued efforts to sustain the circulation. Sometimes, however, it is more truly idiopathic; following causes of overaction of a heart otherwise sound. Thus, violent exercise, self-abuse, coffee, alcohol, tobacco, etc., are, with good reason in predisposed cases, accused of produc- ing it. Treatment of simple hypertrophy; avoidance of exciting causes, of violent exercise, alcohol, and venery, is the main principle. Digitalis was formerly relied upon as a reducer of cardiac action. Lately the question has been opened widely,, whether it does at all tend directly to lower the heart's action; or whether it is not, instead, a tonic to the heart (probably through ganglionic influence), lessening rapidity of action only when that depends on debility. The time has hardly come to pronounce finally upon this question. Evidence has been given to encourage us to use digitalis unhesitatingly where abnormal rapidity of the heart's action exists in condi- tions of debility; and to expect more from veratrum viride as a sedative and palliative, in violent acceleration of the pulse, as in muscular hypertrophy, and in some forms of palpitation. Tincture of cactus is often preferred. Fulfill indications as demanded in various cases. Atrophy of the Heart. Etiology. — Atrophy of the heart may be met with under the following circumstances : 1. As a congenitul condition. 2. In general wasting from old age, starvation, low fevers, phthisis, cancer, and other affections inducing marasmus. 3. From pressure upon the heart, by pericardial agglutinations or effusion, or excessive accumulation of fat. 4. Disease or obstruction of the coronary arteries, the heart being imper- FATTY DEGENERATION OF THE HEART. 373 fectly nourished ; the atrophy is then accompanied with degenerative changes. Anatomical Characters. — Diminution in weight to 3i ozs., or less. The heart is small, its cavities contracted, of normal shape. An eccentric form is described in which there is dilatation as well as atrophy. The muscular tissue is want- ing in tone, and fatty degeneration is common. Symptoms. — Feebleness of the circulation is the symptom attributed to atrophy. When due to pressure on the heart, or interference with its supply of blood, severe symptoms are present, as palpitation, dyspnoea, venous congestion; these are not the immediate results of the atrophy. The physical signs are: 1. A feeble impulse, which may be raised. 2. Diminished area of dullness. 3. Weak or sometimes almost extinct sounds. 4. Pulse small, feeble, but regular. Fatty Degeneration of the Heart. Definition. — Substitution of fatty substance for the mus- cular tissue of the heart, to such an extent as to interfere with its normal action. Symptoms and Course. — Always gradual in its progress, this in many instances fails to make itself known until a late period; sometimes till the moment of death. Feebleness, irregularity of the pulse and heart's impulse, exhaustion and dyspnoea upon exertion. The pulse is slow when at rest; sometimes only thirty, although the heart beats fifty or sixty. Attacks of syncopal apoplexy may occur; at first most like syncope, after repetition becoming more apoplectic. These are distinguished from true apoplexy by the feebleness of the pulse, coldness of the skin, sighing respiration, and slightness or absence of paralytic symptoms, notwithstanding several repetitions of the attack. They are worse by reduction of the system; may be relieved or warded off by timely stimulation; the recumbent posture is most favorable. The first attack may prove fatal. Physical Signs. — Fatty degeneration is often complicate 374 MODES OF SUDDEN DEATH IN HEART DISEASE. by the presence of other structural changes 'of the heart. By itself, it is with difficulty diagnosticated. The heart's impulse is feeble and slow, often irregular, and the sounds weak. A bellows murmur is frequently heard with one or both sounds. Moebid Anatomy. — True fatty degeneration must be dis- tinguished from fatty accumulation about the heart, which may impede its action, but is much less dangerous. In true interstitial degeneration, the heart is, in part or throughout, Habby and pale or yellowish, though it may be more bulky than usual. Minutely examined, the muscular fibrils are found to have lost their transverse striae, and to have resolved themselves into streaks of oil-dots or opaque granules. Death, sometimes, results from rupture of the heart. In other instances that organ has, under some exertion or excite- ment, become exhausted and failed to act sufficiently to keep up the circulation. Prognosis. — Recovery is not to be expected; life may be prolonged to old age. Much depends upon circumstances of living, and care to avoid disturbing agencies. Causation. — In early life this affection is uncommon ; its most frequent cause is, then pericardial or endocardial in- flammation. Most cases are met with after fifty years of age. It then occurs as one of the local manifestations of waning vital energy; but it may be promoted by any or all exhaust- ing or depressing causes. No special or peculiar line of causation can be pointed out. Treatment. — This can be only conservative, not curative. Tonics, with generous diet, sea or mountain air, change of scene, and avoidance of anxiety and exertion, may do much to retard the degenerative process. Violent effort or emotional excitement may be suddenly fatal. Tranquil occupation only; all rapid exercise, and straining at stool, ought to be avoided. Modes of Sudden Death in Heart Disease. To briefly enumerate these: 1. Arrest of the heart's action from debility of the muscular walls; 2. Spasm of the THYRO-CARDIAC DISORDER. t 375 Tentricles ; 3. Extreme obstruction, or regurgitation; 4. Rupture; 5. Heart clot. Indirectly, cerebral or pulmonary -apoplexy. ThyroCardiac Disorder. Synonym. — Ex-ophthalmic Goitre. Basedow's or Graves' Disease. Definition. — Enlargement of the thyroid gland in the neck with over-action of the heart and cervical vessels, and prominence of the eyeballs. Nature. — This uncommon disease is considered by Dr. Stokes to consist in a more or less permanent functional excite- ment of the heart, which may produce finally dilatation and hypertrophy, with dilatation also of the jugular veins, and an aneurismal condition of the thyroid gland. Although con- siderable disturbance and prostration of the system must attend such a state of things, yet it has been repeatedly recovered from. The cause of the affection has not been made out. Treatment. — Tranquil lization of the heart is the main indication. Veratrum viride, in doses not at all nauseating (two or three drops of the tincture every three or four hours), may be persevered in, while watching its effects. Other treatment must depend upon the general condition of each patient. Of course violent exercise and mental excitement must be avoided. General Diagnosis of Chronic Cardiac Diseases. The questions to be decided in making a diagnosis of the heart may be stated : 1 . If there is any real organic mischief, or merely functional disturbance, should^there be any symp- toms affecting this organ? 2. If the former, its nature, exact seat, and amount ? The main conditions are different valvular diseases, alteration in the size or capacity of the heart, changes in its walls, interference with its supply of blood, and peri- 376 CHRONIC CARDIAC DISEASE. cardial effusion or adhesion. These are often presented in various combinations, and an endeavor should be made to determine the exact state of the structures in every particular mentioned. 3. If possible the pathological cause of any lesion present should be ascertained. The data on which this should be founded are: 1. The previous history of the patient, special inquiry as to acute rheumatism, and violent exertion ; any family predisposition to cardiac disease. 2. The age r sex, and general condition ; whether there are signs of degen- eration. 3. The symptoms present, if the circulation is disturbed in any way, and the effects produced. 4. The physical signs. Physical examination is the only positively reliable means of diagnosis, and daily experience enforces the importance of thoroughly investigating the state of the heart in any case which comes under observation for the first time ? and especially when examining for life insurance. The points are : Whether any change in shape or size over the cardiac region ; the characters of the impulse* in every particular ; the position, form, and extent of the cardiac dullness ; the charac- ters of the sounds compared over different parts ; if there is any pericardial or endocardial murmur. Examine carefully the arteries and veins, making use of the sphygmograph in connection with the former; observing whether there are evidences of degeneration in them. It is necessary to give attention to the following facts: 1. The heart may be displaced by conditions external to it, giving rise to abnormal physical signs, when it is not itself affected ; while signs of organic disease may be modified by the state of contiguous structures. 2. Murmurs may be present independently of organic disease, or merely from roughness of the endocardium, unattended with any danger. 3. The bulging or dullness associated with pericardial effusion or cardiac enlargement may be simulated by excessive tem- porary distension of the right cavities of the heart; aneurism of the aorta ; tumor, abscess, or accumulation of fat in the mediastinum; localized pleuritic effusion; consolidation or 'I GENERAL PROGNOSIS. 377 V retraction of the anterior edges of the lungs, especially the left. 4. Positive organic disease may exist without there being any distinctive signs, particularly degeneration in its less advanced stages. 5. Severe symptoms may be complained of, and there may be marked objective disturbance of the cardiac action, amounting to irregularity or intermittency, from mere functional disorder. Much stress has been laid on certain points, whether local symptoms are due to organic mischief, viz., that mere functional disturbance is not in- creased by effort, is inconstant, and usually brought on by some obvious exciting cause. Avoid putting any very implicit reliance on these distinctions, except that grave disorder following slight exertion may indicate degeneration. General Prognosis. Any organic affection of the heart is serious ; numerous circumstances affect the prognosis, and every case has to be considered in several aspects before a satisfactory opinion can be given. Great care should be exercised against mistaking mere functional disorder for organic disease, and vice versa ; it is improper to found an opinion on mere subjective symptoms. The questions to be considered are : 1. Whether there is any danger of sudden death. 2. What is likely to arise in the progress of the case and dangers. 3. The probable duration. 4. Is a cure possible ? 1 . The prognosis depends on the nature, seat, and extent of the disease ; is more than one form present, founded on a satisfactory physical examination? Mere roughnesss of the endocardium, is attended with a murmur. The mischief may spread to the orifices and valves or their appendages. These are serious, but very different at the different orifices, and depend upon their precise condition. In estimating the probable evils, what way the various lesions influence the circulation, and the changes they are likely to produce in the 378 GENERAL PROGNOSIS. heart : upon these points the prognosis will rest. As to sudden death, aortic regurgitation is the form of valvular disease in which it is frequent ; it has been stated to occur in mitral re- gurgitation. Obstructive disease on the left side is injurious by its " back- working/ 7 and its effects on the heart and circu- lation. Aortic obstruction lasts a long time without particular evils ; cases of mitral constriction also go on for a considerable period. Mitral disease is dangerous from its effect on the lungs. Tricuspid regurgitation is a serious affection of the orifices, on account of distressing symptoms by which it is followed, often speedily, by overloading the venous circulation; its course is tedious, leading a miserable existence. Pulmonary constriction acts in the same way. Extensive or double disease at an orifice increases the gravity. It is worse when two or more orifices are involved; an opening secondarily may give temporary relief, as of tricuspid regurgitation following mitral disease diminishes the severity of the pul- monary symptoms. Is valvular disease curable? I have met with cases in which marked mitral constrictive murmur has disappeared in young persons ; though restoration to normal condition is not possible, it is likely that inflammatory deposits, leading to both aortic and mitral obstruction, may be partly absorbed in time. Hypertrophy is a preservative or compensatory lesion, not of evil import. It is dangerous when excessive, as it may lead to rupture of vessels, diseased which it tends to produce through constant overdistension; when on the right side, it is further injurious in keeping^up a constant state of active con- gestion of the lungs. Dilatation is a dangerous condition, in proportion to degree, and excess over hypertrophy. Sudden death may occur in a weak, flabby, dilated heart, and augments the difficulties in the circulation, Contributing to dropsy and other serious symptoms. Degeneration of the heart's walls, fatty disease, is another GENERAL PROGNOSIS. 379 grave lesion ; when this sets in the prognosis becomes worse in compensatory hypertrophy. Extensive fatty degeneration is the most frequent cause of sudden death. Pericardial agglutinations add to the evils of other lesions, and tend to produce changes in the heart ; this condition seems to have influence in bringing a fatal pneumonia. These affections are variously combined, and the prognosis has then to be gathered from a careful determination of the exact lesions present. 2. Severe anginal attacks, great irregularity or intermit- tency of cardiac action, a tendency to syncope or apoplectiform or epileptiform seizures, increase the danger. When venous circulation becomes obstructed, and dropsy sets in, the dura- tion is not apt to be prolonged, yet patients often linger, and may improve under appropriate treatment. Acute pulmonary complications may arise and produce very severe symptoms, increasing the dropsy and the case appears approaching a ter- mination; on the subsidence of these, improvement may take place, and the patient again for some time may feel better. 3. The cause of the disease may influence the prognosis, as regards improvement in valvular disease; it is only when this results from acute inflammation that any such hope can be entertained. If induced by chronic and degenerative changes, matters always tend to worse. Some regard a certain degree of hypertrophy, or even dilatation, as capable of being cured, if the cause can be removed. 4. The state of other organs and structures, especially the lungs, kidneys, and arteries, should modify considerably the opinion in any given case, and hence their condition ought to be carefully investigated. If the vessels are diseased, the structure of the heart is very likely to undergo degeneration. 5. General matters affecting prognosis are the age, the family history indicating a tendency to death from heart- disease; the social position, and habits of the patient. Only in young persons can curative changes be expected. Those who are circumstanced to live quietly, without anxiety or 380 GENERAL TREATMENT. labor, and have a suitable diet, have a better chance of length of life than those not so fortunately situated. Laborious occupations are injurious. Continuance in evil habits, as intemperance or debauchery, will render the prognosis unfavorable. General Treatment. Seldom can hope be entertained of curing chronic cardiac affection; much may be done in prolonging life, averting further mischief in the heart, warding off unpleasant or dan- gerous symptoms, and relieving them when they arise. After an acute affection involving the heart, the patient should be kept under observation until the organ has resumed its normal condition, so far as is possible ; any chronic case ought to be kept constantly under medical supervision. Different forms of heart disease indicate particular modifications of management ; the main principles which apply to all varieties more or less, are : 1. General hygienic management is of essential importance. A patient suffering from heart disease should give up laborious employment, if this originated and is increasing the mischief. Avoid sudden effort ; running or walking hurriedly, and strain- ing at stool. In some instances complete rest should be enforced for a time, which often produces a marked improve- ment. Many cases are benefited by being in the open air during some portion of the day, and carriage driving is often useful. Many patients can go about their usual avocations without any harm resulting, if these are of .a satisfactory character. The amount of exercise must be determined by the conditions present, the effects it produces ; in proportion to the degree of dilatation or degeneration present is the capacity for effort diminished. These lesions, if extensive, and aortic regurgitation, imperatively forbid any great exertion. Avoid all causes of mental disturbance. Anxiety or excite- ment about pecuniary matters, business, politics, excessive study, and all strong emotions must be shunned, and a proper GENERAL TREATMENT. 381 amount of sleep should be habitually obtained. Warm clothiug, but no pressure or constriction about the chest or neck; cold sponging followed by frictions of the skin are use- ful, if well borne. All habits which depress the energy of the heart, as abuse of alcohol, tobacco, tea, late hours, or venereal excesses, etc., must be prohibited. Close inquiry may be necessary to detect mischievous habits. Change of air to a moderately warm and bracing climate does good. 2. Attend to the diet in every particular, and to the state of the digestive organs. When there is degeneration of the heart, a nutritious diet containing protein elements, if these can be digested ; anything which gives rise to indigestion must be avoided. Milk and cream are useful in many cases. As to alcoholic stimulants, no rule can be laid down, a moderate quantity is beneficial; there are frequently symptomatic indications, calling for considerable. The bowels should be kept acting. Improve the tone of the stomach and remove dyspepsia, especially flatulence, which mechanically interferes with the heart's action. 3. If there is any constitutional diathesis, as gout or syphilis, treatment against this is beneficial. Look to the state of the blood ; if there is ancemia, give some preparation of iron. Other tonics are useful, as quinine and mineral acids, strychnine or tincture of mix vomica, if there is degeneration of the heart or want of tone. Therapeutic observations have been made the last few years as to the effects of certain agents upon the heart. Digitalis renders the ventricular contractions more powerful and complete, less frequent, and more regular. Several other remedies influence the heart, as aconite, belladonna ; both are valuable in calming this organ, when it acts excitedly and violently ; hydrocyanic acid, veratria, caffeine, scoparium, squill, etc. Some of these require to be given cautiously, as they are powerful agents. 5. Do we possess any means of restoring the heart to its normal condition when in a state of disease, and is it desirable 382 GENERAL TREATMENT. to use such means'? As regards valvular disease, it is useless to attempt to influence these by any therapeutic measures. As to the diminution in size of a hypertrophied heart, this is not to be aimed at; it is doubtful whether it can be affected in the least. Our object should be to maintain the nutrition of the heart, and prevent it from becoming dilated. We have no means of influencing dilatation, except by improving the tone and vigor of the heart by food, tonics, digitalis, etc. It is possible that the nutrition of & fatty heart may be improved by good diet, tonics, and cod-liver oil. 6. Symptoms arise in the course of a case of heart disease, demanding relief. These are pain and other unusual sensa- tions, 'palpitation, angina pectoris, and syncope. Abnormal sensations are relieved by wearing a belladonna plaster, or using belladonna liniment. The treatment of the other symptoms has been pointed out. Palpitation, attended with dyspnoea, is quieted by subcutaneous injections of (gr. 1-12 to i) of morphia, which relieve spasm of the arterioles, this giving rise to the palpitation (Fothergill). Aconite, in minute doses, is recommended by Ringer and others. Pul- monary symptoms require the usual methods, but are greatly relieved by acting on the heart by digitalis. Needless cough should be subdued; it is necessary to promote expectoration. Cardiac dyspnoea may be influenced by digitalis, or may require sedatives and antispasmodics. Any cause of it, as flatulence, should be got rid of; it is diminished by making the patient sit up in bed, removing pressure on the diaphragm. Haemoptysis in heart disease should not be rashly stopped; if not sufficient to injure the patient, it may afford relief. Local remedies are serviceable in heart and lung symptoms, as dry- cupping, hot or turpentine fomentations, and sinapisms. Some recommend irritation along the vagus nerve, by sina- pisms or gentle galvanism. Dropsy sets in in most cases of heart disease. Diuretics are most beneficial which act upon the heart, and increase the arterial tension in the kidneys, as digitalis. Well-diluted gin, CARDIAC AFFECTIONS. 383 Hollands, and whisky are useful diuretics. Vapor, hot air, or even Turkish baths, are beneficial when they can be borne ; with due precautions they can be persevered in. I have found benefit from local baths, as wrapping up the legs in warm fomentations, their whole extent, covering them with mackintosh. Excite the skin to activity by surrounding the patient with hot-water bottles while in bed. Purgation is attended with marked benefit, but it requires care on account of the depression which may be produced. Frequently it is not desirable to check diarrhoea ; this is a method by which the vessels unload themselves ; it may continue, provided it is not lowering the patient by excessive amount. If cardiac dropsy does not yield to proper treatment, acupuncture should be resorted to, with great relief. Due regard must be paid to position and cleanliness. Much difficulty is experienced to procure sleep in advanced cases. Opiates, hydrate of chloral, etc., are frequently inad- missible, as they would induce a condition unfavorable to respiration, and death might follow. Stimulants should be given freely under these circumstances. When the patient becomes semi-comatose, from carbonic acid poisoning, the bladder must be looked to regularly. 7. Attend to the other principal organs and guard against their becoming involved, especially the lungs, kidneys, and liver. Every source of cold should be avoided, the slightest pulmonary complaint treated. Certain Bare Cardiac Diseases. Pericardial Hemorrhage. — Blood may be found in the pericardium as the result of: 1. Spontaneous rupture, either of the heart or a cardiac aneurism; an aortic aneurism; one of the coronary vessels; or of vessels in cancerous deposits. 2. Injury. 3. Pericarditis, the effusion being more or less hemorrhagic. 4. Diseased conditions of the blood, as scurvy and purpura. 384 RARE CARDIAC DISEASES. The symptoms indicate loss of blood and interference with the heart's action; they vary with the amount of blood present, and the rapidity of its accumulation. Sudden death may occur. The physical signs are those of pleuritic accumulation. Pneumo-pericardium. — Gas is occasionally found in the pericardium, either entered from without, or resulting from decomposition of fluid ; it may give rise to tympanitic reso- nance, and succession-splash, if mixed with fluid. Cardiac Aneurism. — A localized dilatation of the walls of the heart. It may involve the entire thickness, or the endo- cardium and contiguous strata may be destroyed. The size and form vary; there are two types, of general and equable dilatation of part of the parietes, and the sacculated variety, the latter opening into the heart by a wide or narrow orifice. Stratified fibrin or coagulated blood is found in the sac; it may be completely obliterated and cured. The left ventricle which is invariably affected, and more than one aneurism may be present. Cardiac aneurism is the consequence of structural change in the ventricular walls, fatty or fibroid inflammation, softening, rarely ulceration or rupture of the endocardium, or hemorrhage into the walls. It is formed gradually, but may be developed suddenly from violent strain. Death may occur from rupture; there are no reliable symptoms or signs. Degenerations and New Formations in the Walls of the Heart. — 1. Softening of tissue in low febrile conditions, typhus, typhoid, small-pox, scarlatina, and septicaemia. A form of simple softening has been described, chronic in its course. 2. Fibroid infiltration, or degeneration, or cirrhosis. This is local- ized, in the musculi papillares; it may form scar-like patches in the walls. 3. Calcification. 4. Syphilitic grovrfhs. 5. Albuminoid degeneration. 6. Cancer, which is extremely rare, being usually medullary and nodular. 7. Tubercle, also very rare. 8. Parasitic formations, as the cysticercus cellu- losus, and echinococcus. Rupture of the Heart. — Various structural changes have CYANOSIS. 385 been found in the cardiac walls inducing a rupture. The more important morbid conditions are, fatty disease, degener- ation; great dilatation; cardiac aneurism; abscess or gangrene; ulcerative or other destruction of the endocardium; hemor- rhage into the walls; calcification; and parasitic formations. Rupture may occur in aortic aneurism or coarctation. It is induced by some exciting cause, and is much more frequent in males and old persons. The size, shape, and other characters of the rupture vary considerably; more frequent in the left ventricle, but traumatic rupture is more common on the right. The direction of the laceration is parallel to the chief fibres of the heart. The symptoms vary according to the mode in which the rupture takes place, and its dimensions. Death may be instantaneous, or very rapid after sudden insensibility, pre- ceded by a shriek. If this does not happen, the important symptoms are sudden extreme pain in the cardiac region, with oppression and dyspnoea, signs of intense shock and collapse, and interference with the cardiac action. Patients occasionally rally, and there may be repeated attacks, supposed to indicate rupture of successive layers of the heart's fibres. It is stated that recovery may take place. The treatment of these conditions must be conducted on general principles. Malformations of the Heart and, Great Vessels — Cyanosis — Blue Disease. The term cyanosis indicates a certain appearance presented by a patient ; it is observed in most cases of malformation of the heart, and it applies to these ; it is associated with other affections also. Etiology. — The pathological causes of cardiac malforma- 2S* 386 CYANOSIS. tions are either arrested development, or endocarditis or myocarditis occurring during intra-uterine existence; more common on the right side, with the pulmonary orifice; in very exceptional instances, may be acquired after birth, due to rupture of a septum. Anatomical Characters. — The chief morbid conditions in the heart and great vessels, in the class of congenital mal- formations are: I. Cardiac. 1. Patent foramen ovale, or absence of the auricular septum. 2. Perforation, or incom- plete development of the ventricular septum. 3. Owing to these conditions there may be but one auricle or ventricle, or an aaricle and ventricle are thrown into one, or scarcely any separation between any of the cavities. 4. Extreme small- ness of the right ventricle, the septum being too much in this direction, or cicatricial thickening and stricture. This is rare on the left side. 5. Constrictive disease of the tricuspid orifice, or contraction of the valves, leading to obstruction or regurgitation. II. Great Vessels. 1. Incomplete development of the pulmonary artery. 2. Constriction of the aorta. 3. Trans- position of the arteries, the aorta coming from the right ventricle, and the pulmonary artery from the left. 4. Both vessels may spring either entirely or partially from the same ventricle, due to displacement or imperfection of the septum. 5. Occasionally there is but one trunk, which comes from a single ventricle, and then divides into two. 6. The ductus arteriosus is often pervious. Some of these conditions are met with together, the neces- sary consequences of each other. The common malformation is constriction of the pulmonary orifice, with an open foramen ovale, and a pervious ductus arteriosus, through which the blood passes from the aorta into the pulmonary artery, some of it reaching the lungs through enlarged bronchial arteries. If the aorta is closed, the foramen ovale and ductus arteriosus remain open ; the blood is conveyed by the latter from the pulmonary artery into the aorta. CYANOSIS. 387 Symptoms. — They disturb the circulation in one or more of three ways: 1. Allowing a free intermixture of venous and arterial blood. 2. Interfering with its passage into the lungs, while the venous system is overloaded; or with its return from these organs. 3. Making the systemic circulation entirely venous, the pulmonary entirely arterial, the arteries are transposed. Some of the conditions are incompatible with life any length of time. In other cases patients may live up to twenty or more; the symptoms may not show for a con- siderable time after birth ; they are those of deficient blood- oxygenation, and general venous stagnation, presented in these cases in their most intense degree. Discoloration may be blue, leaden, purple, livid, or of a claretty hue, mottled, very marked in the lips, ears, fingers, and toes. It is intensi- fied by anything which increases the difficulty in the circula- tion, such as crying, coughing, etc.; it is the combined effect of intermixture of venous and arterial blood, venous stasis, and imperfect, arterialization. Fits of palpitation, extreme irregularity, and a disposition to syncope or coma. Dyspnoea, cough and other lung symptoms are frequent. The physical signs vary according to the morbid con- dition. If the orifices or valves are affected, there will be corresponding murmurs ; pulmonary murmur is com- mon. A patent foramen ovale cannot give a murmur. In time hypertrophy and dilatation or degeneration is observed. The duration of congenital cyanosis is very variable; it sometimes linger, becoming accustomed to its semi-asphyxiated state. Death is never sudden, usually gradual. Treatment. — Attend to hygienic measures, including moderate exercise, baths with friction, and wearing warm clothing, flannel next the skin ; give plenty of good food, of a hydrocarbonaceous kind, a small quantity of alcoholic stimulant ; and treat anything calling for special 388 DISEASES OF BLOODVESSELS. attention. Iron and other tonics, with cod-liver oil. A dry, warm climate, and every source of cold avoided. CHAPTEE X. DISEASES OF BLOODVESSELS. Arteritis. — Inflammation of Arteries. — Atheroma, &c. Acute arteritis is observed in the aorta (aortitis), and occurs in the course of blood-affections more frequently than is recognized. Characterized anatomically by injection of the vasa vasorum, thickening and softening of the coats, cloudi- ness and loss of polish of the inner surface, rough from fibrinous deposit. Symptoms. — Pain, sometimes extreme, tenderness, or superficial hyperesthesia ; heat and throbbing; severe consti- tutional disturbance and restlessness; a tendency to syncope, and dread of death. The physical signs are objective pulsa- tion, occasionally a thrill and murmur, synchronous with the cardiac systole. In the smaller arteries inflammation might lead to plugging; a clot may be the cause of inflammation. Chronic Arteritis is an important morbid process; is the origin of atheroma, preceded by a parenchymatous inflamma- tion of the inner coat (endarteritis deformans). Etiology. — The chief causes of atheroma are: 1. Local injury from distention of, and strain upon, an artery, thus produced by hypertrophy of the heart. 2. Constitutional diseases, as gout, rheumatism, syphilis. 3. Abuse of alcohol. 4. Senile degeneration. Anatomical Characters. — The deep layers of the inner arterial coat become infiltrated with new cells, softened, relaxed, and thickened. The cells are mainly derived from ARTERITIS, ETC. 389 proliferation. As the result, thickened patches or more extensive tracts over the inner surface of the artery, and two forms are described : soft, jelly-like, moist, and pale-reddish ; and more firm, semi-cartilaginous raised patches, translucent, but more opaque in the deeper layers, compared to boiled white of egg. The superficial coat is unaffected, and can be stripped off. Fatty degeneration beginning in the superficial layers, in the cartilaginous variety in the deeper layers. In some cases, very rapid, owing to the abundance of cells ; a yellowish, soft, pultaceous substance is formed, like a greasy paste, giving rise to a pseudo-abscess or atheromatous pustule, which may burst into the artery ; at first, a small hole in the inner coat, the soft contents pass and are carried away by the blood ; finally an atheromatous ulcer is formed, varying in size and depth, even involving the middle coat. The softened material consists of broken-down fibres, granular cells, abundant fat granules, and crystals of cholesterin. Where the process is chronic, the substance is firmer, becoming caseous ; or organization occurs ; fibroid thickening ; always some degeneration. Ultimately calcification is liable to happen, or actual ossification, hard, depressed plates being originated, or smaller arteries involved and converted into rigid tubes. The calcareous plates are at first covered by the superficial portion of the lining membrane, liable to give way, leaving a rough surface exposed, upon which fibrin is very apt to be deposited. The vessels affected and the extent vary widely ; different stages are usually seen in the same case. Most marked in parts of the vesels subject tojthe greatest strain ; in the ascend- ing and transverse portions of the arch of the aorta; around the opening of arteries which come off laterally, as the intercostals. Atheroma is more advanced in the aorta than in the arteries generally. Fatty Degeneration of Arteries. — Fatty degeneration is a distinct process from atheroma. It begins in the superfi- cial part of the inner coat, may extend into the middle. The 390 epithelial and connective-tissue cells are changed, filled with fat-granules ; in the middle coat the muscular fibres undergo degeneration. The usual appearances are of small, scattered, irregular, opaque, yellowish-white patches, quite superficial, slightly projecting, easily removed, leaving normal tissues underneath. As deeper layers become involved the patches appear more opaque and irregular, and are less easily stripped. In time complete destruction and softening, nothing but fat- granules remaining, carried away by the blood, leaving irregular, superficial erosions. Finally calcification. The capillaries are liable to fatty degeneration. Occasionally a large artery undergoes simple atrophy, the walls becoming thin. Symptoms and Effects. — 1. The elasticity of the arteries is diminished, finally lost, their resistance increased, and ultimately converted into rigid tubes, the calibre diminished. Hence an obstacle which leads to hypertrophy of the left ventricle, followed by degeneration. The circulation is im- paired, disturbance of the cerebral circulation, giddiness and alterations of the special senses. Owing to the impairment of nutrition, structures undergo degeneration prone to inflam- mation from slight causes. 2. When the vessels are rough on inner surface fibrin is deposited from the blood, ultimately causing complete obstruction. As a consequence, softening or death of a part may ensue, as is well seen in chronic soften- ing of the brain and dry gangrene of the lower extremities. 3. A portion of an artery, after the formation of an atheroma- tous ulcer, is prone to yield gradually, and thus an aneurism be produced. 4. The. aifected vessels become brittle, calcified, easily ruptured, causing cerebral apoplexy. 5. Fragments of the degenerate structures, or of fibrinous deposit, may be detached, carried away by the blood-current, and lodged in some smaller vessels as emboli. 6. Physical examination of the vessels affords the best indication of their condition, and the brachial artery, just above the bend of the elbow, is that which can be most readily observed. On bending the elbow, THOEACIC ANEURISMS. 391 the artery is distinctly visible, tortuous, having a vermicular motion with each pulse, and it feels hard, full, incompressible. A sphygmograpkic tracing is characterized by the large dimen- sions of the curves ; the approximation of the secondary waves to the summit ; and the great size of the -first secondary wave as compared icith the aortic, which is much diminished. AVhen the arch of the aorta is extensively diseased, a jerk- ing impulse may be observed above the sternum, occasionally a thrill ; a rough systolic murmur may also be heard along the course of the vessel, or a cardiac basic murmur is intensified in this direction. The vessel somewhat dilated; this will increase the signs mentioned. Diagnosis. — Degeneration of arteries in persons advanced in years is a probable cause of many symptoms of which they complain. Examination of the vessels is the means of diag- nosis, and if the general arteries are affected, probably the aorta is in the same condition. Some attach considerable importance to the sphygmographic tracing as revealing an early stage of degeneration. Peognosis. — This involves a knowledge of the dangers which accompany degeneration, so that they may be guarded against. Many live to a good old age, with the vessels much diseased, but at any moment there is a liability to dangerous lesions. The earlier the degeneration the more serious is the case. Teeatment. — All that can be done is to avoid everything which is likely to throw a strain upon the vessels, and main- tain the nutritive activity of the system as much as possible by diet, tonics, and cod-liver oil, the last being decidely useful. Any constitutional diathesis mut be attended to, and all inju- rious habits checked. Thoeacic Aneueisms. Aneurisms come under the care of the surgeon; for a full con- sideration of the subject reference must be made to surgical 392 TH0EAC1C ANEURISMS. works. It is intended to allude to the main practical facts of aneurisms within the chest, especially aortic. Etiology. — Aneurism results from morbid change in the walls of the artery, as chronic endarteritis, and the athero- matous changes thus produced, but also sometimes fatty de- generation or simple atrophy. Its determining cause is some violent exertion, throwing a sudden strain upon the weak portion of the vessel, and may lead to a rupture of part of its coats. Aneurism is more common among males, whose occupation entails violent efforts; about the middle period of life. It is frequent in the army; is attributed to the combined effect of great exertion; tight clothing, compressing the neck and chest, obstructing the circulation; and heavy accoutrements. The diseases which predispose to changes in the vessels are syphilis, gout, and rheumatism; especially the first. Anatomical Characters. — The varieties of aortic aneu- rism are: 1. A general dilatation of the whole circumference,, either cylindrical, fusiform, or, globular. 2. Sacculated aneu- rism is the most important, a lateral bulging or sacculation, the coats either entire {simple or true), or the inner and middle coats destroyed {compound or false). Sometimes all the coats give way, and the aneurism is bounded by surrounding struc- tures {diffuse). 3. In exceptional cases a dissecting aneurism. The ascending portion of the arch is most frequently affected, on the convex side, where it is exposed to strain; an aneurism may exist on any part. Great variety in size, shape, contents, and other characters. Symptoms. — Not uniform, due to pressure, and influenced by situation, size, form, rapidity of formation, and direction of growth, liable to alter during progress. The symptoms are not in proportion to the external physical evidences of aneurism; the reverse is often true, as the more an aneurism tends inwards the more severe are the symptoms; they may be extremely aggravated. A bulging in front of the chest, in which pulsation is felt, THORACIC ANEURISM. 393. not continuous or identical with that of the heart, and over which resonance upon percussion is dull — is probably an aneurismal tumor. If a thrill is also perceptible in it, with or without a murmur on auscultation, we may be still more confident in the diagnosis; and when the signs of pressure upon the air tubes, oesophagus, sympathetic or recurrent laryngeal nerve,or throracic duct occur, it is nearly certain. Murmur may, however, be absent; so may thrill; the bulging may be slight, and the percussion resonance little altered. The sign of most consequence is, the existence of two points of pulsation in the chest, the cardiac and the aneurismal; the latter coinciding almost with the diastole of the heart. The signs of pressure are chiefly, pain, cough, dyspnoea,, loss of voice, difficulty of swallowing; and emaciation from obstruction of the thoracic duct. Cancerous or other tumors may produce all these latter signs ; but such tumors do not pulsate. In empyema the beat of the heart sometimes impels the fluid so as to throb rather widely; but this is still a single cardiac impulse. Occasion- ally a consolidated lung, in phthisis, may vibrate forcibly, with the pulmonary artery; but other signs then make clear the disease. The course of aortic aneurism is usually very gradual — often lasting for a number of years. Death occurs — 1, from sudden rupture and copious hemorrhage; 2, from slighter rupture and slow leakage; 3, from slow exhaustion by pres- sure, interfering with respiration, deglutition, etc. Treatment. — The first object in treatment is promoting coagulation of a sacculated aneurism. Failing this, protect it, retard its development and treat the symptoms and complica- tions. To induce a cure, rest in the recumbent posture for a considerable time, and avoid every source of mental disturb- ance. A careful regulation of diet, a definite quantity of solids and liquids, at stated intervals. The exact amounts 394 MEDIASTINAL TUMORS. depend upon each individual case; everything should be strictly weighed or measured, the object being to support life with as little food and drink as possible, without inducing nervous irritability. Excess of fluid avoided, all stimulants prohibited. Medicinal agents may be employed ; those which calm and regulate the heart's action, such as digitalis, aconite, or bella- donna; and those which promote coagulation, particularly gallic or tannic acid, tincture of steel, and iodide of potassium. Keep the aneurism covered with cotton ; should it be prominent, some kind of protecting shield might be worn. For relieving pain and procuring sleep, the chief remedies are hyoscyamus, lactucarium, hydrate of chloral, and conium. Subcutaneous injection of morphia is valuable. External applications are belladonna or opium plaster ; belladonna or aconite liniment ; cold poultices of linseed-meal and vinegar, of conium, digitalis, or oak-bark (Walshe) ; ice, ether-spray, or chloroform cautiously applied ; counter-irritation by flying blisters or iodine, which sometimes gives marked relief. If there are severe laryngeal symptoms, evidently due to pressure on the recurrent nerve, it is justifiable to perform tracheotomy. It has been suggested that in some cases the sterno-clavicular ligaments might be divided, in order to allow displacement of the clavicle forwards. Mediastinal Tumors. Aortic aneurism is the most frequent form of mediastinal enlargement. The other chief varieties are cancer (either encephaloid or scirrhoencephaloid) originating in the oesopha- gus, glands, root of lung, or thymus gland; fibro-cellular, fibrous, or fibro-fatty tumors ; enlarged masses of glands in tuberculosis, or Hodgkin's disease; inflammatory exudation and abscess ; or rarely masses of steatoma, or hair. Symptoms and Signs. — Mainly those of pressure, as already mentioned, and present the usual variations ; " currant MEDIASTINAL TUMORS. 395 jelly expectoration is said to be common in cancer. There may be constitutional symptoms of this diathesis. The physi- cal signs of a solid tumor are widely different, bnt the following list may give some notion of those to be sought for. 1. Local bulging in front of variable extent, often irregnlar, not pulsat- ing. This may be absent. 2. Deficiency or absence of respira- tory movements over the seat of enlargement ; in some instances over one side, from pressure on a bronchus. 3. Altered percussion-sound, being dull and toneless, hard, wooden, and high-pitched, occasionally tubular or amphoric ; with marked resistance. 4. Respiratory sounds weak or absent, blowing, or tubular, according to the relation of the enlargement to the main tubes. 5. Vocal fremitus and resonance either deficient bronchophonic, or pectoriloquous. 6. Frequently dry and mucous rales in the bronchi. 7. Displacement of the heart and other structures ; increased conduction of the heart-sounds • occasionally a murmur from pressure on a great vessel. Diagnosis. — Mediastinal tumor has to be distinguished from other morbid conditions in the chest; chronic pneumonia, chronic pleuritic effusion, pericardial effusion, and enlargement of the heart. Careful consideration of the history of the base, its symptoms, physical signs, and progress, will rarely leave doubt as to the diagnosis. It is more difficult to determine the natrue of mediastinal enlargement. In the diagnosis of any doubtful case, as between aneurism and a solid tumor, usually cancerous, the following conditions have weight : 1 . A female under 25 points to a solid tumor ; the family history may suggest ajcancer ; or the occupation favor aneurism. 2. Symptoms, dysphagia, severe pain, especially behind, are more common in aneurism ; oedema of the arm and chest, frequerit haemoptysis, and especially currant-jelly expec- toration, in tumor. Occasionally cancer-elements may be discharged in the sputa. 3. The physical signs are of much value. The limitation of these to the region of the aorta, presence of any thrill, double impulse with doubling of the diastolic share, and gradual approach of any pulsation to the 396 INFLAMMATION OF THE BE A IN. surface, are suggestive of aneurism ; great superficial extent of dullness, absence of heaving character in the pulsation, the want of accordance between it and the maximum dullness, are in favor of tumor. 4. Examination may reveal cancer in other parts, or constitutional evidence of its presence. Treatment. — All that can be done is to relieve symptoms as they arise. CHAPTER XI. DISEASES OF THE BRAIN AND NER VO US SYSTEM. Inflammation of the Beain. Synonyms. — Encephalitis, Phrenitis, Meningitis, Cerebritis. The last two are not technically identical ; but not clinically separable. Inflammation of the membranes derives its import- ance from the implication of the brain. Varieties. — Simple and scrofulous encephalitis or meningo- cerebritis. Simple Meningo-Cerebritis (meningitis). Symptoms. — Intense headache, redness of face and eyes, an excited look, dizziness, roaring in the ears, extreme sensitive- ness to light and sound, restlessness, wakefulness, wild delirium. Vomiting is common; the bowels are usually costive. Late in the attack in adults, at any period in children, convulsions may occur. Rigidity of the muscles is frequent in bad cases; paralysis often follows convulsions. Stages. — These are generally described as three. 1. That of active congestion and inflammation ; with hot, hard, rapid, full, regular pulse, morbid sensitiveness to light and sound, headache and delirium. 2. That of commencing effusion and cerebral oppression; with more moderate heat of the surface INFLAMMATION OF THE BKAIN. 397 stupor, aud sloiv or irregular pulse. 3. That of cerebral disability or disorgauization ; with unconsciousness, convul- sions, muscular rigidity or paralysis, and rapid, feeble pulse. Morbid Anatomy. — Except in traumatic cases the dura mater rarely takes part in the lesions of encephalitis. Bather minute hypersemic injection is found here and there in the arachnoid membrane; sometimes opacity and thickening occur, with adhesions. In the pia mater, generally with considerable increase of redness, serum has been effused; or even pus. The pia mater adheres firmly to the brain. The ventricles contain more serum than usual ; sometimes several ounces. In some cases it is turbid, flocculent, or purulent. The brain itself is most frequently affected, with redness in the convolutions, and dots of blood in the medullary portion ; also, with softening in the gray or white substance, or in both. Diagnosis. — The distinctions between simple and tuber- culous or scrofulous meningitis or encephalitis will be con- sidered. Typhoid fever, delirium tremens, and acute mania may be mistaken for inflammation of the brain. Typhoid fever does not usually have vomiting, long-con- tinued headache, or morbid sensibility to light among its symptoms; while tympanites, diarrhoea, bronchitic cough, etc., make it known. In delirium tremens, the origin of the affec- tion in alcoholic excess, the most horrible illusions, tremor and insomnia, without headache, are characteristic. Acute mania is almost or quite without fever ; often without head- ache ; and the muscular strength is little impaired ; vomiting, also, is absent. Subacute or chronic encephalitis, now and then met with, presents greater difficulty in distinguishing it from mania. The best authorities state that cerebral hyperemia and inflam- mation bear an important part in the pathology of insanity. (See Winslow on the Brain and Mind.) Children afford frequent instances of another question in diagnosis — how far symptoms affecting the brain may or may not depend upon the stomach for their causation. "Gastric 398 INFLAMMATION OF THE BRAIN. fever" and "infantile remittent" are phrases applied often to to attacks occurring in childhood or infancy; in which, with indigestion and vomiting, there is delirium, stupor, or apathy, with or without convulsions. In such cases, the heat of head and fullness of the carotid and temporal arteries are less, the gastric disorder, fur of tongue, etc., greater, than in cerebral inflammation. Cholera infantum is often attended by brain symptoms; but its other features, the time of year, and locality are distinctive. Prognosis. — Simple encephalitis, under good treatment, is not always fatal; but a majority of cases end in death. Causation. — Between fifteen and forty-five is the age most subject to this disease. Males are more liable than females to it. Hot climates predispose to it; and so does intemperate living. Exciting causes are, blows or falls upon the head, exposure to the sun, violent or prolonged mental excitement, erysipelas of the head, scarlet fever, metastasis of rheumatic or gouty inflammation, repulsion of eruptions upon the skin, suppression of accustomed discharges. Extention of inflammation from the ear (otitis) to the brain is a possibility, important not to be overlooked. Treatment. — Purging actively is important; by sulphate or citrate of magnesium, or, if dosing be difficult from delirium, elaterium and euema. After one free purging, moderate catharsis may be, if necessary, repeated every two or three days; and the bowels should be kept open during the attack. Cutting the hair short, or, still better, shaving the whole head, will aid in giving relief, and will allow the effectual application of cold. Pounded ice, in a bladder or bag of India-rubber, will do if watched and changed in place often, to prevent too great an impression upon one part. Many prefer a linen cloth (as a cambric handkerchief) folded once, dipped in ice water, and laid over the head; it should be wet freshly every few minutes, or the good effect is almost lost. Merely wetting the head now and then with cold water TUBERCULAR MENINGITIS. 399 produces a reaction not a sedation, which is required. If the feet be cold, they should be made warm by mustard foot-baths or sinapisms. In children the prolonged warm bath may be useful. Evaporating lotions are often better applications to the head. The diet in the first part of the attack should be as light and unstimulating as possible. Oatmeal gruel, panada, rice, toast- water may come first ; then milk, chicken- water, mutton broth ; later, beef-tea and nourishing diet. Blisters are serviceable after the intensity of the inflam- matory excitement has begun to diminish. The best will be a blister to the nape of the neck and between the shoulders. It need not remain on many hours. In a late stage, with secondary debility, concentrated liquid diet, with alcoholic stimulants, and even opiates at night, may be required to support the flagging energies of the system. Convalescence in the best cases may be slow. The faculties may remain feeble, and the brain morbidly excitable, for weeks or months, needing great care as to all mental impres- sions and efforts, lest a dangerous relapse occur, or chronic cerebral hyperemia, perhaps insanity follow. The case must be looked after until well. Tubercular Meningitis. Acute Hydrocephalus. — From two to fifteen years is the age most apt to yield examples of this fatal disease. Premonitory symptoms usually occur ; dullness, pettishness, and languor ; headache ; disposition to put the head in the mother's lap, or to lie down ; loss of appetite, vomiting, and costivness. The child sleeps ill, with grinding of the teeth, or sudden starting with alarm. After four or five days, constant headache and anxiety of countenance, heat of head, sensitiveness to light, fever and drowsiness, alternated with moaning or occasional screaming, and delirium at night, mark the case. Advanced symptoms are, total stupor, strabismus, con- 400 HYDROCEPHALUS. vulsions, and paralysis. The pulse goes through similar changes to those of simple encephalitis ; first febrile accelera- tion, then irregularity and slowness, lastly the rapidity of moribund prostration. The attack terminates on the average in between two and three weeks. Prognosis is always unfavorable in this disorder. Morbid Anatomy. — Since Papavoine, Kufz and Gerhard showed the existence of a relation between tuberculosis and " acute hydrocephalus/' autopsic inquiry has proved fully : 1. That tubercle-like granulations, with opacity and thickening of the arachnoid at the base of the brain, adhesion between the hemispheres, and serous effusion characterize a number of the cases. 2. That all of these lesions may be found without any tubercle whatever ; and 3. That the amount of such deposits in most cases is not sufficient to modify greatly the course of the local disease, at least in such a manner as tubercle acts elsewhere. It is concluded, hence, that it is rather the diathesis than the deposits that make the disease to differ, as in progress and prognosis it clearly does, from simply meningitis or en- cephalitis. Treatment. — Purge moderatively, not exhaustively ; blister the back of the neck ; apply cold with care, or what is better, evaporating lotions, as alcohol, or ether and water, and allow liquid nourishment, such as milk and beef-tea, mutton or chicken broth, etc., from an early stage. Iodide of potas- sium is recommended by some practitioners, other diuretics and alteratives. Hydrocephalus. Definition. — Water in the head; dropsy of the brain. This is almost always an affection of early life. Sometimes it is congenital. It is mostly a passive dropsical effusion ; cer- tain cases show signs of a chronic or subacute inflammatory condition of the arachnoid membrane. SOFTENING OF THE BRAIN. 401 Symptoms. — Languor, strabismus, convulsions, loss of appetite, increase in the size of the head. This last may be •enormous ; the fontanels expanding, and, in a slow case, the bones growing excessively large. The mental faculties nearly always grow dull. Bodily emaciation and debility attend. Although cases are known and recorded in which hydro- iephalic persons lived for more than twenty years, the general rule is that they die in a few months ; either from cerebro- spinal disability or atrophy, or from some intercurrent disease not endurable by the impaired vital energies of the system. Treatment. — Small as is the encouragement given by experience in this affection, it is certainly justifiable to try measures not out of place in themselves. Such are, moderate purging, every few days, or once a week, sustaining the strength by nourishing food, and, if it be borne, cod-liver oil; diuretics; shaving the head and rubbing it nightly with iodide of potassa ointment ; occasionally blistering the back of the neck ; in a child preferably, by painting it with cantharidal collodion. Pneumatic aspiration may perhaps prove useful in hydrocephalus, to remove the fluid gradually and safely. Softening of the Brain. Pathologists generally recognize two forms of this: 1. Acute red inflammatory softening; and 2. Slow, white, atrophic softening or degeneration of the brain-substance. Both receive the name of ramollissement. The former of these is further definable as a local cerebritis; whose symptoms are not nearly always separable, clinically, from those of meningitis or encephalitis, already described. Cadaveric inspection shows not only hy perse mic redness and softening, but, sometimes, abscess, or even gangrene of the brain. This last is probably always the result of injuries. Induration of the brain may also follow traumatic inflamma- *29 402 SOFTENING OF THE BRAIN. tion of the brain. The cerebrum is more often affected with red softening than the cerebellum. Abscess of the brain is in a certain number of cases latent for a considerable time. Sudden headache is apt to be the earliest symptom. This is attended by feverishness, vomiting, difficulty of speech, numbness, convulsions, paralysis, and coma. Otitis and pycemia are said to be, after injuries, the most frequent direct causes of it. Diagnosis. — Acute Red Softening. — The occurrence of imperfect coma, with rigidity of the muscles of the extremities, or of paralysis without loss of consciousness, will make probable this lesion. Most cases die within two weeks ; some within two or three days. White atrophic softening or degeneration of the brain may take place as a result of old age, or from intense mental labor or excitement, from intemperance, or from embolism; that is,, obstruction of an artery within the brain by a fibrinous clot carried from some other part. Its approach and progress are more slow and insidious than those of acute inflammatory ramollissement. Neuralgic pains in the limbs, followed by numbness and paralysis; general debility, and dullness of the senses, gradually increasing to blindness, loss of hearing, etc., and a corresponding decline of the mental powers ; these are the usual symptoms, which may be extended over a period of many months. Death is sure to be the final result. Treatment. — If inflammatory red softening can be diag- nosticated at an early period, a similar treatment to that named for acute meningo-encephalitis may be advised. Local deple- tion, at least, followed by counter-irritation by blisters, may be resorted to in a case which appears to K be such; the more freely, because apoplexy, which most nearly simulates it, presents very similar practical indications. Chronic atrophic white softening is not amenable to any such measures; nor, indeed, to any active remedial treatment. Prevention, by the avoidance of its causes, and palliation or economy of the waning powers of the system, are alone possi- INFLAMMATION OF THE SPINAL MARROW. 403 ble. The management necessary under such indications must vary with every case. Inflammation of the Spinal Marrow. Clinical Synonyms. — Myelitis, Spinal Meningitis. The symptoms of this uncommon affection are, constant and severe pain in the back, increased by motion; spasmodic contractions or rigidity of the muscles followed by paralysis, fever, consti- pation of the bowels, and retention of urine. Authors state that in myelitis proper, as distinguished from spinal arachnitis, there is no pain nor muscular rigidity, but only paralysis of motion and sensation. Morbid Anatomy. — Diffuse redness and opacity of the arachnoid, swelling and infiltration of the pia mater, and effusion of serum, communicating freely with the cavity of the cranium, are generally found. Adhesions of the membranes from plastic lymph are less common; and still less so, though repeatedly recorded, is suppuration within the arachnoid. The dura mater is occasionally affected with inflammation, and even ulceration and gangrene, commencing from without. The cord may be reddened from injection of its substance, and softened ; more rarely indurated in parts. Treatment. — Cooling evaporating applications along the spine, followed by a blister, and active purgation with saline cathartics, constitute the essential parts of the treatment of simple inflammation of the spinal cord or of its membranes. If the diagnosis be doubtful, the practice must be dispropor- tionately less bold; this is, of course, a principle of very general application in therapeutics* Epidemic cerebrospinal meningitis has been considered as Cerebrospinal fever. Apoplexy. Definition. — Sudden coma, produced neither by injury nor by poison. 404 APOPLEXY. Varieties. — Some terms once used have been shown to be without pathological justification; as serous apoplexy, nervous apoplexy. Good authority still sustains, however, the mention of two forms at least of genuine apoplectic seizure ; congestive and hemorrhagic. Symptoms. — Congestive Apoplexy. — Premonitory symptoms often seen are, flushed appearance of the face and eyes, heat of head, throbbing of the carotids, distension of the temporal arteries and jugular veins; constipation, languor, dullness, drowsiness; dimness of sight, vertigo, headache. The attack is marked by sudden stupor; with slow and sometimes snoring respiration, full and slow pulse, dusky or turgid appearance of the face. The total loss of perception may be brief, its partial absence or deficiency continuing for some time. Slight con- vulsive movements are not uncommon. Paralysis of the muscles occurs only for a short time after the attack, if recovered from. Hemorrhagic Apoplexy. — Generally no clear premonition is given; the attack being very sudden ; a stroke, literally. Un- consciousness is complete, for some seconds, minutes, or hours. After this, general or local paralysis, most often hemiplegia, is left; the mental powers also, in many cases, being impaired at least temporarily. During the coma, the breathing is com- monly stertorous, and the pulse slow, and somewhat full, the head hot, the face more or less dark or flushed. But the full- ness of the bloodvessels and heat of the head are much less, as a rule, than in congestive apoplexy. Anatomy and Pathology. — In the congestive form, excessive cerebral hyperemia produces coma by pressure upon the brain ; the extremest degree of which (vascular pressure) is met with in strangulation. In hemorrhagic apoplexy, from the rupture of a degener- ated artery, either in the substance of the cerebrum or cerebellum, in the ventricles, or under the arachnoid mem- brane, effusion of blood occurs, and a clot is formed. If this be small, it may be gradually absorbed ; autopsic inspection APOPLEXY. 405 sometimes shows the remains of such, where another hemor- rhage has caused death. Fatty degeneration of the arteries of the brain has been repeatedly, but not always observed ; and miliary aneurisms of the cerebral arteries have been often noticed, by Charcot and others. The age of the clot may be ascertained in part by the dis- covery, with the microscope, of blood-crystals ; which are not found until after seventeen or eighteen days from effusion. Diagnosis. — Apoplexy is to be distinguished from uraemia, alcoholic intoxication (dead drunkenness), narcotic poisoning (as from opium), compression of the brain, or concussion, from blows or falls, asphyxia (suffocation), sunstroke, catalepsy, cerebral hysteria, acute softening of the brain, and spotted fever or "cerebro-spinal meningitis;" as well as from all forms of syncope. From ursemic coma it is only to be known by the history of the case, showing a renal origin for the symptoms,, in partial or total suppression of the urine. Alcoholic intoxi- cation is revealed by the odor of the breath, and the attendant circumstances. Similar aid exists sometimes in cases of narcotic poisoning; in opiate narcotism, moreover, the pupil is contracted; in that from most other narcotics, it is as firmly dilated. Concussion and compression of the brain are gener- ally suggested by the position of the body (if found without a history), and the external marks of injury. Asphyxia also is usually pointed out by the condition of things surrounding the patient. In asphyxia, blueness of the lips, and embarrassment of respiration, with coldness of the surface, show the origin to be in the function of breathing. Sunstroke is attended by feebleness of the pulse, at least in the majority of cases; in some, it is, identically, a congestive apoplexy. In catalepsy, there is rigidity of the muscles, with rapidity of the pulse, susceptibility of the pupil to light, brief duration and repeated recurrence of the attack, without any paralysis. Cerebral hysteria is rare, and occurs only in females, whose previous disorders of the nervous system will aid in interpreting even 406 APOPLEXY. coma as belonging to the same category. Acute red softening of the brain may be very difficult to distinguish from apoplexy. It is, however, seldom if ever so sudden in its invasion; there is more slobbering or flow of saliva, and watering of the eyes ; and there is not the partial or entire restoration of the faculties which an attack of apoplexy, not fatal, allows so often. Spotted fever, or "eerebro-spinal meningitis," is especially described, and its diagnosis considered, in another place. Syncope, of any form or origin, is marked by pallor, coldness, and loss of pulse. Peognosis. — This is always alarming; most so when there is the most reason to believe that cerebral hemorrhage has occurred; and, therefore, especially those advanced in life. In younger subjects, where stertor of breathing is absent, under proper treatment, congestive apoplexy may be entirely recovered from. So may a single attack of the hemorrhagic form, with a small clot only, and limited, transient paralysis. Each succeeding attack becomes more dangerous; a third is seldom survived. The immediate danger connected with an attack of apoplexy should not be considered over for ten days at least after the stroke itself. Very seldom, indeed, after a hemorrhagic attack, are the mental or bodily powers so good? for the rest of life, as before. Causation. — Age is the most constant promotive cause of apoplexy. Cases are on record, though of extreme rarity, in children; between thirty and fifty it is much more frequent; but after fifty it is one of the most common modes of death. Arterial degeneration is here the general occasion of the catastrophe; some mental excitement, or bodily shock or effort, as danger, or joy, or a few glasses of wine, or the stoop- ing posture, or straining at stool, causing a rupture of the weak vessel, and fatal cerebral hemorrhage. Neither sex seems to be more liable to this disease than the other. Full living, especially with alcoholic intemperance (even moderate) and indolent habits, predispose to it in a marked degree. So does excessive brain work. Florid, short-necked, APOPLEXY. 407 big-bellied people are most exposed to it. Hypertrophy of the left ventricle of the heart is believed to promote it. After dinner and during sleep are the two most likely times for the attack to occur. Treatment. — The younger the patient, and the more vigorous his antecedent health, the more probable is the existence of the congestive form; and, also, the better the prospect of recovery from hemorrhage within the cranium, if, only, the effects of pressure be averted at the time. If, then, in a person under fifty, not before of broken constitution, we find the head hot, face turgid and flushed, the arteries and veins of the neck and temples full, the pulse also strong, and the heart 9 8 impulse so (or the heart's action vigorous though the pulse at the wrist be oppressed) blood may be taken, by cups or leeches applied to the back of the neck. Older or more doubtful cases may be treated tentatively, with cups alone, aided by mustard plasters to the legs, back, and epigastrium in turn ; with laxative injections into the rectum during the attack, and saline purgatives afterwards. The head should be kept raised, and cooled with wet cloths or evaporating lotions until its temperature becomes normal. If the hair be thick, it should be cut very short or shaved off entirely. When, however, there is reason, as usually is the case in really old or broken-down patients, to believe that structural degeneration, arterial or that of ramollissement, is the source of the attack, loss of blood will be out of place. Such cases, if they survive the first apoplectic fit, require rather nourishing diet, and sometimes even tonics, to support strength, favor repair, and prolong life. Great delicacy of judgment is necessary in deciding in different cases between these appar- ently so opposite modes of treatment. The tendency of medical opinion, for the last twenty years, has been toward the curtailment of the use of any depletion in apoplexy. Where a moderately plethoric condition is present, and the taking of blood, generally or locally, is not decided upon, 408 APHASIA — PARALYSIS. purgation is safe and likely to be useful. Jalap, resina podophylli, or croton oil, in small doses, will have the advantage of convenient administration. Aphasia. I Loss of speech may occur as one of the symptoms of disease of the brain, either functional and transient, or organic and irremovable. Such a loss of language is termed aphasia. Importance has been given to it lately by the observations of Trousseau and others, and resulting speculations (Dax P. Broca) as to the seat of the faculty of speech. Not articulation, as in aphonia, but expression is, in this affection, wanting. The power to write words from memory, to convey meaning, is lost; but, in some cases, at least, they may be copied correctly. Thinking without words may go on in such in- stances ; as Lordat recorded, after recovery, in his own case. Hemiplegia of the right side has in a number of examples coincided with aphasia; and, several times, also, autopsy has shown softening or other lesion of the left anterior portion of the cerebrum. On the suggestion of these facts a hypothesis has been based, that the site of the faculty of language is in the third anterior frontal convolution of the left hemisphere of the cerebrum. This is a very unphysiological supposition, in view of the symmetry of the cerebro-spinal axis throughout; nor does this objection disappear even upon the conjecture that the "organ" upon the right side may exist always in an undeveloped state. Valvular lesion of the heart sometimes accompanies this disease. Cases of aphasia are rare. There are no special measures of treatment for it pointed out as yet by experience. Paralysis. Varieties. — According to the proximate cause: 1. Cerebral palsy; 2. Spinal ; 3. Reflex paralysis ; 4. Toxsemic (e. g., lead palsy); 5. Hysterical palsy. According to the extent of the PARALYSIS. 409 affection : Facial or other local palsy; Hemiplegia; Paraplegia; General paralysis. According to its nature: Motor (acinesia), and Sensory paralysis (anaesthesia). Facial Palsy. — This is an affection of the portio dura of the seventh pair of cephalic nerves, the motor nerve of the face. It occurs at any age, usually from rheumatoid inflammation of the sheath of the nerve at its escape from the cranium through the stylo-mastoid foramen. One side of the face is without change of expression ; and the eye on that side is not closed (in severe cases) from the paralysis affecting the orbicularis palpebral muscle. The tongue is not affected in the move- ments. The facial motor nerve is not often involved in the much more serious cases of cerebral palsy. Absence of disturbance or of incompleteness of control over the tongue, while the power over the eyelid is partly or wholly lost, with the absence also of severe cerebral symptoms, will, especially in a young person, make the diagnosis easy as well as important. The prognosis is, generally, of recovery in a few days or weeks. The treatment of this form of local palsy may be by repeated small blisters behind the ear; followed, when convalescence has begun, by some warm covering (cotton wad- ding, flannel, or silk) to protect the part from cold. Other Local Palsies. — Pressure upon a nerve may cause its paralysis, generally temporary. A man has been known to have his hand rendered powerless for three weeks by sleeping all night with his arm bent under his head. Frictions, the endermic application of strychnia, and galvanism may be used in such a case. Writer's cramp, or scrivener's palsy, is the result of exhaustion of certain muscles from over-use. Its cure is rest and friction. Palsy of the optic nerve is designated as amaurosis ; of the sense of hearing, cophosis ; of taste, ageustia; of smell, anos- mia. Except the first, however, these terms are not much used. Hemiplegia. — Brain-lesion is most often the cause of this 410 PARALYSIS. affection; either an apoplectic clot, a tumor, or softening. Spinal disease may, however, produce it; and some cases are, by writers upon the subject, referred to a peripheral .or reflex origin. There may occur, also, sometimes transiently, epileptic, choreic and hysterical hemiplegia. Owing to the decussation of the anterior pyramids of the medulla oblongata, lesion of one side of the brain produces motor paralysis of the other side. In spinal lesion the palsy is usually on the same side. Brown-Sequard, however, has shown decussation of the sen- sory nerves in the cord; and he explains the symptoms in some cases thereby. Symptoms — Suddenly, almost always, but not always with loss of consciousness, the patient loses the power of motion, and more or less of sensation on one side. In complete cases, the parts involved are the arm and leg, the muscles of mastica- tion (with the buccinator), and half of the tongue. In trying to protude the tongue it is pushed out towards the affected side ; in retracting it, the reverse happens; that is, it is drawn towards the sound' side. The palsied cheek hangs; but the eye can be shut or opened at will. The third, fifth, and ninth nerves are especially apt to show implication by disturbance of the actions under their control; of the fifth, those of the muscles already mentioned, as well as of facial and lingual sensation ; of the third, loss of power to lift the eyelid, strabismus, and dilatation of the pupil ; the ninth, one-sided movement of the tongue, affecting also the speech. Hemiplegia may be attended either by rigidity or relaxation of the muscles ; and the former may be early or late. Where there is decided relaxation in cerebral paralysis, it is probable that white softening, or atrophy from embolism of the brain, is the lesion, with or without a clot ; where early rigidity is marked, an apoplectic clot may be inferred. Late rigidity is probably due to an atrophic state of the muscles ; a " rigor mortis invito," Contradictory accounts are given by authori- ties as to the susceptibility to galvanic excitation of the muscles on the sound and on the paralyzed side. It is PARALYSIS. 411 probable that the loss of excitability of the muscles is in pro- portion to their atrophy. The prognosis in hemiplegia depends greatly on the ascer- tainment of its causation. If it follows an epileptic fit, or attack of chorea, or occurs in a hysterical subject, it may be of comparatively brief duration, ending in recovery. If an apoplectic attack precede it or if any lesion of the brain be inferred from the history of the case, the prospect is bad. Partial improvement may occur, not often entire restoration ; and renewed attacks or " strokes " are likely to follow. Treatment. — Essentially the same principles are applicable to this as have been mentioned in connection with apoplexy. The younger the patient, the more vigorous his or her previous health, and the fuller the circulation, the more appropriate may be the local abstraction of blood, to diminish pressure upon the brain. Where softening is apprehended, exceptional and cautious. Epileptic, choreic, and hysterical hemiplegia indicate no depletion. Rest, regulation of the bowels, and counter-irritation by dry cups to the upper part of the spine, and afterwards a blister ; with frictions, as with brandy and red pepper, or whiskey and hot water, or salt and spirits, to the affected limbs ; these are measures of general utility. An issue on the back of the neck is sometimes recommended. As to strychnia, it is not safe where cerebral or spinal irritation is likely to exist, as near the commencement of most attacks. Even at a late stage it should be used with extreme caution, watching its effects. Precisely the same statement may, upon the best authority, be made as to electricity, in cerebral paralysis. In the hysterical form, if it last long, electricity may be applied locally, with safety and advantage. In any curable case, passive exercise of the weak limbs will be very useful; also moderate friction. Paraplegia. — This is paralysis of both the lower extremities. Spinal disease or injury is its source ; with or without cerebral implication or complication. It may come suddenly or gradually ; generally its beginning, at least, is sudden. Reflex 412 PARALYSIS. paralysis, as described by several authors, is sometimes paraplegic. Symptoms. — In organic or spinal paraplegia, as well as in the reflex form, numbness in the feet and pain in the back are apt to be early signs. The power of motion is lessened or lost in the lower limbs. The muscles may be either relaxed or contracted. The lesion of the spinal marrow, if progressive is productive finally, in many cases, of loss of power over the bladder and sphincter ani. Bed-sores, with deep ulceration and sloughing, may occur in protracted cases. Treatment. — When myelitis is believed to exist, at an early stage, local depletion to a moderate extent, in otherwise good subjects, may be advised. In any case, counter-irrita- tion (not vesication, in a bedridden patient, unless he can lie well on either side), by repeated sinapisms, or stimulating liniments, will be proper. While inflammation, or active irritation of the spinal cord is made apparent by the symptoms (pain, cramps, muscular twitchings, or rigidity), strychnia is not suitable. After these have subsided, it may be given — not more at first than the thirti- eth of a grain twice daily. If it produce jerking movements of the hands or feet, or nervous restlessness, or any marked uneasiness, it should be suspended. Electricity may be used, with similar caution, in a secondary or relatively late stage of paraplegia. Moderate (at first very gentle) shocks of the interrupted circuit are preferred. Hysterical Paralysis.-— In females this is among the many forms of functional disorder which that strange and not yet clearly defined disorder, hysteria, may produce. It is diag- nogticated by the aid of the history of the patient. D*. Todd stated that, in it, the affected limb (it is most often hemiplegic) in walking, is dragged after the other, as if a dead weight ; while in cerebral hemiplegia the palsied leg and foot are brought round in a curve, the body being bent toward the sound side at the time. Treatment. — Tonics, good nourishment, and change of PARALYSIS. 413 air (in a word, analeptic management), are most needed in nearly all hysterical cases. For the paralysis itself, electricity has been found useful. Mild shocks for a few minutes twice a day may be given with the magneto-electric apparatus. Reflex paralysis. — Since Stanley's paper (1833), asserting the production of paralysis, sometimes, by disease of the kidney, a number of medical writers have added to the list of supposed cases of " paralysis without apparent lesion." Worms, dysen- tery, diarrhoea, uterine, irritation, teething, and external injuries are all thought to induce reflex paralysis in certain instances. Diptheritic and scarlatinal palsies have by some been placed in the same category. The simplest and clearest cases are those of wounds. The pathology of this form of palsy is a subject of much controversy. The best explanation is that of Handfield Jones and S. W. Mitchell ; expressed in the term proposed by the former — " inhibitory action." In other words a morbid im- pression, from injury or disease, in one part of the body, being transmitted along a nerve to a nerve-center, overwhelms or paralyzes it ; this effect being shown, of course, in the parts to which it distributes nervous branches. Treatment. — In true reflex paralysis, of short or moderate duration, the removal of the irritant cause produces instant relief; as in H. Jones' case, where strabismus from palsy of the external rectus occuli muscle disappeared after a piece of dead bone was extracted from a whitlow on the thumb ; or Lawrence's, in which blindness of one eye (of thirteen months' standing) was cured by the extraction of a carious tooth, with a splinter of wood projecting from one of its fangs. When the nature of the case does not admit of such prompt relief, if the diagnosis be clear, the same indication remains; to address our remedial measures to the seat or source of peripherial irritation. Palliate, if we cannot cure, the trouble there, and we will obtain palliation, if not relief, of the reflex disability. Electricity has proved signally useful in the subesequent treatment. This form of disorder is very rare. 414 PARALYSIS. Diphtheritic Paralysis. — After the termination of an attack of diphtheria, commonly within three weeks, the muscles used in swallowing and speaking, less often those of the upper and lower limbs, and the sense of sight, may be partially paralyzed. Loss of sensibility usually accompanies the loss of motor power. This condition of things may last for weeks, or even months, but is generally recovered from. Whether the immediate cause of the paralysis is the peripheral lesion of the nervous terminations (in the pharyngeal and laryngeal affection) or the toxsemic influence, upon the nerve-centres, of the morbid poison of diphtheria, cannot yet be decided. In extended palsy as a sequela, the latter is the more probable explanation. Treatment.— Passive exercise, stimulating frictions, and electricity, sometimes with change of air, and general toning of the system, are suitable measures for this affection. Syphilitic Paralysis. — The most unequivocal instances of this nature are accounted for by periostitis within the cranium, involving the dura mater, or, by nodular exostosis, pressing upon the brain. The most remarkable fact connected with such cases is the recorded experience showing the prompt curative effect upon it of iodide of potassium. Obscure paralysis without apoplectic symptoms, and in a syphilitic constitution, may be tentatively so treated, on the basis of such experience, on general principles. Lead Palsy. — Considerable time of exposure to the influence of lead is generally necessary to cause this. So commonly does it first affect the extensor muscles of the forearm, that the cognomen of "wrist-drop" is often applied to it. When it lasts for some weeks, the muscles waste away. A blue line is observed to form along the edge of the gums. Pain precedes the palsy, and attends recovery of power. During the attack, the muscles have their excitability by electricity considerably diminished or lost. Mostly, after a long time, lead palsy is recovered from. Iodide of potassium appears to act as an eliminant of the lead PAUALYSIS. 415 accumulated in the system. Ergot is asserted by some to be curative also. Faradaic electricity has been found decidedly beneficial ; used in moderate strength for a few minutes two or three times a day. Mercurial Palsy is met with in those who work in the metal. Mostly tremor is a predominant symptom. Early withdrawal from the influence of the cause, and the continued use of the iodide of potassium, are the principal measures of treatment. Paralysis agitans, or shaking palsy, is described as a more or less constant involuntary and uncontrollable shaking of the hands, arms, head, or, progressively, of the whole body. Slight or moderate degrees of such tremor are common enough, from general nervous debility. Extreme cases evince the wreck of the cerebro-spinal system, and are therefore incurable. No special treatment can be pointed out for this affection. Wasting Palsy. (Cruveilhier's) — A few of the muscles of one limb, or the voluntary muscles of the whole body, may lose their power, and then waste away almost to nothing. The shoulder and the ball of the thumb are frequent points of com- mencement for the palsy and atrophy. Insidious in its approach, the affection may last from six months to several years. It may end in recovery, in permanent arrest at a certain stage of the disease, or in death. Twelve months is the earliest recorded period for the occurrence of a fatal end. This end is the result always when the trunk is invaded. After death, the spinal marrow has been examined in but a few cases. No lesion has been found in most of them ; in a certain number it has. But our methods of inspection of nervous tissue are yet too imperfect for it to be pronounced that such an atrophic disease is independent of the nervous centres. It may be the ganglia which regulate nutrition that are in fault. General Paralysis of the Insane. — Only a minority of insane persons have this affection. Delusions of an extravagant kind commonly attend it. Difficulty of speech, and general tremor, 416 LOCOMOTOR ATAXIA, ETC. characterize it, followed by the gradual loss of all muscular and sensory power. By the use of the ophthalmoscope, atrophy of the optic nerves has been frequently detected in it. It is incurable. Locomotor Ataxia. Duchenne's Disease. Rheumatoid pains, in this affection, precede loss of power. Occasional strabismus and incontinence of urine may occur. Then there is an awkward, unsteady gait ; the sensibility of the feet becomes blunted, and walking is insecure. If the patient shuts his eyes, he falls down, and even with them open he reels as if drunk. The duration of this progressive disease varies from six months to ten or twenty years. It is most common in males of middle age. That this is a spinal affec- tion is obvious. Sclerosis of the posterior columns of the cord has been several times found after death. In its treat- ment — hygienic management, general tonics, electricity, and very careful use of strychnia, may be tried, without much hope. Epilepsy. Definition. — Periodical convulsions, with unconscious- ness during the attacks. Varieties. — Grand mal and petit mat of the French; the latter is the eclampsia minor of some writers; in which unconsciousness occurs with little or no convulsion. Symptoms. — Premonition occurs in a minority of case s before an attack; headache, dizziness, terror, spectral illusions, or the epileptic aura. This is a creeping or blowing sensation, like that of a current of air or stream of water, beginning in a hand or foot, and extending toward the trunk. It (if it occur) immediately precedes the paroxysm. Then, often with a •scream, the patient falls down, and is violently convulsed. Foaming at the mouth, grinding of the teeth, and biting of the tongue, are common ; the face is flushed, the eyeballs roll. EPILEPSY. 417 the pupils are unaffected by light, sometimes vomiting, or involuntary urination or defecation takes place ; and respira- tion may be very laborious. The fit lasts on an average from five to ten minutes. The interval between the attacks may be from several months down to a few hours. Old cases (as in lunatic asylums) may have two or three paroxysms daily. They vary much even in the same individual. The condition after the attack is also various. Generally, drowsiness or deep sleep follows it; or headache, debility, or delirium; sometimes maniacal frenzy. Homicide has been committed in this state; for which, of course, the person is not criminally responsible. Anatomy and Pathology. — Epilepsy is not often the immediate cause of death. Autopsies of epileptics (Schrceder van der Kolk) have shown changes especially in the medulla oblongata; dilatation of the bloodvessels being prominent. Exaggeration of reflex motor excitability, with loss of the controlling power of the brain over the spinal axis, would seem to be parts, at least, of the morbid condition. Marshall Hall's idea of "trachelismus," or temporary partial asphyxia from spasm of the muscles of the neck, has been exploded. Brown-Sequard's theory of the importance of the aura, as indicating a peripheral irritation at its seat, has, after causing the tentative amputation of a few limbs, suffered the same fate. Diagnosis. — From hysterical convulsions, which also may be periodical and violent, those of epilepsy are distinguished by the total loss of consciousness, which is partially retained during the hysterical paroxysm. Curability belongs also much more to the latter than to the epileptic disease. Prognosis. — Few cases of genuine epilepsy recover. The younger the patient, and the longer the interval, the more hope. Life may last indefinitely with the disease. Gradually, in most cases, the mental faculties are impaired. 30* 418 CATALEPSY. Causes. — Hereditary transmission of this disease is com- mon. Intemperance, venereal excess and self-abuse, blows on the head, and fright, are among the most frequent exciting causes. Treatment. — During the paroxysm, when habitual, little or nothing is to be done. Place the patient so that he cannot strike his head or limbs against anything hard; loosen the clothing about the neck to favor free respiration and circula- tion ; and insure fresh air about the patient ; that is all. An occasional convulsion requires treatment; of that more will be said hereafter. (See Convulsions.) To break up the recurrence of the fits is the problem, for which a vast number of remedies has been tried in vain. To name them would be to go over almost half the materia medica. Prominent, since nitrate of silver was generally abandoned as useless, in this disease, have been belladonna, arsenic, valerianate of zinc, digitalis, and bromide of potas- sium. Self-management is very important to the epileptic. Temperance, with nutritious diet, as the disease is one of asthenia, is necessary. Regularity of the evacuation of the bowels is a sine qua non. Abundant exercise in the open air, short of exhaustion, does good ; systematic gymnastics have even cured some cases. They are worth trying always. Avoidance of, or the extremest moderation in sexual inter- course must be insisted upon. Self-abuse will make recovery impossible. Tobacco ought not to be used. As the attacks may come very suddenly, prudence is necessary, to avoid serious accidents. An issue kept on the back of the neck is well worth trying in every case. Catalepsy. This is a periodical disease, in which the attack is marked by unconsciousness, and fixed rigidity of all or many of the CONVULSIONS. 419 voluntary muscles. It is rare. The attack generally lasts but a few minutes. Sometimes, in lunatics, a semi-cataleptic state of the muscles is permanent. There is no special treatment appropriate for this affection. Management like that suitable for the epileptic will be in place also in catalepsy. Both are now so well understood to be asthenic disorders, with impaired hcematosis (blood-making) as an important element, that all reducing measures are properly omitted from their treatment. This must be essentially tonic and analeptic or restorative in every particular. Convulsions. These may be classified as infantile, epileptic, parturient and puerperal, hysterical and occasional convulsions. During infancy, causes which in an adult would cause deliri- um produce convulsions; excito-motor action having in early life the predominance. They are, usually, of less serious prog- nosis^ the infant than in the adult. The exciting causes of infantile convulsions are numerous. -Constipation of the bowels ; indigestion ; worms ; irritation of the gums in teething; and excitement of the brain, as by fright, are about the most frequent. Many acute and chronic diseases of infancy (as scarlet fever, meningitis, whooping- •cough, etc.) have convulsions among their occasional symp- toms or complications. Sudden drying up of eruptions on the scalp may bring them on, also. . Premonition of a fit is often observed, in the child's fretful- ness, or restlessness, or gritting of the teeth in sleep. When a fit comes on, the muscles of the face twitch, the body becomes rigid at first, then in a state of twitching motion ; the head and neck are drawn backward, the limbs violently flexed and extended. Sometimes these movements are confined to certain muscles, or are limited to one side. Nurses call by the name of "inward fits" cases in which the limbs move but 420 CHOREA. little, but the countenance is affected, the eyes are unnatural in expression, or roll spasmodically, and the body is more or less rigid. Sometimes one attack is followed by another, with intervals of conscious or unconscious quiet between, for many hours. These are the most serious cases, although recovery often happens even from them. Salaam convulsions, or nodding convulsions of infants (eclampsia nutans), are a rare form of disease, usually the precursors of epilepsy. Treatment. — Ascertain, if possible, the cause of the con- vulsion. If the gums are swollen, or have been tender and irritated, at the time of teething, lance them freely ; dividing the tense gum with a sharp gum-lancet down to the coming tooth. If the bowels have not been moved, or if the abdomen be swollen and tense, give at once an enema, of castor oil,, soap, and molasses, or some other laxative material, with warm water. When the head is hot, apply cold water all over it, by wet cloths, renewed every two or three minutes. If the fit lasts long enough for it, place the child in a warm bath; supporting, of course, the head while the body is> immersed. Then mustard plasters may be applied, to the back, epigastrium, and legs, at once or successively. Cupping the back of the neck, in some cases where time is allowed by a protracted fit, may be resorted to ; especially dry cups. Etherization, so much used by some practitioners in puerperal convulsions, requires more caution in its use ini infants. It is less used in the convulsions of childhood ; but it may be regarded as justifiable in an obstinate case at any age; watching its effect. If swallowing is interrupted, use antispasmodics with enema, as chloral, lobelia, etc. Chorea. Synonym. — St. Viim' Dance. Symptoms. — Incessant and irregular movements of the voluntary muscles, over which the will has but partial CHOKEA. 421 control. Walking, in severe cases, is difficult or unsafe; the hands cannot be regulated enough to write or work ; speech may be affected; the muscles of the face often twitch gro- tesquely. During sleep all these movements cease. The pupil is, in some cases, unnaturally dilated ; palpitation of the heart may occur ; and also constipation and indigestion. The urine is of great density. Prognosis. — The mean duration of chorea is about four weeks; but it may last for several months. Recovery, if the attack be uncomplicated, may nearly always be anticipated. Complications. — Endocarditis and pericarditis have been observed in connection with chorea in a number of cases. Generally, however, the affection of the heart precedes the chorea; both probably depending on the same cause, rheumatism. Paralysis complicating chorea increases greatly, of course, the seriousness of the case. Although it may be of the transient, hysterical form, yet the danger exists that it may be the result of organic lesion (as softening) of the brain or spinal cord. Causation. — From six to sixteen, in both sexes, especially often in girls, chorea occurs. Nervous debility is almost always present before the attack. Fright is a frequent cause. Over-fatigue, or mental excitement, blows or falls may pro- duce it. Rheumatic fever is sometimes followed by it. Treatment. — Good diet, salt bathing, and systematic gymnastic exercises (light gymnastics or calisthenics) will suffice for mild cases. Where marked ansemia exists, iron (citrate, phosphate, or pyrophosphate, tincture of chloride, syrup of iodide) is important. Obstinate cases may be treated with Fowler's solution of arsenic, in small doses, gradually increased. Cimicifuga has been a good deal used, perhaps with benefit. Cod-liver oil should be given if great debility exist. Calabar bean has recently been introduced as a remedy in chorea; gtt. v to f3ss of the tincture, or from gr. j to gr. vj of the powder thrice daily. 422 TETANUS. It is well to separate a child having severe chorea from other children; both because of the annoyance of their curiosity, and because sympathetic irritation sometimes extends the affection from one to another. This has been repeatedly observed. Tetanus. Definition. — A disease characterized by continued tonic contraction of the voluntary muscles generally. Symptoms. — Stiffness of the muscles of the jaws commonly begins the attack. This extends to the throat and neck, face, trunk, and lastly to the limbs. Though never ceasing entirely, the spasm of the muscles is paroxysmally increased. Sometimes opisthotonos occurs, i. £., arching of the body upon the back and heels, the abdomen projecting; or emprosthotonos, arching forward, the face approaching towards the toes. Pleurosthotonos, or lateral curvature, is much more uncommon. Chewing of food is impossible ; swallowing nearly or quite so ; respiration becomes very difficult. The patient suffers dreadfully, and cannot sleep ; but delirium scarcely ever occurs. Death in most cases takes place within a week. Varieties. — These are, tetanus from cold (idiopathie), traumatic tetanus (from an injury), and trismus nascentium, or tetanus of infancy. The first is the least certain to be fatal. Causation. — This is principally included in the above. Much the greater number of cases results from lacerated and punctured wounds ; but amputations and other operations may be followed by tetanus. Irritation (not inflammation) of the ends of sensitive nerves, transmitted to the spinal cord, produces the reflex spasm, whose general extension and con- tinuance prove fatal. Strychnia, in poisonous doses, causes a similar state. While there can be no doubt that the spinal marrow is the seat of the disease, no characteristic organic change has been found in it; sometimes not even congestion. Treatment. — A tablespoonful of whisky (to an adult) every two or three hours with milk or beef-tea, and a grain of HYDROPHOBIA — RABIES. 423 opium every three or four hours, may be given. The opium may be, if needful, increased to a grain every hour at night, and every two hours through the day. Chloroform and other anaesthetics, by inhalation, nave been tried, with variable effec#; nearly always without success. Belladonna, aconite, hydrocyanic acid, cannabis indica, tobacco, woorara, quinine, hydrate of chloral, and Calabar bean (physostigma), are among the many medicines favored by different practitioners. In so desperate a disease it is excus- able to give them all further trial. I have had good results from an antispasmodic enema, keeping the system relaxed. Hydrophobia — Rabies. Symptoms. — A month or more after the bite of a mad dog or other rabid animal, the wound having healed, irritation is felt. At first the patient feels despondent, restless, dread, giddiness or alternate chills and heats. Then oppression, deep sighing inspirations, with severe pain in the epigastrium. The subsequent symptoms are : 1. Spasm of muscles of degluti- tion and respiration. 2. Extreme sensibility of surface and special senses. 3. Excessive mental terror. A fit of choking, by an attempt to drink. This condition becomes rapidly worse with intense oppression and suffocation. Soon the sight or sound of any liquid that suggests drinking brings the spasmodic attacks; the patient spits viscid secretion out of the mouth as fast as it forms, so as not to swallow it. Special senses become sensitive, the least touch, sound or light bring on spasms, which extend to other muscles, assuming the characters of general convulsions. Fits of furious mania occur, the patient is dangerous, utters strange sounds, which has given the idea of barking being a symptom of this disease. In intervals the intellect is quite clear. Sometimes curious, persistent delusions. Towards a fatal termination, the special symptoms diminish, or disappear, and the patient sinks from exhaustion and collapse. Treatment. — Immediately cauterize the part bitten by 424 NEUKALGIA. hot iron or potassa fusa, or complete excision. Other modes of preventive treatment are useless. The patient's mind should be calmed and be prevented from brooding over his danger. There is no remedy, I know, of any real service in hydrophobia, once the disease has become developed. Neukalgia. Neuralgia or nervous pain is an important malady of com- mon occurrence and a comprehensive term applied to certain painful affections occurring in different parts of the body, the pain appearing to follow the distribution of particular nerves and having special characters. Etiology and Pathology. — Most cases are dependent upon some general or constitutional condition. The causes are : 1. Exposure to malaria. 2. Certain metallic poisons, as lead, mercury, or copper. 3. Anaemia or malnutrition and debility. 4. Depression and weakness of the nervous system, as pro- longed worry and anxiety, undue mental exertion, strong emotion, concussion of the nervous system, hysteria, fatigue, exposure to heat, ennui and luxurious habits, excessive venery. 5. Degenerative changes with the decay of life, and those which precede locomotor ataxy. 6. Kheumatism, gout, syphilis, exposure to cold and wet. An important group of causes of neuralgia are local. 1. Injury to a nerve, wound, the lodgment of a foreign body, when the pain may be in some distant nerve. When a nerve is cut, either it or some nerve related to it becomes the seat of neuralgia. 2. Pressure by foreign bodies, as a bullet, cica- tricial thickenings, old adhesions, neuromata, tumors, aneu- risms, enlarged glands, callous uniting fractured bones, congested veins, or long sitting, tight boots, hanging the arm over a chair. 3. Irritation by necrosed bone, when it passes through a foramen or canal, carious teeth, surrounding inflam- mation or ulceration, or direct exposure to cold. When neuralgia is local its occurrence is influenced by the general state of the system, one of debility either general or specia NEURALGIA. 425 Predisposing causes are : female sex ; certain periods of life, that of sexual development, and about or beyond middle age ; hereditary tendency to nervous affections ; and a nervous temperament. An acute attack is intensified by fatigue or other lowering influence. It may come on spontaneously, or by mental disturbances, pressure, cold, heat, overexercise, etc. Neuralgia may be some morbid change in the nerve or nerve-centre, or there is no such obvious change. In some cases there is congestion or inflammation. Atrophy with de- generation of a nerve has been found, due to pressure, often so advanced as almost to destroy sensation. In all cases of neuralgia there is either atrophy, or a tendency to it, in the posterior or sensory root of the painful nerve, or in the central gray matter in closest connection. Symptoms. — Pain is the essential symptom of neuralgia. 1. Invariably unilateral. 2. In recent cases intermittent, in sudden paroxysms, at irregular intervals, but occasionally at regular periods, especially in malarial cases ; later it is remit- tent. 3. The pain during the paroxysms is severe, in some cases excruciating, as stabbing, piercing, boring burning, screwing, shooting from a point along branches of the nerve affected, but rarely all ; the darts, twinges, or " tics," in some come on with the suddenness of an electric shock, causing intolerable agony. The pain may extend to contiguous or distant nerves. Strong pressure over the chief point affords relief; in other cases gentle friction does this; in others there is exquisite tenderness. This paroxysmal pain often ends as abruptly as it commenced, with a sense of relief and comfort. The pain in the intervals is much less severe, of dull or aching character, and in the superficial neuralgias presents circumscribed points of tenderness, "points douloureux," corres- ponding to the exit of branches of the nerve through bony foramina or openings in fibrous membranes, though they appear to be more diffused, in some cases the sensation of tolerably extensive contusions. Interesting complications are : local hyperesthesia, hypses- 426 NEURALGIA. thesia, or paresthesia, as numbness, tingling, or formication * disturbances of special senses, especially sight; spasmodic twitchings, tonic spasms, convulsive movements, or local paralysis ; pallor, followed by redness of the skin, pulsation of the arteries, increase in temperature, and swelling of the affected part, with subcutaneous oedema; hypertrophy or atrophy of the tissues in prolonged cases, or increase of adipose tissue ; increased firmness, falling off or whitening of the hair ; the breaking out of skin eruptions, as herpes zoster, acne ; increased vascularity of the conjunctiva, conjunctivitis, iritis,, and other morbid conditions of the eye ; periostitis ; swelling or unilateral furring of the tongue ; erysipelatoid inflammation of the tissues to which the affected nerve is distributed ; im- paired gastric secretion ; increased flow of saliva or tears ; local increase of perspiration. "Varieties. — Neuralgias are primarily divided into — I. Visceral, including Cardiac; Hepatic; Gastric ; Peri-uterine and Ovarian; Testiadar ; Renal. II. Superficial, viz., Tic-. douloureux; Hemicrania or Migraine; Cervico-occipital ; Cervico-brachial ; Intercostal; Mastodynia/ or irritable breast; Lumbo-abdominal ; Sciatica ; Crural. The visceral group will not be further alluded to, some of them having been already considered under their respective organs. The names applied to the superficial group will indicate their respective localities, but a few of them need special comment. Tic-douloureux — Brow-ague — Prosopalgia is a common form of neuralgia, the 5th or trigeminal nerve being involved. Rarely are all the divisions implicated, and it is the ophthal- mic branch which is most frequently affected, the pain being chiefly above the orbit and about the temple. Numerous points of tenderness, the supraorbital and parietal, the latter being just above the parietal eminence, and correspondiHg to the inosculation of several branches. A variety of this neu- ralgia is named clavus hystericus, in which there is extreme pain, as if a nail were being driven into one or more spots^. corresponding to the supraorbital or parietal points. NEURALGIA. 427 Hemicrania — Migraine or Megrim — Sick-headache. — Con- siderable attention has been paid of late to the complaint recognized by the above names. It is considered a form of neuralgia, though there is no unanimity of opinion as to its nature. Most authorities regard it as independent of any morbid state of the alimentary canal, and as essentially a nervous affection. Derangements of the abdominal viscera have an important influence in causing migraine. The chief views are : 1. It is a form of neuralgia of the ophthalmic or occipital nerve, or of the filaments distributed to the dura mater. I favor migraine being a form of trigeminal neuralgia, pri- marily a morbid condition at the root of the nerve in the medulla oblongata, its central nucleus being the seat of atrophic molecular irritation, which has a tendency to communicate itself to nucleus of the vagus. 2. The complaint is due to vaso-motor disturbance affecting the vessels of the head, through the sympathetic nerve. In the premonitory stage of sick- headache, the small arteries are contracted, owing to excite- ment of the vaso-motor nerves, which depends upon a weak- ening of the controlling power exercised over them by the cerebro-spinal system, this originating in the medulla oblongata. During the stage of headache the nerves become paralyzed, and the vessels dilated; this paralysis is the result of depression following excitement. 3. Dr. Liveing has the hypothesis, that the paroxysms of migraine are due to " nerve-storms, traversing the sensory tract from the optic thalami to the ganglia of the vagus, or radiating in the same tract from a focus in the neighborhood of the quadrigeminal bodies." Sick-headache is characterized by periodic attacks, which commence during the period of bodily development from 15 to 25, becoming more frequent and severe, up to a certain time, tending to diminish in frequency or to cease in advanced age, after the change of life in women. The predisposing causes are the female sex, attacks liable to occur about the menstrual periods; hereditary tendency to migraine or other 428 NEURALGIA. neuroses; anseinia and general want of tone, a nervous and excitable temperament. A paroxysm often comes on without exciting cause, or may follow errors in diet, exposure to the sun, breathing vitiated air, undue mental excitement or effort, fatigue with fasting, sexual indulgence, and other causes of physical or mental depression. Sometimes it results from disturbance of sight or hearing. An attack is ushered in by premonitory symptoms, mostly when patient wakes in the morning, as depression, heaviness, or general uneasiness, vertigo, disturbed vision, a wavy glim- mering, chilliness and shuddering, coldness of the hands and feet, tingling in the arm or tongue, irritability of temper, yawning, gaping, or sighing, disorder of speech or hearing, disinclination for food with a slimy taste. Soon pain com- mences and becomes intense. It is unilateral, chiefly in the supraorbital region, or in the Orbit, but may extend over the whole side of the head. The pain varies much, but is gener- ally throbbing. Pressure on the carotid artery diminishes its intensity. Heat, often redness of the conjunctiva, with ex- cessive flow of tears. During the paroxysm patient takes to bed, feels depressed, dreads disturbance, begs to be at rest, and is sensitive to light and noise. The pulse is frequently slow and soft ; the pupils contracted. When suffering reaches its height, nausea and bilious vomiting aggravate the pain afterwards it gradually diminishes, and the patient falls asleep. Vomiting is not remedial, but indicates the lowest point of nervous depression. Vomiting may be beneficial if there is much undigested food in the stomach. On awaking the pain has ceased, leaving superficial tenderness for a day or two. The duration is variable ; an attack does not commonly last more than 24 hours, though it may go on for two or three days or more. Intercostal Neuralgia. — Pain along one or more intercostal nerves. There is a constant pain, increased by a deep inspira- tion or coughing, or moving the arm. Shooting pains at intervals, extending from the spine along the intercostal NEURALGIA. 429 spaces, or from the lateral point backwards and forwards. Three very distinct "points douloureux" can be detected, viz., I. Vertebral. 2. Lateral, opposite the lateral cutaneous branch. 3. Sternal or epigastric, where the anterior cutaneous nerve perforates. This variety is common in ansemic and chlorotic females. It precedes herpes zoster, and a very severe and obstinate form is liable to follow the latter in old people. For the diagnosis from pleurodynia or pleurisy, the condition of the patient, the want of connection of the pain with excessive use of the local muscles, of exacerbation from use, or relief from rest, the characters of the pain with the points of tenderness, and the results of physical examination, are quite satisfactory. The breaking out of herpes is pathognomonic. Sciatica or Hip-gout is neuralgia in the branches of the sciatic and other nerves about the hip. The pain is mainly in the back and outer part of the thigh ; may be in various parts of the lower extremity, down to the leg or foot ; generally a persistent pain near the tuberosity of the ischium, paroxys- mally, shooting up or down, either without cause or the consequence of pressure, movement, a sudden jerk, or cough- ing. The patient obliged to walk carefully, or unable to move. Local anomalies of sensation, convulsive movements, cramps, and partial paralysis are common. Many cases are severe and unyielding to treatment. The limb may waste from want of use. Causes of sciatica are long-continued sitting, exposure to a cold draught, as using windy privies, sitting on a cold or damp surface ; frequently it is associated with gout or rheumatism. Treatment. — 1. Local cause or irritation must be removed. Caution respecting " tic-douloureux." This is often attributed to decayed teeth; these are extracted one after another without improvement, because neuralgia is not dependent upon this cause at all. 2. Those who are subject to neuralgia should adopt means to prevent attacks, by attending to diet, hygiene, wearing warm clothing, regulating the alimentary 430 NEURALGIA. canal, and promoting general health, .avoiding every cause likely to bring on a paroxysm. 3. Treatment directed to the general state of the system or to some constitutional diathesis is in a large proportion of cases of the highest importance. Fatty elements when nutrition is impaired, cod-liver oil or cream. Iron in anaemic subjects ; quinine in full doses, in malarial neuralgias ; Fowler's solution ; strychnine or nux vomica ; valerianate and other salts of zinc, phosphorus, etc. If neuralgia be associated with gout, rheumatism, syphilis, or metallic poison in the system, treatment directed against such a condition is essential. 4. An important class of remedies are those which have a direct sedative effect on the nervous sys- tem ; opium or morphia; belladonna; extract of cannabis indica ; hydrate of chloral ; bromide of potassium ; conium ; atropin ; tincture of aconite ; veratria ; and ammonic chloride in full doses. Of late, two new drugs said to be very effica- cious, viz : eucalyptol, which is an essential oil derived from the Eucalyptus globulus; and the tincture of Gelsemium semper- virens. These medicines are either internally applied to the affected part by plasters, liniments, ointments, tinctures, or some of them introduced by subcutaneous injection, as morphia and atropin. They are not merely for temporary relief, but are important aids in a cure, if employed systematic- ally and regularly every day for such a period as the case may require. In using subcutaneous injection, begin with a small dose — not more than one-tenth to one-sixth gr. of morphia —and increase it as occasion requires, some cases need- ing large quantities in time. The injection need notbe made at the seat of pain, except in advanced cases where there is hyperesthesia, and much thickening and hypertrophy exist about the nerve. Sensibility may be first blunted by the ether spray. 5. Certain anodyne local applications as liniment or plaster of belladonna, opium plaster, tincture of aconite, ointment of aconitin or veratria, and a liniment containing eucalyptol. Dry heat or heat with moisture, chloroform liniment, sinapisms, flying blisters, and light linear cauteriza- NEUEALGIA. 431 tion. In obstinate cases blistering and even stronger forms of counter-irritation are recommended. Cold is useful in some cases, in the form of ice or evaporating lotions, ether spray over the seat of pain for a few minutes three or four times daily. A valuable local method of treatment now recognized is that by electricity. The constant galvanic current is best, sometimes faradization is beneficial, or charging the patient from a friction-machine, or afterwards taking a spark from the seat of pain. In employing galvanism only a very weak current, especially about the head, carefully guarding against giving rise to unpleasant head symptoms; to apply it by well- wetted sponges in the direction of the nerve, the positive pole placed over the seat of pain; not make the application for too long a time, but frequent repetitions. Surgical interference in obstinate cases of neuralgia, the nerve being divided or a piece of it cut out. This is rarely -followed by permanent good results. Migraine during the premonitory stage, the patient should go into a quiet, darkened room, and lie down on the side on which the pain usually occurs, with the head low, the extrem- ities kept warm. Many remedies are recommended; their use- fulness differs in different cases. The most important are diffusible stimulants, as a little brandy or sherry and soda- water, champagne, or spirits of ammonia; a cup of simple strong tea or coffee; hydrate of chloral; tincture of cannabis indica; bromide of potassium ; nitrate of ammonium ; caffein, either internally or by subcutaneous injection; and the now fashionable guar ana powder, which consists of the powdered seeds of the Paulinia sorbilis. This last drug is given in the dose of TO to 15 grains; there is contradiction in the accounts of different observers as to its efficacy. The application of a weak continuous galvanic current is sometimes useful. Warm foot-bath containing mustard, and to breath the steam from this at the same time. In some cases the administration of an emetic, as ipecac, has been decidedly beneficial in my experi- ence. Much relief often results from tightly binding the head 432 DELIRIUM TREMENS. with a wet bandage. Probably the steady application of ice or the cold douche might be serviceable in cases. During the height of an attack leave the patient in perfect quiet; do not give food or anything else. In the intervals many of the measures recommended for neuralgia in general are indicated; among the most useful are strychnine, arsenic, quinine, and bromide of potassium. Tincture of cannabis indica in doses from 5 to 10 minims thrice daily has been found beneficial. Attend to the state of the alimentary canal; avoid the. causes which are likely to give rise to an attack of migraine. Delirium Tremens. Synonym. — Mania a potu. Symptoms. — Sleeplessness, debility, tremors, horror, hallu- cinations; often with loss of digestive power. The insomnia is a cardinal symptom; if the patient sleeps a whole night he recovers. Debility varies in degree in different cases; in a first attack it is not always great. Tremor is nearly always present. The illusions of the patient are wonderfully real, and usually dreadful. He is pursued by demons or beset by mortal enemies; he cannot bear to be alone, especially in the dark. Sometimes, however, the visions are indifferent, or even amusing. The patient may suppose himself to be well, and engage about his usual avocation ; going through all its movements in pantomime, though with empty hands. After several days and nights of sleeplessness, prostration usually increases; the skin grows cold and clammy, the voice feeble, and the patient no longer inclines to move about. Death may result, if sleep be not obtained, within a week, or, at the most, two weeks. In favorable cases, a sound sleep of many hours comes on within three or four days; the patient then wakes up rational and well. Causes. — There is no room for doubt that this affection may come on under two different conditions or circumstances : 1, where stimulants are suddenly withdrawn from one DELIEIUM TREMENS. 433 accustomed to them; and 2, while their use in excess is continued. The second class furnishes the most dangerous cases. Treatment. — Old as this disease is, it is yet the subject of great difference of opinion. If the patient be not much prostrated, give only ale or porter, a bottle or two in the day ; with hop tea ad libitum, and a grain of opium every three or four hours. The latter may be increased, if sleep be delayed, to a grain every two hours; or, as a maximum, a grain every hour. Very weak patients, accustomed to spirits, might have a tablespoonful of whisky or brandy every four, three, or two hours, according to their condition. Hydrate of chloral some- times answers as well as, or better than, opium. Beef-tea and mutton-broth, etc., seasoned with red pepper, are preferred as •diet. In an obstinate case, sleep may follow the raising of a blister upon the back of the neck. Substituting valerian for opium, or combining the fluid extract or tincture of valerian with morphia solution, answers well in some cases. Injection ■of laudanum into the rectum is occasionally resorted to. Other modes of treatment have been urged. 1. The expectant treatment, giving only strong food, without stimu- lants or opium. 2. The treatment by half-tablespoonful doses of tincture of digitalis. 3. That by the internal use of chloroform, in one or two drachm doses. The digitalis treatment, bold as it seems, has a good deal of positive testimony in its favor. Why not try, as some do, less immense, and yet large doses; as half a drachm or a drachm, instead of half an ounce, of the tincture, every three or four hours? Many have recently reported excellent success with one or two drachm doses of chloroform. The corrugated stomach of a spirit drinker will probably bear the pungency of chloro- form better than another's. Generally only one or two such doses of it are said to be required given in mucilage. The large majority of first attacks of mania a potu are 31* 434 HYSTEEIA. curable. Third and fourth severe attacks are said to be often fatal, or are followed by permanent insanity, or idiocy. There are exceptions. I have attended patients having had twelve to fifteen severe attacks prior to such unfortunate results. Hysteria — Functional Nervous Disease. From its occurrence nearly always in females, and from a supposition of its originating in some affection of the womb, this name has been given to a variable disorder, of which the main characteristic is, morbid excitability of the whole nervous system. A "fit of hysterics" is a paroxysm whose nature may vary, from mere uncontrollable laughter or crying, to a severe epileptiform convulsion. This last, however, differs from epilepsy, in there being less complete loss of consciousness,, and in its curability. It is often preceded by a sensation (globus hystericus) like that of a ball rising towards the throat. Simulation of other diseases, indeed the assumption of severe functional disorders of different organs, is a common trait of hysteria. There may be hysterical amaurosis ; hysterical insanity is not uncommon; nor is hysterical paraplegia or coma rare. Retention of urine, cough, aphonia, etc., are often thus produced. Pathology and Etiology. — Hysteria is a very complex morbid condition, of the nature of which it is impossible to- speak definitely. It is a nervous disorder, but its exact seat cannot be localized, though probably the brain is most dis- turbed. No characteristic pathological change has been discovered, but there is probably a nutritive derangement of the entire nervous system. The attempt to localize the primary disorder in the sympathetic ganglia, and to attribute the phenomena observed to vaso-motor disturbance, has no- sufficient foundation. Hysteria is infinitely more common among females, begin- HYSTERIA. 435 ning usually from 15 to 18 or 20 years of age, but sometimes much earlier or later, and rarely only at the change of life. Young girls, old maids, widows, and childless married women are the most frequent subjects of the complaint, and its manifestations often cease after marriage. Fits of hysteria are more common about the menstrual periods. It has been attributed to malpositions of the uterus, undue sexual excite- ment, unsatisfied desire, sexual excess, disordered menstrua- tion, as menorrhagia, amenorrhoea, or dysmenorrhea. Many eminent authorities deny that these constitute the essence of the complaint. Its frequency in women is due to the inherent conditions of their nervous system, often aggravated by their mode of existence, as disordered by conditions, the sexual functions assume an undue prominence in the mind ; thus disturbance produces an exaggerated effect. In many cases there is nothing wrong about the generative organs or func- tions; it occurs often in married women with families. The improvement which takes place after marriage may be due to the change in habits, thoughts, purposes, occupation, and surroundings. Hysteria is often due to digestive disturbances, constipation with accumulation of faeces. Causes referable to the mode in which girls are brought up and their general habits of life aid materially in its production, as want of useful occupation, indolent and luxurious habits, overpetting and spoiling, sub- jection to the worries of fashionable life, keeping late hours at parties, reading sentimental novels, etc. Temperament and hereditary predisposition to nervous affections may have influ- ence; the latter may be explained by the patient imitating a hysterical mother. In many cases hysteria results from depressing influences, as anxiety, grief, disappointed affection, overwork, bad feeling and improper hygienic conditions. It may be due to some chronic disease. In instances the con- dition can only be attributed to perversity. The hysterical state is observed in males, but rarely an actual^. The subjects are from 35 to 50 years of age; due 436 HYSTERIA. to excessive venery or masturbation, overwork, worry and anxiety, excessive and prolonged mental labor, senile degener- ation, or commencing chronic cerebral disease. The exciting cause of the first hysterical fit is some sudden emotional disturbance; may be slight if the patient has been in mental restraint, with pent-up feelings, or subject *to depressing influences for a considerable period. Subsequent ones arise from less disturbance. Suppressed laughter may lead to very severe fits. Occasionally they result from physical disturbance, as an injury, loss of blood, or acute illness. Symptoms. — It is impossible to give even an outline of all the varieties of clinical phenomena which rmiy be presented in eases of hysteria. There is scarcely a complaint which may not be simulated. The prominent features are undue excita- bility of the emotions, defect in the power of the will and intellect ; alterations in the general cutaneous sensibility and •special senses, usually hyperesthesia and dysesthesia; a tendency to involuntary muscular movements or other dis- turbance of the motor functions. Characters of an Hysterical Fit. — As a rule it occurs when -other persons are present, and never during sleep; is not sudden, gradually worked up, having time to place herself in a comfortable position and adjust her dress; often preceded by sighing, sobbing, laughing, moaning, nonsensical talking, gesticulation, or a feeling of globus hystericus; no peculiar cry. During the fit apparent unconsciousness, not complete, as can be determined by touching the conjunctiva; patient generally knows what is going on, looks out from under her eyelids occasionally. Spasmodic movements occur, varying from slight twitchings in the limbs to general convulsions o* al- most tetanic spasms; patients struggle, throw themselves about; thumb is turned in and hand clenched. These movements may last a few moments or an indefinite time, with or without intermissions; no lividity of the face or sign of interference w T ith respiration. Breathing noisy; irregular, gurgling, splut- HYSTEEIA. 437 tering sounds are produced in the throat and mouth. The pupils not dilated; slight internal strabismus; the eyes turned up from time to time. The pulse normal. No biting of tongue, rarely foaming at the mouth. The paroxysm gener- ally terminates with crying, laughing ; sighing or yawning, and followed by exhaustion, not by coma; in rare instances the patient falls into a prolonged trance. Eructations of gas and a copious discharge of pale, watery urine may occur. Earely is followed by a state of hysterical mania, the patient not responsible for her actions. Certain nervous phenomena are : 1 . Catalepsy, the will cut off from certain muscles, and whatever position the affected part, as a limb, is placed, it remains fixed an indefinite time. It may or not be accompanied with unconsciousness. Sensa- tion usually much impaired, and may be lost. This is some-, times associated with organie disease of the brain, or severe organic visceral disease. 2. Trance. The individual lies as if dead, ghastly pale, circulation and respiration almost ceased. Such have been "laid out" as dead. 3. Ecstasy, in which visions are seen. Often this is combined with ridicu- lous dancing movements, as with certain religious com- munities. Diagnosis. — Attention to tho characters described, and the circumstances under which it arises, will enable it to be dis- tinguished from all other "fits." In women, hysteria affords an explanation of many of the ailments of which they com- plain. Among the important affections which it may simulate are diseases of the brain and spinal cord; disease of the spinal column; peritonitis; abdominal tumors; laryngitis; and diseases of joints. The general signs of hysteria; absence of pyrexia, or of characteristic symptoms belonging to the several affec- tions; peculiar superficial nature of any pain or tenderness; characters of the different kinds of paralysis, as described ; and use of chloroform, will generally enable a satisfactory conclusion. 438 HYSTERIA. Treatment. — 1. Of a Hysterical Fit. — Little interference is needed. Important matter is to get rid of the officious, sympathizing individuals who surround the patient. She should be treated firmly, but kindly; gain her confidence, first ascertaining, if possible, the cause of the fit. Care to avoid injury, and the clothes should be loosened. If anything further is needed, affusion of cold water, ammonia to the nostrils, or closing firmly the nostrils and mouth for an instant, so that the patient cannot breathe. In obstinate €ases a moderate galvanic shock. If medicine is needed, spirits of ammonia with valerian or assafoetida. 2. During the Intervals. — The treatment of persistent and marked hysteria is often very difficult. Mental and moral guidance is important; the patient should be taught to look away from herself and her grievances, and to engage in some useful occupation. Any wrong habit must be rectified. Change of scene and associations, with traveling. Any cause of discomfort at home or elsewhere should be removed. General treatment of the state of the system and blood, atten- tion to diet and the digestive organs. Avoid alcoholic, stimulants. Various symptoms call for interference. Pains in different parts are relieved by belladonna or opium plasters, or anodyne liniments; in the joints by warm poultices or fomentations with laudanum sprinkled on. Hypodermic injection of morphia may be required. For restlessness and sleeplessness bromide of potassium is the best. Paralysis must be treated by electricity, and rigidity counteracted by fixing the limbs in other positions by splints or other mechanical apparatus, and by movements. If necessary, chloroform may be used. This may be employed to remove "phantom tumor." I have cured aphonia by a small blister across the larynx, or even a small belladonna plaster, these probably acting through the mind. The vocal cords may be galvanized, or the patient charged with electricity, and sparks taken from over the larynx. It is questionable how far such drugs as assafoetida, valerian, etc., are useful in hysteria, when HYPOCHONDRIASIS. 439 used as a means of cure, except in that they are very disagree- able; they are valuable as antispasmodics. Hypochondriasis. This affection is merely a mental condition characterized by inordinate attention on the part of the patient to his own real or supposed bodily ailments and sensations. Adult males who have no occupation are the usual subjects, but it is common among workingmen. As a rule, there has been some disease, digestive or biliary disorders, venereal disease, or acute illness. In other instances the symptoms are quite imaginary. The sensations complained of vary much, and are liable to be changed or new symptoms added, for which the hypochondriac is on the lookout. These patients generally present a healthy appearance, and sleep and perform their ordinary functions satisfactorily. They go the round of the "doctors," take any amount of physic, which they want to be always changing, particularly trying any new remedy that comes up; are delighted to talk about their ailments, often making use of scientific terms; consult every medical work they can; are much addicted to examining their pulse, tongue, urine, and stools. They are very particular about their food and drink, and often as to their dress and general "get-up." Hydro- pathic and similar places famed for mineral waters are favorite resorts for hypochondriacs. The moral character and feelings towards friends are unaltered. These cases are always very difficult to improve, and frequently quite incura- ble. Ultimately they may become wretched misanthropes, and shut themselves up or away from all society. Treatment. — The main thing in treating hypochondriasis is, to try to get some control over them, and to make them believe in you, by investigating their case properly, and show- ing that you thoroughly understand it. They cannot be talked out of their ailments, but kind argument may often do much, and they should be urged to take their attention off themselves, and mingle in society, travel, or otherwise occup 440 DISEASES OF THE SKIN. their time. Attention must be paid to bathing, exercise, and other modes of maintaining the health. The diet and state of the digestive organs should be regulated. Something has generally to be given, and the best is to treat the prominent symptoms, taking care not to give anything that can do harm. It is often useful to send hypochondriacs to hydropathic institutions or mineral spas, chiefly on account of the change of experience, and society. CHAPTER XII. DISEASES OF THE SKIN. The term "skin disease" applies to every deviation from the 1 normal condition of the structure and function of the skin and its appendages, the glands, hairs, and nails. The so-called surgical diseases of the skin will be omitted and remarks confined to those affections which come under the care of the physician. But in order to study diseases of the skin profitably, we must at the outset adopt some method of classification,, whereby we may arrange into groups and classes the various; affections which bear some relation to one another. The best method, perhaps, would be an anatomico-pathological one, the different diseases being divided into two great classes, namely^ those having a constitutional origin and those purely local. Unfortunately, this is, in the present state of our knowledge, impossible. Many skin affections are clearly constitutional and many purely local; there is an intermediate class which may be local or constitutional, or even partake of the characters of both. For instance, some diseases which are purely local may be- aggravated or determined by constitutional conditions, while many affections, due really to some morbid condition of the- EXANTHEMATOUS INFLAMMATION. 441 general system, are determined by some cause acting locally. A strict anatomico-pathological classification would become too complicated by the never-ending extensions and modifica- tions of morbid processes. The best adapted arrangement for clinical study and the most useful in assisting students in preparing for examina- tions is : 1. The Eruptions of the Acute Specific Diseases. — These have already been described. 2. Local Inflammations, including: Erythematous, as ery- thema, roseola, and urticaria. Catarrhal, as eczema. Bullous, as herpes, pemphigus. Suppurative, as ecthyma, impetigo, impetigo contagiosa, and furunculus. Plastic, as lichen and prurigo. Squamous, as psoriasis, pityriasis, simplex, and pityriasis rubra. 3. Diathetic affections, including strumous, syphilitic, and leprous. 4. Hypertrophic and Atrophic, under which may be classed xeroderma and ichthyosis, keloid, fibroma, scleroderma, as hypertrophies; and atrophy and senile decay, as atrophies. 5. New formations, as lupus, rodent ulcer, and cancer. 6. Hemorrhages, as purpura. 7. Neuroses, as hyperesthesia, anaesthesia, and pruritus. 8. Pigmentary changes. 9. Parasitic Diseases. — Dermatozoic, as scabies, phtheiriasis. Dermatophyte, as tinea favosa, tinea tonsurans, tinea kerion, tinea circinata, tinea sycosis, tinea versicolor, onychomycosis, and, according to some, tinea decalvans. 10. Diseases of Glands and Appendages. — Sweat glands, as miliaria, sudamina, and lichen tropicus, etc. Sebaceous glands, seborrhoea, acne, xanthelasma, molluscum contagiosum. Haws and their follicles. Nails. EXANTHEMATOUS INFLAMMATION. In this there is active congestion or hyperemia of the "der- ma" or true skin. Besides scarlatina, measles, and erysipelas, 442 EXANTHEMATOUS INFLAMMATION. already considered, this order contains erythema, urticaria, and roseola. Erythema. — Superficial, circumscribed red patches, of variable shape and size, on the face, trunk, or limbs, not pain- ful nor very sore, characterize this. Its causes are, all moder- atebut somewhat continued irritants to the skin. Its duration is generally but for a few days or a week or two. No fever attends it ; nor is it either contagious or dangerous. Varieties* of erythema are, erythema fugax, or fleeting ; erythema intertrigo, from friction of two surfaces of the skin, as in not well-cleaned children ; erythema rheumatica, occurring now and then in rheumatic fever; erythema pernio, or unabraded chilblain ; and erythema nodosum, on the legs, with rounded node-like prominent red patches, somewhat more in- flamed than in the other forms. Treatment of erythema must depend upon its cause more than upon its particular form. The stomach and bowels may need attention, with the use of antacids and laxatives ; especially magnesia and rhubarb, or Eochelle salts, or the citrate of magnesium. Local applications may be, finely-powdered starch or arrow- root, dusted on dry; cold cream (unguent, aq. ros.) ; lime-water and oil, equal parts (olive, or lard oil) ; ointment or glycerite of zinc ; glycero-cerate of lead ; or glyceramyl. For erythema pernio or frost-bite of mild degree, astringents are serviceable ; as bathing the feet in tepid infusion or decoc- tion of oak bark, or solution of alum ; or applying cerate or glycerite of carbonate or nitrate of lead. Some recommend cabbage leaves. Urticaria, Nettle-rash. — Elevated round or oval, red or white patches or wheals characterize this. They may come and go in an hour, over the arms, trunk, or legs. Much burning, stinging, or itching attends them. The affection *Here, as in other affections of the skin, only the principal varieties are named. Wilson makes sixteen varieties of erythema. PAPULAE. 443 oommonly lasts only a week or two ; sometimes it is chronic and tedious. Disorder of the stomach from unwholesome food is rather more likely to cause nettle-rash than any other kind of eruption. Mild purgatives, especially salines or the antacid magnesia, with or without powdered charcoal, are suitable for it, after a dose (two or three grains) of leptandrin Light diet is necessary. Vinegar and water, glycerine and rose-water, or the starch-powder, etc., mentioned for erythema, will answer for local applications. Much use of cold lotions should be avoided, lest the eruption be over-hastily repelled, inducing gastric, hepatic, or other internal disturbance. Roseola. — Bright, and yet generally dark red, damask rose- colored patches, irregular in shape and of various size, over any part of the body, without much if any fever, belong to this affection. It is generally of but a few days' duration. Some- times a certain amount of resemblance is presented by it to scarlet fever or measles ; but the peculiar sore-throat of the former, and the catarrhal symptoms of the latter, are wantin Scarcely any treatment is called for in roseola ; no local application, as the rash is but slightly irritating ; and only such medicines as the general condition of the patient may indicate. Papula. These, pimply eruptions, involve depositive inflammation of the skin, which is raised in small, red, round, or conical points or minute tubercles, not very hard, and often, though not always, transitory. Papular affections are Lichen and Strophulus. Lichen. — Pimples numerous, but of small size j red, and more or less heated and irritated. The principal forms of it are lichen simplex, common on the face, neck, etc., lichen trop- icus, or prickly heat, and lichen agrius. The last named is the most inflamed and painful; sometimes quite severe. Lichen simplex, though mild, may be obstinate in its persistence; 444 papula. annoying ladies, sometimes, by remaining long on the face. In lichen tropicus, from which children, especially, often suffer in summer time, the eruption is not prominent, but the sense of irritation is very unpleasant. Lichen agrius may become, in violent or neglected cases, a scabby confluent eruption, with cracks or fissures, and a serous, perhaps purulent, discharge. This is not, however, veiy common. Treatment. — Even for the simple form, and still more for lichen agrius, constitutional alteratives are likely to bo needed, doing more good than local applications. In lichen tropicus, starch-powder, glycerine and rose-water, or glycer- amyl, or weak lead-water will suffice, without any medicine. But in the other forms, rectification of any error of balance in the system must first be made. The plethoric must have low diet ; the ansemic, lean meat, perhaps bitters, aromatic sul- phuric, or nitric acid, or iron. Costiveness must be over- come, as by cream of tartar and sulphur, rhubarb and aloes, or other mild but decided laxatives. Then arsenic may be prescribed ; of Fowler's liq. potass, arsenit., three drops twice daily at first, increased every week one drop until ten twice daily have been taken ; omitting the remedy if headache^ nausea, diarrhoea, or puffiness of the face occur. In lichen agrius, rest in bed may be required ; with lime- water and oil dressing, or poultices of bread and milk, or flaxseed meal, or slippery elm bark powder, glyceramyl, etc. Strophulus — Red gum is a common name for this papular eruption of infancy. Indigestion, reflex irritation from deten- tition and over-thick clothing, or living in hot rooms, may produce it. The eruption is not severe, consisting of many small red pimples, close together, and often nearly all over- the body. Attention to the stomach and bowels is necessary, Lancing the gums is proper if they be swollen, tender, or so- tense as evidently to distress the child. To the rash, only very soothing applications should be made, as starch-powder,, ointment of oxide of zinc, or glyceramyl. Care with the diet,, VESICULJ3. 445 If fed instead of being nursed, is of great importance some- times. Vesicul^e. These are effusive inflammations of the derma ; characterized by numerous and small water blisters ; the smallest are sudam- ina; the largest, herpes; eczema having vesicles of intermediate size, and scattered. Sudamina are met with in low fevers, consumption, etc., mostly when perspiration alternates with the febrile state in an enfeebled system. Eczema. — This has been the subject of much disputation ; as to whether it is a disease per se, going through stages not only of effusion, but also of incrustation, suppuration, desquama- tion, etc., ; or, only a phase of cutaneous irritation and inflammation, called vesicular, whatever its cause, and eczema- tous to distinguish it from the hepatic eruptions. Unable to decide this question with positiveness, we may say, merely, that, while the eczematous vesicular eruption admits of very distinct description and recognition^ it may come from or after a papular rash, and may in the same case be transformed (or progress) into a pustular or scabbing disease. Eczema simplex, rubrum, infantile, and impetiginodes are its principal varieties. Besides others named in the books, there are also eczema solare, from heat, and eczema mtrcurialis, from the impression of mercury on the system. The simple form has but little inflammation ; but there is always some soreness and the vesicles may run together and break, oozing serum or lymph, or scabbing lightly. Eczema rubrum is more inflamed with redness, heat, and some tumefaction. Crusta lactea, or milk crust, is a name often given to eczema infantile of the nursing time. It affects the face, sometimes very unpleasantly ; scabbing, running, and cracking all over it. E. impetiginodes appears to be an intermediate stage, or transition, between eczema and impetigo ; water blisters appearing at first, and pustules afterward. Treatment. — An inflammatory state attends the eczema- 446 VESICULJE. tous eruption, nearly always ; especially in eczema rubrum and advanced crusta lactea. Saline laxatives, diuretics and dia- phoretics (Rochelle salts, bitartrate of potassium, citrate of potassium, etc.) are often called for, perhaps to be repeated in moderate doses. Light diet is, in like case, proper. In children, small doses of podophyllin occasionally do good. Locally, weak lead- water when there is no scabbing ; lime- water and oil when there is great irritation ; decoction of bran ; flaxseed infusion with bicarbonate of sodium (3j in f§iv) ; glyceramyl ; glycerine with rose-water ; carbonate of lead cerate ; ointment of oxide of zinc ; these are among the many applications used with advantage. The whole bath, tepid or slightly warm (never hot) two or three times a week, will be beneficial. In chronic eczema, the " Turkish" or dry, hot air bath (130° to 150°) is highly recommended by some. Chronic eczema requires alterative treatment internally. Arsenic is the alterative in obstinate cutaneous affections. Its peculiar action on the skin tends to displace the morbid process, and thus to restore, after its own transient influence is withdrawn, healthy nutrition and reparation. Five drops of Fowler's solution may be given at first, twice daily, increased gradually until the dose amounts to ten drops ; sometimes even more. The medicine must be intermitted, if the head, stomach or bowels show its decided action. In case of its failure, particularly where syphilitic taint is possible, Dono- van's solution may be given ; three drops at first, cautiously increased. Scrofulous or otherwise feeble children may need cod-liver oil. In crusta lactea, or eczema infantile, the mother or nurse must be instructed not to burden the child with clothes, nor keep it in an overheated room. Daily bathing is particularly important to an infant suffering with such an eruption. Herpes. — This has larger, more separated and less numerous vesicles than eczema ; it is less apt to be chronic. Varieties : herpes phlyctenodes, herpes zoster, and herpes circinatus. The first is the most frequent ; receiving also local names, accord- BULLAE. 447 ing to its seat ; as h. labialis prceputialis, etc. Herpes labialis is commonly called " fever blisters." Herpes zoster is singular, and not very common. Half of the body, about the waist, is covered with vesicles, on an inflamed red surface. Sometimes neuralgic pains, quite severe, attend it. It generally aifects the right side. Its duration is but for a week or two; unless in the feeble or old, in which it may be followed by ulcerations of a tedious, perhaps dangerous character. Herpes circinatus is distributed in circular patches or rings. Minute vesicles appear around the circumference. By these, and the absence of the microscopic vegetation, and by less disposition to chronicity, it is distinguished from tinea tonsur- ans, or true contagious ringworm. Herpes iris, of writers, is an aborted h. circinatus; the rings being incomplete. Herpes rarely appears in old persons; often in children and adolescents. All causes of irritation of the surface of the body may produce it; as febrile or catarrhal attacks, stimulat- ing diet, violent exercise, etc. For the treatment of herpes, the plan stated for eczema is, principle, here also suitable. Cucumber ointment may be added to the applications recommended. Herpes zoster requires confinement to bed. The severe pains, in this, may call for anodynes. Herpes labialis is sometimes very annoy- ing, especially to ladies. Pure cologne-water, applied at the very start, may abort the vesicles. Magnesia powder is used by some to dust about the lips. Calomel ointment is recom- mended when the eruption is chronic, coming out in successive crops. Oxide of zinc powder is often good. Bullae. These are eruptions of large vesicles. Pemphigus and JRupia are the most distinct. Pemphigus.— Bull se of a circular or oval shape,, from half an inch to two inches in diameter, and flattened. They may be distributed over any or all parts of the body. Fever, some- 448 pustule. times considerable, precedes and accompanies the eruption. After the vesicles mature, they burst, or dry away, leaving thin brown scabs. Ulceration may occur, but it is not deep or obstinate, unless in a particularly unhealthy constitution. The duration of pemphigus is from one to three weeks, or more in bad cases. Pompholyx is the name given to a rare variety of pemphigus, in which the space continuously covered by bullae is large, and there is little or no fever. A fly-blister causes artificial pompholyx. Pemphigus is not usually considered to be contagious. One family came under my notice, however, in which five individ- uals were attacked by it, partly in succession, after traveling. It was difficult in that case not to suppose contagion. In the treatment of pemphigus, gentle refrigerant laxa- tives at first, diuretics and diaphoretics next, and, often quite early, tonics and supporting regimen, are called for. No local applications, other than the mildest lotions or unguents, will be suitable. The early puncture of each bulla with a small needle is recommended; but the raised cuticle must not be removed. Rupia is probably but a modification of pemphigus ; with smaller blebs or bullae, followed by thicker conical scabs of dark color ; after whose removal ulcers are left, which may be weeks in healing. Rupia simplex is the variety in which the scabs are low and the ulcers slight ; rupia prominens in which they are elevated into irregular cones ; rupia escharotica, when the ulceration is deep and extended. Syphilitic rupia is quite common ; but every case of rupia is not, by authorities, admitted to be syphilitic. Observation goes to sustain this non-admission. Treatment of rupia requires to be, generally, tonic and Iterative. Quinine, cod-liver oil, and iodide of potassium, with good but simple diet, are apt to be wante d for it, Pustules. Suppurative inflammation of the skin (excluding smallpox. PUSTULJG. 449 furuncle, and carbuncle, as well as the malignant pustule or charbon of the French, a rare affection said to be received from cattle) appears in the two forms, Ecthyma and Impetigo. Ecthyma. — Large, round, prominent pustules, upon any part of the body, not numerous ; ending in thick dark scabs followed by slight (or in cachectic states, obstinate) ulcera- tions. Ointment of tartar emetic, or pure croton oil, or other strong cutaneous irritants, will produce it. Often, however, especially in syphilitic persons, or after acute fevers, etc., it occurs without local exciting cause. Sometimes it is chronic. " In treatment the causation is of great importance. If a local irritant produces it, local emollients, perhaps with general refrigerants, are to be used for its relief. Otherwise, diet, and balancive measures will be more in place; tonics for the feeble, purgatives and light regimen for the plethoric, etc. Arsenic is called for in obstinate cases, as in other diseases of the skin; Fowler's or Donovan's solution, in small doses carefully increased. Impetigo. — Small and somewhat numerous pustules : varie- ties, impetigo figurata and impetigo sparsa. I. figurata is most common on the face, in circumscribed clusters of pustules, which may become confluent and scab. To this, in children, as well as to eczema infantile, the name of crusta lactea is given by authors. II. sparsa has the pustules scattered ovei more or less of the whole body. Treatment. — When much irritation or inflammation exists, lead-water, glyceramyl, ointment of oxide of zinc, lime-water and olive oil, flaxseed tea and bicarbonate of sodium, light poultices of flaxseed meal, slippery elm bark, or bread crumb, are to be applied. Daily use of castile soap and water is serviceable. Purgatives may be needed. Diet must be according to the general condition of the patient. Impetigo may affect the hairy scalp; if so, the hair must be cut and kept 450 SQUAMA. very short. Colchicum and ipecac may be given in acute cases; arsenic in those which become chronic. Squamjs. Scaly diseases are. Lepra {Alphas of Wilson), Psoriasis, Leprosy of the Hebrews, Spedalsked, or Norwegian leprosy, Pityriasis, and Ichthyosis. Lepra. — Always chronic, and very difficult to cure. Not regarded as contagious, though it has been seen to occur suc- cessively in four persons in immediate contact (an infant at the breast, its wet-nurse, another infant suckled by her, and her husband). It is characterized by red desquamating patches, of various sizes, approximating to a circular shape, on any parts of the body ; especially on the arms and legs. Be- sides syphilitic lepra, its varieties are lepra vulgaris, with small patches and few thin scales, and lepra inveterata (alphos diffusus of Wilson) where they are large and desquamate extensively. In both, the margin of the patch is the highest, reddest, and most squamous part. Psoriasis. — Described under the names of ps. vulgaris, gyrata, and inveterata, psoriasis differs mainly from lepra in the irregular and varied forms of the desquamating patches ; and in the absence or less degree of depression near their centres. Wilson's view, that psoriasis is only a kind of chronic eczema, does not seem to accord with the facts of its ordinary history. It is sometimes hereditary ; as also lepra. No disease of the skin is so hard to eradicate, unless it be ichthyosis. Treatment. — For lepra and psoriasis alike, all sorts of alterative agencies, local and systemic, are, if cautiously used, suitable for tentative practice. Our object is to obtain the making of a new skin, unaffected by the morbid habitude of nutrition. Frequent bathing should be practiced. Tar oint- ment, ointment of sulphuret of potassium, etc., may be applied. SQUAMJE. 45 . Arsenic, and the iodide of arsenic given carefully, but repeat- edly, through long periods. Other medication must depend upon the conditions of each case. Ichthyosis (Fish-skin disease). — This is rare. Hard, thick, dry scales form, continuously, over a part, or, sometimes, nearly the whole surface of the body ; without much redness, soreness, or even itching. It is congenital and incurable. Frequent and thorough ablutions, and mild emollient applica- tions, are palliative to it. Pityriasis. — This is a chronic affection in which very numerous small white scales (dandruff) form upon the skin, particularly the scalp (p. capitis). Some redness, and often a good deal of itching, may attend it. It is difficult of cure in many cases. If it be upon the head, keeping the hair short, and washing daily with castile soap, followed by a spiritous lotion, or glycerine and rosewater, will do the best for it. Cleanliness and frequent bathing in tepid, cool, or, if the vigor of the system permit, cold water, are of essential import- ance in all cases. The term pityriasis versicolor is sometimes applied to an epiphytic disease, one connected with a vegetable parasitic growth, better called chloasma versicolor. Spedalshed is a disorder only known in Norway and Sweden, especially among the fisherman. Accounts of it are given in medical journals and books; but the mere mention of It will suffice here. (See Elephantiasis Grcecorum.) Leprosy of the Bible (Lepra Hebrseorum) is of great his- torical interest. It is still recognizable in the East, though not frequently met with. In the Book of Leviticus, three varieties of leprosy are described : dull or darkish white " freckled spots " — dusky or shadowed — and bright white (bahereth lebhana), the worst of all. Tsorat (whence psora, and sore) or malignant disease, was applied to the last two only. Lepra is an early Greek synonym of this term. 452 MACULE. Mason Good thus describes the old leprosy : "A glossy ^ white, and spreading scale upon an elevated base ; the eleva- tion depressed into the middle, but without change of color ; the black hair on the patches, which is of the natural color of the hair in Palestine, participating in the whiteness, and the patches themselves perpetually widening their outline." In favorable cases, after spreading over much of the person,, though without ulceration, the disease would die out; the scales would dry up and gradually disappear. In bad case& ulceration would occur, with extensive sores, as well as- desquamation. Then the leper was made an outcast, and treated as one dead : " unclean for life." Not only the Books of Moses, and others of the Bible, but also Hippocrates, Galen, and Celsus speak of ancient leprosy as a white scaly disease. It thus differs decidedly from any kind of elephantiasis. Macule. Ephelis, Vitiligo and Chloasma may be included under this term ; perhaps better, under, that of Decolor ationes. JEphelis; Lentigo. — Sunburn and freckles best correspond with these names ; which, however, are by some authors ex- tended further. Neither are of importance unless in regard to appearance. For the removal of freckles (which often dis- appear spontaneously with time) or the yellowish-brown spots- called chloasma, or melasma, all applications may fail ; dilute nitro-muriatic acid (fifteen to thirty drops in an ounce), left for some time in contact with the discolored spot, is more likely than anything else to take effect. Nitrate of potassium,, in saturated solution, is asserted to remove freckles after a few applications. Vitiligo. — Literally, veal-skin. Unnatural whiteness from deficiency of coloring matter. When universal over the body (nearly always then congenital) it is albinismus. We see albinoes, sometimes families of them, occasionally, in all the HYPERTROPHIC 453 Taces of mankind/ as well as among the lower animals. Leucoderma, white skin, and Leucopathia, or white disease, are names given by some writers to the affection. When local, vitiligo is seen mostly in rounded patches or spots, which slowly increase in size, though without regular- ity of shape. The head, chest, back, and thighs are the most frequent seat of them. The hairs on the parts involved become white, or fall out, causing baldness — calvities, or alopecia. Treatment for vitiligo must be, first, general, for im- provement of nutrition in the whole system — and then local. Very hard it may be to cure the affection, although its im- portance is chiefly for appearance ; no danger attends it. Tannic acid and oil of turpentine are the preferred local applications for it. Total albinismus is quite incurable. Chloasma (pityriasis) versicolor will be spoken of under Parasitica?. For alopecia, baldness, or premature loss of the hair, many remedies are in vogue. Shaving the hair repeatedly (after an illness) may often save the hair. Stimulating applications, such as tincture of cantharides, ammonia, etc., sometimes help and sometimes hurt the case. Improve the general health and invigorate the scalp. Hypertrophic. Morbid excesses of development of the skin or tissues con- nected with it are thus named: Nsevus, Clavus, Verruca, Elephantiasis Arabum. Ncevus. (Mole, mother-mark.) — This is always congenital. Discoloration and elevation of the part exist, with abnormal development of the capillaries and small veins of the skin; making a small, commonly flat, vascular enlargement. It is seldom more than an inch in diameter. Erectility sometimes belongs to the vessels of naevus. I have seen it much larger and elevated an inch or more. In such cases I use caustic alternated with poultices. If large and elevated, caustic 454 HYPERTROPHIC. alternated with poultices, the ligature, the knife, and vaccina- tion of the part, have all been employed for the removal of such formations. They may leave scars worse than the mole if small; the operation ought to be exceptional. The first is usually the best treatment. Verruca. Wart — A hypertrophy of the skin, with great development of the cuticle, especially upon a small surface ; such is a wart, of which no one needs a further description. Some persons and families are especially liable to them ; why, cannot be explained. Treatment. — Strong nitric acid ; chromic acid ; caustic potassa ; and in slight cases nitrate of silver, carefully applied only to the wart, after paring off nearly all the insensitive portion of it, will always, at least after repetitions, remove warts, also ligation. Clavus. Corn. — Most persons are well acquainted with this sort of localized hypertrophy of the skin of the foot, from irritating friction and intermittent pressure. Prevention is more easy, by far, than cure. Corns are either hard or soft ; the latter may become inflamed ; the former hurt only under decided pressure. Pare a hard corn with a sharp knife or razor, closely, but not so as to hurt or draw blood. Soak the foot then in warm water for thirty minutes, and pick out carefully the center or " core." Two or three thicknesses of adhesive plaster, with the center cut out (making a ring) should be put over the corn ; and another piece, the center not cut out, may be placed upon it and them. Soft and inflamed corns require removal of all pressure for a while, and poulticing, etc., first; then the above treatment. Condylomata. — These are fleshy tumors or outgrowths, more or less hard and wart-like sometimes, in other cases soft; of syphilitic origin often, but not always. They are especially apt to occur about the anus, prepuce, and vulva. To remove such formations, if they be small and hard, nitric acid, pure, may be used, with care to limit its contact to TUBEECULA. 455 the part to be destroyed. "When large and soft, if trouble- some enough to require destruction, the ligature is generally preferred. It may be, with a needle, passed through the centre of the mass, and then drawn and tied tightly about the base. Elephantiasis Arabum. — Bucnemia Tropica of "Wilson; "Bar- badoes Leg." Enormous enlargement of the leg, scrotum, or neck, most often met with in warm countries, but occasionally anywhere, is thus called. The parts become at last hard and nearly im- movable. The connective tissue as well as the dermoid texture proper is greatly hypertrophied. Impediment to the return of surplus material of nutrition by the lymphatics is the probable pathogenetic cause ; the nature of this impedi- ment has seldom been discerned. Ligature of a large artery is asserted to have arrested the growth of elephantiasis. No other treatment appears to be equally successful in treatment for it. TuBERCULA. . Acne, Molluscum, Lupus, Elephantiasis Grwcormn, Fram- bo&sia, Keloid. Acne. — Tuberculous elevations, from inflammation of the skin around sebaceous follicles, in which the secretion is de- tained, or is of a morbid character, are called acne. Three varieties may include all those named by authors : viz., acne simplex, acne pustulosa, and acne rosacea. Acne simplex or punctata has small and moderately red,, rather hard tubercles, on the face principally. When very hard and chronic, it may be called acne indurata. Black points commonly mark the obstructed follicles. Acne pus- tulosa reaches a more mature suppuration, and is often painful, especially if upon the scalp. Acne rosacea always affects the face ; usually in adults, and most often in high livers. A good deal of soreness attends 456 TUBEECULA. the eruption. Firsts the pimples are hard, red, and small ; as they mature they grow somewhat larger; finally a little sanguinolent pus escapes, leaving a small scab. Rose redness around the pimples, or patches of them, has given rise to the name. It is generally a dffiicult disease to cure, and very un- sightly. Not unfrequently it is hereditary. Treatment. — Errors of digestion, brought on by gluttony or intemperance, or more moderate imprudence, often cause acne. They must be rectified for its cure, Attention to the state of the bowels, and to the action of the skin generally, is indispensable. Saline cathartics are useful in plethoric cases. Various mineral waters are recommended — saline and sul- phurous especially. The pustules, when they mature, should be carefully punctured with a needle, avoiding irritating dis- turbances. Solution of carbonate or bicarbonate of sodium (3j in Oj) in water or flaxseed infusion, will be a good wash. Sulphuret of potassium, in dilute lotion or ointment, is also advised ; or ointment or glycerole of nitrate or amide of mer- cury (hydrarg. ammoniat). Obstinate cases justify more decided alterative treatment ; as the application, by a cotton tip upon a knitting needle, of a solution of corrosive sublimate, two to five grains to the ounce of water or alcohol, washing it off in a few moments ; or, similarly, of pure Goulard's extract (liq. subacetat.) of lead, followed by spermaceti ointment, cold cream, or glycer- ine and rose-water. Iodide of sulphur ointment, gr. xv to xxx in 5j of lard, is also much praised. In acne indurata, when very ugly, acid nitrate of mercury (mercury and nitric acid each an ounce) has been applied, and sometimes the face has been blistered with cantharidal collodion. MoUuscum. — Acute molluscum is a somewhat contagious tuberculous eruption. The small tumors form without in- flammation, increasing slowly, till they have almost the size and form of a currant, but without color, and nearly flat- based or sessile. They last from three to six months, either ulcerating finally and then shrinking away, or inflaming and TUBERCULA. 457 sloughing off, leaving a pit or mark. Several crops of tuber- cles may succeed each other on the face and^neck, in either adults or children, but especially in the latter. Chronic molluscum is of still longer duration; it is not contagious, and the tumors are pedunculated, that is, each has a stem, in many cases at least ; they also become larger, and occur over different parts of the body. Neither form of molluscum is common. It is proper to add that some authori- ties do not admit the contagiousness of the acute variety. Treatment of acute molluscum seems not to be to any great extent available. In chronic molluscum the tumors may be cut off at the peduncle, the divided point being then touched with lunar caustic. Lupus. — L. exedens and non-exedens, or 1, superficialis, serpiginosus, and devorans [Neligan]. Lupus superficialis is a rare disease, in which, most often on the cheek, a small, soft, sore, slow-gathering tubercle appears, which in time scabs, and ulcerates superficially, the scab and ulcer spreading for an indefinite time, and leaving behind them a permanent whitish seam or scar. Irritation may make the tubercle very painful, and deepen the ulcer. It may last for years. Lupus serpiginosus exhibits one or more livid, red, indolent tumors on the face, head, or elsewhere, sore, heated, and itch- ing. In the course of months they become filled with pus, and suffer an undermining ulceration, which finally becomes an open, unhealthy-looking sore, forming upon it a hard, brown scab. Creeping from the edge of its original seat, in irregular rings, the disease extends, leaving behind it a depressed cicatrix. The same part may be again reached by its meandering progress. This is a very chronic affection, even of years' duration, without injuring the general health. Lupus exedens or devorans, noli me tangere or rodent ulcer, is characterized by continuous destructive ulceration of the skin, subcutaneous connective tissue, muscles, and other parts, at length involving even bones ; all following tubercles " rounded and dusky red," on the nose, cheek, eyelid, etc. An 458 TUBERCULA. ichorous discharge belongs to it; cicatrization follows it r sometimes, as in the previous form, to be again attacked. Young persons, from ten to thirty, are especially liable to lupus. Its progress is generally an affair of years, and it causes less suffering thati its appearance would lead us to expect. Scrofula certainly and probably syphilis predispose to it. It is very difficult to cure ; sometimes, at least, incurable. The obvious alliance with cancer has induced some authorities to place lupus in a class of affections called cancroid. It differs from cancer, however, in not involving the glands, nor con- taminating the general system. Lupus is a comparatively rare disease. Iodine, as in- LugoPs solution, cod-liver oil, and iron, internally, are commonly indicated in the treatment of lupus, especially the exedens. Fowler's or Donovan's solution may also, or each in its turn, be cautiously given. Chlorate of potassium has been suggested. Sea-bathing is likely to assist in the treatment. Locally, the animal oil of Dippel, made by distillation of hartshorn shavings, has a reputation in Europe for lupus superficialis as well as for 1. devorans. So have dilute solu- tions of chloride of zinc, nitrate of silver, nitric acid, etc. In the superficial variety, collodion, softened perhaps by^adding 1-50 of glycerine, may be painted lightly over the ulceration, every day or every few days. Excision is sometimes practiced for the exedent form, to prevent disfiguration ; but the success of the operation is uncertain. So is that of strong caustics. Among these, nitrate of silver is preferred by most surgeons. Acetate of zinc, used solid for touching the ulcer, and applied every day or two, was much recommended by Neligan. He used a lotion of the same salt, from three to five grains to an ounce of distilled water. Broadbent's treatment for cancer, by injec- tion of acetic acid, might be worth a fair trial in lupus. Its theory is very plausible. Elephantiasis Groecorum. — Called by this name among the TUBERCULA. , 459 Greeks, probably because, as the elephant is a great and powerful animal, so is this a formidable disease. It was the leprosy of Europe in the middle ages ; for whose treatment many hospitals were built, and an order of Christian knight- hood (of St. Lazarus) was established. It is characterized by many round tumors, from the size of a pea to that of an orange, livid, purple, yellowish or brownish, and soft, on the face and other parts of the body. ' The skin around them thickens irregularly, giving a repulsive aspect. Ulceration occurs, deepening even to the bones; all the organic functions suffer, and finally the mental faculties be- come enfeebled; diarrhoea, and perhaps tetanus, precede death. This disease is probably identical with the spedalsked of Norway, already named. Allied to it are radesygeoi Norway, the morphie of Brazil, frambcesia raspberry disease, Sihbens of Scotland, and Aleppo evil, button of Aleppo ; perhaps also the Ngerengere of New Zealand. Pellagra, of Lombardy, Spain, and France is described by some as having a certain resemblance to it ; but tumors do not belong to this disease ; in which, with a general cachexia, the skin becomes discolored and somewhat thickened, with arrest of its normal functional action. Treatment of elephantiasis and its allies must be upon the principles laid down for other serious cutaneous affections, viz, to endeavor to restore the balance of the general functions, what- ever may be wrong ; whether that be by tonics, refrigerants, or purgatives, or other remedies acting upon the secretions ; also improving the nutrition and repair of the skin, by local and general alteratives. There is no specific remedy for either of the forms of disease last named. Keloid. Kelis, Kelois, Cheloid, Sclerema. — This is very rare. Yv^ilson, a few years since, stated that but twenty-four cases of it were upon record ; more have been reported since. An irregular, cicatrix-like, smooth, reddish and whitish, cor- rugated excrescence, painful, with a stinging sensation, some- times, but not always ; nearly in every case forming upon the 460 HEMORRHAGIC— PURPURA. front of the chest ; slow in growth, not ulcerating, and not tender to the touch. It is, not unfrequently, spontaneously removed by absorption ; but has not been shown to be amena- ble to treatment. Rayer and others advise constant firm com- pression. Hemorrhagic — Purpura. Purpura is the only affection of the skin belonging under this head. On parts, or often the whole of the body, appear round red spots, which become gradually of a dark purple color ; and then pass, as bruise marks do, through green and yellow, till they disappear. They are extravasations of blood in or upon the true skin from its capillary vessels. The dura- tion of each spot is about a week or ten days. Feverishness may precede, and prostration may accompany purpura. In bad cases, hemorrhages may take place from the mucous membranes, as those of the mouth, stomach, bowels, bladder, vagina, etc.; producing, sometimes, even a fatal result. Purpura is by some improperly confounded with scurvy. Although extravasation of blood occurs in scorbutus, it may also happen quite independently of it. Deficiency of fresh vegetable food is not at all necessary to engender purpura; the causation and pathology of which, clinical experience and chemical investigation have both failed to show. Treatment. — Although some assert plethora to be, as often as hydrsemia (anaemia), antecedent to purpura, experience goes with the ordinary view, that rather a tonic than a depletory treatment is generally called for in it. Excessive stimulation, it is true, will aggravate its symptoms. Mineral acids, as elixir of vitriol, and Huxham's tincture of bark, or quinine, etc, are much given. Oil of turpentine is also recommended. Neligan prescribed this in large doses; even an ounce at once, with mucilage, and an aromatic. This is a very bold use of it; but it is said that it acts generally safely as a cathartic in such doses. Ammonio-ferric alum, tincture of chloride of iron, tannic and gallic acids, etc., are used as NEUROSES. 461 styptic medicines in some cases. Sponging the body with alum and brandy, or whisky, and water, at such temperature as is not chilling and yet is sedative to the circulation, will be the best local measure. I have used rhus, baptisia, and Phytolacca with good results in different cases. Neuroses. Under this head, of affections involving the innervation of the skin, we class Prurigo, Anaesthesia, and Neuralgia cutis. Prurigo. — Often placed under papulce, because minute pimples occur with it — the essence of this disease is, intense itching without eruption. It is commonly divided into prurigo mitis, formicans, and senilis. Pruritus is the technical name for itching as a symptom. The difference between the first two varieties is one of degree. In the mitis, obstinacy rather than severity exists. In p. formicans, suffering may be extreme, pervading the body. Heat of a fire or of a bed, rubbing of the clothes, etc., may cause an irritation which drives the prtient to rub and tear the skin, yet without relief. Sleep may thus be pre- vented, and the bodily as well as mental exhaustion so produced may be great. The complaint is occasionally inter- mittent. Very often it is confined to one or two portions of the body; as the scrotum, vulva, anus (pruritus scroti, vulval, ani, vel podicis), etc. Pruritus ani is often caused by worms; especially ascarides. Prurigo senilis is so named because of its frequency in old people. Lice cause it frequently. Papulse attend it more often than the other forms. Treatment. — This is sometimes a very hard disease to cure, or even relieve. We must consider and treat the general condition of the body; see that the bowels are regular, the digestion normal, the skin kept clean and open by ablutions and proper change of clothing. Sometimes nervine tonics may be required; as nux vomica, arsenic, or quinine, in small 462 PARASITICA. doses. Tincture of aconite is prescribed by some; three or four drops at a time twice or thrice daily. Conium, bella- donna, and other narcotics have been advised. The hypo- dermic injection of morphia may be resorted to to give rest in very distressing cases. Locally, many things may, and should, be tried in succes- sion, in the search of palliatives. Baths of flaxseed tea, with or without carbonate of, sodium or of potassium; lathering with castile soap, with a shaving brush; strong salt water, or whisky and salt; dilute sulphuric, nitric, acetic, or carbolic acid, etc.; these are only a few of the measures which may be resorted to. The diet should be unstimulating. Advice should be given the patient also to refrain as much as possible from violence in rubbing or scratching the parts affected; and not to sleep in a very warm room or under too much cover. Anaesthesia cutis is only a symptom of a larger affection — involving either the nervous system or the skin itself. It appears in one variety of elephantiasis Grsecorum, called by some lepra ancesthetica. Vitiligo also is often attended by it, at the parts which undergo discoloration. Except stimulating frictions, when not contra-indicated by the other conditions of the case, and galvanism (faradization), under the same limita- tions, we have no special remedies to mention for loss of sensibility in the skin. Neuralgia of the skin, temporarily, at least, limited to it, does undoubtedly occur, though seldom. Its locality does not, however, so remove it from other forms of neuralgia as to require for it a special consideration. Parasitica. Dermatologists are not all agreed upon the question, whether the microphytes or epiphytes (minute parasitic vegeta- tions) discovered by aid of the microscope, in connection with certain skin dissases, are essential to these diseases, or accidental and secondary only. Wilson even denies their PARASITICA. 463 ■vegetative nature; asserting them to be results of spontaneous granular degeneration of epithelium. Most authorities hold the opinion (especially proved by the results of treatment) that the parasites are really the essential causes of the disorders they constantly attend; that they may, under favorable cir- cumstances, be transplanted; and that, to cure those disorders, destruction of the parasitic forms is necessary. Again, Hebra, a high European authority, believes that all epiphytes described are merely modifications of one and the same species, indifferent degrees of development. Tilbury Fox agrees with this opinion. E. Hallier mekes three series (Mucor, Achorion, Leptothryx) of forms, all capable of being educed from the same spores under different circumstances. Devergie believes in spontaneous generation of the epiphytes, although truly vegetable. Dr. McCall Anderson gives proofs, by separate inoculation, of the non-identity of three vegetative parasites at least — trichophyton, achorion, and microsporon. No doubt exists with the large majority of observers as to the cause of the animal parasitic eruption, scabies or itch. Scabies. — Chiefly vesicular, this disease may be papular, scaly, or pustular in some instances. Ordinarily we see, especially between the fingers and on the back of the hand, next often on the arms, legs, and abdomen, occasionally on the scalp, hardly ever on the face — a number of small red elevations with white or watery tops. Extreme itching is always present ; often keeping the individual scratching night and day. Closely looking at almost any of the vesicles, one may see a little red line or track, at the end of which may be found a slightly elevated point. In this is, generally, the animalcule — Sarcoptes hominis (Acarus scabiei) ; one of the Arachnida — flat-bellied, round-backed, tortoise-shaped, eight-legged ; the female larger than the male, which is hard to find. Treatment. — Sulphur is not the only, but the most relia- ble parasiticide for itch. After thorough bathing, and wash- 464 PARASITICA. ing of the whole body with soap and water, strong sulphur ointment must be rubbed well into the parts affected. A few applications will usually suffice. The animalcule is killed, and the cure follows. There is evidence, however, that in some cases of long standing, recovery may follow but very slowly. The habit of the eruption has then become estab- lished in the skin ; this must be treated like eczema, or lichen, whichever it most resembles. Oil of turpentine, kerosene, or petroleum, ointment of sulphuric acid, and other powerful agents, may be also confi- dently relied upon to destroy the itch animalcule. A vinegar pack one or two nights often suffices to destroy the cause, and promote a cure. Army-Itch. — During and since the late war in this country, the inevitable filth of camp-life begot, among other evils, a very troublesome contagious skin-disease, called by the above name. Itching, without any eruption except small papula? characterizes it. Outside of the army it has extended to a considerable number of persons. No better remedy for this affection has been found than a lotion and ointment, composed of iodide of potassium and glycerine ; with water or rose-water for the lotion, and lard or cold cream for the ointment. Sul- phuric acid ointment is also efficacious for it. The other parasitic affections of the skin depend upon the microphytes already alluded to. They are Favus, Sycosis, Tinea circinatus, Tinea decalvans, Chloasma versicolor, and Plica Polonica. Favus. (Porrigo, Tinea favosa.) — Generally appearing on the scalp, this disease is peculiar in the formation of yellow cup-shaped crusts, in each of which one or two hairs may grow. By joining together, these crusts may lose their regu- larity of shape, in a general scabbing ; and a good deal of hair may fall out. A mealy powder is found in the crusts, which, on microscopic examination, is found to contain the formation called achorion Schonleinii by Remak. This presents minute tortuous branching tubes, straight or crooked not branching PARASITICA. 465 tubes, and sporules, free or united in bead-like strings. Granules and cellules of mycelium, the generative portion of the plant, are abundant. An offensive discharge occurs from the eruption in bad cases. Favus is contagious, though seldom conveyed to cleanly persons. It is hard to cure, but not incurable. In its treat- ment, constitutional and local measures must be combined. Arsenic is the most reliable alterative. Neligan has advised the iodide of arsenic, gr. 1-12 thrice daily; intermitted if headache or dryness of the mouth come on. For the local treatment, the hair must be closely cut with sharp scissors. Apply then a large flaxseed poultice for twelve hours or more, perhaj^s repeatedly, to soften the crusts. JSext, wash the head thoroughly, by means of a soft sponge, with solution of carbonate of potassium (one drachm to a pint of water) after which ointment of carbonate of potassium (potass, carb. 5j, glycerine f5j, adipis Sj) may be applied spread thickly on lint^ covered with oiled silk. This may be renewed daily; or, if there be much discharge, twice a day. The crusts then come away in a few days. Ointment of iodide of lead may follow; washing the head night and morn- ing, still with the carbonate of potassium lotion ; and keeping the hair cropped short all the time. Three or four weeks will generally suffice for a cure. Cleanliness of person and regu- lated diet are at the same time, of course, essential. For this and other parasitic affections of the skin, tar oint- ment is a far from contemptible remedy. Sycosis (Mentagra). — This occurs on the bearded part of the face, chiefly the chin. It is contagious; sometimes being transmitted by uncleanly barbers in shaving. It presents slightly inflamed elevations about the roots of the hairs, covered by scurf; shaving decapitates these, inducing irrita- tion and suppuration, as well as scabbing. The whole chin may become swollen and inflamed by it; and parts of the 33* 466 parasitica. beard may be destroyed. The parasitic cause of this disease is the trichophyton mentagrophytes (microsporon mentagrophytes of Gruby). It is seen under the microscope to consist of minute stems, bifurcated at angles of from 40° to 80°, and granulated within. Sycosis is not common. Acne, impetigo, and ecthyma of the bearded part of the face may be confounded with it. It is very hard to cure. In its treatment, keeping the beard con- stantly very short by close clipping (not shaving) is essential. Sponging twice daily with castile soap and water, or carbonate of potassium lotion, will be beneficial. Iodide of lead oint- ment, and ointment of calomel and camphor may be used in succession; besides the internal use of Fowler's solution. Tinea circinatus (Ring-worm, Scald-head). — This is known by its circular form, occurring most often, though far from always, on the head or face. Herpes circinatus resembles it; but in that minute vesicles are usual ; in tinea, rare and few. In tinea a thin powdery crust exists, whose examination will show the trichophyton tonsurans, closely allied to the parasite of sycosis. Tinea decalvans is marked by a destruction of the hair in circular patches, making round spots of baldness. Its parasite is considered by many dermatologists as different from the trichophyton, and called microsporon Audouinii. Its sporules are rounder and smaller than those of trichophyton. The treatment of. both forms of tinea must be, besides cleansing, essentially paraciticide. Tar ointment; solution of corrosive sublimate with care; lotion and ointment of carbon- ate of potassium; lotion of sulphurous acid; carbolic acid; creasote ; cantharidal collodion, lightly applied ; these are among the many applications which may be used for the purpose, with generally successful result. Tinea is seldom transmitted to a cleanly person without very close and continued contact. SYPHILIDA. 467 Chlodsma versicolor (Pityriasis versicolor). — The parasite of this is microsporon furfur. The disease is recognized by the formation of dull, reddish -yellow spots of various size and shape, seldom numerous, on the front of the chest or abdomen. The same local applications may be used for it as for tinea; besides the internal use of arsenic with usual caution. Plica Polonica. — This is an affection of the hairy scalp, endemic in Poland, Russia, and Tartary. The hair-follicles become diseased, and the hair is matted and glued together into felt-like masses. Trichophyton tonsurans and trichophyton sporuloids are the parasitic vegetations described as found connected with it. The disease has not been seen in this country. Syphilis— Syphilida. Sufficient for our purpose and space has already been said of the general history of syphilis. Among its constitutional manifestations, cutaneous eruptions are very frequent. These are seldom vesicular, not very often papular; most often squamous or scabbing. Lepra and rupia, particularly the latter, are prominent among syphilitic affections, though both may occur independently of syphilis. All erup- tions in persons of this diathesis are marked by a coppery color, which remains long, even after their cure, by a disposition to ulcerate, perhaps only superficially; and by preference in locality for the face, shoulders, and back. In the teeatment of syphilitic eruptions, the diathesis must be met by our remedies. Iodide of potassa internally ; after that, in feeble persons, cod-liver oil, perhaps iodide of iron ; locally, cleansing, besides palliatives, if required, as in other eruptions, or medicated vapor bath, should be prescribed. Often, such affections will seem to be cured, but, after weeks or months, will return again ; 468 HEMOEEHAGES. then the treatment should be renewed, and discontinued when they disappear. CHAPTER XIII. HEMORRHAGES. Hemoeehage signifies an escape of blood in its entirety- out of the current of the circulation. It may be due to rupture of the heart itself, or the blood may come from either set of vessels, arteries, capillaries, or veins. Capillary hemor- rhages are most frequent in medical practice. As a rule the vessels are ruptured, but bleeding may occur, without destruc- tion of the walls, as often no lesion can be detected on the most careful examination, and it is known that the corpuscles, both red and white, can make their w T ay through the coats of the vessels. The blood may be poured out on a free surface, such as that of the skin, or a mucous or serous membrane; or into the interstices of tissues, into the substance of organs, or into morbid growths. A collection of blood in a solid organ is named an "extravasation," "apoplexy," or, under certain circumstances, a "hemorrhagic infarct." Yaeieties. — 1. Active; 2. Passive; 3. Traumatic; 4. Symptomatic; 5. Critical; 6. Vicarious. Local hemorrhages are also classified according to the organs from which the blood escapes. Active hemorrhages are those in which determination of blood in excess to the part precedes the bleeding. Passive hemorrhages, those in w T hich, from inaction of the circulation, or passive dilatation of bloodvessels, congestion occurs; or in which the coats of the vessels give way too readily, partly from the blood itself being incapable of main- taining properly their nutrition. The idea of bleeding by HEMORRHAGES. 469 "exhalation" without rupture of capillaries, is generally abandoned. Traumatic hemorrhages are those produced by wounds, coming thus under the department of surgery. Symptomatic hemorrhages are seen in many diseases; as epistaxis in typhoid fever; haemoptysis in consumption; vomiting of blood in cancer of the stomach; bleeding from the bowels in piles, etc. Critical hemorrhages are occasional terminations of febrile disorders; as of yellow fever, remittent fever, etc. Vicarious hemorrhage is that which substitutes one which is normal or habitual; as, spitting of blood when the menses have been suppressed; or bleeding at the nose following arrest, of the bleeding of habitual haemorrhoids. Epistaxis. — By usage this term is applied only to bleeding from the nose. In young persons, especially from ten to fifteen years of age, it is common, and, if moderate, harmless; seeming often to relieve a temporary congestion and prevent a headache. It is more often seriously troublesome in older persons. Generally it is from one nostril only, but not always. Treatment. — When slight it may be .allowed to stop of itself; only not blowing away the clot that forms as a natural* plug. If it continue so as to threaten an injurious loss of blood, applying cold water to the forehead and nose, or ice r there or to the back of the neck, or the roof of the mouth,, will generally stop it. If not, a plug of dry cotton may be introduced and left in the bleeding nostril. Wetting the cotton first in strong alum- water, or dilute tincture of chloride of iron, or dipping it in powder of tannin or matico may make 1 it more effective. When these measures fail, the posterior nares must be plugged. Either the watch spring canula may be used, or an elastic catheter, having a piece of waxed liga- ture or twine passed through its eyelet hole, may be carried back from the nostril to the pharynx. Then the string should be drawn out of the mouth with forceps, a plug of cotton 470 HEMORRHAGES. should be fastened to it, and drawn by means of the catheter till it forces the cotton plug against the posterior orifice of the nares. Raising the arms high above the head is a popular mode of endeavoring to stop nose-bleeding. Bleeding from the Mouth. — This, unless when ulcerative, is generally from the gums; as in scurvy. It is, in itself, scarcely ever serious in amount. Considerable bleeding, sometimes hard to stop, may occasionally follow the extraction of a tooth. Treatment. — Borax in solution, or tannic acid, or myrrh -and rose-water, will be suitable washes for the bleeding and spongy gums of scurvy. For hemorrhage after the removal t>f a tooth, it may be necessary to plug the cavity with lint or cotton dipped in tincture of chloride of iron, creasote or tannic acid. Haemoptysis. — This term (spitting of blood) is generally applied to hemorrhage from the lungs, bronchial tubes, trachea, or larynx. Ulceration of the larynx, trachea, or bronchi may produce it, not often dangerously. More often the source of the blood is the lungs. The diagnosis of this is of great con- sequence. Between pulmonary hemorrhage and that from the stomach, the following contrast of signs exist: 1. From the Lungs. — Dyspnoea; blood coughed up; blood florid, some- times frothy; blood mixed with sputa. 2. From the Stomach. — Nausea; blood vomited; blood dark, not frothy; blood mixed with food. In a majority of instances, spitting of blood from the lungs is a symptom of phthisis. Cases occur, sometimes, during adolescence and early maturity (from 18 to 30 years of age) of more or less active pulmonary hemorrhage, whose subsequent history disproves a tuberculous origin for it. In these cases, there may be immediate danger, more probably than in the frequent bleedings of consumption. Aneurism of the aorta may also cause haemoptysis, by rupture of the tumor, which must cause death. This is rare, and is made known signs by already considered. HEMORRHAGES. 471 Treatment. — For active congestive pulmonary hemor- rhage, in a young and robust person, it was formerly the common practice to take blood from the arm, as a derivant measure. But, dry cupping over the chest and back, with sinapisms to the legs, and ice, salt, or alum, swallowed slowly, the patient at perfect rest in bed, with the head and shoulders raised, will be sufficient treatment at the start for most cases. Then we should prescribe, if the bleeding continue after the first gush, acetate of lead with opium in pill; say a grain or two of the former with half a grain of the latter every four, three or two hours as the case needs, for a day or two. In passive, or tuberculous haemoptysis, rest, with the head and shoulders propped, is also necessary. Ice, salt, and alum, alone or together, may be held in the mouth and swallowed very slowly, till the bleeding has stopped for the time. For medicines, in the anaemic, gallic acid, (gr. x to gr. xxx, in solution with aromatic sulphuric acid), oil of turpentine (gtt. xto gtt. xx in mucilage), and ammonio-ferric alum (gr. v to gr. x), or tincture of chloride of iron, are most recommended. But dosing with these styptics in consumption is not proper for every trifling discharge of blood. They are suitable only when the hemorrhage itself is, or threatens to be, a source of additional debility. Pulmonary Apoplexy. — This is the extremest degree or result of congestion of the lungs; hemorrhage occurring into the air cells, and obstructing respiration, sometimes to a fatal degree. Disease of the heart predisposes to this. Its attack is apt to be somewhat sudden; there is great dyspnoea, with a purple countenance, and skin rather cold. Percussion resonance is dull. On auscultation, at first, a bubbling or mucous rale is heard; after the blood coagulates, no respira- tory sound at all. Treatment. — If diagnosticated early, in a person of toler- able strength, cold applications to the chest at once. Then (or instead, in a feebler subject), dry cups should be applied extensively between the shoulders; followed by a 472 HEMOEEHAGES. large sinapism over the anterior part of the chest, and a hot pediluvium. At the same time the reaction which should aid in unloading the oppressed lungs (the object of venesection, cupping, etc.) may need to be favored by hot drinks, as hot lemonade, carbonate of ammonium, or if coldness be decided, whisky punch. This is usually fatal. Hcematemesis. — Vomiting of blood may result from cancer, or ulcer of the stomach, congestion of the liver, aneurism of the abdominal aorta, etc. We have given, above, the distin- guishing signs between it and haemoptysis. Teeatment. — Of course this must be varied according to the cause. Slight ejections of blood from the stomach may not of themselves require treatment — having only a diagnostic importance. In ulcer of the stomach the greatest danger may occur, except from rupture of an aneurism. In copious hsematemesis, with absolute rest in the horizontal position, ice, creasote (one or two drops pro re nata), in solution or pills, gallic acid, oil of turpentine, ammonio-ferric alum, or tincture of chloride of iron, may be prescribed. Food must be given in small quantities and concentrated. Hcematuria. — This may be either from the kidneys or from the bladder. If the blood is thoroughly mixed with the urine, it is probably renal. If the water flows off nearly pure, and the blood follows or accompanies the last portion, it is vesical. When it follows the use of a catheter or bougie, independently of urination, and flows in a stream or in fresh drops, it is urethral and traumatic. Renal hemorrhage may attend congestion or inflammation of the kidney ; or cancer ; or scarlet fever (generally a late stage) ; or the irritation of a calculus ; or that of cantharides or turpentine ; or, in old persons, it may be passive. In Egypt, a parasite sometimes produces it; the distoma hcema- tobium. Teeatment. — For hemorrhage from the kidney sufficient to deplete at all seriously, astringents, as gallic acid, tincture of chloride of iron, alum, or acetate of lead, may be used. HEMORRHAGES. 473 Rest is important, in this as in all hemorrhages, during the attack. Bleeding from the bladder may be treated by the in- jection, through a catheter, of solution of alum or dilute solution of creasote (gtt. j. in foj of water) or tannic acid (gr. x in f5j). Intestinal Hemorrhage. — The causes of this are, especially, typhoid fever, of which it is sometimes symptomatic, and occasionally critical ; i. e. y the commencement of convales- cence. The same may occur in yellow fever, or in remittent fever (less often). Aneurism of the aorta, congestion of the liver, abdominal cancer, may cause it. Blood is passed, com- monly in small quantity, with the discharges of dysentery. Aged persons not unfrequently have passive hemorrhage from the intestines. Internal piles are very often productive of it. The blood from the latter is bright red ; other bleeding from the bowels is darker and more mixed. Treatment. — Solution of alum by the mouth, with opium, or by enema ; tannic or gallic acid, in pill or by injection in solution ; oil of turpentine ; creasote, and tincture of chloride of iron, or ammonio-ferric alum, are here, as in the other hemorrhages mentioned, the most reliable astringents. For bleeding piles, special treatment has been already alluded to. Vicarious Hemorrhage. —The most frequent instances of this are in connection with suppressed menstruation. Epis- taxis, hsemoptysis, hsematemesis, renal or intestinal hemor- rhage may occur, but it is most apt to be from the stomach or lungs. The prognosis in this form of hemorrhage is much less serious than in the same of other origin. Its treatment should be addressed mainly to the regulation of the disturbed or interrupted uterine function. Warmth to the lower ex- tremities and back, with such emmenagogues as each case may indicate, will generally be required. Astringents are to be avoided in vicarious hemorrhage, unless it be in excess of the ordinary menstrual or other suppressed discharge. Uterine Hemorrhage. — Besides simply excessive menstrua- tion, uterine hemorrhage may occur from placenta prsevia 474 DROPSICAL AFFECTIONS. (" unavoidable hemorrhage ") ; abortion ; subsequent to de- livery ; uterine cancer ; ulceration of the os or cervix uteri ; tumors within, or in the walls of, the womb. Treatment. — In considerable uterine hemorrhage, of either varie'ty, ergot, in substance or the wine, is likely to be of use by promoting contraction of the womb. Ammonio- ferric alum is also a good medicine to give by the mouth in the same case. Locally, ice or iced water may be (with care not to chill too much) applied for a short time over the hypo- gastric region, or thrown into the vagina. Tincture of chlo- ride of iron, in strong solution, will have a powerful effect. Tannic acid or matico may be likewise applied ; or the "styptic rod" of tannic acid and cocoa butter, shaped to fill the vagina. But threatening cases (except post partum) may require the actual tampon, or plug of lint for the whole vagina, or the sponge-tent inserted into the os uteri itself. Stimulants may at times be called for to prevent fatal exhaustion under hemorrhage, either from the uterus or from any other organ. Pressure upon the aorta has been sometimes resorted to, through the abdominal walls, in uterine hemorrhage. Re- cently douching the uterus per vaginum with hot water has proved efficient to stop uterine hemorrhage. Other measures, suitable after delivery, belong to the department of obstetrics. Habitually excessive menstruation requires that the patient so affected should maintain absolute rest, from the beginning of the flow till its cessation. Iron is nearly always indicated in such cases, through the interval ; particularly the tincture of the chloride of iron, or ammonio-ferrie alum. CHAPTER XIY. DROPSICAL AFFECTIONS. Varieties. — 1. (Edema, local infiltration of connective tissue with serum. 2. Anasarca, general cellular dropsy. DROPSICAL AFFECTIONS. 475 ». Hydrocephalus. 4. Hydro-thorax. 5. Hydropericardium. \. Ascites. 7. Other local dropsies, as Ovarian dropsy, Hydronephrosis, Hydrocele of the testis, etc. Causation and Pathology. — Obstruction to the venous circulation, arrest of excretion and absorption, and excess of vater in the blood, are the three cardinal elements of the pathological causation of dropsy. Either one may induce it. Disease of the heart or of the liver brings on dropsy by venous )bstruction. Disease of the kidney, or the action of cold and svet upon the skin may produce it by checking excretion. Wasting diseases are liable in their advanced stages to oedema ind anasarca, on account of the watery state of the blood. Acute general dropsy results from the powerful impression of cold and wet, or of the scarlet fever poison, upon the system ; suppressing both the action of the kidneys and that of the skin at once. Its most common form is anasarca ; but it may take that of ascites, hydrothorax, or even, hydro- cephalus. When from cold and wet, it is much more curable, especially anasarca or ascites, than similar dropsy of visceral origin, e. g., from disease of the heart. Albuminous urine is quite common in acute general dropsy. Hydrocephalus, hydropericardium and hydrothorax have been already sufficiently considered. Ascites: peritoneal dropsy; accumulation of water in the abdomen. The causes of this of greatest frequency are, cirrhosis of the liver, and disease of the kidney. It may also follow obstruction of the portal vein by cancer, or general obstruction of the circulation from disease of the heart, aorta, or spleen ; and it is sometimes ascribed to chronic peritonitis. Symptoms and Diagnosis. — Often with emaciation of the face, neck, and arms, there is great enlargement of the abdomen. When this is far advanced, orthopnea exists, from pressure upon the diaphragm. The patient is generally weak, with poor appetite and deficient rest at night. On inspection, in the upright posture, the fullness is greatest in the lower part of the abdomen ; when recumbent, it spreads 476 DROPSICAL AFFECTIONS. evenly ; on one side, it falls over that way. Palpation will make evident fluctuation, especially when one hand is placed on one side of the abdomen, and the other strikes gently at a distance of a few inches. Percussion discovers resonance above and about the umbilicus, the intestines rising there upon the fluid to the surface under the abdominal walls. Elsewhere, the sound is dull, even flat. The amount of fluid in ascites is sometimes immense ; as much as twenty-five pints or more have been withdrawn at once by tapping. It is generally clear, pale yellow or color- less, albuminous and alkaline. Ovarian Dropsy. — Leaving the history of this, as belonging to the special department of diseases of women, it is proper to state that its diagnosis is important, but not always easy. Like ascites, it produces abdominal enlargement, with dull- ness on percussion and fluctuation. The most nearly constant points of distinction are, that the ovarian tumor begins some- what on one side, and only by degrees becomes symmetrical ; its shape is, throughout, more globular, and coherent, and altered less by changes of position • and the intestines do not float up above the umbilicus so as to make a clearness of percussion-resonance there. The progress of ovarian dropsy is usually slower, and attended by less proportionate depres- sion of the general health. Treatment of Dropsy. — Acute general dropsy, from suppression of the action of the skin and kidneys, should be treated by active purgation and the use of diuretics. Jalap and cream of tartar (gr. x of the former with 5\j to 5iv of the latter), every day or two, will answer well for catharsis. The diuretics most satisfactory are the infusion of juniper berries (a pint daily), acetate of potassium, citrate of potassium, squills, and sweet spirits of nitre. When the patient is hard to purge, elaterium or podophyllin may be given, in gr. Jth doses, every four hours till it operates. Ascites, or other dropsy, from disease of any of the great organs, kidneys, liver, or heart, being less curable, and DROPSICAL AFFECTIONS. 477 attended by greater general debility, needs more economy of strength. No doubt exists that real harm may be done by the routine of severe purging and plying with diuretics. The one may render the blood thinner and aggravate the constitu- tional disease, while the other, failing to remove the fluid by secretion, may even irritate the kidneys to the point of sup- pression of their action. Nourishing concentrated food, tonics, anodynes, etc., may, in visceral dropsy, be of more importance than diuretics. Of course it is desirable to lessen the accumulation of fluid ; but the effects of the reme- dies used must be observed, and one symptom must not be allowed to overshadow all the rest. When enormous distension makes rest impossible, and almost prevents breathing, it is necessary to relieve it by any possible means. Then purging, as by elaterium or podo- phyllum should diuretics fail, must be resorted to. Or, if the patient's stomach or general strength will not bear that, paracentesis, tapping, is called for. Some patients require this many times. The operation is best performed while the patient is lying down upon the side, near the edge of the bed. A trocar and oanula are introduced half-way between the pubes and the umbilicus, and the fluid is drawn out through the canula. Then a bandage, with a compress, is applied firmly around the abdomen. Some practitioners favor keeping open the orifice with a slip of lint, to maintain drainage. If no local irritation occur, threatening peritonitis in consequence, this may be a serviceable measure. If the bolder practice of in- jecting iodine after tapping, as in hydrocele, should be thought of in any instance, it must be in the case of simple peri- toneal dropsy, uncomplicated by serious visceral disease. Sometimes oedema of the lower limbs and scrotum becomes so great as to cause great inconvenience. Then the fluid may be let out by making a number of small punctures with an abscess lancet or small pointed bistoury. The only drawback to this is the possibility of erysipelatous inflammation about 478 INTESTINAL WORMS. the punctures. Such danger will not be at all great if, immediately after the operation, the parts be soothed by bath- ing or anointing the skin with diluted glycerine (f5j in f§j of rose-water), or cold cream (ung. aq. ros.), or glyceramyl (glycerine and starch) or with vasolin. For the treatment of ovarian dropsy, the reader is referred to Surgery. CHAPTER XV. INTESTINAL WORMS— ENTOZOA. Helminthology , the study of worms, has assumed importance in connection with medicine. About thirty entozoa inhabit different parts of the body of man. They have been generally classified as Codelrnintha, or hollow worms, and Sterdminthc or solid worms, as without any well-defined alimentary cavity. Broad or flat worms, Platelmia, and thread-like or cord-shaped worms, Nematelmia, constitute another arrangement. Of the flat worms, some are Cestoid, or ribbon-like; others Trematode, or flute-like. The most important ones are enumerated in the the following table : 1 . Cestoid Worms : Mature : Taenia solium; taenia mediocanellata ; taenia echinococcus; bothrio- cephalus latus. 2. Immature: Cysticercus cellulosse; echin- ococcus hominis; Cysticercus t. mediocanellatse. 3. Trematode Worms : Distoma hepaticum (fasciola hepatica) \ distoma ophthalmobium ; bilharzia hseniatobia ; tetrastoma renale. 4. Nematoid Worms: Ascaris lumbricoides; trichocephalus dis- par; oxyuris (ascaris) vermicularis. 5. Sclerostoma duodenale; filaria medinensis; strongylus gigas. 6. Trichina spiralis. Taenia solium and tamia mediocanellata look a good deal alike; but the former is much smaller. The immature cysticercus of the former is 9-10 of an inch long; that of the latter, of the size of a pea. The t. solium has a circle of hook- INTESTINAL WORMS. 479 lets around a convexity of the head; the medio canellata is club-headed, with larger sucking disks than the solium. One is designated as "arined" and the other "unarmed" tapeworm. The former (t. solium) is from the cysticercus cellulosce of the hog; the latter from the "cysticercus bonis"* (Cobbold); and is the most common. The unarmed is the easiest to drive out. The tapeworm is formed of flat segments, often several hundred in number, connected with the head by a slender neck. Each segment has male and female organs (herma- phrodite); as those at the tail mature, they are cast oif. Some patients thus pass six or eight fragments from the bowels in a day. The whole length of the parasite is from ten to thirty feet or more. The symptoms caused by tapeworm are not very determin- ate. They resemble those produced by other worms; namely,, uneasy sensation in the abdomen, and general nervous irrita- tion ; bad sleep, attacks of faintness, and lowness of spirits, indigestion, irregularity of appetite and of the action of the bowels ; itching of the nose, and sometimes of the anus. Epilepsy and insanity are said to have sometimes been caused by it. The only proof of tapeworm is the finding of frag- ments of it in the stools. It is a common impression that it is never destroyed unless the head is discoverable; but this is not exactly true. Conversely, if the head comes away, the parasite to which it belongs is no longer reproduced. More than one of them may, however, be present at once ; though this is rare. The broad tapeworm, hothriocephalus, is known only in Northern Central Europe ; Eussia, Sweden, Norway, Lapland, Finland, Poland, and Switzerland. Its head is elongated, compressed, obtuse; its length from six to twenty or twenty- five feet. It does not give off detached segments. Cobbold says it is indigenous to Ireland; although he has never met ♦Cobbold states that the hydatid of the cysticercus bovis has never yet been observed in man. Hydatid or "echinococcus" disease is especially frequent in Iceland. 480 INTESTINAL WORMS. with a patient born in that country who has been the subject of it. Prognosis. — Most worms may be readily got rid of if properly treated. Tapeworms are sometimes difficult to remove completely, but with systematic management a cure may almost always be effected. It is safest to see that the head of a tapeworm is discharged, else, if this remains, a further growth will probably take place; however, it is affirmed that if only the head and a small portion of the neck is left the worm will die; and further, the nearer the head any portion is which is detached, the more easily will the rest be got rid of. Worms may now and then prove highly danger- ous by their migrations, or by causing obstruction of the bowels; death may also occur from reflex convulsions excited by them. Treatment. — If worms are present, the first object in treatment is to get them expelled. The remedies must vary with the nature of the parasite. For tapeworm the following plan of treatment is usually efficacious. To let the patient take only liquids, such as milk and beef tea, for a day, then to administer a full dose of castor oil in the evening, and finally, early on the following morning, if the oil has acted well, to give a draught containing the liquid extract of male fern, in a dose of 10 drops to 5i or 5iss., according to age. The draught may be made up with sugar, mucilage, and milk, or with the yolk of an egg and cinnamon-water. The object is to clear out the bowels so as to expose the worm, and then the male fern acts upon it and kills it. Sometimes it is desirable to follow this up by another dose of castor oil, but generally this is not needed, as the drug itself acts as a purgative. Some prefer the powdered fern. In order to see whether the head is discharged, each stool must be received into a separate vessel, then mixed with water and filtered through coarse muslin. Other anthelmintics employed for the destruction of tape- worms are kousso, followed by a cathartic; hamela powder TREMATODE WOEMS. 481 5i to 5iij in treacle or syrup ; decoction of the bark of the root of pomegranate, §ij in Oj, boiled down to Oss.; powdered areca nut; oil of turpentine, 5i to 5ss.; and petroleum, xx to xxx drops. If the worm projects through the anus, it has been recommended to roll it gradually round a piece of stick, and thus draw it out, or to apply some poisonous agent to the protruded portion. Kamela, the Rottlera tinctoria of botanists, infusion of pumpkin seeds, plentifully taken on an empty stomach, are quite effectual. Prevention of Tapeworm. — As immature tapeworms find residence in the bodies of animals used for food, and thus get the opportunity to enter the human alimentary canal, the avoidance of raw or under-cooked meat is the precept of prophylaxis suggested and confirmed by experience. This -applies not only to the prevention of tapeworm, but, also, to that of other parasites, especially trichinae. Tapeworms are -derivable from infested beef, even oftener, (Cobbold) than from pork. Mutton has been found occasionally to contain ■cysticerci. Teematode Worms. These are the Distomata, Bilharzia hcematohia, Tetrastoma renale, and others. They are of a flattened oval shape, soft and smooth. They have a bifurcating alimentary canal, with n mouth, but no anus. Both sexes in distomata are upon one individual. They exist in two conditions, mature and encysted, and immature and free. Their methods of repro- duction are very curious, but of greater importance in .zoological than in pathological science. Distoma hepaticum, found sometimes in the liver and its •ducts, measures about an inch in length when mature, and rather less than half an inch in width. Distoma ophthalmobium has been found in the eye of a 482 NEMATOID, OR ROUND WORMS. child having congenital cataract. It is about half a line (1-24 in.) in length. Bilharzia (or distoma) hcematobia is found in great abund- ance in Egypt; where it inhabits the veins of the abdominal organs of the inhabitants, in the proportion of nearly one- third of the population. Hemorrhage from the kidney, and the symptoms of dysentery, may follow from its presence. It is not more than three or four lines (J to i in.) in length. The sexes are on different individuals. Tetrastoma renale is occasionally found in the substance of the kidney. It is nearly half an inch long. Nematoid, or Round Worms. Ascaris lumbricoides is the commonest of entozoa. It inhabits mostly the small intestines; but may get into the stomach, and of course, the large intestines. This round worm is from five to fifteen inches in length, light brown in color, tapering to a point at each end. A considerable num- ber of them may exist together; it is only then that their presence in the bowels is likely to do much harm, uuless in very susceptible children. Their escape into the stomach may cause nausea, vomiting, and indigestion, sometimes difficult to account for until the throwing up of the worm explains the cause. These worms probably enter the body chiefly in the drinking water of shallow wells, muddy streams, etc. Treatment; Diagnosis. — Two things are wanted: to expel the worms present, and to prevent their reaccumulation. As to the evidence of the existence of lumbricoid worms in the bowels, it is always doubtful unless some of them pass out with the evacuations. Signs of gastro-intestinal and nervous irritation attend them, especially in infants and young children. So, grinding the teeth during sleep, itching of the nose and anus, bad or irregular appetite, and tumidity of the abdomen, are regarded commonly as signs of worms. But other sources of indigestion and disturbance may be thus made known. OR ROUND WORMS. 483 Convulsions may undoubtedly be caused by worms in chil- dren ; and so may laryngismus stridulus and spasmodic croup. When there is good reason to believe that they do exist in the bowels, anthelmintics may be given, with purgatives, in safe doses, watching their effects. Besides the vermicides mentioned in connection with tapeworm, many other drugs have more or less of such effect; as santonin (most certain of all,) pinkroot (spegelia) bark of pomegranate root, azedarach, chenopodium, cowhage (mucuna), powder of tin, etc. Infusion of senna and spigelia, half an ounce of each to a pint; for an adult, a wineglassful every morning before breakfast; this is very popular and often effectual. Instead may be given fluid extract of spigelia and senna, a teaspoonful for a dose. As above said, santonin is the most effectual ot the vermicides or vermifuges. It requires care in its use, however; producing serious vomiting, prostration, and nerv- ous symptoms in over-dose. A child should not take more than half a grain of santonin once 'or twice daily; an adult, from three to six grains. Trichocephalus dispar. — This worm inhabits the large intes- tine. It has a length of an inch and a half to two inches. The head is attenuated or hair-like; whence its name. The sexes are on different individuals. The trichocephalus is much less common than the lumbricoid worm. Oxyuris vermicularis (Ascaris vermicularis) . White seat- worm. — Of this the male is about a line (1-12 in.) and a half long; the female five or six lines. It is found in the rectum, generally of children ; sometimes in considerable numbers. They cause a great deal of itching; occasionally, other nervous irritation. Females may have them to find their way into the vagina; more rarely, they get into the urethra. For treatment of seat-worms, nothing is equal to supposi- tories of santonin; made with cacao butter, three grains of the drug in each ; one to be introduced into the rectum every 484 TRICHINA SPIRALIS. niglit. Other common remedies are, injections of lime-water, infusion of aloes, salt water, etc. Trichina spiralis. — Zenker of Dresden first showed that, although a few trichince may be innocent, they sometimes abound to such an extent as to cause serious disease, and even to destroy life. Such an affection is called trichinous disease, trichiniasis or trichinosis. It has occurred particularly often in Germany, where it has been recognized since 1860. The first cases in America were reported by Dr. Schnetter of New York. At Marion, Iowa, in 1866, nine cases occurred in one family ; five died. In the same county, eating raw ham con- taining trichinae, as proved afterwards by examination, caused the disease in six children at once. An examination of pork in Chicago by a committee of the Academy of Sciences of that city proved the existence of trichinae in 1 in 50 of the hogs inspected ; some of their muscles containing from 10,000 to 18,000 in a cubic inch. Such animals are not themselves nearly always out of health. Cattle, also, are to a less degree subject to the same parasite. The 'meat of those so infected should of course not be used for 'food. In some German cities the butchers have microscopic examination made of the flesh of all their animals. To the naked eye, the muscles of a trichinous animal present whitish dots, which a lens will show to be the capsules or cysts of immature trichinae. Those not encysted are invisible without a microscope. The capsule is hard and transparent; the worm is coiled spirally within it. Under the tougue is the preferred place to search for the trichinae in the living animal ; a delicate harpoon being used. The trichina is a small bi-sexual worm, reproducing in the in- testinal canal of animals or men; the offspring then finding their way out through the walls of the intestines to become finally encysted in the muscles. The disease produced by them has two distinct stages : 1, that of the presence of the .worms in the alimentary canal, and their multiplication there ; 2, that of their migration to and location in the muscles. Of the first GUINEA WORM. 485 period, malaise, vomiting, and diarrhoea are the leading symp- toms. Of the second, fever resembling typhoid, severe pains, with stiffness in the muscles, and prostration. As the muscles of the larynx are often attacked, hoarseness is a common symptom. The complication of pneumonia is not infrequent. The first stage above mentioned lasts about a week or less ; the second may terminate fatally within six days, but usually has a duration of from two to four or five weeks. I am not informed of any success with the treatment of trichiniasis. Its prevention is always possible. Besides proper inspection of animals, every piece of meat which may be suspected must be well coohecl. Reliance cannot be had upon salting and smoking; at least unless they be very thoroughly done. Sclerostoma duodenale is common in Egypt and in parts of Europe. It exists in the small intestines, and causes a chlo- rosis-like anaemia. This worm is from a third to half an inch long. Its vermicide is said to be turpentine. Strongylus gigas (Eustrongylus gigas) inhabits the kidney. It is rare in man. Filaria medinensis (Dracunculus) or guinea-worm lives in the subcutaneous tissue. It is common in the tropical regions of the old world. The female worm it is, that enters the skin of a human being, and develops, with its contained young, in a whipcord-like shape, to a length varying from six inches to four, five, or six feet, and a width of about one-twelfth of an inch. A dozen or more of the worms may exist upon the same person. The lower limbs are especially invaded by them ; but they can migrate almost all over the body. They evidently get into the legs and feet of those who bathe in shallow streams or ponds, or walk barefooted in damp and muddy places. An incubation of a year or more is required for the development of the worm to a perceptible size. A characteristic vesicle appears, generally upon the lower part of the leg, when the worm matures. This bursts, emit- ting the young filarise ; a good deal of itching and irritation 486 THE PLAGUE. ensues, and sometimes ulceration. The natives often rid themselves of the worm by letting a stream of water run or pour for a time upon the leg. When it creeps partly out, they draw upon it until it is dislodged. CHAPTER XYI. "BLACK DEATH"— PE8TI8 BUBONICA OB BUBO PLAGUE. I have thought proper to briefly notice the epidemic now raging in the southern provinces of Russia, as a subject / of general interest. The large number exposed to the contagion who are attacked, its rapid spread, the short interval — only some hoars in many cases — between the appearance of the first symptoms and death, and the enormous mortality, from eighty-five to ninety per cent, of those attacked, are all characteristic of the plague. I know of no exanthematous disease so sudden in its onslaught, with high fever, frequent- pulmonary complications, and glandular swellings, especially in the groin, except the plague. These buboes, where death has not intervened before their appearance, are sufficient to distinguish the disease from typhus fever of however malignant a type. In all descrip- tions of the disease, whether ancient or modern, they occupy the prominent place, and so pathognomonic have they been regarded that the term pest or plague, at first applied to every very fatal epidemic, became long since synonymous with pestis buboniea, or bubo plague. It is not probable that the Russian government has at any time since the middle of December been ignorant of the real nature of the disease, and greater frankness and consistency on its part would have dis- THE PLAGUE. 487 armed the extravagant rumors circulated, given confidence to its neighbors, and caused no more injury to commerce than the course it has pursued. The epidemic had assumed serious proportions by the 25th of November, 1878 ; the government was only officially in- formed of it on the 11th of December; ten days more elapsed before any systematic or energetic means were taken for pre- venting its spreading, since which time the authorities have exerted themselves to the utmost. The precautionary meas- ures adopted are as against the plague : the erection of the in- fected districts into a distinct province with its governor ; the establishment of quarantine stations on the borders of this district, and of a double cordon militaire; an entire cessation of intercourse as far as possible, even postal communication except after thorough disinfection ; the wholesale destruction by fire of depots of provisions, and even villages, — still so late as January 18th the government, though acknowledging a mortality of not less than eighty -four per cent, of the attacked, was using the terms "the epidemic," "the disease," "malig- nant typhus," "galloping typhus with pneumonic complica- tion," represented the disease as diminishing; at the same time private intelligence represented the disease as increasing, and it was openly called the plague in a St. Petersburg med- ical journal. This want of candor has tended to increase the panic and foster exaggerated rumors. Intelligent precautions have been taken in Moscow, as the closing of all basement dwellings, the erection of clean temporary buildings, of furnaces to burn infected clothes, and the gratuitous distribu- tion of cooked food ; the report that cases of the disease had occurred there or at Lower Novgorod was premature. The latest available accounts give reason to suppose that the disease as an epidemic has not appeared to the north or west of the quarantine station of Zaritzin. A telegram announces the appearance of the plague in Thessaly, and any day may modify the situation. The infected district is in the lower valley of the Volga, near the Caspian Sea. The sanitary lines 488 THE PLAGUE. extend on both sides of the river, a distance of one hundred and fifty miles. Zaritzin, a town of fifteen thousand inhabi- tants, and a quarantine station, is at the northwestern extrem- ity of this district on the Volga, and Astrakhan, the capital of the province, at the southeastern extremity. There has been no outbreak of the disease in the town of Astrakhan. Its first appearance was in the village of Wetlianka, where it was in- troduced in the booty of returned Cossacks, which had escaped disinfection. From whence these Cossacks had returned we do not know, but it is certain that plague has been prevalent in the Persian province of Ghilan, at the southwest corner of the Caspian, since 1876 ; the intercourse of Russia with Persia is through the ports of this and neigh- boring provinces, and precautions have been taken by Russia for some time back against the ' introduction of the disease from the Persian province. The sparse population of the infected country, one to three to the square verst (two-thirds of a square mile), the spread of the disease has been rapid, its progress about thirty miles in three days. It seems to have followed the Volga, but Zaritzin is connected by rail with the entire net-work of Russian railways and with the rest of Europe, and the valley of the river Don, which flows into the Sea of Azof, here approaches very near the valley of the Volga. Should this point be invaded there would be great cause for general un- easiness. Hecker's Epidemics of the Middle Ages vividly portrays the progress and consequences of the black death of the fourteenth century. This terrific visitation of disease records one of the most im- portant events in the history of modern civilization. It sur- passed all other epidemics of bubo plague. The first extensive epidemic in Europe occurred in the middle of the sixth century, in the reign of Justinian, and is known by his name ; its last appearances were in Malta in 1813, in Noja, Lower Italy, in 1815, in Majorca in 1820. It is a mistake to suppose that plague only a disease of the past ; cases are probably THE PLAGUE. 489 always to be found in parts of Persia and Syria, and at various times since and before the Christian era. In comparison with past epidemics Europe has in its favor at present the greater cleanliness and better ventilation of its- towns, and the better knowledge of sanitation in quarantine and disinfection ; but the disease is favored by the great rapidity and intricacy of communication between different points, and the difficulty of making practical application of our increased knowledge. Notwithstanding the virulence of the plague of the fourteenth century there elapsed three years from its exportation from Syria in 1347 to its introduction into Russia in 1351, and this was effected by the way of Sweden and Norway, after it had made the complete circuit of Europe. It took the disease three months to travel from the coast of England up to London. There has always been much difference of opinion as to whether the plague is a di- rectly contagious disease, and it is perhaps better to regard the question as an open one still. Liebermeister calls attention to the fact that the same discussion has been and is still going on in relation to typhoid fever, cholera, and dysentery, and classifies the plague with them among the contagious mias- matic or indirectly contagious diseases. The contagion is certainly, as a rule, indirect, that is through clothes and other effects, and not directly transmitted from individual to indi- vidual. The stage of incubation is given at from two to seven days, but the plague poison is supposed to be capable of living a very long time under certain conditions outside the human body. No proper treatment is yet settled. The season of the year and climate have very slight influ- ence upon the disease, but moderate w T armth with dampness seem favorable to its propagation. It is not a disease of tropical climates, and the extremes of temperature, though not hindering the spread of the disease, diminish it. The epi- demic of the fourteenth century is reported to have attacked the robust by preference. Though far removed from its seat he present epidemic is of great interest to us in the United 490 INHALATION AND ATOMIZATION. States in its character and progress. It offers us an opportu- nity to observe the application and efficiency of various sys- tems of quarantine upon an extended scale, and of methods of disinfection, from which much may be learned of value in dealing with those epidemics which threaten our own part of the globe. It is important that medical men thoughtfully watch this epidemic, and acquaint ourselves with epidemic in- fluences and the means of crashing epidemics of every form and character. CHAPTER XVII. INHALATION AND ATOMIZATION. Palliation of pulmonary and bronchial or laryngeal irrita- tion, or diminution of excessive expectoration, as by simple vapor of water, tar-vapor, or that of infusion of hops, poppy leaves, etc., has been often realized. For ordinary inhalation, simple apparatus will suffice. A wide-mouthed bottle, with a cork in it; the cork pierced by two glass tubes, one straight, reaching near the bottom ; the other short and bent outside of the cork. The bottle not quite filled with the liquid (heated according to its volatility); the bent tube not reaching its surface, the other conveying air into it beyond the cork. This is not necessary, in the case of liquids used with water. We may employ these by pouring boiling water into a convenient vessel, the medicament added to it. Cover the vessel with a towel, hold the mouth and nostrils under the edge of the latter. Hops, in infusion, stramonium leaves, or laudanum, etc., may be used. Of laudanum, twenty or thirty drops in a pint of water, for worrying cough. Smoking is a primitive method of inhalation. Tobacco, so used, sometimes relieves in asthma; but cigars of INHALATION AND ATOMIZATION. 491 stramonium leaves, or of paper saturated with nitrate of potassium, are more effectual in the paroxysms of the disease. Recently minute division or atomization of liquids, intro- duced into the air-passages, has been substituted for inhalation. Under the fascination of novelty, the imposing appearance of instrumental appliances, a degree of enthusiasm has existed about it. It is an important means of treatment of the throat, and lungs. Referring to special works for details, I give but a brief account of atomization or nebulization. The idea is, forcing a fine jet of liquid against a solid body, or a strong current of air, so as to convert it into diffused spray. Bergson employed the tubes used for odorators, to spread perfumed liquids in the air. Two glass tubes with minute orifices are fixed at right angles, the end of the up- right tube is near and opposite the centre of the orifice of the horizontal tube. The upright tube, immersed in the liquid to be nebulized, air is forcibly blown through the horizontal one. The current of air, passing over the outlet of the tube com- municating with the liquid, rarefies the air, causing a rise of the liquid in the tube, and its minute subdivision (atomiza- tion, nebulization, pulverization), as it escapes. Silver tubes instead of glass are harder to keep clean. Glass ones may be cleaned with muriatic acid solution, aided by a bristle to remove obstructions. The form of tubes may be varied, to adapt their application to any part of the body. Richardson's spray-producer consists of a graduated bottle, through whose cork passes a double tube, a tube within a tube. The inner reaches near the bottom of the bottle, below, and above to near the extremity of the outer tube. The latter has entering it, above the cork, another tube connected with "hand bellows," — or, two elastic bags, the one nearest the bottle (protected by silk network) acting as an air-cham- ber, the farthest being compressed by the hand to produce a jet of air into the boti^e and tube. An apparatus for the application of steam-power to atomiza- tion : a small boiler is connected with the horizontal tube: in 492 INHALATION AND ATOMIZATION. the boiler steam is generated by a spirit lamp. The jet of steam from the horizontal tube nebulizes the liquid drawn up from the vertical tube immersed in a vessel containing it. The steadiness of action of the steam-apparatus is a great advantage; for many purposes, the hand-ball atomizer is more available. For effectiveness of inhalation, in chronic or subacute cases, the patient must have the instrument at home, learn its man- agement, and use it with regularity for a sufficient time. First inhalations should be short, with warm water, to inure the patient to their use. The distance of the mouth from the tubes vary from six inches to two feet. When pre- pared, one may inhale "medicated spray" for ten minutes; breathing deeply so that the liquid reach the remote air passages. It should not be done after a hearty meal; the patient should remain in-doors a while after the inhalation. Proof has been obtained that atomized liquids inhaled do pass into the trachea; constantly into the larynx. A certain portion may reach the lungs. Trial has been made of this process in croup, diphtheria, oedema of the glottis, catarrh, chronic laryngitis, whooping-cough, asthma, pulmonary hemorrhage, and phthisis favorably. False membrane has been asserted by Kuchenmeister, Bier- mer, Geiger, and others to be dissolved, or removed from the throat, by inhalation of hot lime-water. Cause the patient to breathe the vapor arising from hot water poured on unslaked lime. Dr. Da Costa says : "In most acute diseases of the larynx, more so in acute disorders of the lungs, the value of inhala- tions of atomized fluids, save in so far as those of water may* tend to relieve the sense of distress, etc., and aid expectora- tion, is very doubtful; though in some acute affections, as in oedema of the glottis and in croup, medicated inhalations have strong claims to consideration. "That in certain chronic morbid states of the larynx, par- HYPODERMIC MEDICATION. 493 ticularly those of a catarrhal kind, and in chronic bronchitis, they have proved themselves of great value. "That in the earlier stages of phthisis, too, they may be of decided advantage, 'and that at any stage they may be a valuable aid in treating the symptoms of this malady. "That their influence on such affections as whooping-cough and asthma is not satisfactorily proven. "That they furnish a decided and unexpected augmentation of our resources in the treatment of pulmonary hemorrhage. "That they require care in their employ ; and that in acute affections we should consider whether, as they have to be used frequently to be of service, the patient's strength justifies the disturbance or the annoyance their frequent use may be." Doses for Inhalation. — Alum, 10 to 20 grs.; tannin, 1 to 20 grs.; perchloride of iron, J to 2 grs.; nitrate of silver, 1 to 10 grs.; sulphate of zinc, 1 to 6 grs.; chloride of sodium, 5 to 20 grs.; chlorinated soda, J to 1 drachm; chlorate of potas- sium, 10 to 20 grs.; chloride of ammonium, 10 to 20 grs.; watery extract of opium, J to J grs.; fluid extract of conium, 3 to 8 minims; fluid extract of hyoscyamus, 3 to 10 minims tincture of cannabis indica, 5 to 10 minims; LugoPs solution of iodine, 2 to 15 minims; Fowler's solution of arsenic, 1 to 20 minims; tar water, 1 to 2 drachms; oil of turpentine, 1 to 2 minims. CHAPTER XVIII. HYPODERMIC MEDICATION. Hypodermic injection of medicinal substances is safe; more rapid, certain, and exact, in proportion to the amount, than medication by the mouth. It requires one-third or one-half the quantity necessary when given by the stomach; produces less complicated and less inconvenient results. The medicines mostly used are narcotics, sedatives, and nervine tonics. It is in symptoms affecting the nervous sys- 494 HYPODERMIC MEDICATION. tern that the greatest number of successful cases has been reported. Pain is speedily relieved by it. Hunter says : "When the immediate and decided effect of the medicine is required. "When medicines administered by the usual methods fail to do good. "Where the effect of a medicine is required, and the patient refuses to swallow. "Where, from irritability of the stomach, or other cause (such as idiosyncrasy, etc.), the patient cannot take the medicine by the stomach." The instrument approved is a small glass syringe, holding about half a fluidrachm, graduated for drops or minims, with a tube for puncture, of tempered steel, or of silver with a gold point. The end of the tube must be small and sharp. If the dose of the medicinal agent be not too large, the only danger (unless in an erysipelatous patient) is of a circumscribed in- flammation. Repeated injections should not be made at the same spot. Draw the skin tense with forefinger and thumb of the left hand, and pass the point quickly and steadily through it. Then push in slowly the desired amount of the fluid. Avoid subcutaneous veins ; the puncture of one of them may give rise to an excessive action of the medicine. Glycerine may be used as a vehicle instead of water. The agents most used are morphia, atropia, strychnia, and quinia. For anodyne purposes, Dr. Ruppaner prefers liquor opii compositus, one hundred drops are equal to a grain of sulphate of morphia. Many use the ordinary solution of morphia (gr. j of morph. sulph. in foj). Doses are as follows : — Sulphate of morphia, gr. ^ — J ; sulphate of atropia, gr. 1-60 — 1-30; muriate of strychnia, gr. 1-24 — 1-8; aconitia, gr. 1-30; liq. opii compos., gtt. v — x; sulphate of quinia, gr. i — iv. These for neuralgia, hysteria, cancer and ulcer of the stomach. A case of the latter affection is recorded in which for weeks or months the patient was only able to retain food HYPODEEMIC MEDICATION. 495 upon the stomach after the disposition to vomit had been allayed by a hypodermic injection of morphia. Curative effect has been asserted in cases also of delirium tremens, mania, and tetanus; from quinine (two to four grain doses) in inter- mittent fever. Tentative use of the same mode of practice is justifiable in cholera, hydrophobia, poisoning (as the injection of morphia for belladonna poisoning, and the converse), violent whooping- cough (atropia), pernicious fever, cerebro-spinal fever, heat- stroke, etc. That the operation is always without inconvenience to the patient is not true. Not only pain but local inflammation and even suppuration may sometimes be induced. But many patients, suffering painful complaints, have had a hundred or more injections made in different parts of the body, without any disadvantage, and great relief. Caution is necessary to prevent the habit of using hypodermic injections of morphia; in some instances, it has been known to become as inveterate an indulgence as the habit of taking laudanum or smoking opium. CHAPTER XIX. NATURAL THERAPEUTICS. The marked tendency of modern practice is to rely more upon the resources of nature and to dispense less drugs. The latter are very useful, of course, when wisely employed, but when given to excess or in depressing doses they are always pernicious. The former are the principal means of permanent relief and indispensable to health. Rest is one of the chief natural therapeutic agents, often the only one available or required. Warned through weariness of fatigue, exhaustion or pain, all other living beings, and 496 NATUKAL THEEAPEUTICS. uncivilized man seek rest and are restored from their few maladies without other aid. The quiet child who most sleeps most thrives ; the restless, wakeful child shows little proof of active nutrition. The healthy infant passes a greater portion of time in sleep and rest. Growth — the normal renewal o some parts, and the fresh development of others require rest and sleep. Many well known grave maladies are curable only through absolute rest ; in treating all diseases this agent is the most important one. Kest is the fosterer of repair ; is necessary for the healthy action of every organ ; and the means instituted by nature to secure quiescence and recupera- tion of the various viscera of the body. True, relaxation and due exercise of mind and body, in alternation, promote and perpetuate health. When the forces are expended in useful pursuits, rest is the one therapeutic agent to restore energy for resuming action in vigorous health. In all periods of life, from infancy to decadence, intellectual vigor, moral courage and physical endurance render regular rest and refreshing sleep indispensable. Conspicuous among natural therapeutics are pure air and water, wholesome, nour- ishing food, proper protection and favorable surroundings. Without these other therapeutic means are useless. This should be kept in mind. In early practice the average physi- cian seeks new or vaunted remedies, and puts those in requisi- tion in abundance. Later experience and observation dispel this delusion. Eminent and experienced physicians usually settle upon comparatively few therapeutic agents, to them well known to be efficient in their action, to fulfill the various indications in treating disease. The cardinal rule is: Never severely impress the system, nor employ remedies which can injure it. Support the vital forces through natural therapeu- tics, rendering whatever auxiliary aid may be afforded by the use of drugs, employing few and simple remedies— only those whose nature and known action give good results. Investiga- tion for new remedies and new uses of old ones are commend- ble and should be encouraged. INDEX. Page Anatomical characters 16 Atrophy '. 18 A typhoid ulcer 156 Anseniia — poverty of the blood... 195 Acute yellow atrophy 264 Albuminoid liver 267 Abdominal aneurism 306 Asthma 329 Angina pectoris 355 Acute pericarditis 364 Acute myocarditis 368 Atrophy of the heart 372 Arteritis 388 Apoplexy 403 Aphasia 408 Anaesthesia cutis 462 Army itch 464 Abscess of the lung 325 Abscess of the liver 257 Abscess of the brain 402 Aphonia 334 Addison's disease 201 Aphthae 203 Abscess, retropharyngeal 209 Acne — A. simplex, A. rosacea 455 Ascites 475 Anasarca 474 Ascarus lumbricoides 482 Blood-poisoning 197 Bloodvessels, diseases of, 388 Bowel hemorrhage — melaena 235 Bright's disease 311 Brain, diseases of, 396 Bronchitis 327 Bronchial dilatation 332 Page. Bullae — pemphigus 447 Bilharzia haematobia 482 Black death 486 Causation of disease — etiology 9 Congestion — hyperaemia 33 Classification of diseases 75 Clinical investigation of diseases 88 Catalepsy 418 Contagion, origin and nature of... 77 Convulsions , 419 Chorea— St. Vitus' dance 420 Calcification 58 Colloid degeneration 62 Chronic articular rheumatism 177 Cancrum oris — white mouth 204 Cancer of the stomach 214 Cancer of the duodenum, etc 214 Congestion of the fiver 255 Chronic diseases of the liver 266 Cancerous and other growths of the liver .273 Cirrhosis of the liver 275 Congestion of the spleen 294 Certain rare cardiac diseases 383 Chloasma versicolor 453 Clavus — corn 454 Condylomata 454 Chloasma versicolor 457 Cerebro — spinal fever 141 Cholera — epidemic 161 Constitutional syphilis 189 Chronic gastritis 212 Colic, gouty, bilious, lead, etc 221 Constipation 229 Cholera morbus 227 498 INDEX. Page. Cholera infantum , 236 Csecurn, diseases of, 243 Cirrhosis of the liver 275 Cystitis 317 Collapse of the lung 327 Croup , 336 Consumption 340 Cancer of the lungs 350 Cyanosis — blue disease ..385 Dropsy — hydropsy 37 Dropsical diseases 474 Degenerations 54 Disinfection 85 Diphtheria 107 Diseases of digestive organs....... .202 Dyspepsia — indigestion 215 Diarrhoea 232 Dysentery — bloody-flux 238 Diseases of the liver, etc 245 Diseases of the gall-bladder 280 Diseases of the spleen 292 Diseases of the pancreas 302 Disease of suprarenal capsules 304 Diseases of the urinary organs. .309 Diabetes mellitus — glycosuria 315 Diseases of respiratory organs 319 Diseases of circulatory organs 355 Diseases of bloodvessels 388 Diseases of the brain and nerves.. 396 Delirium tremens 432 Diseases of the skin 440 Dengue — break-bone fever 122 Dietetic treatment 29 Diathesis 169 Dropsical affections 474 Distoma hepaticum 481 Distoma ophthalmobium 481 Etiology 9 Epidemics 82 Epidemic, cholera 161 Embolism 199 Enteritis 217 Endocarditis ....366 Enlargement of the heart 371 Epilepsy 416 Emphysema of the lung 327 Encephalitis 396 Page. Eczema 445 Ecthyma 449 Elephantiasis Ara bum 455 Entozoa 478 Exanthematous inflammation. . . .441 Elephantiasis Grcecorum 458 Ephelis lentigo— sunburn 452 Fatty degeneration 55 Fatty infiltration 57 Fibroid degeneration 60 Fever — pyrexia 64 Fatty liver— hepar adiposum 266 Fatty degeneration of the heart... 373 Favus, porrigo, tinea favosa 464 Fever, types of, 67 Filaria medinensis '. 485 j Gonorrhceal rheumatism 181 Cout — podagra 183 Gastritis, acute 209 Gastritis, chronic 212 Gallstones— biliary calculi 282 General diagnosis of chronic dis- eases of the liver 285 General diagnosis of chronic car- diac diseases 375 Guinea- worm 485 Hypertrophy 17 Hygienic treatment 30 Hypersemia— congestion 33 Hemorrhage 39 Hooping-cough — pertussis 119 Hepatalgia...., 247 Hydatid tumor of the liver 268 Hypertrophy — leucocythsemia....296 Haemoptysis — -pulmonary hem- orrhage 352 Hydrocephalus 400 Hydrophobia — rabies 423 Hemicrania — sick-headache 427 Hysteria 434 Hypochondriasis 439 Herpes 446 Herpes zoster 447 Herpes circinatus 447 Hypertrophia 453 Hemorrhagise — purpura 460 Hemorrhages 468 INDEX. 499 Page. Haemateniesis 472 Hematuria 472 Hypodermic medication 493 Introduction 5 Induration 20 Inflammation 41 Individual diseases 93 Influenza — epidemic catarrh 121 Intermittent fever 123 Induration of pylorus 214 Icterus— jaundice 247 Inflammation of the bile-ducts... 261 Inflammation of the brain 396 Inflammation of the spinal mar- row 403 Intercostal neuralgia 428 Impetigo .' 449 Icthyosis — fish-skin disease 451 Intestinal hemorrhage 473 Intestinal worms 478 Inhalation and atomization 490 Jaundice — Icterus 247 Keloid, kellis, kelois, cheloid sclerema 459 Lardaceous disease 62 Low types of fever...-. 68 Lardaceous or waxy liver 267 Laryngitis 332 Laryngoscope 333 Laryngismus stridulus 335 Locomotor ataxia — Duchenne's disease 416 Lepra — leprosy 450 Leprosy (lepar Hebrseorum) 451 Lupus, L. exedens and non-exe- dens 457 Lichen, L. simplex, L. tropicus... 443 Lichen agrius 444 Mineral or calcareous degenera- tion 58 Mucoid degeneration 61 Measles — morbilli 117 Mumps — parotitis, etc 118 Malarial fever 123 Muscular and tendinous rheuma- tism — myalgia 178 Melasma supra-renalis 201 Page. Melaena — intestinal hemorrhage..235 Myocarditis 368 Modes of sudden death in heart disease 374 Malformations of the heart and great vessels 385 Mediastinal tumors 394 Migraine or megrim — sick-head- ache 427 Maculae — decolorations 452 Molluscum, acute, 456 Molluscum, chronic, 457 Nutmeg liver 256 Nephritis 310 Neuralgia 424 Naevus (mole, mother mark) 453 Neuroses 461 Nernatoid or round worms 482 Natural therapeutics 495 Obstruction of the bowels 226 Other morbid conditions of the spleen 298 CEdema 474 Ovarian dropsy 476 Oxyuris vermicularis 483 Preface to second edition 3 Petrification 58 Pigmentary degeneration 60 Prevention and limitation of epi- demics 86 Pernicious fever 134 Pyaemia — blood-poisoning 197 Pharyngitis 208 Peritonitis 219 Perihepatitis 261 Pneumonia 319 Pleurisy 322 Pulmonary gangrene 326 Pleurodynia — intercostal . rheu- matism 340 Phthisis pulmonalis 340 Palpitation 360 Paralysis 408 Prosopalgia — neuralgia of the fifth nerve 420 Papulae 143 Pemphigus 447 500 INDEX, Page. Pustulse ..448 Psoriasis, P. vulgaris, P. gyrata, etc 450 Pityriasis — dandruff., 451 Prurigo and prurigo senilis 461 Parasitica 462 Plica Polonica 467 Pulmonary apoplexy 471 Pestis bubonica or bubo plague.. .486 Rules for the practitioner 31 Remittent fever 128 Relapsing fever — famine fever.... 148 Rheumatism 169 Rheumatic fever 171 Rheumatoid arthritis — deform- ans 181 Rickets — rachitis 194 Removal of the spleen 299 Rhinoscopy 334 Rare formations in the lungs 352 Rupia 448 Ring-worm 466 Roseola 443 Synopsis of contents 1 Special causes of disease 15 Softening 20 Symptomatology — semeiology ... 22 Scarlatina — scarlet fever 100 Scurvy — scorbutus 187 Scrofula — scrof u losis 191 Syphilization 190 Spotted fever 141 Syphilis — infantile 190 Stomatitis 202 Stricture of the oesophagus 209 Syphilitic disease of the liver 279 Splenitis — hemorrhagic infarc- tion 295 Syncope — fainting 358 Strophulus — red gum 444 Softening of the brain 401 Sciatica — bip.gout 429 Squamse 450 Spedalsked 451 Page, Scabies 463 Sycosis (mentagra) 465 Syphilis — syphilida 467 Scald head 466 Sclerostoma duodenale 485 The use of the thermometer 89 Typho-malarial fever 137 Typhus fever, ship fever, etc 149 Typhoid fever, enteric fever, etc.. 153 Thrush— muguet 204 Tonsillitis — quinsy 207 Tuberculosis of the liver 279 Thyro-cardiac disorder 375 Thoracic aneurisms 391 Tubercular meningitis 399 Tetanus 422 Trematode worms 481 Tic douloureux— brow ague 426 Tubercula 455 Tinea circinatus 466 Tinea decalvans 466 Tape worm...... 479 Types of fever 67 Tetrastoma renale 482 Trichocephalus dispar 483 Trichina spiralis 484 The plague 486 Ursemia 309 Uterine hemorrhage 473 Ulcerations of Peyer glands 154 Urticaria— nettle rash 442 Variola — small-pox 93 Vaccination 97 Varicella— chicken-pox 99 Valvular disease 369 Vesiculse 445 Vitiligo — veal-skin 452 Veryuca — wart 454 Vicarious hemorrhage 473 What we must know of a patient 22 White seat worms 483 Yellow fever 137 Yellow atrophy 264 Zvmotic diseases 93 3 47 7