LIBRARY OF CONGRESS. 
 
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 tJNITED STATES OF AMERICA. 
 
1 
 
"7 
 
 
A COMPLETE 
 
 Handbook of Treatment, 
 
 ARRANGED AS AN 
 
 Alphabetical I 
 
 TO FACILITATE REFERENCE. .' 
 
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 WILLI \\f 
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 COPYRIGHT, 1887. 
 
 By 
 E. B. TREAT, N. Y. 
 
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PREFACE. 
 
 There is, perhaps, no more striking characteristic of the 
 medical practitioner of to-day, and none better illustrating 
 the pervading spirit of the age, than the universally observed 
 tendency among medical men to shun, in medical literature, 
 the unrealities of theoretical discussion, and to appropriate 
 with avidity only facts which they can instantly transform 
 into working force, and the gain from which is conspicuously 
 apparent. 
 
 Now and then we meet with a writer who has in part, at 
 least, appreciated this demand for the practical, the utiliz- 
 able, and has accordingly made some effort to supply this im- 
 perative appetite with the proper food. We have, however, 
 in the whole range of medical literature, no book which is a 
 complete reflection of the treatment of every recognized dis- 
 ease, no book which has taken for granted that the practi- 
 tioner knows what disease he has to cope with, and aimed 
 chiefly to supply him, ready for instant use, with the arma- 
 ment he must rely on to win the victory — an armament 
 which should embrace chiefly the best methods of treatment. 
 
 A book which is at once concise and comprehensive, which 
 is arranged so that the practitioner, given a disease to treat, 
 may have before him in a nutshell, the latest treatment re- 
 commended by the best authorities; and a book which is, 
 above all else, a book of treatment, we here offer to the 
 profession. It is composed of the chapters on Treatment 
 taken from the seventh (latest) edition of Dr. Aitken's Ency- 
 clopaedic work on the Science and Practice of Medicine, 
 which chapters have been revised and rearranged, so as to 
 make them more available for reference. The reader will 
 find that the work does not only embrace the experience of 
 its distinguished author, but also that of every known 
 authority. 
 
 3 
 
A COMPLETE 
 
 HANDBOOK OF TREATMENT, 
 
 ARRANGED AS AN 
 
 ALPHABETICAL INDEX OF DISEASES. 
 
 Acne. — Definition. — Inflammation of the sebaceous glands 
 and hair follicles, with retention of the gland secretion. 
 
 Treatment. — Local and general measures require to be 
 combined. Diet, in the first instance, should be restricted. 
 Wine, spirits, and coffee are to be refrained from. Milk is 
 to be used as a drink, and as an article of diet, combined 
 with light food, fresh vegetables, and succulent ripe fruits. 
 Emollient applications, such as an emulsion of bitter al- 
 monds, a decoction of bran or quince seeds, and tepid milk, 
 are useful. Dr. Anderson has found sulphur ( 3 i.)> mixed 
 with rectified spirit ( 3 i.)> to be shaken before using it; or a 
 mixture of hyd. corrosiv. sublim. (gr. ix.-xii.); hydrochl. am* 
 moniae( 3 ss.)cochinillini (gr. i.); aqae. rosoe ( 1 vi.), particularly 
 serviceable. Generally, if one fails, the other succeeds. 
 
 In that form of acne common to young women at the com- 
 mencement of their menstrual period, Dr. Ringer recom- 
 mends sulphur ( 3 i.), glycerine (/3 i.), water {fz x.\ to be 
 applied twice or thrice daily. 
 
 Whichever of these lotions is used, let it be applied by dip- 
 ping a piece of flannel into the lotion, and rubbing very 
 firmly over the eruption night and morning. Flowers of sul- 
 phur used dry to dust the parts with at bedtime is also of 
 service. To promote resolution of the induration, iodide of 
 sulphur, in the proportion of fifteen or twenty-four grains to 
 an ounce of lard, is of great service in dispelling the tumors. 
 Drastic purgation ought to be avoided. Simple baths at a 
 temperature of 88° or 90 Fahr. are of service. Calomel 
 ointment ( 3 i. of calomel to 3 ii. of lard) has been found use- 
 ful, care being taken against salivation. If there be much 
 thickening of skin, Mr, Milton recommends the internal use 
 
 5 
 
6 ADDISON S DISEASE. — AGUE. 
 
 of liquor potassae, although inferior to arsenic, which ought tc 
 be used. In dysidrosis, the treatment is mainly by carron oil 
 to the inflamed parts, with diuretics and tonics internally. 
 
 Addison's Disease. — Definition. — Disease of the supra- 
 renal capsules, with discoloration of the skin; or, a morbid 
 state which establishes itself with extreme insidiousness, 
 whose characteristic features are anaemia, general langour 
 and debility, and extreme prostration, expressed by loss of 
 muscular power, weakness of pulse, remarkable feebleness of 
 the heart's action, breathlessness upon slight exertion, dim- 
 ness of sight, functional weakness and irritability of the stom- 
 ach, and a peculiar uniform discoloration of the skin, which 
 becomes of a brownish olive-green hue, like that of a mulatto, 
 occurring in connection with a certain diseased condition of 
 the suprarenal capsules. The progress of the disease is very 
 slow, extending on an average over one year and a half, but 
 may be prolonged over four or five. The tendency to death 
 is by asthenia, the heart becoming utterly powerless, as if its 
 natural stimulus — the blood — had ceased to act. 
 
 Treatment- ~If the disease be recognized in its earliest 
 stages, its progress may to some extent be delayed. The 
 asthenia, the depression, the evidence of local irritation about 
 the suprarenal capsules, and the pathology of the disease gen- 
 erally, point to the necessity for tonic treatment and nutri- 
 tive diet, the avoidance of all causes of depression, and the 
 benefit of rest in bed, and of such medicinal agents as may 
 relieve the vomiting. Glycerine, in two drachm doses, com- 
 bined with fifteen or twenty minims of the spirit of chloro- 
 form, and of the tincture of the sesquichloride of iron, have 
 have been of service (E. H. Greenhow). This may be varied 
 by the substitution of twenty to thirty minims of the syrup of 
 phosphates of iron, quinine and strychnia, in place of the ses- 
 quichloride of iron. The greatest caution is necessary in 
 using purgative remedies as fatal collapse is apt to follow 
 cathartic medicine. 
 
 Ague. — Definition. — Febrile phenomena occurring in par- 
 oxysms, which observe a certain regular succession, charac- 
 terized by unnatural coolness, unnatural heat, and unnatural 
 cutaneous discharge, which prove a temporary crisis, usher- 
 ing in a remission. These phenomena continue to be devel- 
 oped in an uninterrupted series or succession of paroxysms, 
 more or less regular, which pass into each other by insensible 
 steps, so long as the ague lasts. 
 
AGUE. 
 
 Treatment. — It is useless to attempt the cure of inter- 
 mittent fever if the sufferer is permitted to remain within 
 the sphere of malarial influences. The old empirical treat- 
 ment in the English fens was first an emetic, then a sharp 
 purge, followed by quinine and arsenic. But an emetic 
 must not be given for ague, without regard to the special 
 circumstances of the case. Emetics are only of use when 
 the tongue is very foul or the stomach overloaded ; or when 
 there is nausea and headache with epigastric oppression. An 
 emetic will then give great relief, and hasten the stage of 
 reaction. In the simple cases, when removed from the 
 sphere of malarial influence, active purgatives are always 
 beneficial in relieving the full and congested state of the 
 abdomen generally ; and they prepare the way for the action 
 of quinine, especially combined with diureties, such as cream 
 of tartar (Wood). There are also cases of intermittent fever 
 complicated with hepatic and other engorgements, which 
 continue to recur despite of all means, until a few doses of 
 calomel, followed by purgatives, are administered ; then the 
 quinine, which before failed, will speedily cure the disease. 
 The compound jalap powder,combined with calomel, is found 
 very beneficial in such cases. If much urinary irritation 
 exist a mixture of 3 vi of bicarbonate of soda, dissolved in 
 \ viiss. of water, to which \ ss. of Sp. -Ethcris nitrosiis added, 
 given in half-ounce doses every two or three hours, with or 
 without tincture of opium, will relieve it. Certain morbid 
 conditions both of liver and spleen, may produce and main- 
 tain the tendency to recurrences of ague. Ramazini relates 
 the case of a patient harassed by an obstinate ague, and who 
 was cured by mercurial frictions administered for syphilis. 
 The influence of splenic disease in keeping up the morbid 
 train of actions of the original fever, and in producing re- 
 lapses, has been recorded by M. Piorry. In more than 500 
 cases of ague in which he observed the state of the spleen, 
 he comes to the following conclusions, namely : — that the 
 organ is invariably enlarged during the progress of the fever, 
 and that by the use of quinine the spleen diminishes in size ; 
 that its reduction in size bears some relation to the quantity 
 of quinine taken ; that the effect it produces upon the fever 
 is in proportion to the reduction of the spleen ; that the dis- 
 ease is cured simultaneously with the subsidence of the 
 splenic enlargement ; and that the fever is apt to recur so 
 long as the spleen exceeds its normal size. The treatment 
 of the disease as to stages is to be managed as follows ; — - 
 
8 AGUE. 
 
 During the cold stage the patient generally desires to be let 
 alone, care being taken that he has abundance of bed-clothes. 
 If the stage continues unusually long without signs of reaction 
 the application of external warmth becomes necessary with 
 warm drinks ; and even ammonia, ether, camphor, and other 
 diffusible stimulants may be required if the vital powers are 
 unequal to the development of reaction. During the hot 
 stage, diluent drinks may be indulged in, if the patient de- 
 sires them, with cooling diuretics ; but the danger consists 
 in the approach of collapse when the sweating stage com- 
 mences ; and when stimulants and support may be required. 
 The first dose of quinine should, then, be given towards the 
 close of the sweating stage. " I always assume," writes 
 Professor Maclean, " that in first attacks the type of the dis- 
 ease will prove to be quotidian, and take my measures ac- 
 cordingly, making sure that the patient shall have thirty 
 grains of quinine between the termination of one paroxysm 
 and the hour when we may look for another ; and looking 
 to the fact that we may look for the setting in of the cold 
 stage, perhaps tovo hours earlier than on the first day, the 
 last ten grain dose of quinine should be given so as to antici- 
 pate that time by at least an hour." It is to be administered, 
 in solution, dissolved by a small quantity of dilute sulphuric 
 add, and the dose mixed with syrup of orange peel. It may 
 also be administered in starch or beef-tea enemata, or by 
 subcutaneous injection. The object and action of quinine 
 are to break the system off " the habit of going through the 
 phenomena of an ' ague fit.' It counteracts the influence of 
 the malarial poison, and prevents the repetition of the 
 attacks. A moderate degree of cinchonism must still be 
 maintained for some days, to the extent of ' ringing in the 
 ears,' by giving three or four grains of quinine in solution 
 every three or four hours, and a day or two before the 
 interval of a month the patient must be again brought under 
 the influence of this remedy. Within this period (a lunar 
 month) there is always a tendency to the repetition of the 
 ' ague fit,' the habit of which must be thus broken ; other- 
 wise it will be strengthened by every successive attack " 
 (Maclean). Next to quinine in the cure of ague comes 
 arsenic. From six to eight drops of Fowler's solution may be 
 given during the interval of freedom from fever. It should 
 be given in small doses, and not persevered in for more than 
 eight or ten days ; and like quinine its use must be continued 
 in diminished doses for some time after cessation of the 
 
Albuminuria. — alcoholism. 9 
 
 fever. The earliest signs of its physiological action must be 
 looked for to determine to what extent it muse be pushed — 
 these being redness of the eyes, watering of the mouth, and a 
 silvery state of the tongue. The dose should always be 
 given after food. In malarial brow-ache (brow-ague) and ma- 
 larial hemicrania it is more efficacious than quinine. Due at- 
 tention must be paid to feeding during the intermission, 
 especially by beef-tea and farinaceous food. 
 
 In all complications of ague, be they cerebral, pulmonic, 
 hepatic, or gastric, quinine must still be the therapeutic agent 
 to be relied upon. Antiphlogistic measures are not to be 
 substituted in place of it on any account whatever. As to 
 the malarious cachexia, removal from the malarious locality 
 is the first essential condition to restoration of health ; the 
 next is a combination of nutritious diet, abundance of exer- 
 cise, pure air and pure water ; and clothing should be warm 
 on first coming into cold latitudes. The prophylactic use of 
 quinine must still be persevered in ; and if appetite fail, a 
 course of syrup of the phosphate of iron, quinine and strych- 
 nia in ten-minim doses, in a large quantity of water (a claret 
 glassful), will be of service. In the experience amongst the 
 invalided soldiers at the R. V. Hospital at Netley Dr. Mac- 
 lean has found this medicine of much use. The chronic 
 malaria cachexia is also much benefited by arsenic, especially 
 when there is diarrhoea. In such cases two minims of 
 Fowler's solution with five minims of laudanum should be 
 given before meals. So also the use of coti bark may be of 
 service in diarrhoea. In the treatment of the anaemic chlorosis 
 of malaria arsenic is especially adapted to those cases in 
 which iron does not agree ; while the efficacy of iron is often 
 also increased by its combination with arsenic. 
 
 Should the spleen continue of large size ointment of the 
 bin-iodide of mercury is to be rubbed in over the gland. A 
 portion about the size of a nutmeg is to be applied with a 
 smooth spatula, the patient sitting before the heat of the fire, 
 as long as he can bear the smarting which follows. The 
 remedy has a not less beneficial influence on enlarged livers 
 (Prof. W. C. Maclean). 
 
 Albuminuria— .S e Bright s Disease. 
 
 Alcoholism. — Definition. — A train of morbid phenomena 
 produced by the slow and cumulative action 01 ah o iol in the 
 various forms in which it is used as a drink. Delirium is one 
 of the most prominent features of the morbid state, which 
 is otherwise characterized by hallucinations, dread, tremors of 
 
10 ALCOHOLISM. 
 
 the tendons and muscles of the hands and limbs, watchfulness, 
 absence of sleep, great frequency of pulse. A thick, creamy 
 fur loads the tongue, and a cool, humid, or perspiring surface 
 prevails ; while the patient gives forth a peculiar odor, of 
 a saccharo-alcoholic description; more or less strong. 
 
 Treatment. — The indications are, — (i.) The elimination 
 of the poison ; (2.) the sustenance of the patient during this 
 period. The two most fatal errors which can be committed 
 in the treatment of delirium tremens are to bleed the patient 
 or to give him opiates. The greatest number of cases of 
 those treated by opiates are apt to terminate by convulsions 
 and coma (Morehead, Peddit, Law, Cahill, Laycock). 
 If it be true, also, that opium and alcoholic stimulants singly 
 are to be deprecated in the treatment of delirium tremens, a 
 fortiori in their combination there is a twofold danger, 
 alike in tropical as in temperate regions it is a course of 
 treatment attended with much hazard, and if systematically 
 followed, is certain of leading to unfortunate results (see 
 Moreheads's "Researches on Diseases in India ;" also, 
 " Notes on Treatment of Delirium Tremens," by W. Hanbury, 
 33rd Regiment, in Madras Quarterly Journal, July, 1863). 
 The strength must be supported by diet of the most nutri- 
 tious kind, in a fluid and mild form, such as yolk of eggs, 
 soups, and the like. Food should be given in small quanti- 
 ties and often. Beef-tea, spiced soup, and egg-flip, are each 
 to be commended at different periods of the day. If the pa- 
 tient continues to digest food, the danger is much diminished, 
 which in the first instance is from exhaustion. Careful 
 nursing is above all things necessary, so that protection from 
 all sources of danger may be adequate and the food ad- 
 apted to the state of the digestion, which is always feeble. 
 The disease must be treated as one spontaneously curable ; 
 not by withholding remedies, but by using them in strict 
 subordination to good nursing and carefully adjusted diet 
 and regimen (Ware, Hood, Peddie, Laycock, W. T. Gaird- 
 ner). Active specifics for delirium tremens appear to be 
 founded on the idea that the disease is one nominally of 
 high mortality. Hence the enormous doses of digitalis 
 (Jones) and of Cayenne pepper (Kinnear and Lyons of 
 Dublin) ; but before resorting to the use of such remedies 
 as digitalis, it will at least be judicious practice to adopt 
 such means as are calculated to restore the powers of nature 
 — namely, nutrients and rest ; while the stimulus of such a 
 spice as Cayenne pepper, given in the soup, on the atonic 
 
ALCOHOLISM. II 
 
 stomach, will have a favorable influence on absorption. 
 Under the care of my friend, Dr. Lyons, of Dublin, numer- 
 ous cases of delirium tremens have rapidly yielded to capsi- 
 cum, in doses of xx. to xxx. grains, in the form of a bolus. I 
 have given it in numerous cases and in all forms of chronic 
 alcoholism. Its influence in soothing the patient and in 
 securing quiet sleep has been certainly remarkable. By 
 some reviewers this influence has been questioned ; but the 
 evidence of its good effects are daily accumulating. Dr. 
 Ringer, in an able article in the Brit. Med. Journ., in 
 187 1, advocates the use of capsicum, " given in doses of 
 the tincture (five to ten drops) in a little syrup of orange 
 peel. Or the powder may be formed into five-grain pills 
 with extract of gentian — one to be taken every four hours 
 till quietude is obtained ; or, twenty grains in a single dose 
 may be taken before meals, or whenever depression or 
 craving for alcohol arises." It induces sleep in the early 
 stages of delirium tremens. It obviates the morning vomit- 
 ing, removes the sinking at the pit of the stomach, the in- 
 tense craving for stimulants, and promotes appetite and 
 digestion. Dr. Wilks prescribes it with nitric acid and nux 
 vomica. Dr. Lauder Brunton has given a great deal of at- 
 tention to this subject, and, according to his experience, a 
 combination of iron and nux vomica (say fifteen minims of 
 the tincture of the perchloride and ten of tincture of nux 
 vomica) is one of the most efficacious remedies for the tre- 
 mors of chronic alcoholism. If the stomach be deranged, as it 
 very frequently is, the indigestion should be treated previ- 
 ously to the administration of iron, by giving ten grains of 
 subnitrate or carbonate of bismuth with ten of magnesia, 
 suspended with gum tragacanth. If there be any tendency 
 to sleeplessness, or if the tremors should not rapidly disappear 
 under the use of the iron ami nux vomica alone, thirty or 
 forty grains of bromide of potassium should be given at 
 night. The chalybeate mixture already mentioned, either 
 alone or with the addition of five or ten minims of tincture 
 of capsicum, tends to alleviate the craving for drink. An- 
 other mixture recommended for this purpose consists of 
 sulphate of iron, magnesia, and oil of cloves ; a third consists 
 of carbonate of ammonia in infusion of gentian, to be taken 
 whenever the craving is felt. Should the craving come on 
 at intervals of several weeks, with complete intermissions 
 between, the case should be treated like one of epilepsy, by 
 the administration of bromide of potassium. 
 
12 ALCOHOLISM. 
 
 Chloral is now a most important and valuable addition to 
 our remedial agents in this disease. It produces sound and 
 refreshing sleep, followed by relief to all the symptoms. It 
 now seems to serve all the purposes intended by opium. 
 
 The late Dr. Jones, of Jersey, gave as much as half-ounce 
 doses of the tincture of digitalis till three doses had been 
 taken ; and then, if excitement were not subdued, nor sleep 
 induced, two fluid drachms were repeated every three or four 
 hours {Med, Times and Gazette, Sept. 29, i860). But Dr. 
 Ringer justly cautions against such excessive doses, and re- 
 cords two instances in which the patient suddenly fell back 
 dead. The disease no doubt proves suddenly fatal, some- 
 times independently of any remedy ; but the powers of digi- 
 talis in a tincture are much too uncertain to be relied upon 
 as safe in such enormous doses. Bromide of potassium has 
 been found of great use in calming the excitement of delirium 
 and procuring sleep, especially in the earlier stages of the 
 disease, before the delirium has become furious. The dose 
 may be xx. or xxx. grains every two hours. Its good effects 
 are, however, vesy uncertain when given alone ; less so when 
 combined as suggested by Dr. Lauder Brunton (Ringer). 
 
 In some cases purgative remedies are indicated from the 
 first. " These cases are known by the flushed, bloated ap- 
 pearance, the very foul tongue, the mawkish, peculiar odor of 
 the breath, the fetid discharges from the bowels, and the his- 
 tory of a recent surfeit of eating as well as drinking " (W T. 
 Gairdner, "Clinical Medicine," p. 271). 
 
 Opium may be administered with safety and advantage only 
 in protracted cases, provided the quantity given in twenty- 
 four hours is never allowed to exceed the full dose which 
 would be considered safe for a healthy person of the age and 
 sex of the patient. Where it appears to be indicated in pro- 
 tracted cases, it ought to be pushed as rapidly as possible for 
 two or three doses, while its effects are carefully watched. 
 Its use must be discontinued for at least a good many hours 
 as soon as a full maximum amount of 3 iss. to 3 ii. of the 
 tincture, in all, has been reached, or even sooner if the pupils 
 have become contracted during its icse. This remedy should 
 always be given in the fluid form, otherwise it is apt to ac- 
 cumulate in the bowels, owing to the weakened state of the 
 digestion ;and a laxative, or even a purgative, should be al- 
 ternated with opium, followed by a bitter tonic, which always 
 operates favorably in lingering cases of nervous and dyspep- 
 tic exhaustion. Narcotics are only safe in delirium tremens 
 
ALOPECIA AREATA. ANAEMIA. 13 
 
 when they are given with the object of aiding and seconding 
 the natural cure of the disease, employed in moderate doses, 
 and given only at the latter stages. The heroic use of them, 
 as heretofore too often advocated by most eminent phy- 
 sicians, is now recognized as a treatment which merely sub- 
 stitutes narcotic poisoning for aico/io/ism or delirium tremens. 
 Envelopment in a wet sheet, and then a blanket round the 
 wet sheet, is recommended by Dr. Wilks and Niemeyer as a 
 valuable sedative appliance. As soon as hot vapor so gener- 
 ated surrounds the patient, he falls into a quiec sleep (Med. 
 Times, Sept. 19, 1868}. 
 
 Alopecia Areata — See Tinea Decalvans. 
 
 All mini a. — Definition. — A disease in which there is 
 either a relative diminution of the mass of blood (Andral), 
 with the general composition and distribution of the blood 
 altered from the normal standard ; or in which the mass of 
 blood is diminished, and the liquor sanguinis is watery, poor 
 in albumen, and containing an excess of salts. These con- 
 ditions, co-existing with relative deficiency of the red blood- 
 corpuscles (Vogel), and a diminution of the urine-pigment 
 (ParkesV with altered innervation of the vascular system 
 Lebert), constitute anaemia. 
 Treatment. — The energies of the physician must be directed 
 to discover and counteract the cause of the anaemia. Nutri- 
 tious substances must be supplied for diet, in the shape of 
 easily digested meats and broths. The purely tonic treat- 
 ment, in the combination of air, exercise and diet ; must be 
 carried out as far as practicable. A change of air is abso- 
 lutely necessary, and generally also of diet. Iron is one of 
 the best medicinal remedies ; and it ought to be taken as 
 largely diluted with water as possible. The astringent pre- 
 parations are pre-eminently tonic ; and are especially useful 
 when the anaemia is associated with or dependent upon inor- 
 dinate discharges. Solution of the perchloride of iron, in the 
 form of tinctura ferri perchloridi, in doses of ten to thirty 
 minims in water, or in an infusion of quassia, or of calumba, 
 has properties in common with the numerous salts of iron, 
 and is one of the most reliable preparations. If the anaemia 
 is associated with diarrhoea, or menorrhagia, or leucorrhoea, 
 the solution of the pernitrate of iron, in similar doses, is at- 
 tended with benefit. A preparation which is no longer new 
 to the pharmacopoeia — the syrup of the phosphate of iron — 
 possesses the general properties of the ferruginous compounds, 
 
14 anemia. 
 
 and is of great service when the anaemia is associated with 
 certain forms of dyspepsia, or with amenorrhcea. It invigor- 
 ates and increases the powers of digestion, and may be given 
 to the extent of one to three drachms for a dose in water. 
 Another phosphatic preparation of very great value is that 
 which was devised by the late Dr. Easton, Professor of Ma- 
 teria Medica in the University of Glasgow. Although it is 
 not in the pharmacopoeia, and although its mode of prepara- 
 tion had not been published before Dr. Easton kindly sent 
 it to me for publication in the previous editions of this work, 
 yet the combination has become very popular throughout the 
 country as a valuable tonic in anaemia and cachexiae generally. 
 As such it has been largely used by my colleagues, Professors 
 Maclean and Longmore, amongst the used-up cachectic and 
 anaemic soldiers under treatment at the Royal Victoria Hos- 
 pital at Netley ; and I would add my testimony to its being a 
 
 most valuable medicine in gene ral practice.* 
 
 * The following is the original formula devised by Dr. Easton for the 
 preparation of the phosphates of iron, quinine, and strychnia, in the form 
 of a syrup ("Syrupos ferri, quinise et strychnia* phosphatum ") : — .1$ 
 Ferri Sulph. 3 v. ; Sodse Phosph. , 3 vi. (a little more phosphate of soda 
 gives a better result, say § i.) ; Quiniae Sulph., grs. cxcii. ; Acid Sulph. 
 Dil., q. s. ; Aquae Ammoniae, q. s. ; Strychniae, grs. vi.; Acid. Phosph. 
 Dil., 3 xiv. ; Sacchar. Alb., § xiv. " Dissolve the sulphate of iron in I 
 oz. boiling water, and the phosphate of soda in 2 oz. boiling water. Mix 
 the solutions, and wash the precipitated phosphate of iron till the wash- 
 ings are tasteless. With sufficient diluted sulphuric acid dissolve the 
 sulphate of quinia in 2 oz. water. Precipitate the quinia with ammomia 
 water, and carefully wash it. Dissolve the phosphate of iron and the 
 quinia thus obtained, as also the strychnia, in the diluted phosphoric acid; 
 then add the sugar, and dissolve the whole, and mix without heat. The 
 above syrup contains about one grain phosphate of iron, one grain phos- 
 phate of quinia, and one thirty-second of a grain of phosphate of strych- 
 nia in each drachm. The dose might therefore be a teaspoonful three 
 times a day. The amount of phosphate of quinia might be increased ac- 
 cording to circumstances ; and if eight grains of strychnia were employed 
 in place of six, as in the above, the phosphate of strychnia would be in 
 the proportion of the one twenty- fourth of a grain in every fluid drachm 
 of the syrup. I would scarcely venture on a much larger dose. In cases 
 of delicate children, with pale countenances and deficient appetites, I 
 have given, with great benefit, a combination of equal parts of the above 
 syrup and of that prepared by Mr. Edward Parrish, often called chemical 
 food. To children between two and five years of age, the dose of this 
 combination may be a teaspoonful three times daily. The preparation 
 ought to be kept as much as possible from light and air, otherwise the 
 preparation loses its characteristic opaline appearance, and assumes a 
 fawn color; a precipitate may be thrown down." It is prepared by 
 Messrs. Murdoch, Chemists, in Glasgow ; by Duncan and Flockhart in 
 Edinburgh ; by Randall and Sons, Southampton j an d by Savory arid 
 Moore, iii London, 
 
ANEMIA. 15 
 
 In some cases the astringent preparations of iron are not 
 suitable, and are apt to irritate delicate stomachs, or those in 
 whom any inflammatory local disease exists. For delicate 
 females and children the saccharated carbonate of iron is a 
 most valuable preparation, in the form of mistura ferri com- 
 posita to the extent of one to two ounces for a dose ; or in 
 the form of the pillula ferri carbonatis, in doses of from five 
 to twenty grains in the twenty-four hours. The citrate of 
 iron and ammonia is another remedy which possesses scarce- 
 ly any astringency, and may often be given in cases of anaemia 
 when the stomach will not bear more astringent preparations. 
 Five to ten grains of this salt may be taken during the twenty- 
 four hours. It is best taken during effervescence, pre- 
 scribed in solution of citric acid, and not in bicarbonate of 
 potash solution. If it is put into the latter, carbonic acid 
 will be given off, and probably burst the bottle. Tincture of 
 orange-peel is the best flavoring agent ; but as the salt will 
 not dissolve in the tincture alone, it is necessary to dissolve 
 the salt in water first, and then add the tincture, otherwise 
 the division into doses is impracticable (Squire). When it 
 is desirable to continue the use of iron for a long time, as in 
 the anaemia of neuralgic affections or tic-douloureux, or to 
 give it in large doses, the magnetic oxide of iron is the best 
 preparation to administer in doses of five to twenty grains 
 twice or thrice a day in water. The reduced iron — the fer- 
 rura reductum of the British pharmacopoeia — is also a reme- 
 dy which does not possess the astringent properties of the 
 other preparations, and is one of the most powerful remedial 
 agents in cases of anaemia. One to five grains may be given 
 several times a day in powder or in pill. It has no taste, and 
 one grain is equal medicinally to five grains of the citrate of 
 iron. The citrate of iron and quinine, either in solution or 
 in the form of a pill, is a new and useful preparation, in dose* 
 of five to ten grains three times a day. 
 
 Generally, such a preparation of iron must be found as 
 will not check the digestion of other food. If loss of appe- 
 tite and feverishness follow its use, the form of the remedy 
 is probably unsuitable, and requires to be changed. Chlorine, 
 in the form of warm hydrochloric acid baths, is highly spoken 
 of by Dr. T. K. Chambers, as an agent of great value, and as 
 a directly restorative medicine in anaemia (1. c, p. 332). The 
 bowels are to be kept regular by four grains of the pills of 
 aloes and myrrh taken at bedtime. Ferruginous remedies 
 are always of use when we have reason to believe that there 
 
l6 ANASARCA. ANGINA PECTORIS. 
 
 is a diminished energy in the formation of blood-cells ; and 
 if the urine be pale and almost neutral during the whole of 
 twenty-four hours, it is as good an indication for the use of 
 iron as the pallor of the skin in cases af anaemia (Parkes). 
 Dr. Trousseau was of opinion, however, that for anaemia, 
 complicated with tubercles, iron preparations were unsuit- 
 able, as tending to hasten their development. Dr. Clymer has 
 found arsenic a valuable remedy combined in the form of 
 chlorides of arsenic, iron, and quinine. 
 
 Anasarca. — Definition. — An accumulation of serum in 
 the areolar tissue throughout the body ; a general oedema or 
 anasarca with effusion into one or more of the large serous 
 cavities. 
 
 Treatment of general dropsy is regulated by the nature of 
 the disease which causes the dropsical state, and will be con- 
 sidered under Heart Disease and Kidney Diseases. 
 
 Angina Pectoris. — Definition. — Pain or spasm of a 
 weakened heart (Chevers), referred to the lower part of the 
 sternum, or to the praecordial region, extending through the 
 chest to the left scapula, and up the sternum to the root of 
 the neck. The pain is characterized by its suddenness, its 
 severity, and by a sense of constriction or of burning. It 
 compels the patient, if walking, instantly to stop, and almost 
 prevents inspiration. The pain is felt likewise in the left 
 shoulder, whence it sometimes reaches to the elbow, rarely 
 to the hand, often with a sensation of numbness in the parts. 
 A tendency to syncope exists, associated with intense anxiety, 
 and a sensation of approaching dissolution. 
 
 Treatment. — The indications are to be found in a study of 
 the lesions on which the paroxysms mainly depend. Med- 
 icine can do little more than mitigate the severity of an at- 
 tack. This is generally best done by diffusible stimulants, 
 such as brandy, ether, chloroform, ammonia, chlorodyne. Al- 
 cohol, in small doses often repeated, sesqui-carbonate of am- 
 monia, in doses of from three to five grains, the muriate of 
 ammonia, in doses of from ten to twenty grains, have each 
 powerful stimulant effects. Hot bottles and sinapisms 
 should be applied to the feet. The bowels may require to 
 be rapidly and efficiently acted upon. Thirty minims of 
 tincture of digitalis, repeated at the end of half an hour, give 
 great relief. It has also been beneficial when the angina was 
 associated with fatty heart. In that form of angina pectoris 
 where there is distension of the right ventricle, accompanied 
 
AORTA, ANEURISM OF. I 7 
 
 by palpitation, dyspnoea, and lividity of the face (cardiac asth- 
 ma), the frequent use of digitalis exercises a stimulating in- 
 fluence on the sympathetic cardiac ganglia and muscular 
 fibres (Fothergill). 
 
 Aorta, Aneurism Of. — Definitio?i. — A spontaneous cir- 
 cumscribed partial dilatation of some portion of the aorta, 
 consequent on lesion or degeneration of its walls. 
 
 Treatment. — Local bleeding is useful when there are pain 
 and tenderness over the aneurismal sac. General blood-let- 
 ting may be useful if the circulation is excited, and the pa- 
 tient be of full habit, but not on the principle advocated by 
 or ascribed to Valsalva. Of all remedies digitalis, aconite, 
 belladonna and veratrin are the most useful in tranquillizing 
 and regulating the action of the heart. The deposition of 
 fibrine from the blood is more prone to take place when the 
 circulation is " slowed." It is the principle of treatment in 
 the cure of aneurisms by pressure. The current of blood is 
 not entirely stopped, but is rendered more slow, so as to 
 have an amount of stagnation of blood in the sac favoring 
 the separation of fibrine and its coagulation. A diminution 
 of from ten to fifteen pulsations of the heart in the minute 
 will greatly tend to the filling of the sac with coagula (Ful- 
 ler). The medicinal agents which tend to promote this result 
 are, ergotine, gallic or tannic acids, tincture of steel, acetate 
 of lead, and iodide of potassium. Mr. Joliffe Tufnell, of Dub- 
 lin, has advocated the treatment of aneurisms of the thoracic 
 and abdominal aorta on the principle here enunciated — 
 namely, that of " slowing " the circulation. It consists of 
 restricted diet and perfect rest in the horizontal position, for 
 periods varying from eight to thirteen weeks, combined with 
 the employment of such remedies as may be necessary for 
 special ends. The horizontal posture must be strictly and 
 absolutely maintained, in a light and cheerful airy room, into 
 which the sun shines, and from which the patient may be 
 able to have as cheerful a view as possible out of the window. 
 The diet must be confined to three meals, served at regular 
 intervals, and restricted to the following in kind and in 
 amount : — Breakfast — Two ounces of white bread and but- 
 ter, with two ounces oi milk or cocoa. Dinner — Three 
 ounces of broiled or boiled meat, with three ounces of pota- 
 toes or bread, and four ounces of water or light red wine. 
 Supper — Two ounces of bread and -butter, and two ounces of 
 milk or tea. These diets should make, in the aggregate, ten 
 ounces of solid and eight ounces of fluid in the twenty-four 
 2 
 
18 AORTA, ANEURISM OF. 
 
 hours and no more. The object of the special diet is to main- 
 tain life on as little food as possible, without inducing restless- 
 ness, as in some irritable constitutions, but if such restless- 
 ness should occur, a little more food may now and then be 
 allowed. Anodynes, aperients, narcotics, sedatives, and tonics 
 are also useful aids in the management of the^ case. Of 
 anodynes lactucarium is the most valuable, given in the form 
 of a pill, by itself or combined with humulin and hyoscyamus 
 {Med. Rep. Army Med. Dep. y 1862, p. 472). The patient 
 must avoid everything which tends to increase the action of 
 the heart. Moderate living, without the plethora of excess, 
 but with sufficient nutrition to maintain the circulation at a 
 uniform flow, is the point to aim at. Fatal results may 
 speedily follow any marked change of diet and regimen (Cop- 
 land). Pain and depression will generally be subdued by 
 the hypodermic injection of morphia, commencing with one- 
 fourth of a grain. Cough is to be relieved by sedatives and 
 expectorants. Dyspnoea may require tracheotomy Dropsy, 
 may be lessened by mercury, digitalis, squills, juniper, and 
 decoction of .broom-tops. 
 
 Since 1861, the following three special modes of treating 
 aneurisms have been proposed, besides Mr. Tufnell's dietetic 
 method : — (1.) The introduction of a quantity of fine iron 
 wire into the aneurismal cavity, with the intention of supply- 
 ing an extensive surface over which fibrine may coagulate. 
 The late Dr. Murchison and Mr. Charles H. Moore practised 
 this method in a case of saccular aneurism of the ascending 
 aorta projecting through the anterior wall of the left side of 
 the chest. Twenty-six yards of wire were passed through a 
 small canula inserted into the tumor when it was evident 
 that the patient could not live many days. With some modi- 
 fications it was shown that the experiment might be justifia- 
 ble in some cases of sacculated aneurisms only {Med.-Chir. 
 Trans., Vol. XLVII., p. 129, London, 1864). (2.) The 
 method of rapid pressure treatment, as practised by Dr. 
 William Murray, of Newcastle-upon-Tyne, and Lecturer on 
 Physiology in the University of Durham. It has been ap- 
 plied to aneurisms of the abdominal aorta. The cure by 
 this method takes place rather by the coagulation of blood 
 in the sac from sudden cessation of the current, than to any 
 deposit of fibrine. The patient requires to be completely 
 under the influence of chloroform, so that he may suffer the 
 application of a powerful pressing instrument on sedative 
 parts, and so as to restrain all muscular movement. AH 
 
APOPLEXY. 19 
 
 movement of the blood in the sac must be completely arrest" 
 ed, and maintained in a motionless state, as in the applica- 
 tion of a ligature to the vessel for aneurism. The duration 
 of the treatment and maintenance of pressure can only be 
 measured by the result as to the time when pulsation ceases 
 in the tumor. The first condition of success is, that complete 
 arrest of circulation in the tumor must be steadily maintained. 
 Irregular pressure for ten hours has been known to fail. Con- 
 solidation has occurred in twenty minutes in a case of Dr. 
 Heath's, of Sunderland, when complete and steady pressure 
 was maintained, having failed in a first trial with irregular 
 pressure. (3.) Dr. Roberts, of Manchester, and Dr. G. W. 
 Balfour, of Edinburgh, have each collected cases, some 
 of them under their own care, in which the treatment 
 of aneurism of the aorta by iodide of potassium was persist- 
 ently carried out with remarkable beneficial results. The 
 dose varied from five, seven, ten, fifteen, and twenty to thirty 
 grains three times a day ; and the relief of pain, one of the 
 earliest symptoms of amendment, does not follow till an effi- 
 cient dose has been taken. It is better to begin with twenty 
 or thirty grain doses at once, and intermit or suspend them 
 for a day or two, if circumstances indicate the necessity of 
 such step. The object is to saturate the system with the 
 drug as speedily as possible. It is believed to owe its cura- 
 tive agency to its power of increasing the coagulability of the 
 blood. A few weeks may be sufficient to bring about the 
 curative result ; but Dr. Balfour's experience is, that any 
 considerable amendment can only be procured by keeping 
 the patient for many months, perhaps twelve or more, per- 
 sistently saturated with the drug. (Balfour, EJin. Med, 
 /our;/., July, 1868, p. 33 ; Chuckerbutty, in Brit.. Med. 
 Journ., July 19 and 26, 1862 ; Roberts, Brit. J fed. Journ., 
 January. 1863). The strict enforcement of the recumbent 
 position is an adjuvant of paramount necessity in the treat- 
 ment of all aneurisms. Tracheotomy may prolong life in 
 some cases where stridor exists, if the laryngeal symptoms 
 are the source of immediate danger (W. T. Gairdner). 
 
 Apoplexy. — Definition. — Hemorrhages within the skull 
 or spinal canal, consequent on the rupture of blood-vessels 
 in the membranes or substance of the cerebro-spinal nervous 
 system. 
 
 Treatment. — It may "incline the balance to recovery or 
 death." Bleeding from the veins of the arm, the jugular 
 vein, or the temporal artery, lias been the most conspicuous 
 
20 APOPLEXY. 
 
 method of treatment from the earliest times. It is now em 
 ployed only under the following circumstances: (i.) When 
 there is an obvious increase of intracranial pressure, it is 
 practiced so as to bring about indirectly a diminution of arte- 
 rial tension. With such intracranial pressure there is cerebral 
 hyperemia, and when a paralysis of the respiratory or vagus 
 centre is threatened, then it is that venesection by diminish- 
 ing this pressure may have the effect of prolonging life. 
 Patients have thus been roused from a state of coma. Clin- 
 ically, the indications for venesection under such conditions in 
 cerebral hemorrhage are: A turgid face with distended veins, 
 and increased pulsation of the carotids; a powerfully acting 
 heart; the radial artery of normal tension; the pulse of nor- 
 mal frequency, or slow and regular; when the respiration is 
 uniform, but of snorting character; when the patient is strong 
 and not too old. Slow and deep respiratory movements, 
 with stertor (indicating paralysis of the respiratory centre), 
 and combined with rapid pulse (indicating paralysis of the 
 vagus), add greatly to the necessity of immediate venesec- 
 tion. The beneficial action of the remedy is shown by the 
 pulse becoming softer, more subdued, and more regular. 
 Venesection is out of place in all cases which do not corre- 
 spond to this description (Nothnagel). Large bleedings are 
 to be avoided. The blood ought to be permitted to flow 
 from a large opening, in order more rapidly to relieve the 
 congestion, to check, if possible, further effusion of blood, 
 and to divert its active flow from the head. The head and 
 shoulders should be raised while the blood is flowing. 
 
 On the other hand, in some cases, bleeding during an 
 apoplectic fit hastens a fatal result — collapse occurring during 
 or immediately after venesection, from which the patient 
 never recovers. It is to be avoided in the old and decrepit, 
 where marked arterio-sclerosis is present; also if the pulse be 
 small and slow, feeble, or almost imperceptible, the skin cold 
 and clammy, with a tendency to death by syncope; if the 
 heart's action be feeble or weak, and the pulse irregular; if 
 the patient has been of intemperate habits, or is suffering 
 from organic disease of the heart and arteries; or if there is 
 a gouty or rheumatic history, no advantage is to be gained 
 by the abstraction of blood at this time and in this way. 
 Blood-letting is therefore absolutely contra-indicated under 
 the following circumstances: (a.) anaemia, (b.) aortic valvu- 
 lar disease, {c.) in cases commencing with syncope. In such 
 cases the use of stimulants must be had recourse to in order 
 
APOPLEXY. 2 i 
 
 to prevent paralysis of the heart. The clinical indications 
 for stimulants are: A pale collapsed expression of face, ab- 
 sence of venous turgidity, slight arterial tension, heart's im- 
 pulse weak, respiration hesitating and intermittent. It may, 
 in some exceptional cases, be necessary to follow or combine 
 venesection with stimulants. The stimulant agents may be 
 (i.) Such as will rouse the depressed activity of the respira- 
 tory centre, — e. g. y sudden sprinkling of the skin with cold 
 water; the application of ammonia to the nostrils; (2.) sub- 
 stances which will stimulate directly the heart's action — e. g. y 
 musk, strong coffee, wine, and preparations of ammonia. If 
 the patient cannot swallow, enemata of musk may be used 
 (Nothnagel). Many still believe with Trousseau, that in all 
 cases; grave or slight, patients do better without either blood- 
 letting or purgatives. He considers the part played by con- 
 gestion of the brain to have been much exaggerated. Dr. 
 Althaus, also, is of opinion (after an experience of more than 
 400 cases of hemiplegia from cerebral hemorrhage) that the 
 former universal treatment by venesection was thoroughly 
 irrational: and he considers that the condition of the brain 
 during cerebral hemorrhage is not one of congestion (as was 
 formerly believed , but is one of anaemia \ that the organ not 
 only loses blood largely, but is also, through compression 
 from the clot, unable to receive a fresh supply; that death 
 takes place chiefly from anaemia; and that by venesection 
 we hasten the fatal result. Instead of doing nothing, how- 
 ever, he recommends ergotine to be at once injected hypoder- 
 mically (a grain of lion jean's ergotine every hour, or even 
 every half hour), into the subcutaneous areolar tissue. Ad- 
 ditional chances of recovery may be given by applying to 
 the head cold cloths, or (rushed ice in a bladder, and mus- 
 tard cataplasms to the feet; also, by placing a drop or two of 
 croton-oil on the tongue, and by throwing up a cathartic 
 enema of castor oil and turpentine. 
 
 After the patient has in some degree revived, some time 
 should be allowed for the absorption of the blood effused be- 
 fore deciding upon the future treatment. A tew hours hav- 
 ing elapsed, the conduct of the practitioner should be guided 
 by the occurrence or not in the patient of pain of the head, 
 which may be taken as a measure of the fullness of the brain, 
 and its tendency to inflammation; but the less that is donedur- 
 ing the first three or four days the better. If pain in the head 
 continue, ten to twelve leeches should be applied from time to 
 time, till that symptom is entirely relieved; or, supposing the 
 
2 2 Apoplexy. 
 
 pulse to be full and strong, and the patient free from head- 
 ache, yet, under these circumstances, leeches should be ap- 
 plied to the head, to subdue that reaction which so generally 
 takes place from the fourth to the seventh day. The further 
 treatment of the case is by moderately purging the patient, 
 both as a means of relieving the head and of improving the 
 secretions of the alimentary canal, which are often black and 
 fetid. Active and searching purgatives generally do good at 
 this stage. Five grains of calomel with a drachm of com- 
 pound jalap powder, given as soon as the patient can swallow, 
 and followed up by black draught, or by an ounce of sulphate 
 of magnesia with camphor mixture every four or six hours, 
 and continued, according to its effects, for a greater or less 
 length of time, are the best means we have for promoting re- 
 covery, and for preventing a relapse. In cases of hypertro- 
 phy of the heart, without valvular disease, eight to ten 
 minims of digitalis may be added to each dose of the purga- 
 tive medicine. If the power of swallowing is in abeyance, 
 then three or four drops of croton oil, with five grains of cab 
 omel, rubbed up with fresh butter, should be put on the back 
 part of the tongue, and stimulating enemata thrown up the 
 rectum. The following are recommended by the late Dr. 
 Tanner: 
 
 1. Enema of Turpenti?ie and Castor -Oil. — IJ,. Olei Ricini, 
 Olei Terebinthine, a a § iss. ; Tincture Asafcetidae, 1 ii. ; 
 Decocti Avense, | xii.; misce, flat enema. To be thrown up 
 the rectum by means of a long stomach-pump tube. 
 
 2. Croton Oil E?iema. — §, Olei Ricini, Olei Terebinthinae, 
 a a | i., Olei Crotonis, m vi., Decocti Avenae, |iv.: misce, 
 fiat enema. 
 
 Although turpentine is objected to by some on account of 
 the intoxicating effects which it is sometimes apt to produce, 
 it is nevertheless an efficient remedy where torpor and insen- 
 sibility exist. It is of great importance to empty the rectum 
 and lower bowel. 
 
 If the intestines are distended by gases, an enema of castor 
 oil and rue may be given: 
 
 3. Castor Oil and Rue Ene?na. — 1>. Confectionis Rutae, 
 
 3 i. ; Olei Ricini, f i. ; Tincturse Asaf cetidae, 3 ii. ; Decocti 
 Avenae, § vii. ; misce (Practice of Medicine, 4th edition, p. 
 6 53)- 
 
 Apprehension of a relapse being at an end, the patient is 
 in general most willing to believe that the palsy which may 
 remain is a mere local disease, and to submit to any treat- 
 
ARTERITIS. ASCITES. 
 
 ment for its removal; but every attempt to act locally on the 
 muscular system is prejudicial so long as any central irrita- 
 tation exists. Such remedies are neither theoretically nor 
 practically useful. (See " Paralysis.") Active or passive 
 exercise of the muscles are remedies highly beneficial. The 
 induced current of electricity is also beneficial. It seems to 
 improve the nutrition of the paralyzed muscles, which tend 
 to atrophy from long disuse, and paralysis tends also to get 
 worse from diminished excitability of the nerves. Local 
 faradization by induced currents of electricity gives artificial 
 exercise to these muscles, and thereby improves their func- 
 tional and nutritive properties. 
 
 Dietetic and Prophylactic Treatment. — The diet of the pa- 
 tient should be limited to milk, boiled vegetables, light pud- 
 dings, and fish. At no subsequent period ought he to in- 
 dulge in a full animal diet, or to drink undiluted wines. At 
 the same time, too lowering a regimen is to be avoided, as 
 thereby the irritability of the system and the heart's action 
 generally is increased'. All the causes of the disease already 
 fully referred to should be avoided, counteracted, or over- 
 come. The diet and the bowels should be carefully T( 
 laud, and the patient placed under the best possible hygienic 
 inflm A sojourn at the moderately warm water 
 
 Wildbad, Pf&ffers, Etagatz, and Laudeck (Teplitz with great 
 caution', and Rehme and Xauhein, are recommended by 
 Niemeyer and Nothnagel. with careful regulation of diet and 
 exercise. 
 
 Arteritis. — Definition. — Inflammation ot the textures of 
 
 an artery. 
 
 Treatment.— latches should be applied freely over the 
 course of the vessel ; and larg l of opium, or of ether 
 
 with chloroform, may be given to relieve pain and dyspnoea. 
 Iodide of potassium or colchicum may also be indicated, ac- 
 cording to the constitutional morbid condition which has 
 brought about the lesion. 
 
 Arthrit is, Kheumat ic— See Ostco- Arthritis, Chronic- 
 
 Ascites.— Definition.— A collection of serum slowly ef- 
 fused into the cavity of the peritoneum. 
 
 Treatment. — When ascites occurs without any obvious 
 organic cause, and without albumen in the urine, the best 
 remedy is the bitartrate of potash, administered in divided 
 doses, as one drachm three times a day, or every six hours ; 
 or in one large dose, as half an ounce, combined, if the 
 
24 ASCITES. 
 
 paitient's bowels be confined, with ten to fifteen grains of 
 jalap. When the smaller doses are used, it may be useful to 
 add ten grains of the citrate or tartrate of iron to each dose. 
 If these remedies should fail, one-sixth to a half a grain of 
 the extract of elaterium every night, or every other night, may 
 be given. When ascites is combined with anasarca, squills 
 afford most relief. Five to eight grains of the pulvis scillae, 
 three times a day, generally relieve the dropsy. If the 
 stomach be irritable, half a grain of opium should be added 
 to each dose. When the ascites arises from disease of the 
 heart, the kidneys being sound, and the urine free from albu- 
 men, the treatment must have reference to the nature of the 
 cardiac lesion. If the valves of, the heart are diseased, the 
 patient may be greatly relieved by the administration of 
 tonics, stimulants, and saline or drastic purgatives. An 
 ounce and a half of camphor mixture, with a drachm of the 
 spirit of nitrous ether, fifteen minims of the tincture of hyoscy- 
 amus, and a drachm of the sulphate of magnesia will form a 
 draught which, taken three times a day, may greatly reduce 
 the , dropsy, ^he tincture of squills (mx. to mxx.), with a 
 drachm of the acetate of potash, has occasionally succeeded. 
 Small doses of elaterium, as one-eighth to one-fourth of a 
 grain three times a day, is a medicine that is also sometimes 
 useful. Should the liver be inflamed or hypertrophied, with- 
 out other alterations of structure, the dropsy may disappear 
 with the cure of the hepatic disease. Bleeding by leeches, 
 if the hepatic lesion be due to the congestion of inflamma- 
 tion, and the neutral salts, such as the sulphates of magnesia or 
 soda, or moderate doses of calomel, may give relief. If due 
 to a cirrhotic liver paracentesis abdominis ought to be re- 
 peated as a systematic method of treatment (F. T. Roberts). 
 Abdominal pains are relieved most effectually by fomenta- 
 tions. The bowels are often greatly constipated, and require 
 drastic purgatives, as the black draught, castor or croton oil, 
 or even elaterium. In ascites depending on enlarged spleen 
 when it is simply hypertrophied, the bromide of potash, and 
 the iodide of potassium, in doses of five to eight grains three 
 times a day, have been found useful. My friend and col- 
 league, Professor Maclean, has found that rubbing the binio- 
 dide of mercury, in the form of an ointment, in the proportion 
 of 15 grains of thebiniodide to one ounce of lard or vaseline, 
 on the skin^ over the enlarged spleen, has a marked bene- 
 ficial effect in reducing the enlargement. The ointment, in a 
 piece about as large as a nutmeg, is to be rubbed into the skin 
 
ASTHMA, HAY. ASTHMA, SPASMODIC. $$ 
 
 while the patient sits before a strong fire or in the rays of an 
 Indian sun ; in the evening of the same day, half the amount 
 is to be rubbed in lightly ; and the ointment is not to be re- 
 peated at a less interval than 14 days. The invalided sol- 
 diers suffering from splenic enlargement invariably ask for a 
 supply of the remedy when they go from hospital. The 
 biniodide of mercury, similarly used, has been of great service 
 in reducing the swelling of a goitre. The dropsy which oc- 
 curs in young chlorotic women, in whom the urine contains 
 albumen (the kidney being healthy in structure though dis- 
 ordered in function), is generally curable, — the most efficient 
 remedy is the bitartrate of potash in drachm doses three 
 times a day, combined with iron. 
 
 Asthma, Hay. — Definition. — A peculiar catharral affec- 
 tion occurring during the summer months, especially during 
 the inflorescence of the g r during the drying and 
 
 conversion of the newly-mown grass into hay in May, June, 
 and July. 
 
 Treatment. — Regarding it as the result of irritation (spc< : i- 
 fic or mechanical) from fine particles of matter (indefinite 
 dust or specific powder) floating in the air, the use of a res- 
 pirator of fine cotton, or of (rape or cambric in several folds, 
 should prevent the affection, and ought to be tried by those 
 who suffer every year about the months of May and June. 
 In other respects the local catarrh must be treated as de- 
 scribed under " Bronchial Catarrh," and M Bronchitis." 
 
 Asthma. Spasmodic. — Definition. — A disease which 
 culminates in paroxysmal attacks of difficult breathing, of 
 varying duration. The dyspnoea seems to be immediately 
 dependent on more or less extensive contraction of the small- 
 er bronchi, due to spasm of their circular fibres. The breath- 
 ing is accompanied by a whec/ing sound, a sense of constric- 
 tion in the thorax, great anxieties, and a difficult cough. The 
 attack usually terminates by the expectoration of a quantity 
 of mucus from the lungs, which varies considerably in ap- 
 pearance and in amount. In some instances the mucus is 
 thick and heavy, in others it is light and frothy, whilst in the 
 severer forms there may be only a few dark pellets coughed 
 up before relief is obtained (Pndham). In the hours imme- 
 diately succeeding the fit, a remarkable diminution of the 
 urea and chloride of sodium may occur, which would imply 
 a considerable arrest either of formation or elimination, 
 probably the former (Ringer, Parkes) ; or to the starvation 
 that is generally enforced at that time (Salter). 
 
26 ASTHMA, SPASMODIC. 
 
 Treatment comprises, (i.) What should be done during 
 the fit ; and,(2.) during the intervals. When a patient is la- 
 boring under a fit of either form of asthma, to tranquillize 
 his suffering and shorten the attack is the aim of treatment. 
 Any exciting case must be removed. An undigested meal, 
 or constipation, must be got rid of — by an emetic in one case, 
 or by an enema in the other. The patient should have a strictly 
 tonic regimen ; and camphor mixture, to the extent of about 
 an ounce and a half, combined with a drachm of the spirits of 
 nitrous ether and some morphia, may be giyen every hour, or 
 every two hours, for a short time. Some milder narcotic may 
 be substitued for morphia, as tincture of hyocyamus, to the 
 extent of about fifteen drops for each dose. Or asafcetida, 
 castor, musk, or hydrocyanic acid, to the extent of miij. every 
 six hours, may be substituted. If the fit should occur after 
 a hearty meal, and after an emetic has been given, the tinc- 
 ture of rhubarb, or the sulphate of magnesia, should be con- 
 tinued in repeated small doses. If the attack be long, arrow- 
 root or sago, with small quantities of wine or brandy, should 
 be given to support the patient under his exhausting suffer- 
 ings. Ipecacuanha, tartar emetic and tobacco are the drugs 
 which most rapidly relax spasm as direct depressants. There 
 is, however, great danger in the use of the latter, from un- 
 manageable and dangerous collapse. Tobacco ought never 
 to be indulged in by the asthmatic, except as an agent in the 
 cure of his disease. Then only can he look to it for relief, 
 and it should be smoked from a pipe. Ipecacuanha ought to 
 be given in a dose of twenty grains at the onset of the parox- 
 ysm. The feelings of the sufferer should be consulted as to 
 the temperature to which he should be exposed during the 
 paroxysm. Where there is any organic lesion the fresh air 
 is grateful and reviving. On the contrary, when the parox- 
 ysm is purely a spasm of the bronchial tubes, warmth, by 
 relaxing spasm at their ultimate divisions, is generally more 
 useful than cold. Patients learn by experience what will 
 give them most relief. Strong coffee, spirits and water, ice 
 rapidly swallowed, may suit individual cases. 
 
 The treatment during the interval is all-important. Few 
 cases will be found of true spasmodic asthma which are not 
 entirely under the control of well-regulated dietetic manage- 
 ment. By many physicians a rule of life as to diet is the only 
 certain treatment of asthma. Extremely strict dietetic treat- 
 ment and sedatives during the intervals of the paroxysms 
 must be prescribed. A plan of treatment somewhat as follows 
 
ASTHMA, SPASMODIC. 2 7 
 
 may be laid down, after that suggested by Mr. Pridham of 
 Bideford and Dr. Hyde Salter of London : — The secretions 
 from thebowekare first to be corrected by Pilulae Aloes cum 
 Myrrha, gr. iii. ; Pilulae Hydrargyri, gr. i. ; Extracti Tar- 
 axaci gr. ii.; Extracti Strammonii, gr. ss., made into two pills 
 to be taken at bedtime, followed by a saline aperient in the 
 morning. Or giving, every alternate night, Pil. Hyd., gr. iv.; 
 Pulv. Ipecac, gr. i., in the form of a pill. And on the fol- 
 lowing morning, Mist. Sennae comp., 3 i. ; Biearbonatis Mag- 
 nesia, gr. x. ; Biearbonatis Sodae, gr. viii. ; and during the 
 day small doses of compound rhubarb powder. After thus 
 attending to the general secretions for about ten days, a strict 
 diet is to be commenced, which must be regularly weighed 
 out and adhered to, the hours of meals being fixed. (1.) 
 Breakfast at eight a. m., to consist of half a pint of green tea 
 or coffee, with a little cream, and two ounces of dry stale 
 bread. Dr. Salter allows an eggw (not and) a mutton chop, 
 or some cold chicken or game. Tea is better than coffer, 
 and milk and water better than either. (2.) Dinner at one 
 P. M., to consist of two ounces of fresh mutton, without fat ( r 
 skin, and two ounces of dry stale bread or well-boiled rice. 
 Beef and lamb should be rarely eaten, pork or veal never. 
 There should be no cheese and no dessert (Salter). Three- 
 hours after dinner (not sooner) half a pint of weak brandy 
 and water, or whisky and water, or dry sherry and water, 
 may be taken, or toast- water ad libitum. Water is the best 
 fluid to drink. (3.) Supper at seven v. m., to consist of two 
 ounces of meat as before, with two ounces of dry stale bread. 
 The patient is not to be allowed to drink any fluid whatever 
 within one hour before his dinner or supper, and not until 
 three hours after either of these meals. At other times he is 
 not limited as to drinks, otherwise than that all malt liquors 
 are to be prohibited. Soda or seltzer-w atcr may be indulged 
 in when thirsty. With this dietetic treatment, sedatives, such 
 as three grains of the extract of conium, are to be taken four 
 times a day — namely, at the hours of seven, twelve, five, and 
 ten, — the dose to be gradually increased to five grains four 
 times a day. To each of these pills a fourth of a grain of 
 the Extract of Indian hemp may be added, which may be 
 gradually increased to one grain in each dose. Under this 
 treatment in a few days distressing symptoms subside ; and 
 after the regimen has been strictly persevered in for at least 
 a month, two ounces more of meat may be permitted, if di- 
 gestion is sufficient. The stools must be repeatedly seen by 
 
2o Asthma, spasmodic 
 
 the physician ; and the stomach must not have more to do 
 than it can accomplish. The powers of digestion are known 
 to be recovering when there is a craving for food as the hour 
 of nourishment arrives. If flesh is gained, strength improves ; 
 and while the tongue cleans, the appetite improves, the dis- 
 tension of the stomach lessens, and the powers of digestion 
 recover. The patient ought to be able to sleep six or seven 
 hours at a time, and to lie in bed all night. If these results 
 follow, the ultimate cure of the disease may be looked for ; 
 but it may at the same time be taken for granted that the 
 asthmatic can never with impunity eat and drink as other 
 people. It is only by the exercise of self-denial that the pa- 
 tient has it in his own power to live a life of comparative 
 ease and comfort. Many patients not possessed of such re- 
 solution, self-denial, and strength of mind, will say such 
 dieting does not suit their constitution, and that they cannot 
 or will not persevere ; but no trial of the remedy can be con- 
 considered sufficient which does not embrace a period of at 
 least six months, the physician taking care to ascertain the 
 weight of the patient, his age and height, before commencing 
 any treatment. It is difficult to persuade many people to live 
 so abstemiously. Many cannot control their appetite ; or 
 they believe that in so limiting themselves in regard to diet 
 they will injure their constitution. It is necessary to subdue 
 by sedatives rather than opiates the abnormal ravenousness 
 of appetite. Asthmatics are generally dyspeptics ; and the 
 most simple rule regarding diet is : — Let no food be taken 
 after such a time in the day as will allow digestion being 
 completed or the stomach empty before going to bed. The 
 time when the last solid food should be taken will depend 
 upon what the bedtime is. If ten, or half-past, then three or 
 four should be the dinner hour, after which no more solid 
 food should be eaten. 
 
 Open air exercise must be freely taken, but not within 
 three hours after eating animal food, and the exercise must 
 be always short of fatigue. The greatest punctuality is 
 necessary as regards the taking of food, of exercise, and of 
 medicine ; and the bowels should act immediately after 
 breakfast, either naturally or by enema. Success depends 
 on the regularity with which all the functions of the body 
 can be performed ; and care should be taken to rest body 
 and mind, at least, for one hour after food. Smoking stra- 
 monium, the inhalation of chloroform, or of ether, or both, al- 
 though they appear to soothe and mitigate the paroxysm in 
 
ASTHMA, SPASMODIC. 29 
 
 some cases, yet they do not appear to shorten the attack in 
 any The inhalation of nitrite of amyl has been recently recom- 
 mended The fumes of stramonium are to be collected man in- 
 verted glass bowl with a narrow mouth.The bowl being charged 
 to its full, is placed under the mouth of the patient, who is 
 directed to inhale, to the fullest extent in his power the 
 smoke which has been collected in the bowl. Or the stra- 
 monium may be smoked like tobacco, then puff the smoke 
 into a tumbler, and inhale it cold into the lungs (Bullar). 
 Or it may be smoked as an Oriental smokes the hookah, in 
 which the smoke is purified by being passed through water. 
 Cigars and cigarettes of stramonium are now sold by the 
 chemists The fumes of brown paper saturated with a solu- 
 tion of nitrate of potash sometimes also relieve the spasms. 
 Indian hemp, in doses of from two to four grains of the ex- 
 tract, or thirty minims of the tincture, will often relieve : the 
 spasm for the tune being; but may fail ever after, (Sec Wat- 
 son, " Lectures on the Practice of PhySIC, \ "1 II). § 
 
 Only one remedy— jaborandi, and its alkaloid pilocarpi*-- 
 
 has been found not only to remove the urgent symptoms of 
 asthma, but to exercise, at the same time, a favorable influ- 
 ence on the disease itself. It produces a powerful revolution 
 In the distribution of the blood, by attracting a large volume 
 to the skin and salivary glands ; and by diminishing its 
 ume through copious perspiration and salivation, congested 
 internal organs are relieved in a proportional degree. Dr. 
 Berkhart has found the alkaloid preferable to jaborandi be- 
 cause— (i ) It acts more rapidly; (2.) it does not produce 
 strangury; (3.) the dose can be more accurately regulated. 
 In cases where the cardiac muscles are in a state of fatty 
 defeneration, the influence of pilocarpus may induce the 
 most alarming symptoms; which soon spontaneously subside, 
 the heart regaining its previous force. But if it lingered to 
 do so a subcutaneous injection of T U or ^ grain of atropine, 
 or one drop of liquor atropia (B. P.), immediately restores 
 the balance. Pilocarpin, or muriate of pilocarpines more 
 suitable in the treatment of the younger asthmatics, but is by 
 no means contra-indicated in patients of more advanced age. 
 The do.c should not exceed one-third of a grain. Dr. berk- 
 hart has never used more than ten drops of a 2 per cent, so- 
 lution, injected under the skin of either arm. During the 
 action of the drug, the patient should preserve the recumben 
 posture— which the almost immediate relief obtained will 
 enable him to do— and he should be carefully watched until 
 
30 ATHETOSIS.— BERI-BERI. 
 
 the effect has passed off. It is desirable to have a solution 
 of atropine or liquor atropine always at hand, in case of need. 
 It is well, also, not to use pilocarpin soon after the patient's 
 meals ; if the dyspnceal seizure occur under these circum- 
 stances, there are, it is needless to say, other remedies more 
 suitable {Brit. Med. Journal, June 19, 1880). Similar re- 
 sults may be obtained in less urgent cases by the internal 
 administration of the powder of the leaves, in doses of 30 to 
 90 grains, infused in boiling water — the water and grounds 
 being swallowed together. 
 
 Athetosis. — Definition. — A form of spasm hitherto ob- 
 served chiefly in the muscles of the hand and of the fore- 
 arm, characterized by the impossibility which the patients 
 find in keeping the fingers and toes in any desired position ; 
 and the inability to prevent a continuous action of them, 
 which is slow, regular, and never ceasing, except when the 
 limb is supported, or during sleep. The movements are not 
 disorderly, like hysteria and chorea, nor tremulous, like those 
 of paralysis agitans and various forms of sclerosis. 
 
 Treatment.—- Beyond improving the general health, any 
 medicinal treatment can only be determined upon by a spe- 
 cial study of each particular case. If syphilis has been an 
 antecedent, its appropriate remedies must be had recourse to. 
 
 Beri-Beri. — Defi?iition. — A constitutional disease, expres- 
 sed in the first instance by anaemia, and culminating in acute 
 oedema. It is marked by stiffness of the limbs, numbness, 
 and sometimes by paralysis of the lower extremities, op- 
 pressed breathing (anxietas in paroxysm), and a swollen and 
 bloated countenance. The urine is secreted in diminished 
 quantity. The oedema is general, not only throughout the 
 connective tissue of the muscles, but throughout the connec- 
 tive tissue of solid and visceral organs in every cavity of the 
 body. Effusion of serum into the serous cavities very gen- 
 erally precedes death. 
 
 Treatment. — Bleeding has been considered applicable to 
 those cases where there is extreme difficulty of breathing and 
 delirium, when the patient is robust, and when the cedema 
 does not pit much on pressure, where there is rapid and full 
 pulsation of the large arteries, and if the urine shows the 
 existence of albumen (Wright) ; but, judging from the 
 pathology of this disease, the constitutional influence of 
 stimulants, of a generous strengthening diet, of tonics, diu- 
 retics and analeptics, ought undoubtedly to be the basis of 
 
15ERI-BERI. 
 
 3* 
 
 treatment. Should there be irritability of the stomach, an 
 effervescing draught, with doses of laudanum and camphor 
 mixture are useful. Saline drinks should be administered, 
 and the extremities should be rubbed with stimulating lini- 
 ments, and rolled in flannel bandages. In the asthenic or 
 chronic form of the disease, the strength must be supported 
 by the most nourishing diet that can be given in small bulk, 
 aided by tonics, and wine if necessary ; while doses of equal 
 quantities of squill and digitalis (ten to fifteen drops of each) 
 may be given twice or thrice daily. In the third and mildest 
 form, a native remedy called Treeak Farook is very useful. 
 The ingredients of this medicine are unknown ; but it pro- 
 fesses to be the "Theriaca Andromachi " of old writers. It 
 is prepared in Venice, and transmitted to India through 
 Arabia, and was first recommended by Dr. Ilerklotts, of the 
 Madras Presidency, as a remedy in beri-beri. It is a thick 
 extract (in which some terebinthine material largely eiv 
 which is only to be procured from the Moghuls, and in those 
 towns which still keep up some communication with the 
 Arabian Sea. Many observers bear testimony to its good 
 effects in removing the oedema and subduing the pulse 
 (Wright, Traill, Madras Quarterly Med. Jour., 1842, Vol. 
 IV., p. 154, Geddes, Malcolmson). In some recorded cases 
 the pulse lias fallen in four days from 108 to 84 beats per 
 minute under its use. The prescription most approved of 
 consists of pills of the following ingredients : — 
 
 \\. Treeak Farook, \ SS. ; Pulv. Rhei., ~ i'^ s ; ConfectlO, 
 Aromat., 3ss.; M ell is, q. s., misce, et divide in pill xlviii. 
 (Malcolmson). 
 
 The electuary form is also much used in India. The 
 remedy does not seem to be an active medicine, except in 
 combination. Four or five stools are obtained daily under 
 its use, and its action is not accompanied by any violent 
 purging, increa ;e of pulse, or determination to the surface ; 
 and after it h; s been used from one to two weeks, the oede- 
 ma generally disappears, when the numbness and paralysis 
 subside. If it purges, the quantity of rhubarb must be 
 diminished. The patient should feed on animal food, 
 wheaten cakes, and milk. In instances where the native 
 remedy has failed to produce a beneficial effect, mix vomica 
 has been more successful, commencing with doses of two 
 grains of the extract daily, and increasing the dose gradually 
 according to the physiological result. The extract of mix 
 vomica, in doses of half or a quarter of a grain, combined with 
 
32 BLADDER, CATARRH OF. BRAIN, TUMORS, ETC. 
 
 iron or gentian in a pill, is the most convenient form. Local 
 abstractions of blood from the spine have also proved useful ; 
 and a blister applied over the loins has given relief in many 
 obstinate cases. No single rule of treatment will apply in all 
 cases. The anaemic condition must be counteracted on the 
 principles of treatment explained under that disease ; and any 
 specially abnormal state, such as diseased heart, must be 
 treated accordingly. When the disease prevailed very generally 
 in the Carnatic, in 1782 and 1783, some cases were most suc- 
 cessfully treated by a pill containing a quarter of a grain of 
 extract of elaterium, combined with extract of gentian, given 
 every hour until copious watery evacuations were procured ; 
 and this plan was repeated every third or fourth day, till 
 with others this plan of treatment was not so successful ; the 
 cases recovering best under large doses of spirits of nitre, 
 antimonial wine, frictions with warm camphorated oil, aperi- 
 ent medicines, wine, and a nourishing diet. Mr. Evezard's 
 method of medicinal treatment consists mainly in the admin- 
 istration of acetate of potash in gin, in the following for- 
 mula : — r>. Qin, § ss. ; Potass. Acet., gr. v. : Aquae, § iii. ; 
 misce. To be given three times a day. If vomiting persists, 
 hydrocyanic acid may be useful in relieving it, to the extent 
 of one drop three times a day, given in milk. In the expe- 
 rience of Dr. Paterson of Bahia, a trip to Europe (if not had 
 recourse to too late) is a certain cure : and medicinally, his 
 patients have derived marked benefit from a combination of 
 ergotine, iron and extract of belladonna, in the form of a 
 pill. Sea-bathing is also acknowledged to be of great service. 
 
 Bladder, Catarrh of —See Cystitis. 
 
 Brain, Inflammation and Suppuration of-^-See En 
 
 cephalitis. 
 
 Brain, Tumors, Etc., of,— Definition. — New growths, 
 parasites, and aneurisms, implicating the cerebral substance, 
 the spinal cord or their membranes, or both. 
 
 Treatment. — Under such circumstances medicinal treat- 
 ment can be only palliative; the patient may be protected as 
 much as possible from hyperaemia of the brain aggravating 
 the morbid state. His nutrition and mode of life must be 
 regulated, and also the functions of the bowels. Apoplectic 
 or local inflammatory attacks may be met by local blood- 
 letting and cold compresses. Hypodermic injections of mor- 
 phia are also to be used in suitable cases, If syphilis exists, 
 
BRIGHT S DISEASE. 33 
 
 or is suspected, anti-syphilitic remedies are at once to be 
 adopted. 
 
 Bright's Disease. — Definition. — A generic term, includ- 
 ing several forms of acute and chronic disease of the 
 kidney, associated with albumen in the urine, frequently with 
 dropsy, and with various secondary or intercurrent affec- 
 tions, resulting from deterioration of the blood. 
 
 Treatment. — a.) Of Acute Blight's Disease. — (i.) Relieve 
 the kidneys as much as possible from the labor of elimina- 
 tion, by avoiding exposure to cold, by keeping the patient at 
 rest in bed, in a room of moderate uniform temperature. (2.) 
 The food should be scanty, consisting of gruel, arrowroot, 
 milk, or weak broth. Pure water is the best drink, and 
 holic fluids are not to be taken on any account (3.) Free 
 action of the skin and bowels must be maintained. The hot 
 air bath and antimonial remedies are the best agents to effect 
 the first of these conditions, and free perspiration is to be 
 encouraged by bedding the patient in blank timonial 
 
 wine may be given in doses of from fifteen to thirty drops 
 every four or five hours. The bowels are to be kept open 
 by the compound jalap powder, in >f twenty to - 
 
 grains, repeated daily or on alternate days. It may be alter- 
 nated with podophyllin or with extra t of colocynth. Mercury 
 is not to be given. (4.) Cupping over the loins relieves pain in 
 the back, and the quantity of urine passed generally incn 
 after eight or ten ounces of blood haw been withdrawn in 
 this w. y from an adult, or two or three ounces from a child 
 three or four wars old. (5.) When the tongue becomes clean 
 and the general symptoms improve, mutton broth or good 
 beef tea may be indulged in; and, as the digestion improves, 
 solid food may be eaten in small quantities, beginning with 
 fish and fowl, and afterwards mutton or beef. (6. Flannel 
 must be worn next the skin. (7.) Iron is of great service 
 during convalescence, for in such cases the anaemia becomes 
 extreme. Phosphate of iron, in the form of syrup, or citrate 
 of iron and quinia, or the ferrum redactum, are the most 
 digestible forms, ami they ought to be given in small doses 
 repeated after every diet. (S.) Diuretics are not to he given. 
 In a case where the urine was suppressed, fomentations, con- 
 sisting n\ infusion of the leaves of digitalis, were found by 
 Christison and Vogel to increase enormously the amount of 
 urine. Parkes found the amount of the albumen to diminish 
 markedly from the use of the tincture of the sesquichloride 
 of iron (1. c, p, 379), 
 9 
 
34 BRIGHT S DISEASE. 
 
 (b) Of Chronic Bright's Disease, general principles only 
 can be indicated, inasmuch as every case requires a special 
 study, and a line of treatment in detail peculiar to itself. 
 Whatever treatment be adopted, a long time is necessary be- 
 fore any appreciable results are obtained. It is, therefore, 
 necessary to persist in one line of treatment steadily from 
 week to week, and even from month to month; and it is ob- 
 viously of great importance to be as accurate as possible in 
 diagnosis as to the probable state of the kidney, so as to de- 
 fine the line of treatment from the first which may seem best 
 adapted for the individual case. 
 
 It is a question of grave importance how far vomiting or 
 diarrhoea ought to be checked. If either of these occur- 
 rences are suddenly stopped, the gastric and intestinal mem- 
 brane acting at the time as an emunctory for the urea and 
 other excreta of the urine, the patient may be suddenly cut 
 off by convulsions, apoplexy, or effusion into some of the 
 serous cavities, such as the pericardium, or the pleurae, or the 
 ventricles of the brain. It is necessary, therefore, in the first 
 instance, to determine in all chronic cases the particular organ 
 or tissue which seems in each case to be acting vicariously. 
 The perspirations are often spontaneously profuse; and the 
 skin is by far the safest emunctory for the vicarious elimina- 
 tion of urinary constituents. Therefore it is important to 
 promote the action of the skin if it be deficient, and to en- 
 courage it even if it is already considerable. Diaphoretics 
 are always of essential service. The best are Dover's pow- 
 der, the warm bath, warm clothing, and, for convalescents 
 especially, a moderately warm climate. In Sir Robert 
 Christison's experience diaphoretics have always appeared 
 most serviceable when they are so given as to excite a gentle 
 perspiration during a part of the night. So it is also safe to 
 promote the discharge of secretions from the intestinal canal, 
 with due caution that they do not become excessive, so as to 
 pass into permanent diarrhoea. Urea and other constituents 
 of the urine are found in such discharges in large proportions. 
 When general anasarca prevails, absorption may be promoted 
 by gentle pressure, which at all times must be very cautiously 
 applied, and the effects closely watched, for such effusions 
 afford great temporary relief to important symptoms which 
 indicate the involvement of vital organs. Bandaging to pro- 
 mote absorption is not justifiable so long as the anasarca is 
 increasing. Patients ought to be encouraged to go about as 
 long as they are able, care being taken that they are clothed 
 
bright's disease. ,- 
 
 with flannel and woolen garments, and othenvise well pro- 
 tected from chills or draughts of cold air. 
 
 In the subacute forms of the disease the action of the skin 
 is especially to be promoted by such saline remedies as the 
 acetate or citrate of ammonia, to which may be added one 
 two, or three drachms of the infusion of digitalis, and ten or 
 fifteen minims of antimonial wine. In such cases, also ten 
 or fifteen minims of the tincture of the perchloride of iron 
 or from five to ten grains of the citrate of iron and ammonia 
 may be given every day with one of the meals. Every second 
 day a dose of the compound jalap powder may be given- and 
 if hyperemia of the kidneys prevail, it may be necessary to 
 take from four to six ounces of blood from the loins by cup- 
 ping or by leeches. As the urine becomes more free from 
 blood corpucles and albumen, the iron medicines mav be 
 more frequently given, and the compound jalap powder'less 
 frequently. A good formula for the administration of salines 
 and iron in the subacute and chronic cases is that given by 
 Dr. Basham and Goodfellow, as follows: 
 
 Liquor Ammonias Acetatis, idi Acetici diluti, - i • 
 
 Tmct Fern Perchloridi, 5 iv.; Aqu Two tea 
 
 spoonfuls for a dose. 
 
 Small doses frequently repeated seem to do better than 
 T ones given at longer intervals. These remedies tend 
 to lessen the watery state of the blood; and the action of the 
 chalybeate medicines is of no avail till after purgation has 
 been free, and when the hot air or warm baths have caused 
 the skin to act freely. A nutritious diet is then to be riven 
 combined with the chalybeate remedy. 
 
 The quantity of urea passed by the urine should be deter- 
 mined day by <Uv, to ascertain how far the kidnevs are capa- 
 ble of secreting and eliminating these excrementitious pro- 
 ducts. According to the results obtained the diet must be 
 regulated, and such measures taken as are calculated to re- 
 duce the quantity of urea, and other constituents formed 
 daily, to the capacity of the diseased kidnevs for the work 
 they are able to do. 
 
 The further treatment of the chronic forms of Bright's dis- 
 ease is influenced by the amount of the anasarca present 
 If considerable anasarca is present, neither cupping nor 
 leeches can be had recourse to, on account of the bruising 
 and erysipelatous inflammation they are apt to induce. The 
 chalybeate mixture already mentioned is still found of ser- 
 vice, taken at least three times daily, and to it may be added 
 
2,6 bright's disease. 
 
 from time to time fifteen or twenty minims of the spiritus 
 aetherus nitrici (Goodfellow). The citrate of iron and am- 
 monia, in from five to ten grain doses, with the sulphuric or 
 chloric ether, are also good and useful remedies; and if the 
 iron medicines are found too stimulating, sulphate of zinc, 
 or tannic and gallic acids, may be used instead. The sul- 
 phate of zinc is to be given, in doses of one to three grains 
 three times a day, in the form of a pill, made with extract of 
 hop, and with or without a grain of the extract of nux 
 vomica; or the same dose of sulphate of zinc may be given 
 in a draught combined with sulphuric or chloric ether (Good- 
 fellow). These latter medicines relieve considerably the flat- 
 ulence and sensation of coldness in the stomach and bowels, 
 so much complained of in such cases. 
 
 If the urine is " smoky," or if blood is seen on microscopic 
 examination, the gallic acid, in five or ten grain doses, may be 
 given, with a few drops of diluted sulphuric acid and a few 
 drops of the tincture of hops, or other aromatic vegetable tinc- 
 ture, in an infusion of the same. The objection to these rem- 
 edies is the constipation they are apt to induce. The bowels 
 should always be kept relaxed, two or three loose evacuations 
 being secured daily. The medicine most generally useful is 
 the compound jalap powder of the London Pharmacopoeia, 
 which should be taken in the morning fasting, in half drachm 
 or drachm doses, in a wine-glass of water. It does not induce 
 prostration, but by repetition it is apt to lose its effect, when 
 elaterium may be necessary in small but repeated doses; two 
 grains of elaterium being dissolved in sulphuric ether, and the 
 eighth of a grain given every six hours till the desired effect is 
 produced. Very abundant watery purgation is thus obtained, 
 and a sensible impression is made upon the distended dropsi- 
 cal parts (Basham). If elaterium may not be deemed advisa- 
 ble, a saline draught of the following composition may prove 
 efficient: 
 
 ^. Magnes. Sulph. vel Sodae Sulph., 3 i. to 3 ij.; Athens 
 Sulph., m x.; Acid. Sulph. dil., m x.; Ferri Sulph., gr. i. to ii.; 
 Aq. Menth3e Vir., § iii. to 3 iv. 
 
 This draught is to be taken the first thing in the morning 
 once or twice a week. It ought to produce two or three loose 
 and watery evacuations (Goodfellow). 
 
 Diuretics are a most certain and speedy remedy when the 
 dropsical effusions are considerable; and they are sometimes 
 advisable when the urine is scanty, although they are seldom 
 necessary in the treatment of the fundamental disease. Sir 
 
bright's disease. 
 
 37 
 
 Robert Christison is convinced that the fears entertained by 
 some of injury being produced by the stimulus of diuretics on 
 the kidneys are visionary. In his experience, over more than 
 forty years, the best diuretics are digitalis, squill, and bitar- 
 trate of potash, taken simultaneously; and, if these fail, Hol- 
 lands spirits sometimes speedily establishes the diuresis. 
 
 When dyspeptic spmptoms predominate, and there is con- 
 siderable flatulence, the following pill is recommended bvl)r. 
 Goodfellow to be taken twice or thrice daily: 
 
 #. Ferri Sulphatis, gr. i.; Ext. Nucis Vomicae, gr. jj to 
 i.; Mas. Pil. Galb. Co., gr. ii. to iii.; misce, fiat pilula. 
 
 And if there be co-existent bronchitis, a draught of the 
 acetate of ammonia, with ten, fifteen or twenty drops of the 
 spiritus cX'theris nitrici, and half a drachm of the oxymel of 
 squills, is to be taken intermediately with the pills. If much 
 nausea prevail three minims of dilute hydrocyanic acid may 
 be added to the draught, with occasional application of mus- 
 tard to the stomach. 
 
 Want of sleep is often complained of, but opiates are in- 
 advisable, because they are apt to check the secretions and 
 to occasion constipation. Henbane may be given in place 
 of opium. 
 
 The patient should select a residence where the soil is san- 
 dy or chalky, where the air is mild and drv, so that as much 
 open-air exercise may be taken as possible. 
 
 Diet should be light, but nutritious; no pastry should be 
 eaten; and stimulant liquors should be used with' caution, al- 
 though, when exhaustion is great, their use may be unavoidae- 
 able. The principal meal should be in the' middle of the 
 day, but not later than three o'clock; and the last meal should 
 be taken two or three hours before bedtime, retiring early to 
 bed, and rising early. Light but warm woolen clothing is to 
 be always worn — m summer as well as in winter. 
 
 The complications of Bright' S disease are extremely diffi- 
 cult to manage. The diarrhoea must not be suddenly 
 checked. Thirty to sixty minims in water of the spiritus 
 ammomae aromaticus, with half a dfachm of the tincture of 
 kmoorof catechu, after every loose stool, will in general be 
 all that is necessary. If there be much griping, the applica- 
 tion of a linseed poultice over the abdomen, with two 
 drachms or half an ounce of tincture of opium sprinkled 
 over it, will give relief (Goodfellow). When it is found nec- 
 essary to use measures for checking the diarrhoea, means 
 should be taken that the skin acts freely, or that the urine 
 
38 
 
 flows increased in quantity. Lead and opium pill (pilula 
 plumbi cum opio), in doses of five or ten grains twice or even 
 thrice a day, is the best remedy for checking diarrhoea. These 
 remedies may be aided by a suppository of the hydrochlorate 
 of morphia occasionally, each suppository containing a quar- 
 ter of a grain of the hydochlorate of morphia (morphiae hy- 
 drochlor. suppositoriae). Vomiting may be controlled to some 
 extent by bismuth, but more frequently by morphia, hydrocy- 
 anic acid, creasote, rectified pyroxylic spirit, chloroform, or 
 chlorodyne, or little fragments of ice; and if these fail, a blis- 
 ter over the epigastrium has sometimes succeeded (Sir Robert 
 Christison). 
 
 Intercurrent inflammatory attacks and effusions into cavi- 
 ties are still more difficult complications to manage. The ap- 
 plication of a few leeches, or the abstraction of a few ounces 
 of blood by cupping, may be borne well in cases with head 
 complications; but the greatest care and caution are required 
 in the employment of similar remedies in the complication of 
 pericarditis, on account of the great danger of death by 
 syncope. 
 
 Bronchial complication are serious, and more or less con- 
 stantly present. They are frequently the immediate cause of 
 death in chronic Bright's disease. The least stimulating ex- 
 pectorants may be administered under such circumstances. 
 The following formula is recommended by Dr. Goodfellow: 
 
 ^. Liquor Ammoniae Acetatis, 3 ii. to 3 iii. ; Spiritus 
 OEtheris Nitrici, mxx. to 3ss.; Oxymellis Scillae (Lond.), 
 3 ss.; Aquae Camphorae et Aquae aa 3 v.; misce, fiat haustus. 
 To be taken every four, six, or eight hours. 
 
 If the expectoration be viscid and difficult to discharge, a 
 few drops of antimonial wine may be added to the draught; 
 or if there be much spasm of the bronchial tubes, as indicated 
 by the asthmatic breathing, a few drops of sulphuric or 
 chloric ether may be given. If, on the other hand, the ex- 
 pectoration be purulent and difficult, a few grains of carbon- 
 ate of ammonia may be given with the oxymel of squills. 
 Every precaution ought to be taken to prevent a fresh attack 
 of bronchitis. So long as the patient is able to bear it, the 
 habit of cold sponging and dry rubbing of the surface of the 
 body every morning with a flesh brush or coarse towel is the 
 best preventive, and being clad in warm woolen clothes. 
 Flannel next to the skin must be invariably insisted on. 
 
 Mercurial preparations are contraindicated in Bright's dis- 
 ease — so great is the tendency to salivation and the otherwise 
 
BRONCHIAL CATARRH. 39 
 
 injurious effects they produce. Podophyllin (the active prin- 
 ciple of the May apple) may be used instead. Its dose is from 
 i to 1 grain; and it ought not to be given in doses larger than 
 one grain. It is best given in a fluid form (see p. 902, ante), 
 or a pill with soap and hyoscyamus. As an occasional mild 
 aperient pill, the following is found to answer well: 
 
 $. Mas. Pil. Rhei. Comp., gr. ii. to iii. ; Vel. Ext. Aloes, 
 Aquosi, gr. i.; Ext. Nucis Vomicae, gr. i.; Mas Pil. Galb. Co., 
 gr. ii.; misce. fiat pilula (Goodfellow). 
 
 Bronchial Catarrh. — Definition. — Infiltration and oede- 
 ma of the mucous membrane of the bronchial tubes, so that 
 tumefaction diminishes their calibre, attended first with dry- 
 ness of surface, followed by a watery secretion, which subse- 
 quently becomes turbid and yellow. The disease is some- 
 times attended with chilliness and the discomfort of what is 
 called a "common (old. 
 
 Treatment.— When the symptoms of a " common cold " 
 first express themselves, when the attack is sudden, attended 
 with marked depression, aching pains in the head, back, and 
 limbs, and febrile disturbance (and even when the sensations 
 have extended to the chest, as indicated by the hoarseness 
 and tendency to cough), the disease may be atonce subdued 
 in a healthy person by a full stimulant (but not narcotic) 
 • lose of opium or morphia. "One-third or one-fourth of a 
 grain of muriate of morphia, or one grain of opium, ought to 
 D€ taken at bedtime. Its influence will begin to be felt in 
 from twenty minutes to half an hour, by the gradual disap- 
 pearance of the sense of intense weakness, the relief of the 
 pains, and that peculiar feeling of thorough and evenly dis- 
 tributed warmth of the whole body which is so different from 
 fever on the one hand, or chilliness on the other" (Anstie, 
 op. tit, p. 120.) An alcoholic diaphoretic drink; or five 
 grains of carbonate of ammonia, or ten to twenty grains of 
 muriate of ammonia; or, if the appetite is unimpaired, a full 
 supper, followed by a hot alcoholic stimulant, may have a 
 similar effect to opium Natural sleep ought to supervene, 
 and the morning ought to find the patient well. The follow- 
 ing formula has been recommended as an anticatarrhal olfac- 
 tory, originally prescribed by Dr. Hagner; # Carbolic acid, 
 5 parts; rectified spirit of wine, 15 pans; strong solution of 
 ammonia, 5 parts; distilled water, 10 parts. The mixture is 
 kept in a stoppered dark glass bottle. When a catarrh is 
 commencing, a few drops are placed on three or four layers 
 of blotting or filtering paper; the patient holding this in his 
 
46 BRONCHIAL CATARRH. 
 
 hand, and closing his eyes, inhales deeply from it as long as" 
 any smell is perceptible. The effect is to cut short the acute 
 stage of the cold, to prevent the occurrence of subsequent 
 coryza and bronchial and laryngeal catarrh; while all trouble- 
 some symptoms are rendered much milder. The remedy 
 should be applied every two hours (Dr. E. Brand, Wiener 
 Med. Wochenschrift, June 15, 1872). Snuffs composed of 
 morphia and subnitrate of bismuth are also found useful when 
 coryza is present — e. g., muriate of morphia, gr. i. ; powdered 
 gum arabic, 3 i.; subnitrate of bismuth, 3 iii.; and oxide of 
 zinc may be added in the proportion of 40 grains. This com- 
 pound powder is to be repeatedly and thoroughly snuffed 
 into the nostrils. 
 
 If such remedies are delayed too long, the object next to 
 aim at is to induce a copious perspiration and a continued 
 action of the skin and kidneys, by small doses, frequently re- 
 peated, of antimonial and ipecacuanha wines, or nitrate of 
 potash, or acetate of potash, as well as bicarbonate of potash 
 and aqua potassse, combined at a later period with tinctures 
 of squills and hyoscyamus. In the early stage of the disease 
 the bronchial membrane has its normal moist condition al- 
 tered to a dry state; and the object of treatment is to bring 
 about a return of the naturally moist condition. This is 
 best effected by the inhalation of the vapor of hot water, the 
 use of tartar emetic in doses of one-twelfth to one-sixth of a 
 grain, the use of ipecacuanha in one-quarter or half-grain 
 doses. From the frequent inhalation of steam great benefit 
 is derived. Opium has often been regarded as hurtful in the 
 first stage, because it has been taught that it interferes with 
 the free secretion of mucus; so as to render expectoration 
 difficult. But the onset of the catarrh — i. e., free expectora- 
 tion, is in consequence of the abatement of the inflammation, 
 which opium tends to subdue, and in this respect it acts as 
 an expectorant. Thus it is often of great service in the first 
 stage of a common cold, as it is in most acute inflammations 
 (Flint.) The inhalation of iodine vapor every three or four 
 minutes for an hour is of service, each inhalation lasting one 
 minute, by merely holding a bottle of tincture of iodine in 
 the warm hand under the nose (Tanner.) Total abstinence 
 from liquids for forty-eight hours, originally recommended 
 by Dr. Richard Lower, one hundred and forty years ago, is 
 a practice recently revived by Dr. C. J. B. Williams. Muri- 
 ate of ammonia, 3 ss. in solution, is a remedy also much in 
 use, combined with liquorice or simple syrup, with one grain 
 
fefcONCHIAt CATARRH. fa 
 
 of tartar emetic and one or two drachms of antimonial wine, 
 dissolved in six or eight ounces of water. Of this a table- 
 spoonful for a dose, frequently repeated, may induce relief, 
 when the discharge from the nose and trachea is viscid. 
 Copious warm drinks and abundant warm bed-clothing, to 
 induce diaphoresis, are efficient remedies to be used early. 
 
 The object aimed at in the treatment of a " common cold" 
 is to establish a free catarrh — to soften the expectoration and 
 make coughing 'Moose" and easy. Niemeyer lays down 
 some practical rules, based on symptomatic indications, to 
 accomplish these ends : — (i.) In chronic colds or catarrhs, 
 where cough is incessant and distressing, and out of propor- 
 tion to the expectoration, narcotics are indicated — such as 
 ten grains of Dover's powder at bed-time, or the camphorated 
 tincture of opium (paregoric elixir). External counter-irri- 
 tants are also ol form of mustard poultice, 
 
 mustard ." or blistering substances, short of vesica- 
 
 tion, such as stimulating liniments. Chlorate of poti 
 also a useful remedy. (2.) J 1 .with extensive sibil- 
 
 lant rhonchus and irritability of the mucous membrane, arc- 
 also relieved by narcotics, combined with ipecacuanha, or 
 with tartar emetic. But narcotics are contraindicated if, ow- 
 ing to the feebleness of the patient, the efforts of expector- 
 ation are inadequate to prevent accumulation in the bronchial 
 tubes. Alkaline carbonates possess the property of thinning 
 and rendering easier of expectoration the viscid bronchial Se- 
 cretion, and are on that account to be recommended, especial- 
 ly where the condition of the urine suggests such remedies. 
 Opium in its many forms is the most Useful remedy, SO long 
 as the first stage of inflammation exists, if care be taken to 
 watch that nothing contraindicates its administration. Pre- 
 parations of conium, hyoscyamus, or hydrocyanic acid, must 
 be used in cases where opium is contraindicated. 
 
 (3.) When secretion is profuse, with relaxation of the mu- 
 COUS membrane of the bronchi, when large, soft, moist rales 
 are heard, stimulant expectorants are indicated, — senega, 
 squills, carbonate of ammonia, benzoin, gum ammoniac, and 
 oilofcubebs. Remedies in the form of gas are also of ser- 
 vice, such as the fumes of tar, by boiling it alone or mixed 
 with water; also vapor of turpentine, half a drachm being put 
 into a bottle of hot water, the patient inhaling for a quarter 
 of an hour, four times a day. In all cases absolute rest, veg- 
 etable diet, demulcent drinks, and small doses of antimonials 
 will greatly tend to bring about relief. A pint of any demul- 
 
42 BRONCHITIS. 
 
 cent fluid (such as linseed tea), with two drachms of anti- 
 monial wine, taken in small quantities, so as to be consumed 
 in twenty-four hours, will be found a good standard prescrip- 
 tion. Gum arabic, in the proportion of one ounce to the pint 
 of water, or decoction of marsh mallow, or of dried fruits, is 
 a good substitute for the linseed, and may be flavored with 
 anything agreeable to the taste of the patient, such as orange 
 or lemon syrup. If much fever exists, a very hot foot-bath, 
 just before going to bed, has a soothing effect. The air of 
 the bed-room must be kept at about 6o° Fahr., not below, 
 and the patient must remain as quiet as possible. 
 
 Generally, in prescribing cough mixtures, which ought if 
 possible to be avoided (seeing that they so impair the func- 
 tions of the stomach), the following conditions ought to be 
 adhered to in devising the mixture: — (i.) That the prescrip- 
 tion should be in the form of fluid remedies, — solution, or in- 
 fusion of wines or syrups of the drugs. (2) That the dose 
 should not exceed one teaspoonful. (3) That the propor- 
 tions contained in the mixture should be so arranged that a 
 dose may be given every two, three, four, or six hours, ac- 
 cording to the urgency and acuteness of the symptoms. Such 
 a mixture may contain in each dose, for an adult, from ten to 
 thirty minims of antimonial wine, or of ipecacuanha wine, or 
 of tincture of sanguinario, or of syrup of squills, or of vinegar 
 of squills, with two minims to four minims of hydrocyanic 
 acid, or thirty to sixty minims of tincture of hyoscyamus or 
 of conium; or from two to four minims of tincture of opium; 
 or from thirty to sixty minims of camphorated tincture of 
 opium. 
 
 Bronchitis. — Definition. — Inflammation of the air-pas- 
 sages leading to the pulmonary vesicles, characterized by 
 hoarseness, moderate cough, heat, and soreness of the chest 
 anteriorly — symptoms which are more and more intense ac- 
 cording to the severity of the disease, and especially the ex- 
 tensive implication of the smaller tubes. The natural mu- 
 cous secretion is at first arrested, but subsequently it becomes 
 increased in amount and altered in quality, tending to assume 
 the corpuscular character. 
 
 Treatment. — (a.) In acute bronchitis. — General bleeding 
 uniformly weakens the patient. In severe cases of acute 
 bronchitis some blood may be taken from the chest, with 
 great caution not to take too much, either by cupping be- 
 tween the shoulders or by leeches, and in general from ten to 
 twelve ounces are sufficient. It is only in extensive conges- 
 
BRONCHITIS. 43 
 
 tion of venous circulation threatening asphyxia, that general 
 blood-letting is imperative. Next to blood-letting, tartarized 
 r antimony, administered in solution in doses of a sixth or a 
 quarter of a grain, every three or four hours, conduces to free 
 secretion, and generally to mitigate the symptoms of the dis- 
 ease. Digitalis is a useful adjunct to the antimonial treat- 
 ment. When the expectoration becomes thicker and less 
 copious, the antimony may be decreased, and squills, or ipe- 
 cacuanha, with paregoric, given. After this a blister should 
 be applied to the chest; and on its removal a large linseed 
 poultice should be placed near the blistered part, and con- 
 tinued for many hours. The bowels should be freely evacu- 
 ated by a purgative dose of calomel, combined with com- 
 pound jalap powder, and they should subsequently be kept 
 in regular and gentle action by some neutral salt, such as sul- 
 phate of magnesia in the liquor ammoni.e acetatis, combined 
 at the same time with some nitrate of potass. The neutral 
 citrates, tartrates, *or acetates of the alkalies are useful elim- 
 inating remedies. 
 
 After the severe symptoms at the outset have been sub- 
 dued, expectoration should be promoted by squills, ipecac- 
 uanha, and tartar emetic, combined with hyoscyamus or 
 conium. Opium in narcotic doses (/. <\, above a grain) is in- 
 admissible, because its tendency is to paralyze the action of 
 the mucous passages in eliminating secretion. After secretion 
 has begun to diminish, in acute casefl opium maybe pre- 
 scribed with benefit in stimulant doses, in the form of solution 
 of the salts of morphia, added at bedtime to the doses of the 
 cough mixtures so usually administered. (See under Bron- 
 chial Catarrh.) If the disease shows a disposition to pass into 
 the chronic stage, quinine, with squills and conium, maybe 
 administered, or a draught containing full doses of cinchona, 
 with five grains oi carbonate of ammonia, or ten to twenty 
 grains of the muriate of ammonia, and thirty or forty minims 
 of the compound tincture of benzoin (Friar's balsam), or of 
 the balsam of Peru, will generally facilitate expectoration 
 and relieve the dyspnoea. If a "hearty cough" is not at- 
 tended by easy and free expectoration, but the chest remains 
 loaded, stimulant expectorants may be given in aid of other 
 remedies, such as the decoction of senega, or the mistura 
 ammoniaci (Fuller). The patient throughout the treatment 
 should remain in a room where the air is kept moist by the 
 evaporation of boiling water from large flat dishes near the 
 bed, and the temperature of the air should be maintained at 
 
44 iiRONCHltlS. 
 
 63 to 68° Fahr. Alike in acute and in chronic cases, io- 
 dide of potassium is of great service. It lias a marked effect 
 in reducing the frequency of the respirations. It is best 
 prescribed with carbonate of ammonia, and if cough is very 
 troublesome, tincture of belladonna and ipecacuanha wine 
 may be added. 
 
 (/>.) In chronic bronchitis, especially in patients who have 
 made considerable progress in the journey of life, a lower 
 tone of the system prevails. A greater laxity of aerian mem- 
 brane — particularly with excessive secretion, often mucopur- 
 ulent — characterizes them ; and after blistering and poultic- 
 ing the chest repeatedly with linseed and mustard poultices, 
 the treatment in general should be more tonic. The cam- 
 phorated mixture or paregoric and stimulant expectoranv 
 remedies are indicated for occasional, but not for constant 
 use. Stimulating embrocations may be rubbed not only over 
 the chest, both before and behind, but along the sides of the 
 neck. 
 
 A liniment composed of the following ingredients was ex- 
 tensively employed by the late Drs. Graves and Stokes in the 
 Meath Hospital, Dublin : — 
 
 5. Spt. Terbinthinae, 1 iii.; Acid. Acet. 3 iv.; Vitelli Ovi, 
 L; Aq. Rosas, § iiss. ; 01. Limon., 3i.; misce. 
 
 It is to be applied as a rubefacient, morning and evening, 
 when it generally reddens the skin and produces small pirn* 
 pies. In several cases the secretion of the kidneys is increas- 
 ed during its use (Maclachlan). Of tonic remedies most re- 
 liance may be placed on the influence of nux vomica, iron, 
 and quinine, in the form of a syrup composed of the phos- 
 phates of strychnia, of iron, and of quinia ; so that, in doses 
 of a teaspoonful three times a day, each dose shall contain 
 the thirty-second part of a grain of phosphate of strychnia, 
 and one grain respectively of the phosphates of iron and 
 quinia. (Formula for the preparation of this compound, see 
 "Anaemia.") The inhalation of slightly irritant vapors has 
 a beneficial effect, as of vinegar, turpentine, chlorine and io- 
 dine. Of the fetid gums, ammoniac in particular is a useful 
 remedy. An emulsion of gum ammoniac in diluted nitric 
 acid, is a combination from which beneficial results are ob- 
 tained. The following is a formula for its prescription — 
 namely, an hundred and twenty grains of the gum ammoniac 
 dissolved in two fluid drachms of diluted nitric acid and 
 twelve ounces of water, compose a mixture of which an ounce 
 may be given in gruel or barley-water three times a day 
 
BRONCHITIS. 45 
 
 (Easton, Glasgow Med. Jour ■., Oct. i, 1863). It may also 
 be advantageous to administer astringent remedies, and one 
 of the most useful is tannic acid, in doses of one to three 
 grains two or three times a day ; or the oil of cubebs to the 
 extent of ten drops three or four times a day on a piece of 
 sugar (see under treatment of "Phthisis"). 
 
 Acute bronchitis is apt to be latent in old people, and to be 
 complicated with gastric or gastro-enteric inflammation 
 (Maclachlan). The stimulants of food (by enema in the 
 form of soup, without salt, if unable to be taken by the 
 mouth) aud of alcohol are the main remedies necessary from 
 the very beginning. Abstinence cannot be enforced with 
 safety. Leeches must be applied to the pained gastric re- 
 gion. When t'he dis< iated with a tendency to 
 gout, colchicum must be given, " It allays the cough, pro- 
 motes the flow of urine, keeps up a regular alvine discharge, 
 and can be given much more generally than squills, because 
 it does not produce that fevenshnesa which results from the 
 of the latter remedy, and can therefore be employed 
 where there is considerate (Forbes). It requires to 
 dministered with great caution in the aged and infirm 
 M ' lachlan). In the protnu ted bronchitic affections of the 
 aged, diuretics are of great servi< e. The followin [formulae 
 are recommended by Drs. M.i< lachlan and Stuk 
 
 ]>. Decocti Senegae, f3vij.; 1' N . gr. iii.; 
 
 Tinct. Camph. Comp. vel Tim t. Conii, m xx.: Spiriti yEthe- 
 ris Nitr., fjss., Oxymellis Scilbe, Fiat haustus ter 
 
 die summendus Maclachlan). 
 
 Ii . I : '|. Vmmon. A . gr. xx.; 
 
 Aceti Scillae, f 3 ss.; spirit. .Eth. Nitr., f 3 ss.; Tinct. Camph. 
 Co., m xx.; Mist. Camph., I \i.; Syrupi Aurant, 3 i. (Mac- 
 lachlan). Fiat haustus ter die summendus. 
 
 $. Decocti Sen .; Tinct. Camph. Co. Tinct. Scil- 
 
 a ; ii.; Syrupi Tolut., 3 iv. Sumat | SS. vel. 3 i. ter 
 die Stokes, Maclachlan). 
 
 When gastric irritation prevails, the administration of bal- 
 sams, gum resins, and terebinthine remedies must be sus- 
 pended. 
 
 (r.) In capillary bronchitis the treatment must be strictly 
 conservative; spoliative remedies lessen, if they do not de- 
 stroy, the chances of recovery. The tendency to death is by 
 apncea, from the imperfect oxygenation of the blood — the 
 area of available respiratory surface being greatly diminish- 
 ed, both from the morbid state of the minute bronchi and 
 
46 BRONCHOCELE— CANCER. 
 
 the accumulation of diseased products in them. The pa- 
 tient must be properly and adequately nourished. Stimu- 
 lants are often required, and tonics should be early adminis- 
 tered. The chest must be covered with hot poultices, and 
 an oil-silk jacket worn over them. Dry-cupping has seemed 
 to give relief to urgent symptoms. The muriate of ammonia 
 — two grains every two hours — either alone or in combina- 
 tion with the chlorate of potash : and the carbonate of am- 
 monia has long had a certain reputation in capillary bron- 
 chitis, especially in the later stages. 
 
 (d.) In bronchiectasis opiates are required to relieve 
 cough ; balsamic remedies (tolu, tar, benzoin, turpentine, 
 copaiba, cubebs) and astringents, like catechu or rhatany, 
 with the use of counter-irritants and the inhalation of vari- 
 ously medicated vapors, are all useful aids in ameliorating 
 the condition of the patient. Muriate of ammonia and the 
 alkalies are also to be recommended. Inhalation of disin- 
 fectants, capable of being so used, such as creosote, carbolic 
 acid, sulphur vapor, turpentine, ,and the like, are of special 
 service (see iinder treatment of " Phthisis "). 
 
 (e.) Plastic Bronchitis. — In the acute form, muriate of 
 ammonia and the alkalies and iodide of potassium may be 
 given, with an occasional emetic, and inhalation of the vapor 
 of hot water. The patient should be carefully protected 
 against damp and sudden changes of weather. 
 
 BroncllOCele— See Goitre. 
 
 Bronchocele, Exophthalmic — SeeGoitre, Exohpthalmic. 
 
 Cancer. — Definition. — A growth consisting of a delicate 
 fibroid stroma, containing within its meshes aggregated but 
 not coherent cell-elements — cells, nuclei, or granules — gener- 
 ally UN-uniform, though often similar to natural cell-ele- 
 ments. It tends not only to spread continuously irrespective 
 of the tissue invaded, and to multiply its elements indefinite- 
 ly, and so to infiltrate into the surrounding structures, especi- 
 ally in the course of the lymphatics and nerve sheaths of the 
 part affected ; but it also tends to infect or reproduce itself 
 in more remote and internal parts of the body ; and finally, 
 it tends to progressive softening and ulceration, with ulti- 
 mate poisoning and exhaustion of the system. It is in this 
 dynamical specific force of growth, spread, infectiveness, and 
 multiplication, that the " malignancy " of " cancer " is ex- 
 pressed ; and by virtue of which it is a disease sui generis. 
 Treatment. — No remedy has yet been found which can in 
 
CANCER. 
 
 47 
 
 any degree be considered curative of the constitutional state 
 associated with cancer, and the efforts of the practitioner are 
 consequently limited to relieving symptoms, and to the adop- 
 tion of such palliative measures as may prolong life. It has 
 generally been believed that to remove a cancerous growth 
 where it is practicable must, on theoretical grounds merely, 
 be attended with as much benefit to the constitutional dis- 
 ease as would attend the removal of a leg for acute rheuma- 
 tism chiefly expressed in the knee-joint. The statistics of 
 cancer show, so far as they go, and as Dr. Walshe long ago 
 showed, that " excision of a cancerous tumor seems to awaken 
 a dormant force. Cancers spring up in all directions, and 
 enlarge with a power of vegetation almost incredible." Never- 
 theless, there are good reasons for removing cancers in some 
 cases, especially mammary cases and others accessible to the 
 knife. The greatest measure of good may be done, as Sir 
 James Paget has clearly shown, "by making a careful selec- 
 tion of cases fit for operation, and rejecting all the rest as 
 unsuited for operation" {Med. Times and Gazette, September 
 27, 1872, p. 319). With regard to excision of the breast for 
 cancer, the main objection in the first instance is, that even of 
 cases selected with some care, 10 per cent. (Paget) to 16 per 
 cent. (Lebert) die of pyaemia, or erysipelas, or tetanus, or 
 secondary haemorrhage, or some calamity subsequent to the 
 operation. On the whole, however, taking the results of some 
 hundreds of cases, it is certain that the average duration of life 
 of those operated on is not less than those in whom the disease 
 runs its course. In well-selected cases it will be found always 
 greater. A recent tabulation of hospital and private cases by 
 Sir James Paget showed that 85 cases operated on lived an 
 average of 55.6 months; and 62 cases not operated on lived 
 an average of three months. It has also been said that the 
 recurrent disease is more painful than the primary one ; but in 
 very many cases Sir James Paget has found that the recurrent 
 disease was much less severe than the continued disease. 
 Considering, therefore, the danger of the operation, and the 
 fact that in every case a recurrence of the disease maybe ex- 
 pected, it is reasonable to submit a patient to the risk of dying 
 from the primary operation for the sake of that interval of 
 health between the operation and the recurrence of the disease, 
 for the good probability of adding a year to life, and for the 
 chance of having a less severe disease ? The average length 
 of the interval before recurrence is little more than thirteen 
 months : more than half return within twelve months ; and 
 
48 CANCER. 
 
 two-fifths return within six months. The extremes between 
 which the average is drawn are very wide. In some cases the 
 return may be within three months ; in others not for ten, 
 twelve, or more years. It is of great importance to determine 
 in what cases the risk of life is greater ; and in what cases the 
 probability of a speedy return of the disease is greater than 
 the average. The old after sixty ; the very large-breasted 
 in cases of mammary cancer ; the fat and plethoric ; the 
 cachectic ; the over-fed on animal food ; the drunkards ; the 
 gouty ; die habitually bronchitic ; the albuminurious ; the 
 very dejected — not timid merely ; in short, those with any or- 
 ganic disease of the internal organs — all such cases are 
 " doubly hazardous" to interfere with by operation (Paget.) 
 The probability of rapid recurrence is great in acute can- 
 cers — i. e. all those that are rapid in their progress — and in 
 those which are observed to increase very quickly before the 
 operation. Great pain, however, is often saved by performing 
 the operation even under such circumstances. In illustration, 
 Sir James Paget records the case of a lady " whose breast he 
 removed when she was five months advanced in pregnancy. 
 She recovered well from the operation, and the benefit pro- 
 cured by its performance was very great. She went to her full 
 term, bore her child, and was able to suckle it for a year be- 
 fore she died, with her most anxious wish fulfilled in compara- 
 tive comfort." Another condition unfavorable to operation 
 is a brawny skin, with firm oedema and wide-open hair follicles 
 or wide adhesion of skin, or in which the skin is cancerous, 
 or where there are scattered tubercles of cancer in the glands 
 and skin ; or where there is considerable affection of the 
 lymph-glands in the vicinity, and especially numerous dis- 
 eased glands. A moderate amount of lymphatic disease is 
 not a serious obstacle to an operation (Sir James Paget). 
 In very chronic cases the operation is needless — where the 
 breast is small, shrivelled, knotty, and sunk down on the pec- 
 toral muscle. By thus selecting with care, on the one hand, 
 cases fit for operation, and refusing to interfere in those cases 
 in which the operation would be attended with more than a 
 proper share of danger, Sir James Paget believes that the life 
 of a large number of those who suffer from cancer may be 
 considerably prolonged. In whatever part the disease may 
 be situated, one great rule is to endeavor to restore the 
 healthy functions of that part, and to alleviate by opiates, 
 chloroform, or chlorodyne internally, the distressing pains the 
 patient endures, These remedies are for a time uccessful, 
 
CANCRUM ORIS. 40 
 
 but make no impression on the disease, which silently pro- 
 ceeds, and the patient finally limits himself altogether to 
 opiates. The quantity of opium or other narcotic known to 
 have been taken in such cases is something enormous — five, 
 ten, fifteen, or twenty grains of opium at a dose, or a propor- 
 tionate quantity of hyoscyamos or of conium, three, four, or 
 more times in the twenty-four hours. But although these 
 large doses have occasionally been given, yet it may be ques- 
 tioned whether they are not more hurtful than beneficial ; 
 for usually they produce headache, delirium, loss of appetite] 
 and narcotism, so that the patient is only the more rapidly 
 exhausted. In general, therefore, the patient does better 
 under moderate doses of opiates, as one or two grains, or its 
 equivalent of morphine or other narcotic, every four, six, or 
 
 eight hours, than when more excessive doses are given a 
 
 larger dose producing headache and much cerebral distur- 
 bance, without in any sensible degree mitigating the suffer- 
 ings. When the disease is seated in the colon or intestine, 
 the tumor is in general difficult to make out. ( )ne 1. 
 testine may open into another; and death bv haemorrhage 
 may terminate the case. The symptoms vary greatly accord- 
 ing to the position of the cancer and the part (it the intestinal 
 canal affe> ted. Great sickness and vomiting generally attend 
 cancer in the duodenum. When the stomach is so irritable 
 that it rejects everything, it is our duty to support the pa- 
 tient by nutritive injection., a> of strong broth, egg-flip, - 
 or other fluid substances. It lias been attempted to impart 
 strength to the patient by means of milk baths, or baths of 
 strong broths ; but the skin has not generally sufficient power 
 of absorption, and it has been found that the heat of the bath 
 has exhausted the patient in a far greater ratio than its nutri- 
 ment supported him. As .1 general principle, diet has little 
 or no influence over the course of the disease when once es- 
 tablished, except it may be that total abstinence from nitro- 
 genous food ma v starve out the growth, and most likely also the 
 patient ; so that whatever agrees with the patient's digestion 
 may be safely indulged in. Preventive treatment must be 
 directed to the infant life of those who are hereditarily pre- 
 disposed. 
 
 CailCrum Oris. — Definition. — The more severe form of 
 inflammation of the mouth. 
 
 Treatment. — The disease is analogous to hospital gangrene, 
 and an early recognition of its nature will suggest an efficient 
 4 
 
50 CATALEPSY CEREBROSPINAL MENINGITIS. 
 
 application of strong nitric acid to the slough. The mouth 
 must be frequently syringed with a solution of carbolic acid, 
 in the proportion of half a drachm dissolved in a gallon of 
 boiling water, and allowed to become warm or tepid. 
 
 Tonics and antiseptics' must be freely given. Beef-tea, 
 wine, brandy, quinine, and chlorate of potash are also in- 
 dicated. 
 
 Carcinoma — See Cancer. 
 
 Catalepsy. — Definition. — A sudden suppression of con- 
 sciousness; but instead of falling down convulsed as 
 in hysteria, the patients maintain the position in w rich 
 they were when the attack commenced. The limbs 
 and trunk persist in a state of balanced muscular con- 
 tractions; the same expression of countenance is pre- 
 served which may chance to be at the moment of seizure. If 
 sitting, the patient continues to sit; if standing, he continues 
 to stand; if occupied in any mechanical employment, he 
 continues fixed in one attitude; and if he is under the in- 
 fluence of any passion, the countenance retains its expres- 
 sion. 
 
 Treatment. — No constant line of treatment can be stated. 
 The individual case must be judged of upon its own merits, 
 and prescribed for according to the principles which have 
 guided the dictates of treatment in the allied nervous affec- 
 tions. 
 
 Catarrh, Epidemic — See Influenza. 
 
 Cephalalgia — See Headache. 
 
 Cerebro- Spinal Teyer — See Cerebro- Spinal Meningitis. 
 
 Cerebro- Spinal Meningitis. — Definition. — A fever be- 
 lieved to be of an acute specific character, of sudden inva- 
 sion, attended by painful contraction of the muscles of the 
 neck and retraction of the head. In certain epidemics it 
 has been accompanied by a profuse purpuric eruption; and, 
 occasionally, by secondary effusions into certain joints. 
 Lesions of the brain, the spinal cord, and their membranes, 
 are found on dissection. The course of epidemic cerebro- 
 spinal fever is rapid, attended with great prostration of the 
 powers of life, severe headache, and pain along the spine. 
 The variations of temperature are so great that no typical 
 range can be given; and the result is generally fatal. 
 
 Treatment. — At the outset, stimulating embrocations to 
 the spine and extremities with moist or dry heat to the 
 
CHELOID CHLOROSIS. 51 
 
 lirnbs, and wrapping in blankets, give some relief. Opium 
 in large doses is the only drug which has appeared to be of 
 any service in subduing the virulence of the symptoms. 
 Quinine, in cases where malaria aggravates the disorder, is 
 also well spoken of. Ether and chloroform inhalation have 
 been of use as sedatives; and tincture of cantharides has been 
 of service in cases marked by extreme depression. Counter- 
 irritation, by the actual cautery applied along the spine, or 
 by blisters, has been followed by alleviation of the pain and 
 other symptoms. The energetic use of cold, as of ice com- 
 presses to the head, of leeches behind the ears, and of 
 calomel, as in sporadic meningitis, are measures to be recom- 
 mended. 
 
 Cheloid. — Definition. — A tuberculated growth or swell- 
 ing of the true skin occurring spontaneously or upon a 
 cicatrix. 
 
 Trcatmc?it is not yet defined; but the history of the dis- 
 ease points to cold applications and tonic remedies as the 
 basis of a rational treatment. 
 
 Chickeil-Pox. — Definition. — A disease the result of a 
 specific cantagium capable of inoculation, and havi: 
 period of incubation of eleven days Murchison and Squire); 
 
 it consists of a specific eruption, in a series of new crops, 
 usually appearing for several days in succession ; so that 
 dried and fresh vesicles are often alongside of each other, on 
 the breast, back, face, and extremities, preceded by fever. 
 The disease may be protracted for a fortnight or longer, and 
 may be epidemic. It affects the system only once. 
 
 Treatment consists simply in abstinence from animal food; 
 having recourse to a milk diet ; and careful attention to the 
 bowels by saline luxations if necessary. The patient is to be 
 kept at perfect rest and cool, by making him repose on a 
 mattress rather than on a feather bed, with light coverings. 
 It is necessary to be on the lookout against catarrh. 
 
 Chlorosis. — Definition. — A deficiency of the blood-cells 
 with redundancy of the serous part ot the blood, occurring 
 in young girls at the age of puberty ; in the young of both 
 sexes before the complete development of the distinctive 
 characters of the sexes towards puberty ; and sometimes dur- 
 ing pregnancy. 
 
 Treatment is chiefly conducted by change of air and diet, 
 by moral and physical hygiene, and by medicines. All the 
 functions of the body mus-t be carefully observed and regu- 
 

 52 CHLOROSIS. 
 
 lated. The residence of the patient must be a reputed 
 healthy spot, in the pure air of the country, rather than the 
 town. Dry frictions of the back and limbs are also recom- 
 mended, with bathing in the sea, where it can be borne. 
 The food must be regulated so as not to be too stimulating 
 nor disgustingly bland ; frequent change is demanded, with 
 a due attention to the proper apportioning of nutritive and 
 respiratory elements. The diet should be generous, and 
 carefully apportioned to the powers of digestion. Any 
 symptoms of dyspeptic oppression, impaired digestion, or 
 offensive stools, demand a careful readjustment of the dietary. 
 Three meals, or perhaps four may be taken during the day — 
 the intervals between the meals being equal ; and, half an 
 hour before each of the meals, two grains of capsicum, with 
 one grain of quinine, maybe given in a pill. The breakfast 
 should consist of biscuit, dry toast, or stale bread, with fresh 
 butter, and perhaps an egg, and one small cupful — not more 
 — of hot black tea. Five or six hours after breakfast, and 
 half-an-hour after the pill, a dinner of well-done meat, such 
 as mutton chops, may be eaten with potatoes — beef-tea, or 
 milk being taken for drink, according to taste and the powers 
 of digestion. The evening meal may be similar to the morn- 
 ing. At first there may be a loathing of all kinds of 
 food in the form of regular or "ordinary diets." In such 
 cases no meals should be prescribed, and no solid food ; but 
 a cup of milk, with a third part of lime-water in it, may be 
 given every two hours, prescribed as a medicine ; and a pint 
 of beef-tea in divided doses may be taken as a drink during 
 the day. This diet may be gradually added to as the appe- 
 tite improves. Trousseau observes that " there are some 
 chlorotic girls who would rather die from inanition than eat 
 ordinary food. We should not hesitate in such cases to 
 make those therapeutic concessions which we are so often 
 obliged to submit to in the practice of our art. I allow ali- 
 mentary substances acknowledged to be very indigestible — ■ 
 caring not for the kind of food so long as it is eaten — as 
 radishes, salads, fruits hardly ripe, highly seasoned sausage 
 meat, old cheese, vegetables, meats prepared with vinegar, 
 acid drinks, and the like. All I require in this whimsical 
 diet is, that there be sufficient variety. By such means we 
 often succeed in rousing the digestive functions, bringing 
 back the sensation of hunger, and gradually leading the pa- 
 tient to proper food." Lebert insists on the importance of 
 artificial feeding in some cases. A mixed diet is essential. 
 
CHLOROSIS 53 
 
 Change of air and bathing will also greatly aid in restoring 
 health. If the patient lives in a town, she ought to be sent 
 into the country ; and, best of all, to the seaside, where sea- 
 bathing may be prescribed, if the strength of the patient is 
 sufficient. Should the patient have been living in the coun- 
 try, a change of air and scene to a lively town, with cheerful 
 society; and, sometimes a little good wine with the food, 
 will be no less useful as remedial agents. The much-be- 
 quacked use of water, in its varied modes of appliance to 
 particular cases, will be found a powerful restorative agent, 
 if judiciously used by the patient under medical advice. 
 
 Of medicines, the preparations of iron have most reputa- 
 tion. They seem to act by promoting the formation of the 
 red blood-corpuscles ; and they operate best in those cases 
 in which the blood is rich in albumen. They also act as 
 stimulants to digestion ; and it is not altogether immaterial 
 which of the numerous officinal preparations of iron are to be 
 prescribed. Almost every physician has some prepara- 
 tion of iron he fancies better than another; and some 
 of them seem to be aided in their good effects by com- 
 bination with carbonate of potash, such as the sulphate 
 of iron, in doses of three to five grains, or of the ferri 
 sulphas exsiccata, in doses of two to five grains, pre- 
 scribed in pills. The use of ferruginous remedies must 
 be persevered in for months, and the general indications for 
 prescribing the preparations are the same as those given 
 under Anaemia. In pills, the iron preparations may also 
 be combined with extract of mix vomica, or with strych- 
 nia, in suitable doses , or the syrup of the phosphates 
 of iron, quinine, and strychnia, may be gi\en see Anae- 
 mia); or the eliminative action of the colon is to be pro- 
 moted by four grains of the pill of aloes and myrrh taken 
 every night at bedtime, or by a grain of the watery*extract of 
 Barbadoes aloes with a little gingerine as a pill. Simple 
 bitter tonics are useful adjuncts to the chalybeate treatment, 
 such as gentian, calumba, and the preparations of cinchona. 
 They aid feeble digestion. Tartarated iron (Ferrum tar- 
 taratum) is also a useful remedy, and may be prescribed 
 with alkalies, in doses of six to twenty grains, dissolved in 
 water. 
 
 Where a high degree of serous plethora exists, and pro- 
 duces violent excitement of the vascular system, palpitation 
 of the heart, and congestion of the head, venesection maybe 
 practised. It not only acts as a sedative, but aids the radi- 
 
54 CHOLERA, MALIGNANT. 
 
 cal cure of the disease, inasmuch as it causes the subse- 
 quently administered ferruginous preparations to be borne 
 more easily. Both general and local blood-lettings may be 
 used ; but the blood must be taken in small quantities, a 
 couple of ounces at a time being quite sufficient (Vogel). 
 Cholera, Asiatic— See Cholera, Malignant 
 
 Cholera, Malignant. — Definition. — A disease essentially 
 specific, existing at all seasons of the year in certain parts of 
 India (its perennial endemic area), capable of being propa- 
 gated or disseminated over the surface of the earth through the 
 atmosphere, or in other ways, but chiefly by means of human 
 intercourse between the healthy and the sick. The seizure is 
 characterized in many (but not in all) cases by premonitory 
 diarrhoea, sudden muscular debility, tremors, vertigo, occa- 
 sional nausea, and spasmodic griping pains in the bowels, 
 depression of the functions of respiration and circulation, 
 and a sense of faintness and oppression in the precordial 
 region. A copious purging of serous fluid (alkaline when 
 passed, and in appearance resembling water in which rice has 
 been washed, sometimes containing blood) is succeeded or 
 accompanied by vomiting and burning heat at the stomach, 
 coldness and dampness of the whole surface of the body, 
 coldness and lividness of the lips and tongue, cold breath, an 
 unquenchable thirst, a feeble rapid pulse, difficult and op- 
 pressed respiration, with extreme restlessness (a state ex- 
 pressed in physiological language by the term " anxietas "), 
 suppressed urinary secretion, blueness of the entire surface of 
 the body, a sunken and appalling countenance, a peculiarly 
 suppressed voice, a peculiar odor from the body, partial heats 
 of the prcecordia and forehead — fatal collapse, a reaction 
 and secondary fever. Under conditions favorable to its 
 propagation malignant cholera often becomes epidemic. 
 
 The College of Physicians defines cholera to be " an epi- 
 demic disease, characterized by vomiting and purging, with 
 evacuations like rice-water, accompanied by cramps, and re- 
 sulting in suppression of urine and collapse."' 
 
 Treatment. — There are few diseases for the cure of which 
 so many different remedies and modes of treatment have been 
 employed as in cholera. In considering the treatment of this 
 disease there are three periods to be provided for, — (i.) The 
 period of diarrhoea, which so frequently precedes cholera — 
 "premonitory diarrhoea." This indication of intestinal 
 trouble must be distinctly recognized as the starting-point of 
 
CHOLERA, MALIGNANT. 55 
 
 all other symptoms, and the true source of danger. (2.) The 
 algide period, or collapse ; and, (3.) Period of reaction. 
 
 (1.) The Period of Premonitory Diarrhoea. — To check or 
 arrest the diarrhoea is the practical result aimed at by a va- 
 riety of formulae. The evacuations ought to be checked as 
 soon as possible. Those in which opium is the main remedy 
 have acquired the most amount of confidence. The manage- 
 ment of a case embraces the following conditions : — (1.) 
 That the horizontal position of the body be maintained ; and 
 patients ought to take to bed at once. The necessity for the 
 horizontal posture of the patient is, that it aids the efforts of 
 the circulative powers, which tend to weakness. (2 ) That 
 the administration of opium, with or without cordial stimu- 
 lants, be at once commenced. With regard to opium, its 
 dose must be regulated by, (a.) The extent of the nervous 
 prostration ; (/>.) The rapidity of the dejections ; [e.) The 
 extent of vascular depletion. In the huh present 
 
 these phenomena in the extreme a much larger dose of opium 
 is required to be given at the outset at one time than in the 
 cases less urgent. (3.) That the induction of perspiration be 
 brought about. 
 
 The extensive experience of my friend. Dr. Fergus, of 
 Glasgow, in whose practice I was privileged to assi.st during 
 the epidemic of 1S49, led him to the conclusion [in which I 
 concur) that " there is a first stage at which cholera is cura- 
 ble and preventible " — namely, that of laxity of the bowels 
 previous to vomiting, spasms, or uneasiness of any kind. The 
 relaxation of the bowels may not even amount to diarrhoea, 
 and may be to the extent of only two or three stools a day, 
 where one only was usual. Such relaxation was generally 
 thought of no moment, being attended with no pain. On 
 the contrary, the evacuations often gave a feeling of relief. 
 This is the only stage at which opium is to be given, and 
 that in a full dose. At this stage, in combination with a 
 stimulant, it is often of the highest value. It is only to be 
 given " if the evacuations are still bilious, the pulse fair, and 
 the skin warm." When vomiting, "rice-water" purging, and 
 cramps set in (the phenomena of collapse) it is then too late 
 for opium. Drs. Ma< pherson and Macnamara record, as the 
 result of their extensive experience in India, that if adminis- 
 tered at the proper stage no remedy is so effectual as opium; 
 and the drug may be safely trusted to cure the premonitory 
 diarrhoea of cholera. A dread has arisen of using opium from 
 fear of secondary effects ; but the same writers ; ustly observe, 
 
$6 CHOLERA, MALIGNANT. 
 
 that if it has a curative effect, we must not shrink from its 
 use from the dread of ulterior consequences. " The vast 
 majority of practitioners have found opium extremely useful 
 in the early stages of the disease. Men like Twining and 
 Parkes, who by no means considered the disease to consist 
 merely in vomiting and purging, were agreed that opium is 
 the medicine to be given in the commencement of the great 
 majority of cases." It calms the brain, relieves the excessive 
 feeling of constriction at the epigastrium, tends to counteract 
 over-secretion from the mucous membrane, favors cutaneous 
 transpiration, and assists the action of such other remedies 
 as stimulants, astringents, carminatives, or absorbents (Gub- 
 ler). The following formula for pills, each containing a grain 
 of opium, with stimulants, is well known as a most useful 
 anti-spasmodic pill in the early stage of bowel evacua- 
 tion : — 
 
 I£ . Pulv. Opii, gr. xii. ; Camphor, gr. xxx. ; Pulv. Capsici, 
 gr. ix. ; Spt. vine, rect, q. s. ; Conserv. Rosar, q. s. ; Misce 
 et divide in pil. xii. 
 
 Moderate .doses of opium or morphine, either alone or 
 combined with stimulants (as the pulvis cretae aromaticus 
 cum opio) are sometimes sufficient to check diarrhoea. When 
 medical men have charge of large numbers of people, as in 
 the army, navy, prisons, workhouses, asylums, hospitals, and 
 the like, it is incumbent on them to make frequent inspec- 
 tions of those under their care, and to seek out any cases of 
 incipient diarrhoea. Responsible officers should be made to 
 take notice of those who go more than once a day to the 
 water-closet at times when a cholera epidemic influence pre- 
 vails. In' military practice, frequent inspection of the men is 
 of cardinal importance. Every man in a regiment should be 
 seen at least three times a day by some medical officer, who 
 should also visit the various guards. By walking down the 
 ranks at roll-call, and picking out the men who show the 
 earliest symptoms, cases are thus caught in the stage of pre- 
 monitory diarrhoea, and saved. The following rules were 
 drawn up by Dr. Fergus, now President of the Faculty of 
 Physicians and Surgeons of Glasgow, and printed and hung 
 up in prominent places, for the direction and management of 
 large numbers of men, in the factories and offices of that city, 
 over which he had charge when cholera was epidemic : — 
 
 ' (i.) Do not be afraid of cholera, or make it the topic of 
 conversation. Fear and all the depressing passions are in ■ 
 jurious. (2.) Do not take brandy ; it is not a preventative ; 
 
57 
 
 and it does harm by disordering the action of the stomach 
 and bowels. (3.) Do not make any change in your usual 
 diet, if it is simple and of easy digestion; take it moderately, 
 and at regular intervals, as long fasting is injurious ; and 
 carefully avoid excess in any intoxicating beverage. (4.) 
 Take no excessive fatigue ; if overheated, beware of any 
 sudden chill, and see that the skin is kept comfortably warm. 
 If the disease appears in winter, much benefit maybe derived 
 from wearing a flannel belt round the body, covering the 
 stomach and bowels. (5.) As soon as cholera appears in a 
 town, a bottle of solution of morphia or laudanum (and a 
 graduated measure) should be kept In every house, place of 
 business, factory, or wherever, in fact, there are a number of 
 people gathered together. Persons travelling should always 
 have it with them, or easy of access, During the existence 
 of the epidemic, one person in each factory, &c, should take 
 the charge of the health of the inmates, and should act as 
 'house physician,' warning all under his or her care to at- 
 tend to the slightest relaxation of the bowels. He should 
 remind them that the le^s pain the more danger, and there- 
 fore the more need of Immediate and energetic action. (6.) 
 Should the slightest diarrhoea occur, the individual so attacked 
 should at once receive forty minims of solution of morphia 
 or laudanum.* If from home or at business, the patient 
 should be at once conveyed home in a cab, put to bed, and 
 kept warm. If chilled, w arm water bottles may be put to 
 the feet. If the first dose has not checked the loosei 
 the patient should take a second, and then have a flannel 
 cloth thoroughly dipped in turpentine, placed all over the 
 stomach and bowels for from forty minutes to an hour, or a 
 large-, soft, warm poultice oi linseed meal and mustard for 
 one or two hours. If the second dose has not effectually 
 checked the diarrhoea, and in -die-. il assistance has not arrived, 
 a third dose may be taken. ; rhe patient must remain in 
 bed two or three days after the diarrhoea is checked. I insist 
 strongly on this, for the patient often feels so well that it is 
 difficult to get him to attend to it. (8.) To relieve the thirst, 
 
 *If a measure is not at hand, a small teaspoonful. Of course this 
 dose is for adults. Below tint age the doses should be a drop for each 
 year till twelve or fifteen, and after fifteen a drop and a half for each 
 year, up to forty minims, or a small teaspoonful. More portable than 
 laudanum, and of e [ual efficacy, would be pills composed of a grain and 
 a half of opium, and a grain of cayenne pepper in each pill, three of 
 which may be taken with sifety, till medical assistance arrives. 
 
58 CHOLERA, MALIGNANT. 
 
 a piece of ice may be given, or a mouthful of iced water, or 
 soda water ; but in no case must more fluid be taken at a 
 time, and all food should be abstained from till from fifteen 
 to eighteen hours after the opiate has been administered. 
 Then, and for two or three days, the diet should consist of 
 such food as rice, sago, arrowroot, Indian corn flour, tea and 
 toast, &c. ; about the third day beef-tea or chicken-soup 
 might be taken. (9.) These rules are for the first stage, and 
 for it only — i. e., the diarrhoea. If a person has neglected the 
 first warning, and is in the second stage — /. <?., has cramps, 
 vomiting, and stools like rice-water, without smell — you 
 should, till medical assistance arrives, place the patient in 
 bed surrounded with bottles of hot water, and give him a 
 little ice, and mouthfuls of soda and water. If the cramps 
 are severe, you must rub the limbs with turpentine, or chlor- 
 oform and oil." — Glasgow Med. Journal, 1866. 
 
 The following cholera mixture (as it was called) was pro- 
 posed by the Board of Health during the prevalence of 
 cholera, and was no doubt useful in many cases of diarrhoea: 
 
 I£ Pulveris Arom., 3 iii. ; Tinct. Catechu, f 3 x. ; Tinct. 
 Cardam. Comp., f 3 vi. ; Tinct. Opii, 3 i- > Mist. Cretae, pre- 
 parat. ad f § xx. Of this mixture the dose is one ounce. 
 
 Bulky doses of remedies are obviously objectionable. The 
 usual remedies known as " astringents" (compared with each 
 other, or with opium) have no decided influence for good. 
 "Astringents," as such, have merely a negative effect. 
 
 Of the various preparations of opium, Dr. Macnamara 
 gives preference, as Dr. Fergus does, to the tincture. Thirty 
 drops of laudanum in water should be administered as soon 
 as possible after the first watery motion has been voided, and 
 this dose must be repeated if the purging does not stop after 
 the first dose has been given. A pill composed of one grain 
 of opium and two grains of the acetate of lead, to be taken 
 every hour till the purging stops, is a useful formula, and 
 more easily distributed than laudanum. Supposing thirty 
 drops of laudanum to have been administered ; and, that 
 within half an hour the patient is again purged, Dr. Macna- 
 mara does not hesitate to repeat the dose at once. It is not 
 advisable to wait until two or three motions have been passed. 
 Watery painless purging should be at once stopped by such 
 means. When the disease is endemic, and still more so when 
 it is epidemic, every family should have a bottle of laudanum, 
 to be resorted to at once after the first watery motion. If 
 the motion is accompanied by a feeling of exhaustion, and a 
 
CHOLERA, MALIGNANT. 59 
 
 faintish sensation at the praecordial region, the dose of laud- 
 anum should be followed by " a stiff glass of brandy and 
 water." " No more erroneous practice can possibly exist in 
 India, or any other place where cholera exists, than that of 
 allowing diarrhoea to go on upon the supposition that the 
 attack is a bilious one, and that the purging is a salutary or a 
 harmless process. More deaths from cholera have been 
 occasioned from this than from any other mistaken notion on 
 this subject. The issue is simply this: Supposing the attack 
 to be a bilious one, we stop it with opium, and may subse- 
 quently have to administer a dose or two of blue pills and 
 rhubarb; or, perhaps, a little judicious starving may answer 
 the same purpose. But if, under the impression that the 
 diarrhoea is bilious, we allow it to run on, it may become, in 
 the course of a few hours, the second stage of cholera, and 
 our opium may then be of little or no u 
 
 In the case of children the dose of laudanum must be 
 regulated by the age of the child. 
 
 But there are certain cases in which, although the diar- 
 rhoea may be altogether checked by such remedies, yet the 
 disease is not cured. Symptoms characteristic of the algide 
 or collapse stage supervene. These are the cases which have 
 
 been held to justify that method of treatment which has for 
 its object elimination by the promotion of purging and of 
 vomiting — excretion of the poison by the alimentary canal. 
 The advocates of this method of treatment also lay stress up- 
 on the fact that those are the worse cases in which the diar- 
 rhoea is the least; and that th< - are the most hopeful 
 in which diarrhoea and vomiting are the most severe. Dr. 
 George Johnson's treatment by castor-oil has for its object 
 the elimination in this way of the specific poison; and it may 
 be said of it, that it is neither more nor less successful than 
 other remedies of its class. It, as well as purely astringent 
 mixtures, excites such loathing in most cases that it cannot 
 be persisted in. Dr. Johnson agrees that "diarrhoea during 
 an epidemic season ought not to be neglected even for an 
 hour." He regards such diarrhoea as an indication of the 
 presence of offending material in the alimentary canal — 
 (1.) Unwholesome, undigested food; or, (2.) A large and 
 unnatural accumulation of the feculent contents of the 
 bowel ; or, (3.) Noxious secretions poured from the blood 
 into the bowels, in consequence of the action of a specific 
 blood-poison. To this latter process Dr. Johnson believes 
 choleraic diarrhoea to belong. Therefore he lavs down the 
 
60 CHOLERA, malignant. 
 
 following rule: — " Not to attempt by opiates, or by other 
 directly repressive means, to arrest a diarrhoea while there is 
 reason to believe that the bowel contains a considerable 
 amount of morbid and offensive material; for, such offensive 
 material must come forth before diarrhoea can permanently 
 cease." Purging he considers the natural way of getting rid 
 of the irritant cause; and the safest purgative he believes to 
 be castor-oil. So far as meeting the conditions of examples 
 (i.) and (2.) as above stated, the treatment cannot be im- 
 proved upon; but that it is the best possible treatment to 
 meet the preliminary diarrhoea or relaxation of the bowels in 
 cholera cannot be regarded as established nor warranted 
 by what we know of the pathology of the disease as set forth 
 in the text. Assuming it to be proven that malignant cholera 
 is a specific disease in which there is poisoning of the 
 blood; and believing, as I do, that such is the pathology of 
 the disease: and, seeing that the College of Physicians enter- 
 tain a similar belief — for malignant cholera has been classed 
 by the College in Section A of the General Diseases, con- 
 cerning whioh it is written, that " it comprehends those dis- 
 orders which appear to involve a morbid condition of the 
 blood, and which present the following characters: — they run 
 a definite course, are attended with fever, and frequently 
 with eruptions on the skin, and are more or less communi- 
 cable from person to person." Assuming the pathology of 
 malignant cholera to be as here represented, I cannot admit 
 that the best indications for the treatment of the disease are 
 those which suggest an attempt to eliminate the poison by 
 the promotion of purging and vomiting. I do not believe 
 we can, by any remedy, nor by the over-stimulation of any 
 eliminative function, ever get rid of any such poisons as 
 those of small-pox, measles, scarlet fever, typhus fever, en- 
 teric fever, or any other general and specific disease-poison 
 comprehended in Section A. No method of treatment, 
 based on the so-called principle of eliminating a poison, has 
 ever effected a cure of any one of these diseases; and I do 
 not see any likelihood of the principle being more successful 
 in cases of malignant cholera than with other diseases of the 
 class. We have never yet been able to '' cut short " any of 
 these diseases by emetics, purgatives, or diaphoretics. Nei- 
 ther emetics nor purgatives have ever cut short small-pox, 
 although, if we are to follow indications of treatment elimin- 
 ative of poison, we ought to encourage such vomiting and 
 purging which mark the initiative stage of most of the ex- 
 
CHOLERA, MALIGNANT. 6l 
 
 anthemata. The early attempts to cure small-pox, scarlet 
 fever, and measles, by promoting copious eruption on the 
 skin, in the belief that the poison was so eliminated, proved 
 a signal failure. The popular belief that "better out than 
 in " was not found to be a safe principle of treatment in the 
 management of those diseases. We have no eliminative 
 method of treatment which will rid the blood of such 
 specific disease-poisons; just as we have no antidote which 
 will destroy or counteract the influence of snake-vemon 
 when once it has got accidentally or artificially into the blood. 
 We do our best when we try only to guide the patient 
 through those spccfiic diseases, by moderating the violence 
 of the expressions of the malignant phenomena, not by in- 
 creasing them. We cannot cure these diseases. The most 
 successful results in the treatment of all of them have been 
 got by those agencies which have led to modified and less 
 malignant forms of disease, such as by vaccination, in regard 
 to small-pox, and by sanitary improvements generally. We 
 do not think of, and dare not attempt to promote, diarrhoea 
 or specific lesion in the intestines during enteric fever. Why 
 should we be induced to promote diarrhoea in malignant 
 cholera, in the belief that we are thereby to free the blood 
 
 from the specific poison of the disease? We have no evi- 
 dence that the body is freed of the poison in this way. 
 The bowel discharges may be, and undoubtedly are, means 
 (but not necessarily the only means) of propagating the 
 disease; but it does not follow that promoting their dis- 
 charge frees the blood from poison either in enteric fever 
 or in cholera. By moderating the catarrhal flow in enteric 
 fever, it is not found that we ate the disease and 
 
 lock up specific poison in the system; certainly by mod- 
 erating, curtailing, or restraining the diarrluea of cholera, 
 the only chance is left us of guiding the patient through 
 that disease; and OPIUM is the remedy which, by actual 
 experience, alike in India and in this country, seems most 
 worthy of reliance; but, — only at the commencement of 
 laxity, or relaxation of the bowels, in seasons when chol- 
 era is epidemic. 
 
 Treatment based upon conflicting theories (which are 
 but theories after all) as to the nature of the disease, is 
 greatly to be deprecated; and on this point Dr. Fergus 
 makes the following pertinent remarks: — 
 
 " The influence of the theories of Dr. G. Johnson and 
 Others is to be seen in the instructions recently issued by 
 
62 
 
 the Board of Supervision in Scotland — very excellent as to 
 the sanitary part, but in the medical portion (like most 
 things issued by a committee) an evident compromise. It is 
 a compromise, I believe, between the facts and a theory. . . 
 . . We are told, under the fourth section, to take castor oil 
 or rhubarb and soda for looseness of the bowels, and after- 
 wards the astringent mixture or pills — the former being in- 
 tended as eliminators to promote the diarrhoea, the latter to 
 check it. If this advice is followed during an epidemic of 
 cholera, the consequences may be very serious. It is well 
 known that during an epidemic there is a general tendency 
 to relaxation of the bowels, and that they become very sus- 
 ceptible of the smallest dose ot even the mildest medicine. 
 Any one who has had much to do with cholera must have 
 frequently met with cases which appeared to be the direct 
 consequence or result of a slight dose of medicine. The 
 risk is that the castor-oil and rhubarb would drive most of 
 the cases into the second stage of cholera, and then the use 
 of astringents and opiates at that stage would increase the 
 danger immensely. As to the remedies ordered, the quan- 
 tity of laudanum — viz., five drops per dose — is too small, and 
 there is no necessity for the chalk and catechu. Before the 
 opiate could produce much effect, the stomach would be 
 overloaded with the chalk and catechu, to the extent of in- 
 ducing vomiting. The pills should be ordered after each 
 discharge from the bowels; but people will find it easier to 
 provide themselves with laudanum than to use complicated 
 mixtures or pills." 
 
 " With regard to castor-oil," writes Dr. Macnamara, " I was 
 acting as House Physician to King's College Hospital, in 1854, 
 when Dr. G. Johnson was treating his cholera patients on 
 eliminative principles. I caught some of his enthusiasm on 
 the subject, and came out to India the same year full of con- 
 fidence and hope in castor-oil. These ideas were destined 
 soon to pass through a severe ordeal; for in the following 
 year I was left at Bhaugulpore in charge of a field hospital. 
 I was the only medical man in the place, when cholera burst 
 out among the Europeans and natives under my care: I 
 went boldly to work with castor-oil, but it absolutely and 
 completely failed; the mortality from the disease was fearful. 
 I have since on several occasions tried castor-oil in cholera, 
 but I have now finally abandoned it, having never seen any 
 benefit arise from its use." In the second or algide stage the 
 object is to promote reaction and to keep it in moderation. 
 
CHOLERA, MALIGNANT. 63 
 
 If the patient is not seen till profuse discharges — rice-water- 
 like — have taken place, the time for all active treatment has 
 passed, and efforts must be directed solely to restoration and 
 repair; and, if possible to rendering the stools acid, by the 
 following draught every half hour for four hours, and then 
 to continue every hour (Macnamara): — 
 
 5. Dilute sulphuric acid, and dilute acetic acid, of each 
 m xv.; carbolic acid, half a drop; water, an ounce and a 
 half; and opium may be added to the first and second doses, 
 as existing circumstances may indicate. 
 
 To promote reaction in cholera and diarrhoea, the follow- 
 ing formula has met with most universal approval in this coun- 
 try and in India. So highly is it valued, indeed,that it is or- 
 dered to be always in store, and in readiness in the " Medicml 
 Field Companion " of the army when on the march: — 
 
 I£ . 01. Anisi., 01. Cajeput, 01. Juniper, aa 3 iss,; ^Ether., 
 3 ss.; Liquor Acid. Halleri, 3 ss.; * Tinct. Cinnam., ? ii.; 
 misce. The dose of this mixture is ten drops every quarter 
 of an hour in a tablespoonful of water. An opiate may be 
 given with the first and second dose, but should not be continu- 
 ed, for reasons already given. 
 
 The nitrite of amyl has also been recommended in the 
 collapse of cholera by several physicians. It ought to be 
 given internally, or by subcutaneous injection rather than by 
 inhalation (Dr. T. L. Brunton, Brit. Med Jointly of Jan. 13, 
 1872). The indications generally followed are to treat the 
 case as we should a similar state in typhoid fever, and to 
 moderate the affection of the bowels by milk opiates, by ene- 
 mata, and by sinapisms to the abdomen; also, to relieve the 
 head by leeches and cold lotions, and subsequently, as t)ie 
 tongue becomes brown, to support the patient with wine, 
 sago, strong broths, and a generally cordial treatment. 
 During the reaction stage Dr. Andrew Clark, of the London 
 Hospital, employed with great success a powder composed as 
 follow: — 
 
 Hyd. c. Creta, gr. ii.; Pulv Ipecac, gr. ss.; Pulv. Doveri, 
 gr. iiss.; night and morning. 
 
 The cases most benefited by this remedy were those in 
 which the tongue had become dry and hard, salines, lemon- 
 ade, and chlorate of potash drinks being freely given. Mus- 
 
 * The Liquor or Elixir Halleri consists of one part of concentrated 
 sulphuric acid to three parts of rectified spirit. It is commonly employ- 
 e 1 111 Germany in the treatment of typhus and allied diseases, in doses of 
 five to twenty drops in solution (Murchison, 1. c, p. 266). 
 
64 CHOLERA, MALIGNANT. 
 
 tard plasters or blisters to the nape of the neck were found to 
 be of use by inducing the return of the urinary secretion. 
 
 The sick-room should be supplied with fresh air. Liquids 
 should be assiduously applied to every surface capable of 
 absorbing them, and the patient should be suffered to remain 
 as free from officious treatment as possible. Heat applied in 
 the dry form is to be avoided, but cloths moistened with hot 
 water may be applied; or the patient may be wrapped up in 
 warm, moist blankets, and hot bottles or bags of heated sand 
 placed around his cold and benumbed body. After the 
 temperature is restored, the surface should still be kept moist, 
 by sponging from time to time, or by the use of the wet sheet, 
 to moderate the reaction. Urgent thirst is, one of the most 
 distressing symptoms in cholera. There is incessant craving 
 for cold water — doubtless instinctive, to correct the inspis- 
 sated condition of the blood, due to the rapid escape of the 
 liquor sanguinis. It was formerly the practice to withhold 
 water — a practice as cruel as it is mischievous. Water in 
 abundance, pure and cold, should be given to the patient, 
 and he should be encouraged to drink it, even should a large 
 portion of it be rejected by the stomach; and when the pur- 
 ging has ceased, some may, with much advantage, be thrown 
 into the bowel from time to time (Maclean). Niemeyer re- 
 commends cold wet compresses to be frequently laid over 
 the abdomen; and, also a grain of calomel every hour. Such 
 compresses are said to be grateful to the feelings of the pa- 
 tient, whose sense of heat is great, although he may be cold to 
 the bystander. The practice also is consistent with the lesions, 
 especially the intensely pink vascularity seen in the intestines 
 after death. The following as a drink is generally relished 
 and retained upon the stomach: — "A raw egg beat up with 
 half a pint of milk, and then mingled with about a pint and 
 a half of water, adding as much salt as will give the whole an 
 agreeable taste " (Dr. Andrew Buchanan,). Or whey, milk 
 and water, weak chicken soup, or any similar decoction, may 
 be drunk ad libitum. Enemata of warm milk, repeated as 
 often as expelled, are of the highest importance if the evacu- 
 ations have ceased, by supplying an absorbable fluid, by miti- 
 gating abdominal pains, and diluting acid secretions. The 
 secreting of uiine may be promoted by dry cupping over the 
 loins, by the use of solution of chlorate of potash, and the 
 like. But suppression of this secretion is most to be 
 dreaded where opium has been too freelv used in the 
 treatment 
 
CHOLERA, MALIGNANT. 65 
 
 In men of intemperate habits we often see, during the stage 
 of reaction, obstinate vomiting of thick, tenacious, green 
 paint-looking matter, probably bile-pigment, acted on by 
 some acid in the stomach orailmentary canal. It is a symp- 
 tom of evil omen, and often goes on uncontrolled until the 
 patient dies exhausted, and this although all other symptoms 
 may promise a favorable issue. It may last for a week, re- 
 sisting all remedies, and proving fatal when the urinary secre- 
 tion has been restored, and all cerebral symptoms have sub- 
 sided. Alkalies in the effervescing form, free stimulation of 
 the surface, and chloroform in small doses, offer the best 
 hope of relief for such cases. The patient should be nourish- 
 ed more by the bowel than the stomach when vomiting is 
 present. Ice should be given ad libitum, where it can be 
 obtained, not only to dissolve in the mouth, but to swallow 
 in pieces of convenient size (Maclean). 
 
 A plan, perhaps peculiar to this country, which was prac- 
 tised to bring about reaction (when the inefficiency of medi- 
 cines was generally admitted), was an injection into the veins 
 of the patient of a solution of half an ounce of muriate of 
 soda, and four scruples of sesquicarbonate of soda, in ten 
 pints of water, at a temperature varying from 105 to 120 
 Fahr. This solution was injected slowly, half an hour being 
 spent in the gradual introduction of the ten pints, and the 
 immediate effects of this treatment were very striking. The 
 good effects were rapid in proportion to the heat of the solu- 
 tion, but a higher temperature than what is stated could not 
 be borne. After the introduction of a fewoun< es, the pulse, 
 which had ceased to be felt at the wrist, became perceptible, 
 and the heat of the body returned. By the time three or four 
 pints had been injected, the pulse was good, the cramps had 
 ceased, the body, that could not be heated, had become warm, 
 and instead of a cold exudation on the surface, there was a 
 general moisture ; the voice — before hoarse and almost ex- 
 tinct — was now natural ; the hollowness of the eye, the 
 shrunken state of the features, the leaden hue of the face and 
 body had disappeared ; the expression had become animated, 
 the mind cheerful, the restlessness and uneasy feelings had 
 vanished ; the vertigo and noises of the ear, the sense of op- 
 pression at the pnecordia, had given way to comfortable feel- 
 ings ; the thirst, however urgent before the operation, was 
 assuaged, and the secretion of urine rjstored, though by no 
 means constantly so. But these promising appearances were 
 not lasting : the vomiting continued, the evacuations became. 
 5 
 
66 
 
 even more profuse, showing that the remedy did not touch 
 the root of the evil. The patient soon relapsed into his 
 former state, from which he might again be roused by a rep- 
 etition of the injection. This amendment, however, was 
 transient, and the fatal period was not long deferred. Of 156 
 patients thus treated at Drummond Street Hospital, Edin- 
 burgh, only twenty-five recovered, — a lamentably small pro- 
 portion ; and small as it is, it seems doubtful if the recover- 
 ies were final or complete (Mackintosh, " Principles of Pathol- 
 ogy," p. 365). Nevertheless, injection of fluid by the veins 
 ought still to be persevered in as a remedy in the right direc- 
 tion — with due regard to temperature — as a means of pro- 
 longing life. A trial made by Surgeon-Major E. Y. Kellat 
 at the close of an Indian epidemic is deserving of more ex- 
 tended experience, namely : — To inject distilled water at a 
 temperature of 99° Fahr. hypodermically, into the connec- 
 tive tissue of the body, or into the cavity of the peritoneum. 
 He thus aimed at establishing an artificial anasarca or an as- 
 cites ; experience having shown that of several instances of 
 cholera attacking persons suffering from such conditions, the 
 effused fluid became rapidly absorbed during the course of 
 the cholera — the patients recovering. The distilled water he 
 thus proposes to inject hypodermically, must filter through 
 the living tissue before it can reach the circulation ; and 
 hence be more fitted to mingle with the blood, than when 
 thrown into the veins directly from contact with air. Water 
 is the cardinal want. The supply of it fails first : and thus 
 introduced it avoids contact with the morbid surface and se- 
 cretions of the stomach and bowels, which are barriers to its 
 absorption in that direction. 
 
 Stimulants tend to irritate the stomach, and are of no use 
 in exciting the heart to any salutary action. Employed as 
 in typhus, they are worse than useless. All violent remedies 
 are greatly to be deprecated. Strychnia, prussic acid, to- 
 bacco, galvanism, boiling water, the actual cautery, or firing 
 the spine, or bags of ice to the spine, or injections of spirits, 
 are proven by trials to be of no use ; nor can their recom- 
 mendation be supported except upon baseless theories, hav- 
 ing no rational relation to the pathology of the disease. 
 
 To generalize on the subject of remedies in cholera, the 
 broadest conclusion seems to be, that remedies with an acid, 
 rather than an alkaline or neutral reaction, have been the 
 most beneficial. 
 
 Prevention of Cholera. — The following summary, from the 
 
CHOLERA, MALIGNANT. 67 
 
 writings of Dr. Parkes and Mr. Simon, will best conclude 
 this account of cholera. The importance of the topics noticed, 
 and the uncertainty that yet enshrouds many of them, may 
 justify, it is hoped, the amount of space which the subject 
 has taken up: — 
 
 " For the first time in the history of cholera a new system 
 of prevention has been brought largely into play in Europe — 
 viz., the addition to the discharges of a presumed disinfect- 
 ing substance. This plan, of course, is based on the belief 
 that the principal (perhaps the only) mode of spread is by 
 means of the putrefying evacuations ; and the results ob- 
 tained by it give certainly some strong evidence in favor of 
 this opinion. In this country the difficulty has been to make 
 the public (and, in SOI , even the medical men) sensi- 
 
 ble of the importance of this plan, and of the necessity of 
 giving it a complete trial. In some cases in which it has 
 really been fairly tested, it appears to have arrested the spread 
 
 of the disease, as at Bristol ; and Dr. Budd's paper in 
 the Brit. Med. Journ., April 13, 1867, good 
 
 evidence on this point. In Southampton also, I be- 
 lieve, the spread was limited in this way, though it was not 
 arrested so perfectly as at Bristol. In London, and several 
 provincial towns, the method was also tried more or less fully. 
 In Germany, owing to the influence of l'ettenkofer, the dis- 
 infecting plan was also brought into play, and the system fol- 
 lowed has been described by that chemist.* Without ana- 
 lyzing all the evidence, I proceed to give the most important 
 practical rules. The dangerous period of the choleraic 
 stools IS supposed to be when they become very ammoniacal. 
 This occurs sometimes immediately they are passed, but 
 usually not to any extent for some time. It is thought (but 
 of course exact scientific proof is not readily attainable) that 
 anything which makes and keeps them acid prevents the 
 changes which cause the poison. The three principal means 
 of doing this are the use yA carbolic acid, and sulphate of iron 
 (with or without permanganate of potassium), and the salts 
 of zinc. Each has its advantages, ami all may be used. The 
 carbolic acid, from its liquid form and from its volatility, is 
 excellently adapted to purify air, and to be used when sur- 
 faces are to be washed. It is also useful for sewers and 
 closets. The sulphate of iron in substance and strong solu- 
 
 *" Cholera Regulativ," von II. Griesinger, M. Pettenkofer, and C. 
 A. Wunderlich, Zietschrift. fur. Biologic, Band. II., p. 435. 
 
68 CHOLERA, MALIGNANT. 
 
 tion is better adapted for being put in the utensils in a room, 
 as it has no smell, but it may be equally used for sewers and 
 for watering streets. The sulphate of zinc (for the chloride 
 is too dear) is better adapted for being put on linen or on 
 floors, as it does not ironmould the linen like the sulphate of 
 iron. The carbolic acid has not been used much in Ger- 
 many, as it is still too dear; but Pettenkofer makes an ob- 
 servation of importance — viz., that when added to sulphate of 
 iron the mixture seems to have more power of preventing 
 ammoniacal development than either substance separately. 
 If so, it might be desirable, as a matter of practice, to use 
 the two together as much as possible. The salts of zinc 
 (sulphate or chloride) may be also used, but are perhaps not 
 so good, and in some forms are dearer than the iron salts. 
 Chloride of lime does not prevent the ammoniacal change, 
 and appears altogether less useful. The quantity in which 
 these substances must be used is as follows: — For each 
 healthy person, daily, about three-quarters of an ounce of 
 sulphate of iron, or one drachm of strong (but impure) car- 
 bolic acid, is 'sufficient. This amount will entirely prevent 
 any decomposition of the faeces for several days. In a town, 
 therefore, where sewers are used, the above amount of sul- 
 phate of iron, or carbolic acid, multiplied by the number of 
 persons, should go into the sewers daily, and, if possible, 
 should be passed in from the houses, so as to act on the 
 house-drains as well as on the main sewers. If the place is 
 not sewered, then the disinfectants should be added to the 
 cesspools, middens, latrines, or whatever plans may be in use. 
 If both sulphate of iron and carbolic acid are used, which is 
 to be recommended, half the quantity of each should be 
 employed. The iron should be dissolved in a good deal of 
 water. 
 
 " In Southampton, is 1866, carbolic acid was chiefly used; 
 and the average amount was about twenty gallons daily for 
 a town of 50,000 people: it certainly appeared useful. If an 
 aerial disinfection is needed, sulphurous acid (obtained by 
 burning sulphur) is perhaps the best. Nitrous acid fumes 
 are certainly very powerful; and one or other of these sub- 
 stances should be used for half an hour daily in all privies or 
 latrines. For washing clothes the iron salts are not ap- 
 plicable, as they stain linen. Carbolic acid gives a disagree- 
 able smell. Either a watery solution of sulphurous acid, or 
 a solution of zinc salts, should therefore be used. Baking 
 the clothes, at a temperature of 250 , or boiling, should be 
 
CHOLERA, MALIGKANT. 6q 
 
 used. In hospital wards, dead-houses, &c, it is a good plan 
 to sprinkle sawdust on the floors, and to moisten it with th? 
 weak carbolic acid (one part of crude acid in sixty or eighty 
 of water). These measures should be commenced when 
 cholera is apprehended. Every privy and sewer should have 
 twice daily the mixed carbolic acid and sulphate of iron so- 
 lution. If cholera is introduced, the amount should be 
 doubled in the privies of all the adjacent houses, while the 
 closet of the affected house should never act without a por- 
 tion of the disinfecting liquid being placed in it. If the dis- 
 ease breaks out, a plan recommended by Dr. Budd is worthy 
 of imitation — viz., to place a layer of carbolic acid powder 
 (carbolic acid and lime) in the bed, under the breech of the 
 patient. The disinfection in this way of the closets and 
 privies of hotels, railways, and workshops, should be com- 
 menced very early." 
 
 A saline antiseptic, " chloralum, has been recently much 
 commended; and on the subject of prevention Mr. Simon 
 has also made some valuable suggestions: — 
 
 " Wherever cholera is known to exist too much importance 
 cannot be attached to the precaution of thoroughly disin- 
 fecting, without delay, all discharges from the stomach and 
 bowels of persons suffering under the disease, and of disin- 
 fecting or destroying all bedding, clothing, towels, and the 
 like which such discharges m iy have imbued; and, of course, 
 neither choleraic discharges, nor any slops which may con- 
 tain traces of them, should ever (even when supposed to be 
 disinfected) be cast into any position from which they may 
 get access into drinking water. But, although the duty of 
 observing those precautions is one which ought never to be 
 neglected, populations cannot prudently stake their lives on 
 the chance that it will be completely fulfilled for them. 
 Apart from all questions of negligence, the degrees of cholera 
 are too many, and the slight and incipient cases far too apt 
 to escape observation, for any such defence against its infec- 
 tion to be more than partial. An 1, therefore, the main object 
 for endeavor must be to secure everywhere such local cir- 
 cumstances that the infective material, though not disin- 
 fected, would be unable to spread its influence among the 
 population. The dangers which have to be guarded against 
 as favoring the spread of cholera infection are particularly 
 two. First, and above all, there is the danger of water sup- 
 plies which are in any (even the slightest) degree tainted by 
 house refuse or other like kinds of filth; as where there is 
 
70 CHOLERA, MALIGNANT. 
 
 outflow, leakage, or filtration from sewers, house-drains, 
 privies, cesspools, foul ditches, or the like into springs, 
 streams, wells, or reservoirs from which the supply of water 
 is drawn, or into the soil in which the wells are situate; a 
 danger may exist on a small scale (but perhaps often re- 
 peated in the same district) at the pump or dip-well of a 
 private house, or, on a large and even vast scale, in the source 
 of public waterworks. And secondly, there is the danger of 
 breathing air which is foul with effluvia from the same sorts 
 of impurity. 
 
 " Temporary security must, as far as practicable, be sought 
 in measures of a palliative kind: — (a.) Immediate and search- 
 ing examination of sources of water-supply should be made 
 in all cases where the source is in any degree open to the 
 suspicion of impurity; and the water both from private and 
 public sources should be examined. Where pollution is dis- 
 covered everything practicable should be done to prevent 
 the pollution from continuing, or, if this object cannot be at- 
 tained, to prevent the water from being drunk, (b.) Sim- 
 ultaneously there should be immediate thorough removal of 
 every sort of house refuse and other filth which has oc- 
 cumulated in neglected places; future accumulations of the 
 same sort should be prevented; attention should be given to 
 all defects of house-drains and sinks through which offen- 
 sive smells are let into houses; thorough washing and lime- 
 washing of uncleanly premises, especially of such as are 
 densely occupied, should be practised again and again, (c.) 
 Disinfection should be very freely and very frequently em- 
 ployed in and round about houses wherever there are re- 
 ceptacles or conduits of filth, wherever there is filth-sodden 
 porous earth, wherever anything else, in or under or about 
 the house, tends to make the atmosphere foul. 
 
 " In the absence of permanent safeguards no approach to 
 security can be got without incessant cleansings and disin- 
 fections, or without extreme and constant vigilance against 
 every possible contamination of drinking-water." 
 
 Then again as to the risk of contagion, Mr. Simon writes : 
 
 " Cholera in England shows itself so little contagious, in 
 the sense in which small-pox and scarlatina are commonly 
 called contagious, that, if reasonable care be taken where it 
 is present, there is almost no risk that the disease will spread 
 to persons who nurse and otherwise closely attend upon the 
 sick. But cholera has a certain peculiar infectiveness of its 
 own, which, where local conditions assist, can operate with 
 
CHOLARA, MALIGNANT. 7 I 
 
 terrible force, and at considerable distances from the sick. 
 It is characteristic of cholera (and as much so of the slight- 
 est choleraic diarrhoea as of the disease in its more developed 
 and alarming forms) that all matters which the patient dis- 
 charges from the stomach and b jwels are infective. Probably, 
 under ordinary circumstances, the patient has no power of 
 infecting other persons except by means of these discharges, 
 nor any power of infecting even by them, except in so far as 
 particles of them are enabled to taint the food, water, or air 
 which people consume. Thus, when a case of cholera is 
 imported into any place, the disease is not likely to spread, 
 unless in proportion as it finds locally open to it certain fa- 
 cilities for spreading by direct infection. In order rightly to 
 appreciate what these facilities must be, the following con- 
 siderations have to be borne in mind : — First, that any chol- 
 eraic discharge, cast without previous thorough disinfection 
 into any cesspool or drain, or other depository or conduit of 
 filth, infects the excremental matters with which it there min- 
 gles, and probably more or less, the effluvia which those mat- 
 ters evolve ; secondly, that the infective power of choleraic 
 discharges attaches to whatever bedding, clothing; towels, 
 and like things have been imbued with them, and renders 
 these things, if not thoroughly disinfected, as capable of 
 spreading the disease in places to which they are sent (for 
 Avashing or other purposes), as, in like circumstances, the pa- 
 tient himself would be; thirdly, that if, by leakage or soak- 
 a g<-' ' pools or drains, or through reckless casting out 
 
 of slops and wash-water, any taint (however small) of the in- 
 fective material gets access to wells or other sources of drink- 
 ing-water, it imparts to enormous volumes <»f water the power 
 of propagating the disease. When due regard is had to these 
 possibilities of indirect infection, there will be no difficulty 
 in understanding that even a single case oi cholera, perhaps 
 of the slightest degree, and perhaps quite unsuspected in its 
 neighborhood, may, if local circumstances co-operate, exert 
 a terribly infective oower on considerable masses of popula- 
 tion." 
 
 The inquiries made through the Epidemiological Society 
 show that special hospitals, or special wards in hospitals, 
 ought to be devoted (with a separate and special staff of at- 
 tendants for day and night duty, or more frequent periods of 
 relief) entirely to the management of cholera patients. 
 
 With regard to India much may still be expected from a 
 thorough improvement of its sanitary condition : and espec- 
 
7 2 CHOLERA, SIMPLE. 
 
 ially of the filthy towns and bustees, or native villages, con- 
 structed without any plan or arrangement, without roads, 
 without drains, ill- ventilated, and never cleaned — the abodes 
 of misery, vice, and filth — the nurseries of sickness and dis- 
 ease. These are the localities within the endemic area of 
 cholera which require special attention and improvement in 
 the first instance ; and which are now receiving the attention 
 of the Indian authorities through their special sanitary ad- 
 ministration. 
 
 Cholera, Simple. — Definition. — An acute catarrhal in- 
 flammation of the mucous membrane of the stomach, which 
 extends into the intestines, attended with nausea, retching, 
 and vomiting, followed by severe watery diarrhoea, consisting 
 of profuse transudation of fluid [containing little albumen ; 
 the whole system generally being affected, as evidenced by 
 fever. 
 
 Treatment. — If the stomach retains undigested food be- 
 lieved to be unwholesome, a mild emetic may be given ; but 
 this is rarely necessary, as the stomach usually empties itself 
 completely. When the solid matters have been ejected, the 
 subsequent treatment will depend on the acidity or acrid 
 nature of the matter ejected. Simple alkaline remedies, like 
 carbonate of soda in solution ad libitum, will sometimes re- 
 lieve the nausea and sickness ; and when the vomiting be- 
 comes liquid, opium is the remedy most to be relied upon. 
 It must be, however, given in solution, such as laudanum, 
 Battley's solution, or with chloroform and other stimulants, 
 as in the form of chlorodyne. A full dose of either of these, 
 or a full dose of muriate of morphia, laid on the tongue, 
 should be administered immediately after the act of vomit- 
 ing. If the first dose should be immediately rejected, a sec- 
 ond is to be repeated ; if that too is rejected, a third may be 
 so given, but no more. An enema of laudanum, one to two 
 drachms, with starch must be given instead, directly after an 
 evacuation of the bowels. If this is rejected after being again 
 repeated, then hypodermic injection of solution of morphia 
 may be adopted ; and in any form when retained, the remedy 
 will require repetition every hour or half hour till the vomit- 
 ing and purging are arrested. The effects of each dose must 
 be carefully watched, so that narcotism may not be induced. 
 It is important that so much fluid may not be taken as the 
 greatness of the thirst desires. A table-spoonful of ice-cold 
 water, given at short intervals, or a bit of ice to dissolve in 
 
CHOREA. 73 
 
 the mouth, is call that ought to be permitted. Gruel made 
 from the boiled fluid in which oatmeal has been soaked, and 
 allowed to cool, and given with ice, is a grateful and sooth- 
 ing drink. 
 
 Chorea. — Definition. — An irregular spasmodic convulsive 
 action of the voluntary muscles, ceasing during sleep, of a 
 clonic kind, especially x profusion of movements of the face 
 in smiles and frowns, and of the trunk and extremities in 
 gesticulations. The movements are either entirely withdrawn 
 from the control of volition, or but little under the direction 
 of the will. The disease is brought on by fear or emotion, 
 or without obvious exciting cause. It has special relation 
 to certain other nerve-disorders, also to rheumatism and to 
 heart affections. 
 
 Treatment. — Having ascertained a time limit to the dis- 
 ease we are able to judge as to the effect of medicinal 
 remedies, observing by how much they shorten its duration. 
 The remedies given may be classed into three divisions : (i.) 
 Anti-rheumatic remedies, as potash, iodides, bark ; (2.) 
 nervine tonics, arsenic, sine, iron ; (3.) empirical, as ice or 
 ether over the spine, galvanism, sedatives. 
 
 From the use of ether to the spine — a plan so strongly 
 commended by a few — Dr. Andrew Clark has seen no bene- 
 fit. In his experience rest and the free use of arsenic are 
 the remedies which shorten most the duration of the disease. 
 Arsenic, in the form of Fowler's solution, is also well 
 spoken of by Romberg, in doses of three to five drops. Dr. 
 Bristowe also is in favor of arsenic, given in small doses, and 
 continued for some length of time. Experience also shows 
 that, in most simple cases, any Special treatment by drugs 
 may be dispensed with ; and that the chief matter to attend 
 to is the general health and nutrition of the patients, which 
 may be sufficiently dealt with by good diet, the withdrawal 
 from causes of excitement and annoyance, and by discipline 
 and sensible management. There are, however, various 
 drugs which may prove valuable auxiliaries ; as, for instance, 
 the salts of iron when there is anaemia, and in all cases cold 
 or tepid bathing ; or the cold douche to the spine, or the 
 shower-bath. In the rheumatic group of cases, much the 
 same course of tonic treatment is generally applicable ; any 
 special cardiac symptoms calling for appropriate remedies. 
 In the rellex group, the rule of action is to remove the cause 
 of reflex irritation. Cases with high temperature and a 
 
74 CHOREA, 
 
 febrile condition indicate the presence of collateral disease, 
 only indirectly associated with choreic movements, and cal) 
 for treatment directed to the removal of the organic mischief. 
 In several cases of very severe chorea, tartar-emetic has been 
 found of great service ; and in many of moderate severity, 
 bromide of potassium was apparently useful (Arlidge). 
 
 Generally, therefore the indications for the treatment of 
 chorea are — (i.) To remove, if possible, all morbid states of 
 the body which may tend to aggravate the disease, such as 
 constipation, anaemia, amenorrhoea, worms ; (2.) By well- 
 regulated purgative medicines to subdue any cerebral con- 
 gestion ; (3.) To sustain the strength and improve the vigor 
 of the nervous system by tonic and stimulant medicines, by 
 food, and by the cold bath. The particular tonic is not of 
 much moment. Dr. Wood recommends the powder of the 
 black snake root (cimicifuga, in doses of from half a drachm 
 to a drachm, or from one to two fluid ounces of a decoction; 
 or from one to two drachms of a saturated tincture should 
 be given three or four times a day, and continued for several 
 weeks, the dose being gradually increased till it produces 
 headache, vertigo, or disordered vision. The sulphate of 
 zinc has also had the credit ascribed to it of curing a large 
 number of cases, beginning with a grain in the form of a 
 pill, three times a day, and increasing the dose till it reaches 
 seven or eight grains daily. The preparations of iron are 
 also frequently resorted to with benefit. But Dr. Walshe 
 did not find any of these remedies at all useful in the acute 
 case he has described. Of all the remedies he tried, the 
 " extract of cannabis Indica " was followed by the most 
 satisfactory results. It exercised a sedative influence on the 
 muscular action in a marked degree, and that immediately. 
 The Indian hemp was given in doses of one-fourth of a 
 grain of the extract thrice daily. The dose was subsequently 
 increased to half a grain, and at the same time one-grain 
 doses of nitrate of silver were administered, and a draught 
 containing eight drops of dilute nitric acid. Nitrate 
 of silver he found to have no mean influence in aiding 
 the cure. Dr. Corrigan had also previously used Indian 
 hemp with much success in chorea {Med. Times and Gazette. 
 1845, p. 29 ; also Dublin Hosp Gazette). 
 
 ^ The tincture of Calabar beans ( 3 i. to § i. of alcohol,) be- 
 ginning with twenty minims three times a day, is also recom- 
 mended by Dr. J. W. Ogle ; the dose to be increased by ten 
 minims a dose, up to 3 i. The student is recommended to 
 
75 
 
 consult a valuable paper %% On the Uses of Indian Hemp in 
 Nervous Diseases," by Professor Russell Reynolds, in Beale's 
 Archives. 
 
 Trousseau and Niemeyer consider narcotics to be of great 
 value in the form of large doses of morphine; others are of 
 opinion that narcotics are not well borne in chorea. 
 
 Gentle applications of the galvanic current along the spine, 
 the patient standing erect, have been successful in the hands 
 cf Benedikt. The current should be just strong enough to 
 be felt distinctly without pain. Chapman's ice-bags to the 
 spine are also of use. 
 
 Chloroform has been used with benefit to control the vio- 
 lent movements. 
 
 The best treatment is the improvement of diet, change of 
 surroundings, and moral discipline. Hence it is that chil- 
 dren with chorea improve so much in well administered hos- 
 pitals, where the food is abundant and discipline well main- 
 tained. ]>ut choreic patients must not be associated together, 
 use the disease tends to be kept up apparently by imita- 
 tion, especially amongst children. 
 
 Of other classes of stimuli, camphor, in five-grain doses, 
 has acquired much reputation, especially after the alvin< 
 charges have become healthy by the action of purgatives. 
 Many young women who attribute the attack to fright, fre- 
 quently get well from the simple administration of the spirit 
 of nitrous ether in one fluid drachm doses three times a day, 
 combined with the officinal camphor mixture. The cata- 
 logue of remedies which have been proposed is endless. In 
 many instances, however, the above medicines may be con- 
 tinued for weeks without any manifest improvement In 
 such cases the cold bath, or the cold showerbath, is an ex- 
 cellent adjuvant; and, unless the patient is suffering from 
 some structural disease, the case uniformly yields to this 
 conjoined treatment; great care and attention being bestowed 
 on the regulation oi the diet, which should be light, nutri- 
 tious, and easily digested. 
 
 Chorea, Rhythmical Ej%Ustit.—DefinHum. — A chor- 
 
 eiform affection under the influence of hysteria, and pre- 
 ceded by it (Charcot). 
 
 Treatment. — Professor Charcot recommends that prolonged 
 and repeated ovarian compression might be maintained with 
 benefit to such cases as occur in the female by means of some 
 such instruments as are used for compression of large vessels 
 
76 COLIC COLIC, BILIARY. 
 
 like the aorta. So also the application of ice bags to the 
 ovarian region for half an hour at a time, repeated several 
 times a day for several days, has had the effect of arresting 
 the attacks, or of lessening their intensity. He prefers, how- 
 ever, the inhalation of ether or of nitrite of amyl. Professor 
 Trousseau has found cases of those forms of chorea to im- 
 prove under the influence of oil of turpentine in capsules 
 containing ten minims each, of which ten were taken daily 
 for twelve to fifteen days a month; and to use warm baths of 
 several hours' duration. 
 
 Colic. — Definition. — A painful affection of some portion 
 or the abdomen, caused by violent contraction of the mus- 
 cular fibres of some portion of the intestinal canal. 
 
 The Treatment is by opiates, chlorodyne stimulants, and 
 purgative medicines. When the bowels are constipated, 
 five grains of calomel, fifteen grains of jalap, and one 
 grain of opium, should be administered immediately, and 
 followed by — 
 
 $. Mist. Camphorae c. Magnesias Sulphat, 3j.; Tinct. 
 Hyoscyami, m xv. to xx.; Tinct. Cardamomi, 3 j. To be 
 repeated every five or six hours, until stools are obtained. 
 
 In mild cases a scruple of rhubarb, or half an ounce of 
 castor-oil, or other mild purgative, combined with a grain of 
 opium, may be substituted for opium, calomel, and jalap. 
 Some have doubted the propriety of administering opiates at 
 the onset of the disease; but it is certain that a mild purga- 
 tive, combined with a mild narcotic, will effect more than 
 a drastic purgative without such combination. Opium in full 
 doses (gr. i. to ii.) is more generally useful in colic than any 
 other remedy. Enemata often give immediate relief. Exter- 
 nally, the application of large bags filled wiftiliot chamomile 
 flowers, or of heated sand, or heated salt, or of the stomach- 
 warmer filled with hot water, are useful. The warm bath, 
 fomentations, or a large linseed or mustard poultice over the 
 abdomen, are also highly useful auxiliaries. The diet should 
 be sago and arrow-root, with a little brandy; and for some 
 time after the patient has recovered it should be light, and 
 perhaps limited to fish and puddings. 
 
 Colic, Biliary. — Definition.— Concretions of certain bil- 
 iary constituents in the biliary ducts, or accumulating gener- 
 ally in the gall-bladder, as gall-stones, the passage of which 
 through the duct into the duodenum gives rise to symptoms 
 known as " gall-stone colic." 
 
COLIC, BILIARY. 77 
 
 Treatment. — When the symptoms of gall-stone passing the 
 duct are present, the curative indications are to facilitate its 
 passage into the intestine, to relieve the intense pain which 
 accompanies it, and to prevent that inflammation which the 
 presence of an extraneous body of any magnitude is calcu- 
 lated to produce in the duct. The first thing to be done is to 
 calm the sufferings of the patient. Half a grain of solid 
 opium, or a quarter of a grain of morphine, or twelve drops of 
 laudanum, or the mistura camphorce, 3 xj., conf. opii 3 ss. 
 to 3ij., c sp. aeth. nitr. 3 j., should be given every hour, or 
 every two hours, till some relief is obtained, or till there is 
 slight narcotism. Similar doses may be repeated every four 
 or six hours, till the pain has ceased. If the vomiting be se- 
 vere, and the remedies be rejected, the opiate may be given 
 hypodermically, commencing with not more than one-fourth 
 of a grain of the muriate of morphia In solution, or opium 
 may be administered by enemata of laudanum. Careful in- 
 halation of chloroform, till anaesthesia is produced, also gives 
 great relief, and is a valuable remedy when paroxysms are 
 most violent. It not only calms pain, but may lead to the ces- 
 sation of the spasmodic contraction of the biliary passages, 
 and thus favor the expulsion of the calculus (Murchison). 
 Chloroform also, when given internally, appears to exercise 
 some influence as a solvent <>f biliary concretions. Dr. J. 
 Barclay relates an instance in which m ii. to m hi. of chloro- 
 form, given three or four times a day, afforded great and im- 
 mediate relief ( Brit AfcJ. Journal, 1870). Dr. Murchison 
 has seen marked benefit from the extract of belladonna, given 
 in half grain doses every two or three hours. The hydrate of 
 chloral, as it produces extreme muscular relaxation, is also a 
 likely remedy. Small pieces of ice in the mouth may relieve 
 vomiting. Emetics or laxatives are not to be given during the 
 attack. A warm bath should be immediately prepared, with 
 a temperature of ioo° to no°, or as hot as the patient can 
 bear it, and the immersion should continue till he is in some 
 degree exhausted. The intention of the bath is to relax by 
 means of heat the muscular fibre of the ducts, and thus re- 
 lieve the pain ami facilitate the passage of the gall-stone. The 
 effect is generally so agreeable to the teelings of the patient 
 that, on the recurrence of the pain, he may ask for a repeti- 
 tion of it, and his wishes should be complied with. If a warm 
 bath cannot be procured, fomentations, or a large linseed 
 poultice, should be applied over the abdomen. Dry heat is 
 always at hand, and hot flannels, hot sand, or hot chamomile 
 
78 COLIC, BILIARY. 
 
 flowers afford some relief. Bleeding is not called for. The 
 calculus having passed, and the patient being relieved, the se- 
 cretions of the liver should be rendered more healthy. A 
 course of neutral salts, or of the Cheltenham or Leamington 
 waters, ought to be taken in this country. Under the use of 
 the Karlsbad waters immense quantities of gall-stones are 
 evacuated with proportionately little difficulty (Niemeyer). 
 The same is true of other alkaline mineral waters, such as 
 Vichy, Marienbad and Kissengen. 
 
 The radical treatment of biliary calculi ought to be at- 
 tempted during the intervals between the attacks of gall-stone 
 colic, by — (i.) Solvents believed to act on the calculi. These 
 are, — (a.) Alkaline solvents, which are to be preferred above 
 all others. Under their influence the calculi seem to be 
 really dissolved or broken up, so as to disappear without leav- 
 ing any trace; or they are expelled entire in abundant bilious 
 evacuations. This alkaline treatment comprises the fixed 
 alkalies, soap-lye, salts of soda, carbonate of ammonia; but es- 
 pecially the waters of Vichy, Vals, Karlsbad and Ems. These 
 are used as drinks and as baths; and they must be employed 
 persevermgly, at different periods, during several years in 
 succession, (b.) Durande's remedy, which consists in the ad- 
 ministration of half a drachm to a drachm every day, in the 
 morning, of a mixture composed of fifteen grammes (/. e. y 
 about 3 iii.) of sulphuric ether, and ten grammes (/. e. f about 
 3 ii.) of oil of turpentine, has enjoyed a reputation since 1790, 
 as a solvent of biliary calculi. It has been extensively used 
 and recommended by many Continental physicians. In this 
 country Copland speaks favorably of it; but whatever virtue 
 the remedy may possess as a solvent, it is probably due more 
 to the ether than the turpentine, the former being a ready sol- 
 vent of cholesterine (Waring). The dose is to be gradually 
 increased till about a pound of this mixture has been taken. 
 Its mode of action is not known; but where it has succeeded, 
 the calculus has been expelled without being dissolved. It 
 seems in some way efficient in promoting the expulsion of 
 calculi, probably by its anti-spasmodic action, rather than 
 acting as a solvent. Recently various substitutes have been 
 proposed in place of Durande's remedy, and also variations 
 from the original dose (Niemeyer). One is a popular remedy, 
 a mixture of oil of turpentine, 3ii. with 3 i. of spirits of sul- 
 phuric ether, which has been prescribed in drop doses by 
 Rademacher. (c.) Diet has a great influence upon the qual- 
 ity of the bile. Fresh laxative vegetable food, grapes, fruits, 
 
CONSTIPATION. 79 
 
 and whey ought to constitute the staple articles of a regulated 
 diet. All fat should be as much as possible excluded from 
 food, and the plainest diet, in the form of roasted meats or 
 boiled meats, with vegetables and farinaceous food, should 
 be rigidly proportioned to the wants of the system. The 
 drinks should be water or lemonade, and an avoidance of al- 
 coholic or malted stimulants. (2.) Treatment which seeks to 
 assuage pain. — With this end in view, Lutten prescribes 
 opium in larger doses than those already mentioned — namely, 
 two and one-third to three grains of solid opium at once; but 
 he considers the hypodermic injection of solution of morphia 
 as preferable ( " Nouveau Dictionaire de Medicine et de 
 Chirurgie Practiques;" also, " Society Med. de Paris, 1866;" 
 and " Sydenham Society's Biennial Retrospect for 1865-66"). 
 The intense agony is more effectually relieved by large doses 
 of opium than by any other remedy, particularly if it be com- 
 bined with the use of the hot bath (Dr. Waring). Two grains 
 of solid opium, or mxl. of the tincture of opium may be 
 given, either by mouth or in the form of enema, to be re- 
 peated in half an hour if the pain is not relieved. It may 
 also be advantageously combined with a full dose of ether or 
 chloroform, care being taken in case of over-dosing with the 
 opiate. 
 
 Large draughts of hot water, containing carbonate of soda 
 in solution ( 3 i. to 3 ii. to twenty ounces of water) give 
 more immediate relief than any other means (Dr. Prout). 
 The first dose or two may be rejected; but the addition of a 
 few drops of laudanum and steady perseverance in the rem- 
 edy will eventually ensure its success (Murchison. No 
 doubt can exist as to the efficacy of alkaline waters in re- 
 moving the symptoms of gall-stones. It is certain that the 
 salts of Vichy and Karlsbad waters relieve the symptoms of 
 this affection, provided they are administered in hot water, 
 and so as to represent nearly the strength of the natural 
 springs. 
 
 Constipation. — Definition. — A retention of fasces beyond 
 the usual period, so that when they are passed it is with 
 difficulty, and in a comparatively hard indurated state. 
 
 Treatment. — There it no rule of health more important than 
 that the bowels be kept regularly open. Enemata are of the 
 first importance, and ought to be much more frequently em- 
 ployed than they are as a habit. They may be simply a pint 
 of warm water ioo° Fahr.; or the same quantity of warm 
 
80 CONSTIPATION. 
 
 water, with half an ounce of common salt. The common 
 soap enema (a strong solution of soap) is likewise a valuable 
 remedy; and when the constipation is great, half a pint to a 
 pint of castor-oil, neat, may be thrown up. For constipation 
 in children and young persons nothing is so efficient as an en- 
 ema of salt and water, repeated night and morning, or every 
 night, or every other night only, according to the urgency of 
 the symptoms. Large accumulations of scybala (stercoraceous 
 tumors) seem visibly to melt away under their continuous in- 
 fluence. These enemata ought afterwards to be followed by 
 one or two drachms of sulphate of magnesia, one grain of 
 quinia sulphatis, in aromatic sulphuric acid in an ounce of in- 
 fusion of gentian, every morning till the bowels assume a 
 healthy tone. A soap suppository, i.e., a piece of common 
 yellow soap, shaped to an oval form, about half an inch thick 
 at the middle part and an inch and a half long, introduced into 
 the rectum, is also a useful stimulant to the action of a torpid 
 rectum in children. When constipation is occasional and ac- 
 cidental, any of the milder cathartics, in the absence of an 
 enema, as the sulphates of soda or of magnesia, castor-oil, 
 rhubarb, atees, or the confectio sennae, or the pilulae colocyn- 
 thidis comp., will in general open the bowels. In obstinate 
 constipation, tartrate of antimony, to the extent of one-fourth 
 of a grain, combined with a drachm of sulphate of magnesia 
 every hour, may often bring faeces away after nausea super- 
 venes. If, however, the constipation is habitual, the healthy 
 habit of a daily evacuation is not easy to be re-established. The 
 remedies, though often successful, yet occasionally fail. In 
 cases of habitual constipation, the combination of tonic with 
 laxative will often produce a more efficient action than a per- 
 severance in the use of purgative medicines alone. Thus, 
 two grains of the ferri sulphatis, or an ounce and a half of the 
 infusion of gentian, combined with one or two drachms of 
 sulphate of magnesia, given according to the urgency of the 
 case, three times a day, or every six hours, will empty the 
 bowel when the salt alone will fail. In old person?, a combi- 
 nation of aromatics with the purgative, as in the decoctum 
 aloes, is a more useful and effective remedy than the same or 
 even a greater quantity of aloes alone. Aloes is a useful 
 remedy when the colon seems specially at fault as a result of 
 fever and debilitating diseases, or of sedentary habits and oc- 
 cupations. The watery extract, combined with essential oil 
 of ginger and jalapin; or with quinia, extract of nux vomica, 
 ipecacuanha, are the most useful combinations. Where slow 
 
CONSTIPATION. 8l 
 
 digestion, with a deficiency of mucous secretion prevails, the 
 following is a formula for pills, of which one ought to be taken 
 an hour before dinner (and before breakfast also) if required: 
 
 IJ. Pulv. Ipecacuanha, gr. viii. to xii. ; Ext. Aloe, gr. xii.; 
 Sulphatis Ferri, gr. xviii. to xxiv. Misce, et divide in pil. xii. 
 
 Or, the ipecacuanha maybe omitted; or the aloes maybe 
 combined only with some bitter extract, such as gentian 
 Such pills ought to be continued regularly till the occurrence 
 of a " loose motion," after which one only, an hour before 
 the principal meal, will be sufficient. 
 
 Another formula for a pill of a similar nature is of use in 
 habitual constipation, namely: 
 
 $. Pil. Rhei. Co., vel Pil. Color. Co., vel Aloe, gr. ii. to iii.; 
 Pul. Capsici, gr. i. To be taken with the food, and repeated 
 daily as occasion may require (Pavy). 
 
 Drastic purgatives ought never to be given. The diet 
 ought to be especially attended to. More food, both 
 and liquid, may require to be taken. When constipa- 
 tion is obstinate, and lias resisted the stronger purgative rem 
 edies, a full dose of opium sometimes seems to relax the 
 spasm of the muscular coat of the bowels, on which the < on- 
 stipation may depend. Belladonna also may be given with 
 advantage, in doses of { to | of a grain every morning at 
 rising, combined with the extract of gentian (Trousseau); 
 or 10 minims of the tincture of belladonna may be similarly 
 taken. All medicines for the relief of constipation ought to 
 
 given just before or with food; and are to be regarded as act" 
 ing With the food in bringing about the result. Pills or 
 draughts at bedtime are not so useful. In the constipation 
 of children the sulphate of potass is recommended alike by 
 Drs. Hiller and West. The following are useful formula:: 
 
 I£. Potas. Sulphatis, gr. \1.; Syrup Rhei. j ss.; A.q. Carol 
 Ad. 3 iil_; Misce. Dose — A table-spoonful for a child six 
 years of age (Miller). 
 
 [A very effective remedy in many cases of constipation is 
 the Cascara cordial in doses from 30 to 60 drops. The 
 movements are painless and natural.] 
 
 A severe case of colic with constipation, in the practice 
 of Dr. Murchison recovered under the use of one-haif grain 
 of the extract of belladonna every four hours, with belladon- 
 na ointment to the abdomen, a warm bath and castor oil 
 enemeta (Lancety Jan. 19, 1871). When constipation arises 
 from torpor of the colon, equal parts of compound gamboge 
 pill and the compound colocynth pill is recommended by the 
 6 
 
82 CONSTIPATION. 
 
 late Dr. Symonds of Bristol (" Lib. of Medicine," Vol IV., p. 
 139). The compound extract of colocynth, or compound 
 colocynth pill variously combined with small doses of blue 
 pill, or with ipecacuanha, or with podophyllin, or with 
 nux vomica, is a safe and useful form for the relief 
 of the bowels. Colchicum (tincture of the root) has been 
 found of service in doses of ten drops several times 
 daily (Chapman). When constipation does not yield to 
 the simple treatment which has been mentioned, re- 
 course must be had to more active remedies. Thus calo- 
 mel, gr. v.; c. jalapae, gr. xv., is a dose which rarely fails 
 to produce motions, and this if necessary, may be followed up 
 four hours after, either by the neutral salts in divided doses, 
 or by a black draught in one dose. If a stronger medicine 
 than the above be necessary, elaterium is of greater power, 
 and from -fa to -J grain, combined with henbane, is sufficient 
 to begin with, so as to avoid hypercatharsis. When the stools 
 indicate a deficiency of bile, inspissated ox-gall has been 
 recommended. It may be given in the following formula: 
 
 I£. Fel.'Bov. Purificat., 3 ii. ; 01. Carni, mx.; Magnes. 
 Carb., q.s.; Misce. Divide in pil. xxxvi. Dose — Two to be 
 taken daily (Waring); or, — 
 
 $. Fel. Bov. Purificat., Pil. Asafcetid. Co., aa. gr. xxx.; 
 Ex. Aloes, gr. xx.; Sapon. Dur. gr. x; Pulv. Ipecac, gr. 
 viii. ; Misce. Divide in Pil. xxx. Dose — One or two may 
 be taken daily before dinner (Copland). 
 
 The resin of podophyllin, to the extent of -J- to J- of a 
 grain combined with compound rhubarb pill, acts similarly 
 to the combination of rhubarb pill with calomel. A length- 
 ened period sometimes elapses before it operates. The 
 tincture of benzoin, to the extent of gtt. xx. three times a 
 day, will, it is said, keep the bowels active and regular (Hast- 
 ings, Streetan). 
 
 Sometimes the faecal matter accumulated in the colon is 
 so large in quantity, and so hard and impacted, that manual 
 assistance is necessary to relieve the patient. Women some- 
 times suffer for years from constipated bowels; and a con- 
 trary state of the bowels may take place from the irritation 
 of hardened faeces, when they are much harassed by purg- 
 ing, existing more or less for many months. At length a 
 violent tenesmus comes on, with a bearing down most intol- 
 erable, much worse than a woman suffers in her confine- 
 ments. On examining the rectum, a mass of hard matter 
 may be found, which cannot be broken to pieces without 
 
CONSUMPTION CONVULSIONS, INFANTILE. 83 
 
 the aid of an instrument. This mass consists of a variety 
 of undigested substances, which when broken down, may 
 be washed away by injections, to the perfect relief of the 
 patient. 
 
 Dietetic Treatment. — Patients suffering from constipation 
 should avoid port wine or brandy, and should eat freely of 
 sub-acid fruits, drink more water, and in some cases eat 
 more food of a kind likely to stimulate the colon, such as 
 bran bread ; and oatmeal, in the form of cakes, or well- 
 boiled porridge, should be eaten for breakfast. They should 
 go daily at the same hour to stool ; for such is the periodical 
 regularity of all the functions of the body, that they are more 
 readily performed at accustomed hours than irregularly. 
 
 ConSU \\ ptioil — See Phthisis. 
 
 Convulsions, Infantile. — Definition. — Convulsive seiz- 
 ures, consisting of contraction of muscles by gradual but 
 rapid shortening of the muscular fibres, causing such hard- 
 ness and stiffness of the muscle or limb that it cannot be over- 
 come. This period of tonic contraction is followed by clonic 
 spasmodic phenomena, characterized by the occurrence of 
 alternating movements of contraction and relaxation inde- 
 pendent of the will, which is as powerless to suspend or mod- 
 erate them as to excite them (Trousseau.) 
 
 Treatment. — Of all the causes mentioned in connection 
 with convulsions, none are so common or universal as indi- 
 gestion. Hence the quantity and quality of the food and 
 condition of the evacuations, by vomiting or by stool, ought 
 to be inquired into at the first. If some unwholesome diet 
 has been given, a good purgative of calomel, mixed with pow- 
 dered sugar, should be put on the back of the child's tongue. 
 If indigestion is traced as the source of the fits in an infant 
 or young child, a few drops of aromatic, spirit of ammonia, or 
 the same quantity of ether, may be given in a teaspoonful of 
 water; or a drop or two of anise oil, rubbed up with sugar, 
 may be given from time to time, by laying the powdered 
 sugar so saturated on the tongue of the child. It is in such 
 cases that mere flatus in the bowels may cause a fit in a pre- 
 disposed child. The belly will be found tumid, when gentle 
 friction over the abdomen (following the direction of the co- 
 lon), combined with the warm bath and those soothing aro- 
 matics, will give relief. 
 
 The clothing must be loosened completely, so as to admit 
 air freely, and anti-spmasmodics, such as ether alone, or com- 
 
84 CONVULSIONS, INFANTILE. 
 
 bined with musk or belladonna, may be given, till the pro- 
 gress, duration, seat, or probable cause of the convulsions 
 may be ascertained. An emetic, a purgative enema, a search- 
 ing purgative, such as calomel, combined with jalup or rhu- 
 barb, may be indicated; or the removal of a pin in the dress, 
 which had been long pricking the skin, or too tight a dress, 
 may, on removal or rectification, cause the convulsions to 
 cease. 
 
 In all cases, however, when a child we have never seen be- 
 fore is found in a fit, it is best to order a warm bath to be 
 prepared, and to have the room freely ventilated. The next 
 points to inquire into are the condition of the pulse and of 
 the child's head as to form and completion of its bones. 
 " Pass one hand quietly and carefully over the child's head 
 while the pulse is felt with the other. Fulness or weakness 
 of the pulse will be a guide to diagnosis; so also if the head 
 be hot or cold, if the anterior fontanelle be tense and pro- 
 truding, or sunk and retracted, and if the face be flushed or 
 pale" (Ellis, Diseases of Children). 
 
 When the child is completely stripped of its clothing, it 
 should be observed if the legs are drawn upwards to its belly, 
 and if so, and the head be hot, and the fontanelle prominent; 
 there is congestion of the head, which may either be the 
 cause or the consequence of the fits. In any case the child 
 should be placed first with its feet in the bath, in which a 
 handful of mustard may be mixed (two ounces of mustard to 
 four gallons of water). At the same time vinegar and water, 
 or spirits and water lotion, may be applied to the child's head; 
 while hot flannel cloths wrung out of the hot mustard and 
 water bath (with more mustard sprinkled on the surface of 
 the flannel) should envelop each leg and foot. If the head 
 be cold or the fontanelle depressed, the entire body of the 
 child should be immersed in the mustard and water bath 
 (temperature about 98° Fahr.); and friction employed over 
 the whole skin. A little sal-volatile map be held to the nose, 
 and a few drops of brandy in a teaspoonful of water may be 
 used to moisten the lips. It is possible the child may be in 
 a state of faint or syncope, and not in a fit. 
 
 During these proceedings it is important to find out the 
 previous medical history of the child, as to, — (1.) Which of 
 the acute specific diseases it may have had. (2.) State of 
 dentition, and also condition of gums to be determined, by 
 passing the finger along them. (3.) What the child may have 
 been eating recently. (4.) The previous existence of diar- 
 
CONVULSIOS, INFANTILE. 85 
 
 rhoea. (5.) The previous occurrence of carpopedal twitch- 
 ings, or drawing in of the hands and feet, with general irri- 
 tability. If this latter condition is found to have existed, 
 and if the fontanelle be prominent, there is some abnormal 
 condition* of the nervous system. A calomel purgative may 
 be required, or leeches, or a rubefacient behind the ear or 
 over the vertex. With headache, vomiting, and some fever- 
 ishness, a pulse of 130 would rather point to stomachal dis- 
 turbance; whereas with a slow pulse (say at 40), these symp- 
 toms would rather indicate an early manifestation of tuber- 
 cular meningitis, where bromide of potassium or ammonium 
 may be required after suitable purgation. If recently con- 
 valescent from scarlatina, and there be albuminuria or an- 
 asarca, a hydragogue cathartic may be required, in the form 
 of twenty grains of compound jalap powder with a grain of 
 scammony, to a child five years of age, repeated every two 
 or three hours till the desired result is produced. It may be 
 necessary at the same time to dry-cup the loins. If convul- 
 sions come on during hooping-cough, apply ice or cold to the 
 head, with free purgation, and use a sedative cough mixture 
 (Ellis, 1. c, p. 
 
 A clyster of one part vinegar and three parts water, the ap- 
 plication of cold compresses to the head, or of leeches be- 
 hind the ear, if the convulsions do not subside, are remedies 
 advocated by Niemeyer. 
 
 If symptoms denote stupor, cold affusion should be pre- 
 scribed; if, on the other hand, they denote some collapse, 
 wine, camphor, musk, and other stimulants must be used. 
 
 If dentition is causing the convulsions, the dense tissue of 
 the gums over the tooth ought to be relieved by lancing it, or 
 cutting it across over the crown of the tooth. 
 
 Dr. Tanner advises the administration of bromide of po- 
 tassium as a medicine from which more may be hoped for 
 than from any other. If there be inability to swallow, it 
 ought to be given in enemata of beef-tea. 
 
 Where great restlessness prevails, dilute hydrocyanic acid, 
 with tincture of hyoscyamus, may be given. 
 
 Compression of the carotid arteries and chloroform inhal- 
 ation, or a mixture of ether and chloroform, are only to be 
 had recourse to in cases of prolonged duration, depending on 
 such irritation as that of dentition. Anaesthesia thus induced 
 is of great value. 
 
 Trousseau is strongly opposed to blisters and general " re- 
 vulsions to the skin," except in some cases of " inward fits " 
 
86 Convulsions, puerperal. 
 
 involving the diaphragm or the heart. In such cases the ac- 
 cion of the remedy, as ammonia, must be immediate. 
 
 Convulsions, Puerperal — Definition. — An acute affec- 
 tion of the nervous system, characterized by loss of conscious- 
 ness and sensibility, by tonic and by clonic spasms. It occurs 
 only as an accessory phenomenon of another disease (gener- 
 ally Bright's, in an acute form) which, under certain circum- 
 stances, spreading its toxaemic effects on the nutrition of the 
 brain and the whole nervous system, gives rise to convul- 
 sions. The blood-poisoning is generally to be referred to 
 anaemia, or to the products of the changes in urea which are 
 retained in the blood, or to the retention of other excremen- 
 titious constituents of the urine (Braun). 
 
 Treatment. — If oedema with albuminuria and tube casts 
 in the urine are observed during the course of pregnancy, 
 the morbid condition may be kept in check, and the exten- 
 sion of the disease may be prevented by hygienic manage- 
 ment and medicinal remedies. The watery and otherwise 
 deteriorate^ condition of the blood is to be ameliorated by a 
 liberal and properly assorted dietary, and by ferruginous 
 tonics ; and a good general effect is often produced by the 
 use of tepid and vapor baths (Caxeaux, Leishman). It has 
 also been suggested by Frierichs that tartaric acid, benzoic 
 acid, or lemon juice should be regularly given, with the idea 
 that these will prevent decomposition of the urea in the blood, 
 or neutralize the carbonate of ammonia already formed. 
 The functions of the bowels must be regulated with care. 
 Purgation as a prophylactic must be resorted to with cau- 
 tion. Compound jalap powder, in electuary, with or with- 
 out guaiacum, are the most efficient and least depressing 
 medicines for this purpose. The quantity and the micoscopic 
 appearances of the urine furnish the best indications as to 
 the necessity for the use of diuretics. When exudation has 
 taken place into the Malpighian capsules and the tubes, it is 
 desirable to clear them of the obstruction, and prevent its 
 reformation. The copious use of diluents may effect this 
 desirable result. But if the secretion of urine be scanty, 
 and ursemic intoxication threaten to come on, the secretion 
 of urine must be increased. The acids already named, and 
 the mineral waters of Seltzer and Vichy, are the remedies 
 best adapted for this purpose (Braun, Leishman). I find also 
 frequently repeated small doses of bicarbonate of soda com- 
 bined with spirits o f nitrous ether in large quantities of cold 
 
COUP DE SOLEIL. CRETINISM. 87 
 
 barley water, an efficient diuretic in such circumstances. 
 Pills of tannin and extract of aloes may be used for restor- 
 ing the normal tone. Labor should only be provoked when 
 the symptoms are such that the life of the mother is in dan- 
 ger (Braun, Leishman). 
 
 In the treatment of the fits, procedure is different accord- 
 ing as they happen during pregnancy, during labour, or after 
 delivery. During the paroxysm, the indications are the same 
 in all cases. As to blood-letting, there are certain cases in 
 which the constitution and temperament of the woman, the 
 violence of the attack, combined with evidence of vascular 
 tension within the cranium (such as throbbing carotids, 
 marked suffusion of the eyes and face), warrant us in believ- 
 ing that by venesection we give the patient the best chance 
 of recovery, or in such cases leeches may be freely applied 
 to the temples and ice to the head. In cases which do not 
 present these indications for blood-letting, the administra- 
 tion of chloroform, ether, and other anaesthetic agents, pro- 
 duces a beneficial effect. Symptoms which suggest the ap- 
 proach of a first seizure, or a repeated paroxysm, are a suffi- 
 cient warrant to adopt this method of treatment. It is the 
 premonitory symptoms which must be held in control by 
 amesthetics, — their use is too late when the respiration is 
 impeded. Chloral hydrate has also been strongly recom- 
 mended, and it has this further advantage, that "when it'is 
 pushed further it produces an anaesthetic effect, under the 
 influence of which a woman may be delivered without expe- 
 riencing the slightest suffering" (Leishman). In ordinary se- 
 dative doses — not more than thirty grains — its effect is safe, 
 and in most cases efficacious ; but if larger and repeated 
 doses are required, its cumulative action is such that very 
 alarming symptoms are occasionally produced, and death 
 has even been the result of what might be considered quite 
 an ordinary dose. Four drachms have been administered by 
 enema within three days. Sponging with warm water, or te- 
 pid vinegar and water, has been found useful. Opium is not 
 to be administered in cases where albuminuria is present. 
 (For obstetric details, see Leishman's "System of Midwif- 
 ery," 3d Edition, p. 776.) 
 
 Coup de Soleil— See Sunstroke. 
 
 Cretinism: — Definition. — A condition of imperfect devel- 
 opment and deformity of the whole body, especially of the 
 head. It is endemic in the valleys of certain mountainous 
 
88 cRotlf. 
 
 districts, and is attended by feebleness or absence of the* 
 mental faculties, and sometimes of the special senses. If 
 is often associated with goitre. 
 
 Treatment. — The indications of treatment are those which 
 suggest improvement in all hygienic measures for the pre- 
 vention of the disease. Dr. Gubbenbuhl, of Zurich, was the 
 first to recognize the fact that the mental state of cretins 
 could be improved by improving the growth and condition of 
 the body. In 1842 he succeeded in buying the mountain of 
 Abendberg, which incloses the plain of Interlaken, and there 
 he established an hospital for these unfortunate children. 
 The infant cretins, removed from the low close valleys (in 
 which the malady too often finds the circumstances most 
 congenial for its development), are there fed and trained in 
 " the free, dry, cool, and bracing air of the open but sheltered 
 and sunny slopes of the Abendberg." Once established, 
 the condition of the cretin can only be ameliorated by insti- 
 tutions similar to those founded by Dr. Guggenbuhl. The 
 condition is beyond medicinal remedies. 
 
 Croup . # — Definition. — A " non-infectious inflammation of 
 the mucous membrane of the trachea, occurring in children, 
 differing from other inflammations in like tissue in the pres- 
 ence of plastic exudation " (Barclay) ; or it is a disease ac- 
 companied by the exudation of a fibrino-albuminous material 
 which rapidly coagulates upon the mucous membrane of the 
 epiglottis, glottis, larynx, or trachea, and sometimes over all 
 of these parts ; indicated by accelerated, difficult, wheezing, 
 or shrill respiration ; short, dry, constant, barking cough, 
 voice altered by hoarseness, with spasm of the interior lar- 
 yngeal muscles, and pain and constriction above the sternum, 
 frequently followed, towards the close of the disease, by ex- 
 pectoration of a membranous albuminous substance, or even 
 of a cylindrical cast of some portion of the breathing tube. 
 The disease occurs in children, and may terminate fatally, 
 either in suffocation or exhaustion of the vital powers. 
 
 Treatment. — Every case of croup demands the most active, 
 efficient, and energetic treatment. Great and diametrical as 
 are the pathological differences of croup and diphtheria, the 
 treatment most effectual in either is not the less decided and 
 opposite. While calomel in purgative doses, tartar emetic, 
 and blood-letting may each and all of them be demanded in 
 croup, these agents would be most baneful in diphtheria, 
 which is most successfully combated by the administration of 
 the mineral acids (especially the nitric and hydrochloric), 
 
CfcOtfP. 89 
 
 chlorate of potash, quinine, and iron (See Diphtheria). Bleed- 
 ing, especially local, should be employed in most cases to a 
 considerable extent (an ounce of blood for every year of 
 age) ; and two to twelve leeches, according to the age of the 
 patient, should be applied over the trachea and larynx. The 
 bleeding should be encouraged by the application of a lin- 
 seed poultice to the throat. This first bleeding often gives 
 great relief, and sometimes averts the danger. If not, the 
 leeching after a few hours may be repeated. As soon as 
 some relief is obtained, a blister should be applied along the 
 lateral aspect of the neck on each side, and not over the tra- 
 chea. The blistered surface should be dressed with mercu- 
 rial ointment. Many practitioners prescribe emetics also ; 
 first, because their emetic effects, and the large evacuations 
 they produce, favor the resolution of the inflammation ; and 
 second, because the effort of vomiting may be the means of 
 detaching and of expelling the false membrane, should it 
 have formed. So soon as croupy cough and dyspnoea occur, 
 an emetic of ipecacuanha with tartar emetic ought at once to 
 be given in doses suited to age. Four to six grains of ipeca- 
 cuanha, combined with a quarter or a third of a grain of tar- 
 tar emetic, will be sufficient for a child of two or three years 
 of age. The action of the emetic may be aided by a warm 
 bath of 98 to ioo° Fahr. If it becomes obvious that the 
 exudation has assumed the form of a membrane, especially if 
 indicated by a diphtheritic coating over the fauces, a solution 
 of the nitrate of silver, varying in strength from forty to one 
 hundred and twenty grains to the fluid ounce of distilled 
 water, should be applied to as much of the fauces and larynx 
 as can be reached. A sponge on the end of a piece of whale- 
 bone should be loaded with the weaker solution, and squeezed 
 against the rima glottidis two or three times a day. Bleeding 
 has no effect in removing or modifying the false membrane ; 
 but the system must be brought as speedily as possible under 
 the influence of mercury. Two, three, or four grains of calo- 
 mel, with two or three grains of James's powder, may be 
 given at short intervals every two or three hours ; and a dose 
 of castor-oil occasionally, till the full effect of the calomel as 
 a purgative is obtained. Green frecal stools, like chopped 
 spinach, are characteristic of this result. Mercury appears a 
 powerful resource in these. cases ; and, introduced either in- 
 ternally or by inunction, so as to affect the mouth, but with- 
 out inducing salivation, uniformly gives relief as soon as its 
 constitutional action is established. 
 
90 CROUP. 
 
 Bleeding, blistering, and mercury, although the rule of 
 treatment in idiopathic infantine croup, are, for the most 
 part, entirely inefficient in those cases in which the affection 
 begins in the fauces, as in the case of many epidemics, espe- 
 cially after scarlatina, which are really cases of diphtheria. 
 Expectorant medicines should be given with the mercurials, 
 and be continued after them. Ipecacuanha and senega are 
 most efficient. 
 
 Tracheotomy, when ndt too long delayed, has saved many 
 a life in croup, while it has proved utterly abortive in diph- 
 theria, which is beyond the reach of any such topical 
 remedy. M. Trousseau has saved one-third of his patients 
 by its means ; and of twenty cases Bretonneau saved six. 
 Perhaps the experience of the profession generally is some- 
 what discordant on this point at present. Those who oper- 
 ate early save some of their patients, while those who wait 
 till a case is advanced, and beyond medical treatment, before 
 they resort to this measure, for the most part lose all their 
 patients. The evidence, however, is daily accumulating 
 which shows that tracheotomy ought to be resorted to much 
 oftener as a remedy for croup than it has hitherto been, and 
 that at a much earlier period in the disease, — not as a last 
 resource, when death from asphyxia appears imminent, and 
 after treatment of the most depressing kind. That this is 
 the secret of success in France and in this country, is shown 
 by the experience of able physicians and good surgeons, of 
 whom the names of M. Trousseau, the late Mr. Jones, of 
 Jersey, Mr. Henry Smith and Dr. Fuller, of London, the late 
 Dr. Cruickshank, of Dalmellington, in Scotland, and Mr. 
 Spence, Professor of Surgery in the University of Edinburgh, 
 Dr. George Buchanan, in Glasgow, and Professor Roser, of 
 Tubingen, may be stated as authorities by experience. In 
 country districts the performance of trachectomy in a case 
 of croup is almost imperatively called for in the majority of 
 cases, if some symptoms of amelioration do not follow the 
 steady use of bleeding, emetics, the warm bath, and calomel 
 purgation, pursued for twelve or sixteen hours. I know 
 from personal knowledge in a wild country district of Scot- 
 land, where croup was very common and fatal, that the late 
 Dr. Cruickshank saved eight out of eleven cases during two 
 years. A valuable paper by Mr. Smith, in The Medical 
 Times and Gazette, January 26, 1856; another by the late 
 Mr. Jones, of Jersey, in the 8th November of that year ; 
 and, lastly, a paper by Dr. Conway Evans, in the The Ediiv 
 
CROUP. pi 
 
 burgh Medical journal for January and May, i860, go to 
 support the same conclusion, — namely that an earlier intro- 
 duction of air, by the operation of tracheotomy, for croup, 
 would not only give a larger percentage of recoveries in this 
 country, but would place the operation in the same favorable 
 light in which it is now regarded in Paris and other parts of 
 France. Tracheotomy in croup is undoubtedly gaining 
 ground ; and it cannot be denied that children perish, in the 
 first instance, almost always from suffocation. Tracheotomy 
 is therefore indicated in croup as soon as there are urgent 
 symptoms of obstruction of the glottis. When the respiration 
 is so impeded that the demand for oxygen is only satisfied by 
 difficult forced respirations, dreadful anguish is depicted on 
 the reddened countenance covered with sweat ; there is 
 extreme restlessness ; the patient tosses from side to side, 
 gets out of bed one minute and into it the next, clutching 
 spasmodically at those around him, as if seeking everywhere 
 for help. This is the proper period for the operation of 
 tracheotomy in croup, — the time when success may be 
 expected (Roser). Should the operation be longer delayed, 
 symptoms of asyhyxia appear, overloading of the blood with 
 carbon ensues, the face suddenly becomes blue, with fixed 
 and staring eyes, convulsive exertions are made, and anxious 
 struggles for breath follow the stage of suffocative agony. In 
 some cases the symptoms of asphyxia come on more slowly, 
 and are apt to make considerable progress before the danger 
 is fully appreciated. This insidious form of asphyxia is 
 denoted by symptoms of great weariness and weakness, rest- 
 lessness, oppression, anxious startings out of short slumbers, 
 loss of consciousness and of feeling, approaching stupor, the 
 face pale, and tending to become cedematous. If tracheotomy 
 is delayed till these symptoms become expressed, it may still 
 enable the child to breathe more freely, and thereby may 
 promote the chances of recovery ; but the child has usually 
 no longer power to resist the advancing bronchitis. The causes 
 of death after the operation are mainly pneumonia, bronchitis, 
 or the severity of the constitutional febrile state (Syden. 
 Society Year-Book, 1863, p. 278). In diphtheria the fatal 
 result depends on a cause acting generally on the system, 
 which ultimately destroys the patient, and which tracheo- 
 tomy will not prevent. Age influences success to a consider- 
 able extent. Under two years of age few cases recover ; but 
 between the ages of six and twelve nearly one-half are saved 
 (Conway Evans). 
 
02 CfcOUP, SPASMODIC— CYSTITIS. 
 
 Croup, Spasmodic — See Laryngismus Stridulus. 
 
 Cyanosis. — Definition. — A peculiar blue condition of the 
 skin, symptomatic of various malformations or derangements 
 of the heart and great vessels, so that a small portion only 
 of the blood is subjected to aeration in the lungs. 
 
 Treatment must depend upon the nature of the lesion or 
 disease which gives rise to the cyanosis. The inhalation of 
 oxygen gas has given relief in some cases- 
 
 Cynanche Tonsillaris—*^ Quinsy. 
 
 Cystitis. — Definition. — Inflammation of the urinary Dlad- 
 der. 
 
 Treatment. — The causes must, if possible, be removed. 
 Purging, together with opiates, diluents, and the warm bath, 
 are the best means of curing the acute affections. Chronic 
 inflammation of the bladder, and especially catarrh, is very 
 difficult of cure, and often our best directed efforts are un- 
 successful. Opium is the remedy of the greatest value, 
 especially aided by hot hip-baths, hot fomentations over the 
 abdomen, and linseed-meal poultices, with or without mus- 
 tard or turpentine, over the hypogastric region. Supposi- 
 tories of morphia are of great use, containing half a grain to 
 a grain of opium ; but if the pain be very great, much larger 
 doses may be given — as much as two to four grains of opium, 
 with ten to fifteen grains of extract of hyoscyamus, in a sup- 
 pository, at the hour of sleep. Alkaline and demulcent 
 drinks should be at the same time given. The state of the 
 urine is one of the surest guides in our attempts to cure the 
 patient. If the urine be acid, the best medicines are the 
 neutral salts or the pure alkalies, with opiates ; while, if the 
 urine be alkaline, or greatly loaded with mucus, the mineral 
 acids are of the most service, combined with an opiate. 
 Thus the infusio rosae c. acidi sulph. dilut. mij. to v., c. mag- 
 nesiae sulphatis, 3 j., c. tinct opii, miij. to v., every sixth 
 hour, is one of our best and most useful remedies. Tonics 
 often succeed when other remedies fail, and of these salicine 
 is one of the best. It may be given in doses of ten grains 
 every six hours. It must be admitted that much difference 
 of opinion prevails as to the best tonic remedy, some pre- 
 ferring uva ursi, others pareira, others the turpentines, as the 
 Canadian balsam, and others again the infusio diosmae. In 
 chronic catarrh, when the discharge is copious, the decoction 
 of uva ursi, in doses of not less than half a pint daily, is very 
 soothing. It is of most advantage in cases of irritability 
 
DELIRIUM TREMENS DENGUE. 93 
 
 rather than of inflammation, prescribed in large doses, from 
 one to two drachms of the extract daily, or from eight to 
 sixteen ounces of the infusion as a drink, made as follows: — 
 5- Fol. uvae ursi, §i.; Aq. Fervid., f § xviii. Macerate 
 for two hours, and boil down to 16 ounces, and strain (Sir 
 Benjamin Brodie). 
 
 Delirium Tremens — See Alcoholism. 
 
 Dengue. — Definition. — A specific continued fever or feb- 
 ricula, eminently contagious, and having an incubation- 
 period of a few hours to one to seven days (Charles), charac- 
 terized by frontal headache, by severe pains in the limbs and 
 trunk, and sometimes by an eruption, resembling that of 
 measles, over the body. The disease occurs chiefly in the 
 West Indies. 
 
 Treatment. — Time is an essential element in the treatment- 
 Emetics and purgation may be given if indicated. Calumba 
 and rhubarb with soda form a useful alterative medicine. 
 Emetics of tartrate of antimony and ipecacuanha bring away 
 large quantities of bile, relieving the pains of the head and 
 limbs almost immediately ; and the eliminative action ought 
 afterwards to be maintained by sulphate of magnesia and 
 tartar emetic. It may be necessary to repeat the emetic 
 till bile is discharged from the stomach. Dr. Charles' ex- 
 perience leads him to say that most patients get on better 
 without any emetic, which ought only to be given where the 
 tongue is much loaded and where there is gastric derange- 
 ment and nausea. Colchicum, sweet spirits of nitre, nitrate 
 of potash, and antimony, in proportions sufficient for dia- 
 phoresis, given every two hours, with an additional efferves- 
 cing draught, exercise a beneficial influence on the pains. 
 After the acute symptoms subside, forty to sixty drops of the 
 wine of colchicum, with twenty-five drops of laudanum, to 
 which thirty^ drops of antimonial wine may be added, always 
 ensure a good night's rest. Dr. Christie treated his cases by 
 purgation during the first day, and in other respects as he 
 would a case of malarious fever, by five-grain doses of 
 quinine. When the febrile symptoms subsided iodide of po- 
 tassium, in four-grain doses, was given, and continued dur- 
 ing the remission, and for a few days after desquamation of 
 the cuticle had taken place. Dr. Charles considers purga- 
 tion ought not to be used in dengue, as it adds to the tor- 
 tures of the disease and is too lowering. He considers bella.- 
 
94 DIABETES MELLITUS. 
 
 donna a sovereign remedy in the pains of dengue, and pre- 
 scribes it thus, — To one drachm of the tincture of belladonna 
 he adds five drachms of orange syrup, and directs a sixth 
 part to be taken every hour by an adult till the third dose is 
 given, which may give so marked relief that no more need be 
 taken. Less than three such doses seldom is sufficient, and in 
 very severe pains two or three doses may be given in one. 
 One-third to half grain doses of the extract, repeated twice 
 or thrice in the twenty-four hours, will also generally suffice. 
 Atropia may be used hypodermically in solution of one grain 
 of the sulphate to an ounce of water ; of which 8 minims are 
 sufficient for most cases, while 10 minims (containing ■£$ of 
 a grain) is a full dose for a powerful, well-developed adult. 
 Such a dose must not be exceeded in any case ; and atropia 
 is only to be used thus to afford rapid relief when pain is very 
 intense, and has lasted for some time. Five minims of the 
 solution is enough for a child of twelve years (containing -^ 
 of a grain). Cold water in the form of cold sponging has 
 been found of great service in the hyperpyrexia of dengue , 
 and the, cold bath is worthy of consideration. 
 
 Diabetes Mellitus. — Definition. — A constitutional dis- 
 ease produced through errors in the processes of assimila- 
 tion either in the stomach, in the solid organs, or in the 
 blood, and characterized especially by an excessive thirst, an 
 excessive discharge of urine, more or less constantly saccha- 
 rine, to an extent of over 10 grammes (154 grains) of sugar 
 per litre (35.3 ounces) of urine (Laseque), and associated 
 with progressive emaciation of the body, often ending sud- 
 denly by coma from acetonsemia or by convulsions. 
 
 Treatment. — There are few diseases in which the treat- 
 ment has been more varied than in diabetes mellitus. Every 
 conceivable medicine has been given, but exact determina- 
 tions of their effects on the sugar have rarely been made. 
 The emaciated state of the patient presents an insurmount- 
 able obstacle to bleeding. Nevertheless, this mode of treat- 
 ment has often been practised : but the pathology of diabe- 
 tes, as given in the text, does not sanction general blood- 
 letting as a mode of cure. 
 
 Mercury alike with lead, antimony, zinc, silver, and cop- 
 per, are indifferent as to their influence on the formation of 
 sugar (Parkes). Opium has been given to the extent of 100 
 grains in the twenty-four hours ; but with an equal want of 
 success, although it does seem to lessen the sugar, probably 
 by lessening the appetite and hindering the taking of food 
 
DIABETES MELLITUS. 95 
 
 (Parkes). Nevertheless opium and its preparations, especi- 
 ally codeia, have among all known remedies the most decis- 
 ive influence on the excretion of sugar ; but the duration of 
 the action is only exceptionally an enduring one (Seegen). 
 The whole materia medica has been exhausted in search of 
 a remedy for this disease. The metals, the fixed and the 
 volatile alkalies, the vegetable and mineral acids, the astrin- 
 gents, purgatives, tonics, diaphoretics, and diuretics, have 
 each in their turn been administered, and each has perhaps 
 afforded some relief ; but the disease has proceeded, and 
 finally, it may be said, nearly every patient dies whose treat- 
 ment is left entirely to drugs. Dr. Prout, who considered 
 diabetes merely as a form of dyspepsia, conceived that each 
 case requires a special treatment. In the early stages of the 
 disease some have found great benefit from the tincture of 
 the muriate of iron, now called the tincture of the perchlo- 
 ride of iron. Dr. Camplin speaks of the citrate of ammonia 
 in the effervescent form, generally combined with the citrate 
 of iron as more useful than any other medicine ; while bit- 
 ters and alkaline remedies did him great service at one 
 period of his attack. Amongst remedies, alkalies, as recom- 
 mended by Miahle and Contour, and mineral waters have 
 proved themselves the best. The use of Carlsbad water 
 has always a favorable influence, the amount and duration 
 of the influence varying with the severity of the disease (See- 
 gen). The quantity of sugar in diabetes decreases under 
 the use of alkalies, and at the same time the patient is better 
 nourished. This action of the alkalies depends probably 
 upon an increased oxidation of the hydrates of carbon in the 
 blood of the non-muscular tissues, by which partly the want 
 of oxygen in the muscles may be compensated. If the un- 
 known cause cannot be removed, in consequence of which 
 the muscles cease to decompose sugar, there are no re- 
 medies by which we might decompose the sugar in a diabetic 
 diseased organism. But we may partly supply, in the blood 
 of diabetic patients, what is wanted. Besides alkalies, we 
 may use paralactic acid ; and as glycerine acts in a similar 
 manner as paralactic acid, — i. e., is easily consumed in the 
 blood — it deserves to be taken into consideration in such 
 cases. It has been given with benefit to the extent of six 
 to eight drachms daily ; and its administration should be 
 continued uninterruptedly for at least one month. In place 
 of paralactic acid, there may be used lactic acid, as it is also 
 consumed in the blood. 
 
g6 DIABETES MELLITUS. 
 
 Opium, combined with ipecacuanha, is eminently useful 
 as a sedative, especially in the form of Dover's powder ; 
 while exercise, warm clothing, friction of the surface, hot 
 bathing, and diaphoretics, improve the cutaneous functions. 
 The functions of the skin must always be inquired into, and 
 must be kept active. The nitro-muriatic acid baths, and the 
 internal administration of the acid, might also be employed 
 with some prospect of benefit in cases requiring acid tonics. 
 This is more generally the case in the young, and in the 
 early stages of the disease, in which the tincture of the per- 
 chloride of iron is also of service, prescribed in the infusion 
 of quassia or of calumba. But each case requires to be 
 made a special study, considering that many, or at least sev- 
 eral, organs are concerned in the disorded working of the 
 system (Prout, Camplin). The mistura ferri composita is 
 another of the iron preparations which has been found of 
 service. With the view of diminishing the morbid ferment 
 in the stomach, Drs. W. Ebstein and Julius Muller, of Bres- 
 lau, have prescribed carbolic acid with advantage. It was 
 given dissolved in peppermint water (the strength being i 
 gramme "to 300 grammes), about six to seven tablespoonfuls 
 of this solution being taken in a day. It has also been 
 found of use in the treatment of the acetonaemia (B. Foster). 
 One to three grains may be given in glycerine or in a pill, 
 twice or thrice a day. Valerian has also been found of use 
 in diminishing the excretion of urea (Bouchardat), and so 
 lessening thirst. He gives it in repeated small doses, and 
 gradually increases the amount taken until he has, in some 
 cases, reached a dose of 30 grammes (450 grains) in twenty- 
 four hours (Med. Times and Gazette, Vol I., p. 568). With 
 regard to the acetonaemia, transfusion has failed in this 
 country and abroad. So also has the injection of a saline 
 solution into the blood, as practised by Drs. E. H. Fagge 
 and F. Taylor, of Guy's Hospital (Guy's Hasp. Report, XIX., 
 p. 173 and 521). Salicylic acid and its salts are also worthy 
 of trial, so is thymol (B. Foster, Burdon Sanderson). In 
 the severe form of cardialgia, I have found great benefit to 
 result from the use of Seller's Bismuth Mixture, prepared by 
 Messrs. Mackay, Sellers & Co., 1 and 2 Bouverie street, Lon- 
 don, in half-drachm doses, mixed with water, three or four 
 times a day. Dr. Garrod writes favorably of the sulphide of 
 ammonium as useful, in so far as it controls the morbid appe- 
 tite ; and Dr. S. Ringer finds sulphide of calcium of use. 
 In the affections of the genitals in the female, I have found 
 
DIABETES MELLITUS. * 97 
 
 the intense pruritus to be best relieved by bathing in solution 
 of Condy's fluid (permanganate of potash; in copious and 
 frequent ablutions, or by vaginal injections without soap. 
 Winckel has found a solution of one part of salicylic acid in 
 300 of water ; but glycerole of lead, zinc ointment, white 
 precipitate ointment, glycerine and tannin, sitz baths with 
 bran, carbolic acid solution (i grain to 4 ounces of water as 
 a vaginal injection, or 5 grains to the ounce as a lotion), 
 may each in their turn be of use in relieving these 
 most distressing of the symptoms and complications of 
 diabetes. 
 
 The little benefit derived from medicine induced Dr. 
 Rollo to try the effects of an entirely azoted or animal diet ; 
 and now it is found that the regulation of the diet is of the 
 first and primest importance in the treatment of diabetes. 
 A full and generous diet is unquestionably useful; but the 
 patient soon gets disgusted with mutton or beef, or both, for 
 breakfast, dinner, and supper *. lie consequently nauseates a 
 meat diet, and abandons it altogether. A diet of salt fish 
 has been attempted, but the patient in a short time so 
 loathes it that it has to be given up. A mixed diet, therefore, if 
 contraindicated by some theories, is at least the best to 
 adopt in practice, if duly regulated and aided by Other 
 means. It will be evident, however, that those vegetables 
 which contain a large quantity of saccharine matter should 
 be avoided, as potatoes, grapes, or other very ripe fruit, and 
 a fortiori, sugar itself. 
 
 " However surely an exclusive animal diet may lessen or 
 entirely remove, the sugar in the urine of a diabetic patient, it 
 is certain that it cannot long be tolerated." In this opinion 
 Niemeyer, Trousseau, and many other physicians now con- 
 cur: " Under its use the appetite fails, and a lo: thing of all 
 food soon happens. The necessity of a mixed diet for man 
 is as necessary for him when suffering from diabetes as in a 
 state of health. In this disease the nervous system is un- 
 doubtedly implicated, and a rigid adherence to animal food 
 alone, were it practicable, would soon be followed by an 
 aggravation of the nervous troubles. There is, from the very 
 beginning, and throughout the course of the disorder, a 
 strong tendency to devitalization, and this too must be 
 guarded against. Fortunately the sugar in the urine may 
 be kept down, and at the same time the general strength of 
 the system maintained, by a properly adjusted diet of mixed 
 food. Along, then, with the carnivorous dietary, whose ITO* 
 
98 . DIABETES MELLITUS. 
 
 portance is not to be undervalued, certain vegetables may be 
 permitted, not only with impunity, but with advantage. 
 These are, cabbage, cauliflowers, onions, spinach, water- 
 cress, sorrel, endive, lettuce, &c. Trousseau has found no 
 ill consequences from eating acid fruits, as strawberries, 
 gooseberries, cherries, and he has allowed apples, pears and 
 grapes. He even suffers his diabetic patients to eat a small 
 quantity of bread, if they greatly crave for it. As he re- 
 marks, there are many persons who are unable to make a 
 meal without it. Such a regimen is more likely to keep the 
 disease stationary, and secure the general comfort of the 
 patient, by upholding his strength, than by confining him to 
 one kind of diet, which his stomach soon revolts against, and 
 which must result in innutrition, general debility, the devel- 
 opment of intercurrent affections, and sooner or later death. 
 Enforced daily exercise in the open air, when possible, just 
 short of fatigue, is as of much importance in the treatment 
 of diabetes as diet. In Professor Bouchardat's estimation 
 exercise is the most efficacious of agents. Gymnastics should 
 be practiced. Trousseau says that he has repeatedly seen, 
 during the hunting season, diabetic patients, abroad with 
 their gun and dog, cease both to drink and urinate to excess, 
 and regain their strength, and even their virile powers. A 
 suit of flannel or buckskin should be worn next the skin. 
 Warm alkaline baths should be frequently taken, and an 
 occasional Turkish bath will be found serviceable, if it pro- 
 duces no disposition to boils; or daily packing with the wet 
 sheet may be tried, carefully watching the effects. The 
 whole body should be hand-rubbed daily. Cream, so long 
 as it agrees, may be permitted, and cod-liver oil is in many 
 cases well borne, and would seem, as anourisher, to do good. 
 The benefit of small doses of the alkalies, not continued 
 longer than a week or ten days at a time, is incontestable. 
 They are the best given in the form of Vichy, Marienbad 
 Kreutzbrun, or Carlsbad Sproudel water. Legroux thought 
 he derived benefit from the administration of arsenic. Dr. 
 Richardson, of London, has recommended the respiration of 
 oxygen, and Berenger-Feraud has shown that during its use 
 there is great diminution in the amount of sugar in the urine 
 (Bui. de Ther. y t. lxvii) The ethereal solution of the 
 peroxide of hydrogen (ozonic ether) has been given with as- 
 serted benefit in half-drachm doses in an ounce of distilled 
 water. Dr. T. K. Chambers has prescribed iodide of potash 
 on purely empirical grounds. The preparations of iron are 
 
DIABETES MELLITUS. 99 
 
 indispensable, and should be varied from time to time. To 
 lessen the thirst and craving for food, small doses of opium 
 are useful. By the use of the mixed diet recommended, par- 
 ticularly if fatty articles can be taken, the obstinate consti- 
 pation, so common in the earlier stages of the disorder, may 
 be obviated without a recourse to drugs. Should this not 
 be the case,castor-oil in capsules, or rhubarb and podophyllin, 
 must be prescribed. 
 
 " This mode of treatment, which secures a proper but va- 
 ried diet, one that will not disgust the patient, but will nour- 
 ish his body, though it may not remove the symptom glyco- 
 suria, will, in a large number of cases, give the diabetic a fair 
 share of conditional health; so that, as Dr. Trousseau re- 
 marks, he would not know he had sugar in his urine, if an 
 occasional chemical analysis did not remind him of its pres- 
 ence." (Dr. Clymer's American edition). 
 
 Nevertheless, there are, as Dr. Camplin justly observed, 
 'certain fixed broad principles upon which the disease is to 
 be treated." In all cases the various influences of the stom- 
 ach, liver, skin, and kidneys on the nervous system and on 
 each other, ought to be sought out and determined, and the 
 basis of treatment arranged accordingly. It is necessary to 
 abstain from all amylaceous food, as well as from every solid 
 and liquid containing sugar, or any substance readily con- 
 vertible into sugar. Fat meat and eggs may be taken, if 
 biliary derangement is not induced by them, and fish is a 
 most important article with which to vary the monotony of 
 the dietary. Milk may also be indulged in occasionally, as 
 it is not found that the sugar it contains is readily converted 
 into glucose. Its influence, however, requires watching. 
 The name of Dr. Donkin is associated with a special treat- 
 ment of this disease in the use of skim-milk as the sole and 
 only diet. He shows that in accordance with the teachings 
 of chemistry and physiology we ought to expect advan- 
 tageous results from it. Dr. Donkin contends that milk-sugar 
 differs so essentially from cane sugar, grape sugar, and pure 
 diabetic sugar, that it is not converted into it, and does not 
 appear again in that form in the renal excretion. "Belong- 
 ing to a different class of sugars, milk-sugar does not undergo 
 alcoholic fermentation in contact with yeast; and, in addi- 
 tion, it does not precipitate the oxide of copper when treated 
 with the reduction test. On the other hand, it is subject to 
 lactic fermentation by the action of ferments. On account 
 of these intrinsic differences, lactose, as an ingredient of 
 
IOO DIABETES MELLITUS. 
 
 milk, cannot undergo the same metamorphic changes as glu- 
 cose in the processes of digestion, and assimilation in health 
 (nor be converted into it in diabetes); its conversion into 
 lactic acid being direct and immediate, not by intermediate 
 changes, through which the latter pass into this substance. 
 For this reason milk-sugar, unlike vegetable glucose, is assim- 
 ilated. It is necessary to notice, however, that milk-sugar, 
 in the presence of acetic acid and some other vegetable acids, 
 and of several mineral acids and other substances, was long 
 ago observed by Simon to be changed into grape-sugar, and 
 so became liable to alcoholic fermentation, and hence pre- 
 sumably as injurious to the diabetic as glucose. Hence 
 milk-sugar may be thus perverted and rendered poisonous 
 by admixture with other articles in the stomach, whereas 
 taken quite alone, it may be the best of foods to the hungry 
 patient. It is not, then, considered to be a fair trial of Dr. 
 Donkin's skim-milk treatment, if any other food be allowed to 
 mix with it in the stomach. It must be made the exclusive 
 article of diet. The use of lactic acid by Professor Cantani, 
 Dr. Balfour, Dr. Foster, and Dr. Ogle, is quite dis- 
 tinct from the treatment recommended by Dr. Donkin. 
 They prescribed lactic acid as a remedy intended 
 to make other foods wholesome; he prescribed skim- 
 milk as a sole nutriment, which the mixture of 
 other foods nullifies. As to the quantity demanded, it ap- 
 pears that a patient can drink as much as a gallon and a 
 ha\£j>er diem: but that is an extreme ration; and when the 
 appetite is so keen, Dr. Donkin advises some of the milk to 
 be made into curd or "junkets." But much less than a 
 gallon and a half will suffice, for much less will supply the 
 calculated daily wants of the digestive organs. Each pint 
 of skim-milk contains half its weight, of casein in a fluid 
 state, which, in fact, is liquid bodily tissue. There is 72 per 
 cent, of water in combination with it, and there is 72 per 
 cent, of water in the primest beef. Thus, in five pints of 
 skim-milk a man would get as much nutriment as in 3^ lbs. 
 of beef-steak, which, in an exclusively meat diet, may be 
 reckoned sufficient even to do a day's work upon. Dr. Don- 
 kin has, no doubt, made out a case for at least a temporary 
 trial of this remedy in all but exceptional instances of dia- 
 betes. But the treatment must be commenced in the earliest 
 stages. I have not found it of any use when the disease is 
 persistently established. 
 
 It is desirable to vary the food as much as possible dur- 
 
tHABETES MELLITUS. 101 
 
 ing the day, "taking the lighter kinds in the later meals. 
 When soups are taken, they ought to be really good, and 
 flavored with aromatics or onions, to the exclusion of car- 
 rots, turnips, and peas. They may be thickened with some 
 bran finely powdered. Lettuces Dr. Camplin found to agree 
 well, when eaten sparingly with oil and vinegar, or with a 
 little salt only, if the vinegar is likely to disagree. Pickles 
 in small quantities may be permitted to convalescents. If 
 cocoa agree, it may be taken, prepared from the nibs only. 
 With regard to drinks: if milk is found to agree, it may be 
 used as a drink combined with half its bulk of lime-water or 
 soda-water, or in the form of what is known as " buttermilk " 
 in Scotland and in Ireland, but which in England is gener- 
 ally given to pigs, not yet being sufficiently appreciated by 
 natives south of the Tweed. Dr. Camplin eventually found 
 it necessary to abstain from all alcoholic dnnks; but, where 
 they are found desirable or necessary, a selection may be 
 made from those wines' and spirits which are freest from 
 sugars. Of these, clarets may be chemically considered the 
 best, then Burgundy. The so-called " fruity wines " must 
 be entirely interdicted; and of all alcoholic beverages weak 
 brandy and water is the safest. The amount of brandy 
 must be always measured, and taken as directed by the 
 medical attendant. From a teaspoonful to a tablespoon ful 
 in a tumblerful of water is generally sufficient for an ordi- 
 nary dinner drink; and Dr. Camplin candidly and feelingly 
 observes, from his own experience, that no diabetic need ex- 
 pect to recover or continue well who cannot exercise self- 
 control, and make up his mind to be temperate in all things. 
 Seeing that under this system of diet the patient is deprived 
 of the use of ordinary bread, Dr. Camplin devised a form of 
 bread prepared solely from bran; and the great value of bran 
 cakes as a substitute for bread in cases of diabetes has now 
 been established by the experience of so many individuals 
 that its use ought to be insisted on. The bran used should 
 be thoroughly washed, so that it may be free from starch as 
 possible, and finely powdered, so that it may not irritate the 
 susceptible mucous membrane of the intestines. Such care- 
 fully-prepared and finely-powdered bran may be obtained 
 from Mr. Batchley, of 362 Oxford Street, London, near the 
 Pantheon; also of Mr. Donges, Gower Street,London, North. 
 But if it is desirable to prepare the powder at home as it is 
 required, a special mill and sieve for the purpose are necessary, 
 and may be obtained of Messrs. Evans Brothers, 54 Brick- 
 
102 DIABETES MELLITUS. 
 
 lane, Spitalfields, London, E. (Dr. Camplin's* "Mono- 
 graph on Diabetes.") 
 
 Consistently with the experiments of Bernard, " cod-liver 
 oil holds out some prospects of a natural plan of treatment 
 by its use." Dr. Pavy recommends ground almond powder, 
 made into biscuits, rusks, and bread, with eggs, as a substi- 
 tute for ordinary bread. Mr. Hill, 60 Bishopsgate Street, 
 London, makes such biscuits. 
 
 An abstinence from water lessens the formation of sugar; 
 but it probably accumulates in the body, so that when fluid 
 is again given, an excessive elimination of sugar occurs 
 (Ringer, Griesinger); and patients become extremely de- 
 pressed and ill if water is withheld from them, probably from 
 the impregnation of the body with sugar (Parkes). Coffee 
 lessens the sugar, but increases the urea. Rennet, as recom- 
 mended by Dr. Gray, of Glasgow, at first lessens the sugar 
 and water; but they afterwards increase again. Warm baths 
 lessen the amount slightly. When the diabetic symptoms 
 
 * The formula for bran cakes is thus given by him: — " Take a quan- 
 tity of wheat bran (say a quart). Boil it in two successive waters for a 
 quarter of an hour, each time straining it through a sieve; wash it well 
 with cold water on the sieve, until the water runs off perfectly clear. 
 Squeeze the washed bran in a cloth, as dry as possible, then spread it 
 thinly on a dish, and place it in a slow oven. When it is perfectly dry 
 and crisp it is fit for grinding into fine powder. The bran thus prepared 
 is ground in the mill for the purpose, and must be sifted through a wire 
 sieve of such fineness as to require the use of a brush to pass it through, 
 and what remains on the sieve must be reground till it is sufficiently 
 soft and fine. To prepare a cake, take of this bran powder three or four 
 ounces, three new-laid eggs, one and a half or two ounces of butter, 
 and about half a pint of milk. Mix the eggs with a little of the milk, 
 and warm the butter with the remainder of the milk; stir the whole well 
 together, adding a little nutmeg and ginger, or any other spice that may 
 be agreeable. Bake in small tins (patty-pans, which must be well but- 
 tered), in a rather quick oven, for about half an hour. The cakes when 
 baked should be a little thicker than a captain's biscuit. These cakes 
 may be eaten with meat or cheese for breakfast, dinner, and supper, 
 and require a free allowance of butter; and the cakes are more pleasant 
 if placed in the oven a few minutes before being placed on the table. 
 When economy is an object, when a change is required, or if the stom- 
 ach cannot bear butter, the cakes may be prepared as follows: — Take of 
 the prepared bran four ounces, three eggs, about twelve ounces of milk, 
 with a little spice and salt, to be mixed and put into a basin (previously 
 well buttered). Bake it for about an hour; the loaf may then be cut into 
 convenient slices and toasted when wanted; or, after slicing, it may be 
 rebaked, and kept in the form of rusks. Nothing has yet been discov- 
 ered of equal utility to these bran cakes, combining, as they do, moderate 
 cost with freedom from starch, and sufficient pleasantness as an article 
 of food." (Camplin, " On Diabetes," third edition). 
 
DIABETES MELLITUS DIARRHCEA. 1O3 
 
 subside, congestions, especially of the head, are apt to super- 
 vene. Such congestion Dr. Camplin found to subside grad- 
 ually under the use of citrate of ammonia and small doses 
 of colchicum wine. Warm flannel ought to be worn next 
 the skin in all cases, and residence in a warm climate will 
 often be of service as an aid to the means of cure employed. 
 
 The great difficulty in the treatment of diabetes is to man- 
 age the dyspepsia and impaired digestion, and, at the same 
 time, to diminish and keep in check the formation of sugar. 
 The first principle consists in varying the alimentation so as 
 to prevent disgust; the second is to add fatty aliments in 
 proper proportion to the alcoholic aliment, the exaggerated 
 use of the latter acting injuriously on the nervous system; 
 and the third is to suppress or considerably diminish for 
 some time the use of feculents. 
 
 Diarrhoea. — Definition. — A frequent discharge of loose 
 or fluid alvine evacuations, without tormina or tenesmus 
 (Good, Copland), in which the intestinal lesion varies from a 
 mere condition of irritation, expressed by the increased and 
 modified secretion (beyond which it does not progress), to 
 those cases in which there is actual inflammation or other 
 lesion of mucous membrane, the latter being a higher degree 
 of the former, the cases passing from one to another by in- 
 sensible degrees (J. J. Woodward). 
 
 The treatment of diarrhoea may be founded on the 
 following indications: (i.) When the tongue is clean, 
 the pulse quiet, and all constitutional reaction absent ; 
 (2.) when the tongue is white and coated, the pulse ac- 
 celerated, some fever present, and the pain or soreness con- 
 stant and increased by pressure. The stools in either case 
 may be black, green, white, or mixed with blood indifferently. 
 When the tongue is clean, if the disease be quite incipient, 
 one dose of an opiate may be given, combined with a gentle 
 cathartic. The form may be one grain of opium, combined 
 with a drachm of compound rhubarb powder, or with three 
 to five grains of calomel. To remove any offending matter 
 that may be present, the action of the bowels may be aided 
 by castor oil, or a saline cathartic, such as a seidlitz powder 
 or compound senna mixture. Sometimes it may be advisable 
 to omit the opium, and to combine antacid remedies with the 
 laxative, as in the following prescriptions : 
 
 fy. Sodae Bicarbonatis Hydrargyri cum creta, a a gr. ii, 
 ad gr. v. ; Magnesiae Carbonatis, gr. iii. ad gr. vi. ; Pulv. Rhei. 
 gr. v. ad gr. viii. ; misce. Or — 
 
t04 DIARRHOEA. 
 
 ^ . Sodae Bicarbonatis ; Pulv. Rhei ; Pulv Calumbae, a a 
 gr. iv. ad gr. vi. ; misce. 
 
 The administration of such a powder may be repeated at 
 intervals — twice or thrice a day ; and ipecacuanha in small 
 doses (a quarter or a sixth of a grain) may be advantageously 
 combined with each dose. Other more astringent remedies 
 may be administered if diarrhoea persists. In many cases a 
 drachm of syrup of poppies after each stool is sufficient to 
 arrest it. In severe diarrhoea a scruple to half a drachm of 
 the compound chalk powder, in some aromatic (peppermint 
 or cinnamon water,) every four or six hours, may be used 
 whether blood be or be not in the stools. If the opiate and 
 aromatics should prove insufficient, it may be necessary to 
 add to each dose some of the class of pure astringents, as a 
 drachm of the tincture of kino, or of catechu, or of haema- 
 toxydon, or of iron. The following formula (Diarrhoea Mix- 
 ture) has been found of service : 
 
 I£. Conf. Aromat., 3 iij . ; Sodae Carb., 3 iss. (Bicarb.); 
 Tinct. Opii., 3 i.; -^Ether Chloric, 3 iij.; 01. Caryoph., m xl.; 
 Mucilag. Acaciae, §i.; Aquae Destil., ad J v.; misce. One 
 teaspoonful for a dose. This quantity may be given every 
 two or three hours, or every hour, or every half hour, should 
 the purging continue. 
 
 Absolute rest in the recumbent posture must be maintained, 
 and warmth applied to the surface of the abdomen. Bland 
 demulcent food, such as arrow- root, with beef-tea or gruel, 
 may be taken. 
 
 There are cases of diarrhoea with a clean tongue, which 
 will not yield to laxative remedies, nor to opiates, astringents, 
 or stimulants, either singly or combined, which probably de- 
 pend on a want of tone in the intestine, associated with de- 
 composition of intestinal contents and fetid stools. In these 
 cases five grains of salicine every four or six hours have often 
 stopped a diarrhoea that appeared fast hurrying the patient 
 to his grave. Salicylic acid and salicylate of soda have also 
 been found useful. Tincture of the sesquichloride of iron is 
 similarly useful in doses of five to ten minutes. In the di- 
 arrhoea of whitish stools, with frequent calls and sudden de- 
 sire to evacuate the rectum, when muco-gelatinous matter 
 like a jelly is passed, no remedy is of so much service as the 
 extract of nux vomica, to the extent of a fourth to a half grain 
 dose ; or strychnia, to the extent of one-twelfth of a grain, 
 in a pill twice or thrice a day, with the sulphate of iron and 
 extract of calumba. Tincture of the pernitrate of iron 
 
DIARRHOEA. 105 
 
 (m x. every half hour) may be given with great benefit (W. C. 
 Maclean). It is in diarrhoea of this kind that iron is of so 
 much service. The ferri ammonia-phosphas possesses some 
 desirable properties, especially as to solubility and freedom 
 from the inky astringent taste of preparations of iron. Its 
 preparation is given in the following note : [Ferri Ammo- 
 nia-Phosphas. — Heat common phosphate of soda to redness. 
 Take of the pyrophosphate of soda so obtained § ij. Dis- 
 solve in one pint of warm water. Then take of protosul- 
 phate of iron § iv. Dissolve in twelve ounces of water. Mix 
 the solutions, collect, wash, and dry the precipitate at a gen- 
 tle heat over a water-bath. Take of this precipitate \ j., 
 Liq. ammonia P. L., | iss., water q. s. Dilute the Liq. ammo- 
 nia with an equal volume of water, and rub up with the phos- 
 phate of iron in a mortar until the latter is dissolved. Then 
 dilute to § viij. Filter the solution, and evaporate at a heat 
 not exceeding 120" Fahr., over a water-bath, and proceed as 
 for the other scale preparations of iron. The dose is one fluid 
 drachm (W. H. Moss, Dispenser, A. H. C.) In fluid extract of 
 coto bark (prepared by Ferris & Co., Bristol), we have also a 
 useful remedy in doses of five to eight minims. Black or 
 dark stools (melaena) are not so much due to bile (atrabilis of 
 Abernethy) as that such stools, resembling pitch, arc princi- 
 pally composed of morbid or impaired secretions from the 
 intestines (Hoffman, Home, Graves). The discharge of the 
 black matter is followed by a feeling of relief to the system 
 generally. In cases of true melaena (where the dark color is 
 due to blood), great debility, and sometimes fainting, may 
 follow the evacuations. Stimulating and tonic remedies, 
 such as turpentine, are of benefit (Graves). When diar- 
 rhoea is accompanied by a white furred tongue, with pain 
 and soreness, it is necessary to give opiates, combined with 
 some mild purgative. Half a drachm to a drachm of Epsom 
 salts, with a drachm of the syrup of poppies ; or fifteen min- 
 ims of the tincture of hyoscyamus ; or, in severe cases, with 
 three to five minims of tincture of opium, every four or six 
 hours, are remedies on which, as a general principle, we may 
 very confidently rely. In other cases, rhubarb, castor-oil, or 
 any other mild purgative, may be substituted for the Epsom 
 salts. In cases of diarrhoea, accompanied by vomiting, a 
 drachm of syrup of poppies alone, repeated every half hour, 
 or every hour, for two or three times, may quiet the stom- 
 ach, and enable it to bear other remedies. Soda-water, or 
 the effervescing draught, with a tablespoonf ul of brandy, with 
 
Io6 DIPHTHERIA. 
 
 or without a few minims of tincture of opium, often remain 
 on the stomach when everything else is rejected. 
 
 Most practitioners lay great stress on the color of the 
 stools, and the necessity of correcting the supposed mor- 
 bid states of the liver ; but the various colors of the stools 
 are in many instances caused rather by morbid secretions 
 from the surface of the mucous membrane of the intestines 
 than by any defective state of the bile in the gall-bladder. In 
 simple diarrhoea, mercury (which is so often given in a routine 
 way) in any form is either unnecessary or injurious in the ma- 
 jority of cases, except as a purgative. It is, however, some- 
 times necessary, especially in children under four years of age. 
 One general rule may be acted on — namely, that in the adult, 
 whatever be the form of the diarrhoea, if the stools be dark 
 at first, and then become light-colored, purgative medicines 
 are no longer beneficial. In no instance ought they to be 
 continued longer than is sufficient to remove any irritative 
 substances accumulated in the alimentary canal. Sulphuric 
 acid, in doses of the officinal or aromatic diluted drug, of 
 twenty to thirty drops, with water simply, or combined with 
 the compound tincture of gentian, has been found a useful 
 remedy. It may be alternated with the diluted nitro-muri- 
 atic acid, and prescribed in a similar manner. The dietetic 
 treatment should be limited to slops, puddings, and white fish 
 boiled, and the drink to weak brandy and water, which acts 
 locally as an astringent, and generally as a diffusible 
 stimulus. 
 
 Diphtheria. — Definition. — A specific disease commencing 
 with fever, and producing a membranous exudation in and 
 upon the mucous membrane (of one or other, or all of 
 it) covering the tonsils, uvula, and soft palate, the root of the 
 tongue, the larynx and air passages, the posterior wall of the 
 pharynx, or the nasal cavities. The disease is attended with 
 great prostration of the vital powers; also, by a very early 
 appearance of albumen in the urine, which may continue for 
 a very short time only, or may become persistent. In many 
 cases a remarkable series of nervous phenomena are apt to 
 supervene, characterized by progressive paralysis, and some- 
 times by fatal syncope. The disease is contagious, and apt 
 to be epidemic. 
 
 Treatment — There are especially three things it is desira- 
 ble to bring about, namely: — (i.) Softening or suppuration of 
 the exudation and its connections — to convert the process 
 into a catarrhal one; (2.) to thoroughly disinfect the air pas- 
 
DIPHTHERIA. tOj 
 
 sages; (3.) to overcome the marked asthenia by which all 
 cases of this disease are marked (Wagenen). To accomplish 
 the first, vapor of water at a temperature of 120° to 130° 
 Fahr. should be inhaled continuously for fifteen or twenty 
 minutes every hour; and where the exudation is considera- 
 ble and tough a very hot poultice should be applied extern- 
 ally, or compresses wrung out of hot water and covered with 
 oil-silk should be used.. Under such means the exudation 
 may break down into a suppurating mass in from twelve to 
 twenty-four hours; but the deposit may return again, if the 
 vapor inhalation is omitted too early. Even in those cases 
 which die, this method of treatment accomplishes euthanasia. 
 The temperature of the room in which the patient is confined 
 to bed ought to be kept at 68° Fahr., and its atmosphere 
 kept moist by the steam from a kettle with a long spout con- 
 stantly boiling on the fire, and by large basins placed about 
 the room, and kept constantly full of hot water. If the pa- 
 tient can be enveloped in a warm moist atmosphere, so much 
 the better; and this may be done by making a tent with 
 blankets over the bed, and, by the aid of a spirit lam}), a tin 
 kettle of boiling water may be maintained at the boiling 
 point, and its steam thus made to envelop the patient. The 
 steam assists very much in dissolving the mucus and in loos- 
 ening and breaking up the membranous deposit To accom- 
 plish the second indication — namely, disinfection — acetic, 
 salicylic, or carbolic acid, or sulphurous acid may be used. 
 Neither is a specific. A wineglass of vinegar to a pint of 
 water is a good proportion (Sir W. Jenner). The solutions 
 ought to be made as strong as the patient will bear them; 
 and should be used with the vapor of water as a spray in a 
 steam-atomizer, as well as by gargling. The steam antiseptic 
 spray is the best, as the steam carries the disinfectant to 
 every part of the diseased surface; while the vapor which 
 escapes into the room is also a carrier of the antiseptic, as it 
 is of caloric, when a large room is heated by dripping water 
 on a hot plate or stone. 
 
 Syringing the throat and nares with the perchloride of iron 
 in solution is also very beneficial. The solution ought to 
 consist of tincture of perchloride of iron, and of glycerine, 
 each half a drachm, with two or three drachms of water. A 
 stronger solution — the strength of the tincture — may be ap- 
 plied with a large camel's-hair brush to a patch of exudation, 
 and the adjacent surface of the mucous membrane; or a pre- 
 paration, twice the strength of the tincture, may be made by 
 
108 DIPHTHERIA. 
 
 mixing equal parts of the liquor ferri perclaloride and of 
 glycerine, and may be used to brush over the patches if the 
 exudation is very thick. But such an application, as it is 
 powerfully styptic, should be confined to the surface of the 
 exudation only. It readily penetrates it, and exerts its bene- 
 ficial influence on the vessels below (Squire). In short, the 
 application of this remedy to the whole of the pharynx with 
 food, or separately as a lotion, to be applied as a gargle, or 
 a medicine to be swallowed, affords relief. 
 
 With regard to topical applications, Sir Wm. Jenner is of 
 opinion that repeated applications to the throat of caustic 
 solutions are injurious. He recommends one single but effi- 
 cient application of a strong solution of nitrate of silver (3i. 
 to 3 i. of water), as a remedy which may stay the spread of 
 the exudative inflammation; but that, on the whole, hydro- 
 chloric acid and water in equal parts will more frequently 
 attain the object. It is especially the surface round the ex- 
 udation, as well as the exudation itself, that should be painted 
 well over with the solution, the brush being passed' over the 
 surface two or three times in quick succession. The white 
 discoloration which results must not be confounded with the 
 spread of the diphtheritic exudation. The discoloration 
 from the acid passes away in about thirty-six hours, and that 
 from the nitrate of silver somewhat quicker. Medicinal car- 
 bolic acid (as prepared by Calvert, of Manchester) is valu- 
 able as a gargle, in the proportion of i of acid to 200 parts 
 of water. 
 
 There are considerable differences of opinion regarding 
 the usefulness of topical applications, and the best means of 
 applying them. The tincture of the perchloride of iron is 
 recommended by some to be gently painted over the fauces, 
 as already directed. The throat should be washed out as 
 often as possible with permanganate of potash (1 to 300), or 
 with lime water in a solution of chlorate of potash. The 
 local application of lime water by frequent gargling or gentle 
 brushing, with the internal administration of nitrate and car- 
 bonate of soda, prove speedily curative in the milder cases, 
 and alleviate distress in the more severe. Ice kept dissolv- 
 ing in the mouth is often also a great comfort, and its use 
 should never be omitted where it can be had. Dr. Green- 
 how remonstrates against the application of the more severe 
 topical remedies. The pellicle or false membrane ought 
 never to be torn off. The bowels should be opened freely 
 by a dose of calomel and jalap; or by calomel and colocynth 
 
DIPHTHERIA. IO9 
 
 pill, followed in the inflammatory or sthenic forms of the dis- 
 ease by a saline aperient — e. g., sulphate of magnesia in the 
 infusion of roses. If feebleness of pulse supervene, if the 
 redness of the throat assume a dusky hue, if the sense of 
 general weakness become extreme, wine in large doses fre- 
 quently repeated is required. Six or eight ounces of port or 
 sherry during the day for an adult may be given from the 
 first, with as good a diet as the stomach can digest. During 
 the course of the disease, much larger quantities of wine and 
 even brandy may be necessary; but the quantity of stimu- 
 lants must be regulated by the habits and age of the patients. 
 A child of three years of age may take with advantage one or 
 two drachms of brandy every hour — i. e. f from three to five 
 ounces of brandy during the twenty-four hours (Sir Wm. 
 Jenner). So long as there is firmness of pulse the physician 
 ought to abstain from alcoholic stimulants, and rest con- 
 tented by giving such saline medicines as exert a slight action 
 on the skin and on the kidneys, or on both. But a rapid 
 pulse indicates the necessity of alcoholic stimulants, which 
 ought to be freely given on the development of the earliest 
 general symptoms. Under all circumstances efficient daily 
 action of the bowels must be secured, and the urinary and 
 intestinal secretions should be examined daily. If blood or 
 albumen appear in the urine, diuretics are contraindicated. 
 Mustard poultices, warm linseed-meal poultices, or the warm 
 wet sheet, as recommended by Dr. Huss in typhoid fever, 
 may be applied to the loins under these circumstances. The 
 hot-air bath applied to the body, without removal from the 
 bed, is also of great service. Diphtheria is most successfully 
 treated by the administration of mineral acids, especially the 
 nitric and hydrochloric; also by guaiacum, chlorate of 
 potash, quinine and iron. Tincture of the perchloride of 
 iron is now fully recognized as having a beneficial local as 
 well as general influence on the disease; and it may be ad- 
 vantageously combined with quinine in the following formula 
 (Tanner): 
 
 $. Quinine Sulphatis, gr. ii.; Acidi Hydrochlorici diluti, 
 m x.; Tincturoe Ferri Perchloridi, m xv.; Infusi Calumbae, 
 3 i.; misce. Fiat haustus, omnibus sextis horis sumendus. 
 
 As soon as nourishment can be retained by the stomach 
 five to ten grains of the perchloride of iron, equivalent to 
 twenty or forty minims of the tincture, combined with half a 
 drachm of glycerine and half an ounce of water, should be 
 given, and repeated every three or four hours (Squire) It 
 
IIO DIPHTHERIA. 
 
 should be commenced on the first day of the illness, or as 
 soon as the nature of the disease is recognized. Evidence 
 of its good effects are shown by a diminution of the secre- 
 tions from the fauces and throat, and improvement in gen- 
 eral symptoms. Guaiacum is of service in keeping the bowels 
 open. It ought to be given in the form of the rectified spirit 
 tincture, to the extent of one drachm combined with two 
 drachms of glycerine for a dose, as recommended by Dr. 
 Balmanno Squire. This makes a clear solution, to which no 
 water must be added. 
 
 The third indication — namely, to overcome the marked 
 asthenia — restoratives are demanded, and feeding is all-im- 
 portant in the treatment of diphtheria. The night should 
 never be passed without either nourishment or stimulant be- 
 ing given; and the quantity of liquid nourishment and of 
 stimulant given in the twenty-four hours must be equal 
 to the estimated requirement of the patient (Squire). 
 A young child (one to two years) may require a teaspoonful 
 of brandy every two hours; a child of three years, two tea- 
 spoonsful, diluted, and given in small portions at a time. 
 Milk, beef-tea thickened with arrow-root, milk punch, are 
 most userXil alteratives. By so averting death, time is gained 
 for the general disease to run its course (Jenner). 
 
 Tracheotomy is of little avail in diphtheria, and the sole 
 object contemplated by an opening in the windpipe is the 
 prevention of death by suffocation. Nevertheless the opera- 
 tion is indicated in every case where the larynx is blocked up 
 by membranous or pseudo-membranous formation; when we 
 can scarcely ever anticipate that the disease will subside in a 
 few days, and before fatal suffocation occurs. The condi- 
 tion of the patient is generally improved for the time by the 
 actual operation, if it is not too long deferred, or done in the 
 death-agony. It is also especially done to gain time; and it 
 is also indicated whether the impediment to respiration is in 
 the larynx only, or whether it extends farther down, or 
 whether secondary changes have already taken place in the 
 lungs. In the two latter cases the chances of recovery are 
 generally very much less; but the operation of tracheotomy 
 does not make the prospects worse for the patient; and it 
 should be done when the existence of a more than merely 
 catarrhal affection of the larynx is indicated by great diffi- 
 culty of breathing, continuing more than two or three days; 
 or by attacks of suffocation. The operation will not cure 
 the disease, In this respect it differs greatly from croup; 
 
DROPSY DYSENTERY. Ill 
 
 and it is chiefly in cases of croup, as distinguished from diph- 
 theria, that tracheotomy is attended with such favorable re- 
 sults. (See under Croup.) Tracheotomy, if not too long de« 
 layed, saves many a life in croup. 
 
 [In consecutive paralyses tonics and local faradization are 
 the most important remedies,] and the bowels should be kept 
 open by a pill, taken morning and evening, containing from 
 a quarter to half a grain or a grain of the extract of nux 
 vomica, with a like quantity of sulphate of iron, combined 
 with two or three grains of compound rhubarb pill mass. 
 These may be varied with the administration of pills con- 
 taining -jJg of a grain of strychnia, the strychnia being tritu- 
 rated with sugar of milk, and made into pills with a sufficient 
 quantity of extract of gentian. Syrup of the phosphate of 
 iron in fluid drachm doses may be given twice a day (com- 
 bined or not with liquor strychnia); and stimulants in the 
 form of malt liquors, especially stout (if free of cocculus in- 
 dicus), are beneficial if taken with or after meals, and the 
 doses of iron may be taken at the same time. The syrup of 
 the phosphate of iron, quinine, and strychnia I have also 
 found of great use. 
 
 Dropsy, General. — See Anasarca. 
 
 Duchenne's Disease. — See Paralysis, Bulbar. 
 
 Dysentery. — Definition — A febrile disease, accompanied 
 by tormina, by straining, and by scanty mucus or bloody 
 stools, which contain little or no faecal matter. The minute 
 lenticular and tubular glands of the mucous membrane of 
 the large intestines, with the intertubular connective tissue, 
 are the chief seats of the local lesion, which sometimes ex- 
 tends into the small intestine beyond the ileo-caecal valve, as 
 in cases in which scorbutus is a predisposing cause. Under 
 some circumstances it is infective. 
 
 Treatment — It is the obvious duty of the physician to direct 
 his attention, in the first instance, to the prevention of the 
 disease. He must enquire especially as to the conditions of 
 the diet, that it be sufficient as to its animal and vegetable 
 elements, and of good quality. Next, he ought to ensure the 
 means of detecting the disease eatly — for time is of the 
 greatest importance in its cure. He must remove the patient 
 from the sphere of action of any of the predisposing or ex- 
 citing causes, and see that his surroundings are free of all 
 those circumstances which co-operate in aggravating the dis- 
 ease, the chief of which are overcrowding, bad ventilation. 
 

 112 DYSENTERY. 
 
 bad food, exposure, and intemperance. With regard to med- 
 icinal agents my friend and colleague, Professor Maclean, has 
 written me the result of his extensive experience in India and 
 China: — He is of opinion that the first thing to bear in mind 
 in the treatment of tropical dysentery is, that the appearance 
 of strength in the patient, given by the acuteness of the 
 symptoms, is delusive. Under the use of antiphlogistic 
 treatment the strength of the patient is apt to fail suddenly; 
 and this is often the case, even when the treatment has been 
 more conservative in its character. It was once the custom 
 in India to deplete freely in this disease, either by a general 
 bleeding or by the repeated application of leeches; but the 
 most judicious and successful practitioners in India rarely 
 bleed now, even in the most asthenic forms of the disease, 
 and confine the use of leeches within the narrowest limits. 
 It is certain, too, that mercury is yearly less and less used in 
 India than it was; and there is much evidence to show that a 
 corresponding reduction in the mortality of the disease has 
 been the result. The objections to its use are numerous, — it 
 entails great suffering on the patient, if pushed to ptyalism, 
 aggravating his miseries, and too often permanently injuring 
 his constitution; it has no specific action on the disease, and 
 its cholagogue effects can be attained by remedies which are 
 not open to such objections as can be brought against mer- 
 cury. In sloughing dysentery it is followed by the worst re- 
 sults; and the observations of clinical observers in India 
 have shown that individuals under the influence of mercury 
 are not only not exempt from attacks of the disease, but are 
 peculiarly prone to be affected by it. This is the case in a 
 very marked degree in Asiatics (Morehead and Maclean). 
 
 Ipecacuanha, in the radix anti-dysenterica, has long been 
 used in South America in the cure of dysentery, — whence, 
 indeed, it came. It was much used in India until the mer- 
 curial notions of James Johnston prevailed. It was again 
 used by Dr. Twining, of Bengal, by whom it was strongly 
 recommended, and also by Dr. Mortimer, of Madras. Twin- 
 ing combined it with blue pill and gentian, and used it chiefly 
 in small and oft-repeated doses. In South America the prac- 
 tice has always been to administer an infusion of the bruised 
 root, — 3 ii. being infused over night in § iv. of water, and 
 given early in the morning. In Peru it is given in doses of 
 3 ss. to 3 i. of the powdered root in a little syrup and water. 
 This practice of giving ipecacuanha in large doses has lately 
 been revived in India with encouraging success, and Dr, 
 
DYSENTERY. II3 
 
 Maclean believes, with the greatest number of cures. It ap- 
 pears to act on the portal capillaries, and on those of the 
 mucous membrane of the bowels, and to determine power- 
 fully to the skin. It is usually given in doses of half a 
 drachm or a drachm, either in pills or bolus, or suspended in 
 mucilage, according to the fancy of the patient. It is advisa- 
 ble to give an opiate half an hour before, and to withhold all 
 drink for some hours. Unless there be hepatic complica- 
 tion, it seldom happens that much vomiting is caused by 
 these large doses; on the contrary, they are often tolerated 
 when smaller doses are rejected. The dose should be re- 
 peated in about six hours. A sufficient interval should be 
 allowed to intervene between the doses of ipecacuanha, to 
 admit of the patient being sustained by nourishment adapted 
 to the stage of the disease. Dr. Cornish, of the Madras 
 army, has shown from official documents, that the mortality 
 from acute dysentery in Southern India under mercurial 
 treatment was 7.1 percent. Since the general introduction 
 of ipecacuanha in full doses it has fallen to 1.3. Ur. Ewart, 
 of Bengal, has shown that equally good results have follow- 
 ed the same system in that Presidency. During the forty- 
 two years, from 181 2 to 1853-54, the mortality among Eu- 
 ropean troops in the Bengal Presidency amounted to 88.2 in 
 the thousand. But during i860, when large doses of ipecac- 
 uanha were administered, the mortality was only 28.87 in the 
 thousand. Although highly useful in some conditions, it is 
 not to be regarded as a specific in all forms of the disease. 
 It is more effectual in the sporadic and mild acute cases than 
 in the chronic forms. Its use should be limited to vigorous pa- 
 tients with acute catarrhal diarrhoea or dysentery; or with 
 the preliminary catarrhal stage of diphtheritic dysentery 
 (Woodward). The large dose method of its administration, 
 which now prevails, is to give as early in the disease as pos- 
 sible grs. xxv. to xxx. of ipecacuanha in as small a quantity 
 of fluid as possible. A preliminary dose of opium may be 
 of service in enabling the stomach to retain the ipecacuanha. 
 It can be swallowed in the form of a bolus, by wrapping it in 
 soluble tissue paper. The patient should then remain per- 
 fectly still in bed, and abstain from fluid for at least three 
 hours. If thirst is urgent it may be appeased by sucking 
 small bits of ice, or taking not more than a teaspoonful of 
 iced water. In from eight to ten hours, from 10 to 15 grains 
 may be again administered, with the same precautions as be- 
 fore. The beneficial results are manifested by the tormina 
 
114 DYSENTERY. 
 
 and tenesmus subsiding, the motions becoming feculent, blood 
 and slime disappearing; and often, after profuse perspiration, 
 the patient falls into a tranquil sleep and awakes refreshed. 
 The ipecacuanha may require to be continued in diminished 
 doses for several days, with sufficient intervals between each 
 dose to admit of food being taken; and for several nights 
 after the stools appear normal, grs. x. to xii. of ipecacuanha 
 should be still given at bedtime. Astringents in any 
 shape during the acute stage are not only useless but 
 dangerous (Maclean, Docker, Waring). Blood-letting has 
 now been totally superseded and rendered unnecessary by the 
 use of ipecacuanha. Ergot has been used in an enema to the 
 extent of 1 2 or 1 5 grains in some bland fluid ; or in 6-grain doses 
 by the stomach, in cases of epidemic dysentery, with the 
 beneficial result of reducing the quantity of blood in the 
 stools (Dr. Gros, Practitioner, Nov., 1868). Opium is not 
 to be regarded as a specific or curative agent, either in acute 
 or in chronic fluxes. Its use should be restricted to the 
 fulfillment of two indications, namely: — (1.) to relieve pain; 
 (2.) to procure sleep. Chronic opium intoxication is to be 
 avoided, by suspending its administration, or by alternating 
 it with other remedies. Hypodermic injections of morphia 
 give the best anodyne or soporific effects. It is most fre- 
 quently indicated in cases of acute gastro-intestinal catarrh. 
 In alcoholic conditions it may be of advantage to combine 
 chloroform with the morphia, repeating the dose after an 
 hour's interval. Dover's powder, — Pulv. ipecacuanha com- 
 posita, is of service in full doses of grs. x to xv. at bedtime, 
 followed up by a five-grain pill of the same, taken every 
 four or six hours for two or three days, or till relief is ob- 
 tained. In smaller doses, frequently repeated, it may be 
 combined advantageously with nitrate of silver (Waring). 
 
 In mild cases, but where the pains are excruciating and 
 attended with tenesmus, the warm bath generally gives in- 
 stantaneous relief in cases following chills, if adopted suffi- 
 ciently early. Dr. Maclean directs that it be brought to the 
 bedside, and kept at a high temperature (not under 99 or 
 ioo° Fahr.), the patient to remain in it till he feels faint. 
 He is then to be carefully and quickly dried, put to bed, 
 and have grs. xv. to xx. of ipecacuanha. Woodward objects 
 to the hot bath except in chronic fluxes. Leeches, to the 
 number of six to twelve, applied round the verge of the anus, 
 often afford sensible relief to the tormina and tenesmus, by 
 unloading the portal and hemorrhoidal veins (Waring). 
 
DYSENTERY. II5 
 
 In subacute and chronic dysentery, " no remedy has proved 
 more useful than nitrate of silver, in doses of half a grain to 
 one and a half grains daily, reduced to a fine powder, and 
 conjoined with Dover's powder in the form of a pill (Dr. 
 Waring). It has also been extensively used in the form of 
 enema, as follows: — First throw up into the transverse colon, 
 by means of a flexible stomach-pump tube, introduced to 
 the extent of six or seven inches, very cautiously and gently, 
 enemata of warm water, or milk and water, to the extent of 
 three, four, or six pints, so as to bring away any faecal ac- 
 cumulations. Then follow up this practice by the injection 
 of two and a half to three pints of distilled water, holding in 
 solution gr. xv. of nitrate of siver " (Hare, Waring). 
 
 In chronic cases a combination of sulphate of copper and 
 of opium is often highly serviceable (J. Brown, Raleigh, 
 Waring), in the following formula: — 
 
 fy Cupri Sulph., gr. % to l / 2 \ Pulv. Opii, gr. ^. Make 
 a pill or powder, of which three are to be taken daily. 
 
 Five grains of Dover's powder may be substituted for the 
 opium. 
 
 Solution of the pernitrate of iron is highly commended by 
 Professor Maclean. It is astringent and tonic in doses of 
 mx. to mxv. diluted in water. It may also be used as an in- 
 jection. 
 
 Nux vomica, combined with opium and iron, may be of 
 use (Graves). In malarial dysentery, full doses of quinine 
 (not less than twenty grains) ought to be given in acute cases 
 before giving ipecacuanha, and it should be continued till 
 there is evidence of cinchonism. The two drugs should then 
 be given in alternate doses till the characteristic good results 
 of each are produced (Maclean). The bark of the root of 
 calotropis gigantea (or mudar) has been recently used in 
 India, and is said to be an excellent substitute for ipecac- 
 uanha. It is used in doses of a scruple to a drachm, is a re- 
 liable cholagogue, and sedative to the muscular fibres of the 
 intestine, rapidly allaying pain, tenesmus, and irritation 
 (Durant, Ind. Med. Journ., May, 1866). On the Continent 
 the neutral salts and mild purgative medicines are highly 
 spoken of. Sulphate of soda is to be preferred to sulphate 
 of magnesia (Mery, J. J. Woodward). It induces a decided 
 increase in the hepatic secretion, which the Epsom salt fails 
 to do (Rutherford and Vignall). Phosphate of soda and 
 Rochelle salts are, for similar reasons, to be preferred to the 
 Epsom salt, which is the least desirable of saline purgatives 
 
Il6 DYSENTERY. 
 
 in dysentery. Castor-oil is similarly objectionable.' It has 
 no stimulating action on the hepatic secretion. In the treat- 
 ment of chronic dysentery in the Seaman's Hospital, London, 
 the Senior Physician, Dr. C. H. Ralfe, states that having 
 watched 200 cases, he recorded in 1876 that those who lin- 
 gered the longest, or at length did well, had little or nothing 
 to owe to therapeutics, an opinion concurred in by Dr. 
 Stephen Ward. He now abstains from action and special 
 treatment, except to meet occasional and urgent symptoms, 
 and places more reliance on the good effects of rest and diet. 
 He has, however, systematized the administration of castor- 
 oil, by giving it on stated days, at least twice a week. It re- 
 moves retained scybalous faecal matter and irritating dis- 
 charges, and prevents their accumulation. Some had bismuth 
 mixture in addition, others had ipecacuanha (12 to 20 
 grains), in single doses, repeated, if necessary, on second or 
 third day whenever a relapse or return to the acute form 
 was threatened. Sixteen out of thirty-eight cases were dis- 
 charged cured; in nine of whom the duration of the disease 
 prior to admission had averaged 18 months, and none less 
 than five months. In painless diarrhoea and in chronic 
 fluxes bismuth is of use after evacuants. From mercurials 
 no advantages are to be expected that can counterbalance 
 the serious objections to their use; but the benefit of the 
 alterative effects of the remedy may be obtained by minute 
 doses of corrosive sublimate. In certain cases of chronic 
 dysentery Parkes found it most useful commencing with 
 doses of one eighth to one sixth of a grain in combination 
 with preparations of cinchona. It increases the hepatic 
 secretion. Ringer gives the 100th of a grain every hour or 
 every two hours, alike in acute and chronic dysentery. 
 
 Dr. Bryson writes that he has seen all the astringents, both 
 mineral and vegetable, mercury both internally and exter- 
 nally, with many other medicines, tried without any benefit; 
 but there were some means which were useful in relieving 
 the more urgent and distressing symptoms. Amongst these 
 he mentions a well-regulated farinaceous diet, opium suppo- 
 sitories, anodynes, astringent injections, in combination with 
 opium, cascarilla, resinous astringents, and the application 
 of leeches to the rectum when tenesmus was distressing, or 
 over the course of the colon when there was deep-seated 
 pain. An injection of warm starch (two ounces) with laud- 
 anum in it, will often give great relief. As much nourish- 
 ment should be given in a liquid form as the patient can be 
 
DYSPEPSIA. 117 
 
 got to take. Milk boiled with flour or arrow-root and bar- 
 ley-meal should be taken as often as possible, night and day. 
 It should be taken cold, even with ice, and in small quantities 
 at a time; and small pieces of ice not only allay sickness and 
 nausea, but seem to soothe the irritability of the intestines. 
 Strong beef-tea, or Liebig's extract of flesh, are most useful. 
 The value of a change of climate as a curative measure is 
 forcibly illustrated by Dr, Bryson. He says that the crews 
 of vessels improve in health almost immediately after quit- 
 ting the station where dysentery prevailed. Where sewage 
 is applied to the soil by surface irrigation, it ought to be di- 
 luted largely with water, and deodorized by carbolic acid. 
 In the scorbutic form we have a valuable remedy in the 
 Bael fruit, which contains a large quantity of tannin, with 
 vegetable mucus, a bitter principle, and a vegetable acid. 
 It is much used in Bengal; and in the scorbutic form Dr. 
 Maclean has seen it successful when all other measures have 
 failed. 
 
 Dyspepsia. — Definition. — Impairment of digestion, aris- 
 ing without perceptible change of structure or lesion of the 
 stomach. 
 
 Treat?nent. — Congestion, catarrh, and functional states as- 
 sociated with what are called dyspeptic symptoms, or " im- 
 perfect digestion," are the results of stomach diseases for 
 which the physician is called most frequently to prescribe. 
 When there is reason to believe congestion exists, a sparing 
 and easily digested diet is to be prescribed, with total absti- 
 nence from fermented drinks ; and in cases where catarrhal 
 inflammation prevails the blandest food must be given in 
 very small quantities. In severe cases leeches are to be ap- 
 plied over the region of the stomach, and the patient may 
 sip iced tea, or suck small pieces of ice, to relieve thirst. In 
 impaired digestion from any cause, a mode of life tending to 
 improve nutrition is to be aimed at. The necessity of strict 
 attention to diet in all cases of impaired digestion is abso- 
 lute: If fulness and uneasy sensations are experienced after 
 dinner, less food should be taken at that meal, and more at 
 breakfast ; the principle being to apportion the amount of 
 food necessary to sustain the body more evenly over the 
 waking hours than is commonly done. The great fault in 
 the dietetic system of this country consists in most people 
 supporting themselves mainly by dinner. This meal is con- 
 sequently too large ; and the quantity taken at dinner should 
 
H8 Dyspepsia. 
 
 be resolutely diminished till breakfast is appreciated (Leared, 
 1. c. p. 150). 
 
 Special symptoms, common to various morbid states, re* 
 quire special modes of treatment Excess of acid is best 
 neutralized by lime-water, magnesia, or alkaline remedies, se- 
 lected according to the state of the patient's bowels ; and 
 the gastric fermentation which is apt to be established may 
 be checked by brandy and various aromatic spirits. Bicar- 
 bonate of potash and nitrate of potash, in the proportion of 
 eight parts of the former to one part of the latter, is useful 
 in cases of habitual acidity : and all these antacid remedies 
 should be taken about three or four hours after a meal. 
 Pills containing from a quarter to half a minim of creasote, 
 given with each meal, will counteract fetid eructations. It 
 checks that fermentation in which acetic and carbonic acids 
 are formed ; while conium and belladonna are the medicines 
 which better than opium allay general nervous irritability. 
 In cases of slow digestion, with deficient secretion of the 
 gastric juice, the rules of treatment are, (t.) To let albu- 
 minoid ^ood be as liquid as possible. Eggs must be eaten 
 when cooked short of coagulation of the albumen. (2.) To 
 let the day's allowance of food be taken in small quantities 
 at regular intervals. (3.) That by the administration of al- 
 kalies the food may pass to the intestines, and be digested there 
 rather than by the stomach. This latter mode of treatment 
 by alkalies, reeommended by Chambers, is contrary to that 
 recommended by Dr. Budd. Both are consistent with phy- 
 siological facts, and the course to be followed must be de- 
 termined by the nature of the case. Both gave large doses 
 of bicarbonate of soda — 3 ii. dissolved in a pint of warm wa- 
 ter — to counteract the excessive acidity, or to promote the 
 passage of food to the intestines. The amount and kind of 
 food taken is of importance to be attended to in cases of 
 slow digestion. If a fair amount of exercise be taken, the 
 following dietary, slightly modified from that proposed by 
 Dr. Leared, will be found appropriate in such cases : 
 
 Breakfast, (8 a. m.) 
 ( Mutton Chop, or other ) Tea, or warm milk and 
 Bread (stale), . 40Z. •< Meat (cooked) free >• water and sugar, or 
 ( from fat and skin, 3 oz. ) other beverage, £• pt. 
 
 Luncheon, (i p. m.) 
 
 iNo solids, such as Meat ) 
 or Cheese. >• Liquid, . . . i pt. 
 
DYSPEPSIA. II9 
 
 Dinner, (5 or 6 p. m.) 
 
 Bread (stale), . 3 oz ( Meat (cooked) free from ) Liquid, not more than 
 Potatoes and other ■] fat and skin, . . 4 oz. f half a pint, 
 vegetables, . 4 oz. ( 
 
 Tea or Supper (not sooner than three hours after dinner.) 
 
 Tea, or weak brandy 
 and water, or sherry 
 and water, or toast 
 
 and water, to the ex- 
 tent of -J pint. 
 
 ■o j / , 1 \ „ 1 No solids, such as Meat 
 Bread (stale). . 2 oz. j or Chec ' se> 
 
 The quantity of wine or other fermented liquor, and also of 
 animal diet, should be thus reduced till the disease subsides 
 and the urine is healthy. Soups, tea and coffee, drank, as 
 they usually are, boiling hot, debilitate the coats of the stom- 
 ach, tend to produce dyspepsia, and are abandoned by many 
 persons from their so often exciting cardialgia. The best 
 bread for the dyspeptic is the unfermented bread, baked by 
 the process of the late Dr. Dauglish, entirely from wheaten 
 flour of the best quality. It is known as " aerated bread," 
 because carbonic acid gas is substituted for yeast. It is more 
 easily digested than common household bread. Pastry and 
 " sweets" must be strictly forbidden. They are " sweet in 
 the mouth, but bitter in the belly." Forms of indigestion 
 marked by excessive acidity and heartburn may be relieved 
 by bicarbonate of soda, in doses of fifteen grains, combined 
 with a few grains of nitre, taken two or three times a day. 
 At the same time, free excretions from the liver and bowels 
 must be sustained by occasional small doses of blue pill or 
 podophyllin, combined with extract of colocynth and hen- 
 bane, while exercise and diet are duly attended to. Weak- 
 ened digestion from over-fatigue may be restored under the 
 use of carbonate of ammonia, conjoined with compound tinc- 
 ture of gentian, or with extract of gentian in the form of a 
 pill. Extracts of mix vomica or strychnia are also valuable 
 remedies. Half a grain of extract of mix vomica, half a grain 
 of sulphate of iron, and four grains of compound colocynth 
 pill, form a combination which, taken early in the morning, 
 or one hour before dinner, generally induces gentle action of 
 the bowels. (Leared). Compound rhubarb pill may be sub- 
 stituted in place of the compound colocynth pill. Another 
 useful ingredient in a dinner pill I find is ipecacuanha, to the 
 extent of one grain, or half a grain in each, in cases of slow 
 or torpid digestion. Indigestion from habitual drunkenness, 
 
i20 ECLAMPSIA ECTHYMA. 
 
 or where there is great irritability or sensitiveness of the 
 stomach is best relieved by the pure bitter infusions, such as 
 gentian, quassia, hops, and calumba, singly, or combined in a 
 mixture, so that a dose may.be taken two or three times a day, 
 an hour before each meal. Grave's tonic I have found espe- 
 cially useful It consists of the tinctures of quassia, calumba, 
 compound gentian, cinchonia flava, of each an ounce, and 
 from two to four drachms of the liquor morphiae hydrochlor- 
 atis ; of this mixture a teaspoonful is to be taken one hour be- 
 fore each meal. Quassia may generally be taken as a cold 
 infusion, and is thus prescribed by Niemeyer ; " In the 
 evening pour a cupful of cold water over a teaspoonful of 
 quassia chips ; by the next morning a bitter infusion will 
 have formed — to be taken fasting ;" or water may be poured 
 into a bowl made of quassia-wood, sold for this purpose, and 
 after standing over night in the bowl, the water is to be 
 taken in the morning. Hop-bitter is most agreeably taken 
 in the form of the many bitter ales, such as are brewed by 
 Bass, Allsopps, Ind-Coope, Salt, and the genuine Bavarian 
 beer, brewed all over Germany. Such ales must be got di- 
 rect from trustworthy brewers who brew from hops, and 
 where no injurious substitute is used instead of hops. For 
 other reasons it is necessary to obtain the ale direct from the 
 brewery. Once it passes into other hands, there is no guar- 
 antee that some of the numerous processes for " stretching," 
 and otherwise increasing the quantity, to the disadvantage 
 of the consumer, will not be practiced. Of the extent of 
 malt originally prepared by Trommer, as a genuine extract, 
 containing the soluble constituents of the malt and of the 
 bitter of the hop, Niemeyer speaks highly in the treatment 
 of cases of " irritable ingestion," as having been almost the 
 only nourishment the patients could take. Small doses of 
 opium, or of morphia in an ammonia mixture, may be given 
 at bedtime, so as to secure sleep at night, or Grave's tonic as 
 above. In prescribing the mineral acids, the following gen- 
 eral rule ought to be kept in mind, namely, that the influ- 
 ence of sulphuric acid is astringent, while that of hydrochloric 
 acid promotes digestion, and of nitric acid secretion (Dr. 
 Bence Jones). 
 
 Eclampsia. — See Convulsions. 
 
 Ecthyma. — Definition. — An eruption of large round pus- 
 tules, generally distinct, and seated upon a hard inflamed 
 base. The pustules are succeeded by dark-colored scabs, 
 
ECZEMA. I2t 
 
 which leave superficial cicatrices behind them, or red stains* 
 which disappear after a time. 
 
 Treatment is chiefly by diluents, simple and emollient 
 baths, and regulation of diet. Moderate exercise should be 
 taken, combined with the use of alkaline or salt-water baths. 
 Mild laxatives are beneficial, and spirits, wine, and beer are 
 to be refrained from. The food should be as nourishing as 
 can be digested. Tonics, such as quinine and iron, are also 
 indicated. A stimulating lotion, composed of muriatic acid 
 diluted with water, is of use to brush over the parts and pro- 
 mote cicatrization. Specific treatment must be adopted 
 when the disease is associated with syphilis or scabies. 
 
 Eczema. — Definition. — An eruption characterized by — 
 (i.) Infiltration of the skin ; (2.) exudation on its surface ; 
 (3.) the formation of crusts ; (4.) itching. 
 
 Treatment of eczema must be constitutional in the first in- 
 stance ; and local applications suited to the nature of the 
 part affected are to be carefully used. Derangements of the 
 digestive organs must be especially rectified. If the tongue 
 is loaded, the appetite bad, the liver torpid, as indicated by 
 light clay-colored evacuations and costive bowels, small doses 
 of grey power in combination with quinine are indicated. 
 Dr. T. M. Anderson suggests the following : — ■ 
 
 r>. Sulphatis Quiniae, gr. xii.; Pulv. Rhei., gr. xxxvi.; 
 Hydrarg. c. Creta, gr. xxx.; Sacchari Albi, 3 i.; misce, et di- 
 vide in Pulv. xii. 
 
 Two of these powders are to be taken daily by an adult ; 
 but at any age the dose must be so adjusted that the patient 
 has at least one full natural evacuation daily. If the patient 
 is robust, but with the functions of the liver and bowels im- 
 paired, occasional doses of calomel, alone or in combination 
 with scammony, will stimulate the torpidity of the digestive 
 organs ; and at the same time the cutaneous inflammation 
 will diminish. If the patient is a full feeder, and will not be 
 persuaded to live more sparingly, one drachm to two drachms 
 of the sulphate of magnesia may be given twice daily, with a 
 sixth to half a grain of tartar emetic added to each dose. 
 The effect of this remedy will be to diminish desire for food, 
 and at the same time keep the bowels freely open. If the 
 patient is scrofulous, or debilitated from insufficient food, or 
 food not nutritive enough, more nourishing food must be 
 given, combined with tonics containing iron and cod-liver 
 oil. Children a few months old, reduced to " skin and 
 bone," recover wonderfully under the influence of twenty 
 
122 ECZEMA. 
 
 drops of the syrup of the iodide of iron in a teaspoonful of 
 cod-liver oil repeated three times daily, the dose of the oil 
 being gradually increased to a tablespoonful (Anderson). 
 Syrup of the phosphate of iron, or of the phosphates 
 of iron, quinia, strychnia, should be alternated with 
 the iodide of iron. The treatment must be steadily 
 maintained for at least six weeks or two months. In severe 
 cases the oil may be rubbed into the skin, in addition to giv- 
 ing it internally. Cod-liver oil and iron preparations are 
 almost equally serviceable to eczematous adults. When 
 there is a difficulty of taking the oil in its pure state, the 
 emulsion of it will often be found useful ; when the appetite 
 is very deficient, a pure tonic, such as quinine and aromatic 
 sulphuric acid, may be of service, as in the following : — 
 
 $. Sulphatis Quinise, gr. xvi.; Acid Sulphurici Aromatici, 
 3iv.; Syrupi Limonum § ss.; Infus. Cascarillae, ad |viii.; 
 misce, et cola per chartam. A table-spoonful to be taken 
 three times a day half an hour before food. 
 
 If the eczematous patients are robust and plethoric, the 
 local abstraction of blood by leeches or scarification is often 
 beneficial ; but in general the action of calomel purgation is 
 sufficient to reduce the inflammatory action, combined with 
 a regulated abstemious diet of mixed animal and vegetable 
 food simply dressed. Dishes of pastry, pickles, spices, strong 
 tea, and coffee, are particularly to be avoided ; while the use 
 of wine, spirits, and malt liquors must be entirely suspended. 
 If the patient has been in the habit of using stimulants, the 
 eczema will be more difficult to subdue than if he had been 
 an abstainer from these fluids. It is sometimes necessary to 
 prescribe milk diet for a time, all animal food being pro- 
 scribed. 
 
 Of internal medicines, arsenic, sulphur, and the alkalies 
 are especially useful (Startin, Anderson). Of Fowler's solu- 
 tion (the liquor arsenicalis of the Edinburgh Pharmacopoeia) 
 an adult may commence with five minims thrice daily ; and 
 at the end of a week the dose should be increased by one 
 drop every second or third day, till the disease begins to 
 yield, or the medicine to disagree (Anderson), " In order to 
 secure the virtues of arsenic as an alterative, it will be 
 necessary to push the medicine to the full development of 
 the phenomena which first indicate its peculiar action on the 
 system. Arsenic as a remedy is too often suspended, or alto- 
 gether abandoned, at the very moment its curative powers 
 are coming into play. The earliest manifestation of its phy- 
 
 
ECZEMA. 123 
 
 siological action is apt to be looked upon as its poisonous 
 operation : and the patient declares that the medicine has 
 disagreed with him. Forthwith the physician shares his 
 fears ; the prescription is changed, and another case is added 
 to the many in which arsenic is said to have failed after a 
 fair trial of its efficacy" (Begbie, "Contributions to Practical 
 Medicine", p. 270). Arsenical solutions should be given im- 
 mediately after food ; and in persons whose digestive organs 
 are weak, a tonic infusion, such as the infusion of cascarill 1 
 or gentian, is the best vehicle for its administration ; and 
 a few drops of morphia may sometimes be added, as in the 
 following : — 
 
 R. Solut. Fowleri ; Solut. Muriatis Morphiae, a a 3 ii. ; 
 Syrupi Limonum, 5 ss. ; Tinct. Cocci Cacti, 3 ss. ; Infus. 
 Cascarilla, ad r xii. ; misce. A tablespoonful of this mixture 
 to be taken thrice daily immediately after food. 
 
 The liquor sodae arsenias, in doses of five to ten minims, 
 is said to cure eczema with less gastric disturbance and with 
 less irritability of the conjunctiva than the liquor arsenicalis. 
 As the disease yields, the dose may be diminished ; but the 
 use of the remedy should not be suspended till some time 
 after the complete removal of the eruption. In the case of 
 infants at the breast, arsenical solutions may be given to the 
 mother; and mercury may be combined with the arsenic, as 
 in Donovan's solution, of which ten minims may be given 
 thrice daily. Mr. Hunt lays down certain conditions for the 
 administration of arsenic; and amongst them he forbids its 
 commencement while signs of active cutaneous inflammation 
 are present. 
 
 The use of the natural mineral waters which contain sul- 
 phur is the best method of securing the full effects of the al- 
 terative action of sulphur in chronic cases of eczema where 
 there is an absence of inflammatory action. These waters 
 are especially, Harrowgate and Moffat in this country; Aix, 
 Bareges, St. Sauveur, Cauterets, on the Continent. Alkalies 
 are most beneficial when the patient has been in the habit of 
 taking stimulants; and when there is a tendency to acidity 
 of the stomach, and to the deposit of lithates in the urine, or 
 to gout, or to rheumatism, aqua potassae may be given, largely 
 diluted with water, in doses of twenty minims three times 
 a day. Dr. Anderson recommends sesquicarbonate of am- 
 monia (now called the carbonate of ammonia in the British 
 Pharmacopoeia), in doses gradually increasing from ten to 
 thirty grains. If gout prevails, colchicum ought to be given 
 
124 ECZEMA. 
 
 with the other remedies; and in rheumatism the acetate or 
 bicarbonate of potash in half-drachm doses should be added 
 to each dose. All these alkaline remedies should be largely- 
 diluted with water. For the relief of pain and procuring 
 sleep in acute cases, opiates must be administered; and when 
 they fail tincture of cannibis sativa, in doses of mxxv., has 
 been found sometimes to procure sleep, or at all events com- 
 parative ease (Christison). With regard to local treatment, 
 the first point is to remove all sources of irritation, and es- 
 pecially the crusts. A poultice composed of crumbs of bread 
 and hot almond oil applied to the eruption at night will 
 usually bring away the crusts in the morning. If they fail 
 to be detached by this application, they must be again lubri- 
 cated with fresh almond oil, and forcibly removed when they 
 are thoroughly softened. If, after the crusts are removed, 
 the surface is seen to be acutely inflamed, and if there is a 
 burning heat in place of itching, local sedatives must be ap- 
 plied. For this purpose Dr. Anderson recommends a cold 
 potato-starch poultice, a small quantity of powder containing 
 camphor being sprinkled over the inflamed surface before the 
 poultice'is applied. The camphor powder may be composed 
 of the following ingredients: — 
 
 ]J. Camphorse, 3 ss. ; q. s. ; Pulv. Oxydi Zinci ; Pulv. 
 Amyli, a a 3 lii- This powder must be kept in a stoppered 
 bottle (Anderson). 
 
 Instead of poultices, a mixture of powdered oxide of zinc 
 and glycerine, in the proportion of half an ounce of the one 
 to two ounces of the other, will be found to be a soothing 
 application ; and to it a little camphor may also be added, as 
 in the following : — 
 
 I£ . Camphorae, 3 i. ; Pulv. Oxydi Zinci, 3 ii. ; Glycerinae 
 et Adipis Benzoati, a a 3 iv. ; Cochinillini, gr. i. ; Spt. Ros- 
 mar., 3 i. ; vel 01. Rosar., mii. ; misce. This mixture must 
 be stirred before using it, a thin layer being then rubbed over 
 the inflamed part twice or thrice daily (Anderson). 
 
 Carron oil (liniment aqua calcis) I have found a soothing 
 remedy. When the disease passes into a chronic stage, as in- 
 dicated by the disappearance of the burning heat and the 
 supervention of itching, the local applications must vary with 
 the condition of the parts. If there be much infiltration of 
 the tissues, treatment by potash applications is the most ef- 
 ficient (Hebra, Anderson). The more extensive the disease 
 the weaker the solution ought to be for application over a 
 large surface. If the infiltration is slight, common potash 
 
ECZEMA. I25 
 
 soap (soft soap, black soap, sapo mollis, sapo viridis), or a 
 solution of one part of it in two of boiling water, a little oil 
 of rosemary or citronella being used to conceal the odor, may 
 be used. A piece of flannel dipped in this liniment should 
 be rubbed as firmly as possible over the affected parts night 
 and morning, the solution being allowed to dry upon them. 
 It should, however, be washed off after each application. If 
 the patient can bear it, a piece of flannel, saturated with the 
 solution, may be left in contact with the part all night. An- 
 other method of treatment is to paint over the eruption night 
 and morning with a large brush, charged with the aqua po- 
 tassse of the Edinburgh Pharmacopoeia, its irritant action 
 being neutralized by means of cold water when the smarting 
 becomes excessive. A solution of potassa fusa may also be 
 employed of various strengths. If the case be mild, two 
 grains to an ounce of water; if more severe, then five, ten, 
 twenty, thirty, or even more grains to the ounce of water 
 may be used. But all these stronger solutions must be washed 
 off very speedily, and they ought not to be employed more 
 than once daily. Such remedies the physician ought to ap- 
 ply himself, and not entrust the control of their action to the 
 patient. As infiltration subsides, the solution ought to be 
 gradually diluted; and great caution is necessary in using 
 such local applications upon infants, delicate females, and old 
 or infirm persons. The affected parts should be bathed re- 
 peatedly during the day in cold water, during the use of po- 
 tash applications. The cold douche may be employed where 
 it is practicable. If the itching is very intolerable, prussic 
 acid may be mingled with the potash applications, as in the 
 following: — 
 
 I£. Potassae Fusse, grx.; Acid Hydrocyan. Dil. (Ed. Ph.) 
 3 ss. ; Aq. Rosarum, 3 ii.; misce. A little of this solutionis 
 to be rubbed firmly over the eruption night and morning, and 
 at any time when the itching sensation is severe. 
 
 If there is a tendency to the formation of fissures, which 
 are apt to result from the use of potash, cod-liver oil, glycer- 
 ine, or carron oil should be applied to the parts every night. 
 Glycerine of aloes is also recommended as a healing agent 
 by M. Chausit and Dr. Waring. It is prepared by evaporat- 
 ing four to eight parts of the tincture of aloes, and incorpo- 
 rating the residuum with thirty parts of glycerine. Tarry ap- 
 plications are of great value in the local treatment of the de- 
 clining stages, when infiltration and itching are subdued. 
 Common tar (pix liquida) or oil of cade (oleum cadini, as 
 
126 ELEPHANTIASIS GR^ECORUM. 
 
 manufactured at Aix-la-Chapelle) should be rubbed firmly 
 over the eruption by means of a flannel cloth, and allowed to 
 dry upon it. It should be applied thrice daily, and washed 
 off with soft soap or petroleum soap. Dr. Anderson recom- 
 mends that common tar should be combined with one of the 
 potash solutions — for example, a mixture of equal parts of 
 common tar, methylated spirit, and soft soap, used as above 
 directed, will be found useful, or the following preparation, 
 as less offensive: — 
 
 $. Saponis Mollis, Spt, Rectificati, Olei Cadini, a a 3i.; 
 Olei Lavandulae, § iss.; misce. A little quantity is to be 
 firmly rubbed over the eruption night and morning; and it 
 must be washed off before each reapplication. 
 
 Of mercurial applications the citrine ointment (Ung.-hyd. 
 nit.) is the best, or the ointment of the iodide of mercury. 
 They may be used of their full strength, or diluted with lard, 
 according to the indications of the case, care being taken 
 that mercurialism is not induced. When eczema has reached 
 the dry stage, Mr. Milton regards the dilute ointment of the 
 nitrate of mercury as the most effectual remedy we possess. 
 In the inching of pruritus — pruritus scroti and prurigo pudendi 
 muliebris — especially the prurigo senilis, the dilute ointment 
 is highly spoken of by Dr. Bowling, United States, and by 
 Dr. Balmanno Squire in this country, as one of the best rem- 
 edies for subduing the irritation and itchiness. Dr. Bowling 
 advises that the parts be first sponged with vinegar or lemon- 
 juice previous to the application of the ointment; and states 
 that for fifteen years he has not failed to effect a permanent 
 cure {Med. Times, June 6, t868). In using ointments, a 
 small quantity should be melted on the finger, and rubbed 
 firmly into the affected part. None should be allowed to lie 
 undissolved upon the skin; and the part should always be 
 cleansed with soap and water before reapplication. Epila- 
 tion should be resorted to in cases of eczema of the hairy 
 parts of the face. In very mild attacks, or with a view to 
 prevent the recurrence of the disease, the skin may be washed 
 occasionally with soft soap and water. Hendrie's " Dispen- 
 sary Petroleum Soap " is recommended by Dr. Anderson, to 
 whose admirable lectures on " Eczema," in the Medical 
 Times and Gazette for May, June and July, 1863, (since pub- 
 lished in a separate volume), the reader is referred for more 
 detailed information. 
 
 Elephantiasis Oraecorum— See Leprosy, True. 
 
EMPHYSEMA ENCEPHALITIS AND MYELITIS. 
 
 Emphysema — See Lungs, Emphysema of. 
 
 127 
 
 Encephalitis and Myelitis. — Definition. — Inflammation 
 of the brain and spinal cord substance, with or without im- 
 plication of the membranes, usually partial. 
 
 Treatment. — 1. Encephalitis. — So soon as there are any cir- 
 cumstances which may lead to " head symptoms " after in- 
 jury, it is well to commence treatment at once with local 
 antiphlogistics, leeches, and evaporating lotions, such as 
 muriate of ammonia in solution with vinegar, applied by 
 cloths, which are to be frequently changed. The patient 
 must be made to observe a rigidly abstemious regimen, and 
 rest with the head elevated above the shoulders. Purgation 
 is to be instituted by means of watery evacuants, and the 
 same general treatment is to be adopted as in meningitis. 
 
 2. Myelitis. — In classing ramollissement of the cord with 
 inflammation, it might appear to infer that the treatment 
 should be strictly antiphlogistic. It may be laid down as a 
 general rule, however, that bleeding ought not to be had re- 
 course to after palsy has occurred. Previous to that symp- 
 tom it may be admissible; and it may be stated generally, 
 that so long as the affected muscles are convulsed, rigid, and 
 irritable, the use of antiphlogistics and counter-irritants may 
 be indicated; but when the means calculated to subdue ex- 
 citation have failed to arrest the further progress of the dis- 
 ease, and paralysis supervenes, stimulants are the only reme- 
 dies which have the power of restoring to functional activity 
 those nerve-cells and conducting fibres which are not irre- 
 trievably destroyed (Meryon). The chances of saving the 
 patient by other antiphlogistic remedies mainly rest on act- 
 ing on the alimentary canal so as to produce three or four 
 motions in the twenty-four hours, and thus create such a de- 
 rivation as in some degree to relieve the parts. The greater 
 number of patients that recover are restored by these means. 
 The particular purgative is not perhaps important; but as 
 the neutral salts act not only on the intestines, but also on 
 the bladder, that class of remedies is generally preferred. 
 
 With respect to local counter-irritants, as blisters, moxas, 
 or setons, little favorable can be said, unless they are em- 
 ployed previous to paralysis, as the tendency to gangrene 
 renders their application of doubtful utility. When had re- 
 course to, however, it will be found better to apply them 
 above the seat of the disease than immediately over it, the 
 greater vitality of the superior parts giving more assurance 
 
128 ENCEPHALITIS AND MYELITIS. 
 
 of the disposition of the wounds to heal. Of all stimulant 
 remedies, electricity and strychnine are the most potent and 
 the best. Secale cornutum has been recommended as a 
 remedy possessing the same power as strychnine (Barbier, 
 Payen, Meryon). When there is no great pressure beyond 
 that which simple congestion produces, nor actual disorgan- 
 ization of the spinal cord, the remedial power of secale 
 cornutum is said to be very great. It seems especially to 
 resuscitate the muscular contractility of the rectum and 
 bladder, the pelvic viscera generally (Guersant, Trousseau, 
 Brown-Sequard, Meryon). The ergot of rye may be given 
 in the forms and doses as follows: — (i.) Ergot, 5 to 10 
 grains, infused in boiling water, three times a day; (2.) 
 Ethereal tincture (not now in the pharmacopoeia), in doses 
 of from ten to twenty drops, twice or three times a day; (3.) 
 Extractum ergotse liquidum, 15 to 30 minims; (4.) Infusum 
 ergotae, made fresh on each occasion, 1 to 2 ounces; (5.) 
 Tincturse ergotae, 15 to 60 minims. It does not relieve the 
 reflex convulsions, which are sometimes alleviated by 
 Purssic acid, digitalis, belladonna (Meryon, chlorodyne 
 or chlor-morphine. [Conflicting statements exist in text- 
 books on Materia Medica as to the best form of ergot 
 for internal administration. 1. Ergot contains one-third 
 of its original weight of oil, got out by percolation with 
 ether (Squire). 2. It contains a large quantity of fixed oil, 
 about 75 per cent. (Garrod). 3, It contains 25 to 28 per 
 cent, of fixed oil (Stille and Maish). Ergot preserves its 
 virtues not much over a year (Stille and Maish). The active 
 principle is a body somewhat resembling gelatine, formed 
 from the gluten of rye ovary, and readily changed by the in- 
 fluence of chemical agents (Bucheim). A number of non- 
 crystallizable compounds, possessing more or less activity, 
 have been isolated from ergot, the most important being 
 sclerotic acid (to the amount of 4 and 4^ per cent.), the 
 other, scleromucin, to the extent of 2 to 3 per cent. This 
 multiplicity of uncrystallizable principles may explain why 
 preparations possessing some activity may be obtained from 
 very different processes — e.g., Wiggers' ergotine, obtained in 
 1830, is soluble in alcohol, but insoluble in water and ether, 
 and is said to have poisonous properties. Bonjean's Ergotine 
 (Germ, pharmacop., as " Extr. Secalis Cornuti ") is a con- 
 centrated aqueous infusion, precipitated by half its weight 
 of alcohol, and the clear filtrate evaporated. Wenzell (1864) 
 proved the presence of two alkaloids (ecbolina and ergo- 
 
ENCEPHALITIS AND MYELITIS. I 29 
 
 tina). They exist in combination with ergotic acid. These 
 have been since shown to be identical, and to possess no de- 
 cided physiological action (Dragendorff and Blumberg). In 
 1875 Tannet isolated another alkaloid, ergotinina, from the 
 fixed oil of ergot prepared by ether, by agitating it with 
 acidulated water. Fresh ergot yields .12 per cent, of ergo- 
 tinina, which is crystalline, but soon becomes resinous. As 
 regards the properties of the oil extracted from ergot by 
 maceration with ether, Stille and Maish write that " it dis- 
 plays even greater energy in producing the same symptoms, 
 and in addition other symptoms (which are specified), than 
 does ergot itself. The effects continue for several days;" but 
 they add that " the oil exhibits no influence upon the gravid 
 uterus, but the residual ergot from which it had been ex- 
 tracted seems to possess the ecbolic power of the drug unim- 
 paired " (The National Dispensatory, p. 545) It does not 
 appear, therefore, that we are warranted in rejecting the 
 ethereal tincture of ergot as an, inert preparation, as Mr 
 Squire has represented it to be (Compan. to Pharg., 1S71). 
 It may still be the best form of reined)' for some cases, al- 
 though it lias become obsolete as a pharmaceutical prepar- 
 ation in our pharmacopoeia; while the residual ergot, pos- 
 sessing ecbolic powers, may be also useful for other pur- 
 poses. Besides, Mr. Squire states that in the directions for 
 preparing the extractum ergotae liquidum doubtless a valu- 
 able and energetic preparation when properly made from 
 fresh ergot), the ether ordered is not sufficient to extract all 
 the oil. The quantity, he states, ought to be doubled. So 
 that this energetic preparation, if prepared as directed in 
 our British Pharmacopoeia, still contains half the oil left by 
 the insufficient quantity of ether which is used, so that the 
 whole of the oil is not now rejected in preparing the ex- 
 tractum ergotae liquidum. A writer in Medical Times and 
 Gazette (Oct. 16, 1875), under the signature of "Eyes 
 Right," has described how " teachers differ " on matters of 
 fart, and gives the teachings of Squire, Aitken, and Garrod, 
 on " Ergot " as an example. But from what I have quoted 
 from the most recent teachings of Stille and Maish, I do not 
 find we are justified in excluding the Ethereal tincture of 
 ergot as an inert preparation.] 
 
 After the local pain in the back has been subdued (by the 
 
 regular and repeated application of two or three leeches to 
 
 the painful part, followed by a large warm poultice over the 
 
 whole length of the SDine, and a belladonna plaster of equal 
 
 9 
 
130 ENDOCARDITIS. 
 
 length to follow it, or an occasional blister on each side of 
 the spine, together with mild, warm purgatives, if necessary). 
 Dr. Meryon has found no remedy so effectual as strychnia, 
 in the dose of one- twentieth of a grain, repeated more or 
 less frequently (twice or three times a day), according to 
 the evidence of its action It may be combined advantage- 
 ously with ipecacuanha in cases where the intestinal mucus 
 seems deficient The absence of pain and of spasmodic 
 muscular contraction necessitates great caution in deter- 
 mining the precise moment when the spinal cord is likely to 
 be benefited by the energetic" excitement of strychnia. The 
 internal administration of this remedy ought, therefore, to be 
 always preceded by its external use, together with other 
 stimulants, in the form of embrocations over the spine, when 
 the stage of excitation has been subdued. In cases with a 
 history of syphilis, and where there may be some reason to 
 believe that hardening or induration of the cord or its mem- 
 branes has taken place, the iodide of potassium may relieve 
 the early phenomena, and by the aid of setons the progress 
 of the disease may be held in abeyance, so long as the dis- 
 charge is maintained from the seton. 
 
 When disorganization of the spinal cord has become an ac- 
 complished fact, the disease is incurable, but yet the exigen- 
 cies of the patient are not the less pressing on the careful 
 attention of the physician, and in nothing more so than 
 in the protection which is called for against bedsores, 
 which will sometimes occur in spite of the greatest care 
 (Meryon. 
 
 Electricity, after the activity of inflammation has been 
 subdued, is a therapeutic agent of great value; and the con- 
 tinuous current of galvanic electricity seems to be just as 
 efficacious as the induction or intermittent current. But 
 whether galvanism or electro-magnetism be employed, no 
 high degree of tension is required for the restoration of mus- 
 cular power; on the contrary, Dr. Meryon justly believes 
 that the favorable course of many a case has been retarded 
 by the employment of strong currents. Dr. Althaus, also, is 
 in favor of weak currents. 
 
 Endocarditis. — Definition. — An inflammation of the 
 lining serous membrane of the heart, covering the valves and 
 lining the chambers of that organ. 
 
 Treatment. — No defined line of treatment can be laid 
 down suitable for all cases; because the circumstances under 
 
ENTERIC FEVER. 131 
 
 which endocarditis occurs are extremely varied. What has 
 been written relative to pericarditis applies equally to endo- 
 carditis; but the management of cases in which the patients 
 suffer from valvular lesions and their immediate conse- 
 quences demands the adoption of various lines of treatment. 
 Stimulants are generally called for in large quantities; and 
 digitalis also may be necessary if the action of the heart is 
 weak and failing. When endocarditis seems lapsing into 
 the chronic stage, the use of iodide of potassium and liquor 
 potassae, combined with bitter tonics and abundant nutri- 
 ment, are to be recommended. Alkalies and carbonate of 
 ammonia are to be given with free stimulation by alcoholics 
 in cases of obstruction from blood coagulation in the cavi- 
 ties of the heart. Cases of malignant, infective, or ulcerative 
 endocarditis (attended with fever and pyaemic symptoms in 
 which retinal haemorrhages are almost invariable), are to be 
 treated in the same way as cases of septicaemia. They con- 
 stitute the diphtheritic endocarditis of the Germans, some 
 septic source poisoning the blood 
 
 Enteric FeTer. — Definition. — A continued specific fever, 
 having an incubation-period of about two weeks, with an 
 eruption on the skin of isolated, elevated, rose-colored spots, 
 chiefly on the abdomen, appearing generally from the seventh 
 to the fourteenth day, occurring in crops, each spot continu- 
 ing visible about three days and vanishing on pressure. 
 Languor and feebleness are prominent from the first,attended 
 by headache, abdominal pains, and (early) by spontaneous 
 diarrhoea; but absolute prostration does not come on till late, 
 the patient rarely taking to bed before the seventh or tenth 
 day. With the advance of the disease the diarrhoea increases, 
 the discharges being for the most part liquid, copious, of a 
 bright yellow color, devoid of mucus, occasionally containing 
 altered blood. In reaction the discharges are alkaline, and 
 contain a large proportion of soluble salts with some albumen. 
 The fever may terminate favorably by a gradual restoration 
 to health during the fourth week. The average duration of 
 the illness is about twenty-three days. Death in the majority 
 of fata) cases occurs towards the end of the third week. 
 There are special symptoms sometimes associated with the 
 characteristic lesion of this fever — namely, fulness, reso- 
 nance, and tenderness of the abdomen; more or less tympa- 
 nites, with gurgling in the iliac fossae; and increased splenic 
 dulness. The specific lesions are enlargement of the spleen 
 and the mesenteric glands, with enlargement, ulceration, or 
 
1-^2 ENTERIC FEVER. 
 
 sloughing of the glands of Peyer and the minute solitary 
 glands of the small, and sometimes also of the large, intestine. 
 
 Treatment and Management of Enteric Fever. — The 
 management of a case of enteric fever resolves itself 
 into two lines of practice, embracing, — (i.) Preventive mea- 
 sures. (2.) Therapeutic Treatment. 
 
 (1). Preventive Measures, or Measures for Checking the 
 Spread of Typhoid Fever. — Whatever may be the view theo- 
 retically adopted regarding either the origin or the propagation 
 of typhoid fever, it is satisfactory to know that, practically, 
 medical officers can employ preventive measures which (to use 
 the words of the late Dr. Lankester) " will cover the issues 
 of both theories." If these are universally carried into ef- 
 fect, it is not too much to expect that this fever might per- 
 haps soon become extinct. At all events, with the facts be- 
 sore us, it is unwarrantable to permit the great bulk of what 
 escapes from the diseased intestine of typhoid fever patients 
 to be let loose upon society, into the cesspool or sewer, or 
 on the dung-heaps, in full possession of all their deadly power, 
 without being first destroyed in the way to be presently re- 
 commended. " The grand fact is clear," writes Dr. Parkes 
 " that the occurrence of typhoid fever points unequivocally 
 to defective removal of excreta, and that it is a disease 
 altogether and easily preventible." Typhoid fever ought 
 therefore soon to disappear from every return of disease, 
 whethei in military or in civil life. The measures about to 
 be specified have been made public mainly through the 
 writings of Dr. William Budd; and, provided they are 
 thoroughly and efficiently carried out, it is believed that the 
 recurrence of typhoid fever may be entirely prevented. To 
 enable us to judge of the extent of the infection to be des- 
 troyed, there are two elements to be taken into account, — 
 First, The amount and duration of the intestinal discharge 
 in each case; and, Second, The number of cases actually 
 occurring. With regard to the first, Louis has found 
 that the average duration of the alvine flux in cases of ty- 
 phoid fever is fifteen days in mild cases and twenty-six days 
 in severe cases. With regard to the second point — namely, 
 the number of cases occurring — the Reports of the Regis- 
 trar-General show that at least 100,000 to 150,000 cases of 
 typhoid fever occur annually in England alone. In other 
 words " every year in England more than 100,000 human 
 intestines, diseased in the way already described, continue 
 each, for the space of a fortnight or thereabouts, to discharge 
 
ENTERIC FEVER. I33 
 
 Upon the ground floods of liquids charged with matters on 
 which the specific-poison of a communicable disease has set 
 its most specific mark " (Budd). 
 
 The measures recommended for preventing the spread of 
 this fever are founded on the power of chemical agents to 
 destroy absolutely the material which contains or carries the 
 specific virus of such communicable diseases. Assuming it, 
 therefore, to be certain that the intestinal discharges in ty- 
 phoid fever are the media of propagation of the disease, it is 
 no less certain that, by subjecting the discharges on their 
 issue from the body to the action of powerful decomposing 
 chemical agents, they may be entirely destroyed or deprived 
 of their specfic virus. The following details of procedure 
 are suggested: — (a) All discharges from the fever patient 
 should be received on their issue from the body into vessels 
 containing a concentrated solution of chloride of zinc, (b) 
 Two ounces of a caustic solution of chloride of zinc should 
 be put in the night-stool on each occasion before it is used 
 by the fever patient, (c.) All tainted bed or body linen 
 should, immediately on its removal, be placed in water 
 strongly impregnated with the same agent. (</.) The water- 
 closet should be flooded several times a day with a strong solu- 
 tion of chloride of zinc, or of sulphate of iron or carbolic acid; 
 and some chloride of lime should be also placed there, to 
 serve as a source of chlorine in the gaseous form, (e.) So 
 long as fever lasts, the water-closet should be used exclu- 
 sively as a receptacle for the discharges from the sick after 
 being thus disinfected. (/.) Pieces of rag should be used 
 for wiping the remains of all discharges from the patient's 
 body, and burned immediately after use. The Privy Coun- 
 cil have now made the principle of this method an integral 
 part of their " General Memorandum on proceedings advis- 
 able to be taken in places attacked or threatened by epide- 
 mic disease." 
 
 (2.) Therapeutic Treatment of Enteric or Typhoid Fever 
 aims at reducing temperature and subduing vascular excite- 
 ment, if these be in excess; restraining and moderating, but 
 not actually suppressing or altogether checking the diarrhoea; 
 stimulating and restoring the nervous system; obtaining a 
 free excretion from the kidneys; and bringing about a gra- 
 dual elimination of the morbid growth from the intestinal 
 glands with as little ulceration as possible. To accomplish 
 the first of these indications the use of digitalis has been es- 
 pecially recommended by Wunderlich. He considers that 
 
134 ENTERIC FEVER. 
 
 it decidedly mitigates the febrile symptoms which are pres- 
 ent in severe cases at the time when the ulcers begin to heal, 
 and which often impede or prevent recovery. He advocates 
 its use in the severe forms of the fever only, especially at a 
 time when most danger is to be apprehended from the vio- 
 lence of the fever in the second week, when the evening 
 temperature is at its highest (105 to 108 Fahr.), and when 
 the remissions in the morning are slight; when the pulse is 
 -frequent, no to 120 or more. In mild cases it is superflu- 
 ous. He finds that in the form of infusion it is easily ab- 
 sorbed by the intestines of patients suffering from fever; 
 and, if given in a suitable dose, has most marked effects in 
 subduing the rate of pulsation, and in reducing animal heat. 
 Large doses of the infusion should be given without inter- 
 ruption until the full effect has been obtained, — 
 
 An infusion of fifteen or twenty grains of digitalis in eight 
 or ten ounces of boiling distilled water may be consumed in 
 twenty-four hours by adult patients. 
 
 It acts more rapidly on animal temperature than on the 
 heart. For the first few days after its use tne decrease of 
 temperature is rather slight, but may afterwards become 
 considerable; and after the temperature has been much 
 diminished and again rises, it never attains its former ex- 
 cessive height. The full effects of the medicine are known 
 to be brought about if the temperature is reduced 2 or 3° 
 Fahr. in the evening; and the action of the remedy does not 
 continue beyond one day after its use has been discontinued. 
 The diminution of the pulse is slight at first, and 
 occurs in some cases on the second day after the remedy, 
 but mostly on the third day, or even later; and on the fourth 
 or fifth day after the medicine has been commenced, the 
 rate of pulsation may be diminished by thirty to forty or 
 fifty beats within from twelve to thirty-six bours. The pulse 
 may continue to fall even below its normal velocity, and this 
 reduction of pulsation may last for several weeks in succes- 
 sion. If the velocity of the pulse should decrease rapidly, 
 the use of digitalis must be discontinued at once (" Arch, 
 der Heilk., 1862, p. 116). Cold and tepid sponging, or the 
 cold affusion, are remedies deserving of further trial for 
 reducing the pulse and temperature. The oppressive head- 
 ache may be greatly relieved by cold to the head ; and in 
 all severe cases the hair should be shaved off. 
 
 To restrain excessive diarrhoea, lime water mixed with milk 
 in equal parts and taken as a drink, is found to be beneficial, 
 
ENTERIC FEVER. 
 
 135 
 
 agreeable, refreshing, and nourishing. It is clear that the 
 diarrhoea ought not to be altogether checked. Professor 
 Gairdner, of Glasgow, is in favor of the French practice of 
 giving saline laxatives rather than astringents ; also of the 
 diligent use of enemata to unload the bowels from below, 
 where anything like abdominal distension has occurred. 
 These enemata may be simply of warm water, to which a 
 little aniseed is added ; or the asafcetida enema may be 
 given. Of the propriety of restraining excessive diarrhoea, 
 there can be no question. Dr. Huss, of Stockholm, is of 
 opinion that the diarrhoea during the first stage ought not 
 to be arrested, but abated and mitigated — only if excessive. 
 If it is suddenly arrested, meteorism is produced ; and pains 
 in the intestines or vomiting may supervene, with cerebral 
 symptoms. The febrile phenomena are then increased. 
 The diarrhoea is too copious or excessive if the evacuations 
 exceed four or five a day, being of considerable quantity, 
 and fluid. Such evacuations weaken the patient rapidly, 
 and should be mitigated by mucilaginous drinks, such as 
 rice-water, infusion of linseed, decoction of althaea officinalis 
 or ipecacuanha in small and repeated doses. This latter reme- 
 dy retards the peristaltic action of the intestines, and lessens 
 the secretion from the mucous membrane. The dose must 
 be regulated so as to avoid vomiting : and the feeling of 
 nausea which is apt to follow the first dose soon disappears 
 with continued use. 
 
 On the other hand, the highest authorities write : " Re- 
 strain diarrhoea and haemorrhage in typhoid fever, and when 
 you have fairly locked up the bowels, keep them so. Pa- 
 tients will go for four or six days, or even longer, without 
 suffering inconvenience from this state of constipation." 
 (Murchison, Todd). The benefits to be derived from the 
 mineral acids — hydrochloric and sulphuric especially — are 
 highly spoken of. From fifteen to thirty minims of the dilute 
 acids may be given every three or four hours ; and with 
 each dose half a grain of quinine, as in the following pre- 
 scription for an adult : 
 
 $ Acid.Sulph. dil., vel Acid.Hydrochlor. dil., m xx. ad.xxx. 
 
 Quinire Sulph. gr. £ ad gr. i. 
 
 Syrup Aurantii, 3 ss. 
 
 Aquae Carui, 3 i. 
 1 Fiat haustus, 3a vel 4a hora sumendus. 
 
 If there be more than two motions in the twenty-four 
 
136 
 
 ENTERIC FEVER. 
 
 hours, with marked prostration, astringents should be had 
 recourse to (Murchison). A starch enema, containing from 
 ten to twenty drops of laudanum, should be administered 
 towards evening, and recourse may also be had to the follow- 
 ing draught : 
 
 3 Acid. Sulph. Aromat., m xxx. 
 
 Liq. Opii. Sedativ. (Battley), m iii. 
 Aq. Menth. Pip. |i.; misce. 
 
 Fiat haustus, 4ta vel 6ta quaque hora sumendus. 
 
 If the mineral acids are not tolerated by the stomach, 
 acetate of lead is worthy of trial, in doses of two or three 
 grains in solution every four or six hours, with or without 
 an eighth of a grain of morphia (Murchison). Alum dis- 
 solved in gum, to the amount of twenty-four grains in a day, 
 which may be increased to one drachm, is best given in the 
 form of alum whey, prepared by adding one drachm of alum 
 to a pint of boiling milk, and then straining. Two ounces 
 may be given after each motion of the bowels (Fouquier, 
 Murchison). A seidlitz powder may sometimes check 
 excessive diarrhoea, by altering the secretions, and is espec- 
 ially beneficial if there be much meteorism (Trousseau, 
 Murchison). 
 
 The question, therefore, of checking excessive or encour- 
 aging moderate diarrhoea, is one which requires the careful 
 study of each particular case ; and my experience in the 
 treatment of typhoid fever leads me to recommend rather 
 the restraining of excessive diarrhoea than either encourag- 
 ing the action of the bowels or locking them up for days. 
 The French practice of giving saline laxatives is not a safe 
 one , and if the action of the bowels is deemed desirable, 
 enemata will be found sufficient. Nitrate of silver, in doses 
 of one to three grains, made into a pill, and taken every six 
 or eight hours, or sulphate of copper, in doses of a quarter 
 of a grain similarly given, are remedies most useful in the 
 diarrhoea connected with atonic ulcers, after the fourth week 
 of the disease (Bell, Murchison). If meteorism or tympanites 
 prevails from the accumulation of air in the colon, it may 
 sometimes be relieved by the passage of a long flexible tube 
 by the anus, as far up the colon as it can be made to go 
 easily. With regard to stimulation it is not decided how far 
 alcohol is beneficial. The fever eventually is attended with 
 much exhaustion, and is often protracted, yet typhoid fever 
 does not seem to bear stimulation so well as typhus. The 
 tendency to prostration is the only indication for its use ; 
 
ENTERIC FEVER. I37 
 
 but stimulation must not be persevered in if the pulse is 
 quickened by its use, the hectic flush made more manifest, 
 the tongue made drier, or if delirium supervene. Food and 
 sustenance are the real preventives of delirium, and the best 
 stimulants when necessary. With regard to the maintenance 
 of free action from the kidneys, it is to be observed that so 
 long as the excretion of urea and uric acid is abundant, no 
 diuretics are necessary ; but whenever the amount of the 
 solids falls greatly (which can be known at once with suffi- 
 cient accuracy by a comparison of the urine passed in twenty- 
 four hours with the specific gravity), means must be taken 
 at once to increase, if possible, the urinary elimination. The 
 warm bath, with repeated small doses of the alkaline car- 
 bonates, or of the nitrate or bitartrate of potash, will often 
 effect an increased elimination (Parkes, 1. c.) 
 
 To accomplish the last indication — namely, to influence 
 the elimination from the intestinal glands, by direct local 
 action on the intestinal membrane — Wunderlich and Parkes 
 especially advocate the use of calomel, if it can be given be- 
 fore the ninth or tenth day. The late Dr. Anthony Todd 
 Thomson used to give it ; and, from the observation of many 
 cases under the care of this physician, as well as from his 
 own experience, Dr Parkes considers that calomel is a med- 
 icine to be strongly recommended in typhoid fever. But it 
 must not be given later than the tenth or eleventh day, and 
 at no time in large doses. In the great majority of cases 
 where it can be given during the first week and before the 
 occurrence of much diarrhoea, the course of the disease is 
 rendered milder and shorter. Such is now the recorded ex- 
 perience of Wunderlich, Niemeyer, Parkes, and Wood. One 
 or two grains twice a day is enough, although Wunderlich 
 gives one to five grains twice daily ; but five grains is con- 
 sidered by Dr. Parkes to be too large a dose. Dr. Wood of 
 Philadelphia bears testimony to the benefit to be derived 
 from mercury about the seventh or ninth day of the fever. 
 He believes " it tends in some degree to arrest the progress 
 of the disease in the glands of Peyer, and to promote resolu- 
 tion of the inflamed patches. He prefers minute doses of 
 the blue pill mass — a grain every two hours — till the mouth 
 is slightly affected, associated with small doses of ipecacuan- 
 ha, when the stomach is not irritable. The beneficial effect 
 of this combination is shown by the tongue becoming moist, 
 the skin relaxed, and the symptoms generally being amelior- 
 ated. Twelve grains of blue pill mass are to be combined 
 
138 ENTERIC FEVER. 
 
 with two grains of ipecacuanha powder, and with two grains 
 of opium powder. The whole is to be divided into twelve 
 pills, one of which may be taken every hour, or every hour 
 and a half, or every two hours (Wood, " Practice of Medi- 
 cine," Vol, I., p. 345, 4th edition). Calomel is, however, 
 contra-indicated if the diarrhoea is excessive, or if there 
 should be excessive pains in the bowels, with early and vio- 
 lent meteorism. It is also not proper to be given if the con- 
 dition of the patient is anaemic, or if there is a decided hae- 
 morrhagic diathesis. It is most useful as a restorative of the 
 intestinal functions in cases where the tongue is dry and 
 coated, where thirst is absent, and when the urine is cloudy 
 and of low specific gravity. If the first dose is vomited, the 
 administration must be repeated. Calomel has no direct ef- 
 fect on the pulsation or respiration, nor on the cerebral func- 
 tions ; but its beneficial influence is very decidedly appreci- 
 able by the modifications of temperature which it induces. 
 No general rules can be laid down to guide the treatment 
 of the intercurrent phenomena or accidents of the disease. 
 Combinations of remedies must be adapted to correct the 
 several functions which may be simultaneously deranged, so 
 that treatment must be varied according to the functions 
 mainly implicated or suspended, and to the degree of their 
 affection. Abdominal pains and meteorism may be relieved 
 by mustard poultices, or turpentine stupes may be applied, 
 followed by simple hot water fomentations. After these re- 
 medies have been used, water compresses over the abdomen 
 tend to lessen the tension and the gurgling in the intestines, 
 and to diminish the tenderness on pressure. They counter- 
 act the inclination to meteorism, and lessen excessive diar- 
 rhoea. Dr. Huss believes also that the ulcerations in the il- 
 eum are prevented from spreading, and that perforations of 
 the intestine have been of much rarer occurrence since he 
 commenced to use these compresses. The compress, after 
 being soaked in warm, but not hot water, is well wrung, and 
 applied so as to cover the whole abdomen ; and it must be 
 changed two or three times a day, according to its tendency 
 to dry. The compress is composed of four to eight double 
 folds of coarse linen, and is to be laid over the whole abdo- 
 men, and afterwards overlaid with a cover of oiled skin or 
 india-rubber stuff, to prevent too rapid evaporation. The 
 compress should fit as closely as possible, and care must be 
 taken that it be not displaced, otherwise air enters between 
 the skin and the compress, so that cold, instead of a moist 
 
 
ENTERIC FEVER. 139 
 
 heat, is produced. These compresses may remain untouched 
 as long as they are moist and warm ; and they may be em- 
 ployed on the chest as well as on the abdomen should capil- 
 lary catarrh or pneumonia supervene. 
 
 Haemorrhage from the bowels, partly fluid and partly in 
 clots, evacuated with the stools, is a symptom of grave import; 
 and one urgent aim of treatment is to arrest the bleeding. 
 Huss found the sugar of lead most serviceable, administered 
 by the mouth, and also by clysters. By the mouth, two grains 
 may be given every half-hour, and even every quarter of an 
 hour ; and it is best given dissolved. Twenty-four grains 
 of crystallized acetate of lead, being dissolved in one drachm 
 of dilute acetic acid, to which six ounces of distilled water 
 is added, —a table-spoonful of this solution may be given 
 every half-hour. At the same time a clyster may be admin- 
 istered, composed as follows : — Ten to fifteen grains of ace- 
 tate of lead are to be dissolved in four ounces of distilled 
 water (warm), to which twenty to thirty drops of tincture of 
 opium may be added ; and the administration of such a cly- 
 ster may be repeated in four or six hours if required. Pieces 
 of ice may also be swallowed now and then ; and even 
 crushed ice may be applied, inclosed in a bladder, over the 
 abdomen. If bleeding from the nose is not arrested by the 
 use of vinegar and cold water injected up the nostrils, nor by 
 the use of cold water compresses applied to the nose, plug- 
 ging by the posterior nares must be had recourse to. Turpen- 
 tine is a most valuable remedy in haemorrhages, and in the 
 stage of ulceration. It was originally recommended by Dr. 
 Graves, and is highly spoken of by Drs. Huss, Wood, and 
 Murchison. It may be given in all cases where the tongue 
 is dry, and when " instead of cleaning gradually from the 
 edges and tip, it often parts with its fur quickly, and in large 
 flakes — generally, first, from the middle or back part of the 
 surface, which is smooth and glossy, as if deprived of its pa- 
 pillae. There is also generally an increase of the tympanites, 
 and the ulceration of the ileum seems to be attended with 
 great dryness of the tongue." Under these circumstances 
 Dr. Wood gives the oil of turpentine in doses of five to twen- 
 ty drops every hour, or every two hours. It is best admin- 
 istered in an emulsion with gum-arabic, loaf sugar, water 
 (Wood) ; or in an emulsion with the yolk of an egg and honey 
 or mucilage (Huss). Amelioration of the symptoms maybe, 
 observed in twenty-four or forty-eight hours — the tongue 
 becoming more moist, and covered with a white fur — disten- 
 
14O ENTERIC FEVER. 
 
 sion of the abdomen ceases to progress, and after a time di- 
 minishes. The use of the oil should be continued under 
 these circumstances ; but the dose should be gradually di- 
 minished. 
 
 Tonics and stimulants may be absolutely essential on ac- 
 count of debility attending the advanced stage of the disease, 
 generally about the third week. When the pulse is slow and 
 feeble, the skin cool, the tongue and teeth encrusted with 
 dark sordes, at an advanced period of the fever, then stimu- 
 lants are obviously necessary. But even when the pulse is 
 teeble, but yet frequent, and the skin hot, stimulants are even 
 then known to be of service. It is necesssry to administer 
 them in every case with great caution, and to watch the 
 effects constantly and closely. If their use is found to aug- 
 ment the heat of the skin, or to increase the frequency of the 
 pulse, or to aggravate the delirium or stupor, it is then nec- 
 essary to suspend their use. They are known to be doing 
 good service, however, if they lessen the frequency of the 
 pulse, and increase its fullness and strength; if the skin be- 
 comes-cool and moist; if the delirium is subdued or moder- 
 ated, and especially if refreshing sleep be procured. Dr. 
 Wood recommends the use of wine whey, prepared by add- 
 ing one quart of good sherry wine to two quarts of boiling 
 milk, and straining after coagulation. Of this a table- 
 spoonful or more may be given every hour or every two 
 hours. If the strength is greatly reduced, it may be neces- 
 sary to give pure wine or brandy; or even sulphuric or 
 chloric ether in cases of great prostration. Opium is also a 
 useful stimulant. It may be given when the pulse is not full 
 nor strong, and when cerebral symptoms do not exist. In 
 the later stages it may be given in doses of half a grain, or a 
 grain, every four, six, or eight hours. It is known to be act- 
 ing beneficially when it promotes sleep, subdues nervous ex- 
 citement, and induces gentle perspiration. Carbonate of 
 ammonia is objectionable, as it may irritate the bowels and 
 increase the diarrhoea. 
 
 The diet is of the utmost importance to be attended to in 
 cases of typhoid fever from the very commencement of the 
 disease. It ought then to be both food and drink combined, 
 in the form of a light nutritious liquid, such as meat fluid, 
 soup, eggs, and milk. Barley-water, rice-water, toast and 
 .water, thickened more or less with solutions of tapioca, sago, 
 arrow-root, the juice of sweet fruits, or the very soft pulp of 
 fruits, or the pure jelly of ripe fruits; but fruit in its crude 
 i 
 
ENTERITIS. 141 
 
 state is to be strictly withheld. It is necessary, as a rule, to 
 give food at certain intervals and in certain quantities. A 
 wine-glassful should be given at least every two or three 
 hours, according to the state of digestion and the demands 
 upon the strength of the patient. It may be that the patient 
 is unable to swallow, from the dry and shrivelled state of his 
 tongue. Before offering him food or drink, therefore, the 
 nurse should put a teaspoonful of lemon juice and water into 
 his mouth. She must then wait a minute or so, until the fur 
 upon the tongue and mouth is softened and moist, after 
 which the patient will often drink or take his food with ease. 
 The patient ought to have his mouth regularly washed out 
 with a linen rag, saturated with waier, in which a little soda 
 has been dissolved. Milk in small quantities frequently re- 
 peated will be found an excellent diet; and animal broths 
 and jellies may ultimately be given. The extractum carnis, 
 as prepared by Liebig or Valentine, is a most valuable nutri- 
 ment for typhoid fever patients. The best drink is pure 
 spring water, or soda-water, or barley-water, or water that 
 has been mixed with oatmeal, but is free from any particles 
 of oats. The patient generally desires and requires to drink 
 freely, in order to replace the loss of fluid by perspiration 
 and diarrhoea; and, in the advanced stages of the fever, plen- 
 ty of drink should be given by the nurse. 
 
 The utmost caution is necessary as to diet and aperients 
 during convalescence; first, as to opening the bowels, castor- 
 oil or simple enemata are the only means which should be 
 resorted to; secondly, as to diet, no flesh meat should be al- 
 lowed till at least seven days after all the febrile phenomena 
 have passed away, and the food should be as free as possible 
 of excrementitious matter. Malt liquors should not be taken 
 before food. 
 
 Enteritis. — Definition. — Inflammation of the small in- 
 testines generally, or limited locally. 
 
 Treatment. — The treatment of enteritis and intestinal ca- 
 tarrh, when not arising from a morbid poison, is by leeches 
 to the abdomen, gentle purgative medicines, combined with 
 an opiate, fomentations, and purgative or opiated enemata. 
 After the inflammation has subsided, mild tonics, as the 
 compound tincture of gentian, with nitro-muriatic acid, may 
 be substituted, with the prospect of recovering the lost tone 
 of the parts. When catarrhal diarrhoea exists, if congestion 
 prevails, connected with the hepatic region, a cathartic dose 
 
142 ENTERITIS. 
 
 of calomel, followed by castor-oil. may be necessary. If the 
 stools indicate an acid reaction, magnesia may be given with 
 advantage. When membranous films or shreds of coagul- 
 able lymph are passed, electro-galvanic applications over the 
 abdomen and dorsal spinal region, combined with creasote 
 or tar, in the form of a pill, is worthy of a trial (Simpson. 
 Cumming, Wood). Next to those remedies are such as de- 
 termine towards the skin. For this purpose combinations o f 
 Dover's with James' Powder, or a solution of tartar emetic 
 with laudanum, are the most useful medicines, and their 
 beneficial action may be aided by the use of the warm bath, 
 and a flannel roller applied with firmness round the abdo- 
 men (Craigie). Where hypersemia is excessive, accompanied 
 by moderate transudation from the intestine, as after exten- 
 sive burns, accompanied by great pain, cold external appli- 
 cations are suitable, as well as in the severer forms of ca- 
 tarrhal enteritis (Niemeyer). The best mode of applying 
 them is by cloths wrung out of cold water and laid over the 
 abdomen. In the chronic form, combined with obstruction, 
 irritating and warm compresses are most suitable Preiss 
 nitz's compress is extensively used for this purpose. A wet 
 towel in folds, covered with a dry one, is laid over the abdo- 
 men all night, to be renewed several times daily. The great- 
 est care ought to be given to the management of the diet. 
 It ought to be strictly antiphlogistic, consisting of slops and 
 light puddings. Animal food must be withheld, and only 
 permitted in the form of soup. The safest diets are those 
 of arrow-root, sago, tapioca, barley-meal, gruel of oatmeal, 
 sowens, [" The husk and some adhering starch separated 
 from oats in the manufacture of oatmeal are sold in Scot- 
 land, under the inconsistent name of 'seeds. These, if in- 
 fused in hot water, and allowed to become sourish in this 
 state, yield on expression a mucilaginous liquid, which, on 
 being sufficiently concentrated, forms a firm jelly known by 
 the name of ' sowens.' Not less than a quart of the seeds 
 are to be rubbed for a considerable time with two quarts of 
 hot water, after which the mixture is to be allowed to rest 
 for several days until it becomes sour. It is then strained 
 through a hair sieve, and the strained fluid left to rest till a 
 white sediment subsides. The supernatant fluid is to be 
 poured off, and the sediment washed with cold water; after 
 which it may be either boiled with fresh water, stirring the 
 whole time it is boiling, or it may be dried and prepared 
 when convenient in the same manner as arrow-root. It may 
 
EPILEPSY AXD HYSTERO-EPILEPSY. 143 
 
 be eaten with wine, milk, or lemon-juice and sugar." — Pe- 
 reira, "On Food, " p. 326.] barley water, toast water, burnt 
 oatcake water. This last-named substance, used as a drink, 
 is said to allay irritation and morbid sensibility of the bowels 
 (Craigie). When the abdominal pains subside, and stools 
 become less frequent and the appetite increases, the diet 
 must be still more scrupulously attended to. Oatmeal por- 
 ridge boiled to the utmost degree of pulpiness, and not too 
 consistent, is one of the best of diets, which may be alter- 
 nated with ground rice alone, or combined with barley flour, 
 all of which may be eaten with diluted milk from the cow or 
 with milk undiluted of town-fed cows. 
 
 Epilepsy and Hystero-Epilepsy. — Definition. — A com- 
 plex nervous state, characterized by chronic convulsive at- 
 tacks not due to organic brain disease, tonic at first, but 
 which subsequently become clonic, and ultimately impede 
 the respiratory process. The attack, lasting from an imper- 
 ceptible period to two, twenty, or more minutes, is followed 
 by some exhaustion and sleep. The expression of the epi- 
 leptic state varies from simple vertigo to the most severe 
 paroxysm, a momentary suspension of consciousness, a fix- 
 ity of gaze, a totter of step, and a confusion which appears 
 and disappears almost instantaneously, which the patient 
 only can recognize. The cases comprehend — (1.) Simple 
 epilepsy, or epilepsy proper, in which there is a paroxysmal 
 loss of consciousness as the first, or nearly the first phenom- 
 enon in the paroxysm, and with this loss of consciousness 
 there is more or less spasm of muscles (including those of 
 the muscular coats of the arteries). (2.) Epileptiform seiz- 
 ures, in which there is no evidence of organic brain disease, 
 but developments of the movements normally represented in 
 some particular parts of the cerebral cortex. (3.) Hystero- 
 epilepsy (Hysteria major of Charcot, the Hysteroid of Dr. 
 \Y. Roberts, or the Co-ordinated Convulsions of Gowers) 
 which presents, with loss of consciousness, varied convulsive 
 momements of more or less co-ordinated spasm, spasmodic 
 movements of a quasi-purposive character, opisthotonos, em- 
 prosthotonos, and the like, forming a series from simple hys- 
 teria to true epilepsy. The co-ordinated spasm may exist 
 alone, or may be combined with epileptoid phenomena, or 
 with true epileptic symptoms. 
 
 Treatment. — The treatment divides itself into what is to 
 be done during the paroxysm, and subsequently during the 
 intervals. 
 
144 EPILEPSY AND HYSTERO-EPILEPSY 
 
 When adults are laboring under the paroxysm, little, in 
 general, can or ought to be done except bringing the patient 
 into the fresh air, taking off what may be around the neck, 
 and baring the chest, together with the more imperative duty 
 of preventing the patient doing himself any injury. Bleed- 
 ing, so often had recourse to, is rarely found beneficial; ex- 
 cept, however, as regards females, in cases of suppressed 
 menstruation. If, however, the paroxysm be greatly pro- 
 longed, the application of cold to the head, and opening the 
 temporal artery, where symptoms of excessive cerebral con- 
 gestion are obvious, may be of some service, as in cases rec- 
 ognized as plethoric. It is of great importance to shorten 
 the paroxysm as much as possible. Dr. Sieveking recom- 
 mends that a trial be made of the galvanic current during 
 the fit. The conductors should be moistened sponges, so as 
 to insure the passage of the current to the deeper-seated tis- 
 sues. The inhalation of ammonia or chloroform, or nitrite 
 of amyl; or a dose of sal-volatile, or of ether, has been found 
 useful. The nitrite of amyl not only postpones, but alto- 
 gether prevents epileptic seizures. "A vinaigrette , or small 
 stoppered bottle, containing a sponge soaked in nitrite of 
 amyl, and carried in the pocket, so as to be at hand, will be 
 found a safeguard to many sufferers from epilepsy. Where- 
 ever there is time after the initiation of the coma, and before 
 the development of the proper phenomena of the fit, to 
 breathe the nitrite of amyl freely, the fit, with its terrible ac- 
 companiments and disastrous sequelae, may in many instances 
 be not merely postponed, but abolished,"' (Dr. Crichton 
 Browne, "West Riding Asylum Reports," Vol. III., p. 154). 
 
 The paroxysm over, the probable exciting cause of the 
 paroxysm should be investigated, and, if possible, removed; 
 the state of the bowels should be particularly inquired into 
 and regulated, and leeches should be applied to the temples 
 if the headache be severe. In women, also, the catamenia, 
 if defective or excessive, should be remedied. These few 
 simple rules are of the first importance, not only as removing 
 the immediate inconveniences incident to the attack, but also 
 as a means of prolonging: the interval, and perhaps prevent- 
 ing its future occurrence. We must take into account, and 
 search out for all causes which may have contributed to the 
 malady. In assuming the charge of an epileptic, it is neces- 
 sary to commence first by regulating the external relations 
 of the patient, his habits, and his bodily health, so that every 
 suspicious condition of his life to which the origin of the dis- 
 
EPILEPSY AND HYSTERO-EPILEPSY. 145 
 
 ease can in any way be ascribed may be corrected (Nie- 
 meyer). In a few instances the patient, by the adoption of 
 certain rules, is cured, and the prevailing principles of treat- 
 ment in epilepsy mainly consist in local derivation, or coun- 
 ter-irritation directed to subdue cerebral congestion, and in 
 the use of such tonic remedies as may be indicated by a 
 careful inquiry into the condition of the individual organs, 
 and how their several functions are performed. The intens- 
 ity of the headache suggests more or less active counter-irri- 
 tation by blisters, dry or wet cupping, ointment of tartrate of 
 antimony, setons, or even the actual cautery applied under 
 chloroform to the nape of the neck. 
 
 The medicinal remedies that have been employed are va- 
 lerian, iron, zinc, quinine, musk, opium, asafoetida, the iodide 
 and bromide of potassium, camphor, and the preparations of 
 turpentine. The nitrate of silver, once esteemed a specific 
 in this complaint, has not only failed, but, by occasionally 
 staining the rete mucosum of a dingy hue, has often perma- 
 nently disfigured the patient. Of the long catalogue of rem- 
 edies which has been mentioned, each medicine is perhaps 
 useful for a few weeks ; but after that period its good effects 
 are, for the most part, lost, so that it would appear to act 
 rather mentally than physically in removing the cause and al- 
 tering the morbid 'tendency. 
 
 " Whatever remedies or course of treatment you pursue, 
 do not appear to despond, or use any other language to the 
 patient than that of hope. Avoid extravagant promises, as 
 inconsistent with that love of truth which ought to character- 
 ize every professional man; but unless you have the strongest 
 evidence against it, do not yourself, nor allow your patient, to 
 abandon hope" (Dr. Todd, "Clinical Lectures," Medical 
 Times, August 12, 1855. 
 
 The employment of purgatives is indicated for the re- 
 moval of waste matter, to act as a derivative /rom the head, 
 to expel foreign matters or worms from the intestines, and 
 generally to regulate the bowels; and the laxatives most 
 suited to epileptics are rhubarb, compound colocynth pill, 
 aloes, castor-oil, taraxicum, sulphur in combination with 
 magnesia or rhubarb; and the Pullna, Hunyadi Janos, Fried- 
 nschall, or Carlsbad bitter waters. Half a tumblerful or 
 less, taken in the morning, generally produces a full pulta- 
 ceous evacuation in two or three hours. The judicious use 
 of an anthelmintic sometimes frees the patient from the dis- 
 ease as well as from a tapeworm or other parasite, which not 
 10 
 
I46 EPILEPSY AND HYSTEROEPILEPSY. 
 
 ^infrequently may be the eccentric source of the fits. Inde- 
 pendently of its anthelmintic properties, however, both Drs. 
 Watson and Sieveking strongly recommend the use of tur- 
 pentine. It may be given in half-drachm doses every six hours. 
 
 If a scar, foreign body, tumor, or neuroma, be found press- 
 ing on a peripheral nerve, its removal by operation may cure 
 the epilepsy. Dr. Echeverria has recently given a table of 
 145 epileptics who were trephined, with the results, which 
 furnishes irrefragable proofs of the utility of trephining in 
 epilepsy produced by injury to the cranium {London Med. 
 Record, May 15, 1879, p. 169). 
 
 The preparations of iron and zinc are the most useful ton- 
 ics; and for the general principles on which iron may be ad- 
 ministered, the reader is referred to the pages on Anaemia. 
 
 Dr. Trousseau believed that belladonna is the least ineffi- 
 cacious of all the remedies for epilepsy, and from its use he 
 not only obtained alleviation and improvement in many 
 cases, but was able to count upon a certain number of cures 
 (Clinique Medicale, t. ii., p. 95). His formula is: 
 
 Atfopiae Sulphatis, gr. j.; Sp. Vini Gallici, mc. M. One 
 drop of this solution is to be given every day in the morning, 
 if the attacks happen in the daytime; or in the evening, if 
 during the night; the dose to be increased by one drop for 
 each succeeding month, and to be always taken at the same 
 period of the day. It should not be pushed beyond the first 
 toxical indications. If the dose is not well borne, it should 
 be increased only every second or third or fourth month. 
 When improvement is apparent, the quantity given in the 
 last dose should be continued for some time, and then grad- 
 ually lessened, and finally stopped, to be, after an interval, 
 resumed. 
 
 A year is scarcely sufficient to test the influence of bella- 
 donna, and if in the succeeding year some improvement fol- 
 lows, the treatment is to be maintained for two, three, and 
 four years (I.e., p. 95). Dr. Trousseau, however, in prac- 
 tice seems to have adopted a mixed treatment, giving bella- 
 donna in the morning, with the nitrate of silver, the sulphate 
 of copper, or the lactate of zinc, in the evening, alternating 
 these last every ten days. The following are his modes of ad- 
 ministration: 
 
 r}. Argenti Nitratis, gr. ij.; Pulv. Acaciae, Aquae distil., 
 aa q. s. Div. in pil. x. One every night. Or, 
 
 %. Cupri Sulphatis, gr. xx.; Pulv. Sacchari, 3 j. Div. in 
 pil. xx. Two every night. Or, 
 
EPIPLEPSY AND HYSTERO-EPILEPSY. 147 
 
 $. Zinci Lactatis, 3j.; Pulv. Sacchari, 3 ij. Div. in 
 pil. xx. One every night. Or, the zinc may be made into 
 pills with the conserve of roses. 
 
 Within the past ten years the bromide of potassium has 
 been largely used in epilepsy, and the testimony to its utility 
 in the disorder is uniform and strong. Dr. C. B. Radcliffe 
 writes: — " In tins summer of 1858 I began to give this medi- 
 cine almost promiscuously in cases of epilepsy and epilepti- 
 form disorder, and from that time to this (1S64) I have been 
 continually finding fresh reasons for persevering in the prac- 
 tice. . . . The conclusion at which I have arrived is, 
 that bromide of potassium is the only remedy in epilepsy up- 
 on which most dependence can be placed." The late Dr. 
 Bazire, in a note to his translation of Trousseau's Clinical 
 Lectures, speaks thus of the experience of the physicians of 
 the Hospital for the Epileptic and Paralyzed in London, 
 and of his own, with this remedy: — "The results obtained 
 are such as to warrant the conclusion that it is infinitely 
 superior to all other remedies that have been recommended 
 against epilepsy. It is certainly far superior to belladonna 
 in its power of diminishing the frequency and severity of 
 epileptic attacks and epileptiform seizures in general; nay 
 more, of warding off the attacks, lengthening the intervals 
 between them, and, in some cases, of bringing on a cure " 
 The most recent, and a very high authority, Dr. J. Rus- 
 sell Reynolds, in his excellent article on Epilepsy (System 
 of Medicine, Vol. II., 1868), says: — " Bromide of potas- 
 sium is the one medicine which has, so far as I know, 
 proved of real service in the treatment 0/ epilepsy. In large 
 doses it has scarcely ever failed to give much relief. Given 
 in doses ranging from ten to thirty grains, three times daily, 
 it has had these effects: — In some cases it has completely 
 cured the patient, and the cure has been permanent for 
 years, and is so now. In others it has arrested the attacks, 
 so that none have occurred for periods varying from a few 
 months to two or three years; but on the omission of the 
 medicine the seizures have returned. In such cases the at- 
 tacks have again ceased on the readministration of the medi- 
 cine. In a third series of cases it has diminished the fre- 
 quency and severity of the seizures, but has not removed 
 them altogether; the patients, while taking the bromide, 
 have had one-half or one-third the number of fits to which 
 they were habituated. Such patients have gone back to the 
 old frequency of recurrence when the drug has been omitted, 
 
148 EPILEPSY AND HYSTEROEPILEPSY. 
 
 and have again improved when it has been readministered. 
 In a fourth but very much smaller number, it has been good 
 for a time, and then has appeared to cease; and in a fifth, 
 and yet smaller proportion, it has been apparently with- 
 out any appreciable effect. . . . It is to be demon- 
 strated that there is yet something ' specific ' in the 
 action of bromide of potassium." Dr. Voisin, of the 
 Salpetriere Hospital says, that it does not cure absolutely, 
 but diminishes the disorder in a marked degree, lessening 
 and even suppressing the nervous erethism (Bui. de 
 Therapeutique, 1867). Dr. Edward Fox reports fifty-two 
 cases in which bromide of potassium, in not less than twenty- 
 grain doses, was found " satisfactory," and ten cases in 
 which it wholly failed, in one of which belladonna was more 
 successful (St. George's Hospital Reports, Vol. II., 1867). 
 Dr. Brown Sequard, than whom few have had as large ex- 
 perience in this disease, began to use the bromide of potas- 
 sium in large doses towards the end of i860. He writes: — 
 " I was soon led to associate the iodide of potassium with 
 the bromide: and it became almost at once evident that, in 
 most cases of epilepsy (whether idiopathic, symptomatic, or 
 sympathetic, but especially in that form, which is much more 
 common than it is admitted to be, in which that convulsive 
 affection is allied with or due to, a congestion of the base of 
 the brain or its meninges), these two remedies did more good 
 than either of them alone. By the end of 1861, after I had 
 ascertained that the bromide of ammonium has a special 
 therapeutic influence in cases of congestion of the medulla 
 oblongata, and of the upper parts of the spinal cord, I began 
 to associate that salt with the bromide and iodide of potas- 
 sium in the treatment of epilepsy. . . . That mode of 
 treatment has been submitted to an extensive trial, which 
 leaves no doubt as regards its superiority. Although cer- 
 tainly it does not often cure permanently, it usually di- 
 minishes considerably, the violence and the frequency of the 
 attacks, and is much more successful than the various modes 
 of treatment by the best remedies against epilepsy, such as 
 atropine or belladonna, the sulphate of copper, the nitrate of 
 silver, strychnine, valerian, zinc, digitalis, or the means of 
 counter-irritation by applications of ice, moxas, croton oil, 
 &c, on the spine or head " (Lectures on the Diagnosis and 
 Treatment of Functional Nervous Diseases, 1868, pp. 81, 
 82). His usual prescription is: — 
 
 ^. Potassii Iodidi, 3j.; Potassii BromidL, |j.; Am- 
 
Epilepsy and HYsf ero-epilepsY. 149 
 
 hlonii Bromidi, 3 ijss.; Potassae Bicarbonatis, 3ii.; Infus. 
 Calumbae, f § vj. M. 
 
 A teaspoonful before each of the three meals, and three 
 teaspoonfuls at bedtime, in a little water. 
 
 Dr. Ayer and others have preferred the sodium salt in- 
 stead of the potassium salt, as it does not seem to have the 
 same depressing effect on the cardiac muscle in large doses 
 as the iodide of potassium has. It may be given in from 10 
 to 30 grains three times a day. Dr. James Ayer's mode of 
 prescription is as follows:— v 
 
 r>. Sodii Bromidi, Iodidi Bromidi, Ammonii Bromidi, 
 aa 3 iii. ; Potassii iodidi, Ammonii iodidi, aa 3'ss., Am- 
 moniae sesqui-carbonatis, 3 i; Tincture Calumbae, f 3 iss; 
 Aquae distillata, ad. § viii. ; misce. 
 
 The full dose of this compound is a drachm and a half be- 
 fore each meal, and three drachms at bed-time. At the out- 
 set the patients are informed that regular treatment must go 
 on for two years, after which the dose must be left to the 
 patient's discretion, when, except for averting threatened 
 attacks, full doses are no longer advisable. As a tonic, 
 drachm doses of the following mixture may at the same time 
 be taken after each meal: — 
 
 $. Strychniae sulphatis, gr. i.; Acidi sulphurici diluti m 
 x.; Aq. distillatae, f 3 iv.; misce. 
 
 The strychnia may be given in smaller doses to begin with. 
 In all cases the diet must be carefully regulated {Land. Med. 
 Record, March 15, 1878, p. 128). 
 
 In syphilitic epilepsy, the iodide of potassium is increased 
 to five or six drachms. Where the attacks begin with violent 
 laryngismus, the bromide of ammonium is raised to three or 
 four drachms, and the bromide of potassium diminished 
 by two drachms. The following rules have been laid down as 
 to the use of these remedies : — The quantities of these 
 medicines to be taken daily should be large enough to pro- 
 duce an evident, though not complete, anaesthesia of the 
 fauces and upper parts of the pharynx and larynx, this quan- 
 tity varying, with the patient's idiosyncrasy, from forty-five to 
 eighty grains of the bromide of potassium, and twenty-eight 
 to forty-five grains of the bromide of ammonium, when only 
 one of these salts is given, and a lesser quantity of each, 
 but especially of the ammonium, when given together 
 (Clymer). 
 
 These remedies very rarely produce a good effect in epi- 
 lepsy without causing an acne-like eruption in the face. arms. 
 
150 EPILEPSY AND HYSTERO-EPlLEPSY. 
 
 neck and shoulders ; and there seems to be a positive rela- 
 tion between the intensity of the eruption and their efficacy. 
 It is important, therefore, when there is no eruption, and also 
 when it begins to disappear, to increase the dose, unless the 
 dose given in the twenty-four hours is already so large that any 
 increase brings on great sleepiness in the daytime, a decided 
 lack of will and of mental activity,dulness of the senses, droop- 
 ing of the head, considerable weakness of the body, and a 
 somewhat tottering gait. It is never safe for a patient tak- 
 ing these drugs to be even one day without them, so long as 
 he has not been quite free from the attacks for at least fifteen 
 months. 
 
 Iron and quinine should be given in epilepsy, unless the 
 ailment is complicated with ansemia or malarial poisoning, 
 except, perhaps, in the form of the double salt of the citrate 
 of iron and strychnine. 
 
 A gentle purge every five or six weeks maintains the power 
 of the bromides (Brown-Sequard, 1. c, pp. 84-86). 
 
 In night-seizures the bromide of potassium would seem to 
 have less influence than in day-fits (Duckworth, Williams). 
 
 The debilitating effect of the bromides ought to be lessen- 
 ed by the use of strychnine, arsenic, the oxide of silver, 
 ammonia, cod liver oil, cold douches or shower-baths, and a 
 nourishing diet. There is an antagonism between strychnine 
 and the bromides, and when prescribed together, the dose of 
 the bromides must be increased. 
 
 Dr. E. C. Seguin has also called attention, in the New 
 York Medical Association, to the evil effects which may fol- 
 low the abuse or over-use of the various bromides. The 
 most important of these results are — conditions of impaired 
 nutrition, and of nervous atony, which continued for 
 months or even years ; general debility, with the weak slow 
 pulse and coldness of the extremities; tendency to stupor, 
 slight difficulty in speaking, the bromic breath, and acne. 
 Regarding the method of using the bromide salts in the 
 treatment of epilepsy and other neuroses, he lays down the 
 following rules : — (1.) The prolonged use of bromides is 
 contraindicated by congenital feebleness, but they are all 
 borne by persons of fairly full habit, and good nervous pow- 
 er. (2.) The bromides are indicated in cases of abnormally 
 great irritability of the nervous system in its motor (muscu- 
 lar and vaso-motor) and ideational tracts ; (3.) These con- 
 traindications are to be less regarded in the management of 
 that formidable neurosis, epilepsy. (4.) Epilepsy is to be 
 
EPILEPSY AND HYSTERQ-EPILEPSY. 151 
 
 regarded as the only disease which justifies the deliberate 
 production of a degree of bromism for its cure. 
 
 Dr. Seguin's method of prescribing the bromides in the 
 treatment of a case of " idiopathic " epilepsy is the follow- 
 ing. Two solutions are employed. 
 
 t>. Potasii bromidi, §i.; Ammonii bromidi, 3 ss. Aquae 
 fontanae, § vij.; misce : to be given by the teaspoonful ; and, 
 $. Sodii bromidi, § i.; Ammonii bromidi, § ss.; Aquae font., 
 § vij.; misce : to be given by the teaspoonful. 
 
 The quantity administered is to be so divided as to give by 
 far the largest dose in the evening. The bromide is to be cau- 
 tiously increased, still keeping the nocturnal dose the largest, 
 until slight bromism is produced; which is usually necessary to 
 be maintained for months, but just as little is to be given as may 
 prevent the attack. The precise quantity required must be 
 studied in each case. Children tolerate the bromides, as well 
 as the iodides, in relatively large doses. It is of importance to 
 thoroughly dilute the bromides in order to facilitate their ab- 
 sorption — the dose to be taken in a wineglassful or half a 
 tumblerful of water. Under no circumstances should the 
 bromides be discontinued; they may be diminished, but not 
 stopped entirely ; they should be continued at least three 
 years after the last attack. The adjunct treatment consists 
 in the use of measures to prevent the acne to a certain ex- 
 tent, such as the occasional use of arsenic, sulphur-ointment, 
 mercurial plaster, alkaline lotions ; to correct the general de- 
 bility of slight paresis, by the use of strychnia, mix vomica, 
 oxide of zinc, and quinia; to relieve the dizziness by the in- 
 halation of nitrite of amyl, by stimulants, and quinia; reg- 
 ulating the patient's diet and hygiene, and the use of cream, 
 cod-liver oil, iron, quinine, phosphorus, strychnia, with nitro- 
 muriatic acid. In certain cases such medicines as acted more 
 directly upon the morbid state of the nervous centres were 
 associated with the bromides, and favorite among these was 
 belladonna {London Medical Record, June 15, 1877, p. 221). 
 
 Picrotoxine has been found to possess anti-convulsive prop- 
 erties. It was originally recommended by Dr. Crichton 
 Browne in the treatment of epilepsy, and his experiments 
 have been recently confirmed by Planat. 
 
 Clinical familiarity with epilepsy, and a history of its the- 
 rapeutics go to show that there are no grounds for belief in 
 any specific against this affection, and the physician who 
 promises a cure, or even relief, by means of any one remedy in 
 this disorder, runs the risk of damaging not only himself, but 
 
i52 EPILEPSY AND HYSTERO-EPILEPSY. 
 
 his art. It cannot, however, be doubted, that, in a certain 
 number of cases of epilepsy not apparently caused by any 
 coarse cerebral lesion, the severity and frequency of the 
 seizures may be greatly abridged, so that the sufferers may 
 be brought to enjoy often a great degree of immunity and 
 comfort. The proportion of such cases to the whole num- 
 ber afflicted is, perhaps, few, but it is still sufficiently numer- 
 ous to give hope and encouragement to further trial. Such 
 results, however, can only be surely gained by means which 
 will increase and develop the vital power generally. It should 
 be borne in mind that tonic treatment does not alone consist 
 in the administration of a tonic drug. Whilst many cases of 
 epilepsy demand the use of tonic medicines to fulfil certain 
 present indications, they should in no sense be looked on as 
 a curative, or even remedial, but only as adjuvants, and when 
 they have done their work should be laid aside. Of this 
 class of remedies none, perhaps, is more valuable than arse- 
 nic, given in minute doses. Where there is anaemia, iron or 
 manganese is required. But a general restorative system 
 must be adopted and persevered in. 
 
 The diet of the epileptic should not consist of much meat 
 (nor much nitrogenized food), nor much of anything. It 
 ought to be spare diet — simple and unstimulative, and to 
 the absolute exclusion of alcohol. After a prolonged inves- 
 tigation on the influence of diet in epilepsy, carried on at 
 the West Riding Asylum, by Dr. John Merson, he came to 
 the conclusion that a farinaceous diet is likely to be more 
 useful in the treatment of epilepsy than a nitrogenous one 
 {West Riding Lunatic Asylu77i Reports, Vol. V., pi). The 
 food should contain, as soon as the state of the digestive 
 organs will permit, a certain portion of fatty and oily con- 
 stituents, and in most cases cod-liver oil may be given with 
 advantage. The hypophosphites, as a vehicle for the intro- 
 duction of phosphorus into the system, would seem to be 
 of service in improving the general nutrition. 
 
 The maintenance of the activity of the cutaneous function 
 is of the first importance. In the beginning an occasional 
 vapor or hot-air bath may be taken ; afterwards tepid salt or 
 fresh-water baths, followed by a general grooming of the 
 skin. Exercise in the open air, gymnastics, both measured 
 by the strength of the patient, are to be insisted upon, as 
 well as such means as will promote the expansion of the 
 lung tissue. With physical training, mental and moral train- 
 ing should be combined. 
 
EQUINIA ERYSIPELAS. 153 
 
 Such are the general principles of the rational or restora- 
 tive treatment of epilepsy, which, it is believed, will give a 
 larger measure of success than a reliance upon any one of 
 the innumerable specifics that have had questionable and 
 temporary repute. If a successful issue is to be had, per- 
 severance and confidence, both on the part of the physician 
 and the patient, are chief conditions of success, and this 
 should be fairly stated at the outset to the sufferer and his 
 friends. 
 
 Ice applied to the cervical spine has caused the severe 
 paroxysms of hystero-epilepsy to cease (Gowers). 
 
 Eqilillia — See Glanders. 
 
 Equillia Mitis. — Definition. — A pustular eruption, pro- 
 duced by the contagion of matter from a horse affected with 
 the grease. 
 
 Treatment. — The greatest relief to the constitutional dis- 
 turbance is obtained by frequent purgation with aloes com- 
 bined with ammonia, and such moist local applications as 
 may relieve pain. 
 
 Ergotism. — Definition. — A train of morbid phenomena 
 produced by the slow and cumulative action of a specific 
 poison in a fungus peculiar to wheat and rye, and which 
 gives rise to convulsions, gangrene of the extremities, and 
 death, or to symptoms of ill-health. 
 
 Treatment. — Considerable differences of opinion prevail 
 regarding the treatment of this dietetic disease. The cause, 
 in the first instance, must be ascertained and removed ; and 
 to obviate the effects it has already produced, the constitu- 
 tional treatment must be directed to improve the state of the 
 blood. Tonics and stimulants are to be administered, after 
 a free employment of evacuant remedies, to clear out the 
 alimentary canal completely. The chlorates of potash and 
 of soda, with antispasmodics, tonics, and narcotics, are 
 especially indicated. Camphor, musk, ammonia, capsicum, 
 may be particularly mentioned ; and the strength of the 
 patient is to be supported by light, nourishing and whole- 
 some food. 
 
 Erysipelas. — Definition. — An acute febrile disease, char- 
 acterized by a peculiar inflammation of the integument, tend- 
 ing to spread indefinitely, and even to involve the areolar 
 tissue beneath the skin. It is accompanied by severe gen- 
 eral symptoms. 
 
 Treatment. — " Experience has proved that general bleed- 
 ing has no other effect than to blanch the eruption, without 
 
154 ERYSIPELAS. 
 
 notably abridging its duration ; " and from the nature of the 
 disease blood-letting in any form is not to be thought of. 
 Rest, saline laxatives, cooling drinks and low diet are the 
 elements of treatment in mild and simple cases. An emetic 
 is useful at the commencement; and I have seen, in the 
 practice of an eminent surgeon (Mr. Syme) that frequent 
 resolution of an erysipelatous attack has followed an antacid 
 laxative, such as forty grains of rhubarb to sixty of bicarb- 
 onate of soda, divided into twelve powders, one to be taken 
 every six hours, together with the counter-irritation of a 
 mustard poultice over the stomach. Laxative and cathartic 
 remedies are to be selected and apportioned according to the 
 violence of the attack and its nature, as tending to the un- 
 favorable results of the specific inflammation already noticed. 
 Calomel is a most valuable purgative, as a sedative in febrile 
 disturbance, especially when followed by castor-oil, or the 
 common black draught. The indications to the use of cer- 
 tain remedies, as given in the treatment of scarlet fever, are 
 equally applicable here. If the febrile state is not subdued, 
 antimonials are of great service ; and so far as they are diapho- 
 retic in their action they tend to subdue the vascular ex- 
 citement. If symptoms of nervous depression ensue, opium, 
 or opium and ipecacuanha are indicated, also wine and quin- 
 ine, ammonia and camphor, in asthenic cases with a tendency 
 to a typhoid state. The tincture of the perchloride of iron, 
 in doses of ten to thirty minims, three, four, or five times a 
 day, in water, infusion of quassia, or calumba, is now also a 
 remedy much in use, and it may be alternated with the syrup 
 of the phosphate of iron, in doses of a teaspoonful three or 
 .four times a day. In cases where the system is obviously 
 gouty or rheumatic, and where the joints are affected, col- 
 chicum with saline diaphoretics are the most efficient reme- 
 dial agents. Local applications are potent for good or evil, 
 and must therefore be used with great caution. The effects 
 seen on the skin do not constitute the whole disease ; and if 
 the development of these processes on the cutaneous tissue 
 is imprudently interfered with, there is imminent danger to 
 internal organs. To check the advance and prevent the en- 
 croachment upon new territory, rather than to subdue it, if 
 already in possession, ought to be the sole aim of local treat- 
 ment, and to mitigate the local pain and uneasiness. Bland 
 mucilage, such as that of viscid linseed tea, from which light 
 muslin cloths have been steeped and spread over the inflamed 
 surface, sometimes affords relief. Dry flour, or rye-meal, 
 
ERYSIPELAS. j e c 
 
 frequently dusted from a dredge-box over the erysipelatous 
 patches, are soothing applications. A thick layer of cotton- 
 wool dusted with tutty powder is also a soothing application 
 to the part. A lotion of nitrate of silver painted daily over 
 the affected parts sometimes gives great relief (one scruple 
 of the nitrate to an ounce of water, to which ten drops of 
 dilute nitric acid are added). Dilute nitric acid should, at 
 the same time, be given internally, if typhoid symptoms pre- 
 dominate, as in the following formula : 
 
 I>. Acid. Nitricj dil, 3i.; Syrup. Zingib., % ss.; Aquae, 
 | vss.; misce. A tablespoonful every four hours. 
 
 To arrest the spread of the process over sound skin, ni- 
 trate of silver in very strong solution, or tincture of iodine 
 have been considered efficient agents. A line of circumval- 
 lation is to be painted round the erysipelatous part, so as 
 completely to enclose it. The nitrate of silver should either 
 be employed in the solid stick; or as proposed by Higgin- 
 botham, in solution of eight scruples of the nitrate with 
 twelve drops of nitric acid in a fluid ounce of water. Dr. 
 Wood has practised with success and recommends the use of 
 tincture of iodine. But in this country the boundary line 
 of nitrate of silver has not been attended with success ; and 
 our best surgeons are now discontinuing the practice as a 
 useless source of irritation (Erichsen, Campbell l)e Morgan). 
 Sulphite of soda, in solution of ten grains to one ounce of 
 water, is recommended by Dr. Addinell Ilewson, of Phila- 
 delphia. He has never seen it fail to arrest the progress of 
 the disease, if it has not advanced to the deeper parts below 
 the skin. Lint soaked in the solution is to be applied to the 
 affected part, and over a considerable distance beyond any 
 visible appearance of redness. The lint is to be covered 
 with oil-silk, to prevent evaporation. The application of 
 sulphate of iron as a lotion or ointment tends to shorten the 
 disease. In lotion, one drachm of the salt to a pint of 
 water ; in ointment, a scruple to an ounce of lard (Velpeau, 
 Luke, De Morgan). It has the inconvenience, however, of 
 soiling linen with which it comes in contact. None of these 
 lotions should be applied cold, but tepid or warm. Collodion 
 and iodized collodion are also worthy of commendation. 
 Long and deep incisions into the inflamed textures are some- 
 times demanded. This is more especially the case if there 
 be tension of fibrous tissue, such as the subcutaneous 
 fascia; ; and erysipelas of the head is frequently greatly 
 alleviated by repeated innumerable minute punctures, made 
 
1^6 ERYTHEMA — FEVER, REMITTENT. 
 
 by the point of a lancet all over the parts of the face and 
 scalp which are affected. 
 
 Erythema. — Definition. — Uniform redness simply, with 
 puffiness of the skin, distributed in distinct patches of some 
 size. 
 
 Treatment. — Rest, quinine, and iron, after aperients ; car- 
 bonate of ammonia, after gentle purgation, in doses of 5 to 
 10 grains three times a day, are the most useful remedies. 
 Oxide of zinc, in fine powder, dusted over the surface, will 
 sometimes allay the local irritation. 
 
 FavUS — See Tinea Favosa. 
 
 Febricula. — Definition. — A simple fever in which the 
 expression of the febrile phenomena is of very short dura- 
 tion, lasting, as a rule, for not more than twenty-four, thirty- 
 six 3 forty-eight, or seventy-two hours, attended with a fre- 
 quent, full, and often firm pulse, white and coated tongue, 
 pains in the loins and limbs, thirst, constipation, a scanty 
 discharge of high-colored urine, hot and dry skin, sometimes 
 an eruption of roseola or erythema about the loins or thighs, 
 coming and disappearing with the fever (Morehead) ; severe 
 headache, sometimes acute delirium, and flushed face. The 
 subsidence of the fever is generally associated with copious 
 perspirations, or herpetic eruptions. 
 
 Treatment of Febricula. — Such means as emetics, purga- 
 tives, tepid sponging, diaphoretics, and antiphlogistic regimen 
 are to be employed. In plethoric individuals, where there is 
 much headache and flushing of the face, leeches to the tem- 
 ples may be expedient, but such remedies are not often 
 necessary (Morehead). 
 
 Fever and Ague. — See Ague. 
 
 Fever, Break Bone — See Dengue. 
 
 Fever, Cerebro-Spinal — See Cerebro - Spinal Menin- 
 gitis. 
 
 Fever, Dandy — See Dengue. 
 Fever, Enteric — See Enteric Fever. 
 
 Fever, Intermittent — See Ague. 
 
 Fever, Malignant Purpuric — See Cerebro-Spinal Men- 
 ingitis. 
 
 Fever, Puerperal — See Puerperal Fever. 
 Fever, Relapsing — See Relapsing Fever. 
 Fever, Remittent — See Remittent Fever. 
 
-GASTRITIS. 157 
 
 Fever, Rheumatic — See Rheumatism, Acute. 
 Fever, Typhoid — See Enteric Fever. 
 Fever, Typhus— See Typhus Fever. 
 Fever, Yellow — See Yellow Fever. 
 
 Gall-Bladder, Inflammation of. — Definition. — Inflam- 
 mation, generally catarrhal, but occasionally croupous or 
 diphtheritic, of the mucous membrane of the biliary pas- 
 sages. 
 
 Treatnient is similar to that of catarrh of the intestines, 
 and especially in the use of nitro-muriatic acid internally and 
 as baths. 
 
 Gall-Stones — See Colic, Biliary. 
 
 Gastritis. — Definition.— -Forms of inflammation tending to 
 exudations and destruction of parts, or condensations of tis- 
 sue, especially about the pyloric opening. 
 
 Treatment. — Emetics may be required in cases where the 
 stomach has been overloaded; and it is certain, from the 
 gases and fluids causing prominence over the stomach, that 
 it contains decomposing food. One scruple of ipecacuanha, 
 with one grain of tartrate of antimony, is tne safest and most 
 efficient emetic. When injurious matters have passed into 
 the bowels, causing flatulence and colicky pains, mild laxa- 
 tives may be required, such as rhubarb; or, compound infu- 
 sion or mixture of senna, or fluid magnesia, in small doses, 
 may be given every hour or two hours, followed by five or 
 ten grain doses of bicarbonate of soda. I n chronic or passive 
 congestion of the stomach, and in chronic gastritis, the ad- 
 vantage of nitrate of silver has been advocated by the late 
 Drs. James Johnson and Symonds, and more recently by 
 many other physicians. Argent. Nitrat.,gr. -J, Ex. Hyoscyam., 
 gr. ii. to gr. iv., made into a pill, may be continued every 
 night, the quantity of the nitrate being gradually increased 
 to two or three grains daily. It may not be continued, how- 
 ever, beyond six or eight weeks. Or Argent, nit. Crystal, 
 gr. ss. to gr. i, Aq. distilat., f 3 ss; may be taken at bedtime — 
 the stomach being empty— and repeated every night, or every 
 second, third, or fourth night, according to the severity of the 
 gastric symptoms. I have found Seller'smixture of Bismuth of 
 great advantage ;and alkalies combined with morphia. In cases 
 of acute gastritis, mercurial purgatives by calomel are of ser- 
 vice. Three to five grains may be given to an adult; followed 
 by a dose of castor-oil or the compound senna mixture of the 
 
158 GLANDERS GLOSSITIS. 
 
 pharmacopoeia. Where it is not desirable to act so search- 
 ingly on the small intestines, blue pill with compound colo- 
 cynth or rhubarb pill in equal parts (a a gr. ii.), combined 
 with one grain of ipecacuanha powder, is a mild and gentle 
 laxative. Iced water to drink in small quantities, or small 
 pieces of ice in the mouth, tends to allay thirst, and to ap- 
 pease pain; and the continuous use of hot water fomenta- 
 tions over the region of the stomach, as hot as the patient 
 can bear them, is of great benefit (Brinton). 
 
 Glanders. — Definition. — A specifie catarrhal inflamma- 
 tion of the nasal mucous membrane, produced by the conta- 
 gion of matter from a glandered horse, and intercommuni- 
 cated between men and horses. It is a febrile disease of a 
 malignant type, characterized by vascular injection of the 
 nasal mucous membrane, from which an aqueous, viscid, 
 glutinous, or purulent discharge proceeds. Chancre-like 
 sores are formed on the mucous surface of the mucous mem- 
 brane extending to the frontal sinus and neighboring mucous 
 surfaces. The lymphatic glands enlarge in the vicinity of 
 these mucous membranes. 
 
 Treatment. — All the remedies hitherto tried in acute glan- 
 ders have failed. The advent of typhoid symptoms has led 
 to the administration of quinia, valerian, serpentaria, am- 
 monia, and other stimulating medicines. In the more chronic 
 forms of the disease the recovery of the patient has appeared 
 to be owing to the excellence of his constitution; during the 
 natural elimination of the poison, to good ventilation, and to 
 generous diet, rather than to any effect produced either by 
 general or local treatment. 
 
 Preventive Treatment. — The prophylactic treatment is the 
 same as that of all other contagious diseases — namely, being 
 careful to avoid all contact with the morbid poison, espec- 
 ially when a finger or other part of the hand is abraded; and 
 if by accident the veterinary surgeon should inoculate him- 
 self, he ought instantly to destroy the part withpotassa fusa. 
 It has been recommended, after the disease has been set up, 
 to extirpate the enlarged glands; but this practice is as un- 
 warrantable as hopeless. 
 
 German Measles — See Measles, German. 
 Glossitis. — Definition — Inflammation of the tongue. 
 Treatment. — Active cathartics are generally of great service, 
 
GOITRE. *59 
 
 and they are to be given as enemata. Blood must be taken 
 directly from the tongue in such cases. Incisions along the 
 superior surface of the inflamed organ, followed by the action 
 of the vapor of hot water, may reduce the swelling and re- 
 lieve congestion. The relief afforded by these measures is 
 frequently almost instantaneous. Two or three applications 
 of six leeches at a time to the inflamed parts may produce a 
 speedy decrease of the tumor (Graves). If suffocation is 
 imminent tracheotomy or laryngotomy must be performed. 
 Erythematous inflammation of the tongue with generally 
 yield to a combination of bismuth in glycerine, such as bis- 
 muthi subnitratis, gr. xx,; glycerini, § i,; aquae, § vii. Of 
 these make a lotion with which to wash the mouth and 
 tongue. 
 
 Morbid sensibility of the tongue may be soothed by a weak 
 solution of bromide of potassium, 3 ss. 3 i. to § vi. of water, 
 used as a mouth-wash (Symonds.) 
 
 Goitre. — Definition. — An enlargement of the thyroid 
 gland, by some regarded as specific, and induced by the per- 
 sistent use of water which has percolated through magnesian 
 limestone rocks, or strata containing the soluble salts of 
 lime in solution; or it is regarded as a circulatory disease, 
 the two-fold blood and nerve supply of the thyioid gland 
 being favorable to its enlargement under conditions of ex- 
 cessive and constant muscular exertion. 
 
 Treatment. — The indications are — (i.) To remove from 
 the district where the disease prevails : (2.) improvement of 
 the water used as drink ; (3.) elimination of the goitrous 
 poison, or change of constitution. As with the poison of 
 mercury and of lead, so with goitre, iodide of potassium has 
 a wonderful effect in subduing the swelling, and probably in 
 eliminating the poison which produces goitre, whatever that 
 may be. Iodine has thus acquired the reputation of being 
 almost a specific against goitre (Coindet, Straub, Gairdner, 
 Manson, Lugol). In robust subjects it has been advised 
 that the administration of iodine should be preceded by 
 general blood-letting, on the principle that the abstraction of 
 blood favors absorption ; but this should not be done unless 
 the iodine does not seem to be producing any effect ; and 
 whatever may be the preparation of iodine employed, it must 
 be persevered in for a length of time, and the dose gradually 
 increased (Dunglison). The best form of administration is 
 that in which the iodine is mixed with and dissolved by 
 
l6o GOITRE. 
 
 iodide of potassium. It is then held in solution, and is 
 sometimes known as Lugol's solution. It is made by dis- 
 solving one part of iodine (five grains) with two parts of 
 iodide of potassium (ten grains), and adding water (to the 
 extent of one pint). It contains one grain of iodine in four 
 ounces of the solution. The treatment ought not to com- 
 mence with a larger dose than one drachm three times a day. 
 Small unirritating or alterative doses are the most efficient, 
 and they may be gradually increased when necessary. The 
 remedy may also be employed externally, in the form of a 
 liniment or ointment — the unguentum iodum compositum, of 
 which a small portion may be rubbed upon the swelling night 
 and morning. In some parts of India the application of an 
 ointment of the biniodide of mercury has been found effica- 
 cious. The ointment is prepared by adding finely- 
 powdered biniodide of mercury to melted lard or mutton 
 suet or vaseline (in the proportion of 15 grs. of biniodide 
 of mercury to 1 ounce of lard. This ointment is then 
 applied to the goitre about an hour after sunrise, and is 
 rubbed in, by means of an ivory spatula, for about ten min- 
 utes — the patient sitting with his goitre held well up to the 
 rays of the sun as long as he can bear the exposure. The 
 ointment may produce a blistering effect, although no vesi- 
 cles appear on the skin ; and in the course of the day it 
 should be gently rubbed in again, and the patient sent home, 
 with orders not to touch it with his hands, but to allow the 
 ointment to be gradually absorbed. A second application is 
 sometimes necessary in very bad cases. In 1855 no less than 
 500 or 600 persons were sometimes treated in a single day ; 
 and it is estimated that altogether about 60,000 patients have 
 been so treated ; so that the cases in the district are now far 
 less numerous than formerly, and the disorder is thus being 
 extinguished (Mouat, in Indian Annals for April, 1857). 
 When medical treatment fails, surgeons have attempted to 
 give relief by one of three operations ; but so long as the 
 disease does not interfere with any of the important func- 
 tions of the body, nor produce serious discomfort, surgical 
 interference is not warrantable. These operations are, — (1.) 
 The introduction of setons through the tissue of the diseased 
 gland — an operation which has been successful. A thin 
 double wire is to be passed through the gland, and left there 
 for a week (Quadri, Tanner, James). (2.) Tying the thyroid 
 arteries which supply the goitre with blood, and so starving 
 the tumor, has been attended with varied success (Coates, 
 
GOITRE GONORRHCEAL RHEUMATISM. l6l 
 
 Brodie, Earle, Wickham). These means having failed (3.) 
 the gland has been extirpated — an operation which few sur- 
 geons would now think of undertaking. 
 
 Regarding these surgical interferences for the radical cure 
 of goitre, Sir Thomas Watson observes, that " there is not 
 one of which the average results have been sufficiently pros- 
 perous to warrant its repetition, except in cases where life is 
 put in jeopardy, or made miserable by the swelling; and where 
 other methods, and particularly the treatment by iodine, 
 have been tried and have failed " (" Principles and Practice 
 of Physic," Vol, L, p. 795). He makes, however, an excep- 
 tion in favor of puncturing any cell or cyst containing fluid, 
 which sometimes makes up a considerable portion of the 
 tumor. Such cysts may be punctured without much risk, 
 and with great relief to the patient. 
 
 Goitre, Exopthalmic. — Definition. — Enlargement with 
 vascular turgescence of the thyroid gland, accompanied by 
 protrusion of the eye-balls, anaunia, and palpitation. 
 
 Treatment. — The use of iron and tonics generally are in- 
 dicated; and the use of digitalis may be indicated in con- 
 nection with the cardiac symptoms. The indications for 
 treatment are, to allay the irritability of the stomach by the 
 use of ice ; to give bland, unstimulating, nutritious food in 
 small quantities and at short intervals; to produce sound and 
 refreshing sleep by morphia, or any such stimulating sopori- 
 fic; to administer digitalis; to steady the weak heart and con- 
 trol its excitement. Iron may improve the state of the 
 blood; but the hygienic conditions in which the patient lives 
 are mainly to be rectified (Fletcher). [The most important 
 and successful method of treatment however is the applica- 
 tion of the galvanic current so as to affect the cervical gan- 
 glia of the sympathetic] 
 
 Gonorrheal Rheumatism. — Definition. — An affection 
 analogous to acute rheumatism, associated with gonorrhoea. 
 
 Treatment. — The condition of the digestive organs gener- 
 ally requires attention and correction. Anodyne fomentation 
 generally affords relief to the pains of the joints. Dover's 
 powder is to be given in the acute stage at intervals; and 
 after the more acute symptoms have been subdued, the 
 greatest benefit is obtained from blisters, repeated several 
 times, when effusion within the capsule of the joint is a 
 prominent symptom. An electuary of guaiacum, sulphur, 
 II 
 
1 62 GOUT, ACUTE. 
 
 and cream of tartar (in equal proportion) in glycerine I have 
 found of use. Vapor baths and Turkish baths are both of 
 great service. The gonorrhoea must be cured as soon as 
 possible by the usual remedies. 
 
 The preparations of iron, iodine, quinine, combined with 
 ammonia, potass, or soda, in bitter vegetable infusions, ac- 
 cording to the nature of the urinary symptoms, are the best 
 tonic remedies, together with fresh air and good diet. 
 Iodide of potassium ought to be used in the chronic form 
 of the disease. Pressure over the joint by strips of adhesive 
 plaster, aided with bandaging from the toes upwards, is often 
 of great service in subduing the swelling which remains, 
 after all other symptoms have subsided. Passive motion 
 must afterwards be used. 
 
 Gout, Acute. — Definition. — A specific febrile disorder, 
 characterized by non-suppurative inflammation, with con- 
 siderable redness of certain joints, — chiefly of the hands and 
 feet, and (especially in the first attack) of the great toe; at- 
 tended by excess of uric acid in the blood, and probably 
 also of phosphoric acid. The constitutional affection tends 
 to culminate, at longer or shorter intervals, in a paroxysm, 
 or " fit of the gout," when various joints, textures, or parts 
 of the body are apt to become affected. 
 
 Treatment. — Seeing that the disease is clearly of constitu- 
 tional origin, its treatment resolves itself into — (i.) The 
 selection and administration of those remedies which shall 
 tend to subdue, control, or eradicate the latent disposition, 
 constitutional tendency, or gouty diathesis; (2.) The adop- 
 tion of such means as may be safely used to modify the 
 severity of or shorten the paroxysms. The paroxysm must 
 be interfered with cautiously. It is the means which 
 nature takes to rid the constitution of the materies morbi, 
 and which it undoubtedly relieves for a time, if allowed to 
 run its course. But the removal of the paroxysm, or its 
 subsidence, does not necessarily remove the constitutional 
 diathesis. That must be modified by promoting the trans- 
 formation of the tissues of the body as much as possible in 
 a healthy way. As to any local treatment during the fit, 
 Sydenham writes, " If outward applications be required to 
 ease the pain of the gout, I know of none, though I have 
 tried abundance both on myself and others, and I have laid 
 aside the use of topical remedies for many years." It is 
 generally admitted that cold is dangerous, while warmth is 
 
GOUT, ACUTE . 163 
 
 productive of little relief. In some instances the urate of 
 soda is deposited in such quantity that the skin ulcerates, 
 and the salt is discharged in considerable abundance in a 
 fluid state. It might appear the right practice to apply a 
 poultice and encourage the discharge, in order that, by its 
 entire removal, the joint might be saved. This, however, is 
 by some considered dangerous practice, for the discharge is 
 so debilitating that patients are said to have sunk under this 
 mode of treatment. It is much safer to wait till the chalk- 
 stone becomes concrete, and then operate, by the smallest 
 possible incision, for its removal. With respect to the use 
 of cold water, the practice is as old as Harvey, and subse- 
 quently it has been adopted and abandoned by many prac- 
 titioners. Dr. Parry had at one time two patients who at- 
 tempted to cut short the fit by plunging their feet in cold 
 water. The relief was instant, but in a few hours both were 
 dead of apoplexy. The fatal result of this remedy in Sir 
 Francis Burdett's case is another instance in point. " A gen- 
 tleman," writes 'Dr. Wood, " contrary to the advice of his 
 physician, and anxious for speedy relief, ordered a bucket 
 of water to be taken into his chamber at bedtime, with the 
 view of employing it in this way. In the morning he was 
 found dead in bed." 
 
 Antiphlogistics neither alleviate the pain of gouty inflam- 
 mation nor shorten the attack ; while their untimely use, es- 
 pecially general and local bleeding and active saline purges, 
 favors the passage of acute into chronic gout. Rest is ab- 
 solutely necessary. Warm anodyne lotions or fomentations 
 may be used, and the part afterwards lightly covered or en- 
 cased in flannel or fine wool, while the limb is at the same 
 time kept elevated. The " bootikins" of Horace Walpole, 
 so strongly recommended and given away by him to all his 
 gouty friends, seem to have been merely a fine bandage of 
 flannel, applied moist and firmly over the limb, and then a 
 roller of oiled silk over it, giving moist warmth like a poul- 
 tice. Writing to Horace Mann, he says, — " You must put 
 them on at night, and tie them as tight as you can bear — the 
 flannel next to your flesh, the oil silk over. In the morning, 
 before you rise, you must dry your feet with a hot napkin, 
 and put on a pair of warm stockings freshly aired. Over the 
 bootikins at night draw a pair of thread stockings" (" Life 
 and Letters, Vol. VII., p. 224). Dr. Wood uses a warm 
 mixture of tincture of camphor with milk, applied by means 
 of linen compresses, and frequently renewed. Tincture of 
 
164 GOUT, ACUTE. 
 
 aconite may be similarly applied (f § iss. to f § iv. of milk). 
 The hypodermic injection of a fourth to a third of a grain 
 of muriate or bimeconate of morphia, in any convenient part 
 of the body, often relieves trie local pain. Blisters have been 
 recommended, and are of most advantage in asthenic chronic 
 cases, when the inflammation has a tendency to linger in the 
 articulations, and to cause liquid effusion. In the early fits 
 of sthenic gout they are unnecessary ; and are contraindi- 
 cated in advanced gout, when the kidneys have become im- 
 paired, and also in cases of extreme gouty deposits (Garrod). 
 As a general rule, however, the less that is done to the local 
 affection the better. When the pain is very intense, relief 
 may be given by the application of a solution of atropine, 
 made by dissolving from two to three grains of the alkaloid 
 in a weak mixture of spirits and water, and applying it to the 
 inflamed joint by means of compresses of lint, preventing 
 evaporation by a covering of oil silk (Garrod). 
 
 In the general treatment of gout bleeding is now generally 
 restricted to two methods, namely — (1.) By leeches to the 
 part where the inflammation rises so high, or is so chronic, 
 as to threaten the patient with the permanent loss of the use 
 of some joint ; and to cases of metastasis of the disease to 
 the stomach or other internal organ, when leeches are abso- 
 lutely necessary ; (2.) By general blood-letting. The fol- 
 lowing rules are laid down by Dr. Garrod as to the use of 
 bleeding in gouty cases : — (1.) Never bleed with the idea of 
 directly subduing gouty inflammation ; (2) Never bleed in 
 advanced gout, or when the constitution is much weakened; 
 (3.) If bleeding be required in order to relieve general or 
 local plethora, abstract only as much as will effect that ob- 
 ject, remembering that further depletion tends greatly to ag- 
 gravate the disease and prolong its duration. Blood-letting 
 produces a decided sedative action on the heart and other 
 parts of the circulating system, and it has a most powerful 
 influence upon the progress of gouty inflammation — an influ- 
 ence not merely limited to the removal of gout when it at- 
 tacks the joints, but also of great efficacy in its marked and 
 irregular forms, in the ophthalmia of gouty habits, in gouty 
 bronchitis, and in headaches connected with the gouty dia- 
 thesis (Sir H. Holland, Garrod). 
 
 With regard to purgatives, Sydenham, who was as great 
 an enemy to purging as he was to bleeding, says, — " I am 
 abundantly convinced, from much experience, that purging, 
 either with mild or strong cathartics, whether used during 
 
60UT, ACUTfi. 165 
 
 the fit or in its declension, or in a perfect intermission or 
 healthy state, . . . endangers the life of a patient by- 
 hurrying on the disease to the viscera, which were quite safe 
 before." The objection taken by Sydenham to purgatives 
 was quite valid against those in use in his day, which were 
 of the most drastic kind ; but it may be laid down as a rule 
 that neutral salts are not only safe but efficient in relieving 
 gout, though perhaps not to be depended on alone for its 
 cure. The theory on which they are prescribed is, that the 
 alkaline base of the neutral salt is absorbed, and combines 
 with the insoluble urates deposited in the joints, forming a 
 soluble sub-urate, which can readily be absorbed ; and, 
 again, more alkali being sent to the kidney, that organ is en- 
 abled to remove more uric acid, in a soluble state, from 
 the system than under ordinary circumstances. The salts 
 most in use are the sulphates of magnesia or of soda, and 
 especially the former ; and half a drachm to a drachm should 
 be given every eight, six, or four hours, according to the 
 state of the bowels and the acuteness of the symptoms. It is 
 also necessary to afford some relief to the patient from his 
 excessive suffering. With that view an anodyne should be 
 added, such as the tincture of hyoscyamus, syrup of poppies, 
 or some preparation of opium. This method of treatment 
 relieves the patient and shortens the paroxysm ; but when 
 the relief is complete, it should be abandoned, for sometimes 
 a paroxysm of gout will return even under its use. Colchi- 
 cum, or meadow-saffron, was long ago introduced as a spe- 
 cific in gout, of which the once popular " eau medecinale " 
 was supposed to be a preparation. Colchium in some cases 
 seems to be almost specific in its effects, and may be given 
 as an extract or tincture, or as a wine, combined with some 
 form or saline draught. Its mode of action is unknown. It 
 very generally promotes secretion from the skin and kidneys; 
 but it is useful even when it does not exercise any such 
 physiological action. The quantity of uric acid and urea in 
 the urine is said by some to be increased during its use 
 (Chelius). Dr. Graves makes an opposite statement ; and 
 Dr. Garrod proves conclusively that colchicum does not in- 
 crease the amount of uric acid. Dr. Laycock suggests that 
 it may have a sedative effect on the vital actions going on 
 in the tissues themselves, and so may arrest the formation of 
 the gout poison. The wine of the root of colchicum is gen- 
 erally the form preferred, ten to fifteen or to thirty minims 
 being given every four, six, or eight hours, and this remedy 
 
l66 GOUT, ACUTE. 
 
 ought to be continued for some time in reduced doses, after 
 all symptoms of gout have disappeared (Budd). The bowels 
 ought to have been freely moved before colchicum is given ; 
 and a full dose having been given at first, much smaller 
 doses may be continued, as from ten to twenty minims two 
 or three times a day, in Seltzer or Vichy water, or in other 
 alkaline solutions, such as bicarbonate of potash much di- 
 luted, or combined with iodide of potassium, carefully 
 watching its effects on the pulse, and never allowing sick- 
 ness or depression to ensue. It may also be given with car- 
 bonate of lithia. Scudamore's mixture of colchicum, mag- 
 nesia and sulphate of magnesia, is said to be an excellent 
 purgative in gout when a purgative is required. Although 
 Dr. Garrod has shown that purging is not necessary to the 
 action of colchicum, yet, there are many who believe that 
 the action of colchicum is promoted by its combination with 
 laxative remedies. Abernethy was wont to prescribe, — 
 
 ]J Sodae phosphatis ; Sodae sulphatis — aa 3 iv. ; Ammo- 
 nias sesqui Carb., 3 ss. ; Acid benzoici, gr. xx. ; Vin. sem. 
 Colchici, 3 iss ; Infus. Calumbae, ad § viii., of which a sixth 
 part is to be taken every four or six hours. 
 
 Dr. Wood is in the habit of using it in the following for- 
 mula in a draught : — 
 
 r^ Magnesiae, J ss. ; Magnes. Sulphat., § ss. ; Vin. Col- 
 chici. rad., m xx. ; Aquae Fluv. vel Aq. Acid Carbon., f J iss. 
 
 Mercury in the form of " blue pill," or in the form of the 
 " compound calomel pill " (Pil. Plummeri), followed by the 
 draught just written, is useful where it is desired to act upon 
 the intestinal secretions. But mercury in any form must not 
 be given if the urine contains albumen. If mere constipa- 
 tion is to be got rid of, rhubarb pill, colocynth and scam- 
 mony pill, or podophyllin, may be advantageously used. 
 The iodide of potassium has been much recommended by 
 Mr. Spencer Wells. Alkaline remedies are of much value 
 in the treatment of the paroxysms of the joint affection, and 
 may be prescribed in the form of the bicarbonate, or of the 
 citrate or acetate of potash. Dr. Garrod prefers the bicar- 
 bonate, and Dr. Parkes has shown that it increases the elimi- 
 nation of uric acid and organic solids by the urine (Parkes 
 on the Urine, p. 298). Much benefit is also derived from 
 the continuous administration of salines in small doses, re- 
 peated two or three times a day, in a very dilute form, and 
 always on an empty or nearly empty stomach, and some lit- 
 tle while before food (Garrod). If acute gout should have 
 
GOUT, CHRONIC. 167 
 
 11 retroceded," as it is called, and the stomach or intestinal 
 canal be inflamed, leeches should be applied to the abdo- 
 men or epigastrium, followed by a poultice, while the neutral 
 salts, with the tincture of hyoscyamus, should be given at 
 least every four or six hours. It is very rare that more act- 
 ive medicines are necessary. 
 
 For further indications regarding the management of gout, 
 see treatment of the next subject — namely, chronic gout. 
 
 Gout, Chronic. — Definition. — A persistent constitutional 
 affection, characterized by stiffness and swelling of various 
 joints, with deposits of urate of soda. 
 
 Treatment. — In chronic gout the treatment is the same as 
 in acute gout ; but, as next to hereditary predisposition, a 
 disproportion between the amount of food and drink taken 
 and the necessity for it, is a great cause of the disease, means 
 ought to be taken to regulate the diet and promote healthy 
 metamorphosis of tissue during intervals of freedom from 
 gouty paroxysms. The habits of the patient ought to be 
 regulated by written rules for him to abide by, if he would 
 be free from gout. The form, the quantity, and the quality 
 of the food ought to be precisely prescribed. Most gouty 
 patients eat too much. Vegetables, with soups and meat, 
 must be allowed only once a day — not oftener. Beer, wine, 
 and alcoholic fluids generally are injurious, and must be for- 
 bidden to gouty patients, as they retard the metamorphosis 
 of tissue. The same is true of tea and coffee. Water, pure 
 water only, taken in quantities as large as possible, promotes 
 the metamorphosis of tissue to a greater extent than any 
 remedies we know of. The drinking of a certain extra quan- 
 tity of water is essential for the maintenance of health in 
 gouty patients. It ought to be taken in the early morning — 
 to the extent of half a pint while dressing in the morning — 
 and before any solid food is taken. Its use does not lessen 
 appetite lor food -as is the case with beer, wine, spirits, tea, 
 and coffee. It promotes the flow of fluid by the kidneys, 
 and increases the excretion oi' urea. Combined with muscu- 
 lar exercise, the use of pure water hastens, to the greatest 
 possible extent, the transformation of tissue ; and combined 
 with the use o( certain mineral waters and baths, a connect- 
 ing link is established between the dietetic and medicinal 
 treatment of gout. Whenever an excess of lithic acid or of 
 lithates is seen in the urine, some alkaline water should be 
 taken in the morning, instead of plain water ; and enough 
 should be taken to render the urine clear and free from de- 
 
i68 
 
 posit. But strong alkaline waters are not to be prescribed 
 in large quantities, else too great depression and a tendency 
 to impair the digestive power of the stomach will be the re- 
 sult. In moderation, the milder alkaline waters taken as a 
 morning draught are of value. The mineral springs which 
 exercise the most favorable influence on the gouty constitu- 
 tion are those of Aix in Savoy, Bath, and Buxton, Ems, Gas- 
 tien, Homburg, Karlsbad, Kissengen, Marienbad, Neuenahr, 
 Pfaffers, Schwalbach, Pyrmont, Spa, Toplitz, Wiesbaden, 
 Wilbad, and Vichy. Dr. Garrod lays down the following 
 general rules as a guide to the use of them : — (i.) Their use 
 should be prohibited when there is much structural disease 
 in any important organ, especially in the heart or kidneys ; 
 and even when organic mischief is slight, the greatest caution 
 in their use is necessary. (2.) They are to be avoided when 
 an acute attack is either present or threatening. (3.) The 
 particular mineral water must be selected according to the 
 nature of the individual case ; for the robust, and those of 
 full habit, the alkaline saline springs should be chosen ; when 
 torpidity of the bowels predominates, the purgative waters 
 may be used ; when the skin is inactive the sulphur spiings 
 should be used, and when much debility prevails, or an atonic 
 state exists, then the more simple thermal springs may be 
 prescribed. 
 
 These waters contain either alkaline carbonates, chlorides, 
 or sulphates. Some are impregnated with sulphurated hy- 
 drogen, and others contain iron ; many, like Wiesbaden, 
 Karlsbad, and some of the Vichy springs — Wildbad and 
 Neuenahr — are of an elevated temperature. 
 
 The beneficial influence of these natural mineral waters is 
 especially perceptible in the reduction of plethora by the al- 
 kaline springs, and in the regulation of the functions of the 
 bowels and skin. The springs of Vichy are all rich in car- 
 bonate or bicarbonate of soda — about forty grains to the 
 pint. Some have a temperature of 101 Fahr. In moderate 
 doses they cause the urine to become alkaline or neutral ; 
 and used as baths, they have a similar effect. They influ- 
 ence especially the functions of the liver and the skin, and 
 are more adapted for the robust and persons of full habit of 
 body ; but if the system is enfeebled by frequent attacks of 
 gout, or if there is a tendency to the formation of chalk con- 
 cretions, the waters of Vichy are not to be recommended. 
 The waters of Wiesbaden contain a large amount of chloride 
 of sodium, and are as high in temperature as 160 Fah_. 
 
GOUT, CHRONIC. l6d 
 
 They are more highly stimulating and more generally debili- 
 tating than those of Vichy, and are of service in those cases 
 where the circulation is slow and the secretions deficient. 
 The springs of Neuenahr range in temperature from 90.5 ° to 
 104 Fahr., and contain nearly 50 per cent., by volume, of 
 free carbonic acid, with a considerable quantity of soda salts, 
 chiefly as carbonates. They stimulate the circulation, aug- 
 ment the excretions from the kidneys and the skin, increase 
 the appetite, and diminish stomachal acidity. They are un- 
 suitable for plethoric habits and where the liver is enlarged ; 
 but where the constitution is impaired or enfeebled, they are 
 of great service. The waters of Wildbad, in the Black For- 
 est, have also a high temperature — 92 ° Fahr. — with much 
 free carbonic acid, holding salts of soda, and magnesia, and 
 iron in solution. They are alkaline, and their influence is 
 similar to the springs of Neuenahr. The waters of Aix are 
 slightly saline, and of a temperature as high as 135 Fahr., 
 containing chloride, carbonate, and sulphide of sodium, with 
 free sulphurated hydrogen. They stimulate the liver, kid- 
 neys, and skin, and are indicated where there may be slug- 
 gish action of these functions, and where the joints are stiff. 
 The Karlsbad waters are rich in sulphate of soda, with car- 
 bonate of soda and common salt. Their temperature is 
 about 167 Fahr. They are purgative, diuretic, and diapho- 
 retic, and are beneficial where there is constipation, with con- 
 gestion of the liver ; and are unsuited for feeble patients. 
 The waters of Baden-Baden contain common salt combined 
 with iron, and are also rich in lithia. Toplitz, Gastien, Bux- 
 ton, and Bath waters are also all somewhat elevated in tem- 
 perature, and are peculiarly adapted for the treatment of 
 gout in the infirm, feeble, and old patients. The chalybeate 
 waters of Spa and Pyrmont are most suitable for anaemic 
 patients and in the asthenic forms of chronic gout. The salts 
 of lithia, so abundant in the waters of Baden-Baden, were 
 originally proposed by Dr. Garrod as a remedy for gout. 
 They have since been extensively used, and found generally 
 beneficial. They abound also in the Karlsbad, Aix, Marien- 
 bad, and some of the Vichy waters. The salts of lithia are 
 actively diuretic, powerful solvents of uric acid, and generally 
 they tend to render the urine neutral. Taken for a length 
 of time in a dilute form, they tend to prevent paroxysms of 
 gout in chronic cases, and cause solution and absorption of 
 chalky matter. They certainly lessen the deposit of water 
 and uric acid in the urine ; and are of service both in the 
 
I?6 GOUT, CHRONIC. 
 
 acute and chronic forms of gout. The dose is from five to 
 ten grains of the carbonate of lithia, dissolved in aerated 
 water, three or four times a day ; of the citrate, eight, ten, or 
 more grains may be given (Garrod, Flint, Clymer). Iodide 
 of potassium is a remedy of very great value, especially in 
 cases where " the pains are increased at night ;" but the 
 bromide of potassium is still more useful. It seems more 
 highly anodyne and soothing. The iodide of potassium is 
 useful in removing the recent thickening in the tissues round 
 joints ; and of gouty inflammation, when fluid is effused into 
 the cavities of joints, and is slow of absorption. Guaiacum 
 is especially useful in the asthenic gout of old subjects, and 
 to younger patients also it is beneficial. A combination of 
 quinine, iron, and arsenic is often of special service, in very 
 minute doses, in the form of chlorides ; and it is advatageous 
 to unite small doses of colchicum with the quinine. 
 
 The patient generally receives some warning by which he 
 may try and ward off the gouty seizure. When such warn- 
 ings are recognized a combination of quinine, colchicum, and 
 colocynth, taken twice or three times a day, is an excellent 
 medicine. The pills of Becquerel are also recommended by 
 Trousseau. They consist of : — 
 
 ]J. Quinine Sulphatis, gr. xx. ; Ext. Digitalis, gr. iii. ; 
 Ext. sem. Colchici, ,gr. x. Divide into ten pills, of which two 
 or three may be taken daily for three or four days. 
 
 Laville's anti gout liquid and pills are French preparations, 
 and are so popularly known and so much esteemed by many 
 sufferers, who have used them with excellent effect, that they 
 challenge attention, although they are open to the objection 
 of being secret as to their composition, like chlorodyne, 
 James' powder, and Warburg's drops. According to Dr. 
 Tanner, " from an analysis, the liquid contains the ar tive 
 principle of colocynth, quinine and chinchonine, with unim- 
 portant salts of lime. It is used at any period of the attack ; 
 a teaspoonful being taken in sweetened water or tea, and re- 
 peated in six hours, if the pain continue and the bowels be 
 not moved. Twenty-four hours are to elapse before the next 
 dose, when half the quantity is to be taken two or three times 
 daily, unless the bowels are irritable. The pills consist cf 
 physalin mixed up with silicate of soda and powdered cham- 
 sedrys." One is taken just before a meal, for several weeks. 
 In the chronic forms of the disorder, where there is no or- 
 ganic disease of the brain, heart, or lungs, wet-packing, and 
 the Turkish bath, cautiously and occasionally used, but not 
 
GOUT, CHRONIC. 171 
 
 during a paroxysm, under the immediate supervision of the 
 attending physician, would sometimes seem to be of service, 
 in lessening stiffness of the joints and restoring or improving 
 the action of the skin (Clymer.) Trousseau speaks well of the 
 wet-packing. Hot salt-water baths are also beneficial. The 
 inhalation of oxygen when followed by clear urine, has also 
 given great relief, and in some cases cures have resulted. 
 
 In atonic gout some light tonic medicine may be given, as 
 five to ten grains of the citrate of iron. A large number of 
 chronic cases, however, though the general health is im- 
 proved by this treatment, are often altogether unrelieved as 
 to the local symptoms, and are often quite unable to assist 
 themselves. In these instances the terebinthine remedies ap- 
 pear to be beneficial, as spruce beer, and Canadian balsam ; 
 or, one drachm of the oil of turpentine may be taken in an 
 effervescing draught once or twice a day. Sydenham's 
 method of treatment by manna may also be used. He re- 
 commends, from experience in his own case, large doses of 
 manna in all cases of what he terms " bloody urine." If the 
 chronic or atonic gout should become retrocedent, and the 
 stomach and intestinal canal be the seat of the spasmodic 
 form of the disease, Sydenham strongly recommends that 
 laudanum should be given ; but perhaps the following draught 
 is more efficacious, namely — 
 
 $. Aquae Camphorae, 3 x. ; Sp. yEtheris Sulphurici, 3 i. ; 
 Sulphatis Magnesiae, 3 ss. 
 
 It will remove from the stomach any undigested matter 
 which may remain as an irritating cause. This should be 
 given every hour till the patient is relieved ; and while it is 
 being prepared, hot brandy and water should be freely ad- 
 ministered, or the spiritus ammoniae aromaticus, in doses of 
 sixty minims, and hot cloths applied to the abdomen, as well 
 as hot bottles to the feet. 
 
 As indiscriminate feeding appears to have a great influence 
 in the production of gout, so we expect the regulation of 
 diet should have great influence in its removal. During the 
 fit the diet should consist of slops and light puddings, and 
 afterwards white fish, till the paroxysm has terminated. 
 Chronic gout is so distressing that many persons are inclined 
 to diet themselves with great strictness during the interval. 
 Sydenham says that a milk diet, or drinking milk as it comes 
 from the cow, or boiled, without adding anything to it, except 
 perhaps a piece of bread, once a day, had been much used for 
 twenty years past in his time, and had done much service to 
 
172 GOUT, CHRONIC. 
 
 gouty patients. But on quitting it, and returning to the mild- 
 est and tenderest diet of other persons, gout has immediately 
 revived; and he adds, that many cannot bear this regimen. 
 An entirely water regimen he considers hurtful. The most 
 digestible meats, such as mutton, well-kept beef and poultry, 
 with the white kinds of fish, as cod-fish, sole, and whiting, 
 may be eaten; but salmon, veal, and pork are to be avoided, 
 as well as cheese, salads, highly seasoned dishes, and rich 
 sauces, or other " elaborate preparations on the part of the 
 cook." The use of alcoholic stimulants requires great cau- 
 tion. For those who inherit the gouty constitution, total ab- 
 stinence should be made a rule absolute in youth; and for 
 all others, unless some obvious necessity arises for their use 
 and prescription by the physician, when the nature and 
 quantity of the stimulant must be definitely stated, and meas- 
 ured out as any other medicine would be. If alcohol in any 
 form is required, it may be taken as weak brandy, gin, or 
 whisky* and water, or pure dry sherry, like Amontilado or 
 Manzanilla. Port, Burgundy, and sweet wines must be 
 avoided; but wines of the Rhine vintages may be taken, if 
 they do not contain a large percentage of alcohol. The 
 wine should be of the highest quality, and fully matured and 
 mellowed. Really good wines are generally used to advan- 
 tage, and the vegetable extractions of the pure, mature, and 
 mellowed wines are easy of digestion by the gouty stomach. 
 The best spirit is whisky, which should also be very old, soft 
 and mellow, and free from the smoky flavor. All of these 
 spirits ought to be taken much diluted with water. The pa- 
 tient should go early to bed, keep the mind free from all dis- 
 quietude, live with the greatest moderation, clothe himself 
 warmly, and ride on horseback. When exercise cannot be 
 taken, friction over the surface of the body is exceedingly 
 useful. He should be rubbed down with a flesh-brush once 
 or twice a day, just as a horse is groomed. Turkish baths 
 taken regularly once a week, or as often as may be indicated 
 by the medical attendant, are most beneficial. The custom 
 of going to bed for an hour or two immediately after the bath 
 — as in Germany — adds greatly to the good obtained from 
 the bath; the body being covered and completely at rest, the 
 nervous system is tranquillized, and the skin acts freely. But 
 much harm may be done by excessive limitation of the sup- 
 ply of nourishment, as well as by the sudden and complete 
 abstraction of spirituous fluids that had been used for years; 
 as well as by other debilitating courses of treatment set about 
 
GRAVES* DISEASE. 173 
 
 too hastily and pursued too vigorously. If the patient is 
 cachectic, debilitating treatment will make him worse. 
 " There should be a due admixture of animal and vegetable 
 food; it is an error to suppose that an animal diet tends more 
 to the formation of uric acid than a vegetable one. The tor- 
 toise, feeding on a simple lettuce, excretes a large quantity 
 of urate of ammonia, far more in proportion to the weight of 
 the animal than is excreted by the dog exclusively nourished 
 with meat. Vegetables, as potatoes, greens, and the like, 
 may be partaken of with advantage; the soluble salts they 
 contain are of value in keeping up the activity of the secre- 
 ting organs. The same remarks bold good with regard to 
 soft fruits when eaten in moderation, as strawberries, grapes, 
 and oranges; also other fruits whet) stewed or baked, as ap- 
 ples and pears; but these latter, as iikewise plums, and stone- 
 fruit in general, should be avoided in a raw state. Extreme 
 moderation should be exercised when saccharine fruits are 
 eaten, as sugar is liable in many subjects to lead to the pro- 
 duction of acidity. The same precaution is necessary in 
 reference to the addition of sugar to other articles of diet." 
 (Dr. Garrod). "Gouty folks should be very moderate in all 
 their food — not, however, too abstemious, for such patients 
 are seldom really vigorous, or able to dispense with a nutri- 
 tious diet. Moderation should be observed, particularly in 
 respect to the use of stimulants; and each patient must 
 select for himself, or be advised to take what suits him 
 best. There is a prevalent opinion that spirits are better 
 than wines; but this is doubtful. The chief point is, that 
 whatever stimulant is taken it should be used in the most 
 strict moderation." (Sir James Paget). 
 
 One other point with regard to the treatment of the patient 
 during the fit is, that if it be necessary to move him, either 
 on account of his restlessness or other cause, this should be 
 done with great care and tenderness by the attendants; for 
 although the pain may be latent while the parts are quiet, 
 yet the least shock often causes the most excruciating agony. 
 The irritable state of mind of the patient during the parox- 
 ysm has been mentioned; and it is well known that slight 
 moral causes will often produce a fit, while powerful emo- 
 tions have sometimes cured one. It is quite essential, there- 
 fore, that the minds of gouty patients should be kept as tran- 
 quil as possible, both for their own sakes as well as for the 
 comfort of those who minister to their needs. 
 
 Graves' Disease— See Goitre, Exophthalmic, 
 
174 GREEN-SICKNESS HAEMATEMESIS. 
 
 Or een- Sickness — See Chlorosis. 
 
 Haematemesis. — Definition. — A discharge of blood 
 from the stomach. 
 
 Treatment of the acute forms of haematemesis is similar 
 in many respects to that of haemoptysis. The great volume 
 of the arteries of the stomach, and their origin almost im- 
 mediately from the aorta by means of the cceliac artery, are 
 reasons which have been alleged for this affection being but 
 little influenced by general or local bleedings. The vast 
 amount of blood sometimes lost by haematemesis renders it 
 necessary to support the patient by acid wines much sooner 
 and to a much greater extent than in haemoptysis. In 
 melaena the only chance for the patient is a liberal support 
 by wine diet and medicines, and by opiates to quiet the 
 stomach. In cases of haematemesis from cirrhosis, or other 
 obstruction to the circulation through the liver, and in the 
 vicarious* haematemesis of women, leeches to the anal region 
 or os uteri, are of service. The action of ice, by swallowing 
 small pieces from time to time, is very beneficial, covering 
 at the same time the epigastric region with ice-cold com- 
 presses, which require to be renewed frequently. Solutions 
 of dilute or aromatic sulphuric acid, in doses of ten to 
 twenty minims, or of alum, are of service. Alum may be 
 given in doses of eight to twelve grains, combined with 
 Battley's solution of opium, or with laudanum or sulphuric 
 acid. In chronic haematemesis, acid, gallici, gr. x. ; acid, 
 sulph. dil., m x.; aq. distil., f § i., has been recommended by 
 Dr. Brinton. Solution of pernitrate of iron, in doses of thirty 
 to forty minims, may be of use. Ergot may also be of service. 
 Tannin is of service, as one of the best astringents in the form of 
 a pill (O. Rees) — three to six grains twice or thrice a day. 
 The patient must maintain absolute rest in bed, and must 
 not rise to stool. Ipecacuanha in doses to produce nausea 
 is of service in arresting haemorrhage, and restoring heat to 
 patients in the collapse of haematemesis (Osborne, Trenor, 
 Graves), in doses of one to two grains every fifteen or 
 thirty minutes till nausea is felt, when the remedy is to be 
 discontinued, as vomiting is to be avoided. If stimulants 
 are required, iced champagne may be given ; and when the 
 vital powers are much depressed, ammon. hydrochlor., 3 iss.; 
 acid, hydrochlor., f 3ss.; decoct, hordei co., oz. i., may be 
 taken every second or third hour (Copland), in doses of two 
 Qr three teaspoonfuls. 
 
HiEMATINURIA, PAROXYSMAL HEADACHE. I 75 
 
 Haematinuria, Paroxysmal. — Definition. — A condition 
 in which the urine contains only the coloring matter of the 
 blood with albumen, but no blood-corpuscles nor fibrine, 
 coming on in sudden and irregular paroxysms. 
 
 Treatment. — Improvement has taken place under the use 
 of saccharated carbonate of iron and quinine in full doses. 
 
 Hematuria Renalis. — Definition. — Haemorrhages in 
 which blood is mixed with the urine, whether it proceeds 
 from the kidney, ureter, or bladder. 
 
 Treatment. — Tincture of the perchloride of iron is one of 
 the most useful of remedies, whether in debilitated patients 
 or in those suffering from Bright's disease, and whether the 
 blood comes from the kidneys or bladder. It is best given 
 in doses of m x. to xx., three or four times daily, in combin- 
 ation with glycerine; and if there be much cardiac difficulty, 
 with arterial excitement, it may be combined with digitalis, 
 as in the following prescription: — 
 
 I£. Tinct. ferri perchloridi, ra xxx.; Tinct. digitalis, m 
 xv.; Aq. menth. pip., f 3 iss., repeated every four hours. 
 
 Gallic acid, in combination with sulphuric acid, may also 
 also ipecacuanha, tannin, acetate of lead and 
 alum, and ergotine, as already referred to under Haemate- 
 mesis. Quinine and arsenic are remedies indicated in 
 malarious intermittent cases. Idiopathic haemorrhage often 
 readily yields to bitartrate of potash, or to the mineral acids. 
 Dr. Elliotson recommends, as also did John Hunter, the ol. 
 terebinthinae, in doses of m x., m xx., or m xxx., every two, 
 or three, or four hours. Injections of cold water or water 
 in which twenty to forty grains of alum have been dissolved) 
 into the bladder or up the rectum, and also a cold hip-bath, 
 are useful applications. Dry-cupping over the loins is also 
 indicated. 
 
 Haemorrhage, Cerebral or Spinal— See Apoplexy. 
 Headache. 
 
 Treatment. — v i) Of Sick-headache. — Looking to the true 
 cause of sick-headache as one which lies deep in the pa- 
 tient's idiosyncrasy, and as an affection which is developed 
 by a hundred different sources of excitement, the advice to 
 sufferers is to give as much tone as they can to their nerves 
 by adopting all those methods which experience has shown to 
 be good, and then avoid, as far as is practicable, all those causes 
 which are known to excite an attack. Purgation has no good 
 result. The only remedies which are of any avail are those 
 
176 HEADACHE. 
 
 which act on the nervous system, such as hot tea and coffee ; 
 or, after the stomach is quieter, and the more urgent symp- 
 toms have passed off, a little wine or ammonia. If the head- 
 ache take more the form of hemicrania, then other remedies 
 are occasionally useful, as the local application of the bisul- 
 phide of carbon, or galvanism, and internally the bromide of 
 potassium. This is the only drug which Dr. Wilks has really 
 seen to be serviceable. Whilst the nausea exists and the 
 worst symptoms prevail, even this remedy is of no avail. As 
 regards tea and coffee, which often relieve, it is possible that 
 these and other stimulants, taken in excess, render the ner- 
 vous system more susceptible to the attacks. 
 
 In the treatment of the paroxysm nothing is so efficacious 
 as complete rest in the recumbent posture, with warmth, in 
 a perfectly quiet and darkened room. A cup of very strong 
 tea or coffee has also given relief. A comparatively new 
 drug — guarana — has also been recommended. A full dose 
 of brandy, or of ammonia, has also sometimes dispelled the 
 headache ; so has continued sipping of a solution of carbon- 
 ate of potash or of soda. Pressure upon the carotid artery 
 of the affected side sometimes also relieves the pain, but for 
 a time only. Evaporating lotions, belladonna, or aconite 
 ointment may also ward off or subdue the headache ; but, as 
 a rule, time is the most" efficient element, with warmth to the 
 feet and to the body, and the induction of sleep. 
 
 Adopting the theory of Dr. Latham, what are the indica- 
 tions for treatment with which it supplies us — (a.) During 
 the stage of disturbed sensation ; (b.) during the stage of 
 headache ; and, (e) during the intervals between the attacks ? 
 The following are the results of his experience : — 
 
 (a.) During the Stage of Disturbed Sensation. — It is found 
 that the longer this stage lasts, the greater will be the head- 
 ache ; and therefore it is desirable to shorten it as much as 
 possible. If the condition depend upon deficient supply of 
 blood to a part, such means must be adopted as shall assist 
 and increase the flow of blood to the part ; and this can be 
 done in some measure by posture and stimulants. Directly 
 the glimmering appears, the patient should lie down with the 
 head as low as possible, and if the glimmering be on the right 
 or left of the field of vision, he should lie on the opposite 
 side. Let him take at once one ounce of brandy, either 
 " neat " or in half a bottle of soda-water. Champagne would 
 be preferable, being more diffusible ; but its administration 
 would often involve a little delay. If alcoholic stimulants 
 
HEADACHE. 177 
 
 be objected to, or if it be not advisable to recommend them, 
 then a teaspoonful of sal-volatile in water may be prescribed 
 instead. If the patient be chilly or his feet cold, the couch 
 should be drawn before the fire, a hot bottle applied to the 
 feet, and his body covered over with a warm blanket or eider 
 down quilt. By these means the heart is enabled to drive 
 the blood with greater force to the brain, and the duration of 
 the vibratory movement is thereby materially lessened. Af- 
 ter it has passed off, the patient should lie still for a time, so 
 that the glimmering may not return. This injunction will 
 only be necessary when the headache is slight; if it be severe, 
 attended with much nausea or vomiting, the patient will be 
 little disposed or able to leave the recumbent position. If, 
 instead of the disturbance of vision preceding the headache, 
 there be a feeling of depression or irritability (fidgets), the 
 administration of such cerebro-spinal stimulants as henbane, 
 valerian, assafcetida, spirit of chloroform, or ether, will often 
 cut short the attack; ten or fifteen drops of the tincture of 
 henbane, with the same quantity of spirit of chloroform, will 
 soothe the nervous irritability in the slighter forms, and may 
 be repeated in three or four hours, if necessary. If there be 
 great mental depression, then valerian or assafcetida should 
 be tried. Stille says, — "Nothing is more astonishing in the 
 operation of remedies than the promptness and certainty 
 with which a dose of valerian or assafoetida dispels the 
 gloomy visions of the hypochondriac, calms the hurry ami 
 agitation of nervous excitement, allays commencing spasms, 
 and diffuses a soothing calm over the whole being of one who 
 but an hour before was a prey to a thousand morbid sensa- 
 tions and thick-coming fancies of danger, wrong, or loss." 
 Dr. Latham gives the preference to valerian, and prescribes 
 from half a drachm to a drachm o( the ammoniated tincture. 
 Or it may be combined, as in the following formula, with 
 bromide of soda ; ammoniated tincture of valerian 3 iv. with 
 3 vi. bromide of sodium, in teaspoonful doses every hour. 
 The assafoetida may be given in the form of the spiritus 
 ammonia? fcetidus of the Pharmacopoeia, also in half drachm 
 or drachm doses. As a rule, alcoholic stimulants are not 
 advisable in this stage of the headache. A small quantity 
 will cause flushing, heaviness, slight confusion of thought, 
 &c, without relieving the depression; and though the severe 
 headache may be averted, alcoholic stimulants do not answer 
 so well as the remedies previously mentioned. 
 
 (/>) During the Stage of Headache. — If the headache be 
 
173 HEADACHE. 
 
 slight and the patient soon able to sit up, there is little to be 
 done; a cup of coffee or tea, cheerful conversation, a walk, 
 drive, or ride, may often help to remove the pain. If, how- 
 ever, the headache and nausea be severe, then the adminis- 
 tration of further remedies is called for. The patient should 
 keep perfectly still and quiet, with the room darkened; for 
 every sound or sight causes pain, and the slightest movement 
 is sufficient to produce gastric uneasiness. Sometimes free 
 evacuation of the contents of the stomach, especially if it 
 contain undigested food, is followed by relief. Dr. Fother- 
 gill says, — " An emetic and some warm water soon wash off 
 the offending matter, and remove these disorders," which 
 may be very well where there is any offending matter to wash 
 off. but it is not' very often that this is the case ; the nausea, 
 frequently continues long after the contents of the stomach 
 have been discharged ; an inverted action of the duodenum 
 is set up,; the bile appears in the fluids excreted ; the patient 
 believes that all his troubles are due to "its overflow ;" " it's 
 all liver," he says, and it is sometimes difficult to persuade 
 him to the contrary. Generally, then, you should try to re- 
 lieve and check the vomiting. Iced soda-water, with or 
 without two or three drops of dilute hydrocyanic acid, or 
 spirit of chloroform ; cold tea ; the effervescing citrate of 
 potash, with hydrocyanic acid, may often afford marked relief. 
 The headache may be lessened by applying cloths dipped in 
 cold water, or evaporating lotions, to the head ; if the ex- 
 tremities be cold and the headache severe, a warm stimulating 
 foot-bath can be tried so soon as the nausea will allow the 
 patient to sit up. If the attacks occur in the early part of 
 the day, as soon as the pain has subsided it is generally better 
 for the patient to sit up, or move about, or take exercise in 
 the open air. During the attack the appetite is diminished, 
 the idea even of food provoking disgust. Still, after the 
 nausea has passed away and the headache has continued a 
 few hours, a plate of hot soup or some easily digested food 
 will often have a good effect in equalizing the cerebral circu- 
 lation. A remedy which may very often be given with ad- 
 vantage if the headache be severe, is bromide of potassium, 
 in doses of five, ten, or fifteen grains, to which thirty or forty 
 minims of sal-volatile may, in some cases, be added with ad- 
 vantage ; and if the nausea still continue, these may be given 
 in combination with the effervescing citrate of potash. A 
 saline purgative at the commencement of an attack is some- 
 times an effectual remedy ; but, as a rule, the use of purga- 
 
HEADACHE. 179 
 
 tives is objectionable. So far, these measures are only palli- 
 ative. 
 
 (e.) During the Intervals between the Attacks. — First of all, 
 the exciting cause is to be discovered and removed. Hours 
 of study or work must be abridged; excessive bodily fatigue, 
 loss of rest, everything, in fact, must be avoided which the 
 sufferers know from individual experience will act as exciting 
 causes. Where the attacks are associated with excessive 
 mental work, they should be regarded as danger-signals, 
 showing necessity for relaxation. The tone of the bodily and 
 nervous systems must be improved by proper medicinal and 
 hygienic means; and the chief remedies are steel, strychnine, 
 phosphorus, and cod-Hver oil. The success, however, fol- 
 lowing these remedies depends a great deal upon the way in 
 which they are administered. Tor a day or two after the at- 
 tack the stomach and bowels may possibly he disordered, 
 and not in a fit state to tolerate such remedies. This must 
 first be corrected. The simple vegetable bitters, such as 
 gentian, with small doses of henbane and some aromatic, may 
 be of service; and, if necessary, one or two grains of blue 
 pill, with four or five of compoudd rhubarb pill, maybe given 
 at night. We may then try steel. In anaemic cases it may 
 be advisable to stimulate the action of the heart, as by the 
 following: — 
 
 fy. Ammoniae muriatis, 3 ss., Tinct actseae racemosae 
 aquae, a a 3 iii. Two fluid drachms for a dose after meals 
 in a wineglass of water. 
 
 If there be despondency with depression of spirits, phos- 
 phorus to the extent of T J- - to - 5 1 - of a grain, combined with 
 mix vomica or carbonate of iron, or both taken with each 
 meal, will improve the tone of the patient. If the attacks 
 have been frequent, or if there be any scrofulous tendency, 
 the iodide of iron may be given in the folowing form: — 
 
 I£. Ferri et amnion, citrat., gr. v.; potassii iodidi, gr. ij.; 
 aqua:, 5ji an d> according to circumstances, fifteen to 
 twenty minims of tincture of henbane or twenty or thirty 
 minims of aromatic spirit of ammonia may be added. 
 
 If the stomach be at all irritable, this medicine may be 
 given in the effervescing form, adding to each dose twenty 
 grains of bicarbonate of potash, and directing it to be taken 
 with a tablespoonful of lemon-juice, or a corresponding 
 amount of citric acid: the dose to be taken twice a day, 
 about eleven and four. The effervescing from may soon be 
 left off, and then to each dose may be added five minims of 
 
180 HEADACHE. 
 
 liquor of strychniae (omitting the henbane and sal-volatile, 
 and continuing the iodide of potassium according as it seems 
 to be indicated or not). In other cases, the citrate of irpn 
 and ammonia with strychnine may be given at the beginning, 
 sometimes combined with infusion of calumba. The iron is 
 indicated by the greater or less anaemia of the patient ; but 
 the strychnine is a very important remedial agent in the 
 disorder. In small doses it acts as a simple tonic, increasing 
 the appetite and improving the digestion ; it dilates che ves- 
 sels, and thus increasing the supply of blood, it augments 
 the activity of the spinal cord (Harley). It promotes the 
 capillary circulation, and therefore its use is advisable for 
 persons troubled with cold hands and feet (Anstie) ; and if 
 it fulfil these conditions, it is clearly 'indicated in this dis- 
 order. Cod-liver oil also often acts very beneficially. " It 
 has been found by experiment that great exertion and pro- 
 longed labor can be endured without fatigue when starchy 
 and fatty foods are alone eaten ; . . . and there is reason 
 to think that cod-liver oil is more easily absorbed than other 
 similar substances " (Ringer). " It improves the digestive 
 process, increases the proportion of red corpuscles in the 
 blood; and invigorates the whole nutritive function" 
 (Wood) ; and it particularly sustains the energy of the brain 
 during prolonged mental exertion. A gentleman in the 
 foremost rank at the bar told Dr. Latham that whenever he 
 was engaged in a jury-trial which was likely to tax his ener- 
 gies to a greater degree than usual, the thing which best 
 sustained him was a good dose of cod-liver oil taken in the 
 morning before going into court ; and others engaged in 
 mental work have confirmed this view. Besides its 
 other properties cod-liver oil is a nutrient and tonic in its 
 action on the cerebro-spinal nervous system. As a remedy 
 for these nervous headaches, Dr. Latham prescribes it once 
 a day, beginning with a small teaspoonful immediately 
 after breakfast, and gradually increasin g the quantity to a 
 tablespoonful, but not beyond, unless in exceptional cases. 
 
 The action of the bowels must be regulated, but not by 
 strong purgatives. Five grains of the Socotrine aloes pill, 
 given at night, are generally sufficient. If the bowels be 
 habitually constipated, then no remedy seems to answer so 
 well as the aloes and iron pill. Five grains given twice a 
 day, half an hour before meals, will act freely ; and in a few 
 days the dose will have to be diminished, for its effect is 
 augmented instead of being lessened by continual adminis- 
 
HEADACHE. I§1 
 
 tration, especially when strychnine is given at the same time. 
 The natural waters of Friedrichshall or Marienbad may, in 
 many instances, be of service, given as laxatives. 
 
 In 1872 Dr. Samuel Wilks, Physician to Guy's Hospital, 
 directed the attention of the profession to guarana as a 
 remedy for sick-headache, and at the same time asked for the 
 experience of those who already had some acquaintance with 
 the drug. His own knowledge of it dated about 1870, 
 when, after the appearance of a lecture of his upon sick- 
 headache, he received a letter from Mr. Helmcken, of British 
 Columbia, inclosing two powders, which he recommended 
 with much confidence as able to cure the complaint. " Upon 
 my first headache after the receipt of Mr. Helmcken's letter, 
 I took the powder, but with only doubtful effect. I there- 
 fore did no more than casually mention the medicine to my 
 friends, but did not recommend it. A few weeks ago, after 
 the appearance of a second communication of mine in the 
 journal upon the same complaint, I received a letter from 
 Dr. Wood, of Montreal, in which he also recommended 
 guarana as a remedy for headache, and gave a history of his 
 own personal sufferings and the relief which he obtained. 
 He says, — ' By taking one of these powders and remaining 
 quiet when I have felt premonitory symptoms by a beginning 
 of pain always in the right temple (headache on the other 
 side, or in any other part of the head, I never mind), I have 
 carried off the attack ; and, with the first box, absolutely 
 put it off for two months — something which had never 
 occurred in my life before.' Upon so good an authority, I 
 determined to try the remedy in a more systematic manner, 
 and requested my neighbor, Mr. Hooper, the chemist, to 
 procure me a packet of the powders. These I have recom- 
 mended to several patients and friends ; and the result is so 
 encouraging, that I have hastened to suggest their trial to 
 my professional brethren. One lady speaks most enthusi- 
 astically of their power, as she has now, on two separate 
 occasions, had her headache arrested by their use. The 
 drug has long been known, for mention is made of it in 
 English and French pharmacologies, but appears never to 
 have come into general use. It consists of the seeds of a 
 tree growing in Brazil, called Paullinia sorbilis ; and these, 
 according to Johnstone, in his Chemistry of Common Life, 
 are used as we do cocoa. The seeds are ground into pow- 
 der, and contain an alkaloid which is said to be identical 
 with that found in tea and coffee. The medicine is manu- 
 
t82 HEADACHt 
 
 factured by Grimault & Co., No. 7 Rue de la Feuillade, 
 Paris" (Wilks, Brit. Med. Joum., April 20, 1872). 
 
 The general outcome of experience regarding the treat- 
 ment of sick-headache seems to be that, — 
 
 (1.) Bromide of potassium, Indian hemp, Guarana or 
 Paullinia powder, are remedies which have afforded relief. 
 With reference to bromide of potassium, it is so valuable a 
 medicine in many cases of sick headache that it can scarcely 
 be superseded by a better remedy. The patient may have a 
 splitting headache, fatigued and worried after a hard day's 
 work. After fifteen or twenty grains of bromide of potas- 
 sium, he presently goes off to sleep in his easy chair, and 
 wakes in an hour well (Wilks). It is a medicine which Dr. 
 Wilks always employs first, having seen such eminent ad- 
 vantages follow its use. " I have known (he writes) many 
 patients declare, that the bromide was the first medicine they 
 had taken in their lives which had the slightest effect in re- 
 lieving their headache." As to Cannabis Indica, it seems 
 best adapted to the interval between the attacks, in doses of 
 a few drops of the tincture, when headaches are recurrent. 
 It is best given in ten-minim doses, three times a day, con- 
 tinued for weeks or months (Wilks, John Murray). As to 
 guarana powder, it seems most of all useful with females in 
 arresting headache, so that it must be taken early when the 
 headache is approaching ; and if headache is not arrested, a 
 second dose should be taken in fifteen, twenty, or thirty 
 minutes after the first. If the medicine is of use, the head- 
 ache will have gone in about an hour. The dose is 15 grains 
 of the powder ; and as it is somewhat astringent, it might be 
 combined as an electuary with some laxative, such as the 
 senna electuary (Hollis). 
 
 (2.) Certain classes of cases ought to be distinguished from 
 each other. There are two principal types : — the congestive, 
 met with in dark or plethoric people, in those with consti- 
 pated bowels and suppressed secretions, and those addicted 
 to alcoholic beverages, or leading a monotonous sedentary 
 life ; and that arising from exhaustion, whether from want 
 of sleep or want of food, or great bodily or mental fatigue, 
 strong emotions, &c. — this may be nervous, or asthenic, or 
 anaemic in many cases. This latter form is very common in 
 slight, delicate, and tuberculous females, and sometimes in 
 the male sex. The treatment of these two forms must, of 
 course, differ widely. An emetic or a purge in the one case 
 will do what only rest, food, stimulants, and such medicines 
 
HEADACHE. 183 
 
 as quinine, iron, opium, hyoscyamus and belladonna may- 
 afford in the other case (Dr. Bathurst Woodman). Rest and 
 quiet, especially sleep, and abstinence from food, give relief 
 and cure by a natural process of restoration. Generally, no 
 relief is obtained till after a night of sound sleep — i. e., " one 
 night through the sheets " — awakening next morning free 
 from pain, but generally more or less depressed. If depres- 
 sion continue, phosphorus with nux vomica in the form of 
 sugar-coated or pearl-coated pills may be given to the extent 
 of one-fiftieth of a grain of phosphorus and one-eighth of a 
 grain of extract of nux vomica three times a day with food. 
 Such despondency and depression are apt to occur in those 
 who are over-worked mentally ; or who are harassed by busi- 
 ness ; or who suffer great mental anxiety. If there be sleep- 
 lessness, the following pill may be of use : 
 
 I£ Camphorre pulveris, gr. xx. ; Ext. Cannabis Indira, 
 gr. xii. ; Ext. Hyoscyam., gr. xxiv., misce bene. Divide in 
 pill xii. signa, one at night, to be repeated in two hours, if 
 necessary, to procure sleep. 
 
 As to local applications, a large sinapism over the stomach, 
 followed by a warm linseed meal poultice, has sometimes 
 been of service. If pressure relieves, the head may be bound 
 round with a handkerchief. When the head throbs and is 
 hot instinct seems to suggest cold and pressure to the part ; 
 and one of the best external appliances on which we can rely 
 to procure relief is the wet bandage tied tightly round the 
 head. The method must be instinctive, for it is universal, 
 and has been used from all time. Shakespeare is often 
 quoted to illustrate the morbid states of the body as well as 
 the passions of the mind, and he also testifies to this ancient 
 practice. For example, in the scene between Huburt and 
 Arthur in King John, the latter, when petitioning for the 
 preservation of his eyes, says : 
 
 " When your head did but ache 
 I knit my handkerchief about your brows." 
 
 And in Othello we have not only the remedy for headache 
 given, but the cause. The former was the handkerchief about 
 which the chief interest of the play centred. 
 
 " Desdcmotia, Why do you speak so faintly ? 
 Are you not well ? 
 
 Othello, I have a pain upon my forehead here. 
 
 Desdenuma % Faith, that's with watching : 'twill away again. 
 Let me but bind it hard, within this hour 
 It will be well." 
 
184 HEAbACk£. 
 
 Sick-headache is not to be cured by gastro-hepatic reme- 
 dies. It is a purely nervous affection, due to hereditary 
 predisposition, and excited by causes innumerable which act 
 on a susceptible nervous system. There is, then, no cure in 
 the proper sense of the term, for this would imply a change 
 in the patient's nature ; and for the attacks themselves, when 
 severe, the only relief which can be reckoned upon is to be 
 found in a wet bandage round the head, profound quiet, and, 
 if possible, sleep (Dr. Bathurst Woodman). 
 
 Considerable relief may be obtained from the use of cold 
 applications, in the form of wet rags, ice in a bladder, or a 
 little of the ether-spray ; but in not a few cases, after all, the 
 best treatment during the attack is absolute rest and quiet, 
 in a dark room, with warmth to feet and body, total absti- 
 nence, except perhaps from fluids (hot and alkaline) in small 
 quantities at a time ; to go to bed at once, and refrain from 
 the use of any remedies. 
 
 In a lecture on the therapeutics of headache, delivered at 
 Bellevue Hospital Medical College, Dr. A. A. Smith sug- 
 gests certain combinations of remedies which he has found 
 of service in certain forms of headache: (1.) Malarial 
 headache, where the pain is most frequently located in the 
 sub- occipital or frontal regions, or on either side — hemi- 
 crania. If distinctly periodical, give ten or fifteen grains of 
 quinine two or three hours before the expected attack. It 
 may be necessary to push the quinine in divided doses until 
 cinchonism is produced, and kept up for several days. Then 
 gradually diminish the dose. If the pain still continues to 
 recur, resort to arsenic and belladonna, five-drop doses each 
 of Fowler's solution and belladonna tincture, after meals, in- 
 creasing the Fowler's one drop each day, until oedema arse- 
 nicalis is produced. This will seldom fail to give relief. 
 
 (2.) In Headache dependent on Gout : 
 
 1^ Vini colchici seminum, 3 iij. ; Lithii bromidi, § ss. ; 
 Syr. zingiberis, § ss. ; Aq. cinnamonii, q, s. ad § vj. ; M. 
 Sig. I ss. in a tumbler of Vichy water every four hours. 
 
 (3.) Rheumatic Headache is characterized usually by ten- 
 derness of the scalp, which is increased on pressure or mo- 
 tion. Use the mild Faradic current on the scalp, and in- 
 ternally the following : 
 
 I> Potassii iodidi ; Ammonise muriatis, aa 3 jss. ; Infusi 
 humuli, I vj. ; M. Sig. § ss. four times a day in a wineglass 
 of water. 
 
 In cases which have not yielded to the above treatment, 
 
HEADACHE. 185 
 
 bromide of ammonium in twenty-grain doses every two hours 
 mav be effectual. 
 
 (4.) Uraemic headache is of great importance as a symp- 
 tom of serious disease. The pain in the head may be the 
 first evidence that there exists renal disease, and that we 
 have to deal with uraemic headache. The judicious plan of 
 treatment in such cases is to call into action one or all of the 
 three great emunctories of the body, the kidneys, the intes- 
 tines, and the skin. To make the kidneys act, apply dry 
 cups over the region of them, and give internally the fol- 
 lowing : 
 
 I£ Potassae acetatis, 3 vj. ; Infusi digitalis, 3 vj. ; M. Sig. 
 5 ss. every third hour. 
 
 The infusion should be made from fresh English leaves. 
 Give this until the kidneys act freely, if you can make them 
 do it within twenty-four hours. If the kidneys do not act 
 freely, and the headache be not relieved within twenty-four 
 hours, give a saline cathartic. A treatment almost domestic, 
 and often very effectual, is to put an ounce of cream of tar- 
 tar in a quart of water, and have the patient drink this in 
 eight or ten hours. It acts both as a diuretic and cathartic. 
 Do not use hydragogue cathartics unless convulsions be 
 threatened. Some prefer elimination by the skin. This can 
 be clone by diaphoretics and the hot, moist, or dry air bath. 
 Diuretics, cathartics, and diaphoretics are only to be used 
 where there is deficient quantity of urinary secretion. There 
 are other causes of headache in Bright's disease which occur 
 independently of the presence of an abnormal amount of 
 urea in the blood, and which yet are dependent on the results 
 of the kidney-disease. These causes may be anaemia, 
 neuralgia, oedema of the brain itself, serous effusion into the 
 ventricles ; and, in acute Bright's disease, cerebral conges- 
 tion. Under the last condition, if the headache be very se- 
 vere and convulsions threaten, blood may be taken if the 
 patient's condition will admit of it, from twelve to twenty 
 ounces, if necessary to relieve distressing symptoms. The 
 best way to take it is by means of wet cups over the region 
 of the kidneys. If the headache be dependent on serous ef- 
 fusion into the ventricles, or on cerebral cedema, improve the 
 vitiated condition of the blood, and stimulate the heart and 
 kidneys by acetate of potash and infusion of digitalis. 
 There is apt to be general anasarca with this effusion and 
 oedema. 
 
 (5.) The Headache of Acute Alcoholism, or inebriety. 
 
l86 HEADACHE 
 
 The first indication is to remove the alcohol from the intes- 
 tinal canal. For this, give of rhubarb and magnesia calcined 
 each a half drachm, and then the following: 
 
 ^ Spiritus ammoniae aromat., 3 ij. ; Tincturae camph., 
 3jss.; Tincturae hyoscyami, 3 ijss.; Spiritus lavandulae 
 comp., q. s. ad | ij.; M. Sig. 3 j- every hour until the head- 
 ache is relieved, and then give capsicum gr. ij, and quinine 
 gr. iij. before each meal for several days. If there be sleep- 
 nessness give r> Sodii bromidi, § ss.; Chloral, hydrat., 3 ijss.; 
 Syrupi aurantii cort., ^ss.; Aquae, § iijss. M. Sig. J ss. at 
 night; repeat in two hours if necessary to produce sleep. 
 
 (6.) Dyspeptic Headache. — If there be indigestible food m 
 the stomach, and it have been there some time, give an 
 emetic, as mustard and warm water, or sulphate of zinc^ gr. 
 xv. If there is evidence of indigestible food in the aliment- 
 ary canal beyond the stomach, give gr xx. of rhubarb and 
 magnesia each, to remove it from the bowels. If the head- 
 ache be frontal, and the pain be located immediately over 
 the eyes, give dilute nitro-muriatic acid in ten-drop doses, 
 well diluted after meals. If the pain be located about the 
 roots of the hair, give an alkali before meals, as gr. 
 xv. of bicarbonate of soda or magnesia. The dyspeptic 
 headache oftentimes is not confined to these regions, but 
 spreads over the entire head. In such cases combine an 
 acid with an alkali, and add to these nux vomica, as in the 
 following prescription: 
 
 I£. Sodae bicarbonatis, 3 ijss.; Acidi nitro-mur. diluti. 
 3 ij- ; Tinct. nucis vomicae, 3jss.: Syr. aurant. cort., 3vj.; 
 Aquae, q. s. ad § vj. M. Sig. § ss. after meals in a wineglass 
 of water. 
 
 If there be gastric pain, a mild counter-irritant, as a mus- 
 tard plaster to the epigastrium will often relieve the pain in 
 the head as well as the pain in the stomach. If flatulence 
 be a troublesome symptom, give the following: 
 
 I£. Bismuthi subcarbonatis, 3 ijss.; Tinct. nucis vomicae, 
 3jss.; Tinct. cardamomi comp.; Spiritus lavandulae comp. 
 aa q. s. ad 3 iv. M. Sig. 3 ij. before meals in a wineglass 
 of water. 
 
 If there be constipation, the following pill may be given, 
 in the morning: 
 
 ^. Aloes pulv., 3 ss.; Ext. nucis vomicae, gr. v.; Ext. 
 belladonnae, gr. iv.; M. Div. in pilulas, xv. 
 
 In some forms of headache associated with stomach in- 
 digestion, small doses, often repeated, of tincture of nux 
 
HEADACHE. 187 
 
 vomica may be effectual. A single drop every fifteen minutes 
 and continue this two or three hours if necessary. In other 
 cases, where the headache comes on soon after a meal, 
 and seems to depend on delayed stomach digestion, large 
 doses of pepsin are effectual. Give a half drachm of sac- 
 charated pepsin in a wineglass of sherry wine, three times a 
 day, and let it be taken during meals. 
 
 (7.) Congestive Headache — Cerebral congestion as a 
 cause of headache may be divided into two varieties, active 
 and passive. These demand almost directly opposite plans of 
 treatment. In the active variety the patient should be kept 
 in a darkened room, perfectly quiet, and have cold and evap- 
 orating lotions applied to the head. A saline cathartic may 
 be given ; and the following prescription : 
 
 $. Sodii bromidi, 3 ijss, ; FL ext. ergot., 3 ijss. ; Syr. 
 zingib., ^ ss. ; Aq.. aurant. flor. q. s. ad 3 iv. M. Sig. 5 ss. 
 every two hours. 
 
 If the skin be hot and dry, and the pulse full and rapid, 
 give two drops of Fleming's tincture of aconite root every 
 two hours, until the heart's action is sensibly diminished. 
 Sometimes also a hot mustard foot-bath will give relief. 
 The passive congestive variety demands a different mode of 
 treatment. It is often found associated with cardiac dis- 
 ease, and most frequently where there is predominant dila- 
 tation. Hypertrophy gives rise to the active variety. Im- 
 prove the condition of the blood by the use of iron, qui- 
 nine, bitter tonics, alcoholic stimulants, good food, and stim- 
 ulate the heart's action by the use of the following: 
 
 $. Tinct. digitalis, 3 ii j - , Spirit, amm. aromat., 3vj.; 
 Spirit. Lavandula: comp. ; Syr simp., a a q. s. ad f iij. M. 
 Sig. 3 j. every four hours. 
 
 (8.) Anccmic Headache. — Cerebral anaemia produces a 
 headache which is often mistaken for the passive cerebral 
 congestive form. It is associated with general anaemia, ner- 
 vous exhaustion, and may occur in heart disease, in con- 
 sequence of enfeebled heart power, such as is met with in 
 enlargement with dilatation, fatty degeneration, and myo- 
 carditis. Improve the general condition of the patient, and 
 stimulate the heart's action as recommended in the passive 
 cerebral congestive variety. Nitrite of amy] will relieve the 
 immediate headache. Let the patient inhale three to five 
 drops of it on a piece of cotton, placed within one nos- 
 tril, while the other is held closed. When associated with 
 nervous exhaustion, employ the following remedies : 
 
l88 HEART, FATTY^-HEART, HYPERTROPHY OF. 
 
 $. Strych. sulph.. gr. ss.; Tinct. ferri chloridi, 3 ij- ; Gly« 
 cerinae, |ss.; Infusi gentian., q. s. ad § vj M. Sig. § ss. 
 after meals, in a wineglass of water. 
 
 Alcoholic stimulants are beneficial in headache dependent 
 on cerebral anaemia. Champagne as a remedy, and not as a 
 beverage, may be given to those who suffer from nervous 
 exhaustion , or a tablespoonful of brandy, diluted with 
 water, after each meal. 
 
 (9.) Cerebral Tumors give rise to headache, often severe. 
 In all such cases, give iodide of potassium ; for it cannot 
 be safely said that in any given case the tumor does not de- 
 pend on syphilis, and by administering the remedy, the pa- 
 tient gets the benefit of the doubt. 
 
 There is reason to believe, too, that patients with cerebral 
 tumors, dependent on other and unknown causes, are bene- 
 fited by the use of iodide of potassium. If there be 
 much sleeplessness, use the bromide and chloral mixture 
 Erg6t has also been used. It is usually given in large 
 doses, beginning with 3 i. of the fluid extract three times 
 a day, and gradually increasing the dose to half an ounce 
 {New York Medical Record and London Medical Record 
 Sept. 15, 1876. 
 
 Heart, Fatty and other Degenerations of the.— 
 
 Definition. — A change in the muscular substance of the 
 heart, which results in elements of the muscular fibers being 
 replaced by molecular fatty particles. The change tends to 
 sudden death by rupture of the heart, or by syncope. 
 
 Treatment. — Iron in its various forms, quinine, and min- 
 eral acids, are the medicinal agents suggested by the nature 
 of this disease. Freedom from anxiety, thorough repose of 
 mind, entire avoidance of fatigue, gentle but regular exercise 
 in the open air, careful attention to the state of the skin, with 
 a generous and nutritious diet at regular intervals, in moder- 
 ate and equable amount at each meal, are the main hygienic 
 indications calculated to impart tone to the system, improve 
 the condition of the blood, and induce a more healthy nu- 
 trition of the heart (Fuller). A salt-water sponging bath 
 should be used daily. In cases where digestion is sufficient, 
 cod-liver oil, cream, and mflk may be given with great ad- 
 vantage (Tanner). The bowels should be so regulated as to 
 render straining at stool unnecessary. 
 
 Heart, Hypertrophy of. — Definition — An abnormal 
 
 growth of the muscular substance of the heart, increasing its 
 
HEART, HYPERTROPHY OF 189 
 
 volume by thickening of the cardiac walls; and generally 
 with dilatation of its cavities. 
 
 Treatment. — As the bad symptoms in valvular affections 
 arise from defective compensation, and as the compensation 
 depends on the integrity of the heart-muscle, the mainte- 
 nance of its nutrition is of prime importance. Palliative 
 treatment is necessarily directed to aid the mechanism by 
 which the ill-effects of valvular incompetency are to be met. 
 In affections of the aortic valves, when the heart-muscle is 
 well nourished, an almost perfect compensation may be main- 
 tained for years upon a nutritious (albuminous) diet, with 
 fluids in small quantity — tonics, especially preparations of 
 iron, being indicated. In the earlier stages a moderate 
 amount of exercise is beneficial. In mitral affections, the 
 compensation can never be so complete as to do away with 
 the tendency to pulmonary complications. While the same 
 nutritious diet and tonics are indicated to promote the nutri- 
 tion of the cardiac muscle, exercise must be taken more cau- 
 tiously; the object being to regulate and moderate the action 
 of the heart, to control the tendency to local congestion, and 
 to mitigate or remove the symptoms which result from the 
 cardiac derangement. 
 
 Any blood-letting required ought to be effected by the ap- 
 plication of a few leeches to the precordial region, and very 
 general relief will be obtained by hydragogue purgatives, 
 aided by dry-cupping, mustard poultices, and turpentine fo- 
 mentations. When, however, active congestion of the lungs 
 exists, venesection, cupping, blisters, and sinapisms may be 
 necessary. The distress from simple hypertrophy may, in 
 the majority of cases, be greatly mitigated by such means as 
 tend to tranquillize the action of the heart. No known drug 
 possesses the power of controlling the growth of the heart. 
 Saline and aloetic purgatives aid the calmative influence of 
 the local abstraction of blood. Diuretics are useful inde- 
 pendently of the existence of dropsy. Sedatives of the 
 heart's action are indicated throughout, such as hydrocyanic 
 acid, acetate of lead, digitalis, belladonna, and aconite, in the 
 form of the alcoholic extract, given in doses of one-eighth of 
 a grain (Walshe). It is chiefly useful in excessive hypertro- 
 phy, with hydrocyanic acid and caffeine. In repeating the 
 doses, the effects must be watched, while they relieve the 
 painful sensations and disquietude about the heart. If anae- 
 mia prevails, animal food should be permitted; and the more 
 soluble and less astringent preparations of iron should also 
 
I90 HEART, HYPERTROPHY OF. 
 
 be given. Fluids must be taken in small quantities. Like 
 hypertrophy, dilatation of the heart is not removable by 
 treatment. To improve the tone and strengthen the action 
 of the heart, without exciting its irritability, are the objects 
 to be aimed at in the management of cardiac hypertrophy 
 with dilatation. For this purpose the beneficial influence ol 
 digitalis has been ably shown by Dr. J. M. Fothergill, in his 
 " Hastings Prize Essay" for 1870, published in the British 
 Medical Journal, commencing July 1, 187 1; and also by Dr. 
 Balthazar Foster in the Medico-Chirurgical Review for July, 
 187 1. It is an efficient agent in helping to co-ordinate, by 
 restoring the regularity of the heart's movements, when 
 they have become tumultuous and irregular. The mechan- 
 ism of compensation in each form of valve disease, therefore, 
 requires to be considered. In hypertrophy digitalis is 
 only of use when hypertrophy exceeds the limits of com- 
 pensation. It slows the pulse and regulates the heart- 
 muscle; but if the heart-muscle is unsound it will not be 
 of service. As a general rule, the drug is most useful in 
 mitral affections, and is contraindicated in aortic valve 
 disease, except in cases in which the hypertrophy has ex- 
 ceeded the limits of compensation, and become the chief 
 cause of the symptoms. It slows the pulse and increases 
 its tension while strengthening and regulating the heart's 
 action. The slowing of the pulse increases the period of 
 ventricular diastole — that is to say, the period during which 
 regurgitation takes place when the aortic valves are incom- 
 petent ; consequently, digitalis does harm in this lesion by 
 augmenting the regurgitation. In mitral obstruction it is 
 most valuable when the rapid, irregular pulse tells of the 
 varying quantities on which the ventricle contracts. Some- 
 times the interval between the ventricular contraction is so 
 short, and the ventricular charge is so small, that the systolic 
 wave does not reach the wrist. Under these circumstances 
 the auricle must have more time to fill the ventricle. This 
 is what digitalis effects ; for by slowing the action of the 
 heart, the period of time during which the blood from the 
 distended auricle can flow into the ventricle is increased ; 
 and as the extra time allows more blood to pass through 
 the narrowed mitral orifice before the final effort of the 
 auricle is made, that effort is made on a smaller quantity of 
 blood, and is consequently more effective ; for the smaller 
 the quantity of blood which the auricular muscle has to push 
 before it, the greater will be the velocity given to the cur- 
 
HEART, HYPERTROPHY OF. I9I 
 
 rent. The ventricle, through contracting less frequently, 
 contracts more effectually. Instead of eighty or ninety 
 irregular contractions per minute, we get some sixty steady 
 equal beats. The pulse grows in force, fullness, and regu- 
 larity ; the arterial tension rises ; the pulmonary congestion 
 diminishes ; the kindeys, before inactive, wake up to their 
 work ; and the advancing dropsy subsides (Foster, Med.- 
 Chir. Rev.. July, 187 1). Digitalis is also most useful in mi- 
 tral regurgitation. In place of a large number of ineffective 
 contractions, it concentrates the power of the ventricle on a 
 smaller number of well-directed steady beats, each throwing 
 a larger charge of blood into the arteries, and so diminish- 
 ing, beat by beat, the over-distension of the right heart. It 
 may be prescribed as an infusion or tincture, and continued 
 as long as the quantity of urine increases or keeps up to the 
 maximum which the digitalis produced. Such diuretie effect 
 is the outward or visible sign of its beneficial action. The 
 high-colored scanty urine, loaded with urates, is then replaced 
 by a clear and copious stream, which tells of a steadily-beat- 
 ing heart and a firmer pulse (Foster). The tincture is the 
 most convenient form for continuous administration (mv. to 
 m x., three or four times a day). The freshly- made infusion 
 acts most rapidly ( 3 ss. to 3 i., three or four times a day) 
 along with potash or diuretics, and is conveniently added to 
 vegetable infusions. Where it is desired to keep up the 
 action of digitalis for a long time, the powder of the leaves 
 is the most desirable form. It can then be given in pill, 
 with the dried sulphate of iron, carminatives, laxatives, or 
 both, twice a day. Half a grain to a grain of powdered 
 digitalis, with an equal quantity of sulphate of iron, and a 
 small portion (J of a grain) of cayenne pepper, in extract of 
 gentian or aloes and myrrh pill, is a useful form which 
 may be continued for months. This pill should be taken 
 shortly after food. The addition of iron to digitalis is of 
 great importance. The absorption of digitalis through the 
 skin, by using poultices of the leaves, or flannel cloths soaked 
 in the infusion and laid over the skin of the abdomen and 
 thighs, is often most beneficial where it cannot be given by 
 the mouth (Christison, Trosseau, Fothergill). 
 
 There are some circumstances, however, under which it is 
 necessary to withhold the administration of digitalis in car- 
 diac disease — namely (1.) The presence of atheroma (endo- 
 carditis) to any appreciable extent, and in aortic valve dis- 
 ease. (2.) Reith, Gull, and Brunton object to its use in 
 
I92 HEART, HYPERTROPHY OF. 
 
 fatty heart. (3.) Intermittency of pulse is also a contraindie 
 cation. If that symptom comes on during its use, the fur- 
 ther administration of digitalis must be suspended, mor- 
 especially if the pulse becomes thready, and the quantity of 
 the urine diminished. On the other hand, where intermit- 
 tency is shown to be the result of the heart's inability and 
 distress, the quantity of digitalis must rather be increased 
 (Fothergill). (4.) The occurrence of persistent vomiting or 
 noises in the head under its use, suggests that it should be 
 left off, for a time at least. 
 
 The action of the heart is also markedly influenced by 
 veratrum viride. The dose of the tincture (from five to 
 twenty minims) should be gradually increased from the 
 smaller to the greater dose, till some obvious effects are pro- 
 duced. If the pulse is reduced, or nausea occurs, no increase 
 of the dose should be made. If vomiting occur, it should 
 be suspended ; and when resumed, the dose should be dimin- 
 ishetl. Veratria may be given in doses of from one-sixteenth 
 of a grain to half a grain. When the pulse is sufficiently 
 reduced, the doses should be diminished one half. Mor- 
 phine or laudanum, with brandy, is an antidote for an over- 
 dose of veratria, which is an exceedingly powerful remedy 
 as a cardiac sedative, and requires to be used with 
 great caution, the patient being constantly watched. Its 
 depressing effects on the circulation and nervous system are 
 often very striking — a pulse of 75 or 80 being reduced in 
 the course of a few hours to 35 or 40 (Record of Pharmacy 
 and Therapeutics, No. V., p. 35, J. C. Braithwaite). Sleep- 
 lessness being one of the most distressing symptoms, opium 
 in some form might be considered advantageous ; but " to 
 give sedatives in such cases would be the refinement of cru- 
 elty. What keeps the patient awake is not a want of ten- 
 dency to sleep, but a condition that makes sleep impossible. 
 Relieve him of his orthopncea, and he would be asleep in ten 
 seconds, and so dead asleep that it would take a great deal 
 to rouse him, like a half-asphyxiated child on whom trache- 
 otomy had just been performed. His great struggle is the 
 struggle between sleep and life ; with opium thrown into the 
 scale of sleep, the struggle for life would only be so much 
 the harder. Only in one way would opium give him ease ; 
 the narcotic of opium, added to the narcotic of the carbonic 
 acid already circulating in his veins, might accelerate by 
 some hours, or even days, the final coma, and make him 
 sooner sleep the sleep of death. But the euthanasia that is 
 
HEART, HYPERTROPHY OF. I93 
 
 purchased by anticipating the natural process of death 
 comes very near to homicide, and is an alternative that few 
 would adopt " (Hyde Salter, Brit. Med. Journal, Feb. 8, 
 1862). Morphia given hypodermically is the best form for 
 relieving the dyspnoea and sleeplessness of some valvular 
 affections, especially in mitral valve disease. The dose to 
 commence with is one-eighth to one-sixth grain of the bi- 
 meconate of morphia (Dr. Clifford Allbut). But all seda- 
 tives require the utmost caution in their use. 
 
 The groundwork of medicinal remedies consists in the 
 administration of general tonics in the form of bitters, min- 
 eral acids, and preparations of iron. Belladonna may be 
 employed to tranquillize undue excitement with greater 
 safety than any other sedative remedy. A plaster of bella- 
 donna and conium over the heart is of signal service when 
 pain is usually felt near the apex, associated with palpitation. 
 Due action of the bowels must be daily obtained, to accom- 
 plish which the aloetic medicines are the best, aided by the 
 gentle action of an occasional mercurial aperient. 
 
 Careful regulation of the patient's mode of life is above 
 all things necessary in diseases of the heart. Excitement 
 of all kinds must be avoided ; and the diet should be light, 
 nutritious, and of moderate quantity ; the clothing warm, 
 and cold should be carefully avoided, especially by those 
 affected with mitral disease. 
 
 When anasarca supervenes, the hydragogue cathartics are 
 required to insure copious watery discharges from the bow- 
 els. Electuary of bitartrate of potash, or of gamboge, ela- 
 terium, podophyllin, and compound jalap powder should be 
 given on alternate days. Stimulants also may be required, 
 the most suitable being Holland gin, or whiskey. 
 
 When dropsy appears, diuretics yield most relief. Ace- 
 tate, nitrate, iodide, and bitartrate ot potass, nitric aether, 
 compound tincture of iodide, the infusion and spirits of 
 juniper, or gin, may all be employed in successive changes, 
 variously combined. Small doses of blue pill and compound 
 squill pill at bedtime, will facilitate their action generally ; 
 and so will cupping over the region of the kidneys, if symp- 
 toms of congestion of these organs prevail. Hydragogue 
 cathartics aid the diuretics in subduing the dropsical effu- 
 sions, such as elaterium, gamboge, bitartrate of potass, and 
 compound jalap powder — the two last made into an elec- 
 tuary. 
 
 *3 
 
194 HEART, MALFORMATIONS OF PALPITATION OF. 
 
 Heart, Malformations Of. — Definition. — Deviations 
 from the normal development of the heart, occurring in the 
 earlier periods of gestation, and before the termination of 
 foetal life. 
 
 The treatment of malformations which are associated with 
 cyanosis is mainly preventive of dyspnoea and palpitation, 
 by the avoidance of fatigue and mental excitement, the 
 maintenance of temperature, and especially by a nourishing 
 diet and warm clothing. 
 
 Heart, Palpitation of. — Definition. — Palpitation and 
 irregularity of the action of the heart, unconnected with or- 
 ganicmis chief, beyond, in some cases, a notable hypertrophy. 
 
 Treatment. — During the paroxysm the patient should lie 
 flat on his back, bare his neck and chest, and allow the air 
 to blow freely over him. The best remedies are, camphor 
 mixture and aether, 3 i., with some slight opiate, as the syr 
 up of poppies, 3 j., or tinct. hyoscyami, m xx. These 
 should be repeated every quarter, or every half hour, or 
 hour, according to the severity of the attack, till the heart's 
 action is soothed. Cold brandy and water may be a substi- 
 tute for, or adjuvant to, such medicines. If the attack oc- 
 curs shortly after a meal, some purgative should be given 
 to clear the stomach and bowels. Bicarbonate of potash 
 (in io to 20 grain doses) is then also an excellent stimulant 
 as well as antacid and sedative. Leeches to the os uteri in 
 females, and to the perineum in males, sometimes relieve 
 palpitation — proceeding in the one case from uterine dis- 
 turbance, or from varicose veins, hypochondriasis, or hepatic 
 congestion in either sex. Bromide of potassium and ammo- 
 niated tincture of valerian are also indicated. Digitalis is 
 useful under the following conditions : — (a.) When there 
 are palpitation and acute depression of the heart's action 
 from shock (Paralysis of the sympathetic of Romberg), 
 marked by a small feeble pulse, coldness of skin, cold breath, 
 diminished temperature, and evidence of the organic system 
 of nerves being acutely depressed. The heart's walls con- 
 tract ineffectively. It does not respond to the stimulus of 
 its contents. Combined with other stimulants, the adminis- 
 tration of digitalis in a case of shock, following parturition, 
 was followed by the most satisfactory results (Drs. Fother- 
 gill and Wilks, Med. Times and Gazette, Jan. 16, 1864). In 
 Dr» Wilks' case, the patient seemed to be in articulo mortis 
 •—the face livid, no pulse at the wrist, and a mere fluttering 
 
HEMIPLEGIA. 1 95 
 
 heard over the region of the heart. Brandy and ether had 
 been given with no result ; and dissolution being imminent, 
 it was determined to administer digitalis, of which half- 
 drachm doses of the tincture were given every hour. After 
 four doses reaction took place, and after seven doses com- 
 plete recovery occurred. The full veins and condition of 
 the heart indicated distension and paralysis (Fothergill, 
 Brit. Med. Journal, July 29, 187 1.) (3.) When there is the 
 irregular action of cardiac asthenia, (c.) When there is pal- 
 pitation in dilated heart. It is useful to continue the medi- 
 cines which have been mentioned, but at longer intervals, 
 for some time. It is important also to counsel the patient 
 strictly as to diet. It is often found that the palpitation re- 
 turns after tea or after breakfast, or whenever hot tea or hot 
 coffee has been drunk. In these cases it is desirable to 
 avoid all hot slops, and to drink cold water at breakfast, and 
 indeed at every meal. There are few tonics so beneficial as 
 the natural tonic of cold water ; and persons once accus- 
 tomed to it feel a return to a modern breakfast a punish- 
 ment rather than a gratification. Wine should not be taken, 
 unless largely diluted with water, to be prescribed as required. 
 
 Hemiplegia. — Definition. — A form of paralysis affecting 
 one lateral half of the body. 
 
 Treatment. — The object to be aimed at in the early treat- 
 ment of hemiplegia is to keep down the frequency and force 
 of the heart's action. For this purpose strict maintenance 
 of the horizontal position is necessary ; and when concious- 
 ness exists, let the mind be kept tranquil by every means. 
 Remove any local impediment to the easy flow of blood, and 
 let the head be slightly raised, in a room of equal tempera- 
 ture. Let the bowels be cleared out, so that no irritation 
 from them may operate injuriously on the brain. Enemata 
 ought to be employed ; and castor oil or calomel, with com- 
 pound jalap powder, may effect an efficient evacuation. 
 Food should be nutritious and easy of digestion, and not too 
 abundant. 
 
 The gradual removal of blood may be of service by re- 
 lieving congestion of the right side of the heart, as shown by 
 engorgement of the veins of the head and neck, and by livid- 
 ity of surface (Bristowe, Watson). The circumstances under 
 which its use is inadmissible are thus defined by Dr. Todd: 
 If the patient be cold and collapsed ; if the heart's action be 
 feeble and intermittent ; if there be an anaemic state ; if the 
 
196 HEMIPLEGIA. 
 
 patient be of advanced age ; if their is evidence of exten- 
 sive disease of the arterial system or of the heart ; or, lastly, 
 if it can be ascertained that already a large amount of 
 haemorrhage has taken place into the brain ; — these, singly 
 or conjointly, are reasons why bleeding ought not to be re- 
 sorted to. If none of these objections exist, it is to be con- 
 sidered whether any of the indications noted require to be 
 fulfilled, and whether they can be fulfilled by a local or gen- 
 eral blood-letting. Modern investigations show that the 
 brain is not generally in a hyperaemic state ; so that it is 
 chiefly to check or to prevent haemorrhage that bleeding is 
 to be resorted to in such cases. The sudden or rapid ab- 
 straction of a moderate quantity of blood, either from the 
 arm or temple, or by skillful cupping, may check haemor- 
 rhage, but the quantity taken should be small ; and so, like- 
 wise, the quantity drawn ought to be moderate, if it is de- 
 sired merely to lessen the frequency and force of the heart's 
 action. " Generally, Dr. Todd came to the conclusion that, 
 in cases of white softening, you are less likely to err by 
 omitting than by adopting the practice." The rigidity of 
 the muscles, which comes on very early and which indicates 
 an inflammatory process going on round the clot, is to be 
 combated by urinary and alvine evacuants, and by counter- 
 irritation. It is not desirable to interfere in the later forms 
 of muscular rigidity. With regard to the use of expedients 
 for promoting the restoration of the paralyzed limbs to their 
 normal condition, Dr. Todd's experience led him to write 
 that nothing is of more decided benefit than a regulated 
 system of exercise — active when the patient is capable of it, 
 passive when he is not. 
 
 Any congestion of the spinal cord apt to supervene on 
 cerebral hemiplegia must be diminished. The patient should 
 not lie on his back, but, if possible, flat on his belly, the 
 arms and legs being encased in flannel, and placed at a lower 
 level than the spine. A hot douche may also be applied to 
 the spine, the water falling from a height of at least four or 
 five feet, through a tube three-quarters of an inch or one 
 inch in diameter ; and its temperature should be between 
 98 and ioo° Fahr. The application should be continued 
 two or three minutes, and continued daily for some time. 
 Dry-cupping over various parts of the spine may also be of 
 service, and so also may blisters, moxas, and cauteries 
 (Brown-Sequard). 
 
 The most useful internal remedies are those which tend 
 
HEPATITIS. 197 
 
 to lessen congestion — namely, belladonna and ergot of rye. 
 The dose of ergot in powder may be at first three grains 
 twice a day, and gradually the dose may be increased till it 
 reaches six grains twice a day. Belladonna may be applied 
 to the spine in the form of a plaster four inches wide and six 
 or seven inches long ; and if no amelioration of the symp- 
 toms follows in a few weeks, the extract of belladonna may 
 be given in doses of a quarter or a third of a grain twice 
 daily: and if after six or eight weeks of this treatment no 
 improvement is observed, iodide of potassium, in doses of 
 five or six grains twice a day, may be given in addition to 
 the belladonna (Dr. Brown-Sequard). If meningitis is be- 
 lieved to exist along with chronic myelitis, then the iodide 
 of potassium should be given from the very commencement, 
 along with belladonna, or with secale cornutum (Dr. Mer- 
 yon). It has been given in doses of x. to xviii. grains daily 
 for two months with success, in a case where loss of feeling 
 over the whole of one side was complete for two years (Bri- 
 quet). Spermatorrhoea may be relieved by pressure applied 
 over the region of the prostate (Thomas and Meryon). 
 Electricity must not be used, even for purposes of diagnosis, 
 in a recent attack. [After a comparatively short time how- 
 ever the faradic current may be used to prevent atrophy of 
 the paralyzed limbs. The use of the flesh-brush is recom- 
 mended and occasionally the galvanic current is called 
 for.] When oedema of the limbs exists, a warm bath to 
 the part every night is of service. The bowels must be 
 kept open ; and if anodynes are required, opium should be 
 avoided, and hyoscyamus, conium, or Indian hemp should 
 be used instead. Iodide of potassium ought to be taken 
 before food in the morning, and an hour before dinner, so 
 as to avoid its presumed decomposition by the gastric juice. 
 The nutrition of the spinal cord ought to be improved by 
 the daily use of the cold douche ; and sea-bathing may be 
 of service. If symptoms of irritation do not exist, bella- 
 donna is not to be given ; it is only in cases of congestion 
 that it may be useful in diminishing paralysis ; and the 
 same rule applies to ergot of rye. Strychnine increases the 
 amount of blood in the spinal cord. It may be employed 
 in paralysis only when there is no sign of irritation, ard 
 ought to be avoided when there are signs of congestion Or 
 irritation (Brown-Sequard). 
 
 Hepatitis. — Definition. — Inflammation of the liver. 
 Treatment. — Tartar emetic, in one-eighth or one-fourth 
 
lg& HEPATITIS. 
 
 grain doses every two or three hours, is of Service in the 
 acute parenchymatous innammation,if given sufficiently early 
 — i.e. within the first three days, when there is much vascular 
 excitement, a full bounding, unyielding pulse, with a dry hot 
 skin and scanty urine. Tincture of aconite may be similarly 
 used. General blood-letting is not to be adopted. Local 
 depletion by leeches over the region of the liver, and also 
 round the anus, so as more directly to unload the portal 
 system, must be at once resorted to in acute cases; followed 
 by fomentations and large linseed meal poultices, made as 
 light and soft as possible, over the hepatic region. Mustard may 
 be added to them, or laudanum may be sprinkled over their 
 surface. Saline purgation and alkalies, with or without col- 
 chicum, are also to be freely administered. Some cases may 
 be best treated by ipecacuanha, as in dysentery. In the 
 early stage of acute primary hepatitis, should there be no 
 diarrhoea, a mild purgative should be given at the commence- 
 ment, to be followed by some mild diaphoretic, such as two 
 drachms of the liquor ammoniae acetatis, with five minims of 
 the tincture of hyoscyamus, every half hour. After the skin 
 has been thus made perspirable, the administration of chloride 
 of ammonium, should be at once commenced in 20 grain 
 doses twice or thrice daily, carefully noting its effects, after 
 the manner advocated by Surgeon-Major Dr. William Stew- 
 art (Madras Monthly Journal of Medical Science, 1872, and 
 Indian Medical Gazette; Philadelphia Med. Times, April 13, 
 1878). Dr. Stewart had previously (1870) published a pamph- 
 let at Rangoon, in which he called the attention of the 
 profession in India to the chloride of ammonium which has 
 since obtained a great and well-deserved reputation in India 
 and other tropical countries for the treatment of hepatic 
 congestion; and it has been found of great use in this coun- 
 try as well as in India (Murchison, " Clin. Lectures on Diseases 
 of the Liver," 2nd Edition, 1877, 'pp. 136 and 624). About 
 fifteen minutes after the first dose a sensation of warmth is 
 experienced in the epigastrium, which gradually pervades the 
 abdomen and becomes diffused over the entire cutaneous 
 surface. The patient may feel "light-headed," and at times 
 drowsy, and the acute pain is either removed or limited to 
 some fixed point. A free and equable perspiration takes 
 place over the entire surface in about a quarter of an hour, 
 and with each dose similar effects will occur. Other pheno- 
 mena may occur which the patient and physician must be 
 prepared for — namely,symptoms referable to the liver or relat- 
 
HERPES. I99 
 
 ed parts, and variously described as a "shock," or succession 
 of "shocks," in the hepatic region, "as something giving 
 way," a "pricking sensation," a "pulling," " clawing," 
 "working" or "gnawing" sensation. Fomentations or bran 
 poultices are to be applied to the seat of pain. The diet is 
 to be limited to arrow-root, sago, and bariey flower made 
 with milk, and barley water may be taken freely. Beef-tea 
 may be added during convalescence. If liver enlargement 
 continue on cessation of the physiological action of the drug, 
 with feeling of stiffness, weight, or uneasiness, it may con- 
 tinue to be given in smaller doses (gr. v. to x.) thrice daily. 
 The patient must be kept in bed, and in the recumbent posi- 
 tion. Alcoholic stimulants, fermented drinks, and solid food 
 must be absolutely forbidden, and the diet restricted to the 
 farinaceous food already mentioned. Hot turpentine epi- 
 thems are beneficial. Iodide of potassium, in combination 
 with taraxacum, is of service in the chronic forms of 
 hepatitis. 
 
 Herpes — Definition. — This lesion is expressed by red 
 patches on the skin, of irregular form and variable size, upon 
 each of which there arises a group, cluster, or crop of ex- 
 tremely minute vesicles, for the most part in a corymbiform 
 arrangement. 
 
 Treatment. — Dry applications, such as enveloping the parts 
 in cotton wool after sprinkling with oxide of zinc in fine 
 powder, or with starch, I have always found better than wet 
 applications. Tincture of aconite and tincture of opium 
 have been applied to relieve the severe intercostal pain. 
 The intolerable burning has been relieved by painting over 
 the vesicated patches with collodion. [The most effective 
 remedy however, not only for the relief of the distressing 
 neuralgic pains, but as radically curative, is the galvanic 
 current applied both locally and to the central nervous sys- 
 tem.] An opiate application, such as Dr. Fuller recommends 
 in siatica, may be of use in some cases of shingles, namely: — 
 
 r^.Tinct. opii, Sp. ^Ether. Sulph. co.;glycerine, aa 3 hi.; Ext. 
 Belladonna, gr. xx; misce. A strip of flannel soaked in this 
 should be applied along the course of the deep-seated pain, 
 and covered with oil-silk, to prevent evaporation (Waring). 
 
 The state of the stomach and digestive organs, and diet 
 generally, should be regulated. Malt liquors should be 
 avoided; and, if pain is severe, opiate fomentations may be 
 applied. Herpes preputialis requires no treatment beyond 
 
200 HOOPING COUGH. 
 
 careful ablution with tepid water, and the interposition of a 
 piece of wet lint between the prepuce and the glans penis. 
 If there is much pain, the lint should be moistened with a 
 watery solution of opium. 
 
 Hooping-COUgh.— Definition. — An infectious and (some- 
 times epidemic) specific disease, preceded and accompanied 
 by fever of variable intensity ; attended in the first instance 
 by catarrh, and subsequently by paroxysmal fits of con- 
 vulsive coughing, which occur in numerous, short, rapid, 
 spasmodic movements of forcible expiration, suddenly fol- 
 lowed by a prolonged and deep inspiration marked by a 
 characteristic sound of a loud, sonorous kind, and variously 
 named the "kink," "hoop," or "whoop." These paroxysms 
 of expiratory and respiratory convulsive movements alter 
 nately recur several times, till the fit ends by a quantity of 
 mucus being brought up from the lungs, or till the contents 
 of the stomach are evacuated. 
 
 Treatment. On the invasion of the disease, beyond put- 
 ting the patient on a low or very moderate diet, and attend- 
 ing to the daily action of the bowels, there is little occasion 
 for medicine. It will run its course ; and although no drug 
 has any direct influence over this disease, one of two indica- 
 tions of treatment may be followed. The first is to prevent, 
 if possible, cerebral irritation or convulsions, or any attack of 
 inflammation, either of the lungs, the stomach, or of the 
 membranes of the brain. The second indication, after the 
 period of danger is past, is to prescribe such medicines as 
 may diminish, mitigate, and control, as far as possible, the 
 frequency of the paroxysms, co check those secretions which 
 are in excess, and to excite those which are in defect. These 
 objects are best obtained by mild sedatives, combined with 
 gentle purgatives or laxatives. The choice of the sedative 
 has been considered a matter of much importance. The 
 Continental physicians have bestowed much praise on bella- 
 donna, others on hemlock, others on henbane, while some 
 have contented themselves with opium. It must be admit- 
 ted, however, that none of these narcotics possess any speci- 
 fic property in controlling this disease, so that the selection 
 of the particular one must be left to the discretion of the 
 practitioner. The mildest sedatives, such as hyoscyamus, 
 or the syrup of poppies, are the safest and best. Should, 
 however, belladonna be selected (as it seems to be the most 
 efficient sedative), if the child be under four years of age, 
 the dose ought not to exceed one-eighth or one-tenth of a 
 
HOOPING COUGH. 201 
 
 grain of the extract, with the same quantity of the powder 
 of the leaves in a pill, the pill being dissolved in syrup at 
 the time when it is to be administered (Trousseau). The 
 dose should be given in the morning ; and only once daily, 
 commencing with one pill, and increasing to two or more. 
 Or if hyoscyamus is chosen, half a grain to a grain every six 
 or eight hours ; while, if it be the syrup of poppies, this 
 medicine should be given in such fractional doses of 
 a drachm as are suited to the age. Powdered belladonna root 
 has been recently recommended by Vollaut. The dose is 
 one-fifth of a grain, given at first once, then twice, then four 
 times a day, and so on until the paroxysms begin to subside, 
 when it is to be given at much longer intervals. Thus, he 
 says, the spasmodic period may be positively arrested in 
 three or four days (Syden. Society Year-Booh, 1862). Cochi- 
 neal is an anodyne which sometimes affords relief. I have 
 found it of marked benefit in cases where the child has been 
 losing flesh from the constant vomiting following the parox- 
 ysms of cough. The tendency to vomit has always disap- 
 peared under its persevering use. It is usually prescribed 
 in the form of a mixture, consisting of cochineal, 10 grains ; 
 subcarbonate of potash, 20 grains ; sugar, % oz. ; water, 
 4 oz.; rub together and strain (Squire's Companion to the 
 Pharmacopoeia, p. 62) Of this mixture, a quarter of a tea- 
 spoonful four times a day is sufficient for a child one year 
 old; half a teaspoonful for a child of two years old; and a 
 teaspoonful for a child of four years. Boiled apples in milk 
 should be given for food. An opiate, in the early stage ot 
 the disease, ought not to be administered alone, as it is apt 
 to check the mucous secretion. Some purgative or laxative 
 ought, as a general rule in all cases, to be combined with it ; 
 such as the confectio seDnae, rhubarb, castor-oil or manna. 
 The neutral salts, however, sit easiest on the stomach, and 
 (as the medicine must be continued) they are the most agree- 
 able to the patient. If at the outset or afterwards the cough 
 is very suffocative, an emetic is useful. Five to nine grains 
 of sulphate of copper dissolved in three ounces of distilled 
 water, and a dessert-spoonful every ten minutes, is the most 
 efficient (Trousseau). Nitric acid, in the following formula, 
 has been found of service : — 
 
 Acid. Nitrici diluti, f 3xii.; Tinct. Cardam. comp., 
 f 3 hi,; Syrup, f 3 hiss.; Aquae, f 3 i.; misce. Of this mix 
 ture, one or two small teaspoonfuls may be given every two 
 hours (Gibb). 
 
202 HOOPING COUGH. 
 
 If convulsions should come on suddenly, and without 
 headache or other symptom of inflammatory action, small 
 doses of any opiate, and mustard poultices to the feet, may 
 relieve the patient ; and should convulsions still continue, 
 an asafcetida injection may be administered. It often hap- 
 pens that convulsions are combined with a suppression of 
 the vomiting, and of the usual glairy discharge. In these 
 cases leeches, followed by a large linseed poultice, should be 
 applied to the epigastrium. If the unfavorable symptoms 
 should advance, and headache or other symptoms show an 
 affection of the membranes of the brain, leeches should be 
 applied to the temples and cold to the head. When the 
 poison excites inflammation of the tissues or substance of 
 the lungs, bleeding to a limited amount by leeches may be 
 required ; but the affection is not to be subdued by bleed- 
 ing, as in simple inflammation. There is in severe hooping- 
 cough* as in typhus, cholera, and many other affections, an 
 unknown element which modifies and gives a specific char- 
 acter to all intercurrent inflammations. If the intestinal 
 canal be affected, some purgative, combined with calomel, 
 may be necessary to free the bowels from their contents. If 
 the stools be white and muciform, and the patient not re- 
 lieved, an enlarged state of the follicles may be suspected, 
 and a linseed poultice should cover the abdomen for some 
 hours, preceded by an enema of syrup of poppies and barley- 
 water, which should be administered night and morning. 
 
 The disease having passed into the third stage, it is desira- 
 ble to attempt to abridge the duration of the cough, which 
 often extends to a most distressing length ; and for this pur- 
 pose tonics, antispasmodics, counter-irritants, and other reme- 
 dies, either externally or internally, have been recommended. 
 For medicine there is, perhaps, nothing better than a few 
 drops of ipecacuanha wine combined with a minute propor- 
 tion of laudanum or belladonna, to be administered every 
 two, three, or four hours. The more stimulant antispasmod- 
 ics, as asaicetida, castor, musk, oil of amber, cantharides, and 
 camphor, are the remedies which have obtained the most 
 suffrages in the cure of this stage of hooping-cough. The 
 two first are in most esteem. Asafcetida should be given in 
 emulsion, in the dose of one or two grains to a child two 
 years old, repeated three or four times a day, or even as often 
 as every two or three hours. Cullen preferred cinchona to 
 asafcetida, and considered it "the most certain means of 
 curing the disease." Many other remedies have been men- 
 
HYDROCEPHALUS, ACUTE AND CHRONIC. 203 
 
 tioned, as alum, hydrocyanic acid, oxide of zinc, arsenic, 
 and many preparations of iron. All of these remedies have 
 been found to a certain extent useful as tonics ; but in esti- 
 mating the results of remedies, we should be careful not to 
 mistake temporary recovery for cure ; and the fact of so very 
 many remedies being highly spoken of suggests doubt as to 
 the value of either. 
 
 When internal remedies have failed to make any impres- 
 sion, relief may be obtained by means of local treatment, or 
 by derivatives, as by some liniment or embrocation, as the 
 liniment of camphor or of ammonia, or with asafcetida, oil of 
 amber, oil of turpentine, or the tincture of cantharides. The 
 general opinion, however, is, that these do little good unless 
 they contain some opiate, whose absorption they facilitate, 
 and this may be attended with danger. The application of 
 strong solution of nitrate of silver to the skin over the larynx 
 has been much recommended. Foot baths and the warm 
 bath have also been used, and often with much efficacy. A 
 change of air is a resource of great value. A change from 
 the bad air of a town to the purer air of the country is at all 
 times a great benefit ; it has also been found that a change 
 from the country to the town is not less beneficial, and that 
 the patient is benefitted even by the removal to a short dis- 
 tance from home. 
 
 Dietetic and General Treatment. — The patient should not 
 be allowed animal food from the commencement almost to 
 the termination of the disease in its acute form It is desira- 
 ble also that the temperature of his apartment should be 
 regulated, and that he should not be exposed to any consid- 
 erable or sudden change from heat to cold. In mild weath- 
 er also, if no local symptom forbids, he should be permitted 
 to take exercise in the open air. He should likewise, next 
 his skin, wear flannel. 
 
 There are no known means of prevention, except an entire 
 removal from every source of contagion. 
 
 Hydrocephalus, Acute — see Meningitis, Tubercular. 
 
 Hydrocephalus, Chronic. — Definition. — Effusion of 
 fluid in the subarachnoid space, or generally distending the 
 ventricles of the brain, and differing from cerebro-spinal 
 fluid in containing more albumen (Hoppe) ; occurring chiefly 
 among children, and when discovered later in life, generally 
 dating back to childhood. The tissue of the brain in con- 
 tact with the fluid, especially the commissural parts, is apt to 
 
204 HYDROPERICARDIUM HYDROPHOBIA. 
 
 be broken down by oedema into a thin white pulp (hydro- 
 cephalic or white softening). 
 
 In hydrorachis the effusion of fluid is within the cavity of 
 the spinal cord. 
 
 Treat?nent. — For chronic cases of hydrocephalus there can 
 be no relief. In cases of hydrorachis, where a tumor is as- 
 sociated with spina bifida, iodine injections have been pro- 
 posed (Velpeau, Debout, Brainard, Gross, Meryon). In op- 
 erating, the puncture should be very small, by a small flat 
 curved needle, directed subcutaneously into the sac. A 
 drain of the fluid may then be allowed to escape through a 
 canula, and the injection used must be very weak at first, the 
 object being to excite a slow process of inflammation in the 
 cyst. One-eighth of a grain of iodine, and a quarter of a 
 grain of the iodide of potassium in solution, is the quantity 
 prescribed for injection by Dr. Gross. Dr. Brainard uses a 
 solution composed of five eighths of a grain of iodine and 
 half a grain of iodide of potassium to one drachm of water. 
 The puncture is to be closed with a twisted suture, and coat- 
 ed over with collodion. An anodyne should be administered 
 and the child kept lying on its face. Mr. W. M. Coates, of 
 Salisbury, has been also successful by a similar method of 
 treatment. If the life of the child be saved, paraplegia is 
 still apt to remain, and perhaps involuntary defecation and 
 micturition (Meryon in Brit. Med. Journal, July n, 1863, 
 p. 28 ; also " Practical and Pathological Researches on the 
 Various Forms of Paralysis," p. 25). 
 
 Hydropericardilim. — Definition. — An increase of the 
 normal liquor pericardii, containing little albumen, and anal- 
 ogus to the fluid of chronic hydrocephalus. 
 
 Treatment must be regarded by the attendant circumstan- 
 ces of the case, and in accordance with what has been already 
 written on the subjects of pericarditis and dropsy. Paracen- 
 tesis may be required. 
 
 Hydrophobia. — Definition. — A disease peculiar to ani- 
 mals of the canine or feline race, the specific poison of which 
 being implanted by them in man, or in other animals, pro 
 duces a similar malady. The saliva or secretion issuing from 
 the mouth of the diseased or rabid animal contains and so 
 conveys the poison which inoculates rabies, either through a 
 wound or through a thin epidermis with abrasion. The period 
 of incubation of the poison after inoculation varies from four 
 to sixteen weeks, or even longer, before the malady becomes 
 
HYDROPHOBIA. 205 
 
 developed. The disease is characterized by severe constric- 
 tion about the throat, spasmodic action of the diaphragm, 
 and distress at the epigastrium : all of which are aggravated 
 or brought about by attempts to take fluid, or by the least 
 breath or current of air on the surface of the body, which 
 produces, in the first instance, an effect resembling that pro- 
 duced upon stepping into a cold bath. Saliva, tenacious and 
 clammy, issues from the mouth. Paroxysms of phrensy, or 
 of uncontrollable impulsive violence (rabidity), supervene. 
 The duration of the disease varies from three to six or seven 
 days, the greater number of cases terminating in death on the 
 second and fourth days from the accession of symptoms. 
 Death is generally sudden, and unexpected at the moment. 
 
 Treatment. — As there are but few authenticated cases of 
 recovery from hydrophobia, so there are few instances of any 
 mitigation of the symptoms by the use of medicine. All that 
 remains is to mention the most leading experiments that have 
 been made, with the hope that, as they have not been suc- 
 cessful, they may not be wantonly repeated. 
 
 Dr. Hamilton gives twenty-one cases, and adds, " many 
 hundreds more are on record," in which venesection has 
 been unsuccessful, though frequent and copious. Opium has 
 been given by Dr. Babington, to the enormous amount of 180 
 grains of solid opium in eleven hours, without the slightest 
 narcotic effect, or the slightest mitigation of the symptoms. 
 Nord has given a drachm of belladonna in twelve hours, 
 without any benefit. Dr. Atterly gives to a child eight years 
 old two drachms of calomel by the mouth, and rubbed in two 
 ounces and a half of strong mercurial ointment in a few hours, 
 with an equal want of success. A case, however, is related 
 by Ligget, which is said to have been successfully treated by 
 half-drachm doses of calomel, given to the extent of ptyalism, 
 induced in three days, after four and a half drachms of 
 calomel had been taken. The case really appears to be one 
 ot hydrophobia ; and recovery is said to have been complete 
 by the twelfth day (Amer. Quar. Journal of Medical Science, 
 Jan., i860). Iron, arsenic, nitrate of silver, camphor, musk, 
 cantharides, turpentine, tobacco, acetate of lead, ammoniacal 
 solutions of copper, hydrocyanic acid, galvanism, strychnine, 
 nitrous oxide, chlorine, and guaiacum, have all been given in 
 equally large doses, but have signally failed. In addition to 
 these, Ploucquet in his " Literatura Medica Digesta," has enu- 
 merated nearly 150 other medicinal remedies. The failure 
 of every remedy by the mouth, and the inefficacy of opium, 
 
206 HYDROPHOBIA. 
 
 of morphine, and of laurel water, even when injected into the 
 veins, so convinced Majendie that in hydrophobia the con- 
 stitution was armed against the action of any medicinal sub- 
 stance, that on a patient laboring under this disease being 
 brought to the Hotel Dieu, he determined to rely for all treat- 
 ment on an injection of warm water into the veins. The 
 patient, at the time of the operation, is represented as being 
 absolutely insane, so as to require to be restrained. In this 
 state, and with a pulse of 150, Majendie injected into his 
 veins, in the course of two hours and a quarter, two pints of 
 water, at the temperature of ioo Q . At the conclusion of this 
 operation the pulse had fallen to 80, and the patient had re- 
 covered his senses, so that restraint was no longer necessary. 
 The sequel, however, renders it doubtful whether this miti- 
 gation was desirable at the price of the intense suffering which 
 followed. The poor man lived eight days afterwards, but the 
 despondency and mental agitation quickly returned, and at 
 the end of three days the poison (or the state of the blood 
 induced by it and the warm water) appeared to setup a new 
 series of actions on the synovial membranes of the wrists, 
 elbows, and knees, attended with excessive pain, so that ne 
 was unable to bear the weight of the bed-clothes, and he died 
 in great torture. The articulations thus affected were found, 
 on post-mortem examination, to be greatly inflamed, and 
 their cavities filled with pus. This case is remarkable as 
 being the one in which life was prolonged for the greatest 
 period of time recorded of this disease. The experiment lias 
 since been repeated by Gaspard and others ; but the mitiga- 
 tion, if any, has been so* slight and transient as to give no en- 
 couragement for repeating it ; and, tried on the rabid dog by 
 Youatt and Mayo, it proved eminently unsuccessful. 
 
 The property which some animal poisons have of controlling 
 and of interrupting the actions of other morbid poisons on 
 the constitution has caused even animal poisons to be tried 
 in the cure of this disease. The rapid and powerfully acting 
 poison of the viper led to the hope that the bite of that rep- 
 tile might prove an antidote to the hydrophobic virus ; but 
 the experiment, tried in France, Germany and Italy, upon 
 animals, has been entirely unsuccessful. M. Grindard con- 
 ceived that the vaccine virus might influence hydrophobia, 
 and he vaccinated a hydrophobic child in three places, and 
 afterwards injected five charges of vaccine lymph into the 
 veins ; but the child died without any marked remission, and 
 in the usual time. The following draught has been found 
 
HYSTERIA. 207 
 
 rather to promote euthanasia than to hold out any prospect of 
 cure : — 
 
 r> Spirit. JEther. Sulph., Tinct. Opii, aa mxx. ; Spirit. 
 Ammon. Aromat., 3 ss. ; Chloroform, mxx ; Mist. Camph., 
 § iss. ; misce. To be given as often as may be considered 
 safe (Cunningham, Carden). 
 
 On the same principle chlorodyne may too be given. The 
 vapor bath is sometimes useful in moderating spasm, 
 Having regard to the symptoms generally, and to the morbid 
 appearances as being in many respects similar to tetanus, the 
 remedies recommended in that disease might be successful in 
 some cases of hydrophobia. Sialagogues have recently been 
 advocated upon theoretical considerations, especially the ex- 
 tractum jaborandi fluidum, of which one drachm represents 
 one drachm of the leaves as prepared by Messrs. Gall & Co. 
 Curare has also been employed, but not with success, mainly 
 at the suggestion of the late Dr. Francis Gibson of St. Mary's 
 Hospital, London. For this purpose, Messrs. Gall & Co. 
 have prepared an injectio curare (three minims being equal 
 to one-third of a grain), which it is advised should be injected 
 at intervals of a quarter of an hour or more, as soon as indi- 
 cations of the physiological action begin to diminish. 
 
 Preventive Treatment. — The probabilities are, that unless 
 the operation of excision, or cauterization, be performed 
 within a few minutes after the bite of the rabid animal, it is 
 impossible to save the patient from the fatal disease, which, 
 according to the susceptibility of his constitution, may 
 threaten him at any moment. In all probability no prophy- 
 lactic medicine exists in nature, and the administration of 
 any potent substance by way of prevention is worse than use- 
 less ; for, without protecting the patient, it may injure his 
 constitution. Mild remedies, if they lend to tranquilize his 
 mind and appease his apprehensions, may be innocently em- 
 ployed. 
 
 The theory which maintains that a zymotic incubation first 
 takes place in the wound, by which the poison is originally 
 implanted, suggests the most rational prophylactic — namely, 
 to destroy entirely by potass fusa the whole cicatrix, where 
 practicable ; or, by some other surgical means, entirely to 
 remove it at as early a period as possible, and previous to the 
 occurrence of symptoms. 
 
 Hysteria. — Definition-. — A complex disorder of all the 
 cerebral functions, of a chronic kind, occurring mainly in 
 females from the age of puberty upwards. It is probably 
 
2o8 HYSTERIA. 
 
 associated with some morbid state of the emotional or 
 sensori-motor centres, and presents every variety of altera- 
 tion, so that the phenomena of hysteria are protean, simulat- 
 ing or mimicking the phenomena of almost every other dis- 
 ease, while the most common and characteristic features of 
 the affection are certain motorial changes of a convulsive 
 nature, usually of paroxysmal occurrence. 
 
 Treatment. — The treatment may be divided into what 
 should be done during the fit, and into what should be done 
 afterwards. 
 
 When the patient falls into a fit of hysteria, the first thing 
 to be done is to loosen everything tight about her person. 
 The window should be opened, and the cold air allowed to 
 blow over her. She should then be laid in the horizontal 
 posture on a bed, or on the floor, as a means of rendering 
 the circulation through the brain more equal, and to enable 
 us the more readily to control the convulsive movements of 
 her body. This being done, many modes of further pro- 
 ceeding may be followed. Some recommend, in plethoric 
 cases, that the patient should be bled — a remedy certainly 
 in many instances manifestly improper, and in all of doubt- 
 ful efficacy. When the jaw is locked, an enema, consisting 
 of the yolk of an egg beat up with two drachms of asafcetida, 
 with half a pint of water added, may be administered; or, 
 still better, an enema of turpentine, in which half an ounce 
 of turpentine is similarly mixed with the yolk of an egg, and 
 half a pint of water added. These remedies, in some in- 
 stances, instantly remove the affection, but in other cases 
 not for some hours. Another remedy is to fill the mouth 
 with salt. The remedy, however, which supersedes all 
 others, and is unquestionably the best, is a good drenching 
 with cold water. 'I believe there is more virtue in cold 
 water than in any other single remedy " (Watson). If the 
 patient lie on the bed, the head should be drawn over its 
 side, and a large quantity of water poured on it from a con- 
 siderable height out of a pail, jug, or other large vessel, and 
 directly over the mouth and nose of the patient, so as to 
 stop her breathing, and compel her to open her mouth. 
 This practice is generally introduced into hospitals ; and un- 
 til it was adopted it was not unusual to see three or four 
 patients in hysteria in the same ward, and at the same time. 
 Under this practice, however, an hysterical case is rare, the 
 fit seldom occurs twice on the same person, and the affection 
 never becomes epidemic. 
 
HYSTERO-EPILEPSY ICHTHYOSIS. 2O0 
 
 After the paroxysm is over, if the patient complains of 
 continued headache, a few leeches to the temples may be 
 necessary, especially if the urine be small in quantity and 
 high colored ; but in all other cases leeches, blistering, or 
 cupping should be avoided, as tending rather to aggravate 
 than to control the disease. The next object is to regulate the 
 bowels by such remedies as may be necessary, and at the 
 same time to support and tranquillize the patient by stimu- 
 lants, such as ether or asafcetida, combined with hyoscyamus 
 in the form of tincture, the syrup of poppies, or small doses 
 of morphia. 
 
 Niemeyer recommends the chloride of sodium and gold as 
 a restorative nerve tonic. He prescribes in the form of a 
 pill, as follows : 
 
 5. Auri. chlorat. natronat, gr. v.; Gum. tragac. Co., 3 i.; 
 Sacc. Alb., q. s.; misce. Divide into forty pills, of which one 
 is to be taken an hour after dinner, and another an hour after 
 supper. After a time, two are to be taken as a dose at one 
 time, and increased gradually till eight pills a day are taken; 
 a cold shower bath twice daily. 
 
 Thestateof the uterine functions must always be inquired 
 into. If leucorrhcea be present, or the menstruation be pro- 
 fuse, the mineral acids, or the bitartrate of potass., will be 
 found most efficacious, by restoring a more healthy state of 
 the deranged organs. 
 
 The urine is often suppressed for a time after an attack of 
 hysteria ; but unless the bladder be sensibly, and perhaps 
 painfully distended, no attempt should made to draw the 
 urine off. Something more should be hazarded to avoid 
 this necessity, for the catheter once passed, that operation 
 will require to be performed morning and night, perhaps for 
 several months. It is important that pity, attention, and 
 sympathy be withheld as much as possible from hysterical 
 patients. The moral and bodily condition deterioates under 
 such influences. Firmness is essential for successful treat- 
 ment. 
 
 HysterO-Epilepsy— See Epilepsy. 
 
 Icterus — See Jaundice. 
 
 Ichthyosis. — Definition. — A lesion which involves the 
 whole tissue of the skin and is characterized by the growth 
 of thick, dry, imbricated scales of a dirty grey color, resting 
 upon a perfectly uninflamed surface, and never accompanied 
 by pain, heat, or itching, 
 14 
 
2 I O ILEUS INFLUENZA. 
 
 Treatment. — Remedial measures are only palliative, con- 
 sisting mainly of mucilaginous and glycerine lotions, with 
 vapor baths to mollify the roughness. Potash solutions, or 
 other preparations of potash, are contra-indicated as local 
 applications. 
 
 Ileus — See Intestines, Obstrurtion of. 
 i Infantile Convulsions — See Convulsions, Infantile. 
 
 Influenza — Definition. — A specific catarrhal inflamma- 
 tion of the mucous membrane of the air passages, and gen- 
 erally also of the digestive organs, with severe constitutional 
 disturbance. The disease is invariable in its essential char- 
 acteristics, frequently prevailing as an epidemic, attended 
 with lassitude and prostration to an extreme degree, with 
 special and early implication of the naso-laryngo-bronchial 
 mucous membrane. Frequent chills occur, and great sensi- 
 bility to cold exists over the surface of the skin; the eyes 
 become injected, and tend to fill with tears, the nostrils dis- 
 charging an acrid fluid; attended with fixed and intense 
 pain in the head, mostly frontal over the eyes, sometimes al- 
 so attended with giddiness. The nights are sleepless, with 
 delirium or lethargy; cough prevails with yellow expectora- 
 tion, most troublesome at night, and tending greatly to in- 
 crease the headache. Fever attends the disorder, some- 
 times slight and sometimes severe, and of a type varying in 
 different epidemics and localities. The duration of the fever 
 is definite, of from four to eight days (Parkes). The sense 
 of taste is greatly disordered, and t here is great anxiety 
 and depression over the region of the heart. 
 
 Treatment. — As a general rule, the great majority of cases 
 in epidemics of influenza have scarcely required any medical 
 treatment. In 1782 it was observed that "many, indeed, 
 were so slightly indisposed as to require little or no medi- 
 cine; nothing more was wanted to their cure than to abstain 
 for two or three days from animal food and fermented 
 liquors, and to use some soft, diluted, tepid drink. A gentle 
 purgative at the beginning of the disease was useful in mod- 
 erating the fever; and nature seemed to point out the repe- 
 tition of it afterwards when there was pain in the stomach 
 and bowels, and a tendency to diarrhoea." The same was 
 observed in 1762. Nothing, likewise, was observed so suc- 
 cessful in mitigating the cough as to open the bowels, and 
 afterwards giving a gentle opiate at night. In the year 1837 
 it was also remarked that, as long as the symptoms werelinv 
 
INFLUENZA. 211 
 
 ited to cough, hoarseness, headache, or other pains moderate 
 in degree, the patients all recovered by putting them on a 
 low diet, by attending to their bowels, and confining them 
 for a few days to the house. It was quickly found that the 
 disease ran a course scarcely influenced by medicine. A 
 small number, however, required medical aid, either from 
 the severity of bronchitis, the occurrence of pneumonia, of 
 angina, or of severe dyspnoea, of the disordered state of the 
 bowels, or more frequently from the debility induced by the 
 disorder. Blood-letting, even by leeches, is always hurtful. 
 It does not relieve the fever, and increases the nervous de- 
 pression. But when pleurisy, bronchitis, or pneumonia may 
 supervene, leeches to the chest, or cupping, may relieve 
 symptoms. A mild purgative dose of calomel (one to three 
 grains) should be given once at first, followed by a saline 
 purgative. Dark-colored motions are brought away, the 
 spirits improve, and the fever abates. But mercury must not 
 be given beyond an occasional purge. Emetics are also to 
 be avoided. They increase depression, and are apt to pro- 
 duce irritability of the stomach difficult to subdue. Hot 
 fomentations, bran, mustard, or linseed meal poultices to the 
 chest, or flannel or cotton wool envelopes, are often of great 
 comfort and usefulness. During convalescence sulphate of 
 zinc is a useful tonic when the expectoration is thin and spu- 
 mous; and alkalies are more useful when it is viscid and 
 glairy (Peacock). Nitrate of potash, highly diluted and 
 mixed with lemon juice and sugar, is a most useful drink. 
 From 60 to 120 grains in twenty-four hours may be taken. 
 Stimulants are early called for on account of the intense 
 prostration. Opium must be used with great caution in the 
 severe pulmonary complications. Its use ought to be put off 
 till the later stages, otherwise it may increase the tightness 
 of the chest and the dyspnoea. It must not be given till all 
 danger of lung congestion is past. When the fever and other 
 immediately alarming symptoms of the influenza had ceased, 
 there frequently remained a teasing cough, and the conva- 
 lescents in general complained of languor, want of appetite, 
 and that their sleep was broken and unrefreshing. For re- 
 moving these complaints, change of air and riding on horse- 
 back were most effectual. To some they were absolutely 
 necessary; and, in addition to these, mild tonics, or the nat- 
 ural chalybeate waters drank at the Spas, were of singular 
 service. In slight cases it was sufficient to limit the patient 
 to white fish and puddings; and in the more severe forms, to 
 
212 INSANITY. 
 
 slops and light puddings. The night air was universally pre- 
 judicial. It does not appear that any precautionary treat- 
 ment was of service in preventing the spread of the disease 
 among the attendants on the sick. 
 
 Insanity. — Definition. — Disorders of the mind consequent 
 on brain lesions, or attendant on affections in which the 
 brain is secondarily or remotely implicated. Feelings, Emo- 
 tions, Intelligence, or Will of the patients, conjointly or sep- 
 arately, are exalted, perverted, or impaired. 
 
 The Treatment of insanity resolves itself into the medical 
 and the moral management of the case. Medicine indirectly 
 acts upon the brain as it does upon other organs, so as favor- 
 ably to influence the course of the disease. It regulates the 
 different actions and secretions of the viscera of the body, 
 and thus improves the general health, so that the happiest 
 results are obtained by the early and judicious use of medi- 
 cinal agents. No uniform method of treatment can be taught. 
 The condition is essentially one of asthenia, feebleness, 
 anaemia, or exhaustion. Local bleeding may be adopted in 
 some cases with reference to a distant viscus. Leeches to 
 the vulva and thighs are beneficial in some cases of mania, 
 monomania, or melancholia, in adults, when such disorders 
 of intellect are concurrent with the menstrual period; and 
 to the sphincter ani in those cases obviously connected with 
 suppressed haemorrhoids or hepatic congestion. In some in- 
 stances leeches may be applied with benefit to the Schneide- 
 rian membrane, particularly in those cases occurring in early 
 life, and in persons of plethoric constitution and of sanguine 
 temperament. Illusions of hearing or of vision, which had 
 embittered the patient's life, have been removed by leeching 
 behind the ears or over the superciliary ridges. The utility, 
 in acute mania, of prolonged hot baths was much insisted 
 upon by the late Dr. Winslow. The patient remains from 
 eight to fifteen hours in them, at 82 ° to 86° Fahr., whilst 
 a current of water at 6o° is continually poured over the head. 
 Various details of what is now known as hydropathic treat- 
 ment have recently been introduced, with great advantage, 
 into English asylums, such as the Russian or vapor bath, the 
 wet sheet, wet pack, and the like. Packing in the wet sheet, 
 warm baths with cold to the head, will often procure sleep 
 more certainly than medicine of the sedative or hypnotic class. 
 
 Sedatives, or agents which modify directly the condition of 
 the cerebral tissue, and which procure sleep or rest to the 
 brain, constitute very valuable remedies. In recent acute 
 
INSANITY 213 
 
 Cases they are generally admissible, and are only contra-in- 
 dicated if constipation keeps up the excitement and sleep- 
 lessness* or if local cerebral irritation exists; or if the gen- 
 eral health and secretions are disordered. In the various 
 chronic forms of melancholia they are most useful, and in 
 suicidal insanity. The meconate and hydrochlorate of mor- 
 phia should be uninterruptedly and perseveringly given, in 
 gradually increasing doses, until the nervous system is com- 
 pletely under their influence. The preparation Dr. Millar 
 has found most useful and the least productive of constitu- 
 tional disturbance, is a solution of opium in water, acidu- 
 lated with citric acid (containing about one-sixth of crude 
 opium) administered every four or six hours, in doses of 
 from 10 to 20 minims, (equal to 10 grains of crude opium 
 daily), and continued until the patient feels he can sleep 
 without it. So also will chlorodyne and chloro-morphine be 
 of use in some cases, as well as chloral, bromide of potas- 
 sium, and hyoscyamus. Indian hemp is an extremely useful 
 sedative, not hitherto appreciated sufficiently for many rea- 
 sons. (See an excellent paper on its uses by Professor Rus- 
 sell Reynolds, in Beale's Archives, Vol. II., p. 154.) It re 
 lieves pain, is soporific, anodyne, antispasmodic; and while 
 conducing to sleep, promotes at the same time diaphoresis 
 and diuresis, without producing headache, vertigo, constipa- 
 tion, or impairing the appetite. The dose varies from one- 
 sixth to one-half grain for a child, and from one-third to one 
 grain and a half for an adult. In cases of mental or emo- 
 tional disturbance it will be found extremely useful, espe 
 cially where there is deranged cerebral circulation, with pain 
 and delirium; in cases of incipient insanity after fever or 
 sunstroke; and in cases of senile ramollissement. Recently 
 digitalis, conium, belladonna, have been extensively em- 
 ployed as calmatives. Endermic medication in insanity offers 
 numerous advantages; and hypodermic injections, especially 
 of calmatives and soporifics, have also recently been em- 
 ployed. Dr. Reissner's experience leads him to recommend 
 morphia, codeia, and narceia, the former being much the 
 most useful, and the others only to be used in special cases 
 when morphia fails. Narceia he recommends in those cases 
 where the injection of the morphia produces unpleasant 
 symptoms of an uncomfortable kind — not to say of a pois- 
 onous tendency. Narceia he considers a special remedy in 
 such cases. Preparations of opium introduced into the sys- 
 tem by the hypodermic method, are more speedily mani- 
 
a 14 INSANITY/ 
 
 fested by the results than when administered by any other 
 mode. The acetate of morphia is the best form with a min- 
 imum of acetic acid, in hot distilled water, in the proportion 
 of five grains of acetate of morphia to one fluid drachm of 
 water or of glycerine. One minim of this represents x 1 ^ of a 
 grain — a safe and useful minimum dose. Two minims (equal 
 to -J- of a grain), is the best commencing dose for relief of 
 severe pain, and as a hynoptic in states of nervous irrita- 
 bility, whether connected with disorder of the intellect 01 
 other diseases. Three minims or % of a grain, is an unsafe 
 dose to commence with; dangerous and even fatal results 
 have resulted from such a dose. It should not be given till 
 smaller doses have been tried. Used endermically, the salts 
 of opium are reckoned to be three times as powerful as when 
 swallowed (Waring). Hydrate of chloral is of use in subdu- 
 ing tne delirium of mania and sometimes in obtaining sleep, 
 combined or not with bromide of potassium. 
 
 Purgatives may be regularly required. When the bowels 
 are constipated the form is best determined by the state of 
 the tongue, and sometimes by the idiosyncrasies or proclivi- 
 ties of the patient in regard to medicine taking. Supposing 
 the tongue to be white and coated, the sulphate of magnesia, 
 or other neutral salt, combined with tincture of hyoscyamus, 
 in the proportion of 3 j- of the former to mxv. to mxxx. of 
 the latter, in camphor mixture, is a formula to be recom- 
 mended ; so also is calomel (five grains) with compound ja- 
 lap powder ( 3 i.), and a little powdered ginger ; and also 
 watery extract of aloes nightly. If, on the contrary, the 
 tongue be clean, the cathartic should be given with some 
 slight bitter, as the infusion of orange peel or of gentian. In 
 some cases the bowels are not only exceedingly obstinate, 
 but the patient may be greatly averse to all medicines. In 
 such cases one or two drops of croton oil placed on the 
 tongue or introduced in food produces free evacuations. 
 Mild purgative treatment formed the basis of cure in the 
 school of Pinel and of Esquirol, usually combined, in cases 
 of violence, with the application of cold to the head, and of 
 warmth to the lower parts of the body ; such as placing the 
 patient in the warm bath, and giving him the cold douche — 
 a remedy since more particularly insisted upon. The fur- 
 ther treatment consists in restoring any other functions that 
 may be in defect or in excess, as the functions of the uterus 
 in the female, and of the liver or heart in both sexes, by the 
 usual remedies applicable for these purposes. 
 
INSANITY. 215 
 
 When there is anaemia, vegetable tonics, combined with 
 the preparations of iron, are of great service. At the same 
 time the patient ought to be supplied with an abundance of 
 nutritious and easily digested food. It quiets the noisy, and 
 lessens the dirty, mischievous, and destructive propensities 
 of others. Where there is an absolute refusal of solid food, 
 as in acute mania, it is essential that the liquids (which the 
 patient for the most part readily takes) should contain as 
 much nutritive material as possible. Strong soup and broth, 
 beef-tea mixed with milk and with arrow-root, must be given 
 often. The best form of food is that in which eggs and 
 milk largely enter. Two or three eggs beaten up, and mixed 
 with a half a pint of warm milk, warm ale, or w r arm porter, 
 may be given with a sedative every four to six, or eight 
 hours, and continued daily till excitement abates, or the abil- 
 ity to take solid food returns. Such stimulant food is well 
 borne, and absolutely necessary in cases of acute mania. In 
 melancholia, three to twelve ounces of wine may be neces- 
 sary in the twenty-four hours ; and there is also a tolerance 
 of opium. Ten minim doses may be given three times a day. 
 If impulsive tendencies are manifest with despondency, bro- 
 mide of potassium should be given in thirty to forty grain 
 doses, with an iron mixture. If the tendency is to atonic 
 lethargy, large doses of quinine, or small doses of strychnia, 
 are to be given with the iron. Easton's syrup is valuable. 
 In neuroses of the stomach and gastralgia, arsenic and bis- 
 muth are both of much service in small doses. Muriate of 
 ammonia is of special use in those cases in which the de- 
 pression is intense and paroxysmal in character. 
 
 The moral management of disorders of the intellect is by 
 many supposed to constitute the more efficient mode of cure; 
 and it must be admitted to be a most important adjunct. 
 The first important rule is to remove the patient at once from 
 his family. In slight cases this step is necessary in order that 
 he may be induced to exercise such command over himself 
 as he possesses, and to remove him from influences which 
 may have been aggravating his morbid state ; such as finding 
 himself a prisoner, instead of being master in his own house. 
 In severe cases it is necessary, in order to prevent his doing 
 mischief either to himself or others. In melancholia no form 
 of treatment is so efficacious. The great object is to break 
 up the monopoly of grief and fear which has obtained pos- 
 session of the mind ; and if a new interest can be awakened 
 or a fresh hope insinuated, this object is in a great part ob- 
 
ii6 iNSANitV. 
 
 tained. At the same time solitary brooding and idleness 
 must not be pjrmitted; and at least cheerful companionship 
 must be secured. It is important also to seek out and to 
 treat visceral or constitutional diseases and relieve them — ■ 
 e. g. 9 goutj syphilis, uterine disorders, climacteric conditions, 
 and the like. The main feature in the moral management 
 of the insane in this country is the abolition and absence of 
 mechanical coercion or restraint. The beneficial action of 
 this system, generally known as "the non-restraint system," 
 is now thoroughly recognized in England and Scotland, 
 where it has been gradually established in every asylum since 
 1847-48. But there are certain exceptional phases of insan- 
 ity, in which some mechanical restraint is the most humane 
 mode of treatment — the only mode, indeed, of avoic *ngr cer- 
 tain catastrophes of too common occurrence. In certain 
 conditions of excitement it is proper to place the patients at 
 once in a darkened room, remote from the noise and the 
 means of injury to himself or others, so that as few objects 
 as possible may irritate him, just as a patient with his eyes 
 affected is kept in a darkened room. The effect of such se- 
 clusion is generally of a soothing character; and in not a 
 few cases of periodic mania it is eagerly sought for by the 
 patients themselves. When a case of melancholia is of se- 
 vere type from the first, muriate of ammonia and tincture of 
 opium are the most valuable egents. There is a tolerance of 
 opium in simple melancholia. So long as depression lasts 
 it is taken with benefit to every function. When depression 
 terminates it may be abandoned at once without inconveni- 
 ence. As convalescence advances the patient should be in- 
 duced to undertake some manual labor, or some office in 
 the asylum or household, which, by amusing his mind, will 
 invigorate his body, and greatly tend to restore the healthy 
 working of his brain. There are no more powerful moral 
 medicines than " occupation," "recreation," and "educa- 
 tion." Occupation should be such that no time is left for 
 idleness; or for sitting brooding over morbid fancies. The 
 curative results of well-chosen means of recreation carihot 
 be over-estimated. When the circumstances of the patient 
 admit of it, traveling, which embraces change of air and 
 change of scene as well as exercise, is oftea highly salutary 
 in incipient cases; and much has of late been done by the 
 judicious introduction of music and other amusements into 
 asylums. Change of scene acts often like a tonic to the de- 
 pressed and jaded powers; but where there is great restless* 
 
INSOLATION INTERMITTENT FEVER. 21 f 
 
 ness and feverish perturbation, traveling and change of scene 
 should not be resorted to (Dr. J. Crichton Browne). Con- 
 certs, balls, conversaziones, evening entertainments, pic-nics, 
 excursions, fetes champetres, athletic games, pedestrian ex- 
 cursions, public amusements in towns, and carriage drives, 
 are all legitimate and well-approved means of maintaining a 
 constant and varied succession of recreation adapted for all 
 classes of the insane. When reason is restored and the af- 
 fections again fix themselves on their natural objects, and 
 when the emotions are under control, the patient may be al- 
 lowed to see his friends, and have his attention directed to 
 the affairs and interests of his family ; but it should be re- 
 membered that the mind remains weak and enfeebled for 
 some time after apparent recovery ; and, consequently, the 
 patient's restoration to society should be gradual. 
 
 An hospital for the insane, or a lunatic asylum, is the 
 most fit and proper place for a "person of unsound mind." 
 But every such asylum ought to be governed by one superin- 
 tendent, who should be a medical man — an officer of health 
 to the community over which he presides. He ought to have 
 the means of controlling all sanitary arrangements in whole 
 and in detail — of avoiding over-crowding — of preventing and 
 destroying effluvia — and of examining the quality of the food, 
 the water, and the drugs furnished to the establishment. 
 Chemical and pathological appliances ought therefore to be 
 at his disposal for his use. The number of patients who 
 may be thus under the supervision of one medical head in 
 an asylum ought not to exceed 200 (Esquirol, American 
 Commissioners in Lunacy). Premature removal from asy- 
 lum treatment, in opposition to medical advice, is greatly to 
 be deprecated ; and its baneful results are frequently to be 
 seen, especially in the sad endings 01 cases of suicidal mel- 
 ancholia. In such cases an acknowledgment should be re- 
 quired 01 the recipient ot the patient, or his friends, that he 
 is removed notwithstanding the assurance given by the med- 
 ical superintendent that the patient is not recovered, and is 
 unfit for removal (Dr. Lindsay, Thirty-second report, p. 14). 
 Such removals not unfrequently induce a change of type 
 from acute and curable to chronic and incurable mental dis- 
 ease. 
 
 Insolation — See Sunstroke. 
 
 Intermittent Fever — See A^ue. 
 
218 INTESTINES, HEMORRHAGE FROM. 
 
 Intestines, Hemorrhage From — Definition. — Loss of 
 blood from some portion of the mucous membrane of the 
 alimentary canal below the stomach. It may have its seat 
 in the small intestines, or in the large, or in both, but prob- 
 ably never flows from the whole length of the canal. 
 
 Treatment. — Ergot is a useful remedy. Dr. Macgre- 
 gor, of Glasgow, records a ! case of persistent periodical 
 haemorrhage from the bowels which yielded to ergot when 
 all other remedies had failed {Glas. Med. Journal, June, 
 1867). In haemorrhage from the bowels in enteric fever, 
 the tincture of the perchloride of iron is often useful, and 
 if associated with much arterial action, it may be com- 
 bined with digitalis, as in the following formula : 
 
 I£ Tinct. Ferri Perchlorid., m xxx. ; Tinct. Digitalis, m 
 xv. ; Aq. Menth. Pip., ? iss., repeated every four hours 
 (Waring). 
 
 In the event of failure, the iron tincture may be used as an 
 enema, combined with opium, in the following formula: 
 
 ^ Liq. Ferri Perchloridi, m xv.; Morphiae Hydrochlor, 
 gr. y 2 \ Aq. Tepid, |iv-.; Misce (Dr. John Harley). 
 
 In cases where there is a tendency to syncope from intes- 
 tinal hemorrhage, oil of turpentine (m x. to m xv.) every half 
 hour or hour has proved an effectual remedy (Dr. John Har- 
 ley). The treatment of haemorrhoids consists — (1.) In fo- 
 menting them with hot water, with the free use of Castile 
 soap, when they are in the acute stage of inflammation, and 
 of a dark red appearance, throbbing, and painfully burning, 
 as if a red-hot coal had been applied to them, In this condi- 
 tion dusting with calomel has been found to give relief (Bid- 
 die, Atkinson, Practitioner, Vol, XXIII ; 1879, p. 104). (2) 
 If the pains continue excessive, a few leeches may be applied 
 to the margin of the anus ; and, at the same time, the bitar- 
 trate of potash, combined with sulphur and guaiacum, in the 
 proportion of one part sulphur and of guaiacum to two of 
 cream of tartar, a teaspoonful being taken three or four times 
 a day, which ought to keep the bowels gently relaxed. Nu- 
 merous cases have now been published which confirm the 
 value of glycerine, in doses of a dessert-spoonful twice a day, 
 in the treatment of internal and external haemorrhoids (Dr 
 David Young, Practitioner, 1. c, p. 251). The protruded 
 bowel ought also to be carefully washed with a sponge and 
 cold water after defecation, and the use of paper entirely 
 discarded. To relieve the weight and tension after use of 
 soap and fomentation, compound gall ointment and bella- 
 
INTESTINES, INFLAMMATION OF OBSTRUCTION OF. 219 
 
 donna extract, in equal parts, should be freely applied every 
 three or four hours till the pain subsides. In the chronic 
 stage, the common pitck ointment is the best application (F. 
 P. Atkinson, 1. c.) Stringent rules ought to be laid down as to 
 diet, which should be light, and the patient limited to 
 French and Rhenish wines. Ablution with cold water 
 should be practiced morning and evening ; and some per- 
 sons are sufficiently sthenic even to bear with advantage 
 an injection of cold water after each evacuation of the 
 bowel. In prolapsus ani and haemorrhoids, Professor Cle- 
 land recommends the use of liquor bismuthi as an enema. 
 A dessert-spoonful of the liquor is to be mixed with half 
 a wine-glassful of fluid starch, and, after getting into bed 
 and returning the bowel to its place, to introduce this enema 
 and retain it. 
 
 Intestines, Inflammation of— See Enteritis. 
 
 Intestines, Obstruction Of— Definition. — An obstacle 
 or impediment which obstructs the passage of contents 
 through the bowel. 
 
 Treatment. — In all cases of intussception, whether oc- 
 curring in children or adults, the administration of purga- 
 tive medicines tends to aggravate the lesion and the symp- 
 toms. Accordingly the rule of practice is absolute — 
 namely, " to withhold all purgative medicines from the com- 
 mencement in cases of intussusception." The bowel being 
 incarcerated, the stimulus of purgation proceeding from above 
 downwards is quite unable to undo the incarceration of an 
 intussusception. A purgative acts injuriously as a stimulus 
 which cannot be obeyed ; and its obvious tendency is to in- 
 crease the peristaltic action of the bowels, and therefore to 
 increase still more the invagination. That such is the case 
 will be readily understood by a physiological consideration 
 of the phenomena of intussuception : for although it is not 
 always easy to account for the first beginning of invagina- 
 tion, yet physiology enables us to understand how an invagi- 
 nation once begun, the lesion tends to increase — (i.) From 
 the peristaltic action of the bowel, gently stimulated and in- 
 creased by irritation of every kind, so long as tonic irritability 
 continues. (2.) From the spasmodic action of the part of the 
 gut above the invagination, preventing spontaneous return. 
 (3.) From the invagination being thus completed, it continues 
 permanent, tenesmus occurs, and the violent and repeated 
 
220 INTESTINES, OBSTRUCTION OF. 
 
 contractions of the abdominal muscles tend still more to 
 maintain and increase the lesion. The constant motion and 
 pressure of parts one upon another in some cases is so great 
 that the end of the invagination has been known to penetrate 
 through the walls of the inclosing bowel, so as to appear in 
 the cavity of the peritoneum. The chief indications are — 
 (i.) To prevent distension, by reducing, in every possible way, 
 the quantity of food and drink, restricting the latter to 
 small but frequent sips (preferably through a long straw or 
 tube) of cool iced liquids. Food is to be given, as strong 
 beef -tea, soup, or milk, with equal frequency and caution. 
 Small doses of alcohol (as brandy with water, or soda-water) 
 is to be alternated. But if any repugnance exists to food or 
 drink, or if vomiting is excited by these articles, the amount 
 given must be reduced. Water, milk, and gruel are to be 
 given "freely in often-repeated enemata. (2.) To assuage 
 pain and to mitigate excessive peristalsis suggest the same 
 kind of remedy — namely, opium, which is to be given con- 
 tinuously and alone in the solid form, preferably as an ex- 
 tract. The limit of the dose is indicated by the comparative 
 arrest of pain, the approach of narcotism, and decided con- 
 traction oi the pupii. Belladonna is only of use as a remedy 
 to diminish the straining peristalsis. It may be given com- 
 bined with opium, as two parts of extract of opium to one, 
 two-thirds, or even one-half part of extract of belladonna in 
 a pill Enemata are useful as a mechanical aid to removing 
 obstruction. They may gradually distend the bowel at the 
 site of obstruction, so as to effect such a change in its posi- 
 tion and arrangement as may release the impacted portion. 
 The administration of enemata is only safe and efficient if 
 undertaken by a person of competent skill. The quantity 
 of fluid must be injected little by little, and must be retained 
 as long as possible ; and the patient must resolve to tolerate 
 some pain in reaching the climax of distension at which only 
 enemata are calculated to relieve obstruction. In cases 
 where the intussusception is in the large intestine, inflation 
 of the bowel with air, as originally suggested by Hippocrates 
 two thousand years ago, in his third book, has of 
 late years been revived and adopted, first in America, and 
 subsequently in this country (Gorham, in Guy's Hospital 
 Reports, and Med.-Chir. Trans., Vol. IX.) This Hippo- 
 cratic remedy has undoubtedly been more successfuRhan any 
 other. Of twenty-eight cases, the details of which were col- 
 lected by Dr. Osborne, there were only seven recoveries; and 
 
INTESTINES, OBSTRUCTION OF. 221 
 
 three ot these were effected by inflation of the colon with air. 
 Dr. Murphy and Mr. Erichsen have borne strong testimony 
 to its value in discussion on the subject ; and the former 
 had recourse to the operation on one of his own children 
 with success (MS. Notes of Dr. Osborne). For its success, 
 the remedy should be employed at an early period, before 
 there has been time for adhesion between the contiguous sur- 
 face of the volvulus. My friend, Dr. David Greig, of Dun- 
 dee, has had recourse to this method of treatment in numer- 
 ous instances with perfect success, and has published an ac- 
 count of his experience in the Edin. Monthly Med. Journal 
 October, 1864. By means of the ordinary elastic enema 
 tube, fitted to the pipe of a small pair of bellows, he was able 
 to pass a considerable quantity of air into the rectum, con- 
 tinuing the process till the belly showed signs of considerable 
 distention, and even till uneasiness prevailed. Its beneficial 
 action is indicated by relief of the urgent symptoms, such as 
 straining and vomiting ; and gradually a faecal evacuation is 
 obtained from the bowels. At the same time warm fomenta- 
 tions are to be applied to the belly. The use of large ene- 
 mata, with manipulation, has also been recommended. A 
 long stomach-tube is to be passed as high up the colon as it 
 will go, and the anus being firmly compressed round it, warm 
 water is to be slowly injected, so as to distend the bowel as 
 much as possible. When the fluid is allowed to come away, 
 the abdomen should be pressed upon with the hands, so as to 
 move about the coils of intestine (Tanner). The earlier any 
 of these remedies are had recourse to, the greater will be the 
 chances of recovery; and the patient may be put under the 
 influence of chloroform to facilitate the manipulations. 
 Gastrotomy, abdominal section, or, as it is now called, 
 laparotomy, has been successful in many cases, where other 
 remedies have failed to give relief. Dr. Hilton Fagge and 
 Mr. Howse have related such a case (Med.-Chir., Trans., 
 Vol. LIX., 1876). The operation was advocated by Benja- 
 min Phillips (see his paper in Med.-Chir. Trans., Vol. XXXI.) 
 The cases for which it seems suitable are in obstructions 
 from bands, diverticula, also intussusception, and the like 
 lesions affecting the small intestine. The object of the oper- 
 ation is to divide the cord-like cause of strangulation (Brin- 
 ton); or to undo an invagination, all of which may be now 
 easily accomplished under the antiseptic spray. If the 
 bowels be much distended with air they may be punctured 
 with a small trocar and canula. Stercoraceous accumula- 
 
2 22 ISCHURIA RENALIS JAUNDICE. 
 
 tions must be mechanically removed. Repeated enemata of 
 warm water, delivered through a long tube, will gradually 
 permeate and disintegrate the mass ; and when it begins to 
 break up, continued 3 ii. doses of Epsom salts, with a grain 
 of quinine, in aromatic sulphuric acid and infusion of gentian 
 will gradually bring the bowels to a normal state of activity 
 
 Ischuria Renalis — See Urine, Suppression of. 
 
 Itch. — See Scabies. 
 
 Jaundice — Definition. — Certain morbid conditions in 
 which many of the different tissues and fluids of the body 
 are dyed yellow, or otherwise discolored, more especially the 
 conjunctiva and the connective-tissue, from the coloring 
 matter of the bile. 
 
 Treatment. — As a general principle, the larger number of 
 cases of jaundice from functional disorder (perhaps four out 
 of five) get well spontaneously, aided by remedies judiciously 
 selected according to the diagnosis already indicated. The 
 first indication is to aim at removing the exciting cause; and 
 in jaundice due to congestion of the liver, purgatives seem 
 to act beneficially in the form of blue pill or Plummer's pill 
 with aloes, and nux vomica with rhubarb pill mass. In cases 
 of acute jaundice — from suppression of the biliary secretion 
 consequent on a powerful nervous shock or mental perturba- 
 tion — Dr. Anstie has seen two or three doses of hydrochlor- 
 ate of ammonia, to the extent of grs. xx. every four hours, 
 produce a restoration of the biliary secretion. He regards 
 it as a most powerful restorative of the biliary functions. 
 Acids and alkalies are alike contra-indicated in cases of 
 jaundice resulting from active congestion of the liver. Ben- 
 zoic acid has been recommended ; and Dr. Harley has found 
 it useful in cases of suppression of bile (by innervation, for 
 example); but in cases of jaundice from obstruction it is 
 injurious. Podophyllin is also of use in jaundice from sup- 
 pressed secretion of bile. It ought to be combined with 
 hyoscyamus. It is especially useful in the cases of feeble 
 liver, combined with vegetable tonics, such as gentian and 
 quinine ; but it ought not to be given in cases of jaundice 
 from obstruction. The medicine of all others which has 
 seemed most generally useful is sulphate of magnesia, in half 
 drachm to drachm doses, combined with fifteen grains of car- 
 bonate of magnesia, and half a drachm of aromatic spirits of 
 ammonia, given three times a day an hour before food. The 
 sulphate of magnesia maintains a free action of the bowels ; 
 
KELOID LARYNGISMUS STRIDULUS. 223 
 
 and the carbonate of magnesia neutralizes any excess of acid 
 in the stomach or bowels. 
 
 Keloid — See Cheloid. 
 
 Kidney, Abscess Of — See Nephritis, Suppurative. 
 
 Kidney, Floating — Definition. — A floating kidney is a 
 condition in which the kidney has a mesentery or fold of peri- 
 toneum attaching it very loosely to the spine, by which it 
 can be moved about to the extent of the length of its mesen- 
 tery. A movable kidney merely slips a little under the 
 fingers. 
 
 Treatment. — Wearing a tolerably tight, elastic abdominal 
 bandage may completely remove the abnormal condition, 
 and will at least relieve the dragging and uneasy sensations. 
 Constriction of the thorax at the lower part by stays or 
 waistbands must be avoided. Constipation and the conse- 
 quent straining, as invariably aggravating the mischief, must 
 be relieved. Treatment generally must be of a tonic nature 
 (Sawyer, 1. c.) 
 
 Laryngismus Stridulus — Definition. — A paroxysmal 
 spasmodic disease in which the muscles of the glottis are 
 contracted, the vocal cords tightly stretched and so approx- 
 imated that the glottis is for a time partially or completely 
 closed. In the latter case there is arrest of the respiratory 
 movements and apnoea. In the former case there is stridu- 
 lus inspiration and dyspnoea. The affection depends upon 
 some morbid excitement of the par vagum and its nerve 
 centres, direct or reflex, and is usually seen in infants, 
 especially during the period of first dentition, and in children 
 before the completion of the second year ; and in the great 
 majority of cases between the fourth and tenth month. It is 
 also seen in adults. 
 
 Treatment. — Two important indications have been fulfilled 
 in carrying out the treatment — viz., the relief of the parox- 
 ysm, and the removal of the morbid condition, whether local 
 or general, which gave rise to it. 
 
 " The immediate treatment generally falls to the nurse or 
 mother. The little patient should be raised and placed in a 
 sitting posture, and then he may be slapped on the back, 
 cold water may be dashed in the face, and ammonia or 
 strong acetic acid held to the nose. These measures are 
 often successful by giving rise to violent expiratory actions ; 
 but remedies calculated to relieve spasms are equally sue- 
 
224 LARYNGISMUS STRIDULUS. 
 
 cessful. The warm bath may be used and emetics given 
 directly there is a sign of the stridor — when the paroxysm is 
 on, the child will not drink. A favorite remedy in Germany, 
 and one that is highly successful, is tickling the fauces with 
 the finger or a feather until vomiting is produced. Depres- 
 sing enemeta, such as tobacco, have likewise been recom- 
 mended, but their use is attended with considerable danger. 
 The ordinary rules for the treatment of disease apply here ; 
 that is to say, gentle remedies should be used in mild cases, 
 and those of a more powerful character in dangerous ones. 
 Putting the lower part of the child's body in a hot bath and 
 dashing cold water in its face, is a simple and sometimes suc- 
 cessful plan. The inhalation of chloroform is a very valua- 
 ble remedy, but of course, must be used with great care, and 
 cannot safely be employed by non-professional persons. ■ If 
 the child appears to be sinking from the apncea, the trachea 
 must, of course, be opened, and artificial respiration resorted 
 to. Indeed this should even be adopted by the practitioner 
 should he arrive shortly after the apparent extinction of life. 
 Some practitioners recommend the use of antispasmodic 
 remedies (whether animal, vegetable, or mineral) between 
 the fits " (Morell Mackenzie). 
 
 Where the exciting cause of the attack can be traced to 
 dentition, the gums should be lanced ; if the affection should 
 appear to be due to intestinal derangement, means must be 
 taken to remove any source of irritation from the alimen- 
 tary canal, and for this purpose perhaps the best remedy is 
 a dose of castor-oil. Thymic enlargement should be treated 
 by the application of leeches (according to the patient's age 
 and strength), and afterwards by counter-irritation. As re- 
 gards the constitutional state predisposing to disease, suitable 
 treatment will be found detailed in the various articles in 
 these volumes which treat of scrofula, rickets, hydrocepha- 
 lus, parasites, and the like. Spasm of the glottis has hither- 
 to been treated as an infantile disorder, but it sometimes oc- 
 curs in adults. It is usually met with in women, and is 
 commonly regarded as hysterical. In these cases, sedative 
 inhalations (which cannot well be used in the treatment of 
 children) generally give prompt relief. 
 
 During the intervals of paroxysm means must be taken 
 to prevent its recurrence. These mainly consist of atten- 
 tion to the state of the alimentary canal. A searching 
 purgative is generally called for to clear out the contents of 
 jhe bowels^calomel, jalap, and castor-oil are the most use- 
 
LARYNGITIS. 225 
 
 fill agents. Belladonna, to the extent of one-sixth of a 
 grain thrice daily, combined with bromide of potassium or 
 of ammonium, may be of use. Sinapisms and liniments 
 are also of use. The diet ought to be carefully regulated. 
 Change of air is generally called for, and the tepid and cold 
 bath must be in daily use. 
 
 Laryngitis. — Definition. — Inflammation of the lining 
 membrane of the larynx. 
 
 Treatment. — In its early stages a warm, moist, and uniform 
 temperature, with complete rest of the parts, is of the first 
 importance. Not only should all use of the voice be inter- 
 dicted, but the tendency to cough should as much as possi- 
 ble be arrested by the administration of small doses of mor- 
 phia, especially in those cases in which paroxysmal cough is 
 a prominent symptom. Inhalations of hot steam, or steam 
 impregnated with the volatile principles of benzoin, hops, or 
 conium, are of the greatest service. Hot poultices and 
 fomentations may also be ordered. Neither local nor general 
 blood-letting, blistering, mercury, antimony, nor other low- 
 ering remedies are to be recommended; after the acute symp- 
 toms have passed off, astringent solutions may be applied to 
 the larynx to hasten a cure. 
 
 In children, a warm moist temperature, poultices, warm 
 emulcent drinks, and if there is much dyspnoea, emetics of 
 sulphate of copper or sulphate of zinc, are the most 
 serviceable methods of treatment. When laryngitis oc- 
 curs in a subacute form, or shows a tendency to become 
 chronic, a regular system of inhaling should be prescribed. 
 Any of the appended forms may be employed ; and there 
 are many others contained in the very useful Pharmacopoeia 
 of the Hospital for Diseases of the Throat, published by 
 Churchill, 187 1. For the admistration of the following rem- 
 edies, the Eclectic Inhaler possesses great advantages; for 
 whilst the vapor to be inhaled is thoroughly saturated with 
 the volatile principles employed, and is kept at a uniform tem- 
 perature, the patient is able to inhale without effort. [It can 
 be obtained of Messrs. Bullock & Reynolds, 3 Hanover 
 Street, Hanover Square, London ; or of Maw, Son, & 
 Thomson, London.] The inhaler devised by Dr. James 
 Adams, of Glasgow, is also to be commended. 
 
 $. Creasoti, fl. dr. iij.; Glycerine, fl. dr. iij.; Aquas ad. fl. 
 oz. iij.; mix. A teaspoonful to be added to a pint of water 
 at 150° Fahr , and inhaled for five minutes twice or thrice 
 daily. 
 
 15 
 
226 LARYNGITIS. 
 
 01. Pini. Sylvestris, fl. dr. ij.-iij.; Mag. Carb. Lev. gr. 60- 
 90 ; Aquae ad. fl. oz. iij.; mix., and use as above. 
 
 In addition Oil of Juniper, fl. dr. i., ad. fl. oz. iij.; Oil of 
 Santal, m xv.; Oil of Myrtle, mxx., are all of service. 
 
 It will be found convenient to prescribe light carbonate of 
 magnesia as a medium, in the proportion of one grain to 
 every two minims of the oil ; and the addition of twenty 
 grains of camphor to any of the above makes the inhala- 
 tion additionally stimulative. When layrngitis is asso- 
 ciated with inflammation of the pharynx, lozenges con- 
 taining guaiacum are very useful in removing the hy- 
 persemic condition. Even when the pharynx is not affected, 
 the experiments of Fournie have proved that lozenges have a 
 decidedly beneficial effect on diseases of the larynx. It is nec- 
 essary after an attack of acute laryngitis to caution a patient 
 that he is very liable to a recurrence of this affection, and that 
 he should therefore be very careful to guard against all prevent- 
 ible causes of the disease. As laryngitis is more common to 
 those engaged in in-door than out-door occupations, and 
 those living in towns than in the country, Niemeyer recom- 
 mends out-of-door exercise, with proper precautions, as a 
 valuable prophylactic measure. Acute laryngitis sometimes 
 occurs as a complication of erysipelas ; but erysipelatous in- 
 flammation of the larynx originating in that part is rare. 
 The local treatment should at first be directed towards ar- 
 resting the inflammation, by sucking ice, &c; but when the 
 morbid process is advanced, the treatment is the same as that 
 required for ordinary acute laryngitis. The constitutional 
 treatment should be that applicable to other forms of erysip- 
 elas. Tracheotomy, although offering a less favorable chance 
 than in the simple laryngitis, should be performed if the 
 symptoms are urgent. Of the other catarrhal forms of 
 laryngitis may be mentioned those of measles and scarlati- 
 na. In measles the affection of the larynx may be either a 
 simple catarrh, or a simple diphtheritic affection. The catar- 
 rhal form may occur before the eruption appears, a day or 
 two after the rash has come out, or when it is beginning 
 to decline. Although the inflammation is often severe, it is 
 seldom sufficient to cause anxiety. The diphtheritic form is 
 much less common, and " seldom begins until the eruption of 
 measles is on the decline, or the process of desquamation 
 has commenced. Its appearance is most frequent from the 
 third to the sixth day after the appearance of the eruption ; 
 but it oftener occurs at a later than at an earlier period " 
 
LARYNGITIS. 227 
 
 (West). The treatment should be the same as that for pri- 
 mary croup. In scarlatina the laryngitis may be either cede- 
 matous or croupous : they are fortunately both rare compli- 
 cations. The cedematous form may be one of the manifes- 
 tations of the exanthem, or may be dependent on debility, 
 or it may be due to the renal affection, which is so common 
 a sequel of scarlatina. The croupy form is not common, 
 and seems to have been peculiar to some epidemics. In all 
 cases of laryngitis associated with scarlatina, there is a great 
 tendency to the ulcerative process. The treatment required 
 is of a tonic and nourishing character, with the free use of 
 well-diluted stimulants. Tracheotomy maybe necessary when 
 there is oedema ; but scarification should always be first tried. 
 
 In all cases of oedema of the larynx, whatever the cause, 
 scarification and hot steam inhalations, as recommended 
 in acute laryngitis, are the most serviceable aids. 
 When suffocation is imminent, tracheotomy should be per- 
 formed. 
 
 Applications of mineral astringents to the larynx, either 
 with the laryngeal brush, or in the form of atomized 
 inhalations, are of the greatest service ; and the " alterna- 
 tion of topical remedies is often as efficacious in the 
 cure of chronic laryngitis as it is in the treatment of chronic 
 inflammation of other mucous passages." Although Nie- 
 meyer is of opinion that " induration of the submucous tissue 
 (of the larynx) is incapable of resolution," it is the daily ex- 
 perience that local treatment of chronic thickening of this 
 region, unless, indeed, it be due to phthisis, is attended with 
 the very best results. Stimulating inhalations may be used 
 with great benefit. " Amongst the remedies I have found 
 most efficacious," writes Dr. Morell-Mackenzie, "are solutions 
 of perchloride of iron (gr. 60-120 ad. fl. oz. i.), chloride of 
 zinc (gr. 20-30 ad fl. oz. 1), sulphate of copper (gr. 15 ad fl. 
 oz. i.), sulphate of zinc (gr. 5 ad. fl. oz. i.), alum (gr. 30-60 
 ad fl. oz. i.), chloride of aluminium (gr. 30-60 ad fl. oz. i.). 
 The perchloride of iron and chloride of zinc are the solutions 
 I use most largely. Glycerine will also be found a most use- 
 ful solvent for these agents, as its consistence is better cal- 
 culated than that of water to keep up prolonged and close 
 contact between the remedy and the affected membrane. I 
 seldom employ solutions cf nitrate of silver as applications 
 to the larynx, for whilst I have not found them more bene- 
 ficial than other mineral astringents, they are much more 
 likely to produce spasm and nausea " (Use of the Laryn- 
 
228 LARYNGITIS. 
 
 goscope, third edition, page 98). Of atomized solutions, 
 those of tannin (gr. 5 ad fl. oz. L), and perchloride of iron 
 (gr. 2 ad fl. oz. i,) are most useful. Bergson's Atomizer, 
 known in this country under the name of Andrew Clark's 
 Spray Producer, Dr. Richardson's Ether Spray Apparatus, 
 and Dr. James Adam's Siegle's Inhaler, are the most con- 
 venient for administering atomized liquids. Functional rest 
 is, of course, of great importance in those cases of chronic 
 laryngitis in which the voice is much affected. If complete 
 silence cannot be enforced, the patient should be recom- 
 mended to speak only in a whisper. Relaxation of the 
 uvula, being a frequent cause of irritation of the larynx, 
 should be treated by astringent lozenges of tannin, rhatany, 
 or Kino; and if necessary the elongated part should be cut 
 off. A warm dry climate is of essential service in obstinate 
 cases of chronic inflammation of the larynx; as are also 
 some mineral waters, particularly those of Ems, Ober-Salz- 
 brunnen, Les Eaux Bonnes, Luchon, Cauterets, Aix-les- 
 Bains. 
 
 Besides the common form above described, there are cer- 
 tain varieties of chronic laryngitis to which it will be neces- 
 sary to give a brief consideration. These are — first, those 
 due to a morbid state of some special tissue of the larynx; 
 and, secondly, those due to a morbid condition of the general 
 system, and mainly dependent on constitutional causes. Of 
 the former, we have glandular laryngitis and phlebectasis 
 laryngea; of the latter, syphilitic laryngitis and laryngeal 
 phthisis. 
 
 Chronic glandular laryngitis, or chronic inflammation of 
 the minute racemose glands of the larynx, is generally asso- 
 ciated with disease of the follicles of the pharynx and tonsils; 
 but, as the glandular of the larynx are all of the racemose 
 character, it is better to use the generic term " glandular 
 laryngitis." It is this disease which has most improperly re- 
 ceived the name of dysphonia clericorum, or clergymen's sore 
 throat. The most common throat affection of the clergy is 
 not, however, glandular pharyngitis or laryngitis, but merely 
 chronic inflammation of the pharynx and larynx, with paresis 
 of the laryngeal muscles. Glandular laryngitis, on the other 
 hand, is not at all peculiar to those whose profession requires 
 them to make sustained use of the voice, but generally occurs 
 in people of feeble constitutional powers. 
 
 The symptoms are similar to those of ordinary chronic 
 laryngitis, but the disease is more intractable. There is a 
 
LARYNX, ABSCESS OF. 229 
 
 constant sensation of a foreign body in the throat, and ? 
 corresponding disposition to hawk and clear the throat, 
 With the laryngoscope, the enlarged orifices of the laryngeal 
 glands may sometimes be made out. Pathologically, the dis- 
 ease is essentially one of the secretory system, the normal 
 secretion of the minute racemose glands, instead of being 
 clear and transparent, becoming thick, white, and opaque. 
 By some observers it is thought to be due to imperfect or 
 perverted digestion; but it is more probable that the glan- 
 dulae of the stomach are simultaneously affected. 
 
 The treatment is the same as that recommended for simple 
 chronic laryngitis, except that the use of strong solutions of 
 nitrate of silver is more often indicated than in that affection. 
 There is frequently considerable feebleness of the voice, in 
 which case stimulating inhalations and the application of 
 electricity are the appropriate measures. 
 
 The second variety, that of phlebectasis laryngea, first de- 
 scribed by Dr. Morell-Mackenzie {Lancet, July 6, 1862), 
 consists of a venous congestion of the larynx. It is very 
 uncommon. The symptoms are slight and usually consist 
 in no more than an uneasy sensation in the larynx, and a 
 more or less frequent cough. With the laryngoscope, dark 
 vessels may be seen on various parts of the larynx, particu- 
 larly on the ventricular bands. The treatment consists in the 
 destruction of the vessels by the electric cautery, and the 
 use of vigorous constitutional remedies. 
 
 The varieties of syphilitic laryngitis and phthisical laryn- 
 gitis depend on a special constitutional condition, and will 
 be treated under Larynx, Ulcer of 
 
 Larynx, Abscess Of. — Definition. — Death of the cartila- 
 ges, by a molecular or truly carious process, usually preceded 
 by separation of the perichondrium, and sometimes attended 
 with circumscribed collections of pus. 
 
 Treat?nent. — The practitioner's treatment must be directed 
 to the relief of the pain, the dyspnoea, and the dysphagia. 
 For the former, subcutaneous injections of morphia should 
 be administered. The dyspnoea may be such as to render 
 tracheotomy necessary; and in cases where the dysphagia 
 is extreme (as nothing can be done to actually dilate the 
 narrowed oesophagus) the patient must be fed by enemata 
 or the oesophagus tube. The preferable way, in cases which 
 will admit of it, is to use an oesophageal tube with a feeding- 
 bottle attached. By means of an instrument of this kind, in 
 
230 LARYNX, BENIGH GROWTHS IN. 
 
 one of the cases referred to, the patient's life was sustained 
 for more than three months ; and after death there was a 
 considerable layer of fat covering the body. Of course, great 
 care must be taken in passing the tube ; but where practicable, 
 this method of feeding is far more satisfactory in every re- 
 spect than the use of enemata per rectum. 
 
 Larynx, Benign Growths in. — Definition. — New for- 
 mations of benign character, forming projections on the 
 mucous membrane of the larynx, generally giving rise to 
 aphonia or dysphonia, often to dyspnoea, and occasionally 
 to dysphagia. 
 
 Treatment. — In cases where the growth is small, does not 
 appear to increase, and does not give rise to functional de- 
 rangement, no treatment need be adopted. Where the op- 
 posite .conditions, however, exist, means should at once be 
 taken to eradicate the growth, or to place the patient out of 
 danger by performing tracheotomy. Radical treatment may 
 be divided into internal, that is, removal or destruction of 
 the growth through the mouth with the aid of the laryngo- 
 scope ; or external, by operations through the neck. Inter- 
 nal treatment may be further subdivided into Mechanical 
 and Chemical. Mechanical traatment consists in evulsion, 
 by common laryngeal forceps, tube forceps, ecraseurs, or 
 guillotines. Added to this, there are a few cases in which 
 crushing or incision of the base of the growth is effectual. 
 Chemical treatment consists in the application of various 
 caustic solutions, — a process seldom satisfactory — and in gal- 
 vanic cautery. This last method has been very successful 
 in the hands of some Continental practitioners ; but it can- 
 not be recommended, on account of the complicated and 
 unwieldy apparatus required by the practitioner, and of the 
 great pain often experienced by the patient. External treat- 
 ment may be divided into thyrotomy, or division of the thy- 
 roid cartilage, supra-thyroid laryngotomy, or division of the 
 thyro-hyoid membrane, and infra-thyroid laryngotomy, or re- 
 moval of the growth through the crico-thyroid membrane, 
 or by an opening made in the trachea. In addition to these 
 various surgical procedures, there is the combined method, 
 in which tracheotomy having been called for, on account of 
 the urgency of the symptoms, the neoplasm is afterwards re- 
 moved per vias naturales. All external measures are attended 
 with less satisfactory results, both as to life and restoration 
 of function, than those resulting from laryngoscope treat- 
 ment ; and it should «be borne in mind that the more serious 
 
LARYNX, CONTRACTION OF. 23I 
 
 surgical methods should never be resorted to unless the tu- 
 mor in the larynx produces symptoms endangering the life 
 of the patient. 
 
 Larynx, Contraction of. — Dejim'tion.~l$a.rrowmg of the 
 
 passage of the larynx, the result of various lesions. 
 
 The Treatment of narrowing of the larynx resolves itself 
 sooner or later into tracheotomy. In cases of syphilitic ci- 
 catricial thickening, iodide of potassium does little good, and 
 local treatment is of no avail. In chronic tubercular nar- 
 rowing, treatment is equally futile. In all cases, if the dys- 
 pncea is extreme, tracheotomy must be performed at once, 
 and measures can subsequently be taken for dilating the 
 contracted passage by any of the mechanical devices which 
 have been invented for the purpose. 
 
 Larynx and Pharynx, Treatment of by Atomized 
 Fluids. — The treatment of diseases of the pharynx and of 
 the larynx by the use of atomized or spray-producing fluids, 
 in which medicated vapor and gases are brought to act upon 
 the parts, has received a great impetus since better appli- 
 ances have been devised for using such remedial agents. The 
 aim of such instruments is to atomize or pulverize, or very 
 minutely to divide the fluid, by causing it to be thrown as a 
 fine shower or spray, so as to be inhaled as such by the pa- 
 tient. Dr. Andrew Clark's hand-balls, fitted with Bergoon's 
 tubes and Maunder's atomizer, constitute an efficient and 
 useful arrangement for applying fluids in this way up the 
 nostrils, to the back of the throat, or over the entrance to 
 the larynx (Da Costa). Dr. Richardson's well-known in- 
 strument for the production of local anaesthesia is also an ex- 
 cellent atomizer of fluid, and may be used for a similar pur- 
 pose. 
 
 Where it is desirable to make the topical application di- 
 rectly upon the diseased part, these are the most simple in- 
 struments that can be used without loss of time by the phy- 
 sician; but where inhalation simply of vapor or heated air 
 variously medicated is all that is required, nothing can be 
 better than that used by Dr. Fergus, of Glasgow; or an im- 
 proved apparatus for spray inhalations devised by Dr. James 
 Adams of Glasgow. 
 
 Siegle's apparatus, and Dr. Morell-Mackenzie's electric 
 inhaler, and Martindale's portable inhaler, are all of them 
 useful and valuable instruments for inhalation of suitable 
 remedies. 
 
232 LARYNX AND PHARYNX, TREATMENT OF. 
 
 On this most useful mode of treatment Dr. Da Costa 
 makes the following observations. "(1.) Inhalations by 
 means of atomized fluids are an unquestionable addition to 
 our therapeutic means; but they are nothing but an addition, 
 and not a substitute for all other treatment. (2.) In most 
 acute diseases of the larynx, and still more so in acute disor- 
 ders of the lungs, their value, save in so far as those of water 
 may tend to relieve the sense of distress, &c, and aid expec- 
 toration, is very doubtful; though in some acute affections, 
 such as in oedema of the glottis and in croup, medicated in- 
 halations have strong claims to consideration. (3.) In cer- 
 tain chronic morbid states of the larynx, particularly those 
 of a catarrhal kind, and in chronic bronchitis, they have 
 proved of great value. (4.) In the earlier stages of phthisis, 
 too, they may be of decided advantage; and at any stage 
 they may be a valuable aid in treating the symptoms of this 
 malady. (5.) Their influence on such affections as hoop- 
 ing-cough and asthma is not satisfactorily proved. (6.) 
 They furnish a decided and unexpected augmentation of our 
 resources in the treatment of pulmonary haemorrhage. (7.) 
 They require care in their employment; and in acute affec- 
 tions 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 cause. 
 (8.) In any case, to be of service, they ought to be carried 
 on as a treatment with a distinct object, and not intermit- 
 tingly or spasmodically resorted to." 
 
 Table of doses for Inhalation (Da Costa; (1.) Alum, 10 
 to 20 grains, to 1 fluid ounce of distilled water. Suitable in 
 chronic catarrhal states of the pharynx and air-tubes, partic- 
 ularly in bronchial affections with excessive secretion, when, 
 as in most inflammatory conditions of the respiratory mucous 
 membrane, it may be advantageously united with opium. In 
 a somewhat stronger solution, 30 grains to the ounce, it is 
 useful in pulmonary haemorrhage. As an astringent, it is 
 generally more of a sedative, and more suited to conditions 
 of irritation than tannin (Fieber). (2.) Tannin, 1 to 20 
 grains. — Useful for the same affections as alum. Employed 
 in cases of laryngeal ulceration and excrescences, in oedema 
 of the glottis (Trousseau), and in croup. Here, as well as 
 in pulmonary haemorrhages, it is used in large doses. In 
 ordinary cases of laryngeal or bronchial disease, it is well 
 to commence with a comparatively weak solution — 5 grains 
 to 1 fluid ounce of water. If the remedy occasion much heat 
 
LARYNX AND PHARYNX, TREATMENT OF. 233 
 
 and dryness, its use should be discontinued. (3.) Iron (per- 
 chloride of), J to 2 grains. — In earlier stages of phthisis; in 
 chronic pharyngitis or laryngitis it may be used in a stronger 
 form — 3 grains to 1 fluid ounce of water. As a weak inha- 
 lation, it is useful in hysterical aphonia. Stronger solutions 
 — 2 to 10 grains to the ounce — are useful in pulmonary 
 haemorrhage. In ordinary cases in which we wish a non- 
 astringent salt of iron, the lactate, citrate, or phosphate may 
 be also used, though they are not, on the whole, as available 
 as the chloride. (4.) h itrate of silver, 1 to 10 grains. — Is 
 useful in ulcerations of pharynx and larynx, and in follicu- 
 lar pharyngitis. A face-shield is always to be used. 10 
 
 rains to the ounce only to be used in cases of ulceration. 
 
 5.) Sulphate of zinc, 1 to 6 grains. — In bronchial catarrh 
 with excessive secretion ; in aphonia connected with chronic 
 laryngeal catarrh. The Chloride of Zinc (2 to 5 grains) is 
 also useful in the same conditions. (6.) Chloride of Sodium, 
 5 to 20 grains. — Promotes expectoration and diminishes 
 sputa; employed in phthisis. (7.) Chlorinated Soda (Liquor 
 Sodae Chlorinatae), ^ to 1 drachm. — In bronchitis with of- 
 fensive and copious expectoration ; in phthisis. (8.) Chlor- 
 ide of Ammonium, 10 to 20 grains. — In laryngeal and bron- 
 chial catarrh, acute as well as chronic, to promote expector- 
 ation ; also in capillary bronchitis. The dose best borne is 
 not above 10 grains to the ounce. (9.) Opium (watery ex- 
 tract of), y± to Yz a grain. — In irritative coughs, and as an 
 adjunct to allay irritation. Also for its constitutional ef- 
 fects. Dose of tincture of opium 3 to 10 drops. Acetate of 
 morphia, one-twelfth to one-eighth of a grain, has been ad- 
 ministered ; but large doses require much caution. (10.) 
 Conium (fluid extract of), 3 to 8 minims. — Irritative cough; 
 asthma ; feeling of irritation in larynx. (11.) Hyoscyamus 
 (fluid extract of), 3 to 10 minims. — Spasmodic cough ; 
 hooping-cough. One-half grain of the extract, gradually 
 increased ; or the tincture may be employed. (12.) Canna- 
 bis Indica (tincture of), 5 to 10 minims. — In spasmodic 
 cough and phthisis. (13.) Iodine, 2 to 15 minims of the 
 tincture. — In chronic bronchitis, phthisis, functional aphonia 
 and hay asthma. (14.) Arsenic (Liq. Arsenicalis). 1 to 20 
 minims. — Nervous asthma (Trousseau). (15.) Tar Water, 1 
 to 2 drachms of officinal solution. — In offensive secretions 
 from bronchial tubes ; in tuberculosis ; as an antiseptic in 
 gangrene of lungs. (16.) Turpentine, 1 to 2 minims. — In 
 chronic bronchitis with offensive secretions ; in bronchor- 
 
2^4 LARYNX, ULCER OF THE. 
 
 rhoea ; in gangrene of lungs. (17.) Lime Water, used of of- 
 ficinal strength, or stronger. — In diphtheria ; in membranous 
 croup. (18.) Water, Distilled. — Cold, in pulmonary haemor- 
 rhage ; warm water in asthma ; in croup ; and in bronchitis. 
 For various other modes of applying tropical applications 
 to the larynx, the student is referred to Dr. Morell-Macken- 
 zie's work On the Laryngoscope. 
 
 Larynx, Ulcer of the. — Definition. — Loss of substance 
 of the larnyx, in rare cases the result of simple inflammation, 
 caused either by syphilis or phthisis. 
 
 (a.) Syphilitic Ulceration. 
 
 Treatment. — Secondary laryngeal affections are sometimes 
 difricuU to cure, but after undergoing certain phases of evo- 
 lution they may disappear spontaneously. If allowed to 
 run their natural course, condylomata generally disappear at 
 the end of two or three months, but chronic congestion is 
 more intractable. Stimulating inhalations, and the local ap- 
 plication of astringents are sometimes of great service. Ul- 
 ceration of the larynx (secondary) is seldom so severe as to 
 require the application of solid nitrate of silver. In tertiary 
 laryngeal syphilis, large doses of iodide of potassium, in 
 combination with ammonia, and freely diluted with water, 
 are of the greatest use ; but local treatment is also of the 
 first importance. The application of solid nitrate of silver, 
 or of strong solutions of the same salt (60 gr. ad. fl. oz. i.), 
 or of sulphate of copper (15 gr. ad. fl. oz. i.), is attended 
 with the most satisfactory results. For applying the solid 
 nitrate the method of fusing a very small portion of the salt 
 on to a curved aluminium wire far surpasses, in simplicity 
 and safety, any other form of laryngeal porte-caustique. 
 
 (5.) Phthisical or so-called Tubercular Ulceration of the 
 
 Larynx. 
 Ln the treatment of phthisical ulceration, remedies similar 
 to those recommended for chronic laryngitis may be employed 
 with advantage. Mineral astringents have a beneficial effect 
 in the early stages, and are useful in relieving the dysphagia 
 when ulceration of the epiglottis has taken place. Sedatives, 
 whether in the form of inhalations or as medicines which al- 
 lay the cough, and so keep the larynx at rest, are also to be 
 recommended. Treatment, however, is at the best but pal- 
 liative. Every effort should therefore be made to carry out 
 preventive measures. Congestion of the larynx in patients 
 
LEAD PALSY. 235 
 
 of a phthisical tendency, should be treated with the greatest 
 promptitude — first, by proper local treatment; secondly, by 
 complete rest of the voice; thirdly, by a suitable climate — a 
 warm, dry, and uniform temperature being most to be com- 
 mended. The constitutional treatment required is similar 
 to that which will be found described under " Pulmonary 
 Phthisis." 
 
 Lead Palsy. — Defi?iition. — A series of morbid phenome- 
 na induced by the absorption of the salts of lead contained 
 in solution in drinking-waters, or in various foods and 
 drinks, or conveyed into the system through the integuments 
 of those who are in the habit of handling the soluble salts of 
 lead; or through the pulmonary mucous membrane of those 
 exposed to the influence of vapors containing lead. 
 
 Treatment. — The objects to be obtained in the treatment 
 of lead colic are to procure stools, a copious discharge of 
 urine, and perspiration, with a view of eliminating the poison 
 from the body. To allay pain is also an urgent necessity. 
 For these purposes five grains of calomel, fifteen grains of 
 jalap, and one grain of opium, should be administered as 
 soon as the patient is seen; and at the end of two hours 
 about two ounces of camphor mixture, combined with a 
 drachm or two drachms of sulphate of magnesia, and twenty 
 minims of tincture of hyoscyamus may be given, and repeated 
 every two or every four hours, till the bowels are freely evac- 
 uated, when relief more or less complete is obtained. The 
 mixture should be continued at proper intervals for three, 
 four, or five days, when the patient, though greatly weakened, 
 has in general recovered. In a few cases, however, the pain 
 continues, and with considerable severity, after the bowels 
 have been freely evacuated. The practice in these instances 
 is to apply a blister to the epigastrium, and to keep the blis- 
 ter open for a few hours. This additional application will 
 generally complete the cure. The patient is also relieved if 
 placed in a warm bath, and at the same time directed to in- 
 ject repeated enemata of hot water, that stools may be readily 
 obtained. In the absence of the warm bath, a large linseed 
 or mustard poultice should be applied over the abdomen. 
 
 With respect to the treatment of lead palsy, it has been 
 believed that sulphur has the power of neutralizing the effects 
 of lead by forming some innocuous compound with it. It is 
 not known, however, whether any such compound is really 
 formed; but lead poisoning in its chronic and constitutional 
 
236 LEAD PALSY. 
 
 forms is more successfully treated by sulphur baths than by 
 any other agent except iodide of potassium, to which they 
 form a most important adjuvant. The ingredients of these 
 baths consist of from two to four ounces of the sulphuret of 
 potassium, mixed with from twenty to thirty gallons of wa- 
 ter. The ergot of rye (secale cornutum) has been said to 
 produce a considerable increase in the power of the flexor 
 muscles of the arm in about a fortnight, and the improve- 
 ment gradually extends to the flexors, till at the end of about 
 three months the patient has recovered. This may have 
 been the natural result of elimination of the lead. The ex- 
 periments of Orfila long ago rendered it probable that lead is 
 removed from the body by the kidneys; and iodide of po- 
 tassium promotes the elimination of lead in this way. It may 
 be used with advantage combined or not with the citrate of 
 iron, the use of iron, in some form or other, having been 
 found of benefit in cases of palsy from lead contamination. 
 Dr. Parkes has chemically proved that lead can be made to 
 pass off by the urine by the action of iodide of potassium, in 
 the same way as mercury is known to be eliminated. The 
 principle upon which the iodide of potassium acts is that the 
 lead is in actual union with the affected tissues, being re- 
 tained among them as an insoluble compound; and the iodide 
 of potassium, after its absorption into the blood, combines 
 with the lead, and forms with it a new and soluble salt. The 
 poison is thus liberated from its union with the injured part, 
 dissolved out from the damaged fibre, and once more set 
 afloat in the circulation. Thus the poison and the remedy 
 are cast out together by the urine (Melsens, William Budd). 
 It is necessary, however, to notice the dangerous phenomena 
 which may at first supervene on the administration of iodide 
 of potassium in cases of lead poisoning; and great caution is 
 necessary in the employment of this remedy in man for the 
 first few days. At the moment when the metallic compounds 
 fixed in the body become dissolved or transformed, the phe- 
 nomena of acute poisoning may occur, caused by their lib- 
 eration. So much is this the case, that the treatment may 
 be supposed to be at first hurtful rather than beneficial. The 
 patient should have beside him a graduated solution oi the 
 iodide of potassium; and should begin with a small dose (fif- 
 teen grains during the twenty-four hours), and afterwards in- 
 crease or diminish it according to his pains and sensations 
 (Melsens). Dr. Fagge has also noticed that the administra- 
 tion of iodide of potassium to a person poisoned by lead, is 
 
LEUCOCYTHiEMIA. 237 
 
 sometimes followed by the development of a line in the gums 
 which had previously been absent, and this when the patient 
 was removed from the influence of lead. 
 
 Electricity, in the form of Galvanization, ought to be used 
 as a local stimulant to the nerves, with the precaution that its 
 application is not to be continued too long each time. Ten 
 or fifteen minutes, at three different periods of the day, or of 
 every second day, and persevered in for not less than four 
 weeks, will be found of great service (Todd, Althaus). The 
 beneficial influence will follow, although, in the commence- 
 ment of the treatment, even a current of very high tension 
 does not cause any movement whatever in the paralyzed mus- 
 cles. In such cases the beneficial influence seems attributa- 
 ble to the restoration of mobility to the molecules of nerve 
 and muscle by a constant current, and which is necessary 
 to enable them to be physiologically active. Severe shocks, 
 especially in the commencement of the treatment, should 
 therefore be carefully avoided, as by such the weakened ex- 
 citability of nerve and muscle may be reduced, in place of 
 being fostered and developed (Althaus, 1. c, pp. 112 and 
 119). It would be rational, however, to defer the applica- 
 tion of galvanism till the lead has been completely elim- 
 inated. 
 
 LeilCOCythaemia — Definition — A disease sui generis, in 
 which the number of white corpuscles in the blood is greatly 
 increased, with a simultaneous diminution of the red. This 
 state is brought about by chronic exhausting diseases, expos- 
 ure to cold and wet, or serious acute affections — such as 
 typhus fever, pneumonia, puerperal fever, affections of the 
 lymphatic glands or of the spleen, and is attended sometimes 
 by cough or diarrhoea, epistaxis, hemorrhagic effusions, 
 furunculus or pustulous eruptions. 
 
 Treatment. — The most varied remedies have been tried 
 without checking the increased formation of colorless cor- 
 puscles ; but it is suggested that if it is possible to discover 
 the glandular or splenic affection early, before the alteration 
 of the blood has made much progress, it is probable that the 
 disease may be averted. Tonics, nutrients, and stimulants, 
 are indicated to support the system. The use of the nitro- 
 muriatic bath ought not to be neglected, and the indications 
 given under anaemia and chlorosis may be followed. Phos- 
 phorus has been administered with some success by Drs. 
 Broadbent and Wilson Fox. Sir William Jenner adminis- 
 tered the drug in capsules containing one-thirtieth of a grain 
 
238 LEPROSY, TRUE. 
 
 of phosphorus, two or three times a day for four months, 
 without appreciable benefit to the patient. The results 
 generally are unsatisfactory as regards any treatment of these 
 cases. 
 
 Leprosy, True — Definition — A constitutional, non-con- 
 tagious, hereditary affection, essentially chronic in its nature, 
 expressing itself mainly by shining tubercles of different sizes, 
 of a dusky red or livid color, on the face, the ears (and often 
 the extremities) — the skin being thickened, wrinkled, rough, 
 unctuous, divested of hair, and the perspiration highly offen- 
 sive — in which there is loss of feeling, or other disorder of 
 innervation, and a tendency to ulceration death of the affected 
 parts. The eyes in extreme cases are fierce and staring, and 
 the voice is hoarse and nasal. 
 
 Treati?ient. — The only hope of exterminating leprosy lies 
 in the adoption of hygienic measures tending to improve 
 the general conditions, physical and moral, of the leprous 
 poor. Medicinal treatment is of no avail, unless combined 
 with the regular use of a nutritive unstimulating diet, suita- 
 ble clothing, protection against the vicissitudes of the weather, 
 personal cleanliness, and exercise in the open air. The med- 
 icines which have been found of most service are tonics and 
 alteratives, especially preparations of iron and iodine. Mer- 
 cury is extremely injurious. Arsenic has for centuries been 
 held in high esteem in India as a remedy in true leprosy. It 
 is given in the following combination: — 105 grains of arsen- 
 ious acid are triturated with five or six times the quantity of 
 black pepper. Thus made into a mass, it constitutes the 
 material of the well-known " Tanjore pill," of which one the 
 size of a " tare" is to be taken night and morning (Waring's 
 Therapeutics, p no). The systematic use of baths, simple, 
 saline, or sulphurated, are decidedly beneficial. Cupping- 
 glasses or moxas, along the line of the spinal column, has 
 been of marked advantage in relieving the lesions of inner- 
 vation, whether of increased or diminished sensibility. At 
 a very early period of the inquiry carried out by the College 
 of Physicians, the nature of the replies received enabled the 
 college to assure the Secretary of State for the colonies that 
 " there was no evidence which, in their opinion, justified any 
 recourse for the compulsory segregation of lepers." After 
 receiving this decided opinion, the Duke of Newcastle forth- 
 with issued a circular to the Governors of the Colonies, ex- 
 pressing his opinion, "that any laws affecting the personal 
 liberty of lepers ought to be repealed; and that, in the mean- 
 
LICHEN — LIVER, ABSCESS OF. 239 
 
 time, if they shall not be repealed, any action of the execu- 
 tive government in enforcement of them, which is merely 
 authorized and not enjoined by the law, out to cease." There 
 appears no more need (or just about the same) for restrict- 
 ing the liberty of lepers as for restricting the liberty of those 
 afflicted with gout. 
 
 Lichen. — Definition. — An eruption commencing as small 
 red papulae, either isolated or confluent. These becoming 
 excoriated, give vent to a serous fluid in considerable abund- 
 ance, which ultimately concretes into a crust. 
 
 Treatment — Glycerine in the following formula is recom- 
 mended by Mr. Startin : I£ . Acid Nit. dil. 3 ss to 3 j j ; Bismuth 
 sub. nit. 3 ss; Tinct. digital., 3j; Glycerini, |j; Aq. 
 Rosae, f \ vii ss. " To be applied as a lotion frequently to 
 the affected parts." 
 
 The alkalies internally and externally are of service. Bi- 
 carbonate of soda, in fifteen grain doses in some bitter infu- 
 sion, to be increased by eight grains daily till 3 j is taken in 
 the twenty-four hours (Divergie). Alkaline baths and lo- 
 tions are to be used at the same time — the lotions containing 
 two or three drachms of the salt to twenty ounces of water. 
 
 Livery Abscess Of — Definition. — Suppurative inflamma- 
 tion, ending in a circumscribed collection- of pus, or in sev- 
 eral separate abscesses. 
 
 Treatment. — The abstraction of blood is most efficiently 
 accomplished by leeches round the anus. They act more 
 directly on the portal circulation than over the hepatic re- 
 gion. When congestion is known to exist, leeches may be 
 applied with benefit, combined with purgative salines, such 
 as sulphate of soda or Rochelle salts, and antimony as a dia- 
 phoretic, to be followed by chloride of ammonium. Hot fo- 
 mentations applied to the region of the liver are of great 
 service, and the diet should be as limited as is consistent 
 simply with the maintenance of life, as long as acute symp- 
 toms exist. Mercury should not be given, except as an oc- 
 casional purgative, when the local inflammation is subdued, 
 and purgatives are only then of use when the intestinal func- 
 tions are sluggish. It is still a question whether or not an 
 artificial opening ought to be made, in the absence of fluctu- 
 ation to justify the operation. " In any cases the opening of a 
 liver abscess is a critical proceeding; but it should be resorted 
 to whenever there is a reasonable prospect of getting at the 
 matter, and when operative proceedings are not so danger- 
 
240 
 
 ous as to be prohibitory, for it is very desirable to anticipate 
 spontaneous opening by any of the usual channels, as all are 
 dangerous. Into the peritoneum, pleura, or pericardium, the 
 result is of necessity almost always fatal; while even into 
 the lung, stomach, or bowel, the danger is often great; and 
 though followed by temporary amelioration, may end in 
 exhausting disease or purulent contamination of the whole 
 system" (Sir Joseph Fayrer). Professor Lister's antisep- 
 tic method of procedure appears to me the one which 
 ought to be adopted in opening all hepatic abscesses. 
 
 " When there is reason to believe that matter has formed, 
 although the physical signs of it may not be clear, attention 
 should be directed carefully to the evacuations, especially if 
 there be diarrhoea, as the abscess may open into the bowel. 
 Thi* is the probable explanation of recovery in cases where 
 it has been thought that the abscess had either never really 
 formed, or that it had undergone absorption. When opening 
 occurs through the lung or stomach, the symptoms are un- 
 mistakable. When abscess has formed, the object is to favor 
 its evacuation, to support the strength, and to allay irritation. 
 Much has been written and said about exploring for liver 
 abscess, and in certain cases, where doubt exists, the pro- 
 ceeding is justifiable, using a small canula and aspirator, 
 when there is enlargement, tenderness on pressure, which 
 causes nausea and disturbance of the heart's action, such as 
 palpitation or sickness, especially if there have been any chills, 
 increase of temperature, or sweats. — In the event of matter 
 being detected at a considerable depth, it may in some cases 
 be aspirated ; but it may happen that, on account of its 
 thickness and the presence of flakes of lymph, pus will not 
 pass through the small canula, and no satisfactory result is 
 obtained ; but if there be any marked probability of its 
 presence, a large canula may be used and left in after if pus 
 is found, the most careful antiseptic precautions being ob- 
 served in the subsequent dressings. Whenever the matter 
 lies moderately near the surface, even though a certain 
 amount of liver- tissue intervene, a free incision is best; 
 hemorrhage, should it occur, soon ceases, and there is much 
 better prospect of a free drain afterwards. A large canula 
 may in some cases be preferable. It would signify little 
 which were selected, provided antiseptic precautions be 
 carefully observed, and the exit be free. In the event of 
 exploration detecting matter deep-seated, but under much 
 liver substance, the canula is preferable to the knife, used 
 
LIVER, ABSCESS OF. 24 1 
 
 with the aspirator, though great care should be taken not to 
 exhaust too rapidly, or with too great force, for fear of injur- 
 ing the liver tissue surrounding the cavity of the abscess and 
 causing hemorrhage." (Sir Joseph Fayrer, Lancet May 8, 
 1880, p. 709). "Cases of doubtful liver-abscesses present 
 symptoms varying in every degree ; at the one extreme cases 
 of general cachexia, with irregular slight febrile attacks, 
 exhibit symptoms as frequently attributable to deranged 
 stomach, or bowels, or lungs only, as to the liver itself ; 
 while at the other, slight general enlargement of the organ 
 would be found associated with that peculiar form of ' ten- 
 derness ' in which pressure over the organ produced an 
 indescribable sensation, inducing either faintness, hurried 
 respiration, palpitation, or nausea with retching, or all of 
 these at once. In all this large class of cases it was the cus- 
 tom of Professor W. S. Palmer, of Calcutta, to plunge a long 
 trocar and canula, of small diameter, into any or all parts of 
 the liver, through a valvular opening, examining on the spot 
 the small quantity of extracted matter for pus globules. It 
 was only in exceptional cases that any signs of pus could be 
 detected. When it was so detected the puncture was gener- 
 ally followed by slight inflammatory action at the seat of 
 puncture, which probably ended in adhesion of the organ to 
 the parietes, and so facilitated the future opening of the 
 abscess. When, on the other hand, no pus was found, a 
 good deal of anxiety was felt in the earlier cases, lest the 
 puncture should be followed by any evil results. Such 
 moments of anxiety soon ceased to recur, for it very rarely 
 happened that the patient did not express himself the next 
 day as feeling very much relieved ; and in no case did any 
 bad consequences result from such punctures. The relief 
 was frequently only temporary, in which case a second, a 
 third, or a fourth puncture was made at intervals of eight or 
 ten days. In some, however, one puncture sufficed to cure " 
 {Lancet^ May 8, 1880, p. 709). 
 
 To prevent the entrance of pus into the abdominal cavity, 
 the following method has been recommended by Begin and 
 Recamier : (1.) Being decided as to the limits of the abscess, 
 the patient is (2) laid on his back, with the upper part of the 
 body bent forward, and the thighs flexed upon the abdomen; 
 (3.) an incision from two to three inches long is to be made 
 over the abscess, dividing the skin, the subcutaneous adipose 
 tissue, the muscles, and the aponeurosis ; (4.) the peritoneum 
 is then laid open, as in operating for hernia, by slitting it up 
 16 
 
242 LIVER, AftSCESS OF. 
 
 on a grooved director to the same extent as the primary in- 
 cision ; (5.) the wound is then to be dressed with charpie, 
 and to remain untouched for three days ; (6.) at the end of 
 three days the dressing is to be removed, when the capsule 
 of the liver will be found to have contracted adhesions to the 
 margins of the wound so firm that the abscess may be opened 
 without the danger of pus passing into the abdomen. The 
 following expedient may indicate whether the liver adheres 
 to the abdominal parietes or not. When the liver is large, 
 and the abdominal parietes are thin, it may be made out 
 " by feeling the edge of the liver, or some prominent part of 
 its surface, and marking the place of this with a pin on the 
 surface of the belly.. If the liver be adherent to the abdom- 
 inal parietes, the line or spot so marked will correspond to 
 the edge or prominence of the liver in all positions of the 
 body. If it be not adherent, the liver will slide along the 
 wall of the belly when the patient draws a deep breath, or 
 changes his posture — the liver will fall, for example, towards 
 the left side when he turns from his back over to that side, 
 and the line or spot will no longer correspond to the edge 
 or prominence in question (Budd, op. cit., p. 122). 
 
 An interesting case of hepatic abscess is related by Sir 
 Henry Cooper, of Hull, in the British Medical Journal for 
 May 23, 1863. He justly takes exception to the method of 
 Begin and Recamier, because it may provoke the very danger 
 it is desirable to avoid. In all cases in which suppuration 
 has extended so near the surface as to give the sense of fluc- 
 tuation, irritation and adhesion of contiguous surfaces have 
 taken place. The process also interposes a serious delay at 
 a critical period. He advocates a direct opening into the 
 abscess, when there is reasonable ground for believing that 
 an external outlet for the matter is the direction taken by 
 the abscess. Peritoneal connections are sure then to have 
 taken place. Tenderness of the tumor is the most satisfac- 
 tory indication for the operation, and hardened base of 
 effused lymph a certain confirmation. Delay exposes the 
 patient to the risk of rupture of the walls of the abscess by 
 coughing, sneezing, or the like, and to the laceration of any 
 adhesions which may have formed ; or it allows him to 
 perish unrelieved from constitutional irritation and conse- 
 quent exhaustion. A middle course was devised and carried 
 out by Dr. Graves, in the Meath Hospital, in a robust man. 
 External elevation, hardness, and pain, eventually confined 
 to one spot in the right hypochondrium (after acute inflam- 
 
LIVER, ABSCESS OF. 243 
 
 mation of the liver), left to doubt of the formation 
 of an abscess. Hardness was followed by deep-seated 
 softness, yet no tendency was shown by the abscess to 
 point outwards. The swelling remained stationary, and the 
 integument of natural color ; but the general strength 
 began to fail, and it became an important question 
 whether the abscess should be opened. It was objected — 
 (1.) That the external tumor was diffuse ; (2.) that the exact 
 site of the abscess was uncertain; (3.) that failure to evacu- 
 ate its contents might prove detrimental. A decision was 
 therefore given against operation by the surgeons of the 
 Meath Hospital. Under these circumstances Dr. Graves 
 remembered that he had seen cases where an incision made 
 over a deep-seated abscess had failed to give vent to the 
 matter in the first instance; yet in the course of a few days 
 the pus found its way to the incision, and burst through it. 
 He therefore proposed that an incision about four inches 
 long should be made exactly over the center of the tumor — 
 that it should be carried through a considerable depth of 
 muscle, and, if possible, be continued to within about one or 
 two lines of the peritoneum. This incision was then to be 
 plugged up from the bottom of the wound with lint, and 
 thus kept open, in the hope that pus might tend towards the 
 incision, and finally burst through it. Such an operation 
 was done. The abdominal muscles were found of consider- 
 able thickness, and healthy; and although the incision was 
 very deep, yet the situation of the hepatic abscess was not 
 felt more distinctly. It now became evident that no pru- 
 dent surgeon would have persevered in an attempt to open 
 directly into it. A result was therefore waited for. In two 
 days the patient sneezed, when purulent matter in very large 
 quantity burst through the wound. It appeared that the in- 
 cision had not been made exactly over the abscess, but 
 rather to one side of it; for the matter did not come from 
 the bottom, but from the side of the wound; and pressure 
 on the liver on that side caused matter to flow out in abund- 
 ance through that part of the wound which communicated 
 laterally with the abscess. Had the original incision been 
 continued, it might have failed to open into the abscess 
 {Dublin Hosp. Report, Vol. IV., p. 40). 
 
 After the abscess has opened, strict rest must be enjoined; 
 and sometimes the cavity is very long in closing up. It 
 must be kept from putrefactive changes by antiseptic dress- 
 ings. Convalescence is always tedious; and sometimes 
 
244 LIVER, ABSCESS OF. 
 
 cicatrization is imperfect, continuing to discharge pus foi 
 years (Frerichs). It has been argued, as already indicated 
 in the experience of Dr. Palmer of Calcutta, that our effort 
 should be directed to detecting by acupunctuie the seat of 
 an abscess, and evacuating , it as soon as possible; and that 
 this method of exploration or of " prospecting the liver," 
 should be commenced as soon as symptoms present them- 
 selves indicating the possibility of abscess. It has been 
 argued that because some cases have recovered after such 
 a method of finding and evacuating an abscess, it is a prac- 
 tice which should be made the rule, in place of waiting for 
 some indications that pus has even formed in the liver (Mur* 
 ray, Cameron). The recommendations to the plan are not 
 yet based on statistical records, and rest upon the opinions 
 or irrrpressions of two or three individual men. Certain it 
 is that the plan recommended is opposed to the well-estab- 
 iished principles upon which surgical interference rests, and 
 is opposed to all that is known regarding the pathology 
 of hepatic abscess, as set forth in the carefully recorded 
 facts of Waring, Martin, Morehead, Frerichs, Budd, Mac- 
 lean and Lowe. It is also stated by Dr. Cameron (the latest 
 exponent of this method of puncture), that in cases of hepa- 
 tic enlargement, where the trocar lias been used more than 
 once in an unsuccessful search for an abscess, the operation 
 was followed by the speedy absorption of an enlargement of 
 the liver, which had resisted all the routine methods of 
 bringing about its dispersion; and that chis is a native mode 
 of dispersing hepatic and even splenic enlargements in India 
 (Lancet, August 8, 1863, p. 169). Puncturing parts, or acu- 
 puncture with a very fine needle, is a surgical operation said 
 to be much in use among the native Chinese and Japanese 
 hakims. But accurate information regarding the results of 
 such operations are not on record. It should be remem- 
 bered, in dealing with large livers or probable hepatic ab- 
 scess, that an hepatic abscess always begins from multiple 
 foci (Rokitansky). We must still look to physicians of large 
 Indian experience for information on this important subject; 
 while the antiseptic method of Lister warrants operative in- 
 terference now which could not have been carried out with 
 safety before. 
 
 The time which elapses after opening an abscess till the 
 patient's recovery is generally from one to two months. 
 When convalescence is established, the functions of the 
 liver remain torpid, and its substance often indurated; sub- 
 
LIVER, ACUTE ATROPHY OF. 245 
 
 sequently, also, the spleen may be enlarged. In such a 
 state Sir Ranald Martin recommends the use of nitro-muri- 
 atic acid baths. They promote the depurative functions of 
 the liver, kidneys, bowels, and skin. 
 
 " The form and manner of preparing and using the acid 
 bath are as follows: — Take of hydrochloric acid, three 
 parts; nitric acid, two parts; mix the two acids carefully 
 and slowly, so as to avoid evolution of heat; and having 
 waited for twenty minutes, add of distilled water five parts, 
 and mix the whole carefully. For a general bath in which 
 to immerse the whole body: — Pour into the bath about five 
 pailfuls of cold water; add two quart bottles, containing 
 sixty-four fluid ounces of the dilute nitro-muriatic acid, pre- 
 pared as above, and then sufficient boiling water to raise 
 the temperature to 96° or 98 . The body is to be quickly 
 and thoroughly dried with warm towels; and afterwards the 
 patient must retire to a well-aired and warm bed. The use 
 of the bath is only to be discontinued when tenderness of 
 the gums or general malaise occur; and cuticular irritation 
 from the acid is to be avoided by diminishing its strength. 
 Iron and other forms of tonic remedies may also be admin- 
 istered at the same time, as well as opiates," (Martin, On 
 Climate, p. 564, et seq). 
 
 Liver, Acute Atrophy Of. — Definition. — Simple jaun- 
 dice, which gradually increases, with sensitiveness over the 
 region of the liver, followed by violent constitutional dis- 
 turbance, expressed by pyrexia, headache, delirium, hemor- 
 rhages from various parts, and finally coma. The liver 
 shrinks to one-half or one-third its normal size. A peculiar 
 chemical decomposition takes place in the liver, whereby ab- 
 normal proximate principles are formed, which, being carried 
 into the blood, may be discovered in various organs of the 
 body, or, passing out by the kidneys, may be found in the 
 urine. 
 
 Treatmefit. — English physicians recommend emetics and 
 purgatives (Corrigan, Griffin, Hanlon). Frerichs recom- 
 mends that the stronger purgatives should be simply to re- 
 move congestion, such as senna, aloes, colocynth ; and the 
 doses should be such as to secure profuse evacuations. 
 When atrophy has commenced, no benefit results from med- 
 icinal treatment. Severe pains indicate the use of leeches, 
 cupping, and cold cloths, or fomentations, as recommended 
 under " Enteric Fever." The occurrence of haemorrhage 
 indicates the use of mineral acids. 
 
2^6 LIVER, AMYLOID LIVER, FATTY. 
 
 Liver, Amyloid — See Liver, Lardaceous. 
 
 Liver, Cirrhosis Of the. — Definition, — Interstitial in- 
 flammation, with increase of the connective tissue and its 
 subsequent contraction, leading to other alterations and re- 
 sults. 
 
 Treatment is the possibility of relieving the disorders of 
 function which threaten life, and so to delay the fatal termin- 
 ation. Absolute abstinence from spirits is indispensable, and 
 the diet should consist of mild, simple articles of nourish- 
 ment, especially easily digested animal food. Coffee, spices, 
 and articles irritant to the liver must be avoided. Swelling 
 and tenderness indicate leeches and fomentations. Mild 
 saline laxatives may be given ; and when the tenderness 
 ceases, the bowels must be kept open by rhubarb and salines. 
 When nausea or vomiting occurs, hydrocyanic acid, belladon- 
 na, morphia, or extract of nux vomica, are particularly suit- 
 able. The gastric and intestinal catarrh require to be sub- 
 dued by alkaline carbonates. They lessen the viscidity of 
 the mucous secretion. When pain prevails, cupping or 
 leeches are indicated over the liver, or leeches to the verge of 
 the anus. Saline purgatives, such as sulphate of soda or tar- 
 trate of potash and soda (Rochelle Salts), should also be ad- 
 ministered, while iced drinks and low diet must be the rule 
 of life. 
 
 What has been said under the subject of simple enlarge- 
 ment or congestion of the liver may be referred to here as 
 indicating a line of treatment under the circumstances there 
 provided for. The saline laxatives are best taken as mineral 
 waters, especially at Karlsbad or Marienbad. Springs con- 
 taining small quantities of iron are also of service, such as 
 Eger, Franzensbrunnen, Kissengen, and Homburg (Nie- 
 meyer). 
 
 Liver, Congestion Of — See Liver, Simple Enlargement of 
 
 Liver, Fatty. — Definition. — (i.) Infiltration or deposit 
 of superfluous fat in the liver-cells, commencing at the cir- 
 cumference of the lobules, from the blood of the portal vein 
 capillaries ; (.2.) Degeneration of the liver-cells, in which the 
 nutritive process within the hepatic cells is disturbed, so that 
 an abnormal increase of the fat naturally contained in the 
 hepatic cells takes place, which remains there, so that they 
 become engorged with oil. 
 
 Treatment. — Dr. Murchison recommends that large quan- 
 tities of common salt be eaten with the food, while, if the 
 
LIVER, LARDACEOUS LIVER, ENLARGEMENT OF. 247 
 
 circumstances permit, the alkaline or saline mineral waters of 
 Carlsbad, Marienbad, Kissengen, Ems, Vichy, Eger, Franz- 
 ensbrunnen, or Homburg, are to be advised. The diet must 
 be carefully prescribed, and regulated daily. 
 
 Liver, Lardaceous. — Definition. — The existence of a 
 peculiar homogeneous, translucent, albuminoid material in 
 the hepatic arteries, cells, and texture of the liver, resembling 
 an infiltration, but the albuminoid material is not found as 
 such in the blood. 
 
 Treatment. — It is desirable to limit the suppuration of 
 bones as much as possible by early surgical interference. 
 Iodine and iron are the remedies indicated by the nature of 
 the disease and the circumstances under which it occurs ; 
 but nothing is known as to the effects of remedies. 
 
 Liver, Inflammation of— See Hepatitis. 
 
 Liver, Simple Enlargement of. — Definition. — Simple 
 enlargement of the liver, from fulness or distention of its 
 blood-vessels and bile-ducts. 
 
 Treatment. — A restricted and judicious diet is of first im- 
 portance, with abstinence from rich dishes and fermented 
 liquors. With regard to medicine, Plummer's pill at bedtime, 
 followed by Rochelle salts in a seidlitz powder, or Pullna 
 water, in the morning, or by the usual black draught, or 
 compound mixture of senna, or by such saline purgatives as 
 sulphate of soda and bitartrate of potash (which cause a 
 drain from the portal system of veins), usually give relief. A 
 purgative dose of calomel, especially combined with com- 
 pound jalap powder, is of all combinations the most efficient 
 in diminishing congestion of the liver. After its action the 
 local weight, the pain, the fulness, and other symptoms sub- 
 side concurrently, with copious bilious stools. In such cases 
 it seems to act by irritating the upper part of the small in- 
 testine, propelling onwards the bile as fast as it flows into 
 the duodenum, thus preventing its reabsorption (Murchison). 
 The bilious accumulations thus evacuated constitute the 
 "bilious stools ; " but they are not to be regarded as the re- 
 sult of increased biliary secretion from the liver itself. An 
 active aperient ought to be prescribed every second or third 
 day for ten days or a fortnight after the action of the calo- 
 mel and jalap purgation (Graves). In chronic congestion the 
 external use of iodine ointment sufficiently diluted is of ser- 
 vice. Dr. Graves bears testimony to the value of setons over 
 the hepatic region. Two leeches every second day to the 
 
248 LIVER, SIMPLE ENLARGEMENT OF. 
 
 verge of the anus, and repeated from ten to fifteen times, 
 yield excellent results. Nitro-muriatic acid is a valuable 
 remedial agent. Podophyllin, in small repeated doses, best 
 relieves the engorgement and torpor of the liver in those who 
 have resided long in tropical climates (Gairdner). It may 
 not act for ten, twelve, or even twenty hours, when the purg- 
 ing which results is due to the large amount of bile passed 
 into the bowels. It stimulates the liver to increased secre- 
 tion. The best mode of administration is to dissolve podo- 
 phyllin in spirits of wine, in the proportion of one grain to 
 the ounce, and combine it with essence of ginger, in the pro- 
 portion of 3 iss. to the ounce. A teaspoonful of this mix- 
 ture in a wine-glass of water every night, or every second or 
 third night, secures all the advantages of podophyllin with- 
 out trie disadvantages which result when given in pills (Do- 
 bell, Brit. Med. Journ., May 24, 1879). Chloride of am- 
 monium is especially indicated when congestion is the prom- 
 inent condition. It should be given in doses of grs. v. to xx. 
 twice or thrice a day after food, combined either with acids 
 or alkalies, according to the special indications of the case. 
 The skin must be first induced to become moist and perspir- 
 able by some diaphoretic. If it is hot and dry, with a tem- 
 perature of 103 or 104 Fahr., a sixteenth of a grain of tar- 
 tar emetic should be given every three or four hours till dia- 
 phoresis occurs (Dr. Wm. Stewart, Philadelphia Med. Times, 
 April, 1878, also under Hepatitis). When colored deposits 
 are present in the skin, chlorate of potass should be com- 
 bined with the chloride of ammonium. Benzoate of soda is 
 another hepatic stimulant of value (Dr. Dobell). Taraxicum 
 diminishes abdominal plethora : — 
 
 Ext. Tarax., gr. xxxvi. ; Ext. Aloes, gr. xii. ; Ext. Acet. 
 Colchici ; Pulv. Ipecac, rad. aa., gr. vi.; misce. Divide in 
 pil. xii. Two pills every night. 
 
 An electuary, composed of equal parts of sublimed sulphur 
 and the powdered gum-resin of guaiacum, will be found use- 
 ful in cases where the congestion of the liver is associated 
 with haemorrhoids. When dropsy prevails, doses of the diu- 
 retic pill of hydrargyrum, squills, and digitalis (a grain and 
 a half of each ingredient), taken night and morning, are at- 
 tended with benefit. In bilious congestion copious draughts 
 of hot water act as an emetic, diluting the bile, and if some 
 saline purgative be added, the congestion of the liver will be 
 relieved. If pain prevails over the liver, leeches and fomen- 
 tations are indicated, with perfect rest in the recumbent posi- 
 
LIVER, WAXY LOCOMOTOR ATAXY. 249 
 
 tion — the diet consisting of arrow-root, sago, milk and water, 
 barley-water, and afterwards beef-tea when convalescent. 
 
 Liver, Waxy — See Liver, Lardaceous. 
 
 Locomotor Ataxy, Progressive. — Definition. — A pe- 
 culiar disease of the spinal cord, characterized by unsteady 
 and disorderly muscular movements (but with muscular 
 power entire), and more or less progressive loss of the faculty 
 of co-ordinating power (voluntary and instinctive). There 
 is sometimes temporary diplopia, with unequal contraction 
 of the pupils. The course of the disease is slowly progres- 
 sive ; and the anatomical lesion is generally a (chronic my- 
 elitis in the form of) ribbon-like sclerosis of the white pos- 
 terior columns and horns of the spinal cord, and posterior 
 roots of the spinal nerves, leading to grey degeneration, some- 
 times with peripheral structure-change in the cranial nerves, 
 and chiefly the second, third, and sixth pairs, in cases where 
 the sight is affected. The disease generally begins in the 
 lumbar region, and may extend throughout the entire cord, 
 as far as the upper cervical portion, and even into the me- 
 dulla oblongata. 
 
 Treatment. — No benefit is to be got from antiphlogistic 
 treatment, unless there be marked evidences of inflammatory 
 irritation. Dry cupping may be of use for the relief of pain. 
 Derivatives are likewise useless. Thermal baths are also in- 
 jurious. Cool sponging of the body is of great use ; and 
 cold-water treatment generally, especially the use of the cold 
 sponge-bath (Erb). 
 
 Phosphorus, in the form of phosphates of metals and salts, 
 of diluted phosphoric acid, as a drink in the daily allowance 
 of water, of phosphate of soda as an aperient, may be given 
 with benefit. Strychnine is objectionable. Nitro-muriatic 
 acid as a tonic, and cod-liver oil as a dietetic agent, may also 
 be of use. Cannabis Indica and belladonna give the great- 
 est relief to the pains. Nitrate of silver is recommended by 
 Wunderlich, in doses gradually increasing to half a grain 
 daily. Phosphuret of iron is also recommended. Dr. Al- 
 thaus recommends sulphur baths as adjuvants, relieving pains 
 and diminishing numbness. 
 
 Flannel should be worn next the skin, and chills from cold 
 and damp carefully avoided, by the use of a chamois leather 
 or spun silk close-fitting jacket over the flannel, and reaching 
 from the height of the clavicles as low as the folds of the 
 nates behind. The diet ought to be of the most nutritious 
 materials which the patient can digest. 
 
250 LUNGS, CONGESTION OF. 
 
 So long as there is active local hyperemia, the use of elec- 
 tricity is hurtful. Faradization may be of use in restoring, 
 to some extent, sensibility to the skin, where local cutaneous 
 anaesthesia has prevailed, after which patients seem to walk 
 better for a time; but when used at all, electricity ought 
 only to be employed during the pauses in the course of the 
 disease, and then with great caution, in the form of a con- 
 stant current, rather than the induced current, or faradiza- 
 tion. The current should be very weak at first, and the 
 daily application for not longer than from three to six min- 
 utes, extended over months. Niemeyer has had no suc- 
 cess either with nitrate of silver or the constant current of 
 electricity; but he recommends them to be tried. 
 
 Lungs, Congestion of. — Definition. — An hyperemia or 
 over-fulness of blood in the capillaries of the lung, resulting 
 in the discharge of blood by expectoration (haemoptysis); or 
 in an extravasation of blood from capillary rupture into the 
 air-cells, terminal bronchi and the interstices of elastic tissue 
 (pulmonary apoplexy). 
 
 Treatment. — The medicines most useful in haemoptysis are, 
 the bitartrate of potash, in doses of a drachm, repeated every 
 four or six hours, to each dose of which may be added a 
 quarter to half a grain of opium. The mineral acids, as 
 the infusion of roses, with diluted sulphuric acid, in doses of 
 from three to five drops, combined with opium or morphia, 
 every four or six hours. One to three grain doses of the 
 acetate of lead, every four or six hours, may be given, with 
 half a grain of opium to each dose, or combined with dilute 
 acetic acid and laudanum (A. T. Thompson). The muriate 
 of soda, in doses of half a drachm to a drachm, is in estima- 
 tion with some practitioners on the continent. 
 
 In atonic haemoptysis, ergot is said to be of service, espe- 
 cially in the following combination: 
 
 ^. Ext. Ergotae Liq., 3 ii. ; Tinct. Digitalis, 3 il. ; Acidi 
 Gallici, 3i-; Magnes. Sulph., 3vi.; Acid. Sulph. Dil., 3i.; 
 Infus. Rosae Acid., ad § viii.; misce. A sixth part of this 
 mixture to be taken every three hours, till haemorrhage 
 ceases (Dobell, Warring-Curran). Wunderlich also recom- 
 mends the secale cornutum, in doses of from five to ten 
 grains, to be pushed until a numb sensation is experi- 
 enced in the fingers and toes. 
 
 The hypodermic injection of ergotine is by far the most 
 efficacious of styptics in haemoptysis. A grain of (Bon- 
 
LUNGS, CONGESTION OF. 25 1 
 
 jean's) efgotine should be injected on the back of the 
 side of the thorax whence the bleeding comes, and re- 
 peated every two or four hours ; and fifteen minims of 
 tincture of digitalis should be given every three or four 
 hours, its effect on the pulse being watched (Coghill). 
 
 When haemoptysis is connected with amenorrhea, prepara- 
 tions of iron often succeed when other remedies have failed. 
 •Two grains of the sulphate of iron, with one drachm doses 
 of the sulphate of magnesia, three times a day, often restore 
 the menstrual secretion, and cure the haemoptysis. It is in 
 this form of amenorrhcea that iron is most successful. When 
 haemoptysis depends on disease of the heart, cupping from 
 the chest, or moderate bleeding from the arm, combined 
 with the use of the bitartrate of potash, or the mineral acids, 
 to which should be added five to ten mimins of the tincture 
 of digitalis, to give steadiness to the irregular, turbulent, or 
 rolling action of the heart. Repeated dry-cupping, aided by 
 the application of ice down the spine, and by the internal 
 administration of full doses of digitalis — half a drachm of 
 the tincture, or a grain and a half of the powder (Fuller). 
 It is chiefly as an adjunct to other means, when haemoptysis 
 is attended with much vascular excitement, that digitalis is 
 of service. Full and frequent doses of gallic acid, or lead 
 and opium, may be given, if the circulation is much acceler- 
 ated; and of spirits of turpentine, in half-drachm doses, if 
 the bleeding is unattended with vascular excitement. The 
 gallic acid is more adapted for chronic cases, and should be 
 given every hour, in eight or ten grain doses, until the 
 haemorrhage is subdued, or till a dark-green color in the 
 sputa indicates its action on the system. Its efficacy ap- 
 pears to be increased by combination with sulphuric acid, 
 and may be conjoined with opium or digitalis. 
 
 The following formula is a useful one: — 
 
 $ Acid. Gallic, gr. xxx.; Acid. Sulph. Dil, 31.; Liquor 
 Opii Sedat., m xxx.; Infus. Rosae Co., f 3 vi.; misce. Two 
 tablespoonfuls for a dose every three or four hours (Dr. L. 
 Earle). 
 
 Absolute bodily and mental rest must be insisted on 
 throughout, in cases of pulmonary infarction. Stimulation 
 must be resorted to in the first instance ; after which the 
 mineral acids, or super-acid salts, appear to offer the best 
 hopes of recovery. If the apoplexy be secondary, and de- 
 pends on disease of the heart, digitalis may tranquillize its 
 excitement. 
 
252 EMPHYSEMA- 
 
 Dietetic and General Treatment. — The patient should be 
 placed in bed, with his head and shoulders raised; the win- 
 dow should be partly open, so as to keep the room cool. It 
 has been recommended that the air respired should pass 
 through a respirator containing ice; and it is common to 
 place a bowl of ice immediately before the patient, so that 
 he may suck small portions as often as he can. A large pad 
 of spongiopiline, soaked in chloroform, should be laid on the 
 chest, over the locality of bleeding. The bedclothes should 
 be light but sufficiently warm. The diet should be slops, 
 and these slops cold; and if cooled to a low temperature by 
 ice, so much the better. No red meat, nor beef-tea or stimu- 
 lants, are to be given; but milk, chicken broth, jelly, and 
 iced lemonade. 
 
 Emphysema. — Definition. — (1) Vesicular Emphysema 
 Relative increase of air in few or many air-cells of the lungs, 
 causing a misshapen enlargement of them, by dilatation or 
 rupture of septa, and the blending of several into one or 
 many great cysts. It is attended with gradual effacement 
 of the functional blood-vessels distributed over their walls, 
 anaemia of the lung in the affected parts, tending to dilata- 
 tion of the right side of the heart, with anasarca. (2) In- 
 terlobular Emphysema. — Air infiltrating the meshes of 
 the sub-pleural and interstitial connective tissue of the lungs. 
 
 Treatment. — Apart from the management of the bronchial 
 congestion, on the principles already given under Bronchitis, 
 little can be done for the special treatment of emphysema! 
 If bronchial spasm prevail, the spiritus aetheris of the British 
 Pharmacopoeia may give relief, of which thirty to sixty 
 minims may be prescribed in camphor water, or in spiritus 
 ammonias aromaticus, or in volatile tincture of valerian; or 
 it may be conbined with stimulant doses (one grain) of 
 opium; or with twenty minims of the aethereal tincture of 
 lobelia, belladonna, conium; or the aethereal tincture of In- 
 dian hemp and hydrocyanic acid may each in turn be found 
 of service (Fuller). Dry-cupping between the shoulders 
 often relieves passive pulmonary congestion; and if an at- 
 tack is imminent, an emetic, or unloading the bowels by a 
 dose of the compound jalap powder, may prevent its acces- 
 sion or moderate the paroxysm. 
 
 Lung, Gangrene Of. — Definition. — Disintegration and 
 breaking up of the tissue of the lung. Shreds of lung-tissue 
 may here and there be distinguished; but the whole mass be- 
 
LUPUS. 253 
 
 comes converted into a heap of amorphous granular matter, 
 of a yellowish-brown or black color, mingled with drops of oil. 
 The tissue becomes soft and flaccid, in some parts perfectly 
 liquescent, and generally emits a fetid smell. 
 
 Treatment. — The chief reliance is to be placed in all forms 
 of stimulants, combined with such tonics as bark or quinine 
 in full and repeated doses. Repeated doses of an ounce of 
 yeast, as well as the influence of chlorate of potass, are sug- 
 gested by Dr. Walshe. Ammonia has not been found so 
 useful as the mineral acids. Inhalation of the vapor of tur- 
 pentine, poured upon boiling water, exercises a distinctly 
 remedial power (Skoda). Gargles of Condy's fluid should 
 be freely used, and antiseptic inhalation, as described under 
 " Phthisis." The mineral acids, especially nitro-muriatic, 
 combined with quinine, are the main remedies in the chronic 
 state of this disease. A generous diet, easily digestible, with 
 as much malt liquor as can be taken, are also recommended. 
 
 Lupus. — Defitiition. — A spreading inflammation of the 
 skin or mucous membrane, usually of the face, characterized 
 by infective cell-growth, tending to destructive ulceration, 
 but only by accident involving textures deeper than the skin. 
 
 Treatment. — The new formation must be removed or de- 
 stroyed; but opinions differ as to how this is best effected. 
 Mr. Jonathan Hutchinson prefers Volkmann's erasion 
 method. Cazenave recommends chloride of zinc, arsenical 
 paste, or the powder of " Come," Vienna paste (equal parts 
 of chalk and quicklime), and other powerful applications of 
 the like kind. Hebra also recommends cauterization and 
 employs usually strong nitric acid over the unulcerated, and 
 nitrate of silver over the ulcerated surface. It is a remark- 
 able fact in the history of lupus, affirmed by Hebra, that the 
 lupus disappears during acute febrile diseases, and especially 
 during typhus. It seems to recur with convalescence. (See 
 Dr. A. Thomson on Diseases of the Skin, edited by Dr. 
 Parkes, where numerous interesting cases are detailed, p. 
 
 3 IQ ) 
 
 The medical treatment has in view the prevention of the 
 
 formation of more similar deposits in the substance of the 
 skin by improving the general health. Cod-liver oil, phos- 
 phorus, quinine, and bitter vegetable tonics, good food, 
 bracing air, and the judicious use of stimulants, are all use- 
 ful in this respect. Iodides and preparations of mercury are 
 to be avoided; but arsenic may be given with advantage 
 (Hutchinson). On the other hand, Dr. M'Call Anderson 
 
254 LUPUS. 
 
 recommends the use of iodide of starch. [The following is 
 the formula for its preparation: Ijk Iodi, gr. xxiv; amyli, f j. 
 Triturate the iodine with a little water, gradually adding the 
 starch and continuing the trituration till the compound as- 
 sumes an uniform blue color, so deep as to approach black. 
 The iodide should be dried with a heat so gentle as to run 
 no risk of driving off the iodine, and it ought to be kept in 
 a well-stoppered bottle. On no account should spirit be 
 used in its preparation instead of water. The dose is a 
 heaped-up teaspoonful in a draught of water or water-gruel 
 thrice daily; but it may be safely increased even up to an 
 ounce in some cases]. In using it, care must be taken, first, 
 that the cases are really undoubted cases of lupus erythema- 
 todes and not lupus vulgaris; and second, that the medicine 
 is freshly prepared, and in accordance with the directions 
 above mentioned. Dr. Balmanno Squire has devised an im- 
 provement upon the treatment of lupus by pricking the skin 
 at short distances with a pointed instrument, as long since 
 advocated by Dubini, of Milan, and subsequently by Volk- 
 mann, of Halle. By means of a many-bladed instrument 
 which Dr. Balmanno Squire has contrived, and which has 
 been constructed by Messrs. Weiss, of London, he cuts the 
 skin into thin strips. The Dubini-Volkmann method 
 (known as punctiform scarification) has been highly success- 
 ful. Dr. Squire's method (termed multiple linear scarifica- 
 tion) has proved still more successful. It has been tested 
 and commended in this country by Dr. Walter Smith, of 
 Dublin, and Mr. Malcolm Morris, of London; while in 
 Paris, at the Hopital St. Louis, Dr. Vidal and his assistants 
 treat every Wednesday as many as from forty to fifty patients 
 by this method. The advantages are the same as those 
 which attend punctiform scarification — namely, the setting 
 up of a traumatic inflammation, under which the disease 
 heals; but the superiority claimed for treatment by closely 
 and regularly spaced incisions is a more rapid and at the 
 same time a more complete cure of the disease than can be 
 effected by means of irregularly distributed punctures. Dr. 
 Vidal had observed, in sections of the skin thus healed, the 
 gradual conversion of the lupus cells into fibrous tissue. The 
 advantages of treatment of the disease by the excitement of 
 traumatic inflammation as compared with other means of 
 treatment, are described as being less painful, as causing less 
 loss of substance, and as leaving less permanent trace of its 
 performance than the customary methods of local treatment 
 
MEASLES. 255 
 
 namely, the application of caustics or semi-caustics {Brit. 
 Med. Journ., August 23, 1879, p. 293). 
 
 Malignant Purpuric Fever — See Cerebro-Spinal Men- 
 ingitis. 
 
 Measles. — Defi?iition. — A purely contagious and infectious 
 disease, the virus or contagium passing off in the exhalations 
 of a patient, causing the surrounding air to be contaminated. 
 The disease is capable of inoculation by the blood and secre- 
 tions. An eruption occurs in crops of a crimson rash, con- 
 sisting of slightly elevated minute dots, about the size of 
 millet-seeds, and having a small papular centre, scarcely per- 
 ceptible to the touch, and without any sensation of hardness. 
 Several of these may unite in irregular circular forms, or 
 crescents, or they may be isolated. The eruption appears on 
 the thirteenth or fourteenth day after exposure to infection 
 (Panum, Archiv. Gen. de Med., April, 185 1, p. 451, and Ed. 
 Med. Journal June, 1858, p. 589, quoted by Murchison). It 
 is preceded by catarrhal symptoms affecting the conjunctiva 
 and air passages for about four days, accompanied with fever, 
 which commences with repeated rigors — i. e., the real incu- 
 bation period is about ten days. It lasts six or seven days, 
 and the whole duration of the disease is completed in from 
 nine to twelve days. Measles affects the system only once ; 
 and sometimes prevails as an epidemic. 
 
 Treatment. — The constitution during measles is little im- 
 paired by the short continuance of the fever. The rule, there- 
 fore, is to interfere as little as possible as long as the disease 
 is pursuing its normal course, and merely to moderate and 
 subdue symptoms when they threaten danger, knowing that 
 the great majority of cases end in recovery without any medi- 
 cal treatment. The morbilli sine catarrho is usually of such 
 a mild form as to require no other treatment than a milk diet, 
 the customary attention to the bowels, and the prevention of 
 exposure to cold and wet. Measles will not bear exposure of 
 the surface of the body to cold so well as either scarlatina or 
 small-pox, on account of the great tendency to bronchial and 
 pulmonary inflammation. Children must therefore be 
 watched night and day to prevent them lying uncovered, and 
 special care must be taken to avoid exposure to cold during 
 convalescence. An even and moderately moist temperature 
 must be maintained in the room, steam from a boiling kettle 
 of water being admitted. The temperature ought to be regu- 
 lated by the thermometer, and kept at 6o° to 65 ° Fahr, The 
 
256 MEASLES. 
 
 room must also be regularly subjected to a current of fresh 
 air daily, the patient being sufficiently protected at the time. 
 In the morbilli mitiores the cough, the frequent vomiting, 
 and the heavy catarrhal symptoms which so generally attend 
 the primary fever, render medical attendance necessary from 
 the first moment of the attack. The treatment of these 
 symptoms, however, and also of the eruptive stage, as long as 
 the patient continues free from any serious inflammatory af- 
 fection of the lungs, need not necessarily be active, it being 
 sufficient to alleviate the cough, allay the vomiting, and check 
 the catarrh by some of the large class of saline laxatives, lin- 
 seed tea, or mucilaginous mixtures, to which antimonial or 
 ipecacuanha wine may be added, if necessary, as a diapho- 
 retic, and to subdue high vascular action. In making a se- 
 lection from these, the physician must be principally guided 
 by the state of the bowels and the condition of the stomach 
 of the patient. If the bowels be constipated, the milder 
 salines, as the sulphate of magnesia, are to be preferred. 
 Often, however, a diet of stewed prunes or fruit will be suffi- 
 cient. On the contrary, if the patient be purged, and the 
 vomiting distressing, a neutral mixture or effervescing 
 draught will be found most beneficial. There are many per- 
 sons in whom the cough and catarrh are the most urgent 
 symptoms ; and in such cases, if the stomach be quiet, the 
 liquor ammoniae acetatis, combined with camphor mixture, 
 from its more powerful action on the skin, is an excellent ad- 
 dition. Another remedy, equal or perhaps still more useful, 
 is ipecacuanha wine. Willan was of opinion that an emetic, 
 given on the second or third evening, somewhat alleviated the 
 violence of the catarrhal symptoms, and contributed to pre- 
 vent the diarrhoea which usually succeeds measles. An 
 emetic is especially useful if the disease be threatened with 
 croup as a complication. During the eruption he adds, " I 
 have not observed any considerable effect from antimonials 
 or other diaphoretics." The use of aconite has been found 
 to moisten -the skin ; and certainly helps the emergence and 
 development of the eruption when due, though it seldom re- 
 duces the temperature before the eruption comes out, but it 
 reduces the pulse (Phillips). Bathing the feet every evening 
 seems a beneficial application. Emulsions and mucilages af- 
 ford but a feeble palliation of the cough and difficulty of 
 breathing ; but if there is much oppression, with a sense of 
 tightness, linseed poultice jackets must be applied to the 
 chest. With respect to opiates, they are not advisable should 
 
MEASLES. 257 
 
 bronchitis be extensive, and in the early stages especially ; 
 opium produces an increase of heat and restlessness, without 
 conciliating sleep. The catarrhal symptoms are frequently 
 accompanied, even in the very earliest days of the disease, 
 with much bronchial inflammation, and sometimes with pneu- 
 monia ; or these affections may occur at any later period, 
 after the decline of the eruption, from the tenth to the twelfth 
 day of the attack. For these a stimulant treatment is re- 
 quired. If pleurisy alone supervenes, mercury is best used 
 in the form of friction with blue ointment over the chest, a 
 little croton oil being added to promote its absorption (An- 
 drew Anderson). In such cases stimulants are called for — 
 e. g. subacetate of ammonia, chloric ether, wine, or brandy. 
 During the whole course of measles it is necessary to enjoin 
 an abstinence from animal food, and to limit the patient to a 
 low diet and to slops. Liquid food should be given in small 
 quantities at frequent intervals. The chamber should not 
 be subject to any sudden change from heat to cold, and the 
 strictest cleanliness should be observed. With a view to 
 protect the eyes, the room should be kept dark, so that the 
 patient may be prevented reading or using his eyes. In large 
 establishments separation is necessary, to prevent spreading 
 of the disease, if possible. Should the eruption disappear 
 (" striking in of the eruption "), or be retarded, and untoward 
 symptoms appear, it is just as unscientific as it is dangerous 
 to attempt its "restoration." It is dangerous, because the 
 rules usually laid down for this emergency may have an inju- 
 rious effect on the course of the disease. The disappearance 
 of the eruption is not to be regarded as the cause, but as the 
 result of a bad form of the disease, and due to the general 
 collapse of the patient, in which the skin participates. But 
 this bad form of the disease usually depends on the appear- 
 ance of some complication, especially pneumonia ; and, if 
 this fact be not remembered, and the patient be rubbed with 
 irritating applications, or be placed in a hot bath, with or 
 without mustard, or wrapped up in wet blankets with decoc- 
 tion of mustard, " to bring the eruption out again," we shall 
 often do much harm, even if we succeed in our object, because 
 these procedures do not generally act advantageously on the 
 pneumonia and other complications, while they increase the 
 fever" (Niemeyer, Text-book of Practical Medicine). When 
 convulsions occur in children, it is in all cases necessary, in 
 the first instance, to determine the most probable source of 
 the irritation giving rise to the convulsions — /. e. x whether 
 17 
 
258 MEASLES, GERMAN MENINGITIS. 
 
 they depend upon the specific poison of the disease, upon 
 dentition, or upon intestinal irritation or cerebral disorder. 
 Hot foot-baths sometimes give relief, as well as sinapisms to 
 the limbs ; after which, if the convulsions do not subside, 
 it may be necessary that blood be taken by leeches from the 
 temples. Diarrhoea should not be checked suddenly, but 
 kept under control. The patient ought to remain in bed so 
 long as fever is present, while desquamation is going on, and 
 the cough is severe ; and he ought to keep his room so long 
 as catarrh is present. A low state of the general health may 
 finally result, requiring quinine, iron, or cod-liver oil ; change 
 of air — especially to the sea-side — and sea-bathing, or cold 
 bathing in salt water. 
 
 Measles, German — Rotheln. — Definition.. — A specific 
 eruptive disease, having an incubation period of ten to 
 fourteen days (Squire), or from two to three weeks (Thomas), 
 followed by fever, watery discharge from the eyes and nose, 
 sneezing, and sore throat. The eruption appears on the 
 third or fourth day, and consists of crimson stigmata, rapidly 
 running together into patches of an irregular shape, with 
 obtuse angles, and of sizes varying from a threepenny to a 
 crown piece, according to the severity of the case. The 
 eruption continues from six to ten days, and terminates in 
 desquamation by furfuraceous scales. 
 
 Treatment. — The treatment is similar to that of scarlet 
 fever. The functions of the skin are if possible to be stim- 
 ulated ; and Dr. Paterson found that the aqua acetatis 
 ammonise, in the proportion of two ounces to half an ounce 
 of antimonial wine, and four ounces of water, was a most 
 useful remedy. The use of colchicum was also had recourse 
 to with decided benefit. 
 
 Meniere's Disease. — {See Vertigo, auditory). 
 
 Meningitis, Cerebral and Spinal. — Definition. — In- 
 flammation of the immediate coverings of the brain and 
 spinal cord, the pia mater, and arachnoid (pia-arachnitis). 
 
 Treatment. — As a general principle, remedies have little 
 influence over those forms of the disease which arise during 
 the progress of any specific or constitutional disease, inde- 
 pendent of the general treatment indicated for that disease. 
 When pia-arachnitis arises from mechanical injuries, the 
 treatment is generally by bleeding. If the first symptoms 
 are characteristic of inflammation of the meninges of the 
 brain, and we can only conjecture what it may turn out, 
 
MENINGITIS, CEREBRAL AND SPINAL. 259 
 
 leeches behind the ears ought to be applied in the first in- 
 stance. If this local abstraction of blood proves beneficial, 
 it may be repeated during subsequent relapses. At the out- 
 set of the disease laxatives and ice compresses may also be 
 used (Niemeyer). There is, perhaps, no class of cases in 
 which the sanative powers of judicious blood-letting become 
 so apparent as in children in whom the disease has been 
 observed early and carefully watched. When the inflamma- 
 tory symptoms are less decided, and the headache slight, 
 and the disease drags on slowly, a single venesection is ad- 
 missible. [Dr. Alison relates the following highly illustra- 
 tive case, confirmed now by the teaching of Niemeyer • — ■ 
 " A boy, aged eight years, of rather delicate habit, and who 
 had complained occasionally for some weeks of headache 
 and disordered bowels, temporarily relieved by laxatives, 
 calomel, antacids, and a careful regimen, but recurring, and 
 attended with gradually increasing febrile symptoms, and 
 shooting pain of head ; impatience both of light and sound ; 
 pulse gradually rising to 10S, distinctly sharp, and beginning 
 to intermit ; and then nausea and vomiting, not referable to 
 any medicine taken, but gradually increasing, until it re- 
 curred every time that he sat up in bed, for nearly twenty- 
 four hours ; and a slight but quite perceptible squint show- 
 ing itself. The full action of laxatives and one application 
 of leeches, as well as cold to the head, having failed to make 
 any impression on this course of things, he was bled at the 
 arm (which in such circumstances and at that age has often 
 appeared to me distinctly preferable) to twelve ounces, and 
 the blood was sizy. I do not know what further evidence 
 we could have had of the existence of such inflammation 
 within the cranium as would infallibly, if let alone, have gone 
 on within a few days to delirium, stupor, dilated pupil, slow 
 pulse, succeeded by very frequent pulse, convulsions, and 
 death, and have left after it the usual appearances of the 
 acute hydrocephalus (of Whytt, Cullen and Abercrombie, 
 now described), dryness of the membranes on the surface of 
 the brain, distension of the ventricles of the brain with 
 serum, and some of the marks of inflammatory action either 
 on the membranes or surface of the brain. Instead of this, 
 however, I am quite certain that from the time of the bleed- 
 ing at the arm, this boy never once vomited, that the inter- 
 mission of the pulse was never again observed, nor did he 
 again complain of lights or sounds. The pain of the head, 
 although less violent, continued in the evening of the same 
 
260 MENINGITIS, CEREBRAL AND SPINAL. 
 
 day, and twelve leeches were applied within eight hours after 
 the bleeding ; and from that time he never once complained 
 of this symptom, nor admitted that he felt it ; and from this 
 moment he recovered perfectly, and much more rapidly than 
 he had done from much" slighter febrile attacks previously ; 
 neither has he suffered from that time to this (now thirty 
 years) any return of serious disease" {Edin. Med. Journal, 
 p. 777, March, 1856.) In short, all the symptoms vanished 
 in twenty-four hours, most of them during the flow of blood, 
 and never recurred — a change, under the circumstances, so 
 sudden and sanative as is rarely if ever seen after the 
 use of any other remedy for the same combination of symp- 
 toms.] 
 
 With preference to the sanative influence of general blood- 
 letting in children for inflammatory diseases, if performed at 
 the outset, Dr. West observes, that such depletion is as im- 
 portant a remedy as in the adult ; nor will the most energetic 
 employment of any other antiphlogistic measure enable us to 
 dispense with blood-letting. In a healthy child two years 
 old, a vein (if easily found) may be opened in the arm, and 
 four ounces of blood allowed to flow, if faintness be not 
 earlier produced, without our having any reason to appre- 
 hend that the plan adopted is too energetic. The immediate 
 effect produced is greater than that which follows local de- 
 pletion, and the quantity of blood abstracted is less (West, 
 Diseases of Children). Bleeding in children and in adults 
 exercises an influence quite different — because under totally 
 different circumstances — not yet inquired into ; but certain- 
 ly blood-letting at ages under adult life is soon repaired 
 compared to its reparation after that period. Hasse recom- 
 mends very small doses of morphia (J$ of a grain) in the 
 early stages. 
 
 The first thing to be done by way of medicine is to purge 
 the patient. The purgative is not of great moment, provided 
 it acts freely. Some prefer two to five grains of gamboge, 
 others five grains of calomel, with thirty grains of compound 
 jalap powder. Such doses are to be followed up by a black 
 draught, or the sulphate of magnesia. So difficult is it to ob- 
 tain the action of purgatives in this disease, that doses of three 
 times the strength for adults have been in some instances re- 
 quired ; but such large doses are never to be given until 
 the inefficiency of smaller ones has been ascertained (Sir 
 Thomas Watson's Lectures, No. XXVI). The stools are 
 generally black, or extremely offensive ; and, this state of the 
 
Meningitis, cerebral and spinal. 261 
 
 bowels corrected, the disease, if sympathetic, often ceases. 
 If, however, the head be not relieved, some leeches should 
 be applied to the temples, and the head should be shaved 
 and surrounded with some cold evaporating lotion, such as a 
 towel dipped in cold spring water, or in vinegar and water, 
 or in solution of the muriate of ammonia, with vinegar. 
 
 In chronic cases, Foville strongly recommends the cold 
 douche — pouring cold water over the head from a pitcher 
 held some distance above it. This remedy must be used 
 with caution, as it is a powerful depressant, yet producing less 
 ultimate debility than bleeding. It acts, doubtless, by cool- 
 ing down the general mass of the blood ; and patients almost 
 always recover consciousness under its influence. To secure 
 a lasting result it must be repeated at intervals of a few hours 
 
 In children I have certainly seen good results from inunc- 
 tion with mercurial ointment. (See remarks under the treat- 
 ment of "Hydrocephalus.") In advanced life it rarely hap- 
 pens that the symptoms are so intense as to demand general 
 blood-letting ; but in vigorous constitutions this measure is 
 sometimes necessary. The cases which demand it are those 
 attended by high cerebral excitement and vascular action. 
 But as a rule local blood-letting is not only infinitely more safe, 
 but more beneficial, and it can be repeated from time to time, 
 as the nature of the symptoms may indicate ; while general 
 blood-letting can very rarely be resorted to more than once, 
 and that only at the commencement of the attack. The 
 beneficial effects of local blood-letting may be greatly aided 
 by keeping the head well raised, and by the constant appli- 
 cation of cold water to the scalp ; or the occasional use of 
 bladders filled with crushed ice. The bowels should be 
 opened as rapidly as possible, unless the patient is feeble, 
 emaciated, or greatly exhausted. The most active and 
 searching purge is obtained by calomel and jalap ; or four 
 or five grains of the compound extract of colocynth should 
 be given, combined with two or three grains of calomel, in 
 cases uncomplicated with gout or Bright's disease, and fol- 
 lowed in a few hours with a dose of salts and senna. A fair 
 proportion of nutriment must be given, in the form of milk, 
 strong beef-tea, sago, tapioca, or arrowroot ; and the patient 
 should be kept in a quiet, cool, well-aired, and darkened 
 room, and with cold compresses constantly applied to the 
 head. The more active symptoms being subdued, but not 
 till then, a blister should be placed on the nape of the neck. 
 The bowels should be kept open regularly, and the strength 
 
262 MENINGITIS, CEREBRAL AND SPINAL. 
 
 supported by mild, unstimulating nutriment. When nervous 
 irritability continues during convalescence, henbane, or mu- 
 riate of morphia may be given. In the chronic form the 
 periodical attacks of headache or of insanity may generally 
 be relieved by a brisk purge ; and the head should be kept 
 cool by cloths dipped in vinegar and cold water. If vascular 
 excitement prevails, leeches may be applied behind the ears. 
 The bladder must be kept empty of urine by the catheter, 
 and although wine must be withheld during the active stage of 
 the disease, it is beneficial when the vital energies begin to 
 fall (Maclachlan). 
 
 The dietetic treatment should be strictly antiphlogistic, the 
 patient especially avoiding all mental excitement ; and, if not 
 secluded, he should at least be kept tranquil, not only in 
 body, but also in mind. 
 
 Spinal arachnitis, seldom depending on a morbid poison, 
 is perhaps in all cases best treated by bleeding and mild 
 purgatives. General bleeding is sometimes necessary ; but 
 local bleeding, either by cupping or leeches, along the verte- 
 bral column, is most useful, and cannot be omitted with 
 safety. The medicinal treatment consists in moderate purg- 
 ing by the neutral salts, as the sulphate of soda or the sul- 
 phate of magnesia ; for, as these act on the bladder as well 
 as on the bowels, they are probably the best remedies. But 
 whatever purgative may be selected, it will be proper to com- 
 bine it with the tincture of hyoscyamus, or other mild opiate, 
 to procure the patient any relief from his sufferings. Ergot 
 of rye (secale cornutum) has been very much used in France; 
 and Dr. Meryon speaks favorably of its effects, combined 
 with iodide of potassium, in a case which manifested no 
 complication of spinal effusion {Medical Times and Gazette, 
 Aug. 31, 1863). The warm bath is an excellent adjuvant in 
 the earlier stages of the disease ; whilst in the later stages 
 blisters, setons, moxae, or the ointment of the tartrate of an- 
 timony, are more beneficial, or at least are deserving of a 
 trial. The paralyzing effusion may disappear during their 
 use, combined with the action of diuretics. The external 
 application of belladonna and chloroform will be found of 
 essential service in diminishing the violent pain which ac- 
 companies meningitis of the cord (Meryon). Cold, in the 
 form of bladders filled with ice, applied along the spinal 
 cord, may be of service where congestion prevails. Abstin- 
 ence from all animal diet should be imperiously prescribed 
 throughout the whole course of the disease. 
 
MENINGITIS, CEREBROSPINAL TUBERCULAR. 263 
 
 Meningitis, Cerebro- Spinal — See Cerebro- Spinal Men- 
 ingitis. 
 
 Meningitis, Tubercular. — Definition. — An effusion of 
 serous fluid between the membranes of the brain, or into its 
 ventricles, associated with miliary tuberculosis of the men- 
 inges or at the base. 
 
 Treatment. — Tuberculous meningitis, in the form of acute 
 hydrocephalus, can only be successfully combated in the 
 first or earliest stage. 
 
 If the disease be advanced, no efficient treatment has as 
 yet been determined. The symptoms do not yield to the 
 lancet like those of simple inflammation. Mercury has been 
 used to a great extent, but with little success. In severe cases 
 mercurial ointment has been rubbed on the back and thighs, 
 even in very young children, to the extent of half a drachm 
 to a drachm three or four times in the twenty-four hours. 
 Calomel also has been rubbed on the gums to the extent of 
 three or four grains every four or five hours. It has like- 
 wise been given by the mouth in does of two g* ains every 
 third or fourth hour. Mercury given in these large doses 
 seldom produces salivation in children under three years of 
 age. But the remedy is not successful, and more generally 
 produces spinage-like stools, and irritates the alimentary 
 canal. 
 
 On the other hand, Professor Golis of Vienna recom- 
 mends, after much experience, calomel in quarter or half- 
 grain doses twice a day; also at the same time inunction of 
 an eighth or a fourth of an ounce of mild mercurial ointment 
 into the shaven scalp once in twenty-four hours. The head 
 is to be kept constantly covered with flannel, to prevent any 
 check to perspiration. After a lapse of six or eight weeks, 
 diuretics in the form of acetate of potash, or tincture of 
 squills, or both, are to be given with the mercury. Counter- 
 irritation by issues in the neck are also advocated by him to 
 be kept open for months. Compression of the head by 
 bandaging, or by well applied strips of adhesive plaster, are 
 also to be applied over the whole cranium. Puncture of the 
 skull, if the fluid is arachnoidean, may also prove of service, 
 — not so if the fluid is ventricular. It is to be done with a 
 small trocar and canula at the coronal suture, about an inch 
 and a half from the anterior fontanelle, taking care to avoid 
 the longitudinal sinus. The fluid must be slowly evacuated, 
 and compression of the skull carefully maintained for many 
 
264 MERCURIAL POISONING MILIARIA. 
 
 weeks while the fluid is allowed to drain away. The opera- 
 tion has been successful in very young children. 
 
 Hygienic measures ought to be of the first importance in 
 the rearing of delicate children, so as to prevent if possible 
 the development of those conditions which lead to effusion 
 of fluid within the cranium. During the course of the dis- 
 ease the diet should be slops and light puddings. 
 
 In congenital hydrocephalus the unassisted efforts of 
 nature are incapable of effecting a cure, and it is extremely 
 problematical if medicine is of any use. When, however, the 
 case is deemed hopeless, the propriety of evacuating the 
 water by means of an operation may be entertained. Golis 
 has given the names of twenty-seven writers who have ex- 
 pressed themselves in favor of it, especially if the fluid be 
 slowly "evacuated, and at several repetitions of the operation; 
 yet he himself, along with seven or eight others, proscribe it 
 altogether as cruel and useless. But it has been successful; 
 and when the operation is performed, it seems an axiom that 
 the fluid should be allowed to escape gradually, for otherwise 
 extreme faintness and collapse may be expected. In such 
 cases small doses of ammonia, or a few teaspoonfuls of 
 brandy and water may revive the little patient. Should re- 
 action take place, however, at a snbsequent period, a few 
 leeches and a cold lotion ought to be applied to the head. 
 It seems also determined that the younger the child the 
 greater are the chances of success; for if it lives a few years 
 the sutures of the craniun, though open at the top, are united 
 by bone towards the base of the skull, and thus present a 
 mechanical obstacle to their closure; consequently, the 
 operation is more apt to fail. If this disease, though exist- 
 ing at birth, should not develop till later in life, blisters, 
 mercury, and iodide of potassium to salivation are the 
 remedies mostly relied on. 
 
 Mercurial Poisoning. — Definition. — -A series of morbid 
 phenomena, especially peculiar tremors, with cachectic and 
 cerebral symptoms, induced by the absorption of mercurial 
 inhalation of vapors from mercu ry or its salts, or from the 
 medicinal administration of the salts of mercury in continu- 
 ous small doses. 
 
 The Treatment is similar to that already described for 
 the elimination of lead. 
 
 Miliaria. — Definition. — An eruption of innumerable mi- 
 nute pimples, with white summits, occurring in successive 
 
MORBILLI MUSCULAR ATROPHY. 265 
 
 crops upon the skin of the trunk and extremities, preceded 
 and accompanied with fever, anxietas, oppression of respi- 
 ration, copious sweats of a rank, sour, fetid odor, peculiar 
 to the disease. The base of the pimples and the skin around 
 are red and irritable. 
 
 Treatment of the disease appears to consist in cooling 
 drinks, purgatives, and antiphlogistics. 
 
 Morbilli — See Measles. 
 
 Mumps. — Definition. — A specific fever with inflammation 
 of the parotid and other salivary glands, which is contagious 
 and sometimes epidemic. 
 
 Treatment. — Constant hot fomentations (after leeching in 
 severe cases) should be applied to the swollen parts. The 
 maintenance of a constant but gentle action on the bowels, 
 by saline cathartics, must be attended to. Absolute rest 
 ought to be enforced, a farinaceous diet enjoined, and no 
 irritating applications ought to be applied to the swollen 
 glands. The disease runs a definite course, and is not likely 
 to terminate unfavorably. 
 
 Muscle, Spasm of. — Definition. — An affection charac- 
 terized by pathological contractions of muscles, some pain- 
 ful and some not, but manifested only during the exercise of 
 certain voluntary or instinctive movements (Duchenne). 
 
 Treatment in all these cases must be directed towards the 
 removal of the probable cause, and improvement of the gen- 
 eral health (see Scrivener's Palsy). 
 
 Muscular Atrophy, Progressive. — Definition. — A pe- 
 culiar wasting of muscles, with atrophy of their substance, 
 associated with lesions of grey matter in the centre of the 
 cord — namely, wasting of the ganglionic cells of the anterior 
 horns, with oleo-granular degeneration, and of the anterior 
 roots of the nerves of the spinal cord, and attended by 
 paralysis. 
 
 Treatment of wasting palsy ought to be strictly a restora- 
 tive one , believing that the disease is one of nutritional de- 
 terioration of the nervous centres. Preparations of wine 
 and cod-liver oil, with localized faradization, are the most 
 likely agents to improve the condition of the body (Althaus). 
 Local means will aid the hygienic — namely, methodical 
 exercise and douche baths, or cold mineral baths; so also 
 thermal or sulphur baths, and galvanism. Frictions, 
 with stimulating liniments (such as camphor liniment), are 
 
266 MUSCULAR RHEUMATISM. 
 
 also favorably spoken of (Duchenne, Gross, Meyer, Roberts). 
 " Faradization " ought to be practised at least three times a 
 week, for from five to ten minutes each, and continued at 
 least a month before it is given up, if negative results are 
 only obtained. Every muscle ought to be faradized in a 
 special manner, according as it has suffered more or less in 
 its electric contractility and nutrition. The power of the 
 current ought never to be strong. When the sensibility of 
 the muscle returns, the intensity of the current may be 
 diminished. Its application should never be protracted 
 beyond ten or fifteen minutes at the most — one minute, on 
 an average, being allowed to each muscle, or distributed 
 over several at a time. 
 
 If, on the other hand, it turns Qut, as the searching exami- 
 nations of Mr. Lockhart Clarke and others would tend to 
 show, that these forms of progressive paralysis or " wasting 
 palsy " are always associated with disease of the spinal cord, 
 the efforts of treatment should, in the first place, be directed 
 to that part of the cord corresponding to the connections of 
 the nerves with the site of lesions — the line of treatment to 
 be pursued being determined by the general symptoms. 
 The application of the constant current of electricity — the 
 positive electrode being placed in the region of the cervical 
 sympathetic, and the negative electrode upon the cervical 
 and upper dorsal regions of the spine — has been followed by 
 long amelioration, if not by positive cure, in the hands of 
 Remak and Benedikt (Clvmer, in New York Medical Jour- 
 nal, 1866, Vol. III). 
 
 Muscular Rheumatism. — Definition. — Pain in the mus- 
 cular structures, increased by motion. 
 
 Treatment. — In muscular rheumatism, the local appliances 
 which ensure rest and warmth afford most relief. In lum- 
 bago nothing is so instantaneously beneficial as strapping the 
 back from the level of the " seat " upwards, in imbricated 
 layers of straps of adhesive sticking-plaster — emplastrum 
 roborans — spread upon chamois leather, or the common 
 warm plaster of the pharmacopoeia may be used (Tufnell). 
 The patient ought to sit with his bare back before a large fire 
 during the process. Calomel purgation is generally indi- 
 cated, combined with rhubarb and soda, as the excretions 
 are generally greatly at fault. The subcutaneous injection 
 of morphia will generally give temporary relief. Opium may 
 also be necessary internally ; and a course of bicarbonate of 
 potash with iodide of potassium may be also indicated. 
 
MYELITIS NEURALGIA. 267 
 
 Myelitis — See Encephalitis. 
 
 Myocarditis. — Definition. — An inflammation of the mus- 
 cular structure of the heart (extremely rare as an idiopathic 
 disease), which becomes softened, flabby, and finally degen- 
 erates in various ways. 
 
 Treatment under such circumstances cannot be indicated 
 beyond what has been stated under "Endocarditis;" but 
 free stimulation will be called for. 
 
 Nephritis, Suppurative. — Definition. — " Inflammation 
 with suppuration of the substance of the kidney." 
 
 Treatment — The treatment of acute nephritis must be 
 according to the usual principles of the treatment of inflam- 
 mation, by keeping the patient at perfect rest, the applica- 
 tion of hot fomentations and poultices, preceded or not by 
 the local abstraction of blood or by dry-cupping. Blisters 
 in such cases are dangerous, and ought to be avoided. The 
 neutral salts, with opiates, are admissible t in some cases, 
 especially where calculi or gravel are sources of irritation. 
 Castor-oil, or other purgative substances which do not act so 
 immediately on the kidneys, are more useful, such as 
 compound jalap powder or podophyllin. Should signs of 
 abscess appear, the pus may be evacuated, as in the case of 
 liver abscess, and with the same antisceptic precautions. 
 
 Nettle-Rash — See Urticaria. 
 
 Neuralgia. — Definition. — Excruciating pains occurring in 
 the course of nerves, and in their area of distribution, usually 
 of a shooting character, which flash with momentary intensity 
 along the fibres of the affected nerve, occurring in par- 
 oxysms composed of momentary shocks following one an- 
 other in rapid succession (Bristowe) ; or returning with re- 
 newed violence in a part after periods of temporary remis- 
 sion, due to some unknown morbid state of the nerves of sen- 
 sation or their centres, a symptom of some local lesion, or 
 more commonly of a general affection or cachexia. 
 
 Treatment. — When the cause of the neuralgia can be dis- 
 covered, its removal is the obvious procedure to follow. 
 There can be no question that the disease has often subsided 
 under the use of various remedies ; but the tendency in neu- 
 ralgia to a spontaneous intermission is so great, that it is 
 doubtful whether in any case medicine can be said to have 
 cured it. Opiates are unquestionably serviceable in mitigat- 
 ing the sufferings of the patient, and perhaps in influencing 
 the disease, but not to the extent generally supposed. Bella- 
 
268 NEURALGIA. 
 
 donna, both internally and as a plaster, may sometimes re- 
 lieve the pain. Stramonium and opium have a similar tem- 
 porary effect. Chlorodyne is also to be recommended ; and 
 the tinctures of gelseminum and of guarana. 
 
 The remedies of most value are the diffusable stimulants, 
 such as sal-volatile, hot tea, quinine, chloral, and croton- 
 chloral, in full doses, and alcohol in small doses, blistering, 
 the application of ammoniacal fluid to the skin immediately 
 over the painful nerves, and the endermic application of 
 morphia. These remedies act by increasing the supply of 
 blood to the painful nerve, and, pro tanto, heightening its 
 vital energy (Anstie, op cit., p. 84). The most speedy way of 
 obtaining a temporary relief is certainly the application of a 
 local stimulant, and more especially of some volatile agent, 
 such as mustard, or, still better, chloroform diluted with seven 
 parts of some simple liniment, such as belladonna (Anstie). 
 A rapidly acting blistering fluid is still more effective. But 
 the more profoundly the general health has been affected, 
 and especially the greater the degree of anaemia, the more 
 necessary is it to join with the use of stimulants (both local, 
 such as above mentioned, and general, such as the carbonate 
 and muriate of ammonia, taken in five and ten grain doses 
 respectively), a treatment directed to improving the condition 
 of the blood by "food tonics/' such as cod-liver oil, arsenic, 
 or steel, or a combination of some of them, joined with the 
 use of local stimulation by means of frictions with dilute 
 chloroform, and the manipulations of the scientific " sham- 
 pooer " (Anstie, op cit., p. 87). Dr. Radcliffe reports favor- 
 ably of the hypophosphite of soda, and believes that the phos- 
 phorus of this salt acts directly as a food to the nervous tis- 
 sue. The subcutaneous injection of small doses {y& to J of 
 a grain) of morphia in solution will give temporary relief, and 
 is especially useful to those patients who are obliged to go 
 through an ordinary day of labor (Anstie, op. cit. t p. 87). 
 
 When these or other general remedies have proved insuffi- 
 cient, recourse has been had to local remedies. The most 
 efficient of these applications is the alkaloid aconitina, rubbed 
 upon the pained part in the form of an ointment, in the pro- 
 portion of one or two grains to one drachm of lard. A more 
 convenient and efficient application is the " anodyne amyl 
 colloid," prepared by Messrs. Ferris & Co., of Bristol, from 
 hydride of amyl, aconitina, veratria, and etheral collodion. 
 Morphia similarly used, and blisters, have often exercised a 
 beneficial effect upon the disease. Holding the head over 
 
NEURALGIA. 269 
 
 steam, and the warm bath, are sometimes beneficial in cases 
 of facial neuralgia. The belladonna plaster is also a favorite 
 application. When the neuralgia is superficial, compresses 
 steeped in a solution of atropiahave a good effect. For this 
 remedy Trousseau recommends the following formula : — 
 
 $. Atropiae sulphatis, gr. v. ; Aquce distillatce, 3 iii. ; solve. 
 Renew the compresses several times in the twenty-four hours. 
 Continue them for at least an hour each time, and cover them 
 with oilskin, to prevent evaporation. 
 
 When general and local applications are unsuccessful, the 
 cause may be sought for in a diseased tooth or stump, and in 
 a very few instances an exostosis of the stump has been dis- 
 covered, removed, and the disease cured. Sometimes, how- 
 ever, even when the patient submits to have every tooth in 
 his head drawn, no relief or benefit may result. The division 
 of a nerve is sometimes had recourse to ; but even this opera- 
 tion is very uncertain. Where the causes of neuralgia cannot 
 be removed, modes of treatment which greatly modify the 
 change of tissue and the nutrition of parts are often benefi- 
 cial: Chief among these is the use of electricity ; and 
 Niemeyer gives the results of his experience in the following 
 propositions : — 
 
 i 1. In treating neuralgia with the induced current, it is 
 best to employ the metallic electrodes known as the electric 
 brush. While one electrode, containing a moistened sponge, 
 is held in one of the patient's hands, or against any part of 
 his body, we stroke the brush along the course of the affected 
 nerve ; if there are any specially painful points, we allow the 
 brush to remain over them rather longer {electric moxoe). 
 
 " 2. Many cases of neuralgia, which' had been previously 
 treated without benefit by the most varied remedies, were 
 completely and permanently cured in from twelve to twenty 
 applications, or even sooner. In other cases no benefit or 
 cure was effected." 
 
 " 3. The first sitting shows whether the neuralgia can be 
 cured by the induced current. We can only expect a cure 
 where the pain is decidedly relieved, or entirely disappears, 
 immediately after the first electrization, even if it should only 
 be for a short time. If this temporary result do not take 
 place, the continuation of the treatment will also prove inef- 
 fectual. 
 
 " The application of the induced current as above directed 
 is very painful. The current employed ought not to be oi 
 greater intensity than the patient can easily bear ; the appl'^ 
 
270 NEURALGIA. 
 
 cations should also be of short duration and frequently re- 
 peated. It is only after the patient has actually experienced 
 benefit that he suffers it with patience." 
 
 The constant current is far more effective than the Faradic 
 in neuralgia. [Some cases that have been treated without 
 the slightest result by the Faradic current have been cured 
 by the constant current.] Niemeyer places both poles along 
 the affected nerve, and, without attending to the course of 
 the current, holds the zinc pole on the most painful part and 
 on those parts where the nerve approaches nearest to the sur- 
 face, as at the supra or infra-orbital foramen, or at the zygo- 
 matico-facial foramen, or at the sciatic notch. If it be pos- 
 sible to get the nerve between the poles, as in the cheek or 
 nose, he introduces one pole into the mouth or nose to the 
 point whence the pains radiate, while the other is placed at 
 the" corresponding point on the skin. " At first the applica- 
 tion of the constant current is not particularly painful ; but 
 an unpleasant, burning, piercing pain soon commences, and 
 gradually increases ; and where the number of electric ele- 
 ments is large, it may become unbearable. 
 
 " The changes induced in the skin at the point of applica- 
 tion of the constant current, if the electrodes be applied for 
 a length of time, are far greater than those caused by the in- 
 duced current. They not only consist in a lively erythema, 
 a decided swelling of the skin, and an increase of the subja- 
 cent tissue ; but papules and blebs arise on the skin, particu- 
 larly at the positive pole. It the action continues long, the 
 surface of the elevations sloughs off. These changes take 
 place not only at the point of application, but occur 
 equally, or at least .similarly, in the deeper parts, as is 
 shown not only by the increase in volume of the sub- 
 cutaneous tissue and muscles, but also by the following ex- 
 periments (Erb), which show a great deal about the mode of 
 action of the constant current in neuralgia and other neu- 
 roses, as well as in some diseases of the muscles and joints: 
 If we cross the forearms, placing the volar surfaces in con- 
 tact, and apply the electrodes to their dorsal surfaces, there 
 will be reddening not only of the parts to which the elec- 
 trodes are applied, but of the corresponding points on the 
 anterior surfaces. Generally, relief immediately follows the 
 application of the constant current, just as it does that of the 
 induced current; but occasionally the pain is at first in- 
 creased, and that should not always induce us to stop the 
 treatment. There seems to me no doubt that the curative 
 
NEURALGIA. 271 
 
 action of the constant current, in most cases of neuralgia, is 
 to be explained by the modification of the circulation, endos- 
 mosis, or change of tissue in the diseased nerve, its neuril- 
 emma, or the parts around. This ' catalytic action ' may 
 result from the chemical disintegration induced through the 
 nerves, or the attraction of the constituents of the nutrient 
 fluids toward the pole, or it may occur in some other way " 
 (Niemeyer). 
 
 Narcotics, in the form of hypodermic injections of solutions 
 of morphia, are of great value, and it is immaterial whether 
 the injection is made near the seat of pain, or at a remote 
 distance from it. " Subcutaneous injections of morphia con- 
 stitute the only decided and effectual, and truly invaluable, 
 method of treating neuralgia" (Von Pitha). The hypoder- 
 mic syringe and the morphia solution are now almost as in- 
 dispensable accompaniments of the physician as the stetho- 
 scope and thermometer. Its use, however, is attended with 
 similar bad results as the taking of opium in any other form. 
 The dose must be gradually increased, and the remedy can- 
 not easily be given up. If it is omitted the patient feels dull, 
 weak, uncomfortable, nervous, and trembles from head to 
 foot, as after an alcoholic debauch. As a palliative it is 
 invaluable, to the extent of one-sixth to one-third of a grain 
 of morphine, injected hypodermically. But in slight cases, 
 and in sensitive persons, and in the young, very much smaller 
 doses may relieve the pain — e.g., the twentieth to the twelfth 
 of a grain. In severe and persistent cases the dose has to 
 be increased; and it is very desirable not to have recourse to 
 such hypodermic injections oftener than twice daily. It is 
 necessary also to employ the remedy with proper caution, 
 with reference to the patient's individuality or idiosyncrasy. 
 The hypodermic treatment with morphia must be commenced 
 tentatively in small doses. The first dose of a morphia in- 
 jection for an unknown individual must not be more than 
 one-twelfth of a grain; and in very sensitive and delicate 
 women and young people not more than one-twentieth, or 
 even yet less. If the patient is the subject of that peculiar 
 idiosyncrasy of extreme sensitiveness to opium, symptoms of 
 poisoning may supervene. Thus, there may be syncope, 
 spasm of the heart, or an asthmatic paroxysm, the skin being 
 covered with a cold sweat. Fresh air should at once be ad- 
 mitted through opened windows, while the patient's face is 
 diligently fanned. An assistant should also bathe the face 
 and temples, as well as the bared chest, with vinegar, and 
 
272 NEURALGIA. 
 
 these parts are to be sprinkled at the same time with cold 
 water. A strong decoction of coffee is to be administered as 
 an enema, or, when possible, given by the mouth; and, in 
 extreme cases, artificial respiration must be resorted to. In 
 most cases these means will succeed, providing that the dose 
 has not been too large. When the vomiting and disposition 
 to syncope persist without yielding to the usual measures, a 
 careful and interrupted inhalation of chloroform may be use- 
 ful. If there is a constant disposition to nausea and sickness 
 after the hypodermic use of morphia, it may be counteracted 
 by adding from a quarter to a third of the tincture of bella- 
 donna to the morphia solution, then the extract, and, finally, 
 minute quantities (about one-hundredth of a grain) of the 
 sulphate of atropia. The extract answers best (Von Pitha). 
 
 The injection should be projected into the subcutaneous 
 tissue, and not into the skin itself; and this may be secured 
 by pinching up a fold of skin, care being taken not to make 
 a double perforation in it. Well known or visible vessels or 
 nerves are to be avoided. The places most eligible for the 
 injections are — the external parts of the arm and thigh, the 
 back, and the integument of the abdomen and nates. The 
 face and neck should be avoided; and the painful regions 
 ought not to be punctured. 
 
 " With respect to the preparation to be employed, it may be 
 stated that the acetate and hydrochlorate may be used in- 
 differently. Only in cases in which very large doses are given, 
 as above a grain, need the acetate be preferred, on account of 
 its greater solubility. It will form a clear solution in six parts of 
 water, whereas the hydrochlorate requires twenty parts. Hot 
 water will dissolve it in ten parts, but, on cooling, half of the 
 alkaloid is precipitated; so that if a concentrated solution is 
 wanted, it has to be prepared only just before using it. On 
 the other hand, the acetate requires great care in keeping it 
 in a cool place and shielded from the light. The solution 
 should always consist of morphia and distilled water, without 
 any addition whatever. The favorite addition of glycerine 
 has the disadvantage of causing white flocculi to be precipi- 
 tated from the originally clear liquid. Belladonna, however, 
 may be added, for the reasons already stated, with great ad- 
 vantage; and although the solution is rendered somewhat 
 turbid, its efficacy is not diminished. It is very desirable 
 that similar combinations with different other substances, 
 and especially other narcotic alkaloids, should be thoroughly 
 investigated " (Von Pitha), 
 
OESOPHAGITIS. 
 
 273 
 
 Frictions of the skin with veratrine ointment, in the pro- 
 portion of gr. iv. to gr. x. of veratrine to 3 i. of lard; or with 
 aconite ointment, in the proportion of one grain of aconite 
 to one drachm of lard, have also been used with advantage. 
 The application of cold water sometimes, but only excep- 
 tionally, does good, especially if the pain is attended by 
 heat — applied as a compress, or as a fine douche. Warmth 
 by means of a hot iron, a stream of warm water, or as a warm 
 cataplasm, may also afford relief. Richardson's spray pro- 
 ducer has also been of use; and also acupuncture as recom- 
 mended by Teale, especially in the neuralgia of joints persist- 
 ing after rheumatism or spasm. As internal remedies chloral 
 and bromide of potassium combined are of great service. 
 
 The treatment of sciatica consists in following out, as far 
 as possible, the removal of the causes and circumstances al- 
 ready noticed as producing the disease. In the rheumatic 
 form, the warm baths are most useful, especially the syste- 
 matic treatment at Neuenahr, Wildbad, Wiesbaden, Teplitz, 
 and Bath. Iodide of potassium, in large doses, and sulphur, 
 especially in the form of the Chelsea pensioner, appear to do 
 most good. Of other specific remedies Niemever mentions 
 the induced, and still more, the constant current of electricity 
 as rarely failing to do good. Oil of turpentine, as an elect- 
 uary, is also recommended in the following : — 
 
 5>. 01. Terebinth. 3i.; Mell. 3 i., of which a tablespoon- 
 ful is to be taken twice a day. This is very highly spoken 
 of by Romberg. 
 
 With regard to the treatment of mastodynia or irritable 
 breast, — a plaster worn on the breast, if composed of anodyne 
 elements, may soothe the pain and prevent the gland being 
 touched by the patient, and it as well may give support to 
 the breast. Cooper recommends the soap plaster with ex- 
 tract of belladonna, and the following pills : — 
 
 I£ Ext. Conii, Ext. Papaver, a a gr. ii.; Ext. Stramonii, 
 gr. % to x /2, are mentioned by Romberg as useful. 
 
 Oesophagitis. — Definition. — Inflammation of the textures 
 of the oesophagus. 
 
 Treatment of oesophagitis is by small local bleedings, by 
 warm cataplasms to the neck, and by moderately acting on 
 the bowels. In the treatment of the more chronic forms 
 some sedative is essential. There is always some danger, in 
 the use of the probang, of rupturing the canal, or of causing 
 an ulcer. When the case is hopeless, from the small quan- 
 tity of aliment which reaches the stomach, life may yet be 
 18 
 
274 OSTEO-ARTHRITIS, CHRONIC. 
 
 prolonged by enemata of soups, milk, egg, wine or other 
 nutritious fluid matters. The question of an artificial 
 opening into the oesophagus or the stomach may have to be 
 considered. 
 
 Osteo- Arthritis, Chronic— Definition. — An affection 
 characterized by pain, stiffness, and deformity of one or 
 more of the joints, associated with the deposition of new 
 bone around them. 
 
 Treatment. — Chronic osteo-arthritis must not be treated 
 either as gout or as rheumatism. Colchicum is considered 
 by Dr. Garrod to be generally injurious! an d so also is alka- 
 line treatment. The course of management may be shortly 
 indicated as follows: — Gregory's powder at bedtime, and 
 more active aperients at regular intervals, are required as a 
 necessity. The action of the skin ought to be encouraged 
 by hot-air baths, the frequent use of the Turkish bath, and 
 Dover's powder at bedtime. Warm bathing is generally at- 
 tended with relief, and recourse should be had to the mineral 
 springs of high temperature. Schwalbach, Spa, Wildbad, Neu- 
 enahr, and Tunbridge Wells, are the best. Guaiacum, if borne 
 by the stomach — combined or not with sulphur, and taken as 
 an electuary in glycerine — is of great assistance (Garrod). The 
 free use of dilute phosphoric acid is recommended by Mr. 
 William Adams. Iodide of potassium is also well spoken of. 
 Whichever of these remedies may be considered suitable for 
 any particular case, it ought to be steadily persevered in for 
 several weeks. Warm clothing and residence in a warm 
 climate, during the winter months, are necessary elements 
 for increasing the comfort of the patient. If much emaci- 
 ation has resulted, cod-liver oil and fats must be prescribed, 
 combined with the usual tonic remedies — quinine, iron, 
 strychnia, arsenic, and mineral acids — according to the 
 nature of the case. The local remedies must be regulated 
 by the surgeon. Chief of these Dr. Julius Althaus has used 
 with advantage that most active stimulant of nutrition — the 
 continuous galvanic eurrent. It acts as a general tonic to 
 the system, more especially to the nervous system; and re- 
 lieves one of the chief complaints, want of sleep, when 
 hydrate of chloral fails. The best mode of application for 
 this purpose is to direct the positive pole, armed with a con- 
 ductor of large surface, to the cervical spine, while the nega- 
 tive pole, similarly armed, is placed on the pit of the stom- 
 ach. A gentle current, which even patients of exquisitp 
 
PACHY-MENINGITIS PALSY, SHAKING. 275 
 
 sensibility can well bear, is thus allowed to flow for from 
 three to five minutes in the direction just described. By 
 this application, the base of the brain, the spinal cord, and 
 the cceliac plexus of nerves, are simultaneously brought 
 under the influence of the current. It also relieves pains, 
 for which object the constant current must be applied to 
 the suffering parts, so that the positive pole, armed with a 
 small electrode, is made to touch the sore points; while the 
 negative, connected with a large electrode, is placed in the 
 neighborhood. The current used may in this instance be 
 somewhat more powerful than where it is employed for 
 general tonic effects; and if a short application, say of one 
 or two minutes, be not successful, this may be extended to 
 four or five minutes. The effect is, in many instances, 
 almost magical, inasmuch as pain, which has been fixed in 
 some particular spot for months and years, is, as it were, 
 charmed away by one or two applications. If such treat- 
 ment is followed up for a sufficient length of time, even 
 extensive deformities may be improved (Brit. Med. Jour., 
 Sept. 28, 1872). 
 
 Pachy-Meningitis. 
 
 Treatment. — Circumscribed suppurations, when recognized, 
 must be dealt with by the surgeon, under rigid antiseptic pre- 
 cautions. Evaporating lotions or ice to the head or spine 
 are also indicated. Free action of the bowels (especially of 
 the lower bowel by aloetic laxatives) should be maintained. 
 Circumstances may also indicate iodide of potassium, and 
 pain is best relieved by large doses of opium or morphia. 
 The patient ought to be kept perfectly at rest. 
 
 Palsy — See Scrivener s Palsy. 
 
 Palsy, Shaking. — Definition. — Involuntary tremors, con- 
 tinuous and permanent, with lessened muscular power, ag- 
 itating various members increasingly, allowing no peace; and 
 while purposed movements may exaggerate the shaking, re- 
 pose does not cause its disappearance, and sleep alone puts 
 a temporary stop to the spasmodic agitation of the affected 
 members. The affection may commence in the hands, arms, 
 or head, and gradually extend over the whole body. 
 
 Treatment. — Hyoscyamine is a palliative merely, while 
 strychnine, ergot of rye, hyoscyamus and opium, nitrate of 
 silver, and Calabar bean all aggravate the tremors. The use 
 of the continued current of a galvanic pile has been attended 
 with success in the hands of Remak and Russell Reynolds. 
 
276 PARALYSIS, LOCAL. 
 
 Paralysis, Local. — Definition. — Paralysis limited to par- 
 ticular sets or groups of muscles. 
 
 Treatment, — Paralysis due to lesions which are destructive 
 of the nerve are beyond medical aid. In cases suitable for 
 treatment, and within the first few days, the agents used with 
 most benefit are, — blood-letting by leeches behind the ear of 
 the affected side, or over the mastoid region. They ought 
 to be applied repeatedly, especially if any pain exists on 
 pressure in that region. Blisters, with dressings to keep them 
 open, medicated by veratria or strychnia (fa to \ of a grain 
 sulphate of strychnia or of veratria), mixed with five or six 
 times their weight of pounded sugar. Electrization in the 
 form of faradization by a Stohrer's two-celled volta-electric 
 machine; or in the form of an interrupted galvanic current, 
 from a continuous current battery (as from a Muirhead's 
 battery of fifteen cells), the number of cells being very grad- 
 ually increased, are agents of much service. 
 
 In using faradization each facial muscle should be sepa- 
 rately influenced, instead of attempting to pass the current 
 through the facial nerve. The muscles are thus more pow- 
 erfully influenced, and they are more apt to regain voluntary 
 contractility at different periods, some muscles before others. 
 At first the apparatus should be one capable of producing 
 currents with very rapid intermissions; but when any mus- 
 cles begin to contract, the intermissions should be few, and 
 the sittings at long intervals (three times a week, for two or 
 three minutes only at a time), otherwise contraction of the 
 muscles is apt to increase and become incurable. The vol- 
 taic current, from a continuous current battery, induces con- 
 tractions when the circuit is closed and when it is opened, 
 and more powerfully at the moment of closure. It is said 
 to restore to palsied muscles the power of contracting under 
 the influence of faradization. When improvement follows 
 the use of the voltaic current from a continuous battery, the 
 number of the cells should be gradually increased as the 
 muscles get less susceptible to their influence, and then the 
 battery may be used oftener. One of the electrodes should 
 be gently moved along the surface of the muscle, just as the 
 brush is used in faradization. During the first weeks it 
 may not be used oftener than once weekly, commencing with 
 six to ten of Stohrer's elements, 
 
 When contracture of muscles supervenes, they ought to be 
 stretched or pulled out mechanically. To remedy contrac- 
 tion of the buccinator, Duchenne recommends the use of a 
 
Paralysis, acute spinal of adults. 277 
 
 small billiard ball worn for a long time inside the cheek, to 
 be replaced after a time by a larger one. The late Bazire 
 gave favorable testimony to the value of this mechanical 
 aid. 
 
 The daily action of the bowels ought to be carefully 
 regulated, especially by such medicines as keep the colon 
 in functional activity. Bichloride of mercury (corrosive 
 sublimate) in small doses, continued till the gums are 
 slightly tender, is sometimes of service. In cases where 
 rheumatism prevails, or periostitic affections, small doses 
 of iodide of potassium, persevered in for a lengthened 
 period, are of service, with the frequent use of phosphate 
 of soda as a daily morning aperient. 
 
 Treatment of most of the forms of local paralyses is main- 
 ly by the continuous voltaic current to the muscles when the 
 acute symptoms have passed away, and when no fever or lo- 
 cal signs of inflammation exist. The use of cutaneous fara- 
 dization, on a dry surface with a feeble and slowly intermit- 
 tent current, has also been strongly recommended by Du- 
 chenne. Friction, stimulant applications, and blisters are 
 also of use. 
 
 Paralysis, Acute Spinal of Adults. — Definition. — A 
 
 sudden feverish attack, with such cerebral phenomena as 
 deafness, coma, delirium, or general convulsions, soon fol- 
 lowed by a rapidly developed and complete paralysis, vari- 
 ously distributed over the trunk and extremities; but gener- 
 ally in the form of paraplegia. There is entire relaxation of 
 the paralyzed muscles; an absence of any severe disturbances 
 of sensation; and there is no paralysis of the sphincters nor 
 bedsores. The original paralysis is not progressive; but im- 
 provement gradually takes place as to the restitution of 
 movement up to a certain point, which is not uniform. In 
 the end the power of movement in some part is lost forever; 
 a paralytic and withered limb for life is all that can be hoped 
 for (Professor W. H. Erb). 
 
 Treatment. — The acute myelitis, if detected, first demands 
 attention. Local abstraction of blood by leeches or cupping 
 should be had recourse to over the cervical and lumbar en- 
 largements. The bowels should be freely moved by cathar- 
 tics, followed by iodide of potassium in appropriate doses. 
 Rubbing in of mercurial ointment and counter-irritation may 
 afterwards be employed the whole length of the spine, or 
 blister, plaster, or painting with the tincture of iodine. Dr. 
 Althaus has most confidence in the subcutaneous injection 
 
278 PARALYSIS, ACUTE SPINAL OF ADULTS. 
 
 of ergotine (Bonjean's solution in diluted water), one-fourth 
 grain for a child from one to two years of age, one- third 
 grain for a child from three to five years, and half a grain 
 for children from five to ten years, and a grain for patients 
 upwards of ten years; to be repeated as symptoms indicate, 
 once or twice a day. When acute symptoms have subsided, 
 the diseased area within the cord should become the main 
 object of treatment, by induction of the catalytic action of 
 the voltaic current. A large electrode, which will cover the 
 entire diseased area, is to be placed over the lumbar or cer- 
 vical enlargement, while the other is to be applied to the an- 
 terior surface of the trunk. First the anode, and then the 
 cathode, are to act alternately for from one to two minutes 
 at a^ time, with a moderately strong current. This treatment 
 must be continued for a long time, or repeated at intervals 
 for several years. The faradic current is not to be used at 
 this period. Such are the recommendations of Erb. They 
 differ somewhat from the injunctions of Althaus. " It being 
 most important that the voltaic current should pass through 
 the anterior cornua, it is better to have one pole on the spine 
 and the other on the front part of the body, than to place 
 both electrodes to the spine. If the cervical cord has to be 
 acted upon, place the positive pole to the nape of the neck, 
 and the negative to the manubrium sterni. When the lum- 
 bar enlargement is diseased, the positive pole is put to the 
 loins, and the negative a little below the umbilicus; while, 
 when the dorsal cord has to receive the voltaic influence, the 
 positive pole should be slowly guided along the whole dorsal 
 spine, the negative being left stationary at the ensiform car- 
 tilage " (Althaus) 
 
 If electric contractility remain, much may be hoped for, 
 so long as nerves and muscles have not altogether degener- 
 ated. The principles of treatment are the same as have been 
 advocated in analogous diseases — namely, restorative and 
 not depressant. The general health must be improved by 
 the use of baths, with a strong and abundant diet; the use of 
 cod-liver oil, and prolonged sojourn in mountain air. The 
 systematic, active, and persistent application of the voltaic 
 current of electricity is the best means of preserving the func- 
 tions of the implicated muscles, and of arresting their atro- 
 phy and degeneration, provided all other hygienic arrange- 
 ments are maintained which have already been insisted on 
 as to food, clothing, ventilation, and open air. The cathode 
 is to be applied over all the paralyzed muscles and nerves, 
 
PARALYSIS AGITANS PARALYSIS, BULBAR. 2jQ 
 
 while the anode is best placed upon the vertebral column at 
 the height of the main lesion. The strength of the current 
 should be such as to produce distinct twitchings and lively 
 redness of the skin. The faradic current may, however, still 
 be used when the muscles retain their faradic irritability. 
 The faradic application is to be made with moist electrodes. 
 
 Mild purgation may be required; alteratives, especially 
 small doses of mercury, continued for a long time, have been 
 of service; and so also have quinine, iodide, of potassium, 
 and iodide of iron. 
 
 Friction, kneading, squeezing (massage), and shampooing 
 ought also to be persevered in. Three or four small circu- 
 lar wooden balls, about the size of a walnut, shut up in a 
 box, with holes in its cover, so as to expose one-third of the 
 surface of the balls on a uniform level, makes a good sham- 
 pooing apparatus. 
 
 Paralysis Agitans — See Palsy, Shaking. 
 
 Paralysis, Bulbar. — Definition. — A chronic and pro- 
 gressive affection of the bulbar nuclei, in which there is di- 
 minution and subsequent loss of the motor power of the 
 tongue, soft palate, and lips, associated with structural 
 changes in the central nuclei and roots of the motor nerves 
 which supply the affected muscles. The disease progresses 
 always more or less rapidly to a fatal termination. 
 
 Treatment. — Faradization is of doubtful efficacy at the 
 commencement, but gives relief at later periods, by tempo- 
 rarily restoring function to the affected muscles, to the les- 
 sening of the trouble of deglutition, and by exciting the re- 
 spiratory acts. 
 
 Dr. Dowse relates one case of cure under his care {Brit. 
 Med. Journal, March 11, 1876, p. 321). The bulbar paraly- 
 sis came on after a severe epileptic attack. The paralyzed 
 parts were brought under the influence of galvanism, and in- 
 jections of one-sixth of a grain of strychnia, and one-twen- 
 tieth of a grain of atropia were daily used to the lower ex- 
 tremities. At first the induced current from a two-celled 
 Stohrer's battery was several times applied to the tongue 
 without any result ; after this the continuous current from 
 six cells of Stohrer's battery was applied, and with the best 
 results, for the tongue was quickly protruded, and as sharp- 
 ly retracted. For some days, however, he had no voluntary 
 power over it ; but the use of the daily galvanic stimulus 
 shortly ensured this, and articulation soon became perfect. 
 
280 PARALYSIS, GENERAL PARALYSIS OF THE INSANE. 
 
 It was for some time almost inaudible, and the letter R was 
 the most inarticulate of all the consonants. With this the 
 power of swallowing soon returned, so that he had complete 
 co-ordinate voluntary power over those parts supplied by the 
 bulbar nerves. The last to regain power and sensation were 
 the lower limbs. The muscular atrophy here was so ex- 
 treme that nothing but the tibiae and integuments appeared 
 left ; but galvanism, frictions, and injections gave excellent 
 effects. He also took cod-liver oil, quinine and phosphor- 
 us. Instead of his being a mute, helpless, and emaciated 
 creature, he had complete voluntary power over every part 
 of the body. 
 
 When initial pains in the head and neck point to the com- 
 mencement of myelitic changes, Professor Kussmaul recom- 
 mends the repeated application of dry-cupping glasses to the 
 nape of the neck every five days, and in full-blooded strong 
 persons he would order blood to be abstracted at the first 
 cupping. Afterwards he would permit the cautious tentative 
 use of the shower douche, and even the jet douche for strong 
 persons. Food and drink of a stimulating kind must be 
 avoided during the first months. As to medicines, nitrate 
 of silver, administered early, is deserving of most confidence. 
 He also recommends galvanization. It may be necessary to 
 administer food through an oesophagus tube, or by nutrient 
 enemata. 
 
 Paralysis, General. — See Paralysis of the Insane. 
 
 Paralysis, Lahio-Glosso-Laryngeal. — See Paralysis, 
 
 Bulbar. 
 
 Paralysis of the Insane. — Definition. — An incessantly 
 progressive form of general paralysis, in which the cineri- 
 tious substance of the brain is the seat of cloudy swelling of 
 its minute elements — the ganglionic brain-cells — with lesion 
 of minute blood-vessels and increase of connective tissue, as- 
 sociated with peculiar disorder of the intellect, general fail- 
 ure of nerve power, muscular debility, frequent blood extra- 
 vasation (haematoma), convulsions of the nature of apoplexy 
 and epilepsy combined, and tending to involvement of the 
 whole brain in degeneration, softening, and atrophy, so that 
 general and complete paralysis of body and mind results. 
 
 Treatment. — Regarding the disease from the commence- 
 ment as essentially a chronic form of parenchymatous in- 
 flammation, confined at first to the convexity of the fore- 
 

 PARAPLEGIA. 281 
 
 half of the hemispheres, and frequently tending to meningitis 
 more or less complete, Dr. Meyer, (following Jacobs of 
 Siegberg) has adopted the method of counter-irritation in its 
 treatment. He keeps open for some months a suppurating 
 surface. For this purpose the head is to be shaven of hair 
 over the centre of the fore part of the skull-cap for a space 
 as large as half the palm of the hand. On the central por- 
 tion of this shaven space as much tartar-emetic ointment as 
 will cover a shilling is to be rubbed in efficiently, and with 
 some energy, with a linen compress or with the ball of the 
 thumb. On a second application caution and gentleness are 
 necessary, in order that the already loosened epidermis may 
 not be torn away, for the deprivation of the cuticular layers 
 causes exquisite pain. Considerable swelling very soon ex- 
 tends over the frontal region and the face in the course of 
 three or four days, which may even advance as far as the 
 back of the head and neck. By this method an eruption of 
 pustules does not take place ; but a large scab comes off in 
 one piece by the frequent application of warm poultices, as 
 soon as the place shows signs of swelling. As soon after the 
 establishment of this suppurating process as the patient's 
 strength will permit, the internal use of iodide of potassium 
 is commenced. The diet must be digestible and of a highly 
 nourishing character. The patient is to be sent out as much 
 as possible for work in the open air, but only in the early 
 and evening hours in the summer months. Exposure of the 
 head to the sun or other source of heat is to be avoided. 
 
 Paraplegia. — Definition. — A form of paralysis affecting 
 the lower parts of the body, in which both legs, and perhaps 
 also some of the muscles of the bladder and rectum, are 
 paralyzed. 
 
 Treatment. — In cases of reflex paralysis means must be 
 taken, first — To diminish the external or peripheral irritation 
 which causes the paralysis ; second, To improve the nutri- 
 tion of the spinal cord ; third, To prevent the ill effects of 
 rest on the paralyzed nerves and muscles. 
 
 In cases of disease of the urethra or prostate, an injection 
 of a solution of one grain of the extract of belladonna, in 
 twenty drops of laudanum, is to be made into the urethra, 
 and the injection should be retained for half an hour, or even 
 an hour, after which some emollient decoction should be 
 used, such as linseed tea, to wash out the passage. Every 
 two or three days this operation should be repeated. If the 
 bladder be diseased, Dr. Brown-Sequard advises a solution 
 
282 PEMPHIGUS. 
 
 of one grain of the extract of belladonna, in twenty drops of 
 laudanum, to be used as an injection, after complete emis- 
 sion of urine. Injections of carbolic acid are also of use in 
 counteracting decomposition of urine and epithelium in the 
 bladder. If the prostate is enlarged, a suppository ought to 
 be put at times into the rectum. One of the best supposito- 
 ries for this purpose is composed of the following ingredients 
 namely: — White sugar, white soap, and gum-arabic in pow- 
 der, of each three grains; opium, in powder, a grain and a 
 half; or belladonna extract, one grain; or both combined. 
 These being mixed together, the mass is to be formed into a 
 conical shape, and being dipped in melted wax, is ready to 
 be introduced, when required, into the rectum (Simpson). 
 When the irritation causing reflex paraplegia starts from the 
 vagina or uterus, a pill of half a grain of the extract of bella- 
 donna, with a grain of opium, surrounded by a piece of cot- 
 ton wool, is to be introduced into the vagina, and made to 
 surround the neck of the womb. By means of a thread it 
 may be withdrawn so soon as pain ceases or diminishes 
 (Trousseau, Brown-Sequard). . Belladonna ought not to be 
 used constantly. Opium, combined with strychnia, is of 
 gseater use in reflex paralysis : and of all remedies, strychnia 
 is best suited for promoting the second indication, which 
 points to increasing the nutrition of the spinal cord. The 
 dose combined with opium must be a small one — namely one- 
 fortieth to one-thirtieth of a grain daily ; and when used 
 alone, its dose may be one-twentieth of a grain ; and when 
 employed together with belladonna, its dose must be still 
 larger. In cases where no congestion or inflammation of 
 the spinal cord exists, strychnia ought to be persistently em- 
 ployed ; but its use to be suspended at once whenever it 
 produces spasms, or even numbness of the feet in getting out 
 of bed in the morning (Brown-Sequard). Sulphur baths are 
 also productive of great benefit. 
 
 The third indication — namely, to prevent the ill effects of 
 rest on the paralyzed nerves and muscles — is best met by the 
 employment of Voltaism and shampooing of the paralyzed 
 limbs. Two or three applications, of ten minutes each, in a 
 week, are sufficient ; but of all things it is necessary that the 
 primary disease (causing by its persistent existence the reflex 
 paralysis) should be cured or mitigated. 
 
 Pemphigus. — Definition. — An eruption of large vesicles, 
 filled with serous fluid, known as bullae. 
 
 Treatment. — Dietetic and tonic, especially by quinine and 
 
PERICARDITIS. 283 
 
 the mineral acids. Arsenic is said to be of use in obstinate 
 cases, improving the general health. Emollient lotions, with 
 or without opium, are useful local applications; also envel- 
 oping the parts with india-rubber cloth dressed with sulphur. 
 
 Pericarditis — Definition. — An inflammation of the fibro- 
 serous membrane containing the heart, and investing it on 
 its external aspect. 
 
 Treatment. — The results of recorded treatment are unsatis- 
 factory in the highest degree. Sir Thomas Watson writes, 
 that " in a large proportion of the cases, whether they be 
 treated well or ill, or not treated at all, the patients will seem 
 to recover." Although blood-letting and calomel have hith- 
 erto been regarded as two most efficient agents in accom- 
 plishing the indications of cure, yet Taylor's analysis of cases 
 shows that pericarditis may come on during salivation. The 
 late Dr. Parkes informed me that he has seen this occur two 
 or three times. It is, then, very doubtful if calomel ever 
 does any good in pericarditis, notwithstanding that its use, so 
 as to affect the gums, is advised by Watson, Graves, Stokes, 
 and Fuller. Professor W. T. Gairdner, Drs. John Taylor, 
 of Hudderford [Med. Times and Gazette, 1S49), and J. Risdon 
 Bennett, of London {Lancet, Dec. 6, 185 1), are all unfavor- 
 able to such a use of mercury. In all the constitutional dis- 
 eases in which pericarditis occurs as a complication, mercury 
 is certainly contraindicated. In rheumatism and in Bright's 
 disease, which furnish by far the larger number of cases of 
 pericarditis, mercury is decidedly objectionable ; and it is 
 now well-known to be productive of most injurious conse- 
 quences in Bright's disease. Its use tends to weaken the 
 heart and the system at large, and thus proves a source of 
 additional irritation to the cardiac tissue, by undue reaction 
 on the system. 
 
 Venesection is never to be practised. Treatment by bleed- 
 ing may be carried out by leeches over the precordial region, 
 or by cupping there in exceptional cases. When the pain is 
 very marked, where it has strongly the characters of angina, 
 leeches are to be applied in moderate numbers over the prse- 
 cordial space. From four to six leeches (W. T. Gairdner), 
 ten to twenty (Niemeyer), so applied, accordingly to circum- 
 stances, followed by fomentations, very commonly relieve the 
 pain, and rapid improvement follows. To judge as to the 
 repetition of blood-letting, the force of the heart must be ob- 
 served as indicated by the pulse at the wrist, by the actual 
 strength of its impulse, and by the character especially of the 
 
284 PERICARIDITIS. 
 
 first sound. If the impulse continues vigorous, and the first 
 sound is undiminished, blood-letting may be repeated by the 
 further local abstraction of blood by leeches ; but if the im- 
 pulse has manifestly declined in force, while the first sound 
 is lessened, great caution is required in the further abstrac- 
 tion of blood. Fomentations, sometimes plain and some- 
 times medicated with opium, are the chief local remedies to 
 be afterwards relied on. In the second stage of the disease, 
 when liquid effusion distends the pericardium, some reliance 
 may be put in treatment by a blister of a large size over the 
 praecordia. Diuretics and iodide of potassium are also to be 
 given. " Stimulants are often imperatively called for. The 
 weakened heart requires to be supported and invigorated. 
 This may be effected by the use of wine, and by the use of 
 opium.*' If depletion has been excessive — if signs of mus- 
 cular weakness supervene — if there be evidence that the 
 heart, previous to the attack, was in weakened state — if a 
 tendency to collapse or to a typhoid state manifests itself — 
 " we must give wine, quite irrespective of the physical con- 
 ditions of the heart" (Stokes). Niemeyer recommends digita- 
 lis as a suitable remedy in cases where the beat of thelieart 
 is very frequent and insufficient, causing cyanotic and dropsi- 
 cal symptoms. Its effect is then very markedly beneficial. 
 Opium, in doses of one grain (/ e., stimulant doses) every third 
 hour, seems " to expend itself solely on the disease," and its 
 beneficial effects are seen to result when it does not produce 
 contraction of the pupil, nor headache, hot skin, furred 
 tongue, nor constipation (Corrigan, Stokes, Graves, Sibson). 
 Battley's solution is perhaps the most useful preparation. 
 This remedy must be watched closely. There are two more 
 important circumstances to be attended to — namely, that our 
 treatment of pericarditis must depend upon the state of the 
 diseases in which it is first discovered to exist; and it is im- 
 portant to know that pericarditis from acute rheumatism calls 
 for a totally different line of treatment from that associated 
 with Bright's disease, or diffused inflammation of a low type 
 (Sibson). In the rheumatic form, colchicum, in the form of 
 a draught, and the administration of alkaline remedies, are 
 indicated by the constitutional state. Warmth, especially 
 moist warmth, and flying blisters are the best agents to pro- 
 mote absorption. Niemeyer considers that the use of cold 
 applications; such as ice-bladders, applied over the cardiac 
 region, is deserving of great reliance; others condemn cold 
 applications. 
 
PERICARDIUM, ADHERENT PERITONTTTS. 285 
 
 Paracentesis is to be recommended in all those cases in 
 which the effusion is so great as to cause alarming distress, 
 orthopncea, obstruction to the venous circulation, and serious 
 interference with the heart's action. In such cases a fine 
 exploring trocar and canula is to be introduced (not plung- 
 ed), so as to make a valvular opening below the heart, either 
 to the left of the xyphoid cartilage, or through the fifth in- 
 tercostal space, close to its anterior extremity, and the fluid 
 drawn off by means of a syringe (Sibson, in Med.-Chir. Re- 
 view, July, 1854). The result may be merely palliative ; 
 but, as Niemeyer justly remarks, "even to afford the sufferer 
 opportunity, after the operation, to pass the night in his bed 
 (perhaps for the first time in a long period), and to enable 
 him to sleep a little, is a great gain." 
 
 The general principles of safe treatment are summed up 
 Dr. W. T. Gairdner as follows : — (i.) To make large allow- 
 ance for the insignificant and spontaneously healing class of 
 cases revealed more by physical signs than by symptoms, 
 and to regard them as demanding little active treatment ; 
 (2.) to consider rheumatic pericarditis in general as a disease 
 susceptible, to a great extent, of cure under palliative local 
 remedies and fitting constitutional treatment; (3.) to hold 
 the general treatment as subordinate to the constitutional 
 treatment of the disease with which the pericarditis is asso- 
 ciated. 
 
 Pericardium, Adherent. — Definition.— -More or less 
 adhesion of the opposed surfaces of the pericardium by in- 
 flammatory exudation (adhesive lymph) becoming organized, 
 and with more or less complete obliteration of the pericardial 
 sac. 
 
 Treatment must be regulated by the functional difficulties 
 of the circulation, and by the source to which those difficul- 
 ties may be traced. 
 
 Pericardium, Dropsy of. — See Hydropericardiu?n. 
 
 Peritonitis. — Definition. — An inflammation of the serous 
 membrane lining the cavity of the abdomen, and covering 
 the viscera contained in that cavity. 
 
 The Treatment of acute peritonitis must be active in pro- 
 portion to the amount of pain, the rapidity of the pulse, and 
 intensity of the inflammatory fever, which is marked by the 
 peculiar depressing influence of the inflammation of the 
 heart's action. In mild cases, when the pain is bearable, the 
 pulse steady and under 100, twenty leeches over the abdo- 
 
285 PERITONITIS. 
 
 men, followed by warm fomentations, with the administration 
 of opium in frequently repeated grain doses, ought to be the 
 basis of treatment. Leeches applied to the abdomen is the 
 only method of blood-letting likely to be useful, and a poul- 
 tice may be required afterwards to encourage the bleeding 
 in sthenic cases. But where the disease is due to blood-poi- 
 soning, constitutional states of ill-health, or to the puerperal 
 state, blood-letting by leeches is injurious. In the severer 
 forms the first indication is to relieve pain. The stomach 
 may be unable to retain food ; and vomiting may be present. 
 Under such circumstances great benefit may follow the in- 
 jection per rectum of a pint of strong meat soup slowly 
 thrown up in three successive portions. After about three 
 hours' relief of pain, a fresh new injection of soup is to be 
 given, .when the same relief to pain will follow, the pulse 
 falling from (say) 124 to 104. Small quantities of broth and 
 wine may then be borne by the stomach, administered every 
 two hours (Dr. Anstie). Action of the bowels should be 
 prevented for several days. Opium should be given in doses 
 of one to two grains, repeated as often as its effects subside 
 — generally every two, three, or four hours. Morphia may 
 be given in repeated doses of a quarter to half a grain. Mor- 
 phia combined with chloroform, as in the formula for chloro- 
 morphine or chlorodyne, will be found useful in allaying 
 pain. It is not proven that calomel (inducing mercurialism) 
 has any curative tendency in peritonitis. It has been pre- 
 scribed traditionally ; but the experience of Dr. Taylor re- 
 garding mercury in pericarditis, as well as of other physicians 
 regarding the influence of mercury generally in the cure of 
 these inflammations, tends to discard it from our methods of 
 cure in such affections. Nevertheless, in the idiopathic and 
 latent forms, Mr. Meade has found mercury the best remedy. 
 In the purely latent forms he prescribes small doses of the 
 bichloride with some demulcent. One-twentieth of a grain 
 three times a day is sufficient. It may be continued for two 
 or three weeks or more. In the more acute cases he directs 
 the abdomen to be covered with dilute mercurial ointment 
 spread thickly upon lint ; and he generally finds that the as- 
 citic fluid begins to be absorbed as soon as the mercury 
 slightly affects the system. Fomentations and water 
 compresses are to be diligently employed on the same 
 principle as described under Enteric Fever. Digitalis, with 
 other diuretics, may assist the cure. In the more chronic 
 forms, where the abdomen has become distended, it is some- 
 
PERITONITIS. 287 
 
 times desirable to let off the fluid by tapping ; after which 
 remedies act more readily, and generally prevent the return 
 of the effusion. Diuretics of iodide of potassium, acetate of 
 potass, and squills, also help to effect the removal of fluid. 
 The entire abdomen may be covered with cold compresses, 
 and renewed every ten minutes ; but warm cataplasms are 
 better borne than cold compresses by many patients (Nie- 
 meyer). In chronic peritonitis I have found iodide of po- 
 tassium, combined with alkalies, most useful, together with 
 inunction of the abdomen with the iodine or biniodide of 
 mercury ointment. Acute peritonitis has been treated by 
 quinine alone, in large and repeated doses, by M. Beau, at 
 the Hopital de la Charite. The remedy was given in the pro- 
 portion of twenty to thirty grains in the twent-four hours. 
 When the abdomen can bear pressure, a flannel roller should 
 be firmly applied round the body. Chronic vomiting is a 
 distressing concomitant to be met by effervescing draughts, 
 with m j. or m ij. of dilute hydrocyanic acid, or with m iij. 
 to m v. of tinct. opii. ; or one or two drops of creasote in 
 aromatic water. Diarrhoea is common, hence it is necessary 
 to combine any laxative remedy with an opiate ; and the 
 bowels may be so irritable as to oblige us to abandon all 
 opening medicine, and to prescribe astringents, as kino, ca- 
 techu, or haematoxylon, or the mistura cretae composita c. 
 opio, or the acetate of lead, and even pure opium, to the 
 amount of two, three, or four grains a day. Under any treat- 
 ment diarrhoea is dangerous and distressing. The diet in 
 the acute forms of peritonitis should be of the mildest and 
 least stimulant kind. During the course of this and several 
 other diseases of the digestive system, immense distress and 
 suffering often occur from the accumulation and retention of 
 gaseous fluid in some portions of the intestinal canal (tym- 
 panites). Tympanites is best relieved by turpentine enema- 
 ta ; and by the introduction of a rectum tube. When this 
 symptom reaches such extreme development as to endanger 
 life, and after the introduction of a rectum tube fails to pro- 
 cure relief, experience justifies the propriety of making a 
 puncture into the cavity of the bowel (generally the colon), 
 through the abdominal parietes, to permit the gas to escape, 
 and to relieve the tympanites. Life may thus be saved, and 
 cannot be materially shortened by the operation, if it is per- 
 formed by a trocar of the very smallest exploring size. The 
 air gradually and rapidly escapes by the very smallest ori- 
 fice, which is rather a separation of tissues than a wound, 
 
2&8 PERTUSSIS PHARYNGITIS, CHRONIC, ETC. 
 
 and soon closes up so completely as to leave no trace behind. 
 The operation gives the greatest possible relief (See Ameri- 
 can Journal of Med. Science, N. S., XXIV., p. 543 ; Obstet. 
 Trans. , for 1869, pp. 47, 48, by Dr. J. Braxton Hicks, in 
 1868 ; Brit. Med. Jour?ial y for Oct. 21, 1871, p. 464, by Mr. 
 J. Hancocke Wathen). The operation is not the same as 
 that usually performed on cattle. In them it is generally 
 the rumen or first stomach that is punctured (M'Bride in 
 Brit. Med. Journal, Nov. 4, 1871). 
 
 Pertussis — See Hooping Cough. 
 
 Pharyngitis. — Definition. — Inflammation of the textures 
 of the pharynx. 
 
 Treatment should consist in hot steam inhalations of a 
 sedative character, poultices externally, and scarification if 
 oedema takes place. When the uvula is much swollen and 
 infiltrated with serum, it should be at once removed. 
 
 Sub-acute Pharyngitis may occur either as an early stage 
 of the acute form, or as a less serious inflammatory affec- 
 tion. In this condition it is the mucous membrane alone, 
 not the areolar tissue, which is inflamed. The symptoms are 
 less severe than in acute pharyngitis; and treatment consists 
 in the application of astringent solutions, and the use of 
 astringent lozenges. The frequent sucking of small pieces 
 of ice is of great service in reducing the hyperaemic condi- 
 tion. 
 
 Pharyngitis, Chronic or Granular. — Treatment. — 
 The patient's general health must be improved by tonic 
 measures, but the most important part of the treatment con- 
 sists in the persevering use of local applications. In the ex- 
 udative form the spots should be scraped, the secretion emp- 
 tied, and solid nitrate of silver applied to each diseased 
 follicle. Lozenges of chlorate of potash and of bitartrate of 
 potash are useful in stimulating the follicular secretion to a 
 healthy condition. In hypertrophic pharyngitis the raised 
 papules must be destroyed one by one. The best applica- 
 tion for this purpose is a paste consisting of equal parts of 
 caustic soda and unslaked lime; this is mixed with water, as 
 required, into a creamy paste, and applied to each papule 
 ~vith a finely-pointed glass or aluminium rod (Dr. Morell- 
 IVlackenzie). The caustic effect of this application is instan- 
 taneous. The patient therefore should be directed to wash his 
 rnouth with water immediately after the application, so as to 
 
PHARYNX, ABSCESS OF — PHTHISIS. 289 
 
 prevent any other part of the throat being burnt by contact 
 with the caustic. A combination of ergotine with tincture 
 of iodine is also efficacious (ergotine, grains xx.; tinct. iod., 
 f 3 i.; glycerine, to make f 3 i.) To be applied to the phar- 
 ynx twice a day with a camel-hair brush 
 
 In all cases of pharyngeal disease, every form of spice, 
 pepper, mustard, and piquant food should be strictly pro- 
 hibited, and all fluids should be taken at a moderate tem- 
 perature. 
 
 Pharynx, Abscess Of. — Definition. — Inflammation of 
 the pharynx, resulting in a limited collection of pus in the 
 form of an abscess. 
 
 Treatment. — It is very rarely possible to prevent the form- 
 ation of pus, and the expedient usually demanded is a speedy 
 opening of the abscess at its most defending part. Cod- 
 liver oil and other anti-strumous remedies are also impera- 
 tively demanded. 
 
 Pharynx and Larynx, Atomized Fluids in Treat- 
 ment of — See Larynx, Pharynx &C. 
 
 Phlegmasia Dolens. — Definition. — Obstruction of the 
 veins, radicles, and capillary vessels, with probable implica- 
 tion of the lymphatics, causing a painful, non-cedematous, 
 hard brawny swelling of one or more extremities, attended 
 with great prostration. 
 
 Treatment. — Leeches and blood-letting, as recommended 
 by Drs. Davie and Lee, are usually inadmissible. Sedatives 
 and alkaline fomentations, perfect rest, simple diet, and opi- 
 ates to relieve pain, is the most rational treatment to be fol- 
 lowed. "The fluid in which the fomentation flannels are to 
 be wrung out is made by adding one pound of bicarbonate 
 of soda and one ounce of extract of poppies to one gallon of 
 boiling water. The flannels ought to be changed every 
 thirty minutes, and applied over the whole limb, and over 
 the groin and lower part of the abdomen, wherever there is 
 tenderness. The heat and steam from these are to be re- 
 tained by means of impermeable cloths." Wine, brandy, 
 milk, raw eggs, animal food, ammonia, and bark are sure to 
 be required; and after the acute symptoms have subsided, 
 there is no remedy so beneficjal as efficient bandaging, to- 
 gether with the preparations of iron, quinine, and tonic veg- 
 l 9 
 
290 PHTHISIS. 
 
 etable bitters, like calumba, aided by change of residence 
 (Tanner). 
 
 Phthisis. — Definition. — Lesions commencing with in- 
 duration of a lobe or lobule of the lungs, ending in disinte- 
 gration of the new material and of the textures involved in 
 the induration; the formation of caverns, and the accumula- 
 tion and constant discharge of purulent secretion, with or 
 without the growth of miliary tubercles. 
 
 Treatment. — Looking to the varied pathological conditions 
 and textural lesions in the lungs comprehended under the 
 name of phthisis, every case requires special study. In one 
 case anaemia is prominent, and calls for iron, perhaps for 
 arsenic; in another, continued but small haemoptysis may 
 call for ergot; in another, a racking and frequent cough may 
 call for special applications and remedies; in another, dys- 
 pepsia may call for alkalies or acid bitters, or pepsine; in 
 another, nervous unrest may call for bromides; in another, 
 laryngeal troubles may call for special local medication; 
 in another, we have to aim at controlling excessive sweating, 
 or checking an exhausting diarrhoea (Dr. James Sawyer, 
 Brit. Med. Journal, 1880, p. 845). 
 
 If, unfortunately, a pulmonary catarrh does not abate, or 
 a pneumonia does not resolve itself within the usual period, 
 but catarrhal symptoms prevail in the apices, and pyrexia is 
 persistent, with the severe disturbance of the general health 
 which has been described, extension of the pneumonic pro- 
 cess must be prevented by absolute rest in bed, talking being 
 forbidden, and coughing as much as possible repressed. 
 Whenever considerable pyrexia exists in the evening, all 
 duty occupations should be given up, strict rest, equal tem- 
 perature, the chest to be covered with linseed poultices, fre- 
 quently repeated, or belladonna liniment, and local bleeding 
 by leeches, if pleuritic pains exist. No counter-irritation 
 should be applied to the seat of lesion while pyrexia lasts. 
 Moderate action of the skin is to be maintained. The body 
 should be sponged with rectified spirits of wine and hot 
 water in equal parts (Coghill). White meats only are to be 
 eaten ; and as much milk as may be desired. A pint of 
 " warm milk from the cow " should be taken as often as 
 possible. 
 
 Should the pyrexia still continue, considerable digitalis, 
 opium and quinine are the remedies most successful in re- 
 ducing temperature. Heim's pill was much employed by 
 Niemeyer, as it still is in Germany, for this purpose, It con- 
 
PHTHISIS. 29I 
 
 sistsof Pulv. herb. Digitalis, gr. x.J Pulv. rad. Ipecac..; Pulv. 
 Opii puri. a a, gr. v. ; Ext. Gentiani, q. s. ; misce et divide in pil. 
 xx. One pill three times a day. It is of advantage that quinine 
 to the extent of gr. xx. be added to this. Each pill will then 
 contain half a grain of digitalis, one-quarter grain of opium, 
 one-quarter grain of ipecacuanha, and one grain of quinine; 
 all of which may be held in form by glycerine or syrup. Dr. 
 Coghill adopts the following modification : namely, one 
 quarter of a grain of opium ; half a grain of digitalis powder; 
 and from one to three grains of quinine, to be given every 
 three to six hours, watching the effect on the pulse. When 
 there is great dryness of skin and tongue, half a drachm of 
 salicine, and two drachms of liquor ammonia acetatis, may 
 be given instead of the pill. Occasional intercurrent attacks 
 of pneumonia mark extension of lesions. They are asthenic 
 in character, and must be treated accordingly; but in all the 
 sthenic pneumonias or acute bronchitic attacks, no remedy 
 equals the tincture of aconite. It acts as we read of blood- 
 letting doing. It should be given at the rate of one minim 
 every quarter of an hour till the temperature is reduced to 
 the normal — the thermometer being in use every two hours. 
 If the temperature drops too suddenly, quinine must be 
 given in place of aconite. 
 
 The general principles of treatment described under 
 "Scrofula," are to be adhered to. The use of so-called 
 "cough-medicines," antimony, ipecacuanha, and squill 
 especially, are to be avoided; also the use of mercury, pur- 
 gatives, and neutral salts. It is unphysiological to administer 
 narcotics or sedatives when cough is accompanied by expec- 
 toration. The latter must be expectorated; if retained, it is 
 injurious. The morbid surface which produces the expecto- 
 ration must be directly acted on. In the suppurative expec- 
 toration of bronchitis or pneumonia, and that from a pneu- 
 monic or tubercular excavation of the lung, the processes 
 are identical with the suppurative processes in surgical 
 wounds or ulcers. Dr. Coghill finds that the best mode is 
 to bathe the suppurative surface in an antiseptic atmosphere 
 by the inhalation of such materials as creasote, carbolic acid, 
 and thymol. Warm moist inhalations do not affect the res- 
 piratory tract beyond the larynx; and are only of value in 
 affections of that region. When used warm they increase 
 the sensitiveness to cold. By using the breath only as the 
 antiseptic medium (inhaling through the mouth and respir- 
 ing through the nose), we get the whole of the residual air 
 
292 PHTHISIS. 
 
 in the lungs saturated with the antiseptic material. This is 
 the principle of Dr. Coghill's " respirator-inhaler," which 
 should be used especially after u fits of expectoration," so 
 as to act immediately on the surface which has furnished the 
 matter expectorated. It cannot be used too often; and 
 should quite supersede " cough-mixtures." It is, of course, 
 only of use in the second and third stages of phthisis and 
 the suppurative stage of bronchitis; and especially in the 
 retained fetid expectoration of bronchiectasis. Dr. Cog- 
 hill's standard formula (to be modified at discretion) for an 
 antiseptic solution consists of one drachm of glycerine, one 
 drachm and a half of creasote, two drachms of carbolic 
 acid, and one ounce of a saturated solution of thymol: of 
 which ten to fifteen minims are to be inhaled twice or thrice 
 a day by the respirator-inhaler. A few drops of chloroform, 
 or of ether, may be added as a sedative to each dose. In the 
 first stage of phthisis and other conditions where there is 
 cough and no expectoration, and in which the cough is inju- 
 rious by shaking and shattering the tender and infiltrated 
 lung tissue, the following is an excellent formula: — namely, 
 Croton-chloral hydrate and codeia, a agr. xij.; AquaLauro- 
 cerasi, glycerine, and Syrup of tolu. a a ad. § ij. A dessert- 
 spoonful, or two teaspoonfuls, may be taken every two hours 
 when cough is troublesome. 
 
 To foster and cherish an appetite for food is another great 
 aim of treatment. One of the best tonics, if pyrexia does not 
 exist, is the syrup of iron, quinia, and strychnia. Let it be 
 given in very small doses at first ; followed up by the use of 
 cod-liver oil, " of the most agreeable, clearest, sweetest, and 
 most scentless kind." The brown oil ought never to be pre- 
 scribed, except, perhaps, to an Esquimaux. Thejoil should be 
 given in teaspoonful doses at first. Dr. B. W. Foster, of Bir- 
 mingham, drew the attention of the Profession to the advan- 
 tages of ether in promoting the digestion and absorption of 
 fatty food, and especially of cod-liver oil. A stomach once in- 
 tolerant of all fat will good-naturedly accept full doses of cod- 
 liver oil after the use of ether. Sometimes it has been given 
 separately, before or after the oil; but it is best given com- 
 bined with the oil — a mixture now generally known as 
 " etherized cod-liver oil." To every two drachms of the oil 
 ten, fifteen, or twenty minims of ether are to be added, 
 according to the wants of the case. The Aither purus of 
 the British Pharmacopoeia must be used, so that the oil 
 may not be rendered muddy, as it will be if the ethei 
 
 
PHTHISIS. 293 
 
 contains alcohol or water. The ordinary dose of oil 
 ought not to exceed two drachms, to which more than 
 twenty drops of ether may be added, if necessary. The 
 ether is indicated wherever there is inability to digest 
 fat, of which it makes an emulsion. It seems to determine, 
 when introduced into the stomach, a considerable flow of 
 pancreatic juice (Claude Bernard; See Brit. Med. Journal, 
 Nov. 21 and 28, 1868; also, Medical Press and Circular ; 
 1869). Extract of malt (Trousseau) is a remedy of recent 
 repute. It is a genuine extract, consisting of the soluble 
 constituents of the malt and of the bitter extractive matter 
 of the hop. Two or three table-spoonfuls of it are to be 
 taken daily, diluted in spring water or in warm milk, or in 
 any other liquid that may be desired. There should be a 
 careful choice of meats and drinks. Meats rich in osma- 
 zone and roasted are to be preferred; wines and malt liq- 
 uors are better than mere alcoholic fluids when alcoholics 
 are required. Broth made of coarsely brown rye meal, 
 beef, mutton, or other flesh meat, boiled to make a soup, is 
 also of service as a diet. I have found the following soup 
 also very serviceable: Take of linseed half an ounce; fine 
 bran, one ounce; water, one quart. Boil these for two 
 hours, and strain; then add beef, mutton, or any other meat 
 that may be fancied, to the amount of one pound, and boil 
 to a soup, with vegetables, to which celery seed or other fla- 
 voring may be added. The whole quantity ought to be re- 
 duced one-third. 
 
 Arsenic is an efficient improver of the general nutritive 
 and assimilative functions. One or two drops of Fowler's 
 solution, or -fa of a grain of arsenious acid, should be given 
 once, twice, or thrice a day, during the meal, continuing it 
 for months, with occasional intermissions (Clymer). Decided 
 benefit may follow the use of iodide of potassium, which may 
 be combined with the ammonio-citrate of iron, or tincture of 
 the muriate, in a bitter infusion with calumba or cascarilla. 
 Chloride of calcium has been used for some years by Pro- 
 fessor James Sawyer, of Birmingham, who writes very highly 
 of its advantages in combination with cod-liver oil or its 
 etherized emulsion. He gives 10 grains, dissolved in a 
 drachm of water and with a drachm of glycerine, in a wine- 
 glass of milk, twice a day, immediately after meals (Brit. 
 Med. Journ., June 5, 1880). Dr. Coghill, from his exten- 
 sive experience at the large hospital at Ventnor, regards the 
 hypophosphites and lactophosphates alternately as the best 
 
204 PHTHISIS. 
 
 general tonics in phthisis. They are in no way specific. 
 They should not be given if the temperature in the evening 
 is above 99. 4 Fahr., and, on account of their pyretic char- 
 acter, should only be given after breakfast and lunch. The 
 hypophosphite of iron is so powerfully pyretic as only to be 
 given in extreme anaemic phthisis, where the whole daily 
 thermometric range is low. Its formula consists of Hypo- 
 phosph. Sodse, Hypophosph. Calcis, a a 3 i.; Glycerini vel 
 Syr. Limonis, |ij.; Decoct. Cascarilla ad., |vj.; of which 
 a table-spoonful in water may be taken as required, to which 
 three to five minims of Liq. strychnise is a good addition to 
 increase appetite. The pharmacopceal syr. of the lactophos- 
 phates is very good; also the French " Dusart's." If an 
 aperient is wanted it should be given early in the morning. 
 Its necessity very often in phthisis depends on a sluggish 
 liver, # hence the following is a good formula : — Salicylatis 
 Sodae, 3 ij. ; Phosph. Sodse, 3 v. ; Sulph. Potass, ad, § ij. ; 
 Pulv. Zingib., 3 i- ; of which a teaspoonful in hot water is to 
 be taken early in the morning. If there is an elongated 
 uvula, the end should be snipped off ; if there is irritation 
 about the pharynx and upper part of the larynx, it may be 
 relieved by the inhalation of some of the atomized fluids. 
 
 Counter-irritation to the chest-wall is a stereotype method 
 of cure in local pulmonary congestions. When properly 
 used in the earlier stages, before there is much loss of 
 strength, it is undoubtedly beneficial ; but later it is weak- 
 ening and annoying. Croton-oil liniment is the chief favor- 
 ite ; but a prompt and not too severe application of the fol- 
 lowing ointment is recommended by Dr. . Fuller : 
 
 IJ. Hydrarg. Chlor. Mit., gr. viij ; Iodinii, 3 ss. ; Alco- 
 hol, f 3 iss. ; Unguent. Simp., J j. M. Rub in a portion over 
 the affected lung, morning and evening, until a pustular 
 eruption comes out 
 
 A solution of the nitrate of silver (thirty grains to the 
 ounce of distilled water) may be painted on the skin beneath 
 the clavicles every evening until the skin is darkened, and re- 
 peated after the cuticle peels off. Gentle and continuous 
 irritation of the skin may be kept up by wearing constantly 
 on the chest a piece of flannel wet with a weak solution of 
 iodine in glycerine and water, covering the cloth with oil- 
 skin, to prevent too rapid evaporation and soiling of the 
 clothes. The night-sweats, so often annoying and profuse, 
 diminish under general systemic improvement and restored 
 cutaneous functions. The best anhydrotic, and almost the 
 
PHTHISIS. • 295 
 
 only one in use at the hospital at Ventnor, in the Isle of 
 Wight, is a pill at bedtime, containing -£ w of a grain of atro- 
 pia, which may be combined with digitalis and quinine. 
 Bathing with vinegar and water, spirits of wine and warm 
 water, alum and water, are well-known remedies, as well as 
 gallic and tannic acids, and infusion of common garden sage. 
 To relieve the diarrhoea Dr. Coghill finds the lead and opium 
 pill of the British Pharmacopoeia the best astringent, with a 
 milk and arrrow-root diet. A flannel bandage around the 
 abdomen should be worn. Bismuth, with opium, is also of 
 use. To control the exhausting attacks which occur in the 
 more advanced stages, Dr. Frank, at Cannes, suggested the 
 use of coto bark ; and Dr. J. B. Burney Yeo (after an expe- 
 rience of over three years) has found it to arrest the flux 
 and relieve intestinal pain and irritation in a short time. A 
 fluid extract of coto is prepared by Ferris & Co., of Bristol, 
 the dose of which is from five to eight minims (The Practi- 
 tioner, 1879, p. 257). 
 
 As regards the prevention of phthisis, although Sir Thom- 
 as Watson states that he does not believe it to be contagious, 
 he adds : — " Nevertheless I should, for obvious reasons, dis- 
 suade the occupation of the same bed, or even of the same 
 sleeping apartment, by two persons one of whom was known 
 to labor under pulmonary consumption " (Lectures on the 
 Practice of Physic). It behooves the physician to warn the 
 patient's friends of the dangers incident to long-continued 
 attendance on him, especially if the disease be in an advanced 
 stage. It would be the height of imprudence for a healthy 
 person, especially if young and of a scrofulous diathesis, to 
 sleep in the same bed, or even in the same apartment, with a 
 consumptive patient ; for although the malady might not be 
 communicated directly from one to the other, unless possibly 
 under the condition of some tubercular matter being acci- 
 dentally introduced into his air-passages or into some other 
 part of his system, the surroundings and the air would be cal- 
 culated to predispose him to the disease " (Fuller, On Dis- 
 eases of the Lungs and Air-passages, p. 431). 
 
 It is of importance to know the physical nature of the cli- 
 mates of the world suitable for the tuberculous patient. (See 
 Appendix to a third edition of Dr. Walshe's work on Dis- 
 eases of the Lungs ; the late Sir James Clark's classic work 
 On Climate ; and Dr. Theodore Williams's Lettsomian Lec- 
 tures in Brit Med. Journ., 1876). Dr. Williams's statistics 
 show the benefit to be derived from life at sea. In cases 
 
296 .PITYRIASIS VERSICOLOR. 
 
 where destructive lung diseases is suspected, but in which 
 actual lesion does not exist, a sea voyage to the Cape, or to 
 Australia, or to New Zealand, round Cape Horn should be 
 resorted to at once. The prevention of certain forms of pul- 
 monary phthisis may be looked for in the unrestricted enjoy- 
 ment of pure out-of-door air. Continuous indoor labor is to 
 be avoided, and measures taken to prevent bronchial ca- 
 tarrhs by sufficient warm clothing and the constant use of 
 flannel next the skin in this country. The effects of hydro- 
 therapeutic treatment and of muscular exercise at the moun- 
 tain sanitoria of Switzerland, along with the prescribed use 
 of wine, fruit, and nutritious diet, are of much importance 
 to be considered. The purity of the air of mountains con- 
 sists practically in the absence of all organic particles. The 
 transparency of the air, which is dependent on its greater dry- 
 ness, and the more powerful action of light, depending upon 
 the same cause, aid materially the operation of its purity. 
 The effect of residence in mountains on the dimensions of 
 the chest is also worthy of careful consideration, and has 
 been studied by M. Armieux, at Bareges, at a height of more 
 than 3,000 feet. He ascertained that in the case of ninety- 
 six soldiers sent up to Bareges there was, after four months' 
 residence, a distinct increase in the measurement of the chest 
 — a fact which has a very important bearing on cases of 
 threatened phthisis in the young ; and that a mountain cli- 
 mate is to be considered as favorable to the development of 
 the thoracic cavity, and consequently as improving the res- 
 piration. (See also Dr. W. Marcet in Proceedings of R. S., 
 Vol. XXVIII., p. 498). Mountain air may thus be useful in 
 certain cases and in certain periods of phthisis. It acts by 
 its purity, by its dryness and transparency, as well as by the 
 diminution of atmospheric pressure. These principles have 
 only, or nearly only, been applied in Switzerland ; but moun- 
 tain stations for similar cases might very well be selected in 
 some parts of France. After all, neither barometer nor ther- 
 mometer, neither hygrometer nor anemometer, can determine 
 what is the suitable climate for such and such a phthisical 
 patient. All depends on the nature of his constitution, and 
 on the way in which the various meteorological conditions 
 affect him, and on the local lesions in his lung (Drs. J. Mac- 
 pherson and Gouraud in London Medical Record, July 15, 
 1876). 
 
 Pityriasis Versicolor (see Tinea Versicolor). 
 
PLAGUE. 297 
 
 Plague. — Definition. — A specific malignant fever which 
 has prevailed at different times and places epidemically, at- 
 tended with bubo or swellings of the inguinal and other 
 lymphatic glands; or occasionally with carbuncles, pustules, 
 spots, petechias of various colors, distributed in different 
 parts of the body; and severe manifestations of implication 
 of the nervous, sanguineous and bilious systems. 
 
 Treatment. — It is to be regretted that recent experience 
 has not in any degree advanced the successful treatment of 
 the plague. In the beginning of the epidemic, when the 
 morbid cause acts with a rapidity so great that some hours 
 are sufficient to compromise the life of the patient, any 
 treatment is powerless to arrest the course of the disease. 
 When, however, the malignancy of the disease abates we 
 may hope for the recovery of patients (Clot Bey). Looking, 
 however, to the pathology of the disease, and regarding it as 
 bearing some resemblance to malignant typhus fever, the 
 principles of the general treatment of plague ought to be 
 similar to those laid down in the account of that disease. 
 We have no sufficient evidence to prove that plague may be 
 carried beyond those geographical limits where it is epi- 
 demic. Quarantine establishments to prevent the trans- 
 mission of such epidemic diseases are now not only unwar- 
 rantable, but they are vexatious interruptions to mercantile 
 enterprise. It is now more than 154 years since any part of 
 Western Europe has suffered from plague; bnt till a com- 
 paratively recent period, more or less of the disease had been 
 habituate or frequent in the Levant, and though occasions 
 have been very numerous when arrivals from the Levant in 
 this country must have been more full of danger than those 
 now represented, the experiments thus performed on the 
 public health of England have in no case led to any injur- 
 ious result. I am informed by a medical friend who visited 
 Malta in 1S61, that a curious instance of the wavering 
 nature of opinion regarding the efficacy of quarantine was 
 afforded during the last Bengazi plague. The Maltese — 
 the most sensitive people formerly on the subject — abso- 
 lutely declined to put any quarantine on arrivals from Ben- 
 gazi, and trade went on as usual, until the Austrians inti- 
 mated that, unless Malta put Bengazi in quarantine, Trieste 
 would put Malta in quarantine; and the poor merchants were 
 obliged to submit. There is little risk of plague being im- 
 ported now because of the great sanitary improvements 
 which have taken place; and it is to be hoped that as sani- 
 
298 PLEURISY. 
 
 tary measures are developed the barbarism of quarantine will 
 entirely disappear; except, perhaps, where the intelligence of 
 the people does not go beyond that of the Russian Governor 
 of Eupotoria, who requested that the allied armies of France 
 and England might go into quarantine when they landed in 
 the Crimea in 1854 ! (.Kinglake.) 
 
 Pleurisy. — Definitio7i. — Inflammation of the serous mem- 
 brane that lines the cavity and covers the viscera of the 
 thorax. It is characterized at its outset by febrile chills, 
 followed by an acute sharp pain in some part of the chest, 
 frequently called " a stitch in the side." It is usually con- 
 fined to one spot about the lateral regions of the thorax. 
 The acts of respiration are performed rapidly. They are 
 shallow, irregular, and incomplete. A dry short cough 
 supervenes, and the pulse is hard and quick. The natural 
 serous secretion of the pleural sac is arrested in the first in- 
 stance, but soon becomes increased in quantity and altered 
 in quality, having a tendency to assume the corpuscular 
 character. The effusion may rapidly increase, and may ulti- 
 mately assume a sero-purulent character, the parietes of the 
 corresponding side of the chest being dilated accordingly. 
 
 Treatment. — In acute pleurisy venesection can be dis- 
 pensed with. It neither cuts short the malady nor prevents 
 effusion. It may only be adopted in cases of severe dyspnoea, 
 arising from collateral hyperemia, if the compressed part of 
 the lung is attended with signs of oedema. At the com- 
 mencement of less severe cases the use of cold compresses, 
 and of local blood-letting by leeches or cupping, may be re- 
 peated in the course of a day or two, until relief becomes 
 permanent ; but the local blood-letting is only to be had re- 
 course to if the cold compresses do not relieve the pain and 
 the dyspnoea within two or three hours. Large hot poultices 
 of linseed with mustard should be always employed when 
 local pain on inspiration is present of a " catching" or "stab- 
 bing" nature. If the pain and dyspnoea are not relieved 
 within two or three hours, the method originally recom- 
 mended by Dr. Frederick T. Roberts, in his " Handbook of 
 Medicine " (page 508), of mechanically fixing the side 
 affected, so as to prevent its movements as much as possible, 
 ought to be at once adopted. " Strips of properly adherent 
 plaster, spread on a firm material, are cut about four inches 
 wide, and sufficiently long to extend round the side from 
 mid-spine to mid-sternum, or a little beyond. These are laid 
 over a variable extent of the chest, according to the severity 
 
PLEURISY. 299 
 
 of the case, it being sometimes requisite to include the whole 
 side — beginning below. The patient is directed to EX-ptre 
 deeply, and at this time a strip of plaster is fixed at mid- 
 spine, and drawn tightly round the side in the direction of 
 the ribs ; then another strip is laid over this, but across the 
 course of the ribs ; the third follows the direction of the first, 
 overlapping about half its width ; the fourth that of the 
 second, and so on in alternate directions. A strip may also 
 be passed over the shoulder, and kept down by another fixed 
 round the side across its ends." Tartar emetic subdues the 
 inflammatory tendency. Its use must be abandoned as soon 
 as the acute symptoms have passed away. Digitalis, rather 
 than tartar-emetic, may be given in recent cases in the form 
 of infusion. In the more latent cases one grain of the pow- 
 der of the leaves may be combined with a grain of quinine. 
 Blisters are not to be used until the acute stage is past. 
 When pain has ceased for some days, and absorption of the 
 fluid proceeds slowly, and the disease promises to become 
 chronic, a succession of blisters may be of use, applied over 
 the lateral region of the chest, but not over the seat of pain. 
 Diuretics ought at the same time to be freely given. The 
 compound tincture of iodine, in doses of twenty minims 
 freely diluted, is a valuable medicine at this juncture f and 
 so also is the liquor iodi of the "British Pharmacopoeia" of 
 1867. After free evacuation of the bowels has been effected, 
 calomel, to the extent of producing the slightest mercurializa- 
 tion, is the most beneficial line of treatment, to be adopted 
 in certain cases only — namely, in otherwise healthy persons 
 in whom the pleurisy is not the result of a constitutional dis- 
 ease. The more rapidly slight men urialization can be pro- 
 duced the better. During the first six hours, small doses of 
 calomel with opium (a grain and a half of the former, com- 
 bined with a sixth of a grain of the latter, or more, if the 
 pain continues acute) should be given every half hour, while 
 mercurial ointment is rubbed into the skin of the affected 
 side near the axilla every fourth hour (Walshe) ; or half 
 grain or grain doses of opium, every three or four hours, in 
 combination with one or two grains of calomel, and half a 
 grain of digitalis, may be given, and the whole side may be 
 covered with a piece of linen spread with mercurial oint- 
 ment : over this is placed a poultice covered with oiled 
 silk. The patient must be carefully watched, so that 
 neither ptyalism nor narcotism is produced. The moment 
 mercurial action has been established, the further admin- 
 
$66 PLEURISY. 
 
 administration of the mineral must cease. Opium and digi- 
 talis are to be continued after the use of calomel has been 
 suspended; and with them may be given two grains of 
 squills or of nitrate of potash, as a diuretic ; or after twelve 
 or more hours very small quantities of tartar emetic in solu- 
 tion may be given at night, combined with small doses of 
 opium and ipecacuanha, to allay general irritation. 
 
 In the chronic stage of pleurisy there is a necessity for 
 generous diet and tonic remedies, such as quinine, in aid of 
 any diuretics and absorbents which may be employed. If the 
 patient be kept too low after the stage of active inflammation 
 has subsided, or be unduly depressed, it will not only be im- 
 possible to induce absorption, but there will be great danger 
 of the fluid becoming sero-purulent. When a succession of 
 blisters has failed in relieving the patient, ioduretted lotions, 
 or ioduretted ointments, combined with the internal admin*, 
 istration of cinchona with tincture of iodine, iodide of potas- 
 sium, and small doses of bichloride of mercury, nitre, acetate 
 of potash, squills, digitalis, and cantharides, have each in 
 their turn effected the desired object (Fuller). The 
 fluid has been gradually reabsorbed, and recovery has en- 
 sued by a combination of iodine remedies, taken internally, 
 and applied externally — e. g., syrup of the iodide of iron 
 ( 3 ii.), w i tn simple syrup ( § ii.), and a teaspoonful taken 
 every two hours, in conjunction with the external application 
 of a weak solution of iodine (iodine, 3ss.; potass, iodidi, 
 3ii.; aq. distil., | ii.) upon the affected side of the chest 
 (Niemeyer). Other formulae most useful in such cases are — 
 (i.) A diuretic in the form of a pill, composed of digitalis, 
 squills, and the mass of pill, hydrargyri, of each a grain and 
 a half. Nitrate of potash (twenty grains), combined with 
 tincture of the perchloride of iron (fifteen minims), three 
 times a day, may at the same time be given (Fuller, Cham- 
 bers). Professor W. T. Gairdner recommends as a diuretic 
 the cream of tartar electuary, in which the cream of tartar is 
 mixed in equal proportions with treacle, honey, marmalade, 
 or syrup of ginger, and in some cases flavored with a few 
 drops of peppermint oil. The dose is a teaspoonful, re- 
 peated as often as the stomach will bear it, or as the urgency 
 of the case demands. Jaborandi, in the form of infusion, 
 has recently been advocated in the treatment of chronic 
 pleurisy with serous effusion. (2.) A lotion, to be applied 
 over the chest by spongeopiline, or by lint covered with oiled 
 silk, composed of — Bichloride of mercury, gr. iv.; tincture 
 
PLEURISY. 3OI 
 
 of iodine (compound), 3 iv. to 3vi.; glycerine, fiii.; and 
 distilled water, 3 ivss. (3.) One or other of the following 
 ointments may also be rubbed upon the skin, over the side 
 of the chest — Bichloride of mercury, gr. iv. to vi.; iodine 
 ointment, 3 iv. to 3vi.; lard, or vaseline, § iv. to fvi.; or, 
 bichloride of mercury, gr. iv. to v.; iodine of potassium, 3 ii.; 
 distilled water sufficient for solution ; and lard, or vaseline, 
 § i.; Ft. Ung. Feeding the patient upon the driest possible 
 diet, and withholding water as much as possible, has been 
 successful in some cases (Schroth). 
 
 As a means of relieving the chest in chronic pleurisy and 
 empyema, the operation of puncturing the chest and letting 
 out the fluid — an operation to which the name of paracente- 
 sis has been given — is a useful one ; and the practical ques- 
 tion is as to the time when it should be performed. The con- 
 dition of the patient's health and respiration, and the absorp- 
 tion or non-absorption of the effused fluid, are the aids to a 
 decision for or against its performance. As long as the 
 breathing is not seriously embarrassed, and the general health 
 does not decline, so long are we justified in making full trial 
 of our remedies. But as soon as extreme shortness and dis- 
 tress of breathing, or lividity and anxiety of the countenance, 
 denotes serious interference with the functions of life, delay 
 is no longer justifiable, and it becomes our duty at once to 
 give our patient the chance which the operation affords. In 
 the hands of the American physician, Dr. Bowditch, and 
 Professor W. T. Gairdner, of Glasgow, and Dr. Budd, of 
 London, this operation has been the means of saving many 
 lives. Its effect is to relieve the mind as well as the lungs 
 of the patient from great oppression. Although before the 
 operation he may be quite weak, he is often able after it to 
 get up and walk. Digestion becomes ut. once improved, and 
 strength is rapidly regained. The cough, however, is apt to 
 augment during the first few days ; the pulse retains its quick- 
 ness ; friction-sounds occasionally become developed, and 
 several months may elapse before the vesicular murmur be- 
 comes properly re-established in the lung. Generally, the 
 operation of paracentesis thoracis in simple pleurisy is not to 
 be performed unless the life of the patient is in ieopardy — 
 that is, in cases " in which the effusion continues and in- 
 creases, and the side, instead of shrinking, enlarges ; the 
 functions of the lung on that side are entirely abolished; nay, 
 the use of the remaining lung is greatly interfered with by 
 the pushing over of the mediastinum ; and the patient is in 
 
302 
 
 PLEURISY. 
 
 imminent danger of suffocation." In such cases the oppressed 
 lung must be relieved by " letting the fluid out " (Sir Thomas 
 Watson, Lectures, Fourth Edition, Vol. II., p. 128). " Life 
 is plainly in jeopardy when the vital functions of the lungs 
 or of the heart are greatly hindered ; when symptoms pre- 
 sent themselves of approaching death by apncea or by syn- 
 cope. If we discover no cause for those symptoms except 
 the increasing pressure of liquid pent up in the pleura, we 
 are warranted in ascribing them to such pressure, and bound 
 to act upon that persuasion." Also, if death by asthenia ap- 
 pears inevitable, the patient losing ground from day to day, 
 and when all other means of getting rid of the pent up fluid 
 have failed, the patient should not be denied the chance 
 which the operation affords. Also, " whenever the effused 
 liquid consists of pus, it should be let out" (1. c, p. 130). 
 The risks of allowing a localized empyema to remain are 
 great (Wilks). With the arrangements of Dr. Bowditch's 
 syringe we are enabled to remove fluid before the false mem- 
 brane thickens over the compressed lung, and so makes it 
 difficult to expand again. The trocar and small canula take 
 the place of an exploring needle. Therefore, if the lungs are 
 not "bound down by adhesion, or prevented from expanding 
 by the thickness of the false membrane which covers it, 
 Bowditch's syringe and stopcocks enable the fluid, even when 
 purulent, to be withdrawn without air being admitted. Mr. 
 Lister's antiseptic method and precautions as to opening an 
 abscess ought to be adopted. But when air has been admit- 
 ted, and when the fluid within the cavity of the chest has be- 
 come changed thereby — is purulent and perhaps fetid — the 
 evacuation, under antiseptic precautions, of the contents by 
 "drainage" seems the most efficient remedy. 
 
 In Pneumothorax. — Puncturing the chest walls may give 
 temporary relief, by allowing the air to escape ; but the op- 
 eration ought only to be done in cases where the dyspnoea is 
 urgent, and the displacement of the viscera such as demands 
 that relief which the operation is calculated to give. Other- 
 wise, the treatment of pneumothorax is best conducted by 
 small doses of morphia — i. e. y stimulant doses — frequently 
 repeated, combined or not with ether or alcohol, with a view 
 to overcome collapse, relieve dyspnoea, and subdue pain. 
 When reaction follows collapse, as indicated by heat of skin, 
 strength and hardness of pulse, soreness and pain of the af- 
 fected side, local blood-letting by leeches, with saline aperi- 
 ents, may be used if the strength of the patient warrants such 
 
PNEUMONIA. 303 
 
 a line of treatment. Turpentine and poppy fomentations, 
 followed by blisters, are also indicated if life is sufficiently 
 prolonged after the primary inflammatory symptoms are sub' 
 dued. The inhalation of small quantities of chloroform is 
 useful. In other respects the treatment is similar to that al- 
 ready stated. 
 
 Pneumonia. — Definition. — Inflammation of the lungs, 
 which, in its acute sthenic form, is often complicated by con- 
 stitutional or specific diseases. It runs a definite course, 
 expressed by severe febrile symptoms, which come on sud- 
 denly, attaining in a few hours a great intensity, but which 
 may undergo a no less sudden abatement or improvement 
 between the fifth and tenth day, in proportion to the severity 
 of the disease and the textures implicated, while the local 
 productive results of inflammation in the form of the lung- 
 lesion are yet intense, but which are eventually removed. 
 The natural course of pneumonia is materially modified by 
 constitutional or specific diseases, especially if any organ, 
 such as the kidney, the heart, or the liver, is involved ; or it 
 may be modified by the secondary contamination of the 
 blood by absorption of lung-exudation in the later stages of 
 the disease, tending to inflammation of the other lung, to 
 pleurisy, to pericarditis, or to blood-coagula in the cavities 
 of the heart or great vessels 
 
 Treatment. — One of the most discordant topics in the Sci- 
 ence of Medicine seems still to be with some — the treatment 
 of pneumonia. At one time (about fifty years ago) large 
 bleedings were the rule. But Laennec and Louis were early 
 convinced that large bleedings were by no means successful, 
 and that in some cases they were absolutely injurious. The 
 some difference of opinion was held with respect to large 
 doses of the tartrate of antimony. At the same time we have 
 it in our power materially to modify the course and to short- 
 en the duration of pneumonia by the judicious employment 
 of blood-letting, leeches, tartar emetic, certain salines, and 
 opium (Parkes). The correlation of the body-temperature 
 the number of the pulse, and the respirations per minute, 
 furnish the best guide as to the course to be pursued in the 
 treatment of pneumonia. If the pneumonia is not intercur- 
 rent to some other disease, but happens idiopathically in a 
 person otherwise healthy ; if the mean body-temperature re- 
 mains below 104 Fahr., the pulse does not exceed 120 beats 
 in the minute ; and if the respirations never exceed forty in 
 
304 PNEUMONIA. 
 
 the same time, the case must be regarded as a typically fa- 
 vorable case, which will certainly begin to get well when the 
 cycle of the pneumonic process is complete — i. e. f in from 
 three, four, seven or eight, to twelve days without any special 
 medicinal treatment ; but with the careful management im- 
 plied by good nursing, absolute rest in the horizontal posi- 
 tion, and a strictly antiphlogistic diet. In such cases it is 
 sufficient to keep the patient in bed, in a well ventilated room, 
 whose temperature should be kept as near 60 ° Fahr. as pos- 
 sible, to relieve thoracic pains by leeches, or fomentations, 
 linseed and mustard poultices ; to relieve thirst by alkaline 
 or acidulated drinks ; and to give frequently repeated small 
 quantities of nutritious fluid food in the form of milk, milk 
 and eggs, oatmeal gruel, or even meat soups. The natural 
 history of an uncomplicated pneumonia shows that it has a 
 definite* cyclical course; that if left to itself in a vigorous pa- 
 tient, uncomplicated by any other ailment, and if it be of the 
 typical intensity as here indicated, it almost always ends in 
 recovery. The expectant mode of treatment of the Vienna 
 school confirms this view, as the statistics collected by Bal- 
 four, Magendie, Skoda, Niemeyer, Schmidt, and Legendre 
 fully prove. In cases of average severity there is a decided 
 tendency to amelioration of all the symptoms by the eighth 
 day. The results obtained by the Homoeopaths have also 
 shown this to be the case. Unless warranted, by certain 
 special indications, active interference has an unfavorable 
 effect upon the course of pneumonia (Niemeyer) ; and when 
 treated by blood-letting, as a rule, it more often terminates 
 fatally than where no venesection has been practiced (Diett). 
 Blood-letting is no specific. It does not cut short a pneumo- 
 nia ; and in epidemic pneumonia it is hardly possible to 
 bleed the patient without rendering him worse. But much 
 must be left to the discretion of the practitioner. That there 
 are cases in which the patient can only be saved by general 
 blood-letting, everybody must admit. The cases of Louis and 
 of Dr. Alison of Edinburgh establish the propriety of bleed- 
 ing early, if blood-letting is to be used at all. As a general 
 rule, the earlier the inflammatory state is detected (if possi- 
 ble before the third day — Alison) the more likely will bleed- 
 ing be followed by well-marked beneficial results, the disease 
 will be sooner cured, and the convalescence more rapid and 
 perfect. Blood-letting in pneumonia should only be had re- 
 course to when the following special indications for it arise : 
 -— (1.) When the pneumonia attacks a vigorous and hitherto 
 
PNEUMONIA. 305 
 
 healthy person, is of recent occurrence (not exceeding fifty 
 or sixty hours after the rigor ), the temperature being at or 
 exceeding 105 ° Fahr., and the frequency of the pulse as much 
 as 120 per minute. The object of such venesection is to re- 
 duce temperature, lessen the frequency of the pulse, and so 
 lessen the danger from the violence of the fever. (2.) When 
 collateral oedema in the portions of the lung unaffected by 
 pneumonia is causing danger to life, the presence of the 
 blood is reduced by bleeding, and further transudation 
 of serum into the air-vesicles is prevented. When the 
 frequency of respiration is due to the pneumonic pro- 
 cess alone — not to fever or to pain — and as soon as a se- 
 rous foamy expectoration appears, together with a respiration 
 of more than forty or fifty breaths a minute at the com- 
 mencement of pneumonia ; and when the rattles in the chest 
 do not cease for a time, after the patient has coughed as 
 well as he can, copious blood-letting is indicated to reduce 
 the mass of blood, and to moderate collateral pressure. (3). 
 When there are symptoms of cerebral pressure indicated by 
 stupor or transient paralysis. 
 
 Antimony, in the form of tartar emetic, is another remedy 
 which has gone through several extremes of administration 
 in the treatment of pneumonia. Rasori introduced the prac- 
 tice of giving it in large doses, and Laennec was so dissatis- 
 fied with his own results of bleeding that he adopted Rasori's 
 method. Few, if any, now believe in the usefulness of such 
 large doses of antimony; and such a use of tartar emetic has 
 justly fallen into discredit. When antimony is cautiously 
 administered as a sedative, or diaphoretic and expectorant, 
 in doses of the eighth or twelfth of a grain, every two or three 
 hours, and in doses of a sixth or a quarter of a grain, in the 
 more sthenic attacks, when the patient is strong and plethoric, 
 it is a valuable remedy. It may be combined with compound 
 tincture of camphor, or dilute hydrocyanic acid. It is contra- 
 indicated in gastric or gastro-enteric irritation. There are 
 cases where the remedy produces severe depression and 
 nausea — cases in which the stomach will retain no food, not 
 even water when given alone. Under such circumstances 
 the administration of alcohol in stimulant doses often re- 
 peated is called for, and may require to be combined with 
 ammonia, chloric ether, and camphor. Alcohol is especially 
 indicated by the occurrence of delirium (if vascular excite- 
 ment does not exist); by a weak, rapid, or dicrotic pulse; by 
 signs of collapse; by age and general debility of the patient; 
 20 
 
306 PNEUMONIA. 
 
 or in cases of pneumonia secondary to those diseases which 
 it frequently complicates. 
 
 A rational treatment of pneumonia is one which must 
 secure to each case its own individuality and consideration. 
 Bleeding, antimony, and blisters may be demanded in one 
 case ; quinine, opium, and wine In the next ; a third may 
 require but little interference beyond a well-regulated diet, 
 moderate stimulants, and absolute rest. It is the proper 
 combination of remedies, not a single agent or mode of prac- 
 tice, which must be sought for in its. treatment (Lawson). 
 The so-called "rational" or " restorative " mode of treat- 
 ment is the one to be adopted in cases of sthenic pneumonia 
 characterized by heat, above 104° Fahr., dryness of the skin, 
 a full resistant pulse, over 120, rusty-colored expectoration, 
 great oppression of the breathing, and to the extent of 
 beyond forty respirations per minute, blood-letting, had re- 
 course to at the beginning of the attack, in the stage of con- 
 gestion before the fastigium of the pyrexia (not later than 
 forty or fifty hours after the initial rigor), not only affords 
 immediate relief to the breathing, but removes the extreme 
 tension of the vascular system, and promotes secretion. The 
 most suitable time is that during the evening exacerbation 
 (Huss). These indications for blood-letting should be de- 
 cidedly marked before it is undertaken ; and the amount of 
 blood to be lost varies in each case, according to the oppres- 
 sion of breathing, the type of the disorder, and the constitu- 
 tion of the patient ; as well as to whether or not there is any 
 prevalent epidemic tendency associated with the pneumonia. 
 It is seldom necessary to draw more than from ten to sixteen 
 ounces ; and eight or ten ounces will usually suffice. After 
 bleeding, the pain in many instances ceases, expectoration 
 takes place more easily, and alters in character ; the skin be- 
 comes moister, and evidence is afforded of the action of 
 remedies which before proved inoperative (Fuller). But in 
 many cases it is either unnecessary or inexpedient to let 
 blood — inexpedient chiefly because of the constitution of the 
 patient being shattered by excesses, constitutional disease, 
 anxiety, and mental distress. Under such circumstances, it 
 impairs the strength, leads to greater impoverishment of 
 blood, arrests the actions on which the absorption of exuda- 
 tion-matter depends, and induces a tardy convalescence. 
 Bleeding ought not to be employed after extensive consoli- 
 dation of the lung has taken place. 
 
 The cases in which tartar emetic, in small doses (one- 
 
PNEUMONIA. 307 
 
 eighth of a grain) fails to exercise a curative action are those 
 in which hepatization proceeds with extreme rapidity; in 
 which crepitation either does not exist at all, or is of very 
 short duration, giving place after a few hours to intense 
 tubular breathing ; and those which are marked by extreme 
 depression almost from the first. Salines and stimulants with 
 opium, if necessary, are found to be the most efficient means 
 of treatment in such cases. Of other proposed remedies, the 
 following may be noticed, namely: — (r.) Aconite is only to 
 be given at the very outset, or first stage of pneumonia, from 
 miii. to mv. of the tincture of B. Ph. every four hours (Wilks); 
 or from mii. to miii. every three hours at the outset of the 
 congestive stage ( Keith, Edin.Med. Journ., Oct., 1868, p. 905.) 
 Half a drop to one drop of the tincture in a teaspoonful of 
 water every ten or fifteen minutes for two hours, and after- 
 wards to be continued every hour, has been useful in febrile 
 catarrh and catarrhal croup, and may be useful in some of 
 the phases of pneumonia, especially to subdue increased 
 action of the heart and circulation, and to reduce the abnor- 
 mally high temperature. Care must be taken that the remedy 
 is not combined with alkalies (Ringer). (2.) Carbonate of 
 ammonia. — A combination of ammonia and chloroform 
 (where antimony in small doses is not indicated) may be 
 taken every three or four hours. Four grains of carbonate 
 of ammonia, twenty minims of the spirits of chloroform, in 
 five drachms of camphor water, combine the beneficial 
 properties of both stimulants (Waters). It is indicated when 
 the symptoms generally resemble those of delirium tremens, 
 when the pulse is small and weak and quick, or if delirium is 
 present. (3.) Digitalis has of late years been employed by 
 Oppolzer, Traube, Schneider, Niemeyer, and others, as one 
 of the best agents for the relief of the febrile symptoms. It 
 lowers the temperature and diminishes the frequency of the 
 pulse, without exercising so weakening and depressing an 
 effect upon the system as bleeding. A pulse of 100 to 120 
 in frequency is an indication for its employment — a less fre- 
 quent pulse does not require it. It is usual to give it in the 
 form of infusion, combined with the neutral salts of nitrate 
 of potass and soda. Digitalis may be advantageously 
 combined with ergot, in the proportion of four drachms 
 of the fluid extract of ergot to one drachm of digitalis, with 
 six grains of the acetate of lead in two ounces of cinnamon 
 water, of which a tablespoonful is to be given every two 
 hours till the blood disappears from the sputa (Wells, 
 
308 PNEUMONIA. 
 
 New York Med. Record, Vol. XV., No. 17). (4.) Opium is 
 of great service. It may relieve the pain of the side, and 
 diminish the distressing cough. It is also of use in warding 
 off delirium, combined with stimulants and nourishment. It 
 ought to be given when there is want of sleep, restlessness, 
 and staring of the eyes, with slight tremors of the hands. It 
 may be used hypodermically. (5.) Hydrochlorate of am- 
 monia is of use in congestion of the lungs, in the advanced 
 stages of pneumonia, and in the cough of old age. One 
 drachm is to be combined with one drachm of extract of 
 liquorice; two drachms of spirit of sulphuric ether, and four 
 ounces of water, of which a tablespoonful is to be given for 
 a dose every two or three hours (Waring). Or it may be 
 given in one or two grain doses every hour or two, mixed 
 with equal parts of glycerine and water. (6.) Iodide of 
 potassium, in the advanced stages of pneumonia, appears to 
 promote the absorption of effusions and indurations. In 
 severe cases of broncho-pneumonia, combined with tincture 
 of hyoscyamus and ammonia it may reduce the frequency of 
 the respiration in a marked degree. (7.) Quinine is of use 
 chiefly in the advanced stages when the patient is old, the 
 constitution debilitated, and typhoid symptoms prevail. It 
 is best given in combination with sulphuric acid, in doses of 
 five grains every third hour. The pulse ought to become 
 slower and steadier under its use, and the respiration freer. 
 It should be given in .loses of two grains every two hours, or 
 in two or three ten grain doses within a few hours, whenever 
 danger threatens from excessive elevation of the tempera- 
 ture of the body. (8.) Alkalies. — Bicarbonate of potash, 
 largely diluted in mucilaginous liquids, five grains up to 
 thirty grains in each dose, — four, six, or even eight doses 
 being given in the twenty-four hours to the extent of two to 
 three drachms of the salt per day), alters the character of the 
 expectoration by the second or third day of its use. The 
 viscid sputa become resolved; the fine bubbles become 
 coarse and large; the red color of the expectoration disap- 
 pears; its tenacity of adhesion lessens, so that it is brought 
 up easily, and the cough becomes moist, soft, and expulsive. 
 Thus the alkali acts as a sedative, allaying the cough and 
 abating the congestive state on which it depends. The 
 white pasty fur over the tongue dissolves away in an in- 
 creased flow of saliva. The urine becomes alkaline, and the 
 physical signs of pneumonia become resolved. It has also 
 a marked action as a nerve sedative. A drachm dose in 
 
PNEUMONIA. 309 
 
 water produces an agreeable, tingling, numbing sensation, in 
 the lips, cheeks, and other parts, extending gradually to the 
 lower limbs. It is especially indicated where the pneumonia 
 is associated with rheumatism. " Flying blisters," applied 
 for four or six hours, so as to redden the skin (not for sup- 
 puration), is a valuable auxiliary. Suppuration from blister- 
 ing is to be avoided as exhaustive and prejudicial (Dr. John 
 Popham, Brit. Med. Journ., Dec. 28, 1867, p. 586). (9.) 
 Stimulants. — The treatment by repeated alcoholic stimulants 
 alone is but the opposite extreme of practice to excessive 
 blood-letting. It has now found its level and appropriate 
 place as a valuable aid to other remedies, especially in pa- 
 tients whose constitutions are depressed under the influence 
 of life imposed upon them by the " great town system." 
 When pneumonia tends to death by exhaustion, as the dis- 
 ease advances; when exudation has been excessive, the 
 fever prolonged, or the constitution debilitated before the 
 attack, such a state of complete adynamia requires the use 
 of stimulants, in the form of large doses of camphor, mint, 
 benzoic acid, alcoholic drinks; and in addition, concen- 
 trated soups and milk are called for in small quantities, 
 given often. In old persons, stimulants, with generous diet, 
 preparations of quinine and iron, are indicated from the very 
 commencement. Alcoholic stimulants are rarely required in 
 young persons, or in previously healthy adults. 
 
 Some local applications require special notice, namely : — 
 (1.) Cold Applications. — The chest of the patient (the af- 
 fected side in particular) is to be covered with cloths that 
 have been dipped in cold water and well wrung out. Com- 
 presses thus made must be repeated every five minutes. 
 After a few hours the patients experience a material relief. 
 The pain, dyspnoea, and frequency of the pulse are reduced, 
 and the body-temperature may go down an entire degree 
 (Niemeyer, Smoler). The treatment is not merely palliative, 
 but tends to shorten the duration of the illness. Few cases 
 delay to improve beyond the seventh day, many improve 
 on the fifth, and a very large number as early as the third 
 day. The remedy is justly held in repute for meningitis and 
 peritonitis, and hence it may fairly claim to have a similar 
 good effect in pneumonia. 
 
 (2) Linseed Meal Poultices. — On the other hand, heat com- 
 bined with moisture in this form, made as Tight and soft as 
 possible, and sufficiently large as thoroughly to inclose the 
 affected side, and changed as often as it gets unpleasant, not 
 
3IO PODAGRA PORRIGO FAVOSA. 
 
 only affords present relief, but exercises a favorable influence 
 on the course of the disease. The skin may be at the same 
 time stimulated by mustard, or terebinthine applications, 
 added to the poultice. 
 
 (3.) Turpentine. — Hot turpentine fomentations may be ap- 
 plied over the affected side also with advantage. 
 
 (4.) In children it is sometimes of importance to be able 
 to induce cough and expectoration. This can be facilitated 
 by using a spray of a weak warm solution of carbonate of 
 soda, to which a little glycerine of carbolic acid is added. 
 It is a valuable resource in promoting the expulsion of the 
 plugs of tough mucus which tend to accumulate in the bron- 
 chial tubes of children with bronchopneumonia (Dr. Burney 
 Yeo, Brit. Med. Journ., Dec. 7, 1878). 
 
 Time is an important element in the cure. As particular 
 phases in the course of the pneumonic cycle call for special 
 treatment, so much more successful will the management of 
 the case be if the indications for interference are understood 
 and acted upon. The natural course of the disease is to go 
 on rapidly to a spontaneous favorable termination, by a pro- 
 cess of resolution through which the solidified lung-tissue 
 regains its natural and healthy state, independently of rem- 
 edies. Those remedies that have been specially noticed may 
 each be of service in safely and surely controlling the circu- 
 lation when the indications for treatment are short of requir- 
 ing the agency of blood-letting. Their effects must be 
 watched so that they do not lower the vital powers nor dis- 
 turb the digestive functions. The indications for nourish- 
 ment, properly adjusted to the circumstances of each case, 
 and each stage of the case, are of paramount importance 
 from the first; and the happy issue of a case of pneumonia 
 depends quite as much upon early and properly feeding the 
 patient as a case of typhus or enteric fever does. A milk 
 diet should be given from the commencement, to be followed 
 by beef -tea and meat-stock soups as the disease advances 
 and the pulse softens. Stimulants cannot be regarded as the 
 equivalent of food (Clymer). 
 
 Podagra — See Gout. 
 
 Pompliolox — See Temp/zigus. 
 
 PorrigO Decalvans — See Tinea Decalvans. 
 
 PorrigO Favosa— See Tinea Favosa. 
 
 
PSORIASIS. 31I 
 
 Psoriasis. — Definition — An eruption characterized by the 
 development of irregularly formed patches of a dusky red or 
 coppery hue, slightly raised above the level of the skin, and 
 covered with thin, dry, white scales. 
 
 Treatment. — Preparations of arsenic are found to be of 
 great service in this squamous form of eczematous inflamma- 
 tion. A form of arsenical remedy, known as the Asiatic pill, 
 is recommended by Cazenave. Its composition is as follows : 
 
 ^ Arsenici Protoxidi, gr. i.; Pip. Nig., gr. xii.; Pulv. Acac, 
 gr. ii. ; Aq. Distill, q. s. — Divide in pil. xii. vel. xvi. One 
 pill to be taken once, twice, or thrice daily after meals. 
 
 It is of the greatest importance that the meals and the diet 
 should be regulated. Small doses of pilulae hydrargyri, or 
 of pilulae calomelanos composita, or hydrargyrac. creta, may 
 be given at bedtime for a few days, followed each morning 
 by a drachm of magnesia, given in combination with a tea- 
 spoonful of lemon juice. The vascular excitement of the 
 stomach is best subdued by dilute hydrocyanic acid, in the 
 following formula (A. T. Thomson) : — 
 
 # Potassae Carbonatis, 3ss.; Succi Limonis Recentis, 
 f 3 iv.; Acid Hydrocyanici Diluti, miv.; Vini Sem. Colchici, 
 mxv.; Aquae Distillatae, f 3 vi.; misce. Fiat haustus 4ta. 
 quaque horae sumendus. 
 
 The tone of the stomach is to be restored by small doses 
 of bicarbonate of potassa, with from twelve to fifteen minims 
 of the tincture of henbane, in a fluid ounce and a half of the 
 infusion of cinchona. The eruption and itching disappear 
 as the mucous membrane of the stomach and bowels return 
 to a healthy state. The diet should be absolutely free from 
 stimulants ; and tepid baths, at a temperature of 96 Fahr., 
 used every morning for half an hour, are most serviceable. 
 The bowels should be regularly relieved by such mild ingre- 
 dients as are contained in the following formula for pills : 
 
 I£ Pilulae Hydrargyri, gr. vi.; Pulveris Ipecacuanhae, gr. 
 vi.; Extracti Colocynthidis Comp., gr. xii.; Ext. Hyoscyami, 
 gr. xviii.; misce. Fiat pilulae duodecem. Sum. ij. h. s. quo- 
 tidie (A. T. Thomson). 
 
 Glycerine and emollient lotions are useful local applica- 
 tions. I have found the itchiness greatly relieved by the 
 following lotion of bitter almonds, rubbed nights and morn- 
 ing over the parts affected : 
 
 I£ Amygdal. Amar. Numero, xx. vel. xxx.; Aquae Rosae, 
 5 vii. Contunde et tere simul, dein cola, et adde Hyd. cor- 
 rosiv. Sublim., gr. xii.; Ammoniae Hydrochloratis, gr. xii ; 
 
3i2 PUERPERAL CONVULSIONS — PUERPERAL FEVER. 
 
 Spt. Vini Rect., § i. ; or, Dilute hydrocyanic acid may be 
 used to the extent of two drachms to the eight ounces, omit- 
 ting the corrosive sublimate ; or let borax replace the hydro- 
 cyanic acid, and omit the spirits of wine. 
 
 When the lotion has dried off, oxide of zinc ointment or 
 glycerine starch ought to be applied to the parts all night. 
 
 Puerperal Convulsions — See Convulsions, Puerperal. 
 
 Puerperal Fever. — Definition. — " A continued fever, 
 communicable by contagion, occurring in connection with 
 childbirth, and often associated with extensive local lesions, 
 especially of the uterine system. 
 
 Treatment. — Having regard to the varied sources whence 
 puerperal fever may take its origin, prophylactic treatment 
 ought to be the first consideration; and especially the burn- 
 ing question as to what ought to be the conduct of the med- 
 ical practitioner in the face of perils of this kind (Priestley). 
 Preventive measures are of vital importance, for such 
 measures have been proven sufficient to arrest the develop- 
 ment of the disease. 
 
 Dr. W. O. Priestley concludes his admirable address as 
 follows : — 
 
 "The method, therefore, to be pursued for guarding lying- 
 in women from noxious influences, consists of all those 
 measures which prevent the formation of poisonous materials 
 in her own system, and which secure her isolation from all 
 contagion from without. In following out the first indica- 
 tion, it is necessary to provide, as much as may be practic- 
 able, for a woman encountering her confinement in the best 
 possible condition of health, by impressing upon her the 
 necessity of obedience to natural laws during her pregnancy. 
 If complications occur during pregnancy, they must be com- 
 bated as the circumstances will permit. Dr. Barnes has in- 
 formed us that albuminuria at the end of pregnancy is ex- 
 tremely apt to go into puerperal fever. On these cases, 
 therefore, a sedulous watch must be kept, the bowels must 
 be carefully attended to, and other suitable treatment 
 adopted. The process of parturition should be conducted 
 with the view to the genital canal of the woman being ex- 
 posed as little as may be possible to the effects of irritation, 
 continued pressure, and laceration. After the birth of the 
 child, a full and perfect contraction of the uterus should be 
 secured, by seeing that the organ is not emptied too sud- 
 denly, and that the hand follows the fundus down from 
 above as its contents are expelled. Subsequently to de- 
 
PUERPERAL FEVER. 313 
 
 livery, the various known methods should be practised 
 which promote the contraction of the walls of the womb and 
 the diminution of the uterine cavity; and any clots forming, 
 should be removed from time to time during the hour after 
 removal of the placenta. It is superfluous to say that the 
 placenta should be extracted in its entirety when possible; 
 and great care should be taken not to leave any detached 
 portions adherent to the uterine walls. The same precau- 
 tions should be observed, when practicable, in cases of 
 abortion. If any considerable laceration of the perinaeum 
 have taken place, the edges of the wound should immediately 
 be united by sutures, not only for the purpose of restoring 
 the perinseum, but also to prevent contamination of the 
 wound by putrid discharges. In the case of other wounds 
 in the vagina or cervix uteri, especial care should be taken 
 to keep them clean by repeated injection, and to leave as 
 small a raw surface exposed as may be practicable. In all 
 cases where the lochia are in the least degree offensive, the 
 vagina should be well injected with Condy's fluid and water, 
 or other innocuous disinfectant, twice in twenty-four 
 hours, or oftener if necessary; and the injection may be 
 carried into the uterine cavity, if it be much distended, and 
 there is a suspicion that it harbors foetid contents. The in- 
 jection of the wound-cavity, however, should be conducted 
 slowly, carefully, and without force. These uterine injec- 
 tions were practised long ago by William Harvey, and there 
 is concurrent testimony in this and other countries of their 
 marked utility in abating the symptoms, even when puer- 
 peral fever has apparently set in. Next in importance is to 
 take care that there is no faecal accumulation in the bowels, 
 and to recollect that the existence of previous diarrhoea may 
 be the indication that retained masses are lying in the in- 
 testines and producing irritation there. It must be within 
 the experience of many how acute febrile symptoms, ac- 
 companied, it may be, by delirium or incipient mania, have 
 passed away with a proper evacuation of the bowels. I may 
 put it, in short, that, to promote recovery a f ter parturition, 
 every direct or reflex source of irritation should be removed, 
 pure air and water ensured, absolute cleanliness observed; 
 and perfect quietude, mental and physical, should be en- 
 joined. Nursing the child should also be recommended 
 when the mother's condition permits, as puerperal ailments 
 have been observed more frequent in women who have not 
 suckled their children. To secure the isolation of a lying-in 
 
314 PUERPERAL FEVER. 
 
 woman from noxious influences which may be communicated 
 to her from without may be difficult, and in some cases per- 
 haps impossible; but as Mr. Callender has informed us how 
 surgeons have learned to banish, for all practical purposes, 
 those affections which may be termed septicemic from surgi- 
 cal wards of hospitals, so I cannot help thinking that the 
 accoucheur will in time succeed in preventing the like affec- 
 tions in puerperal women, so far, at least, as the hetero- 
 genetic cases are concerned. We are all agreed as to the 
 absolute necessity of preventing, directly or indirectly, any 
 communication between cases of erysipelas and puerperal 
 patients. We are agreed also as to the necessity of the mid- 
 wifery practitioner avoiding all post-mortem examinations. 
 His hands should avoid all contact with specific poisons or 
 septic materials; and if perchance his fingers have touched 
 anything suspicious, he should at once carefully and 
 thoroughly disinfect them. The necropsies which seem 
 most baneful are of those bodies which have recently died of 
 erysipelas, peritonitis, zymotic disease, or any other inflam- 
 matory and febrile affections; and in such instances the ac- 
 coucheur should not even be present in the room when the 
 dissection is made, as, though he decline to touch, yet his 
 person and clothes may become infected by the poison. 
 There may possibly be a doubt whether one who dissects 
 bodies altered by decomposition or antiseptic injections, as 
 they are commonly found in the dissecting-room of medical 
 schools, is so liable to contaminate a puerperal patient as 
 he who makes a necropsy soon after a death. Semmelweiss, 
 however, believed that animal matter in a state of putrefac- 
 tion would cause puerperal fever, and immediately lessened 
 the mortality, during the fearful epidemic of puerperal fever 
 which raged in the Vienna hospital in 1846 and 1847, by 
 obliging all dissecting students to wash their hands in 
 chlorine or chloride of lime before making vaginal examina- 
 tions. Impressed by Semmelweiss's views and opinions, I 
 endeavored, during my occupancy of the Chair of Obstetric 
 Medicine at King's College, to prevent students frequenting 
 the dissecting-room and post-mortem theatre from attending 
 midwifery cases, and the result was a very small mortality in 
 the outdoor maternity charity. This care about absolute 
 cleanliness of the hands in attending labors should extend 
 even to occasions when a medical man has had digitally to 
 examine patients suffering from offensive discharges either 
 proceeding from the surface or from the interior of the 
 
PUERPERAL FEVER. £15 
 
 body. Wo have heard in this discussion that the discharges 
 from cancer may produce fever in a lying-in woman; and 
 this is probably true of other putrescent discharges. I have 
 had grave anxiety, extending over some weeks, about a 
 patient after her delivery; because I had gone straight from 
 an instrumental case where labor had been so protracted 
 that febrile symptoms had set in, and the passages had be- 
 come inflamed, so as to pour out an irritating muco-purulent 
 discharge. When a medical man has a bad case of puer- 
 peral fever in his own practice, or is required to see one in 
 consultation, he should certainly not go direct to another 
 midwifery patient without first changing his clothes, besides 
 careful ablution of his hands; and he will be all the safer in 
 his ministrations if he adopt some of those precautions men- 
 tioned by Dr. Swayne and others, such as using a Turkish 
 bath, or the more radical measures for disinfection recom- 
 mended by Dr. Wynn Williams. [No method, however, has 
 been pointed out, or even alluded to, in the course of the 
 discussion by which the septic poison could be got rid of 
 should it have attached itself in any way to the body or 
 dress of the accoucheur or nurse. We have more than one 
 substance — one in particula- — that will not tolerate the 
 presence of putrid animal matter or septic poison: this drug 
 is iodine, which, as soon as it is brought in contact with 
 septic matter, is converted into two harmless substances — 
 acid and carbon. Let any one who has been in attendance 
 on any case, whether a parturient female or any other, where 
 there is any putrid emanation, wasli his hands in water into 
 which he has poured tincture of iodine, and I will answer 
 for it he has no septic matter under his finger-nails. Again, 
 if he fancy that his clothes, hair, and skin are saturated with 
 it, let him go into the water-closet (I mention that as the 
 smallest room in the house), place a few scales of iodine on 
 a plate and put a spirit-lamp under it, and he will soon find 
 himself surrounded by a violet vapor, which will fall upon 
 him in a shower of minute scales, from which he has only to 
 protect his eyes. If he then carry with him any of the 
 puerperal poison, my whole theory of the disease must be 
 wrong. One thing I can assert, that in my own practice I 
 have never had a case of fatal puerperal septicaemia since I 
 have used iodine as an antiseptic, now more than twenty 
 years ago. Iodine is equally efficacious in warding off 
 septicaemia in other surgical diseases. I have injected solu- 
 tions of septic poison under the skin of guinea-pigs, and pro- 
 
3l6 PUERPERAL FEVER. 
 
 duced death by septicemia. I have also injected some of 
 the same solutions, into which I had dropped a few drops of 
 the tincture of iodine, without producing any ill effects. It 
 is needless to observe that the prevention and the cure of 
 this disease go hand in hand together. Should any septic 
 poison be present in the puerperal woman, wash her out 
 again and again with solution of iodine until the solution 
 comes back the same color as it was thrown up. The tem- 
 perature of the patient will probably be 103 or 104 , and 
 it will go down in a very short time to 98 . This I have 
 witnessed since the present discussion began. (Dr. Wynn 
 Williams.)] 
 
 " Many chemical substances have been recommended to 
 be added to water for purifying the hands; iodine, chlorine 
 and its cgmpounds, sulphurous acid, cyanide of potassium, 
 carbolic acid, and the permanganates. It matters not which 
 agent is employed, so long as it is used carefully and effici- 
 ently; and if it be necessary to disinfect clothing, this is 
 readily done by exposing it in an oven to a high temperature, 
 for which many upholsterers have a suitable arrangement. 
 With all deference to Dr. Matthews Duncan, I have no doubt 
 that every medical practitioner who earnestly desires to pro- 
 mote the welfare of his patients and to keep himself blameless, 
 should at once abstain from attending fresh cases of labor 
 when one or more of those recently delivered by him have 
 died with acute febrile symptoms, or are still so ill as to re- 
 quire his constant visits. When, indeed, there is the remo- 
 test suspicion that he may convey the poison in his own per- 
 son, he should not incur the risk of disseminating it. How 
 long he ought to absent himself from midwifery practice, is 
 yet a moot point. Dr. Swayne thinks a medical man should 
 seclude himself for a week only; others think a month 
 hardly sufficient. The remarkable experience of Dr. Huntly, 
 of Yarrow-on-Tyne (Brit. Med. Jown., Feb. 27, 1875, 
 p. 271), led him to believe that he actually generated poison 
 in his own body, as the result of some faulty process, which 
 he communicated to his patients. Taking all the circum- 
 stances into consideration, I am disposed to recommend a 
 week's seclusion after regular attendance has ceased on a sin- 
 gle puerperal fever case. When a series of cases have occurred 
 in the practice of any one medical man, he should absent 
 himself from midwifery practice for a month at least. Dur- 
 ing either the short or long interval of seclusion, the 
 means for disinfection should be fully carried out. 
 
PUERPERAL FEVER. 317 
 
 " Finally, I have to say a word or two as to the propriety of 
 attending patients suffering from scarlet fever or other zymo- 
 tic disease, and lying-in-women at the same time. After 
 what has been said in this debate, I cannot expect the same 
 accord of opinion as on other parts of the ground I have 
 gone over; but I would earnestly beg those who have as yet 
 had so favorable an experience, when attending the two sets 
 of patients conjointly, to ponder well what has been said by 
 others on the reverse side of the question. It cannot be 
 expected that men in general practice„who may be in charge 
 of a scarlet fever or small-pox patient, shall at once relin 
 quish all midwifery practice for the time being, because 
 zymotic diseases are so prevalent that this would practically 
 preclude their attending confinements altogether, or make 
 their attendance on midwifery patients so irregular as to be 
 unreliable. Nevertheless, in view of the dangers which have 
 been indicated by various authorities, albeit their experience 
 may seem to point to different conclusions, they are bound 
 to exercise vigilance, lest perchance they slip into a pitfall 
 unsuspected by them. In seeing an ordinary case of illness, 
 a medical man rarely stays sufficiently long in the sick room 
 to concentrate any considerable dose of contagium about 
 him, and the after-exposure to fresh air in passing from 
 house to house no doubt usefully dissipates any smaller 
 quantity. I would suggest, however, to those treating in- 
 fectious cases, and liable at the same time to be summoned 
 to cases of midwifery, or who may be in attendance on 
 puerperal women, that they should not stay long in the sick 
 chamber; not undertake the duties of nurses, as Dr. Duncan 
 puts it; that they should see puerperal patients before see- 
 ing infectious cases, and never go from the infectious cases 
 direct to the lying-in room, without changing clothes and 
 the most careful ablutions. Some doctors change their 
 clothes and wash with a disinfectant whenever they have 
 seen infectious cases. Whatever either will, or may, con- 
 duce to the wellbeing of patients, will, I am sure, not be 
 regarded as either too irksome or troublesome by any mem- 
 ber of our profession " {Brit. Med. Joum., Jan. 8, 1876). 
 
 If scarlet fever can be prevented, the number of puerperal 
 fever cases would be diminished one-half (Hicks); and 
 every possible step ought to be taken to remove the preg- 
 nant female alike from the influence of scarlet fever and 
 from erysipelas. Dr. Hicks observes, also, "with regard to 
 the medical attendant, although I have found some fully 
 
318 PUERPERAL FEVER. 
 
 aware of the risk of carrying scarlet fever and erysipelas to 
 the woman in labor, yet I have met with not a few who 
 either have not taken care, or have not been fully alive to 
 the danger in which they are placing their patients." He 
 considers it well to have three suits of clothes in use when 
 attending such cases, keeping those out of use before a very 
 warm fire, or hung out in the open air; the hands to be 
 frequently washed and the Kails short; and a good walk in 
 the air should be taken before going to any other patient. 
 Where there are partners, it is advisable for one to attend 
 contagious cases, and leaving the other to manage the mid- 
 wifery. With regard to the nurse, the tendency of women's 
 dress to retain the fomites of contagion must suggest their 
 frequent purification by disinfectants, and the use of material 
 capable «of being boiled in the process of washing, and of 
 otherwise being subjected to the action of disinfectants. 
 With regard to the prevalance of the disease in hospitals, 
 the wards ought to be closed entirely against the admission 
 of patients, at regular intervals, during which the process of 
 purification should go on. The ward to be purified should 
 then be filled with chlorine gas, in a very condensed form, 
 for forty-eight hours at least; the windows, doors and fire- 
 places being kept shut. The floors and woodwork should 
 be covered with chloride of lime, mixed with water, to the 
 consistence of cream. The woodwork should then be 
 painted, and the walls and ceilings washed with fresh lime; 
 the blankets and sheets should also be washed and heated 
 in a stove to a temperature of 120 to 130 Fahr. The 
 hospital beds should be stuffed with straw; and as soon as 
 the case is concluded, the straw ought to be burned, and the 
 covering of the bed washed and heated like the blankets 
 and sheets (Collins's "Midwifery," 388). Patients threat- 
 ened with puerperal fever ought to be isolated. 
 
 With regard to medical treatment, pure air, nutriment, and 
 stimulants are the agents best able to obviate the great 
 depression which marks the commencement of puerperal 
 fever. Quinine in large doses has been found useful after 
 the bowels have been fully evacuated. It ought to be given 
 till the physiological action of the drug is manifest, from the 
 deafness and vertigo it produces. A form of quinine is now 
 made soluble in warm water, which may be injected hypo- 
 dermically. Opium is of great value. It has been given, to 
 a large amount in the twenty-four hours, by Drs. Graves, 
 Stokes, and others, since its great value became known. It 
 
PURPURA. 319 
 
 must be given till incipient narcotism is produced; and the best 
 evidence of its good effects is seen when the respirations become 
 sensibly diminished from the great frequency they attain in 
 puerperal fever. If they can be reduced to fourteen or to 
 twelve, with a pulse below 100, a subsidence of tenderness, and 
 of tympanitis, the amount of opium may be gradually lessened 
 and finally discontinued (Clark). Warburg's tincture (suggested 
 by Professor W. C. Maclean), has been found successful by 
 Dr. Playfair in the treatment of puerperal fever. 
 
 Purpura. — Definition. — A disease characterized by purple 
 spots, patches, or merely points of effused blood, which are 
 not effaced by pressure. They are usually met with on the 
 skin alone ; but they may appear simultaneously on the 
 mucous membrane, when they are sometimes accompanied 
 with more or less hemorrhage. 
 
 Treatment. — To treat this disease with success, it is neces- 
 sary to ascertain the circumstances under which it becomes 
 developed in each particular case. Its treatment may be 
 comprised in the following measures : — The bowels ought in- 
 variably, and without exception, to be first thoroughly and 
 effectually evacuated by means of senna, aloetics, or calomel 
 and jalap. Oil of turpentine administered in moderate and 
 repeated doses, has also been recommended. Dr. Hardy, of 
 Dublin, recommends the tincture of larch bark. He has 
 long used it as a styptic and carminative tonic ; and it is 
 " one of the most elegant forms of prescribing a terebinthi- 
 nate " (Moore). Fifteen drop doses of the tincture may be 
 administered every hour or eight or ten drops three times a 
 day, afterwards increasing the dose according to the age of 
 the patient and the necessities of the case. In young sub- 
 jects otherwise robust, when the disease has appeared after 
 violent exercise or excess, blood may be drawn from the arm, 
 as practised by Dr. Parry of Bath. Under such circumstan- 
 ces also the young patient should abstain from animal food 
 in every form, and should subsist on boiled rice with whey, 
 or the light subacid fruits, as grapes, oranges, strawberries, 
 gooseberries, baked apples, and the like. His drink may con- 
 sist of tamarind-water, or water acidulated with sulphuric 
 acid. Under this plan most cases of the disease in the young 
 will be speedily and readily brought to a favorable termina- 
 tion. If symptoms of local uneasiness continue after the 
 urgent phenomena have disappeared, leeches should be ap- 
 plied in the neighborhood of the part ; and it will be proper 
 to continue the periodical and regular evacuation of the all- 
 
320 PYAEMIA. PYROSIS. 
 
 mentary canal. When the spots have disappeared and the 
 haemorrhage has ceased, the constitution recruits rapidly 
 under the gradual but cautious use of light soups and fresh 
 fruits and vegetables (Craigie). 
 
 Pyaemia. — Defifiition. — A febrile affection associated with 
 a morbid state of the system generally, the invasion being 
 marked by frequently repeated severe rigors alternating with 
 profuse sweatings, and usually sequent on some inflammatory 
 and infective condition of wounds, suppurative inflammation 
 of bone, the puerperal state, or surgical operations, which 
 results in the formation of secondary lesions in the internal 
 visceral organs (most frequently in the lungs, the liver, kid- 
 neys, spleen, and brain), and also in the joints and connec- 
 tive tissue. Sometimes, but not necessarily, it is associated 
 with phlebitis or embolism. The blood becomes poisoned, 
 and contains an excess of white corpuscles and of fibrine. 
 
 Treat77ient. — The aim should be to prevent pyaemia by 
 dressing wounds and injuries by Lister's antiseptic methods. 
 Whenever the antiseptic treatment of Lister is properly car- 
 ried out there is complete absence of pyaemia. The indica- 
 tions are — (i.) To remove all those conditions which favor 
 the degeneration, metamorphosis, or putrefaction of blood- 
 clots or tissue in connection with wounds ; (2.) To subdue 
 the force of the circulating current, so as to prevent excite- 
 ment during the long and slow metamorphosis of a clot when 
 it has formed ; (3.) To sustain the strength and allay the 
 nervous irritability. Wine, brandy, rum, milk, strong animal 
 soups, and nourishing diet, should be freely given from time 
 to time, in small quantities. Opium should be given freely. 
 Exposure of the patients to currents of fresh air — treatment 
 in the open air, in fact — has been shown by Sir James Paget 
 to be the most promising of success. 
 
 The use of disinfectants, and attention to ventilation, give 
 support to the belief that the poison is one generated among 
 cases of accumulated severe wounds and open sores. The 
 patient ought to be isolated. Condy's fluid, carbolic acid 
 wash, and chloralum, are each useful disinfectants. Prepa- 
 rations of iron are the most suitable tonics. 
 
 Pyrosis. — Definition. — Paroxysms of pain at the cardiac 
 or oesophageal region of the stomach, occurring in parox- 
 ysms which do not cease till the patient vomits up a limpid 
 colorless fluid, like water, cold and insipid to the patient's 
 taste, but which sometimes gives an acid and sometimes an 
 alkaline reaction. 
 
PYROSIS. 321 
 
 Treatment consists in saline remedies, such as a drachm of 
 the sulphate of magnesia, with fifteen minims of the tinct. 
 hyoscyami, three times a day. Many other medicines have 
 been recommended, as the tinct. kino, and compound kino 
 powder, and mixtures of bismuth, especially Seller's. The 
 compound tincture of benzoin, to the extent of one fluid 
 drachm with mucilage, is most efficacious. (Baillie, Symonds). 
 Sulphurous acid, in doses mxxx, to one fluid drachm, thrice 
 daily, and shortly before meals, is advocated by Dr. Lawson 
 {Practitioner, Sept. 1868). It is especially useful where sar- 
 cine ventriculi are present in the fluid evacuated. The diet 
 should consist of animal food, and be otherwise nourishing. 
 Oatmeal and brown bread must be avoided. 
 
 Quinsy. — Definition. — Acute inflammation of the tonsils, 
 which may or may not lead to suppuration. 
 
 Treatment must depend entirely on the stage at which the 
 disease comes under notice. In the early period resolution 
 may almost invariably be brought about by the administration 
 of guaiacum, in the form of lozenges. Dr. Mackenzie pre- 
 scribes a lozenge containing three grains of the extract of 
 guaiacum mixed with blackcurrant paste, every two or three 
 hours. But I have found the drug most beneficially pre- 
 scribed in the following formula: 
 
 I£. Magnes. Sulph., 3 vL; solve in aquae 3 viii.; adde 
 Pulv. Guaiaci 3iss.; Pulv. Tragacanth. Co., 3ii.; misce 
 bene. One-sixth part of this mixture may be given every 
 four hours till the bowels are freely moved. 
 
 Minim doses of aconite tincture every hour will maintain 
 a regular and steady action in subduing the inflammation. 
 In addition, ice sucked constantly, and iced drinks, are most 
 grateful to the patient; while, if ice cannot be obtained, cold 
 thick gruel frequently affords relief. In other cases, how- 
 ever, greater relief is experienced by holding hot water in 
 the mouth, and by the inhalation of hot steam, combined 
 with sedatives — such as benzoin or conium. A mixture of 
 mucilage or gruel, containing nitrate of potash or borate of 
 soda, and a small quantity of syrup of poppy, Batley's solu- 
 tion of opium, or prussic acid, should be frequently but 
 slowly swallowed in small quantities, in tea or tablespoonfuls; 
 the amount of narcotic ingredient being carefully regulated, 
 so that a definite quantity is consumed in a given time. Ex- 
 ternally, a mustard poultice should be first applied, and af- 
 terwards linseed poultices. The latter may be constantly re- 
 peated until the attack subsides; spongiopiline may answer 
 21 
 
322 RACHITIS — RELAPSING FEVER. 
 
 better than the linseed poultices, and is more cleanly. If 
 suppuration has commenced before the practitioner sees the 
 case, great relief will be afforded by puncturing the abscess 
 with a guarded knife; the incision should always be made 
 towards the median line. After the abscess has been re- 
 lieved, the recovery of the patient is usually very rapid; but 
 the prostration is sometimes considerable, so that nourish- 
 ment and stimulants are required in abundance. It has 
 been already remarked that a patient who has once suffered 
 from quinsy is likely to suffer again; and the question natur- 
 ally arises as to what preventive treatment should be adopted? 
 In those cases in which there is any chronic enlargement ot 
 the tonsils, excision should be performed; but in some cases 
 the glands, though extensively diseased, do not remain en- 
 larged when the acute inflammation has passed away. Un- 
 der these circumstances the tonsil may be amputated during 
 the attack of quinsy. This plan of treatment is commonly 
 adopted in Germany on its own merits, without any question 
 as to the recurrence ot the inflammation. 
 
 Rachitis — See Rickets. 
 
 Relapsing Fever. — Definition. — A continued fever, hav- 
 ing a very abrupt invasion and short duration, characterized 
 by an abrupt relapse occurring after an interval of apparent 
 health of about a week. There is no eruption on the skin, 
 nor any specific lesion associated with this fever, which is 
 marked by rigors, chilliness, severe headache, vomiting, and 
 often jaundice; a white moist tongue, epigastric tenderness, 
 confined bowels, enlarged liver and spleen, high-colored 
 urine, a frequent, full, and often bounding pulse, pains in the 
 back and limbs, restlessness, and occasionally delirium. 
 These symptoms abruptly terminate by an exceedingly copious 
 perspiration between the fifth and the eighth day; and after 
 a complete apyretic interval (during which the patient may 
 be so well as to get up and walk about), an abrupt relapse su- 
 pervenes on the fourteenth day, counting from the first com- 
 mencement of the fever. The relapse runs a similar course 
 to that of the primary paroxysm, and terminates between the 
 third and the eighth day. In some cases a second, third, 
 fourth, and even fifth relapse may occur. Death is apt to 
 happen from sudden syncope, especially after the excessive 
 perspiration; or from suppression of urine and coma. 
 
 Treatment. — All physicians agree that in the primary at- 
 tack little medicine is required after opening the bowels by 
 
RELAPSING FEVER. ,3 2 J 
 
 castor-oil; or by five grains of the compound colocynth 
 mass; or by two grains of blue pill, and three grains of ex- 
 tract of hyoscyamus given at night, and followed in the 
 morning by two drachms of the sulphate of magnesia in 
 compound infusion of roses (Murchison). The symptoms 
 are not readily under the control of remedies; the vomiting 
 is often especially persistent. Five grains of calomel, with 
 one grain of opium, has been found more efficient in-subdu- 
 ing the severity of this symptom than counter-irritation or 
 effervescing draughts. The violence of the headache in 
 well-fed, or otherwise healthy patients, is best subdued by 
 leeches or cupping; and in the poor, weakly and ill fed, by 
 blisters to the nape of the neck, or by dry cupping there. 
 Till the crisis comes, the symptoms may be mitigated, but 
 not altogether relieved, and cases of ordinary severity are 
 better left to nature without interference on the part of the 
 physician. Active purging is to be av< nd the action 
 
 of the kidneys is to be kept up by the frequent use of small 
 doses of nitre (Ross, Henderson, Cormack, Wardell, Mur- 
 chison). " By keeping up the action of the kidneys from 
 the first" we may ' prevent the occurrence of uraemic intoxi- 
 cation, which is one of the main causes of death in uncom- 
 plicated cases." With this end in view nitre is to be given 
 as follows: — From one to two drachms of nitre are to be dis- 
 solved in two pints of barley-water, acidulated with a drachm 
 of dilute nitric acid, and sweetened with a little syrup. 
 This quantity is to be used up during the twenty-four hours. 
 Acetate of potash and nitric ether may be used for the same 
 purpose; but the nitre has the additional advantage of keep- 
 ing open the bowels (Murchison). Contamination of the 
 blood with urinary products is the great danger in cases of 
 relapsing fever; and therefore particular attention must be 
 paid to the state of the urine, especially towards the period 
 ol the first crisis. When the daily amount is much reduced, 
 or if entire suppression should ensue, and particularly if 
 stupor, confusion of thought, or drowsiness should supervene, 
 the bowels are to be freely moved by compound jalap powder, 
 or by a turpentine enema. Determination to the . skin 
 should be promoted by the hot-air bath; and saline diuretics 
 may be given every two or three hours. No means hitherto 
 discovered will prevent the occurrence of the relapse. The 
 surface of the body should be frequently sponged over with 
 cold or tepid water. Stimulants are not usually necessary, 
 but they may be required in the stage of languor or exhaus- 
 
324 REMITTENT FEVER. 
 
 tion ensuing on the crisis, or in cases where great debility 
 has preceded the attack. If any anaemia exists, or if an 
 anaemic murmur can be detected, stimulants must be given 
 early. When jaundice appears, nitro-hydrochloric acid 
 should be given in combination with nitre, as in the follow- 
 ing formula: — Twenty minims of hydrochloric acid, with 
 ten minims of nitric acid, every three hours, each dose 
 diluted with the drink of nitre and barley-water already pre- 
 scribed (Murchison). 
 
 Remittent Fever. — Definition. — Febrile phenomena 
 of malarious origin, characterized by irregular re- 
 peated exacerbations and remissions being less 
 distinct in proportion to the intensity of the fever, so 
 that in malarious yellow fever the exacerbations and 
 remissions are so connected that the fever resembles a 
 continued fever. There is great intensity of headache, 
 the pain darting with a sense of tension across the forehead. 
 It is accompanied by functional disturbance of the liver, and 
 frequently by yellowness of the skin, as in malarious yellow 
 fever, in which, however, the urine is not suppressed, and 
 continues free from blood and albumen. The malignant 
 local fevers of warm climates are usually of this class. 
 
 Treatment. — With fever so various in its degrees of severi- 
 ty, it is not possible to do more than indicate the nature of 
 the treatment which may be followed, as every special case 
 must be prescribed for and treated by its own special indi- 
 cations, and with a due regard to the nature of the prevail- 
 ing epidemic. The best possible hygienic arrangements 
 should be made, especially to secure efficient ventilation, 
 with a plentiful supply of fresh air. In every form and va- 
 variety of the fever one of the most important guides in the 
 treatment is to be derived from the nature of the prevailing 
 disease, whether endemic or epidemic, whether sthenic or as- 
 thenic, and to study each individual case in relation to the 
 prevailing type. First, the duration of the stage of the fever 
 must be ascertained — i. <?., whether it be of some hours' or of 
 some days' duration, and whether, when the practitioner sees 
 the patient for the first time, the actually existing paroxysm 
 is at its accession or its decline. 
 
 Regarding the method of treatment of remittent fever, my 
 friend and colleague, Prof. W. A. Maclean, whose extensive 
 experience in India gives authority to his conclusions, writes 
 in the following terms :— 
 
 " I have been led to take a view of the treatment of mala- 
 

 REMITTENT FEYER. 325 
 
 rial fevers generally, and remittent fever in particular, differ- 
 ing from that laid down by many authors. It appears to 
 me that the so-called antiphlogistic treatment, so much in- 
 sisted on by many writers, is based on the belief that the 
 phenomena observed in a case of remittent fever are conse- 
 quent on a process of inflammation. It is only on such a 
 belief that antiphlogistic treatment can be justified. During 
 the exacerbation of a remittent fever there is violent disturb- 
 ance both of the vascular and nervous systems. Almost 
 every organ, almost every function suffers, — the gastric in- 
 intestinal membrane is affected, the liver and spleen suffer, 
 the brain is involved, for rending headache and delirium 
 are often present. Is it rational to suppose that an inflam- 
 matory process can be going on at one and the same time in 
 all these various organs? Do the appearances observed 
 post-mortem give any support to such a doctrine ? If not, 
 on what principle can spoliative treatment be justified ? Is 
 it not rather the case that this terrible disturbance of so 
 many organs is due to the presence in the blood of a subtle 
 poison acting on them all ? If so, surely the guiding princi- 
 ple of the physician in his treatment should be to counter- 
 act this poison, to neutralize it, or to expel it from the sys- 
 tem, and so to prevent a recurrence of the exacerbation. 
 This is the principle on which I have long acted, and I am 
 satisfied that it is at once a safe and successful one. In qui- 
 nine we have such an antidote — a therapeutic agent of unri- 
 valled efficacy, which, if skillfully used, will rarely disap- 
 point the expectations of the practitioner. 
 
 " It is always, of course, advisable to have the bowels 
 thoroughly evacuated ; and if the patient is seen when his 
 stomach is loaded, it is well to evacuate its contents by an 
 emetic. In ardent remittents, however, there is generally 
 little call for this, as obstinate vomiting is almost always a 
 troublesome symptom, sometimes requiring to be checked. 
 This done, the period of remission must be watched for, and 
 the moment it arrives, quinine in a full dose should be given 
 — not less than fifteen grains in the case of an adult. If the 
 irritability of stomach be so urgent that the remedy is reject- 
 ed, while measures must be adopted to allay it — such, for 
 example, as alkaline remedies in combination with dilute 
 hydrocyanic acid, turpentine stupes, or even a blister to the 
 epigastrium — time — precious time — siiould not be lost. Qui- 
 nine should be given by the rectum, in a full and efficient 
 dose. By mouth or by rectum, or by both, quinine in 
 
326 REMITTENT FEVER. 
 
 quantity sufficient to induce some of the symptoms of cin- 
 chonism, should be given before the time of expected exac- 
 erbation. According to my judgment and experience, it is 
 bad practice to withhold quinine until an impression has 
 been made on the force and frequency of the heart's action, 
 from fear of increasing headache, causing congestion of or- 
 gans, or the like. An impression on the force and frequency 
 of the heart's action is' best attained by arresting the parox- 
 ysm ; and this is done most quickly, simply, and effectively 
 by the early administration of quinine. I have over and 
 over again had patients brought to me from the malarial 
 quarters of the city of Hyderabad, in whom it was impossi- 
 ble to distinguish any period of remission — the tongue black 
 and dry, sordes on the teeth, the skin hot and parched, the 
 pulse enormously quick, the intelligence feeble or gone — all 
 pointing to a system so charged with malarial poison as to be 
 well nigh overwhelmed. In such cases quinine, with concen- 
 trated beef-tea and brandy, are urgently called for, and should 
 be administered freely ; and it is astonishing how men, by 
 such measures, are often snatched from impending death. I 
 have seen in a few hours consciousness return, a striking re- 
 duction in temperature, in the frequency of the pulse, with a 
 remarkable accession of force and volume, follow the treat- 
 ment indicated above. I do not advise, and never used qui- 
 nine in the heroic doses advised by some. I have never ex- 
 ceeded twenty grains ; but within such reasonable limits I 
 have never seen it aggravate headache. On the contrary, I 
 believe that in remittent fever — in fact, in all forms of malar- 
 ial fever with which I am acquainted — I believe quinine to 
 be a powerful remedy in quieting the tumultuous action of 
 the circulation disturbed by the presence of this terrestrial 
 poison. For some years past Warburgh's tincture has been 
 much used in the treatment of malarial fevers in Southern 
 India. It is a secret remedy, and therefore open to the ob- 
 jections very properly urged against all such remedies. It 
 is now known that quinine enters largely into this remedy, 
 the composition of which is published in the Lancet, Vol. II., 
 1875, p. 716. I have given this 'tincture' a fair trial in 
 some of the gravest forms of malarial fever, and it has also 
 been extensively used by some of the most experienced offi- 
 cers of the Madras army ; and I do not hesitate to say that 
 I think it a valuable remedy. I have known it arrest at once 
 some of the severest cases of remittent fever, no exacerbation 
 appearing after the second dose. It almost invariably acts 
 
Remittent fever. 327 
 
 as a powerful diaphoretic — the most powerful with which I 
 am acquainted. I have seen patients, under the influence of 
 this remedy, saturate not only the bed-clothes, but the very 
 mattress, the patient's room and his person for days after 
 giving out a strong odor of the medicine. For this reason it 
 requires to be used with extreme caution, if at all, in the 
 adynamic form of the disease. 
 
 " In urgent cases I follow the practice of the American 
 physicians. I do not wait for a remission, but give quinine 
 at once ; and in all I am conservative of the patient's 
 strength. I have seen violent delirium follow free leeching 
 of the temples, and over and over again seen extreme and 
 dangerous prostration follow depletive treatment, and that in 
 cases where the violence of the disturbance indicated power; 
 but these signs of power in the system are often must delu- 
 sive, and, if combated by depressing measures, we must be 
 prepared for sudden signs of collapse. Against the system 
 of treating this fever by saturating the system with mercury, 
 I enter my strenuous protest. I know nothing more deplora- 
 ble than the condition of a patient whose constitution, al- 
 ready depressed by the presence of malaria, is further satu- 
 rated by another poison which acts as a powerful ally of the 
 first." 
 
 In the asthenic form of remittent fever, such as that so 
 well described by the late Dr. Murchison as prevailing in 
 Burmah, it is necessary to exercise great caution in deple- 
 tion. All the cases he relates which had been freely bled 
 exhibited the most aggravated typhoid symptoms, and most 
 of them died. Even in the instance of young and robust re- 
 cruits, low adynamic typhoid symptoms were sure to super- 
 vene in a short time after blood-letting ; and, even although 
 it gave temporary relief, it was certain to aggravate, if not to 
 induce, the subsequent typhoid condition. If the headache 
 is very severe and the pulse full ; if the hair be cut short, or 
 shaved off the scalp, cold lotions applied to the head, or the 
 cold douche kept up for ten minutes at a time, gives great 
 relief, and is the preferable remedy (Murchison). As soon 
 as possible after the commencement of the paroxysm the 
 bowels should be cleared out with a purgative of calomel 
 and compound jalap powder ; or by colocynth, antimonial 
 powder, and calomel. If typhoid symptoms betray them- 
 selves, stimulants, such as wine and brandy, must be given ; 
 but, as in intermittent fever, "quinine is undoubtedly the 
 sheet-anchor," and it is best given, as in the former fever, in 
 
328 RHEUMATIC FEVER RHEUMATISM, ACUTE. 
 
 one large dose of twenty grains in solution at the very com- 
 mencement of a remission. Carbo-azotic or picric acid has 
 been lately introduced as an active remedy in the treatment 
 of malarious fever. Prepared by Calvert, of Manchester, it 
 is of a light yellow color ; and in doses of two grains, cau- 
 tiously repeated, it is to be pushed till the patient gets yel- 
 low-skinned. 
 
 The period of convalescence demands no less careful at- 
 tention on the part of the medical attendant, especially as to 
 diet and a timely removal from all malarious influences, by a 
 sea voyage, or a change of climate. It is to the mismanage- 
 ment of convalescence, and a too early discharge from hos- 
 pital principally, that we must refer the numerous and fatal 
 relapses in the fevers and dysenteries of our seamen and sol- 
 diers (MStrtin). 
 
 Rheumatic Fever. — See Rheumatism, Acute, 
 
 Rheiiatism, Acute. — Definition. — A specific febrile dis- 
 order, due to a morbid state of the system by constitutional 
 development, and expressed by inflammation of a peculiar 
 non-suppurative kind in the fibrous tissues about or surround- 
 ing the joints, especially in the white fibrous tissues — such, 
 for instance, as the sheaths of the muscles and muscular 
 fibres, tendons, aponeurosis, bursae, capsular ligaments, per- 
 iosteum, and pericardium. Many joints may be affected at 
 the same time or in succession. The various local pheno- 
 mena of the disease have a tendency to shift from part to 
 part, the most remote from each other; and the febrile state 
 is accompanied by profuse acid excretions from the skin, by 
 the separation, in some cases, of large quantities of uric and 
 sulphuric acid through the kidneys, and by a highly fibrinous 
 condition of the blood. 
 
 Treatment. — It seldom if ever happens that the cure of 
 rheumatism can be entrusted to any single remedy. The 
 constitutional nature of the disease, as already indicated, 
 points to various methods and combinations of treatment as 
 most likely to lead to a successful issue. A successful issue 
 in a case of rheumatism means that the attack should be 
 passed through without any permanent organic mischief be- 
 ing left behind. The treatment of rheumatism must pro- 
 vide, (O for the acute attack; (2), for the management of the 
 system as regards those conditions of the life of the patient 
 which may have been found to contribute to the constitu- 
 tional development of the disease. 
 
KHKLMATISM, ACUTE. 329 
 
 In the acute attack the patient must be made — (i.) 
 comfortable, being protected from pain and exposure to 
 cold air, especially as regards the joints; (2.) to encourage 
 free excretion from the skin especially, and from the kid- 
 neys. The general management of the patient is therefore 
 all important. No linen must touch the skin. A flannel 
 shirt must be worn next its surface, and the patient must be 
 put between soft blankets. ''Bedding in blankets reduces 
 by a good three-fourths the risk of inflammation of the 
 heart run by patients in rheumatic fever, diminishes the in- 
 tensity of the inflammation when it does occur, and dimin- 
 ishes still further the danger of death by that or any other 
 lesion; at the same time it does not protract the convales- 
 cence " ("Chambers's Lectures, chiefly clinical," p. T47). 
 The patient ought to be carefully wrapped up in blankets of 
 the newest and fluffiest kind that can be got, which a: 
 be so arranged as to shut off all accidental drafts of air (Dr. 
 Roberts). On no account are the bed-clothes to be thrown 
 off, however warm the surroundings may become; for an 
 evenly high temperature to the skin, combined with absolute 
 rest, are of the greatest value in rheumatic \c\cv. These 
 two conditions are worth all other means of relief put to- 
 gether (Dr. King Chambers). The bed should be protected 
 by screens from draughts of air. All the joints, whether 
 affected or not (/>., the limbs), ought to be enveloped in 
 cotton wool, a layer of which ought also to be put over the 
 chest on both sides, with an arrangement for permitting the 
 region of the heart to be easily got at for its occasional ex- 
 amination (Dr. Roberts). On the other hand, the following 
 are the indications which have guided Dr. R. Sou they of St. 
 Bartholomew's Hospital, London, in the treatment of acute 
 rheumatism: — 
 
 "To relieve local pains; to reduce fever; to diminish the 
 gravity of the various complications; and to promote early 
 and complete convalescence. I do not consider that the 
 materies morbi are eliminated either by sweating or by purg- 
 ing. A spring bed with a tightly stuffed horse-hair mattress 
 over it, is that which rests and supports the trunk and 
 limbs, and relieves the joints most. I am no advocate for, 
 and have never allowed my patients to be placed between 
 the blankets instead of the sheets; neither will I permit 
 flannel bed-shirts to be worn. The object I have in view is 
 to keep one uniform temperature about them, which the bed 
 provides for; but not to keep the patient swathed in flannel 
 
330 RHEUMATISM, ACUTE. 
 
 reeking and saturated with decomposing perspiration. As a 
 matter of fact I observed that a large proportion of hospital 
 rheumatic patients were persons who habitually wore thick 
 flannel shirts and under shirts, and did not change them very 
 often. Cotton shirts and cotton sheetings are better suited 
 than linen to rheumatic people. My practice has been to 
 keep my rheumatic cases cool rather than hot. They are 
 certainly easier in consequence." 
 
 As to medical treatment, venesection, calomel, combined 
 with purgatives, colchium, and opium, are the remedies 
 which have been hitherto most generally made use of in the 
 treatment of acute rheumatism. To the success of each of 
 these remedies the late Dr. Latham has borne his testimony, 
 " so far as that, under the use of each," he writes, " I have 
 seen patients get well." No disease has been treated by 
 such various and opposite methods, so that " acute rheuma- 
 tism has experienced strange things at the hands of medical 
 men." " Had he written in these days Dr. Latham would 
 have had many other strange things " to add to his list : — 
 Alkalies, acids, salines, hot water, cold water, lemon juice, 
 citric acid, chloral, belladonna, iodide of potassium, ergot, 
 digitalis, aconite, guaiacum, emetics, sulphur, antimony, per- 
 chloride of iron, quinine, iodine, plaster of Paris bandages, 
 galvanism, subcutaneous injection of carbolic acid, blisters, 
 podophyllum, cynara, propylamine, chloro-hydrate of trime- 
 thylamine, and last, but not least, salicine, salicylic acid, and 
 salicylate of soda. All these and many more remedies have 
 been used in rheumatic fever; and each has tteen extolled 
 as more potent than all the rest (Dr. E. Markham Skerritt, 
 Brit. Med. Journ., July 28th, 1877, p. 104). But as the dis- 
 ease, when uncomplicated, tends to terminate sooner or later 
 in recovery, and may sometimes subside with marvellous 
 rapidity under every variety of remedy, it is obvious that no 
 sound inference can be drawn as to the success of any par- 
 ticular method of treatment, unless such treatment has been 
 largely adopted in cases of exactly similar severity — as esti- 
 mated by the correlation of pulse, respiration, and tempera- 
 ture (measured by thermometer) — and been attended with 
 tolerably uniform results. Each and every plan of treatment 
 which has therefore been hitherto proposed is regarded by 
 the profession as unsatisfactory. (See account of a discus- 
 sion upon a paper read by Mr. Dickinson to the Royal 
 Medico-Chirurgical Society of London, and reported in the 
 Medical papers of 21st June, 1862). If in one person's 
 
RHEUMATISM, ACUTE. 33 1 
 
 hands any particular remedial course has proved efficient, it 
 has signally failed in those of another. If at one time a 
 remedy has proved efficacious, it has been found inert or in- 
 jurious at another, under different circumstances of age, sex, 
 constitution, and the like. These facts ought not to appear 
 strange to those who consider the true nature of the disorder, 
 and the variety of circumstances under which the physician 
 may be called upon to minister to his patient's relief. Bleed- 
 ing, which in the young plethoric, and robust, may be neces- 
 sary to allay excessive vascular action and cause free secre- 
 tion, may in the weakly induce irritability of the heart, and a 
 consecpient attack of cardiac inflammation. Opium, which 
 in one person may prove of the greatest service in promoting 
 free perspiration and in allaying the general irritability of the 
 system, may in another check the biliary, "lock up" other 
 secretions, and thus prevent the elimination of effete or 
 deleterious matter from the system The continued use of 
 calomel, and constant purgation by it, may be beneficial to 
 one patient, by removing large quantities of unhealthy secre- 
 tions, but may unnecessarily exhaust the strength of another, 
 and tend very greatly to impede recovery. So, in regard to 
 every remedy which has been proposed: what is useful at 
 one time may prove useless, or positively injurious, at an- 
 other. Special attention has also been drawn to the fact by 
 the mini-water treatment of Sir William Gull and Dr. Sut- 
 ton, " that rapid recoveries were often made when the only 
 treatment was good nursing ;" that symptoms subside wholly 
 irrespective of treatment between eight and ten days. The 
 average duration of acute symptoms under treatment was 9.1 
 days; or from the beginning of the disease 17 days. With 
 regard to heart complication it is affected early in the dis- 
 ease — generally within the first week; and if it escaped for 
 a week it would probably escape altogether. Sir William 
 Gull and Dr. Sutton thus came to the conclusion that drugs 
 had little influence in shortening the disease; and many 
 drugs have had the credit of warding off heart complications 
 simply because the time for the occurrence of these lesions 
 had passed before the medicine was given. 
 
 To learn how to adapt our present remedies to the exigen- 
 cies of each particular case is what is now most of all 
 required. Acute rheumatism is manifestly a highly inflam- 
 matory disease, but of a peculiar constitutional origin, as has 
 been fully shown. The blood drawn presents a more copious 
 layer of buff " than it does in most other diseases. The 
 
332 RHEUMATISM ACUTE. 
 
 proportion of fibrine being greatly increased, we can hardly 
 feel surprised that bleeding has been largely had recourse 
 to. But although bleeding has been extensively adopted, 
 the profession has hitherto been much divided as to the ad- 
 vantage derived from the practice. A careful analysis of 
 conflicting evidence leads to the conclusion that general 
 blood-letting is not to be recommended, and on pathological 
 grounds it is not justifiable. No advantage is gained as to 
 time ; but temporary, if any abatement of sufferings follows 
 its use; lastly, this mode of treatment appears to have caused 
 in the practice of Bouillaud an unusually large number of 
 cases of myocarditis — a larger number, indeed, than has been 
 witnessed by any other person in the profession. A predis- 
 position to cardiac inflammation is doubtless engendered by 
 copious *and repeated blood-letting: one-half the cases of 
 acute rheumatism became so complicated after treatment by 
 bleeding (Dickinson). It undoubtedly increases the irrita- 
 bility of the heart, and consequently favors the production 
 of cardiac complication. General blood-letting is only bene- 
 ficial in first attacks occurring in young, robust, and other- 
 wise healthy persons, particularly in those cases which are 
 marked by unusual severity of their symptoms, or are unac- 
 companied by free perspiration. It ought at all times to be 
 cautiously employed and carried to a small extent only — viz., 
 from eight to twelve ounces, according to the age and 
 strength of the patient, the object being to favor the action 
 of other remedies, and to promote free secretion by its use, 
 rather than to arrest or cut short the disease (Latham, Fuller). 
 If, therefore, perspiration is free, and remedies are absorbed, 
 blood-letting is not to be thought of. In mild cases it is 
 unnecessary; in the delicate, and those of weakly constitu- 
 tion, it is inadmissible ; and in the well-expressed rheumatic 
 diathesis, or when the disease is distinctly ascertained to be 
 hereditary, it utterly fails in modifying the morbid action, 
 is ill-borne by the system, and therefore should only be prac- 
 ticed under the extremely urgent and specific conditions 
 just mentioned (Willan, Fordyce, Alison, Todd, Watson, 
 Fuller, Dickinson). If circumstances, therefore, ever war- 
 rant its employment, it ought necessarily to take the lead of 
 all other measures, and may be used in the young, plethoric, 
 and robust, in whom secretion is insufficient, whose pulse is 
 full and bounding, and whose skin is dry, hot, and burning. 
 A single bleeding is sufficient to relieve the excessive con- 
 gestion, on which the want of secretion in a great measure 
 
RHEUMATISM, ACUTE. 333 
 
 depends, and which forms an obstacle to the action of those 
 remedies on which we rely for effecting a cure. Active pur- 
 gation is also to be avoided. It is injurious for three reasons: 
 First, Because it is not necessary to the cure of the patient, 
 and, like bleeding* tends greatly to reduce his strength and 
 protract recovery. Second, Because, from the nature of the 
 complaint, the patient is quite incapable of moving, and his 
 sufferings are aggravated, his irritability is increased, and his 
 heart's action accelerated, by the repeated shifting of his 
 position, which is rendered necessary by the calls of nature. 
 And, Third, Because it necessarily gives rise to more or less 
 exposure, which must be prejudicial to a person bathed in 
 perspiration (Fuller). After having obtained one full dejec- 
 tion by the following searching combination,which will secure 
 an abundant flow from the glandular follicles of the intestinal 
 mucous membrane, the subsequent aim should be to obtain 
 merely a single free evacuation every morning. 
 
 J£ Calomel, gr v.; Pulv. Jalap. Co., 3ij. -3i. ; Pulv. 
 Zingiberis, gr. iii.-gr. v. ; misce — to be taken in a little 
 milk. 
 
 A daily evacuation of the bowels is then to be maintained 
 by mild salines, such as the potassio-tartrate of soda, sulphate 
 and carbonate of magnesia, taken as a draught in the morn- 
 ing ; and preceded every second night by a Plummer's pill 
 at bedtime, combined or not, according to circumstances, 
 with a full dose of opium ; or, a grain of the watery extract 
 of Barbadoes aloes may be found sufficient on alternate days. 
 If the bowels act only once a day, a laxative do^e of calomel 
 and opium may now and again be prescribed, with the view 
 of modifying the character oi the intestinal secretions. Dark- 
 colored and offensive stools indicate the necessity for the 
 dose, followed by a draught of infusion of senna, together 
 with half an ounce i)( the potassio-tartrate of soda, and twenty 
 minims of the vinum colchici ; and these should be repeated 
 every evening and morning till healthier evacuations are ob- 
 tained — /. c. y till the motions are light-colored, more bilious, 
 and less offensive. Opium may be given with the greatest 
 advantage in the early and most painful stage of the disease 
 Occurring in adults, to the extent of six or eight grains of 
 the powder in twenty-four hours, or two grains of the extract 
 of opium may be given every night ; to children, half-grain 
 doses of the powder, or less, according to age, may be given 
 every three or four hours. The bowels require to be kept 
 open during its use ; and its influence requires to be closely 
 
334 RHEUMATISM, ACUTE. 
 
 watched. If the urine increases in quantity, if the motions 
 become more healthy in appearance, and the coated tongue 
 cleaner and less red, the influence of opium is beneficial. It 
 encourages sweating. Hydrate of chloral is another valuable 
 soporific and sedative. Colchicum administered alone is a 
 dangerous agent ; but its virtue as a remedy may be obtained 
 in small doses in combination with other medicines. It may 
 be given with small doses of ipecacuanha, alkalies, and opium. 
 It promotes evacuation by the kidneys. It is only in some 
 cases, however, that it appears to be of service. It is far less 
 efficacious in the weak and nervous than in the more robust 
 and less easily depressed, and of less value in purely fibrous 
 rheumatism than in cases where the synovial inflamma- 
 tion predominates. It has proved less advantageous in pro- 
 portion «.s the fever has exceeded the articular swelling, and 
 as the urine has been less highly charged with lithates. The 
 operation of this remedy must under all circumstances be most 
 carefully watched ; and a daily evacuation from the bowels 
 must be secured during its use If the lithates disappear 
 from the urine, if the pulse becomes weak, if faintness, nausea, 
 or purging supervene, the colchicum must be at once dis- 
 continued; but till some one of these symptoms occurs, a 
 grain or a grain and a half of the acetous extract or the 
 inspissated juice, or from fifteen to twenty grains of the 
 wine of colchicum, may be safely and with advantage admin- 
 istered two or three times a day (Dr. Fuller). 
 
 Veratria is to be used in small doses The ordinary for- 
 mula recommended is: 
 
 Veratria and extract of opium, one grain each, to be di- 
 vided into ten pills, of which two pills are to be given the 
 first day, three the second, four the third, five the fourth, 
 and so on, increasing one pill each day, until the condition 
 of the pulse or the irritation of the mucous membrane com- 
 pels a diminution. 
 
 The beneficial effects of guaiacum are obtained in those 
 cases which are unaccompanied by perspiration, and in 
 which the excretory organs are gently excited by the action 
 of the remedy; but when the patient is perspiring freely, and 
 when it neither purges nor causes diuresis, very little benefit 
 is obtained from its use. Combined with bitartrate of po- 
 tass, sulphur, and rhubarb, it constitutes the chief ingredient 
 in a celebrated empirical formula, well known to army med- 
 ical officers under the name of " Chelsea Pensioner," which 
 has obtained a high reputation amongst old soldiers as a 
 
RHEUMATISM, ACUTE. 335 
 
 remedy for the "pains, ' or chronic rheumatism. In some 
 large hospitals, both civil and military, this remedy is in 
 common use in the treatment of old chronic cases. Its com- 
 position is as follows: 
 
 IJ. Pulv. Guaiaci, 3 i.; Pulv. Rhei, 3 ii. ; Bitart. Potassae; 
 Sulphur Sublim., a a 3i.; Pulveris Nucis Moschatae, |iL; 
 Mel. vel Glycerina, lbi.; misce bene. Of this compound two 
 large spoonfuls may be taken night and morning. 
 
 Another formula is the following: 
 
 I£. Pulv. Sinapis; Sulph. Sublim., a a 3 iii. ; Pulv. 
 Guaiac. 3 iss. ; Pulv. Rhei, PoUis. Nitratis, a a gr. xlv.; 
 misce bene. Honey, treacle, or glycerine, sufficient to make 
 the dose into an electuary, is the most convenient form for 
 use, of which a teaspoonful every alternate evening is use- 
 ful; or a teaspoonful of the powder may be mixed with 
 milk, and so taken at bedtime. 
 
 But, the general treatment ot the constitutional disease 
 originally recommended by Brocklesby ( 1764), and followed 
 successfully by Macbride '1772), Basham, Fuller, Furnival, 
 Garrod, and now by many other physicians, is that by alka- 
 lies and the neutral salts, with colchicum, a little antimony 
 being sometimes added, with the occasional aid of calomel, 
 used only as a remedy to promote evacuation from the 
 glands of the intestinal mucous membrane. Alkalies, and 
 the neutral salts, may be given in combination with colchi- 
 cum, full doses of opium, and a little antimony. They aid 
 disintegration, and increase the elimination of sulphuric acid 
 by augmenting the alkaline condition of the blood (Parkes). 
 The alkalies ought to be given largely. Patients lose their 
 pains under their influence, and proceed rapidly to conva- 
 lescence. The pulse is generally tranquillized within forty- 
 eight hours from the commencement of the alkaline treat- 
 ment; and if in twenty-four hours the pain is lulled and the 
 local inflammation greatly subdued, the constitution is evi- 
 dently coming under the influence of the remedy. The du- 
 ration of rheumatic fever is undoubtedly shortened by alka- 
 lies: — 6 to 7 days, as compared with 9.1 days of mint-water 
 cure, and the total duration 13 to 14 instead of 17 (Garrod . 
 The form in which the remedy is to be given is 
 that of a simple saline or nitrate draught, to 
 which from two to three drachms of the potas- 
 sio-tartrate of soda may be added, with ten to fifteen minims 
 of the vinum colchici, from fifteen to twenty minims of the 
 vinum antimonii, and from ten to fifteen minims of the tine- 
 
33^ RHEUMATISM, ACUTE 
 
 ture of opium, or of Battley's sedative solution, to prevent 
 the salt running off by the bowels. This draught is to be 
 repeated for the first twelve or twenty-four hours, at inter- 
 vals of three or four hours, according to the strength of the 
 patient and the severity of the attack; and if pain is exces- 
 sive, a pill containing half a grain to a grain and a half of 
 opium, or an equivalent dose of Dover's powder, may be 
 given once or twice daily. In the use of these remedies, 
 constipation and narcotism are to be avoided on the one 
 hand, and diarrhoea to be guarded against on the other 
 (Fuller). If the saline treatment is to be used alone, then 
 a solution of nitrate, acetate, and bicarbonate of potash 
 should be given in such doses that ten or twelve drachms of 
 the two latter salts together are taken in the twenty-four 
 hours. • Half a drachm of the acetate, with a drachm or a 
 drachm and a half of the bicarbonate, and ten grains of 
 nitre, dissolved in an ounce and a half of water and sugar, 
 or lemonade, or barley water, and given every two hours, 
 night and day, until the joint affection and pains have be- 
 gun to yield in severity, are sufficient for this purpose. Or 
 the following: Nitrate of potash, one drachm; acetate of 
 potash, three drachms; water or barley water, eight ounces; 
 — of this mixture one ounce for a dose ought to be repeated 
 every two, three, or four hours, according to the urgency of 
 the symptoms; or from twenty to sixty grains of the bicar- 
 bonate of soda, or of potash, may be given every three or 
 four hours in half a bottle of soda or seltzer water; or in an 
 effervescent citrate of ammonia, or potash draught (Tanner). 
 This is the treatment which most of all seems efficient in 
 warding off the cardiac complications; and Dr. J. J. Furni- 
 val was the first (after Prout) to direct the attention of the 
 profession to the use of alkaline remedies (carbonas potassse) 
 in the treatment of Rheumatism, and especially as a pre- 
 ventive of the cardiac complication {Lancet, 1841, p. 305). 
 The good effects of such treatment as a preventive of the 
 cardiac affections have been since fully demonstrated by 
 Fuller, Garrod, Basham, Goodfellow, and others. Dr. Dick- 
 inson has given statistics in which the percentage of heart 
 disease occurring under the alkaline treatment was 2.1 as 
 against 31.7 under various other remedies. To be effective, 
 the remedy must be carried out with energy and persever- 
 ance, till the articular and febrile disturbance are lessened, 
 and till an alkaline condition of the urine is established as 
 soon as possible. Liquor potassae in 3 ss. doses may also 
 

 RHEUMATISM, ACUTE. 357 
 
 be given to the extent of 3 iii- to 3 vi. in twenty-four 
 hours (Parkes). Brocklesby is the earliest authority for 
 the use of large doses of nitre in the treatment of acute 
 rheumatism. He enjoined, for a diluting drink, water- 
 gruel boiled smooth, in each quart of which he dissolved 
 two drachms of nitre, with or without sugar. He often thus 
 prevailed on soldiers to take ten drachms or more of nitre in 
 twenty-four hours. Dr. Garrod speaks well of the combina- 
 tion of quinine with the alkaline treatment after ten years' 
 trial. It is simply following out the treatment by bark (un- 
 practical, from the large doses required) recommended by 
 Fothergill, Morton, and Haygarth. Five to ten grains of 
 sulphate of quinine are to be given two or three times a day. 
 The alkaline and saline treatment of rheumatism as the basis 
 of operation seems the most rational ; for it has been demon- 
 strated that in cases of acute rheumatism there is an abso- 
 lute deficiency of the saline ingredients of the blood ; and 
 while there is also a liability to fibrinous exudation, the ten- 
 dency of saline remedies is to suspend the separation of fi- 
 brine (Stevens). The treatment which has saline remedies 
 for its basis thus contributes to restore the balance of the sa- 
 line ingredients in the blood, and controls the tendency to 
 fibrinous deposition. The progress of inflammatory action 
 being thus retarded, time is gained for other remedies to ef- 
 fect the diminution of the excess of fibrine present in the 
 blood, as well as the destruction of the rheumatic element, 
 whatever that may be. On the other hand, however, the pa- 
 tient is often left weak and anaemic to a marked degree by 
 the use of alkalies ; and also, that when heart complications 
 do come on under alkalies they are more troublesome, the 
 effusion of pericarditis is often very large in amount, and 
 there is a greater tendency to carditis. Thus alkalies, while 
 they shorten the disease, do not always prevent complications, 
 and they debilitate the patient. Cases treated by alkaline 
 instead of neutral salt are also slow in convalescence, the 
 patients being weak and pallid for some time afterwards. 
 The experience of Dr. Reginald Southey is also against the 
 alkaline treatment, especially in the relapsing cases. The 
 alkaline treatment or mint-water is, however, equally well 
 adapted for the acute continued form ; but alkalies, unless 
 pushed to full and frequent doses, are wholly useless in re- 
 lieving pain ; and in such large doses as half a drachm or a 
 drachm every two or three hours, they quickly reduce the 
 strength, and render the patient extremely anaemic. They 
 22 
 
$$8 RHEUMATISM, ACUTE. 
 
 thus retard convalescence not inconsiderably. ^Bartholo- 
 mew's Hospital Report). 
 
 In 1869, Dr. Russell Reynolds reported, in the Brit. Med. 
 Jonr7i., cases of rheumatic fever treated by the tincture of 
 the perchloride of iron, in doses varying from 15 minims to 
 a drachm every four hours, with or without 20 to 30 minims 
 of glycerine, and spirits of chloroform. In Brit. Med.. Journ., 
 of Oct. 2, 1875, he again gave a summary of results in a 
 series of sixty-five cases, in which the relief of pain was often 
 marked and early. In more than half the cases the pain was 
 gone by the tenth day ; in 22 per cent, all pain had gone by 
 the fifth day. The pulse sometimes fell from 120 to 40 in 
 two days ; and, in several cases, Dr. Reynolds observed a 
 remarkable diminution in the frequency of the pulse, at and 
 after trie time at which temperature had become normal, 
 namely — 40, 30, and even 28 ; but regular in rhythm and in 
 force, the patient feeling neither pain nor faintness. The 
 temperature became normal by the fifth day in 36 percent. ; 
 and in severe cases before the tenth day in 50 per cent. ; in 
 moderate and slight cases in 7 1 per cent. Heart disease was 
 present in 48.1 per cent.; but no distinction is made between 
 those cases in which it existed before, and those in which it 
 came on under treatment. In twenty-three cases treated 
 with iron in University College Hospital in 1875, the heart 
 was affected in 30.4 per cent. — a large proportion when com- 
 pared with those cases of Dr. Dickinson's treated by alka- 
 lies, where the percentage was only 2.1. As to duration of 
 the cases also, the cases treated by iron do not compare fa- 
 vorably with those treated by alkalies by Dr. Garrod, where 
 the average duration of the whole number of cases was six 
 to seven days. Dr. Samuel S. Dyer of Ringwood has also 
 given the treatment by the tincture of perchloride of iron an 
 extended trial, and writes as to the satisfactory nature of the 
 result (Brit. Med. Journ., May 6, 1876, p. 563). Quinine 
 has been largely used in France — in large doses — from 15 to 
 90 grains in the twenty-four hours. The pulse and temper- 
 ature rapidly fell ; the joints were quickly relieved ; and the 
 heart was seldom implicated. Combined with the alkaline 
 treatment Dr. Garrod has found quinine more efficacious 
 than either alone — there being less tendency to relapse ; and 
 the fever leaves the patient in a much more satisfactory con- 
 dition. Salicine, salicylic acid, and salicylate of soda have 
 all been recently and largely used in the treatment of acute 
 rheumatism ; given in doses of gr. x. to gr. xx. at intervals 
 
RHEUMATISM, ACUTE. 339 
 
 of from one to tnree hours, and in larger doses ot gr. xxx. 
 every hour. Under all of these remedies the average dura- 
 tion of the fever has been remarkably shortened — to 4.9 days 
 under salicine, and 4. 1 days under the acid — an advantage 
 of from one to three days over the results of the alkaline 
 treatment , and in comparison with the tincture of iron 
 treatment, in which the temperature became normal in half 
 the cases in ten days, under salicylic acid it became normal 
 in half the cases in three days. The duration of rheumatic 
 fever has, therefore, been shorter under these remedies than 
 it has been under any other plan of treatment. But there 
 is no evidence that either of these are specific remedies, for 
 they do not cut short the disease ; nor prevent relapses when 
 under their influence ; nor do they ward off complications. 
 They seem rather to act by reducing temperature as they do 
 in other febrile conditions, and they lessen the chance of 
 complications in the same proportion as they shorten the 
 disease (Dr. Markham Skerritt). The observations of Fur- 
 bringer, Reiss, Fischer, Strieker, and others have established 
 the fact that these remedies possess a remarkable power of 
 lowering the abnormally high temperatures in febrile dis- 
 eases. In Dr. Strieker's experience of the drugs in acute 
 rheumatism, salicylic acid may be given in hourly doses of 
 from grains vii. to xv. without injury to the human system ; 
 and for a longer time to young and vigorous subjects than 
 to the old and feeble, as toxic symptoms appear sooner in 
 the latter than in the former. These toxic symptoms are of 
 various degrees — such as, noises in the ears, difficulty of 
 hearing, and perspiration, which, when they appear, con- 
 traindicate the further use of the remedy. 
 
 "In an interesting paper in the Lancet of 4th and nth of 
 March, by Dr. T. Maclagan, recently of Dundee, on the 
 treatment of acute rheumatism by salicine, the author relates 
 seven cases of acute and subacute, and one of chronic rheu- 
 matism, treated with this remedy, and gives the following 
 conclusions as the result of his experience: — (1.) We have 
 in salicine a valuable remedy in the treatment of acute rheu- 
 matism. (2.) The more acute the case, the more marked 
 the benefit produced. (3.) In acute, cases, its beneficial ac- 
 tion is generally apparent within twenty-four, always within 
 forty-eight, hours of its administration in sufficient dose. (4.) 
 Given thus at the commencement of the attack, it seems 
 sometimes to arrest the course of the malady as effectively 
 a-s quinine cures an ague, or ipecacuanha a dysentery. (5.) 
 
34o 
 
 The relief of pain is always one ot the earliest effects pro- 
 duced. (6.) In acute cases, relief of pain and a fall of tem- 
 perature generally occur simultaneously. (7.) In subacute 
 cases, the pain is sometimes decidedly relieved before the 
 temperature begins to fall ; this is especially the case when, 
 as is frequently observed in those of nervous temperament, 
 the pain is proportionally greater than the abnormal rise of 
 temperature. (8.) In chronic rheumatism, salicine some- 
 times does good where other remedies fail ; but it also some- 
 times fails where others do good. These conclusions, it will 
 be seen, agree closely with those arrived at by Strieker and 
 Reiss with regard to salicylic acid. The dose of salicine 
 used by Dr. Maclagan was from ten to thirty grains every two 
 three, or four hours ; fifteen grains being an average dose." 
 
 As* to salicylate of soda, Dr. R. Southey gives fifteen 
 grain doses every two hours till sixty grains are taken, and 
 then continues with fifteen grain doses every four hours, to 
 keep up the effect of the drug ; and if pericarditis is present 
 he adds five drops of lio opii. sedativ. with each dose. His 
 experience of the perchloride of iron, as recommended by 
 Dr. R. Reynolds, is not favorable. In the acute continued 
 cases it has been associated too frequently with hyperpy- 
 rexia to regard it as altogether free from danger ; and in the 
 relapsing forms, its administration neither shortened the cases 
 nor prevented relapses. These relapsing cases of rheuma- 
 tism may be kept on salicylate of soda very well for the first 
 seven days ; but the opportunity of the spontaneous remis- 
 sion which then generally takes place, and is indicated by the 
 thermometer and the patient's own sensations, should be 
 seized to shake the periodicity of the complaint. This qui- 
 nine has the power of doing, given in the proper doses, as in 
 ague, and at the proper date. Dr. Southey gives two ten- 
 grain doses at two hours' interval, between five and seven 
 p. m., on the evening of the seventh day, and repeats the dose 
 on the evening of the ninth day again. The natural relapse 
 is then postponed, and the patient may be permitted better 
 nourishment, and given a little pepsine and acid with his din- 
 ner to ensure its better digestion. Should no relapse happen, 
 again on the fourteenth and sixteenth days full doses of qui- 
 nine should be given ; but it is not till the thirty-second day 
 is past that all risk of a relapse is over. During convales- 
 cence, although the patients are anaemic, Dr. Southey does not 
 recommend iron, as the mineral acids and tincture of nux 
 vomica promote appetite and digestion far better. Quinine 
 

 RHEUMATISM, ACUTE. 34I 
 
 and iodide of potassium has long been a favorite draught 
 of his in treating the anaemic relapsing forms. Two grains 
 of quinine are combined in it with five of iodide of potas- 
 sium, to be taken every four or six hours after the fourteenth 
 day (St. Bartholomew's Hospital Report, Vol. XIV., 1878, p. 
 22). Hyperpyrexia may occur suddenly and rapidly in acute 
 rheumatism, as in other diseases. The temperature may 
 rapidly rise to a height incompatible with life, with evidence 
 of profound nervous disturbance ; and usually by the dis- 
 appearance of pain from the joints. Such hyperpyrexyia 
 has supervened under all sorts of treatment. The ex- 
 tremest vigilance on every one entrusted with the care 
 of the patient must be inculcated ; and on the appear- 
 ance of anything strange in the aspect or demeanor, to 
 use the thermometer assiduously ; and, if ever it rose to 105 
 Fahr., to send at once for the physician (Dr. H. Thomson). 
 Treatment directed simply to the reduction of temperature 
 may save the life of the patient. A temperature in rheu- 
 matic fever above 106.5 Fahr. lias hitherto been invariably 
 fatal ; spontaneous recovery has never been known to occui 
 when the temperature has passed 106.5 ° Fahr. ; but death 
 has occurred before this temperature has been reached — at 
 105. 8° and 106 . Hence the commencement of active treat- 
 ment by the cold bath ought not to be delayed when such a 
 temperature has been reached. If left alone, the patient 
 must die ; and the only treatment which has succeeded with 
 such cases has been the effectual external application of cold, 
 by the bath, at a temperature of 90 or 95 ° Fahr. in the first 
 instance ; gradually reduced by the addition of cold water 
 to 70 Fahr., or even lower in some cases. As far as the bath 
 is concerned we must take the thermometer for our guide. 
 
 " It is important to remember that the bath should be pre- 
 pared and everything got ready before this ; for the final 
 rise of temperature is often very rapid — 5.5 in an hour and 
 a quarter — from 104 to 109.5 °, and the patient may die be- 
 fore the treatment can be applied There is another practi- 
 cal point to be borne in mind — that there is almost always a 
 considerable fall of temperature after the patient is removed 
 from the bath, so that it is not cafe to bring the tempjrature 
 down to the normal in the bath. I remember, in the early 
 days of this treatment, how a friend of mine reduced the 
 temperature of a rheumatic patient to normal in the bath, 
 and, to his consternation, found it would not stop there, but 
 kept going down till it reached 93. 2 ; there it was fortunately 
 
342 RHEUMATISM, ACUTE, 
 
 brought to a stand. The amount of this subsequent fall 
 varies, but the average may probably be safely taken as 4 . 
 In accordance with this, I removed the patient from the bath 
 when the temperature was 102 °, and the subsequent fall, oc- 
 curring in the next ten minutes, was exactly 4 , bringing the 
 temperature down to 98 " (Dr. Markham SkerritO. 
 
 So singularly calming is the bath, even when there is no 
 great exaltation of the body heat, that it may be administered 
 as a simple palliative in all exacerbations of delirium and 
 restlessness, although the heat may have fallen far below its 
 maximum intensity, even to 102 Fahr. 
 
 External topical applications are efficient aids in treatment. 
 Warm anodyne fomentations are always employed with ad- 
 vantage ; and of all applications a mixed alkaline and opiate 
 solutiori, applied as a fomentation, is the most powerful in 
 allaying pain. The solution so highly recommended by the 
 late Dr. Fuller for this purpose, is composed of an ounce of 
 the carbonate of potash dissolved in a pint of the decoction 
 of poppies or of rose water, to which six drachms of Bat- 
 tley's solution (Liquor sedativus) is added, or common tinc- 
 ture of opium, which is less expensive and equally efficient 
 as an external application, but less strong. Chloroform and 
 belladonna liniment (as recommended by the late Dr. Sibson) 
 is an excellent pain-relieving local application in either the 
 acute or relapsing form of the disease. If the hands, elbows, 
 knees, or feet are the seat of inflammation, gloves or caps 
 are made of the spongiopiline to fit these parts ; if a greater 
 extent of surface be involved, a portion of the spongiopiline 
 is cut large enough to envelop the entire surface. The spongy 
 surface of this epithem is first moistened freely with water, 
 and any superabundant fluid squeezed from it, so that the 
 linen or bed of the patient may not be unnecessarily wetted. 
 Nitrate of potash, or the salt to be employed, in powder, is 
 then freely and plentifully sprinkled over the moistened sur- 
 face, or rubbed in, to secure its solution and the thorough 
 impregnation of the epithem ; it is then applied to the in- 
 flamed part, and lightly secured by a roller. Nothing fur- 
 ther is required than once in about six hours to remoisten 
 the spongy surface ; fresh addition of nitre is never required, 
 if sufficient quantity has been used in the first instance. The 
 salt in powder is hence better than a saturated solution, 
 which nurses seldom succeed in making (Basham, Med.-Chir. 
 Trans., Vol. XXXII., p. 10). Alkaline baths are recom- 
 mended by Dr. Austin Flint. Two pounds of the bicar- 
 
RHEUMATISM. \CUTE 343 
 
 bonate of potass and one pound of the nitrate of potass are 
 to be dissolved in water, at a temperature of ioo° or 99 
 Fahr. ; and the patient ought to go into the bath at a tem- 
 perature of 98 or 98.5 ° Fahr., and remain for not longer than 
 ten minutes. A tepid bath at 98 or 96 Fahr., into which 
 the patient can be dipped suspended on a sheet, and lifted 
 similarly back to bed, comforts them and secures their 
 cleanliness (Dr. R. Southey). Hot air, or vapor baths, differ- 
 ent forms of cold bath, the hot blanket pack bath (as ad- 
 vocated by Dr. T. S. Dow, see in Brit. Med. Jouni., 1875, 
 p. 40), or sponging the skin with cold or tepid water, are 
 each in turn methods of treatment which have given relief ; 
 but baths ought never to be employed if the skin is acting 
 freely ; only if it is hot, dry, and burning, its action may be 
 successfully stimulated by means of some of these baths. 
 
 In contradistinction to the principle of cure now laid down, 
 and which has been called the method of neutralization. Dr. 
 Herbert Davies, Physician to the London Hospital, has re- 
 cently advocated a method by elimination, originally recom- 
 mended by Dr. Dechilly, of Vancouleurs, in France, in a 
 Memoir to the Academy of Medicine, in 1850 Bui. Je 
 l Acad, de Med., t. xv.), as a safe and rapid mode of combat- 
 ing rheumatic fever. For this purpose his treatment is ab- 
 solutely and entirely local, and consists of free blistering 
 only. Believing that the virus localizes itself for a time in 
 the inflamed joints and that the intensity of the local in- 
 flammation is a measure of the amount of virus collected, he 
 orders blisters varying in width, but of considerable size, 
 according to the locality, to be applied round each limb, and 
 in close proximity to the parts inflamed, 'rims he affords, 
 through the serous discharge from the blistered surface, a 
 ready means of exit for the virus. The blisters are to be 
 applied near to, but not upon every joint inflamed, at the 
 very height of the inflammatory stage, even when the local 
 pains are the most severe, and the constitutional disturbance 
 the greatest. Dr. Dechilly enveloped the whole joint in a 
 large blister, followed by others, according as joints became 
 affected. Dr. Jeaffreson, of St. Bartholomew's, and Dr. 
 Greenalgh, of the Middlesex Hospital, report favorably as to 
 the results of Dr. Davies' method of treatment of acute 
 articular rheumatism. So also does Dr. Thomas B. Peacock, 
 of St. Thomas' Hospital {Brit. Med. Joiirn., Jan. 18, 1873). 
 It has been tried in France also, and reported on favorably 
 by Dr. Laseque, of the Necker Hospital in Paris {Arch. Gen. 
 
344 RHEUMATISM, ACUTE. 
 
 de Med., Nov., 1865). The success of the plan is said to de- 
 pend entirely upon the blisters being applied and allowed to 
 remain until they have thoroughly acted. Linseed-meal 
 poultices subsequently applied will be found highly service- 
 able in promoting a sufficient flow of serum. The blisters 
 should be put entirely round the affected limb ; and when 
 the knees are the joints which suffer, the blisters should be 
 cut at least three inches wide. If this method of treatment 
 be adopted, no medicine ought to be given beyond an occa- 
 sional purge, and no advantage results from combining the 
 alkaline or neutralization system of treatment with that by 
 blisters, or the method by local elimination. If the two 
 methods are combined, the period of convalescence is pro- 
 tracted. In some few cases, however, Dr. Peacock is of 
 opinion* that constitutional treatment ought to be freely used 
 in combination with the blistering. In other cases it is of 
 advantage to combine the blister treatment with such tonics 
 as quinine and iron. In the practice of Dr. R. Southey, of 
 St. Bartholomew's, London, painting the affected parts in the 
 acute continued form with a mixture of equal parts of liniment 
 of iodine and tincture of iodine has appeared to procure all 
 the benefit advocated by Dr. Davies for his blister treatment. 
 That the poison is really thrown out by the blister method 
 of treatment is deduced as well from the rapid and perma- 
 nent relief resulting from the local treatment as from the 
 neutral and even alkaline condition of the urine, which is a 
 usual and early result of the treatment, as well as a rapid 
 diminution in the force and frequency of the pulse {London 
 Hospital Clinical Reports). 
 
 The diet of the patient, in acute rheumatism, should be 
 strictly limited to slops, such as arrow-root, beef-tea (Liebig's 
 Extract of Flesh), milk and lime-water, or milk made warm, 
 to which a little carbonate of soda, nitrate of potash, or bi- 
 carbonate of potash is added ; light puddings, to which 
 sherry or brandy may be added, if depression exist ; and 
 even in many chronic cases it is desirable to limit the diet to 
 puddings and white fish. To obviate the great drain upon 
 the system, it is necessary, however, that the rheumatic pa- 
 tient be better fed than in cases of idiopathic inflammation. 
 Beef-tea and jellies may be given, and strong coffee might 
 also be administered frequently, on the same principle that 
 it has been given in typhus fever by Dr. Parkes, following up 
 the indications obtained from the physiological action of 
 that beverage as expounded by Lehmann. 
 
RHEUMATIC ARTHRITIS RICKETS. 345 
 
 The nature and treatment of the local complication, such 
 as pericarditis, will be considered separately; but in addi- 
 tion to the alkaline remedies, which have an undoubted influ- 
 ence in shortening the duration of the illness, the bedding in 
 blankets, is a most important measure for preventing the 
 cardiac affection, especially in cold weather and in cold 
 climates. 
 
 Rheumatic Arthritis — See Osteo- Arthritis, Chronic. 
 
 Rheumatism, Chronic. — Definition. — Chronic pain, 
 stiffness, and swelling of various joints. 
 
 The Treatment of chronic rheumatism does not differ in its 
 general details from that of acute rheumatism. Decoction 
 of cinchona, preparations of guaiacum, with alkalies and col- 
 chicum, are the best remedies after the action of such search- 
 ing evacuants as calomel and jalap have removed morbid 
 accumulations, and improved intestinal secretions. The va- 
 rious forms of the so-called " Chelsea Pensioner," compris- 
 ing guaiacum and sulphur, the composition of which is given 
 under " Rheumatism, Acute," are of great service. Iodide 
 of potassium is also of great benefit in the arthritic forms of 
 chronic rheumatism, combined or not with preparations of 
 aconite and colchicum. Warmth of flannel and the warmth 
 of bed, with free perspiration, generally tends to mitigate and 
 shorted the severity of the paroxysms of chronic rheumatism. 
 
 Rheumatism, GoilOrrhceal — See Gonorrheal Rheuma- 
 tism. 
 
 Rheumatism, Muscular — See Muscular Rheumatism, 
 Rickets. — Definition — A constitutional disease of early 
 childhood, characterized by a cachexia which precedes for 
 several weeks or months a peculiar lesion of the osseous sys- 
 tem, manifested by curvature of the shafts of the long bones 
 and enlargement of their cancellous extremities. The growth 
 of the bones is characterized by irregularity, by non-solidifi- 
 tion of their growing layers, and by the progressive forma- 
 tion of medullary cavities in the old bone, thus rendering 
 the body laminae thin and brittle (Virchow). Some of the 
 solid visceral organs also exhibit peculiar lesions, such as in 
 the spleen and liver, where there is generally lardaceous dis- 
 ease. 
 
 Treatment. — Ventilation of the room in which the child 
 lives is of first importance. Milk diluted with lime-water 
 (about a fourth part), and a teaspoonful of cream added, is 
 the best of food, or the Swiss preserved milk. Sugar ought 
 
34& RINGWORM — SCABIES. 
 
 not to be added to the milk. Liebig's Food for Children, 
 or Valentin's flesh juice, " Maltine," Parrish's Chemical 
 Food, and Trommer's Extract of Malt, are all valuable 
 agents in the dietary. About once a week a dose of rhu- 
 barb, soda, and calumba, in equal parts, should be given, 
 followed next day by a teaspoonful or more of castor-oil. 
 Prepared chalk and soda may also be given twice or thrice 
 a day, with or without rhubarb and calumba (see under 
 treatment of Scrofula). When the febrile disturbance is 
 subdued, the child should live as much as possible in the 
 open air. Vinum ferri ought then to be given in the follow- 
 ing formula? Ijk. Vin. ferri f 3 i. 3 ii- ; quiniae sulph., gr. i.^ 
 acid sulph. dil. m i.-ii. This form is especially useful when 
 the skin is flabby, covered with perspiration, and anaemia 
 well marked. Or small doses of the syrup of the phosphates 
 of iron, quinine, and strychnia, or syrup of the phosphate of 
 iron and lime, may be given along with the food, or just be- 
 fore meals. Cod-liver oil is of essential service; but the 
 stools ought to be examined daily; and if any of the oil 
 passes by stool its dose ought to be diminished, or its ad- 
 ministration suspended for a time. (Sir William Jenner, 
 The Medical Times of i860, Vol. I). 
 
 Ringworm — See Tinea Tonsurans. 
 
 Rotheln — See Measles* German, 
 
 Rubeola — See Measles. 
 
 Saturnism — See Lead Palsy. 
 
 ScaMes. — Definition. — Lesions consisting of an eruption 
 of distinct slightly acuminated papules or vesicles, accom- 
 panied with constant itching, due to the irritation caused by 
 the burrowing underneath the epidermis of a female Acarus 
 (" Sarcoptes scabei "), for the purpose of depositing hei 
 eggs. 
 
 Treatment. — Such applications are to be made to the skin 
 that, while tending to kill the Acari, they will not increase 
 the irritation of the dermis; and if the Acari are thus de- 
 stroyed, the eruptions will in general subside in due course. 
 If much irritation of the skin prevails, warm baths are to be 
 prescribed, and opium may be given internally. In healthy 
 adults the whole body of the patient ought first of all to be 
 thoroughly scrubbed over with good black (soft) soap, and 
 the process continued for at least half an hour. The patient 
 
scabies. 347 
 
 should then get into a warm bath, in which he should re- 
 main for another half hour. Having thus washed and dried 
 himself thoroughly, he is to rub himself over with the fol- 
 lowing ointment: 
 
 $. Subcarbonatis Potassrc, 3i.; Sulphuris, 3 ii- ; Axun- 
 giae, § xii. ; misce. 
 
 Next morning a warm bath is to be taken to clean the 
 surface of the body from the remains of the anointing of the 
 previous night. The cure ought now to be complete, so far 
 as the destruction of the Acari is concerned (Hardy, Hel- 
 merich, Anderson). The genuine pomade of Helmerich is 
 one-third stronger than that which has been just quoted 
 from Dr. Anderson. The potash in the black soap and oint- 
 ment acts as a solvent of the epidermis, and thus allows the 
 sulphur to come into more immediate contact with the 
 Acarus. A warm bath and plenty of hot water ablution 
 completes the cleansing process. The treatment may, how- 
 ever, be inapplicable to children, females, and men with 
 delicate skins or constitutional affections of the skin. In 
 them, although the principle of treatment is the same, the 
 process of cure must be more slowly conducted by less pow- 
 erfully irritant substances. The patient having cleansed 
 himself thoroughly in a warm bath, with ordinary vellow 
 soap, the following lotion may be applied: 
 
 §. Calcis, §ss.; Sulphuris, 3 i.; Aquae, 3 viii. These 
 ingredients are to be boiled and stirred constantly till a 
 homogeneous mixture is Droduced, which is to be strained 
 through a sieve. 
 
 These ingredients ought to produce a quantity more than 
 sufficient for one person, and should be rubbed into the 
 skin, not too roughly, every night for several evenings. The 
 cases of scabies in the Belgian army are treated by this lotion 
 (Velminskz, Anderson). When the person affected is pre- 
 disposed to exematous eniDtions, the following application 
 is recommended: 
 
 I>. Sulphuris, Olei Fagi, a a 3 vi.; Saponis Viridis, Axun- 
 gios, a a lbj.; Cretae, 3 iv.; misce. 
 
 This ointment should be well rubbed in, after the skin has 
 been prepared for it by the use of the warm bath and cleans- 
 ing the body with common yellow soap. The potash in the 
 black soap of the ointment acts as already stated, the chalk 
 tends to remove the epidermis mechanically, the tar coun- 
 teracts the tendency to eczema, and the sulphur destroys the 
 Acari. The ointment ought to be left on overnight 
 
3-p SCARLET FEVER. 
 
 (if the skin is not too irritable), and should be washed off in 
 the morning (Wilkinson, Hebra, Anderson). Specific print- 
 ed directions should be given to each patient; and cards are 
 useful for this purpose, similar to those in use in the Dis- 
 pensary for Skin Diseases in Glasgow. The following are 
 the directions printed on each card, which is given to each 
 patient along with the quantity of ointment required: 
 
 " is:. Scrub the whole of your body (except the head) as 
 firmly as possible, without hurting yourself, with black soap 
 and water. 
 
 " 2nd. Sit in a hot bath for twenty minutes, or if you can- 
 not get a bath, wash yourself with hot water thoroughly. 
 
 " 3rd. Rub some of the ointment firmly into the skin of 
 the whole body (except the head) for twenty minutes. Let 
 the ointment remain on the bodv all nisrht. 
 
 " Repeat these processes every night for three nights, and 
 then return to the dispensary. 
 
 " Besides, put all your washing clothes into boiling water, 
 and iron all your other clothes thoroughly with a hot iron." 
 
 The ordinary compound sulphur ointment of the pharma- 
 copoeia is also an efficient remedy. The cure being com- 
 plete so far as the person is concerned, care must be taken 
 to destroy the Acarus and its eggs which may be amongst 
 the clothes of the patient. For this purpose they should be 
 exposed to hot air at the temperature of at least 150° Fahr., 
 or boiled in water, or exposed to the action of sulphur by 
 steaming them amongst sulphur vapors. If such methods 
 are svstematicallv carried out, itch cases ought never to oc- 
 cupy hospital beds, either in civil or in military life. 
 
 Scarlet Fever. — Definition — A specific febrile disease, 
 the product of of a specific contagion, which is reproduced 
 during the progress of the affection. The duration of the 
 incubation stage may be only a few hours ; in a large pro- 
 portion of cases it probably does not exceed forty-eight 
 hours, and very rarely exceeds seven days (Murchison). On 
 the second day of the illness, or sometimes later, a scarlet 
 efflorescence appears on the fauces and pharynx, and on the 
 neck and face, which spreads over the whole body, and 
 commonly terminates in desquamation from the fifth to the 
 The fever is accompanied with an affection 
 of the kidneys, with albuminuria, often with severe disease 
 of the throat, or lymphatic glands of the neck, and is some- 
 times followed by dropsy and other lesions. The disease 
 
SCARLET FEVER. 349 
 
 runs a definite course, and, as a rule, occurs only once dur- 
 ing life. 
 
 Treahtie?ii. — Scarlet fever being accompanied by appar- 
 ently inflammatory symptoms, the practice of bleeding has 
 prevailed on the first breaking out of the disease in all coun- 
 tries, and with the most disastrous results (Willan) ; so that 
 Morton speaks of witnessing 300 deaths from scarlatina in a 
 week. This practice prevailed down to the time of Huxham, 
 who abandoned it, and introduced a treatment by bark. 
 Thus an entirely opposite system of treatment has been 
 gradually introduced, and the records of medicine enable us 
 to state the results of these opposite modes: — "Of cases 
 treated at the Foundling Hospital by bleeding in 1786, and 
 of cases treated at the London Fever Hospital in 1829, in 
 the same manner, one in six died after bleeding, while only 
 one in twenty-two died after a directly opposite mode of 
 treatment. The conclusion was inevitable, that the chances 
 of recovery are diminished by the practice of bleeding, 
 nearly in the ratio of four to one, as compared with the 
 chances of recovery supposing the patient not to have been 
 bled. 
 
 It should be laid down as a maxim, that in cases of scar- 
 let fever medical advice ought always to be had recourse to 
 as early as possible ; for the worst cases we meet with are 
 those in which the disease has, from its apparently mild 
 character, been left to itself. In the mildest form of the dis- 
 ease it is sufficient to confine the patient to the house ; to en- 
 join strictly a milk diet ; to regulate the bowels ; and, above 
 all things, to avoid the nimia diligentia medicorum. Any 
 active interference with the normal course of the disease is 
 to be avoided. The sick room ought to be kept at a uni- 
 form temperature, and not exceed 6o° to 65 ° Fahr. The 
 patient must not be overladen with bedclothes ; and the skin 
 ought to be sponged over twice daily with tepid water, dif- 
 ferent parts being exposed in succession, and carefully dried 
 with soft cloths. The water should be used without soap, 
 but with an abundance of Condy's fluid in it. As much 
 fresh air as possible should be admitted to the room. The 
 best drink is water, pure and cold ; while soups of meat, 
 Liebig's extract of meat, stewed fruit, and milk, ought to 
 form the staple diet. Constipation is to be overcome by en- 
 emata of tepid water and salt, avoiding purgation by medi- 
 cine. In the simpler cases of scarlet fever such manage- 
 ment is sufficient. 
 
350 SCARLET FEVER. 
 
 In the cases commencing with much sickness and general 
 disturbance, a gentle emetic at the outset is believed to 
 modify the future course of the disease. Ipecacuanha, with or 
 without tartar emetic, is the best form for administration ; 
 and half an ounce of castor oil ought to be given after the 
 action of the emetic has ceased. Looking to the morbid 
 condition of the blood, and to the tendency which exists to 
 the deposition of fibrine in the right cavities of the heart, 
 small doses of carbonate of ammonia (three to seven grains), 
 administered every hour, or every three hours, as soon as the 
 symptoms are decided, have been recommended (Peart, 
 Witt, Richardson). Or, the liquor ammonia? acetatis may be 
 used with an excess of ammonia, to the amount of from 
 three to five drops of liquor ammoniae added to two fluid 
 drachms o*f the former in a liberal quantity of distilled water 
 (Richardson). It is important to administer these medicines 
 in small and frequently repeated doses ; and, if possible, let 
 the remedy be taken as a drink ; and as such chlorate of 
 potash may be used freely. 
 
 The treatment of the milder forms of the fever, when the 
 tonsils are considerably enlarged, is, first, to tranquillize the 
 stomach and allay its perverted action when vomiting exists, 
 either by small doses of the sulphate of magnesia, or by ef- 
 fervescing salines — medicines which, according to the state 
 of the bowels, may be given every four or every six hours. 
 The gum resin of guaiacum is of great service in subduing 
 the cynanche tonsillaris, and may be prescribed in the fol- 
 lowing formula : — 
 
 ^ . Magnes. Sulp., 3 vi. ; solve in Aqua, f viii. ; adde 
 Pulv. Guaiaci, 3 iss. ; Pulv. g. Tragacanth. co., 2> ij. ; misce 
 bene. One-sixth part of this mixture may be given every 
 four hours, till the bowels are freely moved. 
 
 As soon as this object is effected, and it is ascertained that 
 the tonsils are still greatly enlarged and swollen, it may be 
 necessary to relieve them, if no adynamic symptoms exist, by 
 the application of six to twelve leeches about the angles of 
 the jaw ; and the bleeding may be further encouraged by the 
 application of a poultice. The trifling loss of blood thus 
 sustained does not impair the general strength of the patient, 
 if it is done sufficiently early, while it greatly reduces the 
 swelling of the tonsils, and may prevent them becoming per- 
 manently enlarged. Another advantage is gained by the ap- 
 plication of leeches to the throat — namely, that they relieve 
 the affection of the head symptoms. If the tonsils are thus 
 
SCARLET FEVER. 35 1 
 
 relieved, the fever ought to be permitted to run its course 
 uninfluenced by medicine, beyond the occasional administra- 
 tion of the saline draught and ice, or the inhalation of steam. 
 Such remedies should be persevered in till the disappearance 
 of the eruption, and till the healthy granulations of the throat, 
 and the decline of the fever, give evidence of a state of con- 
 valescence. At this point some mild tonic medicine is de- 
 sirable. With children under ten years of age, however, it is 
 better to trust to the soothing effects of warm poultices round 
 the throat, and inhalation of steam, than weaken the child by 
 loss of blood. 
 
 The severe forms of the disease, characterized by the less 
 swollen state of the tonsils, and by their being more livid and 
 gorged with blood ; by ulceration being deep and spreading ; 
 by the slough being fouler than in the milder varieties ; and 
 by the greater tendency of the inflamed parts to run into 
 mortification — the necessity of adopting a more stimulating 
 plan of treatment, and one more calculated to support the 
 powers of the constitution, is manifest, and experience has 
 shown its good results. Nourishment in the form of soups, 
 meat extracts, or milk, must be given in small quantities fre- 
 quently repeated, in proportion to the prostration of the pa- 
 tient. The administration of wine, and of the ^extraction 
 carnis Licbigii" should therefore be the basis of the treat- 
 ment of such cases. The quantity of wine for an adult may 
 be from four to six ounces in twenty-four hours, and for a 
 child about half that quantity or less. The wine should be 
 taken in small quantities, mixed with two-thirds water ; or it 
 may be given with sago, arrow-root, jellies, or other demul- 
 cent food. The earlier the wine is given in the disease the 
 better, whether delirium does or does not exist ; regardless, 
 also, as to whether the tongue is moist and white, or brown 
 and dry; and it should be continued till the patient is con- 
 valescent. Liebig's extract of flesh may be given like beef- 
 tea, as a drink. While pursuing this plan, it is necessary that 
 the patient's bowels should be attended. In cases more 
 severe, brandy may be required, or carbonate of ammonia in 
 liquor cinchonae ; and iron in some form should be given in 
 frequently repeated small doses, either with the nourishment 
 or with the medicines already mentioned ; or it may be com- 
 bined with quinine and aromatic sulphuric acid. 
 
 If an emetic is first given it may be proper, before adopt- 
 ing any special continuous mode of treatment, to follow its 
 action by a dose of calomel as a purgative, and this especially 
 
352 SCARLET FEVER. 
 
 with robust children, to be followed in six or seven hours by 
 castor-oil or magnesia ; and the bowels are ever afterwards to 
 be kept open by remedies suited to the state of the patient 
 and the nature of the disease. The following are the princi- 
 pal indications which must guide the treatment : — If there is 
 much excitement of the system, in an otherwise strong, well- 
 grown subject, depleting cathartics are to be given ; if nausea 
 and vomiting prevail, a seidlitz powder is of service ; if the 
 discharges from the rectum are acrid and acid, with acidity 
 of the stomach, magnesia is preferable ■ if there is abdominal 
 pain, castor-oil with opium (Wood). 
 
 Again, when the synovial membranes inflame, and the 
 joints become enlarged and swollen, all stimuli should be 
 withdrawn, and a moderate action of the bowels should be 
 kept up by means of the sulphate of magnesia, with camphor 
 mixture, or with carbonate of ammonia, or quinine in infu- 
 sions of chiretta or of gentian ; and if pain be severe, some 
 sedative should be added, as the tincture of hyoscyamus in a 
 dose of fifteen minims. 
 
 The more formidable affection in scarlet fever is dropsy, 
 sometimes with effusion into the pleurae. Bleeding by leeches 
 over the region of the kidneys is then of service, in cases 
 which will tolerate this remedy, especially if oedema appears 
 in the face, and is accompanied by headache, — from two to 
 four ounces in the child, and from four to eight ounces in 
 the adult may be taken. The good results of cupping (even 
 of dry cupping) are also very remarkable ; and of continu- 
 ously hot poultices over the lumbar region, with or without 
 the addition of digitalis. By these means renal conges- 
 tion is relieved, and the urine becomes more copious 
 and less albuminous. Hot air or vapor baths, to ex- 
 cite cutaneous action, may be also of service, combined with 
 diluent drinks. Diaphoretic doses of antimony, and moder- 
 ate but not severe purging, may be had recourse to, if ana- 
 sarca makes progress. The compound powder of jalap, or 
 the bitartrate of potash alone in drachm doses, three times a 
 day, are then most useful, especially as an electuary, in which 
 the cream of tartar is mixed with nearly an equal quantity of 
 honey, treacle, or marmalade, or syrup of ginger, and flavored 
 if necessary, with a few drops of peppermint oil. Squills and 
 digitalis are also of special service as diuretics till the urine 
 resumes its natural appearance. In young children (of five 
 years of age and under) digitalis in scarlatinal dropsy is al- 
 most always beneficial, given in combination with perchloride 
 
SCARLET FEVER. 353 
 
 of iron. It is followed by a steady increase in the quantity 
 of urine, with a corresponding subsidence of effusion. Five 
 minims of the tincture of the perchloride of iron, with a 
 drachm and a half of the infusion of digitalis in anis or cara- 
 way water, may be given three times a day, and continued 
 without intermission for fourteen days. Children bear such 
 doses, and larger ones, of digitalis remarkably well ; and the 
 infusion in preference to the tincture, with iron and a nutri- 
 tious diet (Cheadle, Brit. Med. Journ., November 23, 1872). 
 The muriated tincture has the best reputation. The iodide 
 of potassium in small doses is also useful ; and with this lat- 
 ter remedy the syrup of the iodide of iron may be combined, 
 if it is desirable to continue the chalybeate ; or syrup of the 
 phosphate of iron, combined with glycerine in drachm doses 
 of the combination. 
 
 Gargles are unnecessary for children, for they cannot gar- 
 gle; but they are of the greatest service, especially the de- 
 odorizing gargles or washes, when the patient can be taught 
 to use them. A weak solution of chloride of lime, or of 
 chlorine water, or of Condy's fluid, or permanganate of 
 potash, is well adapted for such a purpose. The following 
 is recommended as a most efiectual gargle : 
 
 Solution of peroxide of hydrogen (containing ten volumes 
 of oxygen), six ounces; tincture of myrrh, an ounce; rose 
 water, five ounces (Richardson). 
 
 This gargle may be used at pleasure; it is refreshing to 
 the patient, and removes the offensive secretions. With 
 young children, who are unable to use a gargle, the throat 
 may be washed out, by holding the little patient with the face 
 downwards, and then pumping the solution over the surface 
 of the fauces through a bit of gum catheter from a double- 
 acting india-rubber bag (Richardson, Clinical Essays, p. 
 no). As an invariable routine practice, Dr. W. T. Gaird- 
 ner strongly recommends that " the steam of hot water should 
 be inhaled from the beginning to the end of the fever, as 
 long at least as the throat is sore." In slight affections it is 
 sufficient to employ infusion of linseed in water, acidulated 
 with nitro-muriatic acid, weak solutions of alum, nitre, or 
 common salt. When membranous diphtheritic patches are 
 observed on the fauces, and the color of the mucous mem- 
 brane is of a dark-red, capsicum infusion, or powdered red 
 pepper, is an excellent application (Wood); and in children 
 who cannot gargle, it may be applied with a hair pencil. So- 
 lutions of zinc, or nitrate of silver, are also of service. Ul- 
 2% 
 
354 SCARLET FEVER. 
 
 cerations may be touched daily with a solution of nitrate of 
 silver (one drachm to two ounces of water), applied by means 
 of a hair pencil or a sponge probang; while a weaker solu- 
 tion (grains v. to x. to two ounces of water) is at the same 
 time injected through the nostrils when there is discharge, 
 and it gives great relief. Turpentine and glycerine in equal 
 parts brushed over the ulcerated throat is also a valuable ap- 
 plication, and the sulphurous acid spray may be of service. 
 In swelling of parotid and submaxillary glands, ice in bags 
 of oil silk fastened round the neck and angle of the jaw, with 
 lumps of ice in the mouth, diminish engorgement, and tend 
 to avert suffocation. These details are given because the 
 physician must decide, upon the merits of the individual case, 
 the nature of the treatment he will adopt. It must be re- 
 membered that cases of scarlet fever, if left to themselves, 
 with rest and careful nursing, will generally get well unless 
 the epidemic constitution is a malignant type. The mere 
 intensity of the fever is no ground for active interference by 
 way of treatment, if the pulse is full and of good strength. 
 Much is to be trusted to the shortness of the fever, remem- 
 bering that there is no disease in which the patient is more 
 apt to be delirious, and in which the temperature may reach 
 a high degree, with less danger, than in scarlet fever, (W. T. 
 Gairdner, Clinical Medicine.) On the other hand, it 
 must also be remembered that any continuous and excessive 
 increase of the temperature of the body may be followed by 
 the occurrence of adynamia and threatened paralysis of the 
 heart from excessive prostration, and that such cases sud- 
 denly and urgently demand such therapeutic interference as 
 may tend to reduce temperature and maintain the strength. 
 Treatment by the cold water douche or affusion, as orig- 
 inally advocated by Drs. Jackson and Currie, is now again 
 recommended in the treatment of malignant scarlet fever, 
 where the cerebral symptoms are early and severe. Nie- 
 meyer and others bear testimony to its having a most markedly 
 beneficial effect. The patient may be placed in an empty 
 tub, and have the cold water poured over him, or his naked 
 body may be wrapped in wet sheets, to be renewed and re- 
 applied at intervals of ten to fifteen minutes, the patient be- 
 ing put to bed in the interval. If either of these measures 
 fail, then such powerful stimulants as carbonate of ammonia, 
 camphor, or alcohol, may be had recourse to, administered 
 by enemata if need be, combined with milk or beef-tea, or 
 gruel. 
 
SCARLET FEVER. 355 
 
 Preventive Treatment. — Mere fumigation will not, it should 
 be remembered, destroy the miasmata in the sick-room; and, 
 consequently, the doctrines of separation, of ventilation, and 
 of cleanliness, are as imperative in this disease as in small- 
 pox. The isolation of healthy persons from those affected 
 with the disease, and from those who have intercourse with 
 such patients, is essential, and is the only rule that promises 
 any good results. The following rules (drawn up from the 
 experience of Drs. Ballard and Budd) ought to be carried 
 out in every house where conveniences can be obtained; such 
 conveniences ought to exist in every hospital, and in the 
 houses of the poor they ought to be carried out as far as 
 practicable (i.) Remove from the sick apartment all su- 
 perfluous woolen or textile matters, such as carpets, curtains, 
 and anything of that nature, which are known to be reten- 
 tive of disease germs. (2.) Measures of disinfection should 
 be used as early and as thoroughly as possible. Carbolic 
 acid in solution, or as carbolate of lime, is especially useful 
 to sprinkle on the floor, and with which all parts of the room 
 may be washed prior to cleansing and lime-whiting; and all 
 articles to be washed ought to be soaked first in a solution 
 of carbolic acid. (3.) A basin charged with chloride or car- 
 bolate of lime, or some other convenient disinfectant, is to be 
 kept constantly on the bed for the patient to spit into, which 
 must be emptied and replaced at regular intervals. (4.) A 
 large vessel (a tub) containing water impregnated with Con- 
 dy's fluid, or carbolic acid solution, should always stand in 
 the room (or near by) for the immediate reception of all bed 
 and body linen on its removal from the person or contact 
 of the patient. (5.) In place of using pocket-handkerchiefs, 
 use small pieces of rag for wiping the mouth and nose, so 
 that each piece, after being used, may be at once burned. 
 (6.) Two basins, one containing Condy's fluid or carbolic 
 acid solution, and another containing plain soft water with 
 carbolic soap, and a good supply of towels, must always be 
 ready and convenient, so that the hands of nurses may be at 
 once washed, first with soap and water, and then in Condy's 
 fluid water without soap after they may have been soiled by 
 specific excreta. The dresses of nurses and attendants 
 should be of linen, or smooth washable material. (7.) 
 Glasses, cups, and other vessels used by or about the patient, 
 are to be scrupulously cleaned before being used by others. 
 (8.) The discharges from the bowels and kidneys are to be re- 
 ceived, on their very issue from the body, into vessels charged 
 
356 SCARLET FEVER 
 
 with disinfectants. (9.) To prevent the minute particles of 
 desquamation from flying off as impalpable powder, their 
 power for evil must be destroyed in situ, by anointing the 
 surface of the body (the scalp included) twice a day with 
 olive oil. It may be slightly impregnated with camphor, 
 which Dr. Budd considers. sufficient, or carbolic acid. The 
 process relieves the itching of the skin, and is very soothing 
 to the patient. So soon as efflorescence is observed on the 
 skin of the neck and arms (as early sometimes as the fourth 
 day), which marks the first liberation of the germ-carriers of 
 the specific disease-poison, the employment of the oil is to 
 begin, and ought to be continued until the patient is well 
 enough to take ,a warm bath, in which the whole person 
 (scalp included) is well scrubbed, carbolic acid soap (Cal- 
 vert's or Macdougall's) being abundantly used during the 
 process. These baths are to be repeated every second day, 
 until four have been taken, when, as far as the skin is con- 
 cerned, the disinfection may be regarded as complete, al- 
 though a further quarantine of a week may be advisable. 
 (10.) The chamber in which the sick person has been con- 
 fined must now be thoroughly washed out, using freely car- 
 bolic acid and soft or black soap (which may now be got 
 combined for the purpose) {Brit. Med. Journ., 1869, Jan. 9, 
 p. 23). 
 
 If a patient be from the outset thus isolated from all who 
 are susceptible of contagion, — if everything proceeding from 
 him is drenched with chemical disinfectants before it leaves 
 the sick-room, — if the exhalations from the skin, and 
 the peeling skin itself, are mechanically imprisoned by 
 inunction with oil until they can be removed by a warm 
 bath, — and if all clothing, bedding, and furniture are 
 disinfected at the close of the illness, a case of scarlet 
 fever ought to remain barren of results. But to carry 
 out such a process thoroughly requires the command of 
 space, of money, and of attendance; and requires also wis- 
 dom and self-denial on the part of relatives and friends. If 
 it were possible to begin to-morrow, and to carry it out in 
 every case, scarlet fever would have ceased to exist in the 
 country at the end of two months, and it is possible, or even 
 probable, that it would never return. " When, however, we 
 look abroad at the actual condition of the people among 
 whom the disease works its ravages, we see at once that, with 
 regard to very many of them, and especially with regard to 
 the poor in towns, isolation and disinfection are no more 
 
SCARLET FEYEK. 357 
 
 than idle words. In the class above the very poor, among 
 small tradespeople, small employers, and the like, where the 
 adoption of proper measures, although difficult, would not 
 be impossible, it is rare to find the intelligence and the ac- 
 tive conscientiousness that would induce them to bear re- 
 straints, to take trouble, and to incur loss, for the sake of 
 preventing injury to their neighbors. Even among the 
 wealthy and educated, disinfection and isolation are but im- 
 perfectly carried out. Such people like to do as they please, 
 and resent dictation from medical men. If the cases are 
 severe, mental anxiety and distress break down the barriers 
 of precaution. If they are trivial, strict precaution would 
 too often be thought fussy and unnecessary. Medical men 
 cannot in such cases enforce what is right. They can only 
 recommend it; and they recommend it subject to the remem- 
 brance that their business is to heal the sick, not to quarrel 
 with the healthy. It is a curious weakness of human nature, 
 that many otherwise rational creatures are angry at the sug- 
 gestion that their loved ones can be sources of danger to all 
 around them, or that their house is properly shunned by 
 the neighbors: and beyond this there is the belief, not alto- 
 gether unfounded, that it is useless to isolate and disinfect 
 in a single case, where there is no reason to believe that a 
 similar course will be generally adopted. In the case of 
 schools and public institutions, it might be well to prevent 
 dispersion by positive enactment. But in other instances, if 
 the principle were once asserted and acted upon, that an in- 
 fectious disease must be registered, as a matter of public 
 concern, public opinion would do the rest. Such provisions 
 as we have suggested are, perhaps, as much as could be at 
 present carried into effect; and their influence, both sanitary 
 and educational, would be of incalculable value." 
 
 There are also beginning to arise some sceptical misgiv- 
 ings regarding our present hygienic views and practice with 
 regard to scarlet fever. " One failure starts a doubt in a be- 
 liever's mind; a second confirms it; a series of failures makes 
 one look out for a better creed. Are we doing any good 
 with our present preventive means ? If they could be uni- 
 versally enforced, as they have been in isolated families with 
 disciplined minds, they would succeed; but when this is at- 
 tempted with large thickly packed communities, can they be, 
 or have they ever been, successfully enforced ? By the imper- 
 fect execution of them through the length and breadth of the 
 land, do we increase or lessen the mortality from disease ?" 
 
35& SCARLET FEVER. 
 
 These questions were put by Dr. Davies, of Bristol, who, 
 writing of an epidemic of scarlet fever there in 1875, con- 
 tinues as follows : — " I feel certain that we increase the anx- 
 iety of the domestic and social troubles of the public by 
 our preventive measures; and I feel doubtful of the answer 
 to the former question. Take, for example, an imaginary 
 but typical case in private practice. There is a family 
 named X., in easy circumstances. They have five children 
 — three boys and two girls. There is an epidemic, of a very 
 mild type, of scarlet fever in the locality. Hundreds have 
 had the disease; but there has been no death. The season 
 is July; the weather rainy, the atmosphere moist. The 
 youngest boy, aged 4, contracts the disease in the prevalent 
 mild type. The other four children, by the advice of their 
 medical attendant, are sent to a distance, and escape the in- 
 fection. The sick child recovers. Two years elapse. The 
 eldest son goes to Eton, Rugby, Marlborough, or some other 
 public school. An epidemic of a severe type has just broken 
 out where he is ; he contracts the disease. The parents are 
 telegraphed for to see their son, supposed to be dying. 
 They travel to and fro three hundred miles. The patient 
 ultimately recovers, and escapes only by the skin of his teeth. 
 The school is temporarily broken up. The convalescent is 
 sent to a fashionable watering-place before he is properly 
 disinfected, and there he spreads the disease. The second 
 son has escaped, through being kept at a distance from his 
 brother. He has, in the course of time, taken his degree at 
 college; has been admitted as a barrister; has, after a long 
 struggle, made his position; has been married. He passes 
 through Paris on his honeymoon. The weather is cold, the 
 wind easterly. In Paris an epidemic of scarlet fever pre- 
 vails. He contracts the disease and dies in a strange land; 
 and leaves his young bride a widow among strangers. In 
 time, the eldest girl is married to a rich man. She is in due 
 time confined of her first-born. The bells* are ringing, and 
 all goes on merrily as a * marriage bell.' A fortnight after- 
 wards, that house is desolate. In that house are now only 
 a bereaved husband and motherless infant; the subtle seeds 
 of this mysterious disease have been inadvertently introduced 
 to the puerperal patient in the nurse's shawl, or on the sleeve 
 of the doctor's coat. I will not follow this case further; but 
 ask, in all seriousness, would not life and suffering have been 
 saved if all the family had been allowed to pass through the 
 disease when it first appeared among them in a mild type, 
 
SCARLATINA SCURVY. 359 
 
 when they were all children ? I wish it to be thoroughly un- 
 derstood that, as a health-officer, I have never had the moral 
 courage to discard my former profession of faith, and to un- 
 dertake the responsibility of giving practical effect to my 
 doubts. I have never used disinfectants so extensively as 
 during the present epidemic, and yet our failure is complete. 
 The doubts I have expressed do not in any way extend to 
 typhus and enteric fevers, small-pox, and Asiatic cholera. It 
 is a fact beyond contradiction that occasionally this tiger of 
 pathology seems to stalk abroad, having left both claws and 
 teeth at home. Could we not play with him then ? Inocu- 
 lation from mild cases of variola previous to the discovery of 
 vaccination proved of immense benefit. We can import 
 scarlet fever. We can choose our type and season of the 
 year. Is there a milder exanthem of an allied species that 
 can prevent or modify this disease ? Rotheln is nearly 
 allied, is very infectious, but harmless. Does it modify 
 scarlet fever, or is it modified by it ? I have for some time 
 looked upon it with affection, but am afraid to theorize on 
 the subject. Can any one throw light on this unexplored 
 field ? Observation convinces me that there is some un- 
 known condition which gives immunity to some persons from 
 scarlet fever: what is this condition ? An analogous condi- 
 tion was known in the Vale of Berkeley regarding small-pox 
 before the days of Jenner, and might have remained un- 
 known to the outer world had not that great man unearthed 
 it. Who will be the Jenner of scarlet fever ?" A somewhat 
 similar argument is used by Thomas in his article on scar- 
 latina in Ziemssen's "Cyclopaedia," Vol. II., p. 300. 
 
 Different prophylactic medicines have been recommended; 
 amongst which belladonna has had the greatest number of 
 advocates, but its value has diminished greatly, as the 
 weight of testimony is against its possessing any prophylactic 
 virtues (Wood). Even when continued for a week, it affords 
 no protection against scarlet fever (Niemeyer). 
 
 Scarlatina— See Scarlet Fever. 
 
 Scorbutus — See Scurvy. 
 
 Scurvy. — Definition. — A morbid state characterized by 
 sponginess of the gums and the occurrence of livid patches 
 under the skin, of considerable extent, which are usually 
 harder to the touch than the surrounding tissue. An altered 
 state of the albumen of the blood is associated with this con- 
 dition, and the phenomena are brought about by a deficient 
 
360 SCtfRVY. 
 
 supply of the organic vegetable acids, or of the salts of fresh 
 vegetables. It is ushered in by debility, lassitude, lowness 
 of spirits, attended by fetor of the breath, and the gums 
 swell by irritation, till they overhang the teeth in palmated 
 excrescences. The livid subcutaneous patches and spots 
 appear upon the skin of considerable extent, especially on 
 the lower extremities and among the roots of the hair. Spon- 
 taneous haemorrhages may take place from the mucous ca- 
 nals; contractions of the muscles and tendons of the limbs 
 occur, with pains, and sometimes superficial ulcerations. 
 
 Treatment. — The disease, " so fatal when left to itself, is 
 cured with the greatest facility. Symptoms apparently the 
 most grave and serious vanish as if by magic, and without 
 leaving behind them any serious injury to the constitution. 
 The sanious discharge from scorbutic sores has been known 
 to change color, and to become healthy in a few hours 
 after the commencement of treatment. In pure cases of 
 scurvy the blood, and the blood only, is at fault," (Parkes) 
 "Lemon juice," writes Dr. Watson, "is really a specific 
 against scurvy, whether it be employed as a preventive or as 
 a remedy. It supplies something to the blood which is essen- 
 tial to its healthy properties." The potato seems to be no 
 less efficacious as a remedy and preventive (Budd), and all 
 the antiscorbutic remedies are most efficient in the form of 
 juice — from raw and uncooked fruit. The reader will find 
 a most interesting account of the efficacy of potatoes and of 
 onions in Dana's Two Years before the Mast — a book well 
 worth reading. The antiscorbudc principle, whatever it may 
 be, is in greatest amount in unripe fruits; it lessens gradu- 
 ally as they ripen; and if the juice be obtained, the princi- 
 ple disappears, or is decomposed and rendered inefficient, 
 when fermentation occurs. When lime-juice becomes musty, 
 a mucilaginous principle is developed at the expense of the 
 citric and malic acids; and the percentage of citric acid 
 gradually decreases (Sir William Burnett, Parkes). Good 
 lemon juice seems to be more effectual, however, than pure 
 citric acid; probably from its containing malic and tartaric 
 acids besides citric, and from the citric acid being in the 
 form most easily absorbed and decomposed by the digestive 
 organs of nan. The Materia Medica gives numerous anal- 
 ogous examples of the superior efficacy of a medicine in its 
 natural combinations (Parkes). This is all we can yet say, 
 however, regarding the actions of either of these means of cure, 
 notwithstanding the researches of the chemists of the pres- 
 
SCURVY. 361 
 
 ent day. Moreover, it is sufficient; and with such remedies at 
 command, the prevalency of scurvy in merchant vessels, or in 
 any navy, ought not to exist. " The one thing wanted in order 
 that scurvy should be entirely banished from the mercantile 
 marine is proper provision for the dietary of the crew, — such 
 provision as is enforced in emigrant ships, where each per- 
 son's weekly allowance must have in it at least 8 oz. of pre- 
 served potatoes, and 3 oz. of other preserve 1 vegetables (car- 
 rots, onions, turnips, celery, and mint), besides pickles and 3 
 oz. of lime-juice; where, also, there is considerable variety 
 of bread stuff; and where, on two days in the week, pre- 
 served (not salted) meats must be given. With such a diet- 
 ary as this, the details of which might be varied, provided 
 its principle were adhered to, the occurrence of scurvy would 
 be impossible. And even with dietaries inferior to that just 
 described, scurvy would not occur as it does, if but the pro- 
 visions of the ' Merchant Shipping Act' (17 and 18 Vic, c. 
 104) were obeyed, — that whenever a crew shall have been 
 consuming salt provisions for ten days, lime juice or lemon 
 juice and sugar shall be served out at the rate of half an 
 ounce each per day; and if, during the voyage, the opportu- 
 nities which offer themselves were fairly used for getting new 
 supplies of fresh animal and vegetable food; but owners dis- 
 obey the law, and captains neglect opportunities to counter- 
 act the results of this disobedience. Owners, notwithstand- 
 ing the law, will send forth their ships on long voyages with- 
 out any provision of lime-juice, or with lime-juice insufficient 
 in quantity, or with lime-juice of which the quality is bad; 
 and captains, with half their crews more or less disabled, are 
 known to run past St. Helena or the Western Isles, when a 
 few hours' delay would obtain sufficient provisions to repair 
 the mischief occasioned by first neglect" (Simon and 
 Barnes's Sixth Report on Public Health, 1864, p. 20). It is 
 perhaps hardly fair to attribute the improved health of the 
 navy entirely to the introduction of a daily allowance of 
 lemon juice, considering that the quantity of the diet was 
 greatly increased, and its quality greatly improved, contem- 
 poraneously with this addition. It is gratifying, however, to 
 see how largely these combined measures have improved the 
 health of the navy, and rewarded the cares of those who su- 
 perintend it. During the nine year, preceding these changes 
 the sick seamen sent to the hospitals were 1 in 3.9, while in 
 the nine succeeding years the proportion was only 1 in 8.4; 
 so that not only has scurvy almost disappeared from ships 
 
362 SCURVY. 
 
 of war and naval hospitals, but the efficiency of the navy has 
 actually been increased threefold. 
 
 Dr. Parkes advises that the following measures be adopted 
 in time of war, or in prolouged sojourn on board ship, or at 
 stations where fresh vegetables are scarce: " (1.) The supply 
 of fresh vegetables by all means in our power. Even unripe 
 fruits are better than none, and we must risk a little diar- 
 rhoea for the sake of their antiscorbutic properties. In time 
 of war every vegetable should be used which it is safe to use, 
 and when made into soups all are tolerably pleasant to eat. 
 (2.) The supply of dried vegetables, especially potatoes, cab- 
 bages, and cauliflowers; turnips, parsnips, &c, are perhaps 
 less useful; dried peas and beans are useless. As a matter 
 of precaution these dried vegetables should be issued early 
 in the campaign, but should never supersede the fresh vege- 
 tables. (3.) Good lemon juice should be issued daily (1 oz.) 
 and it should be seen that the men take it. (4.) Vine- 
 gar (J oz. to 1 oz. daily) should be issued with the rations, 
 and used in the cooking. (5.) Citrates, tartrates, lactates, 
 and malates of potash, should be issued in bulk, and used as 
 drinks, or added to the food. The easiest mode of issuing 
 these salts would be to have, packets containing enough for 
 one mess of twelve men, and to instruct the men how im- 
 portant it is to place them in the soups or stews. Possibly 
 they might be mixed with the salt, and issued merely as salt" 
 ("Prac. Hygiene," 2nd Ed., 1866, p. 466). 
 
 Our recent Arctic expedition, in 1876, is of interest for 
 two reasons: (1.) As regards a peculiar theory as to the ac- 
 tion of lime-juice which the commander of that expedition 
 entertained and acted upon, based as it was upon a ground- 
 less and absurd hypothesis, that by doubling the dose of 
 lime-juice for a month he believed he could, so to speak, 
 " saturate " his men with it before they started on an im- 
 portant sledging expedition, so that they might be able to do 
 without it on these journeys. Lime-juice is simply an article 
 of diet; and is no more " cumulative ''' in its action than any 
 other aliment which goes to nourish the body. Its nutritive 
 influence continues for so long and no longer than the time 
 when it is continued and assimilated as an article of diet. 
 The assumption of the theory was entirely gratuitous and 
 unfounded; and to have acted upon it against competent 
 medical opinion was unjustifiable. (2.) Another theory was 
 entertained to palliate the omission of lime-juice from the 
 sledging rations, namely: — that lime-juice when exposed to 
 
SCURVY. 363 
 
 an extreme degree of cold deteriorates and ceases to have 
 any antiscorbutic properties. 
 
 This theory was not only disproved by the evidence of 
 the medical officers on other sledging expeditions, but was 
 effectually answered by the fact that the whole expedition 
 was virtually saved from the most fearful mortality from 
 scurvy by the opportune discovery of a depot of lime-juice 
 left five years before by the " Polaris " expedition, lying in 
 a cask on the ice exposed to the extremity of cold alterna- 
 ting with heat. It had also been much weather-beaten, and 
 on its surface mixed with snow; but it nevertheless proved 
 to be in no respect deteriorated in its antiscorbutic powers, 
 and served to keep off the last extremities of disease from 
 the sledging parties to whose relief it was sent in time. It 
 appears, indeed, to us, and it will appear, we think, to any 
 one who reads the whole narrative, that, but for the timely 
 discovery of this depot of the " Polaris" lime-juice, and its 
 utilization for the sledging parties, there is good reason to 
 fear that so large a proportion of the crews would have been 
 destroyed by scurvy, that it is doubtful whether the whole 
 expedition would not have been lost from the want of suffi- 
 cient power to bring the ships out of the ice. However this 
 may be, the frozen lime-juice rendered the most essential 
 services, and the theory that freezing destroys its virtues is 
 most effectually disposed of " {Brit. Med. Journal, March 
 10, 1877). 
 
 In fact there is nothing in the history of our latest Arctic 
 expedition of 1876, which does not point to the cause of the 
 outbreak of scurvy as similar to all those which history has 
 already recorded; and which will again produce the disease 
 if the teachings of history are similarly neglected and set 
 aside. 
 
 The great body of evidence taken by the committee ap- 
 pointed to inquire into the causes of the outbreak of scurvy 
 in the Arctic expedition fully shows that " the outbreak was 
 due essentially to the omission — or, rather, to the refusal — 
 of Captain Nares to send lime-juice with the sledge parties. 
 It was shown that the provisions of the ships were ample in 
 quantity and excellent in quality; and, further, the commit- 
 tee having had before them the preliminary memorandum 
 by Sir Alexander Armstrong, the Director-General of the 
 Medical Department of the Navy, strongly and explicitly re- 
 quiring the issue of a daily ration of lime-juice, and having 
 heard Sir George Nares' explanation of the reasons which 
 
364 scrivener's palsy. 
 
 induced him to act in defiance of that memorandum, decided 
 that in doing so he made himself responsible for the out- 
 break of scurvy which occurred, and that he had no suffi- 
 cient reason for not carrying out the rules laid down in the 
 memorandum." 
 
 " It is a satisfaction to find that throughout the whole of 
 this inquiry the Medical Department of the Navy comes out 
 with the utmost possible credit. Nothing could be more 
 clear, more explicit, more absolutely prophetic than the 
 memorandum which was furnished to Sir George Nares^by 
 the Admiralty from Sir Alexander Armstrong, on the im- 
 measurable importance of supplying the men with a daily 
 ration of lime-juice. The whole of his direction for the 
 maintenance of the health of the men are indeed most able, 
 practical, and judicious: and, had they been strictly followed 
 out, the results would have been very different. The con- 
 duct of all the medical officers of the expedition appears to 
 have been such as to merit and to receive the warmest ap- 
 probation of their superiors from first to last, and they show- 
 ed a devotion to duty which is entirely comparable with that 
 displayed by the officers and men of this gallant expedition 
 generally. They can seek for no higher praise, and it is on 
 all hands conceded that they merit no less. One moral of 
 this inquiry, which is salient on the face of it, and which we 
 can hardly be expected to abstain from pointing, is, that 
 combatant officers will do well always to respect the func- 
 tions of the medical officers, and to attribute just weight to 
 medical recommendations. In framing false medical theo- 
 ries, ar.d in assuming the responsibility of refusing to act 
 upon his medical instructions, Sir George Nares brought a 
 great disaster upon this expedition; and he assumed the full 
 responsibility of it " {Brit. Med. Journal, March 10, 1877.) 
 
 Scrivener's Palsy. — Definition. — Morbid excitement of 
 the motor fibres of the nerves of the muscles of the fingers 
 and thumb holding the pen, resulting in cramps, so as com- 
 pletely to prevent writing, and thus the condition becomes 
 equivalent to a local palsy or paralysis. 
 
 Treatment. — Complete rest from the usual mechanical use 
 of the hand must be insisted on. Nourishing food, with a 
 milk diet in abundance, or cod-liver-oil, are essential. In 
 one case division of the muscle in which the cramp seemed 
 first to commence had a good effect (Stromeyer). In four- 
 teen days after subcutaneous section of the long flexor of the 
 thumb, the patient was again able to write. Dieffenbach 
 
SCROFULA. 365 
 
 often repeated a similar operation, but without success. 
 These may be regarded as very radical surgical methods of 
 securing absolute rest to the wearied muscles. Mr. Solly, in 
 his lately published surgical experiences, described several 
 cases of this peculiar affection, in which tonic treatment, 
 with rest from writing, was attended with good results. 
 Niemeyer has been successful with the galvanic current. 
 He applied the current to the muscles of the thumb and 
 index finger. Exercise of the affected muscles materially 
 tends to increase the disease. 
 
 As to medicines, when the disease has not gone beyond 
 the sensation of heat and cramps in the ball of the thumb, I 
 have seen good results from the syrup of the phosphates of 
 iron, quinine, and strychnia; and generally those remedies 
 noticed under the subject of anaemia may be prescribed. 
 Mechanical appliances, such as contrivances which fill up, 
 as by a ball, the palm of the hand on which the fingers rest 
 in writing, have been of service; and there are also appli- 
 ances by which writing may be accomplished without the aid 
 of the fingers, and which therefore may be of service in 
 securing rest to them. 
 
 Scrofula. — Definition. — A constitutional disease, result- 
 ing in the deposit of a soft unorganized matter of a white or 
 pale-yellow color, firm, resembling curd or soft new cheese, 
 but less tough, sometimes granular and friable, and consist- 
 ing of a large proportion of albuminous matter. It is often 
 found mixed with purulent-like fluid, or occurring in round- 
 ed masses of different degrees of firmness, and varying in 
 bulk from that of a millet-seed to a hen's egg or larger ; 
 sometimes contained within natural canals and cavities of 
 the body, and sometimes inclosed in cysts, or occasionally 
 diffused as if by infiltration through the texture of a part. 
 To the rounded masses the name of tubercle has been given; 
 and the substance itself has been named scrofulous or tuber- 
 culous matter. Scrofula also expresses itself in specific 
 forms of inflammation or ulceration. It manifests a remark- 
 able tendency to certain specific forms of nutritive disorder, 
 which are strikingly wasting in their effects upon the body, 
 namely: — (a.) Scrofula with tubercle; (b.) scrofula without 
 tubercle; and (c.) certain local scrofulous affections, such 
 as eruptions of a peculiar kind, many cutaneous ulcers, cer- 
 tain enlargements of the joints, tubercular meningitis, hydro- 
 cephalus, scrofulous ophthalmia, tubercular pericarditis, 
 scrofulous diseases of glands, phthisis pulmonalis or pul 
 
36O SCROFULA. 
 
 monary consumption, acute miliary tuberculosis, tabes 
 mesenterica, and tubercular peritonitis. 
 
 Treatment. — (a.) Preventive — There is perhaps no subject 
 in the whole range of medical science which the student 
 ought to study more carefully than the cachexia, or special 
 form of ill health associated with the occurrence of tubercle 
 and scrofulous affections as here described. As a practi- 
 tioner he will find that he becomes often painfully concerned 
 in the deepest interests of families and society, through the 
 threatened or actual ravages of scrofulous diseases. The 
 extensive prevalence of the scrofulous cachexia — the great 
 and almost inevitable mortality of the scrofulous diseases 
 themselves when completely developed, stamp the morbid 
 state associated with them as a topic which, at the outset of 
 the student's career, ought to engage a large share of his 
 study. Most assuredly the physician will have to turn his 
 knowledge of the pathology of scrofula to account in every 
 phase of his professional life. When he fully appreciates 
 what experience has adequately demonstrated, that the 
 scrofulous cachexia springs from causes over which the pub- 
 lic (rather than the medical profession) have control, he 
 must be at once impressed with the belief and encouraged 
 with the hope, that when he acquires the confidence of fam- 
 ilies in the practice of his profession he may exercise a pow- 
 erful influence for good in teaching how much the public 
 may control the ravages of scrofula and consumption by 
 prudent marriages, by sanitary attention to offspring, and 
 by the necessity of free ventilation and of fresh air in dwell- 
 ings. There are several circumstances which show the great 
 influence of public sanitary measures in controlling the 
 development of scrofula, when these measures are scientific- 
 ally directed to the preservation of general health, especially 
 where men are associated together in great communities — an 
 influence much greater than the best directed efforts of the 
 medical profession can establish through their materia med- 
 ica. It is by the mode of life as citizens of the world, in 
 the social relations of husbands and wives, parents and child- 
 ren; in the public relation of masters and workmen, that the 
 extent and ravages of consumption and scrofula are to be 
 controlled. It is by a strict attention to the rearing of off- 
 spring, and in the subsequent regulation of food, clothing, 
 cleanliness, and occupation; in the choice of a profession, 
 and by many other circumstances which have an obvious 
 influence (perhaps at first sight inappreciable) on the main- 
 
SCROFULA. 367 
 
 tenance of the general health, that our hopes of success as 
 practitioners of medicine must rest in the prevention of that 
 bad habit of body which develops and propagates the scrofu- 
 lous diseases in civilized society. 
 
 (b.) General Treatment. — The general treatment now in 
 most repute is founded on the doctrines — (1.) That 
 scrofulous local lesions will heal of themselves if the 
 nutrition of the system can be maintained and the con- 
 tinuous growth of tubercle arrested ; (2.) that the periods 
 of frequent temporary arrest of all the general and local 
 symptoms of disease ought to be diligently taken ad- 
 vantage of to improve and preserve health by hygienic 
 means (3.) that the efforts of the practitioner should be 
 directed to the digestive rather than to the pulmonary sys- 
 tem; (4.) that the kind of morbid nutrition in the body 
 generally, and altered morphological change in the tissues 
 of the organ where the deposit takes place, appear to be 
 chiefly due to excess of albuminous and deficiency of fatty 
 elements in the chyle. The treatment, therefore, to be pur- 
 sued must be essentially reparative of the waste of tissue 
 generally; corrective of what has been unfit in the indivi- 
 dual diet and mode of life; and, lastly, supplementary of 
 the elements of nutrition which have been deficient. During 
 the past thirty years in Germany, and twenty-three years in 
 this country, the treatment of scrofulous affections has gradu- 
 ally but steadily become more and more firmly based on those 
 pathological doctrines which the late Dr. J. H. Bennett, of 
 Edinburgh, was mainly instrumental in first elucidating, and 
 in earnestly recommending to the notice of the profession 
 generally in this country. The view here taken regarding 
 the nature of scrofula leads to the belief that — (1.) The 
 biood is impoverished through the preliminary dyspepsia 
 which precedes the growth of crude tubercle; (2.) that in 
 pulmonary phthisis the growth of crude tubercle results in a 
 consolidation primarily in the air vesicles; (3.) that the 
 successive formation and softening of these crude tubercles 
 lead to ulcerations of the pulmonary and other tissues — to 
 the infective processes which set up the growth of true 
 miliary tubercle — and, promotes wasting of the body gener- 
 ally. 
 
 It nas been now fully shown, especially by the observa- 
 tions of Dr. Bennett, in the first instance, confirmed by the 
 extensive experience of the physicians at the Brompton Hos- 
 pital for Consumption, in London, that such treatment as is 
 
368 SCROFULA. 
 
 directed to remove the malassimilation of food frequently 
 checks the tendency to the repeated occurrence of tubercles, 
 while those which previously existed remain harmless ; that 
 general symptoms and physical signs may disappear com- 
 pletely ; and that even extensive excavations in the pulmon- 
 ary tissue may heal up and cicatrize. According to the tes- 
 timony of Dr. Wood, of Pennsylvania, the fatal results have 
 not only been postponed, but the death-rate from phthisis 
 has diminished in the principal cities of the United States 
 since such principles of treatment have been adopted. The 
 indications of general treatment are therefore: — (i.) To im- 
 prove the faulty nutrition, which is the cause of the scrofu- 
 lous cachexia, and of the exudations assuming the characters 
 of tubercle ; (2.) To subdue the fever which attends the 
 growth and changes going on in the tubercle-nodules, and to 
 favor the absorption either of the entire exudation, or of 
 such portions of it, that what remains may undergo such 
 changes as are consistent with its future harmless existence 
 in the organs or other parts where it may have grown ; (3.) 
 To prevent the recurrence of fresh exudation by careful at- 
 tention to hygienic regulations, especially during the inter- 
 vals of apparent return to health. 
 
 To fulfil the first of these indications it is of all things 
 important that fatty matter be assimilated in large quanti- 
 ties, and it appears that such is most readily absorbed and 
 assimilated when in the rluid condition. The substance of 
 all others found most beneficial has been cod-liver oil. At 
 the Brompton Hospital more than 600 gallons of this oil are 
 used annually. There, on a great scale, its merits have been 
 tested and compared with the effect of treatment conducted 
 on general principles, and irrespective of its use. The result 
 has been to confirm, in the estimation of the medical profes- 
 sion, the great value of the remedy in the treatment of 
 phthisis, when appropriately administered, and combined 
 with the use of such other measures as any special circum- 
 stances in the individual patient may require (Thomson). 
 The general opinion of the profession with regarj to cod- 
 liver oil may be summed up in the statement originally made 
 by Dr. Bennett, — namely, that " it rapidly restores the ex- 
 hausted powers of the patient, improves the nutritive func- 
 tions generally, and stops or diminishes the emaciation. The 
 night perspirations subside, the cough is quieted, and the ex- 
 pectoration is diminished after the oil has been used for a 
 few weeks, A very constant and well-marked favorable 
 
SCROFULA. 369 
 
 change tinder its use is to be noticed in the diminution of 
 the pulse, which gradually but steadily has been observed to 
 come down at the rate of five or six beats weekly ; and dur- 
 ing the same period the weight of the body has been known 
 steadily to increase at the rate of half a pound to a pound. 
 In females it is a significant and highly favorable symptom 
 when the catamenia return after the oil has been used for 
 some time. The usual dose adopted by the late Dr. Thomp- 
 son, at the Brompton Hospital, is one or two teaspoonfuls 
 twice a day at first, and gradually increasing the quantity to 
 half an ounce three times a day. Dr. Bennett recommends 
 somewhat larger doses — namely, for an adult, a tablespoon- 
 ful three times a day, which may often be increased to four 
 or even six with advantage. When the stomach is irritable, 
 however, a tea or a dessert-spoonful is enough to commence 
 with. It appears from the observations of Dr. Thompson 
 that no additional advantage is obtained by pushing the oil 
 beyond the limits of the doses adopted by him at the Bromp- 
 ton Hospital, from the fact that where its use has most obvi- 
 ously increased the weight of the body, to the extent in one 
 instance of a pound per week for twenty-one weeks, only 
 three pints had been taken during that time. The kind of 
 oil used, as far as coarseness or fineness is concerned, seems 
 not to affect the beneficial result in any material degree. 
 Some patients even prefer the coarse to the fine oil. The 
 experience of some is, moreover, favorable to combining the 
 oil with liquor potassae as an emulsion ; and as it appears 
 that undue acidity prevails as well in the stomach as in the 
 intestinal canal, the addition of the alkali ought, on theoreti- 
 cal grounds, to be advantageous. It seems also that, when 
 cod-liver oil was first used as a medicine, more than fifty 
 years ago, in the treatment of rheumatism, it was then ordi- 
 narily combined with an alkali. It may be taken, however, 
 unmixed, or it may be floated on milk, or nitro-muriatic acid 
 mixtures, or on lemonade, soda-water, lemon juice, or on a 
 saline draught during effervescence, when such combinations 
 are suited to the patient. Creosote has been recommended 
 to be added, as it is said to render the stomach more tolerant 
 of the remedy. The following formula, quoted from Dr. 
 Thompson's "Clinical Lectures on Pulmonary Consumption," 
 yields a palatable mixture, which ought to be combined as 
 an emulsion: — 
 
 "An ounce and a half of cod-liver oil, four drops of creo- 
 sote, two drachms of compound tragacanth powder, and four 
 34 
 
37© SCROFULA. 
 
 ounces and a half of aniseed water. Of this mixture an 
 ounce may be taken thrice daily." 
 
 Besides cod-liver oil, other animal fats and oils, where they 
 can be taken and assimilated, are sure to be followed with 
 benefit. Hence milk rich in fatty matter, such as asses' 
 milk, and milk drawn from the cows at a short interval after 
 the greater part of their milk has been withdrawn, and which 
 is known in Scotland as " afterings," are found to be fol- 
 lowed by improvement where they are persevered in and are 
 assimilated. So also has it been with cream and butter. Dr. 
 Bennett instances the partial success occasionally of caviare, 
 bacon, pork, mutton chops, and the marrow of the bones of 
 oxen ; while Dr. Thompson instances the good effects he has 
 obtained .from the use of oil obtained from the foot of the 
 young heifer (neat's-foot oil). The administration of any of 
 these remedies is quite consistent with doctrines now taught 
 regarding the pathology of scrofula, and it is useful to know 
 their individual value, in order that in particular cases one may 
 fall back upon their use where a change may be desirable. 
 
 It has been considered that some of the good effects of 
 cod-liver oil may be due to the biliary elements with which it 
 has been incorporated. This view is not supported by the 
 experiment of adding ox-gall to other animal oils not derived 
 from livers, as no beneficial results have been observed to 
 follow. But as the active principle of the gastric juice has 
 been now successfully isolated by chemistry, and has been 
 successfully used to aid the digestion of food in the stomach, 
 might not some principle be obtained from the liver which 
 might aid the assimilation of fatty substances when mixed 
 with the intestinal juices ? 
 
 In fulfilment of the second indication mentioned the 
 propriety of abstracting blood has been much discussed. 
 It has been already seen that febrile symptoms of a very 
 severe kind sometimes attend the exudation and consolida- 
 tion of crude tubercle. It is also a more or less frequent 
 clinical observation that pneumonia, bronchitis, and pleuritis, 
 in acute or chronic forms, are intercurrent attendants on the 
 deposit and future changes of tubercles in the lungs. 
 " Hence," as Dr. Bennett justly observes, " there are all 
 kinds of intermediate changes between the simple and tuber- 
 cular exudations constantly going on in the progress of a 
 case of pulmonary tuberculosis. The phenomena of phthisis, 
 pneumonia, pleurisy, and bronchitis, in their acute or chronic 
 forms, may appear together, and be inextricably mingled, or 
 

 SCROFULA 371 
 
 they may succeed each other at intervals." Thus, scrofulo- 
 sis, both as a constitutional and as a local disease, is scarcely 
 ever free from exacerbations, the various local and con- 
 stitutional states acting and re-acting on each other. While, 
 therefore, on the one hand, the system requires an increas- 
 ed and well-directed supply of nutritive materials, on the 
 other hand, there are constitutional states of excitement, de- 
 pending on local irritation, which require to be subdued, and 
 which may even demand antiphlogistic treatment. What- 
 ever theoretical view may be taken as to how the exudation 
 may most readily be absorbed, all physicians are now at one 
 as to the propriety of preserving the general strength, of effect- 
 ing elimination of effete material, and of meeting antiphlogis- 
 tic indications rather by diaphoretics, diuretics, emetics, and 
 purgatives, than by abstracting any considerable amount of 
 blood, either at once or at repeated intervals. In fact it is 
 now observed that the administration of appropriate diet, 
 and abstinence from lowering remedies, with cod-liver oil, 
 while they correct the general nutrition, may be so regulated 
 as to subdue the constitutional irritation by a perseverance 
 in their use for a period of not less than four or six weeks. 
 In fulfilling the third indication, the real power of the science 
 of medicine may be demonstrated. It is by well-directed 
 hygienic measures, successfully and efficiently carried out, 
 that the real strength of the physician may be put forth to 
 prevent the recurrence of fresh exudation; and his hygienic 
 exertions towards the patient are to be redoubled during the 
 temporary intervals of apparent return to health. It is now 
 almost an axiomatic truth, that of all things which deterio- 
 rate the constitution on the one hand, and influence pulmon- 
 ary congestion on the other, none are so detrimental as im- 
 pure and deficient air, together with frequent variations of 
 temperature, and changes from sudden heat to chilling cold. 
 These latter vicissitudes may be considered characteristic of 
 the physical climate of Great Britain and Ireland. " The 
 conditions of preventive treatment which have seemed most 
 useful are nutritious food and proportionate great exercise 
 in the free and open air. So important has this last con- 
 dition proved to be, that it would appear that even consider- 
 able exposure to the weather is better than keeping phthisi- 
 cal patients in close rooms, provided there be no bronchitis 
 or tendency to pneumonia or pleurisy " (Parkes, p. 445). 
 Tonic treatment consists essentially in the adoption of those 
 means which promote or stimulate the healthy nutrition of 
 
37 2 SCROFULA. 
 
 the body. Its elements exist in fresh air, abundant exercise, 
 sufficient repose, and judicious diet. A hygienic code appli- 
 cable to the tuberculous cachexia has been recently laid 
 down by Dr. B. W. Richardson, in the second volume of the 
 Sanitary Review, and very recently in a special work On the 
 Hygienic Treatment of Pulmonary Consumption. It is de- 
 rived from these elements of tonic treatment; and as it puts 
 well-known truths, too little appreciated, in a formal and more 
 important aspect than is wont, its precepts are here quoted. 
 
 I. A supply of pure and fresh air for respiration in constant- 
 ly required by the tuberculous patient. — As it is known that if 
 one per cent, of carbonic acid exist in a room, the air is un- 
 fit for a healthy person, it is therefore much more so for a 
 consumptive one. The temperature of a room ought to be 
 equally maintained at from55° to 56 Fahr., ventilation and 
 heating being effected by open fireplaces. A single room 
 ought not to perform the two offices of a bed-room and a 
 sitting-room. The sleeping-room ought not to afford less 
 than 1,000 feet of space; and if larger, so much the more 
 healthful will it be. In connection with these statements, 
 while it is objected, for obvious reasons, with much justice, to 
 the treatment of tuberculous patients in special hospitals, there 
 is much on the other hand that might be improved in all our 
 hospitals, with reference to the arrangement of the patients, 
 to secure to them fresher air than they generally obtain. 
 " Constant though imperceptible movement of the air is the 
 point to be attended to " — 1. e., thorough ventilation. All 
 who are able to be out of bed ought to have their meals in a 
 common room, which is not used for any other purpose, and 
 is apart from the wards or dormitories. 
 
 II. Active excercise in the open air is imperatively demanded 
 by the tuberculous patient. — In the words of Dr. Jack- 
 son, " He must be made to feel that the risk is in staying in 
 the house, and not in going out of it." But the skin must 
 be perfectly protected; and while a chill, or inclement wea- 
 ther, is to be avoided, the patient must go out in all seasons, 
 without being too fastidious about the weather, walking ex- 
 ercise being persvered in as much as possible. " The best 
 climates for phthisis are perhaps not necessarily the 
 equable ones, but those which permit the greatest number of 
 hours to be passed out of the house" (Parkes). Next to 
 diet, exercise in the open air is, of all things, the most im- 
 portant: it should be carried as far as the vigor of the pa- 
 tient will permit. It should not be done rashly, but boldlv; 
 
scrofula. 373 
 
 and, if possible, the patient ought to have faith in it; for 
 without this he is not likely to pursue it so far as he can, 
 and then he will not derive from it all the benefit which it 
 can afford (Jackson). It is very important to remember, in 
 regard to training animals and young persons, that they have 
 much more extent and range of lung than are required in 
 the quiet everyday pursuits of life. Less lung is used when 
 the young person or other animal lies down or sleeps, or is 
 depressed; and, on the contrary, walking, running, wrestling, 
 the force of the passions, each or all of them bring the 
 greatest amount of lung into action or use. In short, the 
 amount of lung in use is an ever-varying quantity; and just 
 as much lung may come to be used as a habit as the listless- 
 ness or vigor of the individual moment requires. There is 
 every range, every variety, till the top of the wind, the top 
 of the speed (the full vital capacity) is attained (Sibson) 
 Practically, therefore, the more fully the lungs are judiciously 
 used, the more is their capacity nursed; and, conversely, 
 the less they are used and expanded, the more useless they 
 are likely to become, if not absolutely diseased. Under a 
 judicious system of training, an undeveloped man, even al- 
 though he may be feeble, narrow-chested, and sickly, may 
 yet become active, full-chested, and healthy. We have 
 numerous examples of this among the boys in our training 
 ships for seamen. The over-fed, short-winded pugilist, 
 rower, or cricketer, may in a few weeks be changed, by 
 training alone, to the firm-fleshed, clear-skinned, long-winded 
 winner of the boxing fight, the foot race, or the rowing 
 match. It is this want of use that probably renders the 
 apices of the lungs more liable to the growth of tubercle in 
 them than in any other part of their substance. It is a por- 
 tion of the lungs which has less play or expansion than any 
 other portion, and is apt to be bound down by the sur- 
 rounding parts. The apices are, therefore, the parts most 
 likely to remain in a quiescent state of non-expansion, 
 especially when acts of respiration are inadequately per- 
 formed, either owing to the constrained position of the body 
 in certain trades, or from habitual stooping of the body from 
 listles^ness of habit or want of vigor in the system. This 
 quiescent state of the air-cells is favorable to the growth of 
 tubercle; and thus the apices of the lungs are the most com- 
 mon seat of tuberculous growths (Reviewer in Medical Mirror, 
 Vol. I., p. 638). The effects of want of exercise and of im- 
 pure air are thus most potent agencies in causing phthisis. 
 
374 SCROFULA. 
 
 " The mich greater prevalence of phthisis in most of the 
 European armies (French, Prussian, Russian, Belgian, and 
 English) can scarcely be accounted for in any other way than 
 by supposing the vitiated atmosphere of the barrack-room to 
 be in fault." In all the places where phthisis has 
 prevailed, in the most varied stations of the army, 
 in the most beautiful climates, the only common condition 
 was the vitiated atmosphere which our barrack system every- 
 where produced; "and, as if to clench the argument, there 
 has been of late years a most decided decline in phthisical 
 cases in these stations, while the only circumstance which 
 has notably changed in the time has been the condition of 
 the air" (Parkes, p. 91). Indeed, the air is rendered so 
 so impure by respiration, that while an atmosphere so vitiated 
 has a mo'st injurious effect upon the health, contamination 
 of the air has been so great, where lung diseases abound, as 
 to give rise to the idea that phthisis appeared to be propagated 
 by contagion (Bryson, Parkes). It is therefore within the 
 power of the authorities of the Army and Navy so to direct 
 the physical training of young persons, that the apparently 
 sickly and the short-winded may in time be developed into 
 the wiry and active young man, long in wind, sound in body, 
 and lithe of limb — a result which, however, can only be at- 
 tained by judicious feeding, careful exercise throughout the 
 development of the body, and by the gradual nursing of the 
 breathing powers. The opposite of this is seen in the break- 
 ing down of recruits at a very early period of service in the 
 army — within the third year — a result likely to be greatly 
 obviated by the gymnasia introduced by Government for the 
 physical training of recruits before and after they are in- 
 structed in drill, by better and more abundant food, and im- 
 proved barracks. The Austrian runners also furnish instances 
 of breaking down by over-exertion in running at ages un- 
 suited for their strength. They seldom live above three or 
 four years, and gradually die of consumption (Remains of 
 Mrs. Trench, p. 72). In all physical training the condition 
 of the heart must be considered not less than the lungs, see- 
 ing that its movements respond to the movements of the 
 chest and the lungs. They are members of one great system; 
 and in nursing one we nurse the other; for by giving tone 
 and health to one we must give tone and strength to the other 
 (Sibson). If, on the contrary, the development and gradual 
 training of the lungs are not successful, the lesions which be- 
 come developed are of a peculiar character, and are apt to 
 
scrofula. 375 
 
 be thought very lightly of; because, in the first instance, they 
 are so little capable of appreciation by a single observation; 
 and, secondly, because the lesions are insidious, and take 
 some time before they reach a stage to be apparent. 
 
 III. It is importa?it to secure for the patietit a unifor?n, 
 sheltered, temperate, a?id mild climate to live in, with a tem- 
 perature about 60 ° a?id a range of not more than io Q or 15 / 
 where also the soil is dry, and the drinking-water pure and not 
 hard. — The classic work of reference on this topic is that by 
 the late Sir James Clark. If it is possible to give a practical 
 abstract of his extensive and valuable experience, it may be 
 done somewhat as follows: — (1.) After the functions of the 
 digestive organs and skin have been re-established in im- 
 proved action, the patient who labors under a tuberculous 
 cachexia may derive benefit by a residence in a mild or tem- 
 perate climate (such as has been defined), conforming to all 
 the hygienic and medicinal treatment already mentioned. 
 (2.) When symptoms, however slight, indicate that tubercul- 
 ous deposit has located itself in the lung, removal to a mild 
 climate, especially if effected by a sea voyage, under favor- 
 able circumstances, may still be useful as a means of im- 
 proving general health, of lessening the chance of intercur- 
 rent inflammatory affections of the pulmonary organs, and 
 even of arresting the further progress of the disease. The 
 nausea, squeamishness, or even sickness, which with some 
 are always more or less associated with a sea voyage, are 
 beneficial to cases of incipient tuberculosis. The effects of 
 such nausea tend to increase the natural secretion and 
 elimination from the pulmonary mucous membrane; so that 
 minute portions of tubercular exudation, commencing to 
 consolidate in the air-vesicles, are effectually, gradually, and 
 gently passed out with the motion of the pulmonary mucus 
 in the expectoration. The sensation of nausea tends to sub- 
 due any local vascular irritation; and the unceasing motion 
 of a sailing vessel tends to keep up a constant exercise which 
 is advantageous to the patient. (3.) When extensive tuber- 
 culous disease exists in the lungs, little benefit is to be ex- 
 pected from a change of climate; and a long journey will 
 most certainly increase the sufferings of the patient, and 
 hurry on a fatal termination. (4.) There are cases, however, 
 of chronic consumption which may derive benefit from resi- 
 dence in a mild climate, — namely, cases in which the deposit 
 is limited to a small portion of the lungs, and little systemic 
 irritation prevails or in cases in which the disease has ceased 
 
$?6 SCROFULA. 
 
 to extend to the lungs, but where a long time is required to 
 complete repair. 
 
 IV. The dress of the scrofulous patient ought to be of such a 
 kind as to equalize and retain the temperature of the body. — 
 Under this topic waterproof coats, boots, and shoes are to be 
 condemned. Flannel ought invariably to be worn next the 
 skin in all seasons; and in winter a chamois leather vest may 
 be required over the flannel. 
 
 V. The hours of rest should extend from sunset to sunrise. 
 
 VI. Indoor or sedentary occupatio?i must be suspended ; but 
 outdoor employment in the fresh air, even in the midst of snow, 
 has been and may be advantageous. 
 
 VII. Cleanliness of body is a special point to be attended to in 
 the hygienic treatment of tuberculosis. 
 
 VIII. Marriage of consumptive females ', for the sake of ar- 
 resting the disease by pregnancy, is morally wrong and physically 
 mischievous. 
 
 IX. The medicinal treatment must be adapted to the site of 
 the local scrofulous deposits and the general nature of the par- 
 ticular case. — Iron and iodine in various forms are the most 
 useful remedies; but medicine is utterly powerless and use- 
 less unless the hygienic means now insisted upon are carried 
 out to the utmost. 
 
 (c.) Medicinal Treatment. — When medicine is required to 
 move the bowels, as it often is, nothing serves so well as pow- 
 ders of rhubarb, soda, and calumba, taken three times daily, 
 or morning and evening only, or an hour before food. Mer- 
 cury in any form is not borne by scrofulous patients. Lime- 
 water to the extent of half an ounce taken with milk, three 
 or four times a day, is of marked benefit in those cases of 
 long standing where gland after gland becomes the seat of 
 abscess and ulcer (Shapter). The muriate of barytes, next 
 to iodine, exerts the most decided influence over scrofula. 
 It increases the appetite and the secretions (Adair, Crawford, 
 Phillips). The whole class of tonic remedies are of essential 
 service; such as, small doses of quinine with conium; iron in 
 all its most digestible forms (see under anaemia). The em- 
 ployment of acids is often also called for, especially if per- 
 spirations become excessive. A useful formula consists of: 
 
 Acid Hydrocyan. dil. 3 i., glycerine § ii.; acid nitric, dil. 
 3 iii., Infus quassiae ad § xiiiss — a tablespoonful for a dose. 
 
 But of all remedies iodine and its compounds are the most 
 valuable in scrofula. The following formula is that which 
 Dr. Shapter has found most useful: 
 
SMALL-POX. ;J7 
 
 5- Iodine gr. x.; potassae hydriodatis gr. xx., aqu?e § iL 
 From 8 to 12 minims are to be dropped into a glass of water 
 and taken three or four times a day by an adult. 
 
 It improves appetite and the complexion; subdues the 
 general symptoms, and promotes absorption of the scrofu- 
 lous glandular swelling. Iodism or iodic saturation must, 
 however, be very carefully guarded against. 
 
 Small-pox. — Definition. — Small-pox in man is the pro- 
 duct of a specific and palpable morbid poison, which is re- 
 produced and multiplied during the course of the malady. 
 It is contained in the contents of the pustules, and in the cu- 
 taneous and pulmonary excreta of small-pox patients. After 
 a definite period of incubation (of about seven to nine days, 
 in cases of inoculated, and from ten to thirteen days by ordi- 
 nary infection) a remitted fever is established, and followed 
 by an eruption on the skin on the third day of the fever af- 
 ter forty-eight hours' illness, and sometimes on the mucous 
 surfaces. The eruption on the skin passes through the stages 
 of papule, vesicle, pustule, scab, and leaves marks or cica- 
 trices on its site. The disease runs a definite course, and, 
 as a rule, exhausts the susceptibility of the constitution to 
 another attack. 
 
 Treatment. — Since the first accounts by the Arabian phy- 
 sicians of the ravages of small-pox in Mecca, the history of 
 this disease may be considered in three great eras, each of 
 which is characterized by remarkable epochs, and a fourth 
 may be said to be running its course now. The first of these 
 eras is marked by a commencing epoch of improvement in 
 the treatment of small-pox. In few diseases has medical 
 opinion undergone a more obviously beneficial change, and 
 to Sydenham is due the merit of this revolution in medical 
 practice. The epoch of the second era is marked by the 
 discovery of the singular and beneficial phenomenon that 
 the virulence of the poison of small-pox was greatly mitigated 
 by introducing or engrafting the disease into the system, 
 through the cutaneous tissue, thereby causing the transfer- 
 ence of the disease from one person to another, by inocula- 
 tion. To Lady Mary Wortley Montague is due the merit 
 of having introduced the practice of inoculation into this 
 country in 1722 — a deed which must be considered as one 
 of great heroism, when measured by the knowledge possessed 
 by the physicians of those days. The third great era in the 
 history of small-pox is marked by the epoch of that remark- 
 able discovery which has rendered the name of Jenner im- 
 
378 SMALL-POX 
 
 mortal — namely, the modifying and protecting influence of 
 vaccination. He found that a certain disease in the cow, 
 known as the cow pox, could be transferred to the human 
 subject by inoculation ; and that, having been so transferred, 
 it modified, to a considerable extent at least, the course of 
 the disease, if it did not altogether prevent in the human sub- 
 ject the occurrence of small-pox in its natural state. A 
 fourth era may be said to have commenced in this country 
 almost imperceptibly. It may be described as marked by an 
 epoch of transition, in which doubt and scepticism have 
 arisen as to the efficacy of vaccination ; tending to propagate 
 an erroneous popular belief ; and consequently, leading to 
 the ineffective adoption of means which practically have 
 been proved to be sanative in the highest degree. In other 
 countries, on the contrary, and especially in Central Europe, 
 this present period is marked by implicit faith in the virtues 
 of vaccination, and the successful legal enforcement of this 
 sanative measure. The most plausible objections to vaccina- 
 tion must now give way before the one great fact that, dur- 
 ing the last century, one-tenth of the population died of 
 small-pox, while another tenth were disfigured for life by the 
 disease ; and that since the introduction of vaccination, the 
 general mortality from all diseases is less, and that of small- 
 pox is reduced to a minimum. 
 
 An account of the treatment of small-pox resolves itself, 
 therefore, into a consideration of two topics, namely, — (1.) 
 The usual therapeutic, curative, or sanative treatment of the 
 disease ; (2.) The sanitary treatment — i. <?., the means of 
 protecting individuals from the small-pox ; or of modifying 
 the influence of the malady by inoculation or by vaccination. 
 Of these in their order, — 
 
 I. Therapeutic, Curative, or Sanative Treatment of Small- 
 Pox. — The main object, in the first instance, is to prevent, 
 if possible, a copious eruption ; for the severity and danger 
 of the disorder may be measured, in some degree, by this. 
 The vulgar belief, that " better out than in," does not apply 
 in the case of small-pox. The great object is to reserve the 
 strength of the patient ; and the attentions of an experienced 
 nurse are demanded. A third indication is to watch for and 
 deal vigorously with intercurrent inflammatory action, which 
 is apt to be set up. It has hitherto been the belief and or- 
 thodox teaching, that the disease is not under the influence 
 of any specific or antidote ; that there is no remedy which 
 will cut short the disease ; that it must run its course ; and 
 
SMALL-POX. 379 
 
 that it is the business of the physician to assuage the unto- 
 ward symptoms and avert the dangerous accidents which 
 may arise, by all the most approved methods of treatment, 
 in accordance with the science of medicine of the present 
 day. That there are grounds for modifying this belief and 
 dogmatic teaching, the following statements will show : — 
 The chief physician of Iceland, Dr. J. Hjaltenin, believes 
 that it may be stamped out by the action of sulphur- 
 ous acid gas ; and relates how, in its malignant 
 form, it was so treated, and stamped out of that 
 island without a single person of the inhabitants 
 becoming infected. The disease was imported into Iceland 
 by French fishing vessels coming into the harbor of Rey- 
 kjavik, to ask for medical aid; having on board men sick of 
 small-pox. Vaccination and revaccination were immediately 
 instituted; and government at once erected a quarantine 
 hospital, to which the cases were taken from the ships. The 
 epidemic showed a high degree of malignancy; and Dr. 
 Hajaltelin, being a firm believer in the power of disinfect- 
 ants and antiseptic remedies, resolved to try such remedies, 
 one after another; the only question being whether 
 to use those compounds which acted by oxygenizing or by 
 disoxygenizing. He ultimately decided to use the disoxygen- 
 ating antiseptics, as being the most safe; and fixed upon 
 sulphurous acid as less irritant for the respiratory organs 
 than chlorine. He used it externally by fumigation, by 
 burning refined sulphur in the sick rooms, and internally by 
 giving sulphurous acid mixed with pure water — the usual 
 dose being 3 I, mixed with one ounce of water, and repeated 
 every third hour. The patients at first disliked the fumiga- 
 tion, from the strong and pungent odor of the sulphur; but 
 they soon felt its good effects and desired to have more. 
 These good effects were, — the heat of the eruptive fever 
 diminished, and the vesicles dried very quickly, leaving the 
 skin covered with thin brown scales, which soon fell off. 
 Out of 22 patients so treated he only lost one, who came to 
 the hospital moribund, and who died thirty-nine hours after 
 arrival. Seven had confluent small-pox; and of these three 
 were in the suppurative stage. Others were cases of discrete 
 small-pox having the eruption of vesicles abundant. He 
 thus sums up the good effects of the disinfectant method of 
 treatment by sulphurous acid externally and internally: — 
 (i.) It mitigated the primary and secondary fever; lowering 
 the temperature, and thirst was diminished, even when fever 
 
380 small-pox. 
 
 ran high. (2.) The general symptoms were also lessened in 
 severity, such as the headache, backache, and pains in the 
 joints. (3.) He believed the sulphurous acid and vapors 
 had a destructive influence on the small-pox virus. Its de- 
 structive effects on parasite life are undoubted {Brit. Med. 
 Journal, Nov. 4. 187 1, p. 519). 
 
 Treatment by Vaccination. — There are also some grounds 
 for believing that vaccination and the hypodermic injection 
 of vaccine lymph " may curb the small-pox," even when 
 performed at a period subsequent to the reception of the 
 variolous poison: and the observations and practice of Mr. 
 R. C. Furley, detailed in the British Medical Journal for 
 June 8, 1872, show that vaccination will modify small-pox 
 after the eruption has appeared. An impression prevailed 
 that it was dangerous to be vaccinated while small-pox was 
 prevalent; and also that it was of no use to vaccinate so 
 long as the former vaccination mark was quite distinct. 
 Both these ideas are opposed to facts. On the contrary, 
 Mr. Furley's cases show that vaccination, and the injection 
 of vaccine lymph, especially if done about the second or 
 third day of the disease, possess valuable curative powers, so 
 that a disease which promises to be most severe is curbed or 
 modified. Mr. Furley uses a hollow needle for injection, the 
 bore of the tube of which -is large enough to admit a vaccine 
 tube, from which the lymph is forced directly into the circu- 
 lation. He injects hypodermically in both arms. 
 
 Dietetic and General Treatment. — In the first instance, the 
 course to be pursued is for the physician to act on the de- 
 fensive, and simply protect his patient from certain injurious 
 influences to which he may be exposed, — such as, heating 
 drinks to force out the eruption, which are apt to be given 
 by ignorant and officious friends. Throughout the whole 
 course of the disease, the diet should be strictly limited to 
 slops, sago, arrow-root, and ripe fruits, with cold water or 
 lemonade' for drinks, with or without ice. The chamber in 
 which the patient lies should be cool, not above 6o° Fahr., 
 and freely ventilated. The bed-clothes should be light, the 
 body-linen daily changed; and, when the disease is long, the 
 patient's back should be often examined to prevent slough- 
 ing. The scalp, likewise, should be examined, and, if full of 
 pustules, the hair should be cut off, to prevent its matting. 
 If the disease be recognized early, however, it is proper to 
 shave the scalp, because the irritation which attends the 
 suppuration of the pustules is thereby diminished, and cold 
 
SMALL-POX. 381 
 
 may be more efficiently applied to the head, if necessary. 
 In the early stage of the primary fever, in severe cases more 
 especially, it is necessary to have the bowels well opened in 
 the first instance, and to keep them regularly moved daily by 
 saline medicine, or an enema of three parts water to one of 
 vinegar. A cathartic pill, composed of the following in- 
 gredients, will be found to be efficient in most cases, especi- 
 ally if aided by a Seidlitz powder, given six or eight hours 
 after the pill ; namely, — Two grains of calomel, one grain of 
 the compound extract of colocynth, one grain of gamboge, 
 and one grain and a half of scammony, made consistent with 
 a little aromatic oil. The bowels must be daily attended to, 
 and castor-oil, or rhubarb, or magnesia, may sometimes be 
 required. Saline diaphoretics, in the form of James's powder; 
 of the aqua acetatis ammoniae, to which a grain or two grains 
 of tartar emetic has been added, so as to have £ or T V of a 
 grain in every tablespoonful of the mixture, is an efficient 
 and cooling diaphoretic. Spirit of nitric either, or the nitrate 
 of potass, may be added if required. The surface of the 
 body, over the hands, face, and feet, ought to be sponged 
 several times a day with tepid water mixed with Condy's 
 fluid, or with sulphurous acid, with a view to relieve the 
 intolerable itching; but caution is necessary to prevent ex- 
 posure to cold. Cold-cream, or a liniment of olive oil, 
 glycerine, and lime-water, or of Carron oil (linimentum aqua 
 calcis), smeared from time to time over the itching surface, 
 by means of a camel-hair pencil, may be found to afford re- 
 lief; and chlorine lotions are highly spoken of by Eisenmann. 
 With regard to the occurrence of convulsions in children, it 
 is not found that opiates, as recommended by Sydenham and 
 Cullen, are expedient. When the children are robust, or 
 previously in good health, local bleedings, by means of one 
 or two leeches to the temples, are more beneficial. Delirium, 
 violent screaming, intolerance of light or sound, heat of 
 head, all of which indicate a tendency to meningeal conges- 
 tion, still more clearly warrant the application of leeches. 
 With regard to the propriety of bleeding (general) in adults, 
 it is now well ascertained that it will neither eradicate the 
 fever nor diminish the amount of the eruption; moreover, 
 experience has now amply shown that loss of blood is badly 
 borne in all infectious diseases. The persistent application 
 of cold to the head, and repeated affusion of the body with 
 cold water, is to be preferred, in cases where there is much 
 cerebral excitement. When delirium with restlessness, 
 
382 SMALL-POX. 
 
 wakefulness, and a frequent pulse, is continuous, an opiate, 
 or the free use of alcoholic stimulants, are indicated; and 
 opium is most advantageously given combined with tartar 
 emetic. A draught, composed of thirty minims of the solu- 
 tion of muriate of morphia, with half a grain of tartar emetic, 
 will be found beneficial in such conditions, especially when 
 given at bed-time. If the temperature rise higher, large doses 
 of quinine, 3 to 5 grains, every three or four hours, are to be 
 given. Cooling drinks, with or without ice, of lemon-juice, 
 tamarinds, neutral effervescing powders, are always agreeable 
 to the patient, who ought, for the sake of coolness, to be 
 very lightly clothed. After the eruption has fully appeared, 
 this is all which in ordinary cases requires to be done, and 
 if, towards the tenth or' eleventh day, there is much restless- 
 ness or sleeplessness, an opiate may be given. 
 
 In the complications which sometimes ensue, such as in- 
 flammation of the throat and base of the tongue, opiates are 
 found to be injurious. The general treatment must be by 
 cathartic or purgative clysters, if swallowing is difficult. In 
 the other inflammations, however, opiates are of the greatest 
 service, provided the symptoms be not those of cerebral op- 
 pression or bronchitis. In bronchitis, nauseating doses of 
 antimony every hour sometimes procure relief; and if relief 
 does not follow in the course of thirty to thirty-six hours, 
 stimulant doses of mistura ammoniac with squills ought to be 
 given every second hour to promote free expectoration. 
 
 In the advanced stage of the secondary fever the strength 
 of the system requires maintenance and support; because 
 the abundant suppuration and extensive cutaneous irritation 
 combine to exhaust the strength, as shown by the weakened 
 pulse, the dark and dry tongue, blueness, paleness, or cold- 
 ness of the extremities. Tonics, stimulants, and generally 
 nutritious diet, are now called for. Quinine, mineral acids, 
 malt liquors, especially the light bitter ales, light porter, wine, 
 and even brandy, may be demanded. The diet should con- 
 sist of milk, strong animal broths, eggs, raw or lightly boiled, 
 according to the discretion of the physician, and regulated by 
 the digestive powers of the patient. 
 
 The development of a severe eruption on the conjunctiva 
 is to be especially guarded against, by the assiduous employ- 
 ment of cold water applications, or by compresses moistened 
 with a weak solution of corrosive sublimate (one grain to six 
 ounces of water, with or without the addition of muriate of 
 ammonia (Niemeyer). 
 
SMALL-POX. 383 
 
 To prevent the face from being seamed, scarred, or 
 " pitted " by the suppuration of the pustules, has taxed the 
 ingenuity of physiologists and physicians. It has been stated 
 that the influence of the atmospheric air is essential to the 
 development of the pustules, and, accordingly, anything 
 which would effectually exclude this influence would prevent 
 the occurrence of a scar. But it is evident that the chance 
 of scars can only be diminished by those means which are 
 calculated to allay the general violence of the disease. When 
 the eruption is severe, it is almost impossible to prevent the 
 formation of " pits," because the depression results from the 
 expulsion of a small slough; and the more mild the suppura- 
 tive inflammation can be rendered, so in proportion will the 
 chance of sloughing, and therefore " pitting " be dimin- 
 ished. 
 
 The local means which have been adopted to prevent 
 "pitting" may be shortly stated as follow: — (1.) To open 
 each individual pustule after suppuration has commenced. 
 (2.) To cauterize the pustules with nitrate of silver. (3.) To 
 employ both methods — that is, to open each of the pustules 
 when it becomes vesicular, and introduce a strong solution of 
 nitrate of silver into the cavity of the vesicle. At the end of 
 a week scales fall off, and no pit is left. Or, lastly, to paint 
 the face with a solution of nitrate of silver, in the proportion 
 of one drachm of the nitrate to the ounce of water. (4.) The 
 application of a mercurial plaster, with the view of producing 
 resolution of the papulae. The preparation in use for the 
 purpose at the Children's Hospital in Paris consists of twenty- 
 five parts of mercurial ointment, ten parts of yellow wax, six 
 parts of black pitch. With this plaster the face is to be cov- 
 ered, and so to remain for several days. (3.) Sulphur oint- 
 ment, applied several times a day. (6.) Calamine mixed with 
 olive oil, to form a coherent crust (Bennett). (7.) Tincture 
 of iodine, painted over with a brush. (8.) Saturated solution 
 of gutta percha in chloroform (Drs. Graves and Wallace). 
 (9.) To smear the face over with common olive oil. (10.) 
 Skoda prefers compresses moistened with solution of corro- 
 sive sublimate (two to four grains in six ounces of water) to 
 mercurial plaster, which induces too much elevation of tem- 
 perature. (11.) Hebra recommends cold water compresses 
 only. 
 
 All of these applications have been for the most part ap- 
 plied to the face, the hands, and the arms only. 
 
 The severity and the mortality of small-pox have led many 
 
384 SMALL-POX. 
 
 to think of means by which the disease might be completely 
 extirpated. This leads to the consideration of — 
 
 II. The Prophylactic ; Sanitary, or Preventive Treatment of 
 small-pox. — More than half a century a«o it was generally 
 taught, among English physicians, that small-pox attacked 
 the same individual only once in the course of life, and that 
 its double occurrence in the same person was either very rare 
 or next to impossible. The observations of Drs. Willan, John 
 Thomson, Mr. Cross, Dr. Barnes, Dr. Craigie, and others 
 since the time of these eminent physicians, lead to the follow- 
 ing general conclusions : — (1.^ Small-pox, though in general 
 attacking the same individual onlv once during the course of 
 life, may, however, affect him a second, and even a third 
 time. (2.) This happens much more commonly when the 
 first attack has been one of mild distinct small-pox, than 
 when it has been severe ; and if the first attack has been one 
 of confluent small-pox, it is rare for the same individual to 
 have a second attack. (3.) It is established by numerous ob- 
 servations, that an attack of any one of the varieties which 
 have been named spurious small-pox, or abortive small-pox, 
 or chicken-pox, by no means secures the same individual from 
 an attack of confluent small-pox at a subsequent period. (4.) 
 Small-pox produced by inoculation does not necessarily se- 
 cure the individual against an attack of small-pox induced in 
 the natural way. (5.) Every previous attack, however, of 
 small-pox, whether natural or inoculated, exercises some 
 modification on that which succeeds. This modification may 
 be various in degree, from very slight and almost impercepti-' 
 ble to very conspicuous and remarkable. In this modifica- 
 tion the symptoms of eruptive fever may be mild and of 
 short duration ; and the eruption may consist of vesicles or 
 hard pustules, which disappear without suppuration. (6.) 
 The most powerful modifying agent on the course of 
 small-pox is the action of the cow-pox on the 
 constitution, or the disease produced by the appli- 
 cation of vaccine lymph to the exposed skin. The specific 
 disease so induced, in a large portion of cases, not only ren- 
 ders the individual less likely to be affected by the variolous 
 effluvia, but, if he is affected, changes very much the charac- 
 ters of the disease which may supervene. Though the fever 
 which precedes the eruption in cases of this class be similar 
 in form and equal in degree to that by which the inoculated 
 small-pox is attended, the eruption is either papuliform or 
 tuberculatedj without much surrounding inflammation. A 
 
SMALL-POX. 385 
 
 similar eruption is produced when vaccine and variolous mat- 
 ter are inoculated at the same time in the same individual; 
 or when a person who is exposed to the variolous contagion 
 has been inoculated with vaccine lymph early enough to mit- 
 igate, but not wholly to supersede, the eruption of small-pox. 
 In such circumstances the vaccine lymph and variolous mat- 
 ter restrain and counteract the operation of each other on 
 the system and on the skin. To these eruptions of modified 
 small-pox the general name of varioloid eruptions has been 
 applied. (7.) Cow-pox destroys the susceptibility to inocu- 
 lated small-pox almost entirely; but the susceptibility to the 
 natural disease, or that by inhalation^ it does not entirely ex- 
 tinguish. This susceptibility, however, it diminishes in a 
 much greater degree, and much more effectually, than in- 
 oculated small-pox does. (8.) The susceptibility to second 
 attacks of small-pox,* and attacks of small-pox after vaccina- 
 tion, is principally favored by the existence of an epidemic 
 constitution of the atmosphere, and by the circumstance of 
 early life, or the age below ten years. If no epidemic influ- 
 ence exists, the occurrence of second attacks of the disease 
 may not be observed for a long series of years. But if, on 
 the other hand, the atmosphere should possess or acquire an 
 epidemic or variolous constitution, then neither the circum- 
 stance of a previous attack of small-pox, nor vaccination, 
 can insure many of those under ten years of age, and not a 
 few between that and thirty, from attacks of small-pox. 
 
 The preventive management of small-pox consists: (1.) 
 In the artificial production of the disease by inoculation, or 
 artificial variolation. (2.) In the modifying and protective 
 influence of vaccination. 
 
 Inoculation consists in the application of small-pox matter 
 or virus to the surface of the corium, exposed by a puncture 
 or scratch. The result is a local inflammation similar to 
 small-pox, attended with an eruption and a fever, generally 
 milder in form than small-pox acquired by breathing an at- 
 mosphere contaminated with the specific poison of the dis- 
 ease. The poison thus passes through the mucous mem- 
 brane to infect the blood; and hence this is called the "nat- 
 ural way" of contracting small-pox. For obvious reasons, 
 the operation of inoculating the poison of small-pox has been 
 
 * The average number of second attacks of small-pox seems to be one 
 percent. (R. Acad, of Med., Marseilles, i8?8 ; and B. and F. Med- 
 Chir. Review, Jan., 1848, p. 74). 
 
 25 
 
386 SORE THROAT, CLERGYMAN'S — ST. VITUS* DANCE. 
 
 rendered illegal in this country, and the practice of vaci: a- 
 tion has been attempted to be enforced by law. 
 
 Sore Throat, Clergyman's — See Pharyngitis, Chronic, 
 
 Sore Throat, Sloughing. — Definition. — Idiopathic 
 ulceration of an acute form, attacking the tonsils and rapidly 
 running into sloughing of the fauces. 
 
 Treatment. — In all cases of sloughing sore throat a stimu- 
 lating and tonic treatment must be pursued. Tincture of 
 the perchloride of iron, quinine, and chlorate of potash, are 
 the most suitable internal remedies. Disinfecting gargles of 
 carbolic acid or permanganate of potash are not only agree- 
 able to the patient, but very useful in checking the offensive 
 discharges. 
 
 Spasm Of Muscle— See Muscle, Spasm of. 
 
 Spleen, Inflammation of— See Splenitis. 
 
 Splenitis. — Definition. — A primary acute inflammation 
 of the substance of the spleen. 
 
 Treatment. — Bleeding in splenitis will not effect a cure, 
 while mercury is most pernicious. A spleen mixture, not 
 dissimilar to thafrecommended by Celsus, is most in vogue 
 in India. The best, according to Mr. Twining, consists of 
 the following: 
 
 ^. Pulv. Jalap.; Pulv. Rhei.; Pulv. Calumba; Pulv. Zin- 
 gib; Potass. Supertart, a a 3 j.; Ferri Sulphat., 9ss.; Tinct. 
 Sennae 3ss.; Aquae Menthae Pip., § ixss. Of this mixture 
 an ounce or an ounce and a half is to be taken twice a day, 
 or such quantity as may produce three or four stools in the 
 twenty-four hours. 
 
 The iodide of potassium and the bromide of potash have 
 been more recently recommended. The dose of the bro- 
 mide of potash is gr. v. to x. ter die, combined with camphor 
 mixture. The marked influence of the biniodide of mercury, 
 in the form of an ointment rubbed into the skin over the 
 surface of a goitre, in reducing its enlargement, has been al- 
 ready noticed. It has been similarly used in cases of en- 
 larged spleen ; and the invalid soldiers who suffer from 
 enlarged spleens invariably apply for some to take away with 
 them when they are discharged from Netley Hospital. 
 
 Spinal Cord, Inflammation and Suppuration of— 
 
 See Encephalitis. 
 
 St. Vitus' Dance— See Chorea, 
 
3»7 
 
 Stomach, Chronic Fleer Of. — DefiniHon. — Inflamma- 
 tion of the stomach, ending by loss of substance in the form 
 of an ulcer. 
 
 Treatment. — Chronic ulcers are to be treated by rest to 
 the stomach, and by dietetic rather than by medicinal means. 
 The patient must eat in small quantities, especially of milk 
 compounded with arrow-root, macaroni, semolina, sago, 
 tapioca, biscuit power, barley meal, Indian meal, or oat 
 meal gruel. Iced milk, combined with one-quarter to one- 
 third of lime-water, is particularly recommended, two or 
 three tablespoonfuls of which are to be taken at short in- 
 tervals; so that about two quarts of milk may be thus used 
 during the day; rendering regular and more bulky meals un- 
 necessary. The lime-water tends to prevent coagulation, 
 and the milk more readily passes unaltered into the intes- 
 tines, to be digested by them rather than by the stomach. 
 The most complete rest possible ought to be given by stop- 
 ping the supply of all nutriment by the mouth, and support- 
 ing the patient for several days by nutritive enemata. Per- 
 fect quiet in the recumbent posture must be observed, the 
 lips and tongue being moistened from time to time by a 
 little water. The patient may thus be kept for eight or nine 
 days, or even longer, on nutrient enemata alone, when the 
 pain, the irritability of stomach and of the system will cease. 
 The substances most useful for enemata are milk, strong un- 
 salted beef-tea, raw eggs beaten up in milk, occasionally a 
 little brandy, and (generally in two enemata daily) ten or 
 twenty minims of tincture of opium. The enemata should 
 be as small as possible, from two to six ounces only at a 
 time. The interval to the stomach thus gained of complete 
 rest is of the greatest importance towards success in the 
 treatment of gastric ulcer; and, combined with the restricted 
 diet described, will usually effect a cure in three weeks (Dr. 
 Balthazar W. Foster, of Birmingham, Brit. Med. Journal, 
 June 3d, 1865). Next to dieting, blood-letting by two or 
 three leeches, applied to the region of the stomach about 
 twice a week, affords obvious benefit. Blistering applied to 
 the spine may relieve the dorsal pain. Small lumps of ice 
 may be swallowed if the stomach is irritable; and astringent 
 remedies, especially the salts of metals, such as a combina- 
 tion of iron and alum, are of use; and gallic acid, nitric acid, 
 and bitter barks may be administered. Constipation is to 
 be counteracted by enemata. When haemorrhage occurs, 
 small bits of ice may be swallowed, and rest maintained in 
 
388 STOMATITIS. 
 
 the horizontal posture. Astringent medicines are to be ad- 
 ministered, such as oil of turpentine, acetate of lead and 
 opium, alum and tannic acid. Oil of turpentine should be 
 given in doses varying from ten to twenty minims in cold 
 water, and repeated more or less frequently according to the 
 urgency of the symptoms. Ergot may also be employed. 
 When haemorrhage is copious, a mixture containing ten 
 minims of diluted sulphuric acid and five grains of gallic 
 acid in water, taken every two or three hours, is the best 
 remedy (Dr. B. Foster). Vomiting may be relieved by dilute 
 hydrocyanic acid (five minims), combined with bicarbonate 
 of soda (twenty or thirty grains) in solution, repeated every 
 two or three hours. The subnitrate of bismuth, in doses of 
 ten to twenty grains, every six or eight hours, alone or com- 
 bined with five to ten grains of compound powder of kino, 
 has a remarkable effect in relieving pain, vomiting, and 
 diarrhoea (Brinton). Seller's bismuth mixture is also an 
 efficient remedy. 
 
 Stomatitis. — Definition. — Inflammation of the mouth. 
 
 Treatment. — The mouth should be frequently washed with 
 emollient fluids, such as linseed infusion, diluted glycerine 
 and biborate of soda, or honey mixed with biborate of soda. 
 The following lotion may be painted over the lips and 
 mucous membrane of the mouth and tongue, namely: — 
 Sodae Biboratis, fl. dr j.; Glycerini, fl. oz. ii.; Aquae Rosae, fl. 
 oz. iv.; misce (Tanner). Creasote, vinegar, carbolic acid, 
 glycerine, and alcohol are also recommended as local appli- 
 cations. The late Dr. Symonds, of Bristol, recommended 
 combinations of turpentine, with glycerine and alcohol; 
 equal parts of turpentine and glycerine, applied with a soft 
 brush two or three times a day, being, in his opinion, a 
 curative application, whether the lining of the mouth be red 
 and puffed, or pale and ©edematous, or studded with super- 
 ficial ulcers, or opaque yellow accumulation of secretion or 
 epithelium. He also recommended that follicular ulcers on 
 the inside of the lips and cheeks and tip of the tongue should 
 be treated by sulphate of copper applied once or twice a day 
 {Brit. Med. Journal, March 13th, 1868). In severe cases, 
 where the breath becomes fetid, with the submaxillary glands 
 large and swollen, the lips and gums tumid, the face flushed 
 and swollen, and the fever intense, chlorate of potash must 
 be freely given internally, to the extent of five grains every 
 four or six hours. Besides these remedies, the solution of 
 the pernitrate of iron, internally, has a beneficial effect upon 
 
STOMATITIS, GANGRENOUS — SUNSTROKE. 389 
 
 the sores, prescribed in the following formula: — Liq. Ferri. 
 Pernitratis, gtt. xl.; Syrup. Aurant, fl. oz. ss.; Aquae, fl. ozvss.; 
 misce. A fourth part may be given to a child three or four 
 years of age four times a day (Dunglison). In cases where 
 parasitic vegetable productions abound (parasitic thrush), 
 the application of a solution of sulphite of soda (fl. dr. i. to 
 fl. oz. i. of water) removes the deposit in twenty-four hours 
 (Jenner). The secretions of the mouth being acid, the salt 
 is decomposed, and sulphurous acid is set free, which de- 
 stroys the parasite. A change of air is often absolutely 
 necessary to restore the patient to health; and arsenic and 
 iodine, combined with good diet, are useful restorative 
 agents in repairing the faulty nutrition of the child. 
 
 Stomatitis, Gangrenous — See Cancrum Oris. 
 
 Struma — See Scrofula. 
 
 Sunstroke. — Definition. — An affection of the nervous 
 system associated with vertigo and sometimes with head- 
 ache, or the gradual accession of listlessness and torpidity, 
 with a desire to lie down (Longmore, Barclay). These fe- 
 brile phenomena may culminate in more or less sudden in- 
 sensibility, without the power of sense or motion, the breath- 
 ing rapid, and getting more and more noisy as death ap- 
 proaches. Convulsions of the extremities when in a com- 
 plete state of coma, in which the patient gradually dies. The 
 approach of death is indicated by the failure of the heart's 
 action, the fluttering of the pulse, the irregularity of the res- 
 piration; and the fatal event may supervene within five min- 
 utes to a few hours after the disease has become fully ex- 
 pressed. Death is either by syncope, apncea, or by a com- 
 bination of the two. In cases which recover, various seque- 
 lae are apt to supervene, such as forms of paralysis, more or 
 less complete, choreic movements, melancholia, and other 
 forms of disorder of the intellect. 
 
 Treatment. — Keeping in view the nature of this disease, 
 and the various modes in which death may approach, the 
 line of treatment may be indicated as follows: 
 
 With regard to the class of cases in which death tends to 
 occur suddenly from syncope, there is little opportunity af- 
 forded ior treatment; but the measures indicated are, — re- 
 moval to a cooler place, if possible, as from the engine-room 
 or stoker's place onboard steamships to the open deck; the 
 cold douche, but not too prolonged; keep the surface wet 
 and exposed to a current of air, or assiduously fanned: ex- 
 
396 SUNSTROKE. 
 
 elude light as fai as possible; remove 6r loosen tight and 
 oppressive clothing; the immediate employment of stimu- 
 lants, external and internal, by the rectum as well as by the 
 mouth, and ammonia to the nostrils. Depletory measures 
 of any kind are not to be thought of. In the less rapidly 
 decisive cases prompt treatment is of the greatest use, while 
 delay is fraught with the greatest danger. The patient must 
 be immediately stripped of his outer clothing; and, being 
 placed in a semi-recumbent position, the cold douche is to 
 be applied, from a height of three or four feet, over his head 
 and along his spine and chest, his extremities being at the 
 same time sponged over with cold water. Relaxation of the 
 pupil is the first symptom that shows the good effect of the 
 treatment, which may require to be repeated several times, 
 on account of returning insensibility; but if there is any evi- 
 dence of failure of the pulse, this treatment must be discon- 
 tinued, and the application of cold to the head is then all 
 that can be borne. Stimulants administered by the rectum 
 are recommended by Dr. Levick, to counteract the tendency 
 to prostration. In some cases in India rousing by flagella- 
 tion with the sweeper's broom was had recourse to with good 
 effect by Sir Joseph Fayrer. The hair is to be cut short as 
 soon as possible, and a blister applied to the nape of the 
 neck, the surface having previously been well sponged over 
 with the acetum lyttse. When the first violence of the attack 
 is subdued, increasing confidence in the ultimate reiult may 
 be indulged in so soon as vesication takes place; and in 
 cases where insensibility recurs, after an interval of ten or 
 twelve hours, it may be removed by the application of a 
 second blister to the vertex; which may even be again re- 
 peated, there being no doubt as to the good effect it pro- 
 duces. Sir Joseph Fayrer, on the other hand, expresses a 
 want of faith in their efficacy. A blister may also some- 
 times be applied along the spine in the worst cases. Stimula- 
 tion by the use of the electro-galvanic current, with the 
 moist sponges applied along the sides of the neck, chest, 
 epigastrium, ought also to be employed. Sinapisms ought 
 generally to be applied to the extremities, and to the chest 
 or sides. 
 
 As soon as possible after the employment of the douche, 
 a strong purgative enema ought to be given, those of* a stim- 
 ulant nature being preferred. But as the enema may have 
 to be repeated several times before any effect is produced 
 on the bowels, it may be advisable to let the first enema be 
 
SUNSTROKE. 391 
 
 of a simple purgative character, and afterwards let it be fol- 
 lowed up by turpentine enemata. 
 
 If cerebral congestion is indicated by the state of the eyes 
 already described, a few leeches to the temples may relieve 
 the congestion (Longmore, Barclay); but the prevailing 
 opinion among medical officers of experience in the treat- 
 ment of this disease is against the employment of blood-let- 
 ting by venesection, even in severe cases. In all the cases 
 which have been recorded in which it has been employed, it 
 seems to have been generally hurtful, and to have hastened 
 the fatal termination. In cases when it has seemed at first 
 to give relief and to mitigate the symptoms, the improvement 
 has been only transient, and followed by relapse into a more 
 dangerous and fatal condition. But no absolute rule can be 
 laid down in regard to abstraction of blood. There are 
 cases in which it may be necessary, in order to avert suffo- 
 cation; but they are the exception, and it is possible there 
 may be more danger to life in the laboring and distended 
 heart and the embarrassed lungs, than in the loss of a few 
 ounces of blood; which, if it would have tided the patient 
 over the danger, as it sometimes might do, would be the 
 lesser evil, and as such should be chosen. Each case must 
 be treated on its own merits (Sir Joseph Fayrer). 
 
 In cases where the breathing is much oppressed, and the 
 bronchial tubes loaded with mucus, the patient should be 
 turned occasionally over on his face and side. In the con- 
 vulsive form of the disease, where the greatest irritability of 
 the nervous system prevails, the douche is found to be inad- 
 missible, from the agony which it occasions. In such cases 
 Dr. Barclay has seen great benefit from the inhalation of 
 chloroform. After a few inspirations the convulsions for the 
 most part ceased, and sleep was very easily induced; but in 
 one or two instances ? after a considerable interval of con- 
 sciousness, febril : symptoms increased in severity, coma 
 supervened (probably effusion having occurred within the 
 cranium), which was followed by death. But the cases in 
 which chloroform can be used are comparatively few; and 
 very great care is necessary in its employment, so that the 
 inhalation may be suspended at once, as soon as any effect 
 is produced upon the pulse. 
 
 In the most severe forms of the disease the principle of 
 management is to reduce a? quickly as possible the blood 
 heat, and that before tissue changes have begun. As the 
 hyperpyrexia is due not only to the direct operation of heat 
 
392 SUNSTROKE. 
 
 on the nerve centres, blood, and tissues, but to the fever- 
 set up by vaso-motor disturbance, those remedies are 
 indicated which have been already mentioned as useful 
 for the reduction of temperature. The unduly heated blood 
 is a poison for the cardiac and vaso-motor centres tend- 
 to cause death, either by syncope or asphyxia. This 
 is best effected in sunstroke by rubbing the body over with 
 ice, as large as can be handled, as recommended by Dr. 
 Levick, and as has been proved to be successful by Baumler 
 and Dr. Woodman at the London Hospital. Tepid body 
 baths, with cold affusion to the head and back of the neck, 
 or general cold affusion, may be employed; also, injections 
 of iced water. Keeping pieces of ice in the axilla until there 
 is returnieg consciousness, which may not be for several 
 hours, and, therefore, great caution is required in such use 
 of ice, so as not to induce gangrene of the skin, or continued 
 depression, as indicated by a thermometer in the mouth, 
 axilla, or rectum. 
 
 The sequelae of sunstroke are generally, persistent head- 
 ache, fixed or shifting pain in the back, choreic movements 
 of the forearm and hand, convulsive disorders, mental weak- 
 ness. These symptoms are suggestive of hsematoma of the 
 dura mater, as a probable lesion in such cases, and indicate 
 rest, attention to the functions of the skin, and change of 
 air, and removal front a hot to a cold climate. All stimu- 
 lants and all excesses of diet, or errors in diet, are to be spe- 
 cially guarded against. When the pain is fixed and severe, 
 long-continued counter-irritation, at the nape of the neck, 
 and a course of iodide of potassium, may benefit the patient; 
 but many cases are quite unrelieved by treatment, as the 
 records of the invaliding hospital at Netley show every year 
 (Dr. Maclean). 
 
 Measures for the Prevention of Sunstroke. — (i.) If a march 
 is to be undertaken during hot weather in India, all weak 
 and sickly men should be weeded out and left behind. (2.) 
 The costume should be suitable for the early morning hours 
 before sunrise, as well as for the scorching period which fol- 
 lows, when the men are for the most part in their tents. It 
 should consist of materials of slow conducting power, of a 
 color by which heat is not readily absorbed, and its fitting 
 should be as loose and light as possible. A flannel shirt 
 should be worn, to prevent exposure to sudden chills, and a 
 flannel belt round the loins may be worn with advantage, 
 except in the hottest weather. The shirt-collar should either 
 
bUNSTROKE. 393 
 
 be open, or made so wide as to prevent all risk of its press- 
 ing injuriously on the veins of the neck. Above all, some 
 form of knapsack should be devised other than that hitherto 
 in use. The authorities, strongly urged by the late Dr. 
 Parkes, have adopted a valise equipment, which is a great 
 improvement on the older knapsack, and Surgeon-Major W. 
 S. Oliver has devised another, which has also been favorably 
 reported upon. Both of them do away with the use of cross- 
 belts, so injurious to the functions of the organs within the 
 chest. The march ought not to commence too early in the 
 morning. The troops should be on the new ground about 
 an hour after* sunrise, and the pace should never exceed 
 three and a half miles an hour. There should be a halt for 
 seven or eight minutes every hour, or oftener, if the men are 
 exhausted; and a longer halt half way, when each man should 
 have a cup of coffee and a biscuit. They ought also to have 
 their ration before starting in the morning. An ample sup- 
 ply of water should be provided for the men by "bheesties" 
 attached to each company, and always compelled to march 
 with it. No man should be allowed to fall out without be- 
 ing accompanied by a non-commissioned officer, who should 
 bring him to a medical officer at once if sick, and if not, he 
 should bring him up to the column at the halt. All men so fall- 
 ing out should be brought up to hospital tents for examination 
 immediately on the arrival of the regiment in camp. The men 
 should carry nothing on the march but their rifles and am- 
 munition — the quantity of the latter being kept as small as 
 is consistent with safety. They should be allowed to march 
 11 easy " and loosely clad, more particularly in passing 
 through jungles or ravines. No halt should ever take place 
 on such ground when better may be had within a moderate 
 distance. When the sun is up, halts should be so timed that 
 shelter may be obtained by open topes. Camps should be 
 formed on as high and open ground as possible. The sites 
 for camps in India marked out by the ''official " pillars, are 
 generally the most objectionable that could have been select- 
 ed (Barclay, Indian Sanitary Commissioners, and others). 
 As much space should be allowed between the tents as the 
 ground will admit of. Tents should be pitched as speedily 
 as possible, camels and elephants being provided for their 
 transport — carts never. " Kus-kus " mats should be kept 
 constantly wet. 
 
 Troops in the field during the continuance of the hot 
 winds in India should have the best description of tents that 
 
394 SUPRA-RENAL CAPSULE DISEASE — SYPHILIS. 
 
 can be got for hospital purposes, and be provided with the 
 best known means for keeping them cool. An abundant 
 supply of water in camp is of the utmost importance, care 
 being taken that the bags containing it are in good repair, 
 hung up within easy reach of the men, and kept always filled 
 with water. Sentries should be under cover during the 
 heat of the day; and the men should be instructed, when- 
 ever they go out in the extreme heat of the sun, to put a 
 wetted towel or thick handkerchief over the head, under 
 the cap, and around the back of the neck and face. The 
 men should be encouraged to take exercise during the 
 cool of the evening; or, at all events, to leave their tents, so 
 as to permit of their thorough ventilation; and wherever it 
 is practicable, bathing should not be omitted. Rations of 
 spirits ought to be discontinued in India. It may be a ques- 
 tion»as to what should be substituted instead; but all author- 
 ities are agreed that the system of " spirit rations " tends to 
 convert young soldiers into drunkards. The sleeplessness, 
 which sometimes is a premonitory symptom of the disease, 
 may be relieved by chloral hydrate combined with bromide 
 of potassium, followed by a purge. 
 
 Supra-Renal Capsule Disease — See Addison's Disease. 
 
 Syphilis. — Definition. — The result of a specific living 
 poison ; or, of " a something " of an uncertain nature, but ca- 
 pable of self-multiplication, which breeds in the blood and 
 tissues, which is introduced into the system solely by con- 
 tagion, inoculation, or implantation on some part of the body 
 of a healthy person, — i. e., a not yet syphilitic person, gener- 
 ally through an abrasion or sore consequent on sexual inter- 
 course with an infected person (acquired syphilis), or by in- 
 heritance (congenital syphilis). Three weeks or a month 
 after contagion and absorption of the poison, a peculiar se- 
 ries of phenomena begin to show themselves, which mark 
 the general infection of the system, namely, — First, a distinct 
 specific fever is followed by or attends the development of ; 
 Second, the principal anatomical signs of general infection, 
 which consist of — (a.) induration (specific) round the spot 
 where the virus has been implanted ; (b.) induration of the 
 lymphatic system of glands ; (c.) the development of a cu- 
 taneous and mucous exanthem ; (d.) the formation of 'nodes 
 or gummatous nodular tumors in the connective tissue gen- 
 erally, and especially in that of the true skin, bones, mucous 
 
SYPHILIS. 395 
 
 membranes and solid visceral organs, e.g., liver, brain, lungs 
 and heart (visceral syphilis) ; (e.) a cachectic condition of the 
 system which follows and accompanies the phenomena of in- 
 fection ; and (/.) indurations which may remain in the form 
 of hardened fibrous tissue in various parts of the body for an 
 indefinite period of time. The whole course of the disease 
 is characterized by slow, but progressive development, often 
 marked by periods of recrudescence. 
 
 Treatment. — (a.) Preventive. — There are certain facts 
 which must be kept in view in the consideration of prophy- 
 laxis, (i.) The disease spreads principally by sexual inter- 
 course ; (2.) prostitution is the source whence the syphilitic 
 virus is ever freshly drawn, and the experience of thousands 
 of years has shown prostitution, alike in the ancient and the 
 modern world, to be an unavoidable evil, the suppression of 
 which is impossible ; (3.) with the intimate relations existing 
 at the present day between all parts of the world, and the 
 unbounded intercourse between different places at home and 
 abroad, which has been developed in recent times, syphilis is 
 constantly being transported from one place to another. In 
 the interest of public health it is the duty of the State not 
 only to limit prostitution, but to exercise a supervision 
 over it. 
 
 Keeping these facts in view, there are other facts which 
 suggest the direction in which preventive methods for re- 
 pressing the extent of syphilis ought to be persistently car- 
 ried out, namely : — (1.) Official supervision over prostitution 
 has had the most favorable influence in diminishing syphilis. 
 This is shown in many ways : — (a.) Everywhere it is found 
 that secret, unwatched prostitution is far more active in the 
 spread of syphilis than prostitution which is under control ; 
 (i.) In 1866, the second Contagious Diseases Act was 
 passed, after long and careful consideration, and is the one 
 now in force. In the Army Medical Department Report for 
 1875, it appears that during three years immediately preced- 
 ing the operation of those Acts, the average annual ratio of 
 cases of primary and secondary forms of disease was 104.4 
 per 1,000, whereas in 1875 it did not exceed 45.8, and in the 
 period from 1870 to 1878, the average rate of prevalence of 
 the disease fell to 44 per 1,000 men ; and further, it appears 
 that the ratio of primary disease was 53.4 in 1866, but in 
 1875 it had declined to 33.5. (c.) Through the courtesy of 
 Sir W. M. Muir, K.C.B., the Director-General of the Army 
 Medical Department, I am able to give the results for 1878. 
 
39^ SYPHILIS. 
 
 At fourteen stations under the Act, the average annual 
 strength of the troops was 53,813, among whom admissions 
 for primary venereal sores averaged 40 per 1,000, and 78 per 
 1,000 for gonorrhoea. On the other hand, at fourteen other sta- 
 tions not under the Act, the average strength of the troops 
 being 45,316, the ratio of admissions among them was 86 per 
 1,000 for primary venereal sores, and 121 for gonorrhoea. 
 Thus, at the stations not under the act, the average rate of 
 admission for both forms of disease was 103.5 per 1,000, as 
 against 59 at the stations under the Act. At these fourteen 
 stations under the Act, the highest rates of admission for 
 primary sores were 53 and 54 respectively per 1,000, at 
 Aldershot and the Curragh ; whereas at the fourteen stations 
 not under the Act the rates of admission for these diseases 
 ranged upwards to 140 in Warley, 154 in Dublin, 205 in 
 Manchester, and 250 in London. So with regard to gonor- 
 rhoea, the highest rate among the fourteen stations under 
 the Act was no at Winchester per 1,000 ; whereas, at the 
 fourteen stations not under the Act it ranged upwards 
 to 151 in London, 161 in Warley, 163 in Sheffield, and 177 
 in Manchester, per 1,000. (d) In unprotected [The 
 term unprotected district is meant to include the principal 
 cities of the United Kingdom where women can practice 
 prostitution in any public thoroughfare, at any hour of the 
 day or night, without hinderance, and inveigle men to their 
 homes ; and this, too, under the very eyes of the authorities, 
 who are powerless to interfere unless the solicitation be to 
 the annoyance of any passenger or householder, who must 
 in that case accompany the police to the station to charge 
 the woman with the offence, which is rarely or never done. 
 Should the authorities have credible evidence that the woman 
 so conducting herself is suffering from a contagious disease, 
 which she may communicate to others having relation with 
 her, they cannot in any way interfere to prevent it. This 
 woman, when unable any longer (in conseqnence of the se- 
 verity of her disease) to follow her miserable calling, has no 
 other resource (prostitution failing), to procure her a livelihood 
 than to fall back on the foul wards of a workhouse (Acton).] 
 cities like London, Manchester, Dublin, Sheffield, Preston, 
 the severity of the cases is greater than in the protected 
 [A protected district is one where a woman, instead of con- 
 tinuing wholly or in part to gain an honest livelihood, walks 
 the streets, soliciting different men, and consequently comes 
 under cognizance of the police as being a common prosti- 
 
 
syphilis. 397 
 
 tute. The British Legislature has determined that in cer- 
 tain garrison towns such a woman, after being repeatedly 
 warned, and still persisting in a life of prostitution, shall 
 submit to a medical examination, on the ground that, should 
 she be diseased, she would communicate a contagious com- 
 plaint to those having relation with her. It is further enact- 
 ed that if the woman be found diseased, she shall be at once 
 sent to hospital, and not allowed to leave till she is, in the 
 opinion of the surgeon, perfectly cured. If then desirous of 
 abandoning her evil courses, the girl is relieved from further 
 surveillance, and will be sent to her friends at the Govern- 
 ment's expense. If, on the other hand, a common woman, 
 on being discharged from hospital, and released altogether 
 from the operation of the Acts, returns to a protected dis- 
 trict, and is again found by the police acting as a public 
 prostitute, she must again be registered. In every case the 
 authorities wish it to be clearly understood that they do not 
 sanction or authorize prostitution ; they only watch over it 
 from their anxiety to prevent its worst evils, and to ameliorate 
 the condition of the women, and check disease (Acton).] 
 places, where tht great majority (after the Acts have been 
 in operation for a year or two) suffer from very mild forms 
 of the disease. In 1870 a Royal Commission was appointed 
 to consider the questions raised in the House of Commons 
 on a motion for a repeal of the Act. The report of this 
 Royal Commission speaks most decidedly upon the effects 
 of the Acts in the reduction of the worst forms of disease 
 among the lower classes of prostitutes, and acknowledges 
 that they have both directly and indirectly promoted the ob- 
 jects sought to be attained by those Acts. " They have 
 purged the towns and encampments to which they have been 
 applied of miserable creatures, who were masses of rottenness 
 and vehicles of disease ; " and it was agreed that, for the pub- 
 lic good, particular districts which are from any cause pecu- 
 liarly liable to contagious disease should be subjected to 
 special sanitary legislation, (e) In passing these Acts also, 
 Parliament pronounced the strongest protest against the 
 right of an individual suffering from a loathsome disease 
 knowingly to communicate it to another ; hence, in the in- 
 terest of all, the State has the right to limit the personal lib- 
 erty of such persons as may be considered dangerous to the 
 common welfare, and to use force, if necessary, to obtain an 
 examination as to the condition of their health. Regular, 
 frequent, and thorough examinations are absolutely neces- 
 
398 SYPHILIS. 
 
 sary. [It seems useless to argue with the opponents of these 
 Acts, who, while loudly denouncing them as immoral be- 
 cause they render vice easier and safer to men, yet wish for 
 the establishment by Government of voluntary lock hospi- 
 tals and lock wards, which, if they proved equally efficient, 
 must obviously be attended by the same result ; who, while 
 stating that the Acts render vice easy and safe, declare al- 
 most in the same breath that they are hygienically a failure, 
 and that wherever they have been in operation disease has 
 increased instead of diminished : who, while charging them 
 with all sorts of pernicious and degrading influences, yet 
 deny them any credit for the collateral benefits which they 
 have been shown to have produced ; who denounce them as 
 unwarrantably interfering with individual liberty, on account 
 of their compulsory clauses, and yet would not object to the 
 compulsory detention of women in hospital until cured, pro- 
 vided they were left to apply voluntarily for admission. How, 
 they further ask, if the present system is an infringement of 
 personal liberty, is that principle less infringed if the compul- 
 sion is removed from one end of the procedure but retained 
 at the other ? Surely if compulsion is unjustifiable, it should 
 be abolished altogether ; but if it is to be retained at all, it 
 should be retained in the form which has been found most 
 effectual ; and the evidence of those most competent to judge 
 shows that the early detection of disease in public women by 
 periodical examination is essential to the efficiency of the 
 system. Even the Royal Commission were constrained to 
 say, " We are satisfied from the evidence that the frequent 
 examination of women is the most efficacious means of con- 
 trolling the disease." It is not less important in the interest 
 of the unfortunate women themselves, who obtain the im- 
 mense advantage that their disease is discovered and treated 
 at the earliest possible period, so that while they are pre- 
 vented communicating it to others, they are themselves saved 
 from all the serious and painful consequences of neglect. 
 (Brit. Med. Journ., July 22, 1876)]. (/.) The beneficial effect 
 of these Acts on the civil population cannot be ignored. 
 During the five years 1870-74 the annual death-rate from 
 syphilis (including congenital syphilis) in the eleven districts or 
 stations where the Acts were then in operation, was 21 per 
 cent, lower than it was during the five years 1861-65 before 
 the Acts came into operation in 1866 ; whereas in the rest 
 of England and Wales the death-rate from this disease was 
 20 per cent, higher in the second than in the earlier period. 
 

 spphilis. 399 
 
 (g.) Up to the present time, it has been everywhere found 
 that just that class of prostitutes who are the most apt to 
 spread syphilis will not subject themselves to treatment ex- 
 cept under compulsion. All prostitutes found to be syphili- 
 tic should be kept in hospital till they are cured, (h.) It 
 may also be fairly urged and acted upon, that entire classes 
 of men who notoriously contribute largely to the spread of 
 syphilis, as, for instance, soldiers and sailors, should be sub- 
 ject to periodical examinations ; and that sailors especially 
 should be inspected before leaving a port, and again before 
 entering another, and that if found infected they should be 
 placed in quarantine. The workmen in some of the glass- 
 works in the neighborhood of Lyons have of their own ac- 
 cord demanded such examinations, to do away with the pos- 
 sibility of infection from the tubes used by them in blowing 
 glass, which are passed from mouth to mouth (Baumler). (/'.) 
 Not only ought the Contagious Diseases Act to be main- 
 tained and extended to the whole of this country, but the 
 time has come when, as Dr. Baumler observes, it is the duty 
 of all civilized states to combine and adopt some common 
 course of action against these diseases. There is need of 
 universal prophylactic regulations being more and more wide- 
 ly recognized. 
 
 A great responsibility rests upon those who oppose the 
 working of such Acts — so fully proven to be preventive of 
 disease, and in every respect beneficial. " In the eyes of 
 every physician, and indeed in the eyes of most Continental 
 writers who have adverted to the subject, no other feature 
 of English life appears so infamous as the fact that an epi- 
 demic which is one of the most dreadful now existing among 
 mankind, which communicates itself from the guilty hus- 
 band to the innocent wife, and even transmits its taint to 
 the offspring, and which the experience of other nations con- 
 clusively proves may be vastly diminished, should be suffered 
 to rage unchecked because the legislature refuses to take of- 
 ficial cognizance of its existence, or proper sanitary measures 
 for its repression." (Lecky, History of Europ. Morals, Vol. 
 II., p. 301). 
 
 (2.) The facts relative to the Pathology of syphilis which 
 have been stated in the text, show that Prophylaxis ought 
 to take cognizance of the vehicles by which healthy persons 
 are apt to be inadvertently infected — (a) From the use of 
 such drinking vessels, plates, spoons, towels, &c, used by 
 those suffering from secondary forms of syphilis ; (b.) con- 
 
400 
 
 SYPHILIS, 
 
 tamination from surgical instruments which have been em« 
 ployed upon the syphilitic ; (e.) the selection of healthy 
 children from whom other children are to be vaccinated — ■ 
 only those children known to be healthy, and whose parents 
 are known to the physician, should be used as the sources of 
 vaccine matter ; (a 7 .) the choice of wet nurses for healthy 
 children ought also to be carefully selected, so as to exclude 
 those who may show the least suspicion of having had sy- 
 philis ; (e.) on the other hand, it is necessary to prevent 
 children with hereditary syphilis being given to healthy wet 
 nurses ; (/.) the guardians of syphilitic children ought to 
 be warned of the danger of their infecting healthy children 
 through kissing them, and also by the use of the eating and 
 drinking utensils of such infected children (Baumler). 
 
 (3.) Individual Prophylaxis — From what has been written, 
 it must appear clear that the only chance of preventing in- 
 fection, alike on the part of the male and the female, is per- 
 sonal cleanliness after sexual intercourse. Much of the good 
 that has resulted from inspection of females to the females 
 themselves, as in Paris, Brussels, and other places, has been, 
 I believe, mainly attributable to the greater attention to per- 
 sonal cleanliness which such inspections have brought about. 
 Numerous lotions have also been used ; and if a man will 
 have sexual intercourse with a strange woman, let him wash 
 immediately after the act, taking care to cleanse thoroughly 
 the folds of the prepuce, especially near the fraenum, and in 
 the sulcus of the corona glandis. If a woman will have sex- 
 ual intercourse with a strange man, let her use a syringe with 
 hot water, to wash out the vaginal passage, taking care to 
 cleanse thoroughly the folds of the mucous membrane at the 
 orifice of the canal and of the labia pudenda. The real pre- 
 ventive remedy after exposure to infection is the most an- 
 cient, the most simple, and the most efficient — Wash, and be 
 clean. 
 
 (4.) Syphilization. — By this name an operation is meant 
 which has for its object the eradication of syphilis from the 
 system by repeated inoculations of the syphilitic virus itself. 
 Dr. Boeck, of Christiana, is the most persistent advocate of 
 this mode of dealing with syphilitic cases as a remedy against 
 constitutional affections. And it was at one time seriously 
 proposed to introduce syphilization as a prophylactic, from 
 its analogy to the inoculation of the virus of variola (Auzias 
 Turenne). The method is entirely unjustifiable. 
 
 (fr.) Therapeutic treatment. — As in the case of other spe* 
 
SYPHILIS. 401 
 
 ific diseases that are implanted by inoculation, the effect of 
 the virus begins at once at the point of inoculation, and may 
 not be destroyed as to its contaminating powers by any 
 agency we know of. Experience shows that we must not 
 conclude that, even by an early destruction of the sore, the 
 occurrence of constitutional infection will be prevented ; 
 and the application of caustics to abraded surfaces after their 
 exposure to contagion is quite useless to prevent infection. 
 The poison is observed in a very short time — within a few 
 hours (Berkeley Hill). Still, however, in some cases positive 
 results have been obtained which encourage attempts to 
 arrest the local progress of the sores with escharotics, if they 
 are applied at an early period, and before contamination of 
 the system is evinced by indurations. Ricord and Sigmund 
 have found that sores destroyed by the more powerful caus- 
 tics, within from three to five days, have not been followed 
 by syphilitic symptoms. But these may have been cases of 
 soft chancre, which would not infect. The only efficient 
 caustics for this purpose are — (1.) The strong nitric acid ; 
 or, (2.) The potassa cum calce (most conveniently used in 
 the form of small sticks). Nitrate of silver is useless, from 
 its limited action and deficiency of penetration. 
 
 If the sore threatens to slough, the parts should be wiped 
 dry, and fusing nitric acid applied, and afterwards a lotion 
 of the potassio-tartrate of iron, while the same drug is given 
 internally. Chloride of zinc paste (Fell's) is a useful eschar- 
 otic to excite a healthy action round the periphery of a sore. 
 If great pain attends the local progress of the chancre, mor- 
 phia in liquor ammonia acetatis is highly beneficial. " Black 
 wash " of the strength of 8 grains of calomel to the fluid 
 ounce of lime water, or weaker, as 5 or even 3 grains to the 
 ounce, is of use in the treatment of large ulcerating indura- 
 tions. The experience of 300 years has shown that mercury 
 is a remedy which acts as a direct antagonist to the virus of 
 syphilis ; and no unprejudiced person can deny that its ac- 
 tion upon syphilis is quite evident, especially upon the cuta- 
 neous manifestations of the disease. Mercury, administered 
 during a primary sore, seems to be on« of those agents which 
 are able to break the regular order of the manifestation of 
 symptoms, as it does to several other diseases ; although it 
 may not seem to possess any certain prophylactic power. 
 [There are remarkable variations in opinion as to the influ- 
 ence of mercury in curing syphilis. At one time discussion 
 ran high regarding its use ; and, of course, extreme state- 
 26 
 
402 SYPHILIS. 
 
 ments were made on both sides, while the facts adduced 
 never warranted the extreme conclusions. Consequently, at 
 one time mercury has been regarded as capable of absolutely 
 preventing the constitutional affection ; at another time it 
 has been accused of giving to the syphilitic virus the impulse 
 which sets up its worst results. It is now quite certain, how- 
 ever, that mercury administered continuously to the extent 
 of salivation, or approaching it, exerts a poisonous influence, 
 and produces constitutional effects of a very dangerous kind 
 (Graves) ; and Hunter himself says " new diseases arise from 
 mercury alone ;" while it cannot be doubted that in cases in 
 which mercury has been freely given, we are never certain 
 that secondary symptoms may not supervene. Barensprung, 
 of Berlin*, during his most extensive experience, came to the 
 conclusion that syphilis not only can be cured without mer- 
 cury, but, under its use, he believed the disease is often ren- 
 dered latent for months and years, and its complete cure de- 
 layed. Starvation and Zitmann's weaker decoction were the 
 means he employed for cure (Ann. de Berlin Charite, ix., i, 
 i860 ; Syden. Society Year-Book, 1861). Hermann came to 
 similar conclusions, from his experience in the syphilitic 
 wards of the Vienna Infirmary. The experience of Diday 
 is not less decided. He states that mercury cannot now be 
 said to cure syphilis radically, so as to render all relapse im- 
 possible. He does not, however, as is the case with the 
 others, practically withhold mercury in every case. If the 
 primary lesion becomes an indurated, woody chancre, mercury 
 is given. If the chancre is a doubtful one, he recommends 
 waiting till some of the early constitutional phenomena ren- 
 der the nature of the case evident, and indicate the probable 
 gravity of the syphilis with which he has to deal. He em- 
 ploys iodine, iron, and quinine, on the appearance of slight 
 relapses, with a tonic and supporting regimen. He recom- 
 mends iodides, to combat the chloro-ansemia, and to relieve 
 the pain of tertiary ulcerations. 
 
 Numerous examples may be seen in museums, which are 
 placed there to show that the poisonous effects of mercury 
 produce worse lesions than those of syphilis ; and, when 
 combined with the syphilitic virus in a strumous person, the 
 worst lesions of all. In the extreme of syphilitic infection, 
 it ought never to be forgotten that a specific chlorosis results 
 from syphilis, amounting to anaemia ; and that mercury will 
 bring about a similar anaemia. But while numerous instances 
 are quoted by authors of the poisonous effects of mercury 
 
 1 
 
SYPHILIS. 403 
 
 inducing lesions similar to those of syphilis, the investiga- 
 tions of Kussmaul, Professor of Medicine at Erlangen, show 
 that mercurial poison produces no single affection or symp- 
 tom that is identical with, or not easily distinguishable from, 
 those of syphilis. His experience was among the manufac- 
 turers of mirrors using mercury in the town of Furth ; and 
 he shows that mercury has but one influence over syphilis — 
 that is, the power of controlling many of its symptoms. 
 
 Both kinds of treatment (mercurial and non-mercurial) 
 have been extensively tried since 18 16, and formal experi- 
 ments have been organized on the subject, namely, — First, 
 In 1822, in Sweden, by. Royal command, when reports were 
 annually furnished from civil and military hospitals as to 
 trials of the two methods ; Second, Dr. Fricke experimented 
 in the Hamburg General Hospital, and published his results 
 in 1828 ; Third, In 1833 the French Council of Health pub- 
 lished a report on the subject. Long before any of these 
 reports were initiated, however, the surgeons of the British 
 Army had the boldness to declare themselves against the 
 system of treatment with mercury, as it was then carried out, 
 and, running into the opposite extreme, introduced measures 
 of non-mercurial treatment altogether. This change was 
 mainly due — (1.) To Mr. Fergusson, who practised it during 
 the Peninsular Wars (Med.-Chir. Trans., Vol. IV.) ; (2.) To 
 Mr. Rose, of the Coldstream Guards, at the same time, but 
 independently of Mr. Fergusson ; (3.) To Dr. John Thom- 
 son, the first Professor of Military Surgery ; who, by lec- 
 tures in the University and College of Surgeons in Edin- 
 burgh, and by his published writings, was mainly influential 
 in convincing Scotch medical men of the evil effects of mer- 
 cuey in venereal diseases. The inquiry, begun in 1816 by 
 these military surgeons, requires to be re-investigated with 
 all the present advanced knowledge of the nature of the di- 
 sease which we now possess, and with a better prospect of 
 detecting the fallacies which surround the investigations. Un- 
 der the simple treatment of those eminent men, there can be 
 no doubt that mixed cases of soft, as well as of indurated 
 chancres, and specific or syphilitic sores, were allowed spon- 
 taneously, as it were, to develop their distinctive characters. 
 No confidence can now be placed in the results thus pub- 
 lished, as derived from clinical observation, because the cure 
 of soft, suppurating, and mixed sores, gonorrhoea, vegeta- 
 tions, suppurating bubos, are all .indiscriminately given as 
 evidence of the cure of syphilis. Moreover, cases cannot 
 
404 SYPHILIS. 
 
 be accepted as cured at the time they are simply discharged 
 from present treatment, because they may seem to be pro- 
 gressing to a favorable termination, but not absolutely cured, 
 as is the case with the records of Fricke's experiments. 
 
 The great benefit obtained by the experiments, observa- 
 tions and discussions regarding mercury in syphilis, carried 
 on during the first quarter of the present century, as Dr. 
 Berkeley Hill justly observes, has been to show — (1.) That 
 all venereal ulcers can be healed without mercury ; (2.) That 
 this drag is not the cause of the relapses so frequent in syph- 
 ilis ; and, (3.) That very much less mercury is required to 
 control syphilis than had been previously supposed neces- 
 sary. Some interesting cases of syphilis cured without the 
 use of mercury are related by Surgeon-Major Dr. Peter Boi- 
 leau, in the Brit. Med. Journ., for July, 1879.] 
 
 The present position of opinion with regard to mercury in 
 the cure of venereal sores seems to be this, namely, — That 
 it is a very valuable and essential remedy in cases of syphilis, 
 but not in cases of soft chancre ; and the difficulty is to ex- 
 press always the nature of the cases for which it is most 
 suitable. Even those who believe most fully in its virtues 
 acknowledge that in primary affections, as when given in the 
 treatment of the local sore, its administration will not always 
 prevent the occurrence of constitutional symptoms; never- 
 theless the value of mercury in the cure of the induration of 
 the true infecting chancre is now fully recognized. The 
 local lesion, if it appears after the usual prolonged period of 
 incubation, is as much a manifestation that the constitution 
 is already affected as is the developed vesicle of variola 
 vaccina a manifestation that the constitution is affected with 
 variolous poison. Looking, also, to the nature of the virus 
 of syphilis, the excision of the primary lump or sore — the 
 specific induration — as practiced by Dr. Veale, assistant to 
 the Professor of Medicine in the Army Medical School at 
 Netley {Edinburgh Monthly Journal, July; 1864), and by 
 Dr. Humphrey, of Cambridge, {British Medical Journal, 
 August 13, 1864), is a justifiable operation; for the original 
 sore, when it has become a " lump " (as in its state of 
 " woody-like " induration), is an undoubted maintainer of 
 infection and of contamination of the system. If, therefore, 
 it can be easily and completely insulated, as when on the 
 prepuce, the cure of the constitutional symptoms may be 
 facilitated and shortened. There are also certain forms of 
 secondary syphilis for which the administration of mercury 
 
SYPHILIS. 405 
 
 is unsuitable. These are the pustular eruptions, or ecthy- 
 matous states in rupia and in syphilitic anaemia. For the 
 cure of other secondary symptoms mercury is certainly of 
 service. If given to the extent to which I have limited its 
 use in the text, I believe that secondary symptoms disappear 
 more rapidly under its regulated use than by any other plan 
 of treatment. All our treatment of syphilis rests on that evi- 
 dence which must always guide the hand of the physician, 
 namely, — practical experience. That has certainly taught 
 us that the mercurialism of John Hunter's time was an error; 
 and that its regulated administration in cases of syphilis is 
 undoubtedly beneficial, and especially during the evolution 
 of the specific symptoms of infection. Dr. Jeffrey Marston, 
 late of the Royal Artillery, has given an admirable summary 
 {British Medical Journal of Feb. 21, 1863) of the means and 
 indications of treatment by mercury which he has found 
 most useful. His experience shows that the system ought to 
 be affected as slowly as possible; and there ought to be a re- 
 mission of the remedy for a time as soon as that effect has 
 been attained. As soon as the symptoms for which the 
 mercury was given have disappeared, steel and other mineral 
 tonic remedies ought to be given; and in three cases where 
 the general health seemed to have suffered, podophyllin in 
 small doses (one-sixth of a grain), with extract of belladonna, 
 was given with marked benefit. If the system is too early 
 brought under the influence of mercury, and the symptoms 
 are not benefited, chlorate of potash in compound tincture 
 of cinchona may be given with advantage; and in strumous 
 subjects the bichloride of mercury, dissolved in ether and 
 added to cod-liver oil, is found to be most useful. Some of 
 the mos-t intractable forms of syphilitic squama are best 
 treated by a combination of liquor arsenicalis, solution of 
 bichloride of mercury in very small doses, and tincture of 
 sesquichloride of iron; while the use of soap in ablution 
 ought to be avoided (Startin). In the administration of 
 mercury for the cure of syphilis, salivation, or anything ap- 
 proaching to that condition, should never be induced. Ten- 
 derness of the gums should be the utmost physiological 
 effect, very gradually and gently brought about. As soon as 
 the evolution of consitutional symptoms has commenced, 
 such as the specific induration of the sore or glands, cutan- 
 eous, scaly, tubercular, condylomatous affection, or iritis, 
 the sooner mercurial treatment (to the extent indicated) is 
 commenced the greater will be the benefit. The good 
 
406 SYPHILIS. 
 
 effects of mercury are known by the following results : — • 
 " Given early, it promotes the dispersion of the induration 
 at the point of contagion or inoculation, and the enlarge- 
 ment of the glands; it delays and lessens the severity of the 
 cutaneous eruptions, and of all the symptoms which accom- 
 pany the early skin eruptions " (Berkeley Hill). When in- 
 duration is apparent, mercury ought to be at once adminis- 
 tered; and all the useful effects of the remedy are generally 
 obtained when the slightest possible sign of its influence is 
 betrayed by the gums and breath. The most convenient 
 form of administration is either a pill or fluid solution of 
 corrosive sublimate (perchloride). The dose should always 
 be small, and combined so as not to irritate the bowels. 
 Grey powder or blue pill may be compounded in the follow- 
 ing forms, namely : — Two grains of grey powder with two 
 grains of compound ipecacuanha powder, made into a pill 
 with glycerine, two of which are to be taken daily; or two or 
 three grains of blue pill combined with a quarter of a grain 
 of opium powder, with sufficient glycerine to make a pill, and 
 taken every night at bedtime. Either of these forms is suffi- 
 cient for women and young men. In adult men, three grains 
 of blue pill or grey powder twice or thrice a day; or one 
 grain of calomel every night and morning, with a third of a 
 grain of opium, are most suitable. When the mercury is 
 obviously producing its physiological results, it may be 
 omitted for a day, and then again carried on in smaller or 
 less often repeated doses. Dr. Berkeley Hill recommends that 
 the perchloride of mercury be mixed with iodide of potass, so 
 that a freshly formed biniodide of mercury is kept suspended 
 in a solution of iodide of potass, in the following formula : — 
 
 $ Perchloride of Mercury, gr. 3; Iodide of Potass., grs. 
 96; Compound Tincture of Bark, 4 ounces; Sesquicarbonate 
 of Ammonia, grs. 60. Water sufficient to make up 8 ounces. 
 
 The dose of this compound ought to be two teaspoonfuls, 
 half an hour before meals, three times a day. Two-thirds of 
 a grain of perchloride of mercury may be taken daily; but 
 except in such a solution as the above its action is uncertain. 
 In Germany, Zitmann's decoction is much used. It is of 
 two kinds — the stronger and the weaker. The former is 
 compounded as follows : — 
 
 $ Rad. Sarsaparillse, |xii.; Aqua?. Ifoxxiv.; Coque per 
 horas duas et adde Aluminis, ^ iss.; Hydrarg. Chloridi, mitis 
 (calomel), 5 ss.; Antimonii Oxy. sulphureti, 3i.; misce. 
 Coque ad f, et adde Fol. Sennae, § iii.; Rad. Glycyrrhizse, 
 
SYPHILIS. 407 
 
 I iss. ; Sem. Anisi, f ss. Infunde per horam et cola. The 
 
 dose of this decoction is half a pint to' a pint morning and 
 
 evening. 
 
 The weaker decoction is compounded as follows : — 
 Capiat residuum decocti fortioris et adde Radicis Sarsa- 
 
 parillae, | ii.; Aquae, lbxxiv.; Coque per horas duas et adde 
 
 Cort. Canellae, Cort. Limonem, Sem. Cardamomi, a a 3 in. 
 
 Infunde per horam et cola. The dose of this decoction is 
 
 one pint at intervals during the day. 
 
 Another mode of preparing it with somewhat different 
 
 proportions of ingredients is given by Dr. Berkeley Hill, as 
 
 follows : — 
 
 5 . Sarsaparilla, § xii. ; Water, three gallons. Macerate 
 twenty-four hours, and put in a linen bag ; White Sugar, 
 3 vi. ; Alum, 3 vi. ; Calomel, 3 iv. ; prepared Cinnabar, 3 i. 
 
 Hang the linen bag in the liquor and boil down, while add- 
 ing four gallons more water, till the liquor is reduced to 
 two gallons ; remove the bag, and add to the decoction the 
 following ingredients, namely : — Anise Seeds, 3 iv. ; Fennel 
 Seeds, 3 iv. ; Senna Leaves, § i}4 ; Liquorice Root, 3 iss. 
 Press and strain. 
 
 About half a pint to a pint is the daily quantity to be con- 
 sumed of the compound. While the amount of mercury it 
 contains is rarely enough to produce any unpleasant effects, 
 it is enough to control the disease. A weaker decoction of 
 the woods is free from mercury, but is of no value beyond a 
 diet drink. 
 
 Iodide of potassium, in doses adjusted to the individual 
 case, appears to act with rapid benefit in some of the syphil- 
 itic diseases of the interior of the cranium giving rise to ex- 
 treme pain. Its administration often causes intense suffer- 
 ing in patients who have been treated previously by mercuri- 
 als. Two distinct effects are produced : — First, the com- 
 pounds of mercury fixed in the body are rendered soluble 
 and active ; and secondly a form is given to them which al- 
 lows of their elimination, with more or less rapidity, in a state 
 of combination with one of the elements of the iodide ; and 
 thus the patient is subjected anew to a mercurial treatment 
 by the compounds of mercury already present in his body 
 (Melsens, in Brit, and For. Med.-Chir. Review, 1853). The 
 dose of iodide of potassium should at first be small, not more 
 than fifteen grains in the twenty-four hours — increasing the 
 dose if the patient bears it well (Melsens, Guillot). Its ac- 
 
4o$ SVfciiiLis. 
 
 tion is aided by a blister over some portion of the shaven 
 scalp, and by having the blistered surface dressed with mer- 
 curial ointment ; and generally, it may be said that local 
 treatment gives very valuable aid. For example, cutaneous 
 or mucous raised papules remaining persistent, an ointment 
 composed of oxide of zinc, calomel, and simple cerate, has- 
 tens their absorption. Eruptions of lichen, acne, and herpes 
 are similarly benefitted by the application of oxide of zinc 
 lotion or ointment ; and if prurigo and urticaria be also pres- 
 ent, diacetate of lead lotion will expedite the cure. Vesiculo- 
 crustaceous spots will cease to reappear if the affected parts are 
 painted for a few days with a solution of nitrate of silver (gr. 
 x.-xx. to | i), and oxide of zinc lotion applied afterwards. 
 
 In thd more advanced stages of the suppurative affec- 
 tions, the use of pyogenic counter-irritants ought not 
 to be neglected, such as tartar-emetic ointment. They 
 tend to keep up just so much of a discharge as may be 
 consistent with the strength of the patient ; and are worthv 
 of a trial. 
 
 In the dry forms of syphilitic cutaneous diseases, and in 
 chronic eczema of the extremities, tar ointment,or an alcoholic 
 solution of tar, is an excellent application ; and the disap- 
 pearance of indolent glandular swellings is greatly aided by 
 the use of strong solutions of iodine. Superficial forms of 
 ulceration attending the pustules of ecthyma are benefitted 
 by the use of solutions of nitrate of silver or sulphate of cop- 
 per, and generally by caustics and local stimulants. If a 
 sloughing condition threaten ulcerating sores, lotions of the 
 potassio- tartrate of iron will generally improve their aspect. 
 In psoriasis palmaris, and similarly fissured conditions of the 
 skin, glycerine lotions are most useful. But all these local 
 remedies, it must be remembered, are only aids to the con- 
 stitutional treatment, whether by mercury or ioc'ide of potas- 
 sium, or simply by a well-regulated hygiene. The patient, 
 during the whole of the treatment, should be warmly clad — 
 should be fed upon a good but plain diet — should take plenty 
 of exercise in the open air in fine weather — should use occa- 
 sionally (once or twice a week) — warm baths — and avoid 
 stimulants, unless specially indicated and prescribed. Dur- 
 ing the febrile stage and the exanthem stage he ought to be 
 confined to his bed. 
 
 The administration of mercury, to affect the system rap- 
 idly, is best effected through the agency of the mercurial 
 vapor bath. It is a mode of administration not liable to af- 
 
SYPHILIS. 409 
 
 feet the digestion, and it permits other remedies to be given 
 by the mouth at the same time, if they be considered neces- 
 sary. It is also mild, slow, and equable in its action. The 
 mercurial vapor bath is to be managed in either of the fol- 
 lowing ways. The first method is best adapted for the prac- 
 tice of a large institution ; the method recommended by Mr. 
 Lee is better suited for private practice : — 
 
 " The patient is seated on a chair, and covered with an 
 oil-cloth lined with flannel, which is supported by a proper 
 framework. Under the chair are placed a copper bath, con- 
 taining water, and a metallic plate, on which is placed from 
 one to three drachms of the bisulphuret of mercury, or the 
 same quantity of the grey oxide, or the binoxide of this met- 
 al. From five to thirty grains of the iodide of mercury may 
 be employed, or a scruple of the iodide, with a drachm and 
 a half of the bisulphuret. Under the bath and plate spirit- 
 lamps are lighted. The patient is thus exposed to the influ- 
 ence of three agents, — heated air, steam, and the vapor of 
 mercury. At the end of five to ten minutes perspiration 
 commences, which becomes excessive in ten or fifteen min- 
 utes longer. The lamps are now to be extinguished ; and 
 when the patient has become moderately cool, he is to be 
 rubbed dry. He should then drink a cup of warm decoction 
 of guaiacum or sarsaparilla, and repose for a short time " 
 (Langston Parker). 
 
 Mr. Henry Lee's mode of proceeding is more simple : — 
 "A special and convenient apparatus is used (made by Sav- 
 igny & Co.), which consists of a kind of tin case, containing 
 a spirit-lamp. In the centre, over the flame, is a small tin 
 plate, upon which from fifteen to thirty grains of calomel is 
 placed, while around this is a sort of saucer, filled with boil- 
 ing water. The lamp having been lighted, the apparatus is 
 placed under a common cane-bottomed chair, upon which 
 the patient sits. He is then enveloped, chair and all, in one 
 or more double blankets, and so he remains well covered up, 
 for about twenty minutes, when the water and mercury will 
 be found to have disappeared." 
 
 With regard to sarsaparilla as a remedy, Sigmund, Syme, 
 and many other acute observers, have come to the conclusion 
 after long and careful trials of the best sarsaparilla, that it 
 does not,/^r se, exercise the slightest perceptible influence 
 on the course and termination of syphilitic diseases. It is 
 usually given in combination with some mercurial prepara- 
 tion, as in the decoction of Zitmann. 
 
4IO TABES DORSALIS TETANUS. 
 
 As to the original local sore of syphilis, it may be dressed 
 simply with lint soaked in warm or cold water, and renewed 
 every three or four hours. The indurated glands, if they 
 are painful, may be fomented, and the horizontal posture 
 maintained. Moderate exercise may be taken if all local 
 irritation is subdued ; and then slightly stimulating lotions 
 may be used to the sore, such as sulphate of zinc, in the pro- 
 portion of one or two grains to the ounce ; or the liquor 
 plumbi diacet. dil. of the pharmacopoeia ; or the black or yel- 
 low wash if the surface is indolent. 
 
 Tabes Dorsalis. — {See Locomotor Ataxv. Progressive). 
 
 Tetanus — Definition. — Involuntary, persistent, intense, 
 and painful contractions, cramps or spasms, of more or less 
 extensive groups of voluntary muscles ; so that the whole of 
 the body may seem to be affected, the spasm yielding and 
 becoming intermittent in some groups of muscles, while at 
 the same time it exists in others, or the continuous tonic 
 spasms are characterized by paroxysmal aggravation of 
 extreme intensity. 
 
 Treatment. — So long as the phenomena are peripheral and 
 reflex, the removal of the offending part may arrest the dis- 
 ease ; but when it has become central, it is probably always 
 fatal. There are thus two forms of tetanus which demand 
 recognition for treatment as early as possible. Baron 
 Larrey affirms that this disease, if left to nature, is 
 quickly fatal. Sir James Macgrigor says that all the most 
 powerful remedies were fully tried in the Peninsular War, 
 and that little or no dependence could be placed on any of 
 them. There is great tolerance of all kinds of sedatives and 
 narcotics. 
 
 Much good, however, is gained by attempting to restore 
 the secretions to a healthy state ; also by supporting the 
 patient with food and drink, and by endeavoring to tranquil- 
 lize the high irritation under which he is laboring. The 
 medicines to be employed are moderate doses of purgative 
 medicines, with tinck opii m xxv., or its equivalent, 10 grains 
 of Dover's powder, given every three or four hours ; and 
 these conjoined with moderate quantities of wine, sago, mixed 
 with strong beef-tea or soup, or other nutritious diet. Musk, 
 also, in ten-grain doses, has been given with some advantage. 
 Some authors lay much stress on a local treatment in trau- 
 matic tetanus. Baron Larrey, as the result of his great ex- 
 
TETANUS. 411 
 
 perience, says : * When it is caused by the wound, we should 
 not hesitate to operate on the first symptom of tetanus, and 
 thus, as far as possible, remove the causes of irritation." If 
 tetanus follows amputation, he recommends the stump to be 
 sprinkled with powdered cantharides ; and in cases where a 
 nerve has been included in the ligature, that the ligature be 
 removed either by section ur by actual cautery. In the 
 British army, however, all these proceedings have been 
 adopted, and with very little success. Amputation has been 
 frequently performed without any mitigation of the symptoms. 
 The wound has also been excised, submitted to actual cau- 
 tery, been blistered, and dressed with every kind of ointment; 
 but the disease has run its course, either uninfluenced, or its 
 fatal termination has been accelerated. Hennen has even 
 seen the wound heal and the patient die on the same day. 
 Nothing, in fact, is so unsatisfactory as the results yet ob- 
 tained from either the general or local treatment of this fatal 
 affection. Larrey has often attempted, from the difficulty of 
 swallowing fluids that sometimes attends tetanus, to pass an 
 elastic tube; but in all cases he says he met with a contracted 
 state of the oesophagus impossible to overcome, while the 
 attempt was constantly followed by the immediate occurrence 
 of the severest spasmodic attacks. 
 
 " If, however," as Mr. Poland observes, "we can help our 
 patient on one day after another, we gain much. Constant 
 watching and constant attention are required by night as 
 well as by day, and unflinching perseverance on the part of 
 the sufferer to aid all efforts made in his behalf, besides the 
 avoidance of all causes of excitement, and more especially 
 drafts of cold air or winds, taking care to preserve a uniform 
 temperature as much as possible." No hope of recovery 
 may be indulged in unless the spasmodic seizures continue 
 to diminish in length and frequence, distinct relaxation of 
 the contracted muscles occurring during those intervals of 
 diminished spasm ; and unless the patient becomes able to 
 take food, recovery in the fortunate cases takes place with 
 extreme slowness. It is not till after the lapse of weeks 
 that the muscles entirely lose their spasmodic tension. 
 Russian vapor baths are well spoken of by Hasse and 
 Niemeyer. 
 
 Too free use, alike of narcotics and of anaesthetics, must 
 be guarded against. They are valuable aids in maintaining 
 the existence of the patient from paroxysm to paroxysm. 
 Aconite has been used in larjre and repeated doses by De 
 
4t2 TETANUS. 
 
 Morgan, Smith, Sedgwick, Woakes, and Wunderlich. It 
 ought to be used hypodermically, and there appears to be a 
 great tolerance of the remedy. Cannabis sativa or Indian 
 hemp, is a remedy of real value, if it can be got genuine and 
 fresh. Three grains of the extract, or thirty drops of the 
 tincture, may be given every half hour or hour till narcotism 
 is attained. Cold should at the same time be applied to the 
 spine (Muller, O'Shaughnessy, Chuckerbutty). 
 
 The more or less obstinate constipation of the bowels 
 which characterizes this disease, and which is accompanied 
 by a foetid state of the dejections, ought to be overcome by 
 (i.) turpentine enemata, and (2.) calomel and jalap purga- 
 tives. This is most important. 
 
 A cas^ of traumatic tetanus under the care of my friend, 
 Dr. John Liston Paul, Surgeon-Major of H. M. Indian 
 service, is reported in the Madras Monthly Journal of Med- 
 ical Science for July - , 1872, which recovered under the per- 
 sistent use of belladonna tincture, carefully observing the 
 effects of the drug upon the system. The bowels were first 
 freely acted upon by calomel, gr. v., and compound jalap 
 powder, gr. xx.; and immediately on the action of the bowels 
 commencing, ten minims of the tincture of belladonna were 
 given in half an ounce of water. In an hour five minims 
 more were given ; and every hour afterwards an increase of 
 three minims was added to the previous dose, till twenty 
 minims were given at one dose. The administration of 
 belladonna was commenced at 10:30 a. m., and by 4:30 p. m. 
 a dose of twenty minims was thus gradually reached. This 
 dose was continued in half an ounce of water every hour till 
 10 p. m., after which it was given every second hour till the 
 following day, when no relief to the rigidity or paroxysms 
 being obtained, this dose was increased to twenty-five minims 
 every hour. This treatment was persevered in, with the aid 
 also of chloral hydrate occasionally, as well as ice applied to 
 head and spine, and movement of the bowels by active pur- 
 gatives of jalap and croton oil. At three intervals the bella- 
 donna had to be suspended, on account of its poisonous 
 physiological action being obvious in the delirium, thirst, 
 and other symptoms. The patient was under active treat- 
 ment with belladonna for fifteen days ; the amount of tinc- 
 ture taken in that time being ten ounces four drachms and 
 thirty minims. 
 
 Yandell states that chloroform up to this time has yielded 
 the largest percentage of cures in acute tetanus (Brain, Oct., 
 
TETANUS. 413 
 
 1878). He is of opinion that the true test of a remedy for 
 tetanus is its influence on the history of the disease in the 
 following respects : (a.) Does it cure cases in which the dis- 
 ease occurred prior to the ninth day after the injury ? (b.) 
 Does it fail in cases whose duration exceeds fourteen days ? 
 Tried by these tests he asserts that no agent has yet estab- 
 lished its claims as a true remedy for tetanus. But among 
 the numerous medicines used in the treatment of tetanus 
 chloral is one of the latest, and appears to possess many 
 advantages. Bauer, in his article on tetanus in Von Ziem- 
 sen's Cyclopoedia, states that other remedies are practically 
 and properly being more and more supplanted by chloral- 
 hydrate. This is superior to every other means, even the 
 inhalation of chloroform ; and the control of the spasm will 
 be attained most satisfactorily by the combination of chloral 
 with bromide of potassium. Billroth also records success in 
 cases of tetanus from the use of chloral. 
 
 Dr. J. R. Beck has collected (St. Zouis Medical and Surgical 
 Journal, June, 1872) thirty-six cases of traumatic tetanus 
 treated essentially by chloral in which a recovery took place 
 in twenty-one instances. Dr. H. C Wood has tabulated 
 (Treatise on Therapeutics, pp. 292, 293) eighteen additional 
 cases resulting in nine recoveries and nine deaths. In the 
 Practitioner for November, 1872, Dr. Macnamara, of Calcut- 
 ta, gives his experience in tetanus among the natives, and 
 says that he treats them by giving forty grains of chloral at 
 bedtime, and by providing proper diet of a nourishing kind. 
 In severe cases, an additional thirty-grain dose is given at 
 midday. Out of twenty successive cases seventeen recov- 
 ered. Though these cases were probably idiopathic in many 
 instances, the testimony is nevertheless valuable. Within 
 the past few years the medical journals have been constantly 
 reporting cases of recovery from tetanus under the use of 
 chloral, but isolated cases have their value diminished, be- 
 cause the fatal cases are not so likely to appear in print. 
 Nevertheless, the fact remains that many cases of traumatic 
 tetanus have recovered while such treatment has been em- 
 ployed. The drug has been introduced into the system by 
 various channels ; M. Ore* has treated cases of tetanus, 
 though unsuccessfully, intravenous injections of hydrate of 
 chloral (Practitioner, August, 1877); while success has fol- 
 lowed its administration hypodermically in acute traumatic 
 tetanus(A merican Journ. of Med. Sciences, April. 1877, p-554), 
 and it is stated that a case recovered where chloral, in con^ 
 
414 TETANUS. 
 
 junction with bromide of potassium, was given by enema 
 {Hospital Gazette, New York, April, 1877, p. 15, from Lon- 
 don Lancet). Dr. Agelastos, of Bucharest, believes that he 
 prevents the occurrence of lock-jaw in traumatic cases by 
 the timely employ of chloral {New York Med. Journ., April, 
 1877, p. 436). Verneuil says that chloral allays the muscular 
 contractions, and especially those of the respiratory appa- 
 ratus, which in the last stages of the disease cause asphyxia; 
 and that it changes the acute into the chronic form of the 
 disease. He gives instances of cure where the patients took 
 100 grains and 245 daily without any bad symptoms. The 
 first of these tetanic patients recovered after thirty days, 
 having been given § vj. of chloral during that space of time 
 {New York Med. Journ., 1876, p. 97). While in charge, as 
 Resident Surgeon, of Dr. R. J. Levis's ward in the Pennsyl- 
 vania Hospital, Dr. Roberts had the care of four cases of 
 traumatic tetanus, all of which were treated with hydrate of 
 chloral ; of this number three recovered, and one died out 
 of nineteen cases. 
 
 The evidence appears, indeed, to be very strong in support 
 of the efficacy of chloral hydrate in the treatment of tetanus; 
 and if one thing stands more prominently out in the history 
 of medicine during recent years, it is the influence for good 
 which is being exercised and becoming more easily controll- 
 ed by the judicious use of those very powerful remedies. 
 Dr. Van Someren of Madras also records successful cases 
 from the use of chloral hydrate, and recommends a more 
 heroic administration of the drug {Madras Monthly Journal, 
 May 1872). 
 
 Woorara or Curare is reported to have cured thirteen out 
 of thirty-three cases (Demme, Busch). Appropriately given 
 it effectually controls the spasms, and thereby spares exhaus- 
 tion from them. The hypodermic injection of a solution of 
 curare deserves extensive trial, commencing with such small 
 doses as -J to \ of a grain, gradually increasing from \ to in- 
 grains. A solution of one to two grains in 100 drops of 
 water should be made fresh, and 10 drops of this solution in- 
 jected as a dose. The action lasts about four or five hours, 
 and upon this fact its repetition must be regulated (Dem- 
 me). 
 
 The Calabar bean seems next or equal in importance as a 
 remedy in tetanus. In 1874 an analysis of published cases 
 showed that out of 64 cases of traumatic tetanus treated by 
 this medicine, 33 recovered. Since then this unusual pro- 
 
TETANUS. 415 
 
 portion of cures of a disease which was before nearly always 
 fatal, has been considerably increased. When the treatment 
 has failed, the failure has been mainly attributable to an 
 inefficient use of the remedy. The minimum dose of the 
 extract of physostigma which should first be administered, 
 is one-third of a grain. It should be repeated every quarter 
 of an hour, until its specific operation is developed, and the 
 spasms are completely overcome. This effect should be 
 steadily maintained, and then reproduced as often as the 
 spasms recur. It is usually necessary to increase the dose in 
 order to maintain its original impression (Stille and Maisch, 
 The National Dispensatory, p. 1080), In the New York 
 Medical Record of July 6, 1878, Dr. Burke reports two cases 
 which occurred under his care in New York. One was seen 
 on the tenth day after injury to the foot from treading on a 
 rusty nail. Drop doses of fluid extract of physostigma, of a 
 strength of 60 grains to the drachm, were first ordered, 
 together with castor-oil, as the breath was foul. On the 
 following day the dose of Calabar bean was increased to a 
 drop every half hour combined with 3 i. of whiskey to coun- 
 teract the depressing effects of the Calabar bean. Finally, 
 the dose was gradually raised till mxiii. of the fluid extract 
 of Calabar bean were administered every half hour; whilst 
 as much as two pints of whiskey were given daily. The 
 other ingesta were always fluid, consisting of milk, eggs, and 
 beef-tea. As good effects were produced the quantity of the 
 extract was gradually reduced, and finally, in about six 
 weeks, entirely discontinued, good care and nourishment 
 completing the cure. In a second case the dose was gradu- 
 ally raised till mxv. of the fluid extract were given every 
 hour, whiskey, at the same time, being always administered. 
 The full physiological action of the drug was also obtainable 
 by injecting hypodermically mxxii. to mxxxiii. of the alcoho- 
 lic extract of the Calabar bean every hour, 3 iv. of whiskey 
 were also given by hypodermic injection, and about an ounce 
 by the mouth. The patient steadily improved under a treat- 
 ment in which the alcoholic extract was injected hypodermi- 
 cally in doses ranging from mx. to mxxv. every hour. He 
 was ultimately discharged cured. One grain of the extract 
 of Calabar bean may be given by the stomach; or one-third 
 of a grain, mixed with x. or xv. minims of water,and neutra- 
 lized by Carbonate of soda, by subcutaneous injection, re- 
 peated in two hours, and increasing the dose gradually. 
 Sir Joseph Fayrer records two cases of traumatic tetanus 
 
416 TETANUS. 
 
 treated and cured by opium smoking and internal adminis- 
 tration of chloroform and hemp. Both patients were Hindoos. 
 The average quantity of opium-goolic smoked daily by one 
 patient was 84 grains. The chloroform and hemp were given 
 as in the foilowing prescription: — 
 
 ^ Chloroform; mx.; Extract of Indian nemp, gri.; Mucil- 
 age, 3 i; Camohor Mixt. z i. Misce. To be repeated every 
 six hours. 
 
 Surgeon-General Gordon, during the siege of Paris, 
 reports that M. Demarquay saved several patients' lives who 
 had manifested early symptoms in the form of trismus by 
 means of very hot air-baths followed up by the hypodermic 
 injection of morphine. In the fully developed cases these 
 remedies.were not successful. The inhalation of the nitrite 
 of amyl has been recommended by Dr. W. S. Forbes of Phil- 
 adelphia, in quantities of three to five drops. 
 
 A case of tetanus having occurred, the bowels should first 
 be relieved by a large enema with turpentine, after which 
 perfect quietness in a darkened room, free from noise or cur- 
 rents of air, must be insisted upon, as the best means of pre- 
 venting the fits of spasms. The use of the ice-bag along the 
 spine as recommended by Todd, has afforded relief by allay- 
 ing spinal irritation; but its action is very depressing, By 
 far the largest mass of testimony has accumulated in favor 
 of supporting the strength of the patient by the frequent ad- 
 ministration of nutritious foods, tonics, stimulants, and opi- 
 ates, the latter of which must be given in the most liberal 
 and persevering manner. These remedies (nutrient and 
 medicinal) must be administered both by the mouth, by the 
 rectum, and by the hypodermic method (Hamilton). Stimu- 
 lants and abundant nourishment appear to give more pros- 
 pects of success in the treatment of tetanus than any other 
 means; and with the use of chloroform, chloral, and Calabar 
 bean to lessen the spasms, perfect rest, quietness, and free- 
 dom from currents of air,the sufferer may be able to withstand 
 the exhaustion, and live through the acute period of the 
 disease. 
 
 Systematic feeding of patients with liquid and strengthen- 
 ing food, at short intervals, has been employed with very 
 good results in the hospital of the University at Pennyslvania. 
 The food must be given at intervals of every two or three 
 hours; and should consist mainly of milk, with a small quan- 
 tity of alcohol. Solid food is to be avoided. Medicinally, 
 the patient must be brought well under the influence of the 
 
TETANUS. 417 
 
 Bromide of Potassium, by an initial dose of two drachms to 
 half an ounce, to be followed by half a drachm to a drachm 
 every three or four hours. Thirty grains of chloral are to 
 be given with some opium at bedtime. Chloral also is to be 
 used when necessary in the daytime. Nitrite of amyl and 
 chloroform should not be used continuously, but should be 
 resorted to from time to time to stop violent spasms. If 
 bromism should be produced, chloral and opium should be 
 relied on; or, cannabis indica may be substituted for the 
 bromides. Where there is much cerebral congestion a blister 
 may be put on the nape of the neck {Philadelphia Medical 
 Times , Oct. 13, 1877, and Londoti Medical Record, Dec. 15, 
 1877, p. 500). 
 
 Nerve-stretching has been recently advocated as a remedy 
 in tetanus. It is an operation first introduced and recom- 
 mended by Nussbaum for the cure of neuralgia and other 
 painful and spasmodic nervous affections. Within the last 
 few years it has been tried in this country in the treatment 
 of tetanus, by Milner, Verneuil, Callender, Eben Watson, and 
 by Mr. Henry Morris in the Middlesex Hospital, London, 
 and by Surgeon-Major J. J. L. Ratton, in Madras Medical 
 College, with varying success. M. Verneuil's case occurred 
 after a crush of the hand. Traction was made on the median 
 nerve at the elbow, and on the ulnar near the wrist. The 
 man completely recovered, but no particulars are given as to 
 the duration of the case, or as to its being acute or chronic. 
 Two cases reported by Dr. Eben Watson both died. The 
 patient operated upon and reported by Mr. Henry Morris al- 
 so died. The case differed from the others in its very great 
 severity and acuteness; and he did not think that the pro- 
 gress of the case had been in the least retarded or mitigated 
 by the nerve-stretching. On the contrary, the course of the 
 symptoms seemed to become more severe and more rapid; 
 and he could not help expressing his conviction that nerve- 
 stretching in tetanus would not prove a favorable mode of 
 treatment. It seemed to be unscientific in principle; and so 
 far as experience went, most unsatisfactory in practice. The 
 idea was to destroy the conductivity of the nerve-trunk, so 
 as to cut the pinrJ cord off from its communication with the 
 peripheral nerve;; at the seat of injury. In doing this a very- 
 severe shock or irritation was likely to be excited by the 
 nerve-stretching itself; so that the condition of the cord, be 
 it what it may, whether a material change, a state of excite- 
 ment from irritation, or a " bad habit " induced by a " de- 
 
4l8 TETANUS. 
 
 praved current," seemed more likely to be aggravated than 
 mitigated by a new and great disturbance of the same nerve 
 channel at a spot much nearer to the spinal centre. But the 
 operation is still sub judice (Brit. Med. Journ., June 21, 
 1879). 
 
 On the other hand Surgeon-Major Ratton writes hopefully 
 of the operation, aided by the administration of chloral. 
 The case he relates is that of a strong Hindoo woman thirty 
 years of age, in whom symptoms of lockjaw appeared after 
 having taken a cold bath on the third and last day of a 
 menstrual period; and in whom there were also deep syphilitic 
 ulcers over the left ankle, some with sinuses and tense 
 cicatricial bands. He regarded the case as one of traumatic 
 tetanus, tke symptoms of which rapidly developed into an 
 explosion of acute tetanic violence, which he believes would 
 have killed the patient but for the nerve-stretching; and 
 which, at the same time, would not have saved the patient 
 but for the chloral. The sciatic nerve was stretched with 
 " the force required to lift a three-pound weight " for the 
 space of two minutes, and afterwards jerked once or twice 
 with about double that force before being replaced. Not a 
 single spasm recurred for 18 hours after the operation, when 
 slight spasms reappeared; and if at this time chloral had not 
 been pressed, the spasms would have gathered strength. 
 This is the fifth time Surgeon-Major Ratton has stretched 
 the sciatic nerve for traumatic tetanus, and each time the 
 operation has suppressed spasm for many hours; and if dur- 
 ing these valuable hours of rest, chloral is properly plied, he 
 believes the chances are that spasm will not return. He has 
 given chloral very freely, so as to maintain narcotism for 
 ten days. During the three critical days of the case of the 
 Hindoo woman, on and after the operation day, she had 300 
 grains of chloral daily. In such cases there is a great toler- 
 ance of chloral. In this particular case he purposely re- 
 frained from operating until the symptoms of tetanus were 
 alarming, for he desired to test the value of nerve-stretching 
 in acute cases only, for subacute cases often get well of 
 themselves, while acute cases never do. He doubts if any 
 treatment will avail to cure acute tetanus unless age (say 
 about thirty years, or prime of life) and stamina of constitu- 
 tion are with the physician. In this case the duration of the 
 disease was twenty-three days. It is only the strong who 
 can hope to battle through the exhausting effects of tonic 
 and clonic tetanic spasms prolonged for days, generally with 
 

 TINEA DECALVANS — TINEA FAVOSA. 4I9 
 
 insufficient nourishment, often for days at a time able to take 
 nourishment by rectal alimentation only; yet considering tbe 
 well-merited reputation of tetanus as a fatal disease, surely 
 it is a solid gain that even a few cases may, under certain 
 circumstances, be saved by the resources of modern medi- 
 cine (Brain, Part VII., Oct., 1879, p. 483). 
 
 Tinea Decalvans. — Definition. — A fungous disease caus- 
 ing the formation of rounded or oval patches of baldness, 
 sometimes solitary, more generally multiple. It affects the 
 hairy scalp principally; but the beard, the genital organs, 
 and hairy portions of the skin may also suffer. 
 
 Treat?ne?it consists — (1.) In preventing the spread of the 
 disease circumferentially. All the hairs within a quarter of 
 an inch of the circumference of the patch ought to be care- 
 fully extracted. The head should be washed daily with soft 
 or black soap. All the downy hairs within the patch must 
 be similarly removed till healthy hairs begin to grow; and 
 some of the parasiticide lotions or ointments must be in- 
 dustriously used. (2.) Stimulant?, or even blisters, must be 
 applied to the surface of the bald patch alter the fungus has 
 been destroyed. A mixture of equal parts of collodium 
 and of ether cantharidalis (collodium vesicans) is the most 
 useful stimulant. The following lotions may be found ad- 
 vantageous alternately with the collodium stimulant 
 namely: — 
 
 IjL Liquor Ammoniae, 3 iss; 01. Olivae, 3h\; 01. Macidis, 
 3 ss.;Spiritus Rosmarini, 3 iv.; Aq. Rosae, 3 ii.; misce bene. 
 To be used night and morning, applied over the bald 
 patches. 
 
 Mr. Startin recommends a lotion nearly similar, namely: — 
 
 fy. Spt. Amnion, co., f 3 i- ; Glycerine, fjss.; Tinct. 
 Cantharidis, f 3 i. to f 3 ii.; Aq. Rosmar., | viii. 
 
 Mr. Erasmus Wilson recommends the following: — 
 
 $. 01. Amygdal.; Liq. Ammoniae, aa 3 i.; Spt. Rosmarini; 
 Aq. Mellis, aa 3 ii.; misce. To use as a lotion. 
 
 Of course, none of these agents have any good result if 
 there are no bulbs or roots of hair left whose growth can be 
 stimulated by such application; but when hair falls off, or 
 breaks away after debilitating illness, or from dryness of the 
 scalp, they are often useful. 
 
 Tinea Favosa. — Definition. — A fungous parasitic disease, 
 composed of cup-shaped scabs, sometimes distinct and 
 separate, at other times indistinct or confluent. The fungi 
 (Achorion Schonleinii Puccinia favi) are capable of being 
 
420 TINEA FAVOSA. 
 
 implanted by transference from one person to another. The 
 hairy scalp is its most common site, but the disease may be 
 developed on the face, neck, or limbs. 
 
 Treatment. — The treatment of the various forms of favus 
 is now very strictly determined. Some practitioners, how- 
 ever, still rely entirely on a constitutional treatment, such as 
 small doses of rhubarb and soda, small doses of mercury, 
 some preparation of iron; or on vegetable tonics, as the in- 
 fusion of cascarilla or compound infusion of gentian. With 
 such treatment, if the health improves, it is believed the 
 fungus will spontaneously disappear. Others, again, as 
 entirely rely on a local treatment, attempting to exterminate 
 the disease by cauterization, or by applying some favorite 
 ointment. • As in the last described disease, the crypto- 
 gamous parasite must be destroyed, and its germs eradicated. 
 The best method to accomplish this is, in the first instance, 
 to shave the head and apply a poultice till all the scabs, or 
 very nearly so, are removed; and this being affected, the 
 whole hairy scalp, or site of the favus fungus, should be 
 anointed with some of the following applications: — The tar 
 ointment (ungt. picis liquids) has hitherto been the ortho- 
 dox application. This ointment should be washed off night 
 and morning with soft soap and water, and be as often re- 
 applied. The head should be shaved twice or thrice a week, 
 and where there are other children, the affected child should 
 be isolated as much as possible, to prevent the disease 
 from spreading. This form of porrigo, in the early 
 stages, will sometimes yield by washing the part with the 
 oleum terebinthinae night and morning, and cutting the hair 
 close. Two parts of carbolic acid to three parts of glycerine 
 and water used twice a day, with the daily use of carbolic 
 acid soap, have been also found of service. 
 
 But favus is more often rebellious to every mode of treat- 
 ment. It has been known to yield to fomentations, or to 
 bread poultices. The application of the lunar caustic round 
 the patches, about a line from their outer margin, is another 
 favorite method of treatment. In the later periods of the 
 disease, Dr. Willis recommends — 
 
 A solution of sulphate of copper, in the proportion of 
 seven grains to ten ounces of water; or of the nitrate of 
 silver in the same proportions. The mild ointment of the 
 nitrate of mercury, a salve of the black sulphuret of the 
 same metal (sulphuretum hydrargyi nigr., 3 j. ad. 3 ij., 
 adipis | j); the unguentum picis, an ungent of the cocculus 
 
TINEA TONSURANS. 42 f 
 
 Indicus ( 3 j. to 3 ij-, adipis | j.,) may be tried one after 
 the other; and in different instances each may have the 
 merit of the cure. 
 
 The most effectual remedy is unquestionably the eradica- 
 tion of the affected hairs, and the use of such parasiticides 
 as have been already mentioned under the different forms 
 of Tinea. Dr. Anderson finds that when favus affects the 
 head, all treatment is absolutely useless except epilation. 
 The other methods are merely palliative, the disease re- 
 appearing whenever the treatment is stopped. Treatment 
 with olive oil is very useful in many cases before proceeding 
 to epilation. After the hair is cut short, and the favus 
 crusts removed with poultices, the parts affected should be 
 smeared thoroughly night and morning with fresh almond 
 oil; and once or twice a week the head should be washed 
 thoroughly with soft soap and warm water. After a few 
 weeks of this treatment the hair becomes less friable, and 
 epilation is much more easily and efficiently performed, and 
 does not cause so much local irritation. The hairs are to be 
 removed singly with the forceps, not pulled out along with 
 all the healthy growth in their neighborhood, as used for- 
 merly to be done by the barbarous application of the pitch- 
 cap. When favus occurs on surfaces not particularly cov- 
 ered with hair it yields at once to the application of a solu- 
 tion of sulphate of copper, or of the nitrate of silver in 
 water, or to the solution of sulphuric acid, as recommended 
 by Sir William Jenner. The treatment of favus recom- 
 mended by Robin and Bazin is epilation, and the applica- 
 tian of the corrosive sublimate solution, or of acetate of 
 copper ointment (i part to 500 lard), to kill the plant still 
 remaining adherent to the hair follicle 
 
 Tinea Tonsurans. — Definition. — An affection implicat- 
 ing the hairs of the skin, scalp, or chin, and usually assum- 
 ing a circular form. The hair becomes dry and brittle, hav- 
 ing a tendency to crack or break across. Itching accompa- 
 nies the primary eruption, which is generally at first erythe- 
 matous, with slight swelling, and a parasitic fungus ultimately 
 appears (Achorion Lebertii — Trichophyton tonsurans), which 
 had been developing between the epidermis and the true 
 skin. The fungus has a pure white color and powdery as- 
 pect. It covers the epidermis between the hairs, and forms 
 around them a complete white sheath. Inflammation of the 
 hair tollicles and of the surrounding tissues occurs; and when 
 
422 TINEA TONSURANS. 
 
 pus forms, the fungus is destroyed at the expense of obliter- 
 ation of the roots of the hair, when perfect baldness ensues 
 (Bazin, Anderson). 
 
 The Treatment of ringworm has been long one of the most 
 difficult points in dermatology. Its principles, however, are 
 now well understood, and few cases resist the proper meas- 
 ures. The essential point is to apply to the roots of the hairs 
 a preparation which may destroy the fungus; if this can be 
 done, the disease is cured. It is first of all necessary to re- 
 move the hair. This is in part generally accomplished be- 
 fore the case comes under treatment, by the course of the 
 disease; if it has not been sufficiently done, " epilation" can 
 be accomplished by a chemical agent, or by extraction with 
 pincers. The forceps most suitable for this little operation 
 are those about three inches long, having a weak spring, so 
 that the hand may not be fatigued in using them. They 
 should be made so that the two extremities come together 
 very exactly, and do not slide the one upon the other. Each 
 extremity should be a couple of lines broad, so that a fascic- 
 ulus of hair may be caught up at one time when required; 
 and should be furnished on the inside with very fine, but at 
 the same time blunt, transverse denticulations, so that they 
 may not cut across the brittle hairs. M. Bazin recommends 
 an ointment composed of lime and carbonate of soda, of each 
 one part, and thirty parts of lard, as an agent to remove the 
 hair. The oil of cade, however, appears to be the best de- 
 pilatory known, and with this mode of treatment epilation 
 with the pincers may be combined. If the hairs are pulled 
 out in the proper direction, there is very little pain, especially 
 after the sensibility of the skin has been blunted by the use 
 of the oil of cade. The removal of the hairs permits a "par- 
 asiticide" solution to be applied to the hair follicles, within 
 which are the prolific spores of the fungus. For this purpose 
 M. Bazin recommends either a solution of bichloride of mer- 
 cury (i part to 250 of water), or an ointment of the acetate 
 of copper (1 part to 500 of lard), about two grains to an 
 ounce of water; and a little alcohol or muriate of ammonia 
 should be used to facilitate the solution of the mineral. The 
 oil of cade should be mixed with glycerine in the proportion 
 of half a drachm to a drachm of the oil to an ounce of gly- 
 cerine. Kuchenmeister's experience shows that the alco- 
 holic solutions act most powerfully. Dr. Parkes used, with 
 excellent effect, a solution of thepernitrate of mercury, about 
 one part to thirty or forty of water. This is, however, a very 
 
TINEA TONSURANS. 423 
 
 powerful remedy, and is to be cautiously used, as it easily 
 blisters the scalp; also, an ointment composed of sulphate of 
 copper (one part), alum (three ~>arts), and lard (twenty to 
 thirty parts, according to the age of the patient). Probably 
 a better and safer parasiticide than any of these is sulphurous 
 acid (Sir William Jenner). Diluted with equal parts of gly- 
 cerine, or with two or three parts of water, it is to be applied 
 on a piece of lint to the affected part, and covered with oil- 
 silk to prevent evaporation {Med. Times, Aug. 20, 1853). 
 The following formula for sulphur may also be used: 
 
 5-. Sulphur, §iv.; Hydrarg. Ammon.-chloridi, Hydrarg. 
 Sulphuret, a a 3 il. ; 01. Olivse, |i»; Adipis, §iv.; Creasoti, 
 mv. It must be well rubbed into the patches of tinea. 
 
 Or, a lotion of one ounce of hyposulphite of soda in twelve 
 ounces of water (Dr. Tilbury Fox). The internal use of cod- 
 liver oil at the same time that sulphurous applications are used, 
 has also been recommended (J. H. Bennett). My friend, 
 Staff-Surgeon Dr. Davidson, has found the following method 
 of treatment to succeed, namely: to apply tincture of iodine 
 to the affected parts twice a day for fourteen days, and after- 
 wards ointment of the bichloride of mercury (Corros. subli- 
 mat). After the third or fourth application of the iodine, 
 the disease ceases to spread, and the hair (which may have 
 been thinning rapidly) ceases to fall off. A kind of crust is 
 formed by the application of the iodine, which scales off in 
 the form of a scurf when the ointment is applied. Soft soap 
 (black soap) applied to the patches of disease at bedtime, 
 and washed off in the morning, fits the parts for the better 
 reception of other local remedies. Washing the head I e "ore 
 medical treatment is begun, sometimes tends to spread the 
 disease to parts of the head which had been sound before. 
 Goa powder, called also Bahia powder and Araroba powder, 
 first introduced to European medical practice by Sir Joseph 
 Fayrer, has also become a remedy, made into an ointment 
 composed of 20 grains of the powder, 10 drops of acetic 
 acid or common vinegar, and an ounce of benzoin ointment. 
 It is applied by means of a hair pencil (Dr. Da Silva Lima). 
 Its active principle, chrysophanic acid, has the objectionable 
 property of staining; but it forms an efficient ointment in the 
 treatment of some forms of ringworm, to to 60 grains to an 
 ounce of lard being melted together in an oil-bath. 
 
 The iodide of arsenic in doses of one-tenth of a grain, 
 gradually increased to one-fourth of a grain for an adult; one- 
 fifteenth of a grain for a child six years old; and from one- 
 
424 TINEA VERSiCOLOR-^-f ONGUE, ULCER OF. 
 
 eighteenth to one-twentieth for younger children, improves 
 the general health (Neligan, on Diseases of the Scalp). 
 
 Tinea Versicolor o — Definition. — A fungous affection of 
 the skin, characterized by one or more broad irregularly- 
 shaped patches of a yellow or yellowish-brown color, occur- 
 ring most frequently on the front of the neck, breast, abdo- 
 men, and groins, having a predilection for those parts of the 
 body covered by clothing. The patches do not generally 
 rise above the surface of the skin; and there is usually some 
 degree of itching. 
 
 Treatment. — Local applications constitute the principal 
 part of the treatment. A solution of the bichloride of mer- 
 cury, in the proportion of two grains to an ounce of water, 
 applied over'the affected parts once or twice daily, is gener- 
 ally effectual in destroying the progress of the fungus. Mer- 
 curial or sulphur baths have a similar effect, either singly or 
 combined, care being taken to avoid salivation. The use of 
 black soap night and morning is recommended by Dr. An- 
 derson, or the use of the following mixture: — 
 
 $. Bichloridi. Hydrarg., 3i.; Alcoholis, §ss.; Saponis 
 Viridis, et Aquae distillatse, a a fiiss.; 01. Lavandulae, ^i.; 
 misce. To be used night and morning in the same way as 
 the black soap; but if the gums get tender, its use must be 
 suspended. 
 
 Great attention must be paid to cleanliness. The patient 
 should change his flannel clothing very often, and should not 
 sleep in the same flannels that are worn during the day. 
 
 Tongue, Inflammation tot— See Glossitis. 
 
 Tongue, Ulcer of the. — Definitio ;i — Inflammation, sim- 
 ple or specific, terminating in ulcers. 
 
 The treatment of syphilitic ulcerations of the tongue varies 
 according to the severity and form of the affection. In the 
 secondary varieties the local application of solutions of 
 chloride of zinc, with washes of chlorate or permanganate of 
 potash, are frequently sufficient; but sometimes the applica- 
 tion of solid nitrate of silver is desirable. In the tertiary 
 forms of syphilitic ulceration, solid nitrate of silver must be ap- 
 plied daily, and large doses of iodide of potassium frequently 
 administered. In mercurial ulcers, constitutional treatment 
 of a tonic character, disinfectant gargles, and generous diet 
 are indicated. It may here be mentioned that in all cases 
 of diseases of the tongue, all irritants, as spices and pepper, 
 
TONSILS, ENLARGED TYPHLITIS. 
 
 425 
 
 as well as smoking, sucking of lozenges, or any other measure 
 calculated to increase the flow of saliva, must be strictly pro- 
 hibited. 
 
 Tonsils, Enlarged. — Definition.— Hypertrophy of the 
 tonsil, generally with induration. 
 
 Treatment. — Although enlarged tonsils may be the result 
 of constitutional derangement, they in themselves also inter- 
 fere with the proper development and health of the body. 
 Thus, they constantly obstruct the free passage of air into 
 the chest, and thus interfere with the due development of 
 the chest and the proper oxygenation of the blood; they give 
 rise to an unhealthy secretion in the mouth; they sometimes 
 interfere with sleep; and, in the case of adults, they subject 
 the patient to repeated attacks of quinsy, with its associated 
 conditions of difficult deglutition and pain. 
 
 The importance of removing the diseased and redundant 
 portions of the affected gland will be at once evident. 
 Tonics, sea-bathing, and other constitutional means, do not 
 appear to exercise any beneficial effect in either diminishing 
 or arresting the growth of tonsils predisposed to hypertrophy; 
 nor are the applications of caustics of the slightest value, 
 unless they are so strong as to destroy a large portion of the 
 gland. It is better, therefore, to excise the enlarged tonsil 
 in all cases when the respiration is affected, or where there 
 is disease of the follicles predisposing to frequent attacks of 
 inflammation and suppuration. The best method of removal 
 is with a guillotine or wire ecraseur. Dr. Mackenzie has 
 lately invented a double guillotine, by which, in one opera- 
 tion, both tonsils are removed. This is a great desideratum 
 in the case of children; as, after one tonsil has been re- 
 moved, the practitioner has great difficulty in inducing his 
 little patient to allow a second similar ^operation. Haemor- 
 rhage seldom happens after removal of the tonsils; should it 
 occur, ice will generally check it; and if this does not answer, 
 a few half teaspoonfuls of a fluid containing tannic and gallic 
 acids in suspension, slowly sipped, will be certain to stop all 
 bleeding. 
 
 Tremor, Mercurialis — See Mercurial Poisoning 
 
 Typhlitis. — Definition. — Inflammation of the caecum, 
 which may lead to ulceration of its mucous membrane, and 
 not unfrequently of the entire wall of the bowel. 
 
 Treatment. — A full dose of castor-oil ( § ss. to § i.) is in- 
 
426 TYPHOID FEVER TYPHUS FEVER. 
 
 dicated if vomiting does not exist. Drastic purgation is not 
 to be thought of. The use of enemas through long rectum 
 tubes are the most efficient means of relief, which may throw 
 up four or five pints of liquid in a continuous stream, so as 
 to soften, crumble down, and set in motion the faecal collec- 
 tions. Salt, castor-oil, or turpentine, or milk oughi to be 
 added to the.fluid injected (Niemeyer). Any effusion left 
 may be resolved by the use of iodide of potassium. Leeches 
 may be required if pain on pressure continues in the iliac 
 region. 
 
 Typhoid Fever — See Enteric Fever. 
 
 Typhus Fever. — Definition. — A continued specific fever, 
 having a duration of from ten to twenty-one days, usually 
 fourteen, characterized by an eruption on the skin, of a gen- 
 eral dusky mottled rubeoloid rash, appearing between the 
 fourth and seventh days, at first slightly elevated ; disappear- 
 ing on pressure, but, after the second day, persistent, and re- 
 maining so for eleven or twelve days ; and often becoming 
 converted into true petechiae. Languor and weariness are 
 prominent from the first, gradually passing into sluggishness 
 of intellect, with confusion of thought, followed at the end 
 of the first week by delirium, stupidity, oblivion, and com- 
 plete prostration. In still more severe cases, somnolence, 
 stupor, and sometimes coma, with tremors, subsultus, and 
 contracted pupils supervene, when prostration becomes pro- 
 found. The disease may terminate favorably from the thir- 
 teenth to the seventeenth day. If it proves fatal, it is gen- 
 erally between the twelfth and the seventeenth day, leaving 
 no specific lesion in any part of the body, beyond hyperaemia 
 and blood changes, softening and disintegration of the heart 
 and voluntary muscles, hypostatic congestion of the lungs, 
 atrophy of the brain, and oedema of the sub-arachnoid and 
 pia mater. Typhus fever is eminently contagious, and oc- 
 curs in strongly-marked epidemics (Murchison). 
 
 General Indication? for Treatment. — They may be summed 
 up as a combination of measures to reduce excessive heat, to 
 insure proper excretion, and to act on the semi-paralyzed 
 nerves; and, " every remedial agent which shall be found to 
 promote the elimination of urea, without increasing the de- 
 structive metamorphosis of tissue, will deserve a trial in ty- 
 phus " (Murchison, p. 268). To reduce heat and to regu- 
 late elimination are but secondary indications in the 
 treatment of typhus fever, compared with the influence which 
 
TYPHUS FEVER. \2) 
 
 must be exercised over the nervous system ; and one of the 
 greatest objects of therapeutics at the present day is to find 
 substances which will act on the nerves and the blood, and 
 restore them in some way to their normal action. 
 
 Special I indications for Treatment. — Our objects in the 
 treatment of typhus fever should be, — (i.) To neutralize the 
 poison and to correct the morbid state of the blood ; (2.) 
 To promote elimination of the poison and the products of 
 the destructive metamorphosis of tissue ; (3.) To reduce 
 the temperature ; (4.) To sustain the vital powers, and to 
 obviate the tendency to death ; (5.) To relieve the distress- 
 ing symptoms ; and, (6.) To avert and subdue local com- 
 plications (Murchison, p. 265). 
 
 1. In the belief that the morbid condition of the blood in 
 typhus fever may be due to the presence of ammonia in some 
 as yet unknown combination, the use of mineral acids has 
 been recommended by many physicians. Murchison con- 
 siders their beneficial effects in typhus as undoubted, and in 
 this opinion he is confirmed by the experience of Huss of 
 Stockholm, Haller of Vienna, of Mackenzie, Chambers, and 
 Richardson, in this country. Huss recommended dilute 
 phosphoric acid in doses of twenty- five to forty drops every 
 second hour, believing that the phosphorus exerts a special 
 influence on the central organs of the nervous system. But 
 in the advanced stage, and especially if sweating, numerous 
 petechias, or ecchymoses be present, he has recourse to di- 
 lute sulphuric acid in doses of fifteen to twenty drops every 
 hour or every second hour. Dilute hydrochloric acid is pre- 
 ferred by Drs. Murchison, Richardson, Mackenzie, and 
 Chambers. It may be given to the extent of half a drachm 
 of the dilute acid, mixed with a like quantity of the tincture 
 of syrup of orange every three hours. Dr. A. P. Stewart 
 has used with advantage the tinctura perchloridi ferri, in 
 doses of thirty minims every three hours. Dr. Murchison 
 recommends nitro-muriatic acid. He prescribes twenty min- 
 ims of hydrochloric acid with ten minims of nitric acid every 
 three hours each dose being diluted with the patient's drink, 
 such as barley water sweetened with syrup of ginger and fla- 
 vored with lemon peel. But if the " typhoid state " is 
 developed in a marked manner, dilute sulphuric acid, 
 in doses of fifteen to twenty minims every three hours, 
 in combination with ether, and small doses of quinine, 
 are to be had recourse to, as in either of the following 
 formulae: — 
 
428 Typhus fever 
 
 $. Acid. Hydrochlor. dil., mxx. ; Acid. Nit. dil. mx. ; 
 Spt. JEther. Nit., mix. ; Liquor. Cinchonse, mxxx. ; Decoc. 
 S'copar. comp., § i. ; misce. A draught so composed may 
 be administered every third hour. 
 
 Or, 5- Quiniae Sulph., gr. \ ; Acid. Sulph. dil., mxx. ad 
 mxxx. ; ^Ether. Sulph. mxv. ad mxxx. ; Syrup Aurant., 
 mix. ; Decoc. Scopar. comp., § i. ; misce. A draught so 
 composed may be administered every third or fourth hour. 
 
 When the acids are cautiously administered in smaller 
 doses, in conjunction with a few minims of solution of muri- 
 ate of morphia (if the bowels be irritable), sweetened with 
 syrup of orange peel and diluted with water, the draught is 
 generally relished, and the tongue from being dry, and hard, 
 and brown, becomes moist and clean (Perry). 
 
 2. Perhaps the best general method to insure proper ex- 
 cretion is to supply the system with abundance of diluents 
 containing alkaline salts, which are not given in the food, 
 and to maiatain the action of the kidneys, the bowels, and 
 the skin. Plenty of pure drinking water tends to increase 
 the flow of urine, and so helps to wash away the products 
 of metamorphosis. Chloride of sodium, the alkaline salts of 
 potash, and probably also those of soda, tend to aid the for- 
 mation of urea, and its elimination. Dr. Murchison has 
 been in the habit of ordering large quantities of salt to be 
 mixed with the patient's beef-tea. In most cases it was great- 
 ly relished, and apparently beneficial. 
 
 Purgatives tend to insure a proper excretion, probably by 
 removing from the blood some of the abnormal products 
 formed in fever. The great relief which sometimes follows 
 their use, as well as the fall of temperature, seems to show 
 this. Where there is retention of urea, they aid its elimina- 
 tion, because we know that urea passes off sometimes by the 
 mucous membrane of the stomach and bowels. The patient 
 should be allowed to drink freely of water ; and five grains 
 of the nitrate of potash, or a small dose of the tincture of 
 digitalis (miv. to mx.), may be given with each dose of the 
 nitro-muriatic acid already mentioned. Dr. Murchison re- 
 commends nitre whey, prepared by boiling 3 ii. of nitre in 
 a pint of milk, and straining ; or a drink prepared by dis- 
 solving 3 i. to 3 ii. of the bitartrate of potash in a pint of 
 boiling water, flavored with lemon peel and sugar ; but 11 the 
 patient be very prostrate, or if the bowels be relaxed, 15 
 minims of the spine of nitrous ether is to be substituted for 
 the nitrate of potash 
 
TYPHUS FEVER. 429 
 
 Tea and coffee have been recommended in the stupor of 
 typhus ; and it is probable that their good effects are due to 
 their power of eliminating the urea already formed in the 
 blood (Dr. Parkes). The coffee may be given as an extract, 
 or as a strong infusion of the powdered berry made in the 
 ordinary way. Tea has been recommended as an infusion 
 of the green tea leaf. As beverages or common drinks in 
 fever, both tea and coffee have been found to relieve the 
 headache, the pulse becoming fuller and stronger under 
 their use. Bocker, L. Lehmann, and Hammond, all agree 
 in showing that in health they greatly lesson the urea 
 (Parkes On the Urine, p. 76). To restrain excessive metamor- 
 phosis it has been proposed to administer coca — the dried 
 leaves of the erythroxylon coca — which, when indulged in 
 by a healthy person, prevents for a time the feeling of fa- 
 tigue, and diminishes the amount of urea (to be?) excreted. 
 Hence its possible value as a therapeutic agent (M'Bean, 
 Brit. Med. Jouni., March 10, 1877, p. 291). A drachm to a 
 drachm and a half of the tincture is to be given in water 
 every four hours ; or an infusion of the leaves may be taken 
 when thirsty. 
 
 The action of the bowels is to be maintained by emetics 
 and laxatives. In the first instance, if the patient is seen 
 early — /. e., before the sixth day — an emetic of ipecacuanha 
 (one scruple), and of antimony (one grain), or of carbonate 
 of ammonia (two scruples), in place of the antimony, is to be 
 administered. If the bowels remain confined after the emetic 
 a mild laxative of rhubarb and calomel, or of castor-oil, is to 
 be given ; and failing these, or in place of them, a simple 
 enema is to be administered (Murchison, p., 277, 2nd Ed.). 
 The advantages of emetics are, that they relieve the patient 
 to some extent by mitigating or removing headache and gen- 
 eral pains. They also reduce the temperature, abate thirst, 
 and quiet gastric disturbance. Emetics, however, are con- 
 tra-indicated if the patients are unusually weak, or if the dis- 
 ease has advanced beyond the first week. Laxatives and 
 enemata, however, ought to be repeated daily, if required, so 
 as to secure a motion of the bowels once a day. In this re- 
 spect the treatment is different from the treatment which 
 ought to obtain in enteric fever. Excrementitious matters 
 in the intestines must be removed by gentle aperients. The 
 dark offensive matters accumulated in the intestinal canal in 
 typhus fever may have a secondary deleterious effect on the 
 system if they are allowed to remain. Purging, however, is 
 
430 TYPHUS FEVER. 
 
 to be avoided, and fresh-made compound rhubarb pill mass, 
 which tends to stimulate the peristaltic action of the intes- 
 tines, is as good a medicine as can be given, followed, if nec- 
 essary, or alternated, by a small dose of castor-oil, or by a 
 simple enema. 
 
 Diaphoresis is not to be encouraged beyond the insensible 
 transpiration of the skin, to remove which the wholesome 
 detergent of tepid water sponging is most beneficial. It 
 ought to be used twice or three times daily, and quantities 
 of Condy's fluid or of muriatic acid ( 3 i. ad Oj.) may be 
 mixed with the tepid water (Murchison). The measure 
 is a good one in a hygienic point of view ; and it con- 
 tributes — 
 
 3. To reduce temperature, the external application of cold 
 water, as was once practised to an extreme degree by Currie 
 (and originally recommended by Dr. Robert Jackson), has 
 been again recently advocated. In health such an applica- 
 tion as thafr of cold water has a great effect in reducing tem- 
 perature, and tends to increase metamorphosis of tissue 
 (Lehmann, Sanderson). 
 
 4. The vital powers are to be sustained by food in the 
 first instance. For this purpose, nourishment ought to be 
 given often, and at stated intervals — at least once every three 
 or four hours after the fourth day of the fever. Even if the 
 patient is asleep, or ssems to be so, he must be roused at 
 these stated intervals (not oftener) to take his food or his 
 stimulants. But if, towards the period of the crisis, the pa- 
 tient appears to be in a sound sleep, he ought not to be dis- 
 turbed. The indications for treatment just described apply 
 to the earlier stages of the fever, up till about the fourteenth 
 day. Beef tea, broths, meat juice, bread pudding, arrow 
 root, jellies, milk, eggs, and alcoholic fluids, are the foods on 
 which the typhus fever patient must be sustained. Alcohol 
 in small quantities, as well as tea, coffee, lemonade, soda- 
 water, water poured from standing over oatmeaJ, and taken 
 cold or after boiling and then cooling, and other fluids, have 
 a directly stimulant action on the nervous system and on the 
 organs of circulation ; at the same time, alcoholic drinks di- 
 minish the metamorphosis of the tissue elements. Few reme- 
 dies, however, require more discrimination in their use ; and 
 the following guides for their administration are compiled 
 from the careful observations of Dr. Murchison (p. 288, 
 2nd Ed.) : — (1.) Patients under twenty years of age do best 
 without alcohol ; but most patients over forty are benefited 
 
TYPHUS FEVER. 43 1 
 
 by alcohol from the commencement of the second week of 
 the illness, or earlier ; while persons of intemperate habits 
 require alcohol earlier, and in greater quantity than others. 
 (2.) In individual cases the indications for alcoholic stimu- 
 lants are mainly derived from the state of the organs of cir- 
 culation ; and the profession is indebted to Dr. Stokes (1839) 
 for pointing out the importance of cardiac and radial pulses 
 as guides for the use of alcohol in fever. The indications 
 are, — {a.) Extreme softness and compressibility of the pulse. 
 An undulating, irregular, intermitting, or imperceptible pulse 
 more imperatively demands stimulants than a merely rapid 
 pulse. So also an abnormally slow pulse — e.g., 40 to 60 — 
 is a stronger indication for stimulation than a quick pulse. 
 (b.) When the cardiac impulse becomes weak, and when the 
 first sound is impaired or absent, a liberal allowance of stim- 
 ulants is demanded ; and in every case where there are 
 doubts as to the propriety of giving stimulants, the heart 
 must be examined with the hand and witli the stethoscope, 
 because the state of the pulse alone is not sufficient to judge 
 from. The impulse may be found to diminish progressively 
 from the fifth or sixth day to the termination of the disease ; 
 and for several days prior to death or recovery it may be en- 
 tirely absent. The systolic sound of the heart becomes daily 
 more feeble, and ultimately may be quite inaudible, leaving 
 the second sound clear and distinct ; and before the first 
 sound is altogether lost, it may become so short that it is dif- 
 ficult to distinguish it from the second sound. If the action 
 of the heart be rapid, its sounds may thus come to resemble 
 closely those of the fa'tus in utero. A violently excited heart 
 all through the disease, with cold surface, cold breath, and 
 feeble pulse, demands wine from the first ; but even with its 
 judicious use the prognosis in such cases is extremely doubt- 
 ful (Stokes, Graves, Murchison). Other indications for 
 stimulants may be stated as follows : — (c.) If by raising the 
 patient to his semi-erect position a tendency to syncope is 
 induced, or great prostration is manifest, with diminished 
 strength and volume of the pulse, then stimulation must be 
 commenced. (3.) The darker and more copious the erup- 
 tion, the more is the necessity for stimulants, especially 
 if petechias are numerous. (4.) Profuse perspiration, 
 with no improvement in the general symptoms, requires an 
 increased supply of stimulants ; but a burning dry skin is in 
 itself an indication against alcohol. Coldness of the ex- 
 tremities is an indication for alcohol, especially when at the 
 
43^ TYPHUS FEVER. 
 
 same time the temperature of the trunk is considerably ele- 
 vated. (5.) Stupor, low delirium, subsultus, involuntary 
 evacuations, — symptoms generally of the typhoid state, are 
 indications for the liberal administration of alcohol ; but the 
 propriety of giving stimulants in delirium depends on the 
 state of the pulse. If, on the trial of stimulants, the patient 
 becomes tranquil, they do good, and may be continued ; if 
 the reverse, their use must be suspended. (6.) A dry brown 
 tongue is an indication for wine or brandy ; and if it becomes 
 clean and moist at the edges under the use of either, such 
 stimulation is beneficial. (7.) Complications, as a rule, in- 
 crease the necessity for stimulation ; and large quantities of 
 stimulants are called for if pyaemia, erysipelas, bronchitis, 
 pulmonary hypostasis, pneumonia, inflammatory swellings, 
 bed sores, or local gangrene shonld supervene. (8.) Alco- 
 hol, as a rule, is contra-indicated if there be severe darting 
 or throbbing headache, or acute noisy delirium, especially 
 when these symptoms co-exist with great heat and dryness 
 of the skin* flushing of the face, suffusion of the eyes, and 
 little or no impairment of the cardiac and radial pulse. When 
 alcohol is given under such circumstances, it should be re- 
 stricted to the intervals of the paroxysms of delirium. (9.) 
 Scanty urine of low specific gravity, containing little urea or 
 much albumen, and suppression of urine, are in themselves 
 indications against the use of alcohol. 
 
 The effects of alcoholic stimulation require to be most 
 carefully watched throughout the whole period of their ad- 
 ministration. Four ounces of wine in the twenty-four hours 
 is enough to begin with ; for if the blood be overloaded with 
 the products of alcoholic ingestion, further alcoholic stimu- 
 lation will lead to increased contamination, and it is rare that 
 more than eight ounces of brandy in twenty-four hours are 
 necessary. There are differences in the demand for stimuli 
 in the typhus of different countries, and in the fever of differ- 
 ent epidemics. Dr. Wood tells us that in America cases re- 
 quiring wine or brandy are extremely rare. Dr. Stokes says 
 that the typhus in Ireland demands large quantities of wine. 
 In Scotland, also, wine is the great mainstay in the treatment 
 of typhus fever, requiring often to be administered largely. 
 Port, sherry, marsala, madeira, brandy, gin or whiskey, pos- 
 sess no peculiar advantages apart from the alcohol contained 
 in each. Spirits contain 50 to 60 per cent, of alcohol, sherry 
 and port from 17 to 24 per cent, and malt liquors from 6 to 
 8 per cent. Two fluid ounces of spirit will thus be equal tq 
 
TYPHUS FEVER. 433 
 
 five or six of wine, and spirits ought to be given diluted ; and 
 if the prostration is great, and when the skin is cold and 
 covered with perspiration, the best stimulant is brandy or 
 whiskey punch, given as hot as it can be taken, in small quan- 
 tities at a time, frequently repeated. In urgent cases stimu- 
 lants ought to be given every hour ; and, as a rule, a larger 
 quantity will be required during the night and early morning 
 than in the daytime, for it is usually towards morning that 
 temperature tends to get low, and the vital powers are at 
 their lowest ebb (Murchison). At the same time it must 
 ever be remembered, as Sir William Jenner justly observes, 
 that " in no disease is the advantage of refraining from med- 
 dling more clearly displayed than in typhus fever ; and in no 
 disease is the prompt use of powerful remedies more clearly 
 indicated. It is in determining when to act and when 
 to do nothing, that the skill of the physician as a curer of 
 disease, in the case of fever is shown. Interfere by deple- 
 tion or stimulation when nothing should be done, and the 
 patient is lost, who, if it had not been for you, would have 
 been safe. Refrain from depletion or withhold stimulants 
 when the one or the other is required, and the patient sinks 
 into that grave from which judicious treatment might have 
 saved him." 
 
 A large, well-ventilated apartment, fresh air, a cool, but 
 not a cold atmosphere, quiet, abstinence from solids, and a 
 free supply of water, milk and water, coffee, weak broth, 
 beef tea, according to the discretion of the physician, are 
 the conditions and remedies on which a large majority of 
 cases will recover. But the patient must be constantly and 
 carefully watched. There is no disease where the attentions 
 of a well instructed nurse are more demanded ; and there is 
 no class of patients in hospitals so apt to be neglected by 
 the attendants, especially as to the regular administration of 
 the remedies prescribed. It is not uncommon to find that 
 the wine allotted for the day has been administered at a 
 draught, when it ought to have been given in small quanti- 
 ties at regular intervals, with care and watchfulness. How 
 often do we see almost hopeless cases recover under the careful 
 nursing of an intelligent person, regulated by the dictates of 
 common sense and conscientious solicitude, guided by the 
 judicious directions of a physician who knows well the na- 
 ture of the disease with which he has to deal ! The nurse 
 ought to note down the hours at which food or medicine has 
 been given, or any remarkable change in the symptoms. She 
 28 
 
434 tYi»HtJS FEVfcfc. 
 
 might also, if she were instructed, take observations with the 
 thermometer, for the information of the physician at each 
 visit. Dr. Murchison recommends that, in urgent cases, 
 food and alcoholic stimulants must be persisted in as long as 
 the patient is able to swallow ; and even when he can no 
 longer swallow, the case is not to be given up ; for he has 
 seen cases where life appeared to be saved by frequent ene- 
 mata of beef-tea and brandy after the patient had ceased to 
 take anything by the mouth. 
 
 Of special symptons which call for relief, the most urgent 
 is generally headache. If headache should persist after de- 
 lirium sets in, with a rapid pulse (e. g., 120), attended with 
 nausea, some saline, effervescing mixture, with four drops of 
 dilute hydrocyanic acid, may be given every six hours. In 
 the persistence of headache, dry cupping, such as has been 
 recommended by Dr. Sieveking, might furnish an aid to 
 guide the treatment, by determining whether it may not de- 
 pend upon repletion or upon emptiness of the cranial ves- 
 sels. When applied to the nape of the neck, dry cupping 
 may afford relief, if repletion has to do with the continuance 
 of headache. Under such circumstances the face is gener- 
 ally flushed, the conjunctivae red, and the skin dry and hot. 
 If the dry cupping does not relieve such symptoms, the hair 
 must be shaved off the head, and the scalp covered with 
 crushed ice inclosed in a bullock's bladder, or recourse may 
 be had to cold affusion. The application of cold water is 
 best effected by bringing the patient's head over a basin at 
 the edge of the bed, and having a vessel arranged so that the 
 cold water (at 40 or 50 Fahr.) may drip continu- 
 ously from a height of two or three feet upon the 
 head (Murchison). A skein of worsted arranged in the 
 water, with the ends overhanging the basin will main- 
 tain a constant flow of water from the basin, which may 
 be directed to fall upon the scalp. Dr. Murchison recom- 
 mends that in young subjects two or four leeches may be 
 applied to the temples; and in aged or infirm persons warm 
 fomentations to the head are advisable (Graves and Murchi- 
 son); a double fold of lint moistened in warm water and 
 vinegar, is to be laid over the scalp, covered with oiled silk, 
 and the application renewed every three hours. But if 
 ansemia is the cause of the headache, as may be suspected 
 from the state of the vascular system, then stimulants are 
 called for. Four to six ounces of wine may be given in 
 divided doses during the day and night of twenty-four 
 
TYPHUS FEVfcR. 43$ 
 
 hours. If the pulse continues to get weaker, the wine must 
 be increased. It must be borne in mind that the headache 
 of typhus naturally abates about the eighth day; but it is 
 sometimes rendered worse by sleeplessness; and if the reme- 
 dies for headache do not relieve it, nor tend to induce sleep, 
 then opiates may be given, combined with antimony, if the 
 skin be dry and hot and the pulse of good strength. Dr. 
 Murchison thinks that the employment of opium in typhus 
 is more dreaded than it ought to be. The dose of opium 
 should be given about 9 p. M., followed in two hours by half 
 the dose if the patient does not sleep. The form of the 
 opiate and dose may be ten to twenty minims of Battley's 
 solution, or fifteen minims of the solution of the bimeconate 
 of morphia, or five grains of the opium pill or compound 
 soap pill of the British Pharmacopoeia. Dr. Murchison 
 teaches us to distinguish two forms of delirium as a guide to 
 the administration of opium, combined with antimony in the 
 one form, and with ethereal stimulants in the other. When 
 the condition of the patient approaches more to that of 
 delirium ferox, the cardiac and radial pulses being of good 
 strength, after trying the cold affusion, and remedies already 
 mentioned, then opium combined with antimony ought to be 
 given without delay, as in the following prescription: 
 
 I£. Liq. Opii. Sedat. (Battley's) m lx; Antim. Tart., gr. if 
 ad gr. ii.; Aquae Camph. 3 y i-J misce A large spoonful o. 
 this mixture is to be given every hour until sleep is induced. 
 
 On the other hand, if the delirium approaches in its char- 
 acter that of delirium tremens, the radial pulse is usually 
 quick and feebie, the cardiac impulse diminished, and the 
 first sound of the heart more or less inaudible, then the 
 opium must be combined with alcoholic or other stimulants, 
 the amount being regulated by the state of the pulse and 
 heart. Dr. Murchison suggests the following prescription: 
 
 $. Liq. Op. Sed. (Battley's) 3 ss.; Spt. /Etheris, m lx.; 
 Aquae Camph., ad 3 iii.; misce. Commence by giving two 
 tablespoonfuls of this mixture, arid repeat it every hour till 
 sleep is obtained. 
 
 Or opium to the amount of half a grain may be combinea 
 with three grains of camphor in a pill, and such a pill may be 
 repeated, f necessary, every two hours. 
 
 Cases recuiring such treatment ought to be seen at least 
 three or four times daily. If dyspnoea is urgent, and lividity 
 of the face betoken pulmonary lesion, defective arterializa- 
 tion of the blood and venous congestion of the brain, opium 
 
43$ TYPHUS FEVEfc. 
 
 in any form must be withheld; and it must likewise be dis- 
 continued if any tendency to stupor supervene, or if there be 
 any marked contraction of the pupil — e. g., " the pin-hole 
 pupil " of Dr. Graves. This physician proposed the use of 
 belladonna in such cases, and he, as well as Dr. Benjamin 
 Bell and Dr. Murchison, bear their united testimony to its 
 usefulness. Dr. Craves prescribed it as follows: 
 
 I£. Ext. Belladonnae, gr. i.; Ext. Hyoscyami, gr. vi.; Pil. 
 Hydrar., gr. xxx. ; misce. This mass being divided into six 
 pills; one may be given every three hours. 
 
 Dr. J. Harley recommends 15 to 20 minims of the tinc- 
 ture every four hours; or to inject hypodermically from -^ 
 to £$ of a grain of sulphate of atropia. But digitalis is the 
 remedy on which Dr. Murchison places most reliance. 
 From 15 to 20 minims of the tincture; or from 6 drachms 
 to 3 ounces of the infusion may be given in the twenty-four 
 hours (1. (?., p. 284). Musk and camphor are stimulants of 
 very great value, which have fallen into unmerited neglect. 
 Camphor may be given in emulsion in doses of five grains 
 every two hours; or in the form of an enema in doses of a 
 scruple. Huss and Graves also bear testimony to the good 
 effects of these remedies. In a case of complete sleepless- 
 ness Dr. Graves gave the following combination of these 
 medicines with the best results: 
 
 5. Antim. Tart., gr. ss.; Pulv. Moschi, gr. x.; Camphor, 
 gr. v.; Tinct. Opii., mx; Aquae dil., |i.; misce. A similar 
 draught may be given every two hours; and after the third 
 dose the patient will generally fall into a quiet sleep. 
 
 The hydrate of chloral has been found to be preferable, in 
 certain circumstances, to opium in typhus fever. As a seda- 
 tive and hypnotic, it is successful in every form of cerebral 
 excitement; but it seems to have a more immediate and per- 
 manent curative action on cases of acute delirium at the 
 acme of typhus, than in the delirium tremens of the second 
 and third weeks, when the blood is loaded with the products 
 of the fever. It is also of use where there is bronchitis and 
 congestion of the lungs, when opium may not be given. 
 With regard to the dose, 40 grains is found to be a poisonous 
 dose in typhus, producing depression and irregularity of the 
 heart's action. All the benefits without the dangers may be 
 obtained with 20 grain doses for adults; 2 grains for chil- 
 dren of one to two years; 3 grains for three years; and 10 
 grains for children from nine to fourteen years. It is to be 
 
URINE, SUPPRESSION OF. 437 
 
 given in an ounce of water, sweetened with half an ounce of 
 syrup (Dr. J. B. Russell). 
 
 When there is danger of stupor passing into profound 
 coma, the best effects may result from a small cupful of a 
 strong infusion of coffee, given every three or four hours, 
 employing at the same time such measures as have a deriva- 
 tive action on the kidneys — e. g., dry cupping; mustard 
 poultices to the loins; wet compresses of thickly folded flan- 
 nel, wrung out of hot water, passed round the loins, and cov- 
 ered with a piece of water-proof cloth, retained in its place 
 by a bandage or towel. These remedial agents are all the 
 more necessary if the urine contain either blood or albu- 
 men. At the same time free evacuation from the bowels 
 should be secured by a purgative, or by a turpentine enema. 
 If the lethargic state supervenes early, and before there is 
 great exhaustion, the douche has been found to be of great 
 service as a stimulant, provided there be considerable eleva- 
 tion of temperature, and little irritability of the nervous sys- 
 tem (Todd, Armitage, Murchison). 
 
 The region of the bladder should be examined by the 
 physician at least two or three times daily, by manipulation 
 and percussion, and if there be the slightest doubt as to its 
 containing urine, the catheter must be introduced. 
 
 Urine, Suppression tf—Definitwn—\ complete or 
 partial suspension of the functions of the kidney, by which 
 the quantity of urine is greatly in defect, or its secretion en- 
 tirely suppressed. 
 
 Jreatment. — When suppression does not depend on any 
 morbid condition of the blood, and is primary, the patient 
 should be placed in a warm bath, and be purged by substan- 
 ces that act on the kidney, as the neutral salts. Indeed, if 
 the case be slight, purging by any cathartic is sufficient. If 
 this method should not succeed, m x. to xxx. of the tinct. 
 cantharides should be tried every four or six hours, accord- 
 ing to the urgency of the case. Many physicians prefer a 
 tonic treatment, as the camphor mixture and ether, or the 
 tinct. ferri muriatis m xxv. to 1. Belladonna is a useful remedy 
 and so also is digitalis applied as a fomentation of the fresh 
 leaves over the abdomen ; or an ounce of the tincture may 
 be added to a warm linseed poultice, or the dried leaves may 
 be made into a poultice, to which half an ounce of the tinc- 
 ture may be added. It is chiefly in cases in which the pulse 
 is rapid that digitalis is suitable ; and the urine will not begin 
 10 flow till the digitalis has reduced the action of the heart 
 
43^ URTICARIA UVULA, ELONGATED. 
 
 (J. D. Brown, in Medical Times, January 25, 1868). In the 
 suppression of urine attending cholera, Dr. E. Goodeve rec- 
 ommends the following : — 
 
 ]£. Tinct. Digitalis, m v. to m x. ; Spr. ^Ether. nit., m 
 XXX. ; Liq. Amnion. Acet, m lx. ; Aq., f f i. ; misce. Such 
 a draught may be taken every three or four hours. (Rey- 
 nold's System of Medicine, Vol. I., p. 183.) 
 
 The treatment of symptomatic anuria resolves itself entirely 
 into that treatment which will remove the primary disease. 
 
 Urticaria. — Definition. — An eruption of little solid elastic 
 eminences, roundish or oblong, pale in the centre, and red at 
 the circumference. These are commonly called " wheals," 
 similar to the results from the strokes of a lash. 
 
 Treatment — Emetics and purgatives in the first instance ; 
 afterwards the correction of faulty digestion. The surface 
 of the eruption may be dusted over with flour ; or the fol- 
 lowing lotion may be used : — 
 
 Tfc . Carbonatis Ammoniae, 3 i. ; Plumb. Acetatis, 3 ii. ; 
 Aquae Rosarum, § viii. ; 
 
 In the chronic form, especially associated with uterine irri- 
 tation or ovarian tumors, I have found bromide of potassium 
 of much benefit. It ought to be given in a full dose of ten 
 grains twice daily, which is to be doubled at bedtime. Qui- 
 nine is also useful, combined with rhubarb and carbonate of 
 ammonia. 
 
 $. Sulphatis quiniae, gr. xii. ; Solve in Glycerinae, m ii. ; 
 Pulv. Rhei., gr. xxiv.; Carb. Amnion., gr. xviii.; misce et 
 divide in pil. xii. — Signa, " One three times a day." 
 
 Uvula, Elongated. — Definition. — Relaxation or paralysis 
 of the uvula, which becomes so elongated that its top may 
 touch or rest upon the surface of the tongue. 
 
 The Treatment of elongated uvula must depend on the de- 
 gree of relaxation present, and the previous duration of the 
 affection. Slight and recent cases often get well by the per- 
 severing use of astringents. Gargles, containing tannin, 
 rhatany, or perchloride of iron, lozenges, and local applica- 
 tions, may all be used with advantage ; and, indeed, it is 
 found convenient to brace up the mucous membrane by em- 
 ploying these different methods at the same time. When 
 the uvula has been considerably relaxed for some months the 
 elongated portion should be snipped off. While hardly any 
 slight affection of the throat produces such serious symptoms 
 as elongation of the uyula, there is no slight operation that 
 
VARICELLA — VERTIGO, AUDITORY. 439 
 
 gives such complete and permanent relief as its removal. 
 Should any haemorrhage follow the operation, treatment simi- 
 lar to that recommended after excision of the tonsil must be 
 adopted. 
 
 Yaricella — See Chicken Pox. 
 
 Tariola — See Sma/l-Pox. 
 
 YertigO, Auditory. — -Definition. — A condition charac- 
 terised by sudden attacks of vertigo, paroxysmal in their oc- 
 currence, depending on a morbid state of the organ of hear- 
 ing, and especially with lesions of the semicircular canals. 
 
 Treatment. — Of practical importance in the treatment of 
 labyrinthine vertigo, and at the same time in illustration of 
 its pathology, it is to be remembered that the tympanum is 
 supplied with arterial blood from the carotid, and its veins 
 discharge into the jugular; that the labyrinth is supplied by 
 the vertebral, and its veins discharge into the superior pe- 
 trorsal sinus; that the vertebral artery derives many of its 
 vaso-motor nerves from the inferior cervical ganglion; and 
 that these nerves communicate with the brachial plexus. 
 The same ganglion furnishes the inferior cardiac nerve — the 
 principal inhibitory nerve of the heart. Besides these con- 
 nections a fasciculus is given off from the pneumogastric, 
 near the recurrent laryngeal, to the lower cervical ganglion. 
 We have, therefore, in this ganglion an organ connecting the 
 upper extremities, heart and upper portion of the digestive 
 tract, with the labyrinthine circulation. From any irritation 
 there may consequently arise a diminished inhibition, which 
 will relax the walls of the vertebral artery, and so cause 
 pressure on the endolymph with consequent vertigo (Woakes, 
 Chicago Med. /our. and Exam., Nov. 1878). 
 
 Hence such vertigo does not necessarily imply previous 
 disease of the ear. Gunshot wounds of the upper extremi- 
 ties are often followed by dizziness (Weir Mitchell). Qui- 
 nine, in large doses, and tobacco diminish vascular tonus; 
 while bromine, the bromides, and especially hydrobromic 
 acid, stimulate vascular innervation. Hence the antagon- 
 istic effect of the latter on the tinnitus aurium caused by the 
 former (quoted by Mr. D'Arcy Power, London Medical Re- 
 cord, April 15, 1879, p. 152). 
 
 The treatment of labyrinthine vertigo, the result of de- 
 structive lesions, can be but palliative; but auditory-nerve 
 vertigo, due to irritative lesion, may be more or less relieved. 
 Absolute rest is the first essential. The direct treatment of 
 
44° WHOOPING-COUGH. 
 
 labyrinthine affections is a subject for the special aural sur- 
 geon; and it is obvious that when symptoms point to the 
 existence of any disease or irritation in the accessible parts 
 of the ear, special treatment should be directed to those 
 morbid states. When there is evidence of an irritative pro- 
 cess, blistering behind the ear sometimes affords very mark- 
 ed relief to the vertigo. Occasionally there may be evidence 
 of a constitutional condition on which the aural disturbance 
 is dependent. In some cases there may be reason to believe 
 that a gouty change in the membranous labyrinth is the 
 cause of the morbid action (Hinton, Gowers). Marked re- 
 lief is afforded under these circumstances by colchicum and 
 potash. In rare cases the vertigo may depend on a syphi- 
 litic inflammation of the labyrinth. Such a case has been 
 described by Moos of Heidelberg. One of the most severe 
 forms of paroxysmal vertigo which Dr. Gowers has seen was 
 in a child, with almost complete deafness and every sign of 
 inherited syphilis. In all syphilitic cases the specific treat- 
 ment for syphilis is, of course, required. 
 
 It has been remarked that certain drugs have a marked 
 influence on the organ or nerve of hearing. The effect of 
 quinine induced Charcot to employ it, in full doses, in a 
 case of auditory-nerve vertigo, with some beneficial result. 
 Dr. Gowers has tried it; but he has not found that any 
 marked effect was produced on the vertigo. The influence 
 of salicylate of soda upon the equilibrium suggested its use 
 in this disease. It does not remove the giddiness; but in 
 some cases it lessens its intensity, in doses of from five to 
 ten grains three times a day. The most unremitting care 
 in diet and regimen is necessary. Antacids have been found 
 useful in subduing stomachal disturbance, and so arresting 
 an actual attack, and carbonate of bismuth has been of use. 
 The bromides of potassium and of ammonium have been the 
 most beneficial of all medicines in subduing the paroxysms; 
 and the good effects of bromide of potassium are increased 
 by belladonna, and also by its combination with bark. Other 
 sedatives alone, such as opium, Indian hemp, gelseminum, 
 and hyoscyamus, are, in the experience of Dr. Gowers, with- 
 out effect. The affection is a very obstinate one; but when 
 the several factors in the individual cases are sought out and 
 corrected, a considerable amount of relief may be afforded 
 (Dr. W. R. Gowers). 
 
 Whooping-Cough — Sec Hooping Cough. 
 
WRITER'S CRAMP YELLOW FEVER. 441 
 
 Writer's Cramp — [See Scrivener 'sPalsey.) 
 
 Yellow Fever— Definition. — A specific fever of a malignant 
 and continuous type; occurring, as a rule, only once during 
 life, and propagated by contagion. It is attended by yellow- 
 ness of the conjunctivae and skin, delirium, suppression of 
 urine, interstitial haemorrhages and haemorrhages from the 
 stomach, mouth, nares, and rectum (black vomit, black 
 stools), a slow and, at times, an intermittent pulse. It is 
 limited to very definite geographical limits, never having been 
 known to propagate beyond 48 north latitude, nor without a 
 temperature of 72 ° Fahr. at least. It has been imported 
 into Lisbon, into S. Nazaire (in the department of the Lower 
 Loire), into Plymouth and Southampton, where the import- 
 ed cases have run their course and proved fatal, but the dis- 
 ease did not extend to others. It has also been imported 
 and become epidemic as far south as Monte Video. It has 
 occurred as high as 4,000 feet above the sea-level (Newcastle, 
 in Jamaica). But, as a rule, it is endemic in low districts on 
 the sea coast, and rarely occurs over an elevation of 2,500 
 feet above the level of the sea. 
 
 Treatment. — An early attention to first symptoms among 
 the susceptible is of the greatest value in saving hnman life. 
 The diagnosis of cases in which the attack has been said to 
 have been u aborted" by remedies may be questioned, and 
 such a belief is opposed to the doctrines of sound pathology. 
 Moreover, the " heroic " doses of calomel which were given 
 in such cases, combined with quinine, cannot be too strongly 
 discountenanced, for " they were first recommended on the 
 strength of a crazy hypothesis " alone. The practice is said 
 to have frequently proved successful in Jamaica; but ac- 
 cording to Dr. Davy, it was not attended with beneficial re- 
 sults at Barbadoes, and the American physicians at New 
 Orleans have not found it to answer their expectations in 
 stopping the fever. The large and frequently repeated doses 
 of quinine were often also highly injurious (Lawson). This 
 discrepancy may, in some measure, be explained 
 by what has been stated at the outset in explaining the path- 
 ology of this peculiar fever. It is in cases where the fever is 
 of the periodic, paroxysmal, or paludal form, and not 
 the continuous or true yellow fever, that quinine 
 may be of use, if the system can be brought under its influence. 
 The ill effects of quinine in specific yellow fever consist in 
 its checking secretion and deranging the circulation within 
 
442 YELLOW FEVER. 
 
 the head. It is an object to keep the bowels freely open, 
 and to get the skin to act freely. The main object of the 
 physician should be to moderate excessive action in any 
 organ, and to endeavor to bring about as complete a crisis 
 as possible about the fifth day, which seems to be the natural 
 period of resolution of the disease. For this purpose noth- 
 ing is of more importance than to re-establish the secreting 
 function of the colon, and to obtain fceculent evacuations — 
 not mere bilious discharges, but proper dark-brown foeculent 
 stools (Lawson). Gentle excitement of an extensive portion 
 of the lining membrane of the colon, with frequent copious 
 enemata of a pint and a half of warm water, in which a table- 
 spoonful of common salt has been dissolved, and to which 
 has been added a tablespoonful of olive-oil, or more stimulat- 
 ing enemata, such as of turpentine, deserve a full and careful 
 trial. All the depurative functions must be kept in activity. 
 Turpentine is recommended by Dr. Copland, by Dr. Archi- 
 bald Smith, and Mr. Laird of H.M.S. " Medea " — one drachm 
 doses by the* mouth, or half-ounce doses as a lavement, 
 several times daily, using it also as an epithem on the abdo- 
 men. "When the mucous surfaces," writes Dr. Blair, "as 
 indicated by the tongue, were denuded of epithelium, the 
 use of gum water was decidedly beneficial. It lubricated, 
 defended, and soothed the raw surfaces. The strength was 
 generally three drachms of the purest powdered gum arabic, 
 dissolved in six ounces of cold water, and a tablespoonful of 
 this given every one or two hours. The patient at last gets 
 tired of it; but for thirty-six or forty-eight hours of the most 
 critical period of the disease it is used without dissatisfaction, 
 and then can be substituted by, or alternated with, smoothly 
 and thin made arrow-root. When the heat of surface was 
 ardent a wet sheet or blanket was used for the reduction of 
 temperature by evaporation, with frequently very good effect 
 (and if ice could be obtained, its internal use is well worthy 
 of a trial). But in the later stages of the disease, when the 
 skin was cool or cold, the patient seemed to have an instinc- 
 tive craving for its reapplication, and frequently asked to be 
 put into it. There would appear to be two causes for this 
 feeling. We find it to exist in cases in which black vomit 
 has been copious, and the associating thirst distressing; also 
 in cases where there has been no black vomit of any conse- 
 quence, and the breath is highly ammoniacal. In the former 
 class of cases the stomach ceases to be an absorbing viscus 
 in anything like the proportion of its secretions and transu- 
 
YELLOW FEVER. 443 
 
 dations. The skin is therefore employed in reducing the 
 crisis of the blood by the absorption of water, as shipwrecked 
 mariners are said to quench their thirst. But not only does 
 the skin afford an inlet for the imbibition of diluting fluids, 
 but the softening of the cuticle would seem to afford an ad- 
 ditional outlet for the noxious elements of the circulation; 
 and it is probably in this direction we must in future look 
 for auxiliary means of relieving the blood of its poisonous, 
 metamorphosed, and effete constituents, the onus of which is 
 now thrown on such vital organs as the stomach and lungs. 
 At one time the heat of the surface was so ardent and persist- 
 ent that the wet sheet failed to reduce it effectually. The 
 most distressing symptom in yellow fever, both to the patient 
 and the medical attendant, is irritability of the stomach; it 
 is so constantly present, and so often uncontrollable, that 
 the knowledge of every available means of checking it is of 
 the utmost importance. The food during the course of 
 yellow fever should be of the blandest description — chicken 
 tea, arrow-root, sago, and barley-water constituting the chief 
 articles; and these should be taken in minute quantities at a 
 time when the stomach is at all irritable. This rule applies 
 to drinks of all kinds. The patient is greedy for a large 
 draught of fluids; but by sucking them through a glass tube, 
 or a straw, or a hollow reed of small bore, or by the tea or 
 tablespoonful, they are much more likely to be retained. A 
 cold infusion of oatmeal was found an agreeable drink for 
 Scotch seamen, of which they did not seem to tire. A dis- 
 like of sweets was observed among the patients; and when 
 lemonade was asked for, the usual quantity of sugar was ob- 
 jected to, probably from its rendering the liquid too dense 
 for ready absorption by the stomach, and therefore less 
 quenching. Tea was found so uniformly to disagree with 
 the patients, and cause vomiting, particularly in the ad- 
 vanced stages, that at length it had to be expunged from the 
 yellow fever dietary. Dilute alcoholic drinks were given 
 freely, and with good effect. When brandy could be ob- 
 tained pure (tolerably free from acidity and fusel oil), and 
 was well diluted with water, that spirit answered every indi- 
 cation. Sometimes the effervescing wines were relished and 
 retained, but they are very liable to the objections of con- 
 taining foreign matters and the products of mismanaged 
 fermentation (Blair). For or five minims of chloroform pre- 
 pares the stomach for the reception and retention of food, 
 by lessening its irritability; and the dose should be repeated 
 
444 YELLOW FEVER. 
 
 a short time before food is again taken, as the effect of the 
 chloroform is transitory (J. D. Macdonald). On the same 
 principle the administration of chlorodyne may be advocated, 
 the composition of which is given by Mr. Squire in his "Com- 
 panion to the Pharmacopoeia." Lime-water has been also 
 found to have a most beneficial effect in allaying vomiting, 
 and thus enabling the patient to partake of food ; and the 
 essence of beef is well adapted for such cases, or beef-tea 
 and arrow-root in equal quantities mixed. 
 
 During the course of the disease, auxiliary treatment may 
 be required to meet contingent symptoms. This is embraced 
 chiefly in the use of sinapisms and stimulating liniments. 
 Tenderness over the liver may be benefited by them. Dr. 
 Blair writes that when the primary reaction was violent, and 
 the face turgid, and the head symptoms severe, arteriotomy 
 was performed with benefit. In a few such cases, and when 
 the patient was young, strong, and full-blooded, and where 
 the dynamic congestions were so violent that the vessels 
 yielded to the turgescence and impulse, and blood-corpuscles 
 without tube-casts, or even but a haze of albumen, were pres- 
 ent in the urine, a vein in the arm was opened, and free 
 bleeding relieved the tension of the vascular system. In 
 such cases convalescence was slow and unsatisfactory, but 
 the immediate results were beneficial. The severe pain in 
 the loins, which is a constant symptom in yellow fever, is gen- 
 erally associated with renal congestion ; and sinapisms or 
 stimulating liniments afford great relief to the lumbar pain 
 (Macdonald). With regard to the administration of opium 
 in any form the rule is, not to give it when there is suppres- 
 sion, or tendency to suppression, of urine. Restlessness and 
 sleeplessness are best met by chlorodyne, remembering that 
 the effect of yellow fever on the system is to make it sensitive 
 to narcotics. The congestion of the kidneys about the fourth 
 or fifth day requires watching, so as to diminish the chances 
 of suppression, by reducing congestion and preventing the 
 closure of uriniferous tubes by accumulated epithelium. 
 For this purpose Dr. Lawson recommends cupping, either 
 dry or with the abstraction of blood, and the use of frictions, 
 with stimulating liniments over the loins. These, with warm 
 baths or hot-air baths, deserve a full trial ; and small doses 
 of acetate of ammonia, with potash or soda, or their salts in 
 common use, with diaphoretics (so as to act gently on both 
 kidneys and skin), may prove beneficial. 
 
PHOTOGRAPHIC ILLUSTRATIONS OP 
 
 SKIN DISEASES. 
 
 [Forty-eight Quarto Plates, Sixty Cases from Life.] 
 By GEORGE HENRY FOX, A.M., M.D., 
 
 Clinical Lecturer on Sk4n Diseases, College of Physicians and Surgeons, New York: 
 
 Surgeon to the New York Dispensary, Department of Skin and Venereal Diseases; 
 
 Fellow of the American Academy of Medicine ; Member of the New York 
 
 Dermatologlcal Society, ihc American Dermatologlcal Association, etc. 
 
 The large experience and reputation of Dr. Fox in this department 
 eminently qualify him for the preparation of so important a work. 
 As Surgeon to the {Skin and Venereal Department of the New York 
 Dispensary, where upward of five thousand cases are treated annu- 
 ally, he has had ample amount of clinical material from which to 
 select cases. He has had access to and selected from several thou- 
 sand negatives, taken from patients in Bellevue and Charity Hos- 
 pitals. He has also drawn from other Dispensaries and Hospitals, 
 both in New York and Brooklyn, through the kindness of physicians 
 in charge. 
 
 The coloring is a special feature of the work, which has been 
 entrusted to a skillful anatomical artist, .1. <i w-.ktnku. M.D., for- 
 merly a physician and student under IIebka, in the General Hospital 
 of Vienna. These plates are carefully colored by hand and more ac- 
 curately represent disease than any lithographs or colored photo- 
 graphs which have ever been offered to the profession. 
 
 CONDITIONS.— The work is published in Twelve Part^, each part consisting of 
 four plateH printed from the original photographic negatives, liy a new and indelible 
 process, on fine quality of heavy cardboard, lit m U laches, colored by hand, giving 
 in each cawe the characteristic and life-like effects of the disease. Two puges of 
 text accompany eacli plate. 
 
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 Complete, Half Roan Binding, $'26.7o; in Half Turkey Morocco, $28. 
 
 NOW READY. PHOTOGRAPHIC ILLUSTRATIONS OF 
 
 Cutaneous syphilis 
 
 By GEORGE HENRY FOX, A.M., M.D. 
 48 Plates, Seventy Cases from Life. Terms and conditions as above. 
 
 E. B. TREAT, Publisher, 771 Broadway, N. Y. 
 
HOW TO USE THE FORCEPS: 
 
 WITH AN INTRODUCTORY ACCOUNT OF THE 
 
 FEMALE PELVIS; 
 
 AND OF 
 
 THE MECHANISM OF LABOR. 
 
 BY 
 
 HENRY G. LANDIS, AM., M.D., 
 
 Professor of Obstetrics and Diseases of Women and Children in Starling Medical 
 College, Columbus, O. 
 
 This handy volume is an eminently practical work and must prove 
 invaluable to the student, obstetrician, and physicians generally. 
 
 Twenty ye^rs ago it would not have been difficult to have found 
 many respectable physicians in full practice who had never used obstet- 
 rical forceps, and among that number some who considered the employ- 
 ment of forceps as meddlesome midwifery of the worst sort. To-day 
 the best masters of the art of obstetrics teach with great earnestness 
 their proper use, and our medical literature abounds with able articles 
 on the subject. In this work the subject is discussed from an entirely 
 new standpoint, and is endorsed by our best informed obstetricians. It 
 is issued in a handy volume, which is more convenient to consult, and 
 will be found much more full than the section on this subject in most of 
 the text-books. 
 
 It is an eminently practical work, the subject is fully presented in 
 every aspect ; a clear and forcible argument is made for the proper use of 
 the forceps. The practitioner and student will, in this well-written 
 treatise, obtain many valuable hints, more likely to be treasured and 
 retained than those scattered throughout the elaborate and diffuse 
 works on obstetrics. 
 
 The New York Medical Record says : " Prof. Landis has given 
 us a very practical, comprehensive and interesting work upon the 
 mechanism of labor and the use of the forceps. It can be read and 
 studied with profit by every general practitioner." 
 
 One i2mo Volume, fully illustrated with 28 practical outlines. 
 In extra cloth binding. PRICE, $1.50. 
 
 E.B, TREAT, Publisher, 771 Broadway, New York. 
 
SEXU Al , NEURASTHENIA 
 
 ^rmmw^^m m^+^m (nervous exhaustion.) 
 Its Hygiene, Causes, Symptoms and Treatment, 
 
 WITH A CHAPTER ON 
 
 X>±e"t fox* -tlb_e nSTex^^-o-ixS, 
 
 By George M« Beard, A.M., M.D., 
 
 Formerly Lecturer on Nervous Diseases in the University of the City of New York; 
 
 Fellow of the New York Academy of Medicine; Author of "Our 
 
 Home Physician," M Hay Fever;" one of the Authors of 
 
 N Medical and Surgical Electricity," etc. 
 
 [posthumous manuscript.] 
 
 Edited by A. D. Rockwell, a.m., M.D. 
 
 fellow of the New York Academy of Medicine, and Electro-Therapeutist to the 
 
 N. Y. State Woman's Hospital; one of the Authors of ' Medical 
 
 and Surgical Electricity," etc. 
 
 The philosophy Of this "Work W based on the theory that there is 
 a special and very important and very frequent clinical variety of neuras- 
 thenia (nervous exhaustion) to which the term sexual neurasthenia 
 (SOZUal exhaustion) may properly be aj plied. 
 
 While this variety may be and often is involved as cause or effect 
 ©r coincident with other varieties — exhaustion of the brain, of the spine, 
 of the stomach and digestive system — yet in its full development it can 
 be and should be differentiated from hysteria, simple hypochondria, in- 
 sanity, and various organic diseases of the nervous system, with all of 
 which it had until lately been confounded. 
 
 The long familiar local conditions of genital debility in the malj 
 — impotence and spermatorrhoea, prostatorrhcea, irritable prostate — 
 which have hitherto been almost universally described as diseases by 
 themselves, are philosophically jnd clinically analyzed. These symp- 
 toms, as such, do not usually exist alone, but are associated with other 
 local or general symptoms of sexual neurasthenia herein described. 
 
 The Causes of sexual neurasthenia are not single or simple but 
 complex; evil habits, excesses, tobacco, alcohol, worry and special ex- 
 citements, even climate itself, are the great predisposing causes. 
 
 The subject is restricted mainly to sexual exhaustion as it exists in 
 th© male, for the reason that the symptoms of neurasthenia, as it exists 
 Bi females, are, and for a long time have been, understood and recog- 
 nized. Cases analogous to those in females are dismissed as hypochon- 
 driacs, just as females suffering from now clearly explained uterine and 
 ovarian disorders were formerly dismissed as hysterics. 
 
 This view of the relation of the reproductive System to nervous 
 diseases is i.i accordance with facts that are verifiable and abundant; 
 that in men AS in women, a large group of nervous symptoms, which are 
 very common indeed, would not exist but for morbid states of the re- 
 productive system. — [From Dr. BcanV s Introduction. 
 
 The Causes and Symptoms of forty-three cases are given ^fol- 
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 In One Volume, Crown 8vo, Near!* 300 pap-es. $2. 
 
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 "'Our Home Physician' is, in our opinion, the best work 
 upon the subject that has ever been published. It is full, from beginning 
 to end, of intelligible, judicious and conscientious advice." 
 
 —New York Medical Record. 
 
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