LIBRARY OF CONGRESS. T\ t a- t — Chap, Copyright No. Shell _£*:„% % ■ UNITED STATES OF AMERICA. A COMPENDIUM OF PRACTICAL MEDICINE FOR THE USE OF Students and Practitioners of Medicine WILLIS WEBSTER GRUE-E, A. M., M. D., Professor of Physiology and of Clinical Medicine in the Toledo Medical College; Visiting Physician to the Toledo Hospital; Physician to the Toledo Medical College Dis- pensary for the Relief of the Out-door Poor ; Member of the American Medi- cal Association; Member of the Tri-State Medical Association; Member of the Toledo Medical Association, etc., etc. TOLEDO, OHIO: The Hadley Publishing Company. J897. ^-v COPYRIGHTED W. W. GRUBE, 1897. PREFACE. Ill presenting this volume to the medical profession, it may not be improper to state the circumstances which led to the undertaking, and the design which it is intended to accomplish. The frequent requests on the part of medical students whom it has been my pleasure to instruct during the past few years, to prepare a compendium of practical medicine which shall aid them in acquiring established facts, is the only apology I have to offer for its appearance. This work is designed to present the leading facts and prin- ciples of medicine, in a brief, clear and concise manner, so that they may be readily comprehended. My chief aim has been to prepare a book of an essentially practical character — one neither so meager in detail as to be next to useless, nor so overladen with unnecessary matter as to be unwieldy and lacking in precise knowledge. The ever- recurring wants and requirements of the medical student and practitioner have been kept constantly in view. In the preparation of the work, the author has carefully examined all the best material at his command and freely used it; the special object being to have it abreast of the present knowledge on the subjects treated as far as such is possible in a work of this kind; and every effort has been made to give it all the freshness of interest and clearness of expression possible. The discussion or even mention of mere theories has been purposely avoided, for experience has taught us that such dis- cussions serve only to confuse and discourage. In issuing a volume of this character, it is perhaps but just to say that of course it cannot and is not intended to replace the classical works. For more minute information, extended description and elucidation and other minutiae for which the work of reference is consulted, recourse must be had to more extended text -books PREFACE. and similar sources of information. Nevertheless, it is confi- dently believed that the present volume meets a distinct and im- perative need of the medical student and general practitioner, conveying in condensed and convenient form concise and practi- cal information for which they are liable to have continual use. In my endeavor to keep this book within reasonable limits, I have touched but lightly upon the pathology of disease, except in those cases in which such knowledge would aid in the treat- ment, and have purposely omitted all unimportant details. Not- withstanding my utmost efforts at condensation, the work has grown beyond the contemplated size. Much of the matter embraced in a work of this kind is the common property of the medical profession, and credit has been given for facts or opinions by merely inclosing the name of the author in parenthesis. If I have failed to give credit in any case, it is unintentional. I would gladly acknowledge my indebtedness to Prof. J. H. Pooley, M. D., of Toledo, for the preparation of Chapter IV., on "First Help in Surgical Emergencies," and to Prof. W. J. Gillette, M. D., of Toledo, for the preparation of Chapter III., on "Medical Diseases of Women." I also acknowledge my indebtedness to the standard works of Bartholow, Loomis, Flint, DaCosta, J. L. Smith, Skene, Thomas, Pozzi, Anderson, Fox, Noyes, Milton, Keyes, Bosworth, Bryant, Lusk, Habershon, Starr, Hammond, and many others. To the many kind Mends who have encouraged me to un- dertake this work, I return my warmest thanks. W. W. GPvUBE, M. D., 1502 Collingwood Ave., Toledo, Ohio. March, 1897. CONTENTS AND GENERAL INDEX. Examination of the patient. 17. History of. 17. Present condition. 17. Position of body. 18. General aspect. 18. PAGE. The Skin in Disease 19 The Pulse in Disease 19 The Tongue in Disease 24 The Temperature in Disease 27 Chronic Fever 30 Clinical Index 649 Fee Bill 664 Abortion , 32 Abscess 37 Acidity... 40 Acne 41 Acne Rosacea 45 Addison's Disease 46 After-pains 47 Agalactia 48 Ague (See Intermittent Fever)... 48 Ague-cake 48 Albinism 49 Albuminuria 48 Alcoholism 50 Alopecia 51 Amaurosis 53 Amblyopia 53 Amenorrhcea 610, 53 Anaemia 56 Anaesthesia 62 Anaesthetics 635 Anasarca 60 Anchylosis 62 Aneurism 58 Angina Pectoris 60 Anthrax 61 Aphasia 64 Aphonia 70 Apoplexy 64 Aptha? 63 Appendicitis 66 Ascaris Lumbricoides 70 Ascites 66 Asphyxia 72 Asthenia 69 Asthma 6? Atheroma 72 Backache 73 Balanitis 73 Baldness 73 Basedow's Disease 73 Bed-sore 73 Biliousness 74 Bites 75 Bladder Diseases 76 Blepharitis 76 Bloody-flux 76 Blood-poisoning 77 Boils 76 Borborygmus 78 Breasts, Inflammation ol 78 Breath, Foul 77 Bright 's Disease 83 Bronchitis 79 Bronchocele 78 Bubo 84 Bubonocele 7 s Bunions 86 Burns and Scalds 62-3. 87 Calcification 141 Calculi 89 Cancer 95 Cancrum Oris 132 Carbuncle 100 Cardialgia 133 Caries 99 Catalepsy 133 XII. GENERAL INDEX. Catarrh, Nasal and Chronic Gas- tric 100 Cephalalgia 134 Cerebro-Spinal Meningitis 134 Chancre 109 Chancroid 110 Chicken-pox 135 Chilblains 112 Chiragra 220 Chloasma 141 Chlorosis 113 Cholera Infantum 116 Cholera Morbus 115 Chordee ,,,, 118 Chorea 120 Circumcision 135 Cirrhosis of Liver 143 Cold, Exposure to 626 Cold Feet 137 Colic 121 Coma 136 Comedones 140 Condylomata 123 Conjunctivitis . 124 Constipation 125 Convulsions 127 Copper-nose 45 Coryza 128 Cough 137 Cramps 142 Croup , 128 Cystitis 131 Cysts 140 Dactylitis 164 Dandruff 164 Debility 143 Delirium 144 Delirium Tremens 145 Derbyshire Neck 164 Diabetes Insipidus -. 146 Diabetes Mellitus 147 Diarrhoea 149 Disl ocations 627 Dyphtheria 151 Dypsomania 154 Dirt-eating 155 Dropsy 155 Drowning 627-1 64 Dysentery..., 157 Dysmenorrhea 613, 159 Dyspepsia 161 Earache 164 Eclampsia 183 PAGE. Eczema ' 165 Embolism 184 Emissions 169 Emphysema 172 Empyema 173 Endocarditis 175 Endometritis 620, 186 Endosteitis 392 Enteralgia 190 Enteritis 176 Enuresis 184 Ephidrosis 190 Epididymitis 187 Epilepsy 178 Epispadias 189 Epistaxis 180 Epithelioma 189 Eructations (Offensive) 189 Erysipelas 181 Erythema 183 Exophthalmic Goitre 213 Faintings 199 Falling Sickness 199 Fatigue 200 Felon 199 Fetor of Axilla and Feet 191 Fevers (in general) 191 Fissure of Anus. 192 Fissure of Nipple 194 Fistula 195 Fits 199 Flatulence 196 Flooding 199 Flushing Heats 200 Foreign Bodies in Eye, Ear, and Nose 628 Fractures 267-201 Freckles, Sunburn and Tan 197 Frostbite 198 Furuncle 199 Galactorrhea 202 Gall-Stones.. 208 Gangrene 203 Gas, Asphyxiation from 629 Gastralgia 206 Gastric Ulcer 207 Gastritis (Toxic) 223 Giddiness 226 Gingivitis 224 Glanders 226 Glands, Enlarged Lymphatics.... 210 Glaucoma 224 Gleet 211 GENERAL INDEX, XIII. Glycosuria . 227 Goitre 213 Gonagra 227 Gonorrhoea 215 Gout 220 Granulating Lids 226 Gravel 226 Graves' Disease 226 Green Sickness 226 Grocers' Itch 165 Gumma 226 Gums (Spongy) 223 Hematocele 259 Hremidrosis 260 Haemoptysis 230 Hemorrhage 630, 239 Hsemateniesis 227 Hematuria 228 Hay Fever 232 Headache 234 Head-injury 262 Heart-burn 237 Heart Diseases 238 Heat Stroke 255 Hectic Fever 256 Hemicrania 237 Hemiplegia 237 Hemorrhoids ..,,.,... 242 Hepatitis 244 Hernia 630,263 Herpes 245 Hiccough 247 Hives 257 Hoarseness 257 Hodgkin's Disease 261 Hordeolum 258 Horns 262 House-maid's Knee 258 Hydrocele 259 Hydrocephalus 248 Hydr@nephrosis 272 Hydrophobia 274 Hydrothorax 249 Hymen-Imperforate 261 Hyperidrosis 260 Hypochondriasis 250 Hypospadia 261 Hysteria 252 Icterus 296 Icthyosis 275 Impetigo 276 Impotence 279 Incontinence of Urine 282 Indigestion 277 Inflammation 277 Influenza 282 In-growing Toe-nail 284 Injuries to Brain 631 Insolation 296 Insomnia 284 Intermittent Fever 286 Intertrigo 286 Intestinal Catarrh 287 Intestinal Obstruction 287 Intussusception 287 Iodism 296 Iritis 294 Irritability 297 Itch 287 Itching 297 Jaundice 297 Keratitis 299 Kidnev Diseases 300 King's"' Evil 300 Knee-jerk 300 Labor 301 Lactation (Excessive.) 319 Laryngismus Stridulus 302 Laryngitis 303 Lead Colic 320 Lead-poisoning... 305 Lentigo... 320 Leprosy 4 307 Leucocythsemia 308 Leucoderma 320 Leucorrhcea 616, 311 Lice 313 Lichen 314 Lipoma 319 Lockjaw 319 Locomotor Ataxia 315 Lumbago 318 Lupus 318 Lymphadenoma 310 Malarial Fevers 320 Mania 332 Mania, a potu 354 Marasmus 333 Mastitis 332 Masturbation 354 Measles 333 Melancholia 336 Meniere's Disease 357 Meningitis , 337 Menorrhagia 350 Metritis 620 XI V. GENERAL INDEX. Metrorrhagia 350 Migraine 351 Milium 357 Milk-leg 357 Miscarriage » 357 Mitral Disease 351 Moles 357 Morbus Coxarius 358 Morning Sickness 351 Mother's Mark 357 Mumps 352 Muscular Rheumatism 358 Myalgia 354 Myelitis 343 Nsevus 359 Nausea 364 Necrosis 360 Nephritis 360 Nettlerash 360 Neuralgia 360 Neurasthenia 366 Neuritis 364 Nightmare 365 Night Screaming 365 Nipple (Sore) 363 Nymphomania 363 Obesity 366 (Edema 367 (Esophageal Obstruction 379 Onanism 376 Onychia Maligna 367 Opacities in Eye 377 Ophthalmia 368 Opium Habit 369 Orchitis 371 Ostitis 392 Otalgia 374 Otitis 373 Overwork 378 Oxaluria. 374 Oxyuris- Vermicularis 376 Ozena 375 Painter's Colic 320 Palpitation 380 Paralysis 383 Paralysis Agitans 473 Paraphimosis 468 Paraplegia 386 Paresis 383 Paronychia 199 Parotitis 352 Pediculi 387 Pemphigus 387 .PAGE. Pericarditis 388 Periostitis 392 Peritonitis 394 Pertussis 400 Phagedena 402 Pharyngitis 403 Phimosis 468 Phlegmasia Alba Dolens 404 Phthisis 406 Phthisis (Fibroid) 431 Pica and Malacia 472 Piles 242 Pityriasis 164 Pleurisy 433 Pneumonia (Lobar.) 440 Pneumonia (Lobular.) 452 Podagra 220 Poisoning 632 Pollution 170 Polyphagia 473 Polyuria 146 Posterior Spinal Sclerosis 315 Priapism 455 Prickly Heat 456 Prostatitis 456 Prostatorrhcea 458 Prurigo 459 Pruritis 460 Psoriasis 461 Pterygium 470 Ptyalism 493 Puerperal Fever 463 Purpura 465 Pyaemia 466 Pyelitis 470 Pyonephrosis 470 Pyrosis 467 Quinsy 567 Rabies 274 Rachitis 475 Ranula 486 Rashes (Medicinal) 489 Relapsing Fever 490 Relaxed Uvula 488 Remittent Fever 329 Renal Calculi 92 Restlessness 489 Retention of Urine 486 Rheumatism 478 Rheumatism (Chronic Articular) 483 Rheumatoid Arthritis 485 Ringworm 565 Roseola 488 CiENEKAL index. XV. PAGE. Rubeola 333 St. Vitus Dance 120 Salivation 493 Salt Rheum 165 Satyriasis 494 Scabies 494 Scalds 87 Scarlatina 495 Sciatica 361 Scorbutus 507 Sclerosis of Brain 501 Sclerosis, Cerebro-spinal 502 Scrofula 504 Scurvy 507 Sea Sickness 508 Seminal Emissions 169 Septicaemia * 510 Shingles •___ 246 Shock 633,539 Sick Headache 235 Singultus 247 Sleeplessness 284 Small Pox 594 Sneezing 537 Somnambulism 537 Sore-feet 537 Sores 585 Spermatorrhoea 511 Spina Bifida 515 Spinal Irritation 536 Sprains 634, 518 St. Anthony's Fire 181 Stenosis of (Esophagus 379 Stings 538 St. Job's Disease 542 Strangury 514 Stricture 520 Struma 504 Stye (See Hordeolum.) 514 Sudamina 539 Summer Complaint 116 SunStroke 255 Suppression of Urine 540 Sweating 190 Syncope 199 Synovitis 541 Syphilis 542 Tape- worms Tetanus Tic Douloureux Tinea Tinnitus Aurium Thread Worm Thrush Tongue-tie Tonsilitis Tooth ache Torticollis Trachoma Trichinosis .._ Trismus Tuberculosis v ' Acute Miliary.) _. Tympanites Typhoid Fever Typhus Fever Ulcers and Sores Ursemia Urethritis Urticaria Vaccination Vaginismus Vaginitis Valvular Diseases Varicella Varicocele Varicose Veins Variola Varoiloid Vertigo Vitiligo Vomiting Vulvitis Wakefulness Warts Water Brash Wens Whites 311 Whitlow Whooping Cough Worms 376. Wounds (poisoned) Wrist-drop Wry-neck Yellow Fever PAGE. 560 562 360 564 566 376 564 572 567 569 354 572 571 562 432 570 572 583 585 586 215 587 596 588 618 596 593 590 590 594 595 590 320 592 589 284 607 467 141 616 199 400 560 632 305 354 60S CHAPTEE I. THE EXAMINATION OF PATIENTS. To elicit the facts of a case by careful examination is the first requisite for diagnosis. There are two methods of exami- nation — the synthetical and the analytical. The synthetical method is the more scientific, but is too full, and calls for too much labor, to meet the requirements of ordinary professional life. It is the best where the symptoms are obscure and ill defined. It consists in getting the family history and the history anteced- ent to the present disease, before the present condition is ex- plored. In the analytical method the present condition is first ascertained. Da Costa uses the following plan of examination: 1. Date of examination. 2. Name. 3. Age. 4. Color. 5. Place of Birth. 6. Present abode. 7. Occupation. 8. In female, whether married or not, number of children, and date of last confinement. History — I. History antecedent to present disease: (1) Constitution and general health. (2) Hereditary predisposition (family history.) (3) Previous diseases or injuries. (4) Habits and mode of life. (5) Hygenic influences to which ex- posed. II. History of present disease: 1 Its supposed exciting- cause. 2 Date of seizure. 3 Mode of invasion. 4 Subsequent symptoms in order of succession. 5 Previous treatment. Present Condition of Patient. I. General symptoms: 1. Position, in bed — mode of lying — out of bed — movements. 2. Aspect, of body — of countenance. 3. Skin. 4. Pulse. 5. Tern- 18 A COMPENDIUM OF PRACTICAL MEDICINE. perature. 6. Respiration. 7. Tongue. 8. Appetite, thirst, and condition of bowels. 9. General state of urinary secretion. 10. Sensations of the patient as to pain, etc. II. Examination of special regions. Diagnosis. Treat- ment. Position of the Body. If the patient is in bed, note how he lies; if out of bed, how he walks. If a healthy person be suddenly confined to his bed, the inference is that he will have an acute and severe disease. If the patient lies fixed upon one side, it shows, as a rule that the action of the lung of this side is impaired. The patient may be in bed but unable to lie down on account of distress in breathing. This dyspnoea is encountered especially in diseases of the heart, or where fluid is effused into the air cells or into both pleural cavities. In some diseases of the brain the gait is staggering. In one-sided palsy the movements are uncertain. General Aspect. — Expression of Countenance. The eye notices whether the body is bulky or wasted. If the bulky aspect is due to air in the tissues, they crepitate under the finger; if too fluid, the skin j^its under pressure. Emaciation is a more frequent symptom than augmentation. It may take place rapidly or gradually. Among the counte- nances most frequently met with is that of apathy and stupor. The eye is dull and listless; the face pale or flushed with fever. This look is common in fevers of a low type and is combined with dark material on the lips, gums and teeth. Unnatural fulness and congestion of the features are some- times observed in enlargements of the heart, and oftener still in .habitual drunkards. The same aspect is seen in apoplexy and in typhus fever. A pinched expression is found when there is intense anxiety or pain. The Hippocratic countenance denotes the moribund state. It is characterized by marked pallor with more or less lividity, pinching of the nostrils, sinking of the eyes, hollowness of the temples, coldness and transparency of the ears, dropping of the lower jaw. The face of shock, with its great pallor, its anxious or frightened look, is seen after severe injuries and operations. EXAMINATION OF PATIENT. 19 A dusky flush on the face, if associated with rapid breath- ing, is almost a certain indication of inflammation of the lung. Pufhness. of the eyelids in a pallid person is very apt to be expressive of Bright' s disease. There is the straw-colored, anaemic hue of malignant dis- ease; the jaundice, melancholy look of an l^atic affection- Skin. — Coldness of the skin indicates a weakened capillary circulation. Protracted coldness, whether attended with dryness or with clamminess, is of evil augury. The skin is pale when- ever the blood is poor and watery. In wasting and prostrating ailments the skin feels very relaxed and soft. The skin may be dry, moist, or profusely wet and sodden. In most fevers with high temperature the skin is hot. Now, if we make the patient's skin moist, we promote his comfort and well-being. Small, often -repeated doses of tincture of aconite or tartar emetic will induce perspiration. In many cases of diabetes and Bright's disease, it is very difficult to make the very dry skin perspire. The two chief causes of sweating are weakness, and a fall in a febrile temperature, two causes often combined in the same person in exhausting febrile disease, as in phthisis. In exhausting diseases, sleep may produce sweating. Pro- fuse sweating occurs during convalescence from scarlet fever. With the exception of rheumatic fever, profuse sweating at the commencement of an acute febrile disease, when the temper- ature remains high, indicates great weakness. Duskiness of the face, ears and under the nails shows weakened heart action. Pulse. — The pulse is an accurate index of the condition of the heart, and is therefore the most valuable guide in disease. The importance of the pulse is manifest when we consider that disease kills by arresting the heart, Whilst the heart beats there is life and hope. In many instances, the pulse gives the first signs of danger, as in the case of pneumonia, in which dis- ease so long as the pulse continues good we have fair hopes of our patient. In other instances the nervous system first gives way, as shown by sleeplessness and delirium, and this depresses and Aveakens the heart. 20 A COMPENDIUM OF PRACTICAL MEDICINE. In any case it is the ultimate effect of the disease on the heart that destroys life. The pulse -beats may be frequent or infrequent, slow or quick; small or large; compressible or incompressible; regular or irregular; or intermittent. By the frequency of the pulse we mean the number of beats- in a given time. In a quick pulse each beat occupies less than the usual time, that is, each wave is of short duration relatively to the pause between the waves. When the volume of the pulse is greater than usual, it is- said to be large; or the volume may be less than usual, when it is said to be small. When the fingers can easily stop the pulse it is said to be compressible; when on the other hand, it can be arrested only with difficulty or n,ot at all, the pulse is said to be incompressible^ In an irregular pulse, succeeding beats differ in length, force and character. In an intermittent pulse a beat is from time to time lost. The frequency of the healthy pulse varies; thus, in some persons the normal pulse is 100', in others as low as 50 a min- ute. Five conditions produce a frequent pulse: fever, debility T , excitement, hysteria, and cardiac disease. In fevers the pulse is generally accelerated in proportion to the elevation of temperature, more in children than in adults. When a pulse is more frequent than the temperature will explain, it indicates cardiac weakness. In all febrile diseases, a pulse in adults over 120 is serious and indicates cardiac weak- ness; a pulse of 130 or 140 indicates great danger; and with a pulse at 160 the patient almost always dies. In rheumatic fever a pulse of 120 indicates great danger. In such a case, the temperature is 104° to 105° F., the patient is prostrate, the tongue dry, and sordes collect on the lips ; a case like this often ends fatally, and when the pulse rises above 120, the patient will pretty surely die. If pericarditis, a complication of rheumatism, causes the frequent pulse, it is of less import. EXAMINATION OF PATIENT. 21 An irregular pulse from mitral disease may be very frequent, 120, 130, or more, without indicating extreme danger. Sometimes in typhoid fever, though the temperature is high, the pulse remains normal throughout the attack, and this shows absence of cardiac weakness. In chronic diseases a frequent pulse very generally indicates cardiac weakness. A weakened heart diminishes arterial tension, and the pulse becomes soft and compressible. If the heart be- comes still more weak, the pulse becomes small as well as quick, and compressible. Smallness of the pulse, therefore, indicates still greater weakness. When the pulse is very small it is said to be thready. The more frequent, the more compressible, the smaller the pulse, the greater the cardiac weakness, and the greater the need of cardiac stimulants. The general condition of the patient may be good, but the pulse is frequent, small, compressible and quick, and indicates danger. The pulse in some persons is easily made frequent with- out this frequency indicating any danger. In some persons in perfect health we find a very small and compressible pulse. So long as the pulse remains good, we feel that our patient is com- paratively safe. An infrequent pulse occurs in some cases of blood-poison- ing, as in jaundice, uraemia, and in these cases, the tempera- ture is often subnormal. An infrequent pulse is met with, sometimes in fatty degeneration of the heart, and in aortic ob- struction, in irritation of the vagus or its root, as in meningitis, oerebral tumors or compression. The size of the pulse varies in disease. It is often large at the commencement of fever. The pulse is small in inanition, owing to the small quantity of blood. It is small, too, in mitral obstruction, and in mitral regurgitant disease, and in aortic stenosis; also with cardiac debility. In an intermittent pulse, an occasional beat is missed, the rhythm being otherwise regular. An intermittent pulse is very different from an irregular pulse. Some persons have a life-long intermittent pulse, but ordinarily it does not occur till after middle age. It maybe persistent or occasional; and when occa- sional only it is often due to an idiosyncrasy, and is caused by 22 A COMPENDIUM OF PRACTICAL MEDICINE. some article of food, as tea, smoking or indigestion. By the intermission some persons are made very uncomfortable and nervous, and get the sensation as if the heart stopped or rolled over. In most cases an intermittent heart is of no significance. An irregular pulse is of far more serious significance than an intermittent. The pulse is irregular, both in force and rhythm, succeeding beats differing in length, force and character. It is generally due to mitral, and rarely occurs in other forms of heart disease, though sometimes met with in great cardiac prostration, as in an acute febrile illness, a few hours before death. It occurs, too, in fatty degeneration of the heart, and in the first and sec- ond stage of meningitis. The irregular pulse indicates the need of digitalis. Whilst an irregular pulse almost always indicates mitral disease, yet a perfectly regular pulse may accompany either mitral obstruction or regurgitation. Although irregu- larity from mitral disease is rare in children, yet Ringer has seen aconite, in half -drop doses repeated hourly several times pro- duce marked irregularity of the pulse. An irregular pulse is common in children with tubercular meningitis, and it is a diag- nostic guide. In some cases of cerebral disease, with Cheyne- Stokes breathing, the pulse is irregular. An irregular pulse may be due to much smoking, to venereal excess, and to tea drinking. The condition of the blood-vessels influences the pulse. Through the action of the vaso- motor nerves on the mus- cular coat of the arteries, the small blood-vessels undergo relaxa- tion or contraction. When the vessels are relaxed the blood passes easily from the arteries to the veins, hence arterial tension is slight, and the pulse is soft, large and compressible. This pulse is met with in the early stage of some fevers. Arterial relaxation, or low tension, produces a dicrotic pulse. In this pulse one of the normal secondary waves of oscillation becomes greatly exaggerated, so that it can be easily felt by the finger. Indeed, it may be so distinct that an inexperienced per- son may mistake it for the primary wave. Ringer has known a nurse to make this mistake, and thus to double the number of true pulsations. A dicrotic pulse always indicates marked arterial relaxation, and often coincides with cardiac weakness EXAMINATION OF PATIENT. 23 and is frequently met with in typhoid fever. When the vessels are contracted the blood escapes with greater difficulty from the arteries into the veins, and we have the pulse of high arterial tension. In this case the artery is hard and cord-like; it can be rolled under the finger and is easily traced in its course up the fore -arm. With the vessels in this condition, the pulsation is often so slight that it might readily be mistaken for a weak pulse ; but its incompressibility prevents this error. In addition to be- ing small, the pulse is slow and hard. The following conditions give rise to high arterial tension: 1. Degeneration of vessels. 2. Bright's disease, especially the contracted kidney. 3. Gout, jaundice, lead- poisoning, ergot and gallic acid. 4. Affections of the nervous system. 5. The rigor of fevers. High arterial tension and hypertrophy of the heart, asso- ciated with an increased quantity of urine containing a small quantity of albumen, enables us to diagnose the contracted form of Bright' s disease. During the rigor or chill of fevers the arteries contract, and produce a pulse of high arterial tension, which is frequent, small, hard, incompressible and slow. When the chill is over and the fever established, the arteries relax, and the pulse is large, full, and not easily compressed — bounding, as it is called. In well-marked aortic regurgitation, the pulse is often char- acteristic. It is a pulse of extreme low tension. If the radial artery is at all visible with the limb dependent, this visibility becomes much more marked on raising the arm. In advanced aortic regurgitation, the pulse gives to the finger a sharp, quick stroke. This is the diagnostic quality of the pulse. The pulse feels as if a small ball or shot was puffed under the finger, and is called the shotty pulse. Visible pulsation of the whole length of the carotid to the lobe of the ear, and of the temperal and perhaps of the facial artery, is far more frequently due to aortic regurgitation than to high arterial tension, or to low ar- terial tension, or to degeneration of the arteries. Aortic regurgitation is especially a disease of middle or advanced life, being due to age and strain. In arterial degen- eration the arteries become elongated and tortuous, easily visible 24 A COMPENDIUM OF PRACTICAL MEDICINE. in the brachial just above the elbow. The arteries feel hard and cordy, and sometimes calcareous jDlates can be felt. The pulse of aortic obstruction is slow, generally small, in- frequent, and often hard. In marked mitral obstructive disease, the pulse, when not irregular, is small and compressible. Aneurism of the aorta often delays the pulse, and it may do this on one side more than on the other, or on one side alone. In aneurism of the aorta influencing the arteries of one arm only, the artery on this side can be felt to fill more slowly (Ringer). As the full pulse is not always strong, neither is the small pulse always weak (DaCosta). Such are the meanings attached to the various characters of the pulse. The appreciation of these different kinds of pulses requires considerable practice. Tongue. — The tongue is a mirror which reflects the condition of the digestive functions, the complexion of the nervous power and of the blood, and the state of the secretions. We examine the tongue in regard to its movements, its volume, its dryness or its humidity, its color and its coating. The movements of the tongue are impeded and tremulous in exhausted states of the system. It is protruded slowly and with difficulty in fevers of a low type. In hemiplegia one side is crippled, and the tongue turns toward one of the corners of the mouth. The volume of the tongue is changed by its own diseases Yet a broad and flabby tongue, on the sides of which the teeth leave their marks, is sometimes found in chronic ailments of the digestive organs, and as a result of the action of mercury and of certain poisons. It is observed in some diseases of the brain and heart, and in typhus and scurvy. Dryness of the tongue indicates deficient salivary secretion. The tongue is dry in acute visceral inflammations, in the exan- themata, and in typhoid fever. If the tongue be very dry, of a dark color, glazy, or furred or fissured, it denotes depraved blood. A fissured tongue may occur in chronic affections of the liver and intestines, and in some persons it is congenital. The tongue may become dry from persistent openness of the mouth, EXAMINATION OF PATIENT. 25 as during sleep, or from coma, and has no significance. Among chronic diseases the tongue is most apt to be found dry in diabetes. A dry tongue is never a favorable sign. It is present in about fifty per cent, of fatal cases; more than any other it fore- tells death. A moist or humid tongue is a favorable sign. The dryness first invades the tip and extends up the centre. A dry tongue generally indicates nervous depression, often shown by low muttering delirium. This depression is often due to want of sleep. Narcotics, therefore, like chloral, bromide of potassium, or opium, by inducing sleep, soothe and strengthen the nervous system, and indirectly moisten the tongue. The dry tongue is often an indication for alcoholic stimu- lants. The two chief uses of alcohol are to assist digestion and to sustain the nervous system. Now sleep is the best restorative; hence fever patients who sleep well do not as a rule require stimulants. But, if in spite of sleep the tongue remains dry and delirium persists, then alcohol is indicated. Usually a patient with a dry tongue has a frequent, quick and compressible pulse calling for alcoholic stimulation. If the alcohol makes the tongue drier and more coated, it is contraindicated. In the aged, the tongue often becomes dry without fever. The color of the tongue is a useful sign. A broad, pale, flabby teeth -indented tongue indicates anaemia with a relaxed condition of the tissues. This tongue is met with in chlorosis, and in some chronic diseases, as Bright's, and always signifies the need of iron. In diabetes the tongue becomes smooth, glazed, shiny, beefy looking, abnormally clean and often very dry. If the tongue be red, too clean, too smooth or slightly furred, it points to an irritable state of the stomach, to dyspepsia. It is met with in drunkards and in phthisis when the intestines are ulcerated, and in tubercular peritonitis. One minim of Fowler's solution given before meals will improve this tongue. The tongue is exceedingly red in scarlet fever, and is known as the "straw- 26 A COMPENDIUM OF PRACTICAL MEDICINE. berry tongue.'" A red, smooth tongue is a sign of failing nutrition. The " nervous tongue " is very slightly coated and covered with a slight froth, and is met with in persons of nervous tem- perament, and in cases where the nervous system has been de- pressed by overwork, and worry. The coating of the tongue is hardly discernible in health; but in disease the epithelium accumulates, and the tongue has a loaded, whitish appearance due to an excess of white epithelium. The coat is apt to be yellowish in disturbances of the liver, and of brown or very dark hue when the blood is contaminated. There are many healthy persons who wake up every morn- ing with their tongues covered, more especially at the back, with a heavy coating, which wears off after a meal. The tongue may be bare of its epithelium in certain instances of scurvy, chronic diarrhoea, dysentery, malaria, scarlet fever and typhoid fever. Local causes often coat the tongue. Enlarged tonsils often coat the back of the tongue. Decayed teeth often fur a portion of the tongue. Excessive smoking almost always coats the tongue. A coated tongue very frequently indicates derangement of the stomach, bowels or liver. If the patient be constipated, and the stools light colored and the tongue coated, give calomel with extract of belladonna, or hyoscyamus. If the bowels are freely open, and the tongue still coated, give in addition to the above, five drops each of tincture of nux vomica and dilute nitric acid thrice daily. After an acute illness like typhoid fever, the tongue some- times parts with its coating in flakes. The manifestations afforded by the tongue which are indi- cative of danger, are tremulous action, dryness, a livid color, a very red, shining or raw aspect, and a heavy coating of a dark or black hue (Ringer and DaCosta). Sensations of Patients. — Sick persons have many disagreeable feelings. They complain of chills, heat, languor, restlessness and of uneasiness; but their most constant complaint is of pain. Pain may be dull or gnawing, acute and lancinating, per- EXAMINATION OF PATIENT. 27 manent or remitting. A dull pain is generally persistent. It is present in congestions, in chronic inflammations, and in acute inflammations of the parenchymatous viscera, and of mucous membranes. Acute pain is usually remittent and not so fixed to one spot. It is present in spasmodic affections, in neuralgia, and, with ex- tremely sharp and lancinating pangs, in malignant disease. Pain varies much in intensity. It is sometimes so extreme as to cause death. We have to judge of its severity partly on the testimony of the sufferer. The seat to which the pain is referred is far from being always the seat of the disease. A calculus in the bladder may produce dragging sensations extending down the thighs; inflam- mation of the hip joint gives rise to pain in the knee; disorders of the liver occasion pain in the right shoulder. The pain is either transmitted in the course of a nerve involved, or is sym- pathetic. Pain in diseases of the periosteum and bones is mostly boring and constant; in the serous membranes, sharp; in the mucous membranes, dull; and in the skin, burning or itching. Pain produced by pressure is called tenderness (DaCosta). Temperature. — The clinical thermometer may be put under the tongue, or in the axilla, or in the rectum. The rectal tem- perature is about one degree higher than the mouth or axillary temperature. The temperature in health varies in the 24 hours. During the day, between 9 a. m. and 4 p. m., the healthy tem- perature is usually about 99° F., or it may rise to 99.5° F. Any rise above 99.5° F. constitutes fever. At midnight the temper- ature is about 97° F., or even 96° F. The temperature should be taken in the morning about 7, and in the evening at the same hour. If only a single observation be taken, it is best done in the evening. While any elevation of temperature above 99.5° F. in- dicates disease, it need hardly be pointed out that a normal temperature does not necessarily indicate health. Many diseases, both acute and chronic, during their whole courses are unat- tended with fever. As a rule, the morning temperature is Lower than the evening. In rare cases the reverse happens. In some 28 A COMPENDIUM OF PRACTICAL MEDICINE. chronic cases, as phthisis, and snb-acnte rheumatism, the fever may last only a few hours during the day. In ordinary cases, the pulse and temperature rise synchron- ously, and every degree above 98° F. corresjDonds with an increase of ten beats of the pulse. When the temperature ex- ceeds 106° F., the patient may be looked upon as in danger, except the rise be due to malarial fever. Under these circum- stances, it is rapid, occurring in a jDerson who yesterday, or but a few hours before, was healthy. In typhoid fever a tempera- ture of 105° F. is proof of grave disease. In pneumonia, a temperature above 104° F. is a symptom of very serious seizure. Stability of temperature from morning to evening is a good sign; the temperature remaining the same from evening till morning is a sign that the patient is getting worse. If, after the defervescence, the thermometer again indicates a decided rise, it shows a return of the malady or complication. Specific forms of febrile diseases have their characteristic temperature records. In measles, for instance, the temperature rises toward the breaking out of the rash, reaches its height with the period of eruption, and in twenty -four hours succeed- ing it falls rapidly. In scarlet fever the thermometer marks 105° F. or more at the beginning, and the fever gradually sub- sides. Typhoid fever has its characteristic record; so have the malarial fevers theirs. The temperature of tetanus rises to great heights before death. A temperature above 107° F. is almost certain to be the forerunner of a fatal issue. But recovery may take place. Da- Costa reports a case of cerebral rheumatism, in which the ther- mometer marked 110° F., yet the ]3atient got well. In a case of injury to the spine after a fall, reported by Teale, the young lady lived, though the temperature reached above 122° F., and ranged for days between 112° F. and 114° F. A case of hysteria and intercostal neuralgia has been reported, in which the thermometer registered 117° F., and the patient recovered. The temperature may, also, be very high for a short time, from emotion. In children the tempera- ture is relatively higher than in adults with the same disturbance. EXAMINATION OF PATIENT. 29 The thermometer assists us in diagnosis. We should search carefully to discover the cause of the fever. The fever may be due only to the acute contagious diseases, acute inflammation of some organ, rheumatism, gout, or to the diseases causing chronic fever. In the acute specific diseases, fever and sore throat would point to scarlet fever; severe backache, headache and sore throat to small-pox; coryza, with cough, to measles. Severe fever, ushered in by a severe rigor, with severe headache, and pain in the limbs, would suggest typhus; whilst dull, frontal headache, with diarrhoea, would strongly point to typhoid fever. If the second day passes without the occurrence of a rash, the case in all probability, is not one of scarlet fever; for the rash of this disease appears on the first or second day. If the third day passes without a rash, the case is not small -pox, for this rash usually appears punctually on the third day. If the fourth day passes without a rash, the case is not one of measles. If the fifth day passes without a rash, the case is not typhus, for the rash punctually appears on this day. The diagnostic value of temperature is shown in the follow- ing : A patient is suddenly seized with severe pain on the side of the chest. The pain, shooting or stabbing in character, is in- tensified on coughing or deep breathing. This is the character- istic pain of pleurisy and of pleurodynia; one an inflammatory disease, the other a non- inflammatory disease — which is it ( Before the physical signs develop nothing but the thermometer will solve the difficulty. If the attack be pleurisy, an inflamma- tory disease, there is fever, whereas if the attack be pleurodynia, a non-inflammatory disease, fever is absent. The temperature rises rapidly in most inflammations, in typhus, scarlet fever, measles, erysipelas, etc. In some diseases the temperature rises more gradually. This happens in most cases of tuberculosis and in almost all cases of typhoid fe\ ( r. and sometimes in rheumatism and pleurisy. The duration of the fever often aids in the diagnosis. In most acute diseases the fever usually passes away by the fifth or tenth day. In some cases of typhoid fever the symptoms are not sufficiently marked to enable the doctor to decide whether the case is one of typhoid fever, tuberculosis or phthisis. If the 30 A COMPENDIUM OF PRACTICAL MEDICINE. fever goes on beyond thirty days then probably the patient suffers from consumption, and each additional day of fever strengthens this conclusion. A sudden and considerable fall of temperature, if not due to the natural termination of the illness, means sudden collapse. It is oftenest met with in typhoid fever, and it means hemorrhage into the bowels, or rjerforation of the intestines. Each week in typhoid fever a great morning fall often occurs. A fall equal to that due to hemorrhage or perforation, may occur at any time, but the fall with these accidents is more persistent, and is always accompanied by the symptoms of collapse. Chronic Fever. — In some diseases fever may persist for weeks or months, and by its very duration help the diagnosis. In most cases, when the fever has lasted only a short time, the other symptoms reveal the nature of the disease; but frequently the nature of the malady remains for a long time obscure, and then the fever aids in the diagnosis. Since most acute illnesses come to an end, in the great major- ity of cases, before the thirtieth day, we may take that as the limit of acute fever. Chronic fever occurs in phthisis, abscess, syphilis, ague, rheumatism, in most cases of leucocythemia, pernicious anaemia, and chronic pyaemia. The temperature is an index of the activ- ity of the disease. If the fever be high the disease is active. In some very chronic cases of phthisis the disease advances too slowly to elevate the temperature. By the aid of the thermometer we can often diagnose phthisis, before we can detect any physical signs, and at a period when symptoms themselves are insufficient to justify a grave diagnosis. A patient suffers from chronic fever. What is the cause of it? So far as we at present know chronic fever occurs only in tuberculosis, catarrhal pneumonia, large abscesses, rheu- matism, ague, occasionally in syphilis, in some cases of leucocy- thaemia, in lymphadenoma, and in pernicious anaemia and chronic pyaemia. The discrimination of these diseases is rarely difficult. The following cases illustrate the usefulness of the ther- mometer in doubtful cases of phthisis: EXAMINATION OF PATIENT. 31 A patient is taken rather suddenly ill. His face is flushed, eyes bright, pulse quick. The temperature is very high. There is no headache, no delirium, no diarrhoea. So weak is he that he stays in bed. He continues in this state for a month or five weeks when distinct physical signs at the apices of the lungs ap- pear, accompanied by cough and expectoration, and possibly slight haemoptysis. A woman between 30 and 35 years of age, fails slightly in health, complains of slight weakness, is soon tired, but is never ill enough to be confined to bed. Her appetite is bad. There is a trifling cough with expectoration slightly streaked with blood once or twice. There may be a family predisjDosition to phthisis. Xo physical signs are apparent; yet the temperature, rising nightly to 101 or 102° F., declares the true nature of the disease, (Einger and Da Costa). CHAPTER II. DISEASES IN GENERAL, ABORTION. T. Gaillard Thomas says, that the uterus is the organ which divides one sex from the other, that this organ has three entirely distinct and different periods of existence, that from birth to the age of thirteen, or puberty, it is undeveloped and unimportant, and that from thirteen to fifty its career is one of intense activity, and has a marked influence upon the whole being of a woman, that from the age of about fifty, to the close of life it sinks into insignificance again, and becomes an atrophied and unimportant organ — of no use whatever, that impregnation and conception are two entirely different things, that the ova may become impregnated twelve times a year, and yet conception may not result; that conception is the fixation of the impregnated ovum; that up to two and a half months there is no placenta, so far as abortion is concerned, that from the third month the placenta is the all -important element as regards abortion; that abortion is to be defined as the premature casting off of the product of concep- tion before the end of the fourth month; that between the end of the fourth month and the end of the sixth month it is called mis- carriage, and that between the end of the sixth month and the end of the ninth month it is called premature labor. When abortion occurs, one of four things may take place: First, the entire contents of the uterus — the decidua vera, the decidua reflexa, the amnion, the chorion, and the foetus may be expelled. Second, the foetus may be expelled with the amnion ABOBTION. 33 and chorion, wliile the decidua vera and reflexa are left in the nterns. These membranes will come away later in the lochial discharge. Third, the foetus alone may be expelled. This is a complicated case. In this case the uterus must be emptied of its contents or the patient will have a violent chill and high fever, with all the signs of septicaemia. Fourth, the foetus and membranes may be expelled, and the placenta, when one is formed, left behind. Thus, we see that abortion does not always occur in the same way, and that the physician must treat each case according to its character. Causes. — 1. Carbonic- oxide gas inhaled by the mother is more certain to produce uterine contractions than ergot. The crowding together within confined quarters of pregnant women will cause a large number to abort, due to the poisoning of their blood by this gas. This gas, generated after death, produces uterine contraction, and post-mortem delivery of pregnant women. 2. The poisons in the blood produced by small-pox, scarlatina, measles and malaria. 3. Chorea, tetanus, and reflex influences, such as fright. 4. Certain drugs, such as ergot, cotton -root, etc. 5. Anything which will kill the foetus will produce an abortion, such as a twist, or knot in the umbilical cord, syphilis, a kick or blow upon the abdomen. 6. Retroflex- ion of the uterus. In anteflexion of the uterus, sterility is com- mon, but endometritis and abortion are rare. 7. Uterine fibroids and other neoplasms, and laceration of the external os. 8. Some- times jars to the body from vomiting, coughing and straining, from railroad journeys, from violent exercise, from falls, and the like. A large proportion of abortions occur about the end of the third month. During an abortion, the attitude of the physi- cian, beyond the control of hemorrhage, should be an expectant one. In habitual abortion the most common causes are syphilis and retroflexion of the uterus. There are many women of nerv- ous temperament in whom the slightest cause is often sufficient to induce an abortion; while, in others, it is exceedingly difficult for them to get rid of the contents of the uterus before the nor- mal end of pregnancy. This is shown in attempts at criminal abortion. Lusk re- lates the case of a peasant who took his wife, while pregnant, 34 A COMPENDIUM OF PRACTICAL MEDICINE. behind him on horseback and started on 2 with her at fnll gallop, with the view of causing her to miscarry. Having thus thor- oughly shaken her, he dropped her suddenly to the ground with- out slackening his speed. This brutal manoeuvre he repeated twice, without the least success. Thomas mentions cases of pregnant young women in Paris who attempted suicide by jump- ing into the Seine, and were rescued and went on to full term. Pregnant women, excited by an alarm of fire, have jumped from an upper window, breaking several bones, and have passed on to full term as though nothing had happened. Prognosis. — The prognosis is good, except in criminal cases. Dangers. — 1. Hemorrhage'. 2. Putrid intoxication from ab- sorption of the decomposing product of conception. 3. Septi- caemia and jDeritonitis. In this case the septic material is conveyed to the womb by the hand or instruments of the physician. 4. Surjpurative arthritis. 5. Cellulitis and abscess. 6. Embolism. This may cause hemiplegia. 7. Air in the veins. The air is usually introduced through a hollow instrument used in the uterus. 8. Tetanus. This comes from putrid infection. Symptoms. — There are three essential symptoms: 1. Hem- orrhage. 2. Pain. 3. Vomiting; this last may be absent. Treatment.— The treatment is divided into : 1. Prophylaxis in cases of habitual abortion. If the cause be syphilis, give the antisyphilitics. If the cause be displacements of the uterus, correct these. If the cause be nerve irritability, give the patient teaspoonful doses of the fluid extract of viburnum prunifolium three times daily, beginning two days before the menstrual date, and continuing for eight days, with the patient in bed. 2. Ar- rest of threatened abortion. Keep the patient quiet in bed and give the following: Jfc Potassii Bromidi gr. x. Chloral hydratis gr. vi. Morphinae sulphatis gr. \. — M. Sig. : One dose. Repeat if necessary. The chloral induces sleep, the bromide has a sedative effect upon the nervous system, and the morphine robs life of its cares. If the patient be bleeding freely, apply a tampon, and remove it in twenty-four hours. In the first two ABORTION. 35 months little treatment besides rest in bed for a few days is re- quired. 3. The treatment of inevitable abortion. Get the woman through with the abortion as quickly as possible, and leave nothing in the uterus for bacteria to work on. Your hands, instruments, sponges, and tampon, if used, should all be aseptic. If the abortion is going on and the woman is losing large quantities of blood, the tampon is the best remedy. When in the third month the ovum is thrown off without rupture of the foetal membranes, the hemorrhage is rarely dangerous. The treatment is very simple — a carbolized douche morning and evening. When the sac raptures the hemorrhage is usually pro- fuse. The treatment indicated in this case is to check the hem- orrhage by a tampon, and afterwards empty the uterus by means of the finger or curette. Do not give opium to quiet pain. Do not give ergot unless the cervix is well dilated. A good tampon is made by soaking cotton wool in carbolized water, five per cent, solution, and after pressing out the excess of fluid, make into flat pieces, and pack well around the vaginal portion then over the os. A tampon should not remain over twelve hours in the vagina. In emergency a soft towel, handkerchief, strips of cotton cloth and a roller bandage may be used for a tampon. 4. The treatment of neglected abort ion is to clean out the uterus with the finger or dull wire curette and use carbolized douche (5i-Oj). The temperature, if high will soon fall after the curettage and douche. Chances of error in connection with abortion. — 1. Could a woman have an abortion, say, at the end of the third month, and at the end of six months from that time be delivered of a fully -developed living child? Yes, and the explanation is, that one of a pair of twins has been cast off and the other has gone to full term. 2. A woman has an abortion and the feet us is cast off with all its membranes entire. In a month from the date of the abortion the woman suddenly dies in collapse. An examination shows that in addition to the foetus in the uterus there lias been an extra-uterine one, and the fatal result was due to rupture of the Fallopian tube. 3. A woman has an abortion and the foetus is cast off but not all the membranes. The next month the 36 A COMPENDIUM OF PRACTICAL MEDICINE. patient does not menstruate. About the end of the ninth month, the uterus begins to contract, but instead of a living child being delivered, a bucketful of hydatids is cast off. These little cysts developed in the retained membranes. 4. The foetus is cast off with the lower portions of the fcetal shell, leaving the remainder of the shell still in the uterus. This may remain for months or years constituting " molar pregnancy." Artificial Production of Abortion. — Never induce an abortion without first having a consultation. Indications. — Whenever it is felt that the prolongation of pregnancy is going to destroy the life or intellect, or to perman- ently ruin the health of a patient, abortion should be brought on. The methods by which Abortion is brought on. 1. The first method is to introduce a metallic sound into the os- uteri, and push it forcibly through the fcetal shell. If there be a brutal and stupid method of producing abortion, it is certainly this. It is the one commonly practiced in criminal abortions. It will kill the foetus, but it may not come away and thereby produce putrefaction and septicaemia. This method should not be used. 2. The second method is to take sponge tents, and introduce them into the os internum. This method should be avoided. 3. Certain drugs, such as ergot, savin, pennyroyal, viscum album, and the root of the cotton plant. No scientific j^hysician would ever think of placing any dependence upon them whatever. 4. The best method and the one which is sure and safe is as fol- lows: Anaesthetize the patient with ether, and place her in the Sims position. Fill the vagina with bichloride solution, (1 to 2,000). Next you catch the cervix with a little tenaculum and dip it below the surface of the bichloride solution. With a divulsor you stretch the cervical canal until you can introduce your finger. You next introduce a glass plug as large as the finger into the cervix. You then pack the vagina with iodoform gauze and then aijply a tampon. This is all you have to do. The plug and the tampon may be left in position for thirty- six to forty- eight hours. You may have to stretch the os again and put in a larger plug. The plug should be an inch and a half in length with a shoulder which prevents its entrance into the uterine cavity. ABORTION ABSCESS. 37 PRESCRIPTIONS FOR ABORTION. ^ Tincturse opii, ITTxx-xxx. Sig. : Mix with three tablespoonfuls of boiled starch and in- ject into the rectum. — Parvin. I£ Misturse asafcetidse Sviij. Sig.: A tablespoonful several times daily. (In habitual abortion.) — Negri. $ Tincturse ferri chloridi Sss. Potassii chloratis 5j • Syrupi simplicis. Sj • Aquae menthse piperitse ad Siv. — M. Sig.: A dessertspoonful in a wineglassful of water after meals. (When due to fatty degeneration of the placenta.) — Strother. 5 Auri et sodii chloridi gr. iv. Aquae destillatae Sj- — M. Sig.: Six drops in a tablespoonful of water three times daily after meals. (In habitual abortion.) — Martin. ABSCESS. A circumscribed collection of pus in any tissue is called an abscess. Pus in a preformed cavity is called empyema. An abscess is always the result of an inflammatory process. Varieties. — When an abscess forms rapidly it is called acute, hot, or phlegmonous, and its pus is living. When it is of slow formation, it is called chronic, cold, lymphatic or tubercu- lous, and its pus is dead. Symptoms. — We may have, 1. History of an injury. 2. Defective nutrition. 3. Rigor or chills. 4. Elevation of tem- perature. 5. Fluctuation. 6. The five cardinal symptoms of inflammation which are, redness, swelling, heat, pain and loss of function. If the abscess be acute or hot, the pus is thick and creamy, the walls of the cavity are tense, the surrounding tissues are indurated, and there is a tendency to burst at the point of 38 A COMPENDIUM OF PRACTICAL MEDICINE. least resistance. If the abscess be chronic or cold, the pns is thin, serous and gelatinous, the walls are flabby, the surrounding tissues are not indurated. Causes. — The tendency of late is to regard all acute abscesses as due to a special micro-organism, the staphilococcus pyogenes aureus. Chronic abscess is due to the bacillus tuber- culosis. All varieties may start from injury. The origin of pus in an abscess is emigration of white cor- puscles, proliferation of connective tissue cells, granules of fat, and debris of inflamed tissue floating in serum. Varieties of Pus. — Pus when thick and creamy is known as " healthy " or laudable pus, or living pus; when thin and watery " puriform fluid " or dead pus; when blood-stained "sanious;" gummy pus in syphilis; and contagious pus in small-pox, gonor- rhoea and venereal ulcers. Diagnosis. — Abscess must be diagnosed from: 1. Hsemat- ocele. 2. Cyst. 3. Lipoma. 4. Aneurism, and 5. Malignant tumors. Hematocele has a rapid growth, evidence of an injury, and no change in the skin. The walls of a cyst are distended by fluid which distinctly outlines it. In fatty tumor or lipoma, the skin is unchanged and may be lifted up from tumor. In an- eurism there is a distinct expansile pulsation synchronous with the heart's action. Pressure on the artery above the aneurism diminishes its size, while pressure below increases its size. An aneurism has a rasping sound like sawing wood. The pain of aneurism is very characteristic — sharp and lancinating produced by pressure on nerve. Use a hypodermic syringe to make the diagnosis. The pain in acute abscess is at first dull and heavy and then throbbing. There is not much pain in a cold abscess. We speak of an abscess according to its situation, as mam- mary, lumbar, cerebral, perineal, post-pharyngeal, etc. Prognosis. — Depends, 1. On the size of the abscess. 2. On its character. 3. On the age of the patient. 4. Situation of the abscess. 5. Condition of the patient, and 6. On its cause. Treatment. — Never squeeze an abscess but drain it freely. An acute abscess should be opened in the most dependent part, ABSCESS. 39 using a sharp bistoury for the purpose; press out gently the accumulated material, wash it with bichloride of mercury (1 to 1,000), insert a drainage tube, and place upon the outside iodo- form gauze. We do not open a chronic abscess but aspirate it. Do not allow air to go in. A small amount of pus may be ab- sorbed. Constitutional Treatment. Give tonics, such as iron, qui- nine and strychnine together with good nutritious diet and plenty of fresh air. PRESCRIPTIONS FOR ABSCESS. J& Iodoformi oiij- Aetheris 3 vi. — M. Sig. : Inject three to five ounces after aspirating the abscess. (In cold or tubercular abscess.) — Mosetig Moorhof. Jfc Iodoformi oij. Glycerinse Siiss. — M. Sig.: Inject the abscess cavity, after evacuating the pus. (In cold or tubercular abscess). — Billroth. {& Calcii sulphidi gr. ij. Sacchari lactis gr. xx. — M. In chartulas xx. div. Sig.: Take one powder every hour or two. — Ringer. Jfc Emplastrum belladonna? Sig.: Apply to abscess to relieve pain. — Bartholow. |fc Potassii permanganatis 5j- Aquse destillatse Oj. — M. Sig.: Apply to correct the fetor of abscess. — Bartholow. J£ Tincturae iodi oij. Sig. : Apply as counter-irritant, and after pus is evacuated apply to the sac. — Bartholow. Use ether spray to produce local anaesthesia, for opening abscesses. 40 A COMPENDIUM OF PRACTICAL MEDICINE. ACIDITY. Acidity is not a disease, but a symptom. As a symptom it has no special diagnostic value, for it is met with both in functional and in organic disease of the stomach. Excessive acidity occurs from various causes. The gastric juice may be secreted in large quantities, or it may contain an abnormal amount of acid. But excessive acidity is far more frequently due to the de- composition of food, and to a process of fermentation dependent rather upon scarcity than over -abundance of this juice. In this case it manifests itself only after meals. At the same time car- bonic acid gas may be generated, causing great distension and eructations, or belching, of sour liquid. Treatment. — Acids, given on an empty stomach, check the secretion of the acid gastric juice; given on a full stomach, they render its contents more acid; hence, if there is an excess of acid secreted by the stomach, they should be given before meals, in small doses and well diluted; while, if there is too little acid secreted, they may be given after meals, to supply the deficiency. PRESCRIPTIONS FOR ACIDITY. Jfc Acidi hydrochlorici diluti..... Sj. Sig. : Ten drops in water twenty minutes before meals. Jfc Tincturse nucis vomicae Sj . Sig. : Five drops in water fifteen minute before meals. — Ringer. Jfc Sodii bicaibonatis 3iij- In pulveres no xii. div. Sig. : A powder in a wineglassful of water after meals. — Alonzo Clark. {fc Sodii bicarbonatis 3j • Pulveris rhei Bss. Spiriti menthao piperita? 3ij- Aquas — q. s. — ad 5iv. — M. Sig. : A tablespoonful after meals. (For acidity, combined with constipation). — Bellevue Hospital. ACIDITY ACNE. 41 jfc Pulveris ipecac gr. ss. Pulveris rhei gr. ij . Sodii bicarbonatis gr. xij . In pulveres no xii. dividenda. Sig. : One powder every four to six hours to an infant one year old. — J. Lewis Smith. Alkalies after meals are only palliative. jfc Glycerini Siv. Acidi tannici oij . — M. Sig. : A teaspoonful before, with, or after meals. — Bartholow. ACNE. Acne, called also Acne Vulgaris, or Varus, is an inflam- mation of the sebaceous follicles and glands, the result of accumulation and retention in them of sebaceous matter. If the sebaceous matter be retained without inflammation, the surface becomes studded with black specks, and the affection is known under the name of comedones, or black-heads. But, sooner or later, the sebum plugs give rise to irritation, act as thorns in the flesh, and excite inflammation and suppuration in the surround- ing tissues, and the patient is said to have acne. Acne is likely to occur in those whose skins are sensitive, or whose general health is disordered. It is a frequent affection and is resented by the upper classes of society on account of its disfigurement. It is rarely met with before puberty — usually be- gins between the ages of 15 and 25. Some thought that there was a connection between acne and the organs of generation, as a marriage would sometimes moderate its violence, and Eigler very rarely saw acne in eunuchs; but Hebra said, "I cannot agree with Plenck's dictum, ' Matrimonium varos curat, 1 but would rather say, 'Tempus varos curat.' " Symptoms. — Acne affects most frequently the face, neck, shoulders, back and chest. The starting points of the eruption is the accumulation of hardened plugs of sebum in the sebaceous follicles (comedones) which are black upon the surface, owing to admixture with particles of dust. Sometimes a small nodule surrounds each follicle, and we have acne punctata; sometimes the nodule becomes pustular, and we have acne pustulosa; some- 42 A COMPENDIUM OF PEACTICAL MEDICINE. times there is a decided induration, or tubercle, acne indurata. In severe cases some of the sebaceous glands are apt to be the seat of distinct abscesses. If these inflammatory centres are allowed to run their course unchecked, they leave cicatrices which resemble the pits of small- pox, and as the eruption tends to occur in successive crops, in time the disfigurement may be considerable, hence the disease, though trivial, should be treated. A burning heat is occasionally complained of, and itching is common. Diagnosis. — Tar acne may be mistaken for acne, but the history of the patient having been exposed to the influence of tarry preparations, or their external use, would make the diag- nosis. In tar acne there is a black speck in the center of each nodule, as in acne. The eruptions which frequently occur in those who are taking the bromides or iodides sometimes resemble that of acne, but in them there is a history of the taking of one of these drugs, and there is an absence of black specks in the centre of the nodules. Syphilitic eruptions may sometimes be mistaken for acne; but in the former the eruption commences after the poison enters the system, usually affects all parts, is more or less coppery in chronic stage, is often in circles or seg- ments of circles, ulceration is common, itching absent always in early syphilis, eruption easily removed by anti-syphitic treat- ment; in the latter, the eruption commences between puberty and 25, is limited to face, chest and back, is bright red, is never in circles or segments of circles, no tendency to ulceration, itch- ing often present, eruption hard to remove by any kind of treat- ment. Treatments — Is both constitutional and local. If the patient is strumous, phosphorous and cod -liver oil in full doses should be given. If the eruption appears in an aggravated form, arsenic should be given. If suppuration is a prominent feature, the sulphide of calcium may be tried. The local treatment is the most important: 1. Press out the sebum plugs (comedones). 2. Bathe the affected parts every night and morning, with water as hot as can be borne, for ten minutes, and afterwards apply friction with rough towel. 3. ACNE. 43 Acne indurata has been cured by applications of galvanism, both local and central. PRESCRIPTIONS FOR ACNE. |£ Syrupi hypophos comp Sviij. Sig. : A teaspoonful after each meal. (Acne indurata). — Bartholow. Jfc Liquor potassii arsenitis 5 vj . Sig. : Three drops in water after each meal. jfc Liquor potassse 3j. Aquae Rosse Siv. — M. Sig.: Apply with a soft sponge twice daily. Use mutton suet to face afterwards. — Bartholow. Jfc Calcii sulphidi gr. xv. Sacchari lactis 5 iij • In chartulas no Lx. div — M. Sig.: Take one powder three times a day. — Anderson. Jfr Sulphuris iodidi 5ss. Adipis gj. — M. Sig.: Use freely over the eruption night and morning. (In acne indurate and rosacea.) — Ringer. jfc Sulphuris 5j . Glycerini (Price) 5j • Cold cream Sj. — M. Sig. : To be applied firmly every night short of causing pain or inflammation. — Anderson. Jfc Potassii sulphureti Zinci sulphatis aa 5j- Aqua? rosae oj- — M. Sig.: Apply to the face on muslin twice a day and wash the face with tar soap. — Anderson. jfc Lactis sulphuris Glycerini Spirits vini rectificati Potassii carbonatis Aetheris sulphurici aa 5ss. — M. Sig.: Apply to face at bed-time. — Teissl. 44 A COMPENDIUM OF PRACTICAL MEDICINE J& Sulpburis precipitatas 3ij- Camphor.. gr. x. Gum mimosa gr. xx. Aquae calcis Aquas rosas aa S iij . — M. Sig. : Shake the bottle. Apply at bed-time and in the morning remove the sulphur without wetting the skin. — Kummerfeld. J& Hydrargyri chloridi corrosivi gr. xx. Glycerini Sss. Spiriti vini rectificati Svij. Spiriti rosmarini 3iv. — M. Sig.: Apply to face. — Bartholow. Jfc Hydrargyri iodidi viridis gr. x. Adipis Sj . — M. Sig. : Apply to face. — Bartholow. J$- Hydrargyri iodidi rubri gr. v. Adipis , ,Sj.— M. Sig.: Apply to face. — Bartholow. j& Glycerini Sj. Sig. : Half teaspoonful after meals. — Bartholow. {& Sulphuris. 5j • Glycerini Sj . Aquas rosas ,, Sviij. — M. Sig.: Apply to face night and morning. — Ringer. J& Hydrargyri perchloridi Sj. Aquas destillatas Siv. Ovorum xxiv albumen Succi citri Siij. Sacchari Sviij. — M. Sig. : Apply to the face. — Hebra. The above is a cosmetic lotion much used by the Orientals as a beautifier of the skin, and is often of use in acne. (i- Potassii acetatis 5iv. Tincturas nucis vomicas 5ij- Extracti rumicis fluidi, ad Siv. — M. Sig.: One teaspoonful, well diluted after meals. — Bulkley. ACNE ACNE ROSACEA. 45 J& Potassii acetatis Sj. Acidi acetici 3ss. Spiriti setheris nitrosi Siss. Extracti taraxaci fiuidi Sij. — M. Sig. : A teaspoonful before meals in water. — Bulkley. Jfc Sulphuris prsecipitatae 3 v. Glycerini 3iss. Spiriti camphorse Sj- Aquse giv.— M. Sig. : Apply with a brush to the affected part before retiring at night. — Lailler. |fc Sulphuris praacipitatse 5j- Glycerinse 3j • Spiriti vini rectificati Sss. Aquas rosae ad Siv. — M. Ft. lotis. Sig.: To be painted on at night after steaming the face and washing it with sand soap. To be washed off in the morning with warm gruel, and the face powdered with the following : Jfc Zinci oleatis Pulveris talc aa Sj- — M. Sig.: To be dusted on every morning. — Jamieson. ACNE ROSACEA. Called also Rosacea, or Copper-nose, is a very common affec- tion, but not so common as ordinary acne. Causes. — Intemperance is the most frequent cause in males. Debility is the usual cause in females. Those whose faces are exposed to great cold or heat, as cab- drivers, bakers and cooks, are liable to have copper-nose. In males the disease usually ap- pears about middle -life; in females about puberty, or the meno- pause. Symptoms. — The eruption always makes its appearance upon the face, as the nose, chin, cheeks or brow. The symptoms may be divided into three stages or varieties. In the first, there is simply dilatation of the small vessels and capillaries, with new formation of vessels. In the second, redness of the surface 46 A COMPENDIUM OF PRACTICAL MEDICINE. makes its appearance, which is at first congestive and transitory, but finally becomes permanent, and slight desquamation takes place. The skin has a dusky tint, esjjecially after meals and in cold weather. In the third variety, owing to cell infiltration and the new formation of connective tissue, hypertrophy of the tissues of the skin is apparent, and the skin has a thickened and coarse appearance. Hebra describes the brandy -face and the wine -face. The brandy-face is frequently confined to the nose, where it dilates the blood-vessels, and the skin between is healthy. The wine- face is of a dark red color, and the skin has a solid redness, and the whole face has a bloated appearance. Treatment. — Constitutional treatment is very important. In cases of debility, a generous diet, tonics, especially arsenic, are indicated. The local treatment is even more important. If the blood vessels are very much dilated, they should be slit open, or punctured at each end, and touched with caustic, or they may be obliterated by electrolysis. The finest cambric needle, at- tached to the negative pole of the galvanic battery, is inserted into the lumen of the vessel, or perpendicular to the vessel at several points if a long one, and six to ten cells turned on, until the proper electrolytic action is developed. PRESCRIPTIONS FOR COPPER=NOSE. Jfc Hy drargyri 5iv. Terebinth commun 3 ij • Cera? navse oiij. Empl. plumbi Siss. — M. Ft. unguent. (See Acne Vulgaris). ADDISON'S DISEASE. Addison's disease is an affection of the suprarenal capsules. It is sometimes called the bronzed skin disease. Symptoms. — Extreme languor, muscles flabby, the pulse feeble, indigestion, anorexia and nausea, sometimes vomiting after eating. The skin is pigmented, and presents the color of a mulatto. AFTER PAINS. 47 Prognosis. — It is an incurable disease. Its duration varies from one to live years. Treatment. — Sirup of the iodide of iron, cod-liver oil, chlor- ide of calcium, quinia, and arsenic may be tried. Faradism and galvanism have been proposed by Dr. Rockwell. Addison's disease is thought to be tuberculosis of the supra- renal bodies. AFTER=PAINS. The contractions of the uterus in the first few days after the birth of the child are the causes of what are termed after- pains. They may last four days, and are more pronounced in multipara? than in primiparse. They are to be regarded as a normal and favorable event. Where the uterus has been over- distended, as in twin pregnancies and hydramnios, the after-pains are especially severe. Suckling the infant produces reflex con- tractions of a somewhat severe character. PRESCRIPTIONS FOR AFTER=PAINS. |{r Morphinse acetatis gr. i. Extracti digitalis fluid i XRj . Spiriti Mindereri 5j — M. Sig. : One dose. Repeat if necessary. J£ Extracti ergotse fluidi 5iij- Extracti digitalis fluidi ITCxxiv. Quininse Sulphatis gr. xxiv. — M. Sig.: Fifteen drops three times daily. (To aid the process of involution). The quinine may be given in capsules in gr. ii. doses, if preferred. —Sloan Maternity. Jfc Chloral Hydratis gr. xv. Sig.: One dose. May be repeated if necessary. jfc Camphorse gr. x. Morphinse gr. J. — M. Sig. : One dose. — Bartholow. 48 A COMPENDIUM OF PRACTICAL MEDICINE. AGALACTIA. Agalactia is imperfect lactation. PRESCRIPTIONS FOR AGALACTIA. j& Extracti pilocarpi fluidi % ij . Sig. : A teaspoonful two or three times daily. — Bartholow. Jfc Decocti gossypii Oj. Sig.: A wineglassful every half hour. — Phillips. AGUE. ( See Intermittent Fever). AGUE=CAKE. Is an enlargement of the spleen from malaria. Treatment. — Besides quinine in ordinary doses, there is no remedy more efficacious than the ointment of the red iodide of mercury rubbed in daily over the splenic region in the sunshine, until soreness of the skin compels a suspension. — Bartholow. ALBUMINURIA. Is simply albumen in the urine. It is not a disease, but a symptom. The existence of albuminuria is not proof positive of kidney disease. Albumen may be found in the urine in the course of a great many diseases. It is frequently found in the urine of persons who are apparently in perfect health. As a rule, albumen found in the urine denotes some kidney change. PRESCRIPTIONS FOR ALBUMINURIA. JJr Sodii iodidi gr. xv. Sodii phosphatis 3ss. Sodii chloridi Siij- Aquae — q. s. — add ft. sol — M. Sig. : To be taken in the course of the twenty-four hours. — Semmola. ALBINISM. 49 Jfc Olei erigerontis 3ss. Sig. : Five drops on a lump of sugar every three or four hours. (In the chronic forms). — Bartholow. jfc Auri et sodii chloridi gr. iij. Hydrargyri chloridi corrosivi gr. v. Extracti gentianse q.s. — M. Ft. massa et in pil. no. lx. div. Sig.: One pill morning and evening. — Bartholow. Jfc Acidi gallici o i-ij . Acidi sulphurici diluti 5ss. Tincturse lupuli 5j . Infusi lupuli — add Syj. — M. Sig.: A tablespoonful thrice a day. (If urine is smoky). — Aitken. Jfc Misturse ferri et ammonii acetatis.Syj. (U. S. P.) Sig.: Two teaspoonfuls, well diluted, thrice daily. — Basham. jfc Ferri sulphatis gr. xv. Magnesii sulphatis Sij. Potassii bicarbonatis 5iij- Infusi buchu Sviij. — M. Sig. : A tablespoonful once or twice a day in a tumblerful 01 water. (When constipation exists). — Fothergill. The skim -milk treatment of albuminuria is a success. — Donkin. The butter-milk cure may be substituted for the milk-cure in cases of stomach disease and in albuminuria. — Bartholow. ALBINISM. Is defective pigmentation in the skin, hair and eyes. The pigment of the skin is in the mucous layer of the epidermis. In this condition there is congenital absence of the coloring matter, and the skin is milky white, the hair white, long, fine, and silky, and the iris is rose colored, the pupil being red. There is usually intolerance of light and the Albino walks with the head downwards. This deformity is met with in all races, but it occurs most among the negroes of the South. It demands no treatment. 50 A COMPENDIUM OF PRACTICAL MEDICINE. ALCOHOLISM. Is the physical and mental changes induced by alcohol. It may be acute or chronic. Mania a potu is acute alcholic delirium. Delirium tremens is a delirium with trembling occurring in the course of chronic alcoholism. Symptoms. — The symptoms are familiar to all. In the chronic form the appetite declines, the stomach becomes intoler- ant of food, and vomiting occurs. The old alcoholic suffers in the early morning before the morning dram. He strains and retches, and after great anguish, brings up only some glairy mucus and a little greenish matter. His memory grows weaker, his moral sense is blunted, he becomes morose and irritable, has headache, ringing in the ears, attacks of dizziness or vertigo, his vision grows dull, numbness, tingling, trembling, and paresis of muscles occur. He also becomes wakeful and nervous. Liver and kidney trouble supervene with ascites and puffiness of face. Treatment. — Withdraw the stimulant, be careful with his diet, give tonics such as quinine, tincture of nux vomica, etc. PRESCRIPTIONS FOR ALCOHOLISM. Jfcr Potasii bromidi 3j. Sig. : One dose. Repeat every four to six hours if necessary. (For the horrors.) — Bartholow. Jfc Tincturse gentianae comp Tincturse calumbse comp — aa Sij- Tincturse nucis vomicae Siss. — M. Sig. : A dessertspoonful before each meal. — Loomis. jfc Strychnise sulphatis gr. j. Aqua font ...Sj.— M. Sig.: Five minims increased cautiously to twenty minims hypodermically twice daily. (In both acute and chronic forms.) — Dobronravoff. (Jr Sol. nitro-glycerine (1 per cent)..3ij- Sig. : One drop every two hours. (In acute form, with cerebral anaemia and intense depression.) — Van Goidtsnoven. ALCOHOLISM ALOPECIA. 51 jfc Spiriti ammonii aromatici oij. Tincturse camphorse 5iss. Tincturse hyoscy ami 3iiss. Spiriti lavandulse comp. q. s. addSij. — M. Sig. : A teaspoonful every hour until relieved. Then give ffr Pulveris capsici gr. ij. Quininse sulphatis gr. iij. — M. Ft. pulv. no. i. Sig. : To be taken before each meal for several days. — Aitken. Jfc Extracti lupulinae fluidi Tincturse capsici — aa Sj ■ — M. Sig.: One or two teaspoonfuls as necessary. (Best substitute for alcoholic stimulants.) — Bartholow. jfc Liquoris potassii arsenitis.. Sss. — M. Sig.: A half drop every half hour, for six or eight doses. (Vomiting of alcoholics.) — A. A. Smith. Jfc Sodii bromidi ,5ss. Chloral hydratis Siiss. Syrupi aurantii cort Sss. Aquas, ad giv. — M. Sig.: A tablespoonful at night. Repeat if necessary. (For sleeplessness.) — Aitken. Give opium and chloral very cautiously to old alcoholics. For the "alcoholic paralysis," or partial paraplegia use fara- dism and galvanism. ALOPECIA. Is baldness or loss of hair or defective growth. It may be congenital or acquired. It is a common thing for children to be born with very little hair, but it soon begins to grow; in rare cases it never makes its appearance. Congenital alopecia has also been observed in the lower animals, especially in a race of horses found in Little Thibet, on whose hide not a trace of hair can be discovered; also in a race of African dogs and hogs. Treatment. — Is both constitutional and local. Cod- liver oil and tonics, especially nerve tonics, as strychnia, phosphorus, and above all arsenic are usually indicated. The local treatment resolves itself into the use of reme- dies to stimulate the hair follicles, 52 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR ALOPECIA. 9 Tinrturae canthardis Sss. Olei ricini Siv. — M. Sig. : Rub well into the roots of the hair night and morning. — Waring . j& Tincturae cantharidis 3iss. Tincturae capisici ITt.xx. Glycerinae Sss. Spirit! odoratae — add Syj. — M. Sig. : Apply to head two or three times daily. — Gross J& Hydrargyri perchloridi gr. xij. Glycerini 3 vj . Spiriti rectificati Siij. Aquas destillatae — add Syj. Olei rosae XTT.j. — M. Ft. lotio. Apply to scalp night and morning. — Anderson. jfc Liquoris carbonis detergentis Sj. Glycerini (Price) 3 v j • Aquae destillatae Siv. — M. Sig.: Sponge the scalp night and morning. — Anderson. J& Pulveris cantharidis 3j Glycerini (Price) 3j . Unguenti simplicis 3yj. — M. Sig. : Apply firmly to the scalp night and morning. — Anderson. |& Tincturae macis ...3iss. Olei olivae — add Sij. — M. Sig.: Apply two or three times daily to affected spots. — Hebra. Jfc Quininae sulphatis 3iss. Spiriti vini rectificati Siv. Tincturae capsici Tincturae cantharidis Spiriti ammonii aromatici — aa...Sss. Glycerini Siv. Aquae q. s. — add Oj. — M. Sig.: Apply locally. — Brinton. Alopecia depending on Syphilis, Eczema and Psoriasis may be cured by the proper treatment for those affections. Pilocarpus is the most efficient remedy for alopecia which we possess. — Bartholow, AMAUROSIS AMENORRHEA. 58 {& Extracti pilocarpi fluidi 3j. Tincturse cantharidis Sss. Linimenti saponis Siiss. — M. Sig.: The scalp must be well rubbed with this lotion daily. — Bartholow. AMAUROSIS. (Functional.) Amaurosis is partial or complete blindness. Amblyopia is impairment of vision. Since the ophthalmoscope has come into use, making the interior of the globe as accessible to our sight as the exterior, these terms have fallen into comparative disuse, and are used to designate conditions whose pathology is not known (functional). Causes. — 1. Traumatic. 2. By lightning. 3. Hemorrhage. 4. Toxic, such as lead, osmic acid, silver and mercury, quinine, and salicylic acid. Alcohol and tobacco, which excite a peculiar partial neuritis, may cause amaurosis or amblyopia. 5. Uremic. 6. Diabetic. 7. Hysterical. 8. Migraine. 9. Reflex. Treatment, — Depends on the cause. For toxic causes, suita- ble antidotes and abstinence suggest themselves. Galvanization and faradization may be tried. Amaurosis of a functional kind, from lead, tobacco and alcohol, may be cured by strychnine. PRESCRIPTIONS FOR AMAUROSIS. {fc Strychnise sulphatis ,...gr. j: Alcoholis 5j. Aquse destillatae — ad Siv. — M. Sig.: A teaspoonful thrice daily before meals. — Nagel. According to Coursserant, there is no remedy comparable to pilocarpine in the amblyopia of alcoholism and of tobacco abuse. Dose, gr. xVgr. ss. AMENORRHEA. Is abnormal suppression or absence of the menses. Primary amenorrhea, called also emansio mensium, is where menstrua- tion has never occurred. Secondary or accidental amenorrhcea has been called suppressio mensium. Causes. — Amenorrhea is, more frequently than to any other cause, due to anaemia of the ovaries, consecutive to chlorosis or 54 A COMPENDIUM OF PRACTICAL MEDICINE. general anaemia, and dysinenorrhcea may depend, in one of its forms, at least, upon the same condition of the blood. — Bartholow. When the menses are absent at puberty it may be due to atresia of the uterus, vagina or vulva, or to bad hygienic sur- roundings, or to overwork at school. After the menses have become established, they may cease entirely from impoverish- ment of the blood, from debility resulting from a chronic disease or following an acute illness. Anaemia, chlorosis, Bright's disease, diabetes, cancerous and malarial cachexia, and pulmonary tuberculosis are all potent in producing amenorrhoea. Menstruation may be suppressed from some sudden emotion, anxiety, and from taking cold. Symptoms. — Abscence of the monthly flow is of course the chief sign. There may be headache, fever, pain in the chest and pelvis, acne, eczema, herpes, and urticaria. Science has on record some curious examples what may be called substituted secretions. Jones reports the case of a young woman in whom menstru- ation was checked apparently from sudden chilling, who then suffered from amenorrhoea, and for five years had, instead of the menstrual flow, an abundant flow of milk from the breasts which lasted for thirty- six hours. Periodical diarrhoea for three days, or leucorrhoea may replace the normal flow (Pozzi). Haemoptysis (spitting blood), haematemesis (vomiting blood), epistaxis (nose bleed), and rectal hemorrhages may replace the normal flow, and this is known as vicarious or ectopic menstru- ation. Treatment. — Depends on the cause. Where atresia exists, an operation is necessary. If the amenorrhoea be due to bad hygiene, or over- study, or poor health, correct these conditions. Pozzi says that it is a mistake to suppose that amenorrhoea calls for special medication supposed to have an elective action upon the uterine mucous membrane. Iron and aloes, and saline purgatives may be given in certain cases. Permanganate of po- tassium is said to be almost a specific. Apiol is sometimes of service. Mustard foot baths and mustard plasters to the thighs and hypogastrium, and the hot sitz-bath are important aids. AMENORRHEA. 55 Tonics and good food must be given. Electricity (faradic) with one pole upon the lumbar region and the other externally over the site of the uterus has given good results (Rockwell). During pregnancy and lactation menstruation ceases; it re- turns only when the excess of nutritive material is no longer required for these purposes. Menstruation may then be considered a safety valve; its absence indicates a lowering of nutrition when it is not the re- sult of pregnancy. PRESCRIPTIONS FOR AMENORRHEA. |i Tincturse aconiti radicis 3ss. Sig. : One drop every hour. (When checked by cold.) — Ringer. |fc Potassii perrnanganatis 5j Ft. in no. xxx pellets. Sig.: One three times daily after meals followed by a glass of water. (Begin one week before the expected period.) — Bartholow. {i Auri et sodii chloridi gr. iij Aquse o viij . — M. Sig.: A teaspoonful after meals. — Bartholow. Jfc Extracti hydropiperis fluidi Siv. Sig.: Thirty minims four times a day, for a week before the menses ought to appear, when due to functional inactivity or torpor of the uterine system. Bartholow can confirm the statement of Eberle, who reports that " with no other remedy or mode of treatment has he been so successful as with this," in amenorrhcea. J& Apiol (parsley-camphor) 5j. Sig.: Six drops morning and evening for five days before the expected menstrual period. (When torpor of the ovaries and uterus exist.) — Biddle. {& Terebinthina? alba? Pulveris aloes Fern sulphatis exsic — aa gr. xx. — M. Ft. massa et in pil. no. xx div. Sig.: One thrice daily. — Parviu. 56 A COMPENDIUM OF PRACTICAL MEDICINE. Jfc Extracti aloes aq 3j. Ferri sulphatis exsic 3ij • Asafoetidae giv. — M. Ft. massa et in pil. no. 100 div. Sig. : One pill after each meal, gradually increased to three. — Goodell. Jfc Tincturse ferri chloridi 5iij. Tincturse cantharidis 5j • Tincturse guaiaci ammonii gigs. Tincturse aloes Sss. Syrupi — q. s., add Svj. — M. Sig.: A teaspoonful thrice daily. — Dewees. ANEMIA. Is a morbid condition from diminution of blood or its nutri- tive constituents. Anaemia may be only a symptom of some other disease. It may be acute or chronic. Acute anaemia is the result of sudden and excessive loss of blood, as from wounds of arteries, post partum haemorrhage, and fevers. Chronic anae- mia may result from many forms of chronic diseases, as Bright's disease, malignant growths, tuberculosis, etc. Anaemia may also be caused by defective assimilation, an insufficient supply of food, frequent repetition of the sexual orgasm, profuse menstrual flow, prolonged lactation, pregnancy, poison in the blood from lead, malaria, etc. Symptoms. — The patient is weak and pale. His lips and tongue have lost their red color. The eye is pearly. His pulse is feeble, but generally accelerated. The appetite is deficient or depraved. The bowels are apt to be costive. Exercise induces great fatigue, shortness of breath and palpitation (DaCosta). There is mental depression. The hands and feet are always cold. Anaemic females complain of a pain in the left side and a burning sensation on top of the head. Over the jugulars, particularly the right, there is heard a continuous venous hum (Loomis). Prognosis. — Depends upon the cause of the anaemia. It is usually favorable. ANEMIA. 57 Treatment. — The causes of ansemia are to be ascertained, and, if possible, removed. Good food is the first requisite. The appetite and digestion should be promoted by quinia and other tonic remedies. Exercise in the open air, daily sponging of the body, and sea-bathing have a favorable influence. Iron is the one drug that best combats anaemia (Loomis). It should be given after meals. Arsenic is another remedy often of much efficacy in the treatment of anseinia (Flint). It should be given in small doses for a long time. Loomis says that alcohol is food to anaemic patients, and that Burgundy, Madeira, and rich wines are to be preferred; but malt liquors are often more beneficial. Cod-liver oil, and the syrup of the lacto-phosphate of lime are of great service. The physician should encourage the patient. Central galvanization, and general faradization are of use to stimulate the functions of organic life (Bartholow). PRESCRIPTIONS FOR ANEMIA. j& Quininse sulphatis gr. xx. Ferri sulphatis exsiccat gr. xl. Strychnia? sulphatis gr. ss. — M. Ft. massa et in pil no xx. div. Sig. : One pill thrice daily. — Bartholow. jfc Tincturse ferri chloridi 5iv. Acidi phosphorici diluti 3yj. Spiriti limonis 3ij- Syrupi — q. s. add Svj. — M. Sig.: A dessertspoonful in water after meals. — Goodell. Jfc Hydrargyri chloridi corrosivi gr. i-ij Liquoris arsenici chloridi 5j Tincturse ferri chloridi 5iv. Acidi hydrochlorici diluti oiv. Syrupi Siij. Aquae — add 3 vj . — M. Sig.: A dessertspoonful in a wineglassful of water after meals. —A. H. Smith. {& Ferri sulphatis exsiccat Potassii carbonatis aa 5j. Syrupi — q. s., ut. ft. massa — M. Ft. massa et in pil no. xxiv. div. Sig.: One pill after meals. — Bland. 58 A COMPENDIUM OF PRACTICAL MEDICINE. R Liquoris potassii arsenitis 5ss. Tincturse gentianse composite Sivss. — M. Sig. : Half teaspoonful after each meal. (Small doses of iron may be given with the above). R Syrupi calcii lacto-phosphatis Si v. Liquoris potassii arsenitis 3j — M. Sig.: A teaspoonful three times daily. (In anaemia of lactation and of suppuration) . — Bartholow. ANEURISM. Is a tumor, or sac, containing blood which communicates with the interior of an artery. Its walls are formed of the coats of an artery. Causes. — The aorta is the favorite site of aneurisms, because it is subjected to great strain. Powerful, muscular effort, syph- ilis, chronic arteritis, are the chief causes. Degeneration of the vessel walls, overaction of the heart, as in hypertrophy, gout, rheumatism and alcohol may cause aneurism. Exciting causes are: external wounds, fractures and dislocations, and sprains. It occurs most frequently between 30 and 50. Symptoms. — The earliest symptom of thoracic aneurism is pain. This may be a fixed pain, almost constant, and felt in one spot under the sternum, lancinating and tensive in character, shooting up to the neck and shoulders, down the arm to the elbows; or it is felt in the back and shoots around the chest. At times the attacks of pain are most severe, and demand the use of active anodynes (Bartholow). If erosion of vertebrae, sternum, or ribs occurs, there is a peculiar, constant "boring" pain. Pressure of the aneurism on the recurrent laryngeal nerves causes dyspnoea and the voice becomes husky. Pressure on the pneumogastric may cause vomiting and pyrosis. Pressure on the pulmonary plexus gives rise to a harsh, metallic, "brassy" cough. Pressure on the cervical sympathetic causes contraction of the pupil on the affected side, and irritation causes dilation of the pupil (Loomis). Pressure on the external jugular causes the head and neck to become turgid on that side. Pressure on the trachea causes dyspnoea and a stridulous cough (with no ANEURISM. 59 expectoration) like a nervous cough. Pressure on the thoracic duct will cause mal- assimilation, wasting and inanition. The symptoms of aneurisms in general are: 1. Expansile pulsation. 2. Pressure on the artery above destroys the pulsa- tion and diminishes the size of the aneurism. 3. Aneurismal bruit — a rasping sound, like sawing wood. 4. Pain, due to pressure on the sensory nerves. The following tumors may be mistaken for aneurisms: 1. Pulsating sarcoma and soft vascular carcinoma. 2. Abscess lying on an artery. 3. Enlarged glands lying on an artery. A clean hypodermic needle may be thrust into the sac or tumor to make the diagnosis positive (Bartholow). Prognosis. — Unfavorable. Treatment. — Is both medical and surgical. Absolute rest is the first essential. The diet must be nutritive but unstimulat- ing. Iodide of potassium and ergot are the only drugs that have stood the test of time (Loomis). Morphine must be given for the 23ain. For cases amenable to surgical treatment, see works on surgery. PRESCRIPTIONS FOR ANEURISM. |fc Barii chloridi gr. xvij. Aquae Sj . — M. Sig. : Six drops in a tablespoonful of water three times daily after meals, for four or five months. — Flint. J& Potassii iodidi (grs. xv. — 5ss.) Three or four times a day. (This relieves pain and promotes coagulation of blood in the sac). — Bartholow. {& Antipyrin 5 iss. Syrupi tolutan oiss. Aquae — add 3 iij . — M. Sig.: A tablespoonful at intervals of one to four hours until relieved. (For cardiac pain). — See. I$* Potassii iodidi 5ss. Syrupi simplicis 5j . Aquae menthae piperitae — ad 5 iij- — M. Sig.: A teaspoonful three times daily, gradually increased to three teaspoonfuls, but diminished on any increase of pulse rate. — Balfour. 60 A COMPENDIUM OF PRACTICAL MEDICINE. ANASARCA. Is not a disease but a symptom. It is a universal accu- mulation of serous fluid in the areolar tissue. (Edema is a localized collection of serum in the same tissue. These terms, therefore, differ in nothing but extent. (For treatment of these conditions see dropsy.) ANGINA PECTORIS. Is a neurosis of the heart characterized by pain, usually in- tense, burning, tearing or lancinating in character, in the pre- cordial region, radiating into the back, left shoulder and down the left arm, and accompanied by a feeling of constriction of the chest, and a strong sense of impending death. It is frequently associated with organic disease of the heart (Bartholow and Loomis). Treatment. — The affection is paroxysmal. There is a sud- den indescribable anguish, or "heart-pang" with a sense of suffocation, pale face, cold sweat, arterial tension high, action of heart disturbed. The paroxysms may last a few seconds only, or for hours, or even days (Bartholow and Loomis). Prognosis. — Unf ayorable. Treatment. — All causes of disturbance of the heart action, as tobacco -smoking, alcohol, over-ingestion of food, and excite- ment must be removed. Five drops of nitrite of amyl should be inhaled from a handkerchief during the paroxysm. Morphine hypodermically for pain. Nitro- glycerine to prevent the attacks. Fowler's solution, cod -liver oil and the hypophosphites should be given. Electri- zation has been found useful (Bartholow, Loomis and Flint). PRESCRIPTIONS FOR ANGINA PECTORIS. Ify Liquoris potassii arsenitis Sj. Sig. : Ten drops three times a day after meals. (Given during the interval.) — Bartholow. Jfc Amyl nitritis oij- Sig. : Two to ten drops on handkerchief for inhalation. - Brunton. ANTHRAX. 61 Jfc Sol. nitroglycerine (1 per cent.)- • Sss. Sig. : One-half to two drops internally. (When pallor of face exists.) — Pepper. {fc Antipyrin 5j. Syrupi tolutan oj . Aqua? — add gij. — M. Sig.: A tablespoonful at intervals of one to four hours until relieved. — See. ANTHRAX. Commonly known as Carbuncle is a circumscribed, indurated, inflammation of the skin and cellular tissues. It is larger than a boil, and forms on the back or neck, sometimes on the face and buttock. Carbuncle is a far more serious affection than a boil, and occurs generally in men over 45. The pain is severe, sometimes intense; of a heavy, aching, throbbing, sting- ing, burning character. The inflamed area shows no disposition to become accumulated like a boil, but maintains its flat and very hard character. Little ulcers form on the dusky red skin which give it a sieve-like appearance, so numerous are the openings, and from these a whitish discharge exudes. Carbuncle, attack- ing the upper lip, is found to be an extremely fatal form of the disease, and kills by the onset of pyaemia (Flint and Anderson). Causes. — Poisonous, or irritating materials introduced into the skin; prolonged exjjosure of the skin to a scorching heat: low state of the nervous system and of the general health, pre- disjiose to their occurrence (Flint and Anderson). Treatment. — Begin treatment with a calomel purge. Give tonics, such as quinine and iron in full doses. Morphine may be needed to quiet pain. Apply heat in the form of a poultice with acetate of lead and opium. Paint with tincture of iodine. Mr. O'Ferral recommends continued pressure by applying collo- dion to the inflamed skin. Some authorities advise incision. 62 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR ANTHRAX. J& Tincturse ferri chloridi Sj. Potassii chloratis 5 }■ Glycerinse 5 j . Aquae — add 5 iv. — M Sig. : A teaspoonful in a wineglassful of water every two hours. — Ringer. Jfc Lini farinse Aquse bullientis aa. q. s. M. et Ft. cataplasma. Sig. : Apply as hot as bearable and renew when necessary. — Rockwell. Faradization will hasten suppuration. ANESTHESIA. Is loss of sensation. It is of various degrees. It may be complete, or partial, or a mere benumbing, and may be located in any part of the body. It is a symptom of some organic or functional disease of the central or peripheral nervous system. Large doses of Indian hemp, of lead, or of arsenic may cause anaesthesia. We see it in hysteria, syphilis and rheumatism, and as a result of pressure on nerve trunks, and of disturbances of the circulation and abnormal conditions of the blood. In the parts affected with anaesthesia the nutrition is less active, and there is a feeling of numbness and the temperature lowered (Loomis). Treatment. — A good nutritious diet and tonics. For the curable cases of cutaneous anaesthesia, faradization is a specific, if any remedy can be said to be a specific for anything (Rock- well). Bartholow recommends strychnine. ANCHYLOSIS. Is a bony or fibrous union of the joint ends of bones, caus- ing immobility of the joint. Anchylosis is not a disease of itself, but may be the result of any disease or injury which interferes with the normal functions and motions of a joint. Anchylosis may take place even in a perfectly healthy joint by long- con- ANCHYLOSIS APHTHAE. 63 tinned rest. It may be the most favorable termination that can occnr in many diseases and accidents of the joints. If anchylosis is the best result that can be obtained, then the surgeon should see that the elbow is anchylosed at a right angle, as the limb will be more useful, and the knee with the limb perfectly straight (Sayre and Bryant). Treatment. — If the anchylosis be fibrous, we resort to forcible movement to break up the adhesions. If it be bony, we divide the bone, or cut out a wedge-shaped portion. It may be necessary to divide the tendons before applying force. After breaking up the adhesions in the fibrous variety, passive motion may be resorted to. There is no treatment for bony anchylosis if the limb is already in the best position (Bryant). APHTHA. Are small white mucous ulcers of the mouth, especially of infants. Aphthous, follicular and croupous stomatitis are other names for this affection. The "aphthae," or white ulcers, are found on the internal surface of the lips, cheeks, tongue, gums, etc. The smallest of these patches are not larger than a pin's head. Causes. — Indigestion, diarrhoea, unripe fruit, candy and bad hygienic surroundings. Symptoms. — The constitutional symptoms are slight. The ulcers are painful; the child is fretful; the saliva is increased. Treatment. — Correct any intestinal disturbance that may exist with small doses of rhubarb and magnesia. Wash the mouth with a weak solution of glycerine and borax, or chlorate of potash. If the ulcers are slow to heal, touch them lightly with nitrate of silver. Bathe the feet in warm water. PRESCRIPTIONS FOR APHTHAE. jfc Bismuthi subnitratis Sj- Sig. : Apply dry to the ulcer. — Bartholow. Jfc Potassii iodidi gr. iv. Aquas 5J • — M. Sig.: Apply locally. — Bartholow. 64 A COMPENDIUM OF PEACTICAL MEDICINE. J& Mel. boracis 5j. — M. Sig.: Apply to patches with a brush. — Ringer. (& Potassi chloratis gr. x. Aquae Sj — M. Sig.: Apply locally several times daily. — Brunton. J& Sodii salicylatis oiss. Aquae destillatae Sj- — M. Sig.: Apply five or six times daily. — Hirtz. APHASIA. Is inability to use spoken language or to give vocal utter- ance to ideas. Where the memory of words is lost, it is called amnesic aphasia. Where the power of expression is lost and the words remembered, it is called ataxic aphasia. Aphasia is really not a disease, but a symptom. Causes. — Aphasia is associated with a number of intra- cranial lesions; with occlusion either by thrombosis or embolism of the vessels; with cerebral hemorrhage; with encephalitis, abscess, meningitis, tumors; and it may be a merely mental and moral condition (Bartholow). Treatment. — The local disease on which the aphasia depends must be removed. If the aphasia persists after the local disease has been cured, much may be done by suitable training. APOPLEXY. Is sometimes used synonymously with cerebral hemorrhage, but incorrectly, since it is a symptom merely, and not a disease (Bartholow). DaCosta says that apoplexy is coma coming on rapidly, in consequence of the compression of the brain by ex- travasated blood, by the turgescence of the vessels, or by effusion of serum. Loom is limits the term cerebral apoplexy to non- traumatic hemorrhage into the cerebral substance or meninges. Causes. — Apoplexy is rare before 40 years of age. Miliary aneurism, periarteritis, fatty, atheromatous and fibroid degenera- tion of the walls of the vessels are causes of apoplexy, or cerebral APOPLEXY. 65 hemorrhage. Other predisposing causes are: gout, rheumatism, syphilis, chronic Bright's, and chronic alcoholism. The exciting causes are: mental excitement, as in public speaking, sexual intercourse, straining at stool, and violent mus- cular exercises, and sudden stopping of bleeding piles (Flint and Loomis). Symptoms. — The seizure is generally sudden, and the coma quickly developed. The patient falls to the ground, bereft of all consciousness. In other instances, the apoplectic seizure is preceded by vertigo, dizziness, double vision, niuscse volitantes, flushing or pallor of the face, nausea, etc. During the coma the patient lies as if in a deep sleep, breathing laboriously and noisily, and each snoring inspiration is followed by a puffing sound. The pulse is slow, full, and at times irregular; the carotids throb violently. The pupils are immovable, and either con- tracted or dilated, and the eye is half open. In severe cases, the breathing becomes very irregular, of the Cheyne- Stokes variety. The coma may last from a few hours to two, three, or four days. Hemiplegia upon the side opposite to the hemorrhage is one of the most constant attendants of apoplexy, especially in the aged (Loomis). The eyes, and the head also, frequently deviate toward the side affected in the brain and from the side paralyzed; this movement constitutes a means of diag- nosis between cerebral hemorrhage and other causes of profound unconsciousness (Bartholow). Treatment. — The patient should be placed in a cool, airy apartment. Cold should be applied to the head, and heat to the feet. Attention must be directed to the bladder. An active cathartic should be given. If there are any paralyzed muscles, kneading, rubbing and electricity are the proper remedies. PRESCRIPTIONS FOR APOPLEXY. # Olei tiglii 5j. Sig. : Three or four drops may be given at once and repeated in three or four hours if free purgation be not produced. — Flint. 66 A COMPENDIUM OF PRACTICAL MEDICINE. APPENDICITIS. Is an inflammation of the appendix vermiformis. Causes. — The usual causes are foreign bodies, such as in- spissated faeces, fruit seeds, worms, gall stones, catarrhal condi- tion and traumatism. It is most frequent in males from fifteen to thirty years of age. Symptoms. — At first there are slight localized pain and ten- derness in the right iliac region. Later on, there is pain in the groin, extending down the course of the anterior crural and through the hip. The slightest attempt at palpation gives the patient great dread. The thigh is flexed on the pelvis. The following symptoms are diagnostic of perforation or acute peritonitis: a sharp, sudden, intense pain in the iliac fossa which may extend to the navel, liver, or into the back, accom- panied by nausea, vomiting and chill. Temperature 101° to 102°. A circumscribed tumor is usually detected and sometimes fluctuation. Prognosis. — When perforation has occurred, unfavorable. Treatment. — Antiphlogistic measures locally, and opium in- ternally, but according to Loomis, it is best to make an explora- tory incision. ASCITES. Is a local dropsy — an accumulation of serum in the perito- neal cavity. The amount of fluid present in ascites may vary from a few ounces to five gallons (Loomis). It is usually of a light straw color. Ascites is a symptom, or an effect of disease, not strictly a disease in itself. Causes. — Ascites may be the result of disease of the perito- neum, or of obstruction in the main trunk of the portal vein, or in the branches of the vessel within the liver. Cirrhosis, throm- bosis, syphilitic hepatitis, abscess, cancer, and other tumors of the liver may cause ascites. Diseases of the heart or lungs may induce ascites in connection with general dropsy. Blight's dis- ease is a cause of hydremic dropsy. Symptoms. — The first is gradual enlargement of the abdo- men. There is no pain, tenderness, or any local subjective ASCITES ASTHMA. 67 symptoms. The appetite is usually impaired. There is a feel- ing of fullness. There is dyspnoea. The umbilicus is bulged out. Flatulence and diarrhoea are frequently present. The superficial veins on the abdomen or chest are enlarged and tor- tuous. The shape of the abdomen changes with a change of the position of the patient. Fluctuation is present. On percussion, there will be flatness below the level of the fluid. Ascites may be mistaken for an ovarian cyst, a distended bladder, pregnancy, and hydatid cysts of the liver. Prognosis. — In most cases unfavorable. Treatment. — First, treat the cause if known. Try to remove the fluid by means of diuretics and hydragogue cathartics; but do not continue the treatment too long. The most efficient hy- dragogue is elaterium, and the potash salts, nitre, squills and juniper are the most efficient diuretics. As little fluid as possi- ble should be taken. Tapping is the surgical method of remov- ing the fluid. The puncture is made in the median line two or three inches below the umbilicus. Loomis is in favor of tapping before the fluid has caused pressure upon the viscera. The oper- ation of tapping involves little risk. Patients have tapped themselves. For the general health give quinine, iron and cod-liver oil. PRESCRIPTIONS FOR ASCITES. Jfc Elaterii gr. j. Ft. in no vi. pulveres. Sig. : One powder about 5 A. M. every other morning. —Salter. jfc Elaterii gr. ij . Ft. in no viii pulveres. Sig. : One powder at short intervals until abundant liquid evac- uations are produced. — Flint. jjr Pulveris jalapse compositi 3j. Ft. in no viii pulveres. Sig. : One powder in early morning. — liartholow. ASTHMA. Is a disease characterized by spasmodic difficulty of breath- ing, attended with wheezing and a sense of suffocation. It is a neuropathic affection, tonic spasms of the bronchial circular 68 A COMPENDIUM OF PRACTICAL MEDICINE. muscular fibres being induced by a morbid excitation through the nervous system (Flint). Causes. — A peculiar susceptibility in some persons constitutes the predisposing cause. Heredity is traced in about forty per cent. The exciting causes are: irritating inhalations, such as ipecac powder, chemical vapors, smoke, dust, fog, emanations from new mown hay, stables, roses, sulphur matches, cats, horses, etc. (Loomis). Errors in diet, bronchial catarrh and feather beds are causes. Course. — The paroxysms last from two to six hours, but sometimes they persist for days (Bartholow). They take place, usually, during the sleeping hours. The patient is unable to lie down, but sits with the elbows on the knees near an open win- dow. A patient suffering from a severe paroxysm appears to be on the point of death. A frequent symptom is an itching sensa- tion under the chin. Speech is difficult. The patient may be cyanotic (Loomis). Prognosis. — Death rarely, if ever occurs from uncomplicated asthma. Asthmatics are long-lived. Treatment. — To relieve the paroxysm, no medication is so effective as the hypodermic injection of morphine (from A to \ gr). Chloral hydrate (gr. xx-xxx) is often equally effective (Bartholow). Nitrite of amyl by inhalation, three to five drops, sometimes affords relief. Inhalation of ether or chloro- form may be tried. Stramonium leaves may be smoked in a pipe. It often acts like a charm. PRESCRIPTIONS FOR ASTHMA. Jfc Potassii iodidi 3ss. Tincturse gentians comp Siij. — M. Sig. : One teaspoonful gradually increased to two teaspoonsful, three times daily for several months. — Alonzo Clark. Jfc Sodii iodidi gr. ij. Sodii bromidi gr. ij. Fluidi ext. euphorbia pil ZU iij. Glonoin gr. -fa. Tincturse lobeliae ZFL ij. (Hare's anti-asmatic tablet.) Sig. : One three times daily for sometime. ASTHMA ASTHENIA. 69 $ Pyridin Sj. Sig. : Put on a hot plate in a small room, and send patient to inhale vapor several times. — German See. {& Tincturae sanguinarise Tincturae lobelias Ammonii iodidi — aa 3j • Syrupi to lutan 3 vj . — M . Sig.: A teaspoonful every two to four hours. (In humid asthma.) — Bartholow. J$r Ammonii bromidi 3iij. Ammonii chioridi 3 iss . Tincturae lobelias 3 iij . Spiritus aetheris compositi Bj« Syrupi acacias — ad d 5 iv. — M. Sig. : A dessertspoonful in water every hour or two during paroxysm. — Pepper. ASTHENIA. (Nervous). Literally signifies without strength. When the nervous system is without strength it is called nervous asthenia, or nervous debility, or nervous prostration or exhaustion, or simply neurasthenia. It is a morbid condition common in this country. Causes. — Sexual excesses, masturbation, excessive mental labor, late hours, long continued emotional disturbances of any kind, insomnia, improper food and the excessive use of tobacco or alcohol may excite it in persons of a neurotic temperament. Symptoms. — Physicians are often consulted by patients, who, although far from being well, have no well defined malady. They complain of languor, of being easily fatigued, and of aching of the limbs. They suffer constantly from dorsal and lumbar pains, and there seems to be no organ or part of the body free from some kind of disturbance. They imagine that they have some grave organic disease. There is a tendency to melancholia. There is anorexia, and the tongue is coated. Flatulence, dyspepsia, constipation, headache, palpitation of the heart, and tingling and creeping sensations are usually present. Chilly sensations alternate with flashes of heat. Prognosis. — Is always good. 70 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — All causes producing neurasthenia should be removed. Rest, change of scene, nutritious diet, out door life and sound sleep tend to produce a cure. Faradism, galvanism, sea bathing and massage are of great value. Cod-liver oil, iron, strychnine, arsenic, phosphites and phosphates are useful. B Quinise sulphatis gr. xxx. Acidi sulphuriei diluti q. s. Aquse S ij. Tincturse ferri chloridi Bss. Spiritus chloroformi 3 vj . Glycerinse — add ........ Siv. — M. Sig. : ' A teaspoonful three times daily. — Loomis. APHONIA. (Nervous) Is loss of voice. When not dependent on either inflamma- tion or lesions within the larynx it is known as nervous aphonia. Causes. — Paralysis of the nerve of phonation (spinal acces- sory), and pressure on the recurrent laryngeal nerve by an aneurism, or other tumor will cause aphonia. Diagnosis. — In nervous aphonia the patient speaks in a pure, soft whisper, without effort. If the aphonia be due to laryngitis, the whisper is stridulous or husky and labored, and there is usually cough. Treatment. — Tonic remedies and invigorating hygienic measures are indicated. Moderate counter -irritation may be useful. The galvanic and faradic currents are used with much success. Sometimes a single application is followed by recovery of the voice (Flint). ASCARIS LUMBRICOIDES. Is the round worm found in the small intestine. It has a cylindrical form tapering toward both ends, like the common earth worm. The total number of eggs contained in a fully de- veloped female has been estimated at sixty millions. They hatch after being frozen or dried. The round worm occasionally enters the stomach and is vomited. Sometimes it ascends the oesoph- agus into the throat, and enters the larynx and causes death. ROUND WORMS. 71 It has been found in the common bile-duct, gall -bladder, pancreatic- duct and vermiform appendix. These worms, when numerous, collect in balls, and are then difficult to expel, some- times causing obstruction. Length of worm, six to twelve inches. Causes. — The eggs are found in the drinking water, in fruits and vegetables which are eaten raw, and thus develop in the intestine. Filthy surroundings and uncleanliness favor their development. Symptoms. — The usual symptoms are colicky pains about the umbilicus, itching and picking at the nose, foul breath, bloody mucous diarrhoea, perverted appetite, restlessness, and disturbed sleep in which the child grinds its teeth, sometimes nausea and vomiting, tumid abdomen, whey-like urine, bluish color of eyelid, and there may be convulsions. But the only symptom which gives positive evidence of the existence of intestinal worms is their discovery in the stools or about the anus (Loomis). Treatment.— Santonine is the most effective remedy for round worms. Santonine affects the vision and makes all objects seem as if looked at through yellow- colored glasses (Bartholow). One -half grain for a child and three to six grains for an adult is a maximum dose (Loomis). The dose is given at night, fol- lowed by a laxative in the morning. PRESCRIPTIONS FOR ROUNDWORMS. ffc Olei chenopodii 3j. A cacise 5 ij • Syrupi simplicis Sj • Aquae cinnamomi 5 ij • — M. Sig. : Give a dessertspoonful three times a day for three days, and repeat after several days. — Smith. jfc Spiritus terebinthinse rec 3 ij- Olei limonis gtt. v. Mucil. gum acaciae Syrupi simplicis aa 5 yj. Aquae anisi 5 ii-iij . — M . Sig.: One teaspoonful every six hours. —Smith. 72 A COMPENDIUM OF PEACTICAL MEDICINE. Jfc Extracti spigelise fluidi ^j Extracti sennse fluidi §ss. — M. Sig. : One teaspoonful to a child from three to five years. — J. Lewis Smith. ASPHYXIA. If the quantity of oxygen in the blood be greatly dimin- ished, there follows a group of symptoms to which the names suffocation, asphyxia and cyanosis are applied. Causes. — Obstruction or compression of the air passages, as in croup, pneumonia, phthisis, pneumo-thorax, asthma, oedema, etc.; also, obstruction to the circulation in the lungs, as from embolism of the pulmonary artery and in valvular lesions of the heart ; also irrespirable gases, etc. Symptoms. — Dyspnoea, convulsions, lowering of the tempera- ture, elevation of the blood pressure, at first slow pulse, then rapid, dilatation of the pupils, and dark blue color of the surface of the body. Treatment. — The treatment consists in removal of the cause, if possible, and in efforts to increase the quantity of oxygen in the blood. This increase is best affected by artificial respiration (Flint). ATHEROMA, OR CHRONIC ENDARTERITIS. Is an inflammation of the internal coat of the arteries with thickening in patches. Calcareous granules infiltrate the coat and render the artery friable. Atheroma is a common disease. Causes. — It is a disease of advanced life. It is predisposed to by gout, rheumatism, syphilis, Bright's disease, lead poisoning and especially by alcoholismus (Loomis). Symptoms. — Rigidity of the arteries, which are enlarged, lengthened and tortuous, is a prominent symptom. The pulse is feeble. The left ventricle is hypertrophied. The extremities are cold. The skin becomes dry. Prognosis. — It is a condition which cannot be cured (Loomis). Treatment. — Its treatment is altogether hygienic (Loomis). Bartholow gives arsenic when the eyes are puffy, breathing short, and ankles swollen. BACKACHE BALANITIS BALDNESS BED-SORES. 73 BACKACHE. The backache so common in women and frequently due to anaemia of the cord, may be much relieved by a sponge dipped in hot water and passed over the spine. The hot douche to the spine is often more decidedly serviceable in these distressing cases (Bartholow). BALANITIS. Is an inflammation of the surface of the glans, penis and prepuce. Causes. — A long and tight prepuce is always a predisposing cause. The exciting causes are mechanical irritation or unclean - liness, or from prolonged contact with gonorrhoea^ leucorrhceal, menstrual, or other irritating fluids. Symptoms. — Kedness and swelling with ulceration and dis- charge, sometimes followed by phimosis, or paraphimosis. If gonorrhoea be the cause, it is called external gonorrhoea. Treatment. — Wash the parts with warm water, and dry them, and dust with calomel. If the ulcerations are deep, use iodo- form. A piece of lint or old linen is moistened in dilute lead water, or a gr. ij.-iv. solution of sulphate of zinc, and is laid around the glans, and the prepuce is pulled over it. This dress- ing should be repeated two to four times daily. If the prepuce cannot be retracted it may be washed out with a syringe. If the prepuce is much inflamed, rest, position, and evaporating lotions should be used. In cases of relapse circumcision affords a cure (Keyes). i BALDNESS. (See Alopecia.) BASEDOW'S DISEASE. (See Exophthalmic Goitre ) . BED=SORES. May be described as the death of a part from mechanical pressure. Bed-sores may arise in healthy subjects who are kept unmoved for ten to fourteen days. Dirt and moisture, under all circumstances, accelerate their appearance. 74 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — " Prevention is better than cure." Since bed- sores are cansed by continued pressure, a change of the patient's position will relieve. The skin of the part pressed upon should be hardened by washing it twice a day with some camphor spirit and water, vinegar and water, or nitrous ether and water, in the proportion of one part to three. It is a useful practice to wash the parts threatened with bed-sores with whiskey or alcohol ; it hardens the cuticle, and prevents ulceration (Bartholow). Alum Sss., the whites of four eggs and tincture of camphor Sij., is an excellent application to bed-sores (Bartholow). Equal parts of tincture of catechu and liquor plumbi is a useful ajjplication to prevent bed-sores (Ringer). One of the best preventives of bed-sores is glycerine, or glycerine cream, rubbed over the part after washing it with tepid water (Ringer). The above applications are useless when the parts are about to slough. Water and air cushions should be employed to re- lieve the pressure. Dust iodoform over the sores. A linseed and bread poultice, with charcoal sprinkled upon the surface, is a good application (Bryant). BILIOUSNESS. Is a functional derangement of the liver. Causes. — It may be due to gastric and intestinal dyspepsia, to atony of the bowels, to malaria, to faulty diet, the food being too rich, to alcohol, to sedentary habits, and ill- ventilation, etc. (Loomis). Symptmos. — Anorexia, a bitter taste in the mouth, flatu- lency, acidity and pyrosis, a yellowish -coated tongue, yellow conjunctiva, muddy skin, nausea, constipation, headache, pain in the limbs, etc. Treatment. — The bowels should always be kept freely open. The alkalies are useful. The bromide of potassium, combined with ammonium chloride is highly useful. Mercury, in the form of blue pill, is very efficacious (Loomis). BILIOUSNESS BITES. 75 PRESCRIPTIONS FOR BILIOUSNESS. Jfc Acidi nitromuriatici diluti 5j- Sig. : Ten or fifteen drops, well diluted, before meals. — Bartholow. {fc Ammonii chloridi gr. xxiij. Sig.: To be taken thrice daily in a glass of milk. — Murchison. jfc Sodii sulphatis Potassi et sodii tartratis aa...Sj- Infusi cascarillae ....Sviij. — M. Sig.: Two tablespoonfuls three times daily. — Fothergill. 4 |fc Aloni Extracti nucis vomicae aa gr. vj. Extracti belladonnas gr. iij. — M. Ft. massa et in pil. no. xxiv. div. Sig. : One or two pills at night, followed by a saline cathartic before breakfast. — Witherstine. BITES. The weaker solutions of ammonia are sometimes applied to the bites or stings of insects, as wasps, bees, spiders, etc., to neutralize the formic acid, the active principle of the poison (Ringer). Alcoholic stimulants are given to counteract the de- pressing effects of the bites of venomous snakes. The strong aqua ammoniae should be at once applied to the bite of venom- ous serpents, and of rabid animals (Bartholow). Potassium permanganate has been used with success as a remedy for the bites of venomous snakes and other animal pois- ons, applied locally and given internally (LaCerdo). PRESCRIPTIONS FOR BITES (SNAKE). Jfc Aquae ammoniae IHxxx. Aquae oiss. — M. Sig.: To be injected into the vein with hypodermic syringe. — Halford. J& Tincturae iodinii 5j- Sig.: Apply freely to the wound. — Weir Mitchell. 76 A COMPENDIUM OF PEACTICAL MEDICINE. BLADDER DISEASES (See Cystitis). BLEPHARITIS Is an inn animation of the eyelid. There are various degrees and kinds of this affection. There may be a chronic hyperemia of the border, or some redness, with an accumulation of yellow- ish fatty material at the base of the lashes, or ulceration, minute abscesses, etc., and the hair follicles atrophy and the lashes fall out. This disease occurs most often in the young, with delicate skin and light hair, and in the strumous. It is sometimes a kind of eczema. In very many cases it is associated with some re- fractive or muscular error, and the proper glasses will correct it. The ailment is apt to be chronic (Noyes). Treatment. — Soothing lotions, warm water, or warm milk and water are useful; and at night a mixture of boracic acid powder and vaseline (gr. xxx to gj.) may be applied to lids. For the ulcerative forms, two grains of hydrarg. oxid. flavse to one drachm of vaseline, should be applied night and morning. If the patient is scrofulous, constitutional treatment must be in- stituted (Noyes). BLOODY FLUX. (See Dysentery). BOILS. (Called also Furuncle). A boil is a hard, bounded, deep-red, raised and very pain- ful swelling, situated in the subcutaneous tissue, occurring on all parts of the body, and usually terminating in suppuration. Boils, or furuncles, are met with in two forms, one as a subcutaneous affection, attended with little pain until the skin over it inflames and suppurates. It then appears as a conical-pointed swelling, with inflamed indurated areola; this causes severe distress, tension and throbbing, and is followed by relief when the "core" is discharged. The second form of boil begins as an inflamed follicle or pimple. It suppurates slowly. Such boils are usually multiple, and are often caused by the application of moist dressings or of some cadaveric irritant (Bryant). BOILS BLOOD POISONING BREATH. 77 Causes. — No definite cause can be assigned in some cases. Boils occur in men and women who are in perfect health; but they are more common in debilitated jDersons, and in those who work in skin-yards, pathological rooms and dissecting rooms. They occur in the diabetic and cachectic subject, and are often the result of eating diseased meat (Bryant). Treatment. — Is both local and constitutional. The diet should be nutritious; fresh air, exercise, mild laxatives, warm baths, quinine, iron, arsenic and bitters are useful. The usual local treatment is a poultice to the part and free incision. For in- dolent boils, a drachm each of glycerine and extract of opium, and an ounce of resin cerate applied relieves the pain. Painting the boil with iodine is recommended. When the pain is great from tension, lancing relieves it. PRESCRIPTIONS FOR BOILS. Jfc Liquoris potassii arsenitis 5vj. Sig. : Three drops in water, three times daily after meals. {Jr Calcii sulphidi gr. ij. Sacchari lactis gr. xx. — M. Ft. in no. xx. pulveres. Sig. : One powder every hour or two. — Kinger. Faradization will hasten suppuration (Rockwell). BLOOD POISONING. (See Septicemia). BREATH (Foul). To correct fetor of the breath, the following formulae may be used: Jfc Calcis chloratse .., 5iij. Aquae destillatse Sij • Alcoholis S ij . Olei rosse gtt. iv. — M. Sig.: A teaspoonful to a tumblerful of water. — Bartholow. jjr Potassii permanganatis gr. viij. Aquae rosse 3 viij. — M. Sig.: Use as a mouth wash. This is an elegant toilet prepara- tion for destroying the odor of a foul breath, the smell of the axilla, and the fetor of the sweat of the feet. — Bartholow. 78 A COMPENDIUM OF PKACTICAL MEDICINE. BREAST. (Inflammation of). The subcutaneous inflammation may be confined to the areola, and this -form generally terminates in suppuration. In other cases the inflammation may extend beyond the areola and give rise to localized abscesses. The treatment in both of these forms consists in the appli- cation of warm lead-lotions and in the early evacuation of the pus. To avoid cutting into the milk ducts the incision should radiate from the nipple (Lusk). Inflammation of the glandular structure of the breast develops usually in the first four weeks after confinement. The attack usually begins with a sharp chill, pain, high fever, and nodular enlargement of the breast. The mastitis that occurs three to four days after the birth of the child is, as a rule, insignificant, but the mastitis leading to abscess formation belongs to a later period, third or fourth week. Causes. — Are cold, blows, and "caking," but the lesions of the nipples are thought to be the main cause. Treatment. — Take the child from the breast, and in a very large number of cases the inflammation will disappear. For the pain, opium ; for the fever, a full dose of quinine should be administered. Give a saline cathartic. Belladonna in the form of an ointment may be applied to the breast, or lead- and- opium wash, or a large flax-seed poultice. As soon as there is evidence of pus, the abscess should be ojDened with antiseptic precautions (Lusk). BRONCHOCELE. (See Goitre). BUBONOCELE. (See Hernia). When the protrusion takes place above Poupart's ligament, through the internal ring, but does not traverse the inguinal canal sufficiently far to appear through the external ring, the hernia is called a bubonocele (Bryant). BORBORYGMUS. Is a rumbling noise of intestinal flatus, or wind, due to indi- gestion and decomposition of food. The noise can often be heard at a distance of ten feet or more when the person is walking. BORBORYGMUS BRONCHITIS. 79 Treatment. — Give stomachic and intestinal tonics, snch as quinine in half grain doses three times daily, gentian, quassia, Colombo, and wild cherry. Liquids should be withheld and all articles difficult of digestion. BRONCHITIS. Is a catarrhal inflammation of the bronchial mucous mem- brane. Varieties. — 1. Acute bronchitis, of the large tubes. 2. Acute capillary bronchitis. 3. Chronic bronchitis. Morbid Anatomy. — There is first hyperemia or congestion of the mucous membrane, which becomes swollen and soft. Then follows the products of inflammation, such as mucus, pus- corpuscles, and serum mixed with desquamated epithelial cells. Generally the tubes on both sides are equally affected, and thus bronchitis exemplifies the law of parallelism, and is called a bilateral disease. In this respect it differs from pleurisy and pneumonia (Flint). Causes. — Exposure to cold damp Avinds, unsuitable clothing, depression of vitality, bad hygiene, and irritating gases are common causes. The predisposing causes are infancy and old age. Symptoms. — Its invasion is commonly marked by coryza, lachrymation, sore throat and slight hoarseness, with chilliness. The pulse is increased in frequency, and there is aching in the back and limbs. More or less pain and discomfort are felt be- hind the sternum. The cough is at first dry and hacking, but in a few days becomes loose, and is attended with a frothy muco- purulent expectoration. Acute bronchitis lasts from four or five days to two or three weeks. Differential Diagnosis. — Acute bronchitis may be confounded with pneumonia and pleurisy. The absence of lancinating pains in either side, the pain which is felt being substernal ; the pres- ence of more or less expectoration which is not rusty; the absence of accelerated breathing and dysphceia ; absence of the circum- scribed flush of the cheek; the pre-existence of coryza, arc usu- 80 A COMPENDIUM OF PRACTICAL MEDICINE. ally sufficient to distinguish it from pneumonia and pleurisy. Besides bronchitis commences by chilliness persisting for several days — pneumonia by a distant and severe rigor. In bronchitis, the fever declines gradually, in pneumonia, there is a sudden defervescence. Treatment. — The combination of tartar emetic (gr. tV) and morphine (gr. T V) in some syrup of lactucarium, or in water, a mustard- plaster to the chest, and confinement to bed, will afford relief (Bartholow). In children, syrup of ipecac, syrup of tolu, and paregoric, usually suffice. If there is much fever and the pulse active, tincture of aconite root (gtt. j.) should be added (Bartholow). At the onset of the disease, it may be arrested by a Dover's powder (gr. x.) and warm bath at night, followed in the morning by a brisk saline purge ; or gr. xx. of quinine (Loomis). PRESCRIPTIONS FOR BRONCHITIS. jfc Tincturae sanguinariae 3j. Tincturae lobelia? 3] . Vini ipecac 3ij . Syrupi tolutan gss. — M. Sig. : A teaspoonful every three hours. ■ — Bartholow. Jfc Ammonii carbonatis gr. xL, Spiriti chloroformi §ss. Infusi senegae ^viij. — M. Sig.: Two tablespoonfuls every four or six hours. — Fothergill. Jfc Acidi hydrocyanici diluti HI xvi. Syrupi pruni Virginianae Aquae camphorae aa §j • — M. Sig. : A teaspoonful every two or three hours. — Hartshorne. Jfc Vini ipecac 3J . Tincturae scillae 31J. Syrupi tolutan £iv. Aquae %\ — M. Sig.: A teaspoonful every three or four hours. — Delafield. # Terpine hydrate 5ss. Sig. : Two to four drops on sugar every four hours according to child's age. — Cammann. BRONCHITIS. 81 J& Vini ipecac 3ij. Liquor potassii citratis 5iv. Tincturae opii camphoratse Syrupi acacise aa 3j. — M Sig. : A tablespoonful three times daily. — DaCosta. |& Vini ipecac 5ij. Vini antimonialis ^j . Vini xerici 5iij- — M. Sig.: Three drops every hour to a child six months old. — Dessau. BRONCHITIS. (Acute Capillary). Acute bronchitis, by an extension of the inflammation to the finest tubes, becomes capillary bronchitis. Capillary bronchitis is more frequent in infancy and old age than at other periods of life (Bartholow). Symptoms. — So difficult is the breathing that the patient is unable to lie down, he sits inclined forward, and the respirations are shallow, reaching in the adult to forty, in infants to eighty per minute. The difficulty of breathing is incessant. The in- ferior part of the chest and the epigastrium are drawn in with each inspiration instead of being elevated, while the upper por- tion of the chest remains immovable (Bartholow). The speech is short and jerky; the alse nasi dilate, the face is congested and swollen, has a livid aspect, the lips become blue, and there is blueness of the finger ends, with fullness of the jugular veins (Loomis). Cough is more or less prominent. The expectoration is, at first, thick, viscid and tough, and when some is put in water the froth floats and is connected by filaments with the heavier masses underneath the surface. There is great restless- ness and anxiety. As death approaches, the pulse becomes small and thready, muttering delirium conies on, or the patient lies in a state of partial coma (Loomis). Physical Signs. — The presence of muco- purulent liquid in the small tubes gives rise to fine bubbling (subcrepitant) rales. As the affection is bilateral, the rales are heard on both sides. Differential Diagnosis. — Capillary bronchitis may be con- founded with pneumonia, asthma, pulmonary oedema, phthisis 82 A COMPENDIUM OF PRACTICAL MEDICINE. and ordinary bronchitis; Lobar pneumonia is to be excluded by the absence of the symptoms and signs of that disease, such as dullness on percussion, the crepitant rale, pain in the side, the rusty colored sputum, etc. Asthma is not accompanied by pyrexia. In asthma the respirations are not rapid but labored. Prognosis — Unfavorable. Treatment. — Breathing warm vapor is highly useful, and the air of the room should be charged with steam during the -course of the disease. The temperature of the room should be kept at a high point, 85° to 90°. The iodide of potassium should be given freely (Flint). Muriate of ammonia, or chlorate of -potash in five or ten grain doses every two hours to an adult is useful (Loomis). Laxatives are useful and revulsive applica- tions to the chest. Emetics are sometimes indicated to promote the expectoration. In the advanced stage, quinine and stimu- lants must be given. PRESCRIPTIONS FOR CAPILLARY BRONCHITIS. Jfc Liquoris ammonii acetatis Sss. Syrupi ipecac 5j . Liquoris morphinse sulphatis ZHxL. Syrupi acacise Sj. Aquae Siss. — M. Sig. i A teaspoonful every two hours for a child two years old. — Meigs and Pepper. Jfc Tincturse aconiti radicis Sss. Sig.: One or two drops every hour. — Dessau. BRONCHITIS. (Chronic). Is a chronic inflammation of the mucous membranes of the bronchial tubes. When the secretion is retained and undergoes decomposition, as is apt to be the case when the tubes are di- lated, it is known as fetid bronchitis. The diagnosis is easily made. Treatment. — Iron, quinine, arsenic, lacto- phosphate of lime, hypophosphites, cod-liver oil, whiskey and strychnine, and a generous diet are indicated. For fetid bronchitis, the spray of a solution of carbolic acid is good. bright's disease. 83 BRIGHT'S DISEASE. Acute Bright's disease, or acute diffuse nephritis, is a dis- ease of the kidneys characterized by albuminuria and general dropsy. It is an inflammation of the kidneys. Anasarca and serous accumulations in the plural, pericardial and peritoneal cavities are usually met with in the bodies of those dead of acute Bright's disease (Flint). Causation. — Acute Bright's disease may occur at any period of life. In the majority of cases it is a sequel of scarlatina. It may follow diphtheria and epidemic cholera. It may occur in the course of pulmonary tuberculosis, rheumatism, syphilis, typhoid and typhus fever, yellow fever, erysipelas, acute lobar pneu- monia, pyaemia, septicaemia, endocarditis, dysentery, carbuncles, small-pox and measles. As a primary affection it occurs especially in persons addicted to intemperance. It may be caused by exposure to cold, and by extensive burns. Other causes are, cantharides, turpentine, phosphorus, carbolic acid, iodoform, the mineral acids, arsenic, lead and mercury taken in- ternally (Bartholow, Flint, and Loomis). Symptoms. — Dropsy is an early symptom in the great major- ity of cases, but it is sometimes wanting. The oedema is gener- ally first observed on the face, particularly on the eyelids and around the eyes. There may be fever, thirst, anorexia, pain and tenderness in the loins. Pain over the kidneys may be wanting. The quantity of urine is usually diminished, and it may be very scanty. The urine contains albumen frequently in great abund- ance. In some cases the urine has a reddish-brown, smoky ap- pearance from the presence of blood. Blood casts, epithelial casts, and hyaline casts are usually present in the urine. Urea may collect in the blood and cause uraemia. Impaired vision and amaurosis are among the effects of uraemia. Blindness in acute albuminuria is generally sudden; but is often temporary. The ophthalmoscope shows no morbid appearances within the eye. The morbid condition is central. The average duration of the disease is about four weeks (Flint). Prognosis. — Exclusive of uraemia and serious complications the prognosis is favorable (Flint). 84 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — Trie patient should be kept warm in bed. The diet should be unstiniulating. Dry cupping over the loins, saline laxatives, and fomentations over the region of the kidneys are useful. For the dropsy elaterium is the most prompt and relia- ble hydragogue. The diuretics to be used are bitartrate of potassa, the infusion of digitalis, and the decoction of broom. Of all diuretics, water is the best. Good sudorific remedies are pilocarpine and the liquor am- monise acetatis (Flint). PRESCRIPTIONS FOR BRIGHT'S DISEASE. jfc Acidi gallici 3i-ij Acidi sulphurici dil £ss. Tincturse lupuli 3j Infusi lupuli ad 5 vi. — M. Sig. : A tablespoonful thrice daily. (If urine is smoky). — Aitken.. jfc Ferri sulphatis gr. xv. Magnesii sulphatis 5 ij . Potassii bicarbonatis 3iij • Infusi buchu 3 viij. — M. Sig. : A tablespoonful once or twice a day in a tumblerful of water. — Fothergill. fy Infusi digitalis Sviij. Sig. : A tablespoonful morning and evening. (For the dropsy of Bright's Disease. — Bartholow. Albuminuria, dropsy, and uraemia are common to both acute and chronic Bright's Disease (Flint). BUBO. Is a circumscribed swelling and inflammation of the groin,, or of a lymphatic gland, syphilitic or otherwise. Varieties. — 1. Simple inflammatory bubo. 2. Virulent bubo.. 3. Syphilitic bubo. Causes. — Simple inflammatory bubo is very common with chancroid, and may occur with any inflammatory lesion, as gonor- rhoea, syphilitic chancre, herpes, and balanitis. This form is also known as sympathetic bubo. It is the same inflammatory BUBO. 85 glandular swelling as occurs after vaccination, or from an in- flamed corn. Any inflammatory lesion of the penis may be ac- companied by a simple bubo, (single or double) in the groin. Chancroid is the most common exciting cause (Keyes). Virulent bubo, the pus of which is auto-inoculable, can be found in connection with no other conceivable lesion than chan- croid. It is usually single, in one gland, on one side. It sup- purates necessarily. Simple bubo usually does, but may not suppurate. Pure syphilitic bubo does not suppurate. Bubo is more common in the male than in the female. Sometimes in double bubo, simple bubo will exist on one side and virulent on the other (Keyes). Diagnosis. — Syphilitic Bubo: 1. Nature: It is a specific affection. 2. Its frequency: It is a constant symptom attending syphilitic chancre. 3. Number of glands involved: Usually more than one. 4. Date of appearance: It develops during the first or second week of syphilitic chancre. 5. Size: The glands are usually only slightly enlarged. 6. Induration: The glands are specifically indurated, feeling like cartilage, oi wood. 7. Evidence of inflammation: None; the glands are freely movable among the tissues. The skin is neither adherent nor red, nor is there any pain. 8. Termination always in resolution. 9. Auto- inoculability: In cases of suppuration the pus is not auto-inoc- ulable. 10. Natural duration is a few weeks or months. 11. Prognosis is good as far as local results are concerned, but the patient invariably has syphilis. 12. Local treatment is inef- fective (Keyes). Bubo of Chancroid: 1. Nature: It may be simple or viru- lent. 2. Its frequency: It is a complication, occurring about once in three cases. 3. Number of glands involved: Usually consists of a single gland in any part of the body. 4. Date of appearance: There is no fixed date. 5. Size: The gland is greatly enlarged. 6. Induration: No hardness except inflamma- tory. 7. Evidence of inflammation: There is every appearance of inflammation. The gland becomes fixed, the skin adherent, the part feels hot, there is pain, the skin reddens. 8. Termina- tion: Occasionally by resolution, usually by suppuration. Viru- lent bubo invariably suppurates and becomes an open chancroid 86 A COMPENDIUM OF PRACTICAL MEDICINE. ulcer. 9. Auto-inoculability: When the bubo is inflammatory the pus is not auto-inoculable; where it is virulent the pus is invariably auto-inoculable. 10. Natural duration is a few weeks or many months as a chancroid. 11. Prognosis is good for sim- ple, less so for virulent, and, in neither case, does syphilis follow. 12. Local treatment useful and necessary (Keyes). Treatment. — The preventive treatment of simple bubo is rest, and absolute destruction of the chancroid with caustics. Tincture of aconite and belladonna, combined in equal parts, are of some use locally, especially if combined wuth rest. Tincture of iodine is useless, if not harmful, in acute advancing bubo. The above treatment, combined with a light poultice, will often avert impending bubo (simple). Blisteis may avert suppuration. Pressure is sometimes effective, if ajoplied early. If the tendency to suppuration advances, very slowly, the bubo is certainly simple; if rapidly, virulent. When opened spontaneously or by art, the outlet does not enlarge in simple bubo; in virulent bubo it does. If suppuration can be arrested in an inflamed gland, it must have been simple bubo, (unless syphilitic); virulent bubo must necessarily suppurate. It is a good rule to open the bubo early in any case, if pus be present. . The treatment of syphilitic bubo is that of early syphilis (Keyes). PRESCRIPTIONS FOR BUBO. jfc Cerati resinse comp 5j. Olei Olivse oi-ij. — M. Sig. : Spread on lint and apply. (To hasten suppuration and granulation). — Witherstine. Jfc Sol. hydrogen peroxidi...lO vol...Sviij. Sig.: Apply after suppuration has begun. — Ringer. (fc Tincturse iodi Sj Sig. : Apply with brush every other day, till skin becomes tender. — Van Buren. BUNION. Is an enlargement and inflammation of the bursa situated upon the side of the great toe at the metatarso- phalangeal junc- tion. Inflammation of this bursa is frequently so severe that BUNIONS BURNS AND SCALDS. 87 the reflex contractions which follow produce a sub -luxation at this joint. The bursa may suppurate. The pain is sometimes intense and torturing (Sayre). Causes. — Ill-fitting boots and shoes, and weight from over- standing. Treatment. — Under all circumstances, the pressure must be removed. A wide and easy boot should be worn. To the in- flamed bunion water dressing is the best application. By means of Sayre's apparatus keep the great toe in a straight line with the foot. PRESCRIPTIONS FOR BUNIONS. Jfc Acidi tannici , Cosmolini aa 5 ij ■ — M. Sig. : Apply to joint after skin has been removed by blister. — Gross. gr Tincturse iodi Tincturse belladonna aa 5ij- — M. Sig.: Apply twice daily with a brush. — A. U. Med. Sci. BURNS AND SCALDS. A burn is casued by the application . of concentrated dry heat to the body; a scald by the application of hot or boiling liquid. In a burn of the first degree, there is mere redness fol- lowed by desquamation. In the second degree, there is inflam- mation and a blister. In the third degree, the superficial layer of the true skin is destroyed, and when shed, the nerves are ex- posed and pain severe. In the fourth degree, the whole thick- ness of skin is destroyed, and when the dry eschar comes away, a tedious process of suppuration and granulation takes place. In the fifth degree, the skin with the deeper parts is a black mass. In the sixth degree, the whole thickness of the limb is carbonized (Bryant). Prognosis. — A superficial burn spread over a large 1 surface is more fatal than a deep burn on a small surface. When more than half of the body is injured by a burn or scald, a fatal result generally follows. In both old and young all burns of any 88 A COMPENDIUM OF PRACTICAL MEDICINE. extent are serious. Burns of the chest, abdomen, head and face are followed by much more severe symptoms than more exten- sive burns of the extremities (Bryant). Symptoms. — The earliest symptoms are those of shock. The skin is cold, accompanied by shivering. The pulse is rapid and feeble. The pain is severe and of greater intensity in slight than in deep burns. In the worst cases, pain is nearly or quite absent. In children vomiting is an early symptom. The patient may lapse into a drowsy condition followed by coma and death. If life be prolonged, reaction sets in after twenty-four to forty- eight hours, and traumatic fever. In severe burns we may have ulcer- ation of the duodenum (Bryant). Casting Off of Sloughs. — The slough separates in about four- teen days, and then suppuration commences. In the suppuration stage, there is great danger of exhaustion, hectic or pyaemia. The granulating surface is a long time in healing, and is followed by contraction if the whole skin has been destroyed. Cause of Death. — When a person dies from a burn within forty- eight hours, it arises from shock, or collapse ; when he dies in the stage of reaction or of inflammation, it is from visceral complication ; and when during the third or suppurative stage, from exhaustion, visceral changes or pyaemia (Bryant). Treatment. — Is both constitutional and local. Prevent col- lapse by use of stimulants and external warmth ; allay pain by local treatment and morphine ; maintain the strength by such food as milk, beef-tea, eggs, etc. Local Treatment.— Blisters should be opened carefully. Exclude the air as much as possible. At Gruy's hospital the application of carron oil, consisting of equal parts of lime water and linseed oil, applied on lint, has long been the favorite remedy. At University College the burn is covered with wheat flour. Zinc ointment on lint is used at London Hospital. Dr. dross used white lead paint. Bryant uses vaseline and finely powdered boracic acid spread on lint. In small burns, two parts of collodion to one of castor oil is used, or one ounce of carbolic acid to a pint of olive oil, or an ointment of carbolic acid 5iv., lard 5iv., and castor oil 5j. Extension must be kept up to prevent contraction. Skin-grafting may be necessary. BURNS AND SCALDS CALCULI. 89 PRESCRIPTIONS FOR BURNS AND SCALDS. jjr Acidi carbolici gr. viij. Vaseline ^ij . — M. Sig. : Spread on lint and apply where the skin is broken. — Bellevue Hospital. jfc Sodii bicarbonatis ^ij Aquse Oj. — M. Sig.: Apply freely on lint or soft cotton. Jfcr Oleilini Liquoris calcis aa ^iv. Acidi carbolici gtt. xxx — M. Sig.: Apply freely. — Charity Hospital. jfc Cocaini gr. x-xx. Boroglyceridi §ij. — M. Sig. : Apply locally on absorbent cotton. — Eller. ffcr Saloli 3sb. Liquoris calcis Olei olivge ...aa §..ij. — M. Sig. : Use locally. — Nicot. CALCULI. (Biliary, Renal, and Vesical.) When bile is retained in the gall-bladder for a long time it decomposes, and the cholate of soda and other bile salts, with cholesterine, globules of bile -resin and granules are precipitated, and combine to form concretions, which are called biliary cal- culi, or gall-stones. Catarrh of the gall-bladder always accom- panies this retention and decomposition of bile (Loomis). Number of GaII=Stones. — Varies. Single calculi are rare. Eight thousand were found in one case. Their usual number is about thirty. Their size varies from that of a pin's head to that of a goose egg. In shape they are originally spherical, ovoid, or pear-shaped, but when they lie in contact with one another they may have facets. Color. — They may be light brown, or greenish yellow, or white, green, blue, red or black. Gall-stones will not float in water. In most cases a fresh biliary calculus can be crushed between the fingers. A gall-stone may form in the smallest 90 A COMPENDIUM OF PRACTICAL MEDICINE. radical of trie hepatic duct. Trie gall-bladder may be normal or enlarged, and is often adherent to adjacent organs. Ulceration of the walls may take place and form openings, called biliary fistula. When calculi are found in the smaller ducts, they may excite abscess of the liver. Gall-stones may cause intestinal obstruction (Loomis). Causes. — Gall-stones may be formed at any period of life, but are most frequent after thirty- five. They are more common in women than in men on account of their less active mode of life. Those who have to pass the greater part of their lives in bed, and prisoners, are especially liable to gall-stones. The predisposing causes are, a diet rich in fats, animal food, alcoholic beverages, cancer of the liver, catarrh of the gall-bladder, etc. (Loomis). Symptoms.-The severely painful sensation produced by the passage of a gall-stone is called biliary colic. Usually after a hearty meal, or after some jolting exercise, as horseback riding, the patient is suddenly seized with a severe pain in the epigas- trium, which is increased by change of position or pressure. Sometimes nausea precedes the colic. The pain is paroxysmal, situated over the gall-bladder, radiates backward and upward, and may extend over both hypochondriac regions. It is a boring, tearing, piercing, or lancinating pain. It is often so agonizing that patients will roll about the floor or bed. The face is pale and covered with cold sweat. The abdominal muscles are rigid and pressure greatly augments the pain. Fatal syncope has occurred during an attack of gall-stone colic. After a few hours, sometimes a day, of exhausting and intense pain, the patient experiences sudden relief, and the pain entirely disappears. Jaundice is often present, but not until the attack has continued for twenty-four hours. After the attack, gall-stones may be found in the faeces (Loomis). Differential Diagnosis.— Gall-stone colic may be mistaken for cardialgia, intestinal, and renal colic. In cardialgia, pain comes on immediately after eating; gall-stone colic has no neces- sary connection with taking food. In cardialgia, the symptoms are referred to the epigastrium alone, while in biliary colic, the pain shoots to the right shoulder and back. In cardialgia, the CALCULI. 91 pain gradually diminishes; in biliary colic it suddenly ceases. In gall-stone colic, the presence of a gall-stone in the faeces is pathognomonic. In intestinal colic, the pain begins at the um- bilicus, and radiates over the abdomen. In gall-stone colic, the pain has its seat at the free border of the ribs, and shoots to the back and upward to the right shoulder. In intestinal colic, pres- sure relieves the pain; in gall-stone colic it aggravates it. In intestinal colic the pain is intermittent; in gall-stone colic it is constant, though paroxysmal. In intestinal colic, jaundice is never present, while it may exist in bilary colic. In renal colic, the pain shoots from the region of the affected kidney to the inner part of the thigh and end of the penis, and the testicles are retracted; in gall-stone colic the direction of the pain is upward and backward. In renal colic, there is a constant desire to mic- turate. There is no urinary disturbance in biliary colic (Loomis). Prognosis. — Oft repeated attacks of biliary colic are bad. Treatment. — Relieve the pain by morphine hypodermically, inhalations of chloroform or ether; two or three leeches over the gall-bladder is often followed by relief. Large draughts of warm water, containing bicarbonate of soda often relieves the pain. Wrap warm clothes around the abdomen. If there are signs of collapse, give stimulants (Loomis). A gall-stone patient must not have wine or fats. He must exercise in the open air. A prolonged course of alkaline mineral water has been found the best remedy against the formation of gall-stones. Ether, turpen- tine, chloroform and hydrate of chloral have been proposed as specifics, it being thought they have the power of dissolving the gall-stones. According to Bartholow, the most effective remedy for the removal of the conditions which lead to the formation of biliary calculi, or to bring about their solution, is sodium phos- phate. He prescribes this in drachm doses, three times daily, dissolved in sufficient hot water, and taken before meals. This remedy is continued for several weeks or months. Vichy water should be used. 92 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR BILIARY CALCULI. jfc Sodii bicarbonatis £v. In chartas no. xx div. Sig. : One powder three times daily for several months (Prophy- lactic). — Alonzo Clark. Jfc Chloroformi giv. Sig.: To be inhaled, a small quantity at a time until paroxysm ceases. — Ringer. {£r Sodii phosphatis ^ss-iss. In chartas no. xx div. Sig. : A powder before each meal continued for months (Pro- phylactic). — Bartholow. jfc Olei olivse optim Oj. Sig. : To be taken in divided doses before breakfast. jfc Morphinse sulphatis gr. 1 -J . Atropine sulphatis gr. y-J^ Aquae q. s. — M. Sig.; To be injected hypodermically during the paroxysm, and repeat if necessary. — Bartholow. CALCULI. (Renal). Renal calcnli are concretions formed by precipitation of certain substances from the urine about some body or material acting as a nucleus (Bartholow). They may be deposited in the tubes of the pyramids, in the cortical substance, or in the pelvis of the kidney. By far the most frequent variety is uric acid. Oxalate of lime may form the starting point of uric acid de- posits. Phosphatic, next touric, are the most frequently encoun- tered calculi. Mixed calculi are common. They vary in number. A kidney may contain one or a large number of concretions. They vary in size from a pin's head to a hazel nut; the larger ones may fill the whole pelvis; the smallest constitute "kidney gravel." If the larger ones obstruct the ureters, they become the cause of pyelitis, pyonephrosis, hydronephrosis, or abscess (Loomis). Causes. — Renal calculi occur at all ages, and are very fre- quent in children before the fifth year, and from five to fifteen. CALCULI. 93 Males are much, more liable to them thau females. A sedentary life favors their development. The nuclei of renal calculi may be pus, blood, epithelium, or grains of pigment. Symptoms. — Usually there is an aching pain in the lumbar region and loins, which frequently shoots into the testicles, or labia, and down the inner side of the thighs; an itching at the end of the penis, and a frequent desire to urinate. The urine often contains pus, blood and tailed epithelium. The passage of a calculus along the ureter into the bladder is marked by sudden and intense pain in the region of the affected kidney, and is called renal colic. The urine is scanty or suppressed, and what is passed is of a smoky, high color, often bloody, and is dis- charged in drops, with a painful, burning sensation. The testi- cle of the affected side is retracted. When the calculus is washed into the ureter, an atrocious pain suddenly seizes the j)atient, who cries out, rolls from side to side, or rushes up and down the room. The face is pale and torn with agony, and the body is covered with a cold sweat. There may be nausea or vomiting, syncope or convulsions. The thigh of the affected side is be- numbed (Bartholow). The paroxysm, after some minutes or hours, usually terminates suddenly by the escape of the stone into the bladder. If the calculus become impacted in the ureter it will ulcerate through and give rise to a fatal peritonitis. Gravel may occasion no distress at all, or at most some little burning at micturition. After the passage of a calculus into the bladder, it will soon be found in the urine voided, or remain- ing in the bladder, it increases in size, and forms a vesical calculus. Diagnosis. — By remembering the diagnostic points the diag- nosis is easy. Prognosis. — Usually good. Treatment. — To relieve renal colic, give morphine hypo- dermically, warm baths and hot poultices to the loins and abdo- men. Inhalation of ether or chloroform will give relief. If gravel or sand of uric acid is present, probably the best prepara- tion is the officinal liquor potassii citratis, of which a table- spoonful may be taken every three hours (Bartholow). The faithful use of alkaline water not only delays, but often arrests the formation of renal calculi (Loomis). The Lithia, Carlsbad, 94 A COMPENDIUM OF PRACTICAL MEDICINE. Vichy or Ems waters are efficacious. In five -sixths of the cases the urinary concretions consist of uric acid, and this forms the red sand which quickly collects around the sides and bottom of the vessel containing the urine. The urine in these cases is always acid. In cases of uric acid gravel, the urine is too con- centrated. The alkaline remedies above are indicated, with a large amount of water. The concretions may consist of the earthy salts, namely, the phosphate of ammonia and magnesia, and the phosphate and carbonate of lime. Ammonio-magnesian calculi are liable to form in cases of cystitis. These concretions are generally not renal but vesical. The urine in these cases is usually alkaline, and the mineral acids are indicated, either the sulphuric or hydrochloric. The nitro-hydrochloric acid is espec- ially indicated in cases of oxalate of lime gravel. The ingestion of large quantities of water form a highly important part of the treatment in all cases of gravel. PRESCRIPTIONS FOR RENAL AND VESICAL CALCULI. 5 Liquoris potassae 3ij. Infusi buchu 5 viij . — M. Sig. : Three tablespoonsful an hour after meals. (When urine acid.) R Lithii citratis... 5ss. Syrupi aurantii cort 5j. Aquae ad ...giij. — M. Sig. : A tablespoonful in a wineglass of water three times daily. -Guy. Tfr Magnesii carbonatis 3j. Sodii biboratis Acidi citrici aa 5ij • Aquae bullientis S viij . — M. Sig.: A tablespoonful three or four times daily. (When urine acid). — Bartholow. R Acidi nitrici diluti Acidi hydrochlorici diluti aa...3iij- Syrupi auranti cort Aquae aurantii flor aa 3j. Aquae destillatae Sxiiiss. — M. Sig.: A wineglassful three or four times daily. (When urine alkaline). — Druitt. CARCINOMA. 95 R Acidi nitrici diluti Acidi hydrochlorici diluti aa IRxL Infusi serpentarise 5 viij . — M. Sig. : A half wineglassful three times daily. (When urine alka- line). — Bird. R Ammonii benzoatis ■ 5ii-iij. Syrupi Siss. Aquae ad gyj. — M. Sig. : A tablespoonful two or three times daily. (When urine alkaline). — Seymour. R Strychnia^.... gr. j. Acidi nitrici diluti 5j. Aquae Sxij . — M. Sig.: Two tablespoonsful three times daily. (When urine alka- line). — Bird. CARCINOMA, OR CANCER. Is a tumor with a specific arrangement of the cells in spaces called alveoli. Theory. — Conheim has advanced the theory of the embry- onic origin of tumors, the germs of the tumor, perhaps consist- ing of misplaced embryonic cells, are brought by the individual into the world. They may remain dormant for a variable length of time, and then under the influence of some exciting cause, possibly an injury, may begin to grow. Cause. — Nothing is definitely known as to the origin of cancer, in any situation, but there is one thing certain, it is a disease of advanced life, and is more apt to appear from forty to sixty than at any other period. CARCINOMA OF THE STOMACH. Of all the organs of the body, the stomach is most frequently the seat of cancer — more frequently than the uterus, which comes, strictly, next. As regards age, the majority of cases occur at fifty, but the disease may appear at any time from forty -five to sixty. It is very rare from thirty to forty (Bartholow). Ac- cording to Loomis, the stomach, next to the liver, is the most 96 A COMPENDIUM OF PRACTICAL MEDICINE. frequent seat of internal cancer ; one -third of all the cases of primary cancer have their seat in the stomach. According to Welch, quoted by Flint, the stomach, next to the uterus, is the most frequent seat of primary carcinoma. Cause. — Hereditary predisposition is undoubtedly its most important etiological factor. Beyond this its etiology is obscure (Loomis). Symptoms. — Anorexia, nausea, vomiting, pyrosis, soreness over the stomach are the earliest symptoms. After a time the pain becomes lancinating, fixed and constant. There are three prominent causes of the vomiting : First, from obstruction. When the obstruction is at the cardiac orifice, vomiting occurs immediately after eating ; when at the pylorus, the food is re- tained for one or two hours. Second, from irritation. Third, from fermentation. The absence of hydrochloric acid from the gastric juice is held to be an infallible sign of cancer. When the cancer ulcerates, the most constant symptom is hemorrhage (" coffee -ground" vomit). The stools have a dark, tarry appear- ance. Emaciation, debility, haggard look, and yellow skin are often present. By palpation, a hard, irregular and nodulated tumor may be discovered. Differential Diagnosis. — Cancer of the stomach may be mis- taken for gastric ulcer, and abdominal aneurism. Ulcer of the stomach occurs most in young adults, especially females, while cancer is seldom met with in persons under forty. In cancer there is usually a history of hereditary cancer. The pain in cancer is continuous, and described as lancinating ; while in ulcer the pain is intermittent, greatly increased by taking food. Hgematemesis, in cancer, has a sooty or "coffee- ground" appear- ance, is small in amount, and appears late in the disease, while in ulcer it is bright red arterial blood, is profuse, and appears as an early symptom. Vomiting in cancer does not relieve the pain, and is not very severe ; but in ulcer it is severe, and relieves the pain. The presence of an epigastric tumor establishes the diagnosis of cancer. An aneurismal tumor is smooth and ovoid; a cancerous tumor is hard and irregular. In aneurism, there is an expansile pulsation, while in cancer this impulse is lifting in character (Loomis). CARCINOMA. 97 Prognosis. — Is always unfavorable. Its shortest duration is seven weeks, and its longest three and one -half years, the aver- age being one year (Loomis). Treatment. — Is altogether palliative. As to diet, milk and beef juice are the best. The burning pain is much diminished by washing out the stomach once a day with the stomach pump. BartholoAv recommends equal parts of pure carbolic acid and tincture of iodine, of which one or two drops may be given in water three times daily. For the pain, give morphine hypoder- mically. Arsenic, in the form of Fowler's solution, one or two drops, three times a day, has power to allay pain and retard the growth. CARCINOMA OF THE INTESTINE. Cancer of the intestine is usually primary. The rectum is its most frequent seat, then the anus, the caecum, the sigmoid and the colon (Loomis). Cause. — The cause is obscure. It is a disease of advanced life (after forty). Males are affected three and a half times oftener than females. Symptoms. — There are pains in a fixed situation, a gradually developing cachexia, and the presence of a tumor. The pain at first is slight, then acute and sharp. The patient declines in strength and weight, has a feeling of fatigue, a fawn- color com- plexion, bluish- white lips, a skin dry, wrinkled and scurfy. In cancer of the stomach and intestines the patients usually suffer from a profuse salivary flow without apparent cause. Constipa- tion is the rule (Bartholow). In cancer of the rectum, hard nodular masses may be felt. Prognosis. — Is always unfavorable. A fatal termination will be reached in a year or two. Treatment. — The treatment is only palliative. The pain must be relieved by morphine, hypodermically. The diet should consist of milk, nutritive broths, eggs, etc. Arsenic may relieve the pain and retard the growth (Bartholow). The formation of an artificial anus is a surgical means of prolonging life. 98 A COMPENDIUM OF PRACTICAL MEDICINE. CARCINOMA OF THE LIVER. Cancer of the liver may be either primary or secondary. It is secondary to cancer of the stomach in one-half of the cases. It has been estimated that one out of every one hundred persons has cancer of the liver (Loomis). Cause. — The cause is unknown. Hereditary predisposition exists in most cases. It occurs most often between the ages of 40 and 65. Medullary cancer of the liver sometimes occurs in early life. Symptoms. — The patient gradually loses ilesh and strength, complains of a sense of weight and fullness in the region of the liver. The pain soon becomes lancinating, and is localized at some point over the liver, which is tender to pressure. There is loss of appetite, flatulence, nausea, vomiting. Jaundice is pres- ent in one-half of the cases. Ascites occurs more frequently than jaundice. (Edema of the feet comes on late. The temperature is normal or sub -normal. Palpation discloses an enlarged liver, tender to pressure, with hard, smooth nodules over its surface (Loomis). Prognosis. — Cancer of the liver is a fatal disease. The aver- age duration is about one year (Loomis). Treatment. — Is palliative. Regulate the diet. Relieve the pain by a hypodermic of inoiqjhine. There is no remedy for cancer in any situation. Ascites will require attention by tap- ping. CARCINOMA OF THE KIDNEY. Cancer of the kidney may be primary or secondary. Causes. — The cause is obscure. It occurs in early life, be- fore five, and in old age. Symptoms. —There is gradual emaciation, soreness in the lumbar region, and hgematuria. Prognosis. — The prognosis is always bad. The termination is invariably death. Treatment. — Is palliative. Relieve the pain and sustain the patient. CARCINOMA CARIES. 99 CARCINOMA OF THE LUNG. Cancer of the lung is usually secondary, and very often suc- ceeds to cancer of the breast removed by amputation. It may be primary, but rarely so. It is a disease of advanced life and is extremely rare before forty (Bartholow). Cause. — The cause is obscure. Hereditary predisposition is a most influential factor. Symptoms. — There is usually pain in the chest and a cough accompanied by a muco -hemorrhagic expectoration resembling currant jelly (Loomis). There is dyspnoea, emaciation, fever r night- sweats, with failure of strength, and haemoptysis. Prognosis. — Is always unfavorable. Treatment. — Is altogether palliative, and is restricted to the relief of symptoms. CARCINOMA IN OTHER ORGANS. Cancer of the arteries, brain, gall-bladder, heart, tongue, larynx, oesophagus, mediastinum, pancreas, pericardium, plura, and spleen is met with. In some cases it* is primary, in others secondary. The cause is obscure. The prominent symptoms are pain, the cancerous cachexia, and a tumor. The prognosis is unfavorable, and the treatment is only palliative. CARIES. Is inflammation and ulceration of bone; while necrosis is its death en masse. Bones of spongy texture are more frequently attacked by caries than such as are compact. The bones of young persons are more often the seat of caries than those of old subjects. On examination, the bone is found to be soft and dark red; its cells are filled with a reddish, serous, glary fluid, or with soft granulations of feeble vitality. It is always vascular and readily bleeds on being touched. It is occasionally painful. Causes. — The predisposing cause is some constitutional dis- order, scrofula, or syphilis. The exciting cause may be a blow or injury. 100 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — Correct the constitutional disorder and give tonics, fresh air and baths. The usual remedies employed in scrofula and syphilis are indicated. Locally, the best treatment. is to freely expose and remove the diseased portion of bone. PRESCRIPTIONS FOR CARIES. B Cupri sulphatis Zinci sulphatis aa partes xv. Liquoris plumbi subacetatis partes xxx. Aceti partes CC. — M. Sig. : To be injecd through the sinuses. — Villate.. B Syrupi calcis lactophosphatis ^viij. Sig.: A dessertspoonful to a tablespoonful three times daily. — Bartholow. Cod-liver oil should be given to promote constructive meta- morphosis (Bartholow). CARBUNCLE. (See Anthrax). CATARRH (Nasal, called, also, Coryza). Is a catarrhal inflammation of the nasal mucous membrane- It is commonly called "cold in the head." Causes. — Atmospherical causes are the most frequent and influential. The exposure of the neck to a current of cold air, of the feet L and ankles to cold and dampness, passing from a warm to a cold atmosphere, and from a cold to a warm atmos- phere suddenly, are among the most usual causes. Irritating gases and vapors or dust may cause coryza. Epidemic influence now and then prevails on an extensive scale (Bartholow). Symptoms. — Taking cold in the head is announced by chilli- ness, weariness, headache, and general muscular soreness. An intense hyperemia is the first change, with an arrest of secretion.. This is soon followed by swelling of the membrane, and the nose feels dry, stuffed and uncomfortable, and an inclination to sneeze is often felt. Presently the nose pours out an abundant watery and saline discharge. The discharge soon assumes a purulent character. The voice has a nasal tone. The acute ]STASAL AND FAUCIAL CATARRH. 101 form terminates in fourteen days. The chronic may last for years. The discharge of the chronic form consists of greenish, offensive pus, or scales. If the mucous membrane is destroyed ~by ulcerations, and caries of the bone has occurred, the case is then called ozsena (Bartholow). Treatment. — Where there is a strumous diathesis cod-liver oil. the phosphates, iodide of iron, etc., should be employed. Try to abort an acute attack by the administration of a full dose of quinine (gr. xv.) and morphine (gr. ss.) for an adult. When established, the best remedy is Lugol's solution, liquor iodi com- positus, one drop every hour or two. If there is fever, one drop of tincture of aconite root every hour will prove efficient. If the secretion is watery and profuse, tincture of belladonna may be given with the aconite, two drops every two hours. In the local treatment of chronic catarrh, the post -nasal syringe and tepid water containing a little common salt are the best materials for cleansing the passage. The tincture of iodine and carbolic acid may be readily volatilized and inhaled from a small bottle. A cocaine tablet containing gr. i~i in the form of a flattened disc, introduced alongside the septum, one on each side, twice or three times daily, is more successful. Very dilute solutions of chlorate of potassa, chloride of ammonium, sulphates of zinc, cadmium and copper, and acetate of lead, may be tried (Bartholow). According to Bartholow, the most effective application is a powder composed of tannin and iodoform (5i.-gr. x.) applied by means of an insufflator. DobelFs is an efficacious cleansing solution in chronic nasal catarrh, hypertrophic nasal catarrh, atropic nasal catarrh, and fetid nasal catarrh (ozsena). PRESCRIPTIONS FOR NASAL AND FAUCIAL CATARRH, J& Cocaine muriate gr. vj Bismuthi subcarbonatis 5ss. Talc 5iss. — M. Sig. : Enough to cover a silver five cent piece, insufflated into each nostril every two hours. (For acute coryza). — Sajous. {fc Tincture aconiti radicis , .3J . Tincturse Belladonna3 gij . — M. Sig.: Three drops every hour. (Pharyngitis and acute ton- silitis). — Ringer. 102 A COMPENDIUM OF PRACTICAL MEDICINE. j& Chloroformi 3ij. Glycerinse Spiritus vini galici aa Sj. — M. Sig. : One teaspoonful in water every three hours. (For acute coryza). — Sajous. {& Acidi carbolici liq IUxxx. Sodii biboratis Sodii bicarbonatis aa 3j • Glycerinae oiiiss. Aquae q. s., ad., ft Siv. — M. Sig.: To be used with atomizer. (Simple chronic rhinitis). — Dobell. Jfcr Sodii bicarbonatis Sj. Sig.: Insufflate or apply with the finger to the inflamed tonsil. (Tonsilitis.) — Gine. Jfc Resorcin gr. v.-x. Aquas destillatse Sij . — M. Sig. : Used with atomizer twice daily, four minutes each time. — Masini and Maseei. CATARRH. ( Chronic Gastric.) Causes. — In many persons there is an hereditary tendency after middle life, to chronic gastric catarrh. The principal gen- eral cause of this affection is angemia. The most common local cause is the daily use of alcoholic stimulants. Diseases of the liver, heart and lungs which offer an obstacle to the venous return, will induce chronic gastric catarrh. Highly- seasoned foods, condiments, sauces, hasty and insufficient mastication, the frequent use of ices, and overfeeding are the principal causes. The prolonged use of arsenic, mercury, cubebs and purgatives often causes it. Finally, scrofula, syphilis and gout predispose to it (Bartholow and Loomis). Symptoms. — After taking food, the patient has a feeling of weight, or fullness, sometimes of pain. Sometimes when the stomach is empty, sometimes when it is full, the pain is greater. The symptoms of indigestion are usually present. There may be loss of appetite, nausea, vomiting of acid mucous in the morning or after meals. It is this acid material belched up into the oesophagus that causes "heart-burn." There is gaseous disten- CATARRH. 103 tioii of the stomach. Palpitation, headache, and vertigo may be present. Treatment. — Begulation of the diet is the most important in all stomach diseases. When the starches, sugars and fats reach the stomach, fermentation begins. To exclude these articles, then, is the first step toward a cure. A curative measure of the highest importance is the " skim-milk cure," which consists in the exclusive use of milk, about four ounces every three hours, for some time. The stomach pump is very effective for cleansing the stomach in these cases. One or two drops of Fowler's solu- tion, three times daily before meals, continued for a month or more, is a remedy of the highest importance. When there is much acidity it may be checked by muriatic acid given before meals. Carbolic acid alone or with bismuth relieves the fermen- tation and gaseous eructations (Bartholow). PRESCRIPTIONS FOR CHRONIC GASTRIC CATARRH, {fc Liquoris potassii arsenitis 5ss. Sig. : One or two drops before meals. (Vomiting of drunkards.) — Bartholow. J& Extracti hyclrastis fluidi Sss. Sig. : Five to fifteen drops before meals in water, to be continued some time. — Bartholow. {& Tinctura:- cinchonse comp ,..5iv. Tincturae capsici 5ss. Tincturae mucis vomicae 5ij- — M. Sig.: A teaspoonful every two or three hours. (To allay the craving for alcohol.) — Loomis. {t Tincturae opii dedoratae gtt. xvj. Bismuth i subnitratis 3.ij. Syrupi simplicis 5iv. Aquae cinnamomi 5iss. — M. Sig.: Shake bottle. Give one teaspoonful every two to four hours. (For child one year old.) — J. Lewis Smith. 104 A COMPENDIUM OF PRACTICAL MEDICINE. CHANCRE. I. Induration of Syphilitic Chancre. — Can always be felt when present, and in well marked cases it is absolutely pathogno- monic. It exists in three varieties : 1. A thin superficial layer of induration, aptly called "parchment-like," exactly underlying the ulceration. This is the commonest form. 2. The induration may resemble a split pea, situated exactly beneath the ulcer, which is upon its flat surface. This induration is easily felt, is little or not at all sensitive, freely movable over the parts beneath, hard like bone or wood, feels elastic, is sharply defined, ends abruptly. 3. The induration may be very extensive, far surpassing the bounds of the ulceration placed upon it, exca- vated or convex upon its surface. The skin over it is not usually red. Induration is usually greatest in chancres of the skin, lips, nipples, behind the corona glandis, and near the frgenum of the penis. In spongy tissue like the glans penis, the induration is often very slight. Again, when a syphilitic chancre becomes phagedenic, it loses its induration at once. The induration may precede the ulceration or follow it. In the latter case it comes on during the first week. Usually any form of induration will outlast the ulceration, remaining for two or three months, or more rarely for years. Bicord records one case of thirty years standing (Keyes). II. Ulceration of Syphilitic Chancre. — Properly, syphi- litic chancre does not ulcerate. It consists, in more than half the cases, simply of an excoriated surface, looking red and bloody, very superficial, frequently scabbed when exposed to the air. Indeed, it may never even excoriate, the lesion consisting in a simple indurated tubercle, which scales off a little at the top. But chancre of the genitals rarely escapes more or less inflam- mation, hence it is the rule to find some shallow, occasionally deep, ulceration. When shallow, the ulcer is round or oval, with slanting borders, often a red base. When deep, the borders are never abrupt, as in chancroid, but always sloped off. The cavity is funnel-shaped. Sometimes the induration left behind on the healing of a chancre re-ulcerates (Keyes). CHANCRE. 105 III. Character of the Discharge. — Pus does not form as such on true syphilitic chancre, unless it be inflamed. Ordinarily the discharge is sero- purulent or purely serous, often bloody (Keyes). IV. Pain. — In unirritated syphilitic chancre, as a rule, there is absolutely no pain. A patient often carries a chancre some time without knowing it, and sometimes it comes and goes without being discovered at all. In this way may be explained many singular cases of undoubted syphilis, apparently not pre- ceded by any primary lesion (Keyes). V. Cicatrix. — The scar left by chancre varies. In a number of cases, there is no scar left behind. The scars left are at first discolored, of a dark, vinous hue, like the color of raw ham. This color may be followed by the true copper- colored. The scar is finally whiter in the center than the surrounding skin (Keyes). VI. Inoculation. — Auto-inoculations of chancre -secretion have been performed without number, the result having been invariably negative, unless the chancre had been previously irri- tated, or producing pus. Under such circumstances, the pustule and ulceration produced would be the same as the pus of any indifferent abscess would cause. The difference between the inoculation of chancroid and syphilitic chancre is illustrated in the famous case of Lindmann, who inoculated himself a number of times with chancroid pus, always with success, but with no syphilis; finally, believing himself protected (/. <*., syphilized), he inoculated himself with matter taken from the ulcerated tonsils of a syphilitic friend. This was followed on the eleventh day by a papule. The papule ulcerated slightly, and in forty- five days a general syphilitic eruption aj3peared. Lindmann inoculated himself twenty- seven hundred times with chancroid matter. Warnery, under the same "syphilization" delusion, inoculated himself many times with chancroid matter, which took, but produced only local ulcers. Finally he employed the syphilitic virus once, and an indurated chancre appeared, after twenty-seven days incubation, followed by syphilis in due course. Danielssen, a believer in " syphilization," inoculated a man, who had elephantiasis, two hundred and eighty-seven times with 106 A COMPENDIUM OF PRACTICAL MEDICINE. chancroid; after this it would not take (i. e., he was " syphil- ized"). Now, one inoculation was made with true syphilitic virus. An indurated syphilitic chancre appeared, and in sixty- eight days a general syphilitic eruption followed (Keyes). The course of syphilitic chancre observed by hetero- inoculation is as follows : u There may be a pustule which soon heals. No change occurs for a period varying from ten to thirty- nine clays; then the first signs of chancre appear, not as in chancroid by a pustule, but as an indurated papule of a dark color without pain, followed by syphilis. There is one source of error in regard to vaccinal syphilis ; namely, that the vaccinal fever may develop latent, possibly un- suspected syphilis from which a child is already suffering by inheritance, or previous contagion. Here the vaccination will always be accused of being the cause of syphilis. The distinc- tion is easy. If vaccination develops latent syphilis, it does so as a blister would, and a general eruption comes on quickly; whereas in true vaccinal syphilis, there is first a period of incuba- tion, then a local chancre, then indurated glands, and after a second incubation, a general syphilitic eruption (Keyes). VII. Duration of Syphilitic Chancre. — Is from two weeks to several months. In about fifty per cent, of the cases a general syphilitic eruption appears before the chancre has cicatrized. VIII. Number. — Syphilitic chancre is most often unique, because commonly only one point is inoculated. When multiple, however, it is usually so from the first, because its secretion is not auto-inoculable. IX. Size. — Syphilitic chancre may occasionally reach a large size, as large as a quarter or a half dollar. This is, how- ever, exceedingly rare. It is often as small as a split pea and sometimes smaller. In size and general appearance it compares unfavorably with its more formidable-looking rival, chancroid. X. Situation. — Syphilitic chancre occurs indifferently on all points of the body. No regions are exempt from it. Syph- ilitic chancres of the head, face and breast are common, and reach their full size. Chancre of the lip is particularly prominent, large, hard, and chronic in its course. The genitals are the favorite seat, because they are most often exposed. Urethral CHANCRE. 107 chancre is not very common. It may simulate gonorrhoea in its discharge, but when the eruption appears, the diagnosis will he easy. XI. Form of Syphilitic Chcmcre. — Syphilitic chancre appears after an incubation of not less than ten days, usually not till the end of three weeks, as a reddened spot, which quickly excoriates ; or as an elevated papule, which excoriates or ulcer- ates. It may take any one of four forms, in the following order of frequency: 1. Erosion. 2. Ulceration. 3. Deep ulceration, funnel shaped (Hunterian chancre). 4. Indurated papule, which remains dry. Erosion is believed to include two -thirds of all syphilitic chancres. It is very common inside of the prepuce. It discharges serum and not pus. The indurated papule, which does not ulcerate, is found sometimes on the skin after inocula- tion, and even on the mucous layer of the prepuce. The color of these papules is a dark vinous red. The course of all the above chancres is about the same. Chancre uninilamed and unirritated is painless (Keyes). XII Complications of SyphiUtie Chancre: Are (#) veg- etations; (b) inf animation; (c) chancroid, mixed chancre; (77) transformation into mucous patch; ( urethritis, pyelitis, and pelvic cellulitis may cause cystitis. Ureth- ral stricture, paralysis of the bladder, gout and some forms of kidney disease- are accompanied by chronic cystitis (Loomis). Symptoms, — Acute cystitis is always accompanied by fre- quent micturition, only a few drops being voided at each attempt. After its passage the patient strains to pass more. There are dull aching pains over the pubis; sometimes the pains in the vesical region are agonizing, and there is a constant burn- ing sensation along the urethra. The urine is cloudy, deposits mucus on standing, is alkaline, and sometimes fetid. Acute cystitis lasts about one week. Chronic cystitis is often only indicated by a frequent desire to pass urine. Usually there is a constant, dull, aching pain, or a sense of weakness over the bladder. Only a small quantity of urine is passed with each act (Loomis). Treatment. — In acute cystitis, the patient must have perfect rest. Warm hip-baths give relief. Rectal injections of opium and belladonna are always indicated, with large poultices and very r hot fomentations over the bladder. The bowels should be kept free. For the pain, chlorodyne is the best. Twenty minims of liquor potassae in mucilage may be given three times in twenty-four hours. In chronic cystitis, the catheter is to be reg- ularly and persistently used. The bladder should be washed out with weak solutions of borax. Very weak solutions of salicylic acid, carbolic acid, permanganate of potash, and chloride of sodium are also recommended. The daily use of mineral water, like Vichy, is beneficial. Drachm doses after each meal of the " Lafayette mixture" are very serviceable. 132 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR CYSTITIS. B Bals. copab Spts. etheris nitros — aa gss. Liquor potassse 3j . Mucilag. acacise ad giv. — M. — "Lafayette Mixture."' All stimulating drinks are forbidden (Loomis). R Atropine sulphatis gr. j. Acidi acetici gtt. xx. Aicoholis Aquse — aa 5ss.— M. Sig. : Four drops in a wineglassful of water before each meaL (In acute cystitis.) — Good ell. R Extracti tritici fluidi Syrupi amygdalae — aa 3ij- — M. Sig.: A dessertspoonful in water five or six times daily. (In chronic cystitis.) —Thompson. B Potassii citratis Sss. Spiritus chloroformi Siiss. Tincturse digitalis ZHLxxx. Infusi buchu S viij . — M. Sig. : Two tablespoonsful three or four times daily. — FothergilL CANCRUM ORIS. Called also gangrene of the month, noma, aqneons cancer of infants, is a disease of childhood occurring between two and six years. The point of attack, which is most frequently the inside of the cheek, becomes inflamed, thickened and indurated, then a purple hue appears, followed by sloughing and gangrene (J. L. Smith). Causes. — This is a very rare disease. It occurs in debilitated and cachectic children, and in those recovering from acute dis- eases, such as scarlet fever (Loomis). Symptoms. — It commences with pain in the mouth, an ab- normal quantity of saliva, and offensive breath. Finally an ulcer appears, with a dark, ashy- brown colored slough. It may perforate the cheek. Prognosis. — Nineteen out of twenty die (Loomis). CARDIALGIA CATALEPSY. 133 Treatment.— Nitrate of silver, and even strong nitric acid, should be applied to the slongh, and the month washed with solutions of carbolic acid and chlorate of potash. The best internal remedies are quinine, hydrochloric acid and stimulants (Loomis). CARDIALQIA. Signifies pain at the cardiac orifice of the stomach of a burn- ing character and shooting into the chest, and up the oesophagus into the throat. It is vulgarly called heartburn. Everyone has occasionally experienced this symptom. It characterizes certain cases of indigestion, and it is evidently dependent on the presence of an acid in the stomach, as it is quickly and completely re- lieved for a time by an alkaline remedy, such as lime-water, liquor potassse, bicarbonate of soda and magnesia. CATALEPSY. Is a functional disease of the nervous system, closely allied to hysteria and epilepsy. It is characterized by loss of conscious- ness, sensation and volition, accompanied by a peculiar muscular rigidity in which the limbs remain for some time in whatever position they are placed (Loomis). Causes. — Catalepsy may occur at any age, but it is more common in females about the age of puberty. It may precede melancholia and epilepsy. Traumatism, strong emotions, fright, shock, and religious excitement may induce an attack (Loomis). Symptoms. — Catalepsy occurs in parox} T sms. Consciousness is suddenly lost, and the limbs are as rigid as if petrified. The face has a death-like appearance. The skin is cold and temper- ature is sub-normal. The attack may last a few minutes, several hours, or for days. Prognosis. — As a rule, favorable (Loomis). Treatment. — An emetic will generally cut short an attack. The faradic current may be employed to arouse the patient. Morphine may stop the paroxysm, given hypodermically. Asa- fcetida, valerian, camphor and turpentine may be given. 134 A COMPENDIUM OF PRACTICAL MEDICINE. CEPHALALGIA. (See Headache). CEREBROSPINAL MENINGITIS. Called also spotted, petechial and congestive fever, is an in- flammatory affection of the arachnoid and pia mater of both the brain and spinal cord. Causes. — Epidemics have occurred at all seasons, but more often in cold weather. It is most likely to attack those between ten and eighteen years of age. Cold, damp and overcrowded houses predispose to it. The real cause is not known (Loomis). Symptoms. — In some cases the patient is suddenly seized with a chill, loss of consciousness, becomes comatose, and dies in a few hours. Headache in most cases is prominent, and even in a condition of coma, causes the patient to groan. Pain in the back and upper part of the spine is a characteristic symptom of the disease. Attempts to flex the head on the chest increase the pain, and pressure against the back of the neck often induces excruciating agony. Soon the muscles at the back of the neck become stiff, and the head extended (opisthotonos). Attempts to swallow are painful. The temperature, as a rule, is low. The pulse is from 120 to 150. The pupils are often unequal in size. The face is pale and anxious, and has a dusky hue. Delirium comes on. The pains are shooting and lancinating in character. The eruption is usually limited to the face, neck and lips; it is herpetic in character. There is photophobia. Prognosis. — Unfavorable. From 30 to 80 per cent. die. Treatment. — The patient should be put to bed in a dark, cool, well -ventilated room, away from noise. The diet should be milk. Opium, bromide of potassium, quinine, and ergot in proper doses are useful. Cold applications to the head, mustard foot-baths, and mustard to back of neck are serviceable. PRESCRIPTIONS FOR CEREBROSPINAL MENINGITIS. R Morphias sulphatis gr. ss. Acidi sulphurici aromat 3j. Elixir einchonse ad ,^vj — M. Sig. : A teaspoonful every two hours for a child twelve years old. — Meigs and Pepper. CEREBRO- SPINAL MENINGITIS — CIRCUMCISION. 135 R Acidi hydrocyanici dilati Wi. xx-xl. Sodii bicarbonatis gi iss. Sy rupi simplicis Aquse aa q. s., ad giiss. — M. Sig. : A teaspoonful every three or four hours for severe vomit- ing. — Delafield. R Hydrargyri chloridi mitis Pulveris j alapae Sacchari albi aa. 3j . — M. In pulv. no. x. div. Sig. : A powder every hour until free purgation occurs. — Robert. CHICKEN=POX. (See Varicella.) CHIN=COUGH. (See Whooping- cough.) CIRCUMCISION. Was instituted as a religious rite by Abraham, about 2,000 years before Christ. Several Eastern nations still practice it as a hygienic measure. The chosen people preserve the custom as a religious ceremony, performing it on the eighth day. Operation. — Mark off with an aniline pencil the limits of the integument which it is proposed to remove. This line should follow the curve of the corona glandis at a short distance in front of it. Now seize the redundant prepuce with the forceps so that the aniline line shall lie just in front of the closed blades, taking care not to include the glans in the grasp of the forceps. With scissors cut off the outer portion. After the forceps has been removed, the inner layer of the prepuce is to be slit down to the corona upon the dorsum of the glans and the entire mucous membrane to be trimmed away on either side up to the frenum, leaving only enough tissue to serve to hold the sutures. Primary union seems always to occur. In the infant no suture is re- quired. The parts coapt naturally, and healing is accomplished usually in about forty-eight hours. In the adult, horse hair lias proved the best material with which to suture the cut edges. The first suture should be applied at the raphe. The ends of the suture are to be cut off about an inch long, to prevent the wound 136 A COMPENDIUM OF PRACTICAL MEDICINE. from rolling in during the swelling of the first two days. It heals in from four to eight days. An opiate for sleep and a lax- ative are the only medicines usually required (Keyes). COMA. Is complete loss of consciousness, and there is the appear- ance of the profoundest sleep. The face wears a confused look; the pupils are sluggish, often dilated ; the mouth is open, the tongue dry. Sensation may be blunted, but is not destroyed ; nor is motion, for the patient moves when his skin is pinched or tickled. Coma always betokens a serious disturbance of the functions of the brain (DaCosta). Causes. — The cranial causes are : Hyperemia, anaemia, oedema, compression, tumors, thrombosis, embolism, apoplexy, abscess, softenings, shock, and concussion. The most thorough coma is seen in apoplexy; it comes on quickly, and is attended with a noisy respiration and a slow pulse. The extra cranial causes are : Hysteria, epilepsy, uraemia, cholaemia, poisons of drugs, narcotics and anaesthetics, anti-spasmodics, alcohol, poisons of fevers, malaria, etc. (Loomis). Treatment. — Discover and treat the cause. CORNS. Are small callous thickenings of the skin, especially on the toes, the result of occasional pressure. Dr. Sayre writes that a corn is infinitely more painful than a cancer, and is capable of inflicting torment and agony sufficient to destroy the sweetest disposition, and upset the best regulated families. There are two varieties of corns, the hard and the soft. The soft corn is found between the toes, is exceedingly tender, and is liable to become inflamed. The hard corn has a hard, white core in the centre. The irritation produced by pressure upon these forma- tions may give rise to reflex muscular contractions which will draw the toes up. Treatment. — Shoes must be worn which will permit expan- sion of the foot. Pare the corn as much as possible without drawing blood. Then rub the surface with solid stick of nitrate COLD EEET COUGH. 137 of silver, and in a few clays another layer will come off. Now surround the corn with narrow strips of adhesive plaster to pro- tect it from pressure. To the soft corn apply concentrated nitric acid or the solid stick of nitrate of silver, and place a pledget of cotton between the toes. In a few days the hardened mass will come away. Glacial acetic acid, and carbolic acid, are good applications. According to Bartholow, no application is so cer- tain, prompt and effective, for the cure of corns, as liquor potas- sae. It should be applied by means of a glass rod to the summit of the corn and the tissue softened by it scraped off. By suc- cessive applications the callosity is removed without pain or dis- comfort. COLD FEET. Many persons, especially women, are troubled with cold feet, particularly at night; so cold, indeed, as to effectually pre- vent sleep for hours. This condition, which may rank as a dis- tinct ailment, is best treated by immersing the feet nightly for a few minutes in cold water, rubbing them whilst in the foot-bath diligently until they become warm and glowing, and then, after thorough drying, clothing them in thick, over -large woolen or "fleecy hosiery " socks. The feet may be sponged first with water as hot as can be borne, and then for a few seconds with a sponge wrung out of cold water (Ringer). Dr. Chapman asserts that the ice-bag, applied along the lower dorsal and lumbar ver- tebrae, by increasing the flow of blood to the legs, proves very comfortable to persons harassed with cold feet; and he has often seen the feet become comfortably warm a few minutes after the application of ice. According to Dr. Anstie, strychnia promotes capillary circulation, and he recommends it in troublesome cold- ness of the feet and hands. COUGH. Is a sudden and violent expiration, having usually for its object the expulsion of some annoying substance from the air passages. But it may be purely nervous. A nervous cough sometimes occurs in children and in chlorotic girls. The cough is usually in paroxysms, has a peculiar barking tone and resem- 138 A COMPENDIUM OF PRACTICAL MEDICINE. bles whooping cough. It is short, painless, and without expec- toration. Causes. — In children, it may result from diseases of the brain, from dentition, from worms, and spinal irritation. In others, anaemia, hysteria and nervous excitement may be the cause. It may be induced by involuntary imitation. A school for girls was suspended on account of the large number of cases (Flint and Smith). Treatment. — Tonic remedies, a nutritious diet, out- door life, quinia and small doses of strychnia are useful. No remedy is so useful in ordinary cases as iron. Dr. Cameron used the follow- ing prescrirjtion : R Ferri subsulphatis £ss. Acidi nitrici 3ss. Aquae destillatse , , , , , ^ss. — M. Sig. : Three drops four times daily in sweetened water. R Tincturse belladonnas gtt. xxxij. Potassii bromidi Ammonii bromidi — aa 3J . Syrupi simplicis ^ij. — M. Sig.: One teaspoonful three times daily. (For a child three years.) — J. L. Smith. There are several kinds of cough ; according to the amount of expectoration, a cough is dry or moist ; according to its ori- gin, it is laryngeal, tracheal, bronchial, sympathetic, etc. A dry cough is indicative of irritation either in the larynx, trachea, bronchi, or in the lung substance. An elongated uvula, pleurisy, and the earlier stages of phthisis may give rise to a dry cough. But the irritation may not be situated at all in the respiratory system. Affections of the liver, stomach, intestine, uterus or brain will occasion an obstinate dry cough. Cough is frequently preceded by a sensation of tickling in the larynx. Lying down often increases its intensity. PRESCRIPTIONS FOR COUGH. R Misturae asafoetida 3iv. Ammonii muriatis gj. — M. Sig. : A tablespoonful as necessary. (For sympathetic and cough maintained by habit.) — Bartholow. COUGH. 139 R Chloral hydratis Camphorse — aa §ss. — M. Triturate in a mortar till a clear fluid is formed. Sig.: Paint with a camel's hair brush over the larynx to allay spasmodic cough. — Bartholow. R Extracti gelsemii fluidi giij. Sig. : Three to five drops in water every two hours until droop- ing of the eyelids and dilation of the pupil takes place. (For nervous, spasmodic, reflex and irritative cough.) — Bartholow. R Acidi hydrocyanici diluti 3j. Tincturse sanguinarise giv. Syrupi senega? ^ss. Syrupi tolutan £ij . Aquae lauro-cerasi 5vij — M. Sig. : One or two teaspoonsful, according to age, every three or four hours. (For irritable, nervous, and cough by habit.) — Bartholow. Syrup of wild cherry and syrup of lactucarium are excellent vehicles for cough mixtures. R Aluminis 3j. Aquas §vj. — M. Sig.: Use in the form of a spray for chronic coughs and hoarse- ness. — Ringer. ■o v R Chloroformi gj . Morphia sulph gr. iss. Glycerinse §ij . — M. Sig. : A teaspoonful when cough is troublesome. t> Olei morrhuse O.j. Sig. : A teaspoonful three times daily, for a while, then increase to tablespoonful. (For chronic cough.) A drop of pure beech -wood creosote may be given with the cod-liver oil. A teaspoonful of glycerine added to water or a little lemon - juice, is often useful in coughs, even the cough of phthisis. This dose, taken at night, often lessens morning cough (Ringer). Glycerine of tannin is a very useful application to the throat when chronically inflamed and so productive of cough, which is often the case in children. 140 A COMPENDIUM OF PRACTICAL MEDICINE. The tincture of iodine may be used as an inhalation in the chronic forms of phthisis to allay the troublesome cough; and as an inhalation for children with hoarse, hollow cough, accompanied by hoarseness and wheezing at the chest. Use as follows : Pour twenty to thirty drops of the tincture of iodine in a half or a pint of boiling water; then direct the patient to put his face over the mouth of the vessel and breathe the iodized steam for five or ten minutes night and morning with the head covered with a towel to prevent escape of the steam (Ringer). According to Rummo a four per cent, solution of iodoform in spirits of turpentine, used as an inhalation or spray, will diminish the cough of phthisis and chronic bronchial catarrh. According to Ringer, in the obstinate winter cough with difficult breathing and wheezing, the wine of ipecac applied as a spray to the fauces once or twice daily is very efficacious. The wine may be used pure or diluted. COMEDONES.— (See Acne.) CYSTS. Are developed in many ways : some are possibly new growths, some are formed in an accidental way by simple effu- sion of fluid into connective tissue, and others are produced by a dilatation of occluded ducts, or natural gland orifices, the cysts enlarging by the secretion of the ducts or gland contents. Of these the mucous cysts of the mouth and vagina, the sebaceous cysts of the skin, and the milk cysts of the breasts are the best examples (Bryant). Varieties. — Serous cysts, mucous cysts, sebaceous cysts, oil cysts and dermoid cysts. Serous Cysts are most commonly found connected with the kidney, ovary, thyroid or breast. They are sometimes seen in the neck. They contain a limpid, watery fluid, and, are painless. Treatment. — It is dangerous to tap or extirpate a cervical cyst. Let it alone. Mucous Cysts are found wherever mucous glands exist, and are caused by some obstruction to the escape of the gland con- tents. They are found on the lips, within the cheeks, on the CALCIFICATION CHLOASMA. 141 tongue and gums, and beneath the tongue when they are called ranida. They contain a thick ropy fluid. Treatment. — They may be excised, or their walls cut into. Sebaceous Cysts appear as congenital and acquired tumors. Some are caused by obstruction to the orifice of the sebaceous glands. The congenital sebaceous cyst is deeply placed, and is more common about the orbit and brow. They contain a whitish or yellowish liquid secretion and sometimes hair. The acquired sebaceous cyst may be found on any part of the body, but it is more common on the head and face. When on the scalp, they are known as wens. Treatment. — The only correct treatment is their removal. Dermoid Cysts are frequently met with situated deeply be- neath the skin and muscle. They are congenital, filled with sebaceous matter, and often contain hair. Treatment. — They should be dissected out. Oil Cysts are met with but rarely, and are probably always dermoid. CALCIFICATION. Called, also, calcareous degeneration, or cretefaction, is an infiltration of the tissues with the phosphate and carbonate of lime. Calcified tissues are recognized by their hard, sometimes stony consistence. Tissues which have undergone fatty degen- eration are especially prone to calcification. In the vast majority of cases of calcification, the lime is deposited in tissue previously diseased. Of great practical importance is the calcification of the cardiac valves in chronic endocarditis, and of the internal and middle coats of the arteries in old age (Flint). Removing tumors from the pelvic or abdominal cavity, when the tissues and arteries are calcified, gives rise to troublesome or even fatal hemorrhage. CHLOASMA. Is a diffuse form of excessive pigmentation. It is most fre- quently met with in women during pregnancy, and also in un- married females between the ages of thirty and the cessation of the menses, as a result of disordered menstruation, and of (lis- 142 A COMPENDIUM OF PRACTICAL MEDICINE. eases of the sexual organs. It has the appearance of a dirty yellow or brown discoloration, generally implicating the face, and often extending across the forehead from temple to temple, and from near the eye -brows to near the roots of the hair. Treatment. — Careful attention must be paid to the general health and sexual organs. The local treatment is most import- ant. Some local applications, such as mustard, cantharides, and croton oil, are apt to be succeeded by new epidermis which is more deeply pigmented than that which it has replaced, and are, therefore, to be avoided; while others, such as perchloride of mercury solutions, have exactly the opposite tendency. We may use a perchloride of mercury solution of the strength of iive grains in an ounce of alcohol in the following manner: Place the patient in bed and apply compresses dipped in the above solution. Moisten the compresses from time to time with the fluid without displacing them. The compresses are removed in four hours, when the skin is found to be reddened or blistered. If blistered, let out the fluid and dust the surface with starch powder. CRAMP. In writers' cramp, the flexor muscles of the thumb and fingers become rigidly contracted. Pianists, violinists, printers, tailors, etc., are sometimes similarly affected. In the treatment of writers' cramp and allied affections, discontinuance of acts which occasion the spasm is essential. Galvanism is most useful. It seems to be a central, not a peripheral affection. Some persons are liable to suffer much from cramp of the muscles of the leg or feet, occurring especially at night. Bardsley's treatment con- sists in sleeping on an inclined plane, the bed being twelve inches higher at the head than at the foot. Galvanism is very effective in these cases (Flint). Cramp may occur in any muscle. Occasionally the stomach is the seat of cramps, and causes great pain, and ejection of food. Galvanism seems to be more effective than other forms of treat- ment. CIREHOSIS DEBILITY. 143 CIRRHOSIS. (Of Liver.) Called also interstitial hepatitis, is an inflammation of the connective tissue of the liver. It has been named sclerosis of the liver, "Gin -drinkers 77 liver, "hob-nailed 77 liver, etc. Causes. — The chief cause of cirrhosis is the intemperate use of alcohol. When it is taken in a concentrated form without food, it acts as a direct irritant to the hepatic circulation. If this irritation is long continued cirrhosis is the result. Those who take alcohol before breakfast as well as through the day are almost certain to develop cirrhosis of the liver. Those who partake freely and daily of highly seasoned food, even though they may not use alcohol, are also liable to develojD cirrhosis. SyiDhilis, gout and rheumatism cause it (Loomis). Symptoms. — Dull pain and tenderness in the hepatic region, dyspnoea, apathy, headache, nausea and furred tongue, and loss of appetite, especially for meats, are the chief symptoms. There may be slight jaundice. Tympanites as well as intestinal catarrh usually precedes ascites. Before the ascites, the abdominal veins, especially of the right side, are sometimes enormously distended. Ascites is sometimes absent. The stools in cirrhosis are charac- teristic. They are clay- colored in the centre; surrounding this there is a dull pinkish ring, and around this a slate grey ring tinged with mucus. The urine is scanty and very dark colored (Loomis). Prognosis. — Unfavorable. Treatment. — All spirituous liquors must be abstained from. Nitro- muriatic acid and cod-liver oil are useful. Dilute nitric acid and columbo assist stomach digestion. Creosote and sul- phite of sodium are of service, when acid fermentation is a dis- tressing symptom. For the ascites and general dropsy, squills and digitalis are effective; but when they fail, tapping must be resorted to (Loomis). DEBILITY. Dr. Anstie highly extolled alcoholic stimulants in the debil- ity of old age, especially in the condition of sleeplessness, at- tended often with slow and ineffectual digestion and a tendency 144 A COMPENDIUM OF PRACTICAL MEDICINE. to stoinach cramps. He employs a generous and potent wine containing much ether. According to Ringer, the good old- fashioned remedy, ram or brandy and milk taken before break- fast, is useful in phthisis and in exhausting diseases, and is a good prop to town -living women who suffer from morning ex- haustion. Arsenic is useful for the swollen feet of old or weakly persons; or for old people with a weakly acting heart and feeble circulation, who often suffer from breathlessness on exertion. Cod-liver oil is useful in chronic degenerative diseases of old age. In nervous and general debility, cod-liver oil and the hypo- phosphites are highly useful. Quinia is of great benefit to pale and badly fed town dwellers. Sea bathing is recommended in chronic illness with debility. PRESCRIPTIONS FOR GENERAL AND SENILE DEBILITY. R Tincturae ferri chloridi Syrupi simplicis — aa §j. Aquae cirmamomi ^ij . — M. Sig. : A teaspoonful three times daily. — Charity Hospital. R Spiritus chloroformi ^v. Acidi hydrochlorici dil ^ijss. Infusi cinchonae .' ^xv. — M. Sig.: Two tablespoonsful three times daily. — Fothergill. R Quiniae sulphatis gr. xxx. Acidi sulphurici diluti q. s., ad. ft. sol. Aquae §ij. Tincturae ferri chloridi gss. Spiritus chloroformi 3vj . Glycerinae ^iv. — M. Sig. : A teaspoonful three times daily. — Loomis. DELIRIUM. This is a wandering of the mind, the patient muttering incoherent words. It is more common in the young and nervous than in the old. The delirium may be quiet or active. It may be brought on by acute diseases, especially fevers. DELIRIUM. 145 DELIRIUM. (Tremens.) Occurs most frequently in old topers after a severe drinking bout, or it follows the sudden withdrawal of stimulants, or an attack may be induced by some strong moral emotion or excite- ment, or by an accident or injury (Loomis). Symptoms. — The appetite is lost and even the drink is rejected. The trembling increases ; the manner grows excited and irritable. Insomnia is an early symptom. Hallucinations and illusions come on. ■ The delirium usually begins at the moment of falling asleep or in awaking. He then sees frightful objects — goblins, demons and monsters — but fully awake they vanish. This preliminary state is often called "the horrors. 11 As the case progresses the hallucinations become constant. The patient sees snakes on the wall and bed, and endeavors to escape from them. He may be noisy, furious, and dangerous. There may be illusions of smell and hearing. Delirium tremens usu- ally lasts about two weeks, by which time recovery or death will have taken place (Bartholow). Treatment. — Provide suitable aliment for the patient and try to procure sound sleep. Milk and lime-water may be given freely, to which it may be advisable to add whiskey or brandy. Egg-nog, beef-juice and other animal broths should be well for- tified with red- pepper. For securing sleep, one -fourth of a grain of morphine and fifteen grains of chloral may be given, if the heart is not weak. Bromide of potassium in full doses may be given for u the horrors. " Pilocarpine, tincture of digitalis in drachm doses, tincture of cannabis indica, and chloroform inter- nally may be used with advantage. PRESCRIPTIONS FOR DELIRIUM. jfc Potassii bromidi Sodii bromidi aa gr. xv. Chloral bydratis gr. x. Tincturse zingiberis IHx. Tinctune capsici IMv. Spiritus ammonii aromat 3J. Aquae q. s., ad gij. — M. Sig. : Dose, sij. — Starr. 146 A COMPENDIUM OF PRACTICAL MEDICINE. J& Chloral hydratis £ss. Syrupi aurantii corticis Aquae aa gss. — M. Sig. : To be taken in one dose, and repeated if necessary. — Liebreich. |& Potassii bromidi gss. Sy ru pi simplicis §j . Aquae foeniculi q. s., ad giij. — M. Sig. : Two teaspoonfuls every two hours — Ringer. ffc Potassii bromidi 3j. In pulv. no. vii. div. Sig.: A powder dissolved in one-half tumblerful of water every four to six hours (In "the horrors.") — Bartholow. DIABETES INSIPIDUS. Called, also, polyuria, hyperuresis, and polydipsia, is char- acterized by extreme thirst, and the secretion of a large quantity of colorless urine, of low specific gravity, free from sugar and albumen (Loomis). Causes. — Diabetes insipidus may occur at any age and in either sex. Disturbance of the sympathetic ganglia causes dila- tation of the capillary vessels of the kidney, and produces dia- betes. Blows on the head, injuries to the medulla and spinal cord, and violent emotions have all apparently caused its development. Drinking large quantities of ice -water when over- heated, and exposure to cold and wet, are among its supposed causes (Loomis). Bartholow gives syphiloma of the brain as the most usual cause. Symptoms. — Its chief symptom is the passage of a large quantity of limpid urine; the quantity varies from thirty to sixty pints per day. Its specific gravity ranges from 1003 to 1008; it is remarkably clear, and faintly acid. It contains no sugar or other abnormal ingredients. There is intense thirst. The skin becomes harsh and dry; and the temperature sub- normal. There may be salivation (Loomis). Prognosis. — Recovery from diabetes insipidus is rare. It may last many years. Treatment. — At all times the body should be warmly clothed, and the skin kept active. According to Bartholow, the iodides DIABETES. 147 and mercury have quickly cured cases of syphilitic origin. Jaborandi and ergotin have been successful. A course of iodide of potassium should be at first administered, and if the disease does not yield, galvanism should be tried. PRESCRIPTIONS FOR DIABETES INSIPIDUS. jfc Extracti ergotae fluidi 31J. Sig.: A teaspoonful three times daily, increased to two tea- spoonfuls. — DaCosta. Jt Auri chloridi gj. Confect. rosse gr. xx. — M. Ft. massa et in pilulas no. xx. div. Sig.: A pill after meals thrice daily. — Bartholow. Jfc Pulv. Valerianae rad 3ii-iv. In chart, no. xii. div. Sig.: A powder three times daily. — Demange. DIABETES MELLITUS. Called also glycosuria, is a chronic disease characterized by the constant presence of grape-sugar in the urine, by an increased urinary discharge, and by progressive wasting of the body. It has at various times been regarded as a disease of the kidney, alimentary canal, liver, and nervous system, but its exact path- ogeny has never been determined (Loomis). Causes. — Diabetes occurs at all ages, but is most frequent in middle life. It appears to be hereditary in some cases. Shock or concussion of the whole body, or of the brain and spinal cord, blows upon the hepatic and renal regions, mental shocks, anxiety and chagrin may cause it (Bartholow). Pregnancy, impaired digestion, and immoderate use of sugar, new wine, and alcohol have also been named as causes (Loomis). Excessive activity in the glycogenic function of the liver may so overload the blood with sugar as to cause it to appear in the urine (Loomis). Symptoms. — Diabetes may be acute and result fatally within two or three weeks from the time the increased now of urine is noticed. But it usually comes on insidiously; the patient notices for some time that he has been passing more urine than usual. 148 A COMPENDIUM OF PRACTICAL MEDICINE. and has been unusually thirsty. While his appetite is good, yet he is losing ilesh and strength; and there is an abnormal dryness of the mouth, throat and skin, with intolerable itching, followed by desquamation. There is loss of sexual desire. The tongue is red or coated ; the gums are pale, retracted and bleed easily > and the teeth become carious. There are nausea and vomiting, with constipation. The temperature, pulse-rate and respirations are below the normal. In some cases, there will be little thirst or loss of appetite and no emaciation (Loomis). The Urine. — Very rarely the amount of urine passed is but- little increased; generally it rises to twenty or fifty pints in twenty-four hours. The urine is acid, of a light straw color, without sediment. The specific gravity varies from 1030 to 1070 with an average of 1040. In rare cases a low specific gravity of 1008 or 1010 is recorded (Loomis). Prognosis. — The disease may last from a few weeks to ten or twelve years. Boils and carbuncles may complicate it (Loomis), Treatment. — Dieting is of the first importance. All sacch- arine form of food, or any article that can be converted into sugar should be avoided. Hence, starchy foods, bread, arrow- root, tapioca, sago, such vegetables as potatoes, parsnips, turnips, carrots, beans and peas, are to be absolutely avoided. Salads, greens, acids, fruits, all kinds of flesh and fowl, eggs, cheese and butter, unsweetened tea and coffee, can be taken. Baths and moderate exercise should be taken. Extract of opium, morphia, and codeia in small doses are useful. Mineral waters are given. If there is anaemia, iron, cod-liver oil, strychnia, and quinine should be given. Surgical operations should on no account be undertaken on diabetic patients. PRESCRIPTIONS FOR DIABETES MELLITUS. R Sodii salicylatis .^iv-vj. Glycerinse %j . Aquse ad Siij. — M. Sig.. Two teaspoonfuls three times daily. — DaCosta.. li Tincturse opii 3j Tiucturae ferri muriatis 3ix. — M. Sig.: Twenty drops three times daily. — Welleiv DIARRHOEA. 149 R Sodii salicylatis 3iij. Liquor potassii arsenitis 3j. Glycerinse Sj. Aquae cinnamomi ad Siij- — M. Sig. : A dessertspoonful three times daily. — J. C. Wilson. DIARRHCEA. Is the frequent discharge of fluid or semi-fluid faeces. It may Ibe acute or chronic. Varieties, — I. Irritative Diarrhoea is that form induced by improper and unseasonable food, foul water, tainted meats, and drugs. II. Symptomatic Diarrhoea is a part of the natural history of typhoid fever, intestinal ulcerations, all forms of cholera, and other diseases. Ill Mechanical Diarrhoea is that form in which the faeces are made fluid by a large amount of serum poured into the intestinal canal, by the action of Epsom and Rochelle salts. IV. Nervous Diarrhoea may be caused by fright, grief, great anxiety, and severe pain. V. Vicarious Diarrhoea, occurs when the functions of the skin, kidneys or lungs are suppressed; the flux from the bowels affords relief. Chilling the body suddenly, or intense heat, brings on a vicarious flux. VI. Fatty Diarrhoea is the result of faulty pancreatic di- gestion. VII. Colliquative Diarrhoea is a copious flux occurring in wasting diseases toward their close, e. g., phthisis, cancer and Bright's disease. VIII. Chronic Diarrhoea is always associated with some form of chronic organic disease as chronic enteritis, intestinal ulcers, syphilis, malaria, scurvy and phthisis (Loomis). Prognosis. — Depends on the cause. In fatty diarrhoea 50 per cent die. Treatment. — Depends on the causes which produce it. If it depends on undigested food, a full dose of castor oil, or rhubarb and soda should be given. The diet should be restricted to milk and lime-water. Camphor, kino, bismuth, or dilute sulphuric 150 A COMPENDIUM OF PRACTICAL MEDICINE. acid raay be given. If there is griping, opium may be combined with the bismnth and camphor. In the treatment of chronic diarrhoea, bismuth is the most reliable drug (Loomis). PRESCRIPTIONS FOR DIARRIKEA. Jfc Spiritus lavandulae comp Sij. Tincturae opii .^ij . Tincturae rhei 3ss. Olei sassafras gtt. x. — M. Sig. : A teaspoonful after each meal. — Loomis. J£ Olei ricini ^ij . Pulveris acaciae — Pulveris sacchari aa gij. Tincturae opii Itt.xxi. Aquae cinnamomi ad ^iv. — M. Sig.: A teaspoonful every three or four hours. (For children.) —West. (fc Magnesii sulphatis Tincturae rhei Sy rupi zingiberis aa 3j • Aquae carui 5ix. — M. Sig.: A teaspoonful three times daily, to a child one year old. —West. Jfc Tincturse opii deodoratae gtt. xvi. Bismuthi subnitratis 3ij • Syrupi simplicis Sss. Misturse cretae Siss. — M. Sig.: Shake well and give teaspoonful every three hours to a child one year old. — J. L. Smith. Jfc Pulveris ipecac gr. ss. Pulveris rhei gr. ij . Sodii bicarbonatis... gr. xij. — M. In pulv. no. xii. div. Sig.: One powder every four hours to an infant one year old. (In indigestion with acidity.) — J. L. Smith. Jfcr Cretse praep 3ij. Tinct urae catechu 3 ss. Tincturae opii ITT .lxx x. Aquae cinnamomi ad 5 viij . — M. Sig. : Two tablespoonfuls after each motion. — Fothergill. DIPHTHERIA. 151 DIPHTHERIA, Is one of the most dreaded, one of the most fatal, and, un- fortunately, one of the most common maladies of childhood. It is an acute, specific, contagious disease, beginning by an infec- tion of the throat, and characterized by a local exudation, glandular enlargements, and systemic poisoning, and having for its sequelae various paralyses (Barthelow). Causes. — Diphtheria is a contagious disease, propagated by a specific poison, the form of which is not known. It may pre- vail as an epidemic, or occur sporadically. Filth, bad sewerage and drainage, overcrowding, and a general bad hygienic condi- tion favor the development and spread of diphtheria. It is first a local, then a constitutional disease. The stage of incubation usually varies from one to eight days. No age is exempt, but from the second to the fifth year is the period of greatest suscep- tibility. Previous attacks afford no immunity against subsequent ones (Loomis). Symptoms. — Are both local and constitutional. The local symptoms begin with a sensation of dryness, prickling and pain in the throat. There is hyperemia of the fauces, and on the palate or tonsils, minute grayish -white patches appear. The false membrane is sometimes dark-red or even black. There may be swelling of the glands of the neck. The Eustachian tubes, (esophagus, posterior nares, larynx, vagina, and rectum may be involved. The constitutional symptoms are chill, fever, pain in the head and back, nausea, vomiting, and even convul- sions. The temperature may be 103° or 104° F., the pulse 120 to 130. The patients condition grows worse each day. until about the end of one week, when the membrane is thrown off. The loss of tendon reflex often occurs as early as the first, sec- ond or third day. It is a symptom of diagnostic value. Dr. McDonnell made the following statement: "Knee-jerk is absent from the very first day of the illness, in many cases of diph- theria." Symptoms which indicate danger: 1. Diarrhoea may cause exhaustion. 2. Nausea and vomiting coming on late in the dis- ease. 3. Albuminuria, and coma may occur as a result of the 152 A COMPENDIUM OF PRACTICAL MEDICINE. nephritis. 4. An irregular and intermittent pnlse throughout the entire course of the disease. 5. If the temperature falls to the normal, or below, and the exudation shows no sign of ex- foliating. 6. Convulsions occurring late in the disease. Sequelae. — After the exudation disappears and convalescence is apparently established, sequelae may- develop, which may con- tinue for months, and even years. The commonest is paralysis of some of the voluntary muscles ; the muscles most frequently affected are those of the soft palate and pharynx. There is diffi- culty in swallowing and inability to articulate clearly. As the pharyngeal paralysis is disappearing — or from two to ten days after — the muscles of the lower or upper extremity may be in- volved. Before the occurrence of the paralysis there will be a sensation of coldness, pricking, crawling and numbness in the part about to be affected. There may be paralysis of any muscle. Paralysis of the heart may occur. Diphtheritic paralysis is always entirely recovered from. These paralyses may follow the mildest as well as the more severe cases. In mild cases its dura- tion is two or three weeks, while in others it has continued one or two years. Other sequels are nephritis and endocarditis (Loomis). Differential Diagnosis. — The diagnosis of diphtheria rests on the presence of a membranous exudation. Ordinary sore throat or catarrhal pharyngitis is sometimes confounded with diphtheria. Membranous croup is a local affection, while diphtheria is a con- stitutional disease. Croup is not contagious or inoculable, while diphtheria is markedly so. In croup the exudation is on the surface of the mucous membrane; in diphtheria it is in its sub- stance as well as on its surface. The submaxillary glands may be, and often are, enlarged in diphtheria, but never in croup. An erythematous eruption sometimes makes its appearance on the upper part of the chest and back in diphtheria (Loomis). Prognosis. — Death rate is from twenty to fifty per cent. Duration varies from three to fourteen days. Cases that are apparently doing well sometimes terminate very unexpectedly and suddenly by paralysis of the heart. Complications make the prognosis more unfavorable. Death may occur from diph- theritic blood-poisoning. DIPHTHERIA. 153 Treatment. — The patient should be kept in bed, and the room well ventilated, and have a temperature of 70 to 75 degrees. The patient should be kept scrupulously clean. Hot poultices should be applied externally to the throat ; steam inhalation should be constant fiom the onset of the disease, until the exuda- tion has disappeared ; iron and brandy should be given freely; and the diet should be fluid, milk preferably (Loomis). Accord- ing to Bartholow, a solution of lactic acid — strong enough to taste sour — frequently applied by means of a mop, gives excel- lent results. He also recommends highly the inhalation of the vapor, as it arises from the slacking of lime. The false mem- brane may be dissolved by very frequent inhalations of atomized lime-water and lactic acid. Bartholow gives the following to prevent systemic infection: j& Liquor iodi comp gij. Acidi carbolici 3j . — M. Sig. : One-fourth of a drop to two drops in water every four hours. Also, moderate doses of whiskey or brandy for the same pur- pose. He also recommends iron, quinine, strychnine, galvanism and faradism for the paralytic affections of diphtheria. As a solvent for the false membrane, Dr. J. L. Smith recommends the following : Jfcr Olei eucalypti 3ij. Sodii benzoat 3j • Sodii bicarbonatis 3ij . Glycerinse Sij . Aquae calcis 0. j. — M. Sig.: To be used with the hand atomizer from three to five minutes every half hour, or with the steam atomizer almost con- stantly. PRESCRIPTIONS FOR DIPHTHERIA. jfc Papayotin 5j. Aquae. 5iv. Glycerinae 3 viij . — M. Sig.: Apply locally to membrane. — Jacobi. |fc Trypsin gr. xxx. Sodii bicarbonatis gr. x. Aquae destillatae 5j. — M. Sig.: Apply locally to membrane. — Ferriald. 154 A COMPENDIUM OF PRACTICAL MEDICINE. jfc Acidi carbolici gtt. x. Liq. ferri subsulph 3iij. Glycerinse Sj. — M. Sig. : To be applied every three to six hours with a camel's hair brush. — J. Lewis Smith. jfc Tin cturse ferri chloridi 3ii-iij. Potassii chlorat 3j. Acidi muriatici dil ...gtt. x. Syrupi simplicis Siv. — M. Sig.: A teaspoonful every hour or two. — J. Lewis Smith. DIPSOMANIA, Is a term commonly applied to an uncontrollable desire for alcoholic drinks. In cases of dyspepsia there may be a morbid craving for alcohol. The habitual drunkard feels a desire for continued indulgence, and lacks moral strength enough to govern an acquired appetite which represents a morbid condition. Dip- somania is to be treated as a disease of body and mind. The treatment consists in withdrawing the patient from the use of alcohol in any form, and in the employment of medicinal and hy- gienic measures. This morbid craving for alcohol is the sad inheritance from drunken parents (Flint). According to Ringer, ten -minim doses of tincture of capsicum obviate the morning vom- iting, remove the sinking at the pit of the stomach, the intense craving for stimulants, and promote appetite and digestion in dipsomaniacs. PRESCRIPTIONS FOR DIPSOMANIA, Jfc Tincturse capsici IHx. Potassii bromidi gr. x. Spiritus ammonise 3j- — M. Sig. : This to be taken at one dose, and repeated several times daily. Jfc Tincturse gentianse com p Tincturse columbse comp...aa Sij. Tincturse nucis vomicse XTLLxxx. — M. Sig. : A dessertspoonful before each meal. — Loomis. DIRT-EATING DROPSY. 155 DIRT=EATINQ. Is a morbid habit which heretofore prevailed to a consider- able extent among the plantation negroes of the Southern States. The kind of earth selected is loam or clay. According to Dun- can, a very common disease among negroes on plantations is a state of anaemia, very often attributed to the pernicious habit of dirt- eating. Almost every large plantation has three or four such cases. With negroes, dirt- eating proceeds from the same propensity which leads white females to resort to chalk, mag- nesia, and slate pencils, etc., in order to relieve a disordered acrid condition of the stomach. Discover and treat the cause (Flint). DROPSY. Is an abnormal collection of watery fluid in the areolar tissue, or in the serous cavities of the body. Dropsy is not a disease, but a symptom. It is associated with various disorders. Dropsies may be external or internal. To internal dropsy be- long hydrocephalus, or dropsy of the brain, hydrothorax, or dropsy of the chest, and ascites, or dropsy of the abdomen. Ex- ternal dropsies are illustrated by anasarca and oedema: the first is a universal accumulation of serous fluid in the areolar tissues; the second, a localized collection in the same tissue, differing in nothing but extent. Both exhibit painless swelling of the sur- face, devoid of redness; a skin often stretched and shining, pitting upon pressure, and both, if punctured, allow a watery fluid to run out. (Edema is most commonly perceived around the ankles. Anasarca is usually dependent upon disease of the kidneys, or of the heart. The swelling ordinarily begins at the feet and ankles in diseases of the heart, in the face in disease of the kidneys. (Edema may be due to the same causes, or the cause may be purely local, as when we see oedema happening if a bandage be applied too tightly, or if swollen glands press upon the main vein of a limb. We see oedema in venous inflam- mation, in milk-leg, or as a sequel of typhoid fever, in conse- quence of the blocking up of the femoral vein by coagulum. In these cases, the oedema is one-sided. A circumscribed oedema, 156 A COMPENDIUM OF PRACTICAL MEDICINE. also accompanies erysipelas of the skin. Another source of double -sided oedema is anaemia (DaCosta). Causes of General Dropsy. — The most common are diseases of the heart, of the kidneys, or of the liver. Cardiac dropsy begins in the feet and ankles. Renal dropsy is usually much more general than cardiac, and does not, like cardiac, begin in the most de- pendent parts, but is often first noticed in the face and eye -lids. The proof that dropsy is renal is furnished by the presence of albumin and casts in the urine. The most usual kind of dropsy, dependent upon an affection of the liver, is abdominal dropsy (DaCosta). . Dropsies may be divided into three classes : Inflammatory, mechanical, and cachetic or hydremic. Inflammatory dropsy is due to a moderate degree of inflammatory alteration in the coats of the blood vessels, and produces collateral oedema. Of this nature are cases of oedema glottidis, of hydrocele, and of hydro- cephalus. Mechanical dropsy is the result of some obstruction to the current of blood in the veins. The most frequent of the mechanical causes of general dropsy is valvular diseases of the heart. Hydrsemic or cachectic dropsy is the result of an impover- ished and abnormally watery state of the blood. The most important cause of hydrsemic dropsy is Bright's disease. PRESCRIPTIONS FOR DROPSY. |fc Spiritus chloroformi Vfi xx. Tinctune digitalis IH.x. Infusi buchu gj. — M. Sig. : To be taken three or four times daily, and followed by a good drink of water. (In renal dropsy.) — Fothergill. {fcr Infusi digitalis §iv. Sig. : A tablespoonful two or three times daily. — Bartholow. Jfc Potassii bicarbonatis gr. x. Ferri et amnion, citrat gr. v. Tincturae digitalis HI x. Infusi buchu §j. — M. Sig.: To be taken three times daily. (In cardiac dropsy with gouty tendency or debility. — Fothergill. DYSENTERY. 157 DYSENTERY. Called also " bloody flux," is an ulcerative colitis. It is a disease characterized by tormina, tenesmus, mucus, and mucus and blood stools, burning pain, with more or less constitutional disturbance (Bartholow). Causes. — It occurs in both sexes and at all ages. Sudden arrest of perspiration by exposure to cold and dampness is one of the most common causes. It occurs in late summer and autumn and in warm rather than in a cold climate. It is preva- lent in malarious regions. Impure air and water, bad or insuffi- cient food are causes (Bartholow). Symptoms. — In the epidemic form, dysentery may begin suddenly, but in the other forms it comes on gradually. There is more or less catarrh of the intestines, diarrhoea, chilliness, fever, and a feeling of malaise. In two or three clays, pain in the descending colon is felt. It is described by the term tor- mina — "colicky pains." There is pain of a burning character in the rectum, with the sense of the presence of a foreign body, and with the desire to strain for its expulsion. Nothing comes away but mucus, either alone or tinged with blood. The tenesmus con- tinues. There may be ten to fifty stools daily. The patient becomes weak early. His skin is dry, harsh and wrinkled, his pulse small, quick and feeble. The discharges emit a horribly fetid odor. In the severe cases, the patient passes into the stage of collapse, the pulse ceases at the wrist, hiccough comes on, the skin is covered with a cold sweat, the hands become cold and livid, the face is shrunken, the eyes deeply sunk, and the voice husky. In mild cases convalescence is established about the eighth day. In the more severe cases, the duration is more pro- tracted (Bartholow). Prognosis. — Is good in mild cases, but in severe cases bad. Treatment. — 1. Food. If the stomach is irritable, milk, with one-fourth lime-water, is the best food. If the digestion remains good, the patient can take milk, eggs, beef -juice, ice- cream. boiled custard, oyster- soups, mutton, chicken and beef -broth. Where there is much depression of the powers of life, egg-nog may be freely given. 2. Medicine. According to Bartholow, 158 A COMPENDIUM OF PRACTICAL MEDICINE. the sulphate of magnesia in solution with dilute sulphuric acid is entitled to the first place as a remedy. It must be given in laxative doses, early. It serves a triple purpose : it empties the canal of retained faeces, it lessens hyperemia by setting up an outward diffusion ; its after effect is astringent and sedative. Ipecac is an excellent remedy, and must be given in the first stage, before the mucous membrane is stripped off, and in scruple to drachm doses, every four to six hours. The first doses empty the stomach, and the following ones produce copious bilious evacuations, called "ipecac stools. " The utility of ipecac ceases when these stools are produced. It is best given in milk in twenty grain doses with aromatic powder added. Castor- oil, in purgative doses, in the first stage is very efficient. After the first stage is passed, an emulsion of oil (almond oil) and turpentine combined with opium is very serviceable. When destruction of the mucous membrane is beginning, the most effective remedies are corrosive sublimate, sulphate of copper, sulphate and oxide of zinc, acetate of lead, bismuth, arsenic, etc. Of this list, sul- phate of copper and arsenic, combined with opium, are most effective. One drop of Fowler's solution and five to twenty drops of deodorized tincture of opium, every three hours, gives excellent results. One -twentieth of a grain of sulphate of copper with one-eighth of a grain of morphine every three hours is good treatment (Bartholow). Bismuth in large doses (gr. xxx.-xl.) every four hours with carbolic acid is good. Excellent results are obtained by washing out the bowels with warm water. Very great relief is affected by the injection of starch and laudanum. Eight ounces of a strong solution of silver nitrate (gr. xx. to the ounce), thrown into the sigmoid flexure, is effective. Morphine hypodermically is effective. External Applications. — The cold, wet pack, the ice-bag, but generally hot applications afford more relief. The turpentine stupe is useful. If collapse comes on, active stimulation is neces- sary. DYSENTERY DYSMENORRHEA. 159 PRESCRIPTIONS FOR DYSENTERY. |fc Tincturse opii deodorat gss. Bismuth subnitrat ^ij. Aquse menthse pip S yrupi zingiberis— aa gj . — M. Sig. : Shake bottle. Give one teaspoonful every two to four hours, to a child five years old. Half dose for a child one year old. — Smith. {i Vini ipecac ^ss. Sig. : One drop every hour. (In acute or chronic form of chil- dren, with slimy stools.) — Ringer. |fc Plumbi acetat gr. xxiv. Pulv. ipecac gr. iij. Pulv. opii gr. iij. — M. Ft. massa et in pil. no. xii. div. Sig. : One pill every two hours until blood ceases, then at longer intervals. — DaCosta. jfc Hydrargyri chloridi mitis 3J. In pulv. no. vii. div. Sig.: A powder two or three times daily. (In epidemic form.) —Hull. J& Cupri sulphatis gr. ss. Magnesii sulphatis §j. Acidi sulphurici dil 33. Aquse §iv, — M. Sig.: A tablespoonful every four hours. (In acute form.) — Bartholow. DYSMENORRHEA. Is painful menstruation. At the menstrual period women normally feel unwell, have a few vague pains in the loins, and an irritable temper. Varieties and Causes. — 1. Neuralgic or sympathetic dysnien- orrhoea is seen in nervous or hysterical women, and is accom- panied by neuralgia in other localities. 2. Congestive or innam- matory dysmenorrhoea occurs where there is excessive congestion of the uterus and ovaries from any cause. 3. Mechanical or obstructive dysmenorrhoea is due to some cause which mechani- cally obstructs the outflow of blood, as stenosis of the os uteri. 160 A COMPENDIUM OF PRACTICAL MEDICINE. or sharp flexions. 4. Membranous dysmenorrhea is sometimes associated with endometritis. 5. Ovarian (Pozzi). Symptoms. — Pain occurs preceding, during, or following the menstrual flow. In the mechanical, the pain occurs with the appearance of the flow, and consists of a series of uterine cramps due to the effort of the uterus to expel blood clots from its in- terior. In the congestive, the pain precedes the flow, and is re- lieved when the latter becomes free. In the neuralgic, the pain is referred to the hypogastrium, left ovarian, and intercostal regions. It often occurs in the intermenstrual period, but is always aggravated at the time of the sickness. In the membran- ous, the pain lasts throughout the period, and until the expulsion from the uterus of the more or less complete membranous cast. Treatment.. — In the mechanical or obstructive, dilate the sten- osis, correct the flexion, and prevent its recurrence. In the con- gestive, give saline laxatives, hot foot- and sitz-baths, vaginal in- jections, and ergot, with bromide of potassium. Instead of the ergot and bromide, fifteen to twenty grain doses of phenacetine every six to eight hours may be given. In the neuralgic, let the patient exercise in the open air, and give, iron, quinine, and other tonics. Pozzi has found the tincture of pulsatilla, given some days before the period, in five-drop doses, three times daily, quite efficient in the neuralgic form of young women. In the membranous, dilatation of the cervix just before the menstrual period, is sometimes effective. In the ovarian type, the bromides are the most serviceable. In any variety, where the pain re- quires it, potassium bromide and chloral may be given, with mustard plasters applied. As palliative treatment for the pain, give asafcetida, musk, tincture of cannabis indica, belladonnae or hyoscyamus. Oxalate of cerium has been extolled. Wylie praises electricity, he inserts the positive pole in the cervix. Laudanum and valerian douches often afford relief when all other remedies fail. Nitro- glycerine and amyl nitrite are excel- lent for spasmodic cases (Pozzi). DYSMENORRHEA DYSPEPSIA. 161 PRESCRIPTIONS FOR DYSMENORRHEA. R Tincturse cardamonii comp 3ss. Spiritus chloroformi XHxx. Liq. ammonii acetatis £ss. Tincturse belladonna ZTT.x. Aquae cinnamomi q. s., ad Sj. — M. Sig. : For one dose. (In congestive and spasmodic). — Pozzi. R Liq. ammonii acetatis ^iv. Sig.: A tablespoonful every two or three hours, with the fol- lowing: R Pulv. ipecac gr. iv. In pil. no. xii. div. Sig. : One every two or three hours. — Emmet. R Extracti opii gr. v. Extracti cannabis indica Extracti hyoscyami aa gr. x. Pulv. Camphoras gr. xxv. — M. Ft. massa et in pil. no. x. div. Sig.: A pill two or three times daily. — McLane. DYSPEPSIA. Is difficult or painful digestion. It is usually chronic. A disordered digestion, lasting for a short time, is called indiges- tion. Causes. — Dyspepsia is often an inherited condition. It may result from a deficiency in the quantity of gastric juice secreted, due to exhausting discharges, venereal excesses, masturbation, leucorrhcea and phthisis, and from the excessive use of narcotics, the tannin of tea, and the nicotine of tobacco. It may result from an excess in the gastric secretion, due to chronic hepatic and cerebral diseases, and to gout. It may result from a change in the quality of the gastric juice, due to ulcer and cancer of the stomach, gout, rheumatism, diseases of the kidneys, uterus and gall-bladder. Dyspepsia may result from pressure on the stom- ach by tight lacing, from positions assumed by shoemakers, needlewomen, writers, etc. It may result from mental emotion, 162 A COMPENDIUM OF PRACTICAL MEDICINE. prolonged mental labor, anxiety, deficient or excessive physical labor, excess of starchy food, or from deficiency of meats, badly cooked food, too rapid eating, etc. (Loomis). Symptoms. — The most constant symptom is an abnormal ajjjjetite; it may be lost, increased, or perverted. There is a "weight, dull pain, and a sense of burning in the epigastrium after the ingestion of food, accompanied by flatulence, heartburn, gastralgia, constipation or diarrhoea, a dull headache, and languor. Indiscretion in eating or drinking is apt to bring on an attack of sick headache. There is frequently a bitter taste in the mouth. In some dyspeptics the breath has a very offensive odor. Py- rosis, palpitation, dyspnoea and a severe pain referred to the heart (which makes the patient think he has heart disease), may be present. In some cases there is ringing in the ears, spots before the eyes, and vertigo. When in any case the dyspepsia has lasted a long time, chronic gastric catarrh will almost always be developed (Loomis). Prognosis. — Dyspepia in most cases can be cured, but the cure depends for the most part on the will of the patient. Treatment. — First, if possible, remove the cause. When the gastric juice is deficient in quantity, hydrochloric acid and pepsin are indicated. The vegetable bitters are efficient in these cases, and may be combined with alcoholic stimulants. When acid risings occur after ingestion of food, and are due to active fer- mentation, the sulphite of soda, or salicylic acid immediately after meals may prevent such changes. Saline waters will aid. When there is great irritability of the stomach, bismuth acts almost as a specific, and should be given in twenty grain doses before eating. Creosote, codeia, oxalate of cerium, and morphia may be employed to arrest vomiting. Dyspeptics should never wear corsets or belts about the abdomen. They should retire and rise early, eat slowly, and masticate well. No mental or physical work should be performed directly after or before eating. Horseback riding and walking in the open air should be insisted upon. A change of scene and climate works rapid cures in many instances. Dyspeptics should take a cold sponge- bath morning and evening (Loomis). A small quantity of acid wine at dinner is a good stimulant to the digestive function. A DYSPEPSIA. 163 moderate close of whiskey, taken before meals, is a capital remedy to promote the appetite and the digestion (Bartkolow). PRESCRIPTIONS FOR DYSPEPSIA. R Ammonii salicylates 3ij- Syrupi aurantii cort §j. Aqua? menthee pip ad 3iv. — M. Sig. : A tablespoonful half an hour before meals. (In fermentative dyspepsia.) — Sullivan. R Tincturae capsici IH.xvj. Tincturae nucis vomicae ..^ij. Tincturae gentianae comp ad...3ij. — M. Sig. : A teaspoonful in water three times daily, with -i- gr. aloin at bedtime, avoiding starchy diet. (For aggravated dyspepsia with constipation.) — DaCosta. R Bismuthi subnitratis Sodii bicarbonatis Pul v. cubebae — aa 3j . Pulv. zingiberis gr. xx. — M. In pulv. no. xii. div. Sig. : A powder in a wineglassful of water before each meal. —Clark. R Tincturae opii deodorat gtt. xij. Magnesii calcinat gr. xij.-xxiv. Sacchari albi 3j. Aquae anisi giss. — M. Sig. : Shake bottle. One teaspoonful every two hours to a child one year old, until relieved. — J. Lewis Smith. R Bismuthi subnitratis ^iss. Mucil acaciae 5J. Sodii bicarbonatis 3iss. Infusi calumbae ad §viij . — M. Sig.: Two tablespoonfuls before meals. (Irritative dyspepsia with raw tongue.) — Fothergill. Buttermilk -cure may be substituted for the milk- cure in cases of stomach disease (Bartholow). Actaea (cimicifuga) is recommended for the dyspepsia of drunkards. 164 A COMPENDIUM OF PRACTICAL MEDICINE. DACTYLITIS. (Syphilitic). Is gummy in character, and hence belongs to the later stages of syphilis. It is a rare affection. The swelling usually termin- ates abruptly, and is sometimes very great. There is no com- plaint of pain. The skin is natural or bluish from venous obstruction. Treatment. — Is that of tertiary syphilis. DANDRUFF. (See Pityriasis). DERBYSHIRE NECK. (See Goitre.) DROWNING. Remove from the mouth and nostrils all obstructions to the free passage of air to the lungs ; loosen clothing about the chest. Extend the arms in the direction of the body above the head, and when the capacity of the chest is thus enlarged, throw fresh air into the lungs by a flexible tube passed into the trachea, and then rej3lace the arms, pressing firmly upon the sides and sternum. These motions may be repeated ten or fifteen times per minute. A strong solution of ammonia may be passed under the nose. EARACHE. Treatment. — An excellent application in earache is the fol- lowing: R Morphia sulphatis gr. iv. Aquae destillatse Sj. — M. Sig. : Fill the external meatus with the solution. — Bartholow. Cocaine, five to ten per cent, solution, is the most effective remedy for earache (Bartholow). The external auditory meatus filled with water as hot as can be borne is effective. Counter -irritation by blistering fluid or croton-oil liniment behind the ear often removes earache (Ringer). ECZEMA. 165 ECZEMA. Is a non-contagious, vesicular, cutaneous eruption, with oedenia, pustules, exudation, or fission, and usually much itching. Eczema is catarrh of the skin (Tilbury Fox). It may safely be affirmed that very few persons pass through life without suffering from it in some measure. It is by far the most frequent of the diseases of the skin. Causes. — May be constitutional or local, or both combined. It often happens that the constitutional cause has disappeared before the patient is seen, and the affection remains, owing to the skin having contracted a bad habit. The chlorotic, the rach- itic, the scrofulous, and the debilitated, are very liable to be at- tacked. Eczema may be caused by digestive derangement, and the parts most frequently attacked are the face, lips, arms and hands. Improper, insufficient or bad food, is very apt to call it forth. It is often seen in infants whose mothers have a deficient or watery secretion of milk. A fruitful cause of eczema is de- ficient excretion, constipation, or defective elimination by the kidneys. A predisposing cause is rheumatism. Diabetes niel- litus may cause an eczema of the genital organs. Long- continued mental excitement, anxiety, grief, or over -study, may cause it. Eczema is met with at all periods of life, but occurs most fre- quently in children. Derangement of the uterus or its append- ages, irritation of ascarides, or tapeworm, stricture of the urethra, dentition, internal medicines, exj3osure to great heat, or to ex- treme cold, or to acrid substances (as in the case of grocers, bakers, bricklayers, washerwomen, cooks, smiths, etc.), may cause eczema. Varicose veins, pressure by tumors, garters, and trusses, stimulating liniments, as croton-oil, lice, fieas, bugs, irri- tation of the razor, and of discharges from the genito- urinary organs, anus, meatus auditorius, nostrils and mouth, are common causes of eczema. The irritation of poisonous dyes used in some of the colored socks in the market, is apt to give rise to a variety of eczema of the feet. Symptoms. — There are four symptoms which are almost in- variably present to a greater or less extent, namely: 1. Infiltra- tion of the skin. 2. Exudation on the surface of the skin. 3. 166 A COMPENDIUM OF PRACTICAL MEDICINE. Formation of crusts. 4. Burning heat, or itching. The infiltra- tion is due to the transudation of serum from the blood-vessels into the tissues, The exudation, or "weeping" may take place constantly, or at intervals; it is then called moist eczema. If there is no exudation, it is called dry eczema. The crusts, com- posed of hardened exudation, are more or less present. If the patient be cleanly in his habits, the exuded matter is washed off, and the crusts may be wanting; and, vice versa, the crusts may be thick. When the patches of eruption are acutely inflamed, burning heat is complained of. When the disease becomes chronic, the burning heat is replaced by itching. The use of stimulating food or drink, or on getting warm in bed, or the slightest touch of the part, gives rise to an irresistible desire to -scratch. Patients derive much positive pleasure from scratch- ing the part. Instead of itching, formication is sometimes com- plained of. Scratching always aggravates the disease. The elementary lesion is of great importance. This may be: 1. An erythematous state of the skin. 2. A vesicle. 3. A pustule. 4. A papule, or a mixture of all these lesions. When the ele- mentary lesion is an erythematous state of the skin, the disease commences as a simple inflammatory redness of the surface, with- out, at first, infiltration or exudation. The vesicular and pustular forms of eczema often form upon an erythematous ground. Prognosis. — Is rarely serious. Attacks of eczema vary much in their duration. Some cases get well without treatment in a few weeks, others last for months or even years. When the eruption is localized it is more difficult of cure. Relapses are very much to be feared. Treatment. — Some cases may be cured by either constitu- tional or local treatment, but generally it is advisable to employ a combination of both. Constitutional Treatment. — Purgatives and aperients are often useful, but are merely aids to other treatment. If the tongue is loaded, the appetite bad, the liver torpid and the bowels costive, the following formulae may be used : U Hydrargyri chloridi mitis gr. xx. Pulv. scammonii comp gr. xL. — M. Div. in pulv. iv. Sig. : One every week. — Anderson. ECZEMA. 167 B Quinise sulphatis gr. xij. Pulv. rhei gr. xxxvj. Hydrarg. cum cretse , gr. xx. Sacchari purificati gr. xx. — M. In pulv. no. xii. div. Sig. : Two daily. The dose to be so regulated that the patient has at least one full natural evacuation per day. Or the following may be given : R Quiniae sulphatis gr. xLviij. Ferri sulphatis ^iij . Acidi sulphurici dil 3iss. Magnesii sulphatis 5iij . Syrupi zingiberis Tinct. aurantii — aa §iss. Infusi calumbae. ...... ad ^xxiv. — M. Sig. : A tablespoonful in a wineglassful of water thrice daily. Iii some cases of eczema, diuretics are indicated. In strum- ous subjects, nourishing food, stimulants in moderation, and tonics are our sheet anchors. Severe cases of eczema have been cured by the administration of cod- liver oil and syrup of the iodide of iron. Twenty drops of the syrup of iodide of iron in a teaspoonful of cod- liver oil thrice daily, and the dose to be gradually increased to a tablespoonful, may be given. Cod- liver oil may be applied locally with benefit. Of nerve tonics, those which are most likely to be useful are strychnia and arsenic (in form of Fowler's solution). In chronic eczema, electricity is used with some benefit. The diet is of great importance, and must be carefully regulated. Local Treatment. — Some cases of eczema are local diseases throughout their whole course, being due to local irritation, and are benefited more by local than constitutional treatment. The disease sometimes remains from habit. Our skins have the same tendency as ourselves to contract bad habits. The first thing is to remove the crusts with oil. Then dust the parts with absorb- ent powder two or three times daily. Soothing ointments are indicated, such as follows : R Zinci oxidi 3J. Acidi oleici §viij . Vaselini §ix. — M. Sig.: Apply to parts. — Anderson. 168 A COMPENDIUM OF PRACTICAL MEDICINE. R Pulv. camphorae gr. xx. Pulv. zinci oxidi gij. Glycerini 3 # j. Adipis benzoati §j . Cochinillini .. gr. j. Olei rosse ...ZR.j— M - Sig. : Apply to face two or three times daily. —Anderson. R Hydrargyri perchloridi gr. xij. Acidi hydrocyanici dil gij. Glycerini... giij . Eau de cologne ad ^vj. — M. Sig.: Sponge the parts two or three times daily. — Anderson. Of "all the local means for the removal of limited eczematous eruptions, none are superior to blistering. The best and safest blistering agent is cantharides. The local varieties of eczema are: of the head, hairy portions of the face, lips, edges of the eyelids, nostrils, auricle, and external auditory passage, the flexor surfaces of the joints, the hands and feet, the legs and the geni- tal organs. PRESCRIPTIONS FOR ECZEMA. R Acidi citrici gr. xv. Aquae lauro-cerasi 5) . Olei rusci (birch) gtt. xv. Ungt. aquae rosse 3x. — M. Sig. : Use thrice daily. Use starch powder between the applica- tions. Carefully attend to diet. (For acute eczema.) — Monin. R Glyceriti amyli ^viiss. Acidi tannici Hydrargyri chlo. mit aa gr. xv. — M. Sig.: Apply morning and evening. (In dry eczema with itching.) — Vidal. R Ungt. hydrargyri oxidi rubri gij. Ungt. sulphuris 31J. Acidi carbolici gr. iij. Unguenti simplicis ^ss. — M. Sig.: Apply to the affected parts. (In chronic eczema.) — DaCosta. R Tincturae belladonnas ^ss. Sig.: Five drops thrice daily to a child of two years. (In in- fantile eczema.) — Bartholow. ECZEMA — EMISSIONS. 169 R Pulv. acidi salicylici gr. xv.-xxx. Pulv. zinci oxidi Pulv. amyli aa ^iij. Vaselini pari £vj . — M. Ft. iingt Sig. : Apply locally, and cover with cotton after rubbing oint- ment in. (In papulous or squamous eczema.) — Lassar. R Infusi cinchonse ^vj. Aquae calcis ^ixss. Tinct. lupulinae Succi conii aa £ij. — M. Sig. A wineglassful thrice daily. (In chronic eczema of the aged.) — Neligan. R Ferri et ammonii citratis 3J. Potassii citratis gij. Liquor potassii arsenitis 3!— ij . Tinct. nucis vomicae gij. Tinct. cinchonae comp ad ^iv. — M. Sig.: A teaspoonful in water after meals, as a tonic and altera- tive. (In eczema.) — Bulkley. R Resorcin Zinci oxidi aa 3j. Ungt. aquae rosse ^x. — M. Ft. ungt Sig. : Apply locally. (In chronic indurated eczema of infants.) — Fleisburg. EMISSIONS. (Involuntary Seminal.) By involuntary seminal emissions is meant the ejaculation of semen and the venereal orgasm without any voluntary effort, either natural or unnatural. Involuntary emissions occurring during sleep are common, taking place with erotic dreams. Occurring after intervals of several days in persons of continent habits, they are physiologi- cal rather than pathological. They denote simply a certain amount of functional activity of the generative organs. They do not imply a morbid condition nor do they lead to any morbid effects. They occur especially when habitual sexual intercourse is interrupted from any cause. Under these circumstances they are manifestations of health rather than of disease. 170 A COMPENDIUM OF PRACTICAL MEDICINE. Occurring more frequently, the emissions denote a morbid erethism and weakness of the organs of generation. They occur sometimes nightly and sometimes even repeatedly during the same night. They then call for remedial measures. Occurring in persons debilitated from any cause, they may take place without any erection and with little or no venereal excitement. They occur sometimes during the day, and are called diurnal. Venereal excesses, or unnatural abuse, are the causes of this morbid frequency. The mind becomes depressed. The patient fancies he is impotent, his constitution ruined, and that there is danger of insanity. They go from one physician to an- other, and upon patients of this class quacks prey largely (Flint). Pollution is a term applied to involuntary seminal emis- sions, attended by venereal orgasm, more or less marked. Dr. Keyes writes as follows of pollution : " Nocturnal pollutions are exceedingly common. They usually accompany erotic dreams." Nocturnal emissions in moderation are entirely natural, and by no means a sign of disease. Their frequency compatible with health varies with the purity of mind and sexual vigor of the patient. A man who is happily married rarely has noctur- nal emissions while living with his wife, but, if he leaves her for several weeks, it is natural and entirely the rule that there should be a formation and collection of semen, which distending the seminal vesicles, excites erotic fancies, and escapes at the conclusion of a dream. Any man suffering from ungratified sexual desire is normally in a condition demanding relief for his over distended seminal vesicles, and, if that relief be not afforded in some way by the patient, it will come spasmodically during sleep. Occasionally nocturnal emissions may be over-frequent, and indicate a condition of irritation in the deep urethra which requires treatment (Keyes). Treatment. — When emissions do not exceed three times weekly they should be disregarded. Where they become very frequent, as nightly or several times a night for a considerable time, there should be an attempt made to correct the habit. Purify his thoughts, elevate his tone, and get him if possible happily married. The patient should endeavor to sleep soundly EMISSIONS. 171 by tiring himself out through the clay by physical work. Dry friction, cold bath and cold douche locally are useful. He should sleep on a hard bed lightly covered. The stomach should not be full on retiring. Lying on the back with the bladder full of urine, tends to beget erections. To avoid this, the patient should tie a towel around his waist on retiring, with a hard knot in the back over the spine. Besides the above means, bromide of potassium, camphor and lupulin may be given internally, with strychnine and a mineral acid, and locally decided advan- tage may be derived from the gentle use of the steel sound, as in neuralgia of the vesical neck. Mechanical devices appear from time to time for treating pollution, but they usually do more harm than good. Keyes used an appliance which started a battery and gave an electric shock in the back when erection came on. Verneuil used a similar instrument which caused a bell to ring when erection came on. A ring which lightly encir- cles the penis, but when distended by erection causes pain and awakens the patient has been used. Marriage is always remedial in physiological cases (Keyes). PRESCRIPTIONS FOR EMISSIONS. R Potassii bromidi 5j . Sodii bicarbonatis gr. xv. Infusi digitalis §ss. Atrophias sulphatis gr. q\. — M. Sig. : To be taken at bedtime. — Gross. R Lupulinas ...... .gr. x. Pulveris camphorse gr. vj. Extracti belladonnas gr. ij. — M. In pil. no. xii. div. Sig.: One pill thrice daily. — Bartholow. R Tincturas cantharidis ^ij. Tincturae ferri chloridi gvj. — M. Sig.: Twenty drops in water thrice daily. — Wood. 172 A COMPENDIUM OF PRACTICAL MEDICINE. EMPHYSEMA. (Pulmonary.) Emphysema in general signifies the presence of air in the interstitial connective tissue. In the lungs, however, there are two kinds of emphysema — interlobular and vesicular; the former arises from rupture of the air-cells, causing a communication be- tween them and the interlobular connective tissue, and the latter, the more common, consists in an abnormal accumulation of air within the air-cells. Emphysema is essentially a chronic affection; it comes on slowly, and when once developed is permanent (Loomis and Flint). Causes. — Are forced expiratory efforts, the glottis being closed or narrowed, as in violent coughing, straining at stool, etc. It is developed in the upper lobes of the lung. Various injuries and diseases of the chest which limit the movements of the lungs, as curvature of the spine, pleural adhesions, hydro- thorax, tumors, pneumonia, perforating wounds of the chest, or injury of the lung by the extremity of a fractured rib, may cause emphysema of the lung (Loomis and Flint). Symptoms. — The most prominent and constant subjective symptom of emphysema is dyspnoea, which is increased by physi- cal exercise. It is worse during the cold of winter. There is often a smothering sensation in the chest. There is no fever. The pulse is feeble, and the body cool and cyanotic. In extreme cases, lividity is marked. Usually there is no pain in the chest. The nostrils are distended, the voice is feeble, and the capillary circulation is imperfect. The temperature of the body is usually sub-normal. There is distension of the jugular veins, and ver- tigo is common. There may be oedema of the feet and ankles. Emphysematous patients are especially liable to hemorrhoids. Physical Signs. — On inspection, it will be noticed that the chest is "barrel- shaped.'" The lower portion of the chest seems contracted. The apex of the heart will be found beating lower down than normal, and more toward the median line. On pal- pation, the vocal fremitus, varies. In senile emphysema, the vocal fremitus is usually increased. The percussion sound is vesiculo- tympanitic. On auscultation, the inspiratory sound is either EMPHYSEMA EMPYEMA. 173 short or feeble, or actually suppressed, while the expiratory is greatly prolonged (Loomis). Prognosis. — It rarely, if ever, destroys life, but when once developed, is never recovered from. Treatment. — As this disease is incurable, our treatment must be palliative. Iron and the sulphate of quinine in small doses, may be given with benefit. Cod -liver oil, bitter infusions, min- eral acids and stimulants are all useful. The diet should be of the most nutritious character, and composed largely of animal food. Exercise in the open air should be taken. Quebracho is a useful drug for emphysema. For the bronchitis which accom- panies emphysema, iodide of potassium in five to ten grain doses thrice daily is serviceable. For the asthmatic attacks, morphine and atropine are useful. PRESCRIPTIONS FOR EMPHYSEMA. R Liquoris potassii arsenitis gtt. ij. Potassii iodidi gr. x. Syrupi tolu 5ss. Aquae 5ss. — M. Sig.: This dose t. i. d. R Ammonii iodidi 5j- Liquoris potassii arsenitis 5ss. Syrupi tolutan Sj ■ — M. Sig.: A teaspoonful every four hours. — Bartholow. EMPYEMA. Called, also, suppurative pleurisy, or pyothorax, is charac- terized by the accumulation of a purulent liquid in the pleural cavity. It is usually confined to one side. Cause. — Is not always known. It may be of traumatic ori- gin. It may result from exhausting diseases or debility. It often complicates acute and chronic infectious diseases. Chronic tuber- cular pleurisies are very apt to be suppurative in character. It may be secondary to abscess of the liver, or in the abdominal cavity, or to chronic phthisis. It is sometimes secondary to Lobar pneumonia (Loomis). 174 A COMPENDIUM OF PRACTICAL MEDICINE. Symptoms. — If the inflammatory process is acute there will be chills, fever, a rapid pulse, severe pain in the affected side, great prostration, anxious expression and typhoid symptoms ; these cases usually terminate fatally within two or three weeks. The symptoms of chronic empyema are very often obscure. The patient rarely suffers from local pain — there is simply a sense of uneasiness, or weight in the affected side, loss of flesh and strength, pale countenance, diurnal chill followed by profuse sweats. There are cough, weak voice, dyspnoea, etc. A positive diagnosis may be made by an exploratory puncture. If an em- pyema is about to open externally, it will protrude between the ribs, and give a sense of fluctuation, and become red. It may open into a bronchial tube and be followed by profuse purulent expectoration. The chest walls gradually retract. It may open into the peritoneal cavity and be followed by a fatal peritonitis (Loomis). Prognosis. — Unfavorable. Treatment. — An opening should be made at the bottom of the pleural sac, allowing the pus to escape freely. The pleural cavity should be daily cleansed by the injection of tepid water to which a very small quantity of carbolic acid (one per cent.) is added. Aspiration should first be tried. In children simple aspiration frequently effects a cure (Flint). If aspiration is re- sorted to, a large -sized needle should be used, and only a small portion of the fluid removed the first time. Aspirate every third, fourth or fifth day. Never continue the removal of pus in em- pyema after the patient complains of constriction in breathing. If a permanent opening is to be made, let it be made in the ax- illary line in the seventh or eighth intercostal space, and a quarter -inch rubber drainage tube should be introduced, and so fastened that it will remain. The pleural cavity should not be washed out (Loomis). Tonics, such as quinine, cod- liver oil and iron are always indicated and exercise in the open air. PRESCRIPTIONS FOR EMPYEMA. R Misturse ferri et amnion acetat 51 v. Sig.: One to two teaspoonfuls four times daily, with quinine and stimulants. (In chronic cases.) — DaCosta. ENDOCARDITIS. 175 R Liquor iodinii comp... 5j. Aquse destillatse §xv. — M. Sig. : Inject after aspirating the pus. — Bartholow. R Quinise sulphatis ^ij. Aquse §xij. — M. Sig. : Inject after evacuating the pus. — Ringer. R Aquae chlorinii gj. Aquae destillatse ^ix. — M. Sig.: To wash out the pleural cavity after the evacuations of the pus. — Ringer. ENDOCARDITIS. Is an inflammation of the endocardium. In adults the left heart is oftenest affected. The inflammation is, in the majority of cases, situated on the valves and chordae tendineae. Vegeta- tions appear upon the endocardium. These vegetations may attain the size of a pea and are favorable points for the detach- ment of emboli (Flint). Causes. — Primary, or idiopathic endocarditis is extremely rare. It is secondary to pleuritis, pneumonia and pericarditis, but, very more frequently, secondary to acute rheumatism. About one -third of the cases of acute rheumatism are complicated by endocarditis (Bartholow). It is produced by the same cause that produced the rheumatism, and not by metastasis (Flint). Symptoms. — The patient may complain of an obscure sense of distress in the prgecordia, not amounting to pain. The action of the heart may be morbidly excited — palpitation. There is an endocardial murmur. The murmur is of a soft, or bellows char- acter. It accompanies the first sound of the heart. It is heard loudest at or near the apex of the heart (Flint). There may be paroxysmal dyspnoea, the face may be flushed and even cyanotic (Loomis). Prognosis. — The danger is not immediate, but remote. Treatment. — Sinapisms and stimulating liniments to the praecordia are indicated. Alkaline remedies lessen the liability to fibrinous deposits upon the valves. The patient should avoid physical exertion, mental excitement, a stimulating diet, and the use of alcohol. A tablespoonful of the infusion of digitalis should be given every four hours (Flint and Bartholow). 176 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR ENDOCARDITIS. R Tincturse digitalis Sj. Sig. : Ten or fifteen drops every four hours. (When heart's ac- tion is irregular). — DaCosta. R Tincturse aconiti radicis Sss. Sig. : One drop every hour or two. — Ringer. R Lini farinse Aquae bullientis aa q. s. — M. Ft. cataplasma. Sig. : Apply over the heart as hot as can be borne. — DaCosta. ENTERITIS. Is a general term applied to a catarrhal inflammation of the intestinal mucous membrane. It may be acute or chronic. Causes. — Direct irritation of the mucous membrane by im- proper, or decomposing food, impure water, or irritating medi- cines, or by exposure to wet or cold, will cause intestinal catarrh. Extensive burns will cause it. Chronic malarial infection, and chronic Bright's disease may cause it. Predisposing causes are cirrhosis of the liver, chronic valvular lesions, and pulmonary emphysema. It occurs at all ages. The two great predisposing causes in children are dentition and bad hygiene during the hot months (Loomis). Symptoms. — Diarrhoea is its earliest and most constant symp- tom. Watery mucus may be discharged from the bowels, or there may be bilious diarrhoea, with pains and cramps in the calves of the legs, vomiting, headache, furred tongue, and green- ish stools. Serous diarrhoea is the most common, and at first the dejections contain undigested food. There is pain, colicky and griping in character, or it may be dull. Food increases the pain. There is a sense of fullness and distension of the abdomen, and tenderness on pressure. There are flatulence and gurgling. Nausea and vomiting indicate that gastric catarrh is associated with the intestinal. There is usually a mild, remittent type of fever, with Joss of appetite, offensive breath, scanty and dark urine. Thirst is intense (Loomis). ENTERITIS. 177 Treatment. — Keep the patient in bed. It is safe to begin the treatment in every case of acute intestinal catarrh by the admin- istration of castor oil. The diet should consist of milk with lime-water. The yolk of eggs may be given with the milk. Prepared meats and light broths are useful. No fats should be allowed, or bread or any form of starchy food. Stimulants may be given when there is prostration. The abdomen should be covered with warm fomentations. Opium is the most efficient agent and must be given in half grain doses every two or three hours. When the catarrh is of malarial origin, quinine must be given in large doses. If it is the result of exposure to wet and cold, diaphoretics are indicated. Chronic intestinal catarrh may be treated by astringents; the best are nitrate of silver, acetate of lead, and sulphate of copper. Sponging the abdomen with cold salt water is good (Loomis). PRESCRIPTIONS FOR ENTERITIS. R Pulv. ipecac comp gj. Bismuthi subnitratis gij. — M. In pulv. no. xxiv. div. Sig. : A powder every two to four hours for a child five years old. — J. Lewis Smith. R Pulv. opii gr. v. Bismuthi subnitratis ^ij. — M. In pulv. no. xx. div. Sig. : A powder every two to four hours for a child five years old. — J. Lewis Smith. R Liq. potassii arsenitis gtt. L. Tincturae opii 3j . Aquae ad giij. Sig. : A teaspoonful before meals thrice daily. (In chronic and malarial form.) — Bartholow. R Tinct. opii deodorat 3j. Sig.: Ten drops every second or third hour, according to age, to the point of tolerance. — DaCosta. 178 A COMPENDIUM OF PRACTICAL MEDICINE. EPILEPSY. (Falling Sickness. ) Is a chronic paroxysmal affection. The paroxysms are char- acterized by loss of consciousness and convulsive movements of the muscles. Convulsions similar to those of epilepsy are symp- tomatic of different cerebral affections, of anaemia, of injuries of the head, and of strychnia, and are distinguished as epileptiform. Epilepsy is a functional affection. In the majority of cases, the loss of consciousness is as sudden as if produced by a stunning blow upon the head, and the person falls. In a minority of •cases, there is a brief warning of the approaching fit. It is a ;sense of a "cold vapor" emanating from some part of the body and mounting to the head, and has been called the aura epilep- tica (Flint). Cause. — Thirty per cent, of epileptics give a history of an inherited tendency. Children of consanguineous marriages are often epileptics. It most frequently develops between the ages of ten and twenty. Puberty and injury to the peripheral nerves, the skull, meninges, and diseases of the brain substances are ex- citing causes. It may arise from irritation of the genital organs, anomalies of menstruation and phimosis (Loomis). It is very generally believed that the immediately exciting cause of an epi- leptic paroxysm is cerebral anaemia resulting from vaso- motor spasm. Venereal excesses, and habits of masturbation have been supposed to be frequent causes. Flint relates the case of a female patient who experienced the first paroxysm during the first act of sexual congress after marriage. Subsequently, a paroxysm occurred at each marital connection, and she became a confirmed epileptic. It is well known that dogs, cats and other domestic animals are liable to epilepsy (Flint). Symptoms. — (Of grand mal.) — The onset of the paroxysm is often marked by a loud, sharp cry, and the epileptic falls heavily. Drawing the head toward one shoulder is sometimes a warning of an epileptic seizure. There is complete loss of consciousness. The face is extremely pale. The pupil is invariably dilated at the onset and does not contract on exposure to bright light and the eyes are fixed and staring, and the muscles of the face, trunk and extremities are rigid. Opisthotonos may occur. The face EPILEPSY. 179 soon becomes dark from asphyxia. Clonic convulsions succeed the tonic spasms. The tongue is thrust between the teeth. The teeth are sometimes broken. The patient froths at the mouth, and from the injuries to the tongue the saliva is often bloody. The body is often bathed in a profuse sweat. The fit may ter- minate suddenly or gradually. The patient has no recollection of the attack, and appears as if waked out of a deep sleep. (Of petit mal). — There is momentary loss of consciousness, the patient suddenly stops; has a fixed gaze for a second or two, his mind is confused, and then proceeds as if nothing had hap- pened. There may be nocturnal attacks of epilepsy. The only evidence of these attacks may be the tongue which shows indents of the teeth, and the pillows may be blood-stained. Number of Fits. — The first fit may also be the last. They may occur once a year, or two or three times in twenty -four hours. In women it sometimes seems to be connected with the menstrual epoch. Eighty per cent, of all epileptics are attacked oftener than once a month. Results of Epilepsy. — There may be impairment of the mental or physical condition. Of the mental faculties, memory is most often impaired. A subnormal temperature is very common (Loomis). Treatment. — When an epileptic fit is once established there is little to be done but to prevent the patient from injuring himself. Try to discover the cause and remove it. The bromides are at the pre&ent time used more than any other remedies. Cod- liver oil is useful. Nearly all the drugs of the materia medica have been tried (Loomis). PRESCRIPTIONS FOR EPILEPSY. R Ferri bromidi gr. iv. Potassii bromidi 5J . Syrupi simplicis 31J . Aquse ad gviij . — M. Sig. : A tablespoonful twice daily. (In anaemic patients.) — Bartholow. R Extracti conii fluidi (Squibbs)....§ij. Sig.: Fifteen to sixty minims three times daily. — Spitzka. 180 A COMPENDIUM OF PRACTICAL MEDICINE. R Lobelinse hydrobromat gr. ^-j. Aquae destillatse Siiss. — M. Sig. : A teaspoonful three or four times a day. — Bartholow. R Potassii bromidi ,,,, Sodii bromidi Ammonii bromidi aa oiij . Potassii iodidi Ammonii iodidi aa 5iss. Ammonii carbonat 5j. Tincturse calumba? Siss. Aquae q. s., ad. ft Sviij. — M. Sig.: A teaspoonful and a half before each meal, and three at bed time. — Brown-Sequard. EPISTAXIS. Is nasal hemorrhage. Causes. — The mucous membrane of the nose is full of blood vessels, and bleeds easily. It may be caused by ulceration of the membrane, by vascular tumors, and by mechanical causes, as valvular disease of the heart (Bartholow). Symptoms. — There may be a sense of fullness of the head, headache, noises in the ears, and vertigo. The blood may come drop by drop from a single nostril, or from the posterior nares. The quantity of blood discharged varies; it may be an ounce or even a pint or quart. Epistaxis may occur periodically as a manifestation of malaria, or take the place, vicariously, of the menstrual or hemorrhoidal flux (Bartholow). When the bleeding occurs in sleep from the posterior nares,. and is swallowed, there may be, if vomiting of the blood occurs,, much difficulty in ascertaining the true source (Bartholow). Treatment. — Small pellets of ice may be introduced into the nares, while a block of ice, hollowed out to fit the nose, may be put on outside. Simply pressing the nares together, to enable the blood to coagulate, may often suffice. If pressure and cold fail, a solution of tannic acid, or of alum, or of acetate of lead, may be thrown into the nares, and. if these fail, a solution of MonseFs salts. All other expedients failing, the posterior nares must be plugged (Bartholow). EPISTAXIS ERYSIPELAS. 181 Small doses of aconite, given frequently, will often quickly check the nose-bleeding of children and of plethoric people. Cocaine may be used locally. Digitalis controls epistaxis, haem- optysis, and menorrhagia. A hot foot-bath, with or without mustard, is efficient. Spinal hot-water bag to the cervical and and upper dorsal vertebrae is serviceable (Ringer). PRESCRIPTIONS FOR EPISTAXIS. R Pulv. aluminis Pulv. acidi tannici aa 5j. — M. Sig. : To be insufflated into the nares anteriorly and posteriorly. — Sajous. R Extracti geranii mac. fluidi §j. Aquae giij. — M. Sig. : Syringe the nostrils, or plug with cotton saturated with the fluid. — Shoemaker. R Anti pyrin ^ij . In capsules no. xxiv. div. Sig,.: One, two or three to be taken as required. To be used with local treatment. — Robinson. ERYSIPELAS. Is a self- limited febrile affection, characterized by a local inflammation of the skin, and accompanied by constitutional symptoms. It is contagious (Bartholow). Causes. — The streptococcus erysipelatis is regarded as its specific cause. It prevails in hospitals and epidemics follow in the paths of armies. There are two kinds: idiopathic and trau- matic. It is a disease, of all ages, and occurs at all seasons. An abrasion of the surface or wound is the usual starting point. Symptoms. — The initial symptom is a chill. Headache comes on with the fever; and there are nausea, bilious vomiting, and entire loss of appetite. A sense of heat and tension is felt in the skin, which becomes red, cedematous and shiny. The red color disappears on pressure. The inflammation readies its highest point on the second or third day, and on the fourth, -fifth or sixth day the redness is fading. Desquamation of the skin takes place. The margin of the redness is not sharply defined, 182 A COMPENDIUM OF PRACTICAL MEDICINE. but the swelling forms an abrupt ridge (Bartholow). Trauma- tic erysipelas begins as a bright red blush about the point of injury. Idiopathic erysipelas is most commonly facial, starting from either the nose, eyelid or ear (Loomis). Differential Diagnosis. — Erysipelas may be confounded with erythema and urticaria. Erythema is a superficial redness with- out inflammation — without heat and swelling — is without fever, and does not desquamate. Urticaria occurs in the form of wheals that itch a good deal and disappear in a few hours (Bartholow). Treatment. — In the more severe cases quinine combined with belladonna is good treatment. R Quininse sulphatis gr. xL. Extraeti belladonna? gr. iij. — M. Ft. pil. no. x. Sig. : One pill every four hours. Tincture of the chloride of iron, in half- drachm doses every four hours, is much commended. Milk, eggs, animal broths, and when necessary stimulants should be given. The bowels and kidneys should be kept active. Local Applications. — As a rule, irritating applications do more harm than good. Bartholow has seen mercurial ointment diluted ten times with lard very successful ; or vaseline Sj, acid carbolic 5ss, or less, which should be brushed over the inflamed area three or four times a day. PRESCRIPTIONS FOR ERYSIPELAS. R Tincturse ferri chloridi Syrupi simplicis — aa gj. Aquae §ij . — M. Sig. : A teaspoonful well diluted every two or three hours. — Charity Hospital. R Plumbi acetatis 3J. Tincture opii 3j. Aqua; ad 0. j. — M. Sig. : Shake the bottle well, and wet cloths with the lotion and apply to the affected parts. — Charity Hospital. R Acetanilidi 3 j . Ft. in no. xv. capsules. Sig. : Two capsules as required for fever. — Osier. ERYTHEMA ECLAMPSIA. 183 ERYTHEMA. By this term is meant simple, superficial inflammation of the corinm, the most trifling of all inflammations of the skin, and under it we must include roseola, strophulus and pityriasis. Symptoms. — There is no fever. The local symptoms are not severe. There is no distinct abrupt line of demarcation between the healthy and diseased skin. It does not usually spread rapidly. The itching is moderate. The color of the eruption is usually pink. The causes are very various. Erythema capitis or pityriasis is usually a very chronic affection and attacks the scalp and hairy parts of the head. Chilblain is a form of erythema which occurs in cold weather, and attacks the fingers, toes, ears, nose and cheeks. PRESCRIPTIONS FOR ERYTHEMA. R Zinci acetatis gr. ij. Aquae rosae 5j. Ungt. aquae rosae gj. — M. Sig. : Apply locally. — Fox. B Pulveris camphorae 5ss-j. Spiritus vini rectificati 5j • Sodii boratis gr. xl. Aquae rosae Sviij. — M. Ft. lotio. Sig. : Apply locally several times daily. — Tilbury Fox. R Pulveris camphorae 5ss-j. Zinci oxidi oiv. Pulveris amyli oj ■ — M. Sig.: Dust on lightly and do not allow to cake upon the skin. — Bulkley. ECLAMPSIA. Is the term applied to convulsions, tonic and clonic in char- acter, the foundation of which is laid in processes connected with pregnancy, labor, and childbed. It occurs once in about five hundred pregnancies. The attack resembles that of epilepsy, the cry only lacking (Lusk). 184 A COMPENDIUM OF PRACTICAL MEDICINE. Terminations. — In favorable cases, after the expulsion of the ovuni, the attacks cease or diminish in frequency and intensity. Prognosis. — Is always serious. The earlier the convulsions occur in labor the more unfavorable the prognosis (Lusk). Treatment. — The urine of pregnant women should be exam- ined occasionally. If convulsions threaten, the nervous irrita- bility should be held in check by rectal injections of chloral and bromide of potassium (thirty grains each). From one -sixth to one-fourth of a grain of morphia should be injected hypodermi- cally. The lower bowel should be cleaned out by an enema, and a cathartic should be given by the mouth (Lusk). EMBOLISM. An embolus is any solid body floating in the blood current. Embolism is the occluding of a vessel by an embolus. Arteri- oles and capillaries are the usual seats of embolism. In general an embolus is part or all of a dislodged thrombus. Causes. — A slowing of the blood current, or a change in the walls of the vessels, a weak vis-a-tergo, vegetations on the valves of the heart, a foreign body introduced into a vessel, or a frac- ture, may cause embolism (Bartholow). Symptoms. — Embolic obstruction of a member is announced by a sudden and often intense pain and a chill, with numbness, loss or diminution of tactile sense, coldness, pallor of the skin, and a feeling of deadness and weight, and paralysis of the muscles (Bartholow). Treatment. — Ten grains of the carbonate of ammonia may be administered in a tablespoonful of the solution of the acetate, three or four times each day. Another remedy is the phosphate of soda, in drachm doses, three times daily for many weeks (Bartholow). ENURESIS. Called, also, incontinence of urine, is a common and trouble- some infirmity of children. It occurs both in boys and girls, but is more common in the former. In many children it dates back to infancy, but in others it begins at six or seven years. There ENURESIS. 185 is an increase in the circular muscular fibres at the urethral ori- fice which constitutes the sphincter vesicae, an unstriped muscle and not under the control of the will. A second sphincter which aids materially in the retention of the urine is formed by the compressor urethrse, surrounds the whole membranous portion, and is a striped muscle and therefore controlled by the will (Smith). Causes. — In all cases the urine should be examined. The chief causes are: 1. Too great acidity of the urine, which will irritate and cause the bladder to contract. 2. Increased quantity of urine. This occurs from the free use of water or milk, or renal disease. 3. A vesical calculus. This will cause pain in passing water. Sound for stone. 4. Excessive irritability of the muscu- lar fibres of the bladder. This is the most frequent cause of enuresis in children. Belladonna relieves this condition. 5. Weakness of the muscular fibres which constitute the sphincter. This occurs in run down conditions. 6. Reflex action. This may be from phimosis, stricture of the urethra, irritation of as- carides, fissure of the anus, onanism, or vulvitis. 7. A psychical cause to which Bartholow alludes. The patient dreams that he is in a convenient place to pass water. 8. Malformation of the bladder. These are various (Smith). Prognosis. — Depends on the cause or causes. Treatment. — For the excessive acidity of the urine, three to iive drops of the liquor potassse should be given three or four times daily in a wineglassful of water. In belladonna we jdos- sess an agent which diminishes the functional activity, or inherent irritability of the bladder when the latter is in excess. Five drops of the tincture may be given every evening, to a child of five years, and the dose increased by one drop every second day. If the enuresis be due to an abnormally large secretion of urine, the liquid ingesta in the latter part of the day should be re- stricted. If it be due to diabetes, or chronic nephritis, treat these conditions. If it be due to a vesical calculus, lithotomy is indicated. If the cause of the enuresis be due to irritation in contiguous parts, as the rectum, penis or vulva, treat these con- ditions. If the cause be due to atony of the sphincter, mix vomica and ergot are indicated. 186 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR ENURESIS. R Tinturse belladonnse Sj. Sig. : Ten to twenty drops thrice daily. — Ringer. R Acidi benzoici 5ij. Aquae cinnamomi g vj . — M. Sig. : A tablespoonful thrice daily. — Hartshorne. R Tincturse ferri muriatis sj. Decocti uvse ursse Syj. — M. Sig. : A tablespoonful two or three times daily. — Hillis. R Santonini gr. xyj. Olei ricini Sj • — M. Sig. : One or two teaspoonfuls before breakfast for two or three mornings. — Ringer. R Collodii Sss. Sig.: Put a drop in the meatus to seal it at bed time. Remove with finger-nail in morning. — Corrigan. R Chloral hydratis 3j. Syrupi tolutani Siiss. — M. Sig.: A teaspoonful thrice daily. (For infantile incontinence). — DaCosta. R Atropinse sulphatis gr. j. Aquae destillatae Sj . — M. Sig.: Four to eight drops in water. (For children). — Bartholow. ENDOMETRITIS. Is an inflammation of the endometrium. It is acute and chronic. The acute is a rare disease. The chronic is a frequent disease. Causes of the Acute. — This form occurs in young girls after acute fevers, or it may be due to taking cold during menstrua- tion, or to an extension of inflammation from other parts, to chronic catarrh, or laceration of the cervix. Symptoms. — Leucorrhcea. The discharge is thick, and often profuse, and resembles the white of an egg. Menorrhagia may be present. There is a sense of fullness or pain in the pelvis and loins. Treatment. — Treat the cause. Warm mucilaginous injec- tions, salines and rest will give the best results. EPIDIDYMITIS. 187 The chronic form is divided into corporeal and cervical. Causes. — It may follow the acute disease, or start as a chronic affection from specific or other constitutional causes. It may be due to lacerated cervix, violence during coitus, ill-fitting pessa- ries, etc. Symptoms. — Leucorrhcea is the principal symptom. Treatment. — Treat the cause. If from lacerated cervix, reduce the size of the uterus by leeches, scarifications, iodine, hot-water injections and glycerine tampons. If the leucorrhcea still persists operate for laceration of the cervix. If there is eversion of the cervical mucous membrane scarify it. If there be chronic catarrh of the cervix, relieve the congestion by local measures, and use astringent applications to the cervical mucous membrane. If the body of the uterus is involved, the patient is usually sterile. In this case dilate the uterus with tents left in for twenty -four hours. After dilatation wash the cavity with carbolic acid water (40 per cent.) and apply to the endometrium by means of cotton on an applicator, solutions of corrosive subli- mate, zinc sulphate, or Monsel's solution and glycerine, repeating the application every three or four days. There should be absence from sexual intercourse (Pozzi, Skene and Grooddell.) EPIDIDYMITIS. Is an inflammation of the epididymis. It is the most common of all the diseases of the testicle. It occurs at all ages. One attack predisposes to another. It is often double. Fournier states that epididymitis occurs once for every eight or nine cases of gonorrhoea. In some individuals every attack of gonorrhoea is attended by a swollen testicle (Keyes). Causes. — Traumatic violence and cold may cause it. Pro- longed sexual excitement may cause it; but urethral inflamma- tion or irritation from gonorrhoea, stricture, or the passage of in- struments is by far the most active cause. It is an extension of the inflammation from the orifice of the ejaculatory duct to the epididymis. Symptoms. — First attacks, like first attacks of gonorrhoea, are usually the most severe. If there be a gleety or gonorrhoea] 188 A COMPENDIUM OF PRACTICAL MEDICINE. discharge, it stops after the testicle begins to swell, but soon re- turns. There is a feeling as if the cord were being pulled upon, and pain in the back. There is frequent desire to urinate, and intense pain in the testicle, which is swollen. The pain is of the sickening variety, making patients feel faint. Rest on the back with the testicle raised modifies the pain. Epididymitis lasts about two weeks. Hardness of the epididymus may remain be- hind for months or even years. Sterility may be produced if the epididymitis be double. The testicles do not atrophy. The pa- tient is by no means impotent. He ejaculates semen, but it contains no spermatozoa. Treatment. — A suspensory bandage shonld be worn during the existence of urethral disease. Rest on the back, elevation of the testicle, hot flax-seed poultice, and a laxative, maybe all that is necessary. In severe cases, the testicle is enveloped from the start in a tobacco poultice. The poultice is made by mixing a paper of any fine -cut tobacco (Bj.) in about (3x.) of hot water, bringing the whole to a boil, and then adding ground flax seed until the proper consistence. The poultice is sprinkled with laudanum and placed upon the testicle as hot as can be borne, and covered with oiled silk. This poultice should be renewed every eight hours, until the indurated epididymus has lost its sensitiveness to pressure. Powdered opium (gi-ii.) mixed with stramonium ointment (§i.) may be used instead of the tobacco poultice. According to Keyes, the tobacco poultice is more ser- viceable than any other agent. Ice is not good. In extreme pain, when the cord has become strangulated, ten to fifteen leeches above the groin will often calm the pain as by magic. When pain is caused by extreme distention of the tunica vagin- alis with fluid, puncture it, and let out the fluid. Patients should stay in bed about one week in mild cases, and ten to twelve days in worst cases. Tonics and cod-liver oil do good (Keyes). EPISPADIAS EPITHELIOMA ERUCTATIONS. 189 EPISPADIAS. Is a fissure of the superior wall of the urethra, with ectopia of the canal. It is very rare. The urethral opening may be upon the glans, or anywhere along the top of the penis, as far back as its root. When the membranous and prostatic urethra are involved, there is also exstrophy of the bladder. Epispadias is an arrest of development in the upper wall of the urethra. Treatment. — A cure cannot be promised from operative pro- cedure. Operations which have been undertaken very often fail, erections and contact of urine, with smallness of flaps, being the chief causes. A proper urinal is the best treatment. EPITHELIOMA. Is a form of cutaneous cancer. These tumors affect the skin or mucous membrane, and never originate in any other tissue. They infiltrate the parts with which they come in con- tact, and do not, as innocent tumors, simply separate them. They are the common forms of cancer found in the lips, tongue, oesophagus, rectum, scrotum, penis, clitoris, os uteri, vulva, etc. As a local disease, epithelioma may progress slowly for years, and cause little pain, and five^ six, or even fifteen years may elapse before advice is sought. The surface of an epithelial cancer may be dry and warty, or ulcerating; when ulcerating the discharge will be a thin or creamy fluid (Bryant). Treatment. — These cancers should always be removed; and the sooner this is accomplished, the better the prospects of a cure. ERUCTATIONS. (Offensive). Patients are sometimes greatly annoyed by eructations of an offensive gas, with the odor and flavor of rotten eggs — a gas consisting largely of sulphurretted hydrogen. In such cases the urine is loaded with oxalic acid, and to correct the oxaluria on which the eructations depend, the mineral acids should be given in the proper doses (Ringer). 190 A COMPENDIUM OF PRACTICAL MEDICINE. ENTERALGIA. (See Colic.) EPHIDROSIS. Called also hyperidrosis, is an augmented sudoriparous secretion. Causes. — It may accompany any disease, and especially phthisis, as the result of debility. It may occur from excitement of the body or mind. In some cases there is no apparent cause. The perspiration may be general or local. It is sometimes lim- ited to one side of the body or face, when it is supposed to result from faulty innervation of the sympathetic. The sweating is often limited to the soles, palms, axillae, groins and genital organs. The hands are moist, clammy and cold from rapid evaporation of the sweat. In the feet, the secretion is confined by the stockings and shoes, and is apt to inflame the soles, leav- ing them very tender, so that walking or standing is painful. A species of bacteria which grows and multiplies in this sweat is the source of the offensive odor (Anderson). Treatment. — For the general sweating from wasting diseases, tonics, such as quinine, the mineral acids, strychnia and arsenic are recommended. Atropia in doses of yio gr. is the most power- ful of all remedies for general sweating. Some benefit may come from sponging the body with vinegar and cold water. For the local sweating, Dr. Thin advises the changing of the stockings twice daily. Dr. Marten advises washing the feet night and morning with soap and water, and sponging with the following lotion : R Plumbi acetatis 3j Aceti destillati §j. Spiritus vini methylati 3ij. Aquae ad ^xvj . — M. Dr. Simonton recommends the use of finely pulverized alum. The feet and socks are thoroughly dusted with the powder. Repeat this process every two or three days, and the feet will become hardened. In mild forms, tannic acid 5j. to ovj. of alco- hol may be rubbed on several times daily. Dust the feet thor- oughly with pulverized salicylic acid before putting on the FETOR OF AXILLA FEVERS. 191 stockings, and wash them with permanganate of potassium (gr. xxx.-Oj.) evening and morning and apply belladonna lin- iment before going to bed to the feet. FETOR OF AXILLA, BREATH AND FEET. These are very annoying conditions and the physician is often consulted concerning them. Permanganate of potassium is an elegant toilet preparation for destroying the odor of a foul breath, the smell of the axillae, and the fetor of the sweat of the feet, and may be used as follows: R Potassii permanganatis gr. x.-xxx. Aquae £ viij . — M. Sig. : Apply locally frequently. — Bartholow. The following formulae may be used for the above condi- tions : R Sodii bicarbonatis 3iij. Aquae ^viij . — M. Sig.: Apply as a lotion frequently. — Bartholow. R Atropiae sulphatis gr. iv.-viij . Aquae rosae gij . — M. Sig.: Apply to the part with a brush. — Bartholow. R Acidi salicylici gr. xLv. Pulv. amyli 3V. Pulv. talc 3xxij. — M. Sig. : Dust over feet. JSr Sodii biboratis gr. xv. Thymoli gr. viiss. Aquae destillatae Sxij . — M. Ft. sol. Sig.: A mouth wash. (For letor of breath). — Magitot. FEVERS. (Classification of.) Fevers are distinguished as essential and symptomatic. A symptomatic fever is one which is secondary to some local affec- tion, such as an acute inflammation. An essential fever is one which is not secondary or symp- tomatic, but is primary or idiopathic. The essential fevers are as follows : 192 A COMPENDIUM OF PRACTICAL MEDICINE. I. Febricula, a form of fever characterized by its short duration and mildness. II. Continued Fevers, which are distinguished by the un- broken continuity of the febrile phenomena, such as typhoid, typhus, relapsing and erysipelatous fevers. III. Periodical Fevers, which are distinguished by the occurrence of distinct paroxysms of the febrile phenomena, such as intermittent, remittent, typho- malarial and yellow fevers and dengue. IV. Eruptive', or exanthematous fevers, in which an erup- tion on the surface of the body is a prominent feature, as in small-pox, scarlet fever, measles, roseola and typhus. When the decline of a fever is rapid, occupying only a few hours, or a day or two, the fever is said to terminate by crisis. When the decline is protracted the termination is by lysis. (Each of the above fevers will be considered in its proper place.) Causes of Essential Fevers. — Micro-organisms are among the most important of fever -exciting agents, and are probably in- volved in the causation of all the essential fevers. Animal heat is the result of chemical processes, especially processes of oxida- tion, which are constantly going on within the body; but it is not known in what way the abnormal elevation of temperature is produced in fever (Flint). FISSURE OF THE ANUS. Produces more misery than any other local disease, and renders the natural act of defecation an agonizing one. Causes. — It is usually caused by the mechanical splitting of the orifice of the anus, from the passage of a large or indurated motion. It may be due to scratching the parts when highly irritable. Constipation, high feeding, sedentary habits, and want of local cleanliness are the common causes. Symptoms. — There is pain during \he passage of the motion. The motion may be streaked with a line of pus or blood. There is an unnatural contraction of the sphincter, and great pain is caused by attempting to introduce the finger. A careful exam- ination will often reveal the presence of an ulcer on the verge of FISSURE OF ANUS. 193 or within the sphincter. Simple fissures are often associated with piles (Bryant). Treatment. — Happily for patients, the treatment of the dis- ease is as successful as it is simple. Simple fissures are readily treated by the administration of a laxative, the local application of nitrate of silver, or of lead lotion mixed with the extract of opium, and local cleanliness. When the parts are indolent, black wash may be used, or calomel dusted over the part. When an ulcer has existed for some time and has a hard base, the most efficient means of cure is division of the base of the ulcer with the superficial fibres of the sphincter, or forcible dilatation of the sphincter, and its laceration with the thumbs in the rectum. After=Treattnent, — The bowels must be kept slightly loose, and for this purpose the following may be used: {fc Olei olivse §j. Potassii carbonatis gr. xLv. Aquas Mentha? piperita? Sviij. — M. Sig. : One ounce three times daily. PRESCRIPTIONS FOR FISSURE OF ANUS. jfc Iodoformi , Acidi tannici aa 5j • — M. Sig. : Unfold or open the fissure, and fill with and dust over the powder. — -Bartholow. j& Potassii bromidi. 5iss. Glycerinse Sj. — M. Sig. : Apply with a brush locally. — Ringer. |& Acidi tannici.. 3j. Gly cerinse 5 ij . — M. Sig.: Introduce into the rectum night and morning on a tent. — Waring. J& Extracti hydrastis fluidi Sj Sig. : Apply to the fissure. — Bartholow. 194 A COMPENDIUM OF PRACTICAL MEDICINE. FISSURES OF THE NIPPLE, Are excruciatingly painful, and are capable of exciting even a high degree of fever. They occur with greatest frequency in nipples which have been flattened by the pressure of corsets ,(Lusk). Treatment. — The nipple should be kept clean, and all irri- tating matter removed. When one nipple only is affected, the child need only be applied to the sound side. The healing pro- cess may be promoted by lead-lotions, by a solution of tannin, or by some astringent ointment. Keep upon the nipple a rag wetted with Goulard's extract, a teaspoonful to a tumbler of water. If the child be troubled with sprue, its mouth and the nipples of the mother must be washed with a solution of boracic acid. PRESCRIPTIONS FOR FISSURE OF THE NIPPLES. |fc Cocaini muriatis gr. x. Aquae destillatae 5ij. — M. Sig. : Apply with a brush to the fissure half an hour before nursing, and wash well with warm water just before nursing. — L. Starr. Jfc Plumbi nitratis gr. iv-x. Glycerinae §j . — M. Sig.: Apply after nursing, and wash the nipple carefully before the next nursing. — Bartholow. Jfc Acidi carbolici gr. xxiv. Aquse Sj • — M. Ft. lotio. Sig.: Apply several times daily to the nipples. — Parvin. Jfc Acidi boracici gr. xx. Mucilag. acacise Sj- — M. Sig.: Use a nipple shield, and, after nursing, dry the nipple well with absorbent cotton and apply the lotion with a camel's hair brush. Should this fail, touch the fissure with a point of nitrate silver every other day. —Starr. Jfc Tincturse benzoini composita3 §ss. Glycerini 3ss. — M. Sig.: Apply to affected parts. — Stille. fistula. 195 FISTULA. Is an unnatural communication between a normal cavity or canal and the outside of the body or with a second body or canal. According to their situation, they are named vesico- vaginal, and recto -vaginal in women, and recto -vesical in men, gastric, biliary, fgecal, anal, salivary and urinary fistulse. Causes. — They may be congenital or acquired. The acquired fistulge are either due primarily to some suppurative or ulcerative process or to mechanical violence, operative or otherwise, and subsequently to a want of repair. The fistula may be a short or a long narrow tract. When the fistula is of recent origin, the walls will be soft; when old, hard (Bryant). Treatment. — In a general way, it may be asserted that so long as the cause of a fistula exists repair cannot go on; so that in urinary fistula, when stricture is the cause, the stricture must be treated before the fistula. When the cause of the fistula has been cured or removed, then the fistula itself may be treated, and various are the means that can be employed for the same. Vaginal and rectal fistulse usually require plastic operations. The whole margin of the fistula must be pared with nicety and accuracy, and the raw surfaces brought into apposition. The constitutional treatment resolves itself into tonics, good food and fresh air. PRESCRIPTIONS FOR FISTULA. j& Cupri sulphatis gr. ii.-iv. Aquae §iv. — M. Sig. : Inject once a day. — Sir A. Cooper. |& Argenti nitratis gr. ij. Aquas destillatae gviij . — M. Sig.: Inject once a day. (Fistula in ano.) — Druitt. {fc Tincturse iodini 3J. Sig.: Inject once daily. — Waring. Jfc Extraoti sanguinaria) fluidi sij. Sig.: Inject a sufficient quantity to fill and distend the fistula. —Phillips. 196 A COMPENDIUM OF PRACTICAL MEDICINE. FLATULENCE. Trie gas in the intestinal canal may be merely air which is swallowed; or it may result from fermentation or decomposition of food. It causes a disgust for eating, a feeling of distention, and sometimes actual pain, shortened breathing, palpitation of the heart, eructation or belching of gas with or without an odor (DaCosta). Treatment. — According to Wood, the remedy most effective to remove and permanently cure a disposition to the accumula- tion of flatus in the bowels is an infusion made with half an ounce of calumba, half an ounce of ginger, a drachm of senna, and a pint of boiling water, and given in the dose of a wine- glassful three times a day. PRESCRIPTIONS FOR FLATULENCE. |& Aquae camphorae §iij. Tincturae lavandulae comp §j. — M. Sig.: A tablespoonful every hour or two. (For hysterical flatu- lence and flatulent colic occurring at climacteric.) — Bartholow. jfc Spiritus chloroformi Tincturae cardamonii comp...aa...gij. Sig.: A teaspoonful every half hour in water. — Bartholow. Jfc Misturae asafoetidae |iij. Sig. : A teaspoonful when necessary. (For the flatulent colic of infants.) — Bartholow. Jfc Spiritus aetheris compositi ^ij. Aquae camphorae gij. — M. Sig.: Two teaspoonfuls to expel flatus from stomach. — Bartholow. Jfc Spiritus aetheris comp Tincturae ammonii valerian... aa...£J. — M. Sig : A teaspoonful in water every fifteen minutes until re- lieved. (For hysterical flatulence and globus hystericus.) — Bartholow. J£r Olei terebinthinae 3j. Sig.: Three to five drops on a lump of sugar. — Bartholow. FKECKLES. 197 FRECKLES. Called also lentigo, is the most circumscribed form of pig- mentation, and the deformity to which in well marked cases it gives rise, is so well known as to require no description. It is most apt to appear in persons with delicate skins, and in those who have fair complexions, but above all in red-haired people. It is always aggravated by exposure to the sun, hence it is met with on the face, neck and hands more particularly, and is most pronounced during the summer months. Treatment. — Avoid unnecessary exposure to the sun. Ac- cording to Bartholow the following lotion is useful in freckles, sunburn and tan : JSr Potassii carbonatis giij . Sodii chloridi gij. Aquse rosse ^ viij . Aquae aurantii flor gij. — M. Sig. : Apply to part. jfc Liquoris potassse 3j\ Aquse rosse §ij. — M. Ft. lotio. Sig.: Face-wash. (In tan and freckles.) — Todd. (fc Hydrargyri chloridi corr gr. j. Zinci oxidi gij . Zinci carbonatis ,...5ss. Glycerinse ^ij. Aquse rosse j§ viij . — M. Ft. lotio. Sig.: Apply with a sponge. (In freckles and sunburn). — Fox. j& Lactis recent^ gxiiss. Glycerinse ^viiss. Acidi hydrochlorici ZH.Lxxv Ammonii muriatis 3j. — M. Ft. lotio. Sig.: Apply morning and evening with camel's hair brush. (In tan and freckles). — Monin. 198 A COMPENDIUM OF PRACTICAL MEDICINE. FROST=BITE. When concentrated cold is applied for a period sufficient to arrest the circulation in a part, a frost-bite is the result. The first effect of cold upon a part is a sense of numbness and weight and a feeling of tingling. If the cold continue, the part will become stiff and at last insensible, feeling dead. The frozen part is white and waxy. The constitutional effects of cold are at first stimulating, and subsequently depressing. Treatment. — Sudden alteration of temperature is most in- jurious. The aim of the surgeon should be to recall the affected parts gradually to their normal condition by gentle friction in the course of the veins with furs or flannels. Stimu- lants should be administered internally. Friction with snow or ice-water is most useful. On reaction the parts may be raised, and warm milk with a little brandy given. Should reaction be too severe, it must be checked by lead or spirit lotions. When gangrene follows, carbolic acid and oil are probably the best applications. If a whole foot be frozen, amputation may be called for, the surgeon always waiting until the line of demarcation is formed. PRESCRIPTIONS FOR FROST=BITE. R Acidi carbolici gj. Tinct. iodinii ^ij . Acidi tanici 3ij . Cerati simplicis %iv. — M. Ft. ungt. Sig.: Apply locally. — Bartholow. R Linimenti camphorse Linimenti saponis comp Olei cajuputi aa §j. — M. Ft. linimentum. Sig.: Apply to the unbroken skin. —Brande. B Camphoraa 3J . Olei cajuput 3ij. vEtheris gj. — M. Ft. linimentum. Sig.: Apply locally to the unbroken skin. — Tortual. FUEUXCLE — FITS FELON FAIXTIXG. 199 FURUNCLE. (See Boil.) FALLING SICKNESS. (See Epilepsy.) FITS. (See Convulsions.) FLOODING. (See Menorrhagia.) FELON. Called also paronychia, or whitlow, is an abscess of the thumb or fingers. The superficial whitlow or felon consists of inflammation of the surface of the skin of the last phalanx. It is generally seated immediately around and beneath the nail. It is attended with great pain and throbbing, and suppuration at the root of the nail, which may come off. The deep-seated variety is attended with a severe throbbing pain, great tenderness, tense and resisting swelling, and great constitutional disturbance. The inflammation usually begins in or beneath the periosteum. It may lead to suppuration, and leave the fingers stiff and useless. Treatment. — If purgatives and fomentations do not speedily bring relief, the finger must be freely laid open. The knife should be carried deep enough to feel the resistance of the bone or tendon. A strong solution of nitrate of silver in nitric ether applied over the part may abort the affection, if at the beginning (Bartholow). FAINTINGS. Treatment. — In the threatened fainting, it is a good plan to direct the patient, whilst sitting down, to lean forward, and place the head between the legs as low down as possible, so that the blood may gravitate to the brain. Brandy or wine are the best remedies, when the heart is suddenly enfeebled from fright, loss of blood, accidents or other causes. Salts of ammonium, applied to the nose, and breathed into the air-passages, arc commonly used in fainting. Cold water smartly sprinkled on the face of a swooning person is a familiar way of restoring consciousness (Ringer). 200 A COMPENDIUM OF PRACTICAL MEDICINE. FATIGUE. Treatment. — The sitz-bath greatly relieves fatigue and soothes an irritable, restless state of the nervous system. A pedestrian, after great exertion and fatigue, will find it an agree- able restorative, preventing stiffness and aching muscles, to strip and wrap himself in a dripping wet cold sheet, well rubbing himself afterwards; but if stiffness still remains, a few drops of tincture of arnica taken internally will remove it. Tea and coffee are especially useful in a fatigued state of the system, and under ordinary circumstances are preferable in this respect to alcoholic drinks (Ringer). FLUSHING HEATS. The distressing symptoms occurring during the "change of life " are very various. There are heats and flushings, followed by free perspiration, and prostration is sometimes extreme. These symptoms will generally give way to bro- mide of potassium. Eucalyptol is given in the various symp- toms connected with the change of life, as flatulence, palpitation and flushings. A woman, from the sudden arrest of menstrua- tion, or through depraved health, or nervous depression, or more frequently at the "change of life," suffers from frequent attacks of flushings or heats, starting from various parts, as the face, epigastrium, etc., and thence spreading over the greater part of the body. These heats may last a few minutes only, or an hour or more, and may be repeated many times a day. The least ex- ertion or excitement may bring on these heats, and such a patient generally complains of cold feet, and sometimes of cold hands. The flushings are occasionally abruptly limited, reach- ing to the thighs, knees or elbows, and while all the parts above these feel burning hot, the parts below feel icy cold. In many of these cases palpitation or flutterings at the heart occur on the slightest excitement. Nitrite of amyl will prevent or greatly lessen these flush- ings or heats, and should be given in doses of a tenth to a sixth of a minim, in thirty times its volume of rectified spirit, every FEACTUEES. 201 three hours, with an additional dose as soon as the flush begins. Both men and women, but chiefly women about forty or fifty years of age, are apt to complain of a sensation of great weight and heat on the top of the head, with frequent flushings of the face, suffusion of the eyes, hot and cold perspirations, and some- times shooting pains passing up the back of the head In these cases, a drop of laudanum, with two of the tincture of nux vomica, repeated three or four times a day, will give great re- lief. Valerianate of zinc, given in three to five grain doses in a coated pill, will usually remove the flushings of the face, hot and cold perspirations, fluttering at the heart, and heat, and weight on top of the head (Ringer). FRACTURES. A fracture is a solution of continuity of bone, while dislo- cation is a solution of contiguity. Kinds, — 1. Complete. 2. Incomplete. 3. Epiphyseal sep- aration. A complete fracture is where division completely traverses the thickness of the bone. An incomplete fracture is where division does not completely traverse the thickness of the bone. The epiphyseal is where the epiphysis becomes separated from the bone or diaphesis. Complete fractures may be of the following kinds: 1. Simple. 2. Compound. 3. Comminuted. 4. Complicated. 5. Impacted. 6. Multiple. 7. Gunshot. 1. Simple is where the bone is broken in one place only, and with no communication with the external air. 2. Compound is where there is communication with the external air. 3. Com- minuted is where there are a great many small pieces of bone. 4. Complicated is where the fracture is associated with the main vessels, nerves, veins, or some internal organs. 5. Impacted is where compact tissue is driven into the cancellous tissue. 6. Multiple is where the bone is broken into several pieces. 7. Gunshot is where the fracture is the result of the explosion of fire-arms. Any fracture may be oblique, transverse, longitudinal or dentated. Incomplete fractures are the following: 1. Green- stick. 2. Partial. 3. Fissured. 4. Punctured. 5. Stellate. (>. 202 A COMPENDIUM OF PRACTICAL MEDICINE. Spiral. 7. Gunshot. Epiphyseal separations occur in early life, under twenty years. The causes, symptoms and treatment are the same as fractures. Most fractures occur between the ages of twenty-five and sixty. More common in men than in women. More occur in winter than in summer. The clavicle and radius are more often broken than any other bones. Symptoms. — 1. False point of motion. 2. Eotary displace- ment. 3. Angular deviation from the normal axis. 4. Crepitus. 5. Tenderness on pressure. 6. Unnatural mobility. 7. Retrac- tion of muscles. 8. Ecchymosis and swelling. 9. Shortening. Crepitus is the most important sign, but may be absent some- times, because of something between the fragments. General Management. — Give every fracture proper and dili- gent attention. When called to see a case: 1. Do not move the patient to a vehicle and do not set him upright. 2. Put on a temporary splint at once and carry home in a horizontal position. 3. Put patient on a hard mattress and not on a feather bed. 4. Cut off the trousers, boot and shoe, and do not pull them off. 5. Inspect the fracture, have a good assistant to make strong ex- tension of the limb in the long axis, and then he may raise the limb. You may then inspect it to a better advantage. 6. Make extension. Get the great toe in a line with the inner margin of the inner malleolus and patella and then have the foot at right angles with the limb. Give a hypodermic injection of morphine to relax muscles. You may divide every tendon in case you can not keep the muscles from contracting. Diagnosis. — Three signs are sure: 1. Mobility. 2. Crepitus. 3. Displacement. In cases of doubt, give an anaesthetic. Treat any injury as you would a fracture when there is doubt as to what it is. (For the treatment of special fractures, see works on surgery.) GALACTORRHEA. Is a constant dribbling of milk from the nipple. It is an affection which may continue long after lactation has been sus- pended. It acts like any other profuse discharge in exhausting the strength and producing a wasting of the tissues. GALACTOEKHCEA GALL-STONES GAXGKEXE. 203 Treatment. — Consists in interrupting lactation, in compres- sion of the breasts with bandages, and tonics to repair the gen- eral health. Of special measures, saline laxatives and the inter- nal administration of iodide of potassium are of most repute (Lusk). f PRESCRIPTIONS FOR GALACTORRHEA. |& Olei camphorati gvj. Sig. : Apply externally to breasts. — Waring. J& Potassii iodidi gj. Aquae §j. — M. Sig.: Twenty-five to thirty drops in water, once or twice daily. — Roussell. fy Atropinse sulphatis gr. iv. Aquae rosae gj . — M. Sig.: Apply on lint around the breasts, and remove when the throat becomes dry. — Bartholow. QALL=ST0NES. (See Biliary Calculi.) GANGRENE. Called also mortification, is the death of any part of the body in consequence of disease or injury. It is divided into acute and chronic. The acute is known as moist gangrene. The chronic, as dry or senile gangiene. Causes. — Predisposing and exciting. The predisposing causes are : Defective nervous power, as in palsied limbs, or division of large nerve trunks; general debility from poor food and improper nourishment; use of alcoholic drinks; atheroma- tous changes in the arteries of old people. The exciting causes are produced by whatever interferes with or arrests the circula- tion of a part. The arterial blood to a part may be cut off by accident, by ligature, by thrombosis or embolism of the arteries. The circulation through a part may be obstructed by the growth of a tumor or by the formation of bed-sores. Extreme weakness of the heart's action may produce gangrene, or whatever de- stroys the cells of a part, as injuries, chemical agents, prolonged use of mercury or excessive heat or cold (Bryant). 204 A COMPENDIUM OF PRACTICAL MEDICINE. Symptoms. — Are local and constitutional. Locally, at the beginning, the pain and tenderness of the part become most acnte; it is of a severe, burning character; the discoloration is of a vivid-red color; the local heat is increased. The constitu- tional symptoms are of a low typhoid cast. There is a profuse perspiration. When the part is dead, the pain and tenderness cease; it becomes cold, the bright redness disappears, and large blisters form which burst and leave a greenish discoloration beneath. The limb becomes greatly swollen, soft and boggy; a sickening fetid smell is exhaled. When the progress of the dis- ease is arrested, the line of demarcation forms which separates the living from the dead tissue. Treatment. — To avert the threatened gangrene the patient, if young and robust, with a full hard pulse, should be purged. If there is a great deal of inflammation, incisions should be made into the part, and lead water with laudanum applied. The timely use of a blister over the entire surface will sometimes bring about healthy action, and set aside the tendency to gangrene. Iron, quinine, strychnine, stimulants and nutritious diet should be prescribed. The limb should be put in an aseptic condition by washing it with toVo solution of corrosive sublimate, and then applying cotton wool and a bandage. It should be elevated and at rest. To allay fetor, permanganate of potassium, carbolic acid and the chlorides must be resorted to. Cleanliness and thorough ventilation of the apartments must be insisted upon (Bryant). CHRONIC, DRY OR SENILE GANGRENE. Causes. — Diseased state of the arteries, weak heart and con- sequent feeble circulation may cause it. In many cases it begins without any apparent exciting cause. In old people, diabetes is a fertile cause of gangrene of th.t toes and feet. Symptoms. — There will be a sensation of weight in the part, with coldness, numbness, itching and tingling of the feet, and cramps of the calves are complained of. On examination, a small dark or purplish spot will be found on the inside of one of the toes, not larger than a mustard seed. This is followed by a vesicle which exposes a black surface on bursting. This grad- GANG-RENE. 205 ually spreads until the whole foot is involved. It may begin on several toes at the same time, or it may show itself on the instep or heel. The part destroyed becomes black, dry, withered, cold and insensible. Treatment. — As soon as the line of demarcation forms be- tween the dead and living tissue, the health of the patient im- proves. Tonics with stimulants should be given early. Locally cotton wool in thick layers around the foot and limb must be used. Question of Amputation. — If the gangrene is the result of a severe injury, and it is rapidly spreading, or if it arises from a wound or ligature of an artery, the rule is to amputate at once. In the above cases, do not wait for the line of demarcation to form. In chronic gangrene, due to diabetes, or ergotism, wait for the line of demarcation to form. In cases of frost-bite, or burn, or disease of the arteries, wait for the line of demarcation (Bryant). PRESCRIPTIONS FOR GANGRENE. R Brorainii |j. Sig. : Apply to the slough with a glass rod. — Bartholow. R Cerati resinse comp 3J. Extracti opii aquos 3J. Olei olivte ^ij. — M. Ft. ungt. Sig. : Apply locally after the slough has separated. — Witherstine. R Liqour hydrogenii peroxidi §iv. Sig.: Apply locally, pure or diluted. R Acidi nitrici gjl Sig.: Apply to the ulcer with a glass rod until it is converted into a firm, dry mass. — Waring. R Sodii sulphitis gj-ij. Aquae Sx. — M. Ft. lotio. Sig. : Use as a lotion, or apply on compresses. — Waring. R Pulv. acidi salicylici 5J. Sig.: Use locally as a dusting powder. (To destroy fetor and change morbid action). — Bartholow. 206 A COMPENDIUM OF PRACTICAL MEDICINE. GASTRALGIA. Is a painful state of the sensory nerves of the stomach, induced by irritation, and without fever. Causes. — The neurotic temperament, malaria, and the abuse of tea and coffee have no little influence in causing the disease (Bartholow). Strawberries, or honey, or other ingesta, or cold may bring on an attack (Flint). Symptoms. — Severe paroxysmal pain in the epigastrium, radiating upward over the chest and downward through the ab- domen, and through to the back is the most characteristic symptom. The pain is diminished by pressure, and the patient instinct- ively lies or presses firmly on the abdomen. In the severest cases the pain is excessive. The duration of the attacks may be a few hours, or a day or two, or a month with intermissions. Usually the attacks are of short duration, and terminate with eructations of gas and with vomiting. Persons of sedentary habits are more likely to be affected than those engaged in active pursuits (Bartholow). Treatment. — During a paroxysm, the first point is the relief of pain by the hypodermic injection of morphine. The pain and also the nausea and vomiting may be arrested by creosote or carbolic acid. Equal parts of tincture of iodine and carbolic acid, of which a drop may be given every hour in a little cold water, will often stop the pain and vomiting. The paroxysms may be relieved by one drop of Fowler's so- lution and two to five drops of tincture of opium. The long continued use of arsenic in a small dose — one drop ter in die of Fowler's solution — is more effective according to Bartholow's ex- perience than any remedy mentioned. Salicylic acid is sometimes serviceable for intermittent cases. When attacks of gastralgia are due to indigestible food, the first duty is to empty the stomach. Excellent results are often ob- tained from the use of muriatic acid, combined with tincture of mix vomica. The diet should be regulated. A sinapism and fomentations to the epigastrium are useful as aids. Mild cathar- tics may be given (Bartholow). Bismuth in doses from a scruple GASTRALGIA GASTRIC ULCER. 207 to a drachm three or four times a day, has been found to be curative, according to Flint. The constant current in the hands of Leube, Beard, and Rockwell has proved efficacious. Change of habits from those of sedentary to active life is of the first importance. Alcoholic stimulants in moderation with meals may be ad- vised for a time (Flint). PRESCRIPTIONS FOR GASTRALGIA. R Tincturse conii 3j. Tincture Valerianae Tincturse opii camphoratse Aqua? lauro-carasi — aa gij . — M. Sig. : Seven drops in a little milk when the pain appears. — Monin. R Extracti cocae fluidi 3J. Syrupi aurantii flor 3v. Aquae ad ^ij. — M. Sig. : A teaspoonful every hour till relieved. — D'Ardenne. R Liq. chloroformi aq. sat £xv. Aquae aurantii flor 3xiv. Tincturae anisi stellati 3J. — M. Sig. : A teaspoonful every quarter of an hour. — Dujardin-Beaumetz. R Liquoris potassii arsenitis ^j. Sig. : One drop in water three times daily continued for months. — Bartholow. GASTRIC ULCER. Causes. — Ulcer of the stomach is a comparatively common disease, and is found to exist in five per cent, of the deaths from all causes. It occurs in females oftener than in males. The lia- bility to it is greatest between the ages of fourteen and thirty, although no age is exempt; it has been found in the new born babe and in the octogenarian. Amenorrhea, anaemia, chlorosis, the puerperal state, prolonged lactation, and tuberculosis are predisposing causes. Ulcer of the stomach may result from an habitual stooping position, as in milliners, seamstresses and shoe- makers. Burns of the chest and abdomen sometimes causes ulceration of the duodenum (Bartholow and Loomis). Symptoms. — It is a chronic malady usually. There are three important symptoms of gastric ulcer — pain, indigestion. 208 A COMPENDIUM OF PRACTICAL MEDICINE. and vomiting (haematemesis). Pain is one of its constant symp- toms; at first it is dull and heavy, then it becomes burning, gnawing, and fixed, boring through from front to back, and occupying a space which the finger may cover. It usually comes on soon after the ingestion of food, and lasts during the entire period of stomach digestion; occasionally it is not present until an hour or so after eating. Very great tenderness is experienced on pressure over the vertebrae behind and the seat of pain in front. Attacks of gastralgia occasionally come on. Nausea and vomiting may accompany the pain; in some instances there is pyrosis, or "water -brash;" usually the vomiting occurs when the pain is most severe, and temporarily relieves the pain. The matter vomited consists, first of the food taken into the stomach, which has a strong acid reaction; later it is mingled with bile. Vomiting of blood is the most characteristic single symptom, but is not pathognomonic. It is absent in about one -third of the cases, and may occur only at the monthly period. Cachexia is a late symptom, the appetite is rarely impaired, sometimes it is even increased. The face, when the pain is intense, is "drawn" and haggard, which by some is regarded as characteristic of ulcer of the stomach. Obstinate constipation is the rule in ulcer of the stomach, but hemorrhage may cause diarrhoea. The blood gives to the dejections a dark color, and a tarry consistence (Bartholow and Loomis). Differential Diagnosis. — Gastric ulcer may be mistaken for cancer of the stomach, hepatic colic, cardialgia, or gastralgia, and chronic gastric catarrh. In cancer there is usually a history of hereditary cancer. Cancer is seldom met with in persons under forty; while ulcer of the stomach occurs most in young adults, and is usually associated with anaemia, chlorosis, pro- longed lactation, or compression of the stomach, as in cases of shoemakers and sewing- girls. The pain in cancer is continuous, and described as lancinating; while in ulcer the pain is inter- mittent, greatly increased by taking food, often referred to the lower dorsal vertebrae, and described as gnawing or burning. In cancer, haematemesis has a sooty or coffee -ground appearance, while in ulcer it is a bright red arterial blood. Vomiting, in cancer does not relieve the }3ain, is not very severe, and comes on GASTRIC ULCEE. 209 late; but in ulcer it is severe, comes on early, and affords tem- porary relief from the pain. The cancerous cachexia and de- bility are present early and steadily progress in cancer; while in ulcer there may be pallor, but no characteristic cachexia. The presence of an epigastric tumor establishes the diagnosis of cancer. In hepatic colic, the pain is in the region of the gall- bladder, and shoots to the right shoulder and back, comes on suddenly and suddenly ceases. In cardialgia or gastralgia, the pain is not excited or in- creased by the introduction of food into the stomach, but often comes on when the stomach is empty, while in ulcer the pain is associated with ingestion of food. In cardialgia or gastralgia, pressure over the epigastrium, and the ingestion of food, relieve the pain; the reverse is the case in ulcer. Cardialgia or gastral- gia is relieved by the constant current and faradization, which increases the pain of gastric ulcer. In cardialgia there will be a history of neuralgia in other parts of the body. In chronic gastric catarrh with hemorrhage there is the his- tory of diseases of the liver, heart, lungs or kidneys; while in gastric ulcer there is usually no such history. The pain in gas- tritis is not so intense as in ulcer. A coated tongue, great thirst, malaise, and pyrexia are prominent in cases of chronic gastritis, and absent in ulcer. The vomiting in chronic gastritis conies on in the morning, and the matter vomited is stringy mucus; while in ulcer the attacks of vomiting usually follow the taking of food (Bartholow and Loomis). Prognosis. — Must be regarded as serious (Bartholow). Treatment. — Best the stomach by keeping the patient in bed, and restricting the diet to peptonized milk — a tablesj)oonful to a teacupful may be given every two hours during the day and night. Digested beef- juice may also be given. All vegetables, tea, coffee, starchy foods and fruits must be prohibited. If all kinds of food are rejected, rectal alimentation must be practiced, four ounces of defibrinized blood (containing four grains of chloral to prevent its decomposition) may be thrown into the rectum every six hoars (Loomis). Bartholow regards one to three drops of Fowler^ solution three times daily the most im- portant remedial agent. He also gives half -grain doses three 210 A COMPENDIUM OF PRACTICAL MEDICINE. times a day of nitrate of silver. Fifteen grains three times daily of sub-nitrate of bismuth are effective. The flatulence may be mitigated by sulphite of soda, carbolic acid, or the alkalies. The constipation may be relieved by the saline mineral waters, or by castor -oil where the patient will bear it. After some im- provement has been made, rice, soft-boiled eggs, animal broths, stale bread and cocoa may be allowed. PRESCRIPTIONS FOR GASTRIC ULCER. R Creasoti XTIiv. Aquae §ij. — M. J3ig.: A tablespoonful three or four times daily. ■ — Niemeyer. R Liquoris potassii arsenitis ^ss. Sig.: One drop, repeated as required to relieve the pain and •vomiting. — Bartholow. R Skimmed milk two parts and liquor calcis one part, mixed as a steady diet. — DaCosta. R Bismuthi subnitratis gij. Pulv. opii. gr. iij. — M. In pulv. no. xii. div. Sig. : One powder thrice daily, followed continuously by the fol- lowing: R Argenti nitratis gr. v. Tincturse opii 3iss. Aquse anisi ad ^iiss. — M. Sig.: A teaspoonful thrice daily with rest to the stomach. — W. H. Thomson. GLANDS, (Enlarged Lymphatic.) Chronic glandular enlargement is a very common affection. It is found in the strumous and feeble child as a chronic and slightly painful enlargement of a gland or glands, more particu- larly those beneath the jaw and about the neck. At times these glands suppurate and leave ugly sores. Treatment. — For the ordinary or strumous enlargement of the glands in children there is no drug equal to cod-liver oil, the syrup of the phosphate-, or of the iodide of iron, or the tincture of quinine. Good food and fresh air are also essential points in the treatment of these cases (Bryant). ENLARGED GLANDS GLEET. 211 PRESCRIPTIONS FOR ENLARGED GLANDS. R Potassii iodidi 3j.-iv. Syrupi aurantii cort • •...§■ Aquas cirmamom ii ad £iij . — M. Sig. : A teaspoonful in water three times daily. — Ringer. R Calcii sulphidi. gr. vj. In pil. no. xxiv. div. Sig.: One pill every four to six hours. — Ringer. R Syrupi ferri iodidi 3j. Sig.: Five to forty minims, according to age, well diluted, after meals. — Bartholow. R Ungt. plumbi iodidi gj. Sig.: Apply to gland. — Bartholow. R Ungt. iodi comp ^j. Sig.: Apply to gland. — H. B. Sands. GLEET. Is a ruueo- purulent discharge from the urethra, the chronic stage of gonorrhoea. In gleet, a certain amount of sticky bluish fluid, often only a drop at the meatus in the morning— continues to be secreted after gonorrhoea, from altered patches of the urethra, or coming from the congested membrane behind a stricture. Gleet, then, is a symptom of two structural lesions, and signifies that there are patches of congestion in the canal, covered or not by granulations, or that stricture exists, and that the discharge comes from behind it. Prostatic congestion and enlargement are also liable to be attended by a slight gleet. Gleet tends to last indefinitely, and an individual so affected is a ripe subject for bastard gonorrhoea. The sinrple congested patches which furnish the gleety discharge, are kept from getting well by alcohol, malt liquors, sexual excesses, fatigue, violent exercise, anaemia, gouty or strumous habit. Gleet is contagious when purulent, but only if it contains gonococci. All urethral discharges become gleety before they cease (Keyes). Treatment. — Eyerything earthly has an end, even a gleet, as Thiry has sagely remarked, and no treatment will succeed where over-treatment has only served to keep up the evil. As stricture 212 A COMPENDIUM OF PRACTICAL MEDICINE. already present or forming is the most common of all causes for continued gleet, it should be sought for and treated. Where no lesion is discovered, the urine must be kept mildly alkaline,, sexual intercourse avoided, and copabia or oil of sandal -wood or cubebs may be given. Stimulating or astringent injections should be employed, such as follows : R Zinci chloridi gr. j. Aquae Sj.— M. R Cupri sulphatis., g r -j- Aqua? Sj . — M. R Ferri persulphatis 5ss. Aquse 5 vj . — M. Or, R Zinci sulphatis gr. i-ii] . Liquoris plumbi subacetatis..dil...5j. — M. Or, R Aluminis exust gr. x. Aquas Sj. — M. 0r ' R Acicli tannici gr. v-x. Aquse ...Sj- — M. Or, R Zinci permanganatis gr. ss-ij. Aqua? Sj- — M. Or, R Hydrargyri chloridi corrosi gr. ss. Aquse gxij. — M. Alcohol is often efficient, and may be used as follows : To commence with two parts of rose water to one of red wine, and continue increasing the latter until pure wine can be used. Glycerine may be combined with any of the above formulae. Three points must be remembered in regard to injections : 1. They must not be too strong. 2. They must be continued for at least ten days after the discharge ceases. 3. They may produce a hypersecretion of the urethral mucus, and thus keep up the discharge. Any injection, thrown too deeply into the canal, may light up epididymitis, or cystitis. Deep urethral injections may be used, if the discharge comes from the membranous urethra. Locate the granulating area with a bull), and there deposit three minims of a solution GLEET. 218 of nitrate of silver of a strength of gr. i. to grs. xx. to the onnce of water. Repeat the application three times a week. Occasionally a fifty per cent solution in water of the gly- cerols of tannin will arrest a deep urethral discharge after the nitrate of silver fails. Sometimes the passage of a well-oiled smoothly- polished sound as large as the meatus will admit, re- peated every third day will cure the discharge (Keyes). PRESCRIPTIONS FOR GLEET. R Potassii permanganatis gr. i iij. Aquae destillatse 3j. — M. Sig. : Use as injection. — Keyes. R Zinci sulphatis gr. vj. Tinct. opii 3j. Tinct. catechu 3ij . A quae rosse ad ^ij . — M. Sig.: Use as an injection three times a day. — Witherstine. GOITRE. (Simple and Exophthalmic). Simple goitre, or Derbyshire neck, as it is generally known in England, is very common. In its most usual form it appears as a simple bronchocele, or hypertrophy of the thyroid gland. They may press upon surrounding parts and cause dyspnoea, cough, and difficult deglutition. All these tumors rise and fall with the larynx in deglutition (Bryant). Cause. — In the Derbyshire district it is generally believed that it is from the water impregnated with chalk, lime, and mag- nesia, that the disease is produced (Bryant). Treatment. — Simple goitres are to be treated on ordinary principles by tonics, fresh air, etc. The air of the room should be kept iodized by means of solid iodine put into a box with a perforated lid. Bryant has seen goitres rapidly disappear under this treatment. With the above treatment he, at times, rubs in an ointment of the iodide of ammonium, a drachm to an ounce. To paint a goitre with the tincture of iodine is useless. Dr. Mouat of Bengal, spoke very highly of an ointment of the binio- dide of mercury (three drachms to a pound of lard) rubbed in for 214 A COMPENDIUM OF PRACTICAL MEDICINE. ten minutes in the snnshine. He gives his cases of recovery by the thousands. Of late years, Bryant injects 20 or 30 drops of a mixture of equal parts of tincture of iodine and alcohol, with success. In some cases, he reports a cure with one injection. Exophthalmic Goitre is a disease characterized by exophthal- mus (protrusion of the eyeballs), enlarged thyroid, dilatation of the arteries, palpitation of the heart, and anaemia. In Germany it is known as Basedow's disease; in England as Graves' disease. Causes. — Bartholow gives moral emotions, fright, chagrin, reverses of fortune and a peculiar condition of the nervous sys- tem as causes. DaCosta says, "This disease is most commonly observed in females, and connected with hysteria, neuralgia, and uterine disturbance, and is considered to be due to an affection of the cervical sympathetic nerve." According to Loomis the enlargement of the thyroid body is due to dilatation of its vessels and protrusion of the eyeball to a dilatation of the vessels behind the globe. Symptoms. — This disease may come on suddenly or slowly. Palpitation is most often the first symptom. The heart beat is always above normal and may reach 200 per minute. A soft blowing, murmur is heard at the base and over the carotids. Sometimes the goitre is the first symptom observed. The thyroid gland occasionally enlarges in pregnancy, but this is accidental. Exophthalmus may be the first symptom. There is a staring ex- pression. There is more or less fever followed by sweat. The patient is nervous, apprehensive, irritable and lachrymose. The patient is pale, anaemic, and amenorrhoea is present in most cases (Bartholow and Loomis). Prognosis. — Must always be guarded (Loomis). Treatment. — Traube achieved great success with five grains of quinine one day, and ten grains of iron, in the form of Val- let's mass, the following day. Good results have been obtained from belladonna and ergot. Bartholow has found galvanization of the cervical -sympathetic and the pneumogastric, by placing the of anode under the ear, and the cathode at the epigastrium to be of the highest efficiency. GOITEE OOXORRHCEA. 215 PRESCRIPTIONS FOR QOITRE. R Tincture iodinii corap §j. Sig. : Apply locally with a brush. Also five to fifteen minims in water three times daily internally. (In simple goitre). — Bartholow. R Ungt. hydrarg. iodidi rubri Sj. Sig.: Rub in a piece the size of a pea and expose to the sun. (In simple goitre). — Ringer. R Potassii bromidi ^ss. In pulv. no. xii. div. Sig.: A powder in half a tumblerful of water three times daily. (In exophthalmic goitre). — Hutchinson. GONORRHEA, Is a urethral inflammation, a strictly local affection, exerting no poisonous action upon the blood, and is the most venereal of all the venereal diseases. Urethritis signifies simply inflammation of the urethra, consequently gonorrhoea is urethritis, but ureth- ritis may not be gonorrhoea. Gonorrhoea alone produces gonorrhoea. The term urethritis should be reserved for all inflammatory urethral discharges having another origin, and for all cases of doubt. "It is better that a hundred of the guilty should escape than that one innocent person should be accused. 11 Experience proves beyond a doubt that urethral inflammation attended by an abundant discharge may be acquired by a healthy young lover from his equally healthy young mistress, by a young husband from his wife, and presenting nothing to differentiate it from gonorrhoea (Keyes). Causes. — Gonorrhoea is a notoriouslv contagious disease, and it may be acquired from any person having it, by the mere con- tact of the discharge with the mucous membrane of the urethra. The only mucous membranes of the body capable of taking on inflammation from the contact of gonorrheal pus are, the ureth- ral, vesical, vaginal, uterine, tubal, conjunctival and rectal. .V peculiai vegetable parasite, called the gonococcus, is the real cause of o-onorrhcea. The three most common forms of urethral flow are urethritis, bastard gonorrhoea, and gonorrhoea. Mechan- ical violence, such as the rough use of instruments in the urethra, 216 A COMPENDIUM OF PRACTICAL MEDICINE. chemical violence, such as acid urine, cantharides, strongly acid or alkaline injections, leucorrhceal discharges, lochial and the menstrual now may be sufficient to cause urethritis in a perfectly healthy subject. In these cases the patient has a slight uneasy sensation at the meatus, a little smarting, and a pearly drop in the morning (Keyes). BASTARD GONORRHOEA. A patient who has previously had gonorrhoea, comes with a little oozing from the meatus, perhaps with no itching sensation, nor any smarting on urination, and states that (perhaps after copious libations of ale, beer, or champagne) he sinned with a suspicious party, and that while examining himself on the fol- lowing morning, found the little opaline drop. Such a person has a damaged urethra, a patch of chronic congestion, or a stric- ture, and he has irritated this surface and given himself a dis- charge. This is not true gonorrhoea; it is bastard (Keyes). Symptoms. — The period of incubation varies from a few hours to fourteen days. The first symptom in true gonorrhoea is usually noticed on the fifth to seventh day. A tickling, teasing, itchy irritation is first felt at the orifice of the urethra. A slight, bluish discharge is seen between the lips of the meatus, which swell a little and become reddened. A slight stinging is felt on urination. The quantity of the discharge increases, and it becomes opaline. Greater pain is felt in passing water. The meatus feels hot and sore. After the fifth day from its appear- ance the discharge becomes much more copious. It gets thick and purulent, and soon acquires a greenish color. Pain is now felt all along the pendulous portion of the urethra, and the canal is very sensitive to pressure. Pain may be complained of in the groin, testicle, perineum, cord and back. The stream of urine is small, forked, and dribbling on account of the inflammation of the urethra, and retention may come on if the patient has pre- viously had a stricture. The prepuce may become cedematous, occasioning phimosis or paraphimosis. Erections, also, at this time become painful, threatening chordee. Chordee is most fre- quent during the night and toward morning. After the disease BASTARD GONORRHOEA. 217 has continued at its height for from one to three weeks, the pain on urination ceases, and the discharge becomes more watery, and finally diminishes to a drop in the morning. The Duration of Gonorrhoea is Variable. — A well-managed case lasts from three to six weeks as a rule; but the discharge may continue for months and even years. A first gonorrhoea is the most severe, but is the most certain to get perfectly well. If the disease does not get well, it passes into the gleety stage (Keyes). Complications. — Balanitis, phimosis, chordee, possible reten- tion, haemorrhage, epididymitis, orchitis, gonorrhceal cystitis, gonorrhceal rheumatism, gonorrhceal ophthalmia and gonorrhceal conjunctivitis are the most important (Keyes). Treatment. — There are two methods of treatment, the abor- tive and the rational. The Abortive Treatment. — Consists in hot irrigation to soothe the membrane and wash out the poison, and in the use of anti- septic, or antiparasitic drugs to destroy the gonococcus. Nitrate of silver and chloride of zinc do more harm than good. The present favorites are prolonged irrigation and varying strengths of the bichloride of mercury. If the abortive treatment is to be tried, it should be used within the first twenty-four hours of the commencement of an attack. The method by anterior irrigation is simply to put a quart of tepid or hot water, at a strength of half a grain of bichloride of mercury in twenty -two ounces (about 1 in 20,000), into a fountain syringe, and press the blunt glass nozzle into the urethra, so that the water shall trickle but slowly alongside of the glass nozzle. Instead of the fountain syringe a little red soft rubber irrigator, called the universal in- jector, may be used. This irrigation is repeated three times a day. The Hational Method. — Consists first in observing the hy- giene of gonorrhoea, which is as follows: Absolute continence until at least ten days after the entire cessation of the discharge, and avoidance of anything liable to induce sexual excitement. No alcoholic stimulants of any sort, and, above all, no malt liquor should be drunk during the treatment. 218 A COMPENDIUM OF PRACTICAL MEDICINE. Increasing Stage. — If the case is seen early enough, mild bichloride irrigation may be tried. The bicarbonate of soda, or better still, the citrate of potash may be given in doses of gr. x-xx. during the second hour after each meal throughout the entire treatment, to keep the urine alkaline. Occasionally twenty grain doses of the bromide of potassium will moderate the ardor urinse better than the citrate. The following is a good combination: R Potassse citratis 3ii--vj. Bals. copabise 3iii.-yj. Extracti hyocyami fiuidi 3ss.-ij. Syrupi acacise §iss. Aquae menthse piperita? q. s Siij. — M. Sig.: Shake. Teaspoonful in water. Another aid to easy micturition is Milton's plan of immers- ing the penis in hot water before and during the act. A suspen- sory bandage should be worn. When injections are used in the increasing stage, they should be very mild ones, as follows: R Liq. plumbi subacetatis dil §j. Morphia acetatis gr. j. — M. Or, R Zinci sulphocarbolat gr. i-ij. Aquae §j. — M. R Zinci sulphatis gr. i-iij. Aquse 5j— M. (In less acute fom s). Or, R Zinci sulphatis gr. i.-iij. Liq. plumbi subacetatis dil Sj. — M. Or, R Aluminis exust gr. x. Aquse 3 j .— M. Or, if more astringency is required, R Acidi tannici gr. v.-x. Aquaj Bj • — M. A suitable injection may be used two or three times a day. Stationary Stage. — This stage lasts from one to three weeks with very little change. The treatment of the first stage, with- out any injections, must be kept up. Prolonged and frequent warm baths are beneficial in this stage. The most difficult part of the treatment of this stage is to soothe the painful erections GOXOKKHCEA. 219 and keep off chordee. The best course is for the patient to keep his nrine dilute and alkaline, and to immerse the penis for a long time in very hot water before retiring. He should sleep, lightly covered, on his side, on a hard bed, after a small evening meal. Bromide of potassium, in doses of from thirty to sixty grains at night in water, repeated once, if necessary, will control chordee in some cases. When a patient wakes with chordee, the penis should be plunged into the coldest water which is at hand, or laid along a piece of iron which has been exposed to the cold. He must not "break the chordee." Decreasing Stage. — Injections are of great service in the stage of decline. Any of those already given may be used. If copaiba is well borne and properly administered, it is the most efficient of the anti-gonorrhceal internal remedies. Pills or tablets containing copaiba, sandal -Avood oil, cubebs and oil of turpen- tine sometimes act better than any one alone. They may cause an eruption to appear (Keyes). The treatment of the compli- cations of gonorrhoea will be found in the proper order. PRESCRIPTIONS FOR GONORRCEHA. R Balsami copaiba?. Spiritus setheris nitrosi. Spiritus lavandulae comp, aa §ss. Liquoris potassa? 3J . Mucil. acacias, q. s., ad §iv. — M. Sig. : Shake, and take one teaspoonful. ("Lafayette Mixture.") — Charity Hospital. R Balsami copaiba? £ss. Tinct. ferri muriatis. Tinct. eantharidis aa 5ij. Glycerinae 3ss. Syrupi q. s., ad §iv. — M. Sig.: A teaspoonful after meals. — Burnstead. R Potassii citratis 3£s-j- Sp iritus limonis 5ss. Syrupi simplicis §ij. Aquas g — M. Sig.: A dessertspoonful well diluted three or four times daily, fasting. (In the first stage). — Keyes. 220 A COMPENDIUM OF PRACTICAL MEDICINE. R Liq. hydrarg. chlor. corros..( T¥ Vo) Oj. Sig. : Distend the vagina with a speculum and cleanse thor- oughly with the above solution. Then dust over and rub in iodo- form, and tampon the vagina with iodoform gauze. Repeat in three or four days. (Iu female.) — Schwartz. GOUT. In a constitutional malady, inherited and characterized by paroxysms of severe pain in small joint — the great toe usually — due to the presence of uric acid in the blood, and the deposit of the urates in the structure of the joints and throughout the body. Gout in the foot is called podagra; in the hand chiragra; in the knee gonagra. (Bartholow.) Causes. — The gouty diathesis may be inherited or acquired. Gout is a disease of middle life. The direct exciting cause is over -eating and the use of alcohol. Of the alcoholic beverages, the sweet wines and malt liquors are considered more gouty than spirits. Lack of exercise, and failure of the excretive power of the kidney and lead -poisoning are influential factors. Men suf- fer from attacks of gout much more frequently than women. As a disorder of the upper classes, gout has had a position of dis- tinction, and Sydenham consoled himself for his sufferings from gout by the reflection that it is an eminently respectable dis- ease, by which more rich men than paupers, more wise men than fools are afflicted. It is the large consumption of beer which de- velops gout in the laboring classes. Attacks are sometimes at- tributed to prolonged intellectual exertion, anxiety of mind, bodily fatigue, and exposure to cold, and are more likely to oc- cur in the spring and autumn than at other seasons of the year. (Bartholow, Flint and Loomis.) Symptoms. — Acute Gout. — Usually between midnight and four or five in the morning the patient wakes with a burning, throbbing pain in the ball of the great toe, which the slightest pressure greatly intensifies. The affected joint becomes red, swollen, hot and shining; the veins are distended, and it resem- bles a joint about to suppurate. The temperature may in a severe attack reach 105° F. The pulse is full and bounding, but compressible. The pain in the affected joint is so great that the GOUT. 221 patient cannot move it. He tosses about for hours, until finally, in a profuse perspiration, falls asleep. In a few hours he awakes almost free from pain, and remains so during the da}-; but about the same hour the next night there is a recurrence of the local pain and the fever. These nocturnal attacks continue for two or three days, then the maximum of pain is reached. At the end of a week, they have gradually subsided. Following the attack, there is a feeling of well-being. During an attack, there are anorexia, coated tongue and constipation. The urine is scanty and high-colored. The bladder is irritable, and there is a scalding sensation on urination. An individual may have only a single attack, but usually a second supervenes within a year. Chronic Gout. — When tophi (deposits of urate of sodium) form around the joints, and they become distorted or crippled so that walking becomes difficult, it is called chronic gout. Nodules of the deposit are frequently seen on the helix of the ear, some- times on the eyelids and occasionally on the face. When the stomach, intestine, lungs, heart, liver, kidneys and brain are gouty, it is called irregular and misplaced gout. Gout is a very chronic disease. It sometimes produces subluxation of the joints, and this combined with the tophaceous nodules give rise to striking deformities (Flint and Loomis). Differential Diagnosis. — Gout may be mistaken for rheuma- tism. Gout attacks the small and rheumatism the large joints. A rheumatic attack is of longer duration than a gouty paroxysm. In gout the fever is slight, in rheumatism it is high. In acute rheumatism, the heart is frequently involved, in gout rarely. The gouty attack coming on at night in the great toe joint is in marked contrast to the onset of rheumatic fever. Acute articu- lar rheumatism is a disease of early adult life, while gout is rare before thirty-five. In gout there is a history of high living, in rheumatism there will be a history of exposure or exhaustion. In gout there is an excess of uric acid in the blood (uricsemia), this is never the case in rheumatism, but is pathogmonic of gout. Tophaceous masses occurring in the external ear, varying in size from that of a pin's head to that of a split pea, are often of great assistance in the diagnosis (Loomis). 222 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — 1. General Hygiene. — Gouty subjects should take systematic exercise iu the open air, especially horse -back riding, walking, rowing, etc. A country residence, a warm, dry climate, are preferable. The patient should be warmly clad in flannel, retire and rise early, and avoid severe physical and mental strain. 2. Dietetics. — Starving will not cure gout. The principal articles of diet should be beef, mutton, chicken, bread, milk and fruits. All pastry, eggs, tea, coffee, alcohol, cheese, dried meats, tomatoes and strawberries should be avoided. Alkaline mineral waters, seltzers, vichy and lithia may be taken with and after meals. 3. External Treatment. — The affected part should be raised above the body and wrapped in flannel. When the pain is intense opium may be applied to the joint. Vapor and Turk- ish baths should be taken weekly. 4. Internal Treatment. — Colchicum and the alkalies are our chief remedies during the paroxysm. For thirteen centuries colchicum has been used in this disease. Loomis gives one of the following pills every three hours until the specific purgative action of the colchicum is obtained: Be Pulv. ipecac Extracti colchi acet Hydrarg. protochlor (calomel) ... Ext. aloes fid aa gr. j. Ext. nucis vomicae gr. \. — M. Carbonate of potash, Rochelle salts and citrate of lithia are important adjuvants to the colchicum treatment. In chronic gout tonics, as iron, arsenic, etc., are usually demanded (Loomis). PRESCRIPTIONS FOR GOUT. R Magnesii sulphatis 3j. Magnesias optimse 3ij. Vini colchici rad gj. Aquas menthas pip .^x. — M. Sig. : A tablespoonful every hour until it operates. — Scudmore. R Tinct. iodini ^ijss. Glycerinaj 3ij . — M. Sig.: A tablespoonful thrice daily. — Granville. GUMS GASTRITIS. 223 R Parald ehy de 3SS . Syrupi simplicis giss. — M. Sig. : A teaspoonful to a tablespoon ful, well diluted when re- quired (for gouty insomnia). — Hodgson. R Granulated efferv. lithii citrat ^iv. Sig. : One or two teaspoonfuls in water three times daily. — Mattison. GUMS. (Affections of). When the gums are spongy and ill-conditioned, and mani- fest a tendency to recede from the teeth, the following local application is very serviceable: R Aluminis 5j- Vini O.j. Tinct. cinchonas §ss. Tinct. myrrhse 3ij. Mel. rosre Sij. — M. Sig.: As a mouth wash. — Bartholow. The glycerite of tannin is a nsefnl application for spongy and bleeding gums. When fetor is present, carbolic acid and iodoform are most serviceable. The tincture of benzoin, with or without glycerine, is very effective. PRESCRIPTIONS FOR SPONGY OR BLEEDING GUMS. R Chloral hydratis Tinct. cochlearise aa 5iss. — M. Sig. : Apply to gums, by means of a pleget of cotton every day or two. (For gingivitis of pregnancy). — Pinard. R Tinct. myrrhaB 5ii.-iv. Aquae vel. infusi cinchonas 31V. — M. Sig.: Use as a gargle. (For spongy or ulcerated gums). —Phillips. R Glycerite acidi tannici 3j. Sig.: Apply with camel's hair brush. — Bartholow. GASTRITIS. (Toxic.) Is an acute inflammation of the stomach, caused by the in- gestion of irritant and corrosive poisons. 224 A COMPENDIUM OF PRACTICAL MEDICINE. Symptoms. — Besides the vomiting which occurs immediately or very soon after swallowing the irritant, corrosive or toxic sub- stance, purging sets in and the same sloughs of the tissues dis- charged by vomiting pass also by stool. In the case of corrosive sublimate and the metallic salts generally there occur intense colic and tenesmus, and the discharges consist of mucus and blood and strongly simulate dysentery. Arsenic, the salts of mercury, copper, zinc and nitrate of potash, produce an intense inflammation. Sausages, hams, cheese, fish, etc., that have under- gone decomposition produce, in a few minutes or hours after swallowing them a violent gastritis. There is great anxiety and depression, a weak, rapid pulse, cold skin, covered with cold sweat, intense internal heat and thirst and burning in the gullet and fauces (Bartholow). Prognosis. — Death may occur from the immediate effects of the poison. Recovery may ensue if the injury done is not too great for repairs. Treatment. — Vomiting is to be encouraged by the free use of demulcent drinks. If the toxic agent consists of an acid, as speedily as possible, weak alkalies, lime water, soda, common soap, etc., should be given. The other poisons require their proper antidotes. The stomach pump should be used not only to remove the poison remaining, but to thoroughly wash out the stomach. To allay the pain, give a hypodermic injection of morphine. Ice should be given freely and an ice-bag apruied to the epigastrium. No food should be given, but a little cold milk at short intervals (Bartholow). GINGIVITIS. (See Gums, Affections of.) GLAUCOMA. This term is used to express a morbid condition character- ized by an increase in the hardness of the eye-ball. The word glaucoma, literally signifies green, and was employed because in certain advanced cases the pupil acquires a greenish hue. The standard of ocular tension varies in its physiological limits. In women it is normally less than in men, in children than in ad- ults. An average of twelve inches of water is normal. The sense GLAUCOMA. 225 of touch must be relied upon for the tension, and one finger of each hand is to be lightly pressed upon the eye as when feeling for fluctuation in an abscess. When the tension is increased it is called plus, when diminished minus tension (Noyes). Varieties. — 1. Glaucoma simplex. 2. Glaucoma with inflam- mation. 3. Glaucoma hemorrhagicum. 4. Secondary glaucoma (Noyes). Symptoms. — The simple is the most frequent variety, is in- sidious and very slowly progressive, occurs most often after mid- dle age and in hypermetropic eyes. The external appearance of the eye may be normal except a notable whiteness of the sclera. The field of vision will be restricted on the nasal side to a greater or less degree. The tension of the eye will be increased. Un- commonly strong glasses for reading will be needed. Attacks of sudden obscurity of sight for some minutes have taken place. At times colored rings will be observed around a lamp or gas flame. It is usual for one eye to be affected sometime before the other. It may occupy -five to fifteen years for its development, and in old persons be mistaken for senile cataract. When the glaucoma becomes chronic there will be greatly increased hardness with the pupil widely and unequally dilated and fixed, the cornea more or less anaesthetic, the pupil will have a dusky or even greenish hue, and the globe enlarged tortuous arteries. In the inflammatory variety, the person is apt to be taken during the night with severe pain in the eye and forehead. There may be rise of temperature, rapid pulse and vomiting. On inspection of the eye, the cornea may be hazy, the aqueous will be turbid, the iris and lens pressed toward the cornea, the pupil will be obscured and dilated, and the iris discolored, and diminished to a narrow ring. It is not easy to feel the tension through the swollen lids, and the pressure will be painful. Vis- ion is impaired or wholly lost in a few hours. In the hemorrhagic variety, there is effusion of blood in the retina, or optic nerve, and sometimes in the vitreous. There is a sudden loss of sight, followed by pain and inflammation. In the secondary variety, there is increased ocular tension, due to some other disease (Noyes). 226 A COMPENDIUM OF PRACTICAL MEDICINE. Prognosis. — The disease tends to total loss of sight. Treatment. — The merit of having discovered that iridectomy is capable of curing glaucoma, stamps the name of Grsefe with undying honor. Up to his time no remedy was known, and now no remedy, except an operation, is of positive value, and the most favorable results are gained when it is done at an early period. Acute attacks occur in chronic glaucoma, and these are controlled by combining a 4 per cent, solution of cocaine muri- ate with solution of eserine sulphate (gr. i. to Hi.) Each may be put up in gelatine wafers, and put in the eye every hour. Extremely hot fomentations will give relief, and morphine may be given at night. Atropia and all mydriatics should be avoided, as they tend to aggravate the symptoms (Noyes). GRANULAR LIDS. (See Trachoma). GRAVES' DISEASE. (See Exophthalmic Goitre). GRAVEL. (See Calculi Kenal ). GREENSICKNESS. (See Chlorosis). GUMMA. (See Syphilis). GIDDINESS. Treatment. — Cod-liver oil and quinine is the best treatment for giddiness in the aged, that is, when this symptom is not as- cribable to serious organic brain disease, but probably to ather- omatous changes in the brain vessels, or to a weak heart. GLANDERS. Is a contagious disease of horses, which may be transmitted to man. The nodules of glanders are most frequently found in the nose of the horse, but in this animal, as well as in man, the nodules may be found in the skin, the mucous membranes, and viscera. The nodules usually suppurate (Flint). Treatment. — There is no drug which has any influence on the disease. Fresh air, tonics, such as quinine and iron, should be GLYCOSURIA GONAGKA HJEMATEMESIS. 227 given. When the nose or throat is the source of trouble, it should be washed with water rendered antiseptic by iodine, car- bolic acid, Condy's fluid or creosote, nitrate of silver solution, tannic acid, etc. Nitro- muriatic acid lotion, and a gargle of chlorate of potash should be used in the throat (Bryant). GLYCOSURIA. (See Diabetes Mellitus.) GONAGRA. (See Gout.) H/EMATEMESIS. Is vomiting of blood. It is a symptom in a variety of diseases. Rrrpture of a blood vessel is one of its essential con- ditions. Causes. — Injury to the mucous membrane of the stomach by traumatism or poisons, diseases of the wall of the stomach, ob- struction to the portal circulation, blood-poisoning, cancer and ulcer of the stomach, stoppage of the menses in the female, and sudden arrest of hemorrhoidal discharges may cause it (Loomis). Symptoms. — If the hemorrhage is profuse, the patient has a sense of heat and distention in the epigastrium, with nausea and vomiting, becomes pale, has a cold clammy skin. If the blood is vomited in large quantities immediately after the bleeding has occurred, it will be partly fluid and partly coagulated; but if re- tained for a time, it will be fluid and have a black or brownish - black appearance, with an acid reaction (Loomis). Differential Diagnosis.— Haeniateniesis may be confounded with haemoptysis or blood- spitting. Haemoptysis is preceded by bronchial or pulmonary symptoms, and haeinateinesis by gastric symptoms. In haemoptysis there is a sense of constriction across the chest, with dyspnoea and cough. In haematemesis there is nausea, with a sense of oppression and distention in the epigas- trium. In haemoptysis, blood is coughed up in mouthfuls/bright red, frothy, alkaline and mingled with sputa. In haematemesis, blood is vomited more or less profusely, is dark colored, mixed with food, coagulated, and often acid. In haemoptysis there is a sense of trickling behind the sternum, and for a few days after the hemorrhage, small blood-spittings (Loomis). 228 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — During the hemorrhage the patient must be kept absolutely quiet, in a horizontal position. Ice should be taken freely, and ice-bags applied to the epigastrium. Morphine and ergotin may be given hypodermically. Brandy may be given by the rectum or hypodermically. Milk is the only diet allowed for the first week (Loomis). PRESCRIPTIONS FOR H^EMATEMESIS. R Liquor ferri subsulphatis £ss. Sig. : One or two drops in ice water frequently. — Bartholow. R Ferri et ammonii sulphatis gr. xL. Aquae cinnamomi §iv. — M. Sig. : A teaspoonful every two or three hours. — Hartshorne. R Ergotin gr. xij. Aquse destillatse 3J . — M. Sig.: Five to ten minims hypodermically every three hours. — Ringer. R Acidi gallici . gr. x. Acidi sulphuric! dil ITT. x. Aquae §j. — M. Ft. haustus. Sig : To be repeated in four to six hours if necessary. — Bruton.. R Tincturse hamamelis £ss. Sig. : Two to four drops every two hours. — Ringer. R Acidi tannici 5j- A quae Sj. — M. Sig.: A teaspoonful frequently. — Bartholow. HEMATURIA. Is the passage of urine containing blood. The origin of the blood may be at any point from the meatus to the maljoighian tuft. It is a symptom and not a disease. Causes. — Active and passive hyperemia of the kidney, acute suppurative nephritis, tuberculosis and stone in the kidney and pyelitis are causes. Turpentine, cubebs, copaiba, cantharides, etc., may cause blood in the urine. The causes in the ureter are cancer, polypi, ulcers and calculi. The causes in the bladder are cystitis, cancer, abscesses in the wall, polypi, stone, rupture,. HEMATURIA. 229 tuberculosis, etc. The causes in the urethra are urethritis, chor- dee, cancer, fracture of the penis, enlarged prostate, polypi, caustic injections, chancre and chancroids, phimosis, impacted stone, etc. The general causes of hseniaturia are acute infectious diseases, as fevers, especially malarial, scurvy and purpura. Hsematuria is endemic in some localities, as South America and Isle of France, due to a parasite (Loomis). Symptoms. — The urine may be almost black and loaded with clots, or it may be only slightly smoky or pinkish in color. It is albuminous. The blood usually comes from the urethra, the bladder, or the kidneys. To determine the source of the blood the following rules may be observed: Urethral hemorrhages are independent of micturition, as only a residue of blood is washed out at the beginning of the now of urine, and some of the blood will reach the meatus between the acts of micturition. Blood effused into the urethra clots there and assumes the shape of a leech, and usually comes with the first gush of urine. If the bladder is the source of the hemorrhage, the blood flows only at the time of micturition, and follows the discharge of urine. The blood does not equally diffuse through the urine, so that the first passed is clear or nearly so, but at the end of the act the urine is much more deeply colored, or pure blood, in a liquid form, or in clots is voided. There is usually pain over the bladder, with a frequent desire to pass water, and a stoppage in doing so. In renal hemorrhage, there is pain in the lumbar region, and the blood is mingled with the urine, and is commonly as profuse at the commencement as at the end of micturition. Should blood globules, albumen, casts, and blood moulded in the form of renal tubules be found in the urine, renal disease may be regarded as the cause of the haeinaturia. Treatment. — When the haeruaturia is profuse or persistent, the patient should be placed in a recumbent position, ice-bags applied over the seat of the hemorrhage, and haemostatic reme- dies used, such as gallic or tannic acid, ergot, acetate of lead, and astringent ferric preparations (Loomis). 230 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR HEMATURIA. R Mucil. acaciae q. s Syrupi simplicis Siij . Olei gaultherise gtt. viij. Olei terebinthinse 5ss. — M. Ft. emulsio. Sig. : One to three teaspoonfuls every three hours. — Hunter. R Acidi gallici 3ss. Acidi sulphurici dil 5j. Tinct. opii deodorat 5j. Infusi digitalis Siv. — M. Sig. • A teaspoonful every four hours. — Druitt. R Tinct. ferri muriat ITTxxx. Tinct- digitalis ITTxv. Aquae menthse pip §iss. — M. Ft. haustus. Sig.: To be repeated every four hours. — Aitkem. HEMOPTYSIS. Is tlie spitting of pure blood. The sputa are streaked with blood in bronchitis, intimately admixed with blood in pneumonia, (the rusty colored matter), yet we do not call this haemoptysis (Loomis). Causes. — Pulmonary congestion, pulmonary apoplexy, and inflammation of the lungs and bronchi may cause spitting of blood; but hemorrhage from the bronchial tubes is by far the most frequent cause of blood spitting or haemoptysis. Ulcera- tion, over distension, and weakness of the capillary walls of the bronchial mucous membrane are the chief causes of bronchial hemorrhage. Bronchial catarrh, phthisis, inhalation of irritating gases or vapors, passive hyperemia of the lungs from obstructive heart disease, intense active hypersemia, the violent coughing of bronchitis, pertussis, and pneumonia, and suppression of the menses may cause it. Ulceration of an exposed vessel in ad- vanced phthisis will cause it (Loomis). Symptoms. — All bronchial hemorrhages are attended by the spitting of bright red, frothy, arterial blood. They may come on suddenly without any warning, but usually there is a sense of HAEMOPTYSIS. 231 constriction at the upper portion of the chest. Cough may or may not precede the hemorrhage. Usually the patient feels as if some fluid had suddenly commenced trickling under the ster- num, and he notices an unusually sweetish or saltish taste in the mouth. The blood in the throat brings on fits of coughing. Blood may be expectorated only for a few hours, or for several days. The amount varies from an ounce to a pound. The patient has an anxious expression, becomes tremulous and often faints. Hemorrhage from the lungs weakens a patient. The patient goes on coughing for a few days, expectorating small dark coagulated masses of blood, or blood- streaked sputa. Sometimes the hemorrhage is so profuse that the blood spouts out at the mouth and nose, and this points to rupture of an aneurism (Loomis). Differental Diagnosis. — Haemoj)tysis may be confounded with epistaxis, pulmonary apoplexy, haematemesis, and aneurisms rupturing into the air passages. In epistaxis, the blood is always coagulated and dark- colored. It is not attended or followed by a cough, and blood can always be detected in the nostrils and posterior nares. In haematemesis, the blood is black, contains no air, has an acid reaction, is mixed with articles of food, and is vomited; in haemoptysis the blood is bright red, contains air, has an alkaline reaction, and is coughed up, while there is no nausea. When an aneurism ruptures into a bronchial tube, the hemorrhage is gen- erally profuse, and it is soon followed by death. The blood spurts out in jets. There is a history of aneurism. If the blood comes from the mouth or fauces close inspection will reveal the fact. Haemoptysis should always excite a strong suspicion of tub- erculous disease (Loomis and Flint). Prognosis.— As to final result is always unfavorable, but haemoptysis rarely proves immediately fatal (Loomis). Treatment. — Absolute rest in a cool room, with the patient in bed and not allowed to sit up, turn over, or even speak above a whisper, is of the greatest importance. If the cough continues, full doses of opium must be given. Ergot, tannin, gallic acid, acetate of lead, spirits of turpentine, persulphate of iron, or a 232 A COMPENDIUM OF PRACTICAL MEDICINE. mouthful of common salt may be administered. When the pulse is full and strong Loomis uses aconite; when it is weak, he em- ploys morphia hypodermically. Ice-bags may be applied to the chest, and the patient urged to eat ice, and drink freely of cold drinks. Counter irritants are serviceable, such as mustard plas- ter, Hying blister, or turpentine (Loomis and Flint). PRESCRIPTIONS FOR H/EMOPTYSIS, Jfc Extracti ergotse fid gj. Olei gaultherise gtt. iv. — M. Sig. : A teaspoonful every hour at first ; then every four to six hours. — Ringer. j& Infusi digitalis ^iv. Sig.: A tablespoonful every hour until the pulse is reduced. — Brinton. j& Sodii chloridi <|rj. Sig. : Take half teaspoonful dry. Repeat till nausea occurs. — Ringer. {& Pulv. aluminis $j. Sacchari albi 3ss. Pulv. ipecac comp gr. xx. — M. In pulv. no. vi. div. Sig.: One powder every two hours. — Skoda. (& Plumbi acetatis : gr. xx. Pulv. digitalis gr. x. Pulv. opii gr. v. — M. Ft. massa et in pil no. x. div. Sig.: One pill every four hours. — Bartholow. HAY=FEVER, Called also summer catarrh, hay- asthma, rose- cold, June- cold and autumnal catarrh, is an acute catarrh of the upper air passages chiefly, occurring at a fixed period annually, and disap- pearing after a variable duration (Bartholow). Causes. — Emanations from roses, and new mown hay, or grasses, and the pollen of wheat, rye, oats and barley may excite the disease. When the neurotic temperament is present and a special tendency exists, various exciting causes, as heat, dust, etc., may excite summer catarrh (Bartholow). HAY -FEVER. 233 Symptoms. — There are two forms in which the disease mani- fests itself — the catarrhal and the asthmatic. Hay -fever is dis- tinctly periodical. It occurs at certain seasons only. In the catarrhal form, the onset is sudden in the majority of cases. The first symptom is an itching of the eyes, nose, behind the posterior nares, and the palate. This is followed by the flow of a trans- parent serous fluid, and then sneezing begins. Henry Ward Beech er, himself a sufferer from the disease, describes the sneez- ing as follows: " You never before even suspected what it really was to sneeze. If a pane of glass is gone, you sneeze. If you look into the sunshine, you sneeze. If you sneeze once, you sneeze twenty times. It is a riot of sneezes. First a single one, like a leader in a flock of sheep, bolts over; and then, in spite of all you can do, the whole flock, fifty by count, come dashing over in twos, in fives, in bunches of twenty." The eyes water, and the conjunctiva reddens; the nasal mucous membrane swells and becomes hypersemic; the breathing is carried on by the mouth. There is a sense of heat and burning in the nose and eyes, and pain shoots through the orbits. The throat is hot, dry and swollen. In the asthmatic form, the larynx and bronchial tubes are swollen and hypersemic. There is a croupy, or a wheezy bron- chial cough. The patient is unable to lie down, struggles for breath, is pale, and covered with a cold sweat. The duration of hay-fever is from a few days to three months, the average being about six weeks (Bartholow). Treatment. — There is no remedy so effectual as removal from the hay fever zone in time to prevent the attack. The patient may be exempt from the attack if on the ocean. The White Mountains, the Catskills, the Adirondacks, the Rocky Moun- tains, and the highest points of the Alleghenies, and many places by the seashore can be resorted to with confidence of re- lief. Quinine has been more useful than any other agent, and should be given in five grain doses three times a day for a week before the attack, and when the first symptoms of irritation of the nares are felt, a solution of the muriate should be applied to the nares. 234 A COMPENDIUM OF PRACTICAL MEDICINE. When the disease lias begun, the best results are obtained from fifteen grain doses of iodide of potassium every four to eight hours. Morphine gr % and atropine gr 2 i- - are good when there is much secretion. Local applications are more effectual than internal remedies. R Acidi carbolici giij. Tinct. iodi 3 v. — M. Sig. : Add from one to five minims to a gill of water, and apply to the nose by means of a syringe. A few drops of the tincture of iodine may be placed in a warm vial, and cautiously inhaled. Cocaine in solution or in the form of a pellet placed along- side the septum and allowed to dissolve slowly, has proved to be the most effective agent for affording relief. The dose will be i _ i g r (Bartholow). PRESCRIPTIONS FOR HAY=FEVER. R Cocaine muriatis gr. v. Aquas destillatse 3ij. — M. Sig.: Apply to nasal passages with a camel's hair brush. — Sajous. R Syrupi acidi hydriodici 5iv. Sig. : A teaspoonful every two hours. — Judkins. R Quinine muriatis gr. iv.-viij. Aquse Sj • — M. Sig.: Apply to the nares with an atomizer. — Bartholow. R Antipyrin 5ss. Syrupi aurantii cort Sj. Aquas ad Siij - — M. Sig.: A teaspoonful one to three times a day. — Cheatham. HEADACHE. Called also cephalalgia, is properly a form of neuralgia, as it can only be referred to the sensory nerves supplying the men- inges and scalp. It is a symptom occurring in many affections, such as active cerebral congestion, cerebral meningitis, the essen- tial fevers, acute dyspepsia, syphilitic periostitis of the head, in- tracranial tumors, etc. Headache is extremely common. It HEADACHE. 235 occurs in paroxysms, lasting usually from twelve to twenty- four hours (Loomis and DaCosta). Varieties. — 1. Congestive. 2. Astigmatic. 3. Headache from poisoning. 4. Headache in diseases of the brain. 5. Nervous, or neuralgic. 6. Sick-headache. 7. Sympathetic. 8. Uraemia 9. Anaemic (DaCosta). Causes. — An optical defect, as hyperopia, or astigmatism may cause an intense headache. A severe headache may be depend- ent upon decayed teeth, and will disappear with their removal. In acute inilammation of the brain, the pain is agonizing and continuous, and is associated with fever, vomiting and delirium. In abscess of the brain, and in softening, the headache is less violent, and is accompanied by signs of disturbed intellection and of deranged motion. In tumor of the brain, the headache is apt to be severe and paroxysmal, but intellection is not at first much affected. In congestion of the brain the pain is dull, increased by stooping or lying down, by long sleep, and by bodily or mental fatigue, with flushed face and throbbing of the arteries of the neck. A form of congestive headache, apt to be relieved by bleeding at the nose, is often seen in young people at the age of puberty; the attacks are brought on by running or other violent exercise. In diseases of the meninges, the pain is constant and fixed, and sometimes very sharp. Nervous or neuralgic headache is most common in women, especially in anaemic women. It is very severe, yet of short duration. Sympathetic headache is found mainly in connection with disorders of the alimentary tube, and of the uterus, and is often worse in the morning, before food has been taken. Headache may be dependent upon various poisons, as in Bright's disease, the retention of a large quantity of urea in the blood becomes the source of persistent pain in the head. Headache is common in lead poisoning, in opium-eaters, in drunkards, and after the use of strychnine and quinine. Headache increased by the erect posture and relieved by lying down bespeaks an anaemic condi- tion of the brain. Sick-headache, or heniicrania, or migraine, or 236 A COMPENDIUM OF PRACTICAL MEDICINE. megrim, lias symptoms which set it apart. The pain is usually attended by nausea and vomiting, is generally at first one-sided, and the patient vomits bile (DaCosta). The vomiting often ends the attack. The face is flushed and red and light is hurtful to the eyes. The paroxysms may last for a few hours, or a day or two. Women are especially liable to attacks about the men- strual period. Attacks may occur every few days, every week, or every month, and in many they are induced by errors of diet. They usually disappear after the age of fifty. Headache of gastric or hepatic origin is commonly frontal and throbbing in character. Headache at the vertex is symp- tomatic of cerebral disturbances, or it is due to reflex irritation starting in the pelvic organs of the female. Pain in the occipital region is mostly an accompaniment of disorders of circulation, and vaso motor spasm and anaemia in particular. The pain of cerebral compression, or tumor, is generally localized, persistent, and very intense (Loomis and Bartholow). Treatment. — In anaemic headache the inhalation of nitrite of amyl is serviceable. In congestive headache, ergot affords relief. The bromides and hydrate of chloral are sometimes efficacious. The inhalation of a little chloroform is sometimes efficient. Evaporating lotions to the head — alcohol, spirits, vinegar, or ether — in some cases afford marked relief. Hot water to the head sometimes relieves. Strong coffee or tea affords marked relief in some cases. The faradic and galvanic currents may be tried. During the intervals, nux vomica in small doses, arsenic, or small doses of quinia may be tried. The hypophosphites and cod-liver oil, continued steadily for months, have done good in debilitated subjects. Tobacco smoking should be prohibited. PRESCRIPTIONS FOR HEADACHE. R Potassii citratis gr. xx. Spiritus juniperi oj. Spts. setheris nitrosi THxx. Infusi scoparii Sj. — M. Sig. : To be taken thrice daily. (Uraemic form.) — W. H. Day. R Potassii acetatis 3vj. Infusi digitalis *Svj. — M. Sig. : A tablespoonful every third hour. (Uraemic headache.) HEART BURN HEMICRAXIA HEMIPLEGIA. 237 R Gran, efferv. bromo caffeine Siv. Sig. : A teaspoonful in half glass of water — cold. Repeat in half an hour if necessary. (Nervous form.) — R. V. Mattison. R Zinci phosphidi gr. iij. Ext. nucis vomicae gr. x. Confect. rosse q. s — M. Ft. massa et in pil. no. xxx. div. Sig. : One after each meal. (Nervous form.) — Fordyce Baker. HEART BURN. (See Acidity.) HEMICRANIA. (See Headache.) HEMIPLEGIA. (See also Paralysis.) Is a motor paralysis of one side of the body. It is generally the result of the lesion above the medulla, and most frequently of the corpus striatum, but may result from injury to a cerebral hemisphere or eras. It occurs on the side opposite to the dis- ease or injury. (Loomis). Causes. — Its most frequent cause is apoplexy, but it may be due to other cerebral injuries or disease, and is frequently func- tional. The cerebral causes are : Compression from bone, blood, pus, or inflammatory exudations, tumors, especially carcinoma sarcoma and gummata. Partial anaemia from thrombosis, embol- ism, softening, aneurism and apoplexy. Encephalitis, abscess, atrophy and sclerosis. The spinal causes are as above, or any disease affecting a, lateral half of the cord. The functional causes are : Hysteria, chorea, epilepsy, diph- theria, malaria, poisons, etc. The muscles of the arm and leg are chiefly affected, while those of the trunk and neck often escape entirely. Of the cranial nerves the third, fourth, fifth, sixth and seventh and twelfth may suffer. If the fifth nerve suffers there will be anaesthesia of the face and cornea and paralysis of the muscles of mastication on the affected side. If the facial nerve suffers, the face becomes a blank and motionless, and the mouth is drawn toward the healthy side. If the twelfth nerve suffers the tongue will then be protruded with the tip pointed toward the affected side. The history of the case, the matter of in\a- 238 A COMPENDIUM OF PRACTICAL MEDICINE. sion, and other symptoms, will usually give a clue to the location of the lesion. It has been noticed that paralysis caused by lesions in the motor tract above the ganglionic cells in the anterior cornua of the cord is seldom followed by much muscular atrophy or more than would be caused by inactivity, while disease affecting these cells or the peripheral nerve -trunks produces marked muscular atrophy as well as paralysis (Loomis). Hemiplegia may be feigned: but the results of electricity, and the test proposed by Hughlings Jackson, that the arms do not, as in real hemiplegia, fall forward when the patient stoops, but are retained at the side, will usually detect the fraud (Da Costa). Treatment. — In hemiplegia the constant current may be ap- plied to the brain, for the purpose of improving its nutrition, and the faradic current to the muscles, to prevent wasting and * loss of function from disease. In faradizing the muscles in a case of hemiplegia, a current of just sufficient intensity to cause contractions should be used. The hypodermatic injection of strychnine into the paralyzed muscles, after the local troubles have ceased, is very efficacious. In hemiplegia and other forms of paralysis due to intracranial lesions, the indications for the treatment by massage are a lowered state of the nutrition of the paralyzed parts, coldness and blueness of the skin, wasting and contracted muscles, ulcerations, etc (Bartholow). HEART DISEASES. (See each particular affection). Treatment in General. — Overaction of the heart, with hyper- trophy, and without valvular lesion, is benefited by a quantity of aconite sufficiently large to moderate the cardiac movements (Bartholow). In simple hypertrophy of the heart, without valvular lesion, the tincture of veratrum viride diminishes the overaction and gives relief. The irritable heart dependent on the excessive use of tobacco, on mental excitement, and on overstrain, is relieved by five drops of the tincture of veratrum viride three times daily (Bartholow). Digitalis is indicated when the action of the heart is rapid and weak, and the arterial tension low. HEART DISEASES — HEMORRHAGES. 239 Jfc Extracti ergotse fluidi ^iiiss. Tincturae digitalis gss. — M. Sig. : A teaspoonful three times a day. (In enlarged heart with- out valvular lesion). — Bartholow. jfc Ferri redacti Quininse sulphatis Pulveris digitalis (English). ...aa...gr. xx. Pulveris scillse gr. x. — M. Ft. pil. no. xx. Sig. : One pill three or four times a day. (In irritable heart of anaemia and chlorosis, and in fatty heart). — Bartholow. In dilated heart, with difficult breathing, and general oedema, the hypodermic injection of morphine, the eighth to the sixth of a grain, two or three times a week, possesses a high degree of utility (Bartholow). To stimulate the action of the heart when it flags, the am- monia preparations have an undoubted effect. It is a most common practice to inhale ammonia to prevent that depression of the heart's action called fainting (Bartholow). |fc Cocaini hydrochloratis gr. yj. Aquse destillatse §iij. — M. Sig.: • A teaspoonful three times daily. (In nervous cardiac de- bility). — Rosenbach. jfc Tincturse digitalis oij- Spiritus chloroformi 5 v. Infusi buchu ad gxij. — M. Sig. : Two tablespoonfuls in a wineglassful of water three times daily. (In simple cardiac debility). — Fothergill. J& Strychnise sulphatis gr. j. Aquae §j. — M." Ft. sol. Sig. : Eight to fifteen minims hypodermically. (For exhausted heart muscle and its nerves). — Habershon. |& Vini coca3 Mariani 0. j. Sig. : A wineglassful three or four times daily (In overstrain of heart). HEMORRHAGES. Treatment. — Digitalis has an undoubted power to arrest hemorrhage. The mechanism of its action is similar to that of 240 A COMPENDIUM OF PRACTICAL MEDICINE. ergot; it slows the action of the heart and contracts the arte- rioles. R Infusi digitalis §ij. Tincturse kramerise Ext. ergotse fiuidi aa gj. — M. Sig. : A tablespoonful pro re nata. — Bartholow. Active hemorrhage, occnrring in the plethoric, is sometimes stopped by fnll medcinal doses of veratrnm viride (tincture 2\l v). The value of acetate of lead in various forms of hem- orrhage has been attested by an immense clinical experience. In haemoptysis and haematemesis it is a most useful haemostatic, given in five grain doses every three hours. Chloride of barium in dose of gr., 1-10-gr., ss. has proved very useful in hemorrhage. Ipecac is a most valuable remedy in haemoptysis, epistaxis, men- orrhagia, postpartum hemorrhages, etc. It arrests all kinds of hemorrhage, and should be given in frequently repeated doses until vomiting occurs. R Extracti ipecac fiuidi... gij. Extracti ergotse fiuidi ^iv. Extracti digitalis fid 31'j. — M. Sig.: Thirty minims to a teaspoonful at a dose as required. — Bartholow. The fluid extract of ergot will often arrest the bleeding of hemorrhoids and cause such a contraction of the vessels in recent cases, as that the symptoms may entirely disappear. Ergot is used in various forms of hemorrhage. It is used in epistaxis, haemoptysis, renal, intestinal and uterine hemorrhage. One to two drachms of the fluid extract, given every half hour or hour, will be necessary in urgent cases. In haemoptysis the ergot may be given as follows : R Extracti ergotse fiuidi Siij. Extracti ipecac fiuidi. Tinct. opii deodorat aa gss. — M. Sig.: A teaspoonful every half hour or hour. — Bartholow. In renal hemorrhage, the following is useful: R Extracti ergotse fiuidi Tincturse kramerise — aa 5ij • — M. Sig.: A teaspoonful every hour or two. — Bartholow. HAEMORRHAGE. 241 In passive hemorrhages, the following is useful: R Olei terebinthinse jfiij. Extracti digitalis fid 5j- Mucil acacise Sss. Aquas menthse pip Sj. — M. Sig. : A teaspoonful every three hours. — Bartholow. The following mixture is very effective in menorrhagia, he- maturia, purpura hemorrhagica and the hemorrhagic diathesis: R Acidi gallici Sss. Acidi sulph. dil 3j. Tincturse opii deodor 3j- Infusi rosse comp , Siv. — M. Sig.: A tablespoonful every four hours or oftener. — Bartholow. Astringents, such as alum, acetate of lead, iron subsulphate and chloride, sulphuric acid, tannin, gallic acidi and the vegeta- ble astringents are employed locally and systemically in the various kinds of hemorrhage. When the blood pressure is high and cerebral hemorrhage threatened or proceeding, venesection,, or leeches, or purgatives (saline) are the most effective. In uterine hemorrhage, full doses of the fluid extract of ergot will give good results. Ipecac carried to nausea merely is highly effective. Digitalis and sulphuric acid diluted in small doses frequently repeated are highly serviceable. Monsel's solution one part and water three parts may be injected into the uterine cavity to arrest bleeding, if the os is patulous (Bartholow). PRESCRIPTIONS FOR HEMORRHAGE. R Argenti nitratis fusee q. s Sig. : Wipe the wound dry, and apply locally. (In leech-bites.) — Ringer. R Acidi acetici dil Svj. Sig. : Apply locally. (For leech-bites, piles, cuts.) — Ringer. R Tincturas opii 5j- Spts. vini gallici 5j. — M. Ft. haustus. Sig. : To be taken at once. (In flooding after delivery, with uterine exhaustion.) — Ringer. 242 A COMPENDIUM OF PRACTICAL MEDICINE. R Tincturse hsemamelis Siv. Sig. : Use pure or diluted. (In cuts, leech-bites, oozing from wounds, etc.) Also internally three minims every three hours. — Ringer. HEMORRHOIDS, OR PILES. Are small tumors at the anal verge. Kinds, bleeding and non- bleeding. The bleeding piles are generally the internal, and composed of a highly vascular tissue involving the mucous membrane of the rectum and the submucous tissue with enlarged arteries and veins. If the artery is enlarged the tumor has a bright-red aspect and is called the strawberry pile. If the vein is enlarged, the tumor has a dusky hue. The non -bleeding, or external piles, are composed of loose folds of the skin that surround the anus, or a varicose, in- flamed or ruptured vein. The treatment of external piles is simple, and excision is the only radical cure. In the early stage of the affection local cleanliness, and ab- stinence from highly seasoned food and strong wines, are mostly sufficient. The bowels must be kept clear. When local irrita- tion exists, an ointment of zinc and the extract of belladonna is -very useful (Bryant). Causes. — Constipation, sedentary habits or occupations, and high living appear to have the strongest influence. Pregnancy and abdominal tumors are causative. Internal piles are very insidious in their growth — bleeding is often the first symptom that attracts attention. Treatment. — Is both medicinal and surgical. All piles do not require removal. The medical or palliative treatment of piles means attention to diet, the giving up of high living and strong drinks, and the taking of simple, nutritious food in mod- eration. The bowels should be kept open by purgatives, or enema. Absolute local cleanliness should always be observed. By these different means an attack of piles may pass away never to return. When the piles are inflamed, hot or cold applications are useful. Surgical Treatment. — Unless the general condition of the patient forbids, all piles, external or internal, should be removed. External piles ought to be removed by abscission. Internal HEMORRHOIDS. 243 piles ought never to be excised, but destroyed by the galvanic or actual cautery, crushing, or the ligature. In Paris a plan of treatment has been successful which consists of forced anal dila- tation, either by the thumbs, or by means of a dilator, the piles withering after one full dilatation of the anus. The Ligature Method. — -The surgeon grasps the base of the pile to be ligatured by a pair of forceps, and separates the pile from the skin and submucous tissue by scissors, and then trans- fixes it with a needle armed with a double silk ligature. He should then divide the cord and tie the pile tightly in halves, and cut off half of the strangulated portion. The other masses are treated similarly. The ligatures slough off about the seventh or tenth day. After Treatment. — After the operation an oj3iate may be given. The bowels should be left undisturbed for two days, when a dose of castor- oil or enema may be given. If oedema of the parts follow, ice may be applied or a lotion of lead and opium. The Cautery Method. — The galvanic cautery is preferable to the actual. The anus is to be forcibly dilated, and each mass is then to be seized in turn by a clamp, and the projecting half of each mass must then be cut off with scissors, the surface wiped dry, and the cautery, heated to a white heat, applied to the sur- face, the whole projecting portion being burned clown to a level of the clamp. The clamp should be removed so as not to dis- turb the eschar. AYhen all the piles have been treated, the whole projecting mass may be returned into the rectum with the fingers well greased, and a suppository of opium or morphine in- troduced at this time to soothe the pain. The after treatment is the same as in ligature. Treatment by Crushing. — A clamp, is to be adjusted as in the operation for cautery, and the protruding pile cut off with scissors. The clamp which is very strong, is left on the pile for one minute. Treatment by the Subcutaneous Injectfon of Carbolic Acid.— It is applicable to internal piles alone, and one pile should be treated at a time, about a week being allowed between the operations. Al unit one to six drops, of a solution of carbolic acid in thirty of olive 244 A COMPENDIUM OF PRACTICAL MEDICINE. oil or glycerine should be injected with a hypodermic syringe into the pile, which turns white, and in successful cases withers without pain or sloughing. Dr. A. A. Smith of New York, gives the following: R Acidi carbolici . gr. vj . Cocaini hydrochloratis gr. x . Glycerini giij . — M. Sig.: Inject ten minims into the tumor or pile. When a fissure or painful ulcer coexists with hemorrhoids,, its base should be lacerated by forcible dilatation of the anus. In operating on piles the surgeon must be careful not to take away too much tissue. In rectal operations, it is probably advisable to use anaesthetics in all cases (Bryant). PRESCRIPTIONS FOR HEMORRHOIDS. R Ferri sulph gr. xx. Pulv. aloes Soc Extracti opii aq Sapo cast aa gr. x. — M. Ft. pil. no. xx. Sig. : One pill morning and evening: — Fordyce Baker. R Tincture nucis vomica? 33. Ext. ergotse fid gj,— M. Sig.: A teaspoonful three or four times a day. (For bleeding piles and post partum piles). — Bartholow. R Tinct. hamamelis giv. Sig. : One-half to one teaspoonful in an ounce of cold water, in- jected into the rectum daily before rising. Also take internally two to five minims three times daily. — Ringer. R Acidi nitrici Sss.-j. AqusD §viiL — M. Ft. lotio. Sig.: Apply as a wash. (In bleeding piles). , — Ringer. HEPATITIS. (Interstitial). (See Cirrhosis). HEPATITIS. (Circumscribed Suppurative.) Is an abscess of the liver. Causes. — Pyemic infarction, phlebitis, the result of opera- tions on the intestines (as for prolapsus ani, hemorrhoids, and HEPATITIS HERPES. 245 strangulated hernia), and intestinal traumatism, may give rise to abscess of the liver. Hot climates, miasmatic influences and dysentery are regarded as causes of abscess of the liver. Ulcera- tion of the stomach, of the intestine, gall-bladder and appendix, ulcerative endocarditis, and cancer of the stomach are often associated with abscess of the liver. Obstruction to the common duct by worms or calculi may lead to ulceration followed by abscess of the liver (Loomis). Symptoms. — A slight feeling of chilliness, sometimes a dis- tinct chill, is followed by dull pain and weight in the right hypocondrium, the pain often radiating to the tip of the right shoulder. The chilly sensations recur. The pain increases and is aggravated by position and pressure. The tongue is brown and furred, there is loss of appetite, slight nausea, and often vomiting. There is dyspnoea and a short dry cough resembling that of pleurisy. With the formation of the abscess, there are hectic rigors and recurring night sweats, persistent and profuse vomiting, the pain becomes sharp and localized, the temperature rises, and exhaustion and emaciation are rapidly developed. Hepatic abscesses may be discharged in a variety of ways : through the abdominal wall, into the peritoneal cavity, into the stomach, intestines, etc. (Loomis). Physical Signs. — -If the abscess is large, inspection will show a bulging of the right hypochondriac region. By palpation the liver is enlarged and has an uneven feel. The pain is increased by pressure, and localized. Fluctuation may be present. By percussion the area of hepatic dullness is increased. Prognosis. — The majority of abscesses of the liver terminate fatally. Treatment. — When pus has formed, and the locality of the abscess can be determined, aspiration should be performed. The abscess should be opened as soon as possible (Loomis). HERPES, Is an acute, non-contagious affection, characterized by the development of one or more groups of vesicles, and accompanied by burning heat, pain or itching, which runs its course in from one to three or four weeks, and may recur (Anderson). 246 A COMPENDIUM OF PRACTICAL MEDICINE. Varieties. — 1. Herpes facialis. 2. Herpes prseputialis. 3. Herpes iris. 4. Herpes zoster, or shingles. Herpes facialis is the most frequent, and the parts most commonly attacked are the red portions of the lips, but any part of the face, or even the mucous membrane of the nose, palate or tongue may be involved. At first there is redness and burning heat, then little elevations appear, which soon develop into vesi- cles, often of large size; these at first are filled with clear serum, which soon becomes opaque or even purulent. Causes. — In many cases it is consequent upon catching cold, or upon digestive derangement. It is also, a very frequent ac- companiment of febrile affections, especially pneumonia in which disease its occurrence may even aid the diagnosis. Herpes jprasputialis is most often met with on the prep ace, but may be seated upon the glans, or even upon the skin, and in women upon the labia. The vesicles very soon rupture, so that often by the time attention is directed to the part by the burning heat, only a group of little excoriations is to be seen. These are irritated by the secretion and may be mistaken for soft chancres, especially as the eruption sometimes follows connection. This variety of herpes is often very troublesome, and may recur half dozen times in the course of a year. It is said to be more apt to occur in those who have suffered from venereal diseases. Herpes iris is rare, and is met with in young persons. It occurs in spring and autumn, and attacks most usually the dorsum of the hands and feet, and the fingers and toes. All the colors of the rain- bow may usually be observed at one time or another in the course of the disease. Herpes zoster, or Shingles, is the most serious of the forms of herpes, and differs from the others in that the erup- tion follows the course of certain cutaneous nerves. In its most typical form, it affects one side of the chest. It may attack other parts of the trunk as well as the extremeties, the head and neck, where it also follows the course of a nerve. Neuralgic pains usually accompany it (Anderson). Treatment. — In all varieties of herpes the part must be dusted with some soothing powder. Arsenic is the best internal remedy. The diet should be light, and saline aperients should HERPES HICCOUGH. 247 be used. Dr. Meredith recommends the painting of the part with oil of peppermint to relieve the pain (Anderson.) PRESCRIPTIONS FOR HERPES. J& Zinci oxidi.. gij". Glycerine gij . Liq. plumbi subacetat dil ^iss. Liq. calcis ^vi.-viij . — M. Ft. lotio. Sig. : Apply locally. — Tilbury Fox. j& Hydrargyri chloridi mitis gj. Unguenti simplicis §j. — M. Ft. ungt. Sig. : Apply locally. — Pareira. HICCOUGH. Treatment, — Apomorphia cured a case of persistent hiccough when hypodermic injections of morphia and atropia had failed. Camphor has been recommended in hiccough. Chloroform, com- bined with opium, is said to control persistent hiccough (Ringer). A hypodermic injection of morphia often arrests persistent hic- cough. Cases of obstinate and even dangerous hiccough are reported which have been immediately cured by drinking an in- fusion made with a teaspoonful of mustard steeped in four ounces of boiling water for twenty minutes, and then strained (Ringer). PRESCRIPTIONS FOR HICCOUGH. Jfc Pilocarpine muriatis gr. ^. A qu se destillatse IHx . — M . Sig.: Inject hypodermically. — Ortille. Jfc Pulveris sinapis 5j- Aqure bullientis , 5 iv. — M. Ft. infusum. Sig.: Take at one draught. — Ringer. jfc Apomorphise muriatis gr. -fa. Aquae destillate ZTCx. — M. Sig.: Inject hypodermically. — Ringer. 248 A COMPENDIUM OF PRACTICAL MEDICINE. HYDROCEPHALUS. Is dropsy of the brain. It may be congenital or acquired. The congenital consists in an excess of the cerebro- spinal fluid, lying either externally to the brain, or more frequently in its in- terior (Smith). Causes. — Syphilis may be a cause of congenital hydrocepha- lus, but in many cases the cause is unknown. It may be associ- ated with spina bifida (Smith, J. L.) Symptoms. — While the volume of the head increases, emaci- ation of the neck, trunk and limbs is common. In the last stages, there is more or less vomiting. As the liquid increases, the child becomes drowsy and takes no notice of objects, and finally convulsions occur (J. L. Smith). Prognosis. — Unfavorable. Treatment. — Digitalis, squills, acetate of potassium, and iodide of potassium are the remedies for this affection. One or two grains of iodide of potassium may be given every two hours to an infant of three months. A close-fitting cap may partially prevent the expansion of the head. Tapping frequently gives temporary relief, and should be performed with a very small trocar, which should be introduced in the coronal suture about an inch external to the anterior fontanel (J. L. Smith). Causes of Acquired Hydrocephalus. — Meningeal inflammations, tumors or other causes which obstruct the venous circulation, prolonged passive congestion, affections of an exhausting nature, and protracted infantile diarrhoea. Symptoms. — The child has headache, is irritable, is delirious, drowsy, and its head seems too heavy for its body and is buried in the pillow (J. L. Smith). Prognosis. — Unfavorable. Treatment for the Acquired. — Cold applications to the head. The bowels should be kept open, and derivatives should be applied to the feet and back of the neck. The acetate and iodide of potassium may be given, and vesication should be produced behind the ears (J. L. Smith). HYDROCEPHALUS HYDROTHORAX. 249 PRESCRIPTIONS FOR HYDROCEPHALUS. jfc Collodii cum cantharides ^iv. Sig. : Paint the back of neck every few days. ' — Hartshorne. # Olei tiglii IHij. Mucil acacia? ^ij. Aquae destillatse §j . — M. Sig. : The fourth part every four hours. (Said to remove fluid from the ventricles). — Dungleson. jfc Potassii iodidi 3ss-j. Syrupi aurantii cort ,5j. Aquae ad 3iv. — M. Sig.: A teaspoonful every two hours to an infant of six months. —J. L. Smith. HYDROTHORAX. A dropsy having its seat in the pleural cavity is called hy- drothorax, or water on the chest. It differs from pleurisy in the character of the fluid and in the state of the pleura. In pleurisy the effusion is an inflammatory exudation, and the pleura is the seat of an inflammation; in hydrothorax the fluid transudes, and the pleura is unaffected (Bartholow). Causes. — It is due to an organic disease of the liver, heart, or kidneys, and the serum collects in both pleural sacs. An ef- fusion caused by an inflammation of the pleura is nearly always one sided. It may occur in any exhausting disease which causes general hydraemia, and is usually associated with dropsies in other parts of the body. Chronic malarial poisoning and Bright' s dis- ease may cause it. Symptoms. — There is no fever nor pain in the side. The first symptom referable to the thorax is increasing difficulty of breathing, until the patient reaches a condition of extreme dis- tress; the lips become livid, the finger ends blue, and the respira- tion gasping. He is unable to lie down, and can speak with dif- ficulty. There may be a short dry cough- The physical signs of hydrothorax is fluid in both pleural cavities, which is not at- tended by friction sounds or vocal fremitus (Loomis). Treatment. — If there is much effusion, delay is unsafe and thoracentesis should be promptly performed. As serum will 250 A COMPENDIUM OF PRACTICAL MEDICINE. flow through a flue capillary needle, but little pain and no dan- ger attend the operation of aspiration. Such remedies as hydra - gogue cathartics, and diuretics are useful. Elaterium is the best. Digitalis should be given (Bartholow andLoomis). HYPOCHONDRIASIS. Is a disorder of the mind, but the mental aberration is not regarded as amounting to insanity, and patients with this affec- tion are not proper subjects for treatment at lunatic asylums. Cases are frequent and they claim the services of the general practitioner. The characteristic feature of the affection is a morbid apprehension of either the existence of, or a liability to some serious disease (Flint). Forms. — In its mildest form it consists of a feeling of ex- treme delicacy of constitution. Existing in this form, it leads to an anxiety concerning health and over -precautions for its preser- vation. In the severest form of the affection, patients suffer from the conviction that they have an incurable malady. The hypochondriac is the victim of a delusion with respect to his condition. Disease of the heart, consumption, cancer, syphilis, tapeworm, softening of the brain and diabetes are among the diseases which in different cases are supposed to exist. Hypo- chondriacs frequently consult many physicians in succession, but no one is able to convince him of his delusion. Persons of edu- cation and strong mental powers are as liable to the affection as those who are ignorant and of feeble mind. Some patients imagine they have one particular disease, others imagine they have various diseases, or fix upon one for a time and then another (Flint). Causes. — Are both physical and mental. Some persons are constitutionally liable to morbid apprehensions in this direction. Whenever they are ill with any affection, their mental constitu- tion leads to a sense of danger, and to despondency as regards recovery. This state of mind exerts a depressing influence which may interfere seriously with the favorable progress of disease. Masturbation, excessive sexual indulgence and the intemperate use of alcoholic stimulants are causative. HYPOCHONDRIASIS. 251 The reading of legitimate medical works is to be mentioned among the causes of hypochondriasis. Want of mental occupa- tion may cause it; and persons who have relinquished active pur- suits often become hypochondriacs. Misfortunes are causative. The physical disorders are angemia, neurasthenia and dys- pepsia. Treatment. — Remove the supposed causes if possible. Over- exertion, mental or physical, is to be avoided. Sexual abuses, intemperance and any violation of the laws of health are to be inquired into and reformed. Anseraia and dyspeptic ailments claim treatment. Remedies have a useful moral effect within certain limits. Patients often crave remedies. The mental treatment is the most important. It is not wise to attempt to dispel the delusions by ridicule or indifference, but by argument and assurances. The patient's attention should be diverted from himself. Change of scene and new associations should be ad- vised. PRESCRIPTIONS FOR HYPOCHONDRIASIS. R Liq. potassii arsenitis XHxL. Tinct. opii 3J. Aquae menthae pip ad ^iiss. — M. Sig. : A teaspoonful three times daily. (In aged with gloomy fancies). — Lemare-Picquot. R Morphia:- sulphatis gr. i-ij. Sacchari lactis gr. x. — M. In pulv. no. xii. div Sig.: A powder three times daily for at least two months. — Hammond. R Mist asafoetidae %iv. Sig.: One to two teaspoonfuls three or four times daily. — Bartholow. R Potassii bromidi ^ss. In pulv. no. xii. div. Sig.: A powder in cold water three times daily. — Ringer. R Auri chloridi gr. i-iss. Ext. gentianae gr. xv. — M. Ft. massa et in pil. no. xxx. div. Sig.: One pill thrice daily. — Bartholow. 252 A COMPENDIUM OF PRACTICAL MEDICINE. HYSTERIA. Is a functional nervous trouble, characterized by various motor, sensory and intellectual disturbances (Bartholow). Causes. — Hysteria is almost exclusively confined to women. It is most frequent between the ages of fifteen and twenty- five. If the neurotic type of constitution is inherited, in one genera- tion it may assume the shape of hysteria; in the next epilepsy; and in the third insanity. It is not due to derangement of the uterus and ovaries, but to a peculiar morbid state of the nervous system. This peculiar state of the nervous system may be acquired by faults of early training, by a lack of personal discip- line; by mortification or chagrin. Anaemia and an impoverished condition of the blood may cause hysteria. The disturbances may be in the digestive system, in the circulatory, in the sexual, or in the nervous. It is most liable to occur in members of families in which epilepsy, chorea, catalepsy and insanity have occurred. Fright, anger, jealousy, grief and disappointment predispose to its development. Among savage nations and hard working women it is unknown or rare. It is apparently con- tagious (Bartholow and Loomis). Symptoms. — The first symptoms are usually trivial — mere irritability of disposition, rapid changes of feeling, noisy transi- tions of sadness and joy, tears and laughter. There are quick alternations of cold and heat, that are purely subjective; numb- ness, tingling, suffocative feelings, pain around the heart, palpi- tations, quick breathing, a sense of fullness of the stomach, eruc- tations of gas, and the rising of a globe to the larynx (globus hystericus), producing a sensation of choking, restlessness, the whole ending, it may be, in prolonged laughter, but more usually in crying, and in a profuse urinary discharge, the urine being pale and watery. In the more severe attacks, patients laugh and cry, choke, gasp for breath, sob and cough; the jaws are fixed, the face retracted, the teeth grinding together, the hands clinched, the limbs drawn up and rigid. In some cases there are tonic and clonic convulsions. There is no loss of consciousness. In some cases there is a death -like pallor of the face and half- closed eyes. The attack is more apt to occur during the menstrual HYSTERIA. 253 period. Headache is the most common form of pain. Colics are frequent. Paralysis is sometimes a symptom of hysteria. Gas- tralgia, irritable bladder and spinal irritation are frequent symp- toms (Bartholow). During their hysterical paroxysms, they always want an audience; they crave attention and sympathy. Pain in the skull, as if a nail were being driven into the head, or a kettle were simmering on top of it, called by the ancient phy- sicians clavus . hystericus, is by many regarecl as pathognomonic. The whole or only a part of the cutaneous surface may be hyperaesthetic or anaesthetic. There is often pain in the joints. Differential Diagnosis. — Hysteria may be mistaken for epil- epsy, hypochondria and neuralgia. It is distinguished from epilepsy by its slow onset, by incomplete coma, a normal pupil, sobbing and crying. The tongue is not bitten in hysteria. In hypochondria the patient is always morose; there are not those variations in temper that are so characteristic of hysteria. Hypochondria is rare before the thirtieth year, is more common in men than in women. The two diseases may be conjoined (Loomis). Neuralgia, if of hysterical origin, ceases when the patient's attention is diverted. Treatment. — Moral and hygienic measures are most impor- tant. Self-control should be instilled into the mind. Early hours, substantial food, and plain clothing should be insisted upon, while society, the follies of dress and fashion, and dainties should be prohibited. The proper books should be selected for young ladies. Sexual abuses have an injurious effect on the ner- vous system. For anaemia, iron, arsenic, and strychnine should be given. For the seizure, a little fluid extract of valerian, or a few drops of Hoffman's anodyne repeated every few minutes will terminate the attack. In the convulsive form, inhalations of amyl nitrite or of ethyl bromide may be practiced. The mi- graine may be cured by use of mix vomica, arsenic, aconitine. and galvanism. Hysterical aphonia and dysphagia may some- times be cured instantly by faradic applications- Anaesthesia is best treated by the electric brush. The various forms of hyster- ical paralysis require faradic applications. Mitchell has devised a plan of treatment for bed fast hysterical subjects which seems very successful. It consists in the combined use of massage, 254 A COMPENDIUM OF PRACTICAL MEDICINE. faradization, and forced feeding. Massage consists in friction, kneading and tapping of all the muscles, in passive motion to all the joints. The diet consists at first of milk only. No exercise is allowed, but all movements are made for the patient. The patient is separated from all her former associations and the su- perabundant sympathy of home. She is placed in bed in charge of a nurse, and not permitted to move; the desire for action grows out of the utterly monotonous idleness (Bartholow). PRESCRIPTIONS FOR HYSTERIA. R Tinct. opii 3j. Tinct. nucis vomicae gij. — M. Sig. : Three drops in water thrice daily. (For weight on the head, flushings, hot and cold perspiration). — Ringer. R Paraldehyde rrtxxx. Syrupi simplicis gss. Aquae menthae pip. §j. — M. Ft. haustus. Sig.: To be taken at a draught. (To produce sleep). R Spiritus aetheis compositi Tinct. Valerianae amnion aa...^j. — M. Sig. : A teaspoonful in water every fifteen minutes until relieved. — Bartholow. R Apomorphiae muriatis gr. j . Syrupi simplicis 3iv. Aquae ad 3x. — M. Sig. A teaspoonful as required. Repeat in a few hours if necessary. — Ringer. R Ext. salicis nigri. Elixir simplicis aa f j . — M. Sig.: A teaspoonful three times daily. — Hutchinson. R Ferri citratis 31J. Syr. simplicis ^ss. Aquae aurantii flor ad Svi. — M. Sig. : A tablespoonful three times daily. — Hartshorn e. R Ammonii bromidi 3ij. Spiritus ammoniae aromat 5j. Aquae !iv. — M. Sig. : A dessertspoonful thrice daily. — Hartshorne. HYSTERIA HEAT STROKE. 255 Jfc Liquoris potassii arsenitis £ss. Sig. : Three to five drops thrice daily after meals. — Bartholow. JJr Extracti conii fluidi. Ext. hyoscyami flld aa JTtvij. Chloral hydratis,. gr. x. Aquae ad §j. — M. Ft. haustus. Sig.: To be taken as a single dose and repeated as required. — Madigan. HEAT STROKE. Called also sunstroke, insolation, or heat fever, is the com- plex of symptoms occurring in persons exposed to extreme heat under unfavorable circumstances (Loomis). Causes. — It is due to the influence of excessive heat — natural or artificial. The habitual consumption of spirits, beer, and al- coholic beverages, and excessive fatigue and overcrowding pre- dispose to attacks. Workmen, soldiers on the march, cab- driv- ers, or brain workers are more liable to be overcome by the heat. Hot, wet, muggy days — our August dog-days — are the most fa- vorable for its occurrence. In Dakota men can work all day ex- posed to the sun when the temperature of the air is at least 140° to 160° while in New York on a cloudy, wet day in August, with the temperature at only 93 degrees, large numbers of men and animals are prostrated (Loomis). Symptoms. — The majority of the cases occur in the middle of the day. In mild cases the patient suddenly becomes exhausted, and probably faints, or becomes semi- comatose. He is utterly prostrated; the skin is pale, cold and moist; the pulse is quick and feeble, and all kinds of symptoms are referred to the head — floating:, swimming, vertigo, fullness and neuralgic pain. These cases may recover or terminate fatally from heart failure. In a severer form, a man may be struck down suddenly, unconscious- ness suddenly follows; the skin is cold, the pulse is feeble, and death may result from heart failure. In another form called thermic fever, the temperature rises to 108° or 110° F. or even higher. This is due to the influence of heat on the nerve centre. It often occurs at night and in those who are dissipated 256 A COMPENDIUM OF PRACTICAL MEDICINE. or worn out. There is great restlessness, thirst, dyspnoea, and the skin is burning hot. Delirium and epileptiform convulsions are common, and finally the patient passes into a complete coma, with sterterous breathing (Loomis). Differential Diagnosis. — It may be mistaken for acute menin- gitis. In the latter the projectile vomiting, the boat belly, the pale face, and the tense, hard, wiry pulse are in striking contrast to the symptoms of sun-stroke. Acute alcoholismus maybe con- founded with sun -stroke, but the history of the case will decide (Loomis). Prognosis. — Except in mild cases, is very bad; nearly one- half die (Loomis). Treatment. — The patient must have absolute rest and plenty of cool, fresh air. Stimulants are often necessary. In most cases the cold water treatment is the best. The patient should be taken to the nearest pump, stream or water-tank and im- mersed for a considerable time, or a stream of cold water should be poured over the head, neck and back. In the thermic fever form, ice water should be applied to the surface, the bowels should be moved by a saline and morphine and quinine given. The inhalation of ether or chloroform is often of service in this form (Loomis). HECTIC FEVER. Is a fever of irritation. It accompanies many chronic dis- eases in which destruction of tissues occur, especially phthisis. It is a form of remittent fever, consisting of an exacerbation, once or sometimes twice a day, depending on suppuration in many cases (DaCosta). Symptoms. — One of the first symptoms is a slight increasing frequency of pulse, and a small degree of heat of skin, generally toward evening. The heat is especially felt in the palms of the hands and the soles of the feet. The fever reaches its height about midnight and terminates by a profuse perspiration toward morning. The respiration is quick and short. The appearance of the face is characteristic, there being a circumscribed blush in the centre, known as the "hectic flush." The patient loses flesh rapidly. The pulse is above 80 and is soft. The temperature HECTIC FEVER HIVES HOARSENESS. 257 as a rule varies from 99° to 101° F. Hectic fever is always symptomatic of some particular disease, of profuse discharge, as of pus or blood, or of an abscess of the brain, lungs or liver, and is in part due to the entrance of septic products into the blood, as in septicaemia. Treatment. — Kemove the diseased part, or let out the pus. The diet should consist of animal and farinaceous food, eggs, macaroni, milk, wine, beer, etc. Quinine, sulphuric acid and iron are the medicines generally indicated. For diarrhoea, aro- matic sulphuric acid, opium, and chalk mixture are efficient. Night Sweats. — Sponge the surface with cold water, or alum and water. Fifteen drops of aromatic sulphuric acid three times daily, or an sV gr. of sulphate of atropia combined or not with oxide of zinc, two or three grains, may be given at bedtime (Compend). RRESCRIPTIONS FOR HECTIC FEVER. R Quinise sulphatis 5j. In pulv. no. xii. div Sig.: A powder in water three times daily. — Phillips. R Syr. calcis lactophosphat Siv. Sig. : A teaspoonful three times daily. — Beneke. R Tinet. digitalis giij. Tinct. ferri chloridi 3v. — M. Sig.: Fifteen drops in water three times daily. — Bartholow. R Anti pyrin gr. xL. Aqua? oviij.— M. Sig.: Two tablespoonfuls, followed by one tablespoonful every hour till temperature is normal. — Pribram. HIVES. (See Urticaria). HOARSENESS. Treatment. — Chronic bronchitis and hoarseness produced by singing and by simple acute catarrh are relieved by ten minim doses of dilute nitric acid. Aphonia due to fatigue of the vocal cords and hysterical aphonia may be removed very speedily by a 258 A COMPENDIUM OF PEACTICAL MEDICINE. morning and evening dose, (rio-To of a grain) of atropine (Bar- tholow). Ten grains of alum to the ounce of water is used in the form of spray for chronic coughs and hoarseness (Ringer). Dr. Carson finds that a piece of borax the size of a pea, dis- solved in the mouth, acts magically in restoring the voice in -cases of sudden hoarseness brought on by a cold, and frequently for an hour or so, it renders the voice "silvery and clear." Borax is useful in hoarseness common among clergymen and singers. In chronic inflammation of the throat, a few applica- tions of glycerine of tannin brace up the tissues and lessen or remove the hoarseness. The ipecac (wine) spray is useful in hoarseness from congestion of the vocal cords. Where the hoarseness has lasted a few clays only, or one or two weeks, the spray often speedily cures. At the commencement of a feverish cold, a Turkish bath will cut the attack short, remove the aching pains, and relieve or cure the hoarseness at once (Ringer). HORDEOLUM. (See Stye.) HOUSEMAID'S KNEE. Is an inflammation of the bursa of the knee, between the patella and skin, which is common to housemaids, from kneeling. It is usually chronic, but may be acute. It causes great pain and swelling, the swelling being superficial and in front of the patella. An enlargement of the bursa at the elbow is called "miner's elbow." Bryant has seen the bursa enlarge over the acromian process in men who carry timber; over the tuberosity of the ischium in weavers; over the external malleolus in tailors; over the malleoli, and also the instep, from pressure of a boot; over the ball of the great toe in cases of bunion, etc. Treatment. — Rest, leeches, fomentations and purgatives; if these do not bring relief, an incision should be made into the swelling. After evacuating the contents of the sac, a small quantity of equal parts of tincture of iodine and alcohol should be injected into it. Dr. Lewis recommends injections of carbolic acid. It may be tapped (Bryant and others). HYDROCELE HEMATOCELE. 259 HYDROCELE. Is an accumulation of scrum in the tunica vaginalis testis, and it may be of the spermatic cord. The swelling of hydrocele first shows itself at the lower part of the scrotum and gradually rises till it arrives at the abdominal ring. It is of a j)yriforni shape. Usually it is attended with pain. Commonly there is no discoloration of the scrotum. In hydrocele the testicle is two- thircls of the way down the tumor at the posterior part, but it may sometimes be found in front, or at the bottom. The diag- nostic signs are a sense of fluctuation, transparency, lightness and freedom from pain. In very old cases the transparency may be absent. Congenital Hydrocele. — When the tunica vaginalis preserves its communication with the abdomen, and then becomes filled with serum, it is called congenital hydrocele. On being raised and compressed the fluid is slowly squeezed into the abdomen, and slowly trickles dowm again afterward. Treatment. — Is either palliative or curative. The evacua- tion of the serum constitutes the palliative treatment. This is accomplished by a puncture with a small trocar and canula. Palliative treatment is sufficient for children, but rarely so in the case of adults. The radical cure is performed by injecting into the sac a fluid composed of one drachm of tincture of iodine, and one or two drachms of water, after first having withdrawn all the serum from the sac. When the inflammation subsides the fluid generally secretes no longer. Dr. Lewis recommends injec- tions of a half a drachm to a drachm of pure carbolic acid lique- fied with water or glycerine into the sac. In obstinate cases, a free incision into the tunica vaginalis, and the filling of the cavity with carbolic or iodoform gauze to make it fill up by granulation, is also to be recommended (Bryant). HEMATOCELE. Is an extravasation of blood into the tunica vaginalis. It may occur as the result of a blow, strain, or the tapping of a hydrocele, or it may arise without any assignable cause. 260 A COMPENDIUM OF PRACTICAL MEDICINE. There is swelling of the part, which comes on immediately, or soon after the receipt of the injury. It resembles hydrocele as regards shape. At first the tumor is soft, and fluctuation may be detected, but when the blood coagulates it resembles in its character a solid growth. There is testicular pain on pressure. It is a non- transparent tumor, smooth and tense (Bryant). Treatment. — In a recent case the first indications are to arrest the flow of blood and relieve pain. The recumbent posi- tion, with testicles raised, is necessary; the ice-bag and cold lotions must be applied. If the blood remains fluid for a long time, tapping may be performed. In chronic cases where there are signs of suppuration, a free incision should be made into the vaginal sac, and the cysts and clots turned out. Then will follow the usual treatment to promote healing by granulation (Bryant). HYPERIDROSIS, (See Ephidrosis.) H^EMIDROSIS. Is an affection characterized by a flow of blood from the skin independent of any pre-existing lesion as a wound, abrasion or ulcer. The term literally signifies bloody sweat. Discharges of blood from wounds, abrasions and ulcers of the skin in connec- tion with menstruation, are quite common; but cases in which the flow takes place without any lesions are exceedingly rare. Causes. — The disease occurs most frequently in females, and in connection with amenorrhcea or defective menstruation, being in fact, a species of vicarious menstruation. It has been known to occur in infants and in adult males. It has been supposed that the hemorrhage is due to debility and deterioration of the blood. Treatment. — When the disease occurs in females in connec- tion with the anomalies of menstruation, these must be corrected by the usual means. The abstraction of blood, local and gen- eral, is likely to prove serviceable and to stop the discharge. If the hemorrhage seems to be due to debility, a nourishing diet,, stimulants and tonics are indicated (Anderson). HODGKIJs's DISEASE — HYMEN HYPOSPADIAS. 261 HODGKIN'S DISEASE. (See Lymphadenoina). HYMEN. (Imperforate and Eigicl). Imperforate hymen is a condition to be recognized and not confused with adherent labia. The hymen is more deeply placed and nearer the orifice of the vagina. When imperforate, it causes retention of the menses, the accumulation of the secre- tions, and a pelvic tumor usually accompanied by periodic pain and constitutional disturbance (Bryant). Treatment. — Division of the imperforate membrane, or its complete excision to allow of the free escape of the secretions which are usually black, is the proper treatment (Bryant). A rigid hymen is occasionally an impediment to coitus in women who marry late in life; and Thomas Bryant has been called upon on one occasion to divide the hymen of a lady about thirty who had been married for some months and had never had complete connection. HYPOSPADIAS. Is a malformation in which, the canal of the urethra, instead of opening at the apex of the glans, terminates at the base or beneath the penis. It is a congenital deformity and is due to an arrest of development of a portion of the lower wall of the urethra. Hypospadias is much more common than epispadias. In examining sixty thousand conscripts, Marchal did not find a a single case of epispadias ; but among three thousand conscripts ten cases of hypospadias were found. Hypospadias may occur at any point in front of the membranous urethra, but is more fre- quently confined to the glans penis. The only disturbances caused by hypospadias are functional. The patient may not be able to pass water without wetting himself, and if the opening is too low in the canal he may be impotent (Keyes). Treatment. — Simple hypospadias rarely calls for surgical in- terference, and hypospadias of the glans penis is unimportant. The operations which have been performed for its relief are not very encouraging in their results (Keyes). 262 A COMPENDIUM OF PRACTICAL MEDICINE. HEAD INJURIES. Must not be neglected, however trivial. They may be fol- lowed by erysipelas, inflammation and suppuration. Treatment, — They should be sutured at once with edges carefully coapted. Care should be taken to wash away all for- eign bodies and clots with bichloride of mercury solution and a syringe. No part of the scalp however torn should be cut away. The patient should be confined to bed, or to the house, purged and put on a milk diet. The hemorrhage from small vessels is usually controlled by closing the wound and using pressure; larger vessels must be tied (Bryant). Caution. — Every scalp wound should be carefully examined with the finger and probe, to ascertain whether or not fracture of the skull exists. If suppuration occurs as indicated by rigors, chills, dry tongue, with increase of swelling and throbbing pain, the adhesions must be separated and pus let out (Bryant). HORNS. While horns occur normally on the heads of many of the lower animals, they are rarely met with in man. Causes. — We know very little with regard to the causes which induce them. It is probable that in many cases at least local irritation has something to do with their production. Situation. — They are most commonly met with on the head and face, although any part may be implicated. They are more common in females, and are usually seen in persons who have passed middle life. Usually they are solitary, but occasionally multiple. Botge has reported the case of a girl aged 19 who had a horn close to the navel about six inches in length, while on the right labium there was one but a trifle shorter. The most remarkable case is that of a Mexican porter who had a horn on the upper and lateral part of his head which was fourteen inches in circumference around its shaft and divided above that point into three branches. Horns spring from the mucous layer of the epidermis and are composed entirely of epidermic cells. Color. — Horns are usually grayish, yelloAvish or brownish in color. They grow slowly, years often elapsing before they attain HERNIA. 263 their full size. The horns themselves are quite insensitive, but by pressure may give rise to pain. Sometimes the skin at their base inflames and suppurates and they fall off ; but they are apt to recur (Anderson). Treatment. — Consists in tearing out the horn after softening it with poultices, but in order to prevent its return, it is desira- ble to cut out the piece of skin from which it grows, or to caut- erize the bases freely with chloride of zinc or caustic potash (Anderson). HERNIA. Called also rupture, is the protrusion of any viscus from its natural or containing cavity. Rupture is the wrong term, as there is no rupture of the peritoneum; it simply forms a sac or one of the coverings. It includes hernige of the brain, testicle, lung, and mostly of the alimentary canal. Reasons for Studying Hernia. — 1. Because of its frequency; one person in eight is affected with hernia. 2. Because of the effects of the presence of hernia: (a) the individual cannot enter the army or navy; (b) he must pay a higher life insurance; (c) he cannot enjoy the privileges of charity; (d) he is deprived of many pleasures. Classification. — There are ten varieties, five above the linea ilio pectinea, and five below that line. The five above are called abdominal and are: 1. Diaphragmatic. 2. Ventral. 3. Um- bilical. 4. Inguinal. 5. Femoral. The five below are called pelvic and cere: 1. Obturator. 2. Ischiatic. 3. Vaginal. 4. Pudendal. 5. Perineal. Tlie Component Parts of a Hernia are: 1. Coverings. 2. Sac. 3. Contents. The coverings of a hernia vary according to the variety and situation. The skin, fascia, muscle, subperitoneal tissue, and peritoneum cover all herniae. The sac always consists of peritoneum. It undergoes changes and may be thin or very thick. The sac is divided into different parts: 1. Mouth. 2. Neck. 3. Body. 4. Fundus. The mouth is the opening be- tween the cavity and the sac. The neck is the narrow con- stricted portion close to the mouth. The body is the part below the neck. The fundus is the largest portion of the body. Three 264 A COMPENDIUM OF PRACTICAL MEDICINE. kinds of adhesions exist: 1. Adhesions of the guts to each other. 2. Adhesions of the guts to the sac. 3. Adhesions of the sac to the external coverings. The contents of the sac may be the ileum, colon, sigmoid flexure, or caecum. Every viscus except the pan- creas has been found in the sac. Fluid is found in the sac, from one ounce to a pint. The fluid is secreted from the sac, and is generally clear, but is bloody in inflamed hernia. A hernia is named by adding " ocele " to the name of the body contained, or may be named according to situation. Causes. — 1. Predisposing. 2. Exciting. — Predisposing causes are : hereditary conformation of the parts, 34 per cent, are of these, 12 per cent, of which are in the first year; structural defects, as large inguinal rings, lax peritoneum, low attachment of the mesentary, wounds and abscesses and sudden emaciation after great corpulence. Exciting Causes are : forced action of the diaphragmatic and abdominal muscles, as in straining at stool, lifting heavy weights, vomiting, crying, coughing in pneumonia or bronchitis; distension of the alimentary canal; certain forms of violent ex- ercise, as horse-back riding without stirrups; sailors pulling at ropes, and persons riding bicycles. Signs and Symptoms. — By inspection, we observe : a tumor at a hernial opening; a tumor increasing and diminishing in size and weight in the upright and recumbent position; and a tumor with healthy skin over it. By examination, we find that the tumor is reduced by taxis and returns on coughing; that the tumor has an impulse on coughing (unless strangulated); that the tumor may be hard, re- sisting, lobulated as in epiplocele, or soft, elastic and smooth if an enterocele. By inquiry, we learn that the tumor suddenly appeared from above and never from below; that the tumor is not painful, but is uncomfortable; that the tumor is often associated with intestinal disturbance. Diagnosis. — Make the patient stand before you with his back to a table and lean backwards. If in bed make him lie with a pillow under his nates. Note if the tumor is connected with the ring. Place a finger in the ring, through the scrotum, and ask HERNIA. 265 patient to cough; you will feel an impulse on the end of your finger. In women, feel for the spine of the pubes and pass your linger up a little. In femoral hernia, feel for pulsation of the femoral artery and ask the patient to cough. Inquire into the history of the patient. See if the tumor is fixed or movable. Percuss the tumor and if intestinal it will be tympanitic, if epiplocele dull, if solid, flat. Hernia is not transparent. A hy- drocele will transmit light unless it contains blood or gut and then it is opaque. In hernia only there will be an impulse on coughing. Treatment of Ordinary Reducible Hernia. — Place the hernia back into its proper cavity and prevent its return by a truss. A truss should be used and the following points observed : 1. Notice the spring — have it not too weak or not too strong; 2. Notice the pad, it should be covered with kid to prevent irrita- tion to the integument; 3. Use a rubber truss in bathing. Put the truss on while the patient is lying down, as in going to bed at night and rising in the morning. Hernia should be kept back all the time, and the patient should never go without a truss. Prof. Dennis has never seen a hernia which he could not keep back with a truss. You should never guarantee a cure by a truss, but the younger the patient, the more likely is he to be cured by the use of a truss. The neck of the sac contracts and the mouth puckers up. There is danger in wearing a truss which does not fit properly. Never allow the hernia to be pressed. Never allow constipation to exist in hernia. Pathological Conditions. — There are certain pathological condi- tions which distinguish hernige, as 1. Irreducible; 2. Incarcerated: 3, Inflamed; 4, Strangulated. An Irreducible Hernia is caused by adhesions, by the nature of the protrusion, by the shape of the hernia (hour-glass), or by contraction of the ring, or of the abdomen. The symptoms are the same as in reducible hernia. The tumor cannot he made to go back into the cavity. This form of hernia gives rise to colicky pains, intestinal derangement, and is liable to strangulation. As to treatment, the patient should be carefully watched. Let him wear a concave pad truss. The bowels should be moved daily. 266 A COMPENDIUM OF PRACTICAL MEDICINE. Give calomel, or iodide of potassium, to reduce the fat of the patient, and if then the hernia can be reduced, use a truss. An Incarcerated Hernia is an obstruction in the protrusive parts by fluid, solid or gaseous contents. The causes are diar- rhoea, and faulty digestion with flatulence. This form is usually found in elderly people. The signs are pain with an increase in the size of the tumor; a certain degree of fullness; no heat, ten- derness, or tension. The symptoms are eructation of gas, but seldom vomiting; no circumscribed peritonitis; little or no pyrexia. As to treatment, employ gentle taxis, and as this is being done, pull the tumor gently from the ring. Apply hot and cold applications alternately. Give an enema high up in the bowels of warm water, castile soap and glycerine. An inflamed hernia is an inflammatory condition of the gut or the sac. The causes are external violence, pressure of a badly fitting truss, local inflammation of the intestine, or of the omentum. The signs are pain with no enlargement of the tumor, a certain degree of hardness, heat, tenderness and tension. The symptoms are, slight but not continuous vomit- ing, simply the contents of the stomach; circumscribed peritoni- tis radiating from the body and neck of the sac; considerable pyrexia. As to treatment, suspend the tumor and apply local applications to produce warmth and heat to the sac. Apply opium and lead wash to the parts. Perfect rest to the bowel should be insured. Internally, give opium to relieve peristalsis and pain. A strangulated hernia is where the sac or contents are so tightly constricted that they cannot be returned to the cavity, and where circulation is arrested. There are two varieties, active and passive. The active is where the sac is suddenly en- larged, or the contents become strangulated with their first descent. The passive becomes suddenly enlarged by the descent of more intestine or omentum, gas, fluid or solid into the sac. Strangulated hernia occurs most frequently in damp weather. The depression or shock is due to the sympathetic nervous system and not to the cerebro- spinal. It simulates cholera. In all cases of severe, sudden illness, look for a strangulated hernia. HERXIA. 267 The Local Signs are a tumor which has either never aj3peared before, or if it has, is now increased in size; a tumor which is very painful, especially to touch, and is irreducible; a tumor which has lost its impulse on coughing. The Constitutional Symptoms are obstruction in the intes- tine with beginning symptoms of circumscribed peritonitis; un- controllable vomiting stercoraceous in character, with colicky pains radiating toward the umbilicus; small, quick, pulse associ- ated with great nervous prostration. A movement from the bowels may take place in strangulated hernia. The Sructural Changes are as follows: The intestine be- comes first congested, then bright red, then mahogany brown, then ashen gray, then purulent, and then fibro-purulent. The sac becomes inflamed and has a crackling sound and feel which denotes gangrene. The Treatment of strangulated hernia admits of no delay. Relieve the stricture and return the gut to the cavity if it is healthy. Before you employ taxis, give a hypodermic injection of sulphate of morphine (in and around the ring) to produce quiet and relaxation of the parts. Use a warm bath to relax the abdominal muscles, and the hernia may be reduced while in the bath. This bath is indicated in the active variety only. Vene- section may be used to produce fainting, to relax the abdominal muscles, but this is not advisable because danger may result. Elevate the feet so as to employ gravitation toward the abdomen. Use aspiration in a tympanitic gut to allow the gas to escape. It should never be employed where the hernia is of more than one or two hours standing. In taxis the surgeon must overcome all resistance — Hex the legs and relax all the muscles. Invert the patient if the hernia has just happened. Operation. — Operate at once if taxis has been employed by other surgeons; the sooner the better. Employ taxis just before the patient goes under the anaesthetic. There are four stages in the operation: 1. Exposure of the sac; 2. Opening the sac: 3. Division of the stricture; 4. Management of the hernia after ex- posure. 268 A COMPENDIUM OF PRACTICAL MEDICINE. The incision should begin above the external abdominal ring one inch, and go to the bottom of the scrotum. Make the line of incision over the mesial line of the tumor. Cut through the skin first then the fascia. Look out next for three vessels, viz : circumflex iliac, external pudic and epigastric. Next cut through the external oblique, the internal oblique, cremaster and dart os. The peritoneum is recognized by its rough cellular appear- ance, by its adhesions to surrounding parts, by having no blood vessels upon it, and by its bluish color and transparency. The intestine can be seen under it. Open the sac at its lower end by taking it up between forceps. A fluid will first appear which is normal. Pass a director into the opening and it will move about freely in the cavity. Next introduce the finger into the sac, the finger having been immersed in a bichloride of mercury solution. Cut on the finger to open the sac. Then divide the stricture at once, and examine the gut afterward. There are three points where strictures may be situated, at the first ring, neck of the sac, or within the sac. But generally it is at the ring. Protect the gut. Introduce a grooved director into the ring and divide the stricture on the director. If the hernia is at the abdominal rings, cut upward and inward toward the umbilicus. If at the umbilicus cut toward the spleen. If at the femoral ring cut inward. Do not put back gut that is gangrenous, and do not leave out healthy gut. Examine it carefully, pull it down to see how much of a stricture there has been, and how much damage is done by the stricture. Note the color of the gut. If it is bright red and elastic, it is healthy and can go back. If reddish brown or black, take the thumb and index finger and pinch the gut a little, hold for a few seconds and let go to see if the blood comes back again to the part. If so it is healthy. If the gut is ashen- gray, collapsed, and has a cadaverous odor, it is not in a condi- tion to go back. If the gut is right to return, take the thumb and index finger and push it back little by little beginning at the ring. In gangrenous gut, let it slough in the wound; because the patient is in collapse, and the gut is inflamed, engorged and not in a proper condition to go back, and the sac is septic, and the HERNIA. 269 gut may retract and then nature has to restore the gut. If this method fails then later on do resection open the wound and bring together the healthy ends of the gut. Keep the parts warm. Give the patient morphine to keep the intestine quiet. Do not give, however, more than two or three doses. Give no food for several clays, and then begin nourishment with peptonized milk. Give small pieces of ice to quench thirst. Move the bowels with enema of olive oil, warm water and soap. Do not use purgatives or cathartics. The abdomen may be opened and the gut relieved when obstructed with anything in the way of faeces. When the gut cannot be put back with safety, use the following treatment: Opium, cracked ice, and milk diet. Aj3ply warmth to the sac. Let the gut slough and be drawn back into the cavity as nature may direct. If the peritoneum has adhered to the stricture treat it as best you can. Different Kinds of Hernia. I. Diaphragmatic. — Is a congenital hernia in which there is a fissure in the diaphragm. When the opening or rent in the diaphragm is caused by malformation, or the arrest of develop- ment, it is a fatal condition. It may be caused by traumatism, as the fracture of a rib, or other injuries, or by the intestine go- ing through a natural opening in the diaphragm, on the left side because the liver is on the right. Treatment — The first kind is fatal. The second may be op- erated and sewed up. The third demands no treatment. II. Ventral. — Is a hernia anywhere in the abdominal wall, except at a hernial opening, as between the recti muscles, between the ossa innominata, between the linea alba and the linea semi lunaris, and as the result of traumatism. Strangulation never takes place in hernia due to traumatism. It usually follows lap- arotomy. Treatment. — If the hernia is great cut in and stitch the per- itoneum first and then the soft parts over it. Ill Umbilical. — Is a hernia where the cord is tied. Tt is caused by a malformation and comes in early life. It is also caused by the exertion of the infant. One kind may be situated above the umbilicus in the adult and not in it. 270 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment — In children treat the hernia with a truss and one suitable for the purpose. In adults, a hernia above the umbili- cus is dangerous and is liable to strangulation. If this occurs the patient is most certain to die. If the patient does not die, he will have indigestion, which must be distinguished from acute indigestion and can be by persistent vomiting in hernia. It oc- curs four times in the female to once in the male. 1 V. Inguinal. Varieties. — 1. Indirect inguinal hernia, or external, is one that goes through the inguinal canal. 2. Direct inguinal hernia, or internal, is one that makes its way directly through the external ring without having passed down the in- guinal canal. When the protrusion takes place above Poupart's ligament, through the intestinal ring r but does not traverse the canal sufficiently far to appear through the external ring, the hernia is called a bubonocele. Indirect inguinal is also called oblique inguinal hernia. Occurrence. — Three -fourths of all cases of inguinal hernia are on the right side of the body, because the liver is pressing above, and the root of the mesentary is lower down on that side, and most persons are right handed. It is more common in males than in females, because the rings are larger. Out of every 100 cases of hernia, 84 are inguinal, 10 femoral, and 5 umbilical. When an inguinal hernia protrudes through the external ring into the scrotum, it is called a scrotal hernia. The tissues that cover in a hernial sac will necessarily depend upon the seat of the hernia. The treatment is the same as in other hernia. V. Femoral. — Is a hernia below Poupart's ligament, the pro- trusion having come down through the crural ring on the inner side of the sheath of the femoral vessels. It does not appear at birth, nor in early life — about twenty years of age. It is more frequent in women than in men, because Poupart's ligament is longer and weaker, and the pelvis is wider in women. The neck of the sac appears beneath Poupart's ligament and the fundus rolls up over it. Treatment. — Femoral hernia requires an immediate opera- tion. The neck of the sac is surrounded by ligamentous tissue which is unyielding and the danger is great. HERXIA. 271 VI. Obturator. — Is a hernia which coraes out through the obturator foramen. It is most frequent in females on account of the greater inclination of the pelvis. Signs and Symptoms. — There is a tumor at the inner side of the thigh and femoral vessels. There is pain in the knee joint owing to pressure of the tumor on the obturator nerve, and the jDain is increased by extending the leg, and by rotating the thigh outwards. Other signs are the same as in any other hernia. Treatment. — Gentle taxis is generally sufficient. It often becomes strangulated. VII Ischiatic. — Is a hernia which comes out through the ischiatic notch, above or below the pyriform muscle, and under cover of the gluteus maximus. Symptoms. — Same as in any other hernia with one extra — a tumor found on a line drawn from the trochanter major to the sacro-iliac synchondrosis. Treatment. — Careful taxis. If strangulated operate. VIII. Vaginal. — Is a protrusion at the upper and posterior part of the vagina. It comes usually after parturition. Symptoms. — Has all the signs of inguinal hernia and an impulse on coughing. It is a smooth, soft tumor increasing in the upright and decreasing in the recumbent position. It causes tenesmus and cystitis. It is reduced by taxis. Diagnosis. — It may be mistaken for cystocele. The diag- nosis is made by introducing a male sound. It does not become strangulated. Treatment. — It is easily reduced and kept back by a ring pessary. It should be reduced before labor. IX. Pudendal. — Begins like vaginal. Comes out between the vagina and the levator ani muscle, lies in the long axis of the vagina, presents at the side of the ascending ramus of the ischium. Treatment. — It is easily reduced and kept back by a truss. X. Perineal. — Is a hernia between the rectum and bladder in the male, or between the rectum and vagina in the female. It is more frequent in the female on account of a greater pelvis. Signs. — Are the ordinary ones. It forms a tumor between the tuber-ischii, which increases in size when standing. 272 A COMPENDIUM OF PKACTICAL MEDICINE. Treatment. — Use a special perineal truss after reducing it. Tumors Which Are Confounded with Hernia. — 1. Hydrocele. 2. Spermatocele. 3. Hematocele. 4. Varicocele. 5. Undes- cended Testicle. 6. Solid Tumor of Testicle. 7. Abscess. I. Hydrocele. — Signs. — 1. Slow growth from below upwards. 2. It has a tense elastic feel. 3. Transparency. 4. Absence of impulse on coughing. II. Spermatocele. — Signs. — 1. Situated above the testicle. 2. Notched appear- ance from pressure on the cord. 3. Marked mental effect. 4. Spermatozoa seen under the microscope. Ill Hematocele. — Signs. — Sudden growth following traumatism. 2. Soft fluc- tuating feel. 3. Ecehymosis of scrotum, pain and tenderness. 4. Irreducibility. IV. Varicocele. — Signs.— 1. Slow growth from below upwards. 2. Feels similar to a bag of worms. 3. Reducible, but will return with pressure over ring. 4. It does not involve the spermatic cord. V. Undescended Testicle. — Signs. — 1. Testicular sensation. 2. Pain upon pressure. 3. Absence of a testicle in the scrotum. 4. Absence of an im- pulse on coughing. VI. Tumor of Testicle. — Signs. — 1. Circumscribed size. 2. Doughy, lobulated feel. 3. Constant situation below inguinal canal. 4. Absence of an impulse on coughing. VII. Abscess. — Signs. — 1. Sense of fluctuation. 2. Inflamed integument. 3. Returns without a gurgle. 4. Peculiar impulse on coughing. HYDRONEPHROSIS. Called, also, dropsy of the kidney, consists of an accumula- tion of urine and dilatation of the pelvis and calices, with pro- gressive atrophy of the renal structure (Bartholow). Causes. — It is caused by some obstruction in the urinary passages. The obstruction may be seated in the bladder, pelvis, HYDRONEPHROSIS. 273 ureter, bladder, or urethra. It is usually unilateral. It may be con- genital or acquired. Congenital causes are: 1. A supernumerary renal artery compressing the ureter. 2. Narrowing of the lumen of the ureter. 3. A valve -like impediment produced by an oblique insertion of the ureter into the pelvis of the kidney. 4. Insertion of the ureter into the upper, instead of the lower part of the pelvis. The congenital is often associated with mal- formations of other parts, as imperforate anus, hare-lip, etc. The acquired causes are : 1. The ureter may be blocked by a calculus, by coagula of blood, or by parasites. 2. Diseases of the walls of the ureters. 3. Pressure upon the ureter from without, by a tumor, by a displaced uterus, etc. 4. Diseases of the bladder which involve one or both of the orifices of the ureters. 5. Stricture and hypertrophy of the prostate (Bartholow, Loomis and Flint). Symptoms. — An important diagnostic sign is the discovery of a tumor in the lumbar region. The tumor is fluctuating and usually lobulated. It causes no pain except by its pressure. In growing, adhesions form which give rise to acute stabbing pains at the time of their formation. If the tumor presses upon the colon, constipation results; if upon the diaphragm, dyspnoea will result; if upon the stomach, there will be nausea and vomiting; if the tumor rests upon the abdominal aorta, a pulsation will be communicated to it. A symptom of almost pathognomonic value is the disappearance of the tumor coincident with the discharge of a large quantity of pale liquid by the bladder. The course of the disease is chronic, and the formation of the tumor slow (Bar- tholow, Loomis and Flint). Differential Diagnosis. — Hydronephrosis may be confounded with ovarian cysts, ascites, hydatid cysts and pyonephrosis. In ovarian cysts, the tumor develops from below. Vaginal and rectal examinations will aid. In ascites, when the position of the patient is changed there is a change in the level of dullness, which never occurs in hydronephrosis. It cannot be distinguished from hydatid cysts unless hydatid vessels are found in the urine. It is distinguished from pyonephrosis by a non-purulent charac- ter of the urine, and by the absence of constitutional symptoms. Treatment. — Remove the cause of obstruction if possible. 274 A COMPENDIUM OF PRACTICAL MEDICINE. Removal of the liquid by aspiration has proved successful. A small aspirating needle or trocar should be used. Free opening and drainage is a favorable surgical procedure. Medicine will accomplish nothing. HYDROPHOBIA. Called, also, rabies, is a specific disease due to the inocula- tion of a poison contained in the saliva of rabid animals, notably the dog, and characterized by pain and stiffness of the inoculated part; by exaltation of the reflex faculty, by spasms of the throat on the attempts to swallow, and subsequently at the sight of liquids; by delirium, exhaustion and death (Bartholow). Causes. — The inoculation of man with a specific virus con- tained in the saliva of the dog, cat, wolf, fox, and some other rabid animals, is the sole cause of the disease. A certain predis- position seems necessary, for, of all persons bitten by rabid ;animals, only a small proportion are attacked by hydrophobia. The teeth, in inflicting the wound, pass through the clothing, which removes the saliva, and therefore the most of those bitten through the clothing escape infection. All ages and both sexes are liable. Apprehension, fear, excesses of all kinds, fatigue, etc., favor the occurrence of the disease (Bartholow). Symptoms. — The period of incubation varies from a few days to several months or even years. During the invasion of the disease if the wound has not healed, it takes on a livid appear- ance, and becomes painful; if it has healed, the scar becomes red, irritable, swollen and painful. Sometimes a sensation of cold- ness and of numbness is felt in the bitten member. These local symptoms are soon followed by systemic disturbances. The pa- tient is depressed, apprehensive, melancholic and peevish. The first is called the melancholic stage. There may be slight con- striction of the throat, and difficult swallowing. These symp- toms increase in severity for two or three days, when the patient passes into the convulsive stage. In this stage, there is great restlessness, the eyes have a wild look, are bright, staring, and constantly moving. The mouth and throat are dry, congested, and covered with thick, tenacious saliva which gathers about the lips in frothy masses. HYDROPHOBIA ICHTHYOSIS. 275 Thirst is intense, but the patient cannot drink. The sight of water, or the thought of drinking brings on violent spasms of the muscles of deglutition and respiration. There is intense hyperesthesia, and convulsions follow attempts at drinking. In rare cases there is a paraplegic stage. The hawking and spitting of the patient seems like the bark of a dog. Patients often be- come violent. Duration. — Hydrophobia is a very acute disease. The whole duration of the disease is comprehended in three days to two weeks (Bartholow andLoomis). Prognosis. — Is most unfavorable. Treatment. — When the bite of a rabid animal has been re- ceived, the wound should be scarified, cauterized with a hot iron, or every part of it touched with nitrate of silver. Permanganate of potassium should be tried. There is no specific to prevent the disease, unless Pasteur's inoculations with the modified virus, have this power. Of all the remedies proposed, curare is the only one which seems to possess any power over hydrophobia. One-third grain should be given every fifteen minutes (Bartholow and Loomis). ICHTHYOSIS. Called, also, fish- skin disease, is a rare malady. It is not so much a disease as a deformity. Causes. — The cause is unknown. Symptoms. — There is excessive proliferation of the cells of the epidermis. The skin is thickened, dry, coarse, wrinkled, and discolored. There is defective action of the sudoriparous and sebaceous glands. The scales resemble those of a fish (An- derson). Treatment. — A long course of arsenic is useful. The hypo- dermic injection of 1 of a grain of pilocarpine may be used from time to time. The local treatment consists in the frequent use of baths. Oily substances may be applied to the skin to keep it soft (Anderson). 276 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR ICHTHYOSIS. R Cupri sulphatis gr. x. Unguenti sambuci gj. — M. Sig. : Use locally. — Wilson. R Pulv. camphorse gr. x. Ungt. zinci oxidi gj. — M. Ft. Ungt. Sig. : Use locally. — Erasmus Wilson. R Ulmi corticis ^iiss. Aquas bullientis Oj . — M. Ft. haustus. Sig.: A wineglassful or two thrice daily. — Lettson.. IMPETIGO. Is an acute pustular, inflammatory cutaneous disease. It is the pustular form of eczema. (See eczema.) Treatment. — The glycerite of tannin is an excellent applica- tion for impetigo. Skin- diseases, as impetigo and ecthyma,, usually arising from a feeble state of the assimilative function, are cured by quinine. Nitric and nitro- hydrochloric acids have been used with advantage for the cure of impetigo, when depend- ent upon indigestion (Bartholow). PRESCRIPTIONS FOR IMPETIGO, R Plumbi acetatis gr. xv. Acidi hydrocyan dil ZHxx. Alcoholis gss. Aqua) ^vss. — M. Sig.: Apply locally. — Bartholow. R Zinci oxidi gij. Glycerinre ^ij. Liq. plumbi subacetatis ^iss. A quae calcis ad gvj. — M. Sig.: Apply locally. — Fox.. R Unguenti zinci oxidi §j. Sig.: Apply locally. — Ringer. R Syrupi hypophosphiti comp gvi. Sig.: A teaspoonful thrice daily in water. — Jamieson^ INDIGESTION INFLAMMATION. 277 INDIGESTION. (See Dyspepsia). INFLAMMATION. Is that nutritive disturbance which is characterized by ac- tive hyperemia or congestion, and active multiplication or pro- liferation of the cells of a tissue or organ (Gross). Causes. — Are predisposing and exciting. The predisposing are gout, syphilis, scrofula, shock, loss of blood, impaired nerv- ous action, bad habits, diabetes, anaemia, etc. The exciting causes are cold or heat, injuries, acid or alkalies, parasites, and the results of the ptomaines of micro-organisms on the tis- sues. . Symptoms. — A part is acutely inflamed when it is hot, red, swollen and painful. The local symptoms are : 1. Redness, which is caused by an afflux of blood to the part. Redness is not al- ways a sign of inflammation, unless it be permanent. 2. Heat, which is always present, and is due to an increased flow of blood to friction against the walls of the vessels of the part and to cell proliferation. The inflamed part is a heat-producing area, thus causing fever by overheating the blood. 3. Swelling, which is due to capillary engorgement, and effusion of serum into the tis- sues. The swelling is greater where the tissues are lax. And 4. Pain, which is usually felt at the seat of the morbid action. Pain sometimes suddenly leaves a part, which is a sign of com- mencing mortifl cation. The causes of pain, are compression, stretching, irritation and disorganization of nerves. Its charac- ter varies; it may be sharp and lancinating, as in inflammation of serous membranes; acute and throbbing, as in formation of pus; dull and heavy, as in periostitis; annoying, as in toothache; sick- ening, as inflammation of the testes, itching, as in affections of the skin; or burning and scalding, as in gonorrhoea. The pain in inflammation comes on gradually, is persistent, aggravated by pressure and muscular contraction, and is fixed; there is febrile disturbance, accompanied by redness, heat and swelling. The pain of spasm comes on suddenly, is intermittent, relieved by pres- sure; is not fixed, there is no fever, and is not accompanied by redness, heat or swelling. The of pain neuralgia is paroxysmal, is 278 A COMPENDIUM OF PRACTICAL MEDICINE. aggravated by pressure, is not fixed, and is unaccompanied by fever, redness, heat or swelling. Constitutional Symptoms. — In mild cases there is no consti tutional disturbance, but if the inflammation be at all severe fever will follow. The fever is usually ushered in with a chill The tongue becomes furred and unclean, there is great thirst want of appetite, the bowels are constipated, the urine is scanty the skin hot and dry, and the heart's action increased (Com pend). Products of Inflammation. — Are fibrin, serum, pus cells and red blood- corpuscles. The first effect of the application of an infiammatory irritant is a dilatation of the arteries, then of the veins, and last of all, of the capillaries. At the same time the velocity of the blood- current is increased. After a time the blood flows less rapidly, and in the capillaries it may come to a com- plete stagnation or stasis. At this time the white corpuscles migrate from the veins and capillaries, but not from the arteries. The red corpuscles pass through the capillary walls by a process known as diapedesis (Flint). Treatment. — Remove the exciting cause if possible. The general treatment is rest and elevation and relaxation of the affected part. The local treatment in the stage of congestion is bleeding. This may be affected by punctures, scarifications, leeching, or cupping. Leeches should not be put on the inflamed surface, but between the inflamed part and the heart. If it is desired to remove a leech after a certain time, this may be ac- complished by sprinkling salt upon it. The bleeding may be stopped by applying to the part nitrate of silver, muriated tinc- ture of iron, or styptic cotton. The now of blood from a leech- bite may be continued by the application of warm water. The application of cold is frequently of service. It contracts the calibre of the capillaries. When the second stage, or that of effu- sion, is established, compression by bandages is useful. Acetate of lead is applicable to all cases of external inflammation (eight grains to an ounce of water). When the third stage, or that of suppuration, is reached, the application of heat and moisture by means of warm baths and poultices is the best. Constitutional Treatment. — In strong, robust individuals, INFLAMMATION IMPOTENCE. 279 blood-letting may be resorted to in the first stage of inflamma- tion. Arterial sedatives such as tincture of veratrum viride, aconite root, gelsemium and tartar emetic are indicated in the first stage of inflammation. The diaphoretics in general use are acetate of ammonium, citrate of potassium, Dover's powders, fluid extract of jaborandi, muriate of pilocarpine and lemon juice with bicarbonate of potassium. The diuretics in use are infusion of digitalis, salts of potassium, citrate of caffein, coffee, etc. Cathartics are used to evacuate the bowels, deplete the mucous membrane, and to stimulate the absorbents, and thereby remove the inflammatory deposit. Enemata of warm water, or soap and water may be used to unload the bowels. Emetics are indicated when the skin is hot and dry, the tongue heavily coated, and great weight in the epigastrium. Anodynes. — Opium is applicable to the treatment of inflammation in all stages of the disease. It should be preceded by a cathartic. It must be given in full doses, as small doses act as stimulants, while larger doses act as sedatives. Hypnotics. — When the patient is restless, but not suffering acute pain, hypnotics are indicated, such as bromide of potassium gr. xxx., chloral gr. xx., taken at bedtime (Compend). IMPOTENCE, Is a symptom, and means inability to perform the act of coition. Impotence must be carefully distinguished from steril- ity, which signifies inability to beget offspring on account of defect in the semen, whether the individual can have sexual in- tercourse properly or not. A man may be impotent and virile, or impotent and sterile, or potent and sterile. The sexual act is a compound one, physical and mental. The physical organs may be perfect and capable in their way; but if the mental are deficient in energy, or weakened by doubt of competency, or under the influence of some emotion such as shame or fear, the sexual act will be spoilt, and failure to com- plete it must ensue. Impotence may involve absence of sexual desire, or it may exist without loss of sexual desire. Different person- in health differ widely as regards the venereal propensity; in some persons 280 A COMPENDIUM OF PRACTICAL MEDICINE. the sexual desire is intense, in others it is feeble and sometimes wanting. The propensity may be increased by indulgence and diminished by an opposite course. In the marital relation cold- ness may depend on personal antipathy and is a frequent source of domestic unhappiness (Bryant and Flint). Impotence may be considered as true and false. True im- potence is exceedingly rare in the male. Causes. — 1. Absence of penis. 2. Minute size of penis is only a relative cause. 3. Extreme size of the penis is a relative cause. 4. Extreme epispadias and hypospadias. 5. Large size of the prepuce, tight and narrow orifice, tumors or growths upon or about the penis, and excess of abdominal fat. 6. Very tight stricture of the urethra. 7. Aspermatism. 8. Imperfect, irreg- ular and bent erections. 9. Eunuchs. 10. Prolonged sperma- torrhoea. 11. Partial erection, attended by rapid ejaculation, is a common variety of impotence, due usually to continence, over- excitement, etc. In this case, the patient should practice the sexual act in the early morning rather than the evening. Circumcision may sometimes be necessary to diminish the sensi- tiveness of the glans penis, which is often over -acute. Treatment. — Remove the cause if possible. FALSE IMPOTENCE. Causes. — In false impotence, the cause is always nervous, or it may be a moral one; and there is often no impotence at all, except in the mind of the individual. Sexual indifference, as a result of sudden shock, grief, excessive joy, fright, repugnance and lack of affection for the individual, is a cause. Under the two latter circumstances the patient will sometimes think of an- other person than the one with whom he is lying, and thus main- tain erection and effect ejaculation. The sudden flooding of the vagina with warm mucus will sometimes cause erection to cease at once. Rouband speaks of a man who became impotent on diawing a prize of thirty thousand francs in a lottery. The same author mentions another curious cause of false impotence : A young man brought up in the country was, at the age of four- teen, initiated into the mysteries of Venus, by a young friend of IMPOTENCE, 281 the family, twenty -one years old. Her hair was light, and worn in curls, and for precaution's sake, she never had intercourse with the boy except when dressed — that is, wearing a corset, high boots and a silk dress. A dark beauty had no power over him, and a night-dress extinguished all his fire. In after life, he found himself utterly impotent except in the company of a light haired woman, wearing curls, with high boots, a corset arid a silk dress (Keyes). Treatment. — It is necessary to arouse the moral sentiment of carnal desire by favorable relations to the sex — opera, theatre, etc. The power of the organs is increased by general dry friction of the whole body, by massage and flesh-brush, cold-bath, sea- bathing, generous diet, tonics, the mineral acids, strychnine, er- got, and especially phosjjhorus and cantharides, or the two com- bined, commencing at a fair dose, one -fortieth of a grain of the former to ten drops of the tincture of the latter, three or four hours before the desired erection, and increasing the dose care- fully. Cantharides produces erection without desire, and phos- phorus with desire. Electricity, and local applications of mus- tard are sometimes serviceable in recalling erection. Nervous Impotence. — Is the most common form of false im- potence. It occurs in young men. The patient can provoke erection at will and awakes with erection, but when in the pres- ence of a woman, and when he desires to have sexual intercourse, his organs will not respond, or if erection comes on, it lacks full energy. Causes. — This form of impotence is the result of unnatural excitement of the sexual functions. It may come from protracted chastity, ungratified desire, or excessive erotic excitement at the time. After prolonged chastity and great desire, the sufferer has probably approached a female, and at the portals of success his erection has failed him. The mental depression following an experience of this sort is of the most exaggerated nature. He thinks he is impotent beyond all doubt. The cunningly con- ceived advertisements of charlatans in newspapers envelop him further in deep despair. He is now without a ray of hope (Keyes). Treatment. — The best treatment for a man witli nervous im- 282 A COMPENDIUM OF PRACTICAL MEDICINE. potence is to instruct him in sexual physiology and hygiene, and get him married, with the advice to attempt no intercourse, and awaiting some morning when awakening with a vigorous erec- tion, to accomplish coitus promptly, without delay or dalliance. The act once accomplished the charm is broken. The use of the steel sound and of local applications of tannin, often of decided service where ejaculation is too rapid, are also sometimes useful here (Keyes). PRESCRIPTIONS FOR IMPOTENCE. R Tinct sanguinarise giij . Ext. stillingise fid 3v.— M. Sig. : Fifteen or twenty drops in water thrice daily. — Bartholow. R Zinci phosphidi gr. ij. Confect rosse gr. xx. Sig. : One to three pills three times daily. — Bartholow. R Ext. cannabis indicse Ext. nucis vomicae aa gr. xv. Ext. ergotse aquosi ■•••3J- — M. Ft. massa et. in pil. no. xxx. div. Sig. : A pill morning and evening; — DaCosta. R Tinct. phosphori giss. Tinct. cantharides siijss. Elixir simplicis ad %v. — M. Sig. : One teaspoonful three or four hours before retiring. In- crease dose carefully. — Van Buren and Keyes. INCONTINENCE OF URINE. (See Enuresis). INFLUENZA. Called also epidemic catarrh, la grippe and catarrhal fever, is a specific epidemic disease, self -limited, characterized by ca- tarrh of the respiratory organs, and sometimes of the digestive, and by nervous symptoms and debility (Bartholow). In 1830 and 1831 a severe influenza epidemic swept over the whole civ- ilized world (Loomis). Causes. — All conditions and all ages suffer alike. The dis- ease has passed over the whole of Europe in six weeks. It rarely continues in one locality more than two months. The usual dur- INFLUENZA. 283 ation of an epidemic is two to four years. It seems to be clue to some special morbific principle in the atmosphere (Loomis). Symptoms. — Influenza comes on suddenly. A feeling of chilliness, flashes of heat, and a feeling of lassitude are followed by symptoms of a severe naso- pharyngeal catarrh, with frontal headache, pains in the limbs and back, soreness of the throat, hoarseness and a frequent racking cough, difficult breathing and constriction across the chest. The sputa are at first mucous and then scanty, later copious and muco-purulent. There is great prostration. Sudamina appear on the surface and herpes on the lips. There is anorexia. There may be nausea and vomiting. The face becomes congested and livid, the pulse increases, the tongue becomes dry and brown, and the temperature rises. In mild cases the disease is at its height on the third day. In severe cases, convalescence does not commence until the tenth or twelfth day (Loomis). Prognosis. — Is good except in the very old, very young, and the debilitated. Complications make the prognosis graver. The most frequent complications are laryngitis, bronchitis, pulmo- nary congestion, pneumonia and pleurisy. Herpes labialis occurs often (Loomis). Treatment. — Repose in- doors, and at the outset a full dose of quinine and morphia (gr. xv. — gr. ss.) exercises a favorable influ- ence. Also in the early stages, a half ounce of liquor ammonii acetatis, and one grain of pulvis ipecac, every two or three hours is all that is required. The bowels should be kept freely open with salines. If patients are restless, Dover's powders may be given in small doses. For the prostration give stimulants. For the local distress in nose and throat, inhale the vapor of hot water. Bartholow gives the following: R Extracti ipecacuanha fld 3ij. Tinct. opii deodoratse 5iv. Tinct. aconiti radicis gj". — M. Sig. : Six to ten drops every two hours. For the violent head symptoms bromide of potassium may be given. (Loomis and Bartholow). 284 A COMPENDIUM OF PRACTICAL MEDICINE. INGROWING TOE=NAIL. This is a troublesome and painful affection. It occurs most frequently on the great toe. Causes. — Tight narrow- soled shoes and boots. The pressure causes the nail to cut its way into the tissues, the tissues become hypertrophied and ulcerate, and granulations spring up from the side of the nail (Sayre). Treatment.— Remove the exciting cause. In mild cases, insert a small piece of cotton or lint under the nail. After the application of the cotton, the granulations should be brushed over with nitric acid or nitrate of silver. Another plan of treat- ment is to cut a gutter in the center of the nail, which has a tendency, it is said, to elevate the corners. Still another plan is to divide the nail on a line with the incurved edge, and strip it off, together with the matrix (Sayre). PRESCRIPTIONS FOR INGROWING TOE=NAIL. {£ Liquor potassse gij. Aquse 3j . — M. Sig. : Apply on cotton to the margin of the nail at the ulcerated surface to soften the nail. — Bartholow. jfc Acidi tannici Jj. Aquas destillatse 3vj . — M. Sig.: Paint over parts daily. — Biall. Jfc Plumbi (pulv.) acetatis £j. Tinct. opii Sj- Aquse ad ^ viij . — M. Sig.: Shake well and apply constantly until the inflammation is reduced and pain alleviated. Then insert a pledget of cotton under nail, and apply following : |fc Argenti nitratis gr. xxx. Aquse destillatse §j. — M. Sig.: Apply two or three times daily with a brush. — Davidson. INSOMNIA. Is sleeplessness. It occurs in cerebral congestion and in- ilammation. But a person maybe sleepless from excessive pain, from exhaustion, from grief, from mental excitement or fatigue, INSOMNIA. 285 or from the free use of coffee or tea. In several of these states, congestion is the immediate cause of the wakefulness. Insomnia attends the delirium of typhoid fever, but is most marked in delirium tremens. Treatment. — When wakefulness is due to a condition of cere- bral anaemia, a full dose of some alcoholic fluid, whiskey or brandy, will produce sound and refreshing sleep. In some persons a glass of ale or beer answers better. Sulfonal in doses of 30 to 60 grains, causes sleep that is physiological in character, but pain hinders its action. Cases of sleeplessness, due to mental over-work, anxiety or physical fatigue are entirely re- lieved by fifteen to twenty grains of chloral. The bromide of potassium is effective in the same cases. Morphine and atropine is the best sleep-producer in cases of pain, in some kinds of mania, and in melancholia. A hop-pillow has induced sleep. Galvanization will sometimes cause sleep. A tepid or warm bath at bedtime will often produce sleep (Bartholow). PRESCRIPTIONS FOR INSOMNIA. B Paraldehyde oiiss. Alcoholis (90 per cent.) Siss. Tinct. vanillse 3ss. Aquas §ij. Syr. simplicis....ad giv. — M. Sig. : One or two teaspoon fuls every hour. — Yvon. & Ext. piscidiaa erythrin fid.... 3j. Syr. simplicis Sj. Aquas auranti nor 5 i v. — M. Sis:.: A teaspoonful to a tablespoonful at bedtime. — Payne. R= A ntipyrin 5 j . -ij • Syr. auranti cort oj. Aquse cinnamomi ad Siij. — M. Sig. : One tablespoonful every hour or two till effective. — Williams. R Amyl hydratis gr. xiv. Syr. auranti cort 5ss. Aquse 5j . — M. Sig.: Take at bedtime. — Von Mering. 286 A COMPENDIUM OF PRACTICAL MEDICINE. R Methylol gj. Syr. auranti fior Siv. — M. Sig. : One teaspoonful at bedtime. — Richardson. R Potassii bromidi 3iv. Chloral hydratis 5ij. Syr. pruni virgin Sj. Aquas ad Siij. — M. Sig.: A dessertspoonful in a glass of water at bedtime. INTERMITTENT FEVER. (See Malarial Fever). INTERTRIGO. Is chafing of adjacent parts. It is a form of erythema. It occurs at parts where opposed surfaces of skin are in contact with one another, as between the hips, at the flexures of the thighs, in the arm -pits, and under pendulous mammae, the inflam- mation being favored by the heat, moisture, and friction of the parts. It is especially apt to occur in hot weather, in the case of corpulent persons, and in infants. The affected surface has a reddened glazed appearance and the itching is often intoler- able (Anderson). Treatment. — Violet powder is used to prevent intertrigo in infants. In intertrigo and in the erythema which occurs about the genitals of infants, dusting the affected surface with bismuth soothes the pain and promotes healing. Tannin in powder, or the glycerites of tannin, applied to the affected surface is very effective. The following lotion is useful: R Aluminus gr. xx. Zinci sulph gr. x. Glycerinse 3j . Aquae rosse Siv. — M. Sig. : Apply to affected surface. — Bartholow. Camphor is a useful addition to dusting powder to allay the heat, tingling and itching of eczema and intertrigo (Ringer). i^testi]S"al obstruction. 287 PRESCRIPTIONS FOR INTERTRIGO. R Pulveris amyli ,^iv. Zinci oxidi §j • Zinci carbonatis Iss.— M. Sig.: Use as a dusting powder. — Tilbury Fox. R Acidi boracici giss. Vaselini 3J . — M. Sig. : Apply locally after washing and drying the parts. — Waring. R Bismuthi subcarbonatis ^ij. Sig. : Use as a dusting powder. — Bartholow. R Ammonii sulphoichthyolati gr. iij. Cumarini gr. xij. Unguenti petrolei 3v. — M. Sig.: Apply with the finger after bathing and drying the child. — Lorens. R Linimenti aquse calcis gvi. Sig.: Use locally. —Tilbury Fox. INTESTINAL CATARRH. (See Enteritis.) ITCH. (See Scabies.) INTUSSUSCEPTION. (See Intestinal Obstruction.) INTESTINAL OBSTRUCTION. Is a mechanical impediment to the movement of the bowels. It may be complete or incomplete. Inquire of the patient: 1. If he has ever had a previous peritonitis, or intestinal troubles, as colic, pains, etc. 2. The manner in which the attack appeared, whether suddenly or grad- ually. 3. If there is any exciting cause present, as a hernia, swallowing a foreign body, etc. The obstruction may come on while the patient is asleep or in perfect health, or after an indi- gestible meal, or while straining at stool with a distended blad- der. As certain as obstruction occurs in the small intestine, acute symptoms are developed, vomiting of bile comes on sud- denly, and tympanites is absent generally. Collapse is profound. The shape of the abdomen is similar to the pregnant. If the obstruction occurs in the large intestine, chronic symptoms are 288 A COMPENDIUM OF PRACTICAL MEDICINE. developed, and there is fixed pain, and tympanites with disten- sion of the colon. Collapse is less profound. Great distension of the abdomen develops rapidly. It occurs late in life. Causes. — /. Strangulation inside of the cavity. II — Changes within the lumen of the gut. Ill — Changes without the lumen of the gut. The causes of strangulation of the bowels are: 1. Peri- toneal adhesions by bands, over loops, through apertures, or at- tachment to the viscera, (the result of acute peritonitis). 2. False diverticulum. 3. Hernia. 4. Volvulus. 5. Intussuscep- tion. 6. Kinking of the gut. The causes of changes without the lumen of the gut are: 1. Compression from anything outside of the gut. 2. Contraction of the mesentery following inflammation of the same. 3. Chronic peritonitis. 4. Retroflexed uterus especially during pregnancy. The causes of changes within the lumen of the gut are: 1 Stenosis or stricture from malignant growths or ulcerations. 2. Gall-stones. 3. Foreign bodies. 4. Enteroliths. 5. Fsecal im- paction. False Diverticulum. — May be the result of the viteline duct remaining pervious in the fetus, or of a small piece projecting from the ileum like the finger of a glove, from one to three feet above the ileo-cgecal valve, or it may be formed from the mucous coat, by a rupture of the muscular coat, making a hernia of the mucous coat. Hernia. — As a cause of intestinal obstruction, is formed by weakening of the walls of the intestine, and is found on the mesentric borders of the gut. The cause may also be faecal matter. The pouch comes from the ileum three to four feet above the ileo-csecal valve. Volvulus. — Is the twisting of the gut upon its own axis, or upon the mesenteric axis. It occurs most frequently in the ileum colon, caecum and sigmoid flexure. Thirty-three of 1000 cases are due to volvulus. Russians suffer more than other nationali- ties, because they have eight feet more of ileum, and eat a more vegetable diet. In the ileum it goes from left to right and once upon the mesenteric axis. It occurs at about twenty years of age. This variety comes on very suddenly, and with no assignable INTESTINAL OBSTRUCTION. 289 cause. Give an enema early, and reach and distend the colon and percuss it, then you will know whether the obstruction is above the ileo-csecal valve or below it. In the sigmoid flexure, it is very common in chronic constipation as the bowels become filled by faecal matter and gas, and fall over each other. Gener- ally occurs after middle life, after 40 years of age. Tenesmus is very distressing in the bowels. Volvulus may come from trau- matism, as a stabbing into the abdomen; also, from active peris- talsis when the gut twists upon itself. Intassiiscejition. — Is where one part of the bowel is thrust into another part. It is, also, called invagination. One-third of all cases of intestinal obstruction is of this kind. Twenty- five per cent, occur before the first year, and fifty per cent, before the tenth year. It most frequently occurs in the ileum, colon, ileo- cecal valve, and rectum. It is caused by irregular contraction of the bowels, and has been produced on animals by electricity. If there be an intermittent pain, it denotes that the obstruc- tion is incomplete. If there be a continued pain it shows that the obstruction is complete. Bloody stools are seen in eighty per cent, of the cases. Stenosis or Stricture from Malignant Growths or Ulcera- tions — is due to peptic, typhoid, tubercular, catarrhal, syphilitic and dysenteric ulcers. Peptic ulcer is found in the duodenum and is said to be due to the action of the gastric juice. It occurs in middle life. Typhoid ulcers are found in the long axis of the gut of the ileum. The tubercular ulcers are found in the lower ileum, and originate in the lymphatic glands, and lie in the transverse direction of the gut. Catarrhal ulcers are found in the colon, and are produced by chronic constipation. They are in large numbers and produce gangrene of the mucous membrane. Syphilitic ulcers are usually found in the rectum, in the submu- cous tissue, and are broken down gummata. Dysenteric ulcers are found in the rectum and sigmoid flexures. Stenosis from ma- lignant growths are usually from carcinoma (epithelioma) and may be primary or secondary. It usually forms an annular stricture and there comes just above the stricture dilatation and hypertrophy of the bowel. 290 A COMPENDIUM OF PRACTICAL MEDICINE. Gall 8 tones — Which produce obstruction are usually small but become enlarged when passing through the intestine by co- hering together. The symptoms are not so sudden or great, as by bands or loops. There are previous hepatic colic, and the presence of jaundice usually. It is more frequent in women then in men. Foreign Bodies — Are any bodies not acted upon by the gas- tric juice. These may be swallowed for suicide or by the insane or accidentally. Enteroliths — Are intestinal calculi. They are composed of pnosphorus, calcium, magnesium carbonate, with cholesterine, and are formed about a necleus. This form of trouble is fre- quent in Scotland where the peasants live on coarse oatmeal. Fwoal Impaction — Is due to the faeces which become hard and tend to remain in the bowel. The bowels move very seldom once in three or four weeks, and thus it is a cause of local ob- struction. In all cases a tumor can be felt under the integument and the feeling is like that of putty. A bucketful of fsecal mat- ter has been removed. It may lead to peritonitis. It is more com- mon in women than in men. It may be relieved by mechanical means, but the patient may die from exhaustion. Compression from anything outside of the Gut — May pro- duce obstruction. It may be from sarcoma of pelvis. It may be from tumor of the kidneys or abscess connected with Pott's dis- ease, or hydatid cysts of the liver, displaced spleen, etc. Con- traction and inflammation of the gut may produce it. Chronic peritonitis and tubercular peritonitis with adhesions, retroflexed uterus, and enlarged tubes due to pregnancy may cause intestinal obstruction (Dennis). Symptoms. — 1. Pain which is very severe and is present early, is usually referred to the umbilicus, because near this are the great solar and mesenteric plexuses. The situation of the pain is no criterion to the situation of the obstruction in the early stages. Note that continuous pain denotes complete obstruction and paroxysmal pain denotes incomplete obstruction, and if the pain suddenly ceases it denotes gangrene. There is a localized peritonitis. INTESTINAL OBSTRUCTION. 291 2. Vomiting comes on early when the obstruction is in the small intestine. The contents of the stomach are first ejected, then the biliary secretions, and last stercoraceous material about the fifth day. Vomiting usually occurs just after the pain, and when suddenly stopping, denotes gangrene. 3. Constipation is present and continuous. Bowels do not move above the constriction. Note the presence of blood in the stools. If there is blood, it is likely to be intussusception. The blood may come from hemorrhoids. 4. Abdominal Tenderness is important, but is absent at the beginning of the attack. It supervenes quickly, and appears about the third day, and is diagnostic as a symptom because it points to local peritonitis, and if it is diffused it denotes general peritonitis. 5. There is a tumor or swelling in the abdomen. 6. The pulse is thready and rapid, 110 to 140 per minute and small. 7. Temperature is subnormal, as a rule; if peritonitis sets in it may ris^ to 100° F., and if perforation takes place, it falls below normal to 97° F. 8. Respirations are more frequent, superficial and thoracic. 9. Anuria. — Urine is scanty and contains albumen and indican. 10. Physiognomy has a haggard expression from mental suffering, face is drawn, eyes are sunken, and the intellect is good to the end. Collapse finally comes on. Caution. — Do not give cathartics, because they will intensify the pain, produce more vomiting, increase shock, produce stran- gulation, causing perforation and peritonitis. It ma}' convert a chronic into an acute, and may induce intussusception. Metalic mercury is not much used and should not be till the last. Symptoms of Perforation are : 1. Emphysema of the abdomen, which is sometimes due to a gunshot wound or some opening. 2. Shock, the patient is in collapse. 3. Condition of the Pulse is diagnostic, on account of heart disturbance due to perforation. It is rapid, thready and feeble. 292 A COMPENDIUM OF PRACTICAL MEDICINE. 4. Tympanitic resonance over the liver. There are two conditions of tympanites without perforation, namely : 1. When the colon is pushed up and is adherent to the walls; and 2. Em- physema of the lower lobe of the lung. The respirations are rapid and thoracic in character. 5. Sudden tympanites at the seat of perforation. 6. Subnormal temperature. 7. Vomiting. 8. Sometimes bloody stools, especially in traumatism. 9. Retention of urine. 10. Acute peritonitis and anxious physiognomy (Dennis). Treatment. — Give morphine hypodermically. Small doses stimulate and large ones paralyze, therefore large doses and not small ones are indicated. It relieves intense pain, influences shock and relaxes the abdominal walls. It increases the secre- tion of urine, affects the pulse, respiration, temperature, and vomiting. It arrests peristalsis. Caution. — If it is continued too long, retention of the bowels is produced, wdiich is not good. Xourislbment. — We cannot nourish by way of the stomach, for it is filled with regurgitant fluid, and the intestines are filled w r ith gas. Nourish by the rectum and give enema of milk (4 oz.). We may use hypodermics of brandy. Let the patient have ice in his mouth to quench his thirst. It will help to control vomiting and keep the tongue moist. Local Applications. — Warm ones will relax the abdominal muscles. Turpentine stupes over the abdomen is good. Hot flannels and poultices are good. Place a pillow under the popli- teal space. Enemata. — Copious ones in intestinal obstruction are good. They must be introduced slowly. If a fountain syringe be used, it must be lower than six or seven feet for children, and lower than 15 to 18 feet for adults. Warm water with soap-suds and olive oil is good. If glycerine is added it will be better. Do not use the injection late in the disease, for gangrene will be produced. Aspirations, or Paracentesis. — Should we aspirate or not ? It is dangerous and must not be done only in extreme cases, and INTESTINAL OBSTRUCTION. 293 then must not be done without consultation of some other surgeon. Operation. — Laparotomy: Results are good when the oper- ation is done early, and before the patient is exhausted, and before peritonitis sets in. Do not ojjerate if there is suppuration with general peritonitis, or if the cause is. some malignant dis- ease. First, have the parts thoroughly cleansed with a warm solution of bichloride. In the cavity do not use a solution stronger than 1 to 10,000, and never use the same sponge twice. Always empty the bladder before the operation. Make the in- cision in the median line, and the higher we go above the umbil- icus the worse it will be, for the gut cannot be easily returned. If the ileo-csecal valve is collapsed the obstruction is in the small intestine and not in the large. If by bands strangulation is caused, cut the bands between the ligatures. If by a slit, through which the gut has gone, sew up the slit. If by a false diverticu- lum, cut it off, and bring the edges of peritoneum together, and let an adhesion form. If by hernia, cut out the damaged gut and make an artificial anus. If by volvulus, and it involves the ileum, simply untwist it, but if the sigmoid flexure is involved, do a left lumbar colotomy. If by intussusception, which occurs in childhood largely, and if it affects the small intestine, simply draw it out; if that cannot be done, make an artificial anus just above the obstruction. Do the operation early. If the obstruction is caused by stenosis from ulceration or malignant disease, do a laparotomy and remove the disease and make an artificial anus, then later on re-establish the contiguity of the gut. If by gall- stones, open the gut and remove them or any other foreign bodies. If by faecal impaction, it may be removed by manipula- tion. If by growth or neoplasm, remove the growth if possible, and if not, open the gut. We have sarcoma of the pelvis, tumors of the kidneys, mesentery, omentum, and abscess of Pott's dis- ease. In chronic peritonitis, wash out the cavity with bichloride solution 1 to 10,000. It is successful where there is tuberculous disease, but not in carcinoma. In contraction of the mesentery, do a laparotomy. If the obstruction is caused by retro-flexed uterus, bring it forward. 294 A COMPENDIUM OF PRACTICAL MEDICINE. Laparotomy for Acute Intestinal Obstruction. — The results of laparotomy are encouraging. Before the days of aseptic and antiseptic surgery, the death rate was 75 per cent.; after that time 58 per cent. The percentage of deaths is due to two causes: 1. Shock. 2. Sepsis. Shock may be diminished by an early and rapid operation. Sepsis may be diminished by adhering strictly to aseptic and antiseptic surgery. If there is suppuration do not operate. Duration of life in acute obstruction of the in- testines is six days; so operate early. If laparotomy is done and the cause removed, the per cent, of deaths is 56. If the cause is not removed the percentage of death is 66. If the gut is gan- grenous, and is opened, and afterward sutured, the percentage of death is 86 (Dennis). PRESCRIPTIONS FOR INTUSSUSCEPTION. R Fellis bovini gr. xx. Aquae ferventis Oij . — M. Sig. : Inject slowly into the bowel until it is fully distended. (Knee-chest position is best.) ' — Hawkins. R Lobeliae 5ss. Aquae bullientis Oj . — M. Sig.: Inject one-fourth, or one-half, and repeat if necessary. — Bartholow. R Extracti belladonnas gr. iv. Aquae ferventis Oj . — M. Sig. : Inject into the rectum. — Waring. R Sodii bicarbonatis g;j. Aquae §vj. — M. Sig.: Inject into the rectum and follow at once with, R Acidi tartarici pulv gr. xxxv. A quae g iv. — M. Sig.: Inject into the bowel at once after the preceeding. — Bartholow. IRITIS. Is an inflammation of the iris. Causes. — Are local and constitutional. It may come from functional strain, from injury, from operations, from penetration of foreign bodies or by extension of inflammation from adjacent iritis. 295 structures. The constitutional causes are syphilis, rheumatism and gout. About fifty per cent of all cases is caused by syphilis. Rheumatism aud gout cause obstinate, painful and recurrent at- tacks of iritis. In syphilitic iritis, a plastic or gummy exudation is thrown out. Gonorrhoea occasionally causes iritis. Other causes are malaria, variola, scrofula, and tuberculosis (Noyes). Symptoms. — Are objective and subjective. The former are change of color of the membrane, abnormal behavior of the pupil and injected blood vessels. A blue iris will change to a dull gray, a hazel to a dirty brown. The aqueous humor is turbid, and the pupil is smoky instead of a clear jet black. The pupil will be small and will not respond to light. Adhesions will be- come apparent upon dropping a solution of atropia into the eye. In severe cases, the whole front of the eye will be intensely red. The lids will be imperfectly opened. The subjective symptoms will be, impairment of sight, intolerance of light, and pain. The pain is first situated in the globe, and is a conspicuous feature from the outset, is most severe toward night, or early morning. Iritis may attack one eye or both. It generally lasts two to six weeks, if neglected it may continue for months, with entire loss of sio;ht. Sequelce of Iritis are: 1. Adhesions of the iris to the capsule of the lens. 2. The exudation may become organized and fill the whole pupil, and thus resemble cataract. 3. The capsule of the lens may become thickened (Noyes). Prognosis. — In simple cases, vision will be perfectly restored, but if adhesions take place, sight will be impaired (Noyes). Treatment. — Avoid use of eyes, and all sources of irritation. The patient must be kept in a dark room. The essential and master remedy in iritis is a solution of atropine; it is the begin- ning, middle and end treatment. A solution of four grains to the ounce must be used and dropped in four to six times daily. If poisonous symptoms ajopear from the use of the atropine it must be stopped, and the proper treatment instituted. Appli- cations of warm water to the eye are useful. For the nocturnal pain, hot fomentations are to be used, and morphia administered. Constitutional treatment will be necessary in cases of syphilitic, rheumatic, or gouty iritis. Gonorrhoea] iritis demands urethra] 296 A COMPENDIUM OF PRACTICAL MEDICINE. treatment. For severe serous iritis with deep anterior chamber and much pain, paracentesis will be effectual. When mydriatics fail and the pupil is much bound down, iridectomy is the remedy (Noyes). PRESCRIPTIONS FOR IRITIS. J& Atropine sulphatis gr. iv. Aquae destillatse ^j. — M. Sig. : A drop or two in the eye three times daily. Used with hot water, bathing for fifteen minutes every hour till pain is relieved. —Chilton. R Hy drargyri chlor . corros gr . j . Potassii iodidi gj . Tinct. calumbse ,^ij. Aquse destillatse ad 5yj. — M. Sig. : A dessertspoonful in water three times daily. — Lawson. R Scopolinse gr. j . Aqua? destillatae . : gj . — M. Sig.: Two drops into the eye three times daily. — Dunn. R Emplastri cantharidis 1 in. by 1 in. Sig.: Apply behind the ear, and poultice when blistered. — Hartshorne. R Duboisiee sulphatis gr. j. Aquae destillatae 3j . — M. Sig.: One drop into the eye twice daily. — Tweedy. ICTERUS. (See Jaundice). INSOLATION. ( See Heatstroke ) . IODISM. If iodine or the iodides are administered in too large doses, or to persons of irritable stomach, and for too long a time, they will produce gastro- enteric symptoms, headache, giddiness, marasmus, sometimes discoloration of the skin, occasionally sali- vation, and frequently a wasting of the mammae and testicles. This train of symptoms is called iodism. Treatment, — Withdraw the drug and give arsenic. Atropine is quite effective as a remedy for iodism (Bartholow). IRRITABILITY — JAUNDICE. 297 IRRITABILITY. Cause. — All those practices and habits which cause nervous strain, and result in nervous exhaustion, may produce irritability. Treatment. — Give five grains of chloral two or three times a day in irritability with nervousness and restlessness. A sitzbath with the water between 60° and 80° greatly relieves fatigue, and soothes an irritable restless state of the nervous system. ITCHING. (See Pruritis). JAUNDICE. Called also icterus, is a yellow discoloration of the skin due to the presence of bile or blood pigment (Loomis ). Jaundice is a symptom common to many affections of the liver. Causes. — I. Of Hepatogenous Jaundice. — Duodenal ca- tarrh, biliary calculi, inspissated bile and mucus, hydatid vesicles, foreign bodies from the intestinal canal, such as stones of fruit and round worms, congenital plugging of the duct and cancer of the ducts are causes within the duct. The causes which ob- struct the duct by external pressure are : Tumors of the pyloric extremity of the stomach, of the head of the pancreas and of the kidney; pressure from a pregnant uterus, from ovarian and fibroid tumors, from omental tumors, from large impaction of faeces, from enlarged lymphatic glands in the transverse fissure, from waxy cancerous or tubercular change, from abdominal aneurism and from hypertrophic cirrhosis of the liver. II Causes of Hematogenous Jaundice are : Yellow, typhus, typhoid and malarial fevers (Loomis). Symptoms. — Jaundice first appears in the conjunctiva, then the skin of the face appears sallow or fawn- color. The urine early undergoes a change and becomes intensely colored with bile-pigment, which it imparts to linen and white paper dipped into it. The best test for bile in the urine is the nitric acid test. Pour into a test tube an inch of nitric acid, and drop the urine slowly on top of the acid. If bile be present, there will be a red line next the acid and green uppermost with violet and blue between. The stools in jaundice are grayish or slate-colored, 298 A COMPENDIUM OF PRACTICAL MEDICINE. sometimes quite white. Jaundice is usually unaccompanied by pain. Headache is a common symptom. There is drowsi- ness, hebetude of mind and despondency. In some cases there are nausea, a persistent harassing cough, and muscular soreness. The temperature in jaundice is usually below the normal. In many cases the pulse is slow; more or less itching of the skin; sometimes an intolerable itching is observed in many cases. The taste is bitter. The vision may be yellow (Bartholow). Differential Diagnosis. — The yellow staining is slight in hem- atogenous jaundice, but it is more intense in hepatogenous. There is great itching of the surface in hepatogenous jaundice which is absent in the hematogenous variety. The faeces are dark in hematogenous jaundice and white or clay- colored in hepatogenous (Loomis). Determination of the Cause. — If the jaundice comes on in the course of a gastro- duodenal catarrh, it is probably a case of' simple catarrhal jaundice. If it occurs in the course of malarial fever, it is probably due to malaria. If the jaundice is preceded by sudden violent pain in the right hypochondrium, it is due to the passage of gall-stones. If the jaundice be persistent — lasting many months — and intense, and follow an attack of pain which has not been repeated since, it is probably due to a permanent occlusion by a gall-stone. If the jaundice be intense, persistent and painless with enlarged liver, it may signify obstruction by hydatids. A faint jaundice lasting many months, with ascites and enlargement of the superficial veins of the abdomen, is pro- duced by sclerosis or cirrhosis or nutmeg liver. Jaundice with persistent pain or soreness in the right hypochondrium indicates cancer (Bartholow). Treatment.-— Laxatives and diuretics are useful. Grain doses of calomel given at night is the best laxative in these cases. Saline laxatives which have a diuretic action are very useful. The compound jalap powder is efficient. In malarial jaundice, ten to thirty grains each day of quinine is useful. JAUNDICE KERATITIS. 299 RRESCRIPTIONS FOR JAUNDICE. (Catarrhal.) R Ammonii chloridi gss. Ext. taraxaci fiuidi ^iij. — M. Sig. : A teaspoonful three times daily. — Bartholow. . R Ext. hydrastis fiuidi gj. Sig.: Ten drops before meals for some weeks. — Bartholow. R Sodii phosphatis §ij. In pulv. no. xvi. div. Sig. : A powder every four hours. — Bartholow. R Ammonii iodidi 5j- Liq. potassii arsenitis 3ss. Tinct. calumbse Iss. Aquae Siss. — M. Sig.: A teaspoonful before meals. — Bartholow. KERATITIS. (Phlyctenular). Is an inflammation of the cornea. It is characterized by one or more slight elevations of a grayish-white or yellow color, which are about the size of a pin head. Sometimes they are visicles and sometimes semi -solids, and soon their summit is eroded, leaving a little ulcer (Noyes). Symptoms. — Are subjective and objective. There will be hyperemia, severe pain, photophobia and lachrymation. It is especially a disease of children, and attacks the ill -fed or over- fed, the weakly and the dirty. There is usually eczema of the head or face. In bad cases the cornea may be perforated (ISFoyes). Causes. — Are scrofula, gout, syphilis, malaria, eczema, herpes, struma and exanthematous diseases. Treatment. — Must be both local and constitutional. If there be only one or two eruptious, and they recent and situated on the cornea, they may be scraped out clean by a sharp spud. Then tie up the eye, and wash it out ouce in three hours with a two per cent solution of boric acid. Instead of the scraping, the ointment of yellow oxide of mercury, gr. ij. to dr. j. may be rubbed well into the eye once daily. If there is an iritis along with the keratitis, a solution of atropine may be dropped into the eye thrice daily. The chief remedy against photophobia is cocaine which may be 300 A COMPENDIUM OF PRACTICAL MEDICINE. used several times daily. Cold water and boric acid will be grateful. The constitutional and hygienic measures are never to be neglected. Cleanliness, pure air, exercise and a suitable diet will be needed. Mild purgatives as rhubarb and soda are some- times useful. Cod-liver oil and the syrup of the iodide of iron, are standard remedies (Noyes). PRESCRIPTIONS FOR KERATITIS. Jfc Atropinse sulphatis gr. ij. Aquae destillatse §j. — M. Sig. : One or two drops into the eye three times daily. — Bartholow. jfc Hydrarg chloridi corrosive gr. j. Aquse destillatse §iv. — M. Sig.: Apply as a bath to the eye by means of a reservoir eye- cup. — Grandmont. KIDNEY=DISEASES, (See Albuminuria, Bright's Disease and Uraemia.) KINGS'=EVIL ( See Scrofula. ) KNEE=JERK. In most healthy individuals a vigorous contraction of the quadriceps extensor muscle is produced by striking quickly with the ulnar side of the hand, the ligamentum jDatellas when the leg is flexed and the muscles are relaxed. This contraction is called the knee-jerk, or patellar reflex, and may be increased, dimin- ished or abolished in certain diseases of the spinal cord. The centre for the patellar reflex is in the gray matter of the lumbar portion of the spinal cord. Disease of the gray matter in this situation, and of the posterior columns of the lumbar enlarge- ment, cause the patellar reflex to disappear. In various condi- tions causing spastic paralysis, the patellar reflex is increased. In posterior spinal sclerosis, knee-jerk is absent; it is also absent in disease of the anterior cornua. Knee-jerk is absent in many cases of diphtheria from the very first day of the illness (Flint). LABOR. 30 I LABOR. Is the expulsion of the foetus from the uterus. Normal labor occurs when the foetus is mature. The Pains of Labor. — The pains of labor are first felt over the sacrum, and radiate to the rectum, bladder, across the abdo- men and down the thighs. At first the pains are dull, but finally reach the point of supreme agony. Stages. — There are three stages of actual labor: 1. The stage of dilatation of the cervical canal. 2. The stage of expul- sion of the child. 3. The stage of placental delivery (Lusk). Duration of Labor. — The average for primiparse is seventeen hours, for multiparas twelve hours. For the after-pains the fol- lowing prescription of Witherstine may be used: gr Morphia sulphatis gr. ij. Aquae camphorae ^ij. — M. Sig. : A teaspoonful every three hours. Leishman's formula may be used for precipitate labor: j& Morphiae sulphatis gr. j.-ij. Olei theobromae 3ij. — M. Ft. massa et in suppositoria no. iv. div. Sig.: One as required. In retained placenta, Atthill's formula is useful: {& Tinct. nucis vomicae 3j. Ext. ergotae fluidi gvi. Elixir simplicis ad §vi. — M. Sig.: A teaspoonful in a wineglassful of water every three hours. In hour-glass contraction of the uterus, Barnes gives three to five drops of amyl nitrite to be inhaled from a handkerchief. In protracted labor due to rigid os, Ringer gives the fol- lowing: |& Morphiae sulphatis gr. ij. Aquae des tillatae 3J . — M. Sig.: Five or ten minims hypodermically, repeated as necessary. In protracted labor from atony of the uterus, Leishman gives the following: j& Extracti ergotae fluidi 5]. Olei gaultheriae gtt. iv. — M. Sig.: A teaspoonful every four hours, only if os is dilated, and soft parts not rigid. 302 A COMPENDIUM OF PRACTICAL MEDICINE. LARYNGISMUS STRIDULUS. Called, also, spasm of trie glottis, internal convulsions, child crowing, etc., is spasm of the muscles of the larynx. Violent emotion, especially anger, may induce a temporary suspension of respiration in young children. In the midst of their crying, they suddenly hold their breath, but it is not fol- lowed by a stridulous inspiration as it is in true spasm of the glottis (Smith). Causes. — Laryngeal spasm is most frequently met with in children, when indigestion, teething and impressions of external cold are usually assigned as causes. Cerebral irritation is given as a cause. Scrofulous and cachectic children are said to be es- pecially subject to spasms of the glottis (Loomis). Symptoms. — There is generally previous ill-health. The at- tacks are more frequent and severe at night, in or after the first sleep, than in the day. A peculiar crowing sound is heard now and then during inspiration especially when the child is crying. In severe paroxysms respiration often ceases entirely for a mo- ment. The face becomes livid. The duration of the paroxysm may be a quarter, a half, or even a whole minute. The parox- ysms may occur almost daily for several weeks (J. L. Smith). Treatment. — During a paroxysm it is customary to employ means to produce a strong impression on the surface, as slapping the back or sprinkling cold water on the face. A ready and effective mode of arresting a paroxysm is to introduce a finger into the throat. If the stomach is overloaded an emetic is indi- cated. Employ a hot foot-bath, and warm fomentations to the neck. Laxatives should be given. From ten minims to one drachm of paregoric often arrests the paroxysm (Bartholow and Flint). PRESCRIPTIONS FOR LARYNGISMUS STRIDULUS. B Syrupi ipecac ,^ij. Sig. : A teaspoonful every ten or fifteen minutes until free emesis occurs. — Bartholow. R Chloroformi gj . Sig. : A few drops inhaled from a handkerchief. — Bartholow. LARYNGITIS. 303 R Tinct. aconiti rad gss. Sig. : One drop in a teaspoonful of water every hour for three doses, then every two hours. — Ringer. LARYNGITIS. (Acute and Chronic.) Is an inflammation of the mucous membrane of the larynx. It may occur at any age. There is an acute and chronic form of the disease. Causes. — Acute catarrhal laryngitis is caused by atmospher- ical changes, by exposure to wet and cold and by chilling of the surface, especially of the neck and feet. " Taking cold' 1 is a fruitful cause of laryngitis. Anything that irritates the laryn- geal mucous membrane may produce a laryngitis (Loomis). Symptoms. — Usually at first there is soreness of the throat, accompanied by a sense of constriction, or a tickling sensation with a tendency to cough; the larynx is tender on pressure, there is difficulty in swallowing. The expectoration is at first tena- cious; later it may become thick, purulent and abundant. The voice is hoarse or is reduced to a whisper. The face is flushed, the skin hot and dry, there is fever and a frequent pulse (Loomis). Treatment. — The patient should be confined to bed. The air of the apartment should be kept moist by vapor of water. Tincture of aconite root — one drop for a child and two drops for m adult every two hours — is highly efficient. If there be much cough, two to iive drops of the deodorized tincture of opium and one or two drops of the fluid extract of ipecac may be given to- gether. A spray of a solution of morphia to the throat is an excellent means of relieving cough. A very minute quantity of tartar emetic, with paregoric and syrup of lactucarium is also an efficient combination. A hot or cold pack should be wrapped about the throat, after a brief application of mustard; and if the ■case is just beginning the feet should be placed in a hot mustard foot-bath. Prophylaxis. — Those who have frequent attacks should wear flannels, and protect the feet against dampness. Avoid furs about the throat. The tendency to take cold may be obviated by a daily morning cold sponge-bath. The access of an impend- 304 A COMPENDIUM OF PRACTICAL MEDICINE. ing attack may be prevented by a full dose of quinine and mor- phine (15 grs.-gr. J to i) (Bartholow). Causes of Chronic Laryngitis. — It maybe a sequel of acute laryngitis. It may occur from constant use of the voice in public speaking or singing. It constitutes the chief morbid condition in what is termed "clergyman's sore throat. 7 ' It is frequently secondary to chronic nasal catarrh. It most frequently occurs as an accompaniment of other affections, as syphilis and pulmonary phthisis (Loomis). Symptoms. — Of chronic catarrhal laryngitis are local. In some the voice is hoarse and husky; in other cases, the patient is only able to speak in a husky whisper. There is a hoarse strid- ulous cough, with more or less abundant muco- purulent expect- oration frequently streaked with blood and of a fetid odor. In- spiration and expiration are often accompanied by a whistling or stridulous sound. In some cases the act of swallowing fluids or solids excites spasm of the glottis. Talking is very fatiguing. In the morning the most severe paroxysms of coughing and strain- ing are experienced : the secretion accumulates during the night, and is detached with difficulty, so that much coughing, hawking and straining are necessary (Loomis and Bartholow). Treatment. — -Mild astringent solutions of alum, perchloride of iron, tannin or sulphate of zinc, from one to twenty grains to the ounce of water may be used. For steam inhalations, a few drops of oil of creosote, oil of pine or oil of juniper, added to half a pint of water at a temperature of 150° F., maybe employ- ed. The spray and steam inhalations may be repeated three times daily. A solution of carbolic acid (two grains to an ounce of water) as a spray, may be used with benefit in cases where the laryngeal secretion has a fetid odor (Loomis). The treat- ment of chronic catarrhal laryngitis of phthisis and syphilis is the same as in simple chronic laryngitis, with the constitutional treatment of those affections added. LARYNGITIS — LEAD POISONING. 305 PRESCRIPTIONS FOR LARYNGITIS, R Sodii biboratis gr. viij. Aqure 3 ij • Aquae cologniensis gtt. x. — M. Sig. : Use frequently with atomizer as a spray (chronic form). — Sajous. R Potassii permanganatis gr. ij. Aquoe destillatse §ij. — M. Sig.: Use with atomizer several times daily. (In fetid variety of chronic laryngitis). — Sajous. R Tinct. aconiti radicis Sss. Sig. : One drop in water every hour. When it has existed some days then give the following: R Vini mariani Oj. Sig. : A wineglassful every three hours, with absolute rest of voice. (In acute laryngitis). — Sajous. LEAD POISONING. Is a morbid condition produced by the introduction of the salts of lead into the system, either through the mucous surface or the skin (Loomis). Causes. — The sources of lead-poisoning are numerous. Painters and workers in lead are those most frequently affected. Drinking water, wines, and ales often become impregnated with it. The application of lead powder as a cosmetic to the face and neck has caused lead- poisoning. Some persons are more suscep- tible to its poisonous influence than others. Lead taken as a medicine, a dressing for the hair containing acetate of lead, a lo- tion for the eye, and vaginal injections containing lead may pro- duce lead-poisoning. Lead may be inhaled in sufficient quanti- ties to produce lead -poisoning, as in paper staining, grinding of colors, plumbing, shot-making, etc., lead-poisoning has re- peatedly occurred from sleeping in newly-painted rooms. Soda- water may contain lead, and articles enclosed in lead foil may produce poisoning. Children may be poisoned by sucking lead toys (Flint and Loomis). Symptoms. — In chronic lead -poisoning, the general health is impaired. The skin becomes sallow, dry and harsh. There arc 306 A COMPENDIUM OF PRACTICAL MEDICINE. dyspepsia, loss of appetite, and constipation. A blue line forms along the edge of the gums adjoining the teeth. The most im- portant symptom is intestinal colic. It has been called painters' -colic, plumbers' colic, colica pictonum, and dry bellyache. Pain is oftenest referred to the region of the umbilicus. It is & dull aching pain, sometimes acute. Patients are inclined to lie upon the belly with a folded pillow placed under them over the seat of pain. There may be nausea and vomiting. Hiccough and eructations of gas are common. The urine is scanty, and micturition is sometimes difficult and painful. There is no fever. The most frequent of the nervous affections is drop -wrist from paralysis of the extensors of the forearm. There is no loss of ■sensation in the paralyzed limb. The diagnosis can be made by the history of the case, and from the symptoms (Flint and Xoomis). Treatment. — Remove the patient from all sources of lead- poisoning. The bowels should be kept freely open. Five to ten grains of iodide of potassium three times daily should be given. A drachm of dilute sulphuric acid in a quart of sweetened water may be taken in twenty-four hours. Faradization for ten or fifteen minutes three times a day for two or three months is the only effectual remedy for restoring the paralyzed muscles. Chloro- form given by the mouth and applied over the abdomen some- times acts promptly and efficiently in relieving the pain. Opium in some form may be required to relieve the pain. The warm bath is useful as a palliative soothing measure (Flint and Loomis). PRESCRIPTIONS FOR LEAD=P0IS0NINQ. R Magnesii sulphatis %]. Acidi sulphurici dil 3j. Aqua) ^iv. — M. Sig. : A tablespoonful three times daily, preceded by five to tea grains of potassium iodide. — Brunton. R Morphia) sulphatis gr. iv. AquaB destillatse --Sij- — M. Sig.: Five to ten minims hypodermically repeated every fifteen minutes till relieved. — Bartholow. LEPROSY. 307 R Pulv. opii gr. xij. Ext. belladonnse gr. ij . Oleitiglii gtt. xij.— M. Ft. massa et. in pil. no. xii cliv. Sig. : A pill every two hours until relieved. — Loomis. LEPROSY. Is an infectious and contagious disease of very ancient date, characterized by nodules which occur most frequently in the skin. It has been endemic in Egypt, India and China. It was prevalent among the Hebrews. Leper houses, for the isolation of the diseased, were estab- lished in the seventh century. There was an intense dread of the disease, and lepers had to wear a special costume, usually a long gray gown with a hood drawn over the face; they carried a wooden clapper to give warning of their approach. They were not allowed to enter churches, inns, mills or bakehouses, nor to touch healthy persons, nor to eat with them, nor to wash in the streams, nor to walk in narrow foot paths. A leper woman, quick with child, was buried alive. Leprosy is still common all over the east, and there are leper villages in China, Japan, Persia and Crete. The disease is also common in Africa, India, Mada- gascar, St. Helena, Maderia, Canaries, Azores, West Indies, Mexico, Brazil, Central America, Norway and the Hawaiian Islands. Sporadic cases occur in England and France. Causes. — It is an hereditary disease, and there is the strong- est repugnance to marriage into a family where leprosy is known to exist. It is an infectious and contagious disease. It never originates cle novo. The lesions of leprosy contain characteristic bacilli which would seem to be the real cause. Climate, poverty and bad hygiene are predisposing causes (Anderson). Symptoms. — Leprosy appears as a constitutional disease, marked externally by the deposition of a peculiar albuminous substance in the skin, appearing as discolored patches and no- dules, and effecting the nerve centres and peripheral nerves. Leprosy has been divided into two forms, viz: the tuberculous and the anaesthetic. The tubercular is characterized by (lis- 308 A COMPENDIUM OF PRACTICAL MEDICINE. colored patches and nodules, and the anaesthetic by depositions in the nerve centres. After an uncertain prodromal stage, there will appear successive out- breaks of the eruption, in the form of blotches on the skin,, which come and go before tubercles make their appearance. The tubercles appear on the site of the patches. When the tubercles are fully formed, they are brown and the skin is thickened, and the hyperesthesia is succeeded by anaesthesia. Sometimes there is an irregular thickening of the entire skin of the face. Tuber- cles are most frequently developed on the head, face, ears, nose, extremities, the mammary gland and nipple, the scrotum and around the anus and vagina. There is but little pain in this stage of the disease. The tubercles are extremely apt to ulcerate from personal uncleanliness, and then the odor of the patient is extremely offensive. Ulceration most frequently commences at the tips of the ears, then at the toes and fingers, and it often termi- nates in necrosis, the fingers and toes dropping off joint by joint leaving a well healed stump. Ulceration and sloughing may take place with but very little pain. In about nine years the disease reaches its climax, the whole system is poisoned, and the patient presents an aspect the most loathsome that can be im- agined. The natural duration of the disease is about fifteen years (Anderson). Treatment. — The disease is incurable, and the treatment is merely palliative. To cure the disease the ancient kings of Egypt bathed in the blood of slaves. The Hindoos, drank cows' urine. Chaulmoogra oil and Grurjon oil are the best remedies known for leprosy. LEUCOCYTH^EMIA. Called also leucaemia, is a disease characterized by the enormous increase of the white corpuscles of the blood, accom- panied by enlarged spleen and enlarged lymphatic glands (I>artholow). Causes. — The real cause of this malady is unknown. It occurs at all ages and conditions, but is most frequent between thirty and forty-five. It is twice as frequent in men as in women. In women there seems to be a connection between the generative LEUCOCYTH^EMIA. 309 organs and this disease. Cold, wet, and all anti-hygienic condi- tions predispose it. The morbid alterations begin in the spleen, then attack the lymphatic glands, then the marrow of the bones and finally become general (Bartholow and Loomis). Symptoms. — Leucocythaemia develops gradually. There is usually a history of the gradual appearance of weakness, mental and physical anaemia, ringing in the ears, vertigo and palpita- tion. The patient becomes pale and assumes a waxy appear- ance. In about eighteen months, the ansemia becomes profound, the lymphatics of the neck, groin, or other superficial parts are found to be somewhat enlarged. The spleen is also enlarged. There are dyspnoea and at times profuse sweating, feverishness toward evening, rapid pulse, oedema of the ankles and puffiness of the eyelids. The least cut bleeds severely. A soft blowing murmur — anaemic murmur — is heard at the base of the heart. In leucocythaemia the blood is paler than normal. The contrast is nicely shown, when a drop of the blood is compared with a drop of healthy blood, on a piece of white linen. In this disease there is one^vhite corpuscle to six of the red. There is consti- pation at first, and finally diarrhoea persists. It is a chronic malady, and the average duration of the whole disease is two years (Bartholow and Loomis). Prognosis. — All cases are fatal. Treatment. — Must be symptomatic, as we have no specific for this disease. Quinia, iron and ergotin can be given together in pill form; five grains of quinia, one grain of reduced iron, and two grains of ergotin should be administered three times a day. Electricity should be applied to the splenic region. Good results are obtained from the local application of the ointment of the biniodide of mercury to the splenic region. The ointment should be rubbed in daily, before a bright fire, until the skin begins to vesicate, then discontinued for a few days. As the blood is im- poverished in this disease, careful alimentation is of the greatest importance. Fats, starches and sugars should be excluded from the diet, and the patient fed on fresh meats, milk, eggs and fish. Pepsin and muriatic acid should be administered after each meal. Fowler's solution, and the compound syrup of the hypophos- phites may be given with benefit (Bartholow). 310 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR LEUCOCYTH/EMIA. R Acidi nitro-muriatici dil |j. Sig. : Ten to twenty drops in a wineglassful of water thrice daily. — Hartshorne. R Quinise sulphatis 3J. Ferri sulph. exsiccat ^iss. — M. Ft. massa et in pil. no. xxx. div. Sig.: Four or five pills daily. — Bartholow. LYMPHADENOMA. Called also Hodgkin's disease, because it was first described by Dr. Hodgkin in 1832; known also as pseudo-leucocythaemia or leukaemia, is a disease characterized by enlargement of the lymphatic glands and spleen, and by progressive anaemia, but without an increase of white corpuscles in the blood (Bar- tholow). Causes.— Are unknown. It is not hereditary. It may come on in a person in apparently perfect health; it is more common in men and in youth and old age than in the middle period of life; but it may occur at any age (Bartholow). Symptoms. — The lymphatic glands in the neck, armpit or groin are first attacked, and become greatly enlarged. Unlike scrofulous glandular enlargement they undergo no caseation, suppuration or retrogressive changes. All the lymphatics of the body may be enlarged. The spleen is enlarged. Emaciation and ansemia aie marked and progressive. There may be dull pains from pressure on the sensory nerves. The pulse is small and rapid. There is usually fever in the evening. The number of white corpuscles in the blood is not in excess of the normal in the majority of cases. The course of the disease is chronic. One year is its average duration; two months and three years are its extremes (Bartholow and Loomis). Differential Diagnosis. — Lymphadenoma may be mistaken for leucocythsemia. In leucocythaemia the changes in the glands succeed to those in the blood, whereas the glandular enlarge- ment is first in Hodgkin's disease. By microscopic examination, when the ratio between the white and red corpuscles reaches one LYMPHADEXOMA LEUCORRHCEA. 311 to twenty the case must be regarded as one of leucocythaemia (Bartholow and Loomis). Prognosis. — Is bad. Treatment. — Fowler's solution increased to ten, fifteen or twenty minims, thrice daily, according to the forbearance of the stomach seems to be effective; and one to five minims in distilled water may be injected into the enlarged glands. Iodide of po- tassium may be tried. The syrup of the iodides of iron and manganese has seemed to do good. Cod- liver oil is useful as a nutrient and tonic (Bartholow). LEUCORRHCEA. Is a morbid alteration and exaggeration of the physiological uterine and vaginal secretions. In a state of health these parts secrete in small quantity a mucous liquid which always contains a few leucocytes. As soon as this has become abundant and purulent, it is morbid and constitutes a leucorrhcea. Leucorrhcea is also called ivhites, and is a catarrhal condition of the vagina and uterus. The purulent discharge may be from two sources, the uterus or the vagina. Vaginal leucorrhcea may often be found alone; it may be a discharge of very thin fluid of a milky appearance, which does not stain the linen much, or it may be charged with pus and be of a greenish -yellow color; its reaction is acid. Leu- corrhcea from the body of the uterus is of a somewhat viscid nature; that from the cervix is jelly like and in the normal state is transparent, like the unboiled white of egg^ staining the linen strongly; in disease it is of a greenish-yellow color. Its reaction is alkaline. The leucorrhceal secretion is constantly produced, but is voided a little at a time. Causes. — Leucorrhcea may depend simply on a general de- bilitated condition, as anaemia, chlorosis, etc. This symptomatic form is so frequent that Marc d'Espine has claimed to find it in two-thirds of the women. 312 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR LEUCORRHCEA. R Aluminis 3j. Zinci sulphatis ^ss. Sodii biboratis gr. iv. Aquae rosse ^viij . — M. Sig. : Use as injection. — Bartholow. According to Bartholow, uterine and vaginal leucorrhcea, ul- cerations, and erosions of the cervix uteri, are quickly improved by the topical application of the fluid extract of hydrastis, which may be used in an undiluted state. The same author knows of no more effective application in leucorrhcea than tan- nin and iodoform applied in the dry way, well packed around the cervix uteri. Carbolic acid diluted and used with care is an excellent deodorizer when the discharges from the vagina are fetid. According to Ringer, a drachm of bicarbonate of potash, soda, or alum to a pint of water is a useful injection to check leucorrhcea, when this discharge depends on an increased secretion of the glands of the os uteri. The alum solution constrings the parts, and sometimes causes severe cramp-like pains. PRESCRIPTIONS FOR LEUCORRHCEA. R Acidi tannici ,^iv. Glycerinae ^x vj . — M. Sig.: A tablespoonful into a quart of tepid water, used as a va- ginal injection for five minutes, night and morning. — T. G. Thomas. R Sodii bicarbonatis ,. 5j. Tinct. belladonnas ^ij. Aquae Oj . — M. Sig.: Use as a va_inal wash. — Ringer. R Tinct. sulphatis. Aluminis sulphatis aa 3iss. Gly ceri nse §vj . — M. Sig.: A tablespoonful to a quart of water, as a vaginal injection. — Thomas. R Acidi boracici 5j. Aquae ferventis Ovj. — M. Ft. lotion. Sig. : To be used as a vaginal injection. — Ringer. LICE. 313 R Potassii permanganatis 3ss. Aquae ^xv. Sig. : For vaginal injection. In fetid discharge. — Bartholow. R Sodii biboratis H i j - Sig.: A teaspoonful to a pint of water as a vaginal wash. For leucorrhcea of pregnancy. — Parvin. R Potassii chloratis gij. Sig.: A teaspoonful to a pint of water as a vaginal injection. (In simple cases.) — Parvin. LICE. There are three varieties of this affection, each dependent npon a separate parasite, namely : 1. The pediculns corporis, which is met with exclusively upon non-hairy parts. It secretes itself among the folds of the clothing, and is rarely seen upon the body except when feeding. 2. The pediculus capitis, which is met with exclusively upon the head. And 3. The pediculus pubis, which is met with on all hairy parts except the head, but the hair on the pubis and neighboring parts is its favorite hunt- ing ground. The crawling and biting of these parasites produce irritation and itching, to relieve which the part is scratched (Anderson). Treatment. — Is very simple. The most effectual remedies are carbolic acid, sulphur, mercury, staphisagria, sabadilla and pyrethrum, the essential oils and alcohol. The following for- mulae are good : R Acidi carbolici gij. Spts. rosmarini 3j . Spts. rectificati gss. Aqua? destillatae ad § vj . — M. Sig. : Sponge the affected parts night and morning. — Anderson. R Hydrargyri perchloridi gr. xij. Spts. rectificati Jj. Aquae destillatae %v. Olei rosae IHj.— M. Sig.: Sponge the affected part night and morning. — Anderson. R Pulv. staphisagriae 3J. Adipis 5iv. Olei rosmarini gtt. xxx. — M. Sig.: Apply once daily. — Anderson. 314 A COMPENDIUM OF PRACTICAL MEDICINE. LICHEN. Is a papular inflammation of the skin. It consists of minute conical papulae, generally of reddish color, and occurring in clusters. It is most frequently encountered in the summer months and in adults, and often in persons who are in good health, but who have been exposed to much fatigue or anxiety. Disordered digestion may produce it. It is commonly chronic (DaCosta). Treatment. — Arsenic sometimes relieves lichen and other obstinate skin affections (Ringer). Cantharides is useful in lichen. An ointment composed of half a drachm of chloroform to an ounce of lard will often allay the itching of lichen or of urticaria. Patches of obstinate lichen and psoriasis, especially of the hands, even when not syphilitic, will sometimes yield to mercury treatment. The calomel and nitrate of mercury oint- ment may be mixed, and the addition of tar ointment sometimes increases the efficacy of this combination (Ringer). In lichen psoriasis, eczema, ichthyosis, urticaria, prurigo and scabies and the warm bath may be employed with much benefit. PRESCRIPTIONS FOR LICHEN. R Cretan prseparatse 3vi. Sulphuris sublimati Olei cadini — aa -Six. Saponis nigris Adipis — aa gxx v. (Melt the lard and then add other ingredients.) Sig. : Apply locally. — Hebra. R Sodii arseniatis gr. iss. Aquas destillatse .5xxv. — M. Sig. : A teaspoonful every morning at meal time. — Vidal. B Glyceriti amyli 3 v. Pulv. acidi tartarici gr. xv. — M. Sig.: Apply locally. — Vidal. LOCOMOTOR ATAXIi. 315 LOCOMOTOR ATAXIA. Called also Duchenne's disease, known also as posterior spinal sclerosis, tabes dorsalis, gray degeneration of the posterior columns, and leuko- myelitis posterior chronica, is one of the most frequent diseases of the spinal cord, and is a form of myel- itis which does not extend transversely, but longitudinally, and is limited to the posterior columns (Bartholow). Causes. — An inherited tendency is probably the chief cause. It occurs between twenty and sixty, but is most frequent between thirty -five and fifty. It attacks males six times as often as females. Exposure to cold and dampness, fatigue and depress - ing moral emotions favors its development. Sexual excesses, rheumatism, sy23hilis, excessive use of tobacco and blows on the spine are predisposing causes (Bartholow and Loomis). Symptoms. — The distinctive characteristic of the affection is impairment or loss of the ability to combine and direct volun- tary muscular movements. Stages. — 1. The initial period or first stage. 2. The ataxic period, or second stage. And 3. The paralytic or third stage. During the first stage or period, there are sharp, tearing, light- ning pains in the lower limbs, clysuria, incontinence, spermatorr- hoea, nocturnal pollutions, excitement of, or loss of sexual desire, a sense of weariness in the limbs and nausea and vomiting, at- tended by severe and paroxysmal aching in the stomach. A sense of numbness and formication in the limbs is common in this period. There may be a girdle sensation, not only about the waist, but also in the limbs — chiefly about the knee and ankle. Rectal and urethral colic are frequent. The pains during this period are usually in the feet and legs, but they may have their seat in the back, stomach, intestine or bladder. At first they do not come on often, and are of short duration. The muscles of the eyes may be affected, causing double vision, or strabismus, which may last a few days, and then disappear. Sometimes the patient will complain of a sensation of some soft substance be- tween the feet and the ground. One portion of the surface may be anaesthetic, another hyperaesthetic. The pupil on one side may be contracted to the size of a pin's point, showing paralysis 316 A COMPENDIUM OF PRACTICAL MEDICINE. of the sympathetic, and on the other side dilated. Oftener both pupils are contracted. A symptom which possesses considerable diagnostic value is the absence of contraction of the pupil on exposure to light, while there is normal contraction in the acts of accommodation; this is called the "Argyll-Robertson pupil." The "Knee- jerk, '■' or patellar tendon refiex, is found to be absent in 76 per cent, of the cases, according to Buzzard. The duration of this stage varies from a few months to several years, and then begin the symptoms characteristic of the second or ataxic stage. The ataxia is generally first manifested in the lower extremities. The legs are thrown forward with a quick, jerking movement, and the feet are brought to the ground on the heels with force and are liable to strike against each other. The patient is unable to button or unbutton clothes, when the upper extremities are affected. There may be double vision and night-blindness. A symptom even when the affection is slight, is inability to stand with the feet in apposition and the eyes closed. The patient's eyes are directed to the feet and ground in walking. Impotence occurs in this stage. The patellar reflex is wanting and this is diagnostic. Cutaneous sensibility is more or less impaired. During this period the joints some- times rapidly swell. In the third or paralytic stage, notable paralysis is added to the ataxia. The muscles waste, the patient falls into a cachectic state, cystitis and bed-sores occur, and death takes place from exhaustion. During this third stage, there is always complete impotence, and loss of sensation about the rectum. Locomotor ataxia is a non-febrile disease. The whole duration of the disease is on the average seven years, but may continue thirty years. The shortest duration is three years (Bartholow, Flint and Loomis). Differential Diognosis. — Locomotor ataxia may be confounded with paraplegia, multiple cerebro- spinal sclerosis, cerebellar dis- ease, chronic myelitis, and chronic spinal meningitis. In para- plegia, there is true paralysis; the limbs merely dragged in walk- ing; there is no resistance to artificial movement; the nutrition of the muscles is greatly impaired; neuralgic pains are absent, and there are no ocular symptoms. In ataxia these symptoms are re- versed. In multiple cerebro- spinal sclerosis, there are a peculiar LOCOMOTOR ATAXIA. 317 shaking tremor, impairment of voice and speech, and nystagmus. In ataxia these symptoms are absent. In ataxia there are iron band sensations, bladder symptoms, the lightning-like pains and the heel walk, all of which are absent in the former disease. In cerebellar disease there is vertigo. The patient can stand and walk better with his eyes shut than open. There is absence of neuralgic pains; and headache, vomiting and convulsions are prominent symptoms. In ataxia this is not so. In chronic myelitis there are no disorders of co-ordination. In chronic myelitis the limbs are dragged, and the ocular symptoms are ab- sent. The reverse in ataxia. In meningitis there is pain in- creased on pressure, slight paralysis, but no inco- ordination, and no ocular symptoms (Loomis). Prognosis. — Unfavorable. Treatment. — About one grain a day in divided doses of nitrate of silver is recommended. The galvanic current is nearly always of service. Some cases will be benefited by the iodides, others by the bromides. Strychnine, phosphorus, arsenic, the chlorides of gold, sodium, and barium, belladonna and ergot all have been recommended. The patient should remain at rest and not expose himself to cold or wet, and should wear flannel next the skin. Coffee, tea, tobacco and alcoholic stimulants should be given up. Cold water baths are favorable (Bartholow and Loomis). PRESCRIPTIONS FOR LOCOMOTOR ATAXIA. R Ext. physostigmatis gr. x. Ext. gentianse gr. xL. — M. Ft. massa et in pil no. 100 div. Sig. : One pill every three hours. — Murrell. R Antifebrin 3J . In pulv. no. xv. div. Sig. : One powder every half hour for two doses, then every four hours. R Strychnise sulphatis ...gr. iss. Syr hy pophosphiti sxij . — M. Sig.: A teaspoonful thrice daily. — DaCosta. 318 A COMPENDIUM OF PRACTICAL MEDICINE. LUMBAGO. (See Muscular Kheumatism.) LUPUS. Is a chronic tubercular skin disease. In lupus, a tissue is formed like granulation tissue. Tubercles form, which may ulcerate, and are of a dull red color. When they heal, they leave a whitish scar (DaCosta). Causes. — The disorder occurs in syphilis, or in scrofulous persons. It appears often in childhood, and is attended with some pain and itching, and pursues a very slow course. The nose and cheeks are the favorite sites. In strumous subjects, lupus has a warty appearance. Some hold that lupus is the offspring of syphilis in the parents (DaCosta). Treatment, — Anti- strumous remedies should be given. Our sheet-anchor in most cases is cod-liver oil given for a long time. Next to cod-liver oil must be placed phosphorus. Arsenic may be given, also the syrup of the iodide of iron. Nitrate of silver should be applied locally (Anderson). PRESCRIPTIONS FOR LUPUS. R Zinci chloridi Antimonii chloridi aa gr. xx. Pulv. iridis florentinse rad gr. x. Acidi hydrochlorici puri XHx. — M. Sig. : Use as a caustic, spread on linen strips and leave on 24 hours. — Kaposi. R Acidi pyrogallici 5j- Cerati simplicis gix. — M. Sig.: Apply locally. — Kaposi. R Acidi lactici puri Sj. Sig.: Apply to ulcer on absorbent cotton. — Wichmann. R Iodini Potassii iodidi aa gr. xv. Glycerinse HI. xxx. — M. Sig. : Apply locally. — Kaposi. LIPOMA LACTATION. 319 LIPOMA. Is a tumor formed of a fat tissue. The fat tissue occurs in lobules and is similar to normal fat. Fatty tumors may undergo partial calcification. They are usually sharply circumscribed, but may infiltrate surrounding tissue. They are frequently pe- dunculated, and sometimes grow to enormous size, and may ulcer- ate. They are usually single but may be multiple. They are the most common of tumors. They are benign, or innocent tumors, not forming metastases. Occurrence. — They occur at all periods of life from infancy to old age, and are even congenital. They are more common in the female. As a rule, these tumors are encapsuled. They are soft, movable and free from pain. Situation. — Their most usual situation is the back of the neck and shoulders. Cause. — Unknown . Diagnosis. — Not difficult. The tumor will feel more or less firm and made up of lobes. The skin is usually loose over the tumor. Treatment. — When no necessity exists for their removal, tumors should be let alone. When large, unsightly and grow- ing, they should be removed by excision (Bryant and Prudden). LOCK=JAW. (See Trismus.) LACTATION. (Excessive.) Treatment. — When it is desirable to arrest the secretion of milk the gland may be enveloped by a belladonna plaster. A more elegant method is to envelop the breast in lint wet with a solution of atropine, four grains to the ounce of rose water. In- flamed breasts may be treated in the same way. Quinia has been recommended in excessive secretion of milk. An ointment made by boiling half an ounce of tobacco in eight ounces of lard kept constantly applied to the breasts, is also said to arrest the secretion of milk (Bartholow and Ringer). 320 A COMPENDIUM OF PRACTICAL MEDICINE. LEAD COLIC. (See Colic). LENTIGO. (See Freckles). LEUCODERMA, Called also vitiligo, is an affection characterized by an ab- sence of pigment at certain parts surrounded by portions of skin in which it has accumulated to an excessive degree, so that brown patches are seen enclosing white ones. The white spots are at first circular in form, but uniting with each other become irreg- lar in shape. It may involve almost the whole body, but is usually confined to the hands, face and neck. It is most com- monly met with in persons of color. It is a rare affection (An- derson). Causes. — Some hold that it is a congenital affection. Its cause is very obscure, but there can be little doubt that it is a neurotic affection, and probably dependent upon perverted innervation of the sympathetic nerve. The exciting cause is sometimes apparently a lesion of some kind; as a burn, surgical operation, etc., (Anderson). Diagnosis. — Leucoderma is met with in all parts of the world. The general health of the patient is unaffected. The white patches are round and of a dead-white tint. There is no altera- tion in the structure of the skin. Sensation is normal (Anderson). Treatment. — Nerve tonics, such as phosphorus, strychnia and above all arsenic should be tried (Anderson). MALARIAL FEVERS. Are characterized by their prevalence in certain regions of the world known to produce the poison malaria, by their period- icity, and by the regular succession of the cold, hot and sweating stages. There are many varieties of malarial fever and they have received various names, such as fever and ague, chills, bilious fever, bilious remittent, remittent, intermittent, pernicious inter- mittent, congestive, "mountain fever of Colorado," continued malarial, typho- malarial, Chickahominy fever, "the shakes, ,r MALARIAL FEVERS. 321 swamp fever, "Panama fever," "carnp fever 1 ' and periodical fever (Bartholow). Causes. — All varieties of malarial fevers have a common origin in a poison which has received the name of miasm, or malaria, and which is subject to certain variations in quantity. By some this miasm, or malarial poison, is regarded as gaseous in its nature, by others it is thought to be a living vegetable or- ganism, and. again others think it a specific poison, having no tangible, chemical or microscopical constituents. Certain proto- plasmic bodies have been found in the red corpuscles of malarial patients, which were called " plasmodium sanguinis malarise," but it is not known whether they are normal or are the cause or result of the malarial infection. But while we do not know the true nature of malaria, yet we do know something of the circum- stances which are necessary for its production. First, a certain amount of vegetable matter on or in the soil is absolutely neces- sary. Second, a certain amount of moisture on or in the soil is indispensable. Third, a certain degree of temperature is neces- sary. It cannot be developed below an average temperature of 58° F. for the twenty- four hours. Infected Regions.— Marshes are especially favorable to the development of this poison, and may generate it for an indefinite period. The Pontine marshes, between Rome and Naples, have been malarial for more than two thousand years. But not all marshes produce malaria. The "Dismal swamp," for example, is free from marsh -miasm, although apparently well adapted to produce it. Its exemption is supposed to be due to the growth of the cypress -tree. If the marsh contains an abundance of water, malarial fevers are rare. If the marsh be covered with a thin sheet of water, or has dried up, malarial poison will abound. As a rule, salt water marshes are especially free from malaria, but when salt and fresh water are mixed in the marsh, the best conditions for malaria exist. Damp "bottom lauds 11 are as fruitful as swamps in the generation of this poison. Another condition which favors the development of malaria is the up- heaval of new alluvial soils in cultivating, or in excavating for railroads. Regions otherwise non-malarial may have malarial poison brought to them by the waters of rivers which have their 322 A COMPENDIUM OF PRACTICAL MEDICINE. source in or flow through malarial districts, as along the banks of our Western rivers; or it may be brought to them by the wind. Circumstances which are inimical to the production of malaria are : I. High Latitude. — In this country malarial poison is not -generated in higher latitude than that of Quebec. The limit of its development is 63° north and 57° south latitude. The nearer the approach to the Equator, the more severe the type. 77. High Elevation. — As a rule, it is not generated above an elevation of 1000 feet above the sea, but there are exceptions to this afforded by the so-called ''mountain fever" of Colorado, of the Pyrenees, and of the mountains of South America. 777. Drainage and Cultivation. — In the majority of marshes, malaria can be prevented or arrested by free drainage. Yet there are marshes upon which millions have been expended in drainage and which still remain pestiferous, as for example the Jersey Flats and Pontine marshes. IV. Cold. — This is a powerful agent in arresting malarial generation. If the temperature should fall below the freezing point, only for one night, nothing more need be feared in that region from malaria, until the average temperature shall have again reached 60° F. This law holds in all malarial districts. Malaria is most active from June till November. Malaria is soluble in water, and Bartholow found the surface water of Kan- sas to produce malarial fevers and cholera. Some trees and plants possess the property of absorbing the malaria. The eucalyptus -tree has changed the nature of the malaria-breeding portion of the Algiers. The common sun- flower, planted in moist low-lands, will render the air salubrious. All ages are susceptible to malarial poisoning; and all races are equally so, except the black. Malarial poison may gain entrance into the human body through the respired air, or through food or drink (Bartholow and Loomis). Pathological Anatomy. — The changes caused by malarial poisoning are essentially the same, except degree, in all forms in which the disease manifests itself, and two organs (the liver and sjneen) are chiefly concerned. In acute cases, the spleen is INTERMITTENT FEVER. 323 much enlarged. In some chronic cases the spleen undergoes enormous enlargement, and is known as u ague-cake." The liver becomes hyperaemic and swollen. The brain is also hyperseniic (Bartholow). Symptoms. — Prodromal stage. The incubation period is about fourteen days. During this time there are symptoms indicating that the infection is working. These are called prodromes. The patient has a feeling of lassi- tude and weariness, backache and general muscular soreness; he yawns and stretches, has headache, coated tongue and deranged stomach; in the evening his skin is warm and dry, but he has pro- fuse sweat in the morning. There may be yellow sclerotic, and a general yellowish hue of the skin, loss of appetite and consti- pation. The urine is loaded with bile pigment (Bartholow). INTERMITTENT FEVER, Called also, a fever and ague," " chill fever," "the shakes," " swamp fever," "Panama fever," is characterized by the occur- ence of febrile paroxysms in regular succession, and by the ab- sence of febrile movement between the paroxysms. The inter- mission is the distinctive feature of this form of fever, as its name implies. Like typhoid fever, intermittent fever is met with in all parts of the world, except in the extreme north or south. Morbid Anatomy. — The essential anatomical lesion in all forms of malarial fever is the presence of dark pigment in the blood and in certain organs. The only constant pathological le- sion of intermittent fever is congestion of the internal organs. The spleen and liver are always more or less enlarged, but the enlargement is due to simple hyperemia; no structural changes occur in these organs until the intermittent paroxysms have been often repeated, and the malarial poisoning has been of long dur- ation. There is also more or less hyperemia of the kidneys and mucous membrane of the intestine (Flint and Loomis). Cause. — Malarial poisoning introduced either through the lungs or intestinal tract (Loomis). 324 A COMPENDIUM OF PRACTICAL MEDICINE. Symptoms. — Intermittent fever occurs in paroxysms. There are three simple types of this fever. The first and most common is the quotidian type, in which the paroxysm occurs every day, and there is an interval of 24 hours between the paroxysms. The second is the tertian type, in which the paroxysm occurs every third day, with an interval of 48 hours between the paroxysms. The third is the quartan type, in which the par- oxysm occurs every fourth day, with an interval of 72 hours between the paroxysms. There are other types, but they are only modified forms of those already mentioned, such as double quotidian, in which two paroxysms occur daily. Usually one paroxysm is severe, the other mild; the severe one generally occurs in the morning, the milder in the afternoon or evening. There is also the double tertian, in which a paroxysm occurs daily, but it differs from quotidian as the paroxysms that resem- ble each other occur at intervals of 48 hours. There is also the double quartan. In this type a paroxysm occurs on two suc- cessive days, and on the third day there is no paroxysm. Cases have been observed in which the paroxysm occurred on the fifth, sixth, seventh and eighth day, giving us a quintan, a sextan, a heptan, and an octan type of intermittent fever. The types most frequently met with are the quotidian, tertian and quartan. In the quotidian type the paroxysm occurs in the morning, in the tertian it occurs about noon, while in the quartan it occurs in the afternoon or evening. Duration of Paroxysm. — In the quotidian it lasts from eight to ten hours, in tertian it lasts from six to eight hours, in quartan from four to six hours. Description of a Paroxysm. — Paroxysms may occur at any hour of the day, but rarely at night. A paroxysm consists of three stages — the cold, the hot, and the sweating stage. Gold Stage. — Pain in the head, a sense of languor, and some nausea usually precede this stage. When the cold stage comes on, there is a sensation of coldness along the back, which soon extends to the extremities, and gradually creeps over the whole body. The skin becomes shrivelled, the finger ends and lips become blue, the face is pale, the eyes are sunken, chills rapidly follow each other, the teeth begin to rattle together and the bed INTERMITTENT FEVER. 325 shakes. Tlie skin assumes the appearance of goose-skin. The temperature rises to 104° or 105° F., although the surface of the body feels cold. The pulse is small, rapid, and the tension high. There is precordial oppression and the voice is weak and husky. The respirations are rapid, short and sighing. The urine is in- creased in quantity and paler than normal, and there is a frequent desire to empty the bladder. There is extreme thirst and often nausea and vomiting. There is congestion of internal organs. The duration of this stage varies from a half hoar to two or three hours. Children do not have a regular chill; they merely grow cold, blue and livid. Hot Stage. — The skin becomes red, hot and swollen, and the blood recedes from the internal organs to the surface. There is intense pyrexia. The face is flushed and eyes red and fiery. The pulse grows full, rapid and strong. The headache con- tinues, but the pain in the limbs and precordial oppression dis- appear. The temperature marks 106° or 107° F. Thirst is intense. Sometimes herpetic vesicles appear about the mouth. The tongue becomes dry, the carotids pulsate, the head feels full; there are noises in the ears; there are nausea and vomiting, and there may be excitement and delirium. The urine in this stage becomes scanty and high colored. The duration of this stage is between three and eight hours and it is followed by the sweating stage. Sweating Stage. — The sweat appears first on the face and then on the trunk and extremities. The fever gradually abates and at length disappears. The heat of the surface, cephalalgia, thirst, restlessness, etc., cease. The patient obtains refreshing sleep. With this stage the paroxysm ends. The average dura- tion of the sweating stage is three or four hours. As a rule, the successive paroxysms recur precisely or nearly at the same hour. When the paroxysm comes on a little earlier each day, it is called anticipating, and indicates that the fever is not being controlled; when it comes on later each day, it then indicates that the fever is being controlled, and is called a postponing intermittent (Bartholow, Flint and Loomis). Intermission. — The intermission, called also the apyrexial period, is the space of time between two successive paroxysms. 326 A COMPENDIUM OF PRACTICAL MEDICINE. During the intermission at first the patient may feel perfectly well, but if the disease continue, there will be a loss of vitality, he becomes pale and feeble with a yellowish, or sallow tint to the skin. There will be enlargement of the spleen and liver, and pigmentation of the tissues. These characters denote what is called the malarial cachexia (Loomis and Flint). Duration. — Of the disease is indefinite. It may continue for weeks or for months. The liability to relapse remains for many years. Dumb Ague, or Latent Intermittent Fever. — When the chill and sweat are absent, but a sense of heat, malaise, headache and lassitude come on at pretty regular periods in a malarial district, the thermometer showing a fever of 102° to 104° F. the patient is said to have ''dumb-ague" (Loomis). Differential Diagnosis. — Intermittent fever may be mistaken for remittent fever, pyaemia, and pulmonary phthisis. In remit- tent fever there is never a complete intermission, whereas in in- termittent there is always a period in which there is no fever. In remittent, there is usually but one chill, while in intermittent a chill precedes each paroxysm of fever. Pyaemia is very irregular in its course, no defined intervals occuring — intermittent is regular. Pyaemia is due to wounds, suppuration of veins, etc., intermittent to malaria. The former is a fatal disease over which quinia has no influence, the latter is promptly cured by quinine. Febrile paroxysms resembling those of intermittent fever are sometimes, observed in connection with pulmonary phthisis. They may present the three stages well marked, and recur at regular intervals. But they oftener occur in the afternoon than in the forenoon, whereas the reverse obtains in intermittent fever (Flint and Loomis). Treatment. — The treatment of the paroxysm is simply to render the patient comfortable. The patient should be kept in bed during the paroxysm. During the cold stage, cover him with blankets, surround him with bottles of hot water and let him drink freely of hot water. During the hot stage, the external heat should be gradually removed and cold drinks given. If nausea and vomiting are present give opium hypodermically. During the sweating stage let him alone. The treatment for the INTERMITTENT FEVER. 327 intermission is to prevent the occurrence of another paroxysm. A patient should never be allowed to have a second intermittent paroxysm. The sulphate of quinia is our sheet anchor in this disease, and it is all powerful if skillfully used. At least thirty grains of quinine should be administered between the termina- tion of one paroxysm and the hour when another is to be ex- pected. The first dose of ten grains should be given toward the close of the sweating stage, and twenty grains about two hours before the time of the expected paroxysm. A moderate degree of cinchonism should be maintained for a number of days. About two hours before the time of day at which the first par- oxysm occurred from ten to fifteen grains of quinine should be daily administered. A full close of opium with the quinine will sometimes prevent a recurrence of the paroxysm. In some chronic forms of malaria, arsenic is of great service. Salicin, strychnia, piperine, eucalyptus, and hydrastia sometimes act when quinine fails. Flint has known a sinapism applied over the whole length of the spine at the beginning of the cold stage to arrest the paroxysm and effect a cure. A full opiate at the be- ginning of the cold stage often appears to shorten and modify the severity of the paroxysm. For the treatment of the enlarged spleen there is, besides the exhibition of quinine, no remedy more efficacious than the ointment of the red iodide of mercury, which is rubbed in daily over the splenic region in the sunshine, until soreness of the skin compels a suspension (Bartholow, Loomis and Flint). Prophylaxis. — Those living in, or going to malarial regions, susceptible to the action of the poison, must avoid all excesses of every kind, exposure to fatigue, to heat, to night air, and should take five or ten grains of quinine daily in the morning, in some black coffee, to procure immunity against malarial infection (Bartholow). PERNICIOUS INTERMITTENT FEVER. Called, also, malignant congestive or tropical typhoid is a severe form of the remittent or intermittent fever. It occurs in those places where the malaria is most concentrated, and the malarial fevers most severe. 328 A COMPENDIUM OF PRACTICAL MEDICINE. Varieties. — There are several varieties, namely : the coma- tose, the delirious, the algid, the icteric and the gastro- enteric. Symptoms. — In the comatose variety during the hot stage the patient passes into a state of stupor and unconsciousness, lies upon his back, with a flushed face, congested conjunctiva, dilated pupils, slow, deep and stertorous respiration. He some- times passes into a condition of apparent death which may last for hours. If the patient survive the first and second paroxysms, he usually dies during the third. In the delirious variety, the patient after passing into the hot stage, becomes wildly delirious and requires restraint. This delirium may continue for hours. These attacks of delirium may be repeated three or four times before the patient dies. In the algid variety, after the patient enters the hot stage, the surface of the body begins to grow cold, has a marble -like feel, and the temperature in the axilla may fall to 88° F. or 84° F., while the rectal may range from 104° F. to 107° F. The pulse becomes slower and slower, falters, and disappears at the wrist. The patient has a death -like appearance. In the icteric variety, the patient has a violent long- con- tinued chill, during which jaundice shows itself. The jaundice gradually deepens and extends over the whole body. There is nausea and vomiting of bile. The temperature reaches 106° F. or 107° F. In the gastro enteric variety, the patient after passing into the hot stage, is seized with almost incessant vomiting and purg- ing. The discharges are stained with blood. There is a sense of burning in the stomach, cramps in the calves of the legs, cold- ness and blueness of the surface and sunken eyes (Loomis). Prognosis. — Unfavorable. Treatment. — Quinine and opium are the only reliable agents for this disease. From five to seven grains of quinine should be given hypodermically every hour until the paroxysm has passed away, then three grain doses every four hours. One -fourth of a grain of morphia should also be given and repeated if necessary. Warburg's tincture may be used with good results. A half ounce may be given at the outset of the paroxysm and this dose repeated if necessary (Loomis). REMITTENT FEVER. 329 REMITTENT FEVER. Called also bilious fever, and bilious remittent fever, is a form of malarial fever characterized by the occurrence of re- missions instead of intermissions. Cause. — Malarial poisoning. Symptoms. — There are oppression in the epigastrium, lassi- tude, nausea, loss of appetite, and pain in the limbs and head. It does not come on gradually, like typhoid fever, but abruptly, usually with a chill. The chill is neither so complete, nor so long continued as in intermittent fever or pneumonia. There is no shaking; of the bodv or chattering of the teeth. Following the chill the temperature may reach 105° F. or 106° F. The face becomes flushed, the eyes congested, and there is vomiting of bile. The febrile symptoms increase in severity for ten or twelve hours, when a slight moisture appears upon the surface, and the tem- perature falls one or two degrees, but there is not a complete in- terruption; the fever is continuous. At the same hour the fol- lowing day all the active febrile symptoms return, and are more severe. This rise and fall of temperature constitutes the exacer- bation and remission. The febrile career ends during the second or third week. It eventuates in intermittent fever in a certain proportion of cases (Loomis). Treatment. — Quinine is all powerful in this disease. Loomis gives ten or twenty grains of quinine at a dose and repeats it every two hours until cinchonism is produced. He also gives full doses of bromide of potassium to promote sleep. Bartho- low gives thirty grains of quinine the first morning, twenty the second, fifteen the third, and ten the fourth, single doses, and all taken at once. CONTINUED MALARIAL FEVER. Called also typho-malarial, camp, and Chickahominy fever is an association of typhoid and remittent fevers. Many doubt the existence of such a form of fever, and regard the so-called typhoid element as nothing more than a typhoid condition, liable to be developed in connection with remittent fever, as well as with many other diseases (Loomis). Causes. — Are malarial poison, and some other poison. It is met with only in malarial districts. In large cities in which 330 A COMPENDIUM OF PRACTICAL MEDICINE. malarial diseases are prevalent, anti- hygienic conditions, such as over- crowding and bad sewerage, seem to furnish the element so essential to its development (Loomis). Symptoms. — There are usually a distinct chill, pains in the limbs and back, headache, loss of appetite and a feeling of great exhaustion. The countenance has a peculiar waxy, yel- lowish tinge. There may be nausea and vomiting, abdominal tenderness in the right iliac region and diarrhoea. The tongue has first a white, then a red, and then a brown coating. Sordes may collect upon the teeth and lips. The average duration of the disease is three or four weeks (Loomis). Treatment. — When the malarial element predominates, quinine and Warburg's tincture are the best remedies. When the typhoid element predominates, give the regular typhoid remedies. CHRONIC MALARIAL INFECTION. Or malarial cachexia, may be a sequel of any form of acute malarial disease. It may develop in those who have never suf- fered from any form of malarial fever, but who have resided for some time in a malarial district. The patient becomes anaemic with enlarged spleen and liver (Loomis). Cause. — Malarial poisoning. Symptoms. — Some complain of vertigo, ringing in the ears, loss of memory, disturbances of sight, loss of appetite, nausea dyspetic symptoms, and pain and oppression in the epigastrium. Diarrhoea is often present. The sleep is disturbed. There may be pains in the back and loins. Some become easily fatigued on exertion, have shortness of breath and palpitation of the heart. There may be tingling and numbness of the limbs. Hemiplegia sometimes occurs. There may be catarrhal inflammation of the stomach, intestine and bronchial tubes. Neuralgia is quite com- mon in this affection (Loomis). Treatment. — The patient should be removed from a malari- ous district to a high, warm, mountainous region. He should wear flannel next to the skin and avoid exposure to wet and cold, and the damp air of evenings and nights. Quinine must be given in full doses. If there is angemia iron must be given. The iodide MALARIAL FEVERS. 331 of iron combined with cod liver oil will he found of great service. One -half an ounce of Warburg's tincture taken daily for ten da vs. two hours before breakfast, is often efficacious when qui- nine fails. Aloes or rhubarb should be given, if the bowels are constipated. Arsenic may be tried. A nutritious diet and the daily use of brandy in small quantities are often of great service (Loomis). PRESCRIPTIONS FOR MALARIAL FEVERS. R Quinia? sulphatis ^iss. Acidi sulphurici dil, 3ss. Spts. setheris uitrosi 5ss. Syrupi tolutan. Aqua? aa.-.q. s....ad,...§iij. — M. Sig. : A teaspoonful three or four times a day. — DaCosta. R Chinoidini gr. xL. Resina? podophylli gr. iv. Ferri sulph exsic gr. xx. — M. Ft. massa et in pil. no. xx. div. Sig. : One three times daily. — Bartholow. R Tinctura? iodi 3vj. Potassii iodidi 5ij- Aqua? cinnamonii ad 5iij. — M. Sig.: A teaspoonful three times daily. — Charity Hospital. R Acidi carbolici gj. Tincturse iodi comp ^iij . — M. Sig.: Four drops every four hours well diluted. — Bartholow. R Quinina? sulphatis gr. xyj. Ext. glycyrrhizse 5j- Syr. rubri idaei oij- — M. Sig.: A teaspoonful three to five times daily for a child three years old. — J. Lewis Smith. R Pulveris opii gr. xij . Pulveris capsici gr. xxxvi. Quinina? sulphatis 5j- — M. In pulveres no. xii. div. Sig.: One powder three times daily. — Alonzo Clark. 332 A COMPENDIUM OF PRACTICAL MEDICINE. MASTITIS. (See Inflammation of Breast). PRESCRIPTIONS FOR MASTITIS. R Ammonii carbonatis §j. Aquse Oj.— M. Sig.; Apply locally. — Starr. R Cerati resinse comp Sj. Olei olivse gj-ij. — M. Ft. ungt. Sig.. Apply, spread generously on soft linen. (When suppura- tion is threatened). — Witherstine. R Lini farini Aquae bullientis aa q.s... Ft. cataplasma. Sig.: Apply as hot as can be borne. — Witherstine. R Linimenti camphorse Sviij. — M. Sig. : Apply locally, rubbing gently from the circumference toward the nipple. (In incipient mastitis.) — Parry. R Atropinse sulphatis gr. viij. Aquas rosse 5ij. — M. Ft. lotio. Sig.: Apply locally, but discontinue in case of dilatation of pupils, or dryness of throat. — Starr. MANIA. (Acute and Chronic.) Maniacal conditions are so familiar and so readily recognized that they need not be described here. There are mainly two disorders with which acute mania is liable to be confounded, namely — acute meningitis and delirium tremens. In acute meningitis, there are severe headache, drowsiness, tingling and numbness in the extremities, tense pulse, decided fever, etc. In acute mania, the patient has little if any fever, no spasms; his pupils are not contracted; his stomach is not irrita- ble, and has no headache. In delirium tremens, he is talkative and restless, has a moist skin, compressible pulse, and creamy tongue. In acute mania these conditions do not prevail (DaCosta). MANIA MARASMUS MEASLES. 333 PRESCRIPTIONS FOR MANIA. Jfc Potassii bromidi gj. Tinct. cannabis indicse gj . Syrupi simplicis ,^ij . Aquae q. s., ad §iv. — M. Sig. : A tablespoonful thrice daily. — Clouston. |fc Hyoscyamise sulphatis „ gr. j. Aquas destillatse gxij . — M. Sig.: Five to twelve minims hypodermically. MARASMUS. Is a general wasting, emaciation, or atrophy. There are many constitutional diseases which produce a condition known as marasmus. The following prescriptions are useful in this con- dition : jfc Tinct. cinchonse comp Tinct. gentinse comp aa §j. — M. Sig. : Fifteen drops to a teaspoonful in sweetened water, thrice daily. J. Lewis Smith. j& Syr. ferri iodidi gj. Sig. : Three to five drops in water thrice daily after eating. — Eustace Smith. jfc Olei morrhuae Sij. Aquae calcis giv. Syr. calcis lactophosphites...ad...§iv. — M. Sig.: A teaspoonful two or three times daily. — Bosley. MEASLES. Called also rubeola and morbilli, is an eruptive fever, with catarrhal symptoms referable to the broncho-pulmonary mucous membrane, self-limited and terminating in about two weeks (Bartholow). Measles is a disease from which few persons es- cape. It is essentially a disease of childhood, but it may occur at any age. A second attack is of rare occurrence. It is char- acterized by an eruption of red spots. It is contagious (Loomis). Causes. — Measles appears in .alljparts of the globe. The dis- ease may be communicated not only by contact with the sick, but the morbific principle adheres to articles of clothing by which 334 A COMPENDIUM OF PRACTICAL MEDICINE. it may be conveyed long distances, or in other words it is a port- able disease. Measles prevails as an epidemic, and in the spor- adic form. All are not alike susceptible. Infants at the breast are not liable. The disease prevails mostly in the fall, winter and spring. The duration of the period of incubation varies from one to thirty days; the average being ten days (Bartholow and Loomis). Symptoms. — The course of this disease is definite and is di- vided into the stages of invasion, eruption and desquamation. Stage of Invasion. — At the end of the period of incubation, the patient begins to suffer from cough, fever, anorexia, thirst, chills, a feeling of weariness, muscular soreness, headache and backache. There is an acrid muco- serous discharge from the nostrils. The eyes are irritable, reddened and watery, and have a brilliant appearance. The buccal and faucial surfaces are in- jected. Sore throat is complained of, and the voice is a little husky. The bronchitis, laryngitis and coryza which accompany this disease are due to the efflorescence which takes place on the mucous membrane of the air-passages prior to its appearance on the skin. There may be nausea and vomiting. The face is flushed and somewhat swollen. Epistaxis is frequent. The average duration of the stage of invasion is three or four days. It may, however, be a single day or seven days; then the erup- tion appears (Flint, Smith and Loomis). Stage of Eruption. — The eruption is first seen upon the forehead, chin and sides of the nose, then upon the neck, chest and over the body, afterwards upon the legs and arms, and lastly upon the back of the hand. The eruption on the face feels like small shot early in the disease. The eruption fully develops in 36 to 48 hours, and then begins to fade. Convulsions may occur in this stage. The eruption has at first an appearance of minute red dots and specks which soon enlarge to the size of a pin -head or to three pin -heads; they disappear upon pressure and return when the pressure is removed. These spots are usually discrete and separated by tracts of normal skin. The eruption is sometimes attended with considerable itching. The efflorescence may be seen on the hard and soft palate one or two days before it appears on the face. In this stage the constitu- MEASLES. 335 tional and local symptoms increase in severity. The face is swollen, the eyes still watery and sensitive to light; the tongne is covered with a moist thin fur, and its papillae are prominent, though less so than in scarlet fever. The cough continues, the appetite is lost, and thirst is intense. A severe form of the dis- ease is characterized by the occurrence of petechia and hemorr- hage in various situations. In these cases the eruption presents a livid appearance, and is called hemorrhagic rubeola, or rubeola nigri or black measles. Some writers describe measles without catarrh, and on the other hand with catarrh, but without the rash. On the fourth day of the eruption it begins to fade, and the stage of desquamation commences (Flint, Smith, Loomis and Bartholow). Stage of Desquamation. — The duration of this stage is be- tween four and eight days. It is characterized by a scanty fur- furaceous exfoliation of the epidermis. In this stage all the symptoms rapidly abate, but the cough continues several days (J. Lewis Smith). Complications. — The most important complications are bronchitis, capillary bronchitis, broncho -pneumonia, meningitis, ophthalmia, otorrhoea, entero- colitis, eclampsia, diphtheria, and acute tuberculosis. Nephritis is a rare complication (Smith). Prognosis. — Is always good in uncomplicated cases, but the various complications render the prognosis unfavorable (Smith). Treatment. — Uncomplicated cases require little medical treatment. The child should be kept in an airy room at a uni- form temperature of about 70° F. The diet should be mild and for the most part liquid. Stimulation by wine or brandy may be necessary. For the troublesome cough, flaxseed tea or infus- ion of slippery elm bark, with lemon juice added may be given. A small Dover's powder is good for the cough. The chest should be covered with cotton wadding, after rubbing on camphorated oil. If the patient complains of itching and burning of the sur- face, he may be frequently sponged with tepid water. If there is thirst, cold water may be freely taken in small quantities at a time. Inhalations of steam are most useful for the lung compli- cations. In capillary bronchitis and pneumonia the following prescription is most serviceable : 336 A COMPENDIUM OF PRACTICAL MEDICINE. R Ammonii carbonat gr. xvj. gss. Aquae purse Sij . — M. Sig. : Give one teaspoonfal in three or four of milk every hour or two. The chloride of ammonium is also good in double the dose of carbonate (Smith). If the temperature is high during the initial stage, and the cough troublesome, the following is most effective : Jfc Tinct. aconit. rad gj. Ext. ipecac fid.. 3ij. Tinct. opii deodorat , . ^iij . — M. Sig. : Six drops every hour or two. — Bartholow. During the time of the eruption, if the temperature is high the skin should be rubbed every four hours with lard, suet, vase- line or cocoa- butter. A simple saline laxative ought to be given. Quinine may be used to reduce the fever (Bartholow Loomis and Smith). MELANCHOLIA. Is a form of insanity characterized by a condition of mental depression. Melancholiacs have gloomy visages. Causes. — Diseases of the brain, angemia, and physical pros- tration. Symptoms. — The patient is dreadfully depressed and his ex- pression is completely altered. He suffers from no appreciable disease. Usually he gazes toward the ground. The tendency of the melancholic is frequently to suicide. Treatment. — It is necessary to isolate melancholic patients from their friends and relatives. The use of opium in the form of the tincture, in gradually increasing doses, is productive of the best results. A prolonged warm bath (one -half to two hours) is a good hypnotic agent in melancholia. Frequent feeding is of the greatest importance (Starr). The bromide of potassium is most serviceable for the unendurable despondency (Ringer). PRESCRIPTIONS FOR MELANCHOLIA. Jfc Qninia3 valerianatis Ferri valerianatis , Zinci valerianatis— aa gr. xx. — M. Ft. rnassa et in pil. no. xx. div. Sig.: One pill three times daily. — Witherstine. MENINGITIS. 337 Jfc Potassii bromidi >..-3ij. Tinct. calumba giij. Spts. ammonise aromat ^ij. Aquse cinnamoni §iij . Aquaa q. s., ad §viij. — M. Sig.: A wineglassful two or three times daily. — Lawrence. {£r Tinct. ferri chloridi Syr. simplicis — aa gj . — M. Sig. : Twenty drops well diluted thrice daily. — Bartholow. MENINGITIS. Inflammation of tlie pia mater is usually called meningitis. The term pachymeningitis is applied to inflammation of the dura mater (Loomis). Sometimes inflammation of the pia mater is denominated leptomeningitis. It may be acute or chronic. Acute cerebral meningitis is also called simple meningitis of the convexity, cerebral fever, and arachnitis. Causes. — Acute alcoholismus, prolonged and intense mental anxiety and grief are among its predisposing causes. Injuries of the cranial bones, as fractures, severe blows, or punctured wounds are the most frequent exciting causes. Diabetes, cerebral tumors, disease of the cranial bones, suppuration of the middle ear, and eyeball, and large carbuncles about the cranium have caused it. Meningitis may occur as a complication, in measles, small -pox. scarlet fever, ulcerative endocarditis, Bright 's disease, acute pneumonia, typhus, typhoid fever, diphtheria, pyaemia, and rheu- matism. Long continued exposure to intense heat of the sun may cause it. It is more common in males than in females. It is most frequent in early adult life and in young children (Flint and Loomis). Symptoms. — May be divided into three stages of headache, delirium, and coma. It may be ushered in by a distinct chill or chilly sensations. The first prominent symptom, as a rule, is a violent headache. With the headache there is vertigo, intense photophobia, loud ringings in the ears, nausea, and projectile vomiting. The face is flushed, and has an anxious expression. The conjunctiva are injected, and the pupils are contracted. The bowels are constipated and the abdomen is retracted. The fever 338 A COMPENDIUM OF PEACTICAL MEDICINE. is more or less intense, and the pnlse is accelerated, strong and full. The carotids and temperal arteries pulsate strongly, and the head is hot. The duration of this stage is one or two days. In the second or stage of delirium, there are great restless- ness and mental confusion. The delirium is sometimes wild, simulating acute mania. In adults, muscular twitchings of the face and extremities are present in this stage; the eyeballs roll about vaguely, the flexor-muscles are often powerfully contracted in one or both limbs, and there may be opisthotonos. The tem- perature rises to 104° F., the pulse becomes more frequent and ir- regular; the abdomen is retracted, the vomiting continues pro- jectile. Herpetic eruptions appear. This stage lasts from one to three days. The third stage is called the stage of coma. It comes on gradually. The delirium and headache subside. There is a ten- dency to stupor and deep sleep. The pulse becomes slow, irreg- ular and intermittent. The pupils are greatly dilated. There is rigidity of the muscles of the back of the neck. Strabismus and loss of vision may occur. The patient rolls his head and grinds his teeth and picks stupidly at the bedclothes. Gradually the coma becomes profound. Subsultus tendinum is marked. As the disease advances, the pulse may run up to 160 or 170 or more; the Cheyne- Stokes respiration of ascending and descend- ing rhythm becomes established. The expirations are puffing. The body is bathed in cold sweat (Flint and Loomis). Differential Diagnosis. — Acute meningitis may be confounded with cerebral hyperemia, acute uraemia, variola and delirium tre- mens. From cerebral hyperemia, meningitis is differentiated by the higher temperature, longer duration, and the symptoms of depression succeeding to a stage of excitement. In uraemia the temperature is usually below rather than above the normal; the urine is scanty and contains albumen, and there is or has been dropsy. In small -pox, the face is flushed, the pulse full and bounding, there is intense pain in. the back and loins, the vomit- ing is retching in character, and at the end of the third day the characteristic eruption appears. In delirium tremens, the patient imagines persons and animals about him, and is wild in his ges- tures and utterances. The surface is bathed in a profuse, ]ME^s T IXGITIS. 339 clammy sweat in delirium tremens; it is hot and dry in meningitis. In delirium tremens the temperature, pulse rate, and pupils are normal, and there is no headache (Bartholow and Loomis). Prognosis. — Is very unfavorable. The duration varies from two days to four weeks; fatal cases rarely last more than eight days. Strabismus, hiccough and local paralysis are very unfavor- able symptoms. Treatment. — The head should be raised; the room dark and quiet. The ice-bag should be put to the head. Leeches may be applied to the nape of the neck and mastoid bone. The bowels should be moved freely. Blisters may be applied to the back of the neck. Bartholow recommends during the stage of excita- tion, tincture of aconite (two drops) every two hours. He also gives bromide of potassium (5ss.) andiluid extract of ergot (5ss.) every four hours. Iodide of potassium in five to ten grain doses four or five times daily may be given. PRESCRIPTIONS FOR ACUTE CEREBRAL MENINGITIS. R Acidi tannici 5j. In capsulas no. xx. div. Sig. : A capsule every three hours, with ice to head. — Lardier. R Sodii bromidi 5ij Chloral hydratis 5j • Syr. auranti cort Jj. Aquae q. s., ad oiij. — M. Sig : A dessertspoonful every hour or two until excitement abates. — Herrman. R Tincturae ferri chloridi oj . Sig.: Twenty to thirty minims every two hours. — Klapp. Chronic Cerebral Meningitis. — Is an interstitial inflamma- tion of the pia mater which causes thickening and opacity of the membrane (Loomis). Causes. — It is a disease of adult life, especially after fifty years of age. It may be a combination of chronic alcoholismus, syphilis, rheumatism, gout and chronic Briglit's disease ( Loomis). Symptoms. — Are obscure. The patient grows dull, stupid and apathetic. There is headache and a constant desire to sleep. 340 A COMPENDIUM OF PRACTICAL MEDICINE. Vomiting occurs. There is muscular weakness, vertigo and tin- nitus aurium (Loomis). Treatment. — The patient must be kept quiet mentally, and the diet must be fluid and nutritious. The bichloride of mercury and iodide of potassium are considered the best remedies. The bowels and urine need careful attention (Loomis). Tubercular Meningitis. — Called also basilar meningitis, is an inflammation of the basal pia mater caused by gray miliary tubercles and occurring most frequently in children (Loomis). Causes.- — It is rare before the first and after the fifth year. It occurs most frequently in scrofulous children. An}^ debili- tating disease may excite it. The immediate cause is the same as in all forms of tuberculosis (Loomis). Symptoms. — There is loss of appetite; the breath is offen- sive; the tongue coated, constipation and diarrhoea alternate. The child becomes dull, languid, and desires quiet. The face has an anxious appearance. There may be convulsions. In the first, or irritative stage, the patient will moan and clasp the head with his hands. He awakes with a piercing hydrocephalic cry, grinds his teeth, rolls his eyeballs, and the facial muscles are contorted. The hands will be clenched. The abdomen is re- tracted and hard. Projectile vomiting occurs, and resists all treatment. The pupils are contracted, there is photophobia. In the second, or stage of depression, the muscles at the back of the neck become rigid; the head is rolled slowly from side to side; sometimes distinct opisthotonos occurs. The pulse becomes slow; convulsions, ptosis, strabismus, loss of sight, anaesthesia and local paralysis may occur. There is difficult swallowing. Oheyne- Stokes' respiration is common. There is anorexia, the tongue and mouth are covered with sordes; and the passages are unnatural and offensive. In the third, or stage of coma, the pulse runs up to 150 or 170 per minute, is feeble, small and irregular. The pupils are widely dilated. The breathing is sighing or snoring in character. Dysphagia is marked. The contents of the bladder and rectum are passed involuntarily; the body is covered with a clammy sweat. The abdomen becomes tympanitic and subsultus tendinum is marked (Loomis). MEXIXGITIS. 341 Differential Diagnosis. — Tubercular meningitis may be mis- taken for acute meningitis, gastro- enteritis, acute Bright' s dis- ease and infantile remittent fever. Acute meningitis is sudden in its onset and rapid in its pro- gress, not so in tubercular. The ocular symptoms and the boat- shaped abdomen are more prominent in the tubercular than in other forms of meningitis. In gastro- enteritis, there are diar- rhcea, abdominal pain and tenderness. But headache, contracted pupils, photophobia, the slow irregular pulse, reflex movements during sleep, projectile vomiting and the hydrocephalic cry of tubercular meningitis are wanting. In B vigli f s disease, the oedema, with the presence of albu- men and casts in the urine, will establish the diagnosis. In infantile remittent the vomiting is retching in character, diarrhoea is prominent, and the discharges pea -soup in character, the abdomen is distended and tender; there is great thirst, rapid pulse and normal pupils (Loomis). Prognosis. — It is one of the most fatal diseases of childhood. The duration varies from five days to four weeks (Loomis). Treatment. — The prophylactic treatment is cod-liver oil, and the patient kept out of doors as much as possible, also good hygienic surroundings. The treatment is symptomatic after the disease is developed. The bowels must be kept open, and abso- lute quiet enjoined. Ice-bags may be put to the head. Opium and bromide of potassium are serviceable in the stage of excite- ment (Loomis). PACHYMENINGITIS. Is an inflammation of the dura mater. There are two forms, namely : Pachymeningitis, externa and interna. Causes. — Pachymeningitis externa is caused by injury and disease of the cranial bones, by suppuration of the internal or middle ear, or of the orbit. The causes of the internal form are chronic alcoholismus, pyaemia and Bright's disease. It is rare before forty, most frequently between sixty and eighty (Loomis). Symptoms. — Somnolence, headache, dizziness, photophobia, followed by delirium, and perhaps convulsions and coma, are the 342 A COMPENDIUM OF PRACTICAL MEDICINE. cliief symptoms. The course of the disease varies from one day to a year or more (Flint). Treatment. — For the external form, rest, a mild diet, a free purge, and cold to the head are indicated. Trephining may sometimes save life. If there are symptoms of suppuration alco- holic stimulants, quinine, and opium should be given. The ex- ternal form must be treated symptomatically. The prognosis is unfavorable in both forms (Loomis). SPINAL MENINGITIS. Is an inflammation of the spinal pia mater and arachnoid. It may be acute or chronic. Causes. — Acute spinal meningitis may be caused by a fall, blow, dislocation, fracture or other injury to the vertebrae, or concussion; by any disease of the spine, such as caries, cancer, prolonged exposure to cold — especially damp cold- — or brief ex- posure to intense cold when the body is heated, as well as ex- posure to intense heat. Operations for spina bifida have been followed by rapid and fatal spinal meningitis. Syphilis, venereal excesses, alcoholismus, chorea, tetanus, and hydrophobia may cause it. The chronic form may follow the acute (Loomis). Symptoms. — More or less pain is felt in the spine radiating therefrom to the extremities. The pain is increased by move- ments of the body and is constant. The surface of the body be- comes hyperaesthetic, and the reflexes are increased. There may be a chill, nausea, vomiting, fever, and the muscles along the spine' become rigid. There is constipation, and the abdomen has the well known boat shaj^ed appearance. The duration of this disease is seven to ten days. The majority of cases are fatal (Flint). Treatment. — The indications for treatment are the same as in acute cerebral meningitis. The patient should be put to bed in a cool room and a brisk purge administered. Ice or counter irri- tation may be applied along the spine. Ergot and belladonna are said to produce contraction of the arterioles, and retain the inflammatory process. MENINGITIS MYELITIS. 343 When the symptoms denote the presence of the products of inflammation, vesication of the spine and iodide of potassium in large doses are indicated. Warm baths are grateful to patients (Flint and Loomis). The different varieties of meningeal inflammation and the terms applied to each may be made clearer by the following definitions : 1. By the term meningitis is usually understood inflamma- tion of the pia mater or of the pia mater and arachnoid. 2. By the term leptomeningitis is meant inflammation of the pia mater, or of the pia mater and arachnoid of the non- tu- bercular variety. 3 By the term simple cerebral meningitis is understood in- flammation of the pia mater either of the convexity or of the base of the non- tubercular variety. 4. By the term tubercular meningitis is meant an inflam- mation of the basal pia mater caused by tubercle bacilli. 5. By the term pachymeningitis is meant inflammation of the dura mater. The same terms are applied to spinal meningeal inflam- mation. MYELITIS. Is an inflammation of the substance of the spinal cord. It may be acute or chronic. Forms. — When the inflammation occurs chiefly in the central gray matter, it is called central myelitis; when the white matter and meninges are involved it is called cortical myelitis; when both white and gray matter of the greater portion of the cord are inflamed the process is called diffuse myelitis; when the in- flammation is confined to the anterior-horns of gray matter, it is called anterior polio -myelitis; when all the tissues of the cord over a circumscribed space are involved it is called transverse myelitis; when there are spots of inflammation along the cord at various points it is called disseminated myelitis. Acute myelitis in the majority of cases, appears under the form of softening of the cord. Chronic myelitis, on the other hand appears as indu- rated or sclerosis (Flint). 344 A COMPENDIUM OF PRACTICAL MEDICINE. Acute Myelitis. — Causes. — Acute myelitis is a rare disease. It is more common in males than in females. It is a disease of children and young adults. In children it takes the form of acute anterior polio -myelitis or spinal paralysis. Injuries of the cord from contusions, blows, fractures of the vertebra, intense and prolonged muscular action, prolonged exposure to cold, as in sleeping on damp ground, sudden chilling of the surface when overheated and excesses in coitus are given as causes. It is said that suppression of the menses and checking hemorrhoidal fluxes may cause it. Acute infectious disease may give rise to myelitis. Continued jarring of the spine from travel on railways will produce it (Bartholow, Loomis and Flint). Symptoms. — Acute myelitis usually begins with fever, intense pain in the back, the sensation of a girdle around the trunk, ten- derness over certain of the vertebrae, pains and muscular soreness of the limbs, tingling, formication, a feeling of weight and drag- ging in the rectum and bladder, and priapism. Preceding paralysis, the muscles which are to be paralyzed are sometimes affected with tremor or spasm. The early occurrence of paralysis is a distinguishing feature. It occurs within a day or two, and some- times within a few hours after the symptoms have pointed to a spinal affection. The paralysis is mostly paraplegic, affecting both bladder and rectum, is motor and sensory, and may develop so rapidly that in 48 hours the patient will be unable to move his legs. Loss of reflex excitability is an effect of destruction of the gray matter in the lower part of the cord. Notable wasting of the paralyzed muscles is indicative of destruction of the gray matter. In myelitis, the parts exposed to pressure take on gan- grenous inflammation. Acute myelitis is a progressive disease, and may run a rapid course, destroying life in a few days or weeks. Complete recovery is rare (Bartholow, Loomis and Flint). Differential Diagnosis. — Acute myelitis may be confounded with acute spinal meningitis. In meningitis, there are acute pain on motion, rigidity, spasms and contractions of the muscles of the back, hyperesthesia, and incomplete paralysis; in myelitis, there is no pain on motion, the muscles are flaccid and relaxed, MYELITIS. 345 there are anaesthesia and paraplegia, or hemiplegia (Loomis and Bartholow). Prognosis. — In acute myelitis death may occur in twelve to thirty hours, or be delayed two or three weeks (Loomis). Treatment. — Absolute rest must be enjoined. Frequent applications of hot water to the spine is very serviceable. The ice-bag to the spine is recommended. Bartholow recommends a mustard plaster the length of the srjine and four inches wide, to be applied twice daily. Dry cupping over the spine and leeches are indicated. Internally ergot and belladonna have been highly recommended. Authorities recommend a tablespoonful four times daily of the infusion of digitalis. Twenty to thirty grain doses of quinine may have a good effect at the very beginning of the congestive stage. Purgatives should be given. Bed-sores must be prevented. Cystitis may be avoided by the frequent use of the catheter and washing out of the bladder (Bartholow, Loomis and Flint). CHRONIC MYELITIS. Causes. — Are much the same as those of acute myelitis. Symptoms. — Pains in the limbs simulating rheumatism, mus- cular weakness, tingling, formication, numbness of the limbs, and a girdle sensation are the first symptoms. These are fol- lowed by paraplegia, muscular atrophy, cystitis and chronic bed- sores. Patients with chronic myelitis always complain of cold feet. Prognosis. — Always unfavorable. It may continue from two to ten years (Loomis). Treatment. — The treatment for the acute will be of service in the chronic form. Chronic Myelitis includes several distinct affections, among which are posterior spinal sclerosis (which has been considered under the name of locomotor ataxia), multiple cerebro- spinal sclerosis, sclerosis of the lateral columns, anterior polio-myelitis. and progressive muscular atrophy. 346 A COMPENDIUM OF PKACTICAL MEDICINE. MULTIPLE CEREBRO=SPINAL SCLEROSIS. Is a malady characterized by the formation of isolated patches or nodules of sclerotic tissue in the brain, pons, medulla, cerebellum, and spinal cord (Bartholow). The nodules vary in number and range in size from minute objects to the size of a walnut (Loomis). Causes. — It is very rare after the age of forty -five and be- fore ten. Heredity is a predisposing cause. The exciting causes are damp and cold, sudden chilling of the body, traumatism, and severe and long- continued brain work or physical exercise. Moral emotions, chagrin, anxiety, and continued jarring of the body are thought to produce the disease (Bartholow and Loomis). Symptoms. — The disease may come on gradually or sud- denly. If it appears gradually, the patient complains of head- ache, vertigo, muscular weakness, mental disturbance, and queer feelings, as formications, itchings, burnings, etc., in the limbs. There may be nausea and vomiting. There is a loss of co-ordi- nating power, and the patient cannot control his hands in writing, or his feet and limbs in walking. There is a shaking tremor; this tremor is peculiar in not occurring until an attempt is made at voluntary motions, and at once ceasing when the parts are allowed to rest. Even the head participates in it. The voice is changed, and the patient talks in a low monotone or a whisper, dividing the words as in scanning a line of poetry. Amblyopia, diplopia, nystagmus, and inequality of the pupils are frequent symptoms. In the advanced stage, vesical symptoms, acute bed sores, loss of sexual power and control of the sphincter become marked symptoms. Differential Diagnosis. — Cerebro- spinal sclerosis may be mis- taken for paralysis agitans or locomotor ataxia. In paralysis agitans the fine tremor exists when the patient is at rest, and is not accompanied by shaking of the head; while in the shaking of the cerebro -spinal sclerosis the head is always involved, the symptom ceasing as soon as the patient is at rest. The former is rare before forty; the latter is rare after forty. Changes in the voice and speech and ocular symptoms are present in cerebro- SCLEEOSIS. 347 spinal sclerosis, and absent in paralysis agitans. In locomotor ataxia the peculiar shaking tremor, impairment of voice and speech, and nystagmus that belong to disseminated sclerosis are absent. In the former there are the girdle sensation about the trunk, the lightning-like rjains and the peculiar double beat in walking, all of which are absent in the latter (Loomis and Bar- tholow). Prognosis. — The disease is progressive and always terminates in death. The duration varies from one year to twenty, but the average is five to ten years. The patient is apt to die from an intercurrent disease (Bartholow and Loomis). Treatment. — Various remedies have been proposed for this malady. Erb gave arsenic hypoclermically in one case with im- provement. Hammond thinks the chloride of barium does good. According to Bartholow the chloride of gold and sodium, with small doses of corrosive sublimate, is most useful. Cod-liver oil, nitrate of silver, phosphate of zinc and galvanism have all been used by authorities. LATERAL SPINAL SCLEROSIS. Called also by Charcot, spasmodic tabes clorsalis, and by Erb spastic spinal paralysis, is a disease having similar lesions to those of posterior spinal sclerosis, but a different seat. The site of the lesions is the lateral white columns, and the changes consist in gray degeneration. Causes. — It develops under the same conditions as posterior spinal sclerosis. It is more common in men than in women, and occurs between the ages of twenty and fifty. Traumatism and exposure to wet and cold are given as causes (Loomis). Symptoms. — There will appear first weakness and paresis of the lower extremities; then twitching of the muscles and muscu- lar rigidity follow. The tendon reflexes in this disease are much exaggerated. The sensibility is unaffected; there is no atrophy of the muscles; and the functions of the rectum, bladder and sexual system remain unaltered. There is marked ankle clonus, in which the muscles of the calf or the whole limb are put in a state of tremor when the foot is flexed, or when the patient puts 348 A COMPENDIUM OF PRACTICAL MEDICINE. his toes to the ground. The patient drags his limbs. The dura- tion of the disease extends over many years (Bartholow, Loomis and Flint). Treatment. — The galvanic current is most useful. Iodide of potassium, arsenic and cod -liver oil, with careful attention to rest and diet, are to be recommended. Rubbing and massage afford great comfort. Calabar bean may be given for the cramps (Loomis). ANTERIOR POLIOMYELITIS. Called also infantile spinal paralysis, is a disease occurring in children suddenly, and is due to an inflammation of the an- terior cornua of gray matter of the cord. It may, however, occur in adults, but much less frequently (Bartholow). Causes. — This is a disease of the first three years of life. Cold, dentition and traumatism have been assigned as causes. It is frequently developed during convalescence from the exanthe- mata and other acute febrile affections (Loomis). Symptoms. — The usual onset of the disease is a fever which lasts a day or two, and on recovery from which it is observed, with surprise, that the child is paralyzed. There maybe head- ache, pain in the back, and limbs, nausea, vomiting, vertigo, de- lirium, convulsions and coma. In some cases the paralysis occurs without prodromes. If only one lower limb is involved at first, the other soon becomes so, and it is not unusual for all four extremities to be affected at once. Sensibility is not affected. The bladder may be paralyzed, and the urine retained. Paralysis is complete at once, and soon begins to lessen, some restoration of power taking place in from one to three weeks. All the paralyzed parts may be restored, or one arm and one leg may re- main paralyzed. The muscles remaining paralyzed are affected permanently, and by a rapidly progressive atrophy. The para- lyzed parts become cool, to the touch, and have a blue cyanosed appearance. The muscles waste till there is nothing but con- nective tissue and fat, and the growth of the limb is arrested. The mildest cases recover in a few weeks or in a month or two (Bartholow). MUSCULAR ATEOPHY. 349 Treatment. — From \ to 4 grains of quinine and from ^V to \ grain of belladonna extract have acted "best according to Bar- tholow. Hot douche to the spine, galvanism, and rest, with massage and faradism are of service. Strychnia may be injected into the paralyzed parts two or three times a week. Tonics are clearly indicated (Bartholow). PROGRESSIVE MUSCULAR ATROPHY. Called also wasting or creeping palsy, is a disease charac- terized by a progressive and chronic wasting and atrophy of the voluntary muscles due to atrophic changes in the anterior cornua of the cord (Loomis). Causes. — It is an hereditary disease, and is met with chiefly in males. The period of greater liability is between the ages of thirty and fifty. The disease may be excited by over -exertion of a group of muscles in certain occupations. Injury to the spine and exposure to cold and wet are said to excite it. In children the disease is invited to the lower limbs by prolonged effort on the legs. Exhausting diseases, the poison of lead and syphilis, and certain dyscrasise seem to exert an influence in developing the disease (Bartholow and Loomis). Symptoms. — The disease usually comes on insidiously, the first indication of its presence being wasting and loss of power of some muscles; as a rule those of the hand are first atrophied, then the muscles of the forearms, arms and shoulders. Just before wasting begins, the patient will remember that he had for weeks or months a feeling of slight numbness or formication, and that his fingers have seemed clumsy. The patient complains of a sensation of cold air being blown on him. Wandering pains frequently precede the wasting of the muscles. A peculiar fibrillary tremor is present early (Loomis). Prognosis. — Is extremely unfavorable. Its course is slow. The average duration is five years. As its name implies, it is always progressive (Loomis). Treatment. — Bartholow recommends injections of a solution of ^ glycerine three times a week into the wasting muscles. A descending current of galvanism should be applied to the whole 350 A COMPENDIUM OF PRACTICAL MEDICINE. length of the spine daily, for two minutes. Massage, using with friction lard, should consist of friction, kneading and tapping the muscles. Hot douches to the spine and rubbing a wet pack over the affected members are also highly to be commended. MENORRHAGIA AND METRORRHAGIA. Menorrhagia is an increased flow of the blood and mucus occurring at the menstrual period. Metrorrhagia is a flow of blood from the genitalia in the inter -menstrual period. Causes. — May be general or local. The general causes are hemorrhagic diathesis, scurvy, fevers, tuberculosis, super-lacta- tion, icterus, Bright's disease, obesity and cachexia. The local causes are reflex stimulus from the genital organs or simply from nervous derangement, as at puberty, first intercourse or the menopause. Reflex stimulation from the mammary glands during lactation will cause metrorrhagia. Other local causes are endo- metritis, fibromata, cancer, ovarian tumors, and affections of the Fallopian tubes (Pozzi). Treatment. — The cause should always be sought and treated. The local measures are prolonged irrigation of hot water (110° to 120° F.) and tampon of the vagina. Astringents, such as tincture of iodine with glycerine or Monsel solution diluted, may be applied to the endometrium. The general measures are: Rest in bed with elevation of the pelvis; opium in the form of lauda- num, rectal injections; ergot by the stomach and infusion of digitalis leaves. In many cases fluid extract of hydrastis given in half- drachm doses every four hours during the time of the flow, and in twenty- drop doses before meals in the intervals, is very efficient. Oil of erigeron in five -minim capsules every three hours is also effective (Pozzi). PRESCRIPTIONS FOR MENORRHAGIA. R Extract! ergotse fluidi WTix. Ammonii chloridi gr. x. Sodii bromidi gr. v. — M. Sig. : For one dose, to be taken in half tumbler of water ; may repeat every two hours. — Goodell. MENORRHAGIA MORNING SICKNESS. 351 R Ext. gossypii fid Syr. simplicis aa §j- — M. Sig. : A teaspoonful every four hours. — Parvin. R Ext. rhois aromat fid %iv. Sig. : A teaspoonful every hour for a few doses, then every three or four hours. — Shoemaker. R Acidi gallici 5ss. Acidi sulphurici dil gj. Tinctopii deodorat 33. Inf. rosse comp Siv. — M. Sig.: A tablespoonful, every four hours. — Bartholow. R Tinct hamamelis Bij. Sig.: One-half to one teaspoonful thrice daily. — Ringer. R Ext. ipecac fid gij. Ext. ergotse fid siv. Ext. digitalis fid 31J. — M. Sig.: A half to one teaspoonful as required until emesis occurs. — Bartholow. R Potassii bromidi 31J. In pulv. no. xii. div Sig.: A powder in a wineglassful of water three times daily. (In flooding of young women who menstruate too often as well as too copiously). Begin before the period and continue till it is over. — Ringer. R Tinct. sabinse ,..Sss. Sig. : Five to ten drops in cold water every half to three hours. —Phillips. MIGRAINE. (See Headache). MITRAL DISEASE. (See Valvular Diseases). MORNING SICKNESS. The nausea and vomiting which occur in pregnant women 011 waking in the morning are called morning sickness. It is due to spasmodic contractions of the diaphragm and stomach. It usually recurs daily during the first three months of pregnancy and then gradually disappears (Lusk). Treatment, — Nearly every drug of the Materia Medica has been tried at one time or another for the nausea and vomiting of pregnancy. Spraying the pit of the stomach with ether is effect- ive in some cases. To many, ice-cold effervescent drinks are 352 A COMPENDIUM OF PRACTICAL MEDICINE. grateful. Lusk orders ten grains of the subnitrate of bismuth combined with five to ten grains of oxalate of cerium to be taken ten minutes before eating. He also gives ten drop doses before meals of the tincture of nux vomica in cases of gastric catarrh. Droja doses of Fowler's solution at meal-time are said to exert considerable influence in allaying stomach irritability. After eating, digestion may be promoted by ten grains of pepsin given alone or with dilute muriatic acid. If the vomiting is literally uncontrollable, the patient should be placed at rest in bed (Lusk). PRESCRIPTIONS FOR MORNING SICKNESS. j& Cocaini muriatis gr. j. Extracti belladonnse — 3vi. — M. Sig. : Apply locally to the cervix uteri morning and evening. — Fenn. Jk Cocaini muriatis gr. j. Aquse. g. — M. Sig.: A teaspoonful three times daily before meals. — Parvin. J% Atropia sulphatis gr. j. Morphias sulphatis gr. iv. Acidi sulphurici aromat £iij. Aquse. 3v. — M. Sig. : Ten to twenty drops in water thrice daily. — Boys. jfc Cerii oxalatis gr. xxiv. Extracti hyoscyami gr. xxxvj. — M. Ft. massa et in pil. no. xii. div. Sig. : One pill twice daily. — Goodell. MUMPS. Called also parotitis, or parotiditis, is a constitutional or blood disease with local manifestations. It is a specific inflam- mation of the parotid gland (rarely are the other salivary glands involved), self- limited, and characterized by a tendency to mi- grate into the mamma or testes. Parotitis is of two varieties, specific and non-specific (Smith and Bartholow). Causes. — It occurs chiefly in childhood, youth, and early manhood, cases being rare in infancy and old age. It is highly 3ir:\ips. 353 contagious, and commonly occurs as an ejrideniic. It prevails most in crowded localities and among those who live in cold damp cellars. It is probably a microbic disease (Smith and Loomis). Incubation. — The period of incubation varies from ten to eighteen days (Flint). Symptoms. — Mumps begins wtih languor and fever, and usually chills or chilly sensations. There are frequently dull pains in the limbs, loss of appetite, headache and delirium. In 36 to 48 hours, there is a sensation of stiffness about the angle of the jaw, followed by pain and swelling. The pain is in- creased by speaking, swallowing and by pressure. The disease reaches its height in from three to five days, and the swelling of the gland begins to subside on the seventh or eighth day. A metastatic orchitis may occur in males after puberty. In females, the mammary gland and ovary may become inflamed. It is one of the diseases which affect the same person but once. Xon- specific parotitis developing during some severe constitutional disease, shows a tendency to suppurate from its beginning, and discharges laudable pus (Bartholow, Flint, Loomis and Smith). Prognosis. — Is favorable in the specific variety; but very un- favorable in the non-specific (Loomis). Treatment. — Warm applications to the affected parts will give relief. Morphine and quinine may be given internally. A mild saline cathartic may be administered. The diet should be non- stimulating. Inunctions of oil to the swollen gland are useful. A mustard foot-bath should be given (Bartholow and Loomis). PRESCRIPTIONS FOR MUMPS, |& Antipyrine 5j . Potassii bromidi 5iij • — M . In pulvus no. xv. div. Sig. : Give one powder in water every three hours till the fever abates. — J. Lewis Smith. Jfc Hydrargyri cum cretae gr. iv. Saccharri lactis gr. xx. — M. In pulvus no. xii. div. Sig.: One powder three or four times daily. — Ringer. 354 A COMPENDIUM OF PRACTICAL MEDICINE. MYALGIA. Called also muscular rheumatism, is a rheumatic affection of the voluntary muscles accompanied by pain and tenderness, but by no other evidences of inflammation. It has been named according to its seat, torticollis (wry- neck), cephalalgia, pleuro- dynia, lumbago, etc. (Loomis). Causes. — Exposure to cold and damp draughts are often the exciting causes of an attack. Over-fatigue and sudden straining of a muscle may induce it. Malaria may cause it. It may come on suddenly in a rheumatic or gouty subject (Loomis). Symptoms. — An attack usually comes on suddenly with severe, deep-seated pain in the muscles affected. The pain is of a stretching or tearing character, increased by movement or pres- sure. It is more severe at night. The pain may shift or remain fixed in certain muscles. Certain positions mitigate the pain. Lumbago is the severest variety. In all varieties there is pain and rigidity of muscles, but no fever or constitutional symptoms. The duration of myalgia varies between a few hours and a week. The duration of the chronic form is indefinite (Loomis). Treatment. — In the young, cod-liver oil acts as a preventive. A hot air or Turkish bath will be of service at the beginning of an attack. In chronic cases the favorite drugs are arsenic, sul- phur, and guaiacum. Quinine is almost a specific in the malarial form. The patient should wear flannel and sponge the body with cold water every morning. In lumbago hot applications and anodyne liniments will often give relief. A hypodermic of morphia may be required. The constant and faradic currents may give relief (Loomis). MANIA=A=POTU. (See Delirium Tremens.) MASTURBATION. Called also self- abuse or self- pollution, is not a disease. It signifies that an orgasm is produced by means of friction with the hand. It does not necessarily produce disease unless it is carried to excess. Masturbation is not confined to man. Monkeys, bears and goats indulge in it. Turkeys practice it MASTUKBATIOX. 355 Tipon a round, smooth stone. In the human being, both sexes practice it. Females are much less given to it than males. The majority of women have very little passion, and suffer the ap- proaches of a lover or husband largely as a matter of complais- ance. As a rule, the female learns what passion is only as the result of education after marriage. With the male it is different. He often has erections in childhood and sexual yearnings long before puberty. A boy, when handling himself during erec- tion, is apt to find the sensation agreeable and go on until he has formed the habit. Male babies are sometimes handled by their nurses to keep them quiet, and this begets the habit. Boys usually receive instruction from other boys at school, and this is the most common incentive. A large proportion of mankind have masturbated more or less at some period of life, and it is safe to assert that at least ninety per cent, of such masturbators are not injured by the habit. Sexual indulgence in the natural way will produce evil effects if carried to excess, yet it is proba- ble that sexual intercourse is not only harmless, but even bene- ficial in moderation. It is not the loss of seminal fluid which is of the first importance in producing disease from sexual excess, but the nervous shock of the oft-repeated orgasm. Babies and young children lose no seminal fluid, women have none to lose, yet in all these, evil results follow excesses, as certainly as they do in the male after puberty. Any succession of nervous shocks as sharp and decisive as the sexual orgasm, such as joy or fear, would shatter the vitality and nervous tone of an individual as much as masturbation. The cunningly conceived advertisements in newspapers, books and circulars by quacks, implant errors in the mind concerning this vice which years of sober after thought are scarcely able to erad- icate. Masturbation is not confined to youth; middle and old age are not free from it. The use of tobacco and alcohol in- flicts as much injury upon the human race as does the secret vice, if both are carried to excess. The chief reason why so much is said of venereal excess by masturbation, and so little of sexual excess in the natural way, is, that the former is so much more common and not that the act itself is physically more harmful. The former may be practised 356 A COMPENDIUM OF PRACTICAL MEDICINE. on all occasions, even in company, by the hand in the pocket, in bed or in solitary places, but the latter requires the consent of two individuals, and opportunities which relatively are hard to find (Keyes). Symptoms, — A young child who masturbates, has many erections, and handles his genitals frequently. Such children are fretful, peevish, thin, nervous, excitable and sleep badly. Boys who masturbate usually have a long prepuce; they have a sallow look, and sheepish, hang- dog expression. They are melancholy, sit by themselves, become absent minded, and the innocent frank- ness of youth is absent. The young man is over shy, unambi- tious, he shrinks from a steady gaze, blushes readily, and seems conscious of having done something unmanly and little. Men who masturbate often show no sign of the habit, and it is rare for them to practice it to excess. In the vast majority of in- stances, masturbation does little harm to the individual except in regard to his morals. The practice is a base one (Keyes). Treatment.- — If a nurse handles an infant she should be dis- charged. If the infant has already acquired the habit his hands must be tied when he sleeps, and at other times watched. Boys should always be made to sleep alone. The best treatment is to elevate the boy out of his bad habit, to shame him, to make a man out of him, to sympathize with him, and to treat him morally. When a man comes complaining of the results of mas- turbation, it will be found that he is a hypochondriac, and his malady ungratified sexual desire. He should be encouraged and advised to marry. Medicines are of little or no value. Cold- sponge baths, out- door sports, physical fatigue, sleeping in a cold room on a hard bed, with light covering, eating lightly at night, and not retiring until very sleepy are all useful in breaking up the habit (Keyes). MOLES MILIUM. 357 MILK=LEG. (See Phlegmasia Alba Dolens.) MISCARRIAGE. (See Abortion.) MENIERE'S DISEASE. (See Vertigo.) MOLES. Are very common, few people being without one or more upon the surface of the body, while many have them in numbers. Moles are sometimes congenital, constituting one of the varieties of " mother's marks," and sometimes acquired. They occur in the shape of circumscribed brown patches, and on the face in the gentler sex are often regarded as beauty spots. They are rarely of any great importance beyond the disfigurement they produce. Occasionally they become the seat of a cancerous disease; the melanotic sarcoma has frequently its origin in such congenital spots. Many of the most virulent forms of multiple cancer the surgeon sees have their origin in moles (Bryant). Treatment. — The surgeon should excise any mole that has a tendency to grow or become indurated in middle life. When they are situated on the face, it is generally desirable to let them alone, for if they are small they often adorn it, while if large there is risk of leaving scars. They may be removed by caustics, such as potassa fusa (Bryant and Anderson). MOTHER'S MARK. (See Nsevus). MILIUM. A milium is a little round slightly elevated, pearly- white spot, about the size of a millet- seed or larger. They are scat- tered over the surface in variable numbers, but are principally met with on the face, especially near the eyes, and on the eye- lids (Anderson) Cause. — Obliteration of the glandular duct and retention of the sebaceous matter is the sole cause. Treatment. — Consists in punctuiing the upper wall of each milium and expressing its contents (Anderson). 358 A COMPENDIUM OF PRACTICAL MEDICINE. MUSCULAR RHEUMATISM. (See Myalgia). MORBUS COXARIUS. Is a disease of the hip -joint. Causes. — The disease may begin as a synovitis, or it may be- gin in a rupture, partial or complete of the ligamentum teres, thereby interfering with the nutrition of the head of the femur. It may begin from rupture of some minute blood vessels in the bone just beneath the cartilage. The synovitis is almost always the result of exposure to sudden changes of temperature after violent exercise, such as skating, racing, jumping, playing at foot- ball and other movements that over exercise the joint. In other words morbus coxarius is almost invariably due to a trau- matic cause, and not dependent upon some constitutional taint, as scrofula, etc. (Sayre). Symptoms. — There are three stages: 1. The stage of irrita- tion or of limited motion, before the occurrence of effusion. 2. The stage of apparent lengthening, or of effusion, the capsule of the joint remaining entire. 3. The stage of shortening, or of ruptured capsule. The first thing that attracts the attention of the patient is generally a stiffness about the joint and a limping gait in the morning. In the first stage, there will be slight abduction and slight flexion at the knee and hip. Abduction, adduction, and rotation are also limited. There is atrophy of the thigh or entire limb. There are pain and tenderness. The pain may be re- ferred to the knee, and thus mislead the surgeon. In the second stage, the pain, tenderness, swelling, atrophy, and limited motion of the first stage are increased in severity. The limb is appar- ently longer, abducted, everted, and flexed in both joints. The foot touches the ground with the sole. The toes are everted as in fracture of the neck. The pelvis is lowered on the diseased side, and projects forward. The natis is low and flat. The pain is most intense. In the third stage, the capsule ruptures and the fluid escapes into the surrounding tissues and the patient is com- paratively free from pain. The limb is shorter, adducted, in- verted, and flexed in the hip- joint only. The foot touches the ground with the ball only. The toes are inverted. The pelvis jsnevus. 359 is raised, projected backward, and natis is high and round (Sayre). Treatment. — Is both local and general. The general treat- ment will consist of tonics, cod liver oil, stimulants, good food and hygienic surroundings, sunlight and frequent baths. The local treatment consists of absolute rest and freedom from pres- sure of the parts involved in the disease (extension). If milder measures fail, exsection of the joint is justifiable (Sayre). NyEVUS. Is essentially a disease of the capillaries and is made up of a mass of vascular tissue. Nsevi are almost always congenital. Some nsevi are pigmentary and are then termed " moles " (Bry- ant). Situation. — Their commonest situation is in the skin and subcutaneous tissue, and occurs on the head and face much more frequently than elsewhere. If entirely subcutaneous the skin is not discolored, but if the nsevus invade the skin there is a dis- coloration of its surface, or a pedunculated outgrowth like a piece of cock's comb (Anderson). Varieties. — There are three varieties of nsevus — arterial, ven- ous, and capillary according as arterioles, veins, or capillaries predominate in their structure. Arterial and venous nsevi are always congenital and subcutaneous. They may be emptied by pressure. The morbid erectile tissue of the venous nsevi resem- ble pretty closely natural erectile tissue of the penis and nipple. A capillary nsevus called also "mother's mark," " port wine mark" or " strawberry mark," is the most disfiguring, but the least harmful of the three varieties. It occurs more frequently on the head, face, neck, shoulders and arms than elsewhere; and consists of bright red or purple patches on the surface of the skin. It is sometimes prone to take on unhealthy ulceration. At birth these nsevi are often no larger than a pin point, but may grow rapidly (Anderson). Treatment. — The methods of treatment are various. The artery leading to the nsevus may be ligated. The part in which the nsevus is situated may be amputated. The nanus may be 360 A COMPENDIUM OF PRACTICAL MEDICINE. injected with various astringent fluids. The actual cautery, various caustics and electrolysis have been tried. Multiple punctures and scarifications of port wine stains have been em- ployed, but it is not very successful (Anderson). For small superficial birthmarks, S. D. Gross applies with a brush locally sixteen grains of corrosive sublimate to half an ounce of collo- dion. Bartholow recommends the following : R Acidi chromici ^iss. Aquae destillatse §j . — M. Sig. : Apply with care locally. Waring paints the spot daily with creosote. NECROSIS. Is the death or mortification of bone, and is applied to cases in which part of the shaft of the bone dies. Causes. — Injury or violent inflammation. Necrosis of the lower jaw frequently results from the inhalation of the fumes of phosphorus by persons employed in lucifer match factories. The bone in necrosis dies from obstruction of its circulation (Bryant). Treatment. — The indication is to remove the sequestrum as soon as it is sufficiently loose. It may require an incision if the dead bone is large (Bryant). NEPHRITIS. (See Bright's Disease.) NETTLE RASH. (See Urticaria.) NEURALGIA, Is a functional affection of which the chief characteristic is pain. In a purely neuralgic disease there is neither inflamma- tion nor any appreciable lesion in the painful part (Flint). Causes. — Neuralgia is often an hereditary disease. Any dis- ease causing anaemia is a marked predisposing cause. Among exciting causes are damp, cold, lead, mercury, traumatism and chronic blood poisoning. Reflex neuralgia is induced by genito urinary diseases, decayed teeth, dyspepsia, worms, constipation, 1STETTKALGIA. 361 etc. Neuralgia may follow or accompany herpes zoster. It is rare before puberty, and most frequent between 20 and 50 years of age. Women are more liable than men (Loomis). Symptoms. — The pain is at first intermitting, later it is con- tinuous wuth slight remissions. It may be dull, boring, stabbing, tearing, or darting, and is confined to the course of a nerve. Turning and coughing increase the pain. Increase of pain on pressure is an important point. Tri-facial neuralgia is one of the most common forms. It is usually attended with painful spasm, called tic douloureux. Clavis hystericus is a variety of tic in which there is a sensation as of a nail being driven into the skull. It is usually met with in anaemic females. Sciatica is a neuralgic affection of the sensory nerves of the sciatic plexus. It may be caused by pressure of tumors, by caries of vertebrae and by rheumatism as the result of taking cold. Chronic malarial infection may be the cause of sciatica. The pain is more intense at night. Cramps in the muscles of the legs are common. It is a very obstinate affection lasting from six weeks to two months, though it may last for years. Relapses are com- mon (Loomis). Intercostal neuralgia is an affection of any of the dorsal nerves; the anterior branches of tw T o or three of the nerves upon the left side are those usually affected. It occurs in women as a rule. The pain is intermittent, tearing or stabbing in character, increased by coughing or sneezing. There are three diagnositic points of tenderness; namely, at the exit of the nerves from the spine, at the side of the chest where they become subcutaneous, and near the sternum or median line at the terminal branches. Cardiac palpitation, dyspnoea, nausea and vomiting are frequent symptoms of inter- costal neuralgia. Herpes zoster, intolerable itching, and attacks of angina pectoris often complicate it. Cervico- occipital neuralgia is usually attended with pain along the course of the occipitalis major, and often resembles that form of muscular rheumatism called torticollis, or wry neck. Coccyodynia is common in women, and is due to neuralgia of the coccygeal plexus (Loomis). 362 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — Neuralgia lias been well said to be the cry of a nerve for better blood. If there be anaemia, a good diet, cod-liver oil, the hypophosphites, quinine, iron and strychnia should be ordered. Neuralgia due to syphilis demands iodide of potassium; to rheumatism, the anti- rheumatics; to gout, colchicum; and to malaria, quinine, but in many non- malarial cases also, especially in tic, quinine is the most effectual remedy. Local Treatment. — Blisters, galvanic current, chloroform, opium, belladonna, veratria liniments, and cold or very hot water may be applied, and usually these remedies afford relief. Acon- ite is an effective remedy applied locally. Firing, sinapisms and the actual cautery are frequently beneficial. A warm dry climate is favorable. Morphine is the most effective for immediate relief of pain. Neuralgic attacks and headache that are accompanied by flushing of the face are often relieved by ergot. But when the face is very pale, nitrite of amyl is to be preferred. Good results are obtained by the use of antipyrin. In severe chronic neuralgias a portion of a nerve may be excised. In sciatica nerve stretching is effective in some cases (Loomis). PRESCRIPTIONS FOR NEURALGIA. R Menthol gr. xxiiss. Cocaini muriatis gr. viiss. Chloral hydratis gr. ivss. Vaselini ' ^iiss. — M. Ft. ungt. Sig. : Apply to the painful part and cover with a strip of court plaster. — Galezowski. R Menthol 3j. Linementi saponis comp §ij. — M. Sig.: Use locally. — Witherstine. R Quinise sulphatis gj. Morphise sulphatis gr. iss. Strychnia? sulphatis gr. j . Extracti aconiti gr. xv. Acidi arseniosi gr. iss. — M. Ft. massa et in pil. no. xxx. div. Sig.: One pill thrice daily. — S. D. Gross. NIPPLES NYMPHOMANIA. 363 1£ Chloral hydrastis Pulv. camphors aa .^iv. — M. Sig. : Apply with a camel's hair brush. — Geo. Bird. NIPPLES. (Sore). Sore nipples are sources of great distress and too often the precursors of mammary abscess. Causes. — They are doubtless often caused by some aphthous condition of the child's mouth, but they frequently result from some unusual sensibility of the skin of the part, and at times from want of care. A simple erythema, associated with great tenderness, is a common trouble at the beginning of lactation to which primiparse are more subject than multiparas (Lusk). Treatment. — It is a good plan to anticipate this difficulty by instructing the patient to wash the nipples daily during the last weeks of pregnancy with some astringent or alcoholic solution. In child-bed, in addition to strict cleanliness, great benefit is de- rived from folding a linen rag around the nipple and keeping it constantly wetted with Goulard's extract, a teaspoonful to a tumbler of water, until the sensitiveness and redness have dis- appeared. Before applying the child to the breast, care should be taken to wash away the deposited carbonate of lead. Where the nipples are not sufficiently prominent, a breast glass or gutta-percha shield should be worn. The apjjlications of glycer- ine of tannic acid, Richardson's styptic colloid, tincture of cat- echu, a solution of nitrate of silver gr. v. to the ounce of water, and an ointment of extract of rhatany gr. viii. mixed with 5. ii. of the oil of theobroma, are good applications. Castor oil as an external application or collodion is sometimes useful (Lusk and Bryant). (See also fissures of the nipples). NYMPHOMANIA. Is an irresistible sexual desire in females. It is the analogue of satyriasis. Causes. — As a rule, nymphomania is caused by cerebral lesions. It is also a functional nervous affection (Bartholow). Treatment. — Twenty grains of the bromide of potassium thrice daily will exert a decided control over excessive sexual 364 A COMPENDIUM OF PKACTICAL MEDICINE. propensity (Ringer). As a rule, nymphomania dependent on cerebral lesions are not diminished or prevented by the bromides (Bartholow). Large doses of camphor (from five to twenty grains) diminish the venereal appetite and the vigor of the erec- tions, and are therefore useful in priapism, satyriasis, nympho- mania, chordee, etc. (Bartholow). There is no doubt that ex- cessive use of tobacco lessens the venereal appetite; hence, slightly nauseating doses of the wine of tobacco will effectively check chordee, priapism, satyriasis and nymphomania (Bartho- low). NAUSEA. (See Vomiting.) NEURITIS. Is an inflammation of a nerve or nerves. Varieties: 1. Sim- ple neuritis. 2. Toxic neuritis. 3. Diathetic neuritis. 4. Mul- tiple neuritis. Causes. — Simple neuritis is produced by wounds, injuries, and extension of inflammation from adjacent tissues, as an inter- costal neuritis is caused by an adjacent pleuritis or tuberculosis of the lung; sciatica, by a pelvic abscess or inflamed haemor- rhoids. Toxic neuritis is caused by lead, copper, arsenic, etc. Diathetic neuritis arises from some systemic condition, such as rheumatism, gout, syphilis, etc., and septic diseases. The cause of multiple neuritis is not known (Bartholow). Alcohol must be recognized as an unquestioned cause, especially of chronic neuritis. Exposure to cold and sexual excess are frequent causes (Loomis). Symptoms. — There may be chilliness followed by fever, headache, and general muscular soreness. The most prominent symptom is pain in the nerve. The pain is of a very distressing kind; it is a burning, tingling, tearing and intense pain, and is increased by motion or pressure. At first, there is great sensi- tiveness in the inflamed nerve, and ultimately the parts supplied by the nerve become anaesthetic, then will follow paresis, and finally paralysis, if the nerve is compressed or destroyed. Wast- ing and degeneration of the muscles are results of neuritis. Various forms of cutaneous eruptions appear, as herpes, eczema NEURITIS NIGHTMARE NIGHT -SCREAMING. 365 and glossy skin; the nails become clubbed, the hair falls out, and the joints swell and change in structure. The reflexes are diminished (Bartholow). Differential Diagnosis. — Neuritis may be mistaken for neural- gia. In neuralgia the pain is paroxysmal; there are isolated points of tenderness and absence of paralysis. In neuritis the reverse (Flint). Prognosis. — Is very uncertain. Treatment. — In acute cases, leeches may be applied along the course of the nerve, if the patient be vigorous. A fall dose of morphine and quinine should be given at once (gr. ss.-gr. xv. for an adult), and two drops every two hours of the tincture of aconite root. In chronic cases the most effective remedies are galvanism and morphine. The electric brush, blisters and the oleate of morphine may be used locally, and iodide of potassium internally (Bartholow). NIGHTMARE. Is a sensation in sleep, as of a pressure of a weight on the chest or stomach, and of an impossibility of speech, motion, or respiration, from which one wakes after extreme anxiety, in a troubled state of mind (Dunglison). Treatment. — The bromide of potassium is the most effective remedy for nightmare (Ringer). NIQHT=SCREAMING. Is a symptom which appears to be allied to nightmare (Ringer). Treatment, — Bromide of potassium is of great service in the treatment of children subject to night- screaming. Children from a few months to several years old may be attacked with this affection. Sometimes the attack occurs only once or twice a week, or it may be repeated several times each night. The screaming may last only for a few seconds or it may endure for several hours. The child is generally horribly frightened. With the screaming and fright, squinting sometimes occurs, which after some time becomes permanent. In these cases bromide of 366 A COMPENDIUM OF PRACTICAL MEDICINE. potassium will prevent the screaming and remove the squinting. This screaming in children is very generally connected with deranged digestion, which should be treated (Ringer). NEURASTHENIA. (See Asthenia). OBESITY. Is the excessive accumulation of fat in the organism. Causes. — The accumulation of fat in the organism is the re- sult of its incomplete oxidation. It may be due to excessive sup- ply or excessive formation of fat. Too abundant ingestion of rich food, especially of fat and carbohydrates, leads to obesity. The tendency to obesity may be hereditary or acquired. In the former it is cured with difficulty; in the latter a suitable regimen will accomplish much. The use of alcohol favors the accumula- tion of fat by diminishing its normal oxidation (Bartholow and Flint). Treatment. — In the treatment of obesity, it is necessary to withdraw all fats, starches and sugars from the diet. This is the method of Mr. Banting, now called Bantingism. Obesity, which is frequently diminished by a course of alkalies, is better treated by alkaline waters, for at the springs these patients can be in- duced, more easily to conform to the plan of exercise and diet necessary in these cases. It is stated that the bromides, especi- ally bromide of ammonium, diminish the deposition and hasten the retrograde metamorphosis of the fat in obesity. Permanga- nate of potassium has also appeared to be very serviceable as a remedy for an abnormal and excessive deposition of fat. The vegetable acids are sometimes taken by young ladies to keep down the formation of fat; but it accomplishes this object by im- pairing digestion (Bartholow). Dr. Neligan states that he has often removed an uncomfort- able excess of fat by the use of liquor potassse, without in any way injuring the patient's general health. OBESITY ONYCHIA MALIGNA. 367 PRESCRIPTIONS FOR OBESITY. Jt Potassii permanganatis gr. vj.-xxiv. Aquae destillatae Siij. — M. Sig. : A teaspoonful three times a day. — Bartholow. J& Liquoris potassae Sij. Sig. : A half teaspoonful in milk thrice daily. — Waring. (EDEMA. (See Dropsy.) ONYCHIA MALIGNA. This is a disease of the nail matrix. Causes. — It is most commonly found in unhealthy children, and as a rule is started by some local injury such as a squeeze (Bryant). Symptoms. — It commences as a swelling of the end of the toe or finger, with redness, heat and pain. These symptoms are soon followed by exudation from beneath the nail of a serous and often fetid fluid; the nail itself loosens, sometimes falls off, or either flattens out or curls up at its edges. In rare instances the disease involves the last phalangeal joint or bone. The fingers and thumbs of both hands may be involved, and the disease may exist for years (Bryant). Treatment. — In mild cases, tonics internally and water dres- sing externally suffice to bring about a cure. In severe cases, it may be necessary to take away nail and soft parts and even the extreme phalanx. The application of the powdered nitrate of lead to the ulcer has been strongly recommended. The disease at times may have a syphilitic origin when it will be wise to adopt specific treatment (Bryant). Ringer recommends mercury ointment applied for ten minutes every hour, and poultices at other times. He also advises nitrate of lead to be dusted on the diseased tissues night and morning. Bartholow applies a solu- tion of chloral to the part or iodoform in powder or ointment. 368 A COMPENDIUM OF PEACTICAL MEDICINE. OPHTHALMIA. Is an inn animation of the eye. It is a severe form of con- junctivitis called purulent. Varieties. — Ophthalmia neonatorum which occurs in infants at or soon after birth, and gonorrhceal ophthalmia which occurs in adults (Noyes). Causes. — In both classes the disease is essentially the same, and originates from a contagion in the great majority of cases. This contagion is the gonococcus. Ophthalmia Neonatorum. — At birth the eye-lids are al- ways agglutinated by the parturient secretions. It is common too for the eye -lids to remain red and sticky for a clay or two. The great proportion of these simple cases will not require ser- ious attention, and will clear up if the eyes be washed with warm milk and water, or with a solution of boracic acid several times a day. But it is the purulent form clue to gonorrhoea which de- mands active treatment. In this form there is swelling of the lids w T ith thick yellow secretion issuing from the eyes. The cornea may ulcerate (Noyes). Prophylaxis, — The importance of preventing this disease will be appreciated when it is learned that nearly one third of the inmates of blind asylums were made blind by this disease. Where there is a suspicion of gonorrhoea, the vagina may be washed out for some time before parturition and while labor is going on with a three per cent solution of carbolic acid. As soon as the child is born, Crede drops a single drop of a two per cent, so- lution (gr. x. to Sj.) of nitrate of silver between the licls of each eye. Dr. Noyes thinks a one per cent solution will suffice. Treatment. — At first when the secretion is watery, cold lotions and three per cent, solution of boracic acid may be used. As soon as the secretion grows a little thicker, and the swelling of the lids grows less, a solution of nitrate of silver (gr. v-gr. x.to Sj.) may be applied to the everted lids, carefully avoiding the cornea, once in 24 hours (Noyes). Gonorrhceal ojmthalmia in adults is essentially the same disease as ophthalmia neonatorum. The gonorrhceal poison is conveyed to the eyes through the fingers, OPIUM HABIT. 369 handkerchiefs, towels, etc., from acute or chronic gonorrhcea (Noyes). Symptoms. — Are hyperemia, swelling of the lids which speedily closes them, and at first a thin discharge. The secretion in a little time becomes more and more purulent. Ulceration of the cornea may occur. Treatment. — The patient should go to bed. Four to six leeches may be put upon the temple in robust subjects. Con- tinuous cold applications must be kept to the eye. Absolute cleanliness is imperatiye. Boracic acid four per cent, solution must be used to cleanse the eyes. When the secretion becomes creamy and distinctly purulent, a solution of nitrate of silver (gr. x. to 5j.) may be applied to the everted lids, care being taken to avoid the cornea. This is applied once in twenty -four hours. Should the cornea become invaded, a solution of atro- pine sulphate (gr. ij. to 5j.) should be instilled every three to six hours (Noyes). Crede irrigates the eye frequently with a solution of corrosive sublimate (gr. j. to Sxij.). OPIUM HABIT. In chronic opium poisoning, the opium is not always taken by the mouth; it may be taken in the form of morphine hypo- dermically. Some persons take thirty grains of morphine per day. Opium eaters are entirely unreliable. They are chronic liars, owing to their incapacity to tell the truth. Not all persons will contract this habit, but in a minority of people opium is unu&ually pleasant, and these are the persons who are most liable to become opium eaters. Opium affects some people unpleasantly. Many smoke opium and say they can get effects which they cannot get in any other way. The opium habit is, as a rule, contracted unconsciously. In order to get the effect which we get at first, it is necessary to increase the dose. Neuralgic patients often become opium eaters. In some it stim- ulates the mental faculties. De Quincey took 320 grains daily and wrote beautifully. Opium is a much more dangerous drug than alcohol. The opium habit is much harder to break up than the alcohol. Any one who takes two grains of morphine or 370 A COMPENDIUM OF PRACTICAL MEDICINE. more in twenty-four hours might be said to have contracted the opium habit. In chronic opium poisoning the pupils are usually contracted. Later on it takes a large amount to cause this con- traction of the pupil. A chronic opium eater is apt to complain of pain which varies in location from time to time. This is done with a view to justify the taking of opium. Such patients are great seekers of sympathy; are subject to vomiting. At first opium is apt to cause constipation, but later on, if continued, it usually causes diarrhoea. An obstinate form of diarrhoea should always create suspicion (A. A. Smith). Diagnosis. — Always examine the urine or perspiration for opium. A very small quantity in these fluids may be detected. This should be done when the patient will not own up (Smith). Results. — The chronic opium habit will destroy a man men- tally, physically and morally. Renal disease is very apt to develop sooner or later because of changes in the nervous system. Myocarditis of a sub-acute character is apt to develop. Pneu- monia in such cases is apt to be fatal. Opium causes a man to become old while yet young. It hastens degenerative changes. There is oedema in the lower extremities usually in chronic opium eaters. It destroys the will power (A. A. Smith). Treatment. — Two methods of curing the habit may be adopted : 1. Cut it off short. Prof. Flint advocated this method most of his life, but altered his opinion later. 2. Grad- ually withdraw the drug. This is the best method. When we think we are getting the patient down to two grains a day (from thirty grains per day), he is probably taking a great deal more. If such a patient who is thought to be taking a small amount of opium feels well and does not complain of any inconvenience, we may know that he is deceiving us. He will even bribe his nurse. It requires the most careful watching in such cases, else he will deceive us. The more rigid and positive we may be the better for the patient. If the patient has been taking 30 grains per day, Prof. Smith always tries to get him down to one grain per day in 30 days. Should keep the patient under treatment for at least six months. Build up and improve the digestion as the dose of opium is reduced. The horrors which opium-eaters suffer when the drug is withheld are well known; so great, OPIUM HABIT ORCHITIS. 371 indeed, is the suffering that few have sufficient resolution to re- linquish it. Ringer thinks that moderate indulgence of the habit is not perhaps more prejudicial to health than tobacco - smoking. PRESCRIPTIONS FOR OPIUM HABIT. R Ext. cannabis indicse Sij. — (Squibb). Sig. : A teaspoonful every hour or two, as required. (For rest- lessness). — Mattison. R Zinci oxidi / gss. Syrupi simplicis q. s. Ft. massa et in pii no. xxx. div. Sig. : One pill once daily increasing to tolerance. (For vomit- ing and diarrhoea). — DaCosta. R Spartein sulphatis gr. j. Aquae destillata? 3j . — M. Sig.: Ten minims hypodermically, for the collapse produced b}^ withdrawing the drug. — Ball. R Tincturse nucis vomicae gtt. xij. Acidi phosphorici dil gtt. xx. Syr. pruni Virg gss. — M. Sig. : To be taken twice daily. ORCHITIS. Is an innammation of the testicles. Causes. — True orchitis is very uncommon. As corurjlicating mumps, no rational theory has been advanced to account for it. Orchitis due to mumps is most often observed at about the age of puberty. It occurs in about five per cent, of the cases. It comes on near the end of the first week of the mumps and is us- ually confined to a single testicle. The affection runs a quick course of about a week or ten days, and usually clears up. Orchitis after severe injury to the testis is not uncommon. It tends to terminate in abscess or gangrene. Orchitis as a result of cold is possible. Excessive sexual excitement has been ad- duced as a cause. It may complicate variola, typhoid fever and gout. Orchitis may come on secondarily during epididymitis (Keyes). 372 A COMPENDIUM OF PRACTICAL MEDICINE. Symptoms. — In true orchitis the increase in the size of the testis generally advances rather slowly. The pain is often ex- cruciating, and always out of proportion to the amount of swelling. It has been compared to renal or hepatic colic. No position gives rest and any handling of the organ is liable to in- duce syncope. If the pain suddenly ceases, it may mean mortifi- cation of the organ. The shape of the testicle is rarely altered in orchitis. The organ feels indurated. Terminations. — It may terminate in gangrene, in complete resolution, or in atrophy. The general symptoms are often severe; chills, high fever, anorexia, nausea, vomiting, hiccough, constipation, sleeplessness, anxiety and nervousness (Keyes). Prognosis. — Is always grave. Treatment. — The patient should be put to bed, with the testicle supported in a sling. If the case is seen early, ten to fifteen leeches may be applied in the neighborhood of the abdominal ring. The testicle may be enveloped in strong bella- donna ointment, or a paste composed of powdered opium and glycerine, or if the pain be not too excruciating, in a light tobacco poultice. Saline cathartics should be given. The diet should be low, non- stimulating, and easily digested. On the slightest susjjicion of gangrene, it is wise to resort to subcutaneous section of the tunica albuginea to take off tension. If abscess form it should be opened (Keyes). PRESCRIPTIONS FOR ORCHITIS. R Tincturse Pulsatillas 5ss. Sig. : One to three drops every hour or two in water. — Brown. R Antimonii et potassii tart gr. j. Aquae Sviij. — M. Sig.: One or two teaspoonfuls every hour or two. — Ringer. R Morphias sulphatis gr. xvj. Hydrargyri oleatis (10 per cent.)..5ij. — M. Sig.: Apply twice daily. (To remove induration). — Marshall. R Tincturse iodi §ss. Sig.: Apply to swollen testicle after acute symptoms are over. — Bartholow. otitis. 373 ft Sodii salicylates 3ss. Syrupi simplicis §ij. Aquae menthse pip ad §vj. — M. Sig. : A tablespoonful every hour till the pain is relieved, then every four to six hours. — Pigornet. OTITIS. Is an inflammation of the ear. If the inflammation is con- fined to the external ear, it. is called otitis externa; if confined to the middle ear, it is called otitis media; if to the internal ear, otitis interna. Otitis externa is an inflammatory affection of the external auditory meatus involving the cutaneous tissues of that canal, the periosteum of the osseous part of the canal, and the mem- brana tympani (Purves). Causes. — Irritation or injuries to the ear, the prolonged use of injections, the pressure of foreign bodies, the passage of cold currents of air or water, the non- drying of the ear after washing, the presence of fungi, and anything which will cause congestion or irritation, are causes. Symptoms. — The patient conrplains of a continual itching sensation with a feeling of heat and dryness in the canal. There is a feeling of fullness in the ear. The discharge is at first watery, but finally becomes purulent. Treatment. — Discover and treat the cause. Frequent injec- tions of warm water are useful. If there are foreign bodies present remove them. Prevent the formation of pus. Otitis media is an inflammation of the middle ear. The symptoms are acute pain and fever. It is nearly always followed by perforation of the membrane. The treatment is to evacuate the pus as soon as formed. Leeches, opiates, purgatives and warm water injections into the meatus are usually found suc- cessful. When the discharge occurs, the ear should be syringed with lukewarm water to which is added an antiseptic (Purves). 374 A COMPENDIUM OF PRACTICAL MEDICINE. OTALGIA, Is a neuralgia of the ear. Causes. — When a patient complains of pain in the ear, and no innanimation is found either in the external or the middle ear, the teeth should be suspected as being at the root of the trouble. In the majority of cases of otalgia, sufficient dental disease is found to justify the belief that this is the primary cause, and the otalgia simply a reflex condition. The cause of otalgia m?v be malarial, rheumatic or syphilitic (Buck). Treatment. — If the cause of otalgia be a carious tooth, it should be extracted or properly filled. In any case discover the cause and treat it. PRESCRIPTIONS FOR OTITIS AND OTALGIA. R Morphise muriatis gr. v. Atropise sulphatis gr. j . Olei olivas 3j. Glycerinae ^iss. — M. Sig. : Five drops in the ear every hour till relieved (Otalgia). R Acidi carbolici 3j. Glycerinse £ix. — M. Sig.: A few drops in the ear three times daily. =Hartmann. OXALURIA. When oxalate of calcium occurs constantly in the urine, it produces the so-called oxaluria or oxalic acid diathesis, and is apt to lead to the formation of the mulberry calculi and in time exert its poisonous effects on the brain and S23inal cord (Loomis). Sometimes the crystals appear accidentally in the urine from the free use of rhubarb or tomatoes. Disturbed or exhausted nerve power and imperfect digestion, nervous prostration produced by excessive venery and over stimulated or ungratified sexual desires are associated often with oxaluria (Keyes). Treatment. — If enough of any alkali be given to render the urine abundant and limpid, the oxalate of lime will occasionally
  • appear for a time. Baths are beneficial. The true curative treatment is purely hygienic and based upon a correct apprecia- OXALURIA OZGEXA 375 tion of the causes. The mineral acids and strychine seem some- times to do good as tonics; an outdoor life sometimes cures (Keyes). PRESCRIPTIONS FOR OXALURIA. R Acidi nitro-muriatici dil ^ij.-iij. Tinct. gentianae comp Tinct. cinchona? comp. — aa Sj. Elixir curacoa ad Siij. — M. Sig. : A dessertspoonful in a wineglassful of water thrice daily. — Ringer. B Glyceriti pepsins Siss. Acidi lactici ad 5 ij • — M. Sig. : A teaspoonful after meals. — Bartholow OZ(ENA. (See also Catarrh, Nasal.) In chronic nasal catarrh, if the mucous membrane is destroyed by ulcerations, and caries of the bones has occurred, the case is then called ozcena. The morbid process extends through the nasal passages and into neighboring cavities. The discharge consists of a greenish, offensive pus, or of scales taking the form of casts of the bones which are also offensive from decomposition (Bartholow). The disease is very obstinate and hard to cure. The follow- ing prescriptions may be tried: R Sodii biboratis Ammonii chloridi — aa gr. xx. Potassii permanganatis gr. x. — M. Sig. : To be dissolved in one pint of tepid water and used thrice daily with a syringe or douche. — Sajous. R Extracti hydrastis fluidi Sij- Sig.: Five minims in water three times daily. Also add one teaspoonful to half a pint of tepid water and use as a lotion for syr- inging the nares. — Bartholow. 376 A COMPENDIUM OF PRACTICAL MEDICINE. ONANISM. (See Masturbation.) OXYURIS VERMICULARIS. Called also thread worm from its resemblance to pieces of ordinary white sewing thread, also seat -worm "from its habitat, is frequent in childhood and not infrequent in the adult (Smith). Size. — The length of the male oxyuris is about one -fourth of an inch; that of the female about one -half inch. They are cylin- drical and taper to both extremities. Habitat. — The habitat of the oxyuris is the large intestine of man, especially the rectum, and they insinuate themselves into the folds of the mucous membrane and skin at the margin of the anus. They migrate into the vagina and upward into the large intestine and lower part of the ileum in great numbers. The eggs are oval, each female containing about 10,000. All their stages of development take place within the intestinal canal. The ova enter by means of the food or directly through personal contamination (Bartholow). Symptoms. — They excite by their presence in the rectum an intolerable itching, sometimes severe pain, tenesmus usually, and these sensations are propagated to the genito- urinary organs. The itching is most troublesome at night, when warm in bed. The stools are usually relaxed, fetid and coated with mucous. The skin about the anus is reddened. Various reflex phenomena are induced by the irritation of the worm such as epilepsy, chorea, catalepsy, etc. (Bartholow). Treatment, — Santonine aided by calomel should be first given. As soon as this has acted, the bowel should be irrigated by a weak decoction of quassia or of aloes. If the vagina is in- fested, it must be irrigated with the same solution. The next step consists in carefully sponging out all the folds and crevices of the anus and perineum and the external genitals also with a one per cent, solution of carbolic acid. Vix has found water and castile soap to be the most effectual enema. A variety of sub- stances administered by injection will speedily destroy thread- worms. Thus a teaspoonful of common salt in solution, or a drachm of sesqui -chloride of iron in a pint of water are very ef- 0XYURIS VERMICULARIS OPACITIES IN EYE. 377 ficacious; so is lime water, solution of alum and in fact any sub- stance which coagulates the albumen of the worms (Bartholow and Ringer). PRESCRIPTIONS FOR OXYURIS VERMICULARIS. jfc Santonini gr. xij. Olei theobromse 3J . — M. Ft. suppositdria? no. iv. Sig. : One at bed time introduced into the rectum. — Hartshorne. j& Tinct. rhei gtt. iij. Tinct. zingiberis ..gtt. j. Magnesii carbonatis o v. Aquae giij. — M. Sig.: This dose should be taken three or four times daily ac- cording to the effect on the bowels. — Martin. R Sodii chloridi 3x. Aquas 3vi. — M. Ft. sol. Sig.: To be injected by the rectum. — Eillard. R Tinct. ferri chloridi ...gss. Aquae Oj.— M. Sig.: One fourth to one third as a rectal enema. — Ringer. OPACITIES IN EYE. The opacity is a cloudiness in the transparent media of the eye. Causes. — The causes are various. They result from ulcera- tions, burns, injuries, inflammation from excision of a pterygium, etc. Discovery. — To discover a very faint opacity, one must use oblique illumination in a dark room or examine with the ophthal- moscope and feeble light. A plain mirror having behind it a convex glass of three inches focus will do the best service. Dis- tant vision is always more disturbed by faint opacities than near vision. A well defined opacity partially covering the pupil is much less damaging to vision even if dense, than a faint haze with filmy edges (Novesi. 378 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — The more recent the opacities the more likely are they to improve. So long as blood vessels remain in their vicinity the improvement will continue. The restorative action will go on for months. The treatment consists in stimulating applications. The most serviceable are: very finely powdered calomel dusted daily into the eye and which is especially suited to children; ointment of yellow oxide of mercury (gr. ij-x to the o. j.) to be used every night, or once in two or three nights, ac- cording to susceptibility: astringent drops in various strengths, as sulphate of zinc, alum, sulphate of cadmium, tannin in glycerine (5. ss. to o. j.) tincture of opium diluted 1 to 10, solution of iodide potassium, 1 to 3; common salt 1 to 5 or 20; hot fomenta- tions: powdered sugar, molasses, etc. The object is to irritate and cause hyperemia, not to last longer than a patient can toler- ate. Opacity will grow fainter for at least a year. When no further absorption is possible and a dense opacity exists, two proceedings remain, and they are often combined, namely, iridec- tomy and tattooing. An artificial pupil should, as a rule, never be made during the recent stage of an opacity unless very dense and extensive. When the pupil is covered or the iris is pro- lapsed and a marginal part of the cornea is more or less clear, an iridectomy will be in place. The spot at which a pupil is to be placed is frequently not a matter of discretion because there may be only one clear region. If a choice is possible the lower seg- ment of the corneals to be preferred to the upper. Very dense opacities which are a blemish both to sight and to personal ap- pearance may be tattooed with India ink. The fine and expen- sive quality of ink is to be used. A bit of the ink j3aste equal to the size of the spot to be colored is placed upon the cocanized cornea. Numerous and rather forcible pricks with a bunch of needles driven obliquely in various directions will force the ink under the epithelium, and if it be thick enough one sitting may be sufficient (Noyes). OVERWORK, Treatment. — When there is sleeplessness caused by worry or over-work, or that occurring at the menopause, or from men- strual disturbances, the bromide of potassium in twenty grain (ESOPHAGEAL OBSTRUCTION. 379 doses at night is invaluable. A drop of laudanum with two of tincture of nux vomica, three or four times a day, will relieve the distressing symptoms of hysterical women or nervous over- worked anxious men. Persons in broken health from over-work are benefited by A to ^o of a grain of phosphorus, thrice daily for several months. A sitz-bath for ten minutes at 70° to 80° on return from business tired and irritable, and one-half hour before dinner is highly beneficial (Ringer). (ESOPHAGEAL OBSTRUCTION. As its name implies, is an obstruction of the cesophagus in any part of the tube from whatever cause. Causes. — When a patient complains of difficulty in swallow- ing, or rather the difficulty in passing food onward down the cesophagus after the act of swallowing has been performed, and of its subsequent return into the mouth, the surgeon in looking for the cause should first think of thoracic aneurism, then of cancer of some portion of the tube, and lastly of syphilitic or simple ulceration. He should a] so always inquire into the his- tory of the case, as to whether the patient sustained any local injury from the swallowing of a foreign body, of boiling water, or of corrosive fluid. If injury and aneurism can be excluded, there is little doubt that the true cause is cancer (Bryant). Symptoms. — So long as solid food passes, the patient is hardly aware of any obstruction existing, and seldom consults a physician. The first symptom that attracts notice is the regurgi- tation of food. As the disease advances some sign of ulceration may appear, such as the discharge of pus or blood, which usually comes up with the regurgitated food, and when this occurs there is no better indication of the presence of ulcerative action. If the patient be middle-aged, the probabilities of the disease being- cancer are very strong; and should there be any local thickening behind the larynx or glandular enlargement, the probabilities are enhanced. The following case which occurred in a patient of the writer illustrates the above very forcibly. The patient, aged 53, was dying from starvation caused by inability to swal- low on account of obstruction of the (esophagus. By question- 380 A COMPENDIUM OF PRACTICAL MEDICINE. ing it was learned that the trouble had commenced nine months before. There was no history of injury. Upon examination there was found a thickening behind the larynx and enlargement of contiguous lymphatic glands. All liquids or solids swallowed by the patient were immediately returned into the mouth together with pus and stringy mucus. The patient died seven days after the examination. The autopsy showed almost a complete closure of the oesophageal tube in its upper third due to cancer. Treatment. — The treatment by dilatation must be looked upon as a dangerous measure, except when the stricture is of the cicatricial form, the passage of an instrument in cancerous or any ulcerative disease being likely to hasten the fatal termination by causing perforation of the ulcer into the air passages or pleura. In these cases fluid nourishment should be taken. When swallowing becomes impossible, a fine flexible tube may be passed through the stricture. The powers of the patient may be kept up by nutritious enemata. When all these means fail, the ques- tion of opening the stomach by an operation must be enter- tained. Billroth recently has cut down upon the oesophagus and excised the cancerous growth but without success; the operation is commended to our consideration only by the eminence of the surgeon who performed it (Bryant). PALPITATION OF THE HEART. Is a functional disturbance of the organ characterized by increased rapidity of movement, with more or less irregularity of rhythm (Bartholow). Causes. The heart has a power of independent motion, motor apparatus, but it also receives force from the great centres. To maintain the movement at a uniform rate, there is a regulator apparatus, designed to prevent overaction or to inhibit. Besides this mechanism for evolving force and applying it so as to produce uniform results, the action is affected by the state of the vessels, by the density of the blood, by the movements of the respiratory organs, and by the functions of animal life. Hence, to maintain the action of the heart, there are: 1. A motor apparatus — motor ganglia — situated in the substance of the PALPITATION OF THE HEART. 381 heart. 2. Excitors of activity, branches from the cervical sym- pathetic, and also from the spinal cord, irritation of which in- creases the movements of the heart. To regulate the movements of the heart, there are : 1. The pnenmogastric, irritation of which may arrest the heart in diastole. 2. The depressor nerve of Ludwig, 'which acts by dilating the blood vessels. The fibres of the sympathetic, dilator and constrictor, affect the work of the heart by increasing or lessening the tension at the peri- phery. The direct cause of palpitation is over- stimulation of the cardiac muscle or the excitability from functional derangement of the pnenmogastric, or cardiac ganglia, which is either induced bv direct or reflex causes. Muscular exercise, breathing rarefied air, as in the ascent of mountains, and blows on the epigastrium may cause it. Mechanical interference with the movements of the organ, as contracted chest, thoracic effusions, tumors of the mediastinum, flatulence, distension of the stomach and atheroma of the arterial system generally may induce it. Moral and emo- tional causes, as grief, hope, anxiety, fear, excessive mental effort, etc., increase the action of the heart. Various reflex troubles have the same effect, such as uterine disease, gastralgia, worms, etc. Palpitation is a very frequent symptom in states of debility or anaemia. The cardiac ganglia are rendered irritable by the excessive use of tea, coffee, tobacco and spirits. Sexual excesses, enervating habits, diabetes, sudden shock or fright, chorea or derangements of the digestive organs may cause it. Gout, chronic disease of the liver and Grave's disease may be ac- companied by palpitation (Bartholow and Loomis). Palpitation may accompany organic cardiac disease (DaCosta). Symptoms. — The normal cardiac impulse is so slight that the motion is not perceptible, unless the hand be applied to the precordial space. Whenever a person becomes sensible of the beating of his own heart, he may be said to have cardiac palpi- tation. The cardiac impulse is unnaturally strong, and the action of the heart unnaturally rapid, which may be irregular or intermitting. Sometimes there is a loss of three or four beats which causes a sense of oppression, or even of impending death. Palpitation may be accompanied by a choking, paroxysmal, fluttering: sensation. The heart-sounds may be audible to the 382 A COMPENDIUM OF PRACTICAL MEDICINE. patient when he lies on his left side. There may be precordial pain or anxiety. The carotids throb. The attack may last from a few minutes to some hours, or a day. There is dyspnoea. The heart seems almost to tnrn over, to rise np into the throat. The patient cannot lie down. There may be vertigo, faintness and flashes of light. The face may be pale or flushed. Speech is difficult. At the end of the paroxysm a quantity of pale, limpid urine is usually passed. Dr. Cotton reported a case in which the pulsations were 240 per minute, and ceased on the evacuation of of a tape -worm (Bartholow and Loomis). Differential Diagnosis. — Cardiac palpitation independent of organic disease of the heart may be mistaken for cardiac palpita- tion depending upon organic cardiac disease. The former comes on suddenly and is not constant; the latter comes on slowly and is persistent. In functional palpitation, all the physical signs of organic cardiac disease are absent. Palpitation of organic heart disease is increased by exercise (Loomis). Prognosis. — Is always good in functional cardiac palpitation, but may cause the patient great uneasiness (Loomis). Treatment. — Discover and remove the cause. Tea, coffee, tobacco and alcoholic stimulants must be given up. Errors of digestion, reflex disturbances and curable diseases must be cor- rected at once or cured. Anaemic subjects should take iron in large doses for a long period. The body should be sponged night and morning in cold water. In the absence of any explan- ation of the paroxysms, the presence of a tape worm maybe sus- pected. For the immediate relief of the attack, there is no remedy so efficient as the hypodermic injection of morphia. If the surface is pale and the extreme vessels contracted, inhalation of nitrite of amyl (two to three drops) affords prompt relief. The application of the ice-bag to the precordial region is an effective means of quieting the heart. The galvanic current, from ten to thirty elements, passed through the pneumogastric and cervical ganglia of the sympathetic, often gives great relief. Chloral, the bromides, camphor, asafcetida, and valerian are sometimes useful. Digitalis should never be given in purely nervous cardiac palpitation. The physician should assure the PARALYSIS. 383 patient that there is no danger attending the paroxysm of func- tional cardiac palpitation (Bartholow and Loomis). PARALYSIS. Is the loss of muscular contractility, and, as a consequence, of the power of motion. The term is also applied to the loss of sensibility. The former is motor and the latter sensory paralysis. Paralysis is not a disease, but a symptom. A slight incom- plete paralysis is called paresis. Origin and Extent. — Paralysis is nearly always of nervous origin. It may be general or partial. It may affect the majority of the muscles of the frame, or be limited to one muscle. It may be strictly confined to one side (hemiplegia), or exist solely in the lower half of the body (paraplegia). It may be complete or incomplete. It may come on rapidly or slowly (DaCosta and Flint). Causes. — Paralysis may be neuropathic or myopathic. A myopathic paralysis depends on a primary morbid condition of the muscles paralyzed. Neuropathic paralysis depends on either a morbid condition of the nerve centres or nerves. The neuro- pathic is divided into central and peripheral paralysis. Central paralysis depends on morbid conditions seated in either the brain or spinal cord, and are divided into cerebral and spinal. Peripheral paralysis depends on morbid conditions affecting the nerves at any point between their terminations and their central connections with either the brain or spinal cord. The causes may be thus summed uj) : 1. Paralysis due to a lesion or any morbid condition of the nervous centres as hemorrhage into or softening of the central nervous textures, and certain diseases of the brain and spinal cord. To this class must be added the functional palsies which depend upon a functional derangement of the great centres of innervation, such as hysterical paralysis, and that occurring after overwork or excesses, and from nervous exhaustion. 2. Paralysis due to a lesion in the course of a .nerve, such as a wound or compression. Palsy from this cause is local, and 384 A COMPENDIUM OF PRACTICAL MEDICINE. is apt to show morbid nutritive changes in the affected part, such as glossy fingers and swollen joints, and to be associated with pain. rS. Paralysis due to an affection of the nerves at their ex- tremities, such as exposure to cold. Peripheral palsies lead quickly to atrophy of the muscles. 4. Paralysis due to reflex action, such as irritation of the dental nerves in teething children, disorders of the intestines both in adults and in children, or disease of the bladder, urethra, prepuce, uterus, lungs, plura, or irritation of the nerves of the skin. In these cases, the paralysis is produced through the reflex centres, which reflect the irritation communicated to them to parts healthy in themselves. How else can a wound of a nerve on one side of the body lead to palsy on the other ? Reflex paralysis is rarely of long duration. 5. Paralysis due to serious interference with the circulation as after the ligation of a large artery. 6. Paralysis due to a morbid state of the muscles, as certain forms of rheumatic palsy and of muscular atrophy. 7. Paralysis due to the presence of poison in the system, such as lead, arsenic, mercury, alcohol, sulphuret of carbon, ma- larial poison, and the poisons of rheumatism, gout and acute diseases (DaCosta). Condition of Paralyzed Parts. — The nutrition and secretion are disturbed and the circulation is sluggish. They are fre- quently swollen and cedematous, the pulse is weaker than in the sound members, and the sensation is impaired, the nails grow slowly, so do the hairs, the perspiration is defective, the skin feels cold and is prone to break. The muscles may be relaxed or rigid, and diminished in size. The mode in which palsies are investigated at the bed side. We must notice the size, appearance said feel of the stricken part. Then we test the sensibility to contact, to tickling, to pinch- ing, to cold and to heat; we measure the tactile sense by the M'slhcsiometer and note the reflex movements. We next contrast the muscles and their motion with the healthy side. We test the power by the grasp and by other means. But the most valuable PARALYSIS. 385 agent to judge of the state of the muscle is electricity. We should compare the contractions of the sound side with those of the diseased (DaCosta). Differential Diagnosis. — There are certain points of difference in the effects of cerebral, spinal and peripheral paralysis. In cerebral paralysis the reflex excitability of the affected muscles is retained and may be increased. The electro -muscular con- tractility is intact in cerebral palsies. The muscles do not speedily become atrophied. The cutaneous sensibility is often undiminished. In spinal paralysis, the paralyzed muscles do not retain their reflex and electrical excitability; but there are exceptions to this. Sensibility may be retained, diminished or lost. There may or may not be trophic disturbances. In pe- ripheral paralysis the reflexes are generally diminished. The af- fected muscles undergo rapid trophy, and the nerves and muscles take on the action of degeneration. Peripheral paralysis may be the result of syphilis or diphtheria. In all cases of paralysis we must get the history of the case (DaCosta andFlint). " Paralysis from Commotion" — Cases in which paralysis occurs after a variable period dating from railway accidents, have been described especially by Erichsen. These cases have been considered as important in a medico -legal point of view. GENERAL PARALYSIS. Exclusive of general cerebral paralysis, general paresis, or paralysis of the insane, general palsy dependent upon morbid conditions of the brain is rare. Causes. — It may be a result of two attacks of hemiplegia, the first attack affecting one, and the second the other side. Hemorrhage into the central portions of the pons or bulb may give rise to double hemiplegia, or general palsy. In the great majority of cases general paralysis is spinal. The seat in the spinal cord is to be inferred whenever cranial nerves are not in- volved and there are no symptoms denoting cerebral disease. General spinal paralysis is incident to inflammatory and struc- tural affections of the spinal cord and its meninges. In rare in- stances it follows diphtheria, and is sometimes connected with 386 A COMPENDIUM OF PRACTICAL MEDICINE. hysteria. It may be caused by exhaustion and exposure to cold. Spinal hemiplegia, with motor paralysis on one side and anaesthesia on the opposite side, probably always implies a lesion limited to the half of the cervical portion of the cord on the side of the motor paralysis. Paralysis may affect the upper limb of one side and the lower limb of the other side; and may be produced by lesions situated at the crossing of the pyramids in the bulb. In hemiplegia or one sided palsy, the face may be paralyzed on the same side as the rest of the body, and the reason of this lies in the fact that the facial nerves decussate. Should, then, the lesion be situated in the brain above this crossing, both face and body are paralyzed on the opposite side to the diseased spot. Should, however, the lesion involve the facial nerve -fibres at a point below or after the decussation, there will be paralysis of the face on one side; and of the limbs on the other. This is cross paralysis, and is always indicative of a lesion of the pons Varolii. Paralysis may come on suddenly or gradually. A sudden paralysis almost always has its origin in an apopletic effusion, cerebral embolism, and softening. A gradual development of palsy indicates some chronic cerebral disorder, such as softening, a tumor, or any affection compressing the nervous substance. Monoplegia is a paralysis of a muscle or a set of muscles, of one limb, or of one side of the face. / PARAPLEGIA. Is paralysis of the lower half of the body. Causes. — Its almost invariable cause is a lesion of the spinal cord. Exhaustion, exposure to cold, sexual excesses, hysteria, diphtheria, syphilis, poisons, small clot in the pons, injury to cord, spina-bifida, tumors, shock and concussion of the spine are the principal causes (DaCosta, Flint and Loomis). Treatment. — Of remedies having direct reference to the para- lysis, electricity holds the first rank. When the paralysis is due to diseases involving inflammation, we must not apply the cur- rents until the proper time. Frictions, massage, kneading and PARALYSIS PARAPLEGIA. 387 stimulating liniments are nseful. Of drugs, strychnia or nux vomica and phosphorus are to be recommended. The cause in each should be removed if possible. Strychnia is contraindicated in the cases of hemiplegia when the injury to the brain or cord has been recent. It generally does no good, but harm, when the paralyzed muscles are rigid. In local paralysis, the solution of strychnia should be thrown into the substance of the paralyzed muscles (Bartholow and Flint). PEMCULI. (See Lice). PEMPHIGUS. Is a skin disease characterized by an eruption of bullae. Bullae differ from vesicles only in their size. They resemble large blisters. Pemphigus is the typical bullous disease. Description. — This is a comparatively rare affection; it is more common in children than adults. It appears in very large vesicles or bullae, surrounded by a slight zone of erythematous redness. The blebs occur in crops and look like small blisters filled with serum. They are not met with on the scalp; where there are few bullae we generally find them on the ankle, or on the hand. The disorder may be acute or chronic. It occurs mostly in persons of feeble constitution. Relapses are frequent. Pemphigus may be produced by the administration of iodide of potassium, or by syphilis. Syphilitic Pemphigus. — Is mainly met with on the soles of the feet and the palms of the hands of the newly born syphilitic children. The bullae vary in size from that of a pea to a walnut (Anderson and DaCosta). Causes. — Are unknown. Treatment. — Tonics must be given, and of these the most important are quinine and arsenic. Local treatment is effective. The bullae, if tense, may be opened, and afterwards dusted with a soothing powder. Baths are highly recommended (Anderson). 388 A COMPENDIUM OP PRACTICAL MEDICINE. PRESCRIPTIONS FOR PEMPHIGUS. R Sodii biboratis 5ss. Tragacanth 3j . Spiritus rectificati 31J . Glycerinse ^iv. Aqua? destillatse ^iss. — M. Sig. : Smear a little over the excoriated part and allow it to dry. — Anderson. R Pulveris lycopodii Jj. Sig. : Use as a dusting powder after the bullse are cut. Then use zinc ointment, and then use the following : R Argenti nitratis gr. iij.-iv. Adipis £j — M. Ft. ungt. Sig. : Apply locally. —Tilbury Fox. PERICARDITIS. Is an inflammation of the serous membrane (the pericard- ium) investing the heart. The inflammation may be circum- scribed or diffused, acute or chronic. Causes. — Primary pericarditis may arise from injuries to the pericardium, or from cold. Secondary pericarditis is more common, and is due to two causes: 1. To an extension of in- flammation from neighboring parts, as in pneumonia, left pleu- risy, pulmonary tuberculosis, caries of the sternum or ribs, aneu- rism of the aorta, endocarditis, etc. 2. To the rheumatic dyscra- sia. It also occurs in the course of Bright's disease, acute infectious diseases, as scarlet fever, smallpox, typhus and typhoid fever, and of syphilis and chronic alcoholismus. It is of most frequent occurrence in connection with acute articular rheuma- tism, Bright's disease and pneumonia (Bartholow and Loomis). Symptoms. — Pericarditis occurs most frequently between the ages of 15 and 30. The two prominent rational symptoms are ]> bo clear. The feelings are usually cheerful and buoyant. Patients are hopeful respecting their condition, and are readily persuaded 420 A COMPENDIUM OF PRACTICAL MEDICINE. that they are improving, and hence • they fall an easy prey to quacks. They sometimes dislike to be told the truth, and take offense at an intimation that they are consumptive. The expec- tation of improvement, prolonged life, or even recovery, amounts in some cases to an insane delusion. Patients are sometimes occupied in forming plans for the future when it is obvious to an observer that they are on the verge of the grave (Flint and Loomis). Physical Signs. — 1. Of the stage of consolidation: Inspection reveals diminished expansion, on inspiration, in the supra- and infra -clavicular regions of the affected side. Palpation shows more distinctly the loss of expansion on the affected side, and increase of vocal fremitus over the consolidated lung. Percus- sion elicits relative dullness and sometimes even flatness. If the consolidation is slight, the percussion sound may remain normal. To recognize a slight consolidation at the apex of the lung, it is important to percuss from the trachea rather than toward it. In all cases percussion should be performed at the end of a full in- spiration and at the end of a full expiration. Auscultation shows increase of vocal resonance. Over the affected portion, the respiratory sounds maybe feeble or exaggerated, interrupted or wavy. In addition there are certain adventitious sounds or rales. The earliest of these audible is a fine, dry, crackling sound (sub -crepitant) appearing at the end of inspiration. The subcrepntant rales heard within a circumscribed space at the summit of the chest on one side are highly significant of tubercle. They proceed from secondary circumscribed bronchi- tis. A crepitant rale, in like manner limited to a small space at the summit on one side, has the same significance, being due to .secondary circumscribed pneumonitis. Crumpling and crackling sounds are significant, provided they be limited to the summit on one side. A pleural friction sound limited to the summit on one side denotes a secondary circumscribed pleuritis. 2. Of the stage of softening and excavation. — Inspection shows a greater frequency of respiration and a more marked de- pression above and below the clavicle on the affected side, as well as increased difficulty in local expansion. In fibroid phthisis the retraction is more marked than in any other variety. Palptaion PHTJHISIS. 421 shows diminished expansion of the affected side, on forced in- spiration. Vocal fremitus is increased. Percussion shows more uniform and widely spread dullness. Auscultation shows bron- chial breathing, and bronchophony becomes more distinct. Numerous, moist, crackling rales are heard. When cavities form, inspection shows greater depression in the infra -clavicular region and less expansive movements. Palpation shows intensified vocal fremitus over large cavities containing air and communi- cating with a bronchus. Percussion gives a tympanitic reso- nance, and the varieties of this resonance, called "cracked -pot" and amphoric, denotes cavities. If the cavity is filled with liquid there will be dullness on percussion. Auscultation. Over small cavities, cavernous respiration will be heard. Over large cavities near the surface amphoric respiration will be heard. The incom- ing air may bubble up and cause gurgles (Loomis and Flint). The Diagnostic Points Pertaining to Symptoms. — 1. Cough and expectoration, not succeeding an attack of acute bronchitis, and not connected with chronic pharyngitis, the cough at first dry and expectoration small and transparent, and becoming gradually more abundant and opaque. 2. /Stitch- pains at the summit, not connected with intercostal neuralgia. 3. Chills not referable to malaria. 4. Haemoptysis. 5. Accelerated breathing. 6. Loss of weight. 7. Pallor or anaemia not otherwise explicable. 8. Hoarseness, or huskiness of the voice proceeding from chronic laryngitis. 9. Chronic peritonitis not traumatic. 10. Suppres- sion of the menses. 11. Buoyancy of mind instead of despond- ency (Flint). Differential Diagnosis. — The diagnosis of pulmonary phthisis rests mainly upon an examination of the sputum and upon phvsi - cal signs. Incipient phthisis may be confounded with atonic dyspepsia. A cough may be present in atonic dyspepsia, the so- called stomach cough; but in this case there is no irritation about the air-passages. In advanced phthisis, hectic fever may be con- founded with intermittent. In phthisis, the fever has been pro- ceeded by a period of cough, and loss of flesh and strength, whereas in intermittent, these symptoms have followed the access of fever. In phthisis there is not enlarged spleen and the luetic is not arrested by large doses of quinine. Laryngeal symptoms 422 A COMPENDIUM OF PRACTICAL MEDICINE. are often so pronounced in the beginning as to obscure the pul- monary affection. When tubercular deposits occur in the larynx, the tone and quality of the voice are quickly affected, so that the larynx may seem to be the only seat of tubercular deposit. The coexistence of pulmonary disease ought to be suspected, because of the relation known to obtain between them. Acute phthisis may be mistaken for croupous pneumonia, bronchiectasis and capillary bronchitis. In pneumonia the pro- longed ushering in chill, the continuous high temperature, the characteristic sputum, the dullness limited to a lobe, and the pneumonic countenance, are symptoms which readily distinguish it from acute phthisis. Bronchiectasis accompanied by wasting, fetid expectoration, haemoptysis, and night sweats with the phys- ical signs of consolidation, may well be mistaken for the ad- vanced stage of acute phthisis. But in phthisis the signs of con- consolidation precede those of cavities; in bronchiectasis they follow them. Fever and emaciation are always greater in phthisis than in bronchiectasis. In capillary bronchitis there is no dullness on percussion, subcrepitant rales are heard on both sides of the chest, and there is no bronchial character to the re- spirations. The early stage of chronic phthisis may be con- founded with bronchitis, pulmonary infarction, pleurisy, acute lobar pneumonia, anaemia with cough and expectoration and cancer of the lung. The evidence of consolidation of lung-tissue is essential to the diagnosis of phthisis. So long as bronchitis is accompanied by a temperature of 100° F., and the physical signs show that the bronchitis is general, phthisis is readily excluded; but if the temperature rises to 103° F., and localized crepitant rales develop at the apex of either lung, accompanied by dullness on percussion over the seat of the rales with a bronchial charac- ter to the respirations, then there is reason to believe that phthisis is being developed. The diagnosis between chronic bronchitis and fibrous phthisis rests upon the evidences of consolidation and retraction in phthisis, and their absence in bronchitis. Pulmon- ary infarction* are attended by haemoptysis and localized areas of dullness. Heart disease is their chief cause. The blood ex- pectorated in phthisis is of a bright scarlet color; in infarctions if is dark and in the form of coagula. Infarctions are most fre- PHTHISIS. 423 quently situated in the lower lobes; in phthisis the dullness is apical. In pleurisy with effusion, flatness will exist from the base of the lungs to the level of the fluid; the line of flatness will change with a change in the position of the patient. The cough is more hacking and is not accompanied by expectoration, and vocal fremitus is diminished or absent. A localized pleurisy at the apex of the lung, not the result of a general pleurisy, is indicative of tubercular development. Anosmia with cough and expectoration is attended by no febrile symptoms, and by none of the physical evidences of pulmonary consolidation. In cancer of the lung there is usually bulging of the chest at the seat of the cancerous development; in phthisis there is retraction. In cancer the temperature is often subnormal; in phthisis it is more or less elevated. The currant- jelly expectoration of cancer is diagnostic. Pain is constant in cancer and intermittent in phthisis. The difference between caseous and tuberculous phthisis is as follows: Tubercular phthisis is distinctly hereditary; caseous phthisis is not hereditary, but occurs in the scrofulous. Tuber- cular phthisis occurs at all ages; caseous from youth to middle age. Tubercular phthisis occurs insidiously with catarrh of the bronchi and larynx; caseous results from acute inflammations of the bronchi and lungs. In tubercular phthisis the lesions are apt to be on both sides; in caseous on one side. The laryngeal symptoms are much more common in tubercular than in caseous phthisis. Fibroid phthisis is distinguished from the other forms by its slow progress, by the long period of bronchial troubles before the pulmonary lesions begin and by the merely purulent expectoration (Bartholow, Flint and Loomis). Prognosis. — The duration of phthisis is extremely variable. In the vast majority of cases it is essentially a chronic affection, but sometimes it runs a rapid course destroying life in a few weeks. The disease in such cases has been known as "galloping consumption," or phthisis florida, or acute phthisis. The prog- nosis of acute phthisis is always unfavorable. Its average dura- tion is from five weeks to five months. Flint distributes fatal cases into groups as follows: "One group will consist of cases in which the disease continues from three to six months; in another 424 A COMPENDIUM OF PRACTICAL MEDICINE. group death takes place between six months and a year; and in a third group the career extends from one to two years; and in another group the fatal termination is held in abeyance for many years."" Flint says, u The generations of bacilli may die out or be destroyed, and the tuberculous products may be either ab- sorbed or calcification may occur. Cavities may completely cicatrize. In these modes complete recovery may take place. Cavities may exist without any fresh products, giving but little inconvenience for an indefinite period, and even through a long life." Of 670 cases analyzed by Flint, 44 ended in recovery, and in 31 cases, the disease became non-progressive. He claims the es- tablishment of the fact that in a certain proportion of cases phthisis is self limited. The most rational explanation of the manner in which this disease ends by self -limitation is to suppose that the conditions which are essential for the multiplication of the bacilli and which constitute the tuberculous predisposition or diathesis, after a time cease to exist. The vegetable parasite is destroyed because the soil becomes incapable of maintaining longer its existence. Persistent frequency of the pulse, fever, anorexia, and progressive emaciation oj3pose reliance on self- limitation. In proportion as phthisis is well tolerated there is room for hoping that it will prove self-limited. Haemoptysis \& very rarely an immediate cause of death. The disease proves fatal generally by asthenia. Bartholow says, "Phthisis is the great enemy of the human race since nearly two - sevenths of the deaths from all causes are due to this disease." He also says, "Cures are now not uncommon." Under prognosis Loomis says, "Chronic pulmonary phthisis is not necessarily a fatal disease. Its morbid processes may be arrested in the early stage or in the stage of cavities by proper treatment. Recovery has occurred in one- sixth of my recorded cases during the past ten years. The average duration of phthisis is three years and four months. Phthisis can in no sense be regarded as a self-limited disease. Some cases, after a period of activity, become stationary and then recover; others slowly but steadily progress to a fatal termination; others again pursue a more rapid and fatal course." The prognosis is unfavorable when there is a strong hereditary tendency, when phthisis de- PHTHISIS. 425 velops early in life, when scrofulous or glandular disease has ex- isted in childhood, when the patient is narrow-chested, when the ordinary pulse rate is high, and when there is great variation in weight without any apparent cause. Frequent haemoptysis in an early stage of the disease is not unfavorable. When cedenia of the feet and lower extremities conies on in advanced phthisis, the prognosis is very unfavorable, and a fatal issue is not far off. Advanced cases may die suddenly from heart failure or syncope. The majority waste to a skeleton, but the mind is perfectly clear and the patient is hopeful of recovery, and makes plans for the future as if perfectly well (Bartholow, Flint and Loomis). Treatment. — The two main objects of treatment are the de- struction of the parasite and the removal of the tuberculous pre- disposition or diathesis. There are no known remedies which will accomplish either object. /. Prophylactic Treatment. — When a phthisical tendency exists, prophylaxis becomes highly important. It is possible to prevent the development of phthisis. Children born of phthis- ical parents should not be nourished in infancy by their own mothers, but should be placed with a healthy wet-nurse. During childhood they should be fed chiefly on good cow's milk, take systematic physical exercise in the open air, removed from the city to the country. They should not lead a sedentary life. They should not breathe air laden with foul vapors or fine par- ticles of dust. Their sleeping apartments should be large and well ventilated. Sudden changes in temperature must be avoided, also hot, crowded apartments. Change of climate may be necessary. All those agencies which tend to develop pulmo- nary hypersemia and bronchial catarrh should be avoided. Flannel should be worn next the skin the whole year. The diet should be simple and nutritious. Cold bathing should be prac- ticed every morning to diminish the susceptibility to cold. The "milk-cure" and " grape-cure" will often be useful. All milk fed to children should be boiled, and they should not be allowed to come in contact with phthisical parents, except under guarded conditions. //. Medicinal Treatment. — Alcohol. Clinical experience shows that alcohol, in a certain proportion of cases, has a salu- 426 A COMPENDIUM OF PRACTICAL MEDICINE. tary effect. If alcohol produces a sense of comfort, increases the strength, and does not excite the circulation or nervous system, benefit maybe expected from its use; and vice-versa. As regards quantity, some patients will tolerate a large, some a moderate, and some only a small quantity. Phthisis is one of the diseases which in certain cases induce a remarkable tolerance of alcohol. Some patients are benefited by spirits, some by wine, and some by malt liquors, but in each case alcohol is the remedial princi- ple. Bartholow says: "Small doses of alcohol after meals (half an ounce for adults) are highly useful to promote appetite and tissue formation. Large quantities of alcoholic fluids impair the function of digestion, and lessen tissue forming.''' Cod-liver Oil. — The utility of cod-liver oil in incipient phthisis is very great. Its usefulness consists in the fact that it is a fat, having a special digestibility, owing to its containing bile elements. It is most useful in chronic tuberculosis and fibroid phthisis. It is better to give it with a little ether (IHxx.-5j.), because of the action of the ether in promoting the flow of pancreatic fluid. If cod- liver oil be taken without great repugnance, if it do not impair the appetite or digestion, or occasion derangement of the bowels, it may be expected to do good. Loomis says, "It has been claimed that if cod-liver oil is commenced very early it has the power of arresting the phthisi- cal processes. I doubt if it exerts any specific influence upon the disease. Unless the patient gains in weight while using the oil, it seldom or never proves remedial. A great gain in weight will sometimes immediately follow the administration of a small quantity of oil. It always acts remedially with more certainty in young persons and children than the aged. In some instances diarrhoea will be arrested by its use and also vomiting of food after eating. A teaspoonf ul once or twice a day is sufficient to commence with, the dose being gradually increased to a table- spoonful three times a day. Most patients take the oil best im- mediately or soon after meals." The pure oil is better than the emulsions and may be taken in whiskey or brandy to disguise its taste. The lacto'phxm'pliate of lime, if well prepared, is a most valuable agent in the treatment of incipient and the more chronic PHTHISIS. 427 cases of phthisis. It may be given in a close of a tea- to a des- sertspoonful of the syrup three times a clay after meals with cod- liver oil. The hypophosphites are valuable agents to promote the con- structive metamorphosis. Arsenic is deserving of special com- mendation, in incipient phthisis, to promote the appetite and favor tissue building, while it corrects the disordered state of the stomach mucous membrane. It must be given in small closes, two drops of Fowler's solution three times daily. The iodide of iron and cod-liver oil will control the tendency to catarrhal attacks. In tubercular and fibroid phthisis, among the earliest symptoms are stomach disorders, poor appetite, atonic or acid indigestion, and especially repugnance to fatty elements of food. The mineral acids, with a bitter, such as tincture of nux vomica, are especially serviceable. If there be acid eructations, pyrosis and heart-burn, the mineral acids, especially dilute nitric (ten to fifteen drops, well diluted t. i. d.) should be administered before meals; but if the conditionbe atonic indigestion, the acicl should be given after meals. The nux vomica tincture should be given before meals — fifteen drops in water. Quinine. — In some cases of phthisis sulphate of quinine is one of the most reliable and satisfactory antipyretics. One tenth of a grain of morphine combined with the quinine increases its antipyretic powers (Loomis). Loomis also gives five grains of antifebrin two or three times in 24 hours to phthisical patients whose temperature ranges much above the normal, and finds that their appetites are improved during its use, and nervousness lessened. In many cases, after the disease has passed the first stage, the fever cannot be controlled. Couqh. — If the couo-h is verv distressing, o-aro'lino- the throat with a solution of bromide of potassium, or applying a mixture of chloral and camphor by means of a camel's hair brush to the fauces, and the atomization of a solution of cocaine or of mor- phine, are temporarily beneficial. FothergiU's prescription of hydrobromic acid diluted and spirits of chloroform sometimes acts well. A combination of codeine, atropine and strychnine is highly efficient as a remedy for cough, for night- sweats and reflex vomiting. Picrotoxin allays the vomiting which accom- 428 A COMPENDIUM OF PRACTICAL MEDICINE. panies the cough almost as efficiently as strychnine. The patient should try to suppress the cough. The irritable feeling in the fauces may be allayed by a bit of gum arabic, candy, or troche. The officinal troche of licorice and opium, or of morphine and ipecac, may be used. Paregoric will often allay the cough. The inhalation of a few drops of chloroform will often control the cough. Ammonium carbonate in the infusion of wild cherry bark is one of the best stimulating expectorants, and it never nauseates. A solution of morphine in glycerine applied to the fauces with a brush, relieves the cough of phthisis. A better mixture is glycerine two parts, whiskey one part and crystalized sugar enough. This should be allowed to trickle slowly down the fauces. Tannic acid (gr. xx. to Siv. of aquae) is good in chronic throat troubles. It may be used as a spray. Night- sweats are a part of hectic. When quinine does not control them, quinine and opium may do so. Oxide of zinc (gr. ij-iv.) gallic or sulphuric acids, arseniate of iron (gr. \ to-J-), ex- tract of belladonna, or sulphate of atropia hypodermically, picrotoxine, ergot, all may be tried at different times. Atropia is the most reliable. Sponging the body with hot water, or vinegar and water, is sometimes effective. Sponging with as- tringent waters (alum in alcohol) is sometimes efficacious. Diarrhoea. — If the diarrhoea is dependent upon catarrh, with or without ulcerations in the small intestine, cod-liver oil and the hypophosphites of lime and socla will often be of ser- vice. Five grains of pancreatin given two hours after eating will often relieve the intestinal pain even in the later stages of the disease. Ten grains of bismuth, combined with a twelfth of a grain of morphine, after each movement, will almost certainly control the diarrhoea. If the diarrhoea depends upon ulceration of the large intestine, all that can be done is to give temporary relief by opium suppositories. When diarrhoea is persistent and accompanied by rapid emaciation, it is tubercular. For the diarrhoea, Bartholow gives two drops of Fowler's solution and ten drops of laudanum. Vomiting after meals is often a trouble- some attendent of phthisis. Champagne with the food, hydro- cyanic acid, and pepsin are useful, but the most certain relief is PHTHISIS. 429 obtained by giving the patient a glass of hot water every two hours, followed in half an hour by a teaspoonful of raw scraped beef made into a sandwich. Creosote. — Bartholow thinks that from one to five minims of pure beech -wood creosote given three times daily, has distinct curative power in suitable cases of phthisis. Hcemoptysis. — The most valuable remedies for the arrest of haemoptysis are rest and opium. Lead, ergot and ice are recom- mended. Turpentine is more reliable than any remedy except opium. Local pains in the chest may be relieved by blisters, sinapisms, liniments or the belladonna plaster. Antiseptic Treatment by Inlialation. — Bartholow says, "The value of antiseptics by the method of protracted inhalation is just being recognized. The method consists in charging the air of a suitable apartment with a volatile remedy which the patient can breathe for a half to one hour or longer. I advise the inhal- ation by the protracted method of ethyl iodide, carbolic acid, car- bolic acid and^tincture of iodine, iodol, iodoform, oxygen, etc. The method of germicide treatment by rectal injection of sul- phurretted hydrogen, and carbonic acid, has fallen into disuse in this country. I hope I may not be considered egotistic and pre- judiced when I say that this mode (atomization of solutions) of using the remedies is not good — is not effective." Loomis says, " The antiseptic treatment of phthisis has not thus far given satisfactory results. Carbolized inhalations have been quite extensively employed with very favorable results ac- cording to some observers; but, after quite an extensive trial, my experience is decidedly against their use. The injection of cav- ities through the chest walls has not been followed by satisfac- tory results. I have found the hypodermic use of antiseptics to fail, not only in counteracting the sepsis, but in reducing the high temperature. I believe it is utterly futile to attempt to reach the bacilli imbedded in tubercular or caseous products." Again Bartholow says, "Cases of phthisis have been recently re- lated as cured by the inhalation of highly heated air. If the air is deprived of its moisture the temperature at which it can be in- haled ranges from 150° F. to 300° F. This method is based on the power of heat to inhibit or destroy the bacilli. It is proba- 430 A COMPENDIUM OF PRACTICAL MEDICINE. ble that this mode of treatment will develop into a highly suc- cessful one." Hygienic Treatment of Phthisis. — Phthisical patients should sleep in large well -ventilated and well -lighted rooms with a southerly or westerly exposure. Flannels should be worn next the skin. Cold sponging or baths often act as tonics. The patient must live as much as possible in the open air, and should avoid sedentary occupations. Diet. — The diet should be generous as regards quantity, quality and variety. The articles should be highly nutritious and adapted to the digestive powers. Phthisical patients should drink from one to three quarts of milk each day. Cream, butter and sugar should enter into the diet as 'largely as possible. Change of Climate. — Bartholow says, "No change of climate can be beneficial, as a rule, after cavities have been formed, unless of slight extent. It is in incipient phthisis that a change of climate, dry, bracing and elevated, really exerts a curative influence. " Loomis says, "It is well known that some consump- tives thrive best in a warm, moist air, others in a cool, dry air; some are most vigorous in winter, others in midsummer. Each case must be carefully analyzed, before any definite directions can be given as to the climate best suited to it. We know of no climate which is entirely and absolutely antagonistic to its devel- opment. It was once thought that a warm, dry atmosphere alone was beneficial, but we now know that a cold climate not only does not hasten, but often arrests phthisical processes. The purity of the air is the chief reason that elevated regions are so beneficial in phthisis. Organic germs are more abundant in the air in the city than in the country. Rain and ozone free the air from them, the latter by oxidation. Rain cleanses the air of solid particles and purifies it by washing down ammonia and carbonic acid. The presence of ozone in the air is presumptive evidence of its purity. The air of high mountains and plateaux and along the shore of the ocean is richer in ozone than that of the plains. The benefit which phthisical patients derive from living near pine forests has long been known. Turpentine exhaled from pine or hemlock forests converts oxygen into ozone, and thus the PHTHISIS. 431 air of pine forests becomes pure. Both sea and mountain air are cooler and less subject to frequent variations in temperature than the air of the plains. The question arises, will the patient be benefited by sea or by mountain air ? Patients with exhausted nervous systems, with an overtaxed brain from excessive mental labor, or an all-absorbing business, and who still retain consider- able muscular power should go to the mountains; while those past middle life, who have developed phthisis late, who are in- capable of much muscular activity do best in sea air. The health resorts of this country are those of Colorado, Minnesota, Southern California, Georgia, South Carolina, North Carolina, the Rocky Mountain regions and New Mexico. Loomis obtained the best and most permanent results in Asheville, N. C, in New Mexico, and in the Adirondack region of New York state. FIBROID PHTHISIS. In typical cases the lung is shrunken in size, with a corres- ponding retraction of the chest -wall and often a lateral deviation of the spine. In the substance of the lung there are firm, dense bands and masses or nodules of fibroid tissue, frequently deeply pigmented. Tubercles with cheesy centres are also usually present. This variety of phthisis is comparatively rare (Flint), Causes. — It is a disease of mature life, after the middle period, and is extremely rare before thirty (Bartholow). In the majority of cases the age of patients is under forty years (Flint). Next to heredity, chronic bronchitis and pleurisy are the most influential causes (Bartholow). Symptoms. — Fibroid phthisis is the most chronic form of the disease; its early history is that of bronchial catarrh, or of dry pleurisy; and it is not until after months, even years, that, exten- sion taking place to the lungs, the progress becomes more rapid. For months there is merely a dry cough, not very troublesome, but persistent. The expectoration is slight, and is nothing but mucus. The appetite is but little impaired, and the weight and strength are not materially reduced. The symptoms increase in severity during the fall, winter and spring months for two or three years; then fever comes on toward evening, the appetite 432 A COMPENDIUM OF PEACTICAL MEDICINE. lessens, digestion becomes poor, the weight declines, the cough is harassing and prevents sleep, the expectoration becomes more profuse and entirely purulent; there is some difficulty of breath- ing, the pulse is small and weak, and finally slight chilliness is felt in the morning, fever in evening, and sweating occurs during the night. When the bronchi dilate, the expectoration becomes profuse, especially in the morning — a cupful or more may be brought up in an hour or two. The sputum usually contains tubercle bacilli. The matter expectorated is often notably fetid. The fingers often become clubbed (Bartholow and Flint). Physical Signs. — As regards physical signs, they are the same in all forms of phthisis. Differential Diagnosis. — Fibroid phthisis is distinguished from the other forms by its slow progress, by the long period of bronchial troubles before the pulmonary lesions begin, by the merely purulent expectoration, and by bronchial dilatation long before the cavities by excavation form. The initial period, ter- minating in a bronchiectasis, may occupy a number of years; at first for several years, there is winter cough only, the warm season being free or nearly so (Bartholow). Prognosis. — The most chronic of all the forms of phthisis is the fibroid. The course of this disease may occupy several years, indeed, an ordinary lifetime, and prove fatal at last, as it involves lesions which do not admit of recovery (Bartholow). Treatment. — Same as in the other forms. ACUTE MILIARY TUBERCULOSIS. Is characterized by the presence of miliary tubercles in most of the organs of the body. The organs almost constantly affect- ed are the lungs, the liver, the spleen, the medulla of the bones, the kidneys, thyroid gland, the heart, the choroid coat of the eye, the lymph-glands and the serous membranes (Flint). Causes. — It is caused by the entrance of tubercle bacilli into the blood current, and their transportation to most parts of the body. All varieties of local tuberculosis may be followed by acute miliary tuberculosis. It frequently develops in persons TUBEBCULOSIS PLETTBISY. 433 i apparently in perfect health. All tubercles contain bacilli (Flint). Symptoms. — Cases of this disease are rare; they occur mostly after puberty and before the middle period of life. The general symptoms denote a febrile disease. The disease sets in with a chill, a rather rapidrisein temperature from 103° to 107° F., with remissions and a rapid pulse 120 to 150, small, soft and compres- sible. The respirations are from fifty to sixty per minute. Cough is more or less prominent. There is complete anorexia and the prostration is great. The circulation in the extremities is feeble; the finger nails are blue, the lips and nose have also a cyanotic hue, and the countenance soon becomes dusky. The tongue be- comes dry; sordes accumulate about the teeth; food is rejected; tympanites and diarrhoea supervene, the stools have a light yel- low color; there is delirium of a low muttering character and stupor comes on which soon passes into coma. The cases, as a rule, present a striking analogy to typhoid (Bartholow and Flint). Prognosis. — Is unfavorable. The duration of the disease is from a few days to six or seven weeks, with an average of three weeks (Loomis). Treatment. — The consideration of the treatment of acute miliary tuberculosis is a rather barren subject, since it does not appear that any remedy has the least influence over the disease. The condition of the patient is hopeless, and all that the physi- cian can do is to palliate symptoms and sustain the powers of life. This is one of the diseases in relation to which recovery is proof of an error in diagnosis (Bartholow and Flint). PLEURISY. Called also pleuritis, is an inflammation of the pleural mem- brane. It may run an acute, sub -acute, or chronic course, and have for its products fibrin, serum and fibrin, serum, fibrin and pus, or new connective tissue. It may he primary or secondary to some other disease (Loomis). 434 A COMPENDIUM OF PRACTICAL MEDICINE. Pathological Anatomy. — Normally the pleural membrane is smooth, polished and covered with a single layer of en- dothelial cells. The pleural cavities contain normally a small quantity of serum. The first noticeable change in pleuris^ or pleuritis is redness of the pleura from active hyperemia of the vessels. Small extravasations of blood may take place on account of the blood pressure. The pleura loses its glistening appearance, and becomes dull, opaque and rough; the endothelial cells are rapidly cast off. Very soon the surface of the pleura becomes covered with a fibrinous exudation and it becomes rough and shaggy in appearance. The opposing surfaces of the pleura 'may be agglutinated by the fibrin. If any serum exudes it gravitates to the most de- pendent portion of the pleural sac. Those are examples of dry pleurisy, in which a very plastic exudation is throwm out on the two surfaces over a small extent of the membrane, union taking place, there being no other effusion. More commonly, the pleu- risy is of the sero -fibrinous variety. In this variety, in addition to the fibrinous coating of the pleura, the cavity contains serum, varying in quantity from a few ounces to several pints. When pus- cells accumulate in sufficient number, the exudation becomes purulent and the disease is called suppurative pleurisy or empyema (see empyema). The red blood corpuscles may be so abundant as to stain the fluid red; it is then called hemorrhagic pleurisy. In from four to six days after the onset of the inflam- mation newly formed capillaries, which are off- shoots from the pleural capillaries, make their appearance in the deeper parts of the layer of fibrin and cells covering the pleura. The termina- tions of acute pleurisy are either in death, in resolution, in chronic pleurisy, or in empyema. It will be noted that after the most favorable termination of pleurisy the pleura does not return to its normal state, but is left with a new growth of con- nective tissue which binds the pleural surfaces together over a greater or less extent. In this way the pleural cavity may become entirely obliterated by adhesions. The adhesions are at first weak, and may be broken by active exercise or by acts of coughing. Chronic pleurisy differs only in time and extent from the acute form. In pleurisy deformans the exudations are of PLEURISY. 435 great thickness and extent, and by adhesion and subsequent con- traction, extensive deformity of the lung may result. Pleurisy may be general or circumscribed (Bartholow, Flint andLoomis). Causes. — Pleurisy may be primary or secondary. Exposure to wet and cold has been regarded as one of the most frequent causes of primary pleurisy. It may result from a penetrating wound, or blows upon the chest wall, or fracture of the ribs. It is common in early life up to the middle period, but is uncom- mon in old age. It is secondary to lobar and lobular pneumonia, pulmonary tuberculosis, infarctions, abscesses and gangrene of the lung, bronchitis, pericarditis, etc. Pleurisy is a frequent complication of many infectious diseases, such as scarlatina, var- iola, pyaemia, septicaemia, acute rheumatism, Bright's disease, scorbutus and gout. Pus is usually formed in the pleurisies of children (Bartholow, Flint and Loomis). Symptoms. — Acute pleurisy may be mild or severe. There are three stages. The first stage is the period from the attack to the time when effusion takes place. The second stage will extend to the time when the liquid begins to diminish. The third stage is the time occupied in absorption of the liquid. The first stage rarely extends beyond twenty-four hours; the second and third stage are variable. Acute pleurisy with effusion, the ordinary form, sets in as any other acute inflammation, with chill, general malaise, and fever with pain in the side. There may be a well -pronounced chill, but more often chilly sensations for the first few days. The pain is usually acute, lancinating, circumscribed, and is increased by breathing, coughing, or abrupt movements of the body. It is felt at the side of the chest, some- times at the base of the thorax, occasionally in the lumbar and iliac junction. It may be covered with a finger or two. It is commonly called "stitch in the side. 17 The pain may be diffused and ill- defined. It may cease in three or four days, or continue. The respiration is hurried and difficult. The fever, may continue with little variation for about eight days. The temperature in ordinary cases rarely rises above 100° F.; but in very severe cases it may reach 104° F. Cough is usually present, but is sometimes wanting. It is usually suppressed on account of pain. It is a dry, short, tear- 436 A COMPENDIUM OF PRACTICAL MEDICIJSTE. ing, hacking cough. When effusion comes on, the cough de- clines. The expectoration is slight or wanting, and when pres- ent it consists only of a little frothy mucus. The decubitus of the patient is highly characteristic. Before effusion has taken place the patient lies on the sound side; but when the effusion begins to compress the lung the patient lies on the diseased side. If a considerable amount of liquid be rapidly effused the respira- tions are rapid; the patient suffers from a painful sense of tha want of air or dyspnoea, and may be obliged to maintain the sit- ting posture. The pulse is accelerated, beating from 90 to 120 per minute. The countenance has an expression of weariness, anxiety and exhaustion and may be pale or cyanosed. It is a unilateral disease — that is, it affects the pleura of one side only (Bartholow, Flint and Loomis). Physical Signs, — During the first 24 hours of acute pleurisy, inspection shows restrained movements on the affected side, pal- pation, percussion, and mensuration will give negative results. On auscultation the respiratory murmur will be found feeble over the affected side, and a grazing friction sound will be heard. As the plastic exudation takes place inspection will show a, greater loss of expansive motion on the affected side ; palpation shows diminished vocal fremitus; percussion gives slight dull- ness: auscultation shows feeble respiratory murmur, and a fric- tion murmur will be heard on inspiration and expiration. If the pleurisy is confined to the pleura of the diaphragm or medias- tinum the friction sound will not be heard. When there is con- siderable effusion, inspection will show more restricted move- ments; palpation shows absence of vocal fremitus at the bottom of the pleural cavity, (on the sound side the vocal fremitus is exaggerated); on percussion, dullness or flatness is found at the base of the chest, and the finger which serves as a pleximeter, feels an increased sense of resistence. Changing the position of the patient changes the line of dullness. The resonance overtjae lung above the level of the liquid is increased, constituting vesiculo- tympanitic resonance. On auscultation the respiratory sound will be absent below the level of the fluid, and feeble above it. (In health the vocal fremitus is greater on the right side). When the pleural cavity is completely filled with fluid, PLETTEISY. 437 inspection will show an enlargement of the affected side, and a bulging of the intercostal spaces. On the sound side the respir- atory movements are increased. If the effusion is in the left pleural cavity, the heart will be displaced to the right, and the apex-beat may be noticed under the right nipple; if it occupies the right pleural cavity the apex-beat will be carried to the left, beyond its normal position. The circumference of the affected side at the end of expiration, will be one or two inches greater than that of the healthy side; but at the end of inspiration the difference will be but slight. Palpation shows absent vocal fremitus, or in rare cases vocal fremitus may persist and even be increased. Percussion shows flatness. Auscultation shows entire absence of the respiratory sounds, and vocal sounds will be dis- tant and indistinct. At the upper portion of the pleural cavity bronchial respiration and bronchial voice, or bronchophony will be heard. As the fluid is absorbed the friction murmur returns, and is sometimes so loud as to be heard by the patient himself (Bartholow, Flint and Loomis). Differential Diagnosis. — Pleurisy may be confounded with pneumonia, intercostal neuralgia and pleurodynia. Pleurisy begins by chilliness, which persists for several days — pneumonia by a severe rigor, rarely two; the pain in pleurisy is a stitch, a lancinating pain, which can be covered by the finger, pneumonia by a sense of soreness and pain much more diffused; the fever in pleurisy is continuous — in pneumonia there is a distinct crisis or lysis, somewhere from the fifth to eleventh day; the duration of pleurisy is indefinite — of pneumonia self -limited; the expectora- tion of pleurisy is simply frothy mucus — of pneumonia rusty or bloody; in pleurisy the vocal fremitus is absent — in pneumonia it is not only present but exaggerated; in pleurisy there is a fric- tion sound, no crepitant rale, and the bronchophony is not so well defined — in pneumonia there is no friction sound, the crepi- tant rale is present, and bronchophony is loud and clear; in pleurisy with effusion there is more decided dullness, the inter- costal spaces are pushed out, and the thorax enlarged; in pneu- monia the percussion note is not so fiat, the intercostal spaces and the size of the thorax remain normal. Intercostal new*algia denotes a neuralgic affection of the intercostal nerves. The term 438 A COMPENDIUM OF PRACTICAL MEDICINE. pleurodynia is applied to a painful affection of the muscles of the thorax. Both affections may be characterized by pain resem- bling that of either acute pneumonia or pleurisy; that is, a lanci- nating pain felt especially in the act of inspiration. They may be accompanied by a dry cough which is acutely painful. In cases of pleurodynia there may be pyrexia, and this may acci- dentally exist in cases of intercostal neuralgia. But intercostal neuralgia, as a rule, is not accompanied by pyrexia, and has three isolated points of tenderness, namely, behind, near the dorsal vertebrae; laterally in one, two or three intercostal spaces; and anteriorly, in one or more intercostal spaces near the sternum or over the epigastrium. In pleurisy there are signs denoting effusion and a friction murmur. Pain in pleurodynia and inter- costal neuralgia is more marked, as a rule, in movements of the body than in the respiratory movements, the reverse being true of the pain of pleurisy and pneumonia. Persons affected with intercostal neuralgia are frequently anaemic, and sometimes tubercular (Bartholow and Flint). Prognosis. — The tendency is to recover. Treatment. — In the first stage, the patient should receive a full dose of quinine (gr. xx.) and morphine (gr. ss.) for an adult, and the effect of this kept up by HYe grain doses of quinine combined with gr. -J- of morphine every four hours. Besides the power of morphine to relieve pain, it is an effective remedy in serous inflammation. By relieving pain opium diminishes the determination of blood to the inflamed part; for pain is alone sufficient to occasion an increased afflux of blood to a part. Opium places the system in a condition to tolerate better the local affection. Aconite is a valuable sedative remedy in the early stage of this, as of other acute inflammations. It should be given in drop doses of the tincture every fifteen minutes for two hours, and then hourly. Saline purgatives should be given. When the exudation is poured out, carbonate of ammonia in a solution of the acetate (gr. v.-x. in Sss.) should be given. They should take the place of the quinine and morphine. Saline laxa- tives must be given, and once a day gr. | of pilocarpine may be administered to keep the skin active. PLEURISY. 439 Diuretics are sometimes effective in removing the effusion. Half an ounce of the infusion of digitalis, freshly made from English leaves, given three or four times a day, with the bitar- trate or acetate of potassium, is highly effective. The quantity of fluid ingested should be as small as possible. According to Loomis, if the patient presents the signs of anaemia, the syrup of the iodide of iron should be given in teaspoonful doses three or four times each day. Loomis says: "The remedial agent which seems to me to have the greatest power in promoting the absorp- tion of an effusion is the syrup of the iodide of iron." The diet should be nutritious, tonic remedies are useful, and a little wine or spirit may be allowed. Going out of doors and gentle exercise are to be encouraged. Counter irritation may do good. Cod-liver oil and extract of malt may be given, and the digestion stimulated by bitters and mineral acids. When a large effusion exists, especially if puru- lent, it becomes necessary to remove it by the operation of thoracentesis (see empyema). As death has occurred several times very unexpectedly after the operation of thoracentesis cer- tain precautions are necessary. When the effusion is large, the whole amount should not be withdrawn at once (Bartholow, Flint and Loomis). PRESCRIPTIONS FOR PLEURISY. R Morhpise sulphatis gr. i. Quinise sulphatis gr. xv.-xx. — M. Ft. pulv. no. 1. Sig. : Take at once. (To abort a beginning pleurisy) . — Bartholow. R Tinct. opii deodoratse 3vj. Tinct. aconiti radicis 5ij. — M. Sig. : Eight drops in water every hour. (In acute pleurisy be- fore effusion). — Bartholow. R Tinct. iodini comp oiij. Sig. : Divide the affected surface into three sections and paint one section every day. (For chronic pleurisy with effusion). — Bartholow. R Potassii iodidi oiv. Aqua} 3 vj . — M. Sig. : Take one teaspoonful in milk three times a day. 440 A COMPENDIUM OF PRACTICAL MEDICINE. PNEUMONIA. Is an inflammation of the pulmonary substance or paren- chyma. Pneumonia is the name commonly used, but pneu- monitis is the more appropriate term. The parenchyma of the lungs is composed of pulmonary lobules which are composed of air cells, infundibula, alveolar passages and bronchioles. A bronchus after it enters a lobule is called a lobular bronchus or bronchiole. It divides dichotomously once or twice, and termi- nates in the alveolar passages, into which open the air cells, air vesicles or alveoli. The alveolar passages also divide a few times, and end in funnel shaped spaces called infundibula, the walls of which are composed of thickly placed air vesicles. Pneumonia is known in common language as " lung fever," " winter fever," etc. (Flint). Varieties, — I Acute lobar pneumonia called by German writers croupous pneumonia, by French writers fibrinous pneu- monitis, and by others pneumonic fever. II. lobular, catarrhal or broncho -pneumonia and III. JEmbolic pneumonia, suppura- tive pueumonia or abscess of the lung (Flint). Acute lobar or croupous or fibrinous pneumonia or pneu- monitis is an acute general disease characterized by an inflam- mation of the vesicular structure of the lungs, with an exudation into the alveoli which renders them impermeable to air. A sin- gle lobe, the whole of a lung or both lungs may be simultane- ously involved (Loomis). Morbid Anatomy. — Lobar pneumonia may be divided into three stages. 1. A stage of congestion or engorgement, or hyperemia. 2. A stage of consolidation or red hepatization. 3. A stage of gray hepatization. Another division is into the stage of congestion; the stage of exudation (red hepatization); the stage of resolution (degeneration and extrusion of the exu- dation); and the stage of purulent transformation (gray hepatiza- tion). In the stage of congestion, there are an increased blood supply and the pouring out of an exudation. The lung does not collapse when the thoracic cavity is opened, has a reddish-brown appearance, is heavier, floats in water, but sinks lower than the PXEUMOXIA. 441 normal lung, crepitates but little when pressed, and is no longer elastic. On section a thin, frothy, blood-stained serum exudes. It may be tenacious. In the stage of exudation or red hepatization, there is a pouring out and coagulation of the exudation. There is exuded into the alveoli and bronchioles an albuminous or fibrinous fluid of great viscidity, and with it leucocytes which have wandered from the vessels, and red-blood -corpuscles present by diapedesis, and blood by the rupture of distended capillaries. In the cap- illaries of the inflamed area the blood current is finally stopped. The albuminous or fluid exudation remains fluid for a short time, and then solidifies or coagulates. When this process is completed, the inflamed part is solid, entirely without air, and falls immediately to the bottom when placed in a vessel of water. The volume of the affected lung is increased; so much so that it often bears the impress of the ribs. The lung is friable, easily torn and non- crepitant. On section a dirty red viscid fluid oozes from the surface. The cut surface has a reddish color, and is granular, resembling liver -tissue. This granular appearance is due to the little masses of coagulated exudation filling the cavity of the alveoli. The granules can be lifted out of the mold in which they are formed by means of a fine needle. There are two directions which the inflammatory process may now assume: to- ward resolution, or toward purulent transformation. When resolution takes place, the albuminous material which had solidi- fied undergoes liquefaction, the watery parts being absorbed and the solid expectorated. When the purulent transformation takes place, there is a change in the density and color of the affected lung. The pus- cells become numerous. The consistency becomes less and less until the tissue is a mere pulp, readily breaking down on pres- sure. On section the surface presents a uniformly dirty gray appearance. On slight pressure a reddish gray or dirty white puriform fluid flows from the cut surface. The granular look of the second stage has disappeared. Termination. — Lobar pneumonia may terminate in: 1. Reso- lution. 2. Suppuration. 3. Abscess. 4. Gangrene. 5. Chronic pneumonia. 442 A COMPENDIUM OF PRACTICAL MEDICINE. Abscess may follow suppuration. These abscesses vary in size from that of a pea to one which may occupy an entire lobe. They may open into the pleural cavity. Gangrene occurs in about two per cent, of all cases. It is liable to occur when there is great constitutional weakness, and in chronic alcoholismus or in septicaemia. In childhood, except before the second year, croupous pneumonia is rare. Double pneumonia is more frequent than in adult life. In old age, the pneumonic process usually begins in the upper lobes. Gangrene is far more frequently a termination of lobar pneumonia in old age than at any other period. It is a law of the disease that lobar pneumonia attacks the lower lobe of the right lung most frequently; the next most frequent seat is the lower lobe of the left lung; then the upjoer lobe of the right, the middle lobe of this lung being least fre- quently involved. According to statistics of Juergensen the right lung was affected in 53.7 per cent., the left lung in 38.23 per cent., both lungs in 8.07 per cent. According to Bartholow, the inferior lobe of the right lung is the point of election, being the seat of the inflammation in three -fourths of the cases. Ac- cording to the analysis of 121 cases by Dr. Flint, in 29 cases it was limited to the lower lobe of the right, and in 25 cases to the lower lobe of the left lung. It extended over the whole of the right lung in 27, and over the whole of the left lung in nine cases. It was limited to the upper lobe of the right lung in eight, and to the upper lobe of the left lung in three cases. It was seated in the lower lobe of both lungs in eight cases. The name u crossed pneumonia" has been applied to the disease when the lower lobe of one lung and the upper lobe of the opposite lung are affected. Double pneumonia occurs in from 5 to 15 per cent, of cases, and is more frequent in senile than in the adult period of life. According to Loomis the stage of congestion lasts from one to three days; red hepatization from three to seven days; and gray hepatization from two to thirteen days. In old age the stages merge rapidly into each other; abscess of the lung may occur within 36 or 48 hours after the onset. Over a pneumonic lung there is usually a circumscribed pleurisy. In a strict sense, nearly every case of pneumonia is a pleuro-pneumonia (Bartholow, Flint and Loomis). PNEUMONIA. 443 Causes, — Among the predisposing causes age ranks first. There are three periods in life in which the liability to pneumo- nia is greatest : early childhood; 20 to 40; and after 60. From reliable data it appears that lobar pneumonia is Hve times more frequent in the first two years of life than in the whole succeed- ing eighteen. Xine- tenths of all deaths after the sixty -fifth year are caused by lobar pneumonia. The disease occurs much oftener among males than females. In-door life, a vitiated at- mosphere, excesses, especially alcoholic, and bad hygienic influences of every kind which induce debility favor attacks of pneumonia. Frequently the attack is excited by some unusual exposure, such as working in the cold and wet or sleeping out of doors at night. Diphtheria, measles, erysipelas, small-pox, and other acute infectious diseases must be regarded as predisposing causes. One attack of pneumonia predisposes to others; twenty- eight attacks have been noted in one individual. Pneumonia may follow a severe blow or injury to the chest or shock from any traumatic cause. In the aged, lobar pneumonia has devel- oped as soon as four hours after fracture in the hip joint. Those parts of the year characterized by humidity, high winds and Ioav temperature invite the disease. In this country it prevails most in winter and spring. Pneumonia is unknown in the Polar regions. North and east winds favor its development. Loomis gives the following facts which tend to prove that lobar pneumonia is not a local malady: " Cold does not influ- ence the prevalence of pneumonia as it would were it a local disease (e. g. bronchitis). Wet and cold increase a bronchitis but not a pneumonia rate. Lobar pneumonia is more prevalent in our Southern than in our Northern states, affecting especially the negro population, and often proves the scourge of cotton and sugar plantations. The prevalence of pneumonia increases from pole to equator. All acute general diseases increase with the population, pneumonia does this. Statistics show pneumonia to be more frequent in Xew York City now than twenty years ago. Again, there is no relation between the amount of lung involved and the intensity of the symptoms. In local in ii anima- tions the reverse of this is true. No second chill occurs when another lobe is attacked. The absence of a known period of in- 444 A COMPENDIUM OF PRACTICAL MEDICINE. cubation, of a typical temperature range, and of characteristic surface phenomena, and the fact that the disease is not contagious are the reasons advanced by those who regard it as a local, not a general disease. The resemblances of pneumonia to acute general diseases are: distinct chill, an orderly pyrexia, a rather typical course, i. e. a day of abrupt crisis, a definite duration, and the symptoms following in regular sequence. There is a peculiar facies; an oc- casional herpetic eruption; nephritis is not rare; the cerebral symptoms resemble those of the exanthemata; there are sweats and sudamina; and its mode of commencement. Coma in the old and convulsions in the young indicate that it is an acute general disease. We have abortive cases of pneumonia, just as we have abortive cases of typhoid. Pneumonia is allied to acute general diseases by the fact that certain complications occur. It is some- times a disease of intra-uterine life. No local disease occurs in the fetus. The success of modern methods of treatment based on this belief bears evidence to its being a general, self -limiting, acute febrile disease. Pneumonia is thus admitted to be a gen- eral constitutional disease with local manifestations. It seems probable that the real exciting cause is a microbe (Bartholow, Flint and Loomis). Symptoms. — /. Subjective Symptoms. — For a day or longer there may be malaise, anorexia, headache, dull pains in the limbs, back and lumbar region, vertigo, epistaxis, slight diarrhoea or jaundice, and flashes of heat and rigors. In most cases the in- vasion is sudden, and the disease is ushered in by a distinct chill. Generally the patient is seized with a chill in the night. This chill is intense and prolonged, more so than in any other disease except pyaemia and malarial fever. It lasts from one -half to three hours. Its abruptness and violence are characteristic. A distinct chill is less frequent in the pneumonia of old age; yet when an old person has a marked chill pneumonia may always be suspected. The initial chill is rarely repeated. A child may awake in the night with a burning skin, bounding pulse, flushed face and hacking cough as the first symptoms. With the initial symptoms there are rise in temperature, pain in side, accelerated breathing, dyspnoea, cough, expectoration, flushed and anxious PXEUMOXIA. 445 countenance, headache, loss of appetite, intense thirst, scanty urine, and heavily- coated tongue. The symptoms increase until the day of crisis, when they either suddenly remit and the patient breaks out in a profuse sweat, or they subside by lysis. The defervescence is usually reached between the fifth and ninth day. II Objective Symptoms. — 1. Hespiration is more con- stantly increased in frequency in pneumonia than in any other acute disease, and varies from 30 to 80 per minute. The resjDira- tions may be 80 per minute and the pulse rate not more than 100. The acceleration is not in proportion to the amount of lung in- volved. It is panting, not catching in character. It may or may not be accompanied by dyspnoea. Expansion of the nostrils is an early symptom in the pneumonia of children. 2. Dyspnoea is by no means constant. It does not depend upon the amount of lung involved. It is often so great that the patient is unable to lie down. The greatest dyspnoea occurs where there is marked nervous prostration, and in complicated pneumonia. In children dyspnoea is most marked when the apex of the lung is involved. 3. Pain follows the chill. It is situated under the nipple of the affected side. It is sharp and stabbing, often located over the pneumonic spot, and is intensified by coughing, sneezing, and deep inspirations. It is the pleurisy that causes the jDain. Pneumonia itself is a painless disease. Pain in the affected side rarely continues beyond the third or fourth day. If it continue beyond the eighth day it is evidence of pleuro -pneumonia. It is present in 85 per cent, of all cases. In old age pain is never severe. 4. Cough is present in over 90 per cent, of the cases. It comes on within 24 hours after the advent of the disease. At first it is short and "hacking" in character. Old people with pneumonia often have no cough. 5. Expectoration is characteristic. In the first 48 hours of the disease it is simply frothy mucus. Then it becomes semi- transparent, viscid, gelatinous and tenacious, but never opaque. So tenacious is it that the cup containing it may be inverted without spilling the mass. This tenacity in great part causes the difficulty of expectoration. Its color varies. About the 446 A COMPENDIUM OF PRACTICAL MEDICINE. second day the "brick -dust" or "rusty" sputa may be observed. This color is due to the presence of blood. The sputa may be creamy and yellow, or of a very dark or prune juice color; the latter occurs especially in alcoholic 1 subjects. Greenish sputa may occur in the middle of the disease and during resolution. When resolution occurs the sputum becomes abundant, and of a yellow creamy color. There may be no sputum throughout; or it may not appear until the sixth or even the twelfth day. The sputum may remain brick dust till the ninth or tenth day. In children sputa are usually absent. In senile pneumonia expecto- ration is never an early symptom. The sputa are rusty in about 33 per cent, only of such cases; frothy or catarrhal sputa are the rule. A chocolate -looking serous sputum, appearing soon after the onset of pneumonia, shows a depraved condition and indi- cates "typhoid pneumonia." 6. Temperature-range of a typical case of lobar pneu- monia indicates that it belongs to a remittent or sub-remittent type. The temperature rises suddenly during the initial chill, and in two or three hours after it may range from 102°tol05°F. After the first twenty-four hours the temperature is subject to morning and evening exacerbations and remissions. It is usually highest on the evening of the third day. A sudden rise of tem- perature may indicate a complication. The sudden fall of tem- perature on the fifth or sixth day indicates a crisis, and the beginning of convalescence. The fever may reach its highest point just before the crisis. Pneumonia is one of the few diseases terminating by crisis. When the temperature declines gradually ("lysis"), a normal point is usually reached by the ninth day, sometimes not until the twelfth or fourteenth. A continuously high temperature after the tenth day indicates purulent infiltra- tion. Pneumonia at the apex has the highest tempeiature range. The fifth and seventh are the days of crisis in the majority of uncomplicated cases. Of 867 cases, 677 ended before the eighth day. 7. Pulse varies with the severity, extent and stage of the pneumonia. In mild cases it ranges from 90 to 120; if it con- tinue above 120 the case is severe. The pulse is soft and full at the onset. Later it becomes small and feeble. It is not the most pnetjmostia. 447 extensive pneumonia that is accompanied by the greatest flag- ging of the heart. Heart failure may exist before, or just as hepatization is commencing. "When the heart is failing the pulse shows that the artery is unequally filled by each beat. In chil- dren the pulse rate may be 200 per minute. 8. The skin is often hot and dry until the crisis, but it may be bathed in perspiration from the onset. When the parched skin becomes moist at the acme of the disease and the patient is not relieved, it is an unfavorable symptom. 9. Cowitenance. — In most cases the expression of the coun- tenance is characteristic. The face is anxious, and over the malar bones is a mahogany flush, not diffused as in typhus fever, but well defined and circumscribed. It is called the " pneumonic spot." The rest of the face is pale. Usually one cheek is more flushed than the other; this is due to disturbance of the vaso- motor system. The lips may be cyanosed, but at the crisis they become pale. 10. Herpetic eruption upon the cheeks, nose, lips or eyelids occurs in about fifty per cent, of cases. It is rare before the sec- ond or third day and may not occur until the crisis. Sudamina may accompany profuse sweating. In children while the surface of the body is hot and dry, the extremities are cool and the pneumonic flush is bluish. Cyanosis of the extrem- ities is more frequent than in adults, and herpes IdbialAs is more constant. In old age the pneumonic flush is often the first ob- jective sign of pneumonia. The eye-lids alone are cyanotic. The face assumes a sallow hue and the surface heat is succeeded bv a cold, clammy perspiration. 11. Cerebral symptoms are headache, slight delirium at night (it may be active), coma and convulsions in children. 12. Digestive symptoms may be nausea and vomiting, anorexia and thirst. The tongue and lips may become brown, dry and cracked, and sordes collect on the teeth. The urine in pneumonia is scanty and high colored. Epistaxis is most fre- quent at the onset and at the crisis. Swelling of the veins of the hands in children is an unfavorable symptom. When pneumonia is to terminate fatally, dyspnoea increases, the patient "sinks," the pulse becomes small, rapid and intermittent, moist rales are 448 A COMPENDIUM OF PRACTICAL MEDICINE. heard in the bronchi, the face is livid and the body is bathed in a profuse cold, clammy sweat. Abscess. — Acute pneumonia terminates in abscess in two per cent, of all cases. In these cases, the sputa are copious and fetid, yellowish in color, and consisting almost wholly of pus. The fever is of the hectic type, and is accompanied by rigors and sweats. Gangrene, as a termination of pneumonia, has been found in about 14 per cent, of cases. In these cases there is sudden collapse, rapid, feeble, intermittent pulse, face pale and death- like, and profuse expectoration of blackish -green masses. The breath is offensive and the body has a cadaverous smell. The sickening odor of pulmonary gangrene is most perceptible after coughing. Gangrene has its seat in the lower lobes of the lung. Purulent infiltration may be suspected when resolution does not take place at the period of crisis and the temperature remains high, accompanied by symptoms of prostration and profuse purulent expectoration. Death results from exhaustion. Typhoid pneumonia is a term that has been applied to a pneumonia attended by typhoid symptoms. There is no sputa, no dyspnoea, no pain, no cough. Sordes collect on the teeth and gums. The tongue is thickly coated, and later covered with thick black crusts. There is stupor, somnolence and continual low, muttering delirium. This form is common in the aged. Bilious, or gastric pneumonia, is lobar pneumonia occurring in malarial districts, accompanied by gastro- enteritis with hepatic symptoms. Physical Signs.—/. First Stage, or Stage of Congestion. — Inspection shows diminished respiratory movements on the af- fected side. Palpation shows increased vocal fremitus over the affected lung. Percussion shows slight dullness. Auscultation shows a feeble vesicular murmur. There is broncho-vesicular breathing. Within 24 to 36 hours there is heard with or at the end of inspiration a fine crackling sound over the inflamed region — the crepitant rale. This rale is highly diagnostic of pneumo- nia. It has been compared to the sound produced by rubbing a lock of hair between the fingers in front of the ear, and to the burning of grains of salt on live coals. As the sound is produced by the separation of the bronchioles and alveoli, adherent by the PNEUMONIA. 449 viscidity of the albuminous exudation, it is obvious that it can occur only during inspiration. When consolidation takes place, the crepitant rale ceases. IT. Second, or Stage of Heel Hepatization. — Inspection shows lost respiratory movements of the affected side, and in- creased on the sound side. Palpation shows increased vocal fremitus. Percussion gives complete dullness. Auscultation gives bronchial respiration and bronchophony is heard over the whole of the consolidated lung. If the pleural cavity be partly filled with fluid, the voice sounds may be segophonic at the level of the fluid. Pectoriloquy may be heard (i. e., when the voice sounds directly into the ear from the chest). Ill Third, or Stage of Gray Hepatization. — Inspection shows returning respiratory movements. Palpation shows vocal fremitus gradually diminishing. Percussion shows diminishing dullness. Auscultation shows broncho -vesicular breathing, and rale redux (i. e., resolving subcrepitant rale). Differential Diagnosis. — Pneumonia may be confounded with pulmonary congestion and oedema, capillary bronchitis, pleurisy, hypostatic congestion, catarrhal pneumonia, pulmonary infarc- tion, meningitis and typhoid fever. Pneumonia commences with a chill, followed by a rapid rise in temperature and pain in the side. There is no chill, no fever, and no pain in pulmonary congestion and oedema. The expec- toration of pneumonia is viscid and rutsy; in pulmonary congest- ion and cedema, it is profuse, watery and blood-stained. As a rule, pneumonia is unilateral; pulmonary oedeina is bilateral. In capillary bronchitis there is heard all over the chest the sub- crepitant rale, the expectoration is niuco- purulent, the tempera- ture range is low, there is no dullness on percussion, no bronchial breathing, and cyanosis is marked. The breathing is labored in bronchitis, and panting in pneumonia. Acute plev/risy begins with chilliness, or several rigors, and low temperature; pneu- monia with a distinct chill followed by fever. In pleurisy tie face is pale and anxious, and the pulse is firm, small, tense, and wiry; in pneumonia the face has a mahogany flush, and the pulse is full and compressible. The breathing in pleurisy is catching; in pneumonia it is panting. In pleurisy there is a dry. hacking 450 A COMPENDIUM OF PRACTICAL MEDICINE. cough with mucous expectoration; in pneumonia rusty sputum. In pleurisy with effusion, vocal fremitus is diminished, there is flatness on percussion, the respiratory sounds are feeble, and there is friction sound; in pneumonia vocal fremitus is increased, dullness on percussion, crepitant rales and bronchial breathing is present. In hypostatic congestion, the expectoration is copious, watery and blood-stained. It disappears when the patient sits up. Catarrhal or lobular pneumonia in children is usually secondary to bronchitis, is developed in both lungs, has no days of crisis, and no chill. Pulmonary infarction is rare without cardiac disease or pyaemia, is non febrile, and has intense dyspnoea. The expectoration is small black clots. Cases of pneumonia with cerebral symptoms may be mistaken for meningitis, but this can only happen should the chest not be examined. In meningitis there are no thoracic symptoms, no dyspnoea, and the face is pale and anxious. Pneumonia with typhoid symptoms is sometimes mistaken for typhoid fever. But the pneumonia which compli- cates typhoid fever does not come on until late in the fever, and the regular history of typhoid fever precedes its development (Bartholow and Loomis). Prognosis. — About twenty per cent, of cases of pneumonia die. The prognosis depends on the age of the patient. After sixty the prognosis is always unfavorable. Most "sudden deaths" in the old are from acute lobar pneumonia. Double pneumonia is rarely recovered from. Complications such as pleurisy, capillary bronchitis, and pericarditis render the prognosis unfavorable. The symptoms which are unfavorable are as follows: frequency and feebleness of the pulse; great frequency and labor of respira- tion; lividity of the prolabia and face; an abundant purulent or muco-purulent expectoration; prune- juice expectoration; active violent delirium; low muttering delirium with prostration and subsultus tendinum. The occurrence of purulent infiltra- tion, abscess, or gangrene renders the prognosis unfavorable (Bartholow and Loomis). Treatment. — Acute lobar pneumonia is a well defined, self- limited disease. It is thought to be a constitutional disease with a local lesion. Loomis says " The pneumonic lung no more re- quires treatment than the intestinal ulcers of typhoid fever. It is PNEUMONIA. 451 the general condition of the patient not the local changes, which is to govern ns in the management of each case." If a patient be seen during the stage of congestion, Bartholow would apply five to ten f nil -sized leeches. Flint states that full doses of quinia, that is from 20 to 40 grains, given either at once or within eight or ten hours, may arrest the disease. Aconite is an effective sed- ative. Two to five drops of the tincture of aconite root may be given every two hours in the first stage. A large mustard poul- tice should be put on the chest, and removed when the skin is reddened, to obtain its stimulant effect on the vaso- motor nerves within, and the feet should be immersed in a hot mustard foot- bath. Bartholow states that modern researches have shown that calomel has a sedative action on the liver; lessens bile production and probably the whole functional activity of the liver; and as all cases of pneumonia are accompanied by hepatic disorders, it is clear that calomel is indicated. Calomel acts as an antipyretic and should be given on the first, second and third clays of the disease in doses of from three to five grains. When the exudation begins to coagulate a solution of the carbonate of ammonia (gr. v.-x.) in liquor ammonii acetatis (oss) every three or four hours is very useful. The Germans prefer the muriate in the same doses. The chest may be surrounded with cotton -batting or flannel jacket. Absolute rest is essential. The sick room should be well ventilated, and its temperature between 65° and 70° F. The diet should consist of milk, eggs, beef- tea, and concentrated broths. For the first four days Loomis would keep the patient under the full influence of opium by hypodermic injections of morphine. There are two sources of danger — heart failure and high temperature. Alcohol is the most efficient means for pre- venting heart failure. It is best to begin with small doses, when the pulse is frequent, feeble and irregular, and not more than six or eight ounces of brandy should be given in twenty-four hours. A dicrotic pulse, delirium, muscular tremor and collapse are indications for alcohol. To reduce the temperature there are two plans of treatment: the application of cold and internal antipyretics. Coldsponging may be practised when it is grateful to the patient. Of fche antipyretics, antipyrin and antifebrin are employed. Antifebrin 452 A COMPENDIUM OF PRACTICAL MEDICINE. is to be preferred. In some cases of pneumonia quinine is more efficacious than antif ebrin in reducing fever, given in doses of gr. x-xx. every two hours. If there is restlessness or wakefulness in the third stage, chloral hydrate serves a most useful purpose. Fifteen grains at night is usually all that is required. To pro- mote the expectoration and to relieve the cough the proper reme- dies should be given. In weak subjects a little wine may be given from the beginning (Bartholow and Loomis). PRESCRIPTIONS FOR PNEUMONIA. j& Potassii iodidi 3j. Ammonii muriatis ^iss. Mist glycyrrhizse co 5yj. — M. Sig. : A tablespoonful four times a day, to promote absorption together with blisters to the chest. — DaCosta. {& Pulv, digitalis gr. vj. Quinige sulphatis gr. xij. Ext. opii Ext. ipecacuanha aa .gr. iij. — M. Ft. massa et in pil. no. xii. div. Sig. : One pill three times a day with the preceding mixture. — DaCosta. Jfc Ammonii carbonatis gr. xl. Infusi serpentarise , %iv. — M. Sig. : A teaspoonful every three hours. (As a stimulant about the crisis). — Bartholow. jfc Tinct. veratri viridis ZHxl. Spts. setheris nitrosi gvj. Liq. potassii citratis ^ivss. Syr. zingiberis ad gvj. — M. Sig. : A tablespoonful every three hours. (In early stage.) — DaCosta. Jfc Pulv. sinapis ^ss. Pulv. seminis lini Iviij. — M. Ft. cataplasma. Sig. : Apply to the chest covering with oiled silk. — J. Lewis Smith. Lobular Pneumonia. — Called also catarrhal or broncho -pneu- monia is always secondary, being preceded by inflammation and obstruction of the smaller bronchi, which lead to the consolidat- ed lobules (Loomis). PNEUMONIA. 458 Causes. — It may be excited by an extension downward of a catarrhal process from the tubes to the air cells. It is most frequent between the ages of one and three, and in old age. The bronchitis of measles, whooping cough, influenza, etc., often leads to lobular pneumonia. Bad hygienic influences as to dress, habitations, humidity and exposure, favor its development (Bar- tholow and Loomis). Symptoms. — The beginning symptoms are chilliness, followed by fever, soreness of the chest beneath the sternum, cough, ex- pectoration of a frothy mucus and some difficulty of breathing. Soon the breathing becomes rapid, superficial and labored, and the alse of the nose work quickly and continuously. The face at first is flushed and rather animated, and the eyes have a glaring expression, but the lips soon become bluish and cyanosis spreads over the face. The cough, which during the preceding bron- chitis was loose, loud and bronchial, now becomes dry, hacking, and is usually very painful. The pulse ranges from 140 to 200 per minute. The temperature will gradually rise to 104°- 105° F., unlike the sudden rise of lobar pneumonia. As the dyspnoea in- creases, there is increasing restlessness, never a moment of quiet, the struggle for breath and search for an easier position being incessant. The respirations are panting and may be 100 per minute. As the struggle for breath continues, the superficial veins grow into thick black cords, the result of carbonic acid poisoning, and the patient, a child, may tear the skin about the neck and face with its nails in a vain effort to remove supposed obstructions. The tongue becomes dry; sordes collect on the gums and teeth, and aphthous stomatitis is common (Bartholow and Loomis). Physical Signs. — Inspection shows a deep depression of the abdomen from retraction of the lower ribs on inspiration. Pal- pation shows increase of vocal fremitus when a considerable number of lobules have collapsed. Percussion shows no change until the atelectasis occurs, and then slight dullness. Ausculta- tion shows abundant rales all over the chest. They consist of subcrepitant rales which are somewhat coarser and louder than the crepitant, and are audible with both inspiration and expira- tion. There are also mucous and sub-mucous rales produced in 454 A COMPENDIUM OF PRACTICAL MEDICINE. the larger tubes. There may be bronchophony (Bartholow and Loomis). Differential Diagnosis. — Catarrhal or lobular pneumonia may be mistaken for croupous pneumonia, bronchitis, acute tubercu- losis and oedema of the lungs. Croupous pneumonia is, as a rule, unilateral and limited to a certain area; catarrhal pneu- monia is bilateral and diffused over both lungs. The one is a self -limited disease, the other has no fixed duration. Capillary bronchitis may be primary; lobular pneumonia is always second- ary. The breathing is labored in capillary bronchitis and pant- ing in pneumonia. The one gives resonance on percussion, the other dullness. In acute tuberculosis the fever is higher than in pneumonia. Acute tuberculosis occurs in early adult life. Lob- ular pneumonia occurs oftenest in the child of one to four years. In oedema of the lungs there is no fever (Bartholow and Loomis). Prognosis. — Half the cases die. The average duration of acute lobular pneumonia is from ten to fourteen days (Bar- tholow and Loomis). Treatment. — To promote the expectoration Bartholow would give three to six grains of the carbonate of ammonia and four to eight grains of the iodide of ammonia in solution every two hours. Some authorities would give the muriate of ammonia. Oil of turpentine, eucalyptol and copaiba may be used for the same purpose. If there is excessive dyspnoea Bartholow would give two to three grains of the subsulphate of mercury to produce vomiting, and thus dislodge the muco-pus. For the high fever the same author would give two drops of tincture of aconite root, and one of tincture of belladonna, every two hours to a child of two years. For the continued high temperature three grains of quinine and one-fourth of a grain of digitalis can be given morn- ing, noon and evening to a child of two years. The patient should be kept in a warm room well ventilated. The air of the room may be filled with the vapor of oils of eucalyptus and tur- pentine, by heating them with water. The chest should be enveloped in linseed or mild mustard poultices, or in very young children a stimulating liniment may be rubbed on the chest two or three times a day and cotton -batting applied. The food should be fluid and nutritious. Stimulants must be given from PEIAPISM. 455 the onset of the disease. Brandy or gin in milk, ten to twenty drops every three or four hours, may be given to a very young infant. If the disease is prolonged and emaciation is marked, cod -liver oil and the syrup of the iodide of iron should be given, with a change of air (Bartholowand Loomis). PRIAPISM. Is more or less continuous erection without desire. Inter- course with ejaculation may take place in some forms of priapism (Keyes). Causes. — Erection has long been observed to follow injuries to the cerebellum and spinal cord. Out of eleven cases of cere- bellar hemorrhage, erection of the penis was noted six times by Serres. Death by hanging is often accompanied by partial erec- tion. Erections are often absent after some diseases and injuries of the spine producing paraplegia; but in other cases the disease or injury is attended by priapism. Lallemand mentions the case of an officer who was thrown from his horse, and at once became paraplegic, and had priapism. As his paraplegia gradually got well his priapism ceased. The same author states the case of a soldier, who climbing out of garrison to see his mistress, fell upon his sacrum, and became partially paraplegic with priapism. As the priapism produced retention of urine, he attempted to free himself of it by masturbation, but without success. On one occasion, he indulged in copulation with his mistress almost con- tinously for several hours, until he had exhausted his partner — but all to no effect. He had no pleasure or ejaculation. Large doses of cantharides will produce erection without desire. Prolonged mental exertion, over-anxiety, etc., are some- times attended by priapism, due perhaps to some local injury, as gonorrhoea, the passage of a stone or a sound. Some prostatic affections are attended by priapism. Many writers mention leucocytlicemia as a cause of persistent priapism. Salzer gives as causes extravasation of blood in the corpora cavernosa, impeded circulation in the smaller vessels and the formation of thrombi. Mackie notes a case of persistent priapism lasting twenty- one days in an old man of seventy. After nineteen days the right 456 A COMPENDIUM OF PRACTICAL MEDICINE. corpus cavernosum swelled and was relieved by incising it. He thinks that a small extravasation in the corpus cavernosum was the immediate cause of the priapism. Priapism in children is often due to stone in the bladder, tight prepuce, worms in the rectum, etc. (Keyes). Treatment. — Is hygienic and symptomatic. The lower part of the spine and peringeum may be blistered. Electricity, strych- nine, ergot and bromide of potassium may be tried. Iodide of potassium has been successfully used (Keyes). PRICKLY HEAT. Called also lichen tropicus because it is met with in tropical climates in its most typical form, is a congestion or slight inflam- mation at the orfices of the sudoriparous follicles (Anderson). Cause. — Heat is the exciting cause. Symptoms. — Little, bright red, acuminated papules, about the size of pinheads, make their appearance in great numbers, giving to the skin a rough feeling. They may be closely set to- gether, but generally remain discrete, the intervening skin having a healthy appearance. Here and there little A^esicles, such as are observed in sudamina, often make their appearance. This erup- tion is found chiefly upon the trunk and forehead, and is accom- panied by a tingling, pricking, or itching sensation. It is aggra- vated by the use of stimulating food and drink, as well as by heat and over -clothing. The rash frequently occurs in successive crops and the duration is indefinite (Anderson). Treatment. — Keep the patient cool. The skin may be fre- quently sponged with vinegar and water, or a weak lotion of carbolic acid followed by a soothing dusting powder, such as equal parts of oxide of zinc, lycopodium and starch. The diet should be very light and unstimulating. Saline aperients are useful, as well as diuretics and cooling acidulated drinks (Anderson). PROSTATITIS. Is an inflammation of the prostate gland. Congestion "of the prostate occurs physiologically during venereal excitement. If such excitement be unduly prolonged without being gratified, PROSTATITIS. 457 or if the imagination be given up to erotic fancies, the mucous follicles of the organ secrete more or less of a peculiar, viscid, bluish mucus, without odor, which mixed with urethral mucus, finds its way out at the meatus. This is perfectly natural. It is analogous to the watering of the mouth of a hungry individual at the sight, smell, or even thought of food. This drop of mucus appearing during erection excites in the minds of many individ- uals whose sexual requirements are not met, the most lively alarm, and they hasten to consult a physician. Marriage, to place him in natural sexual relations, will effect a cure. If this physiological hyperseinia be kept up for a long time, the prostate is liable to remain congested, and cause frequent urination and a gleety discharge. Slight congestion of the prostate frequently complicates gonorrhoea and stricture, and it may pass on to actual inflammation. Congestion may be excited in the prostate by sexual excess and lead to prostatitis (Keyes). Causes. — Among the causes of parenchymatous prostatitis may be mentioned gonorrhoea, stricture, extreme and prolonged sexual excitement, acid urine, cold, injury, strong injections, and cantharides internally. Gonorrhceal inflammation after the first week, may run down the urethra and involve the prostate, if the patient indulge in alcohol, sexual intercourse, takes violent exer- cise, or uses strong injections deep in the canal. The inflamma- tion behind a stricture may run back to the prostate. Termination. — Prostatitis commences as congestion and passes on to true inflammation. It terminates by resolution with exu- dation of pus, by abscess, or it may linger indefinitely as a chronic inflammation (Keyes). Symptoms. — The prostate swells rapidly and often attains the size of an orange. The mass may be felt with the finger in the rectum, and is exceedingly sensitive to pressure, unlike hy- pertrophy of the prostate. In prostatitis, the finger in the rectum or pressure over the pubes brings on a desire to urinate. The patient is conscious of something protruding into the rectum. The perinseum feels hot and is sensitive to pressure. There is a feeling of weight and dragging in the pelvis, penis and scrotum. There may be pain in the back and limbs. The stream of urine is small and is passed with effort. The prostate may swell to 458 A COMPENDIUM OF PRACTICAL MEDICINE. suet, an extent as to cause retention. There is a constantly recurring, never -satisfied desire to urinate. Voiding the urine causes pain, but the pain is most severe as the last drops are being expelled. The patient has fever, and is irritable, despond- ent and suspicious. Recovery is complete in from one to three weeks (Keyes). Treatment. — The main treatment is rest in bed with hips raised, some alkaline diluent for the urine, and enough anodyne to control severe pain. Rectal injections of hot water may be given. The patient may drink flaxseed- tea, infusion of triticum repens with some citrate of potash or Vichy water. If the pros- tatitis is due to gonorrhoea all active treatment and urethral injec- tions must be discontinued. Ten to fifteen leeches may be applied to the perinseum. Hot applications to the pelvis are useful. At night full doses of bromide of potassium with from gr. v.- xx. chloral hydrate maybe given to produce sleep (Keyes). PROSTATORRHCEA. Is also called follicular prostatitis. In this disease, the mucous surface of the sinus of the prostate and of the mucous follicles and ducts are inflamed, while the substance of the organ for the most part escapes. Symptoms. — It runs a chronic course. It may come on dur- ing gonorrhoea as the inflammation extends backward. The main feature of the disease is a slight oozing from the meatus of a muco- purulent matter. The discharge may be more profuse when at stool. The patient thinks the discharge to be semen. This discharge is exceedingly rebellious to treatment. If the prostatorrhoea, or follicular prostatitis, and the parenchymatous coexist, then a peculiar weight is felt in the perinaeum with pain. Walking becomes painful. Crossing the legs decidedly increases the pain, as does the sitting posture. There is frequency of urination. There is pain on passing water, which contains pus and blood. The pain may be felt at the end of the penis. The stream of urine is sometimes suddenly interrupted. The patient may be feverish and depressed. A slight gleety discharge accom- panies this condition (Keyes). PRURIGO. 459 Treatment. — Xo remedy is so efficacious as blistering of the perinaeum. Cantharidal collodion may be painted on one side of the perinaeum, and the patient confined to bed for forty -eight hours, then the other side may be painted. Alkaline diluents may be given, and the bowels kept regular. A good diet and tonics are necessary. If this treatment fail, nitrate of silver (gr. v.-x. to the 5j.) may be injected into the membranous urethra (Keves). PRURIGO. Is a papular skin disease with intense itching. Causes. — Yerv little is known concerning its cause. The fact, however, that it is met with almost exclusively amongst the neglected children of the poor, seems to lead to the conclusion that defective diet and absence of proper hygienic surroundings are favorable to its occurrence (Anderson). Symptoms. — As a rule it begins in infancy, usually at first upon the legs in the form of wheals like those of nettle-rash. These come and go until the child is iive to seven years of age. At this time many solitary papules, about the size of hemp- seeds, make their appearance. They may be more readily felt than seen. The papules are irritable and soon become congested by scratching. The skin assumes a dusky tint and is covered with a fine mealy dust, and short stiff hairs. In some cases the skin feels as rough as a file and is thickened. The papules may sup- purate. The eruption is more severe upon the extensor sur- faces of the legs and arms than on the flexor surfaces. The trunk suffers some but the head, neck, scrotum, penis, palms and soles are usually free. Prwrigo is a most loathsome disease when fully developed. It is common in parts of Europe, but is rarely met with in England and America (Anderson). Prognosis. — Is very unfavorable. Hebra said that the patient may do whatever he pleases yet his malady will follow him to his grave (Anderson). Treatment. — The diet should be generous and the hygienic surroundings good. Tonics are indicated and a long continued course of arsenic in full doses. Carbolic acid internally thrice daily is beneficial. Local treatment is important. Warm, vapor 460 A COMPENDIUM OF PRACTICAL MEDICINE. or Turkish baths should be ordered. A mixture of equal parts of soft soap, rectified spirit and oil of cade may be rubbed firmly into the skin in the morning and removed in the bath at bedtime, after which the following ointment may be applied: K S ulphuri? Glycerinae 01 ei rusci aa 3 vi . Ung. rumicis 3ij-— M. Ft. ungt. Sig. : Apply locally. In some cases baths of corrosive sublimate, (5ij to the bath) are beneficial (Anderson). PRURITUS. Is a functional affection of the skin characterized by irrita- tion or itching and unaccompanied by eruption. Pruritus is a common affection. It may be continuous or intermittent, and is most complained of after getting warm in bed. It may involve the whole body, as we often see in old people whose health is failing; but more commonly it is localized, and the parts most liable to be attacked are the anus, the scrotum, and the labia (Anderson). Causes. — In any case, it is the result of direct or reflex irrita- tion of the cutaneous nervous filaments. Derangement of the digestive organs and constipation may cause it. Diseases of the kidneys, uterus and ovaries may produce it. It often results from impediment to the free return of venous blood from the part. It accompanies jaundice and results from the poisonous action of the bile acids, circulating with the blood, upon the nerves of the skin. A frequent source of pruritus is the presence of sugar in the urine, especially of that form which attacks the genital organs. Elderly women who have intense itching in and around the vulva, probably have glycosuria. Sometimes the cause of the pruritus disappears, while the itching continues owing to the cutaneous nervous filaments having contracted a bad habit. Finally, it may result from cold, and is then chiefly met with on the lower extremities (Anderson). PRURITUS PSORIASIS. 461 Treatment. — Try to ascertain and remove the cause. If de- pendent on haemorrhoids, jaundice, diabetes niellitus, or digestive derangement, treat these morbid conditions. If the cause cannot be discovered, the treatment will be purely empirical, and in these cases it is desirable to have a good many strings to our bow since the affection is very obstinate. In such cases carbolic acid may be tried in the following formula: Be Acidi carbolici ^ij. Syrupi aurantii §j. Aquse %v. — M. Sig. : A teaspoonful in a glass of water three times daily on an empty stomach. Nerve tonics, as strychnine, phosphorus, and arsenic may be beneficial. Atropine may be tried as a nerve sedative. Dr. Eulkley, of New York, would give ten drops of the tincture of gelsemium every half hour till relief is obtained, or until one drachm is taken. If these remedies fail, bromide of potassium, sodium, or ammonium may be tried. Occasionally relief is ob- tained by sponging the surface with a warm decoction of poppy heads, or by the application of a weak continuous current of electricity. Alkaline baths may be tried (Anderson). PSORIASIS. Is a chronic eruption characterized by the appearance of dusky -red, or even coppery, slightly elevated patches of various sizes, covered with silvery -white, imbricated, and very adherent scales, with slight itching, but no exudation of the surface of the skin. Frequency. — It is by far the most frequent of the affections of the skin, except eczema and scabies. Parts Attacked. — The eruption may occar on any part of the body, but in the majority of cases it commences on the elbows or knees, and is frequeutly limited to these parts. Next to the elbows and knees the head is the part most commonly attacked (Anderson). Causes. — Are very obscure. Psoriasis is an hereditary dis- ease. Sir E. Wilson was of the opinion that psoriasia is "a manifestation of the syphilitic poison, after transmission through 462 A COMPENDIUM OF PRACTICAL MEDICINE. at least one, and probably through several generations. " There is a non- syphilitic and a syphilitic form. Psoriasis may be in- duced by debility, but usually patients are in apparently good health. Long continued mental fatigue, as from over- study, great anxiety, etc., is very apt to call out the disease. It is met with in all ranks of life. Sea- air and sea -water are apt to call out an attack in one predisposed (Anderson). It is severest in the winter season. Symptoms. — As a rule, psoriasis does not occur before the sixth year, and usually comes out before the age of twenty -five. It is throughout a dry eruption. It is a non -febrile affection. The nails of the fingers and toes are sometimes affected and fall off. At the outset of the disease, little silvery- white scattered spots about the size of pin-heads make their appearance. As the disease advances, these spots may increase in size, being two to three inches in diameter. There is scarcely any itching. It is not contagious, but can often be traced to hereditary taint. The eruption may be on any part of the body, but almost always on the elbows and knees. Relapses are the rule. Psoriasis may last five, ten, fifteen, twenty or thirty years, or even a whole lifetime (Anderson). Prognosis. — The disease is not fatal, but relapses are common. Treatment. — The patient should take a course of baths, have plenty of fresh air, take his meals at regular hours, go to bed early, rise early, and have nothing to worry him. We should tone up the digestive powers. Nitro- muriatic acid and gentian often do good. Balsam of copaiba is occasionally of service. Tar and carbolic acid internally are often effectual. Liquor potassse in doses of from twenty to thirty drops thrice daily in water is highly praised. Acetate of potash in doses of one-half drachm thrice daily is beneficial. A course of carbonate of ammonia may be tried, also strychnia. Arsenic is the most valuable internal remedy which we possess in the treatment of psoriasis, and few cases resist it if given long enough. Five or six drops of Fowler's solution may be given thrice daily after meals. It agrees better with the stomach if given in bitter infusion — gentian. Next in value to arsenic comes cod-liver oil. PUERPERAL FEVER. 463 The two may be combined. The syrup of the iodide of iron may be given also. Some cases are cured by a course of Bant- ingism — i. e., by a meat diet. The patient should be urged to eschew a too sedentary mode of life, to take open air exercise, and to try change of air and scene. Local treatment is of much value. Warm baths and soothing ointments may be used. Cold cream, cucumber ointment, the benzoated oxide of zinc ointment, ointment of carbonate or subacetate of lead, or a mixture of zinc and almond oil may be employed with advantage — three or four applications daily. The hydropathic treatment may be tried. Chrysophanic acid may be used in the form of an ointment, as follows : jfc Acidi chrysophanici gr. x. A dipis sj . Lanolini , , . . §j . — M. Sig. : Use locally night and morning. PUERPERAL FEVER, Is an infectious disease, due as a rule, to the septic inocula- tion of the wounds which resuult from the separation of the cle- cidua and the passage of the child through the genital canal in the act of parturition (Lusk). Frequency. — The total number of deaths to the entire num- ber of confinements is estimated to be in the proportion of 1 to 85, or from puerperal fever alone in the proportion of 1 to 146 (Lusk). Causes. — One source of puerperal fever is a contaminated atmosphere. Another and frequent source of puerperal fever is by direct inoculation. Any material of a septic character, in- troduced into the genital passages of a woman during or after confinement, may produce a general infection of the system. Pathogenic bacteria are invariably associated with puerperal fever, and to them the infectious qualities of the disease are due. Puerperal fever is really a surgical fever modified, however, by the peculiar physiological conditions which belong to the puer- peral state. It is a matter of ordinary experience that the reten- tion of a small bit of the membranes within the uterus will pro- duce fetid lochia, and as the result of infection, a febrile condi- 464 A COMPENDIUM OF PRACTICAL MEDICINE. tion which as a rule, subsides with, the expulsion of the offend- ing body and the use of disinfectant washes (Lusk). Prevention. — The physician should insist upon the value of plenty of light and fresh air as a means of contributing to the speedy recovery of child- bed women, otherwise they may become poisoned with their own exhalations. Complete antisepsis be- fore confinement will prevent the introduction of germs and after confinement will paralyze their action. Employ means to pro- mote uterine contraction. Refrain from attending a case of labor when fresh from the presence of contagious diseases or septic material. In every case of labor the hands and forearms should be freely bathed in a carbolic solution before making a vaginal examination. All instruments employed during confinement should be disinfected. The warm carbolized douche after deliv- ery stimulates uterine retraction and promotes the rapid healing of wounds in the vaginal canal. The fountain syringe should be used (Lusk). Symptoms. — The first febrile symptoms usually occur within three days of the birth of the child. The third day is the one upon which, ordinarily, the beginning of the fever is to be antici- pated. After the fifth day an attack is rare. In most cases the fever is ushered in by chilly sensations, or by a well-defined chill. A frequent pulse is always a suspicious symptom in childbed, even where the other symptoms are apparently normal. There may be headache, sleeplessness, pain, vomiting, anorexia, and coated tongue (Lusk). Treatment. — It is to be recommended that in every case of puerperal fever, the vagina be cleansed with a two to three per cent, solution of carbolic acid, or corrosive sublimate (1:3,000) every four to six hours. The douche in itself is absolutely harm- less. No portion of the injected fluid should be retained in the vagina. All necrotic patches of the vagina or cervix should be touched with hydrochloric acid, or with a ten per cent, solution of carbolic acid, or with iodoform. Intra-uterine injections should be resorted to with extreme circumspection. Rarely are they indicated. Opium must be given for the pain. Purgatives (castor- oil in two or three tablespoonful doses) should be ad- ministered with caution. For the fever quinia may be adminis- PUKPUPA. 465 tered in five grain doses at intervals of fonr to six honrs. Stimu- lants in the form of whiskey, rum, or brandy may be given in doses of one or two teaspoonfuls hourly. Ice-cold drinks should be freely allowed (Lusk). PURPURA. Is a general disease, characterized by circumscribed extra- vasations of blood into the skin (Loomis). Purpura may be simple, rheumatic, hemorrhagic, or symptomatic. In simple pur- pura there are only minute extravasations into the skin (petechia) ; in rheumatic purpura there is a combination of purpura and rheumatic pains in the joints; in hemorrhagic purpura there is great constitutional disturbance, petechia not only appear in the skin, but ecchymoses, and there may be hemorrhage from all the mucous tracts; in symptomatic purpura, the purpuric spots accompany the exanthems and contagious fevers, and are purely symptomatic (Bartholow, Loomis and Flint). Morbid Anatomy. — There are changes in the walls of the vessels, or in the blood, or in both (Loomis). Causes. — Purpura occurs more frequently in women than in men. It may appear in the healthy and robust. The leading causes are bites of insects, passive congestion, various drugs, such as iodide of potassium, phosphorus, copaiba, ergot, chloral, and mercury; snake -bites, embolism and thrombosis of cutaneous vessels, cachexia, as tuberculosis, cancer, Brighfs disease, cirrhosis of the liver, anaemia, leucocythsenria; diseases of the nervous system, small -pox, typhus and typhoid fevers, measels, scarlet fever, malaria, cholera, yellow fever, cerebro- spinal meningitis, icterus, scorbutus, etc. Purpura may be accidentally present in the course of any disease (Flint). Symptoms, — In many cases for days before the eruption appears, there is a feeling of malaise with digestive derangement. Purpuric spots are bright-red, livid, or dark purplish -red in color, they do not disappear on pressure, and are unattended by itching or other signs of local irritation. As a rule the spots are not elevated. They vary in size from a pin's head to a large pea, or a spot may measure an inch in circumference, and change in color 466 A COMPENDIUM OF PEACTICAL MEDICINE. successively from bluish-red to greenish brown, and yellow. It is more common from fifteen to twenty than at any other age. In ordinary cases a crop of purpuric spots lasts from a week to ten days, and usually first apppear on the legs. Purpura is common in fruit seasons (Bartholow, Da Costa and Flint). Differential Diagnosis. — Purpura may be confounded with scurvy and shin diseases. From scurvy it is distinguished by the absence of spongy gums and painful swellings. The fact that there is no itching, no desquamation, no suppuration or discharge, and no change in purpuric spots upon pressure suffices to dis- tinguish them from the eruption of any form of skin disease (Loomis). Prognosis. — Most cases terminate in recovery. Treatment. — The diet should be nutritious and varied, and digestion is to be aided by tonic remedies, together with wine or spirits in small quantities. Dilute sulphuric acid may be given in doses of from five to fifteen drops every two hours combined with quinia. Ergot, gallic acid, and tincture of the chloride of iron may be of service (Flint). PYEMIA. Is an infectious disease, characterized by the formation of infarctions, metastatic abscesses and diffuse local inflammation. Venous thrombosis and embolism are essential features of this disease, and cause metastatic abscesses in the lungs, liver, kidneys, spleen, muscles, heart and brain. Metastatic abscesses vary in size from a pea to a large walnut (Loomis). Causes. — Many regard the pyaemic and septicaeniic poison as identical, and pyaemia as nothing but a metatistic septicaemia. Inflammation of bone is a very frequent cause of a phlebitis which leads to pyaemic infection. Cellulitis, carbuncle, erysipe- las, malignant pustule, and dissecting wounds are often compli- cated by pyaemia. Endometritis or lacerations about the genital tract are fruitful sources of pyaemia in the puerperal state (Loomis). Symptoms. — Pyaemia is ushered in by a distinct chill or rigor followed by a gradual rise of temperature to 101° or 104° F. The PYJEMIA PYROSIS. 467 chills of pyaemia occur irregularly, aud are followed, after the first two or three, by profuse and exhausting sweats. The pulse is frequent, 120 to 140, small and often intermittent. The skin may be jaundiced. The breath has a peculiarly sweet, sickish odor. The tongue becomes coated, glazed, dry, brown and fis- sured. Sordes collect on the teeth. There are anorexia and great thirst. There is usually diarrhoea with nausea and vomit- ing (Loomis). Differential Diagnosis. — The diagnostic points of pysemia are, irregularly recurring chills and sweats, great variations in tem- perature, with the signs of multiple abscess in the internal organs. . Pyaemia may be confounded with septicaemia, intermit- tent fever, acute yellow atrophy of the liver, acute articular rheumatism, typhus and typhoid fever. Pyaemia is ushered in by a distinct chill; septicaemia by slight shivering, or mild rigors only. In pyaemia the chills recur; in septicaemia there is but one chill. In pyaemia there are profuse sweats which recur; in septicaemia, they are slight and never recur. In pyaemia the temperature gradually rises to 102° to 104° F.; in septicaemia it is high at the onset, 105° to 1 07° F. In pyaemia the skin is jaundiced; not so in septicaemia. There is a sweet, sickish odor to the breath in pyaemia, absent in septicaemia. In pyaemia multiple abscesses develop, never in septicaemia (Loomis). Prognosis. — Is always unfavorable. Treatment. — Cleanliness, good ventilation, sunlight and quiet are important measures. Quinia, carbolic acid, salicylic acid and oil of turpentine may be used internally. A good diet and stimulants should be administered in large quantities (Loomis). PYROSIS. The regurgitation of a considerable quantity of a liquid which is either insipid or saltish or brackish and is sometimes acid when the stomach is empty of food and usually in the morn- ing is called pyrosis or waterbrash. This liquid consists mainly of saliva. Sometimes there is not only a feeling of oppression in the thorax but a severe pain is referred to the heart accompanied 468 A COMPENDIUM OF PRACTICAL MEDICINE. by palpitation and dyspnoea. In such cases the patient is very apt to imagine he has heart disease. Pyrosis is not a disease but a symptom of certain cases of gastric dyspepsia (Flint and Loomis). PARAPHIMOSIS. Exists where the prepuce gets behind the corona glandis and cannot be replaced (Keyes). Causes. — An unnaturally tight preputial orifice is a predis- posing cause. Young boys who retract the prepuce for the first time often find themselves unable to replace it. Rings of metal forced upon the penis retracting the prepuce may be a cause. Inflammatory paraphimosis may depend upon balanitis, gon- orrhoea, herpes, chancroid, chancre, etc. (Keyes). Symptoms. — In paraphimosis the glans penis is swollen and livid. If the patient is seen at once, there may be no inflamma- tion, either of the prepuce or the glans. If the stricture of the prepuce is tight enough to arrest the circulation it will cause gangrene (Keyes). Treatment. — /. Of paraphimosis with strangulation. In strangulation the glans penis is turgid, swollen, blue-black, cold and devoid of sensibility. Ice should be first used locally to produce shrinkage and a few small punctures may be made to let out serum from the ridge in front of the stricture. In these cases ether should always be given to relax the tissues and reduc- tion attempted. If a prolonged, careful attempt at reduction fails, the strictured point must be divided. After reduction the treatment consists in position, rest and cleanliness, syringing the preputial cavity with warm water. II. Of paraphimosis without strangulation. — In recent cases reduction must be effected or inflammation will surely set in. Reduction may be accomplished by using the above means (Keyes). PHIMOSIS. Exists where the orifice of the prepuce is so small that the glans penis can not be uncovered. Phimosis is congenital or acquired, simple or inflammatory, complicated by other diseases, phimosis. 469 or by adhesions. With very young children, phimosis is so common that it may be considered normal. The foreskin of a child is developed out of all proportion to the rest of the j^enis. This long prepuce is often a source of anxiety to young mothers. A positive indication for operation, in the case of a child, does exist, where the preputial orifice is smaller than that of the urethra. This condition is known to exist when the prepuce "balloons" during micturition. When the prepuce is too tight in the adult, an operation may be called for as a prophylactic against future disease, such as chancre, chancroid, gonorrhoea, or an attack of herpes (Keyes). Causes. — Phimosis may be caused by frequent attacks of preputial inflammation, leaving a thick, long, indurated, inelastic prepuce, interfering not only with sexual intercourse, but some- times with urination. Another common cause of acquired phi- mosis is the cicatrization of multiple chancroid around the orifice of the prepuce. Diabetes is said to be a cause of phimosis. Marx reported a case of phimosis where a passionate and jealous woman made her lover wear a gold padlock (sometimes two) with which she secured the preputial orifice, keeping the key herself. The victim of her charms carried his padlocks, which were replaced from time to time through new punctures, during four or five years, until such a degree of irritation had been set up as to require removal of the prepuce. Inflammatory phimosis is a transient condition, but may leave true phimosis behind (Keyes). Treatment. — It is better not to circumcise when the prepuce is inflamed, if it can be avoided. Keep the patient in bed, and elevate the penis. Evaporating lotions may be used locally, con- taining a little spirit or a (gr. x.-xx.) solution of tannin, fre- quently washing out the cavity of the prepuce by means of a syringe with dilute lead- water or carbolic acid (gr. ij. to the gj.). Remote Results of Phimosis. — It leads to imperfect develop- ment of the glans penis, is an obstacle to sexual intercourse, causes spermatorrhoea, frequent desire to urinate and cystitis. According to Dr. Sayre, of New York, phimosis may cause curvature of the spine in children, and priapism (Keyes). 470 A COMPENDIUM OF PRACTICAL MEDICINE. PTERYGIUM. Is a triangular thickening of the conjunctiva, which ad- vances from the caruncle to the cornea and encroaches more or less upon the surface. The favorite site is the inner side of the eyeball. The structure grows very slowly. It may impair sight before it reaches the pupilary area. The apex is more or less rounded and seems to dip into the substance of the cornea. The edges near the apex will be found to be rolled under and will admit a fine probe to be thrust beneath for a short distance. It appears mostly in persons who are exposed much to the weather, or to dust, and who are of advanced age. A variety of fleshy ptergium may occur at any portion of the eye (Noyes). Treatment.- — Is surgical and preferably by excision. Seize the corneal portion with toothed forceps and as it is lifted, push beneath it a cataract knife and shave it from the cornea. Cut away as much of the base as may be needful. The raw surface may be covered by flaps of the adjacent conjunctiva sutured by silk. Cocaine will annul the pain. An opacity of the cornea is left, which will continue for months. It may ultimately dis- appear (Noyes). PYELITIS. Is an inflammation of the mucous membrane of the pelvis of the kidney. There is hyperemia of the mucous membrane, and exudation of pus and mucous takes place. In many cases with profuse production of pus there is an obstacle to the passage of the urine, and the pus is retained in the dilated pelvis, causing the condition known ^pyonephrosis (Flint). Causes. — Pyelitis is seldom, if ever, a primary disease. Its most frequent cause is the presence of calculi in the pelvis of the kidney. Obstruction to the flow of urine is a cause of pyelitis. Such obstructions are furnished by calculi, tumors pressing on the ureter, enlarged prostate, stricture of the urethra, phimosis, and paralysis of the bladder in cases of paraplegia. In these cases the urine is retained and decomposes, and thus produces irritation. The pressure of a retroverted or pregnant uterus may cause obstruction to the flow of urine. Pyelitis may be due to PYELITIS. 471 gonorrhoea, specific vaginitis, and urethritis in females. In these cases cystitis is nearly always present. Copaiba, turpentine, and cantharides passing through the kidneys may cause pyelitis. Pyelitis may be a complication in pyaemia, puerperal fever and the exanthemata (Bartholow, Flint and Loomis). Symptoms. — Pain in the back is present in the mild as well as in the severe cases. This pain, as a rule, is severest over one or both lumbar regions, is often of an aching character, and shoots down along the course of the ureters. The voiding of urine is almost incessant, and is attended by severe pain. Acute pyelitis is usually ushered in with rigors. Symptoms of hectic fever may also mark the occurrence of permanent obstruction of the ureter and the development of that condition termed pyone phrosis, There is lassitude and more or less pain on motion. There are changes in the urine. In its early stage the urine contains blood mixed with mucus and epithelium cells from the pelvis of the kidney. The presence of these epithelial cells is its most certain diagnostic indication. The specific gravity of the urine ranges from 1025 to 1030, and usually has an acid reac- tion. The urine may be ammoniacal. Calculous pyelitis is attended with more pain and hemorrhage than the other forms. In the advanced stage of pyelitis, the discharge of pus is con- stant, but if the ureter becomes blocked, for a time the urine may be quite normal, but the removal of the obstruction is fol- lowed by a copious flow of purulent urine. If there be perma- nent obstruction in the ureter, a tumor develops in the lumbar region. The existence of the tumor is determined by the pres- ence of bulging between the crest of the ilium and the false ribs on the side involved. Palpation shows deep-seated fluctuation over the tumor and tenderness on pressure. Percussion shows dullness over the tumor. A hypodermic needle will complete the diagnosis (Bartholow, Flint and Loomis). Differential Diagnosis. — The diagnosis of pyelitis in the acute stage rests mainly on the presence of the characteristic epithe- lium of the pelvis mixed with blood and mucus. In a more advanced stage, in addition to the above, there is pus. The presence of pus and acid urine, with pain in the lumbar region, accompanied by the development of a tumor at the seat of pain. 472 A COMPENDIUM OF PRACTICAL MEDICINE. which tumor gradually increases in size and suddenly disappears at the same time that a copious discharge of pus takes place from the bladder, which discharge is attended by a sense of great relief to the patient, renders the diagnosis of pyonephrosis very certain. Pyonephrosis may be confounded with hydronephrosis, hydatid cyst and perinephritic abscess. Hydronephrosis is dis- tinguished fi 'om pyonephrosis by the non- purulent character of the urine, and by the absence of constitutional symptoms. An aspirating needle will generally decide the diagnosis. In perinephritic abscess neither pus, blood, mucus, epithelia nor al- bumen will be found in the urine; in pyonephrosis they are common and constant. Pain on motion and fever are marked symptoms in abscess and slight or absent in pyonephrosis. In women a pyonephrotic tumor has been confounded with an ovarian cyst. The exploring trocar will very quickly remove all doubts. Pyelitis is distinguished from cystitis by the absence of vesical pain and frequent micturition and by lumbar pain. In pyelitis the urine is acid; in cystitis it is alkaline (Loomis). Prognosis, — Depends much on its causes. Treatment. — Remove the cause if possible. In acute pyelitis if there be fever, pain, and bloody urine, wet cups should be ap- plied to the loins followed by a hot bath and a hypodermic of morphine to relieve pain. Alkaline drinks should be given and the patient kept in bed. If the urine is acid, liq. potassii citratis should be given. In ammoniacal urine benzoic acid is extremely serviceable. In chronic pyelitis, eucalyptol, oils of turpentine, copaiba and cubeb limit the formation of pus. Cod-liver oil and quinine should be given with a nutritious and non -stimulating diet. Alkaline mineral water and milk should be freely given. If a tumor exist aspiration may be performed (Bartholow and Loomis). PICA AND MALACIA. Are terms applied to perversions of appetite. Malacia de- notes a morbid craving for certain articles of food, whereas pica denotes a desire for innutritious substances. The craving for strange kinds of food during pregnancy and in hysterical women PICA AXD MALACIA POLYPHAGIA. 473 is familiar to all. The innutritious substances frequently craved are charcoal, chalk, slate, and certain kinds of earth. In some cases of pica the articles are at first taken with the idea of im- proving the complexion and in this way the habit is formed; but in other cases a morbid uneasiness in the stomach leads to their use. This appetite is chiefly confined to young females and is generally associated with anaemia or chlorosis. Treatment. — Treat the associated disorders and prohibit the use of the above substances (Flint). POLYPHAGIA. Called also bulimia denotes a craving for food beyond the wants of the system. These terms are not correctly applied to the increased appetite during convalescence from fevers or other acute diseases. In true bulimia the amount of food craved far exceeds the requirements for nutrition. Bulimia may be another name for gluttony. The love of eating may be cultivated to such an extent that little else is thought of, and persons who fall into this habit may be said to live to eat, rather than to eat to live. Habits of gluttony may lead to dyspepsia, obesity, fatty degen- eration of the heart and to various affections. Bulimia may be a symptom of mental disease, or of diabetes. Cases have been reported in which the morbid appetite appeared to be insatiable, all kinds of food — raw meat, candles etc., — being eaten in some cases with avidity and in enormous quantity (Flint). Treatment. — Recovery from this condition is to be expected. The indications are to regulate the diet, to establish the general health, to correct any disorder of digestion, and to palliate the excessive craving for food by oj)iuin, or sometimes by nauseant remedies. Swallowing pieces of ice has been found effective as a palliative measure (Flint). PARALYSIS AGITANS. Sometimes called Parkinson's disease, or shaking palsy, or the trembles, is a disease of advanced life characterized by motor weakness and tremors of the voluntary muscles, especially of the limbs, occurring independently of muscular exertion (Loomis). 474 A COMPENDIUM OF PRACTICAL MEDICINE. Morbid Anatomy. — Paralysis agitans is a neurosis, a func- tional disorder. As yet no constant changes have been dis- covered. Some authorities consider it of spinal, others of cere- bral origin (Bartholow and Loomis). Causes, — It rarely occurs before forty, and is more common in men than women. It is not known to be hereditary. The principal causes are strong emotion, fright, grief, anxiety, dis- tress of mind, great bodily fatigue, and exposure to cold and dampness (Bartholow and Loomis). Symptoms. — Tremor is the chief symptom of paralysis agi- tans. The trembling consists of fine small movements. Paraly- sis agitans comes on slowly, and progresses slowly. It usually begins in one foot, hand or possibly a single finger, and gradu- ally becomes general. The tremors are often confined to one side of the body for a long time— hemiplegic type; less fre- quently to both lower extremities — paraplegic type. Any effort of the will, as grasping, writing, or walking, will stop the irreg- ular motions. Sometimes the disease sets in abruptly in conse- quence of some sudden shock. Mental emotion and exercise in- crease the trembling, and sleep and chloroform narcosis suspend it. The trembling consists in muscular contractions and relaxa- tions. The hands are apt to assume a position as in writing. As a rule, the bead and neck are not affected. The countenance assumes a fixed, staring look of distress, the head is drawn for- ward and the trunk fiexed. The voice is often tremulous and speech is slow, hesitating and laborious. The muscles are easily tired. The patient rises slowly and is deliberate in starting, but when under way, he goes in a dog-trot with the head and body bent forward (festination). Complaints are made of cramps, of muscular stiffness, of a sense of excessive heat, and of restless- ness. The knee-jerk is normal (Bartholow, DaCosta, Flint and Loomis). Prognosis. — Although the disease may last for twenty or thirty years, death most commonly results from some intercur- rent disease. The outlook is never favorable (Loomis). Differential Diagnosis. — Paralysis agitans may be confounded with disseminated sclerosis, senile trembling, alcoholic, lead and mercurial trembling. In disseminated sclerosis tremors occur RACHITIS. 475 only when the muscles are m use; the disease begins in the lower limbs, affects younger persons, and paralysis occurs early. The patient has no tendency to run forward and does not have the peculiar countenance. In paralysis agitans the tremor is not dependent on volition; it begins in the upper limbs, and per- sons under forty years are exempt from this affection. Paralysis occurs late. The patient has a tendency to run forward and has a fixed, staring countenance. In senile trembling the head is chiefly affected and there is no paresis of muscles, no stiffness, no deformity of the extremities, and no impulse to run forward. Alcoholic, lead and mercurial trembling are readily diagnosti- cated by the previous history (Bartholow, Flint and Loomis). Treatment. — No plan of treatment is satisfactory. Hyoscy- amine, according to Charcot, is the best remedy to moderate the trembling. Gelsemium is useful. The chloride of gold and so- dium, corrosive sublimate in small doses, nitrate of silver, and the lactophosphate of lime with arsenic may be tried. The gal- vanic current may be tried (Bartholow and Loomis). RACHITIS. Called also rickets, rachitismus and osteomalacia, is a con- stitutional disease of the first years of life, characterized by a disorder of nutrition in which the growth of the bones is irregu- lar, calcification imperfect, and deformities ensue (Bartholow). Causes. — Rickets is a common result of faulty diet and of anti-hygienic surroundings, and is therefore frequent among the poor of cities, and especially in families who dwell in crowded tenement -houses. It is more common in the great cities of England and Europe than in this country. Acute disease and troublesome dentition predispose to it. It is more apt to occur in children of rachitic, syphilitic or phthisical parents. The off- spring of consanguinious marriages, of those too old, or of the feeble and cachectic, are, as a rule, rickety. The rickety consti- tution may also be inherited. Of the exciting causes, the most common is the use of food not sufficiently nutritive, or, if nutri- tious, not suited to the age and digestive powers of the child. Thin and poor breast-milk and artificial food of poor quality arc 476 A COMPENDIUM OF PRACTICAL MEDICINE. common causes of rickets. The presence of lactic acid in the intestinal canal of the infant may produce rickets according to some authorities. The disease is rare before the fourth and after the seventh year of life. Children of well-to-do families are also liable to rickets (Bartholow, Loomis and J. L. Smith). Symptoms. — Usually gastro- intestinal disturbances are the earliest symptoms of rickets. There may be vomiting, and the stools are frequent, pasty and offensive. The stools are light in color, because of the absence of bile, and have an acid reaction. The appetite is poor. The child wastes and grows dull, listless and peevish. Pains about the joints are complained of. The anterior fontanelle remains open. Profuse perspirations of the head, neck, and upper part of the chest, appear chiefly while the child is asleep, but at the same time the abdomen and extremities are dry and hot. The child kicks off the covers from its legs. There seems to be tenderness of the whole body, and the rickety child cries out when it is taken up, or moved, or pressed on. It is languid, its counten- ance wearied, depressed, and aged, the face grows broad and square, the hair is thin, dry, and dead, the muscles are wasted, and flabby, the head sinks between the shoulders, and the abdo- men is swollen and protuberant. Now the extremities of the long bones swell and have a knobby appearance, and the bone bends readily. The child may be knock-kneed, or have bow-legs. Curvature of the spine also takes place. The lower jaw is short- ened, so that the upper teeth overlap the lower. The teeth appear late. Rachitic children are usually pigeon-hreasted, and there is often marked deformity of the pelvis. The ribs, being softened, yield to the atmospheric pressure, thus projecting the sternum forward. The head of a rickety child appears larger than that of a healthy child of the same age, is flat on top, and the forehead is large and square. The limbs of the child are short in propor- tion to the trunk. Rachitic children are anaemic and very sensi- tive to changes of temperature. As the osseous changes go on emaciation goes on at the same rate, the abdomen enlarges still more, the muscles waste and grow weaker, there is less and less disposition to voluntary exertion, the perspirations aremorefree, the thirst increases, the bowels become more deranged, thejstools RACHITIS. 477 fetid, and the food passes unchanged. All rickety children do not emaciate. Persons who were rachitic in infancy frequently be- come very strong as they reach adult life (Bartholow, Loomis and J. L. Smith), Differential Diagnosis. — The only disease with which rickets in its early stage may be confounded is inherited syphilis. Rickets does not appear, as does syphilis, during the first days of life. The "snuffles 11 and cutaneous lesions do not belong to rickets; the sweats about the head, the osseous changes, the enlargement of the spleen and liver, the weakuess of the legs, the rims around the cranial bones, the large, lax joints, and the gastro- intestinal disturbances are symptoms of rickets which dis- tinguish it from any other disease (Bartholow and Loomis). Prognosis. — Is usually favorable, provided no serious com- plication arises. The complications of rickets are bronchitis, pneumonia, enteritis, laryngismus stridulus, convulsions, difficult dentition, diarrhoea, and chronic hydrocephalus (Loomis). Treatment. — Good air, warm clothing, daily bathing, and a nutritious diet are essential. Children kept too long at the breast often become rickety, and should be weaned at once. Good cow's milk, diluted by one-third to one-fourth of lime- water is the most suitable aliment. Scraped raw beef, with a small amount of wine, often produces marked improvement. Pepsin with bismuth may be given for the vomiting and diar- rhoea. Pepsin with diluted muriatic acid is also useful. Cod- liver oil should be taken as early and in as large doses as the child can digest. Beef tea may be given. Rachitic children should not sleep on feather beds or high pillows. The perspira- tions may be relieved by sponging with vinegar and water. The following formula will be found useful in most cases: Jfc Olei morrhuse 5iv. Aquas calcis Syrupi calcis lactophosphatis — aa5ij. — M. Of this, one teaspoonful should be given four or five times daily to an infant of one year (Bartholow, Loomis and J. L. Smith). 478 A COMPENDIUM OF PRACTICAL MEDICINE. RHEUMATISM. Is a constitutional disease characterized by certain local manifestations seated in the articulations and the fibrous tissues in other parts (Flint). Varieties. — I. Acute articular rheumatism. II. Sub-acute articular rheumatism. III. Chronic articular rheumatism. IV. Arthritis deformans. V. Muscular rheumatism, " Myalgia " (Loomis). Acute articular rheumatism frequently called rheu- matic fever and ,p.ol/y arthritis rheumatica is the variety charac- terized by fever, inflammation of the joints occurring in succes- sion and by a tendency to attack the peri- and endocardium. Causes. — It is more frequent in men than in women because men are more exposed to the influences producing it. Protracted stay in damp apartments, lying between damp sheets all night, exposure of the body to cold and wet, when in a heated and per- spiring state act only as an exciting cause. A special predisposi- tion is requisite. This predisposition or diathesis may be con- genital and inherited or it maybe acquired. There is an hered- itary tendency in about thirty per cent, of cases. It occurs mostly between fifteen and thirty years of age. It is rare in old age. The seasons of greatest prevalence are winter and spring. Some claim that an excess of sulphur or lactic acid in the blood will produce rheumatism if the vice of constitution exists. Erysip- elas, dysentery, scarlatina, gonorrhoea, syphilis, pregnancy, scrof- ula, phthisis and cancerous affections seem to act as exciting causes (Bartholow, Flint and Loomis). Symptoms. — In the majority of cases, acute articular rheuma- tism begins with a sudden attack at night. In some cases the pyrexia precedes the local manifestations for a few hours to one or two days. Before the attack patients often complain of mus- cular soreness, of a good deal of pain, stiffness and soreness of certain joints, of loss of appetite, coated tongue and constipa- tion. The development of the disease is denoted by an affection of one or more of the larger joints. The local symptoms are pain, tenderness, increased heat, swelling, and redness of the skin. Pain is especially excited by movements of the affected joints, or by jarring the bed, or by joressure over the joints. RHEUMATISM. 479 Swellvng is most apparent in the knee, wrist, elbow, ankle, and smaller joints of the hands and feet, and is due to an effusion into the synovial cavity and surrounding tissues. The redness is due to an erythema. In some cases several joints are affected. but in other cases a single joint. The most characteristic featwre of a cafe rheumatism is its tendency to migrate from one joint to another. Rheumatism illustrates the law of parallelism in that corresponding joints are often affected together. In an analysis of 21 cases. Flint found but a single violation of this law. This disease, therefore, is eminently one of the bilateral or symmetri- cal diseases. The joints most frequently affected are the ankle and knee: next the shoulder, elbow and wrist; then the hip and fingers, and finally the -pine, the toes and the lower jaw. Acute articular rheumatism is always accompanied by more or less pyrexia. The axillary temperature in different cases varies be- tween 102° and 110° F. The pulse rarely exceeds 100 per minute. Sweating is a symptom more or less prominent, occur- ring especially at night. The sweat emits a notably sour odor. In connection with profuse sweating, sudamina or miliary vesicles frequently appear on the neck and trunk. Urticaria, erythema and herpes labialis sometimes occur in the course of the disease. The appetite is lost, thirst is urgent, the tongue is coated, the saliva is acid, usually the bowels are constipated, and the urine is diminished. There is sleeplessness. Endocarditis occurs in some cases of rheumatism. The inflammation, as a rule, affects the membrane situated upon the mitral valve. Pericarditis occurs less frequently. It is convenient to speak of these affections as complications, but, properly speaking, they are to be reckoned among the local manifestations of the disease. They rarely occur in patients beyond forty. Other rare complications are purulent meningitis, cerebral embolism, uraemia, insanity, bronchitis, pneumonia, peritonitis, nephritis, myocarditis, phlebitis, suppur- ative arthritis, erysipelas and pyaemia. In a small number of cases of acute rheumatism, important symptoms develop which are described under the names of cert hral rheumatism and rheu- matic hyperpyrexia. In these cases, there are very high fever, delirium, muscular twitchings, stupor, face cyanosed, etc. T: symptoms seem to be referable to some profound infection or in- 480 A COMPENDIUM OF PRACTICAL MEDICINE. toxication which acts upon the thermic and other nervous cen- tres. The disease ends by self -limitation. The duration of acute articular rheumatism is three weeks to thirty days (Bartholow, Flint and Loomis). Differential Diagnosis. — Acute rheumatism may be mistaken for gout, pyaemia, synovitis, or simple acute arthritis, urethral rheumatism, and hysterical joint. Gout attacks the small and rheumatism the large joints. In gout the fever is lower, and the duration of the attack shorter than in rheumatism. Sweats and cardiac mischief distinguish rheumatism from gout. In gout the attack comes on at night in the great toe joint; there is a history of high living, and an excess of uric acid in the blood; not so in rheumatism. Gout is rare before thirty- five, while acute rheu- matism is a disease of early adult life. Tophi never form, in rheumatism, but are always present late in gout. In pyaemia there are recurring chills, sickly, sweet breath, slow development, jaundice, multiple abscesses, etc. Synovitis or acute arthritis is distinguished by its persistence in one joint, by the absence of sweats, of constitutional disturbance and of cardiac lesions, and by the graver local symptoms. Urethral or gonorrhoea!, rheuma- tism attacks one joint, usually the ankle or wrist, does not mi- grate, is slower to recover, is unaccompanied by fever, and is coincident with a urethral discharge. Hysterical joint is without swelling or change of temperature, and is only sensitive when the patient's attention is fixed on it (Bartholow, Flint and Loomis). Prognosis. — This disease is rarely fatal. The rule is that no crippling of the joints follows the acute attack. The worst legacy acute rheumatism leaves is a crippled valvular apparatus in the heart. Some authorities say that seventy-five per cent, of all cases of rheumatic fever are accompanied by cardiac inflam- mations, others say ^ve per cent. The complications — pericar- ditis, endocarditis and embolism make the disease serious. Ul- cerative endocarditis is a grave sequel of the disease, giving rise to fatal pyaemia. A strange sequel of rheumatic fever is chorea (Flint and Loomis). Treatment. — Rheumatic patients should have good hygienic surroundings. The temperature of the apartment should range from 68° to 70° F.; all draughts should be avoided, and the RHEUMATISM. 481 patient should be clothed in flannel and covered with flannel sheets. The diet should be milk and seltzer-water, beef-tea and broths. Animal food and alcoholic stimulants should not be given during the active period of the disease. External Applications. — Cold, by means of ice-bags to the joints, has been strongly recommended. Friction with chloro- form and the tincture of aconite is a favorite plan with some. u Hot-packs" by means of flannel, or bathing the joints in warm laudanum and then covering them with oiled silk, is always grateful to the patient. Ethyl chloride or ether may be rubbed over the affected joints. Loomis is of the opinion that the blis- ter-treatment is no better than simply surrounding the joints with cotton-batting and oiled silk. But Dr. Greenhow finds that the blister-treatment is quite as successful as the treatment by sali- cylates, and open to less objection. The blistering- plaster should be applied about the inflamed joint, but not on it. Blisters re- lieve the pain remarkably, change the reaction of the urine from acid to neutral or alkaline, and prevent complications. Blisters may be utilized in all forms of the disease and combined with other plans of treatment. Internal Medication. — Rheumatism is the most unmanageable of all diseases so far as remedies are concerned. Grarrod thinks colored water is about as potent as anything. He claims that rheumatic fever is a self-limited disease. The alkaline treatment is the treatment in which alkalies play an important part. Two drachms of the bicarbonate of either potassium or sodium may be given in a state of effervescence by means of an ounce of lemon juice, or a half drachm of citric acid in four ounces of water every three or four hours. If the urine is alkaline at the end of twenty- four hours the quantity of alkali is diminished one -half. If the urine continues alkaline at the end of forty - eight hours, three drachms of alkali only are given on the third day. If the alkalinity of the urine persists, on the fourth day three grains of quinine with a half drachm of potassium bi- carbonate may be given three times daily. Cathartics may be given as required. The alkaline treatment relieves the pain, seems to shorten the duration, lessens the violence of the disease and prevents heart complications. The average duration of the cases 482 A COMPENDIUM OF PRACTICAL MEDICINE. thus treated is put by Dr. Fuller at eleven days. Of 439 cases subjected to this plan there was not a fatal case, and only about two per cent, of cardiac complications. Loomis thinks that if long continued the alkalies do positive harm. The alkaline treat- ment is particularly applicable to the obese, florid, but flabby drinkers of malt liquors. The iron treatment is applicable to the pale, delicate anaemic young subject attacked with acute rheu- matism, in whom the alkalies are too depressing. A half drachm of the tincture of the chloride of iron to six ounces of water, may be taken through a glass tube every four hours. The salicylic or salicylate treatment is most applicable to the vigorous, able-bodied subjects of the rheumatic diathesis. Sali- cin, salicylate of soda and salicylic acid, to be effective, must be given in sufficient quantity to lower the temperature — a half- drachm of salicylate of sodium every four hours, until the pulse and temperature decline, may be taken as the standard. Al- though relief follows the administration of these remedies in two or three days, yet the tendency to relapses, heart depression and irritability of the stomach is very great. The salicylate treatment does not prevent the heart complications. The best results are obtained by the combination of the salicylate and the alkaline treatment. Loomis prefers salol to salicylic acid. He seldom uses the alkaline, or salicylate treatment, but extols anti- pyrine as the most efficient drug. Flint gives antipyrine in fifteen grain doses hourly, but does not give more than two drachms in twenty -four hours. For the intense hyperpyrexia in some cases, large doses of quinine may be given and cold spong- ing practiced. Dr. Kinnicutt gives 10 to 15 minims of the oil of wintergreen every two hours until eight doses have been taken. DaCosta has reported 30 cases treated with the bromide of am- monium in doses of 15 to 20 grains every three hours (Bartho- low, Flint and Loomis). Subacute Articular Rheumatism. — Is usually a sequel of the acute; it is attended by slight if any fever; the pain in joints is not severe, except on motion; swelling and redness are slight and usually limited to one or two large joints. It may last six weeks or even four months. There is always anaemia. The RHEUMATISM. 483 treatment is a niilk diet, iron and cod-liver oil, a warm climate, and heat to the affected joints (Loomis). CHRONIC ARTICULAR RHEUMATISM. Is an affection of the articulations characterized by pain and stiffness, with some swelling, occurring chiefly after middle life, and influenced by atmospheric changes (Bartholow). Causes. — The chronic may succeed to the acute, or the case may be chronic from the first. It is a disease of adult and ad- vanced life. Bad hygienic surroundings, exposure to wet and cold, sudden atmospherical changes, and a residence in dark and damp dwellings predispose to it. It is often hereditary (Bartho- low and Loomis). Symptoms. — The affection remains fixed in certain joints; that is, it does not shift from joint to joint, as in cases of acute rheumatism. There is aching and constant pain in one or more of the larger joints. The affected joints are tender, painful to the touch, sometimes swollen, and their movements restrained. There is no fever. The aching and deep-seated pains are often worse at night. When it is the result of exposure, heat will give a grateful sense of relief; when a rheumatic diathesis exists, dry cold is better. Old people with rheumatic joints are great " weather prophets" often being able to foretell the coming of a storm. In the morning, on rising, the joints are stiff, their movements slow, rigid and jerking, so that dressing is accomp- lished with difficulty; but use renders them limber and supple. Movements of the joints may cause more or less creaking like rusty machinery (Bartholow, Flint and Loomis). Differential Diagnosis. — Chronic rheumatism may be mistaken for rheumatoid arthritis, or arthritis deformans. In the latter occur anatomical changes, dislocations, and distortions which do not belong to the history of chronic rheumatism. Arthritis de- formans is a steadily progressive disease, one joint after another being involved and never recovered from. In chronic rheuma- tism the large joints are mainly involved; in arthritis the small joints are usually first involved, then the large (Loomis V Prognosis. — Chronic rheumatism never affects the duration of life. It may persist throughout life (Loomis). 484 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — Chronic rheumatism is benefited most by local treatment, such as blisters, iodine, belladonna, aconite, opium and chloroform liniments. If there is but little pain in the joints, ammonia and turpentine liniments are of service. Thick flannels should always be worn about the joints. Sponging the joints with hot water will relieve the pain and stiffness in some cases. Warm baths, the Turkish or Russian baths, with local douches, are often highly useful. Many of the hot saline springs for bathing have acquired a great reputation in the treatment of this form of rheumatism, cures being effected in cases that had resisted all other methods of treatment. The best results are obtained from the baths of the Hot Springs of Arkansas, the warm and hot springs of Virginia, the sulphurous waters of Kentucky and Saratoga, the Michigan springs, and St. Cather- ine's of Canada. Mud-baths are also employed on a large scale, for the relief of rheumatism and affections of the skin, in certain parts of Germany. Frictions of the affected parts with cod-liver oil are efficacious. The method of friction and movements, known as massage, is probably the best of the local means of treatment. Galvanism has been found serviceable. The posi- tive pole should be placed over the principal nerve-bundles .above, and the negative pole brushed over the joint-region. The electrical treatment must be kept up for a long time. Internal Medication. — Tonics such as iron, quinine, and strychnine should be employed. Cod-liver oil, according to Loomis, is the most useful of all internal remedies, and should be given for many months. Cod-liver oil should be given with a little ether to assist its digestion. A course of iodide of potas- sium often renders important service, if given many months. Muriate of ammonia may absorb deposits about the joints but it must be given for a long time. Bartholow has had excellent re- sults from the bromide of lithium. Colchicum, arsenic, bichlor- ide of mercury, guaiacum, oils of turpentine and cajeput, com- bined with sulphur have been recommended. The diet must be highly nutritious and absolutely non- stimulating. The patient should reside in a dry, warm climate (Bartholow, Flint and Loomis). EHEUMATOID ARTHRITIS. 485 RHEUMATOID ARTHRITIS, Called also arthritis deformans, rheumatic gout, rheumatic arthritis, nodosity of the joints, dry arthritis, etc., is a chronic inflammation of the joints, without fever and without suppura- tion, progressive, and causing enlargement and deformity of various articulations (Bartholow). Causes. — It may occur at any age, but in the majority of cases patients are in middle life. Women are more liable to it than men. The smaller joints are most often involved in women; the larger in men. Damp dwellings, poor food, and mental de- pression are powerful predisposing causes. It is not an inherited disease. It occurs in the poorer classes of society, as a rule, and among those who suffer from hardships, exposure, and depriva- tions. Garrod holds that it may have its origin in the tubercular diathesis. A state of the nerve-centres is invoked to account for this disease (Bartholow, Flint and Loomis). Symptoms. — The disease is usually from the first and during its course, sub- acute. A feature of the disease is its progressive character. There is usually no constitutional disturbance. The affected joints are painful, especially on motion. A characteris- tic deformity of the fingers is a lateral deflection in the uluar direction. In the progress of the disease the anatomical changes lead to permanent extension or flexion of parts, subluxations, dislocations, nodulations and notable distortions. The soft parts about the joints usually atrophy. Early in the disease a friction crepitus is heard as the articular surfaces are rubbed upon each other. The skin is dry and harsh, and there is a great acidity of the stomach. In the worst cases all the joints are fixed in bony ankylosis (Bartholow, Flint and Loomis). Differential Diagnosis. — Arthritis deformans may be confound- ed with chronic rheumatism and chronic gout. Gout is hered- itary and occurs more in males. Arthritis deformans is rarely hereditary and occurs oftenest in females. Attacks of gout are periodic. Arthritis is progressive. Chalk-stones develop in the joints in gout and are never present in arthritis. Trie arid is al- ways in excess in gout, and never in arthritis (Loomis). Prognosis.— It is one of the most chronic of diseases. It may continue for ten, twenty or thirty years or longer. It never de- 486 A COMPENDIUM OF PRACTICAL MEDICINE. stroys life, and is never recovered from. Patients with this dis- ease may attain very old age (Bartholow and Loomis). Treatment. — Qninine, iron, cod- liver oil, arsenic and strych- nine are indicated. Flannels should always be worn next the skin. Mineral waters and warm saline baths often do good. Bartholow recommends iodine and galvanism. He gives five minims of the compound solution three times daily. Iodine oint- ment may be rubbed into the affected joints. The galvanic cur- rent is often of great benefit (Bartholow and Loomis). RANULA. Is a sublingual cyst. Cause. — Banula is caused by an obstruction of one of the mucous glands situated beneath the tongue. They were once thought to be due to an obstruction of the salivary ducts. They are analogous to the mucous cysts of the lip. They contain a clear, glairy, mucoid fluid. They may be congenital. They may form a large swelling beneath the jaw. When large they press the tongue upward. They are, as a rule, painless, and merely give trouble by pressure (Bryant). Treatment. — The best treatment is to raise the upper wall of the cyst by means of a pair of pointed forceps, or a tenaculum, and with scissors to cut it off. Panas, of Paris, has lately in- jected these cysts with three to ten drops of a solution of chlo- ride of zinc (forty- five grains to the ounce) with success. In large tumors the cavity may be plugged with lint soaked in iodine, or with iodoform gauze, after it has been freely incised. Encysted tumors are also met with beneath the tongue, and may be mistaken for ranula; but these tumors have a distinct capsule and contain a cheesy, sebaceous secretion. They are probably congenital (Bryant). RETENTION OF URINE. When a patient is unable to pass his urine, he is said to have retention. When no urine comes clown from the kidneys, he is said to have suppression (Keyes). Causes. — Stricture (organic or spasmodic), enlarged pros- tate, inflammation or acute congestion of the prostate, spasm of KANULA KETENTION OF URINE. 487 the cut-off muscles, true vesical paralysis, urethral calculus and inflammation of the urethra are capable of producing retention. Voluntary retention, often repeated and long kept up, may result in retention. Blunted sensibility of the bladder in typhus, small -pox, coma, in some syphilitic and inflammatory brain diseases, in shock from injuries, and in all conditions of spasm of the deep urethral muscles, are causes. Excess of drinking, with or without exposure to wet and cold, is an exciting cause. Re- tention in a child is generally from stone impacted in the urethra; in an adult from stricture; and in an old man from prostatic disease (Keyes). Symptoms. — The bladder may be often seen and felt, filling up the hypogastrium, perhaps reaching the navel. Pressure upon it usually causes a desire to urinate. Fluctuation may be made out between a finger in the rectum and the hand upon the hypogastric tumor. In retention there is always flatness over the pubes (Keyes). Treatment. — In retention from atony, paralysis, fever, etc., a soft catheter of medium size should be passed as often as re- quired and the bladder should be washed out on each occasion with a hot solution of borax in water. A piece of ice about the size of a chestnut introduced into the rectum may relieve reten- tion. In retention from spasmodic stricture caused by exposure to wet or cold and excess of drinking, the simple passage of a large metallic catheter well warmed and oiled is indicated. If the instrument will not pass no force should be employed, but an anaesthetic should be given and then it may pass. The old rem- edy of a hot bath cannot be too highly extolled in retention. A full opiate is also an invaluable remedy relieving the involuntary contraction of the bladder and the pain. In retention from in- flammatory stricture caused by gonorrhoea, the passage of a small catheter, or a hot bath and a full opiate are the best remedies. In retention from a blow in the perinamm, the simple passage of a catheter will usually suffice. In retention from presswre of an abscess in the perinceum, the treatment is to open the abscess (Keyes and Bryant). 488 A COMPENDIUM OF PRACTICAL MEDICINE. ROSEOLA. Is a self-limited eruptive disease pursuing a course similar to measles. It is also called rose-rash, false measles, German measles, rotheln, etc Modern German authors call this disease rubeola (Bartholow). Causes. — Roseola is contagious and is essentially a disease of childhood. The causes are in a measure obscure. The delicacy of the skin in infancy and the active cutaneous circulation no doubt predispose to roseola and erythema. Summer weather with the derangements of the system which it produces is the most frequent cause of idiopathic roseola in young children Loomis and Smith). Symptoms. — Roseola is one of the mildest of the eruptive fevers. The eruption consists of rose -colored spots, varying in size from a pin's head to a large pea, slightly elevated, so that when the hand passes over the surface of the skin it feels some- what rough. Sometimes these spots occasion intense itching, are quite distinctly separated by healthy skin, and disappear under pressure. The eruption is frequently the first symptom of the disease. There may be slight soreness of the throat and mild catarrh of the air -passages. The eruption usually com- mences upon or about the neck and face. It bears considerable resemblance to that of measles. There is no fever in a majority of the cases. The whole duration of the eruption is from two to four days. There is a symptomatic roseola which appears in the course of various acute febrile diseases with the exception of syphilis (Bartholow, Loomis and J. L. Smith). Prognosis.— Is favorable. Treatment. — Regulate the diet and keep the patient in- doors. RELAXED UVULA AND PALATE. Treatment. — Tannic acid is much employed in relaxed con- dition of the mouth and throat. Elongated and relaxed uvula, relaxed palate, and follicular pharyngitis are effectively treated by insufflation of tannin. In chronic affections of the larynx mucous membrane, and of the vocal cords, no inhalation is more RASHES RESTLESSNESS. 489 frequently serviceable than a solution of tannin (grs. x.-xx. to Si v.) applied by means of the handball atomizer. In chronic inflam- mation of the throat when the mucous membrane is relaxed, swollen, granular-looking, and covered with mucous or jms, a few applications of glycerine of tannin brace up the tissues and lessen or remove the hoarseness (Bartholow and Ringer). RASHES. (Medicinal). The administration of certain drugs has a tendency to bring out eruptions which are likely to be mistaken for diseases of the skin. Some persons are peculiarly prone to them and we know not why. Arsenic produces an erythema or an urticaria in some persons, when given in large doses. Belladonna or atrqpia may produce a scarlet rash. Bromides produce a rash similar to acne when given for some time in full doses. Quinine may give rise to an erythematous eruption. In some persons quinine jDroduces large patches of erythema, and always excites a violent urticaria. Chloral hydrate occasionally gives rise to a rash not unlike that of scarlet fever. Copaiba and cubebs produce a rash in some per- sons. Iodine and the iodides given for some time will produce a rash. Opium and morphia may produce an erythematous or urticarial rash which is very itchy. Tar, creosote, carbolic, digitalis, stramonium, strychnia, or salicylic acid occasionally produce an eruption in those who are taking them (Anderson). RESTLESSNESS. Einger says, that in several cases, he has seen aconite quiet the distressing restlessness of "fidgets," which affects men as well as women, and has known a few drops at bed -time calm the patient and give sound, refreshing sleep; if one drop is insufficient, it may be repeated hourly for three or four hours. Sponging with hot water will often induce perspiration, soothe the restless- ness of convalescence, and induce sleep (Ringer). 490 A COMPENDIUM OF PRACTICAL MEDICINE. RELAPSING FEVER. Called also febris recurrens, typhus recurrens, spirillum fever, five- clay fever, seven- day fever, short fever, mild yellow fever, famine fever, hunger -pest, and dynamic fever, is an acute, infections, febrile disease, self -limited, and characterized by the occurrence of a febrile paroxysm, lasting about one week, suc- ceeded by an entire intermission of four or five days' duration, which is in turn followed by a relapse like the first seizure, although shorter. It has never been indigenous in this country. It is by no means a new form of disease. Accounts in the writ- ings of Hippocrates leave no doubt but it prevailed 2,000 years ago in the islands off Thrace. It has prevailed as an epidemic disease in most of the countries of Northern Europe. In 1844 there were fifteen cases of relapsing fever in Philadelphia. The patients were Irish immigrants, all coming over in the same vessel. Dr. Dubois reported a few cases in 1848, and Dr. Flint fifteen cases in 1850-51. All these were among recent Irish im- migrants. It prevailed as an epidemic in New York City in 1872-3, the disease having been imported by foreign immigrants. In 1865 there was a great epidemic in St. Petersburg. The name relapsing fever is to be preferred to any of the other appella- tions, as it is based on one of the most striking of the peculiari- ties of the disease (Bartholow, Flint and Loomis). Morbid Anatomy.— The lesions are those of an acute infecti- ous disease. The spleen is enlarged, due to congestion and hyperplasia of its lymphoid elements. The liver is also enlarged and is the seat of parenchymatous degeneration. The kidneys are swollen. The mucous membrane of the intestine is inflamed. Petechige of the skin are present in about 10 per cent, of the cases. The myocardium may be affected with a fatty degenera- tion almost as intense as that in phosphorus- poisoning. The blood is dark and coagulates imperfectly. In 1873 Obermeier discovered a spiral -shaped bacterium in the blood of relapsing fever patients. This parasite has been found in the blood in no other disease (Flint). Causes. — Pelajjsing fever is a distinctly contagious affection. The poison acquires the greater activity the more filthy, crowded RELAPSING FEVER. 491 and unhealthy the population amid which it prevails. Articles of clothing will retain the contagious principle for a long time, and those who have been in the presence of the sick can convey the poison to the healthy at a distance. Drinking water may be contaminated and spread the poison. The disease attacks by preference the young, the liability lessening after thirty and ap- parently ceasing after fifty. One attack does not afford immun- ity against subsequent attacks. The natural home of relapsing fever is Ireland. The period of incubation ranges between five and seven days, rarely nine. Facts go to show that it is not a highly contagious disease. Considerable exposure is generally necessary. The disease is not likely to be contracted from single 23atients in well ventilated rooms. Destitution and deficient alimentation are auxiliary causes. That the contagium is con- tained in the blood does not admit of doubt. In accordance with the germ theory, the first paroxysm of relapsing fever is due to a brood of spirochoetce. Their existence terminates in about a week, as a rule, and the first febrile paroxysm then ends. The germs remaining in the body give rise to a second brood and there is the relapse of the fever. In rare instances a third and a fourth brood are produced. The contagium is probably contained in the breath and the cutaneous exhalations (Bartholow, Flint and Loomis). Symptoms. — The recurrence of the paroxysm of fever, or the relapse, is the distinctive feature of this disease. The attack is sudden. It is marked by a distiuct chill with fever, frontal head- ache, vertigo, pain in the limbs, joints and back and usually nausea and vomiting. Sweats may, at first, follow the chills. The vomit consists first of the contents of the stomach, then of a yellowish material and this may be followed by black vomit similar to that of yellow fever. The temperature usually attains its highest point within the first twenty-four hours — 104° F. to even 109° F.; and the pulse reaches 140, 150, or even 160 beats j3er minute. The cessation of the fever is as abrupt as its invas- ion. The duration of the primary paroxysm in the majority of cases is between five and seven days. It maybe two or fourteen days. The average duration of the apyrexial period or inter- mission is about seven days. The relapse, like the primary attack, 492 A COMPENDIUM OF PRACTICAL MEDICINE. is sudden, with chilly sensations, fever, etc. The relapse also ends suddenly with profuse sweat. The duration of the relapse varies between three and five days. It may he one or ten days. The relapse does not always occur. But two, three, four, and even fine relapses have been observed. The duration of the second intermission is eight or nine days, and that of the third paroxysm about three days. The duration of the disease aver- ages about twenty-five days. The tongue is coated and soon becomes very dry and sore. Herpes labialis may occur. Epistaxis is frequent. There may be diarrhoea or constipation. Meteorism is common. Tenderness in the epigastric and iliac regions on pressure is common. Jaundice is developed in some cases. A dirty, yellowish color of the skin is present in most cases. During the first paroxysm, pains in the loins, the calves of the legs, and the muscles in other situations are generally much complained of. They are never wanting. The muscular pains do not cease with the ending of the paroxysm, but continue dur- ing the intermission. They are more or less prominent during the relapse. The pains are sometimes referred to the bones. The mind is clear. The perceptions are not blunted in this disease as they are in typhus and typhoid fever. There is no coma- vigil, no subsultus and no carphologia. There is no characteristic erup- tion. Sudamina or miliary vesicles, sometimes are observed when profuse perspiration occurs. The face is more or less flushed but there is not that degree of capillary congestion, marked especially on the cheeks which exists in typhoid fever or the dingy complexion which characterizes typhus. Eelapsing fever, when it attacks pregnant women, always leads to miscar- riage or abortion. The patient goes on from day to day gradually getting worse; the fever becomes more and more intense; loss of strength and emaciation are progressive and the muscular pains are more severe; when on the seventh day of the fever a remis- sion suddenly occurs. CEdema of the feet due to general anaemia is often quite marked during convalescence. Recovery is tedious ( Bartholow, Flint and Loomis). Differential Diagnosis. — Relapsing fever may be confounded with typhus, typhoid, yellow fever, small -pox and measles. In typhus, the dusky face, contracted pupils, absence of all abdoin- RELAPSING FEVER SALIVATION. 493 inal pain, peculiar smell, stupor, apathy of mind, and the path- ognomonic eruption on the fifth or seventh day will be sufficient to distinguish it from relapsing. In typhoid the slow invasion, the "step-ladder" rise in temperature, the eruption and the characteristic diarrhoea will distinguish it from relapsing. In yellow fever the pulse is rarely over 110, the spleen is normal and only a remission occurs. In small-pox^ the eruption appears on the third day. In measles the eruption follows a common cold in the head. Of course the prevalence of relapsing fever will assist the diagnosis (Loomis). Prognosis. — Is always good. About three per cent, of the cases die. Sudden syncope is the greatest danger (Loomis). Treatment. — Dr. Rutty stated more than a century ago that all those cases of relapsing fever which were abandoned to whey and the good providence of God recovered. Loomis would give very little medicine in this disease. If there is any evidence of heart- failure, he would give digitalis and stimulants, with milk diet and free ventilation. For the pains, Bartholow advises morphine hypodermically; and for the nausea, half a grain of carbolic acid in cherry-laurel water. Tonic remedies are indicated. SALIVATION. Is harmful and should not be aimed at. The greatest effect that it is allowable to produce by mercury is to "touch the gums. 11 When the gums are touched there will be an increased flow of saliva, a faint coppery taste in the mouth, and some ten- derness of the gums, tongue and mouth (Keyes). Causes. — The cause of salivation is special idiosyncrasy with a small dose of mercury, or no idiosyncrasy with large doses. A mouth kept dirty or containing bad teeth is more apt to suffer. The influence of cold and wet during a mercurial course may produce it (Keyes). Symptoms. — In salivation, the salivary fluids flow freely, sometimes to an enormous extent; the breath is fetid, the metal- lic taste is very marked; the gums are sore; the teetli fee] too long for the patient to shut his mouth; the tongue swells, show- ing marks of the teeth, and the lips and cheeks may also become 494 A COMPENDIUM OF PRACTICAL MEDICINE. tumefied. Often there is fever. The teeth may fall out, or portions of the soft or bony parts necrose. The articulation is indistinct and painful and deglutition almost impossible (Keyes). Treatment. — During salivation, or any sore mouth from mercury, ten to twelve grains of chlorate of potash to the ounce of water, or any bland fluid, may be used as a mouth wash and gargle. At least one drachm of chlorate of potash should be taken by the stomach daily. A mild solution of carbolic acid, or of permanganate of potash, should be occasionally used as a gargle where there is great fetor of the breath. The free use of the hot bath is of advantage, and a mild diuretic may be given. A little tincture of belladonna may be given to restrain the sali- vary flow. Astringent gargles, Labarraque's solution, tincture of myrrh, hot milk, cold tea may be used as mouth washes (Keyes). Alcohol diluted with water may be used as an astrin- gent gargle in salivation. Bromide of potassium checks the salivation sometimes occurring in pregnancy. A gargle of two drachms of tincture of iodine to eight ounces of water has been recommended to allay mercurial salivation (Ringer). SATYRIASIS. Is constant desire with erection; erotic delirium. It is also a brain disease. Acton mentions the case of an old man who was eminently satyiiasic, so much so that he would masturbate in the presence of ladies. Dying, a tumor of the size of a split pea was found in the pons Varolii (Keyes). SCABIES. Called also "the itch" is a highly contagious disease, especi- ally in persons who are inattentive to cleanliness. It is com- municated by sleeping with, or on the beds of those who are affected, or by coming much in contact with them in any way. It may also be transmitted from the domestic animals, such as the cat. It is oftener met with in winter than in summer (Anderson). Causes. — The cause of u the itch 11 is an animal parasite, called adarus scabiei. This burrows into the skin particularly SCABIES SCAELET FEVER. 495 between the fingers and toes, about the wrists, on the buttocks r abdomen, and the upper part of the penis (DaCosta). Symptoms. — The disease is attended with excessive itching T which is increased at night, and with an eruption usually due to the irritation of scratching. At the close of our civil war we had a form of itch very prevalent in this country, the so-called army itch, which was a very chronic affection and no age or social state was exempt from it. The itching was intense (DaCosta). Treatment. — Scabies can be easily cured. The treatment should be exclusively local. The indications are: 1. To destroy the acari and their eggs. 2. To do so without irritating the shin. 3. To remove the eruptions called forth by the scratch- ing. At the Glasgow Hospital for skin diseases, each patient affected with scabies, is told to scrub the lohole of his body (ex- cept the head) as firmly as possible with black soap and water, and to sit in a hot bath for twenty minutes; also to rub some of the ointment given him firmly into the skin of the whole body (except the head) for twenty minutes. Let the ointment remain on the body all night. Repeat these processes every night for three nights, but no oftener. Besides the above, he is ordered to put all his washing clothes into boiling water, and to iron all others with a hot iron. The best parasiticide in this disease is sulphur / but it is apt to irritate and inflame the skin. Anderson prefers an ointment of storax, for it not only kills the acari, but also has a pleasant aroma, and rather soothes than irritates the skin. Burchard strongly recommends the use of balsam of Peru. One thorough application to the dry skin is sufficient, or the bal- sam may be diluted with two parts of lard and applied oftener. Lard may alone effect a cure if applied for two weeks. SCARLET FEVER. Called also scarlatina, is an acute infectious and contagious disease, self-limited, characterized by a peculiar exanthem, an affection of the throat and albuminuria, and terminating in des- quamation of the epidermis. This name has been given on account of the bright red appearance of its eruption. It is a disease of childhood, but may occur at any age (Bartholow and Loomis). 496 A COMPENDIUM OF PRACTICAL MEDICINE. Causes. — The cause of scarlet fever is a contagion, a micro- organism, which is transferable from the sick to the healthy. No specific microbe of the disease has as yet been discovered. It occurs both in the sporadic and epidemic form, but never arises spontaneously. It may be conveyed by contact, through the atmosphere, by animals, and by clothing; it is therefore a porta- ble disease. An epidemic of scarlet fever has been traced to the milk supply. Quain says : "Milk is a great medium for carry- ing scarlet fever, and cream even more than milk often carries it from the sick to the well." The susceptibility to scarlatina is not universal. Some seem to have a certain idiosyncrasy which prevents them from contracting the disease. Scarlet fever can be communicated from one individual to another by inoculation with the serum from a minute vesicle on the skin of a scarlet fever patient. But those who have been inoculated for scarlet fever have suffered more severely than those who con- tracted the disease in the ordinary way. The scarlet fever poison can be conveyed by clothing, but when a physician makes a visit of ordinary length, he is not likely to so convey the disease. Nurses who have been with a scarlet fever patient for a number of days and whose clothing has become filled with the poison, may carry the disease. The poison is probably contained in the skin and its excretions and epithelium and also in the breath and exhalations from the throat. The period at which the disease is most infectious is probably the highest point of the disease; but it is present at any period from the beginning to the end. The disease but rarely occurs twice in the same individual; although it may recur from one to three weeks after the close of the first attack and is then de- scribed as a relapse. The period of incubation varies from one to fourteen days, the average duration being from three to seven days. The shortest period is that of a patient mentioned by Trousseau, in whom the disease appeared in a day after expos- ure. Within the first six months of infant life there is little lia- bility to the disease; but the greatest susceptibility to the influ- ence of the poison exists between the second and seventh years, and declines slowly to the tenth, and after this more rapidly; but it does occur in old age. Those who have just undergone SCARLET FEVER. 497 surgical operations seem to be especially prone to contract the disease. Women during convalescence after child-birth are very liable to contract scarlet fever. Contagiousness. — The area of the contagiousness of scarlet fever is small; it apparently embraces only a few feet. It is not so contagious as pertussis, variola, varicella, or measles. Variations in Type. — The type of scarlet fever varies greatly in different epidemics. One child may have it so mildly that little treatment is required; while another has the malignant form, and soon succumbs (Bartholow, Flint, Loomis and J. L. Smith). Morbid Anatomy. — It has no characteristic anatomical lesions except those which occur in the skin and mucous membranes. The eruption is due to an intense hyperemia, which is limited to the area of the spots, but which is general when the spots coalesce (Bartholow and Loomis). Symptoms. — There are three stages of scarlet fever: First, the stage of invasion. Second, the stage of eruption. Third, the stage of desquamation. The period of invasion is sudden and violent. A strong chill is the initial symptom in adults; in children there is a violent convulsion, or a severe attack of vom- iting, with prostration. Headache of a very intense character, general muscular pains and high fever succeed to the chill. In a short time the temperature rises to 104°, 105°, or higher; the skin is hot; the throat burns and is red and swollen; the tongue is coated. The affection of the throat is due to the efflorescence which appears in this situation before its appearance on the skin. Epistaxis is common. The average duration of this stage is about twenty -four hours, and the eruption usually appears on the second day. It may appear earlier or later. Stage of Eruption. — This stage in children is sometimes ushered in by a transient convulsion. The eruption appears on the neck and upper part of the chest first, and then on the cheeks and forehead. The first appearance is in the form of minute red dots or specks, and these may coalesce and form a solid redness. Exceptionally, the eruption remains punctiform, that is, in the form of distinct maculae or spots. The redness is vermilion or scarlet. It is not uniform like erysipelatous redness, but on close 498 A COMPENDIUM OF PRACTICAL MEDICINE. inspection the patches are seen to be studded with points. The redness momentarily disappears on pressure, and white lines are produced by drawing a pointed hard substance over the reddened surface. In some cases the whole cutaneous surface is covered with the efflorescence presenting an appearance which has been compared to that of a boiled lobster. The integument is slightly swollen. This is evident of the face and is apparent to the pa- tient wmen the hands are closed. The feet are swollen. The eruption is sometimes accompanied by more or less burning and pruritus. The eruption attains its maximum of intensity and diffusion on the third day after its iirst appearance. In certain cases the eruption may be slight or wanting. The throat is more or less affected in the vast majority of cases. The tongue is coated early, and while the coating remains, frequently the papilla projecting through it have the appearance of a number of red points. In the progress of the disease, the coating exfoliates, leaving the surface of the tongue clean and reddened; and the papillae being enlarged, the appearance is strikingly like that of a ripe strawberry. The strawberry -like tongue is a pathognomonic symptom, and is peculiar to this dis- ease. The pyrexia is not diminished, but, as a rule, is increased after the appearance of the eruption. The pulse is frequent, from 100 to 140 or more, is quick and always compressible, and is never dicrotic. The skin usually is dry and the heat as felt by the hand is often pungent. The thermometer in the axilla shows an increase of temperature to 105° F. and in severe cases it may reach 112° F. The duration of the stage of eruption in the ma- jority of cases is between four and six days. Stage of Desquamation. — With the disappearance of the rash, desquamation commences. The period of desquamation lasts about two weeks, during which time there is the greatest danger of communicating the disease. At the end of this period, if no complications occur, the patient is well. Where the skin is thick, as on the palms and soles, the ejDidermis peels off in extensive patches. The entire period of scarlet fever when it runs its regular course is from two to three weeks. Scarlet fever is liable to irregularities. In a certain class of cases, complications arise from the overwhelming of the cere- SCAELET FEVEE. 499 bro-sjnnal system with the scarlatina poison. In these cases there are delirium, stupor, restlessness, wandering, and picking at the bed-clothes. The most common sequel of scarlet fever is albuminuria with general dropsy. This follows the disease in a considerable proportion of cases. The time of its occurrence is between ten and twenty days after the date of desquamation. The symptoms are those of acute diffuse nephritis. CEdema of the face and lower extremities is first observed, and anasarca frequently follows. Effusion sometimes takes place into the serous cavities. The urine is scanty; sometimes it has a smoky appearance, and it may be distinctly bloody. It is usually loaded with albumin. Ursemic coma and convulsions, pulmonary oedema, and oedema of the glottis are grave accidents incident to the renal affection. Acute nephritis after scarlet fever rarely ends in chronic renal disease. Pleuritis, pericarditis, and acute articular rheumatism are occasional sequels as well as concomi- tants of scarlet fever. Chorea, external otitis and otitis media are sequels in some cases. A purulent discharge takes place from the ears, and sometimes there is considerable deafness. A serious complication of scarlet fever is diphtheria (Bartholow, Flint, Loomis and J. L. Smith). Differential Diagnosis. — Scarlet fever may be mistaken for measles, small-pox, roseola and an erythema which sometimes ap- pears in surgical cases. In measles the appearance of the erup- tion is preceded by a cough and coryza, not so in scarlatina. Be- sides, the eruption of measles first appears on the face, whereas the eruption of scarlet fever first appears on the neck and chest. The incubation period is shorter and fever higher earlier in scarlet fever than in measles. In small-pox, the eruption, if confluent, may resemble that of scarlet fever for the first twenty -four hours yet the development of the first vesicle settles the question. In erythema the redness spreads in a very irregular manner, and the throat symptoms and strawberry-like tongue of scarlet fever are absent. In roseola the throat affection is much milder than in scarlet fever. In roseola the white line that the finger leaves disappears immediately, while in scarlatina it remains (Loomis and Flint). 500 A COMPENDIUM OF PRACTICAL MEDICINE. Prognosis. — Is always uncertain in scarlet fever. The rate of mortality ranges from one death in five to one in twenty. The conditions of a favorable prognosis are early eruption, mild throat symptoms, a temperature not higher than 104° F., pulse not above 120 and mild cerebral symptoms. Autnmn is the most unfavorable season. Malignant cases of scarlet fever in which no eruption appears, prove rapidly fatal. The patient is over- whelmed by the scarlatina or active blood poison. The period of greatest mortality is from infancy to five years of age (Loomis). Treatment. — I. Prophylaxis or Prevention. — The prophy- laxis of scarlet fever is a system of the strictest quarantine. The sick must be removed from the healthy. Fresh air renders the contagion of scarlet fever less powerful; therefore, free ventila- tion is of the utmost importance. All the clothes and excretions of the patient, the nurse and everything contaminated by the contagion should be disinfected. The funeral of those dying of scarlet fever should not be public. The sick should not be .allowed to leave their apartment until desquamation is com- pleted. Belladonna has no power to prevent this disease, as was •once thought. II. Medicinal Treatment. — The medicinal treatment of scarlet fever is almost entirely expectant. It is a disease which cannot be aborted, but tends to recovery. The bed and body linen should be frequently changed. The patient should be bathed with warm water once or twice daily during the period of desquamation. The baths will relieve the kidneys by keeping the skin active. If the temperature of the patient rises above 104° F., it should be reduced by some means. Loomis says, "Unless the temperature in a case of scarlet fever ranges above 105° F., do not apply cold to the surface or give antipyretics. " In all cases the patient is to be sponged frequently with tepid water, and if there is intense burning of the surface, a saline is to be added to the water. Sponging in this manner will give the patient very great comfort. Of all the remedies which Loomis has employed for the throat complications, cold carbonic acid water or pieces of ice afford most marked relief. In the ad- vanced stages of the disease, hot applications may be used extern- SCLEROSIS OF THE BRAITsT. 501 ally to the neck and warm water gargles and steam inhalations internally. For the ulcers sometimes seen in the throat of scarlet fever patients, a spray of carbolic acid, tincture of iron, chlorate of potash, or tannic acid may be used. Stimulants may be given early if there is much depression. Whenever kidney symptoms are developed, dry or wet cups should be applied over the region of the kidneys, upon either side of the spine. At the same time the temperature of the sick-room is to be raised to 73° or 74° F., the body of the patient covered with flannel, hot-air or warm- baths are to be given and also diuretics. Of the diuretics, digi- talis will act most favorably. Small doses of calomel may be combined with the digitalis and continued for two or three days. The patient may drink water freely. If convulsions occur, opium may be given (Loomis). SCLEROSIS OF THE BRAIN. By the term sclerosis is meant a disease characterized by the formation of isolated patches or nodules of sclerotic tissue (har- dened tissue). We have sclerosis of the liver, of the kidney, of the lung, of the brain and spinal cord, etc. Independent of cerebro- spinal sclerosis 1 this is a compara- tively rare condition. Cerebral sclerosis is a chronic interstitial inflammation, following hyperemia of the neuroglia. It may be diffused or multiple (Loomis). Morbid Anatomy, — On section, masses of gray, hard, well- defined, transparent sclerotic tissue are found, varying in size from one -fourth to one inch (Loomis). Causes. — Are obscure. It is intimately connected with changes in the vascular system. Sclerosis of the brain is often found in epileptics and in the insane (Loomis). Symptoms.— Are a gradual enfeeblement of the mental powers, especially memory, muscular tremors, headache, dizzi- ness and vertigo. One group of muscles after another becomes paralyzed. Melancholia, pains in the extremities, and a sense of formication are common. Patients may gain flesh with this disease. Strabismus may be present. . A peculiar symptom is festination — the patient bends forward and trots along like one 502 A COMPENDIUM OF PRACTICAL MEDICINE. trying to run after he is tired out. In rare instances the first symptoms are convulsions of an epileptiform character, followed by hemiplegia (Loomis). Differential Diagnosis. — Sclerosis of the brain may be con- founded with cerehral softening, paralysis agitans or tumors. Softening occurs in old age ; sclerosis occurs from youth to middle age. The paralysis in softening is in one set or group of muscles, and if it extends, does so in an orderly manner. There is anaesthesia, and the symptoms develop more suddenly than in sclerosis. Paralysis agitans is marked by rhythmic tremor passing from one upper to the corresponding lower limb; there is a peculiar deformity of the fingers and toes; the facial muscles are not affected, and the patient inclines to the paralyzed side in walking. Paralysis agitans occurs only after the fortieth year, and is accompanied by no cerebral symptoms. Cerebral tumors are attended by headache, convulsions and signs of brain irrita- tion without loss of mental power (Loomis). Prognosis. — Sclerosis of the brain may continue from five to eight years, but it is progressive and always fatal (Loomis). Treatment. — Little can be done for this disease except to im- prove the general health. Vulpian recommends chloride of iron, Mitchell the bi- chloride of mercury, Hammond the chloride of barium and many the phosphate of zinc. Nitrate of silver and strychnia are said to relieve tremor (Loomis). CEREBRO=SPINAL SCLEROSIS. Is a disease characterized by the formation of isolated patches or nodules of sclerotic tissue (hardened tissue) in the brain, pons, medulla, cerebellum and spinal cord (Bartholow). Morbid Anatomy. — The disease in the brain and cord to the naked eye, appears as glistening nodules underneath the pia, varying in size from a minute object to that of a walnut (Bar- tholow). Causes. — The exciting causes are damp and cold, sudden chilling of the body, traumatism, severe, long- continued brain work or physical exercise, powerful and prolonged moral emo- tion, chagrin and anxiety. The most powerful predisposing CEREBRO SPINAL SCLEROSIS. 503 cause is heredity. Continued jarring of the body is also thought to produce the disease. It occurs in nervous people with hys- teria and after acute febrile diseases. It is essentially a disease of early life, few cases occurring outside the limits of fifteen and thirty -five (Bartholow and Loornis). Symptoms. — It may be insidious or sudden in its develop- ment. If it come on insidiously, the patient complains vaguely of headache, vertigo, muscular weakness, mental disturbances, and queer feelings as formications, itchings, burnings, etc., in the limbs. There are nausea, vomiting, cardialgia, loss of co-ordin- ating power, and impairment of the special senses. There is more or less paresis in the extremities, and shaking tremor when an attempt is made at voluntary motions. In some cases the patient becomes childish or morose. During prolonged fits of yawning, sobbing, or laughing, the respirations become stridulous. The patient talks in a low monotone or whisper, dividing his words in syllables, and empasizing them as when scanning a line of poetry. A girdle pain is felt about the abdomen. Amblyo- pia, nystagmus, diplopia, and inequality of the pupils evidence invasion of the base of the brain and optic tracts. In the ad- vanced stage acute bed-sores, loss of sexual power and control of the sphincters become marked symptoms (Bartholow and Loomis). Differential Diagnosis. — Cerebro- spinal sclerosis may be mis- taken for paralysis agitans, locomotor ataxia, and cerebral hem- orrhage. In paralysis agitans the fine tremor exists when the patient is at rest, and is not accompanied by shaking of the head; while in sclerosis the head is always involved, the symp- tom ceasing as soon as the patient is at rest. Paralysis agitans is rare before forty; and multiple sclerosis is rare after thirty - Hve. Changes in the voice and speech and ocular symptoms are present in disseminated sclerosis and absent in paralysis. In locomotor ataxia, the peculiar tremor, impairment of voice and speech, and nystagmus that belong to disseminated sclerosis are absent. In the former disease we notice the peculiar iron- band sensation, vesical symptoms, the Meniere's vertigo, the very slow and late appearance of paretic symptoms, the lightning-like and agonizing neuralgic pains, and the peculiar double beat in 504 A COMPENDIUM OF PRACTICAL MEDICINE. walking, the heel being put down first, all of which are in marked contrast to the symptoms of multiple cerebro- spinal sclerosis. When sclerosis is ushered in by loss of consciousness which rapidly deepens into coma, with marked hemiplegic symptoms, it may be mistaken for cerebral hemorrhage / but in sclerosis the temperature is very high during these peculiar attacks — 104° or 105° F., — the hemiplegia passes off soon (Loomis). Prognosis. — The average duration of this disease is five to ten years. The termination by death is the only one known. After six or seven years emaciation sets in, a marasmus is devel- oped, and the patient is apt to die from intercurrent disease (Bartholow and Loomis). Treatment. — Improve the nutrition. Chloride of gold, phos- phate of zinc, nitrate of silver, chloride of barium, potassium, iodide and bromide, arsenic, belladonna, calabar bean, and ergot have all been used with some success. The galvanic current benefits in some cases. For the pain morphine should be given (Bartholow and Loomis). SCROFULA. Is a constitutional dyscrasia, hereditary or acquired, charac- terized by changes inflammatory and hyperplastic, occurring for the most part in the lymphatic system, the skin, mucous mem- branes, connective tissue, osseous structures and viscera. Scrofula is also known as struma, the strumous diathesis, tuber- culosis, the tuberculous diathesis. Scrofula is a disease chiefly of infancy and childhood, but early adult life is not entirely exempt. Scrofulous persons are liable to chronic inflammations of the lymphatic glands, especially those of the neck, which enlarge, often coalesce with each other, and undergo cheesy metamorpho- sis (Bartholow, Loomis and Smith). Morbid Anatomy. — The characteristic lesions of scrofula are to be found in the lymphatic glands, although the skin, mucous membranes, bones, joints, and organs of special sense may be in- volved. Anaemia necrosis or suppuration sometimes occurs in the glands. On the skin the lesions appear as eruptions. Im- petigo of the eyelashes and external otitis are common strumous SCROFULA. 505 diseases. Scrofulous inflammation of mucous membranes is marked by a thick, sticky exudation with a tendency to form scabs. The bones most frequently involved are those of the ankle, lower part of the femur, and the vertebrae. The scrofulous development may assume the form of synovitis, osteitis, perios- teitis, or general arthritis. A pharyngitis often gives rise to hyperplasia of the tonsils (which are lymphatic glands) in scrof- ulous individuals (Loomis). Causes. — Scrofula is congenital or acquired. The children of intemperate, jDhthisical, syphilitic, cancerous and very old or very young parents, develop early all the characteristic features of the scrofulous diathesis. Children of consanguineous mar- riages are especially liable to scrofula, and to this has been attri- buted the scrofula of royal families. Healthy children may ac- qire scrofula through antihygienic surroundings, from improper food, overcrowding, lack of fresh air, exercise and sunlight. In the infant scrofula is sometimes produced by insufficiency or poor quality of the breast-milk, or too protracted nursing at the breast. Some think that scrofula is a local tuberculosis from the fact that scrofulous glands sometimes contain the tubercle bacillus. Birch -Hirchf eld found tubercles in nine out of ten lymphatic glands removed from the necks of scrofulous patients. Others think that the tubercle bacillus found in scrofulous glands is accidental. Rabl tabulates 1,000 cases of scrofula as regards the causation, as follows: 79 had scrofulous parents, 446 had tuberculous parents, 356 lived in damp dwellings, 25 were subjected to other bad hygienic surroundings, 69 could be as- cribed to acute infectious diseases, such as small -pox, measles, scarlet fever, etc., 14 to vaccination, 7 to decrepitude and 4 to consanguinity of parents. Kabl also expresses the opinion that in certain cases scrofula results from syphilis in the parent or grand-parent. He believes that syphilis in the parent causes scrofula in the child by diminishing the power of resistance to the causes which produce the latter affection. He thinks that in this matter parental syphilis gives rise in some children to symp- toms identical with those of scrofula, while in other children it gives rise to syphilitic symptoms. Dr. J. L. Smith is of the same opinion (Bartholow, Loomis and J. L. Smith ). 506 A COMPENDIUM OF PRACTICAL MEDICINE. Symptoms, — Some children with a scrofulous habit have a transparent, white skin, with delicate blue veins; large, lustrous eyes; bright red lips, etc. Others may have large heads with coarse features, a thick skin, which has a flabby, spongy feel, an enlarged abdomen, and cervical glands. Chronic inflammations of the skin about the face and scalp are frequent. Coryza, con- junctivitis, otorrhcea, laryngitis and bronchitis are persistent. Synovitis may appear. A slight injury may be the starting point of caries and necrosis. Glandular enlargements are the most common symptoms. This enlargement, which is non-inflam- matory and due to cellular hyperplasia, is very gradual, and forms a smooth, firm tumor. These glands may inflame and sup- purate. The disease progresses slowly, but toward puberty pul- monary disease is apt to be established (Loomis and Smith). Prognosis. — Is good when the patient is seen early. Scro- fulous children may die from tuberculous intestinal disease, acute hydrocephalus or croup. Treatment. — The diet should be nutritious and easily di- gested. Cod-liver oil should be given daily during the greater part of infantile and adult life. The syrup of the iodide of iron should be given in one to two -drop doses three times daily to a child of six months, and Ave drops to a child of four years. The following is a good formula: Jfc Olei morrhuse §iv. Syrupi calcis lactophosphatis Aquae calcis — aa §ij. — M. Sig. : One teaspoonful to a dessertspoonful four times daiJy. —Smith. Fresh air, outdoor exercise and daily bathing are necessary. Farm-life, sea-air and sea-bathing have been found efficacious. The following is a useful iodine mixture for external application: {fc- Liquor iodini composita Gly cerime — aa , Sj • — M. Sig.: To be applied over the gland as an inunction. The synovitis or strumous arthritis must be treated appropri- ately when it occurs. When it occurs in two or more joints, it may be mistaken for rheumatism (Loomis aud Smith). SCURVY. 507 SCURVY. Called also scorbutus, is a chronic blood disease, which may be regarded as a peculiar form of anaemia arising from deficiency of vegetable diet. This disease appears to have been known to the ancients. During the last iive or six centuries it prevailed very entensively in armies and among crews of sailing vessels, and hence it was called sea- scurvy. It prevailed enormously in the English and French armies in the Crimean War, and also in the late Civil War in our own country (Flint and Loomis). Causes. — Deprivation of fresh vegetable food for along time will very surely induce scurvy. It is rarely met with from any other cause, although an unvaried diet of poor quality may in- duce it (Loomis). Symptoms. — The skin of the face and eyelids changes color and appears bruised and swollen. The pulse is soft and the temperature lower than normal. There is great despondency and a sense of weight in the lower limbs. The skin is dry, rough and of a muddy pallor. The conjunctivae are pearly white, the tongue is clean and pale, the teeth loosen and are surrounded by bright red ulcerated and spongy gums which bleed upon the slightest provocation. The breath is exceedingly offensive, fre- quently from necrosis of the jaws. Ecchymoses and petechial spots cover the body. Severe darting pains are felt in the limbs, about the calf of the leg and the popliteal space. Node-like swellings occur over the tibia. Slight exertion may occasion palpitation, dyspnoea, and even syncope (Flint and Loomis). Differential Diagnosis. — Scurvy may be mistaken for mercy/r- ial poisoning and pwpwd. The history of the case and a close inspection of the gums will enable one to distinguish scurvy from mercurial poisoning. Scurvy is distinguished from pur- pura by the spongy gums, painful swellings, and more profuse though less numerous hemorrhages. Purpura is not affected by lime juice, or change in diet, while scurvy is (Loomis). Prognosis. — Scurvy is not a fatal disease, if uncomplicated, and appropriate treatment applied. It Avas the cause of death in a large proportion of those who died during the potato famine in Ireland (Loomis). 508 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — In long sea- voyages or campaigns lemon or lime juice or citric acid should be taken daily when fresh or pre- served vegetables cannot be obtained. By their use in the English navy, scurvy has been diminished nearly ninety per cent. Orange -juice is also an effectual antiscorbutic. One of the most efficient of antiscorbutic vegetables is the potato. It is most efficient when eaten raw. Pickles, onions, raw cabbage or sauerkraut, the water- cress, green corn and green apples are valuable antiscorbutics. One who is seriously ill of scurvy should be kept in bed, and his diet should be fresh vegetables and acid fruits with fresh meats. Three or four ounces of lime or lemon juice largely diluted with cold water should be taken daily. Tincture of the chloride of iron and ergot are given to arrest hemorrhage. Whiskey may be given when indicated. To arrest local hemorrhage, alum, tannin, subsulphate of iron and the chloride of iron are most useful. A wash of chlorate of potash will afford relief to the mouth symptoms. Quinine, iron and strychnine act both as tonics and appetizers (Flint and Loomis). SEA=SICKNESS. Is a peculiar form of functional disturbance of the nervous system characterized by severe depression and persistent nausea and vomiting (Loomis). , Causes. — Sea-sickness is most commonly the result of the motion of a ship, but it may be the result of any unusual motions to which the person is unaccustomed, as the motion of a swing or an elevator. Waltzing, riding backwards, turning a somersault, or the sudden jerk of a railroad train as it starts or stops may each produce a similar condition. In some persons, a mild form of sickness may be produced by simply watching oscillating objects. Some persons never suffer, while others are unable to endure the slightest motion on the water or elsewhere. The nerve centres are embarrassed, and the resulting nervous irritation manifests itself through vaso-motor disturbances in precisely the same manner as is seen when persons blush under embarrassing circumstances, or pale when startled (Loomis). SEA- SICKNESS. 509 Symptoms. — Seasickness usually presents the two stages of first, depression and exhaustion, and second, reaction. It begins with a sense of weight and epigastric oppression, occuring only during the rapid rise and fall of the vessel. It speedily becomes continuous and is accompanied by vertigo and headache. Nausea is always most intense and at the same time the vomiting is often sudden and projectile, as in cerebral vomiting. The appetite is entirely lost. The mental depression is great. In the majority of cases this condition continues from three to five days, provided the voyage is of that length during which time the nausea, vomit- ing and mental depression continue and is then followed by reac- tion. There is now a ravenous appetite and a feeling of well being. In some cases the stage of depression lasts for weeks, and the pa- tient may pass into a stage of partial collapse and coma (Loomis). Prognosis. — It is very rarely fatal, but occasionally a condi- tion of collapse develops which, if not assiduously treated, may pass into coma and death (Loomis). Treatment. — For the vaso-motor disturbance and spinal con- gestion, counter -irritation to the spine, or ice-bags and the bro- mides and nitrite of amyl have proved the most useful. The ice- bag controls the spinal congestion. The bromides must be be- gun some time before the voyage and continued in large doses until the patient is accustomed to the motion. Amyl nitrite seems to be the most efficacious remedy yet proposed. It should be given in full doses upon the first appearance of epigastric dis- tress and repeated as necessary. Dr. Clapham reports 121 suc- cessful cases out of a total of 124 in which amyl nitrite was used. Sometimes stimulants are effective but often fail (Loomis). Ac- cording to Bartholow sea- sickness is relieved sometimes by the subcutaneous injection of atropine in small quantity. A little chloroform (2ftii-2T£v.) dropped on sugar and swallowed is some- times effective in sea- sickness. Chloral in fifteen to thirty grain doses every four hours, is probably the most effective remedy, but it must be given before decided nausea sets in. The bromide of sodium in half to one drachm doses before embarking is one of the first remedies in sea-sickness. Nitro- glycerine by the stomach may afford relief (Bartholow). 510 A COMPENDIUM OF PRACTICAL MEDICINE. SEPTICEMIA. Is a constitutional disease due to the absorption into the blood of a septic material which is developed in decomposing animal matter by the action of putrefactive bacteria. The dis- ease is closely allied to surgical or traumatic fever (Loomis). Causes, — The nature of the septic poison is still a matter of dispute. Some claim that it is a chemical substance formed in a wounded part, while others regard the bacteria the sole cause of the septic infection. Decomposing tissues which cause septi- caemia may be in the body, on the surface of the body, or outside of the body. I Thus, a decomposing placenta in utero, sloughing ulcers in typhoid, necrotic processes in chronic phthisis, diphtheritic sloughs, ulcerative endocarditis, abscess and gangrene of the lung — these are some of the internal conditions which may induce septicaemia. II. Wounds, gangrene, decomposing membranes, or sup- puration and necrosis in small -pox, any ill-conditioned wound, especially if lacerated and contused, may cause septicaemia. Ill Dissecting wounds and post- mortem manipulation of those who have died of infection, even without a surface abra- sion, may induce septicaemia. The respiratory and the gastro- intestinal tracts are sometimes the mode of entrance of the infec- tion (Loomis). Symptoms. — The symptoms of septicaemia or blood-poison- ing will vary with the amount of the septic material introduced into the system and the length of the infection. In a well- marked case, after a rigor, or feeling of chilliness, but rarely a distinct chill, there is a rapid rise in temperature; 105° or 107° F. may be reached within the first twenty-four hours. The pulse is rapid, 120 to 140, feeble and thread-like. The mouth, tongue, and surface of the body become hot and dry. If sweats occur they are very slight. Vomiting is frequent. The countenance is dull, and the patient generally free from pain. There is rest- lessness and low muttering delirium. The respirations are feeble, labored, and hurried. The skin may be slightly jaundiced. Diarrhoea is present in nearly all severe cases. In severe cases SEPTICEMIA SPEKXATOKRHCEA 511 death may occur within twenty-four to seventy-two hours, the patient dying in complete collapse. Typhoid symptoms, a dry tongue, rise in temperature, diarrhoea and muttering delirium, following an abortion or child-birth, should always excite sus- jDicion (Loomis). Differential Diagnosis. — Septicaemia may be mistaken for pycerma. Pycemia is ushered in by a distinct chill; septicaemia by a slight chill. In pyaemia the chills recur; in septicaemia there is but one chill. In pyaemia there are profuse sweats, which recur; in septicaemia there are slight, if any, sweatings, and they are never recurrent. In pyaemia the temperature grad- ually rises to 102° to 104° F.; in septicaemia it is high at the onset, 105° to 107° F. There is a sweet "sickish" odor to the breath in pyaemia, absent in septicaemia. Pyaemia develops slowly, septicaemia rapidly (Loomis). Prognosis, — When the symptoms of the disease are well marked the prognosis is bad. Its duration is from two days to two months. Treatment. — Discover and when possible remove the cause. Antiseptics should always be used at the seat of the infection. The bowels must be freely acted upon by salines throughout the whole course of the disease. Quinine, salicylic acid and brandy are the three drugs on which we place our reliance. Tanner recommends quinine and nitric acid. The diet must be as nour- ishing as possible. Billroth's treatment is cooling drinks, a fever diet, morphine at night to secure sleep, from six to ten grains of quinine during the afternoon and warm baths (Loomis). SPERMATORRHEA. Is an escape of seminal fluid containing spermatozoa, without ejaculation and without pleasurable orgasm, usually at stool, with the urine, or to a slight extent at all times. During pro- longed erection under intense sexual excitement, a small amount of true seminal fluid is apt to escape into the prostatic sinus, and to be passed at the next urination. This may happen to any one occasionally, and does not amount to disease (Keyes ). 512 A COMPENDIUM OF PEACTICAL MEDICINE. Varieties. — /. True Spermatorrhea. II. False Sper- matorrhoea. True spermatorrhoea may exist, but it is a very rare disease. It falls to the lot even of the specialist to see but very few cases of true spermatorrlicea. False spermatorrhoea, is, however, a more common com- plaint. It is supposed to be present when nocturnal emissions are frequent, when diurnal emissions* take place on any sexual thought, and urethral discharge of a glairy fluid attends defeca- tion, when erections with discharge follow the slightest irritation, such as that produced by riding or walking, from the friction of trousers, etc. Such cases are common and are usually due to masturbation, but are not cases of true spermatorrhoea, although they often preceed it. Nocturnal emissions may be too frequent; but if associated with sexual feeling, they are natural. If too frequent, they should be checked as they may lead on to the true disease. The glairy fluid pressed out in defecation is rarely seminal, but is prostatic, of a transparent, tenacious character, and not milky. Most of the symptoms which a patient usually mistakes for spermatorrhoea are a gleety discharge, phosphatic urine, vesical mucus, decomposing urine, etc. The young man into whose hands some pamphlet on u Manhood Restored " has fallen, imagines himself hopelessly doomed to impotence, paraly- sis, and idiocy, because the pamphlet tells him that he has sper- matorrhoea, which spermatorrhoea consists in nocturnal pollution, escape of mucus during prolonged erection, of phosphates in the urine, etc. Sometimes, where the diseased mind of a youth suf- fering from ungratified sexual desire can find nothing else to con- firm its suspicions, the natural healthy flocculent cloud of mucus collecting normally in all urine, after it has stood awhile, is pointed to, in dejected triumph, as a demonstration of the never- ending loss of seminal fluid (Bryant and Keyes). Causes. — Spermatorrhoea sometimes follows excessive mas- turbation, general prostration, as after typhoid fever, imperfect digestion and general nervous distress from overwork, or other cause, or follow chronic disease of the prostatic sinus and seminal vesicles. It is sometimes associated with constipation and rectal irritation, spasmodic action of the levator ani acting on the SPERMATORRHEA. 513 vesiculae seminales and prostate gland. The worst cases are asso- ciated with wasting of the testicles and varicocele. It is some- times due to excess of venery. Lallemand holds that sperma- torrhoea is nearly always dependent upon irritation of the pros- tate gland and its ejaculatory ducts. Trousseau believes that spermatorrhoea or incontinence of semen is due to some imper- fection in the nervous system of organic life, since it is so commonly found in men who have had incontinence of urine in childhood (Bryant and Keyes). Symptoms. — In true spermatorrhoea it is usual for spermatic fluid in small quantity to pass from the meatus during defecation and urination; while jolting or riding, etc., cause oozing of a bluish fluid from the meatus, which contain spermatozoa. Pa- tients with true spermatorrhoea have little care for their sexual functions and are not disturbed on the subject of impotence and present in this respect, a most strongly marked contrast with the hypochondriacal patients imagining themselves impotent from false spermatorrhoea. Patients with true spermatorrhoea are not by any means necessarily impotent, but their sexual appetite is usually morbid, excessive or feeble perhaps unnatural and per- verted, while sexual power is generally diminished. According to Bryant, spermatorrhoea commences almost always with nocturnal emissions which gradually become more frequent. These are at first attended with erotic sensation, but finally occur without erection. If copulation be attempted the ejaculation takes place at once, often before the introduction of the organ. In many cases the general symptoms are those of great lack of nervous tone, dyspepsia, headache, melancholy, neuralgia, loss of spirits, pains in the back, groins, testicles and vesical irritability. Such patients tend to grow thin, to lose their ambition and to fret. At last the penis shrivels, the testicles become small, flabby and very sensitive and the patient becomes truly impotent, incapable of erection. This malady does not kill. Dr. Keyes knows an old gentleman who enjoys excellent health and who lias had true spermatorrhoea more than fifty years (Bryant and Keyes). Treatment. — Many cases are positively incurable, some gei well — medicine is of little or no value. It is unfortuate that so many text-books ascribe value to the use of drugs in this malady. 514 A COMPENDIUM OF PRACTICAL MEDICINE. All the hygienic, general and local measures advised for cases of pollution may be tried. The use of the steel sound helps to give tone to the parts. Rouband thinks well of ergot — two to eight grains daily — in atonic cases. The use of a local astringent to the prostatic sinus is often of marked advantage. The best agent for effecting this is nitrate of silver in solution (gr. x. to 5j to the ounce), three to five drops of this thrown into the deep urethra. Bryant thinks half-grain doses of the extract of bella- donna twice a day, with some tonic such as iron, zinc, strych- nine, or quinine, are valuable. The rectum should be kept empty by a nightly injection of cold water. If a positive local treatment, with perhaps some tonics when required, fails to cure, the patient will be wise to accept his malady as he would some deformity which others cannot see, and think as little of it as possible, keeping his mind pure and his thoughts away from the subject (Bryant and Keyes). STRANGURY. Is the painful passing of urine in drops. It is not a disease but a symptom. The following prescriptions have been tried and recommended : J& Tincturse cannabis indicae ^ij. Sig. : A half-teaspoon ful every few hours. (When strangury is due to spinal disease with bloody urine.) — Ringer. jfc Pulv. opii gr. ii.-iv. Olei theobromse 3j . — M. Ft. suppositoria no. ii. Sig.: Introduce one into the bowel, and repeat if necessary in four hours. — Hartshorne. STYE. Called also hordeolum, is a small red and painful swelling situated on the outer surface of the lid or near its margin, and consists in a circumscribed phlegmonous inflammation of the lid dependent on morbid change in the Meibonian glands (Bryant and Noyes). Causes. — Styes generally occur in weakly, delicate persons, and are apt to be associated with chronic blepharitis or conjunc- STYE SPINA BIFIDA. 515 tivitis, and often depend on general debility. Another frequent concomitant and favoring condition is nasal catarrh, which will also need attention. Several styes may appear simultaneously, or there may be a succession of them. They give rise to con- siderable irritation and are often extremely painful. The innammation usually goes on to suppuration (Bryant and Noyes). Treatment. — In its inception it may sometimes be checked by applying a bit of ice wrapped in muslin for a few minutes repeatedly, or by pulling the cilium which passes through it. When suppuration is unavoidable, a poultice of ground slippery elm bark is most comforting, and a puncture should be made at an early period. Good living, general tonics, and mild astrin- gents are the proper remedies to prevent their recurrence; but it is important also to investigate the state of refraction, because what causes eye strain will provoke styes (Noyes). The follow ing lotion may be of service: Jfc Acidi boraeici ^iss. Aquae destillatee , 5V. — M. Sig. : Apply to the eyelids several times daily. — Abadie. SPINA BIFIDA. Called also hydrorachitis, is a congenital defect of the ver- tebral column, accompanied by a protrusion of the surroundino* membranes of the cord, due to an arrest of ossification of the vertebrae of the foetus at this point. It is essentially a congenital hernia of the membranes of the cord through an opening iu the spine. It is analogous to the meningoceles of the cranium, and is similar in nature to hare -lip and cleft palate. The liquid in hydrorachitis is simply a portion of the cerebro- spinal fluid which normally exists in the subarachnoid space in the brain and spinal cord. It often contains the spinal cord itself or large nerve trunks (Bryant and Sayre). Characters of the Tumors. — The spinal hernia is sometimes covered by the whole thickness of integument; at others the in- tegument, though present, is very thin; while occasionally the walls are represented only by a transparent membrane. The tumor may have a broad base and free communication with the 516 A COMPENDIUM OF PRACTICAL MEDICINE. central canal of the cord, or a narrow and more or less peduncu- lated one. The cord is more likely to be involved in the greater than in the less base. The tumor is always more or less globu- lar, tense and elastic. When the child is asleep or quiet the swelling may be soft; but when the child cries the tumor will rapidly fill out. The skin of the tumor may be ulcerated at birth or have a small opening (Bryant). Associated with Hydrocephalus . — The tumor is often asso- ciated with hydrocephalus and in exceptional instances is double. A nwvuB is not seldom found situated over the tumor. Club- foot ox paralysis of the lower limbs frequently co- exist with it, and in these cases it is tolerably certain that the cord is included in the hernia. Paralytic symptoms are more common in the broad- based hernia than in the narrow. Incontinence of urine or of feces may co- exist with the paralysis (Bryant). Situation of Tumor. — The lumbo- sacral portion of the column is more frequently affected than any other, but the cervical and dorsal portions are also liable to the defect. Of twenty -seven cases of Bryant's, thirteen occured in the lumbar region, four in the lumbo- sacral, and nine in the sacral, and one was double, a small tumor being in the lumbar and a large one in the sacral region. Twelve of these cases were uncomplicated with any paralysis or deformity. In eleven there was incontinence of urine and feces, associated in four with paralysis of the lower ex- tremities. Four were complicated with hydrocephalus, two with nsevus, and one with talipes. Bryant has seen but two cases in which the tumor was in the cervical region. In exceptional cases the spinal hernia may protrude on the anterior part of the spine. When the tumor is complicated with hydrocephalus "fluctuation may often be felt between the two parts, pressure on the head causing a fullness of the spinal hernia, and vice versa (Bryant). Diagnosis. — In general, there is no difficulty in diagnosing a spina bifida. In any infant a congenital tumor over the spine is probably a spina bifida; if globular and tense or capable of becoming tense when the child cries, the probabilities are almost converted into a certainty. The only cases for which spina bifida is liable to be mistaken are congenital tumors, unconnected with , the spine, such as cystic, fibrous, fatty or fcetal tumors. These SPI^A BIFIDA. 517 may be hard and tense, but they are rarely, if ever, made so much more tense from the child crying, as is the spinal hernia (Bryant). Prognosis. — The majority of these cases prove fatal. Many of the subjects are ill -developed and die within a few days of birth; death from convulsions is very usual when the sac bursts and its fluid contents escape, more particularly when the escape is rapid. The rupture of the sac is not necessarily followed by a fatal result. Bryant had a case in which at birth the tumor was transparent and soon burst, and subsequently discharged at inter- vals for three years, and finally contracted up into a solid mass. This case is an example of a natural cure by gradual closure of the bony orifice. The more pedunculated the tumor the better the prognosis (Bryant). Treatment. — The treatment of these cases is very unsatisfac- tory. In the majority of cases, palliative treatment is all that can be adopted; although in exceptional instances operative interference promises to be of service. The tumor must always be guarded from injury by some soft protective material. Slight pressure to prevent rapid increase of the tumor is always bene- ficial. The application of collodion is sometimes useful. Aspira- tion, subcutaneous puncture with a trocar, and injection of the iodo- glycerine solution have been practiced with more or less success. Successful cases are recorded in which tapping of the hernia has been performed. The practice is dangerous, as the drawing off of the fluid has been followed by convulsions and even death; yet it is the least dangerous form of practice, and may be undertaken. The puncture should always be made at the side of the tumor, and the whole of the fluid should never be drawn off at once. Mr. W. E. Image, of Bury St. Edmund's, cured a case by puncture with a darning-needle at intervals of two or three days, four or six times, and applied a compress. In this case con- vulsions were produced whenever any pressure was applied to the tumor, but ceased after tapping. Dr. Morton, of Glasgow, has advocated the injection at intervals of seven or ten days of half a drachm of a solution made by dissolving ten grains of iodine and thirty grains of iodide of potassium in an ounce of 518 A COMPENDIUM OF PRACTICAL MEDICINE. glycerine. The injection should be thrown into the sac after the withdrawal of a small portion of the spinal fluid. Dr. Morton reports, in 1881, that out of twenty-nine cases operated upon, there were but six failures. This success is encouraging*. In a case of Bryant's, after the second tapping, there was so much draining of the fluid from the cord that the child died from ex- haustion. In no case where the base or neck of the tumor is large or the cord involved should this or any other operation be per- formed. In pedunculated tumors an operation may be attempt- ed. In the case of a tumor with a small pedicle Dr. Sayre ligated the base of the sac with success. He passed a needle armed with a double ligature through the centre of the pedicle and after tying one ligature on each side, passed two circles entirely around the pedicle, drawing them so tight as to strangulate the mass and then excised it with one stroke of the knife. On the twenty -third day the ligatures came away leaving the wound entirely healed. Dr. Wilson, of Clay Cross, reports a successful case in which he removed the tumor five days after the closure of its neck by means of a clamp. In some cases of spina bifida nature effects a more or less perfect cure by closing in the defec- tive portion of the spinal canal. The child should be fed upon the most nutritious diet with the administration of the j3hos- phates, lime, etc. (Bryant and Sayre). SPRAINS. May be very slight or very serious indirect injuries. They include more or less severe overstretchings, if not lacerations of the muscles or ligaments that bind the bones of an articulation together, some fracture or tearing away of the bone at the attach - meut of the ligaments — "sprain fractures," In children under ten, sprains of joints are liable to be complicated with some epiphysial separation. In the more severe instances are included lacerations of the muscles, tendons, and soft parts that surround the joint. All such accidents require rest and time in their treat- ment in order that repair may be complete, since neglected sprains arc often the cause of joint or bone disease (Bryant). SPRAINS. 519 Contusions of joints as direct injuries always ought to be regarded in a serious aspect, for a large amount of internal mis- chief may often be sustained with very slight external evidence of injury. Under certain conditions of health a slight blow upon a bone is often enough to set up severe local action or to excite chronic changes which may involve the integrity of the joint (Bryant). Sprain of the hack is an accident of common occurrence. Any twist of the spine or forcible flexion may injure some of the joints. Hemorrhage may take place into the spinal canal as a result of the sprain or laceration of the ligaments. Prognosis. — Sprains may be followed by acute or chronic joint disease of a serious and insidious nature; and this truth should ever be before the surgeon to influence his practice. In every case of wounded joint, however trivial, aud in all doubtful cases of wounded joint, the prognosis must be very guarded and the treatment cautious (Bryant). Treatment. — About one hundred years ago John Hunter said: u In sprcvms of joints rest is the first principle" At the present day the same words are as pregnant with truth as when then spoken. In simple cases of sprain rest is all that is needed. When swelling and effusion into the joint ensue in the course of the second or third day after the accident, the evidence of inter- nal injury is more marked, for such effusion means inflammation or synovitis, which is to be treated by absolute rest, ensured by the application of a splint, and the local use of cold or warmth. If swelling of the articulation follows immediately upon the injury, effusion of blood into the joint is indicated with or with- out fracture, but always with severe local mischief. Such cases should be treated by the employment of a splint, to ensure im- mobility of the joint, elevation of the injured part, and local ap- plication of a bag of pounded ice until hemorrhage lias ceased, and all risks of inflammation of the joint are gone. As soon as the primary effects of the sprain and all signs of inflammation have passed, the application of pressure to the joint by means of a bandage with passive movement is very striking. When the joint is rendered very tense from effused blood, it may be aspir- ated. In children all falls upon the hip followed by pain should 520 A COMPENDIUM OF PRACTICAL MEDICINE. be treated by rest and extreme care, as hip disease may originate from such cause (Bryant). After Treatment. — When the immediate effects of the sprain have passed away the local use of a stimulating liniment and moderate friction of the part expedites the cure. A local warm bath at intervals likewise relieves the stiffness of the joint. Whenever movement excites more than a momentary pain, rest should be observed. When weakness of the joint alone remains, a good bandage or strapping around the part to give support is of great benefit. Where much laceration of ligament has taken place it is necessary for the joint to have some artificial support in the form of either a splint, felt, leather casing or bandage; for no parts are repaired with less permanent power than liga- ments. In the wrist when much swelling exists, a sprain maybe mistaken for a fracture or a fracture for a sprain. Much care is necessary in the diagnosis of such cases. Many sprains of the ankle are also really cases of fracture of the fibula above the malleolus. The popular notion that a severe sprain is worse than a fracture is in the main true; and when the sprain is neglected the case is always more tedious than that of a broken bone (Bryant). STRICTURE OF THE URETHRA. An unnatural narrowness of any portion of the canal of the urethra constitutes stricture. This contraction of the canal to constitute stricture must be unnatural, for the urethra has certain points of normal contraction — namely, the meatus, the middle of the pendulous, and the beginning of the membranous urethra, and these are not strictures. They become so, if they are unduly small. Thus, an individual may have a congenital stricture of the meatus. Any inflammatory condition of the walls of the canal, or spasmodic contraction of the same, constitutes stricture, as does also any growth upon or beneath the mucous membrane, as cancerous, tubercular, syphilitic and membranous (Keyes). Varieties of Stricture. — Stricture is of two kinds : 1. Mus- cular, or spasmodic. 2. Permanent, or organic — the latter may be congenital, or acquired. Inflammatory stricture does not STRICTURE OF THE URETHRA. 521 exist as a disease of the urethra. Xo amount of simple inflam- mation of the urethra would occasion serious inconvenience (retention \ unless occurring in connection with organic stric- ture, assisted by muscular spasm or complicated by prostatic congestion. I. Muscular or Spasmodic Strict are. — -Is of the commonest occurrence; an active predisposing cause is a sensitive, high- strung nervous organization. The exciting causes are any local irritation, inflammation, foreign body, irritation of the rectum, (reflex action), ingestion of certain substances, as cantharides, turpentine, quinine, opium, etc.. mental emotions, and malaria. Take a nervous, excitable young man with a healthy urethra, or better still with an irritable bladder or inflamed urethra, and attempt to pass a bougie for the first time, and the chances are that it will be arrested. It may be grasped and firmly held at' any part of the canal, but this is more liable to occur just as the instrument is entering the membranous urethra, where its point may be detained for manv minutes by an involuntary contraction of the cut -off muscles. If the end of the sound is held quietly for a few moments against the contracting muscle, the spasm will yield, and the instrument pass on into the bladder. What surgeon has not witnessed spasmodic stricture, caused by modesty, shame, anxiety, fear, and irritated mind, as shown by the total inability of some patients to pass water before a class of students or even in the presence of a physician alone in his office \ In such cases there is a failure of the compressor urethra? to relax. The patient contracts his abdominal muscles and his diaphragm, and uses all his will, but to no purpose. There are two cases on record of malarial spasm where sj)asinodic stricture occurred paroxysmally every twenty-four or forty - eight hours, and was cured by quinine after other means had failed. Irritation and reflex action of neighboring parts, as inflamed hemorrhoids, ulcer or worms may cause spasmodic stricture and retention. Thompson gives a case where all the symptoms of stricture existed, and where a diagnosis of stricture of the mem- branous urethra was made, when it was discovered that the patient had tapeworm. After the worm had been discharged, 522 A COMPENDIUM OF PRACTICAL MEDICINE. the stricture disappeared. Necrosed coccyx and abscess of the right seminal A^esicle have caused spasmodic stricture. Keyes saw complete retention from one application of the tincture of delphinium to the scrotum to destroy pediculi. Remote surgical lesions may occasion retention by reflex spasmodic stricture. Dr. Davenport records the case of an old man who had all the evi- dences of permanent deep urethral obstruction for ten years, and who was relieved at once and permanently by a single passage of a silver catheter. Keyes has met a large number of cases in which reflex spasmodic stricture was caused by a decidedly narrow meatus, by a very moderate organic stricture, by changes in the seminal vesicles, prostate, bladder, kidney, and strongly concentrated acid urine (Keyes). Diagnosis. — Spasmodic stricture always occurs suddenly, the stream of urine between the paroxysms being of normal size. It is occasionally continuous, and acts exactly like organic stricture (Keyes). Treatment. — Discover and remove the cause. Retention pro- duced by simple spasm can often be relieved by the hot bath, rest, an opiate, and ice in the rectum, or at once by an anaesthetic and the catheter (Keyes). II. Permanent or Organic Stricture. — If not congenital, is the result of a previous pathological process. Form of Stricture. — 1. Linear. 2. Annular. 3. Tortuous. A linear stricture is like what would be caused if a thread were tied around the canal; or it may consist of a thin membranous diaphragm, with its orifice at the centre or on one side; or be a crescentic fold or free band. An annular stricture is broader, as if a flat tape had been tied around the canal. Tortuous stric- tures include all other varieties. They may be an inch or more long. The amount of contraction in stricture varies from a slight narrowing to nearly absolute occlusion (Keyes). Number of Strictures. — Stricture is usually single; but Thompson found in a single urethra, four; Hunter, six; Lalle- mand, seven; Colot, eight; and Otis fourteen (Keyes). Seat of Stricture. — The urethra is divided into three regions: Region one, the bulbo-membranous, contained 215 strictures out of a total of 320, or 67 per cent.; region two, the middle portion, STKICTITRE OF THE URETHRA. 523 contained 51 strictures, or 16 per cent.; region three, the first two and one-half inches of the canal from the meatus, contained 54, or 17 per cent. (Thompson). Otis places a majority of all stric- tures within the first one and one-quarter inch from the meatus; next the middle portion, and the least number in the deep urethra (Keyes). The Lesion in Stricture. — May be a mere thickening of the mucous membrane, the surface having lost its polish, being con- gested and perhaps covered with granulations. These changes are the result of chronic inflammation. This process takes place just within and beneath the mucous membrane. If the stricture is extensive and far advanced there will be a mass of dense, fibrous callous material encircling the canal and holding it per- manently contracted. This tissue may be slight in extent, cicatri- cial in character and tightly contracted, or it may be exuberant, knobbed and excessive in amount so that it may be readily felt from the outside of the canal, having a cartilaginous or even w^oody hardness (Keyes). Causes of Stricture. — Omitting congenital and other varieties of stricture already alluded to (cancerous, etc.) organic stricture is always caused by inflammation or a traumatism. Inflamma- tion of the urethra is the most common cause, whether this be sim- ple urethritis or gonorrhoea. Of 220 cases of stricture studied critically by Thompson 164 (seventy- five per cent.) owed their origin to gonorrhoea. The longer the duration of a given gon- orrhoea the more certain it is to be followed by stricture. This is almost surely the case where gonorrhoea prolongs itself in- definitely in the gleety stage, the latter condition being nearly conclusive proof of forming stricture. Gonorrhoea attended by chordee is more apt to be followed by stricture than otherwise. Should the chordee be "broken, 11 stricture becomes inevitable and that too of the traumatic sort. The new fibroid and cicatri- cial tissue has a tendency to contract more and more. Traumatic stricture may be produced by falling astraddle a beam, chair, stump, fence or wheel, or a kick in the perinaeum from man or beast. The only treatment of gonorrhoea which may cause stricture is the use of injections. The nozzle of a syringe, if long or 524 A COMPENDIUM OF PRACTICAL MEDICINE. roughly used against an inflamed mucous membrane, may irritate it sufficiently to keep up local inflammation, until it becomes chronic, and passes on to that cell -proliferation and thickening which constitute stricture. Too strong injections may cause strict- ure, usually situated from two to four inches down the canal, rarely lower. As a general rule, it may be stated that any in- jection strong enough to produce either blood or subsequent prolonged pain, is capable also of originating organic stricture (Keyes). Time of Occurrence of Stricture after Gonorrhoea and In- jury. — Of the one hundred and sixty-four cases of stricture fol- lowing gonorrhoea, tabulated by Thompson, in ten, symptoms appeared immediately after or during the attack; seventy -one within one year; forty- one, between three and four years; twenty - two, between seven and eight years; twenty, between eight and twenty-five years. J. D. Hill makes the shortest period of strict- ure after gonorrhoea two years; longest, thirteen years; after in- jury, shortest period four months, longest, eighteen months. Boys have been kicked at school or have fallen on a fence, and symptoms of stricture did not occur for ten or twelve }~ears after (Keyes). Irritable and JResilient Strictures. — A stricture is said to be irritable when it is very sensitive. A resilient stricture is one which is elastic, contracting quickly after being dilated (Keyes). Diagnosis. — Organic stricture of the urethra is easy of diag- nosis. In exploring a given urethra for the first time for stricture, Keyes prefers to use a blunt steel sound which will just pass the meatus. The blunt sound causes less pain than either the bulbous bougie or the urethrameter. It should be warmed, lubricated, and introduced with all gentleness. If it is obstructed anywhere, there is stricture, for the meatus is nor- mally the smallest part of the canal. When an obstruction is encountered, a smaller blunt sound is selected, and then another, until some sound will enter the bladder. It is always well in searching for stricture to commence with a large size and work down rather than to begin with a small instrument. Keyes has had cases referred to him, as cases in which a filiform instrument could not be made to enter the bladder, and STEICTUEE OF THE UEETHEA. 525 he lias at once passed a full- sized blunt steel sound easily into the bladder. The explanation of this is that spasm of the deep urethra frequently fails to allow a fine instrument to pass, while spasm in that region always yields to gentle pressure slowly and accurately applied with a blunt steel sound. Moreover, a false passage, or a pouched sinus, or a dilated follicle, will frequently catch the point of a fine instrument, while a blunt sound will escape the obstacle. Having detected stricture, it may be located, calibrated and measured either with a metallic bulbous bougie or the urethrameter in the anterior urethra, or with a flexible bulbous bougie in the deep urethra. Obstructions beyond six and a half inches may generally be set down as due to prostatic enlargement, particularly in patients older than fifty years. There is a point of physiological narrowing at about the middle of the pendulous urethra, which is by some regarded as a stricture requiring treatment by cutting, when there is no real occasion for the operation. If this point be covered by granula- tions, and bleeds as the bulb passes it, it is in a morbid condi- tion, and may require cutting, although no true stricture exists at the point. These are the so-called strictures of large caliber so popular at the present day, so common in occurrence, a rich field for the young surgeon, and sometimes the occasion of un- necessary cutting, for the gleet they occasion may often be removed permanently by a few passages of a large sound. Just within the meatus — at an eighth to a quarter of an inch — there is very often a point of congenital narrowing which may be assumed to be a stricture, and cut if there is any occasion for using an instrument larger than this point of narrowing will admit. It is always wise to divide it if stricture exists beyond. Always when there is a pouched condition of the meatus at the lower commissure, it should be cleanly and freely cut down upon the floor of the urethra (Keyes). Symptoms and Results of Stricture. — Stricture may exist for years without giving rise to a single symptom of sufficient im- portance to attract the patient's attention. In fact, it may be said that stricture has no symptoms until it has become so tight as to sensibly obstruct the outflow of urine and semen. 526 A COMPENDIUM OF PRACTICAL MEDICINE. The symptoms usually described as those of stricture are mainly the symptoms of the results of stricture. A certain small amount of gleety discharge from the congested, or it may be granular surface usually accompanies the forming stage of strict- ure but this may be so slight as not to attract attention or may be entirely absent. Exceptionally urethral or other neuralgia depends upon stricture in the forming stage. The results of stricture are mainly mechanical. The strict- ured portion acts like a dam, and the urine coming down with great force tends to dilate the urethra behind it. If more than one stricture exists the urethra may be dilated between them. This forcible stretching of the mucous membrane behind the stricture at every act of micturition weakens the tone of the stretched portion of the canal, congests it, and leads to the for- mation locally of an excess of mucus. Soon a drop of urine is retained behind the stricture in the dilated portion of the canal, the mucus acting upon it as a ferment alkalinizes and decom- poses it, liberating carbonate of ammonia. This acts upon the stretched urethra, and produces inflammation. This mild in- flammation behind stricture is very constant. It furnishes the gleety discharge or the morning drop of muco-pus, which glues the lips of the meatus together. The gleet of stricture gets better or worse according to the general condition of the patient, the degree of acidity of the urine, and the amount of sexual indulgence or venereal excite- ment. Exacerbations of gleet from slight causes often constitute the most marked feature of the case in a patient with stricture. In fact, it is the rule in mild cases that the patient is wholly un- conscious that his urethra is at all narrowed. He applies for treatment, on account of his gleet, and often refuses to believe that he has stricture, and he repeatedly asserts that he makes as large a stream of urine as ever. Nothing so well as the bulbous bougie will convince such a patient of his condition. The gleety dis- charge, once commenced behind the stricture, rarely ceases en- tirely until the constriction has been relieved. The same dis- charge will be seen in the urine in the shape of small stringy shreds, formed of pus -corpuscles, and appear as small white threads in the voided urine. These shreds may be all caught in STRICTURE OF THE URETHRA. 527 the first gush of urine, what follows being perfectly free from them. When these white filaments are seen settling clown in a glass of urine freshly passed, they constitute strong presumptive evidence of the existence of stricture; they may he due to other lesions. As the stricture tightens, a cartilaginous hardness may often be felt from the outside of the urethra at the constricted point. The meatus urinarius looks blue and congested, as does some- times the whole glans penis, from obstructed circulation. The gleet continues, the stream of urine is small, often forked. The last few drops of urine are retained in the canal. Erection is sometimes rendered imperfect and painful. The surface congestion of the stretched urethra behind the stricture in time extends backward to the bladder, and brings on irritability of that organ. The intervals between the acts of micturition grow shorter and shorter, and symptoms of mild cystitis appear. This frequency of micturition is the symptom of stricture, next to gleety discharge, which is least often absent. A slight narrowing of the canal may occasion it. The conges- tion of the urethra behind a stricture easily becomes greater, is kindled into positive inflammation by dining out, a little excess in drink, or a chilling of the legs; the mucous membrane swells up, the stricture closes, and the patient has retention of urine. If this retention is unrelieved, the bladder becomes over- dis- tended and the contractile power of the bladder may be perma- nently injured. Retention maybe the onlg disagreeably promi- nent symptom connected with a case of stricture. The spasm and inflammation which caused the narrow canal to become oblite- rated in these cases, cease after a few hours, and then the patient goes on perhaps for a year or more, without having another retention, not suffering noticeably in the meantime. If retention does not come on, the inflammation, once aroused behind the stricture, travels back through the prostatic urethra into the bladder, and we have cystitis of the neck. Now commences a frequent desire to pass water, and when the patient seeks relief, he may be passing water in a fine stream every half- hour with great pain and straining. Hcematuria may be, excep- tionally, the most prominent symptom of stricture. Keyes has 528 A COMPENDIUM OF PRACTICAL MEDICINE. had several such cases, and has seen the hematuria cease upon relieving the stricture. Along with symptoms of vesical irritation, are found pains in the urethra, aching of the glans penis, or in the testicle, along the cord running up into the back, pains across the lumbar region, in the peringeum, around the anus, over the pubis, in the thighs, legs, sole of the foot, or in the great toe, all of which pains are cured by the dilatation of the stricture. The sexual appetite is often impaired, sometimes nearly obliterated, in old severe cases. But in mild cases, the congestion kept up behind the stricture may be just enough to excite and irritate the patient, causing frequent erections, erotic fancies, and nocturnal emissions. The constant straining in urination may cause piles. The inflammation of the bladder caused by stricture is usually superficial, and the bladder walls, as a rule, thicken and contract, but rarely dilate. The ureters enlarge in connection with old stricture, also the pelvis of the kidney. It may bring on abscess of the kidney (Keyes). Extravasation. — The thinned and inflamed urethra behind the stricture may ulcerate and during one of the violent parox ysms of straining give way and allow a little urine to escape into the cellular tissue around the canal. If the amount of urine extra vasated is small we have abscess or perhaps blind internal fistula. Its presence is indicated by a hard lump around the urethra from the size of a pea to that of a walnut. Urethral fe- ver comes on, generally described by the patient as "dumb ague;" the appetite fails and the general health runs down, finally pus forms and finds its way out through the perinseurn, leaving a fistula behind. If the quantity of urine which escapes is a little larger acute perineal abscess forms. The pus may bur- row in all directions and find an exit through the scrotum along the body of the penis, upon the thighs, nates or groins, or even upon the lower part of the abdomen. Sometimes the whole porinseum is riddled with holes through which the urine escapes. Civiale reports a case of urinary fistula with fifty-two external openings. Fistula will not close until after the stricture has been relieved. Extravasated urine should be let out as soon as possible. Normal urine does not possess septic qualities but STKICTUEE OF THE UKETHKA. 529 ammoniacal and putrid decomposing urine is deadly in its effect (Keyes). Complications of Stricture. — Infiltration of urine is a serious complication. Rupture of the bladder is a rare complication of stricture. A comparatively healthy bladder will not rupture from retention. It will become immensely distended and then be relieved by drops (overflow) through the urethra. Epididymitis is a very common complication of stricture. It may affect one or both sides, and leaves behind a good deal of knotty induration, which is slow in disappearing, and may block up the canal and entail subsequent sterility (Keyes). Constitutional Disturbance. — A patient with very tight stric- ture may enjoy robust health. But when the urethra behind a stricture begins to inflame, and the bladder to show symptoms of congestion of the neck, and cystitis; when paroxysms of urethral fever become frequent; when epididymitis and abscess come on, then the whole organism shows signs of distress. The appetite and strength fail, the skin becomes dry, pale and harsh, the mouth coated and shiny, and the patient runs down to a shadow, a living picture of misery, while his main business in life is to pass water (Keyes). Causes of Death in Stricture Cases. — Are three: 1. Extravasation of urine] which, if extensive kills at once by shock, or later by exhaustion and blood-poisoning with sup- puration, abscess, gangrene and pyaemia. 2. Uraemia, from implication of the kidneys, by the exten- sion of inflammation up the ureters. 3. Cachexia and exhaustion (Keyes). Recapitulation of Symptoms of Stricture. — Briefly the symptoms of stricture are narrowing of the canal, with dilata- tion of the urethra behind, blueness of the meatus, irregularities in the stream of urine, shreds of pus-corpuscles in the urine: pain, neuralgia of the urethra, retention of urine, overflow, dribbling, imperfect erection, irritability of the bladder, haeina- turia, and impotence. The remoter results of stricture are cvstitis with changes in the bladder, ureters, kidneys and rectum often terminating fatally, and stone in the bladder, infiltration. 530 A COMPENDIUM OF PRACTICAL MEDICINE. perineal abscess, fistula, rupture of the bladder, epididymitis, and sterility (Keyes). Sexual Hygiene. — An unmarried man frequently tortures himself with fancied ailments, which he ascribes to stricture. He declares himself strictured when the canal is sound. Fancied stricture, next to fancied spermatorrhoea, is a very common hypo- chondriacal expression of perverted sexuality. The trouble is in the mind. These patients must be put right about the cause of their troubles, and their sexual hygiene must be regulated. This can be accomplished only by marriage or by purity of thought and absolute continence (Keyes). Treatment. — May be considered under three heads: 1. Treatment of Uncomplicated Stricture.-— (a) Of large caliber; (/>) of small caliber; (). Of Small Caliber. — To this class belong strictures ad- mitting any instrument less than No. 15. This class of strictures requires the same kind of treatment as those of large caliber, but arc better treated with soft than with steel instruments. There is danger of making a false passage in an obstructed urethra with a small metallic instrument. Below No. 15, soft instruments only should be employed, unless there be a guide through the stricture. Dilatation is carried on as already direct- STRICTURE OF THE URETHRA. 533 eel, steel instruments being used as soon as the stricture will ad- mit No. 1?. Progress is slower with soft than with steel instru- ments. Cutting (internal urethrotomy) and stretching (divulsion) operations are growing daily in favor in the treatment of strict- ures of small caliber, yet stricture in the deep urethra is best treated by dilatation, no matter how tight it may be. Cutting and divulsion are only helps. They are attended by danger. The sound must be used after them. The patient need not lose a day from business on account of treatment by dilatation. It is safer, and more tedious. Divulsion or internal urethrotomy may be better in two classes of cases: 1. If the patient cannot give time enough to carry out dilatation properly. 2. If pretty severe urethral fever follows attempts at dilatation. All true strictures of the pen- dulous urethra maybe radically cured by free cutting internally. Otis proved this. Radical cures are accomplished by free cut- ting anteriorly — not so in the deep urethra. In commencing the treatment of stricture of small caliber, it may be impossible to enter the bladder with any instrument, either on account of the tightness of the stricture, or because the point of the instrument does not engage in the latter. In these cases gentle perseverance and skill will rarely fail of success. Keyes mentions one case of his own in which it required ten sittings, most of them over one hour long, before any instrument could be made to enter the bladder. On the tenth effort, the instrument passed. It entered the bladder, and at once the stricture was divulsed. In two weeks the patient passed his own full -sized instrument. In the so-called impassable stricture, where urine passes out, but no in- strument can be made to enter the bladder, a filiform bougie can invariably, with patience, be inserted into the orifice of the stric- ture (Keyes). (c) Stricture of tire Meatus. — Stricture at or near the meatus is usually made worse by attempts at dilatation. It must be cut. (J) Traumatic Strictures. — Are not usually amenable to treatment by dilatation. (e) Resilient Stricture*. — Will not dilate, must be cut (Keyes). Treatment of stricture complicated by — 534 A COMPENDIUM OF PRACTICAL MEDICINE. (a) False Passage. — Results from rough or unskillful use of small instruments in an obstructed urethra. On the with- drawal of the instrument, blood flows freely from the meatus. The treatment for a fresh false passage of this sort is to let it alone absolutely for two weeks. To avoid a false passage of any kind, when searching for the orifice of a narrow stricture, con- sists in filling the urethra with whalebone filiform bougies, thus mechanically filling up the false passage, until some instrument will glide by its orifice and enter that of the stricture. (b) Retention. — A patient, with stricture, may be enjoy- ing good health, when suddenly, after exposure to cold, after a dinner or a carouse, he finds that he can not pass water. If no instrument can be passed, the patient should be placed in a hot bath for 15 or 20 minutes, or a sitz-bath. He will often be able to pass water while in the bath. A piece of ice in the rectum may be tried. A grain of opium may be given every hour until four or five doses have been taken. (^) Infilftration of Urine. — The infiltrated urine must be drained off, and the stricture relieved, The operative indica- tions are three : 1. To stop progressive infiltration by extensive dependent incisions. 2. To provide an escape for urine con- stantly collecting in the bladder, by free central incision of the urethra behind the stricture. 3. To divide the stricture thoroughly. (e) Abscess. — The abscess should be opened. (/) Fistulce. — A simple fistula with one or two openings will close of itself, as soon as the stricture has been dilated fully. In all these cases treat the stricture first, and then the fitsulae. If the fistulse remain after full dilatation of the urethra, the patient must pass no urine except through a catheter for one month. If this fail, the hard edges of the fistulous tract should be incised, or cauterized with the gal vano- cautery. A silver probe coated with fused nitrate of silver may be passed into the fistulse (Keyes). Instruments. — The instruments necessary to treat all cases of stricture are: different varieties of bougies, sounds and catheters with a scale; instruments for divulsion, internal and external urethrotomy, and an aspirator. STRICTURE OF THE URETHRA. 535 Bougies. — Filiform bougies are such as measure one milli- metre or less in diameter. There are three varieties: the French, English, and whalebone. The whalebones are olive-tipped. Whalebone filiform bougies have displaced all others at the present date. These bougies may be used as guides for larger instruments, if made about two feet long. In employing a whalebone as a guide it should be first introduced into the blad- der then threaded into the instrument to be guided. In intro- ducing a filiform bougie when it catches, partially withdraw and slightly rotate it, pushing it forward while making the rotatory movement. An excellent method of finding the orifice of a strict- ure, especially where false passage exists, consists in cramming the urethra full of filiform bougies, engaging their points in all the lacunae and false passages, and then trying them, one after another until one is pushed through the stricture. Injecting the urethra full of warm oil is a great aid. Of the other bougies (not filiform) the French and English conical are used. The French conical are necessary in the treatment of stricture up to size 12 or 15. English yellow bougies are smoother and stiffer than the preceding. All of the foregoing instruments are intro- duced without a stylet by simple direct pressure with rotation. The Bulbous Bougie. — Is an instrument necessary for the accurate diagnosis of stricture. They consist of a flexible, woven shaft, headed by an acorn- shaped extremity. A set of them, running from five to thirty, is required. The urethrameter of Otis was designed to take the place of a whole set of bulbous bougies from size twenty to forty. Sounds. — The steel sound is the most necessary instrument for the treatment of stricture. Steel sounds are conical or blunt. The conical are the better instruments and should run from No. 13 to 35, inclusive. For dilating stricture soft instruments are better in the low sizes — below No. 13, and steel for all sixes above No 13. Thompson's rapid dilator and Otis 1 dilating urethrotome are much used in the treatment of stricture (Keyes). 536 A COMPENDIUM OF PRACTICAL MEDICINE. SPINAL IRRITATION. Is always functional and in most cases is associated with congestion or anaemia (Loomis). Causes. — It occurs chiefly in women between the ages of fif- teen and twenty-five. Spinal shock, or concussion from any cause, and all those practices and habits which cause nervous strain and result in nervous exhaustion, may also produce spinal irritation. Chronic alcoholism and the opium habit may also induce it. All severe diseases may cause it (Loomis). Ansemia of the posterior columns of the cord is a cause (Hammond). Symptoms. — The one constant and special symptom of spinal Irritation is tenderness all along the cord or over a single verte- bra, which maybe excited by pressure, motion, heat, cold, elec- tricity or other irritants. The spinous process is the place where pressure causes greatest pain. Tactile hyperesthesia is very marked. Motor disturbances are common. Weariness, and heaviness occur in the lower limbs. Contraction, twitchings and spasm may occur in the muscles of the forearm. Cardiac palpi- tation, nausea and vomiting, nervous cough, embarrassed phona- tion and breathing, and attacks of fainting are not uncommon. Patients are depressed, melancholy, and irritable, and subject to insomnia, headache, dizziness, etc. Vaso- motor changes are marked; the extremities are cold, sometimes blue, and the face alternately pales and flushes. When the point of tenderness is in the cervical region the pains are referred to the head, pharynx and chest. When it is lower there are respiratory and cardiac symptoms, and if in the dorsal region, there is pain in the stom- ach with dyspepsia, nausea and vomiting (Loomis). Differential Diagnosis. — Spinal irritation may be mistaken for spinal congestion, meningitis, myelitis, tumors and tetany. In spinal congestion there is no tenderness; and the symptoms are aggravated by the supine position; in spinal irritation the reverse is the case. Spinal meningitis is accompanied by pyrexia, and the pain in the spine is increased by motion, and muscular spasms occur in the back and neck. The iron band sensation about the waist, paralyses, etc., arc almost diagnostic of myelitis. In spinal SPINAL IRRITATION. 537 tumors the symptoms are localized and permanent. In tetany there are muscular contractions (Loomis). Prognosis. — Is favorable. Treatment. — Alcoholic stimulants, meat diet and exposure to sunlight and fresh air are of service. Aconite and veratria may be applied locally in the form of an ointment. The galvanic current and the Faradic current in some cases will give imme- diate relief. The daily application of the ice -poultice is recom- mended. Absolute rest in the country with a good diet does much for these patients (Loomis). SNEEZING. Treatment. — Camphor is an excellent remedy in incessant sneezing with profuse running from the eyes and nose. The powder should be sniffed or the alcoholic solution inhaled from a handkerchief. One, two or three drops of Fowler's solution three times a day are very efficacious in the paroxysmal sneezing allied to asthma. In ten -grain doses several times a day iodide of potassium is said to cure that troublesome and obstinate af- fection, violent paroxysmal sneezing (Ringer). SOMNAMBULISM, Is a condition incident to sleep. It embraces the mental and physical performances, sometimes very extraordinary, which are observed in sleep-walkers. Similar phenomena are observed in the condition known as the hypnotic or mesmeric or magnetic sleep (Flint). Treatment. — In these cases bromide of potassium is probably the best remedy if given in large doses (Ringer). SORE FEET. A tablespoonful of common washing soda, added to half a gallon of warm water, is useful in the treatment of tenderness of the soles. The feet should be immersed for half an hour twice a week or oftener (Ringer). 538 A COMPENDIUM OF PRACTICAL MEDICINE. STINGS. Insect- stings in the United States are not very severe, and unless inflicted in large numbers are rarely brought under the notice of physician or surgeon. Slight fever and constitutional disturbance may follow them in children who are very suscepti- ble to external influences, whilst local swelling, heat, and red- ness are very marked in others. Should a wasp or bee acciden- tally be taken into the mouth with fruit and the base of the tongue, pharynx, or larynx stung, serious symptoms may arise from oedema and swelling of the parts impeding respiration. When this accident happens, scarifications should be employed with fomentations; but if life be threatened, the wind-pipe must be opened. The sting should be removed, if possible, with forceps. A drop of liquor ammonia, or sal volatile, or oil of lavender ap- plied to the part generally gives relief. The parts should be protected from the air by collodion, flour, chalk or strapping. For mosquito -bites Dr. J. Stevenson advises the use of a moist cake of soap, the thin lather from the cake being allowed to dry upon the bitten part. All pain and itching, he states, disappears within ten minutes of this application. In South America the mosquito -bite is at times attended with severe local inflammation and sometimes with ulceration. In Africa and Asia the scorpion, which is from six to ten inches long, is so venomous as to cause by its bite, at times, loss of life. Olive oil is the usual application for the wound, but liquor ammonise is probably better. Brandy and ammonia should be given internally when great depression exists. The bite of the tarantula is very troublesome and is often followed by nervous depression, vomiting and local pain. The bite of the spider is very similar in its effects to that of the scor- pion, though the wonderful stories as to its poisonous qualities are now regarded as fabulous. Serpent-bites are often serious, and at times fatal. Stimu- lants should be given in large quantities and the part cauterized by nitric acid, carbolic acid, or nitrate of silver (Bryant). SUDAMINA— SHOCK AND COLLAPSE. 539 SUDAMINA. Is an eruption which consists of little elevations of the cu- ticle, about the size of pinheads, filled with a watery fluid (niiliaiy vesicles), which consists of the secretion from the sudoriparous glands. It is usually clear and transparent. These vesicles never run together, are most abundant on the neck and trunk, and are met with in those who have been perspiring freely as the result generally of some acute affection, such as rheumatic or enteric fever or pneumonia, etc. The vesicles dry up in a day or to. The vesicles are due to the excessive secretion of sweat (Anderson). Treatment. — If there be much irritation of the skin, a mild astringent lotion may sometimes give relief. We should do our best to keep the patient cool (Anderson). SHOCK AND COLLAPSE. Are terms used to signify the loss of power which imme- diately follows severe injuries, esj)ecially those attended with violence. It is due to reflex paralysis of the vaso-motor system of nerves. The gradations of shock and collapse are innumera- ble, and the symptoms by which they are characterized vary from a passing faintness or disturbance of the heart's action to final syncope. The state of collapse may be regarded as a chronic syncope (Bryant). Causes. — Slwch may be caused by any severe injury, especi- ally gunshot wounds, compound fractures, severe burns, pro- tracted surgical operations and all cases in which serious injury is attended with violence, pain and loss of blood. Mental shocks may be as severe and fatal as those of the body, as for instance: A man receiving unexpectedly, some startling news which excites severe emotion and dying suddenly is said to die from shock; a second receives a fatal blow upon the epigastrium; a third is struck dead by lightning; death in each case is said to be due to shock. In all the heart's action is suddenly arrested through the nerve centre — in one case through the mind, and in the others through the body (Bryant). 540 A COMPENDIUM OF PRACTICAL MEDICINE. Symptoms. — A man receives an injury and is not killed, but collapsed. He has sustained a shock more or less intense and as a consequence becomes cold and almost pulseless. His skin ap- pears to be bloodless and covered with a cold clammy sweat. He breathes with sighs and gasps. His nostrils dilate, his eyes are dull and vision is imperfect. Sometimes shock is so severe that the patient sinks from it without reaction. It should be noted that vomiting is often the first indication of reaction in general collapse as it is often in that of head injuries. Patients with bad kidneys are very liable to surfer from shock and to succumb to any operation, however trival (Bryant). Treatment. — The patient must be kept in a horizontal posi- tion; free access to air provided; and cold water dashed into his face. In severe cases whisky should be injected under the skin. Hot brandy and water, if the patient can swallow it, is probably, more efficient than anything else. External warmth should be secured by means of blankets, hot flannels, and hot water bottles. Bleeding, if any exist, must of course be checked (Bryant). SUPPRESSION OF URINE. In suppression no fluid comes down the ureters into the bladder. Causes. — Suppression may be caused by fright or strong mental emotions, injury to the kidneys, or the onset of an inflam- matory attack, and by the effect of cold, or if the kidney be the seat of previous chronic disease, by operations on the bladder or urethra, or even by the introduction of a sound or lithotrite, by the passage of kidney-stone, etc. (Keyes). Symptoms. — Are depression, languor, with apprehension, more or less fever, with hot, dry skin, and hard pulse. There may be chill, vomiting, headache, and pain in the back and loins with constipation. No urine is voided, or only a little high- colored secretion. Suppression may come on gradually from ad- vancing cl ironic kidney disease. In this case, there is usually anasarca. The area and other products of waste accumulate in the blood and the patient becomes poisoned by them. Drowsi- ness and stupidity, perhaps delirium and coma, come on; there SYNOVITIS. 541 may be convulsions, and the patient dies in from two to five days. On the other hand, cases of suppression after scarlet fever, one of seventeen and another of thirty days, have been reported. Sup- pression for seventeen months, with recovery has been recorded (Keyes). Diagnosis. — Is easy. In retention the bladder is full, in suppression empty (Keyes). Treatment. — Dry cups and hot fomentations over the kidneys, hot-air bath and hydragogue laxatives, the free use of warm drinks, flaxseed-tea, etc.; and if there be no inflammatory condi- tion full doses of acetate of potash and infusion of digitalis may be tried. SYNOVITIS. Is an inflammation of the synovial membrane. It may be acute or chronic. Causes. — This disease may be caused by wrenches, blows, punctures, strains, exposure to cold, or sudden changes of tem- perature after violent exercise, or may be dependent u/pon con- stitutional affections, such as rheumatism, gout, or syphilitic or gonorrhceal poisons, etc. Scrofula may cause a synovitis (Loomis and Sayre). Symptoms. — The knee is the joint most frequently affected. There is severe aching pain in the joint, increased by motion, great swelling, redness of the surface, tenderness and fever. As a rule, synovitis does not affect more than one joint; and as there is scarcely any or no effusion into the surrounding tissue, the out- line of the joint can be distinctly discerned and fluctuation is readily detected. When the knee is affected the patella is pushed forward and there is great fullness on each side of it and at the lower and front part of the thigh (Sayre and DaCosta). Treatment.- — -The limb must be kept absolutely motionless. A splint must be applied so as not to touch the affected part. Leeches to the joint, cups in the neighborhood and evaporating lotions or hot fomentations are useful. Calomel purgatives should be administered and opiates to relieve pain. When there is a tendency of the disease becoming chronic iodide of potassium should be administered. And if the disease be connected with 542 A COMPENDIUM OF PRACTICAL MEDICINE. rheumatism ammonia and potash should be prescribed. Where there is a tendency to gout, colchicum with potash is to be em- ployed. In syphilitic cases, mercury in its different forms is most to be relied upon (Horwitz). SYPHILIS. Is a general dyscrasial blood-disease caused by the absorp- tion of a peculiar virus into the circulation, manifesting itself primarily by the appearance of a poisonous sore at the point where the virus entered, and afterwards by a succession of morbid manifestations occurring at longer or shorter intervals, which may affect every organ and tissue of the body. The virus is only known by its effects. Exactly what it is has not yet been determined. But it is more than probable that it is a living contagious element. Diday and Rollet failed to inoculate syphilis upon cancerous patients, and assume an antagonism between the two maladies; but Keyes says, u This surely does not exist, as I have seen many of the varieties of cancer upon syphilitic patients.'" Hutchinson has happily compared syphilis to the contagious exanthemata, small-pox, measles, scarlet fever, as possessing all the peculiar characters common to this group of diseases, namely: it is communicated only from one diseased person to another healthy one; it has a stage of incubation before any sign of the disease appears; it has a stage of efflorescence, which indeed in syphilis is prolonged and marked by relapses; it has a period of decline and sequelae — the later tertiary lesions — which^ do not always occur, and during which the disease often ceases to be communicable. Again, most of the varied efflorescences of syphilis, like those of the other exanthemata, tend to pass away spontaneously after a time; thus, as Fournier aptly puts it, affording a triumph to every method of treatment. One attack confers immunity from another often for life, always for a long period. The dis- ease; is transmissible by inheritance, as in the case of the other exanthemata when the child is born before the mother recovers from disease. Finally the sequelae do not constitute transmissi- SYPHILIS. 543 ble disease even by inheritance. As in the other zymotic dis- eases, a portion of the virus, however small, is capable of infect- ing the whole body as if by fermentation. Thus the analogy of syphilis with the contagious exanthemata is clear, only its febrile symptoms are less marked, its efflorescences more varied, and its course much more protracted — counted by months instead of days — and more subject to variation as well as more amenable to treatment. Syphilis is fortunately only contagious, it is not in- fectious; its poison is not volatile, is not diffused in the air; direct contact of the virus with a surface capable of absorption is essential to the production of the disease. A patient may have malignant scarlet fever and die in a day without a sign of eruption, but still he has scarlet fever, as no one denies. Even if one syphilitic chancre out of twenty w x ere not indurated the other nineteen would be amply sufficient to establish a rule. But the proportion is far larger and there is perhaps no symptom of any disease more constant than is the in- duration of syphilitic chancre, yet the patient does not have syph- ilis because his chancre indurates, he already has syphilis before his chancre appears. If he did not have it he could have no chancre at all and the induration of that chancre is just as much one of its symptoms as is ulceration of a chancroid. A patient who has absorbed syphilitic virus has syphilis at once, and because he has syphilis he gets a sore at the point of en- trance of the poison after a period of incubation, as the first symptom of the disease. This chancre may be destroyed by caustic, or the knife, but the disease will run its course unaltered (Keyes). Interval Before Absorption. — Clerc tells of a medical student who washed himself immediately after sexual intercourse and on careful examination for several days subsequently detected abso- lutely nothing; twenty- eight days afterward chancre appeared, followed by general syphilis. Hill relates the case of a man who in sexual intercourse tore his framum which bled freely and fear- ing infection called upon Hill within twelve hours after the acci- dent to cauterize it with fuming nitric acid. About one month afterward the scar indurated. It never ulcerated again but the 544 A COMPENDIUM OF PRACTICAL MEDICINE. regular manifestations of true syphilis came on at the usual in- tervals. Diday cauterized a syphilitic chancre within six hours after its appearance; but although the sore healed promptly, general syphilis followed. The rapidity of absorption of the poison of a snake -bite is well-known, as is also that of rabies and the poison of a dissecting wound, and there is no reason why that of syph- ilis should be less so (Keyes). Second Attack of True Syphilis. — Hutchinson saw a well marked case, in a physician, of two attacks of syphilis, each pre- ceded by its characteristic syphilitic chancre. The same patient had had small -pox twice. He records a case in which a woman with mild inherited syphilis got a new attack in the usual way at the age of twenty. Diday has collected twenty-five cases, of which he personally saw twenty, of reinfection. In all of these cases there was syphilitic chancre with characteristic induration, occurring a second time after a previous syphilis. Diday con- cludes that the minimum time for the cure of syphilis is twenty - two months, and that, where syphilitic chancre appears twice in the lifetime of an individual, the second attack should not be treated until symptoms of secondary syphilis appear, as these may never come on, the whole attack consisting simply in syph- ilitic chancre. Keyes says that he can honestly state that he has never seen a case of syphilitic reinfection to recognize it. He also says, "While, then, a second true syphilitic infection is pos- sible even while the subject bears the marks of late tertiary dis- ease, yet such infection is eminently exceptional, and allowance must be made in the reported cases for (1) chancroid accom- panied by some eruption, as a coincidence; (2) ecthyma mis- taken for syphilis, after which the first true syphilitic infection might pass for a second; (3) false chancre, indurated mucous patch; and (4) cases of tertiary ulcer faultily diagnosticated 1 ' (Keyes). Transmissibility to Animals. — Besides this peculiarity of only appearing once in a given individual, syphilis differs from chanc- roid in not being transmissible to animals. So faras experimen- tal demonstration yet goes, it must be asserted that the sad privi- lege of having true syphilis belongs only to man (Keyes). SYPHILIS. 545 Incubation of Syphilis, — After the poison of syphilis has been absorbed, the break in the epithelium through which it entered heals, and the virus ferments as it were, in the blood, until it is ready to give itself local expression, first at the point of entrance in the form of syphilitic chancre. This period of incubation or hatching, has been critically studied by many authors, both by inoculation upon healthy subjects and clincially by close observa- tion of patients. The usual period after contact, or inoculation, at which a chancre first appears is about the end of the third week. In exceptional cases it may be ten weeks. The longest period of incubation that Keyes could find among the authentic cases of experimental inoculation is forty- six days. There is no case on record of an incubation less than nine days, except one case reported by Taylor, and one by Hammond. During the jDeriod of incubation the patient bears no sign of disease. Dur- ing the fourth week after exposure a syphilitic chancre appears, and this is, perhaps, the most valuable mark of a syphilitic chancre, and practically all sores appearing later than ten days after suspicious contact must be regarded with distrust, while those coming sooner may be more lightly considered (Keyes). Multiple Inoculation. — It has been found, that where many points were inoculated at the same time, usually all took and appeared simultaneously as chancres. Inoculations made upon different individuals, with virus derived from the same lesion, have required different periods of incubation for their develop- ment. Hunter said, that syphilis was not reinoculable upon an already infected person. Fournier believes that about two per cent, of auto -inoculations of syphilitic chancre take. The rule then is this : Keinoculations of syphilitic virus upon patients already syphilitic produce no results. Auto- or hetero- inocula- tion upon a patient with very young chancre is occasionally suc- cessful. Hetero-inoculation during the late tertiary stao-e of the disease is more often successful. At both of these periods the patient is not fully protected, the system not being saturated with the syphilitic poison at first, and the virus being at a minimum toward the end (Keyes). Secretions i'ain in the head; great muscular weakness; the temj^era- ture rises rapidly to 104° or 105° F., before the end of the second day: emaciation is slight; the eruption appears upon the arms and chest on the fifth or sixth day; the spots are numerous and of a dark pinkish hue; constipation is the rule; the abdominal -ymptoms of typhoid are never present in typhus fever. Typhus fever is contagious, typhoid fever is non-contagious. Typhus is generally epidemic, typhoid is always endemic. In typhus, the dusky face, contracted pupils, and peculiar smell will distinguish it from typhoid. In typhoid, the slow invasion, the wt step-ladder' 1 rise in tem- perature, the eruption, the characteristic diarrhoea, and the con- tinuance without remission or intermission will be sufficient to distinguish it from relapsing fever. Acute miliary tuberculosis is to be discriminated from typhoid by the notable frequency of the respirations, the prom- inence of the cough, haemoptysis in some cases, the abundance of sub-crepitant rales; by marked lividity and presence of choroid tubercle-, and by the absence of the abdominal and other events of typhoid. 582 A COMPENDIUM OF PRACTICAL MEDICINE Acute meningitis is distinguished from typhoid by more in- tense headache by intolerance of light and sounds, early and ac- tive delirium by frequent vomiting, by rigidity of the muscles at the back of the neck and by somnolency and coma succeeding the delirium and by depressed abdomen. In pycemia and sep- ticaemia the surface of the body has a jaundiced hue, there are no spots, the fever is irregular, recurring chills followed by pro- fuse sweatings take place early. Pneumonia with typhoid symp- toms is sometimes mistaken for typhoid fever. The physical signs, the cough, the characteristic pneumonic expectoration, no eruption, etc., will distinguish it from typhoid (Bartholow, Flint and Loomis). Prognosis. — Death may occur at any stage of this fever. The average mortality from typhoid is about ten per cent. The prog- nosis is always bad in those who are fat. Complications render the prognosis more unfavorable. Death rarely occurs before the fourteenth day. The direct causes of death are: toxcemia, asthenia, suppression of the urine, oedema of the lungs, exhaustive diarrhoea, intestinal hemorrhage or perforation and peritonitis (Bartholow, Flint and Loomis). Treatment. — The typhoid stools should be thoroughly disin- fected as soon as passed, and should never be emptied into a privy or water-closet, but into trenches. The bed- linen should be disinfected and kept scrupulously clean. Typhoid fever cannot be aborted by any remedy known. The patient should be placed in a large and well- ventilated apartment. Only the nurse and attendants should be allowed in the room. Milk is the proper diet, and fruits are not to be allowed in any case. Frequent sponging of the body with tepid water will be of service. When the temperature reaches 104° or more, sponge the body with cold water. Of the internal antipyretics, Loomis prefers antifebrin in five to ten grain doses three times daily. Stimulants. — When signs of failure of heart-power begin to manifest themselves, stimulants are indicated. If under their use the tongue becomes dry, the patient more restless, the deli- rium more active, the temperature higher, and the pulse more frequent, it is very certain that stimulants are contraindicatecl ; and vice versa. Bartholow's experience is, that the administra- TYPHOID FEVER TYPHUS FEVEPv. 583 tion of iodine has a favorable effect on the course of the disease, and he has used with decided success the combination of iodine and carbolic acid (jfc Tinct. iodi 5ii., acid carbolici 5i. — M. Sig.: One to three drops three times a day). Diarrhoea. — For the diarrhoea, there is but one remedy which can be relied upon, and that is opium. Tympanites. — Turpentine stupes to the abdomen, and tur- pentine internally and by rectum will give relief to the tym- panites. Intestinal Hemorrhage. — Can best be controlled by an ice- bag to the abdomen, and the administration of opium in small doses frequently. Peritonitis. — Is best treated by opium. For the bronchitis, carbonate of ammonia is very effective . For the active delirium, opium and sedative remedies. For bed- sores, cleanliness and the proper dressings (Bartholow, Flint and Loomis). TYPHUS FEVER. Is a febrile affection, self -limited, contagious, usually pre- vails epidemically, and characterized by profound adynamia, a peculiar petechial eruption, favorable cases terminating by crisis at the end of the second week. It has received a great variety of names, such as ship fever, hospital fever, jail fever, camp) fever, petechial fever, putrid fever, Irish ague, brain fever, spotted fever, continued fever, etc. (Bartholow and Loomis). Morbid Anatomy. — In typhus the abdominal lesions which are characteristic of typhoid fever are wanting. The small in- testine may have the shaven -beard appearance. There are no lesions peculiar to the disease and constantly present. The spleen is usually large, soft, and of a dark, bluish -red color. The blood is unnaturally dark and fluid. Hypostatic congestion of the lungs, bronchitis, lobular pneumonia, pulmonary oedema, cere- bral congestion, and parenchymatous degenerations are frequent (Flint and Loomis). Causes. — Typhus is seen in this country only at our seaport towns. It depends upon a specific poison, of whose exact nature we are ignorant. This poison is communicated from the sick to 584 A COMPENDIUM OF PRACTICAL MEDICINE. the healthy mainly by personal contagion — that is, the recipient of the poison must be brought in contact with the exhalations of the infected person. Where there is free ventilation, contagion is confined to narrow limits. Typhus poison passes into the body mainly through the respired air. This disease is not indigenous to this country. It is imported from Ireland, Italy, and Russia, which seem to be the great endemic centres. It has been proved by actual experiment that the contagious distance of small -pox in the open air, does not exceed two and one -half feet and it would seem that the contagious distance of typhus fever is even less. It requires the concentration of the poison and prolonged exposure to render it infectious. The per- iod of incubation is about fourteen days. A single patient in a spacious, well -ventilated apartment seldom communicates the disease. Typhus fever prevailed in New York City as an epi- demic in 1861 to 1864; 1428 cases were admitted into Belle vue Hospital during this time (Bartholow, Flint and Loomis). Symptoms. — Its advent is usually sudden. As a rule, the onset is marked by a distinct chill, followed by a severe and steadily increasing headache and by pain in the back and limbs and by great muscular weakness. The face has a dusky or dingy hue. In some cases there are coma -vigil delirium, stupor, p> in -hole pupil and convulsions. The tongue is covered with a thick brown or black coating. Sordes collect on teeth and lips. A characteristic eruption appears about the third to the fifth day. It is a macular not a papular eruption. The spots become of a dull, dingy or dark- red color, and do not disappear on pres- sure. They are smaller than the papules of typhoid. They do not come and go like the rose papules of typhoid. The odor from typhus patients is stated to be characteristic. The temper- ature the first day may rise to 104° or 105° F., and remain so the first week. The pulse ranges from 100 to 130. Loss of muscu- lar strength is so great that the patient is unable to turn in bed. The duration of typhus is about fourteen days. One attack serves to exempt from future attacks (Bartholow, Flint and Loomis). Prognosis. — In certain epidemics the mortality runs as high as forty to fifty per cent. Average fifteen per cent. ULCERS AXD SORES. 5S5 Treatment. — The same means of treatment pursued in typhoid are equally applicable to typhus fever (See treatment of ty- phoid) (Bartholow). ULCERS AND SORES. Ulceration is the result of an inflammatory process by which a sore or chasm is produced. An ulcer is a loss of sub- stance without a tendency to heal. An ulcer is molecular necro- sis, the nutrition of the tissue being so disturbed as to allow the chemical or disintegrating changes to have their way. A sore is a chasm, a solution of continuity, caused by ulceration, the result of injury or otherwise, upon an external or internal surface of the body. When a sore is being formed or is spreading by the process of ulceration, an ulcer is said to exist; when the ulcera- tion has ceased, a sore remains (Bryant and Dennis). Situation. — Ulcers are found upon the skin, mucous mem- brane, serous membrane, and inner wall of blood-vessels (Dennis). Varieties According to Condition of Ulcer. — Ulcers may be healthy, inflamed, weak, indolent, sloughing from excess of in- dolence, or irritable. Causes. — Are predisposing and exciting. Predisposing causes are: 1. Age. 2. Malnutrition. 3. Poor blood supply. The exciting causes are: 1. Injury — mechanical, chemical, and thermic. Mechanical injury, as a splint, pressure, blows, etc. Chemical injury, as the extravasation of urine. Thermic injury, as frost-bite, burns, lightning, etc. 2. Disturbances in the circulation, as varicose veins, atheroma of the vessels, weak- ened heart action. 3. Disturbances in the nutrition. These may be local or general. Under local disturbances are oedema, con- gestion, hemorrhage and inflammation. Under general disturb- ances are syphilis, scurvy, gout, rheumatism and tuberculosis. 4. Disturbance of innervation, associated with diseases of the spinal cord, as bed-sores, etc. We find ulcer in the stump due to innervation. Causes of ulcers on the leg are due to traumatism, syphilis, or varicose veins. Traumatic and varicose ulcers arc situated in the lower third, and' syphilitic ulcers are situated in the upper third of the leg, as a rule (Bryant and Dennis). 586 A COMPENDIUM OF PRACTICAL MEDICINE. Description of an Ulcer. — The base may "be shallow or deej^; the margin may be everted, undermined, or indurated; the dis- charge may be muco-purulent or bloody. Treatment, — 1. Relieve the congestion. The best way is to take a sharp knife and cut the indurated edge. 2. Encourage healthy granulations by an antiseptic poultice. 3. Elevate the limb and so encourage the circulation. We cannot cure an ulcer without rest. Stimulate granulations by balsam of Peru, aro- matic wine, cinchona bark, iodoform, bismuth, or oxide of zinc. Inquire into the constitution of the patient. If he has syphilis, gout or tuberculosis, you must treat these diseases. If the pa- tient suffers from varicose ulcers support the blood-vessels per- manently by elastic stockings, if it returns ligate the veins twenty to forty times. Shin-grafts may be used. Take the skin from the thigh and plant it over the ulcer (Bryant and Dennis). URAEMIA. By uraemia is understood the accumulation in the blood of excrementitious substances of the urine. Causes. — The primary cause is a failure of the kidneys to perform their normal function of elimination, and the consequent accumulation in the circulation of some or all of the poisonous elements of the urine. This condition may occur in the course of any disease in which suppression of the renal secretion takes place ; but it is more frequent in acute Bright's disease (Loomis). Symptoms. — Acute uraemia is usually preceded by certain signs, such as oedema in various parts of the body, restlessness, or an almost irresistible desire to sleep, vertigo, headache, deli- rium, nausea, vomiting, diarrhoea and impaired vision. The countenance has a pale, waxy or dingy appearance, and the urine is scanty, high-colored, bloody, albuminous, and contains casts. The convulsions may consist of a single paroxysm, and may simu- late epilepsy. There is a strong urinous odor emanating from the perspiration. The temperature may be as high as 107° F. Urcemic coma may come on gradually or suddenly. The patient may be easily aroused. Urcemic coma is always accom- URAEMIA URTICARIA. 587 panied by stertor. The stertor is peculiar; it is not the " snor- ing " of apoplexy, but a sharp, hissing sound. The respirations are at first accelerated but they soon become slow and labored. After a time the temperature falls below the normal standard; the face is pale (Loomis). Differential Diagnosis. — Uraemia may be mistaken for epi- lepsy, cerebral apoplexy, hysterical convulsions. In epilepsy the temperature is not elevated. The initial cry and corpse -like pallor of the face in epilepsy are wanting in uraemia. In cere- bral apoplexy coma always precedes convulsions. In hysterical convulsions the patient falls with a scream into a convulsive con- dition and afterwards passes a large quantity of pale urine (Loomis). Prognosis. — Will depend upon the amount of the poison in the system. Treatment. — Diaphoresis, by the hot-air baths and by the use of pilocarpin is of service. Digitalis acts efficiently — is diuretic without stimulating the kidneys. It increases the power of the heart's action. The diminished secretion of urine is due to obstruction in the capillary circulation of the kidneys. Digi- talis, by increasing the heart power, overcomes such obstruction. Chloroform is not a good remedy in uraemia. Loomis believes morphine administered hypodermieally to be the most efficient remedy for the treatment of uraemia. It arrests muscular spasm. It establishes profuse diaphoresis. It facilitates the action of cathartics and diuretics. Dry and wet cupping over the loins aid in establishing the renal function (Loomis). URTICARIA. Called also hives and nettle-rash, is an ephemeral eruption of the skin, with wheals and itching, from malassimilation, etc. Causes. — The cause may be neurotic. The vasomotor nerves are principally at fault. This vaso-motor nerve disturbance may result from direct irritation of the skin, or may be reflex, arising from the irritation of distant organs and tissues. The sting of the common nettle is the most familiar instance of local irrita- tion. It is often called forth, in those who are predisposed, by 588 A COMPENDIUM OF PRACTICAL MEDICINE. scratching the skin, or by the bite or sting of insects, such as the nea, the bug, the mosquito and the. wasp. The washing of the face with warm water often brings out hives. The internal causes which may produce nettle-rash by reflex action are: irrita- tion of the uterine nerves; in some persons mental emotion; in- digestion, certain kinds of food, such as oysters, crabs and lob- sters, nuts, onions, pork, sausages, and medicines, such as valerian, copaiba, cubebs, turpentine and quinine (Anderson). Symptoms.— The rash is familiar to all. The centre of each wheal is pale, while the periphery is red. The rash comes out with great rapidity, and may disappear in a few hours (Anderson). Treatment. — Discover and remove the cause or causes. A sharp purge is of use. Atropia and bromide of potassium are sometimes useful. Locally the parts may be sponged with vine- gar and water, or with a lotion of carbolic acid (Anderson). VAGINISMUS. Called also vulvismus, is a spasmodic contraction of the muscles of the pelvic floor — not of the sphincter vaginae muscle alone. It is seen alike in single and in married women, and is caused by violence in sexual intercourse, as when, in a newly married couple, there is some difficulty of entering the vagina, and repeated attempts set up an irritation resulting in reflex 'contraction whenever the penis strikes the anterior margin of the perinasum. It is sometimes seen after child-birth caused by injury to the pelvic floor. It may be caused by local disease of the parts, or it may be due to some disease of the spinal cord. The spasm of the muscles is usually accompanied by pain, often severe, and rendering the accomplishment of the sexual act not only difficult, but impossible (Morris). Varieties. — Vaginismus inferior, where the muscles of the pelvic outlet alone are involved, and vaginismus superior, where the levator ani muscle participates in the contraction; the last is a rare affection, and particularly that form where the latter muscle only is at fault. This variety sometimes comes on at the cud of the sexual act, and the penis may be grasped by its con- traction and retained in the vagina for some time. vulvitis. 589 Treatment. — Discover and remove the cause. If an irritable hymen is the cause of the trouble, the patient should be ether- ized and the hymen dissected out. If no inflammation is present gradual dilatation of the vagina does good. VULVITIS. Is an inflammation of the vulva. It may be either ca- tarrhal, follicular, diabetic or aphthous. Cause. — /. Of Catarrhal Vulvitis. — Want of cleanliness: gonorrhoea, exposure to cold; extension of inflammation from other parts: masturbation. Symptoms. — Those of an ordinary catarrhal inflammation, viz: swelling, redness, heat, pain and dryness of the parts, fol- lowed by increased discharge. Treatment. — The parts must be kept perfectly clean and warm hip-baths should be freely employed. Dusting with bis- muth subnitrate and borated cotton between the labia are of service. If the disease be of specific origin (see vaginitis). II. Follicular vulvitis is that form in which the sebaceous follicles are involved. Treatment. — The best treatment consists in warm sedative applications, warm baths, and alkaline washes. Ill Diabetic Vulvitis. — Is dependent upon the presence of a fungus developed from the sugar in the urine, and spreading from the orifice of the urethra to the vulva. The parts become dry and hard and of an intensely red color. The affection is attended with intense and very troublesome itching. Treatment. — The general condition of the system must be treated as well as the local (Morris). IV. Aphthous Vulvitis. — Is a disease of childhood follow- ing the exanthemata, or any debilitated condition of the system. Treatment. — Constitutional remedies are as important as local means. Cod-liver oil, quinine, and iron should be given and the most scrupulous local cleanliness insured (Morris). 590 A COMPENDIUM OF PRACTICAL MEDICINE. VARICOSE VEINS. Are an enlarged and tortuous state of the veins, which are usually thickened, rigid, and formed into irregular pouches. Situation. — They are most frequently seated on the lower extremities, scrotum and rectum. Varicose veins of the leg are accompanied by pain, weight, and fatigue on taking exercise; they cause ulcers and excoriations of the skin; they sometimes burst, causing profuse hemorrhage, and occasionally blood clots in the veins, which may terminate in an abscess. Treatment. — The palliative treatment consists in applying strips of leather over the part or a common roller or an elastic stocking, which should be applied in the morning before the patient rises. For the radical cure many methods have been devised (Morris). VARICOCELE. Is a varicose state of the veins of the spermatic cord. It is more common on the left side. Treatment. — Keep the bowels open; wash the scrotum fre- quently with cold water; support the scrotum with a suspensory bandage. For the radical cure, it is recommended to pass a ligature subcutaneously. Operations on the veins are always attended with some risk. Many surgeons cut down on the veins and ligate them with cat-gut (Morris). VERTIGO. Has been well defined as the consciousness of disordered equilibration. It is not properly a substantive disease, but may be the only symptom of the morbid state to which it is referable. It is a subjective state, in which the individual affected, or the objects about him, seem to be in rapid motion, of a rotary, circu- lar, or to -and- fro kind. In common language vertigo is known as dizziness. It may be momentary or of long duration (Bar- tholow and Loomis). Causes. — Vertigo is a purely functional affection. It has been divided into ocular, aural, stomachic, nervous, epileptic, cardiac, cerebral and gouty. VERTIGO. 591 I Paralysis of a single muscle may cause ocular vertigo. II. Aural vertigo is named after its discoverer — Meniere's disease, and may be caused by disease of the semicircular canals, or other ear troubles. Ill Gastric vertigo is the most common, and is an almost invariable attendant on dyspepsia and hepatic disorder. IV. Nervous vertigo is induced by physical or nervous excesses, and Ramskill ranks vertigo from overwork as next to gastric in frequency. It is also caused by excessive use of tea, coffee, tobacco and alcohol. V. Epileptic vertigo precedes an epileptic seizure. VI. Cardiac vertigo is a condition of anaemia of the brain and is closely allied to fainting. The subjects of cardiac vertigo have a swimming sensation in the head, darkness falls on the eyes and they become chilly and weak. It is associated with fatty heart and dilatation of the right cavities. VII Cerebral vertigo occurs as a symptom in cerebral anaemia and cerebral congestion; in meningitis, in tumor of the brain; in abscess of the brain; in cerebral hemorrhage; in scler- osis of the brain; in chorea, hypochondriasis and chronic alco- holism. VIII. Gouty vertigo is due to the blood changes which characterize the gouty diathesis. The vertigo of the aged is a result of disordered cerebral circulation produced by the senile condition of the heart and vessels. Chronic malarial infection may induce vertigo (Bartholow and Loomis). Symptoms. — The sensation may be that of objects moving around the patient, or of the patient moving around objects which remain stationary. There is no loss of consciousness. Nausea, vomiting, and ringing in the ears are frequent. The first symptom in ocular vertigo will be the running together of the letters on the page, headache, nausea, and pains in the eyes. In Meuiere's disease, tinnitus aurium accompanies the vertigo. After the attack of vertigo passes off deafness remains. Gastric vertigo is accompanied by dyspeptic symptoms, nausea, pyrosis, heartburn, flatulence, diarrhoea, or coustipation. The mental state is often deplorable, and true melancholia may ensue. 592 A COMPENDIUM OF PRACTICAL MEDICINE. Nervous vertigo is apt to occur after excessive mental effort (Loornis). Treatment. — Gastric vertigo demands the treatment given under the head of dyspepsia. In ocular vertigo, rest for the eyes and proper glasses will remove it. In aural vertigo, full doses of bromide of potassium are of service. In nervous vertigo, iron, quinine, strychnine, and the removal of the cause are sufficient. The vertigo of old age is benefitted by the bichloride of mercury and tincture of iron, with small doses of Burgundy wine (Loomis.) VOMITING. Is not a disease but a symptom in a large number of dis- eases. As a symptom it often demands treatment. Treatment. — Tablespoonful doses of iced champagne every fifteen minutes will sometimes arrest the vomiting of pregnancy, of sea- sickness, of cholera, yellow fever, etc. A little chloroform (IHij.-IHv.) dropped on sugar and swallowed, will remove some kinds of nausea and vomiting. The bromides are serviceable in cerebral vomiting, and in cholera infantum in children, and in some cases of reflex vom- iting. Chloral is highly useful in vomiting of sea- sickness, cholera, and reflex vomiting. A minim of wine of ipecac, given every half hour or hour in a little water, will sometimes relieve the vomiting of preg- nancy, vomiting of drunkards, of migraine, etc. Drop doses of Fowler's solution, given before meals, will stop vomiting of irritative dyspepsia, of pregnancy, of chronic gastric catarrh, etc. Hydrocyanic acid can be prescribed in the vomiting of acute stomach troubles. Pepsin, milk and lime-water, and bismuth are proper in the vomiting of indigestion, of stomach inflammation, of acidity and of acute intestinal disorders. Calomel in very minute doses, every half hour or hour, will stop some kinds of vomiting. VARICELLA. 593 Cerium oxalate, mix vomica and carbolic will in certain cases control vomiting. Counter -irritation at epigastrium often allays vomiting (Ringer and Bartholow). VARICELLA. Known in common language as chicken-pox or swine-pox, is a febrile affection, characterized by the appearance of a vesicular eruption with the first elevation of temperature, the vesicles drying up and falling off in from three to five days. It has been called spurious variola. Varicella is the shortest and mildest of the eruptive fevers (Bartholow and Smith). Causes. — It is due to a specific poison. It is highly contag- ious, so that few children escape who are exposed to it. It is a disease of childhood. It occurs sporadically and epidemically. It attacks the same individual but once. Inoculation has given negative results. The period of incubation varies from eight to seventeen days (Bartholow, Loomis and Smith). Symptoms. — Twenty -four hours preceding the eruption there is usually lassitude and a feeling of malaise. The eruption generally appears first on the body then on the head. About the second day vesicles may appear upon the tongue, lips and palate. The vesicles appear in crops. They vary in size from a pin's head to that of a pea, or even larger, and contain a clear watery and sometimes yellowish fluid. The number of vesicles vary from ten to a thousand. The duration of the disease is eight or ten days (Bortholow, Loomis and Smith). Differential Diagnosis. — Varicella may be mistaken for vario- loid. The stage of invasion of varioloid is longer than the stage of varicella. The mildness of the symptoms in varicella is diag- nostic. The vesicular character of the eruption from the start is characteristic of varicella. In varioloid the vesicles are preceded by papules. In varioloid the eruption appears first on the face, in varicella it appears first on the body. The umbilicated ap- pearance of the vesicles is wanting in varicella (Flint). Treatment. — Varicella claims no treatment, Rest in bed, cleanliness, and a non -stimulating diet are important. 594 A COMPENDIUM OF PRACTICAL MEDICINE. VARIOLA. Is an eruptive disease characterized by the presence of pus- tules which make their appearance at the end of the third exacerbation of the initial fever, when the temperature declines, but this apyrexia is followed by a secondary fever, or fever of maturation. It is known in common language as small-pox (Bartholow). Morbid Anatomy. — The characteristic lesion of small -pox is the eruption. The successive stages of the eruption are the macule, the papule, the vesicle and the pustule. The pustule undergoes desiccation. The macule is a reddish, slightly- elevated spot due to congestion of a circumscribed portion of the skin. A characteristic appearance of the small -pox vesicle is produced by a central depression in its roof, the so-called umbilication of the vesicle (Flint). Causes. — Small -pox is spread by a peculiar virus whose nature is unknown. In the open air the distance of contagion is about two and one-half feet. Rarely does an individual have a second attack. The period of incubation varies from live to thirty days, average fourteen days. The negro and Indian races are particularly susceptible to the disease (Bartholow, Flint and Loomis). Symptoms. — Stage of Invasion. — The disease is ushered in by a chill in the great majority of cases, and the chill is usually more marked than in the other eruptive fevers. Fever follows the chill. It is known as the primary fever. It is often intense, 104° or 105° F. There are nausea, vomiting, coated tongue, pain in the stomach, also in the limbs andloins, headache and delirium. The duration of this stage, as a rule, is two days. The eruption begins to appear on the third or fourth day. Stage of Eruption. — The eruption, as a rule, appears first on the face, about the lips and chin, then on the neck and wrists; next on the chest and arms; then over the body. At first the eruption appears in the form of small red spots or specks. It is now a maculated eruption. The central part of the maculae be- comes hard, elevated and pointed. It is now a papular erup- tion. The papulae feel like small shot under the skin. Next a VARIOLOID. 595 clear liquid becomes visible in the papulae, which now become vesiculce. On the fifth day of the stage of the eruption the vesi- cles are one-quarter to one-thircl of an inch in diameter. More or less of the vesicles present a depression in the centre. They are said to be umbilicated. This appearance is highly characteris- tic, indeed, almost pathognomonic. After this the vesicles be- come pustules. In other words suppuration takes place. On the appearance of the eruption the primary fever falls almost to the normal. This is a highly diagnostic feature of small-pox. Stage of Suppuration. — Usually on the sixth day after the first appearance of the eruption, there is a recurrence of the fever called suppurative or secondary fever. The face, hands and feet swell. The duration of this stage is four or five days. Stage of Desiccation. — This stage begins on about the twelfth day of the disease. The pus collects into a thick scab. During this stage the skin exhales a sickening characteristic odor. The whole duration of small-pox is between seventeen and twenty -four days (Flint and Loomis). Prognosis. — Varies— from ten to twenty-five per cent. die. Treatment. — -There is no special plan of treatment. The dis- ease will run its course and hence the expectant plan is to be pursued (Flint). VARIOLOID. Is modified small-pox. Small-pox is modified as a rule when produced by inoculation. Inoculation had been practiced from time immemorial in China and Persia. The eruption in cases of inoculated small-pox is usually slight. The pocks rarely exceed one hundred. Many of them abort. As a rule, variolation or inoculation affords complete pro- tection ever thereafter against small -pox. It was a great bless- ing prior to the discovery of vaccination. At the present day in most cases of varioloid the modification is due to vaccination. Vaccination does not always afford complete protection against small -pox, but in general the disease is materially modi- fied. The treatment of varioloid is the same as ordinary small-pox (Flint). 596 A COMPENDIUM OF PRACTICAL MEDICINE. VACCINIA, OR COWPOX. Vaccinia and cowpox are names of a disease of the cow which, communicated to man, destroys in the great majority of cases for a certain period the susceptibility to small- pox. Cow- pox is transferred to man by the introduction of a virus. The operation for its communication is called vaccination. For the employment of vaccination as a means of preventing small- pox the world is indebted to the immortal Jenner, who published his discovery in 1798. The history of vaccinia in man is as follows: On the third day after vaccination red points or small papules are apparent where the vaccine virus was inserted. On the fourth day the papules are more developed. On the fifth day vesicles appear, and on the eighth day they are fully developed. On the ninth or tenth day the contents of the vesicles become purulent-, or pustules are formed. The pustules desiccate and fall off about the twenty -fifth day from the date of vaccination. Cowpox is not identical with small-pox, although allied to it. In a large majority of cases vaccination affords, for a time at least, absolute protection against small -pox. In a minority of cases the susceptibility to small -pox is not destroyed, but the disease is materially modified, constituting what is called vario- loid. Revaccinating every fixe years is to be advocated. The bovine virus should be used. The dangers following some cases of vaccination are abscesses, erysipelas, and blood-poisoning (Flint). VALVULAR DISEASES. Include those alterations in the structure of the valves them- selves or of the orfices which render the former incapable of per- forming their office in the closure of the latter. The lesions may be of two kinds — obstructive or regurgitant / that is, the orifice may be so narrowed as to obstruct the passage of the blood, or the valves may be so damaged as to permit the blood to regurgi- tate The narrowing of an orifice is termed stenosis; the incom- petence of a value to close the orifice is termed insufficiency. There are four points at which these lesions may occur, viz: mitral, aortic, tricuspid, and pulmonic orifices (Bartholow). VALVULAR DISEASES. 597 Cardiac Murmurs. — A cardiac murmur is an abnormal sound produced within the heart or blood-vessels, either by obstruction to the blood- current, an abnormal direction of the blood- current, or a change in the blood constituents. Should any obstruction exist at either of the auriculo- ventricular orifices, the blood while passing through the opening at the end of a cardiac diastole, will impinge on such obstruction and cause a presystolic murmur. During a cardiac systole, if the semilunar valves obstruct the outgoing current, or if the mitral or tricuspid valves do not wholly close the auriculo ventricular orifices, then, in the one case, the blood -current as it passes over the obstruction at the semi -lunar orifices, will produce a systolic murmur, and in the other a systolic murmur will be produced by the backward current through the abnormal opening at the auriculo- ventricular orifices. If the pulmonary and aortic system have back of them a semilunar valve that does not completely close that end of the circuit, the blood will regurgitate into the ventricles during the period of cardiac rest, so that semilunar incompetence causes a diastolic murmur. The following is the order of relative frequency of cardiac murmurs: (1) Mitral regurgitation; (2) aortic obstruction; (3) aortic regurgitation; (4) mitral obstruction; (5) tricuspid regurgitation; (6) tricuspid obstruction; (7) pulmonary ob- struction; (8) pulmonary regurgitation. Of the eight cardiac murmurs, four are systolic, two dias- tolic and two presystolic. After determining whether the cardiac murmur be systolic, diastolic or presystolic, we next find the point of its maximum intensity. Murmurs arising at the mitral valve are loudest at the apex of the heart, or just above it; tricuspid murmurs are loudest over the lower part of the sternum; pulmonary murmurs, in the second left intercostal space close to the sternum, and aortic murmurs in the second right intercostal space at the edge of the sternum (Loomis). Rational Signs and Symptoms of Valvular Defects. — When stenosis exists at an orifice, the amount of blood passing through is necessarily lessened, with the effect to cause tschaemia and lowered tension in front, and stasis and abnormally liiu'h tension 598 A COMPENDIUM OF PRACTICAL MEDICINE. behind. The same result follows if the contractions are feeble and the cavity dilated. Lesions of the aortic orifice, either ob- structive or regurgitant, lead to dilatation of the left ventricle, to diminished blood- supply, and lowered tension in the vessels of the aortic system, and to increased pressure and distention in the left auricle and pulmonary veins. Mitral lesions, either obstruc- tive or regurgitant, cause abnormal fullness and distention of the left auricle and pulmonary system, and ischsemia and lowered tension in the left ventricle and aortic system. Lesions of the tricuspid orifice induce dilatation of the right auricle and in- creased pressure in the venae cavge, and ischaemia and lowered pressure in the right ventricle and pulmonary artery. Lesions of the pulmonary orifice bring about dilatation of the right ventricle and elevated tension in the right auricle and venae cavae, and ischsemia and lowered tension in the pulmonary artery. All valvular lesions bring about, sooner or later, a state of the circulatory organs in which there are ischgemiaand lowered tension in the aortic system and stasis and high tension in the venous S} 7 stem. When compensation takes place this is not the case. Stenosis of an outlet is compensated by dilatation of the cavity and hyper- trophy of the walls. But the compensation may be easily over- come, and symptoms of valvular disease ensue. The most usual pulmonary disturbance induced by valvular disease is stasis of the blood, which leads to catarrh of the bronchi, and is accom- panied by cough, mucous expectoration, mucous and sub-mucous rales, etc. There is difficulty of breathing. There may be cyanosis with pain in the chest, shoulder, and down the arm. The condition of over-fullness of the venous is seen in the dis- tended state of the superficial veins (Bartholow). AORTIC OBSTRUCTION, OR STENOSIS, This is a common cardiac lesion, and is always accompanied by more or less hypertrophy of the left ventricle (Loomis). Causes. — Aortic stenosis is most frequently met in middle and advanced life; the mean age being forty-seven years. Inter- stitial endocarditis of rheumatic origin is its most frequent cause. VALVULAR DISEASES. 599 Chorea and chronic Bright's disease may cause it. Atheroma or arteritis deformans extending to the valves somestimes gives rise to it. Men suiter from aortic stenosis oftener than women. Occupations that involve repeated, sudden and sever muscular effort induce it (Loomis). Symptoms. — The subjective symptoms of aortic stenosis are rarely well marked. When the compensation is overcome, then the pulmonary vessels and the venous system are abnorm- ally full. The scanty arterial supply causes pallor of the face, and syncope may occur from cerebral anaemia, but these are late symptoms. The pulse is normal in frequency, diminished in volume and fullness, and as a rule regular. Signs of arterial anaemia usually precede those of venous engorgement. There may be slight palpitation and paroxysmal pain in the chest. Aortic stenosis is more often associated with cerebral embolism than any other valular lesion. The left middle cerebral artery is the most common seat of cardiac emboli (Loomis). Physical Signs. — Inspection shows the area of cardiac im- pulse to be abnormally increased. Palpation. — The impulse is felt to be forcible, and may be accompanied by a heaving or lifting sensation. The apex is dis- placed to the left and slightly downward. Percussion. — The area of cardiac dullness increases. Auscultation. — Aortic obstructive murmurs are loudest and most distinct at the second right intercostal space and at the sternal insertion of the third left costal cartilage. They are sys- tolic and accompany the first sound of the heart. These murmurs are always harsh, and heard most distinctly at the commencement of the systole. The area of diffusion of this murmur follows the law that a murmur is propagated in the direction of the blood- current. It is conveyed along the aorta into the carotids and one of its characteristics is that it is heard in the great vessels of the neck. It may be heard in the abdom- inal and thoracic aorta (Loomis). Differential Diagnosis. — Aortic obstruction may be mistaken for mitral and tricuspid regurgitation, an ancemic bruit, or the murmur of a thoracic aneurism. Both mitral and tricuspid regurgitation and aortic stenosis produce 4 a systolic murmur. The 600 A COMPENDIUM OF PRACTICAL MEDICINE. murmur of aortic stenosis is heard with its maximum intensity at the third left sterno- costal articulation, and diminishes in inten- sity toward the apex of the heart. The murmur of mitral regur- gitation is heard loudest at the apex -beat. The murmur of aortic stenosis is conveyed into the vessels of the neck; that of mitral regurgitation to the left, in the direction of the apex -beat, and is heard behind, between the fifth and eighth dorsal vertebras, at the left of the spine, with very nearly the same intensity as at the apex. Thejmfodin aortic stenosis is normal in frequency, di- minished in volume and fulness, and, as a rule, regular in rhythm; while in mitral regurgitation it is irregular in rhythm and force, and is easily increased in frequency. Gastric, intestinal, renal, hepatic, and bronchial symptoms are present in mitral regurgita- tion, wmile the subjective symptoms of aortic obstruction are cerebral in character. The murmur of aortic stenosis is harsh, that of mitral regurgitation soft, and often musical. Tricuspid regurgitation is accompanied by a systolic mur- mur which is rarely heard above the third rib ; while that of aortic stenosis has its point of maximum intensity at the second right intercostal space and at the sternal insertion of the third left costal cartilage. Tricuspid regurgitation is accompanied by jugular pulsation / while the murmur of aortic obstruction is heard in the arteries of the neck. The pulse in tricuspid disease is normal; in aortic stenosis it is diminished in volume and ful- ness and is sometimes hard and wiry. Anosmia produces a murmur heard loudest in the carotids and accompanied by a venous hum. In anaemia there are three murmurs: cardiac, venous, and arterial. The murmur is soft and blowing in anaemia, and harsh in aortic obstruction. In thoracic aneurism the dilating impulse on palpation, the normal force of the heart-beat, the single and double bruit, and the pain are all important signs, which are absent in aortic sten- osis (Loomis). VALVULAR DISEASES. 601 AORTIC INSUFFICIENCY, OR REGURGITATION, This is an abnormal condition of the aortic valves, which prevents their complete closure, and allows a backward current of blood to now from the aorta into the left ventricle during its diastole (Loomis). Causes. — Rheumatic endocarditis is the chief cause; but it may follow sudden and violent muscular effort, atheroma of the aorta, or endarteritis. Dilatation of the aorta at its origin may induce it. Alcoholismus and gout predispose to it. Fagge says only fifty per cent, of the cases give a rheumatic history (Loomis). Symptoms. — So long as hypertrophy compensates for the re- gurgitation, there is little or no inconvenience experienced by the patient. In time the hypertrophy induces excessive heart - action during excitement or violent muscular effort. The heart- action then becomes labored, and the patient is anxious, nervous and fretful, and knows well that exercise will increase his un- comfortable symptoms. The respirations are accelerated with the cardiac palpitation; as the disease advances, attacks of head- ache and vertigo become more and more prolonged and severe; the patient complains of muscce volitantes, dyspnoea, and giddi- ness, and is compelled to sleep with his head elevated. Palpita- tion and a visible carotid impulse are now constantly present. A frequent symptom is a distinctly paroxysmal shooting or stab- bing pain over the heart, in the left shoulder, or extending down the left arm. The pain may pass from the middle of the sternum down the right arm. The pain may be accompanied by numb- ness. When mitral insufficiency exists with the aortic, the sys- temic veins become overloaded and cyanosis and dropsy result; the dropsy appears first as oedema of the feet, and gradually ex- tends upward until there is general anasarca. Later in the disease, there is orthopnoea, sudden startings in sleep, angina pectoris, and there may be albuminuria and en- largement and tenderness of the liver. Attacks of syncope occur. These patients may die at any moment. The pulse is visible in the vessels of the head, neck and upper extremities. It is often called the "piston pulse" tk Corrigarts pulse" ">r t. i. d. is of the highest utility in chronic albuminuria. Nitro=glycerine ( T ^ gr.) daily, increased gradually will relieve the high arterial tension in acute and chronic Bright's disease. Digitalis may be used when the quantity of urine is much diminished. Pilocarpine may be used cautiously. ALCOHOLISM. — Bromides in drachm doses may be given for the "horrors." Arsenic, in drop doses before breakfast for the morning vomiting. Cimicifuga for the dyspepsia of drunkards. Morphine with tonics before meals for pain, nausea and want of appetite. Capiscum and nux vomica may be given as stomachic tonics. AMAUROSIS. — Strychnine will cure amaurosis of a functional kind, from lead, to- bacco and alcohol. AMENORRHCEA.— Aconite tincture in drop-doses every half hour, for sudden sup- pression of menses. Aloes and iron may be given when due to anaemia and torpor. Apiol in a dose of fifteen grains daily for five days before the expected period, is effective in amenorrhoea due to anaemia and torpor of the ovaries and uterus. Hydropiper in thirty minim doses of the fluid extract four times daily for a week before the menses ought to appear. Chloride of gold and sodium in 27 S r - dose thrice daily when dependent on torpor of the ovaries. Hot mus= tard sitz. baths for five days before the period. Potassium permanganate, one grain thrice daily for a week before the period. It may restore it after two years delav. ANiEMIA,— Cold sponging is useful in anaemia. Hypophosphites of lime and soda, a grain thrice daily. Phosphate of lime, a grain thrice daily, in anaemia of growing persons, and of women weakened by rapid child-bearing or excessive menstruation. Trinitrin in doses of one minim of the one per cent, solution gradually increased to many will cure many cases of anaemia. Quinine in doses of one grain three times daily, for badly fed, pale town-livers. Iron in all forms of anaemia. Arsenic is effective in proper doses. Wines with good body. Galvanism to stimulate the functions of organic life. AN>ESTHESIA.— Galvanism to the spine and affected parts. The electric brush is useful in anaesthesia. Strychnine, hypodermically, -^ gr. daily increased gradually. ANEURISM. — Potassium iodide, in full doses relieves the pain and promotes co- agulation of the blood in the sac. A low diet with absolute repose in the recumbent posture. Barium chloride one-fifth of a grain, three times a day for four weeks, then two-fifths may be given for months. Aconite slows the cir- culation and thus facilitates coagulation in the sac. Ergot, especially ergotin hypodermically has been very effective. Galvano=puncture has but rarely suc- ceeded. ANGINA PECTORIS.— Arsenic (Fowler's solution) in full doses, is very efficient to prevent attacks given during the intervals. Amyl nitrite, two to five drops by inhalation affords prompt relief in cases characterized by elevated arterial tension. Nitro=glycerine one minim of a one per cent. sol. at stated intervals is superior to amyl. Ether, in small quantity by inhalation, may abort a mild attack, hypodermically in the worst cases. Nitrite of sodium, one grain sev- eral times daily. Morphia, gr. J, may be given hypodermically for the pain. ANTHRAX.— Carbolic acid applied locally. APHONIA. — Atropine ( T ^y gr.) morning and evening will remove aphonia due to fatigue of vocal cords. It will also cure hysterical aphonia. Nitric acid in ten minim doses of the dilute, is effective in the hoarseness of singers and when aphonia is reflex. Electricity (galvanism) usually cures when due to paresis of the vocal cord. APHTH/E.— Bismuth subnitrate may be applied to ulcers. Potassium chlorate (gr. x. to oz. j.) may t be used (locally. Iodoform dusted on is an excellent topi- CLINICAL INDEX. 651 cal application. Quinine in tonic doses (gr. ss. togr. j.) is highly useful. Car=» bolic acid (pure) may be applied to the ulcers, as an anaesthetic and alterant. Alum may be applied dry a few times a day to aphthous ulcers which will not heal. Borax with honey, or as glycerine of borax may be applied to ulcer. APOPLEXY. — Croton oil in one-third minim dose, may be given every hour as a purgative. Venesection or leeches, when the blood pressure is high and hem- orrhage threatened or proceeding. ASCARIDES — Quassia, an infusion, as a rectal injection, is one of the most ef- fective agents for the destruction of thread worms. Carbolic acid is an efficient but unsafe parasiticide when injected into the rectum. Iron, ten drops of the syrup of the iodide, three times daily by the stomach to prevent reproduction and dr. j. of the tinct. to Oj. of water by rectal injection. Santonin in dose of five grains for adult at night with or without calomel and a laxative in the morning. ASCITES. — Copaiba resin may be used as in the following: Res. copaibas dr. iij., alco- hol dr. v., spirit chloroformi dr.^ j., mucil. acacias oz. ij., aquas ad. oz. xij. — M. Sig.: A tablespooniul t. i. d. Pilocarpine very serviceable when given to pro- duce free diaphoresis. Jalap (compound powder) in teaspoonful doses taken in the early morning. Elaterium in dose of gr. T Vgr. I, must be given cautiously. Milk diet or dry diet will aid remedies. ASTHMA. — Oxygen, pure or diluted by inhalation. Amyl nitrite four or five drops by inhalation. Nitro=glycerine (gr. T ^) by the stomach. Arsenic one drop three times daily to prevent. Alum ten grains powdered and placed on the tongue is said to arrest a paroxysm. Bromides, in spasmodic asthma, may be given as follows: Potassii bromidi oz. j., potassii iodidi oz. ss., aquas oz. iv. — M. Sig.: A teaspoonful in water every half hour or hour. Chloral in twenty grain doses may arrest the paroxysm but danger of the chloral habit. Chloroform by inhalation relieves. Ether by inhalation is safer than chloro- form. Atropine gr. ■£$ at bed time may prevent paroxysm. Morphine (gr. J) and atropine (gr. T ^) hypodermically are the best agents to cut short a parox- vsm. Potassium iodide in full doses succeeds remarkably in some cases. Quinine may be given during the intervals in grain doses thrice daily. Strych = nine used persistently may lessen the number of attacks. Galvanization of the pneumogastric and cervical spmpathetic relieves the spasmodic difficulty of breathing and sometimes effects a cure, and faradization of the chest muscles has lately been reported successful in effecting a cure. Coffee, a very strong infusion, is often useful in a paroxysm. Lobelia tincture in ten drop doses every ten minutes till dyspnoea gives way. Stramonium, gr. xx. of the dried leaves may be smoked. Tobacco smoked sometimes gives relief. BALDNESS.— Pilocarpine may be used locally in the following formula: Extracti pilocarpin oz. j., tincture cantharidis oz. ss., linimenti saponis oz. iss. — M. Sig.: To be applied to scalp daily. BED-SORES — Alcohol in form of brandy to harden skin of parts exposed to pres- sure. Alum with tinct. of camphor and whites of eggs is a good topical appli- cation. Resorcin in form of powder may be dusted on. Copaiba and castor oil equal parts, locally. Naphthol as an ointment with vaseline is said to be the most efficient of all. Iodoform dusted over sores. Charcoal sprinkled over the black slough which is then covered with a poultice. Glycerine rubbed over the part exposed to pressure after washing morning and evening is one of the best preventives of bed-sores. Silver nitrate gr. xx. to oz. j. painted on the unbroken skin as soon as it becomes red to prevent bed-sores. BILIOUSNESS.— Mineral acids before meals in acid indigestion. Hydrochloric acid and pepsin after meals in atonic dyspepsia. Sodium p'hosphate in tea- spoonful doses thrice daily for a long time. Calomel and blue pill in small quantity as laxative merely. Ammonium chloride in five grain doses three times daily. Tincture of nux vomica, gtt. v., t. i. d. for three weeks. BITES. — Ammonia, weak solutions, in bites of insects to neutralize the formic acid. The strong aqua ammonia should be at once applied to the bite of ven = omous serpents and of rabid animals. Potassium permanganate, a strong solution applied locally. Alcohol stimulants internally. BLADDER, CATARRH OF.— Alkalies after meals, when the urine is acid. Ben- zoate of ammonia in gr. v. to gr. xx. thrice daily may be given when the urine is alkaline and loaded with phosphates. Copaiba, cubebs and juniper are use- ful. Cantharides, tinct. gtt. iij. to gtt. v. very useful. 652 A COMPENDIUM OF PRACTICAL MEDICINE. BLADDER, IRRITABILITY OF.— Belladonna tinct. in ten minim doses until phys- iological effects. Alkalies when urine is acid. Benzoate of ammonia when urine is alkaline. Tinct. cantharides sometimes succeeds in irritable bladder of women. BOILS. — Arsenic, Fowler's solution, in three drop doses after meals for a long time when there is a succession of boils. Nitrate of silver gr. xx.-xxx, dis- solved in nitrous ether, and painted on early will abort boils. Sulphide of calcium half grain three times daily will hasten maturation and prevent the formation of fresh boils. No use in the boils of diabetes. Collodion may be applied in the papular or pustular stage. Belladonna with glycerine locally to allay pain. Counter=irritation by blisters or iodine around the boil. Menthol forty per cent, solution locally. Poultices assist maturation and allay pain. They may be smeared over with belladonna or opium. BRAIN, DISEASES OF.— Bromide of potassium in gr. xxx. doses at bed hour, when over-taxed from study, or over-application to business. Phosphorus sV to 3^ grain thrice daily for several months in cerebral softening and over- taxation. BREASTS, INFLAMMATION OF —Belladonna, especially as liniment to check secretion of milk when inflammation is imminent. When inflammation has set in, continuous application of belladonna for twenty-hours often arrests it. It is also useful when an abscess has formed. Digitalis as an infusion locally. BREATH, FOUL. — Camphor is a common ingredient of tooth powder and is a cor- rective of foul breath. Chlorine-water properly diluted. Carbolic acid in dilute solution as a mouth-wash and by the stomach. Potassium permanganate gr. ij. to oz. j. of rose-water as a mouth-wash. Tinct. of benzoin internally and as mouth-wash. BRIGHT'S DISEASE.— Milk=cure especially an exclusive skim-milk diet, or a diet composed largely of milk, has been very successful. Water and large draughts of weak alkaline waters. Bitartrate of potassae as lemonade, drunk freely as a diuretic. Digitalis the infusion for the dropsy. Potassium iodide in the chronic cases. Iron to relieve the anaemia. Pilocarpus highly useful in many cases of uraemia. Nitro»glycerine has proved highly useful when there is in- creased vascular tension. Cod=liver oil in the chronic. Tannin in chronic Bright's to lessen albumen. BRONCHITIS.— Aconite tinct. in small doses frequently in the acute form. Car= bonate of ammonia in gr. v. doses every three hours if the secretion is viscid. Morphine or Dover's powder with quinine may abort an acute attack if given early. Squills, the compound syrup with paregoric is useful. Terebene may be given for the cough. Cod=Iiver oil may be given in the chronic form. Iron as a tonic. Strychnine is the best remedy to check the reflex vomiting. Acids to lessen the secretion in the chronic. Tar, two grains in pill every three or four hours in chronic paroxysmal winter cough. Wine of ipecac used as a spray to the pharynx is invaluable in many cases of bronchial asthma and winter cough. BRUISES. — Capsicum, a strong tincture applied with gum is said to act like a charm on discolored bruises. Hamamelis applied on lint or cotton-wool. Sul= phurous acid a solution constantly applied. BUBO. — Iodine applied to produce vesication round a bubo relieves the inflamma- tion. Nitric acid may be applied to indolent and broken bubo. BURNS AND SCALDS.— Carbolic acid, a one per cent, solution on lint frequently renewed relieves pain. Cocaine as a lotion painted on scalds relieves the pain. Collodion painted over slight burns subdues inflammation. Lime in the form of lime-water combined with oil, enjoys a high reputation. Carbonate of soda in saturated sol. to relieve pain. Boracic acid most useful in Mr. Lister's hands. Carbonate of lead and linseed oil, white lead paint, is an excellent ap- plication to burns. CALCULI, BILIARY. — Aliment, as starches, sweets, and especially fats should be avoided. Alkaline mineral waters are highly useful. Sodium phosphate, dr. j. t. i. d. for three months. Turpentine and ether equal parts, gtt. x. t. i. d. for the solution and cure of biliary calculi. CALCULI, RENAL. — Nitric acid very dilute as an injection for phosphatic calculi. Alkalies to dissolves uric acid calculi. Alkaline mineral waters as vichy, Bethesda, etc. CLINICAL INDEX. 653 CANCER. — Arsenic relieves the pain and retards the growth of cancer of the stomach and also of epithelioma. Bismuth relieves the vomiting in cancer of the stomach. Carbolic acid, pure, as an anaesthetic before applying caustics. Arsenious acid, pure, may be used to set up active inflammation in epithelioma. Carbonic acid may be injected up the vagina in cancer of the uterus to relieve the pain. Chloral in ten grain doses t. i. d. has relieved most severe pain of cancer. Chloroform as a vapor to raw, painful surface. Conium may be ap- plied as poultice to ease pain. Glycerine of carbolic acid and glycerine of tannin combined checks the discharge and stench of uterine cancer. Iodoform applied locally relieves the pain of cancerous sores, florphia dissolved in glycerine and" spread on lint, is very useful where there is much pain. Opium is also used in cancer of the stomach. Poultices of starch applied cold soothe open cancers. Warm enemata relieve the pain and straining in intestinal cancer. CANCRUM ORIS.— Arsenic in medicinal doses useful. Nitric acid applied to the surface. CANKERY TASTE.— Podophyllin small doses ^ grain nigfht and morning. Pur= gatives as mercury and podophyllin, are best. Water, half a glass of pure cold, daily, half hour before breakfast. CARBUNCLE. — Arnica as an ointment on plaster. Belladonna with equal part of glycerine as a local application to allay pain. Carbolic acid and glycerine 1 to 4 on lint to sinuses. Iodine applied round the carbuncle reduces inflammation. Menthol, ten to fifty per cent, in ether or alcohol, painted on several times daily. Opium, an extract of the consistence of treacle applied three or four times a day. CARIES.— Phosphate and carbonate of lime to furnish needed materials. Cod= liver oil to promote constructive metamorphosis. CATARRH, ACUTE— COMHON COLD.— Aconite tinct. and belladonna tinct., equal parts', two drops of the mixture every half hour for six or eight hours and then every two hours. Quinine gr. xv. and morphine gr. ss. may at the outset, abort an attack. Dover's powder in full dose of gr. x-xv. at the incep- tion may arrest the attack. Iodide of potassium gr. v , tartar emetic gr. ss., syrup of orange peel oz. j., water oz. iij. — M. Sig.: Teaspoonful doses hourly for children. Warm foot=bath before going to bed. Turkish bath is useful in chronic catarrh. Carbolic acid is of great value by inhalation of vapor and spray. CATARRH, CHRONIC NASAL — Alum in powder, may be insufflated. Iodoform and tannin may also be applied by insufflation. Iodine in vapor may be in- haled. Ethyl iodide five to twenty drops put on a handkerchief inhaled every three hours. Sanguinaria ten drops of the tincture t. i. d., and the local ap- plication of the powder. Cubeb in powder by insufflation. CATCH IN THE BREATH.— Cold sponging night and morning will improve or even cure this curious complaint in infants. CHANCRE. — Eucalyptol with iodoform may be applied to both kinds of sores. Iodoform may be dusted over soft chancres. Iodol dusted over sore is effective. Nitric acid applied by means of a glass rod or pine stick to the chancre is one of the most valuable caustics. Acid nitrate of mercury is the most efficient escharotic for the destruction of chancre which we possess. Carbolic acid may be applied pure in mild cases. Chlorate of potassium in powder is also an ex- cellent local application. Iodide of iron internally is valuable. CHANGE OF LIFE. — Aetata is one of the most useful remedies for many of the dis- tressing symptoms occurring at the change of life. Ammonia in the form of Raspail's sedative lotion to be applied to the painful part of the head in the headaches of this period. Bromide of potassium in gr. xx.-xxx. doses at bed- time, for the despondency with sleeplessness and irritability often also with heats, flushings and perspirations. Calabar bean for the flatulence of this period. Change of air and scene where other treatment fails. Eucalyptol for various symptoms as palpitations, flushings and flatulence. Iron the tincture of the chloride gtt. xv. t. i. d. in fluttering of the heart with fullness of the head, heat and weight on the vertex, frequent flushings and hot and cold per- spirations. Nux vomica tinct. gtt. ij. and opium tinct. gtt. ij. combined t. i. d. are most useful. CHAPS. — Collodion is sometimes used but for chapped hands and lips glycerine of starch, arnica cerate or eau de cologne and glycerine better. Compound 654 A COMPENDIUM OF PEACTICAL MEDICINE. tinct. of benzoin and glycerine, equal parts, is the best remedy for chapped hands and lips and fissured nipples. Sulphurous acid and glycerine, equal parts, combined are most useful for chapped nipples, Vaseline and petroleum are effective. CHEST PAINS. — Iodine, as an ointment, in muscular pains of the chest. Belia= donna is better when the pain is in the skin. CHILBLAINS.— Sulphurous acid is an efficient application to chilblains, applied as follows: Acidi sulphurosi dr. iij., glycerine dr. j., aquae oz. iss. — M. Benzoin tincture applied locally is the best. Turpentine is efficient. Balsam of peru in ointment for broken chilblains. Capsicum tinct. painted over un- broken chilblains. Iodine tinct. or ointment is better painted over the part. Carbolic acid may be used as follows: Acidi carbol. dr. j., tinct. iodi dr. ij., aciditannici dr. ij . , cerat. simplicis oz. iv. — M. Sig\: Ointment. CHLOROSIS —Arsenic, gtt. iij. of Fowler's sol. t. i. d. after meals. Hypophos= phites of lime or soda may be given in grain doses, t. i. d. for some time. Iron reduced gr. v., t. i. d. gives excellent results. Iron may be given with rnan = ganese or arsenic or with aloes if constipation exists. Water of iron spring most beneficial. Massage with inunctions of oil. Nux vomica may be com- bined with iron. Pepsin and pancreatin aid digestion. Galvanism and faradism to the central nervous system. CHOKING. — Bromide of potassium gr. iij. -v. t. i. d. to a child six years old, which, from the time of his birth, can swallow solids with ease, yet is choked every time he tries to drink. CHOLERA, ASIAT1CA.— Morphia, gr. %-±, hypodermically, of the greatest value even in the stage of collapse. Mercury in form of gray powder, gr. \ hourly is of the greatest service in infantile cholera. A starch injection with a minute quantity of laudanum assist the gray powder. Arsenic, Fowler's sol. with opium of service. Camphor gtt. iv.-vj. of the strong spirit, every ten minutes at first then hourly. Chloral combined with morphine as follows: Chloral hydratis dr. iij., morph. sulph. gr. iv., aquae laur-cerasi oz. j — M. Sig.: Fif- teen to thirty minims. Chloroform a few drops frequently to stop vomiting. Calomel, minute doses (gr. 2V) every hour will sometimes stop vomiting. AI= cohol in form of iced brandy to stop vomiting. Acetate of lead with opium and camphor as follows: Plumbi acetat. grs. xxiv., pulv. opii grs. xij., pulv. cam- phorae dr ss., sacch. alb. q. s., Ft. pulv. no. xij. Sig.: One powder every hour. Chlorodyne very effective. CHOLERA HORBUS — Horphine and atropine (gr. ± and gr. 1-120) hypodermically is the most efficient remedy. Chloral with morphine if cramps occur. Carbolic acid and bismuth as follows: Acidi carbolici grs. iv., bismuthi subnitrat. dr. ij., mucil. acacias oz. j., aquas menth. pip. oz. iij. — M. Sig.: A tablespoon- ful every three hours. CHOLERA INFANTUM.— Carbolic acid is very effective. Bismuth subnitrate, gr- iij. every twb hours. Calomel in minute doses arrests vomiting. Oxide of zinc given in the following formula: Bismuthi subnitrat dr. iss., pepsinas sacch. dr. ss., zinci oxidi grs. vj-grs. xij. — M. Ft. pulv. no. xij. Sig.: One powder every four to six hours. Brandy is serviceable. CHORDEE. — Camphor, ten to twenty grains very successful. Potassium bromide dr. j., every four hours. Cantharides tinct. one drop thrice daily. Aconite tinct one drop each hour. Morphine gr. \ and atropine gr. 1-150, hypoder- mically will most certainly relieve. Tartar emetic will relieve if carried to nausea. Tobacco wine a few drops at bed-hour. CHOREA. — Cold effusions and cold bath. Cod=liver oil when the nutrition is poor. Iron may be given for the anaemia. Arsenic, Fowler's sol. gtt. iij. to x. t. i. d. very successful. Chloroform inhalation t. i. d. in severe cases. Strychnine in increasing doses until stiffness of the muscles of the neck and spasmodic jerk- ings. Hyoscyamus gr. 1-50 daily. Morphine in large doses. Chloral at night is highly useful. Conium is said to be good. Sulphate of zinc pushed to nausea. Galvanism to the spine. CIRRHOSIS.— Iodide of sodium or ammonium in small doses t. i. d. before meals in first stage. Phosphate of sodium, dr. j., t. i. d. for a long time. Gold and sodium chloride in doses of gr. 1-10-1-20 t. i. d. seem to have curative power if given in time. Arsenic, Fowler's sol. gtt. v, t. i. d. retards or arrests the over- growth of connective tissue. CLINICAL INDEX. 655 COLD-FEET. — Sponging with vinegar and water or hot and cold water alternately. Ice to spine. Strychinia gr. 1-60 t. i. d. to promote capillary circulation. COLIC— For the flatulent colic of infants no remedy is better than mistura as- afoetidae which may be given in teaspoonful doses. Chloroform a few drops frequently useful in flatulent colic and in hepatic. Ether internally and by inhalation. Camphor, a few drops of the saturated tinct. frequently. Morphine and atropine hypodermically the most prompt and successful. Hot fomenta= tions in all kinds of colic. COLICA PICTONUM.— Sulphuric acid diluted gtt. x. t. i. d. flagnesium sulphate to overcome constipation. Morphine and atropine for pain. Iodides and bro= mides in proper doses to cause excretion of lead. COLIC, HEPATIC— Morphine and atropine hypodermically for the pain. Phos- phate of soda dr. j. doses t. i. d. for a long time to dissolve the calculi and prevent the formation of others. CONDYLOMATA.— Calomel dusted over. Nitric acid dilute solution as a wash. lodol dusted over. Iodoform powder applied freely. Carbolic acid undiluted applied to the part. CONJUNCTIVITIS.— Calomel dusted over the membrane. Bismuth in powder ap- plied directly. Ergot fluid extract, applied undiluted, very effective. Castor oil, a drop in eye, to allay pain. Yellow oxide of mercury gr. viij.-x. to oz. j. of vaseline is a most efficient remedy for granular lids. Zinc sulphate in the following formula is one of the best remedies: £inci sulph. gr. ij.-iv., mor- phinae sulph. grs. ij.-iv., atropine sulph. gr. ss., aquae rosae oz. j.— M. Sig.: One drop in the eye t. i. d. CONSTIPATION.— Aliment as unbolted Hour, corn-meal bread, fruits and vegeta- bles. Cascara sagrada in ten to fifteen minim doses t. i d. of the liquid ex- tract. Arsenic and nux vomica may be given. Faradizations of the intestines. Aloes with iron good in chronic cases. Saline mineral waters are effective. Podophyllum and the rhubarb and soda mixture very efficacious. Compound licorice powder in milk for children. Tobacco, a smoke after breakfast some- times efficient in habitual constipation. Enemata to unload the bowel, but habitually used is harmful. CONVALESCENCE.— Alcohol before or at meals in form of whisky or brandy. Fats, as cod-liver oil. Bitter tonics as gentian, colomba, etc. Lime water is useful. Pepsin and pancreatine are of service after meals. CONVULSIONS.— Ice should be applied to the head. Morphine gr. %, hypoder- mically in uraemic or puerperal. Chloroform and ether by inhalation. Choloral gr. v. for children. Bromide of potassium in all forms. Warm bath for in- fants and children. CORNS. — For the cure of corns no application is so certain, prompt and efficient as liquor potassae. It should be applied by means of a pine-wood splinter to the summit of the corn and the tissue softened by it scraped off. By successive applications the callosity is removed without pain. COUGH. — Paregoric in teaspoonful doses every three hours to a child eight years old. Cod=liver oil in chronic coughs. Creasote in winter coughs. Glycerine and lemon juice are effective. CROUP. — Ipecac the syrup, in teaspoonful doses every half hour until vomiting is produced. Alum dr. j. in honev or syrup every fifteen minutes until vomiting is produced. Hercury subsulphate in grs. ij.-v. is the most efficient emetic in croup. Quinine in large doses is highly useful. Carbolic acid in solution as a spray. CYSTITIS. — Alkalies to render urine neutral. Cantharides one drop of the tinct. t. i. d. Laudanum and starch injected into the rectum relieves the pain. Pereira, dr. ij.-iij. of the liquid extract every three or four hours for chronic cystitis. DANDRUFF.— Borax saturated sol. for sponging the head several times daily. DELIRIUM TREMENS.— Acohol may be of great service. Potassium bromide in dr. j. doses for the "horrors." Chloroform by inhalation to procure sleep. DIABETES. — All saccharine and starchy foods must be excluded. The milk-cure has succeeded remarkably in some cases. Butter=milk may be better. Alka= line mineral waters are of great value. Codeine restrains the waste of sugar. Gold and sodium chloride is a promising remedy. 656 A COMPENDIUM OF PRACTICAL MEDICINE. DIABETES INSIPIDUS.— Ergot in large doses is the best remedy.' Dry diet. Iodide of potassium has cured cases of syphilitic origin. DIARRHOEA..— Bismuth subnitrate in dr. ss. doses t. i. d. Chalk=mixture with opium in diarrhoea of children. Calomel in small doses. Castor oil in the early stage to carry away the irritant. Camphor with or without opium for summer diarrhoea. DROPSY.— Digitalis infusion in tablespoonful doses t. i. d. Saline purgatives in general dropsy. Iodide of potassium in some cases of Bright's disease. Dry diet and milk-cure. Nitro=glycerine in gradually increasing doses in cases of high vascular tension. DYSENTERY. — Salol is highly efficient in arresting intestinal fermentation. Fowler's sol. with opium. DYSMENORRHCEA.— Hot sitz=bath two or three times daily. Aconite and pul= satilla for the congestive form. Amyl nitrite by inhalation, affords relief quickly. Gelsemium and apiol give relief in the neuralgic form. Ergot mav give relief. Morphine and atropine give prompt relief. DYSPEPSIA.— Milk=cure. Pepsin, ingluvin and pancreatine assist digestion in atonic dyspepsia. Muriatic acid after meals. Alkalies may be given after meals. Simple bitters may be gi /en with acids. Fowler's sol. drop doses, re- lieve irritative dyspepsia. Nux vomica and wild cherry useful stomachic tonics. Acohol in the form of wine in small quantity before meals. EAR-ACHE.— Morphinas sulphatis grs. iv., aquae destil. oz. j.— M. Sig.: Fill the external meatus with the solution. Cocaine, four per cent, solution, one drop in the ear is the most effective remedy. Water as hot as can be borne, fill the external meatus. Counter=irritation by blister behind the ear often relieves. ECLAITPSIA.— Morphine subcutaneously in uraemic form. Chloroform by inhala- tion. Chloral grs. xx. every two hours. Potassium bromide in dr. ss. doses every two hours. Pilocarpine in small dose must be watched. Veratrum viride dr. ss. of the fluid extract every fifteen minutes until nausea or vomiting ensue. ECTHYflA.— Quinia in full doses often effects a cure. Cod=Iiver oil internally and externally. Iodoform, iodol and naphthol useful topically. ECZEMA. — Arsenic, Fowler's sol. gtt. iij.-v. t i. d. after meals in chronic form. Bismuth subnitrate as a dusting powder to surface. Salicylate in powder freely to eruption. Tannin in powder dusted over. Boracic acid mixed with starch as a dusting powder. Atropine internally in acute cases. Electricity (galvan- ism) in chronic cases. Iodoform and vaseline in dry stage. Milk diet exclu- sively. Lime water and glycerine equal parts locally. Oxide of zinc ointment sometimes beneficial. EMPYEITA.— Carbolic acid, a weak sol. to be injected after evacuation. Iodine solution to be injected after tapping to prevent reaccumulation of pus. Chlorine solution for washing out the cavity. ENDOCARDITIS.— Quinine, a 20 to 40 grain dose at the onset to check the inflam- mation. Morphine gr. % to gr. ^, hypodermically, will sometimes abort ser- ous inflammation. Salicylic acid may be given in the rheumatic form. The potassium salts liquefy the exudation. ENDOMETRITIS.— Undiluted carbolic acid is an efficient application to ulcers of the cervix uteri, chronic endo cervicitis and endo=metritis. It may be ap- plied undiluted without risk to the mucous membrane of the uterine cavity on the cotton-wrapped probe, after preliminary dilatation of the canal. There is probably no better means of treating uterine catarrh. Iodoform and tannin applied locally. Chronic acid (grs. xv. to dr. j. of hot water) has been injected into the uterine cavity with success. ENERGY, LACK OF.— The Turkish bath, like sea-air and sea-bathing, is a true tonic in this condition. EPIDIDYMITIS.— The oleates of mercury and morphia ten to thirty drops are suf- ficient for one application. It should be applied twice daily for five days, then at night only for five days, and afterwards every other day until a cure is ob- tained. EPILEPSY.— Potassium bromide grs. xv.-xxx. t. i. d. for the diurnal variety. Chloral full dose at bed-time may prevent nocturnal attacks. Iron to prevent anaemia. Amyl nitrite inhaled when the aura is felt may prevent the seizure. CLINICAL INDEX. 657 Nitro-glycerine may prevent an attack if given in time. Nitrite of sodium in grs. xx. doses t. i. d. EPISTAXIS. — Aconite tinct. in small and frequent doses check nose-bleed in chil- dren and plethoric people. Alum in powder insufflated or a solution injected. Cocaine four per cent. sol. applied locally to nasal mucous membrane. Tannin in solution locally applied. Compression of the facial artery Spinal hot water bag and a hot foot-bath. Ergot in grs. ij.-v., hypodermically, to con- tract blood-vessels. EPITrlELIOriA.— Carbolic acid applied undiluted to the cancerous sore and a syringef ul of a five per cent. sol. injected daily beneath the new formation. Salicylic acid (pure) may be applied in powder. Boracic acid finely levigated applied in -nowder. Dried sulphate of zinc may be dusted over the affected surface. Chloride of zinc one part and flour four parts may be dusted over the surface. Potassium chlorate (powdered) is thickly applied over the sore, and is said to allay pain and remove fetor. ERUCTATIONS, OFFENSIVE.— Mineral acids to correct the oxaluria on which the eructations depend. ERYSIPELAS, — Aconite tinct. one drop hourly until fever is reduced in facial erysipelas. Belladonna tinct. five drops every two hours along with the aconite. This has a real curative power. Quinine in full doses. Tinct. chlor- ide of iron in large doses. Carbolic acid (one per cent, sol.) applied to surface frequently on lint. Iodine tinct. paint affected surface and surrounding skin to prevent spreading. Nitrate of silver eighty grains to dr. iv. of distilled water, to be applied two or three to the inflamed surface and two inches be- yond. ERYTHEMA.— Bismuth subnitrate dusted over surface allays irritation. Hydro- chloric acid diluted gtt. x. internally t. i. d. Zinc, alum and lead as lotions. Quinine in tonic doses for some time. EXOPHTHALMIC GOITRE.- Iron for the existing anaemia. Digitalis good in some cases. Ergot of service to raise arterial tension and slow the heart. Galvan- ism in uncomplicated cases is decidedly curative. FAINTINGS.— Cold water sprinkled on the face. Ammonia to the nostrils. Brandy for feeble heart. FEET, FETOR OF.— Calicylic acid in powder freely dusted over the feet and stock- ing is very effective. Sodium bicarbonate a saturated solution locally. Po- tassium permanganate in solution will remove fetor temporarily. FELON. — Nitrate of silver a strong solution in nitrous ether applied over the part may abort it. Carbolic acid to benumb the surface during incision. FEVER. - Cold-baths. Tinct. aconite, one drop, tinct. belladonna two drops every hour until fever is reduced. Antipyrine grs. v. every two hours until three doses have been taken. Quinine in large doses. Phenacetine in grs. v. doses. FISSURE OF THE ANUS.— Forcible dilatation of the sphincter under an anaesthetic. Iodoform dusted well over the fissure. Cocaine to allay irrita- bility. Hydrastis the fluid extract applied undiluted. Bromide of potassium in five parts of glycerine locally. FISSURE OF THE NIPPLES.— Collodion applied to close fissure. Lime water as a lotion. A solution of iron subsulphate and glycerine applied with a brush to fissure. Tannin in powder to part Tinct. of benzoin with glycerine. FLATULENCE. — Avoid sugar, starchy food and tea. Asafoetida one drachm of the tinct. to oz. iv. of water, a tablespoonful for adults. Bismuth and char- coal equal parts, ten-grain doses. Chloroform in drop doses every fifteen minutes. A tumbler of hot water between meals. Camphor as follows: Aquae camphorae oz. iij., tinct. lavendulae comp. oz. j. — M. Sig.: A tablespoonful every hour. Turpentine gtt. iij. -v. on lump of sugar. FLUSHING HEATS.— Nitrite of amyl £ of a drop in five drops of rectified spirit t. i. d. Nux vomica tinct. and tinct. of opium, equal parts, four drops t. i. d. Bromide of potassium fifteen grains t. i. d. FRECKLES. — Biborate of soda, a saturated solution, is a safe and often successful lotion. The following lotion is useful: Potassi carbonatis dr. iij., sodii chloridi dr. ij., aquae rosae oz. viij., aquae aurantii flor. oz. ij. — M. Sig.: Lo- tion. GALL-STONES — (See Biliary Calculi). 658 A COMPENDIUM OF PRACTICAL MEDICINE. GANGRENE. — Antiseptics, as carbolic acid, salicylic acid, resorcin, salol, iodoform and thymol are most effective. GASTRALGIA. — Arsenic one or two drops t. i. d. of Fowler's solution, is the most generally effective of all remedies. Chloroform two to five minims dropped on sugar and swallowed will relieve. Alum is useful in the cases with acidity and pyrosis. Injections of water under the skin over the epigastrium affords much relief. Bismuth, creasote and glycerine are useful. Nux vomica may remove the morbid state on which the pain depends. Morphine hypodermically s'tops the pain at once. Galvanism has been successful. Diet is of great importance. GASTRIC CATARRH.— Arsenic is the most important remedy. The milk cure is ef- fective. The bitters, as calumba, gentian, nux vomica and cinchona infusion are useful. Bismuth and alum are of service. GASTRIC ULCER.— Bismuth allays pain and arrests vomiting. Fowler's solution in drop doses lessens pain and vomiting. Horphine and atropine arrest pain and vomiting, even in very minute quantity. Milk-cure may be tried. Rectal alimentation may be necessary. Silver nitrate in solution promotes healing and relieves pain. GLEET. — Blisters to the perinagum are very beneficial. Iron when the subject is anaemic. Turpentine, juniper and cantharides tinct. may be tried. Bismuth half an ounce, glycerine half ounce and water three ounces, as an injec- tion t. i. d. GOITRE.— Electrolysis has succeeded in some cases. Red iodide of mercury oint= ment rubbed in, in the sunshine. Tinct. iodine injected into the gland applied locally. Iodide of potassium in ten grain doses internally. GONORRHOEA. — Avoid all alcoholic drinks. Alkalies to render urine neutral. Aconite tinct. one drop each hour in acute stage. Cantharides drop doses t. i. d. Bismuth with fluid ext. of hydrastis is one of the best injections. Chloride of zinc two grains to a pint of water injected hourly often removes the disease in twenty-four to forty-eight hours. Zinc sulphate two-grains to an ounce of water injected three to six times daily. GUMS, AFFECTIONS OF.— Glycerite of tannin for spongy and bleeding gums. Alum for the same condition as above. Carbolic acid when fetor is present. Benzoin tinct. may be applied to the gums. H/EflATEMESIS. — Iron subsulphate and pernitrate solutions, one or two drops, well diluted with ice-water and frequently. Alum especially useful in passive. Lead acetate may be used in all conditions. Ergot may be used in doses of half- fluid drachm. Ice to be sucked and small pieces to be swallowed. Tannin may be used in solution. Turpentine in five to ten drop doses frequently. HEMATURIA. — Camphor two to five grains when bloody urine is due to drugs. Cannabias indica is said to relieve this condition. Ergot may be given by the stomach. Gallic acid is one of the most useful remedies. Quinine is effective in malarial hematuria. Turpentine in very small doses. HAEMOPTYSIS. — Common salt half teaspoonf ul taken dry and repeated till nausea is induced. Digitalis infusion in large doses useful. Ergot thirty to forty minims overy two or three hours. Ice to be sucked. Morphia in small doses hypodermically. Gallic acid and ergot by the stomach. Spinal hot water bag to cervical and upper vertebrae. H/EnORRHAGE, CEREBRAL.— Venesection or leeches when blood pressure is high and haemorrhage threatened or proceeding. Purgatives may be given. E/rgotine, hypodermically, in two to five grain doses. H/EHORRHAGE, INTESTINAL.— Ice should be applied to the abdomen. Ergotine two to five grains subcutaneously. Opium (laudanum) in doses of thirty minims to quiet intestinal movements. Turpentine in small doses frequently. Sulphuric acid diluted in ten drop doses. Tannic acid in solution and other astringents. H/EMORRHAGE, UTERINE.— Ergot, fluid extract, in teaspoonful doses. Ipecac carried to nausea is highly effective. Turpentine one drachm every three hours. Monsel's solution diluted, injected. Tincture opium in one drachm dose with brandy. Ice or hot water in uterine cavity. Acid sulphuric diluted, small doses frequently. H/EflORRHOIDS. — Nitric acid half to one ounce in half pint of water, as a lotion to bleeding piles. Bromide potassium one part to five parts of glycerine lo- cally to ease pain. Potassium chlorate half to one ounce of a saturated solution CLINICAL INDEX. 659 with ten drops of laudanum as injection to inflamed piles. Carbolic acid six grains, cocaine ten grains and glycerine one drachm. — M. Sig.: Inject ten minims into the tumor. HAY=FEVER. — Quinine is useful at the onset as a spray locally and later in tonic doses. Aconite is efficacious in the early stage. Ethyl Iodide by inhalation of service. Morphine is most beneficial in any stage. Cocaine to the nose, as a spray, is a very effective remedy. Potassium iodide ten grains at bed-time will often cut short the attack. Atropine in doses of a sixtieth of a grain when the secretion is profuse. HEADACHE. — Tea or coffee will relieve headache from nervousness or exhaus- tion. Belladonna three minims of the tincture every three hours, when pain is over brows and in eyeballs. Arsenic in three drop doses t. i. d. for neuralgic headache. Bromide potassium in thirty grain doses for sick or nervous head- ache. Sodium phosphate teaspoonful t i. d. in bilious headache. Acetanilid in five grain doses every thirty minutes until relieved or until three doses have been taken. HEART, DISEASES OF.— Horphine, hypodermically, in dilated heart and general dropsy therefrom. Iron is of great utility in the irritable heart of anaemia. Ergot is useful in dilated heart. Digitalis is remarkably beneficial in rapid ac- tion with low tension and valvular lesions. Bromide potassium in ten grain doses t. i. d. is useful for over-action and simple hypertrophy. Quinine in tonic doses for cardiac weakness. Atropine is a prompt cardiac excitant. Acohol in form of brandy or wine, when the heart is suddenly enfeebled by fright, loss of blood, accident, etc. Arsenic Fowler's sol. in three drop doses t. i. d. after meals, for breathlessness on exertion from weakly-acting heart. Strychnine in medicinal doses strengthens the heart beats. HEMIPLEGIA. — Strychnine by hypodermic injections into the paralyzed muscles most useful. Massage. Galvanism to brain and cord and farad ism to the to the muscles if they waste HEPATIC DISEASES.— Chloride of gold and sodium is effective in sclerosis. Phosphate sodium is one of the most useful and certain cholagogues. Am= monium chloride is useful in catarrh of the bile-ducts. Rhubarb, aloes and podophyllum are effective. Nitro=muriatic acid is useful in ten drop doses t. i. d. in torpor of the liver. HERNIA.— Chloroform by inhalation to assist reduction. HERPES.— Morpha oleate applied locally in herpes zoster. Iodine liniment ap- plied once. Hot fomentations will often disperse the development of herpes labialis. Calomel and zinc ointments are curative. Galvanism in cases of herpes zoster. HICCOUGH.— Morphia grs. % hypodermically. Apomorphia gr. T V, hypoder- mically, will sometimes cure. Mustard one drachm infused in four ounces of boiling water has cured obstinate cases. HOARSENESS.— Turkish bath at the onset will cut it short. Borax the size of a pea dissolved in the mouth. Ipecac wine as a spray to throat. Alum as a spray, ten grains to an ounce of water. Nitric acid is highly effective in hoarseness of singers and reflex from the stomach in ten minim doses of the dilute acid. Atropine in hysterical aphonia. HYDROCELE.— Iodine tinct. injected into the sac after removal of the fluid. Carbolic acid and nitrate silver a strong solution injected in the same way. HYPOCHONDRIASIS.— Patassium bromide fifteen grains t. i. d. Gold and sodium chloride in gr. jVto doses -t. i. d. gives excellent results in the hypochondria of the aged. Laudanum in small doses is a remedy of the first importance. Arsenic gives good results in the aged. Asafcetida in cases with flatulence. HYSTERIA.— Cod=liver oil and the "rest cure " are useful. Aconite tinct. for flut- tering of the heart in nervous persons. Potassium bromide in large doses pre- vents paroxysms. Opium, a drop of laudanum with two of the tinct. of nux vomica four times daily for weight on head and flushings. Valerian useful IMPETIGO. — Quinia in tonic doses very efficient. Mineral acids in cases of indi- gestion. Zinc ointment applied relieves. Sulphur internally is of service. Poultices may be applied at night to remove scabs. Glycerine of tannin is a good application. Sugar of lead in solution may be applied. IMPOTENCE. — Strychnia in large doses sometimes useful when spermatorrhoea ex- ists. Cantharides tinct. in twenty to thirty drops t. i. d. with iron and nux 660 A COMPENDIUM OF PRACTICAL MEDICINE. vomica very useful. Cannabis indica and phosphide of zinc stimulate the func- tion. Ergotine a hypodermic injection about the dorsal vein of the penis. Ergot by the stomach increases the vigor of the erections. Gold and sodium chloride increase sexual activity in gr. ^ t. i. d. INCONTINENCE OF URINE.— Belladonna tinct. ten to twenty drops t. i. d. is the best remedy for children. The child should be waked at midnight to pass water. Ergot said to be useful when due to paresis of bladder. Iron syrup of the iodide in ten drop doses t. i. d. in anaemic subjects. Collodion painted to form a cap over end of prepuce. Chloral is sometimes effective in children. Strychnia good in old people with paralysis of the bladder. Cantharides tinct. two drops t. i. d. INDIGESTION.— Acid hydrochloric ten minims t. i. d. of the diluted acid. Lactic acid good in atonic dyspepsia and indigestion. Alcohol in small doses is an ex- cellent stomachic tonic. Bismuth for painful indigestion and nausea. Aloes in indigestion with torpor of large intestine and pasty motion. INSOMNIA.— Potassium bromide in thirty grain doses at bed-hour. Paraldehyde thirty to fifty minims is said to be very effective. Chloral is the most direct and generally useful hypnotic in fifteen to twenty grain doses at bed-time. florphine and atropine hypodermically is the best sleep producer in cases of pain, mania, and melancholia. Alcohol is efficient when due to cerebral anaemia. Warm bath at bed- hour often succeeds. INTERTRIGO.— Bismuth subnitrate dusted over the surface. Tannin in powder is a useful application. Zinc ointment is very efficient in some cases. INTESTINAL CATARRH.— Ammonium chloride five grains t. i. d. is a valuable remedy. Salol is a useful drug- into three to five grain doses t. i. d. after meals. Bismuth is one of the best remedies. Calomel in minute doses fre- quently is of great service. Hydrastis is a useful drug- in this condition. IRITIS. — Atropine two to four grains to the ounce, a drop or two in the eye, four to six times daily to prevent adhesions. Hserine to break up adhesion and di- minish intra-ocular tension. Mercury in specific iritis. JAUNDICE. — Mercury, in form of gray powder, gr. ^ four times daily at the onset, is very valuable. Calomel in small doses gives good results. Benzoic acid, to remove bile from the system. Sodium phosphate, a teaspoonful t. i. d. very useful. Skim=milk cure. Ammonium chloride gr. v. t. i. d. is beneficial. Nitro=muriatic acid dil. in ten minim doses t. i. d. Rhubarb, aloes and podo= phyllum are excellent remedies in this condition. JOINTS, DISEASES OF. — Blisters, a succession of them about the joints, in cases of synovitis. Nitrate silver, grs. xx. to an ounce of nitrous ether, is an efficient application to check inflammation. Oleate of mercury and morphine rubbed into the joint is of great service in inflammatory affections of joints. - Galvan- ism and massage are highly useful. LACTATION. — Atropine, four grains to the ounce of rose water, applied on lint to the gland to arrest secretion. Phosphate of lime is highly useful in the debility of lactation. LARYNGITIS.— Aconite tinct. in small doses frequently. Tannin and glycerine applied to the throat. LEUCORRHCE A.— Bicarbonate of potash, or soda one drachm to a pint of water when discharge is alkaline. Carbolic acid, one drachm to a quart of water. Alum, one drachm to a pint of water, is a useful injection. Zinc sulphate may be used also. Iodoform and tannin packed about the cervix is highly useful. Acetate of lead properly diluted is an excellent local application. Bismuth may be combined with fluid extract of hydrastis. LICE. — Bichloride of mercury solution destroys lice on all parts of the body. All the essential oils will destroy lice. LUMBAGO. — Chloroform, a few drops injected deeply, is remarkably beneficial. Galvanism usually effects a cure. Faradism is sometimes useful. Morphine, hypodermically, affords prompt relief. Heat to the back for three hours. Massage is curative in some cases. MENORRHAGIA.— Ergot is very useful in all forms. Gallic acid sometimes suc- ceeds well. Potassium bromide in fifteen to thirty grain doses t. i. d. often arrests promptly. Cinnamon, the oil in drachm doses given several times daily, is highly recommended. CLINICAL INDEX. 661 MYALGIA.— Massage will usually do good. Galvanism will surely cure. Faradism may succeed. Acetanilid is an efficient remedy. Laudanum, applied with friction, gives relief. NEURALGIA. — Morphine, hypodermically, is the most efficient remedy for the relief of pain. Galvanism is the most decidedly curative agent, flassage gives much relief. Iron, for the existing anaemia. Bromide potassium is useful in some cases. Arsenic will benefit some cases. Strychnine long continued in depressed states of the nervous system. Anaesthetics promptly relieve. Ace= tanilid will relieve in some cases. OBESITY.— Acids, alkalies, bromides and potassium permanganate will promote destructive metamorphosis. ORCHITIS.— Mercury, the oleate painted over. Ice in a bag kept applied. Iodine tinct. locally applied. Nitrate of silver in nitrous ether painted over. PARALYSIS. — Strychnine, injected into the muscular substance, is of the greatest utility in all forms of paralysis, but must be used after local trouble in the nerve-centers have subsided. Phosphorus should be given to restore nerve- matter, and in hysterical paralysis. Cod=liver oil is useful to restore nervous matter. Ergot is useful in some cases. Iodide of potassium in paralysis due to gumma. Galvanism and faradism are first in importance in the treatment of paralysis. Massage is an important adjunct to other kinds of treatment. PEMPHIGUS. — Arsenic, Fowler's sol., five drops t. i. d. after meals, for chronic form. Belladonna tinct., five minims t. i. d. for the acute. PERITONITIS. — Morphine, hypodermically, is the most efficient drug. Must be given freely. Quinine in full doses at the onset. Turpentine when there is tympanites, especially useful in puerperal peritonitis. Aconite for the fever at onset. Locally, ice-bag to abdomen; counter-irritation; heat; poultices; leeches. PERSPIRATION, EXCESSIVE.— Belladonna, as a liniment, locally to the affected part, and tinct. internally. Ergot is said to arrest sweating. Picrotoxin, a minute dose, will stop for several nights the sweats of consumption. Atropine for " night-sweats. " Pilocarpine in ■£$ grain doses thrice daily. Oxide of zinc in two grain doses nightly to control profuse colliquative sweating. PHARYNGITIS.— Silver nitrate two grains to the ounce of water is effective in many cases. Tannin locally, in powder or solution. Hydrastis is an excellent topical application. It may be taken internally in doses of five to ten drops t. i. d. SALIVATION. — Alcohol diluted as a gargle. Iodine two drachms of the tincture to eight ounces of water. Acids in small medicinal doses as astringents. Bro- mide of potassium very beneficial in salivation of pregnancy. SCABIES.— Carbolic acid locally to destroy the parasite. Sulphur after a warm bath with soap and water, rub in ointment composed of two parts of sulphur, one of carbonate of potash and eight of lard. Clothing, submit all clothing which cannot be boiled to a temperature between 250° and 300°. Sulphate of copper used as a lotion is successful. SCIATICA. — Methylal a twenty per cent, mixture with oil, rubbed in along the nerve is effective. Morphine hypodermically. Chloroform and ether injected deeply in old cases is beneficial. Poultices applied very hot. Galvanism very effective. Nitrate of silver inject ten to twenty drops of the solution deeply near the affected nerve. Aquapuncture is much used recently. SCLERODERriA.— Cod=Iiver oil an important remedy. Galvanism (central) is recommended. Phosphates and hypophosphites with or without cod-liver oil. SCROFULA.— Calomel ointment to sores The Phosphates are very beneficial to im- prove the nutrition. Iron long continued is useful. Tinct. of iodine applied over scrofulous glands. Cod-liver oil is of great service. Chloride of calcium in ten to twenty grain doses in milk after food is effectual in enlarged glands and chronic diarrhoea. SEA=SICKNESS.— Chloral fifteen to thirty grains every four hours. Spinal ice= bag sometimes of service. Nitro glycerine has been recommended. Chloro- form one drop by the stomach frequently repeated. Bromide of soda one-half to one drachm taken before embarking is the best remedy. Morphine in small doses hypodermically. Nitrite of amyl inhaled for prevention. Nitro=gIycer- ine by the stomach is useful. SLEEPLESSNESS.-(See Insomnia). 662 A COMPENDIUM OF PEACTICAL MEDICINE. SNEEZING.— Iodine inhalations in sneezing with itching of nose. Camphor inhal- tions or the powder sniffed up the nose is useful in sneezing with running from nose and eyes. Arsenic one drop of the liquor three times a day in sneezing of asthma Iodide of potassium ten grains several times daily. SORE-FEET.— Washing soda, one tablespoonful to one-half gallon of warm water as foot-bath. SORES. — Alum in powdered form to secreting sores. Iodoform is good used as a dusting powder over all forms of sores. Opium and glycerine as an applica- tion for pain. Sulphate of zinc is applied locally to sloughing sores with bene- fit. Carbolic acid, boracic acid and salicylic acid are applications of great value as antiseptics, deodorants and alteratives. Potassa chlorate in powder is remarkably beneficial. Camphor as a dusting powder is effective. SPERMATORRHOEA.— Nux vomica is useful as a tonic. The tincture of the chloride of iron and arsenic are remedies of value when anaemia is present. Belladonna, one-fourth grain of the extract with one and one-half grains of zinc sulphate three times a day is often of use. Camphor in large doses may be used with benefit. SPRAIN.— Cold douche with salt added is beneficial to relieve stiffness. STINGS.— Weak solutions of ammonia are effective. SUN=STROKE. — Cold douche when patient is struck down unconscious. SWEATING. — Atropine is very efficacious in sweating of phthisis, one-sixtieth of a grain at bed-time. Oxide of zinc is very effective in night-sweats of phthisis. Oxide of zinc three grains and one-half grain of belladonna, given at bed- time. Picrotoxin from one hundred and eightieth to one-sixtieth of a grain, has been very successful. Pilocarpine in one-twentieth of a grain doses thrice daily, is often useful. Sponging with acidulated water, often effective. SYNOVITIS.— Blisters every night are useful. Cod=Iiver oil is useful if patient is debilitated. Iodine, applied to joint in chronic cases, riassage may be tried. Nitrate of silver in nitrous ether may be applied to the joint. Mercury and Morphia, oleate of, applied locally. TETANUS. — Bromide of potassium in large doses, one drachm every three or four hours is a remedy of great value. Morphine injected into the affected muscles gives relief. Paraldehyde given in sufficient quantity has often proved suc- cessful. The maximum dose (two and one-half drachms) has been given with- out ill effect. Chloral in large doses is of great value. Ether spray to spine every two hours. THIRST. — Hot drinks are of service. Ice, allowed to melt in the mouth, is useful. Acid drinks are effective to allay thirst in fevers. THRUSH.— Boracic acid solution mixed with honey Q) is very useful. Sulphur= ous acid solution, strong or diluted, applied locally. Salicylic acid, one part (dissolved in alcohol) to 250 of water. TOE NAIL, INGROWING.— Liquor potassae, two drachms to the ounce of water. A piece of cotton saturated with the solution is pressed under the ingrowing nail, repeated each morning; the nail becomes thin and can be pared away without pain. TOOTHACHE.— Opium or morphine (solution) dropped in the cavity. Oil of cloves, carbolic acid or resorcin in the decayed tooth are effective. Carbonate of soda (a saturated solution) held in the mouth stops the pain. ULCERS.— See Sores. URTICARIA. — Chloroform ointment for .the itching. Nitric acid, diluted, as a wash for itching. Alkaline washes should be used. Warm baths. VOMITING. — Alum in six to ten grain doses in obstinate vomiting of phthisical patients. Nux vomica and ipecac are useful when tongue is coated, florphine hypodermically. Mercury as gray powder, one-third of a grain every two hours. Lime water and milk in vomiting of infants. Chloroform, in drop doses. Bismuth, ten to fifteen grains every two hours, very effective in vomit- ing caused by gastric disturbance. Champagne or brandy, iced, in small doses frequently repeated, often useful. VULVITIS.— Lime water, locally. Alum, sixty grains to a pint of water, every two hours, as injection. Glycerine of Tannin can be used with advantage. WARTS. — Mercury, nitrate of, locally applied. Arsenious acid as caustic. Chromic acid, a solution of 100 grs. to the oz. applied carefully with a glass rod CLINICAL INDEX. 663 to growth; dress with dry lint. Nitric acid one drachm or two of the dil. acid to a pint of water, as wash to keep warts constantly moist. WHOOPINQ=COUQH.— Belladonna, ten minims of tinct. each hour, to child three years old, especially during- third week if no complications. Chloroform or ether to lessen violence of paroxysms. Carbolic acid inhalations are some- times useful. Castanea, fluid extract in doses of one drachm t. i. d. WORMS. — Iron, tincture of the chloride, one-half ounce in a pint of water, a g-ood injection for thread worms, coagulating the albumen. Common salt, weak solution injected into the rectum for thread worms. Potassium bromide, five grain doses, t. i. d., in convulsions caused by worms. Areca nut, a half or whole nut is to be powdered and mixed with some syrup and swallowed for tape- worm. Chloroform in drachm doses taken in the morning - , fasting-, for tape- worm. Lime water injection for thread worms. Santonin, five grains for adults at bed- time for round worm. Turpentine as a poison to tape and thread worms. REE BIEE. Administration of anaesthetics $ 5 to $ 10 Consultation visits 5 to SO Examination for life insurance 3 to .10 Office prescription.. .50 to 2 Expert testimonv (medico-legal) perday.. - 10 to 50 Thorough examination in office. 5 to 10 Microscopical examination of urine. 2 to 10 Urine tested chemically 2 to 10 Day visit in city 1.50 to 3 Night visit in city 2 to 5 Country visits, extra per mile. 1 Vaccination... .50 to 1 Visit in case of poisoning 5 to 10 GENITO URINARY AND VEN- EREAL DISEASES. Gonorrhoea (in advance) — $ 15 to $ 20 Syphilis (in advance) 25 to 100 Sounding for stone in bladder 10 to 20 Removing stone in bladder. 50 to 200 External urethrotomy 50 to 250 Internal urethrotomy- 25 to 75 Urinary fistula.- 50 to 100 Aspirating the bladder - 20 to 50 Circumcision - 25 to 50 Varicocele.. 20 to 75 Tapping of hydrocele 10 to 15 Radical cure of hydrocele - 25 to 75 Phimosis or paraphimosis . 10 to 25 OBSTETRICS AND GYNECOLOGY. Labor, ordinary cases $ 10 to $ 30 Abortions- 10 to 50 Instrumental delivery, additional..- 10 to 15 Delivery of placenta 5 to 10 Consultation 10 to 15 Embryotomy -. 25 to 50 Perineorrhaphy (primary) 10 to 30 Perineorrhaphy (late) 25 to 100 Laparotomy 50 to 200 Ovariotomy 50 to 200 Hysterectomy 150 to 500 Hysterorrhaphy 100 to 300 Amoutation of cervix 50 to 100 Colporrhaphy 50 to 100 Trachelorrhaphy 50 to 100 Alexander's operation 50 to 150 Curetting 25 to 75 Removal of polypi - 25 to 75 Removal of tumors of labia . 20 to 50 Removal of urethral caruncle.. 25 to 100 Colpocleisis 50 to 150 Examination by speculum 5 to 10 Endocervicitis, operation for 25 to 50 Intrauterine douche 5 to 15 Fitting of pessary... ,. 5 to 15 Replacement of uterus 5 to 15 Vesico-vaginal fissure, operation for 50 to 100 Dilation of cervix in stenosis 15 to 25 Atresia of vagina, operation for 50 to 150 OPERATIVE SURGERY. Laparotomy $ 75 to $200 Hemorrhoids, internal 25 to 75 Hemorrhoids, external 10 to 50 Hare-lip 25 to 100 Excision of mammary gland 50 to 100 Trephining- 100 to 200 Removing large tumors 100 to 300 Removing small tumors 30 to 100 Staphylorrhaphy 50 to 100 Nephrectomy 100 to 250 Necrosis oi bone 25 to 50 Fistula in ano 25 to 50 Radical cure of hernia 100 to 150 Strangulated hernia 100 to 200 Strangulated hernia (reduced by taxis) 25to 50 Polypus of rectum 25 to 50 Anal fissure 25 to 50 Hernia (Warren's operation) 25 to 75 Varicose veins (radical cure) 25 to 50 Aspiration of joints. 25 to 40 Selecting and adjusting truss 5 to 10 AMPUTATIONS. Knee $ 50 to $200 Hip-joint... lOOto 200 Leg.. 50to 150 Foot 50 to 75 Toes 25to 50 Thigh lOOto 150 Shoulder-joint 100 to 150 Arm 50 to 100 Hand.... 40 to 75 Finger 15 to 30 DISLOCATIONS. Shoulder $ 50 to $ 75 Hip 50to 100 Knee.. 25 to 75 Ankle 25 to 50 Arm... 25 to 50 Maxillary bones 25 to 50 Wrist 25to 40 Toes lOto 25 Fingers 10 to 25 FRACTURES. Scapula $ 25 to $ 50 Femur 50 to 100 Fibula 25to 50 Leg (both bones). 50 to 75 Ribs 25to 50 Humerus 25 to 50 Radius or ulna 25 to 50 Elbow-joint 25 to 50 Nose 25to 60 Smallbones 10 to 25 Forearm (both bones) 50 to 75 Coracoid or coronoid process 25 to 50 Clavicle 50 to 75 RESECTIONS. Ankle-joint or foot... $ 50 to $ 75 Elbow $ 50to 75 Femur (head of)... 100 to 200 Knee 75 to 100 Shoulder 75 to 100 Maxilla 50 to 100 Ribs 25to 50 LIGATIONS. Brachial artery $ 50 to $ 75 Subclavian or iliac artery.... 100 to 200 Axillary, femoral, carotid, popliteal or poterior tibial artery 50 to 100 All other arteries 20 to 40 EYE. Sclerotomy $ 50 to $100 Strabismus (each eye) 40 to 100 Trachoma (each eye)... 50 to 100 Canthotomy (each eye) '.. 40 to 75 Opening lachrymal duct 25 to 50 Cataract 100 to 250 Artificial pupil (operation for) 50 to 100 Pterygium (each eye) 50 to 100 Tumor of lids 25 to 75 Enucleation 100 to 200 Astigmatism 25 to 50 Glass fitting 10 to 20 EAR. Polypus, removal of $ 50 to $ 75 Foreign bodies, removal of 10 to 40 Opening of mastoid bone 100 to 200 NOSE, THROAT AND CHEST. Nasal tumors .$ 25 to $ 75 Deflected septum.. 50 to 100 Tonsil, excision of 25 to 75 Uvula, excision of 25 to 50 Tracheotomy 100 to 200 Laryngeal tumors 50 to 200 Adenoid vegetations -. -- 25 to ?5 Larynx, intubation of 50 to 100 Lungs, thorough examination of 5 to 10 H?}/*