Class . lit Book 1 COPYRIGHT DEPOSIT HUGHES' CO MP END OF PRACTICE SIXTH PHYSICIANS' EDITION. TO PHYSICIANS. The several essential qualities which a good Visit- ing List should possess are compactness, conveni- ence of arrangement, and strength to resist the unusual hard wear it receives. These qualities are all combined in Lindsay & Blakiston's Physi- cians' Visiting List, which has now been pub- lished for forty-six years, and no better evidence of the practical worth of this book can be offered than the uniform increase in popularity it has enjoyed with each successive issue. One of the chief features is its size : it measures 6^x3^ inches, and the smallest size weighs but 3^ ounces, and is only ^ of an inch thick. The large sizes are a little thicker and heavier ; it is, however, the smallest and lightest Visiting List published. Our many years' experi- ence has enabled us to put it together in the best manner, and to add many improvements during the past few years. It is arranged for 25, 50, 75, and 100 patients per day or week, dated, undated, and monthly. Prices range from 75 cents to $2.25. Complete circular will be sent you upon application. P. Blakiston's Son & Co., Medical Publishers and Booksellers, 1012 Walnut Street, Philadelphia. COMPEND PRACTICE OF MEDICINE BY / DAN'L E. 'HUGHES, M.D., RESIDENT PHYSICIAN, PHILADELPHIA HOSPITAL; PHYSICIAN-IN-CHIEF, INSANI DEPARTMENT, PHILADELPHIA HOSPITAL J LATE DEMONSTRATOR OF CLINICAL MEDICINE IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA, ETC., ETC. SIXTH PHYSICIANS' EDITION. THOROUGHLY REVISED AND ENLARGED. INCLUDING A SECTION ON MENTAL DISEASES AND A VERY COM- PLETE SECTION ON SKIN DISEASES. PHILADELPHIA : P. BLAKISTON'S SON & CO., IOI2 WALNUT STREET. 1899. ^ V- 41799 Copyright, 1899, by P. Blakiston's Son & Co. ;» «ac SECOND COPY, WM. f^ FELL & CO., ELECTHOTYPEnS AND PRINTERS, 1220-24 SANSOM STREET, HHILAUtLHHIA. TO HIS ESTEEMED FRIEND AND TEACHER, 3-. /lib. 2>a Coeta, /lfo.2)., PROFESSOR OF THE PRACTICE OF MEDICINE IN THE JEFFERSON MEDICAL COLLEGE, THIS COMPEND IS RESPECTFULLY DEDICATED BY THE AUTHOR. PREFACE TO SIXTH EDITION. The continued demand for the Compend of Medicine has en- couraged the author to make its sixth edition the most complete of any similar book. It was never intended that the Compend should in any way replace the text-books upon the practice of medicine, but, on the contrary, it was written to be an aid to the medical student, at a time when practical demonstrations and ward classes were the exception in the college curriculum. The book has, however, somewhat outgrown the original plan, and having met with considerable favor from physicians, the author has en- deavored to make it more useful to the profession without changing the arrangement which has made it so popular with the student, always keeping in mind, however, that it is a compend and not a treatise on medicine. The addition of the section on Mental Diseases has been kindly received, and has justified the statement in the preface to the fifth edition that no medical student's education should be considered as completed without some knowledge of insanity, the increase of which is the alarm of the closing hours of the century. D. E. H. CONTENTS PAGE INTRODUCTION, 9 FEVERS, 15 General Treatment of Fevers, 16 Continued Fevers, 17 Periodical Fevers 39 Eruptive Fevers, 51 DISEASES OF THE MOUTH, 68 DISEASES OF THE STOMACH, 76 DISEASES OF THE INTESTINAL CANAL, 99 INTESTINAL PARASITES, 134 DISEASES OF THE PERITONEUM, 140 DISEASES OF THE BILIARY PASSAGES, 147 DISEASES OF THE LIVER, 151 DISEASES OF THE KIDNEYS, 159 DISEASES OF THE BLOOD, 195 ACUTE GENERAL DISEASES, 209 DISEASES OF THE RESPIRATORY SYSTEM, 244 DISEASES OF THE NASAL PASSAGES, 263 DISEASES OF THE PHARYNX, 269 DISEASES OF THE LARYNX, 274 DISEASES OF THE BRONCHIAL TUBES, 290 DISEASES OF THE LUNGS 316 DISEASES OF THE PLEURA, 346 DISEASES OF THE CIRCULATORY SYSTEM, 352 DISEASES OF THE NERVOUS SYSTEM, 401 vii Vlll CONTENTS. PAGE DISEASES OF THE CEREBRAL MEMBRANES, 402 DISEASES OF THE CEREBRUM, 409 DISEASES OF THE SPINAL CORD, 449 DISEASES OF THE NERVES, 475 GENERAL OR NUTRITIONAL DISEASES, 4S4 MENTAL DISEASES, 504 DISEASES OF THE SKIN 531 INDEX 611 COMPEND OF THE PRACTICE OF MEDICINE INTRODUCTION. The Principles of Medicine constitute what may be termed Medical Science. The Practice of Medicine is the exercise of medical art, and embraces all that pertains to the knowledge of, prevention, and cure of the diseases which the physician is called upon to treat. Disease may be defined as any departure from the normal stand- ard of structure or function of an organ or tissue or in both com- bined : Organic disease, when associated with an organic change in the affected part ; Functional disease , when the abnormal phenomena are independent of any discoverable structural lesion. It is question- able whether alterations of function can occur without alteration in structure. The study of disease, whether organic or functional in character, is termed Pathology. Pathology is the science that treats of disease in all its aspects, and explains the origin, causes, clinical history, and nature of the various morbid conditions which may disturb the economy. The study of individual diseases constitutes Special Pathology, 2 9 10 PRACTICE OF MEDICINE. while the study of the morbid conditions common to a greater or less number of diseases constitutes General Pathology. Nomenclature, or the naming of diseases, is a subdivision of gen- eral pathology. The real value of nomenclature applied to disease is that the name chosen shall express the morbid condition involved, and, if possible, its location. If the morbid condition be an inflammation, the suffix His is added to the anatomical name of the part affected ; thus, if the disease be an inflammation of the peritoneum, it is termed peritonitis. If the morbid condition be catarrhal, such as a transudation or flux, the liquid escaping upon a mucous surface, the suffix rhoea is used ; thus, a catarrhal inflammation of the intestinal tract is termed diarrhosa and enterorrhcea. If the morbid condition be a flow of blood or a hemorrhage from a mucous, surface, the suffix rhagia is used ; thus, a hemorrhage from the small intestines is termed enterorrhagia. If the morbid condition be pain without inflammation, the suffix algia is used. The various forms of neuralgias are examples ; for instance, neuralgia of the stomach is termed gastralgia. If the morbid condition be in the blood, the suffix ?nia is impoverishment of the blood ; Ur&mia, the morbid accumulation of urea in the blood ; Septicaemia, putrid infection of the blood ; Pyaemia, purulent infection of the blood. If the morbid condition be in the urine, the ending uria is used. Albuminuria, when albumin in the urine ; Hematuria, when blood in the urine ; Oxaluria, when oxalates occur in the urine. If the morbid condition be a dropsical affection, the prefix hydro is added to the part affected. A dropsical accumulation in the perito- neum is termed hydro peritoneum. If the morbid condition be that of air in an unnatural part, the prefix pneumo to the name of the part is used, as in pneumothorax. If the morbid condition be an inflammation of the membrane investing the part inflamed, the prefix peri is used. Thus, an inflam- mation of the investing membrane of the kidney is termed perine- P J iritis. Inflammation of the connective tissue surrounding an organ is designated by the prefix para. Thus, parametritis for inflammation of the connective tissue about the womb. A termination in oma signifies a tumor, as \\\sarco?na ox carcinoma. INTRODUCTION. 11 The suffix pathy is used to designate a morbid condition of a part, without indicating its particular character, an example being the use of the term encephalopathy. Morbid Anatomy, or pathological anatomy, a subdivision of pathology, is the study of the changes in the tissues and fluids of the body after death, appreciable either to the naked eye or with the aid of the microscope. Bacteriology is that division of science concerned with the study of bacteria, an important and developing etiological factor in the field of medicine and surgery. Histology is the study of the minute anatomy of the tissues and fluids of the body with the microscope and clinical chemistry. Hsematology, or the science of the blood, its nature, functions, and disorders. Pathogenesis is the study of the origin and development of pathological processes or disease. Lesions {Icedo, to hurt) are appreciable anatomical changes. Etiology is that subdivision of general pathology which treats of the causes of disease. The knowledge of the cause of any mor- bid action is of value in the prevention, management, and removal of disease. The Causes of disease may be divided into internal, external, ordinary, specific, primary, secondary , predisposing, and exciting. Examples of internal or intrinsic causes are those having their origin in the mind, such as prolonged mental application, intense or long-continued emotional excitement, long-continued mental depres- sion, and the possession of and concentration upon a predominant idea. Other examples are the accumulation of certain products in the blood, such as urea, uric acid, or lactic acid, or the absorption of ptomaines from the gastric or intestinal tract. External or extrinsic causes are such as infectious miasms, viruses, poisons, wounds, and injuries. An ordinary cause is one to which all are more or less exposed, such as atmospheric changes. Specific or special causes are those producing a distinct and specific disease, such as the bacillus tuberculosis, causing Tuberculosis; comma bacillus, Asiatic Cholera ; oscillaria malaria?, Malaria ; Loffler bacillus, Diphtheria. A contagious disease is one whose causative agent is a specific 12 PRACTICE OF MEDICINE. poison that, introduced into the system of another, will give rise to the same disease. An infectious disease is also due to a special cause that under certain conditions is capable of unlimited increase or mul- tiplication. An infectious disease may or may not be contagious. An example of a primary cause is any external traumatic injury. A secondary cause is well seen in the secondary pericarditis result- ing from an accumulation of urea in the blood, the retention of the urea in the blood being due to a diseased kidney. A predisposition to disease is a special liability or susceptibility to its occurrence, and may be either inherited or acquired. Inherited or constitutional predisposition to certain diseases is also termed Diathesis ; an example is the offspring of phthisical parents, who are said to be of a. phthisical diathesis. Acquired predisposition is such as arises from — I. Habits: Strain upon the nervous system resulting in nervous diseases, or the changes resulting from alcoholic or other excesses. II. Age: Children are very liable to catarrhal disorders. Young adults, to fevers and perverted sexual disorders. Middle age, to heart, kidney, and digestive disorders, and cancer. Old age, to degeneration of the heart and vessels. III. Occupation: Miners, weavers, and cutlers, lung diseases; or painters and printers, to lead colic. IV. Sex : Women, emotional nervous diseases. Men, as more exposed, rheumatism and pneumonia. V. Race : Negro, phthisis and scrofula ; often exempt from mal- aria. Exciting causes are those giving rise to morbid conditions in indi- viduals already predisposed to certain diseases, but lacking the action which determines their occurrence, to wit : persons predisposed to acute rheumatism, on being exposed to certain atmospheric changes have an attack; fear has produced chorea; anger has caused jaundice ; worry has produced cardiac and mental diseases. The Clinical History of diseases includes all the symptoms and signs which may occur from the period of incubation until its final termination. Symptomatology is the study of the signs and symptoms of e or such alterations in the healthy functions giving evidence of INTRODUCTION. 13 the existence of a diseased condition or perverted function. Symp- toms may be either objective or subjective : Objective, when evident to the senses of the observer, as redness, swelling, high temperature, or disorders of locomotion ; Subjective, when felt or known only by the patient, such as pain, numbness, vertigo, or nausea. Physical signs are, strictly speaking, objective symptoms, requir- ing for their elucidation special methods, such as inspection, mensura- tion, palpation, percussion, and auscultation. These methods are chiefly used in examinations of the chest and abdomen. Associated with the study of symptomatology should be considered the complications and sequelce of disease. Complications are certain conditions which may arise during the course of the original disease, but are not considered necessary accompaniments of the disease ; thus hemorrhage from the lungs or haemoptysis is a complication of tuberculosis ; intestinal hemorrhage, a frequent complication of typhoid fever. Sequelce (sequor, I follow) are the morbid phenomena left as a result of a disease ; thus, valvular disease of the heart often results from an attack of acute articular rheumatism. The Period of Incubation is that interval between the en- trance of a poison into the system and the manifestation of its symptoms. The Prodromes are the earliest recognizable symptoms ; as the rigors or chills during the invasion of fever, and the various aurse preceding an epileptic attack. An acute disease is one in which the invasion is sudden and rapid, and as a rule severe ; when the symptoms develop less rapidly and are less intense, the disease is said to be subacute ; when gradual or slow in development, duration, and intensity, the disease is said to be chronic. It must be borne in mind, however, that there may be disturbed action in every intermediate degree between these extremes. Pathognomonic is the term applied to such symptoms as belong to one particular disease, and are therefore characteristic of it, thus : the rusty sputum of pneumonia, or the eruption of variola. The Termination of a diseased action may occur in one of three ways, to wit : Cure, Secondary Processes, or in Death. Cure may occur by — Lysis, or slow return to health. Crisis, abrupt termination, usually 14 PRACTICE OF MEDICINE. with a critical discharge. Metastasis, or changing from one location to another. Secondary Processes are those in which the diseased action is sub- stituted by a new morbid process, to wit : rheumatism followed by- endocarditis ; apoplexy by cerebral softening. By Death is meant a complete cessation of tissue change occurring by- Asthenia, or an ever-increasing debility, to wit : phthisis, cancer, Bright's disease. Ana>?nia, or insufficient quantity or quality of blood. Apncca, or non-aeration of blood, to wit : acute lung dis- eases, or croup. Coma, death beginning at the brain, to wit: urae- mia, narcotic poisoning, or cerebral hemorrhage. Diagnosis of disease, or the discrimination of diseases, implies a complete, exact, and comprehensive knowledge of the phenomena under consideration, as regards the origin, seat, extent, and nature of all its morbid condition. A direct diagnosis is made when the morbid condition is revealed by a combination of clinical phenomena, or some one or more pathog- nomonic symptoms. A differential diagnosis is the result when the diseases resembling each other are called to mind and eliminated from each other. A diagnosis by exclusion is by proving the absence of all diseases which might give rise to the symptoms observed, except one, the presence of which is not actually indicated by any positive symptoms. The X- (or Rontgen) Rays, now in its infancy in diagnosis, will in the near future revolutionize the study of diseases of internal organs and structures. Prognosis of disease is the ability or knowledge to foretell the most probable result of the condition present, and involves an amount of tact or knowledge only acquired by prolonged clinical experience. Treatment. The ultimate and most important object in the study of medicine, from a practical point of view, is to be able to cure, relieve, or prevent disease. This does not consist solely in the ad- ministration of drugs, but requires strict and faithful attention to diet, hygiene, and exercise. When the object is to prevent disease, such as small-pox by vacci- nation, it is called Prophylactic or Preventive treatment. When disease is to be broken up, although already begun, such as ."boiling the < hill of malaria, it is called the Abortive treatment. FEVERS. 15 When the disease is allowed to run its natural course without attempting its removal, but being constantly on the alert for obstacles to its successful issue, such as the generally adopted plan of treating continued fevers, it is called Expectant treatment. When the disease is incurable, and removal of marked suffering is the object, it is called Palliative treatment. When marked weakness and prostration are to be overcome, it is called Restorative treatment. FEVERS. Fever is a condition in which the temperature of the human body is raised above the normal limit, — 98. 2° F., — and there are present the phenomena of quickened circulation, marked tissue change, and disordered secretio?is. The primary cause of the fever phenomena is still a mooted ques- tion, and is either a disorder of the sympathetic nervous system giv- ing rise to disturbances of the vaso-motor filaments, or a derangement of the nervous centres located adjacent to the corpus striatum, which have been found, by experiment, to govern the processes of heat pro- duction, distribution, and dissipation, or a toxaemia, — viz. : ptomaines, uraemia, or other poisons, — or of a bacterial origin. Rise of temperature is the preeminent feature of all fevers, and can only be positively determined by the use of the clinical thermometer, The term feverishness is used when the temperature ranges from 99 to ioo° F. ; slight fever if ioo° or 101 ; moderate, 102 or 103 ; high if 104 or 105 ; and intense if it exceed the latter. The term hyper- pyrexia is used when the temperature shows a tendency to remain at 106 F. and above. Quickened circulation is the rule in fevers, the frequency usually maintaining a fair ratio with the increase of the temperature. A rise of one degree Fahrenheit is usually attended with ah increase of eight to ten beats of the pulse per minute. 10 PRACTICE OF MEDICINE. The following table gives a fair comparison between temperature and pulse : .V temperature of 9S F. corresponds to a pulse of 60 i c a 99° F. " " " 70 (< « ioo° F. " tt " 80 « << ioi° F. it 1 1 " 90 102 F. 103 F. a ti a " 100 " no it a ( C ft 104° F. IC5 F. 106 F. n a a " 120 « 130 " 140 The tissue waste is marked in proportion to the severity and dura- tion of the febrile phenomena, being slight or nil in febricula, and excessive in typhoid fever. The disordered secretions are manifested by the deficiency in the salivary, gastric, intestinal, and nephritic secretions, the tongue being furred, the mouth clammy, and there occurring anorexia, thirst, con- stipation, and scanty, high-colored, acid urine. GENERAL TREATMENT OF FEVERS. 1. Reduce the temperature. The cold bath or cold pack will do this most decidedly, but entails much labor, and is not altogether free from danger, and so its use is advised only in proper cases. Cool sponging is of decided value. Quinines sulphas, in gr. xx (1.3 Gm.) doses, repeated, rarely fails. Antipyrin, gr. xx (1.3 Gm.), repeated, antifebrin, gr. x-xv (0.65-1.0 Gm.), repeated, and phenacetin, gr. v (0.32 Gm.), rep^c ?d once or twice, are also recommended, but their tendency to depression must be watched. 2. Lessen the circulation. If the pulse be full, strong, and rapid, use aconitum or veratrum viride. If the circulation be weak, stimu- lants with digitalis, caffeina, and nitroglycerin are indicated. 3. Attend to the secretions. Remove the waste of the tissues by diuretics, diaphoretics, and, if particularly indicated, laxatives. It is better for every fever that the skin should be moist, than that it should be harsh and dry. It is better that the urine should be abundant, than that it should be scanty and thick with tissue waste. Watch the Stools that you may judge whether the food, be it solid or liquid, is FEVERS. 17 propeily digested. The free use of water is beneficial in promoting the various secretions. 4. Nourish the patient. " Don't starve a fever." Administer milk, beef-tea, animal broths, peptonized and other light nutritious food, in small quantities, but at frequent intervals, watching that tympanites does not develop. Alcohol is only indicated in long-continued fevers or those of asthenic type. Check or discontinue alcohol when its odor is notice- able on the breath. 5. Watch the nursing. Much of the success in the management of fever patients can be attributed to good, sensible nursing. Through it are secured the five important essentials of every sick-room ; to wit : cleanliness, cheerfulness, regularity, ventilation, and light. CONTINUED FEVERS. All continued fevers are characterized by a steady progress of the febrile movement, without either a too decided rise or fall in the tem- perature to modify the impression of a continuous action. SIMPLE CONTINUED FEVER. Synonyms. Irritative fever ; febricula ; ephemeral fever ; synocha. Definition. A continued fever, of short duration, mild in charac- ter, rarely fatal, but when death does occur, presenting no character- istic lesion. Causes. Fatigue, mental and physical ; exposure to the sun ; great heat or cold ; excesses in eating and drinking resulting in an attack of indigestion ; excitement and violent emotion. Most common in childhood. It is not a miasmatic fever, neither is it contagious. Symptoms. Onset sudden with an abrupt feeling of lassitude, followed by a decided chill or chilliness, a sudden and rapid rise of temperature, quick, tense pulse, headache, dry skin, great thirst, coated tongue, costive bowels, and scanty, high-colored urine. Cases due to errors in diet are accompanied by nausea and vomiting. Attacks occurring during childhood, due to excitement, fright, or the emotions, may be associated with convulsions. The temperature may within an 18 PRACTICE OF MEDICINE. hour or two reach 103 F., or more, when slight delirium may occur. The affection has no constant or characteristic eruption. Duration. From twenty-four hours to six or seven days. Termination. Usually within a few hours, to a day or two, the temperature rapidly falls to the norm, an instance of crisis ; or it may continue for several days, gradually falling to the norm (lysis). Herpes about the lips and nostrils are often observed at the close of an attack. Convalescence is rapid. Diagnosis. Unless the fever can be attributed to some one of the causes mentioned, a doubt as to its character may exist for the first twenty-four hours, after which time it can hardly be mistaken for any other disease. The following is a familiar instance of this affection. A child, apparently in the best of health, at play, or, may be, at school, suddenly complains of nausea and may vomit, the skin becoming hot, dry, and flushed, or soon cov- ered with an erythematous rash ; the pulse is quick and tense, there is head- ache, pains in the limbs, and great fretfulness or nervousness. The axillary temperature may reach I02°-I04° F. The whole aspect is most alarming. A laxative is administered, the surface sponged with a tepid lotion, sleep follows, during which there may be free perspiration, and the following day the child is and continues perfectly well. Prognosis. Recovery, without sequelae, the rule. Treatment. Rest in bed. If evidences of gastro-intestinal dis- order be present, order a dozen or more powders containing hydrar- gyri chloridi mite, gr. l /e (001 Gm.); sodii bicarbon., gr. ij (0.13 Gm.), pulv. ipecac, gr. ^ (0.005 Gm.), one every two hours, and some hours after the last powder has been taken, an enema or a seidlitz powder. Much comfort follows sponging the surface with tepid or cold water and the use of saline diaphoretics and diuretics. If the pulse be very quick, add small doses of aconitum. Cases not associated with digestive disorder have the fever and nervous symptoms relieved by acetanilidum, gr. ij-v (0.13-0.32 Gm.), accord- ing to age, every two or three hours. Liquid diet is the most palatable. Cases in which the nervous symptoms or insomnia are prominent should have a few doses of potassii bromidum during the day, or a bedtime dose of trional, gr. v-xx (0.32-1.3 Gm.). During convales- < cm e tonic doses of quinines sulphas or tinctura nucis vomicce. FEVERS. 19 INFLUENZA. Synonyms. La grippe ; grip ; contagious catarrh ; epidemic or catarrhal fever. Definition. An acute, specific, infectious fever, moderately con- tagious ; sporadic, epidemic, and pandemic ; associated with catarrhal inflammation of the respiratory tract, sometimes of the digestive, muscular pain, and always accompanied with disturbances of the nervous system and a debility out of all proportion to the intensity of the fever and the catarrhal processes and apt to be attended with serious complications and sequelae. The disease was almost unknown upon the appearance of the pandemic in the winter of 1889-90. Causes. A specific poison, the bacillus of Pfeiffer, which is unin- fluenced by soil, climate, season, or atmospheric changes. The mode of development of the remarkable outbreaks of influenza is not yet understood. One attack rather predisposes to another attack. Morbid Anatomy. There are no characteristic anatomical lesions. Any anatomical changes are those of the complications. Symptoms. The clinical history of this disease presents the greatest variations as regards intensity, from the most trifling indis- position in one, to an illness of the gravest kind, terminating in death, in another. The onset is, in the majority of cases, sudden, with a chill ox chilli- ness followed by fever, the temperature reaching 101 to 103 , a quick, compressible pulse, and severe shooting pains in the eyes and frontal sinuses and myalgic pains in the joints and muscles. The chill and fever are rapidly followed by chilliness along the spine, pain in the throat, hoarseness, deafness, coryza, sneezi?ig, injected, watery eyes, and a dry, irritative, laryngeal cough, sometimes becoming bronchial. Rarely there is severe and obstinate cough, the result of a bronchial spasm, with little or no secretion. The tongue is furred, there is anorexia, epigastric distress, nausea, occasionally vomiting, and often- times diarrhoea. In some instances the digestive symptoms are the most prominent, when dysentery may occur. Associated with either the respiratory or digestive form of attack may be marked disturb- ances of the cerebro-spinal functions, or these latter may be the most prominent symptoms present. The above symptoms are always associated with depression of 20 PRACTICE OF MEDICINE. spirits, and a debility altogether out of proportion to the intensity of the fever and the catarrhal phenomena. Delirium is rare, but marked hebetude and cutaneous hyperesthesia are common. Duration. The fever declines in from four to seven days, when begins a protracted convalescence. Relapses frequently occur, and second, third, or even more numerous attacks in the same individual may be observed, the susceptibility of the system after an attack being remarkable. Complications. The most frequent are those associated with the respiratory organs. Severe bronchitis, associated in the feeble or aged with fever, typhoid delirium, and tendency to oedema of the lungs. Croupous and catarrhal pneumonia are frequent and fatal complications. Cerebro-spinal meningitis is also noted. Sequelse. A persistent headache ; neuralgia; neuritis; insomnia; neurasthenia or a confusional insanity ; depression of spirits often obstinate and needing treatment ; mania ; enlargement of lymphatic glands. The great increase in pulmonary phthisis since the pan- demic of 1889-90 is more than a coincidence. Diagnosis. Isolated cases maybe mistaken for a "bad cold." But when epidemic, the sudden onset, ?7iarked general catarrh, and decided prostration should prevent error. At the onset of an epidemic Dengue will be remembered. Cerebro- spinal Fever has many symptoms in common with the nervous form of influenza. Prognosis. Recovery is the rule when it occurs in the healthy and vigorous ; according to Pepper less than one-half of one percent, die. Grave when the very young, the very old, or those suffering from organic disease, such as Bright's disease, fatty heart, emphysema, or the tubercular diathesis, are attacked. Treatment. No specific. During the prevalence of the epi- demic influence exposure to cold should be avoided. Support the system and pursue a purely symptomatic method of medication. All measures, of whatever kind, which tend to depress the general nervous system, or the functional activity of the respiration, and particularly the heart, are to be avoided. Patients should be kept in bed until fever declines or longer. Keep the bowels soluble. If many individuals must come in contact with the patient, some isolation and disinfection of the nasal and bronchial secretions should be prac- tised. FEVERS. 21 The catarrh, pains, and cough are at least ameliorated by the following : $. Phenacetin., gr. iij .2 Gm, Pulv. camphorae, gr. j .065 Gm. Caffeina citrata, gr. j .065 Gm. Every two or three hours, alternated with quinines sulphas, gr. ij (0.13 Gm.). Excellent results follow the use of the following combination : rjc . Sodii benzoat. , .' 3 ij 8. Gm. Salol, gss 2. Gm. Phenacetin., gr. xl 2.6 Gm. Strychninse sulph. , gr. \ .012 Gm. M. Ft. chart, vel capsul. No. xij. Sig. — One every three or four hours. Sodii benzoas, gr. x (0.65 Gm.) every four hours, is strongly recom- mended. During the last pandemic the disease was frequently aborted in those of vigorous health by a few ten- or fifteen-grain (0.65-1 Gm.) doses of antipyrin, although in those of feeble resisting power much harm resulted from the indiscriminate use of this drug. Dr. Roland G. Curtin warmly recommends salicinu7?i as coming " as near to being a specific as we can get with the drugs now in our possession." Quinines sulphas, in full doses at the very onset, often aborts the disease. I have seen excellent results in neuralgic cases from cinchonidina salicylas, gr. v (0.32 Gm.), every four hours. The frequent inhalation of tinctura benzoin. co?np., f^ss-j (2-4 Cc.) in aqucE but., Oj (475 Cc), relieves the naso-pharyngeal and bronchial catarrh. If the bronchial symptoms become troublesome, use — R . Ammonii chlorid. , Tinct. hyoscyami, Syr. ipecac, . . Spts. frumenti, . Aquae chloroformi, f^iss 6. Cc. M. Every three or four hours diluted. The complication of pneumonia requires prompt stimulating treat- ment. Dr. Pepper recommends strychnin a sulphas in full doses as gr. x .65 Gm TT\,xv 1. Cc. n\v .3 Cc. f ^ss 2. Cc. fgiss 6. Cc. 22 PRACTICE OF MEDICINE. the most important remedy against this complication, and suggests the following combination as often valuable : & . Morphinse sulph., gr. j .065 Gm. Quininge sulph., . . gr.xxxv 2.3 Gm. Strychninse sulph., gr. ss .03 Gm. Acid. phos. dil., f^ iij 12. Cc. Glycerini, . . f^ v 20. Cc. Aquae, . q. s. ad f ^ iij 90. Cc. M. SlG. — A teaspoonful four to six times daily, in water. Dr. Bartholow recommends the early use of pilocarpine, gr. l /e (0.01 Gm.), repeated until its mild physiological effects ensue, when it is sub- stituted by duboisine, gr. -g^o _ ^o- (0.00022-0.00032 Gm.), twice a day, and for the depression ferri iodidum, one of the official pills every four hours, and inhaling one or two drops of pyridine every few hours. During convalescence administer strychnines sulphas, gr. -fa (0.0013 Gm.) four times daily. Always have in mind that influenza is often the exciting cause of a phthisical development in those so predisposed. Insomnia is a symptom calling for prompt treatment. The anaemia and general weakness of convalescence calls for ferrum. TYPHOID FEVER. Synonyms. Enteric fever ; gastric fever ; nervous fever ; entero- mesenteric fever ; abdominal typhus ; autumnal fever. Definition. An acute, infectious febrile affection, due to a special poison ; characterized by insidious prodromes, epistaxis, dull headache followed by stupor and delirium, red tongue, becom- ing dry, brown, and cracked, abdominal tenderness, early diarrhoea and tympany, and a peculiar eruption upon the abdomen; rapid prostration and slow convalescence ; a constant lesion of Peyer's patches, the mesenteric glands, and enlargement of the spleen. Causes. Predisposing and exciting. The chief predisposing causes are Age and Season. It is claimed by Pepperthat a particular susceptibility exists in certain individuals and families to typhoid fever. The most frequent age is between fifteen and thirty years, and FEVERS. 23 cases are rarely seen in those of forty-five years and over. I have seen well-marked cases with typical symptoms at eighteen months, and at five years of age. The autumn months show the most cases, and particularly following a hot and dry summer. The exciting cause is a special typhoid germ, the typhoid bacillus or bacillus of Eberth, which is found in the lesions and blood. The poison usually results from the decomposition of the typhoid stools and the sputum, although it has been claimed that the disease may be generated under certain undetermined circumstances, de novo, from ordinary filth and decomposition ; this view has less advocates each year. The contagiousness of typhoid fever is again advanced. The atmosphere is never impregnated with the fever germ. The poison gains its entrance into the system by means of infected water, milk, ice, meat, or other food. The germ is easily destroyed by thorough disinfection of the stools and sputum with heat, mercuric bichloride, or acidum carbolicum, but extreme cold will not destroy the typhoid germ. Pathological Anatomy. The specific anatomical lesions of typhoid fever are invariably present, and are so characteristic that an examination of the body after death will in any case make known the nature of the disease, even had the symptoms been unknown. These lesions consist in changes in the Peyerian patches and solitary glands, which may be divided into well-defined stages, as follows : First. Stage of Infiltration, or Swelling from infiltration and ex- cessive proliferation of their cellular elements ; the surrounding mucous membrane is also infiltrated with cells. The Peyer's patches are thickened, hardened, and elevated above the mucous membrane. The number of patches and glands involved is from three or four up to nearly the entire number. The above changes have been noted as early as the second day. Second. Stage of Necrosis, Softening, or Sloughing of the solitary and agminate glands. Not all the patches necessarily slough ; in a certain number of them the morbid changes are arrested before soft- ening. This stage constitutes the anatomical changes of the second and third week. Third. Stage of Ulceration following and depending directly upon the softening and sloughing, the sloughs gradually separating, begin- ning at the periphery of the swollen gland and finally, at about the 24 PRACTICE OF MEDICINE. end of the third week, become detached, leaving ulcers of various sizes. Fourth. Stage of Cicatrization, or in rare cases Perforation. The ulcer gradually diminishes in size, the surface becoming covered with a delicate layer of granulations, which is soon transformed into con- nective tissue and covered with epithelium, the resulting scar being slightly depressed. The gland-structure is never regenerated. The Mesenteric glands become infiltrated, enlarged, and softened, but seldom ulcerate. In about one-third of the cases the large intes- tine is also involved. The Spleen also enlarges and softens, the increase being twice or three times its normal size, beginning in the middle of the first week, and reaching its height at the end of the second week. There are, besides, parenchymatous degenerations , or granular cha7iges in all the active organs and tissues of the body. Symptoms. Stage of Prodronies. — The onset is insidious, with a feeling of general malaise, vertigo, headache, particularly occipital pain, disordered digestion, disturbed sleep, epistaxis, depression, and muscular weakness, followed by a chill ox chilliness, the patient being unable to designate the day when the symptoms began. In rare instances the disease begins abruptly with a chill, followed by high fever ; this is particularly the case in malarial districts. The exact duration of these premonitory symptoms is not known, and may be said to vary from a few days to two or three weeks. First Week, dates from the onset of the fever, when are present in- creasing temperature, frequeiit pulse, headache, listlessness, the eyes closed as if asleep, coated tongue, nausea, diarrhcea (there may be constipation), the abdomen moderately distended and, upon pressure in the right iliac fossa, gurgling sounds and tenderness. Upon the seventh day a few reddish spots resembling flea bites appear upon the abdomen, chest, or back. Second Week. The foregoing symptoms are exaggerated ; fever is now continuous, with a frequent and compressible and dicrotic pulse, tympanitic, tender abdomen, gurgling in the right iliac fossa, nocturnal delirium, severe and constant headache, often stupor, a short cough with distinct bronchial rales on auscultation, irregular muscular con- tractions (subsultus iendinum), sordes upon the teeth and lips, the tongue losing its coating and becoming more or less dry, the diarrhaa continuing. During this stage deafness develops, often increasing FEVERS. 25 until profound, and continuing into convalescence. Disturbances of vision are frequent in pronounced cases. The spleen increased in size. Third Week. Fever changes from continuous to remittent ; the evening exacerbations continue as high as the preceding week, the morning fall growing more decided each day, but all the other symp- toms remain about the same until near the end of the week, when a marked amelioration begins. In a fair proportion of cases all the symptoms grow worse toward the end of the second or during the third week. The prostration is extreme, the stupor so marked that it is hardly possible to rouse the patient, the tongue dry, hard, cracked, and covered with a brown crust, sordes collect on the gums, teeth, and cracked lips, the pulse is rapid and feeble, the respirations shallow and quickened, retention of urine, which contains albumin. The stools are often voided invol- untarily, and bed-sores develop, this condition terminating in death, or passing thus into the fourth week. Fourth Week. The fever decidedly remits ; almost normal in the morning, the pulse becoming less frequent and more full, the tongue gradually becoming clean, the abdomen lessens in size, the diarrhoea ceases, the patient passing into a slow convalescence, greatly emaci- ated, which convalescence may continue for several weeks. Analysis of Symptoms. The temperature record of typhoid fever is characteristic. The fever on the morning of the first day may be stated at 98.5 F., evening 100. 5 ; second morning 99. 5 , evening 101.5 ; third morning 100. 5 , evening 102. 5 ; fourth morning 101.5 , evening 103. 5 ; fifth evening 104.5°. From that time until end of the second week the evening temperature ranges between 103° and 105°, the morning temperature being a degree or more lower. During the second or third week hyperpyrexia, or fever above 105° F., may develop and adds to the gravity of the attack. A high temperature during the third and fourth week is of grave import. Temperatures of io6°-io7° with recovery are reported, but they must be rare. Afebrile cases of typhoid fever are reported, all other symptoms with the prostration, but the step-like temperature, being present. Diarrhoea is the principal intestinal symptom ; if absent, the lesion may be slight. The stools are at first dark, but early in the second week they become fluid, offensive, ochre-yellow in color, resembling " peasoup," and may be streaked with blood. They number from three to fifteen during the twenty-four hours. 3 26 PRACTICE OF MEDICINE. Constipation occurs more frequently than is supposed. I have seen one hundred cases with constipation within the past ten years. The urine has the ordinary febrile characters. Retention is very common. Ehrlich describes a reaction which he believes is rarely met with save in typhoid fever. In examinations of the urine by Ehrlich's diazo-reaction in fifty cases of typhoid fever in the wards of the Philadelphia Hospital, the reaction was found in thirty-eight. It has also been found in a number of other conditions, particularly those having gastro-intestinal symptoms. Eruption is almost constant. Consists of from. Jive to twenty small, rose-colored spots on the abdomen, chest, or back, sometimes on the limbs, appearing in crops, lasting about five days, disappearing on pressure and at death. Returning with relapses. Eruption day from the sevetith to the ninth. Rarely spots of a delicate blue tint — the "taches bleuatres " of French authors — are observed. Nervous symptoms are, pronounced headache, early and severe, dullness of intellect soon following, passing into drowsiness and stupor, with great prostration. Deafness pronounced. Sight im- paired, and in grave cases double vision. Deliriuin low and mutter- ing, generally pleasant in character ; always present in severe cases. Coma vigil \s a grave symptom, the patient lying perfectly quiet with eyes open, taking no heed to his surroundings. Splenic enlargement is an almost constant clinical feature. A ver- tical dullness exceeding two ribs and an interspace signifies enlarge- ment. Palpation is a valuable aid for determining splenic enlarge- ment. Muscular symptoms are developed late in the second or early in the third week, and consist of irregular contractions, carphologia, or subsultus iendinum, and are the result of the great debility. The reverse of muscular contractions, to wit, lying perfectly motionless in bed, attempting no muscular effort of any kind, is a grave sign. Convalescence shows great debility and emaciation, extreme anaemia, and severe nervousness, often very protracted. It is during convalescence that irritability of the heart, profuse night-sweats, and insomnia occur, and in women loss of hair. Complications. Intestinal hemorrhage is the most frequent and at times the most critical of any of the complications of typhoid fever. The hemorrhage may occur any time between the fourteenth FEVERS. 27 and twentieth day ; a sudden decline of the temperature to the norm or below frequently precedes the passage of blood by stool. The hemorrhage is due to the erosion of a vessel during the ulcerative stage. Perforation makes the case almost hopeless. Peritonitis without perforation adds to the gravity, but is not necessarily fatal. Lobar pneumonia, hypostatic congestion, and bronchitis are fre- quent occurrences. There are few cases that do not have slight bronchial cough from the onset. Albuminuria and acute nephritis may occur, as may phlegmasia dolens, the result of thrombosis of the femoral vein, usually the left. Bed-sores are frequent, resulting from the impaired nutrition, emaciation, and pressure over bony promi- nences, and the difficulty of keeping the patient clean. Ulceration of the tongue and mucous membrane of the cheek is sometimes seen. Sequelae. Paralysis, — either mono- or paraplegia, — due to an acute neuritis. Post-febrile insa?iiiy occurs more frequently after typhoid than any other febrile condition, save influenza. Acute Nephritis associated with cedema. Alopecia, complete or partial. Trans- verse markings of the nails. Tuberculosis may develop in those predisposed. These sequelae of typhoid fever are all the result of the impaired nutrition and great prostration. Relapses are common, Da Costa reporting five in one patient, and Wilson (J. C.) four in one of his cases. The symptoms all return abruptly ; the duration is half the time of the original attack ; occur at the end of the fourth or beginning of the fifth week. Not so. fatal as generally supposed. Abortive typhoid fever are cases of mild character, having many of the typical symptoms, running its course in about two weeks. The so-called walking cases are often of this character. Diagnosis. The Widal reaction or serum-test gives brilliant promise for the early and correct diagnosis of the disease. Widal and others showed that " if to a drop of blood-serum, or to a drop of water containing a solution of dried blood from a typhoid patient, a moderate number of typhoid bacilli were added, a peculiar reaction occurred," seen under the microscope as a loss of the natural motility and an agglutination of the bacilli — a clumping into masses. An error that is constantly being made is that of confounding 28 PRACTICE OF MEDICINE. typhoid fever with the typhoid (depressing) symptoms or conditions developing during the course of many acute diseases. The absence of the characteristic diarrhoea, the peculiar eruption, and the typi- cal temperature record and enlarged spleen should prevent the error. Enteritis has intestinal derangement and an irregular fever course. Peritonitis, abdominal symptoms only, with constipation and rapid early prostration and collapse. Acute miliary tuberculosis is often mistaken for typhoid fever, an error difficult to prevent at times. The perfection of the Widal reaction and diazo- urine reaction may remove the doubtful points in the near future. Meningitis lacks the intestinal symptoms and fever record. The so-called typho-malarial or malario typhoid fever has many symptoms in common, but lacks the diarrhoea, eruption, and temper- ature record. Prognosis. A positive prognosis cannot be made. Favorable indications are constipation, or slight diarrhoea, low temperature, and moderate delirium. Unfavorable symptoms are obstinate and severe diarrhoea, early high temperature, cardiac exhaustion, marked ner- vous symptoms with coma vigil or stupor, albuminuria, and repeated intestinal hemorrhages. The prognosis is always more favorable in winter than in summer. When death occurs, it is usually during or about the third week, the result of exhaustion, cardiac failure, or some complication. Children under puberty usually recover. More women than men die, although less women have the disease. Pregnant women and fleshy people usually succumb. The mortality in typhoid fever in private practice is about one death in twenty ; in hospital practice it varies from one death in five to ten cases, although the cold bath treatment has greatly reduced the hospital mortality. Treatment. There is no specific treatment for typhoid fever. The indications are to sustain life and meet the urgent and danger- ous symptoms as they arise. Flint held that, as it was a self-limited disease, "if the patient can be kept alive after three, four, or more weeks, recovery will take' pla< e provided there be no serious complication. In a case of severe uncomplicated fever the patient is in a situation not unlike that of a FEVERS. 29 person in danger of drowning not far from or perhaps very near the shore. If he drown, it is because his strength gives way before the shore is reached. As a person in this situation requires only to be buoyed up by some support, so the fever patient in a similar emer- gency may only need supporting measures to live." It is important to secure intelligent nursing, a quiet, airy sick- room with an average temperature of 65° F., and the most scrupu- lous cleaiiliness of patient, bedding, and utensils. The patient must go to bed from the moment of suspicion that typhoid fever is developing, and remain in bed until convalescence is well established. The stools and urine must be disinfected the moment voided, and quickly discharged into a sewer or buried. The diet should be nutritious and liquid at intervals of every two or three hours. Diluted milk is the best article, but broths, soups, liquid peptonoids, coffee, and cold milk and tea may be alternated. A word of caution, however, as to the quantity of food administered. The amount should be small, as the digestive capacity of the patient is greatly lessened by the febrile phenomena. Much harm results in typhoid fever from stuffing the patient. Watch stools for undigested milk. The tendency to bed-sores must be kept in mind. The use of finely powdered boric acid over irritated parts will often prevent their devel- opment, or if developed, are healed by constant applications of bov- inine on several layers of gauze. Attention should be given to the mouth, and the dryness and ten- dency to collections of sordes prevented by frequently washing with glycerine and water or weak boric solution. The following remedies have advocates, claiming that they modify the course of the disease : hydrargyrum, iodum, acidum carbolicum, mineral acids, argentum nilras, guaiacum, and ergola, but no one drug can claim specific action. The reduction of temperature is one of the most important indica- tions in the majority of cases of typhoid fever. There is now no doubt that the former views regarding the amount of fever a patient could stand for one or two weeks are responsible for the high mor- tality in this disease. A temperature of 103 to 105 for a dozen days is dangerous and should be combated. Among the measures that have been used with success in many instances is quinines sulphas, gr. xv-xx (1-1.3 Gm.), morning and night. A strong prejudice has 30 PRACTICE OF MEDICINE. arisen against quinina within the last few years, nevertheless, I know I have seen great benefit from its use, and strongly recommend it. Cold sponging with water alone or alcohol and water is often of great value in mild cases, and when sponging it is essential to leave the surface very wet. The cold pack is a very powerful antipyretic and, in cases with temperature of 104 or 105 , in which the cold bath cannot be employed, can be made use of. The bed should be pro- tected by a rubber cloth, and the patient, with his clothing removed, should be wrapped in a sheet wrung out of cold water. The surface should be rubbed briskly through the sheet, and from time to time cold water is freely sprinkled over the sheet. Friction must be con- tinued during the pack, and ice cloths or cap placed on the head. The duration of the cold pack is determined by the temperature and the reactive powers of the patient. It is often well to administer an alcoholic stimulant or a hypodermic injection of strychninae sulphas before the pack and, may be, after. The cold bath, after the method of Brand, or " tubbing," has proven most prompt and decided for reducing temperature. It consists in the systematic employment of general cold baths, with frictions when- ever the temperature reaches 102. 2 F. As often as the temperature, taken every three hours in the mouth or rectum, is over 102. 2 , the patient receives a bath lasting fifteen or twenty minutes. He wears a thin muslin garment or is wrapped in a sheet ; he is given a stimulant and carefully lifted into the bath of 65 or jo°, some cold water being poured over his head and shoulders to lessen the shock ; the head rests on an air pillow, the body submerged to the neck. During the whole period of the bath the patient must be briskly rubbed. The friction and affusion are of value in preventing chill and cyanosis. After the bath the wet linen is quickly removed and the patient placed in bed wrapped in a dry sheet and covered with a blanket. A stimu- lant is again given after the bath, and if a tendency to cyanosis or heart failure, a hypodermic injection of strychnina. The temperature is taken after the patient is placed in bed and again in half to three- quarters of an hour, and if not then 102 , is not again taken for three hours. The good effects of the bath are seen in a reduction of tem- perature, clearer intellect, and lessening stupor and muscular twitch- ing. Sleep usually follows a bath, with a general stimulating effect upon the heart and the nervous system. There are no counter- indications to the cold bath save intestinal hemorrhage. FEVERS. 31 Diarrhaza should not be checked unless it exceeds three or four stools in twenty-four hours, when may be used — K. . Bismuth, subnit., gr. xx 1.3 Gm. Acid, carbol., Try .06 Cc. Tinct. opii deodorat. , ttl xv *■ ^ c - Mucil. acacia;, f^j 4. Cc. Aquas, f^iij 12. Cc. M. SlG. — Every three or four hours. Or— l£ . Cupri sulph., ...» gr. ]/e .011 Gm. Extracti opii, g r - X • OI ^ Gm. M. SlG. — In pill, every four hours. At the onset of a suspected case of typhoid fever, when there are present coated tongue, fetid breath, anorexia, chilliness followed by feverishness or fever, nervousness, costiveness or frequent tenesmic stools, and general soreness associated with mental unrest and head- ache, excellent results follow the use of the following combination : R . Hydrargyri chlor. mite, .... gr. viij .52 Gm. Sodii bicarbonatis, gr. xv I. Gm. Pulv. ipecacuanha;, gr. Ij .13 Gm. Salol, ............ gr. xv I. Gm. M. Ft. chart. No. xv. Sig. — One powder every three hours until decided bowel action. Or— r£ . Salol, gr. iij .2 Gm. Bismuth, salicyl., basic, . . . . gr. v .3 Gm. M. Sig. — In powder, after each stool. Or— H< . Acid, sulph. aromat, TTLxv I. Cc. Tinct. opii deodorat., rr\_x .6 Cc. Sig. — In water, every three hours. For Tympanites : cold compresses or an ice-bag to the abdomen, or a turpentine stupe is of value. Page recommends the gentle introduction of a catheter far up the rectum to relieve a powerless bowel, as urine is drawn from a paralyzed bladder. Tympany with constipation is relieved by the use of olei terebinthince, rr^x 32 PRACTICE OF MEDICINE. (0.6 Cc), olei ricini, rr^xv (1 Cc), in emulsion every three or four hours. For Thirst: cooling drinks in moderation, or pellets of ice slowly dissolved in the mouth, and washing mouth, lips, and tongue fre- quently with cold water is acceptable. Headache : cold to the head, mustard to the neck, and foot baths ; if these fail to relieve, morphina or atrophia hypodermically, and rarely leeches to the temples may be needed. Delirium : if from debility, increase the stimulants ; other causes, use morphina if the delirium is active. Insomnia : if of long duration, use trional, gr. xv-xxx (1-2 Gm.). Restlessness and coma vigil : stimulants and an ice cap. Debility : food every two or three hours ; do not permit sleep to in- terfere with nourishment. Stimulants are indicated early, the best guide being the heart's action ; an average amount would be spiri- tus frumenti y fgss (15 Cc.) every three hours, but the amount and fre- quency of the dose must be guided by the condition of the heart, pulse, and general prostration. Spiritus ammonicz aromaticus , f^j (4 Cc.) every couple of hours in milk or water, is a valuable stimu- lant and stomachic tonic. Spiritus chloroformi, n\,ij-v (0.12-0.3 Cc) every hour or two, is also a valuable stimulant. The bladder should be examined at each visit. Intestinal hemorrhage : at once morphina, hypodermically, and ext. ergotce fid., f£j (4 Cc), repeated p. r. n., or MonseTs solution, TT\,v-x (0.3-0.6 Cc.) every two hours, or olei terebinihince, rr^x (0.6 Cc), and cold to the abdomen. Perforatio)i and peritonitis : at once morphina sulphas, gr. x / z (0.032 Gm.), hypodermically, followed by extrachim opii, gr. j (0.065 ( mi.) every hour, hot applications to the abdomen, and bold stimula- tion. lobar pneumonia and bronchial catarrh : dry cups and the use of the following: \i . Ammonii chlorid., ^ij 8. Gm. Strychninae sulph , Q r - l A ° 2 Gm. Spts. chloroformi, f zj 4. Cc. Aq. lauro-cerasi, . . . q. s. ad f^iv 120. Cc. SlG. — Dessertspoonful every two, three, or four hours, diluted. In cases in which the tongue is dry, brown, and with a tendency FEVERS. 33 to fissure, excellent results are obtained from turpentine in emul- sion : R. Olei terebinthinse, f3 ss T 5- Cc. Mucil. acacioe, q. s. q. s. 01. sassafras, T^lxv I- Cc. Aq. chloroformi, . . . q. s. ad f 5 iv 120. Cc. M. One teaspoonful every two or three hours, diluted. In patients with whom the above disagrees, good results are ob- tained from acidum hydrochloricum dilutum or one of the other of the mineral acids, in doses of tt\,xv (0.9 Cc), well diluted every three or four hours. During the entire course of the disease use strychnines sulphas, gr.^ (0.002 Gm.), every four hours. Convalescence : The patient must be most guarded in exercise or mental occupation. Liquid diet for ten days to two weeks after nor- mal afternoon temperature. Cardiac palpitation and excessive sweat- ing are not infrequent, and can be controlled by a combination of quinina and belladonna. If the stools continue quite liquid with a little bright blood now and then, showing some remaining ulceration, use argentum nitras in pill form with nucis vomica or strychnina. The addition of extract of malt or porter to the diet is of value in a prolonged convalescence. TYPHUS FEVER. Synonyms. Contagious fever ; ship fever ; jail fever ; exanthe- matic typhus (German) ; petechial typhus ; spotted or putrid fever. Definition. An acute, infectious, febrile, epidemic disease ; highly contagious, and characterized by sudden invasion, profound depres- sion of the vital powers, sickening odor, and a peculiar maculated and petechial eruption, favorable cases terminating by crisis about the fourteenth day. No lesion. Cause. A special infecting germ, the character of which is un- known, but which is influenced by filth and overcrowding. Rarely seen in the United States except in seaports, where brought by emi- grants. Pathology. No constant lesion peculiar to the affection. Blood is profoundly altered, dark, thin, with lessened fibrin ; tissues dark, soft, and flabby. 4 34 PRACTICE OF MEDICINE. Symptoms. Begins abruptly ; chill followed by violent ftver, temperature within a few days reaching 104 to 105 F. ; a frequent, bounding pulse, soon becoming small, weak, and rapid ; the cardiac impulse and first sound almost effaced, severe headache, followed by violent delirium ; from the fifth to the seventh day, a coarse, red, diffused, measly eruption, with a mottling of the skin all over the body, except the face, not disappearing on pressure ; the face has a uniform deep, dusky flush, the skin has a glazed appearance, the pupils are contracted, the eyes injected. With the development of the disease there is cuta)ieous hyperesthesia, muscular soreness, and le?iderness over the tibia. There is great prostration, great muscular feebleness, vertigo, tremor, and subsultus ; constipation the rule. End of the second week, the temperature suddenly declines and the patient passes into a rapid convalescence \ Complications. Pneumonia and swollen parotid glands are common. Diagnosis. From typhoid fever, the age, season, onset of the disease, temperature record, character of the eruption, and the intes- tinal symptoms. Measles begin milder, with coryza and cough, and never have such pronounced nervous phenomena, but there occurs an early eruption, appearing on the face. Cerebrospinal fever has many symptoms in common, and but for the rarity of typhus in this country would be more puzzling. The headache and rigidity of the muscles of the neck are much more pro- nounced in cerebro-spinal fever and the prostration less than in typhus fever. The eruption of typhus is characteristic and should prevent error. Prognosis. Unfavorable indications : high temperature, frequent pulse, early stupor, presentiment of death. Favorable : youth, mod- erate temperature and pulse, and mild nervous phenomena. The duration about two weeks ; mortality varies from five to thirty- five per cent. Treatment. Symptomatic. As typhus fever is distinctly conta- gious, isolation is imperative, with immediate removal and disinfection of the patient's excreta. All cases are benefited by small doses of the mineral acids alternat- ing with quinines sulphas. For high temperature, cold sponging, cold pack, or full doses of FEVERS. 35 quinince sulphas. Also the systematic use of the cold bath or " tub- bing," as now employed in typhoid fever. For the headache and delirium cold to the head. In the young and strong, a few leeches to the temple, and chloral, with or without the bromides. For constipation, mild laxatives. Debility : alcohol early and in full doses, or spiritus chloroformi'm. drachm doses whenever danger of collapse. Convalescence : such tonics as quinina and strycJmina. CEREBROSPINAL FEVER. Synonyms. Epidemic cerebro-spinal meningitis ; epidemic cere- brospinal fever ; spotted fever ; cerebro-spinal typhus. Definition. A malignant epidemic fever, characterized by head- ache, vomiting, painful contractions of the muscles of the back of the neck, retraction of the head, hyperesthesia, disorders of the special senses, delirium, stupor, coma, and frequently an eruption of petechiae or purpuric spots — a subcutaneous extravasation of blood. Lesions of cerebral and spinal membranes are found at the post- mortem. Cause. A special micro-organism, of oval shape, occurring mostly in pairs and faintly tremulous, resembling those found in pneumonia and erysipelas, though hardly identical. Bad hygiene seems to favor the development of this affection, but can hardly be considered its cause. The disease seems to have a predilection for the young. Occurs most frequently in the winter months. Slightly if at all contagious. We have no positive knowledge of the manner in which the virus gains entrance into the system. Pathological Anatomy. The extent of lesion present in a given case depends upon the duration of the illness. In cases rapidly fatal it is probable that the individual is overwhelmed by the poison ere the characteristic anatomical changes have had time to develop. The changes in this disease are twofold : those due to the direct action of the infecting poison upon the blood, producing the group of symptoms constituting the fever and complications, and those giving rise to the local inflammation — viz., hyperemia of the membranes of 36 PRACTICE OF MEDICINE. the brain and spinal cord, followed by an exudation of lymph and an effusion of serum, resulting in pressure upon the brain and cord. The inflammatory changes are more marked in the membranes at the base of the brain than elsewhere. The lungs, spleen, stomach, liver, kidneys, and bladder are in various stages of congestion. If the patient survive long enough, inflammatory changes occur in the cranial and special nerves and the organs of special sense. Symptoms. Divided, according to the severity of the lesion, into three groups : the conwion form, the fulminant, and the abortive. The Co7iimo7i Form begins abruptly with a chill, excruciating head- ache, persistent nausea, vomiting, vertigo, and an overwhelming sense of weakness. Within a few hours the muscles of the back of the neck become rigid and retracted (tonic spasm), with decided pain upon moving the head ; this rigidity and retraction soon extends to the back, when opisthoto?ncs occurs. There is great restlessness, and the surface of the body becomes highly sensitive (^hyperesthesia). Cramps in the muscles of the legs and elsewhere, and spasmodic twitchings of the lips and eyelids come and go, and, finally, convul- sions or delirium occur. Intolerance of light, and in some cases amaurosis, more or less deafness, loss of sense of smell and taste soon following. The temperature and pulse records are irregular. From the first day to the fifth an eruptio?i of petechias or purpura occurs in the majority of cases, and also an herpetic eruption, begin- ning as herpes labialis, appears. The tache ck>ebrale is usually to be obtained. The disease reaches its height in from three to eight days, and passes into stupor and coma, or ameliorates and passes into a protracted convalescence. The Fulminant Form. Severe chill, depression, and in a few hours collapse. The patient is overcome by the poison and never reacts. The Abortive Form consists of one or more pronounced character- istic symptoms during the course of an epidemic. Complications. Pneumonitis; endocarditis; pericarditis; typhoid fever; pleuritis ; intestinal catarrh in infants. Sequelae. Result from thickening of either the cerebral or spinal membranes. Persistent headache ; blindness, or deafness, partial or complete; mental feebleness; chronic hydrocephalus; epilepsy, or different forms of spinal palsies. Diagnosis. Typhoid fever begins slowly, has a characteristic temperature record, without so intense headache, and muscular FEVERS. 37 rigidity, opisthotonus, vomiting, and early delirium, not ending in coma. Typhus fever has higher temperature, is of longer duration, and has a peculiar measly eruption, is not attended with muscular rigidity and retraction, hyperaesthesia, nor disorders of the special senses. Tubercular meningitis is not epidemic, has no characteristic erup- tion ; is preceded by long prodromes, and runs a tedious course. A congestive chill resembles the fulminant cases in suddenness of depression, but the latter has not the history of the former. Inflammation of the meninges of the cord is due to exposure to cold or syphilis, and is not attended with cerebral symptoms or an eruption. Small-pox in the first days, with the severe lumbar pains, headache, vomiting, and rash, may cause error. Prognosis. Varies according to epidemic ; from twenty to fifty, and even seventy-five per cent. die. Treatment. There is no abortive plan of treatment for cerebro- spinal fever, nor can the antiphlogistic treatment for the inflammatory symptoms be advised. Like the infectious diseases in general, sus- taining measures are indicated in all but the most sthenic cases. Nutritious and easily assimilated food, such as milk, eggs, meat- juice, and broths, should be given at regular intervals night and day. If food cannot be taken by the mouth, nutritious enemata should be substituted. The drug that holds the highest place in the treatment of this dis- ease is opium. The hypodermic use of morphines sulphas, gr. ]i~Yz (0.016-0.032 Gm.) every two or three hours, or exir actum opii, gr. j (0.065 Gm.) eveiy hour until the stage of effusion, when quinines sulphas in tonic doses, and potassii iodidum are indicated. Prof. Da Costa alternates potassii bromidum with opium, especially in children. Ergota in the early stages would seem to be indicated, but in prac- tice it is of little or no value. For the convulsions or spasms that are so often present no remedy is comparable with chloral, gr. xxx (2 Gm.), repeated as indicated. Caution in the use of the coal-tar products must be exercised, as the relief of pain and spasm may be the onset of the stage of collapse instead of the beneficial effects of these drugs. Locally, cold compresses to the head and spine is a most valuable measure, continued for hours at a time. 38 PRACTICE OF MEDICINE. For sequelce, potassii iodidum, a course of hydrargyrum, oleum morrhua, and flying blisters along the spinal column, or touching the back of the neck with the Paquelin cautery. RELAPSING FEVER. Synonyms. Febris recurrens; famine fever; bilious typhoid fever; spirillum fever. Definition. An acute infectious, contagious, epidemic, febrile disease, self limited, characterized by a febrile paroxysm, lasting about six days, succeeded by an entire intermission of the same dura- tion, which is in turn followed by a relapse similar to the first seizure. Associated with alterations in the viscera, and by the presence in the blood of a specific micro-organism — the spirillum of Obermeyer. No specific lesion. Cause. A specific poison; contagious; acquiring the greater activity the more filthy, crowded, and unhealthy the population amid which it prevails. Pathological Anatomy. During the febrile paroxysm only, the blood contains minute corkscrew-shaped organisms or spiral fila- ments, — spirilli, constantly twisting and rotating, — the spirillum Ober- meicri. The spleen is enlarged and usually covered with a fresh fibrinous exudation. The capsules present a mottled appearance. The splenic pulp is more or less softened and swollen and shows en- larged Malpighian bodies. The liver and kidneys are swollen and congested. Symptoms. No prodroines. Onset abrupt, with fever, 102 - 104 ; frequent, rather weak pulse, headache, nausea, vomiting, and lancinating pains in limbs and muscles, marked in the calf of the leg; second day, feeling of fullness and pressure in right and left hypo- chondrium, due to swollen liver and spleen ; jaundice is frequent ; seventh day fever ends by crisis ; fourteenth day symptoms return in milder form, continuing about four days, when enters slow convales- cence, much emaciated. No eruption. Several relapses may occur. Diagnosis. Yellow fever has many points of resemblance, but has a shorter febrile stage, remission not so complete, vomiting late and characteristic, normal spleen, and the late appearance of yellow color. FEVERS. 39 Remittent fever 'begins with a decided chill, followed by fever and sweats, and not the progressive rise of temperature until the fifth or seventh day. Prognosis. Recovery the rule, but protracted, and decided emaciation results. Treatment. Expectant. Act on the secretions ; nourish patient and meet urgent symptoms. For fever, antipyretic doses of quinince sulphas which, however, has no power to prevent the relapses ; for pain, hypodermic injections of morphines sulphas ; for nausea and vomiting, acidum carbolicum or cerii oxalas ; during remission, fer- ritin and quinince sulphas in tonic doses. PERIODICAL FEVERS. These affections are characterized by the distinct periodicity of the phenomena, having intervals during which the patient is wholly or nearly free from fever. INTERMITTENT FEVER. Synonyms. Ague ; chills and fever; malarial fever ; swamp fever. Definition. A paroxysmal fever, the phenomena observing a regular succession ; characterized by a cold, a hot, and a sweating stage, followed by an interval of complete intermission or apyrexia, varying in length according to the variety of the attack, and the presence in the blood of a protozoon, known as the Plasmodium malaria. Cause. The presence in the blood of a specific vegetable micro- organism. Klebs and Tommasi-Crudeli claim to have isolated a germ — Bacillus malaria — from the low-lying atmosphere over marshes and from the soil, which produced a malarial paroxysm with enlarged spleen in an inoculated rabbit. Laveran discovered a germ in the human blood of patients suffer- ing from malarial fevers which is now known as the hcematozoa of Laveran, and which has since been found always present in malarial attacks. These germs are true parasites and exhibit several varieties of form and size, and it is possible that there may be several species 40 PRACTICE OF MEDICINE. which are capable of causing the distinct types of the disease, as ter- tian, quartan, intermittent, or remittent. Laveran describes the chief forms of the hsematozoa as consisting of amoeboid spherical bodies with nuclei ; crescentic shapes with nuclei; rosettes; and fiagellate bodies. Laveran considers the para- sites as a single but polymorphic organism, and a particular form of the germ is peculiar to a particular type of the disease. Osier, who has devoted much time to the study of the subject, "believes that different forms of the germ belong to distinct species, and that they are not all different stages in the development of one microbe." The period of incubation varies from a few days to weeks, months, or even years, an auxiliary condition, such as exposure to cold, over- exertion, excesses in eating and drinking, or great excitement, often being necessary to give efficiency to the special cause. Either sex and all ages are susceptible to the poison. The mode of infection is not positively understood. It often enters the system in the inspired air, and no doubt also in contaminated drinking-water or other fluids. Pathological Anatomy. Blood dark, from the formation of pigment (Afelanczmia). Spleen engorged and swollen {Ague cake). Liver swollen and engorged during paroxysm. Varieties. Quotidian when a daily paroxysm ; tertian when every other day ; quartan when it occurs first and fourth days ; octaii when weekly; duplicated quotidian when two paroxysms daily; duplicated tertian, two every second day ; double te?'tian, daily paroxysm, but more severe every second day. Dumb ague, or masked ague, presents irregularity of the characteristic phenomena. Symptoms. Each paroxysm has three stages — the cold, hot, and sweating. Cold stage begins with prodromes, lassitude, yawning, headache, and nausea, followed by a chill ; the teeth chatter, skin pale, nails and lips blue, the surface rough and pale, the so-called goose-skin, or cutis anserina, nausea, and great thirst, while the thermometer in the axilla or mouth shows a decided rise of temperature, io2°-io_l° F. ; these phenomena continuing from one half to an hour. Hot stage begins gradually, the shivering ceases, the surface be- comes hot and flushed, the temperature rising to 106 F. or moie, pulse full, headache, nausea, intense thirst, dry, flushed, swollen skin, FEVERS. 41 scanty urine, and other phenomena of pyrexia, continuing from one to eight or ten hours. Sweating stage begins gradually, first appearing on the forehead, then spreading over the entire surface; the fever lessens, the tem- perature rapidly falling to 99 or 98 , pulse less full, headache lessens, and a general feeling of comfort exists, sleep often following; dura- tion of the sweating from one to four hours, when the intermission occurs, the patient apparently well, except for a feeling of general debility. The occurrence of the next paroxysm depends upon the variety of the attack. The paroxysm may be ushered in by a decided pain in one or more nerves, instead of the cold stage, to wit : " brow ague." Diagnosis. No difficulty when the characteristic chill, fever, and sweats occur and enlarged spleen, and the presence of the organism in the blood. Hectic fever. Distinguished by its irregularity, and occurring secondary to an organic disease ; spleen usually normal size, and absence of the organism in the blood. Pycemia produced by other causes than malaria. Nervous chills show an absence of the temperature rise. Prognosis. Recovery the rule. Without treatment many cases end favorably after several paroxysms, others passing into the chronic form, or malarial cache xice. Treatment. Cold stage can be averted and the other stages greatly modified by a hypodermic injection of either morphines sulphas, gr. l /%-]i (0.008-0.016 Gm.), or pilocarpines hydrochloras, gr. yi (0.008 Gm.), or chlorofornii spts., fgj (4 Cc), by the stomach. Hot stage, cool drinks and cold sponging. Sweating stage : when ex- cessive, sponging with alumen and hot water. Intermission : at once a brisk purgative, followed by cinchona in some form, the most efficient being quinines sulphas, gr. xvj-xxiv (1-1.6 Gm), in solution or freshly made pills, in one or two doses, three to five hours before the expected paroxysm. Many substitutes are lauded to replace the salts of cinchona bark, but without a doubt quinina is a specific in the strictest sense of the term. Free action on the bowels is essential to success, a good combina- tion being hydrargyri chloridi mitis, sodii bicarb., aa gr. v (0.32 Gm.), followed by an active saline. 42 PRACTICE OF MEDICINE. After the paroxysms are broken up use liquor potassii arsenitis, n\,v-x (0.3-0.6 Cc), for a long time, or tinct. ferri chloridi, n\,xx (1.3 Cc), every four hours or a combination like the following : R . Ferri reducti, Quininoe sulph. , aagr. lx 4. Gm. Acidi arsenosi, gr. j .065 Gm. 01. pip. nigr., ti\xv 1. Cc. M. Ft. pil. No. xxx. Sig. — One pill after meals, continued for one month or longer. Relapses being common, quinines sulphas should be given on the second or third day, fourth to the sixth, twelfth to the fourteenth, and ninetee?ith to the twenty-first days. If the spleen be enlarged, — and it usually is in long-continued cases or those becoming chronic (marked anaemia, gastric distress, consti- pation with depression of spirits associated with headache coming in paroxysms are the prominent symptoms of the cachexia), — use locally ung. hydrargyri iodidi rubri, and internally ergota, or ergotine (aq. ext.), hypodermically over the splenic region, and tonic doses of quinina, ferrum, and arse?iicum. REMITTENT FEVER. Synonyms. Bilious fever ; bilious remittent fever ; marsh fever ; typho-malarial fever. Definition. A paroxysmal fever, with exacerbations and remis- sions, but in which the temperature is constantly above the normal ; characterized by a moderate cold stage (which does not recur with each paroxysm) ; an intense hot stage, with violent headache and gastric irritability ; and an almost imperceptible sweating stage, which is frequently wanting. Cause. The presence in the blood of a specific vegetable micro- organism, either the Bacillus malaria (Klebs and Tommasi Crudeli), or the hcEmatozoa of Laveran {vide Intermittent Fever). Pathological Anatomy. Blood dark (Melan&mia) ; spleen enlarged, soft, filled with blood, and of an olive color ; liver congested and swollen, and of a bronze hue ; the brain hyperaemic and olive- colored ; gastro-intestinal canal markedly hyperaemic. Symptoms. Cold stage : moderate chill, the temperature rising FEVERS. 43 one or two degrees, coated, dry tongue, oppression at the epigastrium, slight headache, and pains throughout the body. Hot stage : persistent vomiting, furred tongue, full pulse, rising to 100 or 120, flushed face, injected eye, violent headache, pains in limbs and loins, hurried respiration, the temperature rising to 104 F., or 106 . The bowels costive, stools tarry and offensive, the urine scanty, high colored and ureaic, and the surface becoming yellowish. Deli- rium occurs when the temperature is very high. Sweating stage : after six to twenty-four hours the above symptoms abate and slight sweating occurs, the pulse, headache, and vomiting subside, and the temperature falls to ioo° F., or 99 F. This is the remission, during which the symptoms of a mild pyrexia are present. After some two to eight or twelve hours the symptoms of the hot stage return, generally minus the chill, and this is termed the exacerbation, which is in turn again followed by the remission. Duration. From seven to fourteen days the average. Fre- quently the fever ceases to re?nit, and instead becomes continuous, the symptoms resembling, if they are not identical with, the typhoid state, whence the term typho-malarial fever, or malario-typhoid fever. Sequelae. The malarial cachexia results when the poison has not been eliminated from the system. Persistent headache and vertigo are the results of the intense meningeal hyperemia that sometimes occurs. Diagnosis. In intermittent fever each paroxysm begins with a chill, while the chill seldom recurs in remittent fever; a distinct intermission follows each paroxysm of the intermittent form, while a remission occurs in remittent, the thermometer showing that the fever does not wholly disappear ; during the intermission the patient is appa- rently well ; such is not the case in the remission of intermittent fever. Typhoid Fever is mistaken for remittent fever, but the absence of the characteristic temperature record, diarrhoea, eruption, tympanites, deafness, severe prostration, and the Widal reaction, with the pres- ence in blood of the malarial organism, should prevent such an error, as a diagnosis can always be made with absolute certainty by an examination of the blood. Prognosis. Uncomplicated cases are favorable. Treatment. Quinines sulphas, gr. xvj-xx (1-1.3 Gm.) per diem, is the remedy. Better administered during the remission, if possible. gr. v .3 Gm. gr. v .3 Gm. gr. ss .03 Gin. 44 PRACTICE OF MEDICINE. If an irritable stomach prevents its administration by the mouth, use it by the hypodermic method or in a suppository. During the hot stage, cool sponging, cold to the head, and if a tendency to cerebral congestion, dry or wet cups to the nape of the neck and — R. Tinct. aconit. rad. TTljj .12 Cc. Liq. potassii citrat., fgij 8. Cc. Liq. ammon. acetat., f 3 ij 8. Cc. M. Every two hours. During the remission relieve the intestinal canal with — R . Hydrargyri chlor. mitis, . . Sodii bicarb. , Pulv. ipecac, gr. ss .03 Gm. M. In pulv. p. r. n. The same precautions are essential after the paroxysms are broken up to prevent their return on the septenary periods that were recom- mended for intermittent fever. It is but fair to mention the statement of Koch, seconded by Hare, that quinina is a nephritic irritant, but if so, it must be in toxic amounts, which are not recommended. For convalescence : Ferritin, arsenictim, and sirychnina are indi- cated. PERNICIOUS MALARIAL FEVER. Synonyms. Congestive fever; malignant intermittent fever; malignant remittent fever ; the congestive chill. Definition. A malignant, destructive malarial fever, which may be of the intermittent or remittent form; characterized by intense congestion of one or more internal organs, together with dangerous perversion of the functions of innervation. Cause. A high degree of malarial poison. {Vide Intermittent Fever.) Varieties. Gastro-enteric ; thoracic; cerebral ; hemorrhagic; algid. Symptoms. Any of these varieties may begin either as an inter- mittent or remittent fever; again, the first paroxysm is rarely per- nicious, but appears as the ordinary malarial attack. FEVERS. 45 The gastro-enteric variety has, as distinctive features, intense nausea and vomiting, purging of thin discharges mixed with blood, tenesmus, burning heat in stomach, intense thirst, frequent, weak -pulse, face, hands, and feet cold, with shrunkefi features, and an intense depres- sion of all the vital forces. This condition continues from half an hour to several hours, when either an inter- or a remission occurs. Thoracic variety often combined with the one just described. Its characteristic features are due to overwhelming congestion of the lungs, such as violent dyspnoea, gasping for air, fifty to sixty respira- tions per minute, oppressed cough with slight amount of blood-streaked sputa, frequent, weak pulse, cold surface, and terror-stricken features. Duration same as the above. Cerebral variety, due to intense congestion of the brain ; sometimes effusion of serum into the ventricles, or even rupture of small blood- vessels. Characterized by violent delirium, followed by stupor and coma, slow, full pulse, the surface either flushed or livid. Cases may either resemble apoplexy — comatose variety — or acute meningitis — delirious variety. Duration same as the other forms. Hemorrhagic variety, or the yellow disease, as it has been termed, begins as an ordinary inter- or remittent fever, soon followed by signs of internal congestion, to wit : nausea, vomitmg, dyspnoea, severe pains over liver and kid?iey, continuing for a few hours, when the surface suddenly turns yellow and bloody urine is voided, after which an inter- or a remission and marked abatement occur, to be sooner or later followed by a second paroxysm, which is more severe, with signs of cerebral congestion. Blood may also escape from other parts than the kidneys. Algid variety is characterized by intense coldness of the surface, while the rectal temperature ranges from 104 to 107 F. The attack begins with a chill, which is soon followed by fever of variable dura- tion, when the body becomes cold, the axillary temperature falling to 90 , 8S°, or even 85 F., a cold sweat covers the surface, the tongue is white, moist, and cold, the breath is icy, the voice feeble and indistinct, the pulse slow, feeble, and often absent at the wrist, and with all these symptoms, the patient complains of a sensation of burning and intense thirst. The mind is clear, but the countenance is death-like. Duration. Pernicious malarial fever, in any of its forms, may 46 PRACTICE OF MEDICINE. continue from a few hours until one, two, or three days. Recovery- is rare after a second, almost never after a third, paroxysm. Diagnosis. A positive diagnosis can always be made by an examination of the blood. Yellow fever is most apt to be confounded with the hemorrhagic variety, and as they both occur in the same localities, the diagnosis is difficult; the early yellowness of the surface, with hematuria and the absence of the black vomit and epidemic prevalence, are the chief points of distinction. The cerebral variety may be mistaken for cerebral apoplexy, men- ingitis, and urcemic convulsions. Nor is it always an easy matter to differentiate between these conditions. The gastro-enteric variety may be mistaken for the early stage and the algid variety for the later stage of cholera, but the epidemic prevalence of the latter should be of material aid in determining the diagnosis. Prognosis. In all varieties the result is unfavorable, unless it can be controlled prior to the second paroxysm. Cases in which an intermission occurs are better controlled than where a remission follows. The mortality is one in eight from all plans of treatment. Treatment. The first indication in all varieties is to bring about reaction. In the cold stage, heat to the surface, and stimulating lotions ; in the hot stage, cold to the surface and the hypodermic injec- tion of morphince sulphas, gr. % (0.016 Gm.), at once. After reaction, quinina? sulphas, not less than gr. xl (2.6 Gm.), repeated p. r. n.; administer by stomach, rectum, or, better still, by hypodermic injec- tion. Dr. Bartholow pronounces the following one of the best formuke for the hypodermic use of quinina : li . Quininae disulph., gr. 1 3.3 Gm. Acid, sulph. dil., rr\ c 6. 15 Cc. Aquae font, f^j 30. Cc. Acid, carbol. liq., V(\y .3 Cc. M. The new salt, quinina bimuriatica carbamidata, is highly recom- mended for hypodermic use, being very soluble. The following formula, known as " Warburg's Tincture," has (luring the last few years gained considerable reputation in the various forms of malarial fevers : FEVERS. 4 J R . Rad. rhei, P. aloe soc. , and Rad. angelica officinalis, ... aa ^ iv 120. Cc. Rad. helenii, Crocus Hipsan., Sem. fceniculi, and Creta prse- parat., aa ^ ij 60. Cc. Rad. gentian, Rad. zedoar, P. cubeb, G. myrrh, G. camphor, and Boletus Laricis, ... aa %') 30. Cc. Confect. damocratis,* ^iv 120. Cc. Quininse sulph. , J lxxxij 2460. Gm. Spts. vini rect., Oxx 600. Cc. Aquae purse, Oxij 360. Cc. M. Macerate in a water bath twelve hours, express, and filter. Each half ounce (15 Cc.) contains quininse sulphas, gr. viiss (0.46 Gm.). If the stomach is too irritable to retain the tincture, the tincture may be evaporated to dryness and administered in capsules, each containing the equivalent of either one or two drachms. For the gastro-enteric variety, Prof. Da Costa suggests : rj< . Morph. sulph., gr. 14 .016 Gm. Pulv. camph., gr. j .065 Gm. Mass. hydrarg. , gr. ij .12 Gm. Pulv. capsici, gr. ss .03 Gm. M. In pills every half hour until the character of the stool is changed. For the thoracic variety, dry or wet cups and ammonii carbonas, * Formula of Confectio damocratis : Cinnamon, 14. Gm. Myrrh, 11. Gm. White agaric, Spikenard, Ginger, Spanish saf- fron, Treacle, Mustard seed, Frankincense, and Chian Turpentine, aa 10. Gm. Camel's hay, Costus arabacus, Zeodary, Indian leaf, Mace, French lavender, Long pepper, Seeds of harwort, Juice of rape cistus, Strained storax, Opponex, Strained galba- num, Balsam of Gilead, Oil of nutmeg, Rus- sian castor, aa 8. Gm. Water germunder, Balsam tree fruit, Cubeb, White pepper, Seeds of carrot of Crete, Poley mont, Strained bdellium, aa 7. Gm. Gentian root, Celtic hard, Leaves of Dittany of Crete, Red rose, Seeds of Macedonium, Parsley, Sweet-fennel seeds, -Seeds of lesser cardamon_, Gum arabic, Opium, aa 5. Gm. Sweet flag, Wild valerian, Anise seed, Saga- pernum, aa 3. Gm. Spigrul, St. John's wort, Juice of acacia, Cate- chu, Dried bellies of skunk, aa 2.5 Gm. Clarified honey, 915. Gm. The roots to be finely powdered and the whole mixed thoroughly. 48 PRACTICE OF MEDICINE. spiriius ammonia aiomaticus, caffeina citrata, and hypodermic injec- tions of strychnine sulphas. For the cerebral variety, venesection, or cups or leeches to the neck, cold to the head, prompt purgation, and free action on the kidneys and skin. For the algid variety, warmth to the surface, hypodermic use of morphince sulphas and atrophia, and the free use of ammonii car- bonas and alcoholic stimulants. For the hemorrhagic variety, purgatives, morphines sulphas hypo- dermically, and either acidum sulfthuricum dil., acidum gallic, Af onset's solution, or terebinthina. The following is highly spoken of for hemorrhages : H- Ext ergotcefld., f£ ss 15. Cc. Acid, sulpli. dil., f^iss 6. Cc. Acid, gallic, 5{j 4. Gm. Syr. zingib., • . . . f^iij 12. Cc. Aquae, q. s. adf^iij ad 90. Cc. Sig. — Dessertspoonful every four hours, well diluted. After the paroxysms are controlled, a long course of ferrum and arsenicum, with quinina on the septenary days. 1/ YELLOW FEVER. Synonyms. Yellow Jack; bilious malignant fever ; typhus icter- ode; Mediterranean fever ; sailor's fever ; black vomit. Definition. An acute, infectious, paroxysmal disease, of three stages — the febrile, the remission, and the collapse ; characterized by violent fever, yellowness of the surface, and " black or coffee-ground vomit." Tendency fatal ; one attack confers immunity from a sec- ond. Not contagious. Cause. A specific poison, existing only with a high temperature and destroyed by frost. Not due to the malarial poison. Usually seen during the months of June, July, August, and September. The true home of yellow fever is in the tropics. Guiteras mentions three areas of infection : 1. The focal zone in which the disease is never absent, including Havana, Vera Cruz, Rio, and other Spanish-American ports. 2. Peri-focal zone or regions of periodic epidemics, including the ports of the tropical Atlantic in FEVERS. 49 America and Africa. 3. The zone of accidental epidemics, between the parallels of 45 north and 35 south latitude. Epidemics are due to the introduction of the specific germ, either from patients affected with the disease or through infected articles. Neither age, sex, race, nor social condition has immunity. One attack protects the individual. Pathological Anatomy. Skin lemon or greenish-yellow color, due to dissolution of the red blood corpuscles ; heart softened by granular degeneration ; stomach, veins deeply engorged, the mucous membrane softened, and containing more or less "coffee-ground" matter, which consists of blood corpuscles deprived of their haemo- globin, white corpuscles, epithelial cells, and debris. Intestines much the same as the stomach ; liver, yellow color and a fatty degeneration of the hepatic cells ; kidneys, granular degeneration of the epithelium of the tubules. The spleen presents a singular lack of pathological change. Symptoms. The incubation lasts from twenty-four hours to six and exceptionally ten days. The more severe the epidemic, the shorter the period of incubation. First stage, the febrile, beginning either with the prodromes of malaise, headache, and anorexia, or suddenly with a chill, high/ever, in a few hours reaching 104 to 106 F., rapid pulse, 90-100 beats, brilliant eye, flushed countenance, coated tongue, irritability of the stomach, and severe neuralgic pains in the head, limbs, epigastrium, back, and large joints. The patients are restless and anxious, with a feeling of general prostration. In severe attacks delirium is fre- quent. The urine is scanty, acid, high colored, and contains albu- min. A peculiar and characteristic odor is emitted from the patient. Duration of the first stage from thirty-six hours to three or four days. Second stage, the reniission, when the temperature declines to ioo° or 99 F., and all the distressing symptoms abate or subside, and with some critical evacuation convalescence occurs, or, more com- monly, after from a few hours to one to four days, the — Third stage, the stage of collapse, or the period of secondary fever, is ushered in by a return of all the symptoms of the first stage in an exaggerated form, followed by yellowness of the skin, passing to a deep mahogany color, black vomit, and hemorrhages from other parts, feeble pulse, cold surface, irregular respiration, and death from ex- haustion, the mind remaining clear until the end. 5 50 PRACTICE OF MEDICINE. The above symptoms represent a sthenic case ; other varieties are the algid, hemorrhagic ', and typhus. Duration. Depends upon the variety ; from a few hours to a few- days. Rarely continues longer than one week. Diagnosis. Pernicious fever, hemorrhagic variety, is apt to be mistaken for yellow fever. Yellow fever is a disease of one paroxysm and one remission, epidemic, with albuminuria and black vomit. Pernicious fever has more than one paroxysm, not epidemic, rarely black vomit or albumin in urine. A valuable diagnostic point from malarial fevers is that quinine has no similar influence over yellow fever. Prognosis. One in four perish. Short cases unfavorable, as are the hemorrhagic and algid varieties. Treatment. No specific : a " self limited '" disease. The indica- tions are to keep the patient quiet in bed, and to treat the symptoms as they arise, and to nourish the patient. Good nursing, ventilation, early emesis and purgation, with diaphoretics and diwetics, are apparently beneficial. Large doses of quinince sulphas, early in the attack, for high temperature, by hypodermic method. For the irrita- ble stomach, ice slowly dissolved in the mouth, and acidum carbolicum, gr. X (0.016 Gm.), in aqua menthce pip., every two hours, alternated with liquor calcis and milk, each an ounce ; or — R . Hydrargyri chlor. mite, .... gr. ^ .005 Morphince sulph., gr. fa .003 M. Every two hours until nausea is controlled. Surgeon-General Sternberg suggests the following toward a specific action : R. Sodii bicarb. , gr. cl 10. Gm. Hydrargyri chloridi corr., ... gr. y^ .02 Gm. Aquce destillat., Oij 950. Cc. M. SlG. — Three tablespoon fuls every hour. For the black vomit and hemorrhages, either liquor ferri subsul- phatis or plumbi acetas. The pains, restlessness, or delirium are best controlled by the hypodermic use of morphince sulphas or atrophia?. Free stimulation from the onset is needful. When an epidemic of yellow fever breaks out all persons whose duty does not keep them with tlie sick should leave the infected dis- FEVERS. 51 trict at once. " The cardinal principles involved in prophylaxis dur- ing an epidemic are summed up in the oft-quoted words, 'Isolation, disinfection, and depopulation.' " ERUPTIVE FEVERS. As a group, the eruptive or exanthematous fevers have many feat- ures in common. All have a period of incubation, are characterized by a fever of more or less intensity preceding the eruption, by an eruption which is peculiar to each, occurring most commonly in childhood, rarely attacking the same person twice, very prone to occasion serious sequelae, and are contagious. Their origin is as yet undetermined. SCARLET FEVER. Synonym. Scarlatina, from the (old) Italian scarlattina, scarlatto (red). Definition. An acute, self-limited, contagious, infectious disease, usually of childhood ; characterized by high temperature, rapid pulse, a diffused scarlet eruption, terminating with desquamation, inflam- mation of the mouth and throat, and frequently more or less grave nervous phenomena. Serious sequelae frequently follow an attack. One attack confers immunity from the disease. Pathological Anatomy. An acute inflammation of the skin, with exudation — a true Dermatitis. A granular change in all the glandular structures, most marked in the Peyerian glands, although also occurring in the stomach and kidneys. Streptococci are usually found in abundance in the glands and areas of suppuration. Cause. A specific poison, maintaining its vitality for a long time. Highly contagious, the contagion residing chiefly in the desquamated epidermis. Klebs' micrococci, the " monas scarlatinosum," may prove to be the poison. Incubation short, one to seven days. Varieties. Scarlatina simplex, scarlatina anginosa, and scar- latina ?naligna. Symptoms. A mild attack is a very trivial affection, but in its severest form there are few diseases more malignant. Onset sudden with a decided c/zilland vomiting (in infants, convul- 52 PRACTICE OF MEDICINE. sions), pain in the throat followed by high fever, soon reaching 105 ; a rapid pulse, no to 140, being frequent. At the end of twenty-four hours a bright scarlet rash appears on the neck and chest, spreading over the entire body within a few hours; the eruption is not raised, there is no intervening healthy skin, and scattered irregularly are points of a darker hue. With the appearance of the eruption occurs burning heat of surface, pain in the throat, and difficulty in deglu- tition, the throat on inspection presenting the appearance of a catar- rhal inflammation. Tongue at first furred, later red, with prominent papillae — the "strawberry tongue." There also occurs headache, great restlessness, and in severe cases delirium. Diarrhoea quite common. On the fourth or fifth day the fever declines by lysis, the eruption fading, and on the sixth or eighth day desquamation begins, con- tinuing for ten days, two weeks, or longer, the convalescence being slow, the patient emaciated and pale. Scarlatina anginosa are cases like the above with the addition of great inflammation and swelling of Xhe pharynx, nose, palate, tonsils, and neighboring glands, the swollen glands pressing upon the sur- rounding parts, causing difficulty of breathi?ig and of deglutition. Frequently the enlarged glands suppurate, increasing the constitu- tional symptoms and the distress of the patient. Scarlatina maligna are cases with decided nervous phenomena, to wit : convulsions, delirium, and muscular twitching, the temperature reaching 107 to 1 io°, the pulse rapid, feeble, and irregular, the erup- tion delayed, of a purplish color, and in patches. Complications. Three conditions are always to be looked for in all cases of scarlet fever ; otitis, affections of the joints, and acute nephritis, each adding to the gravity of the attack. The association of diphtheria with scarlet fever adds to the severity of the attack. The engrafting of these two diseases on the same individual is not an infrequent occurrence. Sequelae. Chronic sore throat; conjunctivitis ; otorrhcea; chronic diarrhoea ; subacute rheumatism ; chorea ; endocarditis ; pericarditis ; pleuritis; acute Bright' s disease, and cutaneous dropsy. Diagnosis. A typical case should cause no difficulty ; the high fever, rapid pulse, sore throat, and early scarlet eruption, followed by desquamation, should leave no doubt. Measles : the above symptoms are absent, and catarrhal symptoms FEVERS. 53 present, the later appearance of the eruption and the difference in its character. Small-pox : eruption on the third day in spots, changing to pustules with secondary fever. Dengue or break-bone fever : absence of the above typical symp- toms, and presence of severe pains in the bones. Diphtheria : gradual invasion, great prostration, and no eruption, but the frequent complication of scarlatina and diphtheria must be remembered. Meningitis may be suspected from the symptoms of scarlatina maligna ; the epidemic influence, eruption, and rapid pulse are points of difference. Prognosis. Depends upon the character of the attack and the association of complications. Acute nephritis, endo- and pericarditis, and pleuritis add to the gravity. The prognosis is more grave, how- ever, from the association of diphtheria, the inflamed naso-pharynx presenting fertile soil for the ravages of that grave malady. Never can be positive of the result. Mortality ranges from ten to twenty- five per cent. Treatment. As with other eruptive fevers, so with scarlatina, there are no specific remedies by means of which it can be arrested or controlled. Symptomatic treatment judiciously applied, however, may afford relief and diminish the fatality. The indications are for rest in bed, good ventilation, isolation, dis- infection, cooling drinks, action upon the skin, and light nourishment. For a case of scarlatina simplex small doses of hydrargyri chloridi mite, sodii bicarbonatis, and pulvis ipecac, every two or three hours until thorough movement of the bowels occurs, will favorably influence the fever and rapid pulse and general distress. For cases with high/ever and rapidity of pulse, aconitum, digitalis, quinines sulphas; or, antifebrin, gr. j-ij (0.065-0.13 Gm.), every couple of hours, or phenacetin, gr. j-ij (0.065-0.13 Gm.), every two or three hours, with cool sponging, cold bath, douche, or pack. When, how- ever, the temperature reaches 102. 5 , at once use full bath at 90 F., for eight to ten minutes, then dry child quickly, wrap in blanket and put to bed, repeating bath if temperature and nervous phenomena are marked. If the surface be pale, the circulation feeble, and the eruption tardy in appearing, benefit will follow the administration of tinclura digi- 54 PRACTICE OF MEDICINE. talis or tinctura belladonna, TT\j-v (0.06-0.3 Cc), according to age, and a hot bath or pack. With the appearance of the eruption anoint the entire body, save the head, with — R. Eucalyptol, f^j 4. Cc. Ung. petrolei, ^j 30. Gm. M. The inunction acts beneficially in many ways. It reduces the fever by soothing the cutaneous burning and irritation ; later on, when desquamation occurs, it limits the source of further infection by pre- venting the diffusion of the otherwise dry scales in the air ; and, finally, it protects the surface from the influences of sudden changes of temperature, thus to a great extent avoiding the danger of nephritis. For scarlatina anginosa, the internal use of the following combina- tion is valuable as a blood tonic and throat astringent : R. Tinctune ferri chlor., f^ij 8. Cc. Glycerini, f^j 30. Cc. Aquae, q. s. ad f^ij ad 60. Cc. M. Sic — One-half to one teaspoonful every two hours, undiluted, according to the age. Externally, ice or cold compresses, unless they cause chilliness, if so, heat. Astringent gargles and small pellets of ice dissolved in the mouth are of use. The throat and nasal cavities are kept clean and the breathing relieved by the use of Dobell's solution used with a hand atomizer every hour. The formula is : R. Acid, carbolici, f^iss 6, Cc. Sodii biboracis, Sodii bicarb., aa gij 8. Gm. Glycerini, f^ij 60. Cc. Aqua?, q. s. ad Oij ad 950. Cc. M. The use of this solution proves grateful to the patient, relieving the breathing through the nose by loosening the tenacious secretions. An excellent gargle for those old enough to properly use one is : R. Thymol, gr. iv .26 Gm. Glycerini, f5j 30. Cc. Aq. de.-^t. , 13 j 30. Cc M. SlG. — A throat wash. If necessary, dilute further. FEVERS. 55 An excellent mouth and throat cleanser as well as gargle is aqua hydrogenii dioxidi, full strength or diluted. For scarlatina maligna, in addition io ferrum and quinince sulphas, the chief reliance must be on alcoholic stimulants, guiding the amount by their effects. In children, wine-whey, milk-punch, and egg-nog are eligible for the administration of stimulants and nourishment. Convulsions, or only great restlessness and muscular twitchings, are the result of the high grade of fever, and call for prompt treatment. Experience in such cases is against the group of antipyretic drugs, as not meeting the indication promptly enough. The cold wet pack or the cold bath with cold affusion or the ice cap are the most efficient and rapid means of reducing the temperature and relieving the nervous disturbances. Prof. Da Costa advocates the administration of ammonii carbonas, in small doses at frequent intervals, to prevent the liability of heart- clot, and for its salutary influence over the disease. It is claimed that a characteristic micrococci is found in the blood, and that, consequently, the disease can be favorably influenced by acidum carbolicum, thymol, or acidum boricum ; an eligible way of administering acidum carbolicum is the syr. ammonia phenatis (Declat), fgss-j (2-4 Cc), four to six times daily. There can be no doubt but that the complications and sequelae attending scarlet fever constitute the principal dangers of the dis- ease. If diphtheria develop, the combination of ferrum and hydrargyri chloridum corrosivum with free alcoholic stimulation are the indica- tions. Acute nephritis is so commonly associated with, or follows the decline of scarlatina that it is a prudent practice to examine the urine daily. If albumin appear, add to the ferrum, tinctura ca?i- tharidis in minute doses, and dropsy and uraemic symptoms may be prevented. If, however, true scarlatinal nephritis does develop, the following mixture of Hughes-Bennett, with saline purgatives and either a hot bath or the hot-air bath twice or oftener daily, will be followed by improvement : R. Potassii acetat., 5?ij 8. Gm. Spts. aetheris nitrosi, f.^ ss I S- ^ c - Aquae, q. s. ad f 3 ij ad 60. Cc. M. Sig. — Teaspoonful every two hours, well diluted. 56 PRACTICE OF MEDICINE. Or— R • Hydrargyri chlor. mite, Pulv. scillae, Pulv. digital., aa gr. X - /^ .016-032 Gm. M. Ft. pil. No. j. Sig. — One such pill every three or four hours. If uraemic convulsions occur, use the hot-air bath, cupping over the kidneys, hypodermic injections of pilocarpines nitras, the inhala- tion of chloroformum, or, may be, the rectal use of chloral hydrate with or without potassii bromidum. Uraemic symptoms are often re- markably controlled by full doses of sodii benzoas. The elimination of the poison producing the convulsions is assisted by the high bowel enema of the normal salt solution. For scarlatinal rheumatism the use of ferrum alternately with the following : R . Ammonii salicyl., ^ij 8. Gm. Elix. simplicis, f.^ ss l S- Cc. Syr. simplicis, f 5j 30. Cc. Tinct. card, co., fj ss J 5- Cc. M. SlG. — Teaspoonful, diluted, four times daily. For inflammation of the middle ear it is much better to puncture the drum membrane than to allow its ulceration ; insufflations of acidum boricum and the internal use of ammonii chloridum. For the various other sequelcz the treatment is the same as if they occurred primarily, plus tonics. The disease being contagious, every means should be taken to prevent its spread — to wit, isolation, cleanliness, disinfection, and fumigation. Small doses of quinina, in those exposed, is said to prevent or modify the severity of an attack, but no true prophylactic is known. . J MEASLES. Synonyms. Morbilli ; rubeola. Definition. An acute epidemic and contagious disease ; charac- terized by catarrhal symptoms, referable to the naso broncho-pul- monary mucous membrane, fever, and a crimson mottled, papular, eruption which terminates by desquamation. FEVERS. 57 Cause. A specific micro-organism, with a special susceptibility for childhood. Contagious by contact, and can be communicated by inoculation. One attack, as a rule, protects from a second. Incuba- tion, ten to fourteen days. Pathological Anatomy. There are no special anatomical characters exclusive of the eruption, which is considered among the symptoms of the disease. Symptoms. Onset gradual, following a chill or with irregular chills, fever, the temperature rising to ioi° or 102 , muscular soreness, headache, and intense nasal, pharyngeal, and laryngeal catarrh. The eyes are reddened and suffused and tears flow over upon the face. The throat is reddened and swollen. On the evening of the second day a decided remission takes place in the fever, the catarrh continuing ; on the fourth day occurs an eruption of a crimson color on the face, soon spreading over the body, in the form of papules and blotches, which coalesce into irregular circles or crescents, with islands of white skin between, and with the appearance of the eruption the fever returns, the catarrh is aggravated, but the character of the dis- charge, instead of remaining clear and watery, becomes turbid, thick, and yellowish, and extends to the bronchial mucous membrane. About the ninth day (the fourth of the eruption), the eruption fades, the symptoms abate, and slight desquamation occurs. Some cough and catarrh may remain for a long period. Black measles, sometimes called hemorrhagic rubeola, or camp measles, is a variety occurring in camps and jails, in which occur dangerous chest symptoms, and black spots or rjetechiye from deteri- orated blood, and severe prostration. Koplik, in 1896, described a peculiar eruption found on the buccal mucous membrane (lining lips and cheeks only), consisting " of small, irregular spots of a bright red color ; in the center of each spot a most minute bluish-white speck. These minute bluish-white specks in the center of a reddish spot are pathognomonic of beginning measles." I have almost invariably found them at the onset of the chill and catarrhal symptoms, and been able to make a diagnosis before the characteristic eruption of measles appeared. These tiny spots fade with the appearance of the mottling of the skin. Rather common complications are tonsillitis, and lobar ox catarrhal pneumonia. 6 58 PRACTICE OF MEDICINE. Sequelae. In those of strumous diathesis, scrofula or tuberculosis may develop. Diagnosis. A typical case begins gradually, with chilliness, nasal catarrh, watery eye, and fever, which decline before the erup- tion, rising afterward; the eruption is crescentic in shape and of a crimson color, beginning on face, followed by desquamation. If ex- perience shall determine that the eruption mentioned as occurring on the buccal mucous membrane at the onset is invariable, the diagnosis will be readily determined. Scarlet fever : absence of catarrh, and earlier appearance and dif- ferent character of the eruption, with high fever and rapid pulse. Prognosis. As a rule, a perfect recovery. If tuberculosis de- velop, the prognosis is bad. Black measles, the majority succumb. Treatment. No specific. Mild cases require no medicine, sim- ply regulating the diet and bowels, and cool sponging; the indica- tions are to render the patient as comfortable as possible, the disease pursuing a favorable course without therapeutical interference. If the febrile reaction is high, the following soon controls it : K . Tinct. aconiti rad., W\,ss-j .03-.C6 Cc. Spts. retheris nitrosi, ttlx-xv .6-1. Cc. Liquor potassii citrat., . . . . adf^j 4. Cc. Every two hours. For the pruritus of the eruption, the local use of oils and fats, par- ticularly of eucalyptol, f^ss-j (2-4 Cc), ung. petrolei, 3J (30 Gm.). For catarrhal symptoms, inunction of the nose, neck, and chest with camphorated oil and small doses of pulv. ipecac, et opii at bed- time ; if the catarrh extends to the bronchial mucous membrane, expectorants. During convalescence, for the strumous, protect from exposure, and administer oleum morrhua with syr. ferri iodidi. For black measles, bold stimulation, and ferrwn and quinina. RUBELLA. Synonyms. Rotheln ; epidemic roseola ; German measles ; French measles; false measles. Definition. An acute, self-limited, contagious disease; charac- FEVERS. 59 terized by mild fever, suffused eyes, cough and sore throat, enlarge- ment of the lymphatic glands of the neck, and a rose-colored eruption, in patches of irregular size and shape, appearing on the first day. Many so-called second attacks of measles and scarlet fever are attacks of rubella (Tyson). Cause. Propagated by contagion. That a peculiar germ exists is probable, but thus far it has not been isolated. Incubation from one to three weeks. Rubella bears the same relation to measles that chicken-pox does to small-pox (Tyson). Symptoms. Onset sudden, with mild fever, suffused eyes, with little or no coryza, sore throat, and enlargement of the cervical glands, not limited to those about the angle of the jaw, as in scarlatina. Any time from the first to the fourth day appear rose-colored spots, size of a pin-head, slightly elevated, which coalescing, form irregular shaped and sized patches, with intervening healthy skin, fading on the upper part of the body while just appearing on the lower. Symp- toms all terminate within a week by lysis, the patient showing no ill effects from the attack. Diagnosis. From scarlet fever, by absence of high fever, the rapid pulse, the color and character of the eruption, and the sequelae. From measles, by absence of intense catarrhal symptoms, the late appearance of eruption, and its crescentic shape. Prognosis. Most favorable. Treatment. Mild laxatives and restricted diet. If fever high, saline mixture. For itching of skin, sponging with vinegar and water, or inunction with vaseline. SMALL-POX. Synonym. Variola. Definition. An acute epidemic and contagious disease ; charac- terized by severe lumbar pains, vomiting, and an initial fever, lasting from three to four days, followed by an eruption, at first papular, then vesicular, and afterward pustular ; the development of the pustule being accompanied by a secondary fever, during the presence of which grave complications are prone to occur. Causes. A specific poison whose nature is unknown, maintaining CO PRACTICE OF MEDICINE. its contagious vitality for a long period. " There is no contagion so strong and sure as that of small-pox, and none that operates at so great a distance" (Watson). There is no period, from the initial fever to the final desquamation, when the disease is not contagious, although the stage of suppuration is the most virulent. One attack, as a rule, protects from a second. Vaccination has a positive pro- tective influence from the disease, an extensive observation having fully proven that in proportion to the efficiency of vaccination is the rarity and mildness of variola. Incubation, fourteen to sixteen days. Pathological Anatomy. A granular and fatty degeneration occurs in the liver, spleen, kidneys, and heart. The pustules are found in the larynx, trachea, bronchial tubes, and on the pleura. Varieties. Discrete ; confluent ; malignant ; varioloid or modi- fied small-pox. Symptoms. Discrete for?n. Onset sudden, with a viole7it chill, vomiting, and agonizing pains in the back, shooting down the limbs; fever, in short time rising to 103 or 104 F. ; full, strong, and rapid pulse, ranging from 100 to 130; the face red, eyes injected, intense headache, and sleeplessness; prostration great from the very onset. Delirium and convulsions occur at times. During the third day the characteristic eruption makes its appearance, first on the forehead and lips, consisting of coarse red spots. With the appearance of the eruption all the marked symptoms of the fever abate, the patient feel- ing quite comfortable. On thefflh day of the disease the spots be- come papules ; on the sixth day, transformed into vesicles, which are soon umbilicatcd ; on the eighth day the vesicles change to pustules ; on the ninth day the pustules are entirely purulent, and each sur- rounded with a broad red band — the halo or areola, the face becom- ing swollen and the features distorted ; on the eleventh day, pus oozes from the pustules, and drying, -forms the scab, or crust, which, on the seventeenth to twenty-first day, drops off, leaving a red, glisten- ing depression or pit, soon changing into a white cicatrix. With the formation of the pustules {eighth day) severe rigors and fever set in, and a characteristic odor is emitted, all the original symptoms return- ing. This secondary fever, the fever of suppuration, is the most critical period of the disease, and is generally attended with violent delirium. In favorable cases the secondary fever subsides after three or four days, and convalescence is established. Confluent small-pox differs from the discrete in the greater severity FEVERS. 61 of all the symptoms and the marked prostration of the patient, the eruption appearing during the second day, the pustules coalescing into large patches, causing great distortion of the features. Malignant small pox is characterized by the greater intensity and the irregularity of the symptoms, death resulting before the character- istic eruption appears, by convulsions or coma. In these cases hem- orrhages are frequent and petechias are observed. Varioloid, or modified small-pox, is the form modified by previous vaccination, or by a former attack of small-pox. Its course is shorter and milder than the other forms, the eruption appearing a day later, and is not attended with secondary fever. During some epidemics two other eruptions are observed, appear- ing on the second day, one petechial, in the form of a fine macular or spotted eruption on the abdomen and legs, "Simon's triangle" ; the other an erythematous eruption on the sides and inner surface of the legs. Both disappear within forty-eight hours. Complications. During the course of the secondary fever there is a great tendency to grave inflammations, such as pleurilis, pneu- monitis, and dysentery. During convalescence, boils and abscesses on the skin are frequent. Diagnosis. Cannot be confounded with any other disease if it has typical symptoms, such as chill, vomiting, pains in back and legs, high fever and pulse, all declining on third day, when the erup- tion appears, first spots, then papules, then vesicles, finally pus- tules, drying and forming crusts, and with the marked secondary fever. Prognosis. Depends upon the variety of the attack, the age of the patient, and whether vaccinated or not. Discrete, mortality four per cent. ; confluent, fifty per cent. ; malignant, all perish. Under five years and over forty years of age, fifty per cent. die. Treatment. If the patient is seen early, vaccination should be performed at once; it may modify the attack. In the absence of a specific, the treatment is entirely symptomatic. Rest in bed, good ventilation, the temperature kept at 65 F., avoiding draughts. For the initial fever, full pulse, and pains, phenacetin, gr. x (0.65 Cm.), or antifbrin, gr. v (0.32 Gm.), or acetanilidum, gr. v-x (0.32-0.65 Gm.), or, what is still better, as more soluble, a7itipyrin, gr. x (0.65 Gm.), repeated p. r. n., are of great service, rendering the symptoms more endurable. Depressing doses must be avoided. 62 PRACTICE OF MEDICINE. Fur the headache, ice bags to the head and a mustard sinapism to the nape of the neck. For sleeplessness and restlessness or early delirium, full doses of potassii bromidum, chloral, or trional. F 'or secondary fever the best remedy is quinina, gr. v (0.32 Gm.) every three hours, and for cerebral excitement of this period, either full doses of potassii bromidum, by stomach, or the following by rectum : R . Chloral, . . gr. xx 1.3 Gm. Mucil. acacise, fgij 8. Cc. Inf. digitalis, ad q. s. f^j ad 30. Cc. p. r. n. The secondary fever being pyaemic in character, the depression should be anticipated by large doses of tinctura ferri chloridi and judicious stimulation, brandy in tablespoonful (15 Cc.) doses being most efficient. From the onset, milk, eggs, animal broth, oysters, and beef-juice should be administered every three hours. Ice is always grateful and should be given freely, and if pustules appear in the mouth, ice should be held in the mouth as long as possible, and washes of potassii chloras or acidum carbolicum employed. The disease being contagious, isolation, ventilation, cleanliness, and disinfection are imperative. To prevent pitting, keep patient in a dark room, well ventilated. Masks of some unctuous material, thoroughly applied to exclude the air, have a beneficial effect. Success is claimed by a number of ob- servers from the use of collodium applied once or twice daily. Cold water dressings constantly to face and hands are beneficial, besides allaying heat, pain, and swelling. Hot water can be used if more grateful. The water dressings should be made antiseptic with subli- mate solutions, 1 : 5000 or 1 : 10,000; fchihyol,five to twenty percent, solution, painted over the pustules several times a day, is recom- mended to hasten the drying up, check extensive suppuration, and prevent pitting. If water dressing seem undesirable, anoint the body with eucalyptol, f 3 j (4 Cc), rubbed into unguentian petrolei, %) (30 Cc), or acid, carbolic, gr. x (0.65 Gm.) to an ounce (30 Cc.) of vaselin or lanolin. FEVERS. 63 VACCINATION. Synonyms. Vaccinia ; cow-pox. Definition. Inoculation with the matter of vaccinia or cow-pox — bovine virus. The person properly vaccinated is, as a rule, pro- tected from an attack of small-pox, and especially from a severe or fatal attack. Vaccination should be performed at least twice in every individual, during infancy and at puberty ; and it is safer to have it again per- formed if special exposure be liable or has occurred. In practising vaccination the skin should be rapidly scraped until the true skin is reached and is ready to bleed, the lymph being then brushed over the abraded surface ; or, instead, make three or four horizontal and transverse cuts, about four lines long, and rub the virus over them ; a little blood, but not much bleeding, should result. Symptoms. If the vaccination "takes," on the third day a Papule appears ; on the sixth day a vesicle has formed, with a central depression ; on the eighth day a pustule, fully formed and distended with lymph, with a reddish areola, which becomes very wide. The areola begins to fade on the tenth day, the pustule begins to dry, and by the fourteenth day a brown mahogany scab or crust has formed, which is detached about the twenty-third day. The cicatrix is circu- lar, depressed, radiated, and foveated, becoming, after a time, paler than the surrounding integument. During the course of a vaccination more or less constitutional dis- turbance occurs, especially in children. Eczematous and papular eruptions often develop in strumous chil- dren, for which the virus is unjustly held responsible. VARICELLA. Synonym. Chicken-pox. Definition. A mild, slightly contagious, febrile affection ; char- acterized by a moderate fever, and the appearance of a vesicular eruption, drying up and falling off in from three to five days. Cause. A peculiar poison ; attacking only children ; occurring sporadically and as an epidemic. Symptoms. Moderate fever, thirst, anorexia, and constipation, 64 PRACTICE OF MEDICINE. followed by the eruption of vesicles, which rapidly dry, and within the week drop off, leaving a slight///. Pustules almost never occur. Symptoms are so slight that, were it not for the vesicles, the affection would be often overlooked. The eruption appears on the body and extremities, very rarely on the forehead and in the mouth. Prognosis. Most favorable. Treatment. Entirely symptomatic. If vesicles on the face, efforts may be used to prevent pitting. ERYSIPELAS. Synonyms. Erysipelatous dermatitis ; the rose ; St. Anthony's fire. Definition. An acute, specific, infectious disease ; characterized by more or less severe febrile reaction, and a peculiar inflammation of the skin generally of the neck and face. This inflammation exhibits a marked tendency to spread, to induce serous infiltration and suppu- ration of the areolar tissue, and to affect the lymphatic vessels and glands. Cause. A specific virus ; a micrococcus, the Streptococcus erysipe- losus. Feebly contagious. One attack predisposes to another. The etiology of idiopathic (medical) and traumatic (surgical) erysipelas are identical. Incubation, from two to seven days. Pathological Anatomy. Erysipelas is a simple inflammation — a dermatitis. The visceral changes, if any occur, are of a septic character. Infarcts occur in the lungs, spleen, and kidneys. Septic endocarditis and pericarditis and pleuritis are found post-mortem. Acute nephritis may occur. Symptoms. Onset sudden ; a chill, followed by fever, which soon reaches 104 to 105 , frequent pulse, 100 to 130, coated tongue, nausea and vomiting, severe pains in the limbs, with epistaxis in adults and convulsions in children, and often diarrhoea. There is usually more or less pharyngitis, and even tonsillitis, causing painful deglutition. Delirium is frequent, and in those of alcoholic habits it resembles delirium tremens. The eruption soon follows the chill, beginning in red spots, which rapidly coalesce and spread ; a sense of heat, tension, and tingling is caused by the great oedema, which presents a tense, shiny appearance, FEVERS. 65 the swelling being so great at times as to close the eyes and distort the features. In many cases small vesicles develop, which may coalesce, forming blebs of considerable size, containing a clear yellow serum. After five or six days the eruption begins to subside, the symptoms abate, the part affected remaining tender, and there occurs moderate desquamation. During the height of the attack albumin appears in the urine, so that the possibility of urcemic symptoms must be remembered. When extensive infiltration into the areolar tissue occurs, the swelling and tension become greater, and it is termed p hlegmonous erysipelas. When the eruption spreads to different portions of the body, it is termed erysipelas ambulans. Da Costa cites a case of migratory, wandering, or ambulans erysipelas, beginning on cheek and spread- ing from part to part until the entire body was affected, lasting three months and recovering. Complications. Thrombosis of the cerebral capillaries or sinuses, or, as it is sometimes called, " erysipelas of the brain," is explained by the intimate anatomical connection of the facial vein with the pterygoid plexus and cavernous sinus. (Edematous laryngitis, from extension to the larynx. Pneumonia, pleurisy, and meningitis are frequent complications. Diagnosis. Not difficult. The fever, early spreading eruption, with burning, swelling, tension, and tingling, and albuminous urine, distinguish it from the other eruptive fevers and erythema. Prognosis. Usually favorable. Unfavorable if it attack drunk- ards ; if it become gangrenous ; if thrombosis of sinuses occur, or if it extend to the larynx. The convalescence, even from the mildest attack, is slow, the patient continuing weak and anaemic for several weeks. Treatment. Mildest cases only require a laxative, nourishing diet, and locally vaseline or bismuth oleate, to modify the heat and burning. Professor Da Costa strongly urges the use of free purgation before the use of the remedies usually administered. Excellent results fol- low the use of: R . Hydrarg. chlor. mitis, gr. j .065 Gm. Sodii bicarb., gr. ij .13 Gm. M. Ft. chart. SlG. — One every two hours until four, followed by a saline. 66 PRACTICE OF MEDICINE. According to Reynolds, aconitum will cut short a sthenic attack. He administers tr^ss-j (0.03-0.06 Cc.) every fifteen minutes for the first two hours ; then in hourly doses, until the surface is moist and the temperature lowered. The aconite can be used with the above powder. The author corroborates this plan from a personal experi- ence. Watch the kidneys. In severe cases, after bowel action, tinctura ferri chlor., n^x-xx (0.6-1.3 Cc.) every third hour, well diluted. Also quinince sulphas, gr. ij (0.13 Gm.) every third hour. Ext. belladonna, gr. % (0.016 Gm.), added, with benefit. The diet from the onset should be of the most nourishing character, and administered at regular intervals. Professor Da Costa reports excellent results in cases with rapid spreading tendency, from the use of pilocarpifice hydrochloras, gr. l /e (0.011 Gm.), hypodermically, or ext. pilocarpi fluidum, tt^xx-xxx (1.3-2 Cc), every two hours. Good results are obtained in a fair number of cases from potassiiiodidum. I have obtained good results in rapidly spreading cases from injection of 10 Cc. of the anti-strep- tococcus serum. Cerebral symptoms, stimulants, opium, and chloral, with ice cap. Extension to throat, argenti nitras, brushed over parts. If symp- toms of cedema of the glottis develop, tracheoto?ny is indicated. Locally, soothing applications are indicated — to wit : Vaseline, ung. zinci oxidi, ol. oliva cum glycerin, bismuth oleat., or u?igt. hydrar- gyria)!. Excellent results are obtained by the use of ichihyol, gr. xx-xxx (1.3-2 Gm.), lanolin, %) (30 Gm.), applied on gauze; if the face be the seat of disease, cover with a mask of gauze spread with the ointment. The following solution painted over the inflamed area and beyond, every two or three hours, sometimes seems beneficial : H- Acid, carbolic, f 3 ss 15. Cc. Olei terebinthince, f Sj 30. Cc. Tinct. iodi, f^j 30. Cc. Alcoholis, fjjj 30. Cc. Glycerini, fgss 15. Cc. M. Ft. solutio. Keeping the inflamed parts bathed with a twenty per centum solu- tion of glyceriium boroglycerini, occasionally wetting the cloths with solution of hydrogen peroxid, is cooling, or gauze spread with euca- lyptol ointment, f^j (4 Cc.) to an ounce of lanolin, is soothing. FEVERS. 07 In the phlegmonous variety, argenti nitras, gr. xx (1.3 Gm.), spts. cetheris nitrosi, f 3 ij (8 Cc), brushed over and beyond the affected part, with the internal use of large doses of qicinina,ferrum, and stimulants. DENGUE. Synonyms. Break-bone fever ; neuralgic fever ; dandy fever. The word dengue is pronounced dangay. Definition. An acute, epidemic, febrile disease, consisting of two paroxysms of fever with an intermission. The first paroxysm is char- acterized by high fever, distressing pains in the joints and muscles, and a peculiar eruption ; the second paroxysm is characterized by a milder fever, an eruption of different character, attended with intense itching, by some recurrence of the joint pains, and by debility. Cause. Unknown ; but it is evident that a peculiar condition of the atmosphere has some influence in its development. Incubation, from two to six days. Symptoms. Onset sudden— -fever, 103 to 105 , intense headache, burning pains in the temples, backache, severe aching and swelling of the joints and stiffness of muscles, nausea, vomiting, constipation, and the appearance of a rash, resembling scarlatina, from which the disease has been mistaken for scarlatinal rheumatism. After some hours to two or three days a distinct intermission of one or two days' duration obtains. The onset of the second paroxysm is also sudden, but the symp- toms are much less severe, although the patient is greatly debilitated ; it is at this time that the characteristic eruption appears, being either erythematous or rubeolous, and attended with intense itching, remain- ing for about two days, when desquamation occurs and convalescence is established, but is prolonged by the great debility of tha patient. Average duration of the disease eight days. Relapses are common. Diagnosis. Most apt to be mistaken for acute articular rheuma- tism, especially during the first paroxysm, but the course of the dis- ease and the epidemic influence should prevent such an error. The eruption might mislead for scarlet fever or measles, were it not for the severe joint and muscular pains. On the first appearance of the pandemic of La Grippe in 1889 the 68 PRACTICE OF MEDICINE. similarity of the early myalgic symptoms with those of dengue was particularly noticeable. Prognosis. Favorable. Treatment. No specific. Entirely symptomatic. At the onset, fate, purgation and diaphoresis. For the fever, quinines sulphas, gr. v (0.32 Gm.) every five hours, or antipyrin, gr. x-xx (0.65-1.3 Gm.), repeated p. r. n. For the pains, opium or phenacetin. For the itching, a lotion of acidum carbolicujn. DISEASES OF THE MOUTH. CATARRHAL STOMATITIS. Synonyms. Simple stomatitis ; erythematous stomatitis ; catarrh of the mouth. Definition. An acute catarrhal inflammation of the whole or a portion of the mucous membrane of the mouth and tongue, charac- terized by pain, redness, swelling, and disordered secretion. Most common in infants and children. Chronic stomatitis occurs mostly in adults, the result of alcoholic or tobacco excesses. Causes. Introduction of hot and irritating substances into the mouth ; difficult dentition ; secondary to disorders of the stomach, to measles, scarlet fever, diphtheria, and variola. Pathological Anatomy. The buccal mucous membrane and tongue have a dark red appearance, are much swollen, the tongue often appearing as if too broad to lie between the teeth, the sides showing the impressions of the teeth ; the secretions are at first less- ened, afterward increased, a turbid mucus covering the cheeks, gums, and tongue. Symptoms. Oral catarrh begins with the ordinary signs of inflammation, burning, smarting pain, and tension in the mouth, in those old enough to describe their suffering. Very young children DISEASES OF THE MOUTH. G9 refuse to nurse or allow their mouth to be touched, taking hold of the nipple, giving one or two pulls and suddenly letting go and beginning to cry, have s tight fever, disordered stomach, are fretful and sleep- less, craving cooling drinks. The sense of taste is blunted, and there is usually an unpleasant, bitter taste in the mouth. If the catarrh becomes chronic, the breath has a fetid odor and the tongue is coated in the morning, the taste is disordered, and there is generally more or less depression of spirits. Diagnosis. If the buccal cavity be examined, the condition is readily discerned. Prognosis. Recovery is the rule for the acute variety. The chronic cases are usually due to the use of tobacco or alcohol, and are only modified by the absolute withdrawal of the exciting cause. Treatment. The most important point in the treatment is the removal of the exciting cause, attention to the secretions and diet, and gently mopping out the mouth at frequent intervals with a soft wad of absorbent cotton and cold or iced water, infusum coptis, or diluted Dobell's solution (see Scarlet Fever), or the following : & . Sodii boratis, gr. xc 6. Gm. Aquae destillat. , f.^iss 45- Cc. Mel. rosae, f^iss 45- Cc. In severe or aggravated cases a dilute solution, argentum nitras, gr. ij-v (0.13-0.32 Gm.), aquae, fgj (30 Cc), should be applied. APHTHOUS STOMATITIS. Synonyms. Follicular stomatitis ; vesicular stomatitis ; croupous stomatitis. Definition. An acute inflammation of the follicles and mucous membrane of the mouth and tongue, characterized by a fibrinous or croupous exudation; the exudation first appearing in isolated spots {aphtha discrete), afterward coalescing, and forming large and irreg- ular sized patches {aphtha confluens), which rupture, leaving an ulcer, which slowly heals. Causes. A disease principally of childhood. Difficult dentition ; disorders of digestion ; uncleanliness, such as neglect to rinse the 70 • PRACTICE OF MEDICINE. child's mouth after nursing ; a symptom of measles and diseases of the buccal cavity. Pathological Anatomy. Begins as a small, whitish papulo- vesicular elevation, semi-transparent, hard, and tender, with a distinct red zone about the base ; there may be as few as six or as many as twenty ; they may remain isolated (aphtha discrete) or coalesce (aphtha conflue?is) ; they are regarded as either a peculiar deposit or a local croupous exudation. After a day or two they rupture, leaving an irregular white or grayish ulcer, which slowly heals. The seat of the affection is the internal surface of the lips and cheeks, the gums, tongue, and roof of the mouth. Symptoms. The condition begins with redness of the mucous membrane of the mouth, followed rapidly by the spots or vesicles on the inner surfaces of the lips, the edges of the tongue, and the cheeks ; in infants the pai7i is so severe that the child refuses to nurse ; in older children, pain from talking, mastication, and deglutition ; saliva- tion is marked, the saliva dribbling from the mouth. There is slight feverishness, frelfubiess, and sleeplessness. Digestion is impaired, and quite commonly diarrhoea occurs. A disagreeable, penetrati7ig odor escapes from the buccal cavity. Diagnosis. Impossible to confound with any other affection if the buccal cavity is examined. Prognosis. Always favorable. Treatment. Removal of the exciting cause. Attention to the dietary and the secretions is paramount. If constipation occur, the use of a few powders of hydrargyri'chloridiwi mite, containing gr. j 1 ^ (0.005 Gm.), adding a small amount of sodii bicarbonas or small doses of pepsinum. Also small doses oiinfusiun coptis, which seems to have also a specific action in all forms of stomatitis and gastritis. Protracted cases require tonic doses of quinina sulphas. Locally, good results are obtained from strong solutions of potassii ch loras, infusum coptis, or touching the ulcers with arge?iti ' nitras . ULCERATIVE STOMATITIS. Synonyms. Diphtheritic stomatitis ; gingivitis ulcerosa. Definition. An acute diphtheritic inflammation of the mucous membrane of the mouth, continuing until extensive and unhealthy DISEASES OF THE MOUTH. 71 ulcerations occur. It usually begins on the margin of the lower gums, and often extends to the lips, cheeks, or tongue. Causes. Usually seen in children only. Most frequently in the families of the poor, the result of unfavorable hygienic surroundings, personal uncleanliness, and poor food. Often seen in those reduced by severe acute disease. Perhaps contagious, as epidemics are not rare. Prevails in institutions, jails, and camps, in which the sanitary conditions are defective. Pathological Anatomy. The gums first appear congested, swollen, bleeding readily, and separated from the teeth ; soon a firmly adherent deposit in the form of patches appears, at first whitish, speedily becoming gray or even black, from disintegration, becoming soft and pulpy, the separated slough leaving irregular-shaped ulcers, with raised margins, from cedema of the surrounding tissue. They are not deep, and their surface is covered with a pulpy, yellowish substance. The morbid process usually extends to the inner side of the lips, cheeks, and to the tongue. Symptoms. Begins with swelling of the mucous membrane about the base of the teeth, followed with pain aggravated by mastication or deglutition ; food and drink must be of the bland- est character. The mouth is hot, the saliva dribbles away, mixed with blood and shreds of pulpy matter, the breath is fetid, the appe- tite, digestion, and bowels disordered. The patient is feverish, fretful, and sleepless. There is always enlargement and tenderness of the submaxillary glands. The affection is often associated with entero-colitis. Diagnosis. Apt to be confounded with gangrenous stomatitis, than which, however, there are less constitutional symptoms and a slower course of the malady. Prognosis. Favorable. If promptly and properly treated, the ulcerated surface heals rapidly, although quite commonly some teeth are lost. Treatment. The etiology of the affection must be borne in mind and remedied. Strict attention to the diet, to the secretions, and ab- solute cleanliness. Internally, the prompt use of potassii chloras, gr. j-v (0.065-0.32 Gm.), alone or with infusum coptis, frequently repeated, often acts like a specific. The general health frequently calls for quininajtrruin, and stimulants. 72 PRACTICE OF MEDICINE. Locally, a strong solution of potassii chloras, or keeping the ulcer covered with bismuth, or frequent applications of alumen exsiccatum are valuable. Cases which resist these remedies should have applied the following combination, proposed by the late Dr. Dewees : U. Cupri sulphat., gr. x .65 Gm. Pulv. cinchonoe opt., gr. cxx 8. Gm. Pulv. g. arab. , gr. Ix 4. Gm. Mel. commun., f^ij 8. Cc. Aquoefont., f^i'j 9°- Cc. Ft. sol. Sic — The ulceration to be touched twice daily with the point of a camel's hair pencil. If a spreading tendency develop, the application of argenti nitras dilutus, or a diluted solution of acidum nitricum, is indicated. THRUSH. Synonyms. Parasitic stomatitis ; muguet ; sprue ; white mouth. Definition. An inflammation of the mucous membrane of the mouth, associated with or caused by the growth of & parasitic plant, the o'idium albicans ; characterized by pain, disorders of digestion and of the bowels. Causes. The development of the thrush-fungus o'idium albicans, is promoted by all those conditions designated as unhygienic, by de- bilitated conditions of the general system, and by neglect to thor- oughly rinse the mouth after nursing or bottle-feeding. It is claimed that a catarrhal stomatitis is the soil upon which the fungus develops. The age is considered a predisposing cause, seldom being seen after two years of age. In adults, only toward the last stages of cancer or consumption. Pathological Anatomy. The mucous membrane of the mouth presents a dark red appearance in isolated patches, on which whitish points appear, which rapidly coalesce into large areas. They closely resemble curdled milk, from their soft consistency. These whitish points consist of epithelium and fat, in which are embedded the sj) >rules and filaments of the fungus. The deposit first appears about the angles of the mouth, soon DISEASES OF THE MOUTH. 73 extending to all parts of the cavity, often to the pharynx and oesophagus. The mouth is usually swollen and tender, the breath often fetid. Symptoms. Pain, aggravated by nursing or mastication. The lips are swollen, the saliva is increased, the breath hot and some- what fetid. There is usually increased temperature. Diarrhcea is frequent, the stools green and sour, causing an erythema of the buttocks. Diagnosis. The curd-like appearance of the deposit, showing the presence of the fungus upon microscopical examination, will prevent error. Should not be confounded with aphthous stomatitis, in which ulcers, preceded by the formation of vesicles, are perfectly » distinctive. Prognosis. Favorable, unless occurs toward the termination of exhausting diseases. Treatment. Absolute cleanliness of the mouth is all-important. Internally, remedies should be directed to the removal of the dis- orders of the gastro-intestinal tract. Prompt relief has followed the use of sodii hyposulphitis saturat. iolut., TTiiij-x (0.18-0.6 Cc), every two or three hours, and the local application of the same solution. Locally, solutions of sodii boras often answer every indication, the best vehicle being glycerinum or infusum coptis, and not mel or sac- charum, a good formula being : $. Sodii boratis, gr. lx 4. Gm.. Glycerini, f^ij 8. Cc. Aquae, f ^ vj 24. Cc. Sic — Thoroughly applied four or five times daily, and continued for a week after the disappearance of the affection. GLOSSITIS. Definition. An inflammation of the parenchyma of the tongue ; haracterized by great swelling of the organ, with difficult mastica- on, deglutition, and vocalization. The affection may be either acute or chronic. Causes. The acute variety is usually the result of some direct citation to the tongue, such as direct injury, contact of boiling 7 74 PRACTICE OF MEDICINE. liquids, the action of acrid or corrosive substances, or the sting of the tongue by an insect, such as the bee or wasp. The chronic variety is generally circumscribed ; it may follow the acute ; be due to the sharp edges of the teeth, or the use of a tobacco pipe. Pathological Anatomy. Acute glossitis begins with intense hyperaemia, redness, and swelling of the organ ; the size often be- comes so great that the tongue is too large for the mouth, and thus protrudes between the teeth ; its surface is covered with a thick secretion, and it becomes of a pale or grayish color. The swelling may rapidly decline, or abscesses may form, which leave a more or less decided depressed cicatrix. Chronic glossitis occurs usually along the edges of the organ, the cicatricial changes being in circumscribed hard spots. If the entire tongue is affected with chronic inflammation, the action is superficial, and has been termed " psoriasis of the mouth." Symptoms. Acute glossitis begins rather abruptly with fever, increased pulse, restlessness, anxiety, enlargement of the tongue, a sensation of heat in the mouth, with pain, and increased flow of saliva. Mastication and deglutition become difficult if not impossible, the voice muffled, and dyspnoea decided. The glands at the angles of the jaws are enlarged, which, in turn, compress the vessels of the neck. When suppuration supervenes, the constitutional symptoms become severe and the oral symptoms are intensified. Death has occurred from suffocation in severe cases. Chronic glossitis presents fain as the chief symptom, aggravated by movements of the organ. Diagnosis. The rapid course of acute glossitis should prevent its being mistaken for any other affection. Chronic glossitis, if severe, might be mistaken for cancer of the tongue, although the slow and mild progress of the former contrasts strongly with the rapid, severe, and painful course of the latter, with its marked constitutional symptoms. Prognosis. Acute glossitis usually terminates in recovery within a week, although the danger of suffocation must always be remem- bered. Chronic glossitis is an incurable malady in the majority of in- stances. Treatment. For acute glossitis prompt measures are demanded. DISEASES OF THE MOUTH. 75 For the fever and rapid pulse, tinctura aconiti, n\, j-iij (0.06- 0.18 Cc.) every half hour or hour until its physiological effects are produced. For the enlargement of the organ, either ice constantly applied internally and externally, at the angles of the jaw, or the persistent use of hot water held in the mouth and externally ; if prompt relief does not follow these measures, or if the case is an aggravated one, the prompt deep scarification of the tongue must be resorted to. If abscesses form, promptly open them and administer quinince sulphas. If suffocation appear imminent, tracheotomy must be performed. For chronic glossitis, the removal of the exciting cause and the local use of argenti nitras to the ulcerated edges. " For psoriasis of the tongue," the local use of argentum or acidum carbolicum. The general health must always receive proper attention. GANGRENOUS STOMATITIS. Synonyms. Cancrum oris ; noma ; water-cancer. Definition. An acute, rapidly progressive gangrenous ulceration of the mouth, leading to extensive sloughing and destruction of the affected tissues. Causes. It is probable that gangrenous stomatitis is due to some parasitic micro-organism, but its character is as yet unknown. It attacks feeble and sickly children by preference; now and then observed in adults. It is seen as a primary affection and as a sequelae to measles, scarlet fever, typhoid and typhus fevers, and pneumonia. Pathological Anatomy. The process is essentially a rapidly progressive moist gangrene. Symptoms. Noma usually begins insidiously by the destructive process developing upon an ulcerative stomatitis, or the appearance of a sloughing ulcer on the gums or the inside of the cheek of an apparently healthy mucous membrane. Often the gangrenous odor is the first symptom noted. The cheek swells, becomes (edematous, and the skin waxy looking ; within a day or two the process may spread, involving the whole side of the face, and as the ulcer becomes 76 PRACTICE OF MEDICINE. deeper and approaches in its progress the integument, the skin be- comes red, blue, purple, black, or a combination of these shades, followed by the development of a bulla filled with ichorous fluid, the skin softening and breaking down. The constitutional reaction is very severe ; pulse rapid and feeble ; temperature io2°-io4° F. ; extreme prostration ; pain but little com- plained of, but the odor fills the house ; diarrhoea is common, hemor- rhages from the mouth rare. Death usually occurs in a week to ten days, the patient often presenting a frightful picture. Very rarely recovery occurs. Diagnosis. No other disease or condition can be confounded with gangrenous stomatitis. Prognosis. Nearly all cases die. Treatment. There is but little to say about the treatment of noma. Destruction of the ulcer by the use of argentum nitras in stick, fum- ing acidum nitricum, or the Paquelin cautery might be tried. Washes of antiseptic solutions, and the application of quantities of finely powdered acidum boricum are useful. Keep up the strength of the patient with ferrum, arsenicum, quinina sulphas, and stimulants. DISEASES OF THE STOMACH. ACUTE GASTRIC CATARRH. Synonyms. Acute simple gastritis ; gastric fever ; bilious fever ; acute indigestion ; subacute gastritis. Definition. An acute catarrhal inflammation of the mucous membrane of the stomach ; characterized by feverishness, loss of appetite, nausea, with occasional vomiting, painful digestion, irregu- larity of the bowels, and in severe attacks, vertigo {stomachic vertigo). Causes. Deficient quantity of or quality in the gastric juice. Errors in diet, insufficient mastication of food, swallowing liquids DISEASES OF THE STOMACH. 77 which are either too hot or too cold, and particularly the abuse of alcoholic liquors, cold beer, and iced soda-water. Certain drugs in medicinal doses, such as iodides, bromides, and arsenic. Often secondary to infectious diseases, such as scarlet fever, measles, smallpox, diphtheria, and typhoid fever. Occasionally the result of wet, changeable weather. Pathological Anatomy. The mucous membrane is irregularly congested and engorged, and covered with a grayish, semi-transparent and tenacious mucus, having an alkaline reaction. The true gastric juice is secreted in lessened amount or is entirely suspended. Symptoms. At first, loss of appetite, at times disgust for food, heavily coated tongue, bad taste and breath, persistent nausea, and at times vomiting, first of undigested food, then viscid mucus, acid and bitter, and, finally, bilious matter ; moderate irritative fever is present, with headache, considerable thirst, and flashes of heat with sensations of burning in the palms of the hands and soles of the feet ; acid drinks eagerly sought after ; digestion imperfect, giving rise to pain, tenderness, feeling of weight, and eructations ; bowels may be loose, but are oftener constipated. Vertigo with pain in the nucha is a prominent symptom in many cases, causing great anxiety and depression of spirits. The urine is scanty, containing lithates and pigment. The symptoms are aggravated by errors in diet, and if saccharine or fatty articles are taken heartburn occurs. Toward the termination of an attack, herpetic eruptions appear about the mouth. Diagnosis. Acute gastric catarrh with fever may be confounded with remittent and typhoid fever of the first week, but all doubts will disappear as these maladies develop. The vertigo may be mistaken for cerebral disease, but the disap- pearance of this symptom when stomachic treatment is inaugurated removes all apprehension. Prognosis. Favorable. Duration about a week ; recovery slow, even under treatment, as far as perfect digestion is concerned. Treatment. Give the stomach as complete a rest as possible, and as anorexia is a prominent symptom, the error should not be made of insisting upon the patient eating for a day' or two at least. If the stomach is overloaded, a rare incident, an ipecac emetic, or apomorphina hydrochloras, gr. }i (0.008 Gm.), by hypodermic injec- tion, is indicated, or, if vomiting has begun, it may be encouraged by 78 PRACTICE OF MEDICINE. swallowing large draughts of hot water, which will act as a sedative if the stomach be empty. The majority do better by an active purgation with either hydrar- gyri chloridi 7nile, gr. v-x (0.32-0.65 Gm.), with sodii bzcarbonas, gr. v (0.32 Gm.), followed in six or eight hours with an ounce dose magnesii sulphas, or a full dose of Hunyadi Janos water; or small doses every two hours of powders containing — R. Hydrarg. chlor. mite, gr. %-% .016-.032 Gm. Sodii bicarb., gr. ij .13 Gm. M. Every two hours for a dozen, followed the second morning after the last powder with a saline purgative. After the stomach and bowels have been thoroughly cleansed, the diet may be more liberal, and some one of the following drugs used : tinctura nucis vomica, rr^v-xv (0.3-1 Cc), well diluted, every four hours, or fiepsinum or papoid. The following is an excellent stomachic sedative : R. Sodii bicarb., ^iij 12. Gm. Bismuth, subnit., \ ij 8. Gm. Aq. chloroformi, f^iij 9°- Cc. M. et adde Aq. menthoe pip., f^j 30. Cc. Aq. lauro-cerasi, f ^ ij 60. Cc. M. Sig. — Tablespoonfal four times a day. Another excellent formula after the acute symptoms have subsided is R. Strychninx sulphas, gr. ss .03 Gm. Acid, hydrochlorici dil., . . . . f.^iv 15. Cc. Glycerini, f 5j 30. Cc. Tinct. card. comp. , f'n ss J 5" ^ c " Aq. lauro-cerasi, f!|j 30. Cc. M. Sic. — One teaspoonful, diluted, four times daily. ACUTE TOXIC GASTRITIS. Synonym. Toxic gastritis. Definition. An acute and violent inflammation of the mucous, submucous, and muscular coats of the stomach, with loss of tissue; characterized by great pain, constant vomiting of blood-streaked DISEASES OF THE STOMACH. 79 or bloody mucus, and whatever may be ingested, and symptoms of collapse. Causes. Ingestion of irritant and corrosive poisons, such as the mineral acids, arsenic, corrosive sublimate, copper, and carbolic acid. Pathological Anatomy. The mucous membrane is vividly red and injected, more marked at some portions than at others ; it is soft and friable ; erosions are irregularly scattered, and the submu- cous, muscular, and at times serous coats show decided destructive changes. The gastric tubules are destroyed in large numbers. In many cases the oral mucous membrane presents signs of severe in- flammation. Symptoms. Immediately or soon after swallowing the irritant there ensues a deadly nausea, with rapid and persistent vomiting ; first, of the contents of the stomach acted upon by the poison, after- ward, shreds of mucous membrane and blood clots ; there are also present great anxiety and depression, a weak, rapid pulse, slow and shallow respiration, cold skin, covered with a cold sweat, intense burning pain and heat at the epigastrium, thirst with burning in the fauces and gullet, and exhaustive purging ; the features are more or less retracted or sunken; these symptoms terminating in collapse and death, or slow convalescence and recovery with a crippled stomach. If death be delayed some hours, marked nephritic symptoms appear. A diagnosis of the character of the poison swallowed is often afforded by the stain of the lips, face, and mucous membrane, to wit : sulphuric acid, blackish eschar ; nitric acid, yellowish eschar ; caustic potash, spreading widely and softening the tissues ; corrosive subli- mate, whitish or glazed ; carbolic acid, white and corrugated ; chro- mic' acid, yellowish-white, changing to grayish brown. Prognosis. Very grave. Many perish from shock, and the de- struction of the mucous membrane of the stomach, which prevents nourishing. Early treatment when no perforation of the walls of the stomach has occurred' and recovery is possible, the organ being ever after much weakened. Treatment. At once, hypodermic injection of morphines sulphas, repeated as often as indicated. Vomiting should be encouraged by the free use of demulcents. If the case be seen within a short period of the swallowing of the poison, the proper antidote should be used, but if some hours have elapsed, it is useless. 80 practice of medicine. Irritant and Corrosive Poisons. Poison. ■ Antidotes. {Chalk, magnesia (plaster of wall in emergency), solution carbonate soda, emollient drinks, fixed oils. Ammonia ("household ( , 7 . . ... ,-, , .-, . • },,. v • Vinegar mixed with a bland oil, and sustain ammonia ) or lini- < . b . ., A , . ' 1 heart with strychnia, ment. ^ J ( Moist peroxide of iron (obtained from perchloride of . . J iron and calcined magnesia) or the ferri oxidum j hydratum, U. S. P., charcoal, ammonia to nos- [ trils. f Castor oil, olive oil, and the sulphate of magne- Carbolic acid. -j sium or sodium as a chemical antidote. Prompt ( stimulation. r-u • -j f Acetate of iron, ten per cent, solution nitrate sil- Chromic acid. < c • • 1 V i -i i_ I. ver, forming insoluble silver chromate. r* . ,,. f Albumen, white of egg (four grains sublimate Corrosive sublimate. < . ' , .. c \ n -n |^ require white ot one egg), hour, milk. Iodine. Demulcent drinks, starch or flour in water. {Magnesia, turpentine, demulcents. Wash stom- ach by use of stomach tube or pump and warm water, afterward using Epsom salts. Silver nitrate. Solution common salt in demulcent drinks. Soda, or "caustic pot- f Olive oil, demulcents, vinegar, lemon juice, and ash." "Lye." \ hypodermically stimulants. c i i . f Albumen or white of egg, stomach pump, and Sulphate copper. -< , A , . A , &&» t r > r l r ( wash stomach with soap water. Ice, internally and externally, gives great relief. The stomach should be washed out with the stomach tube or pump, thereby re- moving any remaining poison, which at the same time acts as a sedative to the inflamed membrane. Bismuthi subnilras, gr. xx-xxx (1.3-2 Gm.) every hour or two, is beneficial. Milk and lime-water \s the only food that should be given by the stomach, enemata being used to support the system. Strychnines sul- phas and atropine sulphas hypodermically to sustain the heart and nervous system. DISEASES OF THE STOMACH. 81 CHRONIC GASTRIC CATARRH. Synonyms. Chronic gastritis ; chronic dyspepsia ; drunkards' dyspepsia. Definition. A chronic catarrhal inflammation of the stomach, with thickening of the coats and atrophy of the gastric glands ; char- acterized by tenderness over the epigastrium, impaired appetite, pain- ful and imperfect digestion, thirst, and great depression of spirits or melancholia. Van Valzah describes three forms of chronic gastritis — viz. : (i) Gastritis catarrhalis chronica, or chronic asthenic gastritis ; (2) gas- tritis glandularis proliferans, or chronic hypersthenic gastritis ; (3) gastritis glandularis atrophicans, or progressive atrophy of the gastric glands. Causes. Repeated attacks of acute gastric catarrh ; habitual and excessive use of spirituous liquors, tea, coffee, and the free use of ice- water during and between meals ; improperly prepared and unsuit- able food ; irregularity of meals and imperfect mastication ; excessive tobacco-chewing ; malaria ; disease of the heart, lungs, pleura, liver, or kidneys, producing chronic congestion of the stomachic vessels ; cancerous or other degenerative diseases of the stomach. Pathological Anatomy. The mucous membrane is of a brown- ish or slate color, elevated into ridges from hypertrophy, the result of constant congestion ; the peptic glands first increase in size, then un- dergo granular change, atrophy of their cells resulting. The mucous membrane is covered with a thick, alkaline, tenacious mucus. Ewald describes the minute anatomy as that of a parenchymatous and inter- stitial inflammation, which may lead to such widespread degenera- tion of the glandular elements that ultimately scarcely a trace of secreting tissue remains. These changes may affect the entire organ or be limited to portions of the stomach. Symptoms. The persistent and manifold symptoms of indiges- tion, varying somewhat with the extent of the mucous surfaces and se- creting glands involved, are the first indications of the disease, such as loss of appetite, disagreeable feeling of gnawing and at times full- ness in the stomach, tenderness at the epigastrium, but slightly influ- enced by eating, prominence of the epigastrium, from distention by decomposing gases, occasional 7iausea and vomiting after meals, of undigested food, or, when the stomach is empty, of colorless fluid. A 82 PRACTICE OF MEDICINE. colorless vomit joined to symptoms of long-continued indigestion is always very characteristic of chronic gastritis. Drunkards suffer from an early morning vomit consisting of glairy mucus and saliva swallowed during sleep, raised only after great retching. The tongue is usually heavily coated, although it may be clean ; thirst is often constant, water and more frequently stimulants being craved ; burn- ing at the pit of the stomach and under the sternum (heartburn) is very common; pain, sharp and diffused, after eating; the bowels are constipated, the urine high-colored and contains an excess of phos- phates or urates, or exhibits crystals of oxalate of lime. In advanced cases the circulation is feeble, there is depression of spirits amount- ing in some instances to delusional melancholia; sleeplessness is persistent, and occasionally there are attacks of vertigo (stomachic vertigo), which greatly alarm the patient. All of these symptoms re- sult from either a deficient secretion of the gastric juice or from a less- ened proportion of hydrochloric acid in the juice secreted, and also from the excessive mucus and from diminished peristalsis of the stom- ach, such morbid conditions favoring the fermentation and decom- position of the food. Follicular pharyngitis of an aggravated type adds to the general distress of the patient. The imperfect digestion causes more or less loss of flesh, the fat disappearing, the muscles re- laxed and the skin dry, harsh, and of a dirty-pale color, and not in- frequently eczema and other cutaneous diseases develop. Diagnosis. Chronic gastritis is associated with so many chronic diseases that a correct diagnosis is of great importance. Among the affections likely to lead to error in diagnosis are gastric ulcer, gastric cancer, gastric dilatation, cerebral vertigo, cardiac disease, and dis- ease of the kidneys and liver. Prognosis. Complete recovery is hardly to be expected, but great amelioration of symptoms occur and with guarded diet and mode of life good health may be enjoyed for many years. It is usually a disease of middle life. Treatment. The first indication is the correction of the indiges- tion, which is usually the most pronounced and distressing symptom ; this is accomplished by carefully regulating the amount and charac- ter of the food used, avoiding fatty, saccharine, and starchy articles or highly seasoned food or stimulants. A milk diet is beneficial, to which may be added beef in small amounts, eggs, oysters, and a few fresh green vegetables. If beef is allowed, it had better, for a time, DISEASES OF THE STOMACH. 83 be in the form of " Salisbury steaks " — made of lean beef shaped into flattened cakes and broiled. This or whatever other articles of diet are allowed to be taken an hour or more after sipping slowly a half pint (237 Cc.) of water, at iio°-i5o°. The hot water should also be taken before retiring. The second important symptoms to correct are the constipation, which is often most obstinate, and clearing the stomach of the tenacious mucus which neutralizes whatever gastric juice is secreted. Appropriate purgatives are the natural mineral waters, such as Bed- ford Water, Saratoga, Hunyadi Janos, or — |& . Magnesii sulph., gr. Ix-cxx 4.-8. Gm. Sodii et potass, tart., gr. xxx-lx 2.-4. Gm. Acid, tartaric, gr. xx 1.3 Gm. M. Dissolved in a glass of water and drank, effervescing, an hour before break- fast. An excellent purgative and promoter of stomachic peristalsis is : R. Ext. cascarse sagradse fid., . . . . fjfj 30. Cc. Glycerini, f^ ss I 5- Cc. Tinct. nucis vomicae, f,^ ss I 5- Cc. Aq. chloroformi vel inf. glycyrrh , f ^j 30. Cc. M. SiG. — One to two teaspoonfuls after meals, well diluted. For the purpose of cleansing the stomach of the tenacious mucus as well as for its stimulating action on the glands, lavage or irrigation of the stomach with lukewarm water is valuable. The water can be medicated with a solution of salt, or sodii bicarbonas or acidum boricum. Ewald considers the morning, on an empty stomach, the preferable hour for the practice of stomach washing. Those patients who object to lavage obtain relief from the system- atic drinking of one-half to one pint (237-475 Cc.) of hot water an hour before meals, as mentioned above. For the irritable condition of the mucous membrane, associated with the poor appetite and slow digestion, good results are reported from stronlii bromidum, gr. xv (1 Gm.), well diluted, before meals. For the morbid condition of the mucous membrane may be used, liq. potassii arsenitis, tt\j-ij (0.06-0.12 Cc), before meals, or bismuth, subnil., gr. x-xx (0.65-1.3 Gm.), on a comparatively empty stomach, one hour before or two or three hours after meals ; it may at times be 84 PRACTICE OF MEDICINE. combined with sodii bicarbonas. The following combination often gives great comfort for a long time if the diet is regulated : R. Sodii bicarb., giv 15. Gm. Bismuth, subnit., Zvj 24. Gm. Aquoe chloroformi, f 3 iij 90. Cc. M. et adde Aquoe lauro-cerasi, f^ n j 9°- Cc. Strychninse sulph., gr. j .065 Gm. M. Sig. — Two teaspoonfuls at meal-time in a little water. Argenti ' nitras , gr. )( (0.016 Gm.), or argenii oxidum, gr. ss-j (0.032- 0.065 Gm.), in pill, before meals, or acidum hydrochloricwn dilutum, rr^x-xv (0.6-1 Cc), in water, before meals, are useful remedies. Pain is so severe in some cases that resort must be had at times to opium or belladonna in small doses, after meals. Emplastrwn bella- donna over the stomach is useful. Cocaincz hydrochloras, gr. l /e (0.01 Gm.), is also recommended. To aid digestion, acids, pepsinum, pancreatinum, papoid, and bitters are of value, the following being an excellent prescription : R. Pepsini (cryst. ), gr. lx 4. Gm. Acid, hydrochlorici dil., . . . . fgiv 15. Cc. Glycerini, f^iv l S- Cc. Strychninse sulph. , ...... gr. ss .032 cm. Aquce chloroformi, . . q. s. adf^iij ad 90. Cc. M. SlG. — One teaspoonful at meal-time in a little water. Rest of the body and mind is almost as important as rest of the stomach. GASTRIC ULCER. Synonyms. Peptic ulcer; chronic gastric ulcer; perforating ulcer. Definition. A solution of continuity, involving the mucous membrane and one or more layers of which the walls of the stomach are composed ; characterized by gastric pain, disorders of digestion, and vomiting of blood. Causes. There is no generally accepted view of the etiology. Van Valzah truthfully says, "Ulcer is not a disease with a single cause and one mode of genesis." Ewald attributes it mainly to an DISEASES OF THE STOMACH. 85 "altered composition of the blood, and the resulting insufficient nourishment of the cells." Riegel claims that the ulcer is due to a self-digestion of the stomach at a limited spot, and it is certainly more than a coincidence that in ulcer the gastric juice is nearly always hyperacid. More common in young females than males. Anaemia or its sequela a chief factor ; disorders of menstruation ; blows over the epigastrium; burns of the integument; syphilis; tuberculosis. Virchow claims that emboli or thro7nbi form in the nutrient gastric arteries which have lost their tonicity, an ulcer form- ing at the point of obstruction. Pathological Anatomy. In the majority of cases the ulcer is solitary. The posterior wall near the pylorus is the most frequent location. In a typical case there is a circular hole, with sharp borders in the serous coat of the stomach ; the loss of substance is greater in the mucous membrane than in the muscular coat, and greater in this than in the serous coat, so that the ulcer looks like a shallow funnel, the apex at the outer wall, the base at the inner wall of the stomach ; it is first round, growing, becomes elliptical, bulging at portions, be- coming irregular ; size, from %-yb inch in diameter. When the ulcer heals before all the coats are perforated, a distinct cicatrix marks the location. During its progress nutrient vessels are eroded, causing profuse hemorrhage. Chronic gastric catarrh complicates the majority of cases. Symptoms. More or less prominent symptoms of indigestion. Pain constant at the " pit of the stomach," increased by taking food, especially of an irritating character, the pain often felt in the back, of a burning, gnawing character. Tenderness at one or more points, extending from the front to the back. Vomiting is almost as constant as pain, coming on soon after eating if the ulcer is at the cardiac ori- fice, an hour or so after if it is located at or near the pylorus. Rejected matter may be undigested or partly digested food, or simply acrid mucus. Vomiting of blood in large quantities and arterial in color is almost diagnostic of gastric ulcer; the blood may be dark in color if it has remained in the stomach some time before being rejected. Severe and frequent attacks of gas tralgia may add to the suffering of the patient. The general condition of the patient is not significant, some being greatly debilitated, while in others the nutrition is but little deranged. 86 PRACTICE OF MEDICINE. Duration. The ulcer is slow in forming, and runs a very chronic course, an average duration being, perhaps, about a year. Cases are recorded in which the disease has suddenly developed and terminated by perforation, peritonitis, and death within two weeks, but such in- stances are rare. Diagnosis. Duodenal ulcer presents symptoms so akin to those of gastric ulcer that a differential diagnosis is impossible. Chronic gastritis is often confounded with gastric ulcer; the dis- tinctive points are : absence of vomiting of blood, no localized con- stant pain aggravated by food, and no tenderness in the back ; while the symptoms of indigestion are marked and persistent, with, as a rule, a history of spirit drinking, and the age of the patient — middle life ; ulcer in the young. The points of distinction between gastric cancer and gastralgia will be pointed out when considering those affections. Prognosis. Gastric ulcer is a dangerous disease, and the prog- nosis should be very guarded. Recoveries are frequent. The dangers -axe perforation, ■peritonitis, or fatal hemor?'hage. Treatment. Give the stomach as complete a rest as possible ; this is accomplished by rectal alimentation, or when it cannot be carried out, an exclusive milk diet, adding lime-water to enable the stomach to better retain the milk, or a strictly skimmed-milk diet, to which may also be added lime-water ; the amount of milk should be one or two ounces every two hours. Rest in bed and keeping the stomach empty by rectal feeding give the most favorable condition for the healing of the ulcer. If a severe hemorrhage occurs and col- lapse is imminent, a pint (475 Cc.) of warm physiological solution of common salt (3j or 4 Gm.) to one pint (475 Cc.) should be slowly introduced into the rectum. Additional amounts of the salt solution may be injected into the subcutaneous cellular tissues. At the same time sustain the heart by hypodermic injections of strychnines sulphas, 7iitroglycerinum, and a?nmonia. To correct hyperacidity use a combination of sodii bicarbonas and magnesia calcined, in large doses after each feeding, if stomach ali- mentation is allowed, and, if not, every four hours. Belladonna is a valuable drug for excessive acid secretion. For pain, small doses of ?norphincz sulphas should be used as needed. For hemorrhage, hypodermic injections of ergota are most reliable. DISEASES OF THE STOMACH. 87 Plumb i acetas, gr. j-iij (0.065-0.2 Gm.), arrests the bleeding and exercises a favorable influence over the ulcer. An ice-cap or bag over the epigastrium is most valuable. For the ulcer, liquor potassii arsenitis, 1T\J— ij (0.06-0.13 Cc), every five hours, has given excellent results in several cases treated by the author; bismuthi subnitras, gr. xx-xxx (1.3-2 Gm.), combined with sodii bicarbonas, gr. v (o 32 Gm.), three times a day, often does well; argenti nilras, gr. X~K (0.016-0022 Gm.), every four hours, or argenti oxidum, gr. ss (0.032 Gm.), every four hours, are at times beneficial. For the associated anaemia, ferrum and arsenicum, alone or com- bined, are indicated. Ferri albuminate would seem to be particularly indicated, or the following : R. Pulv. ferri albuminatis, gr. ij .13 Gm. Sodii arseniat., . . gr. Jq •°°3 Gm. M. Ft. pil. or capsule, taken three or four times daily. The bowels must be kept soluble. If perforation and peritonitis result, full doses of opium are indi- cated. Surgical aid is indicated for the perforation. GASTRIC CANCER. Synonyms. Cancer of the stomach; gastric carcinoma. Definition. A peculiar malignant growth, occurring for the most part at the pyloric extremity of the stomach, making constant pro- gress, destroying the gastric tissues and infecting the lymphatic glands ; characterized by disorders of digestion, pain, vomiting, marked anaemia, and terminating in all cases by the death of the patient. Cause. Hereditary. Develops after forty years, for the most part. The question of a cancer germ is gaining ground. Twice as many cancers occur in women as in men. Pathological Anatomy. Cancer of the stomach is the most common form of cancer. It is, as a rule, a primary cancer. The variety is most commonly the scirrkus, next in frequency, medullary, the least frequent, colloid. As regards the location, eighty per cent. 88 PRACTICE OF MEDICINE. occur at the Pylorus. Those portions of the stomach remote from the cancer are normal or comparatively healthy. It originates usually in the tubules, rapidly infiltrating the remain- ing tissues, thickening everywhere as it progresses, and either remains a hard nodulated mass or undergoes ulceration. The hard nodulated growth at the pylorus constricts the orifice, resulting in dilatation of the stomach. The lymphatic glands adjacent to the stomach are infiltrated, secondary cancers resulting. Ulceration into an artery causes hemorrhage into the peritoneum, resulting in local peritonitis. Complications. Fatty heart ; thrombosis ; tuberculosis. Symptoms. The development of gastric cancer is insidious, with indigestion, progressive in character, associated with marked acidity, flatulency, and a fetid breath. The majority of cases have vomiting, occurring immediately after eating, if the disease is at the cardiac orifice, and some hours after if located at the pylorus ; if much dilatation of the stomach develop, the vomiting occurs some days after eating. The rejected matter is food in various stages of digestion, associated frequently with black grumous masses of altered blood and tissues. Hematemesis is fre- quent, rarely profuse, usually oozing of blood altered into a dark brown or black color — "coffee-ground" vomit or the oozing blood passes into the intestinal canal, causing tary stools. Absence of hydrochloric acid in the stomach is a very constant observation in gastric cancer. Boas and Stewart (D. D.), in 1895, found, by the use of the test-meal (flour soup), that lactic acid was always present in gastric cancer, and they were unable to find this acid in any other stomach condition. Pain, marked and constant, dull, heavy, increased by pressure or food, seldom lancinating. Marked ancemia and emaciatio7i soon occur, the surface having an earthy or fawn color. CEdema of the ankles is an early diagnostic symptom in carcinoma of the stomach, often occurring as early as the third month, and may progress to a general anasarca. A tumor is found in three-fourths of the cases, occupying the epigastric region, not moving with inspiration. As the carcinoma progresses, the lymphatic glands enlarge, particularly the supra-clavicular and inguinal glands. Jaundice frequently occurs, and the liver is enlarged. The urine often contains albumin. An irregular temperature occurs in some patients. The duration of the disease is about one year, the patient dying DISEASES OF THE STOMACH. 89 from exhaustion, peritonitis, or he?norrhage, the mind clear but despondent. Diagnosis. The continuous absence of free hydrochloric acid and the presence of lactic acid in the stomach are diagnostic signs of great value in determining the probable existence of gastric cancer. It is possible to make a positive diagnosis by study of the rational symptoms and the aid of the X-rays. Chronic gastric catarrh differs from gastric cancer in the absence of a tumor, bloody vomit, characteristic pain, peculiar color of the surface, dropsy, and the rapid emaciation. Gastric ulcer differs in the character of the pain, age of the patient, large amount and color of bloody vomit, the absence of a tumor, and progressive emaciation. Still the diagnosis is often difficult. Abdominal tumors may raise the question of a gastric cancerous tumor; the points of distinction are the characteristic symptoms of gastric cancer, and that abdominal tumors, especially of the liver and spleen, the ones most apt to cause error in diagnosis, are influenced by inspiration, while tumors of the stomach are not so influenced. When a scirrhus of the pylorus lies upon the aorta, a pulsation may be communicated to it, raising the question of aneurism of the abdominal aorta, but the expansile pulsation of aneurism (Corrigan's sign) is wanting, as are the other symptoms of the affection, and if the patient is made to rest upon his hands and feet, the stomachic tumor falls away from the aorta and pulsation ceases. Mikuliez claims that, by the use of his gastroscope, regular rhyth- mical motions can be seen when the pylorus is not the seat of cancer, and that such movements are absent when it is the seat of cancer. Prognosis. Unfavorable. Internal medication offers no hope, the patient usually succumbing from starvation. Gastric carcinoma occurring under thirty years of age is rapidly fatal, not conforming to the usual symptoms as seen later in life ; the characteristic cachexia is commonly absent and hsematemesis is rare. Treatment. We possess no means of arresting the disease, although it is but fair to mention that in Germany condurango in the form of decoction is recommended as a specific in gastric cancer. I have faithfully used the fluid extract with some benefit for the accompanying gastritis, but without effect on the tumor. Six operations have been recommended for the relief of stenosis of 90 PRACTICE OF MEDICINE. the pylorus: ist. Pylorectomy ; 2d. Gastro-enterostomy ; 3d. Gas- trectomy; 4th. Gastrostomy; 5th. Duodenostomy ; 6th. Digital di- vulsion of the pylorus. Professor Billroth has excised the pylorus, thereby prolonging life ten months in one case and five years in an- other. During the past year (1898) two successful operations for the re- moval of the entire stomach have been reported, both patients being alive some weeks after. For acidity and fetor of the breath, acidum carbolicum, gr. %-}i (0.016-0.022 Gm.), or carbo animalis purificatus, gr. x-xxx (0.65-2 Gm.), affords some relief. For vomiting and pain, bismuth and opiu?n, or lavage or the wash- ing out of the stomach. The lavage should be performed an hour before breakfast, followed in half an hour with : & . Strychnince sulph., gr. ss .032 Gm. Acid, hydrochlor. dil., f^iv x 5- Cc. Inf. condurango, . . . q. s. adf^viij ad 240. Cc. M. et ft. tablespoonful before meals, diluted. Yor pain, morphina, or the following, recommended by Osier : R . Morphinse sulph., gr. y& .008 Gm. Sodii bicarb., . . gr. v .3 Gm. Bismuth, subnit., gr. x .6 Gm. M. Sic. — Repeated p. r. n. Avoid stimulants. GASTRIC DILATATION. Synonyms. Gastrectasis ; pyloric obstruction ; pyloric stenosis. Definition. An abnormal increase of the cavity of the stomach, with the walls either hypertrophied, or decreased in thickness; char- acterized by pronounced indigestion, vomiting of partly digested and partly decomposed food at intervals of a day or two, and noisy mov- ing of flatus within the abdomen (borborygmus). Causes. Most common cause a stricture of the pylorus, the result of cancer ; pressure of tumor against the pylorus, preventing exit of stomachic contents. Loss of muscular tone, occurring in anaemia. Prof. Bartholow cites cases resulting in excessive beer-drinkers, who drank thirty to forty glasses of beer habitually, every day. DISEASES OF THE STOMACH. 91 Pathological Anatomy. When obstruction exists at the pylo- rus, the whole organ is dilated, with hypertrophy of the muscular layer of the stomach. In dilatation without pyloric obstruction, the muscu- lar layer is thinner than normal, paler in color, and presents signs of fatty degeneration ; the mucous membrane is also pale, thin, and without rugae. Symptoms. Those of the disease producing the obstruction plus those of obstinate chronic gastric catarrh, with characteristic vomitifig ; the cavity having a greatly increased capacity, large accumulations take place, which are rejected every day or two, partly digested and partly decomposed. Regurgitaiioji of partly digested aliment, acrid, acid, and offensive, is very common. Bowels constipated, the stools hard and dry. Physical signs of gastric dilatation are : on inspection, abnormal prominence of the whole epigastric region, with a tumor in the pyloric region which seems to be connected with the stomach ; percussion, if empty, tympanitic note extending to or below the umbilicus, having a metallic quality ; if the stomach be filled, high-pitched flat note ; auscultation, splashing and rumbling sound, the succussion sound being distinct if the body be shaken. Diagnosis. Copious vomiting of food partly digested, once in twenty-four hours or less often, epigastric distress and pain resulting from foul-smelling and acid eructations and from obstinate constipa- tion. And on percussion the tympanitic note of the stomach as low or lower than the umbilicus, with some dullness, may be due to food or liquid in stomach. If a doubt then exist, give large amount of food and note dullness, or, what is not so pleasant, sodii bicarbonas, gr. xv (i Gm.),with acidum tartaricum, gr. xx (1.3 Gm.), and the tympanitic outline of the stomach will be evident. Dr. Leonard has determined the presence of gastric dilatation by the X-ray and use .of bismuth solution to produce a shadow in stomach. Penzoldt's modification of Piorry's method of determining gastric dilatation is to withdraw the contents of the stomach by means of the oesophageal tube and then refilling the stomach with fluid. By noting the lower limit of percussion dullness thus produced, the lower bor- der of the stomach can be accurately determined. Treatment. Regulated diet. Restrict the use of fluids, using a " dry diet" exclusively. 92 PRACTICE OF MEDICINE. If the result of pyloric stenosis, one of the operations mentioned for pyloric cancer may be indicated. Regardless of the cause, washing out the stomach with the stomach tube every day or two, gives relief, and, if no stricture be present, administer strychnines sulphas or nux vomica, and very favorable results may follow. GASTROPTOSIS. Definition. A displacement of the stomach downward, associ- ated with prolapse of the bowel (enteroptosis or Glenard's disease) and prolapse of the kidney (nephroptosis). Causes. Relaxed condition of the abdominal walls due to impaired development or loss of tension, causing improper intra- abdominal pressure ; wearing corsets or other tight, unyielding gar- ments ; occupations favoring stooping posture, leading to decreased tension of the abdominal walls, such as seamstresses, tailors, and shoemakers, or other sedentary work ; frequent pregnancies, which stretch the abdominal muscles. It is probable that there exists a predisposition to imperfect devel- opment of abdominal and other muscles, or their early loss of tension with wasting. More common in women than men, as would be expected from a study of the causes. Anatomical Conditions. The transverse colon is the first organ to prolapse, soon followed by the ascending colon. The stomach is tilted, as it were ; its lower border reaching below the umbilicus, while its lesser curvature lies between the ensiform carti- lage and the umbilicus. In some cases the pyloric end is down to or below the umbilicus without as much prolapse of the fundus. The right kidney is displaced and often floating or movable. The left kidney is less often displaced. Any or all of the conditions named may be associated with any of the organic gastric conditions. Symptoms. Impaired digestion with eructations of gases. Dis- tress or feeling of weight after eating, often amounting to intense pain. Loss of flesh with marked ancemia and 7ieurasthenic symptoms are almost characteristic of the gastric and intestinal prolapse. Con- stipation is the rule, although cases with diarrhoea have been reported. DISEASES OF THE STOMACH. 93 Physical phenomena. In the standing position the lower part of the abdomen projects and the upper part sinks in. In the recumbent position the abdomen shows a lateral extension. Aortic pulsation is frequent. There is often " a ridge lying across the abdomen" to be determined by palpation. Glenard termed this ridge the " corde- colique transverse" and thought it was due to a prolapse of and partial occlusion of the transverse colon. Other observers think it is the pancreas that is felt on account of the prolapse of the transverse colon. Inflation of stomach often detects its prolapsed position with a lowered gastric splashing. The X-ray, with the aid of the bismuth solution for shadow, will determine the location of the organ. Treatment. Unless surgery can give aid, medication is but pal- liative. Abdominal bandages are recommended, but seem of small use. The chief indication is to improve the general health. GASTRIC HEMORRHAGE. Synonyms. Haematemesis ; gastrorrhagia. Definition. Gastric hemorrhage is not, strictly speaking, a dis- ease, but a symptom ; still, vomiting of blood occurs under such a variety of conditions that a separate consideration is desirable. Causes. Ulcer of the stomach ; cancer of the stomach ; cirrhosis of the liver ; scurvy ; purpura ; haemophilia ; hemorrhagic malarial fever ; congestion of the liver or spleen ; cirrhosis of the liver ; vicarious at menstrual period ; yellow fever ; toxic gastritis. Symptoms. Added to the symptoms of the cause of the hem- orrhage, are a feeling of faintness and sinking at the pit of the stom- ach, followed by the ejection of blood of a black, grumous, or coffee- ground appearance. Rarely, and then generally in gastric ulcer, the ejected blood may have a bright red appearance, the gastric juice not having had time to act upon it. If the amount of blood escaping into the stomach is large, blood will be voided by stool. Diagnosis. Hemorrhage fro?n the lungs may be confounded with gastric hemorrhage. In the former, the blood is red, is coughed up, not vomited, and is associated with a history of pulmonary dis- ease. The chief point of distinction between pulmonary hemorrhage and the vomiting of red blood is that in the former you can discern rales on auscultating the chest, and they are absent in the latter. In 94 PRACTICE OF MEDICINE. hemorrhage from the stomach there is almost invariably food mixed with the blood. Prognosis. Depends entirely upon the cause, the most unfavor- able being the result of either gastric ulcer, cancer, hepatic cirrhosis, or haemophilia. Treatment. Complete rest in bed. Ice, internally and applied in bladders over the epigastrium and along the spine, or hot water, as hot as can be borne, in quantities of four to six ounces at very fre- quent intervals. Hypodermic injections of morphines sulphas quiet the patient's fear, and at the same time have a constringing effect upon the vessels. Extractum ergottz fluidum or ergotin hypodermically after the patient is quieted, or liquor ferri subsulphaiis, ntj-v (0.06-0.3 Cc), well diluted, by stomach. Cases resulting from congestion of the liver or spleen are benefited by saline purgatives. Allow no food by the stomach for several days, nourishing the patient by rectal alimentation. The hemorrhage controlled, the future treatment is guided by the exciting cause. GASTRALGIA. Synonyms. Cardialgia; gastrodynia; stomachic colic; spasm of stomach ; neuralgia of the stomach. Definition. A painful condition of the sensory nerves of the stomach, induced by various sources of irritation ; characterized by violent paroxysms of gastric pain and spasm, associated with feeble cardiac action, and symptoms of collapse. Causes. The affection belongs to the group of neuralgias. The most important factor in its causation is general nervous depression or neurasthenia ; other causes are gastric cancer or ulcer, malaria, rheumatic or gouty diathesis, syphilis, anaemia, and certain articles of diet. Occurring in chronic nervous affections, the so-called " gastric crises." Symptoms. Like most neuroses, gastralgia is distinguished by \ts paroxysmal character. Romberg thus describes an attack : " Suddenly, or after a feeling of pressure at the praecordiumi there is severe griping pain in the stomach, usually extending to the back, DISEASES OF THE STOMACH. 95 with a feeling of faintness, a shrunken countenance, cold hands and feet, and an intermittent pulse . The pain becomes so excessive that the patient cries out. The epigastrium is either puffed out, like a ball, or retracted, with tension of the abdominal walls. There is often pul- sation in the epigastriwn. External pressure is well borne, and not unfrequently the patient presses the pit of the stomach against some firm substance, or compresses it with his hands. Sympathetic pains often occur in the thorax, under the sternum, and in the oesophageal branches of the pneumogastric, while they are rare in the exterior of the body. "The attack lasts from a few minutes to half an hour or longer; then the pain gradually subsides, leaving the patient much exhausted; or else it ceases suddenly, with eructation of gas or watery fluid, or with vomiting, and with a gentle, soft perspiration, or with the passage of reddish urine." Besides such severe attacks, we often see painful sensations in the epigastrium, of various degrees of intensity, with passing faintness or sinking at the "pit of the stomach," associated with heartburn, or pyrosis, ending with sensation of hunger, drowsiness, and a free dis- charge of clear urine of low specific gravity. Diagnosis. From myalgia of the abdominal muscles, by the pain of gastralgia being more acute and lancinating, accompanied by nausea and vomiting and the absence of tenderness on pressure. From intercostal neuralgia, by the fact that in this affection the pain is in the left hypochondrium, with painful spots along the course of the nerve "trunk and at the spine, and absence of nausea and vomiting. From gastric cancer, by the age, character of the vomited matter, constancy of the pain, the cachexia, emaciation, and the tumor. From gastric ulcer, by the localized pain and its constancy, with tenderness and vomiting of blood, and constant dyspeptic symptoms, which is not the case in gastralgia. From hepatic ox gall-stone colic, by the pain being to the right of the median line radiating to the right and to the right scapula and shooting toward the right ilium and the sclerotic jaundice after an attack. Prognosis. As to perfect recovery, unfavorable, but not danger- ous to life. A chronic affection, in that attacks are prone to return from time to time. The cause has much to influence a radical cure 9G PRACTICE OF MEDICINE. Treatment. For the paroxysm, hypodermic injections of mor- phines sulphas, gr. yi-% (0.02-0.03 Gm.), or the stomachic adminis- tration. of the " compound of anodynes," the so-called chlorodyne, in doses of tt^x-xxx (0.6-2 Cc.) p. r. n. The relief afforded by opium in some form is so decided that it is apt to lead to the opium habit when the attacks are frequent. A mild attack may be relieved by antipyri?i, gr. x (0.65 Gm.). A hot-water bag over the stomach is of great value. In recurring attacks Van Valzah recommends : R . Codfin., g r - X - OI ^ Gm. Ext. cannab. indicae, g r - To •°°^ ^ m - Atropinse sulphas, gr. 2^ .00032 Gm. Aconitinae, gr. ^^ .00016 Gm. M. Ft. capsul. SiG. — One every four or six hours. Galvanization often gives prompt relief. In the interval, regulated diet and one or more of the following remedies : argenti nitras, qtiinince sulphas, arsenicum, bismuth sali- cylas,ferrum, liquor iodii co?np., or small doses of potassii iodidum. ATONIC DYSPEPSIA. Synonyms. Dyspepsia ; indigestion ; heartburn ; pyrosis. Definition. A functional derangement of the stomach, with either deficient secretion in the quantity ox quality of the gastric juice; char- acterized by disorders of the functions of digestion and assimilation and the presence of sympathetic nervous symptoms. Causes. Imperfect mastication ; bolting of food ; eating large quantities of food ; same diet long continued ; depressed nervous system, from worry and fatigue ; sedentary habits or occupations. It is often inherited. Symptoms. Perverted appetite, capricious or lost ; difficult di- gestion, a feeling of weight or fullness in the epigastrium ; acidity from the decomposition of albuminoids ; heartbwn, flatulency \ regur- gitation % or vojniting of portions of partly digested food or acrid fluid — water- brash or pyrosis. Pain or soreness at the "pit of stom- ach " during digestion. Tongue either clean or broad, flabby, and pale, showing marks of the teeth. Bowels constipated ; urine gener- ally scanty and high-colored, with excess of urates or oxalates, or, in DISEASES OF THE STOMACH. 97 persons of nervous type, it is pale, of low specific gravity, and con- tains phosphates. Drowsiness after meals, with wakefulness at night, defective memory, headache, and absent mental vigor, with flashes of heat, followed by more or less perspiration. Palpitation of the heart with irregularity in rhythm. Varieties of Dyspepsia. — I. Nervous dyspepsia, atonic form, seen in active business or busy professional men, especially those of thin, spare build, of nervous temperament, who eat meals rapidly and hurry off to their business. These cases present all the marked nervous phenomena, such as drowsiness after meals, and feeling worse after a nap ; inability for mental exertion after meals, defective memory, headaches, at times vertigo and sleepless nights. II. Flat- ulent dyspepsia, seen in hysterical individuals, and showing immense development of gas throughout the abdomen, associated with vertigo and mental worry or hypochondria. III. Acid dyspepsia, water- brash. Seen when the diet is coarse. Acidity of the gastrointes- tinal canal and of the urine. IV. Irritative dyspepsia. Vomiting a prominent symptom. In these cases the tongue is small, red, and pointed. Prognosis. With careful living, dyspepsia, functional in charac- ter, is curable. It has been aptly termed " remorse of the stomach." Treatment. The most important indication is to regulate the diet. Forbid saccharine, starchy, or fatty articles of food. Eat small amounts at a time, underojpae, meats or " Salisbury steaks," eggs, fish, oysters, and green vegetables, with stale or brown bread. Per- fect insalivation and mastication. Rest after eating, from a half to an hour. Allow but small quantities of liquids with the meals. In the vast majority of cases, forbid the use of stimulants with the meals. Aid digestion with pepsinum, with or without acidum hydrochlori- cum dilutum. R. Pepsini purse, ^j 4. Gm. Acid, hydrochlorici dil., . . . - fgiv 15- Cc. Glycerini, f ^ iv 15. Cc. Aq. lauro-cerasi, f^ij 60. Cc. M. SiG. — One teaspoonful with meals, diluted. Excellent results have followed the use of a new remedy known as taka- diastase, gr. ij-iv (0.13-0.26 Gm.) at meal time. 9 98 PRACTICE OF MEDICINE. Sumulate stomachic peristalsis with nux vomica, gentian, or cin- chona. For acidity, alkalies at time of acidity, the very best being sodii bicarbonas. Y ox flatulency , carbo animalis purificatus, gr. x-xx (0.65-1.3 Gm.), or one or more of the carminatives, with tinctura nucis vomicce before meals. F "or pyrosis, bismuth, gr. xx (1.3 Gm.), and pulvis aromaticus, gr. v (0.32 Gm.). For vomiting, sodii or strontii bromidum in small doses, or acidum carbolicum, gr. Ye-% (0.011-0.016 Gm.), three or four times daily, or chloral hydrate, gr. x-xv (0.65-1 Gm.), in a demulcent by the mouth or rectum, repeated p. r. n. For constipation, resina podophyllum at bedtime, or Hunyadi Janos water before breakfast, hot, or — R. Ext. cascaras sagradae fid., . . . f^j 30. Cc. Tinct. nucis vomicae, f.l ss l S- Cc Syr. zingib., f.^ ss J 5- Cc. Inf. sarsaparillae, . . . q. s. ad f^iij ad 90. Cc. M. SiG. — Teaspoonful three times daily, diluted. For ance7nia, massa ferri carbonatis or ferri lactas. Irrigation of the stomach or lavage often gives remarkable relief. The drinking of hot water one-half to one pint an hour before meals is of benefit. A homely but efficient combination for atonic dyspepsia associated with scanty, acid urine and constipation, is — R. Sodii bicarbonatis, gij 8. Gm. Tinct. nucis vomicae, f.^iv 15. Cc. Tinct. capsici, f^j 4. Cc. Tinct. rhei, f Jiss 45. Cc. Inf. gentian, comp., . . . . adfjvj ad 180. Cc. M. SiG. — Half tablespoonful after meals, in water. I have seen excellent results in many cases of dyspepsia and indi- gestion from the following combination : &. Papoid (purae), gr. xxx 2. Gm. Sodii bicarb., gr. lx 4. Gm. Pulv. zingib. jam., gr. v .3 Gm. M. Et capsul. or pil. No. xx. SiG. — One at meal-time and bedtime. DISEASES OF THE INTESTINAL CANAL. 99 DISEASES OF THE INTESTINAL CANAL. INTESTINAL INDIGESTION. Synonym. Intestinal dyspepsia. Definition. A derangement in the functions of intestinal diges- tion, resulting in the more or less complete decomposition of the chyme, caused by defects in the pancreatic, biliary, or intestinal secretions or from deficient peristalsis, one or more of these, singly or combined ; characterized by abdominal pain and distention and tympanites developing some hours after meals, and nervous perturba- tion, anaemia, and emaciation. Causes. Imperfect diet ; over-eating ; irregularity in eating ; de- ficient exercise ; worry ; immoderate use of tobacco or stimulants ; diseases of the stomach, intestinal tract, liver, or pancreas ; malaria. Frequently inherited. Symptoms. Intestinal indigestion may be either acute or chronic, the latter the more common. Acute variety, the result of an irritant in the duodenum, rapidly developed pain, flatulency, borborygmi, slight feverishness, coated tongue, loss of appetite, headache, pains in the li?nbs, usually termi- nating in a mild attack of diarrhoea. If the attack develops rapidly, the sudden formation of gases causes a paroxysm of colic. Severe attacks are associated with disordered hepatic function, light-colored stools, slight jaundice, and high colored urine. In these severe attacks the symptoms develop gradually with general malaise, or abruptly with chill or chilliness followed by fever ioo°-io2°, in- creased pulse, headache with or without vomiting, the tongue white coated, soon becoming red, dry, and glazed, with abdominal pains increased by pressure, tympanites and flatulency succeeded by diar- rhoea, the stools averaging from two to a dozen, at first soft and nor- mal with fecal odor and color, later becoming watery and frothy with a most persistent, offensive odor, containing mucus and particles of undigested food. The reaction of stools is alkaline, rarely acid. The 100 PRACTICE OF MEDICINE. microscope shows epithelial cells, round cells, occasionally blood- cells, bacteria, Charcot's crystals, crystals of oxalate of calcium, calcium phosphate, etc. Cramps in lower limbs, often very severe. Chronic variety, resulting from a greater or less decomposition of the partly altered food from the stomach. Pain, varying in character, occurring f^om two to four or six hours after meals, with slight tenderness and some fullness in the right hypochondrium, epigas- trium, or the umbilical region. Tympanites and borborygmi are marked, the result of gaseous accumulations which have developed from the decomposition of the intestinal contents. Dyspnoea, the result of pressure against the diaphragm, is of frequent occurrence. Marked nervous phenomena develop, the result of the anaemia from deficient assimilation and from the depressing influence on the nervous system of the absorption of the " gases of decomposi- tion." The skin is harsh and dry, the bowels are sluggish or constipated, the urine is high colored, of increased density, decidedly acid, and, on cooling, deposits lithates, uric acid, and oxalate of lime crystals. Functional derangement of the liver follows after a time, adding to the general discomfort. AncEmia and emaciation result if the attack be protracted from the imperfect secondary assimilation. Diagnosis. With our present knowledge it is usually impossible to designate forms of intestinal indigestion due to defects in the quantity or quality of either the pancreatic, biliary, or intestinal secretions. Acute intestinal indigestion differs from gastric indigestion in the time of development of the various phenomena, in the latter the symptoms appearing almost immediately after meals, while in the former not appearing until two, four, or six hours after. Chronic intestinal indigestion may mislead the physician if the various nervous phenomena are of a marked character, and a careful history of the case is not developed. Prognosis. Favorable if proper and early treatment be inaugu- rated, unless the result of an organic lesion. Treatment. Acute variety, the result of undigested food, is best treated by opium in some form, to relieve the acute suffering, warmth to the abdomen, and a prompt cathartic to cause its rapid expulsion, % .02 Gm. y .13 Gm. Ve .01 Gm. u ) .2 Gm. DISEASES OF THE INTESTINAL CANAL. 101 or six or eight calomel powders two or three hours apart, followed the next morning by a saline — R. Hydrarg. chlor. mit., gr. Sodii bicarb., . gr. Pulv. ipecac. , gr. Sacch. lact. , gr. iij .2 Gm. M. Ft. charta. After which stimulate the gastro-intestinal canal with : f£. Tinct. nucis vomicce, f^iv 15. Cc. Acid, hydrochlorici dil., . . . fgiv 15. Cc. Tinct. card, comp., f^iv 1 S- Cc. Ess. pepsin., q. s. ad f 5 iij ad 90. Cc. M. SlG. — Teaspoonful every three hours, diluted. For the more severe variety of intestinal indigestion (or catarrh), wash out large bowel with — R. Magnesii sulph., %] 30. Gm. Glycerini, f 5j 30. Cc. Aquae bul., f'^iv I2 °« Cc. M. Slowly injected into bowel from a fountain syringe. Internally either of the following excellent combinations : R. Naphtalini, gr. Bismuth, salicyl., gr. Acid, carbolici, gr. Glycerini, f^j Aq. chloroformi, ....... fjiij 90. Cc. M. SlG. — Two teaspoonfuls every two or three hours, diluted. Or— U . Sodii phosphat., %] 30. Gm. Acid, phosph. dil., Syr. limonis, . . Aq. chloroformi, XXX 2. Gm. lxxx 6. Gm. iv .26 Gm. 30. Cc. J 90. Cc. fgiv 15. Cc. f|j 30. Cc. f5iij 90. Cc. fliiiss 100. Cc. M. Aq. menth. pip., SlG. — One tablespoonful after meals, well diluted. In all cases carefully designate the character and amount of food, and times of administration. Chronic cases. Of the first importance is the diet, which should be restricted in amount and confined almost entirely to articles which are readily digested in the stomach, such as beef, eggs, and milk. 102 PRACTICE OF MEDICINE. Aid intestinal digestion by the administration of — R. Papoid, gr. j-ij .065-. 13 Gm. Naphtalini, gr. j .065 Gm. Ext. nucis vomicae, gr. y$ .022 Gm. M. Ft. pil. One such to be taken every four or six hours. Or liquor pajicreaticus, f3j-iv (4-15 Cc); or extractum pancreatis, gr. ij-v (0.13-0.3 Gm.), with sodii bicarbonatis, gr. v-x (0.3-0.6 Gm.), two or three hours after meals ; or fel bovis purificatum, gr. j-iij (0.065-0.2 Gm.), after meals. Excellent results from the use of the following pill : R. Sodii arseniat, gr. ^ .003 Gm. Strychninse sulph., gr. 3V .002 Gm. Pepsinoe purse, gr. ij .13 Gm. After each meal. For constipation, bitter waters, such as Bedford, Friedrichshall, Pullna, or Hunyadi Janos, or resina podophyllum, or extractum cascarcE sagrada fluidum, at bed-time. INTESTINAL COLIC. Synonyms. Enteralgia ; tormina ; gripes. Definition. A spasmodic contraction of the muscular layer of the intestinal tube ; characterized by acute paroxysmal pain near the umbilicus, relieved by pressure, and associated with feeble cardiac action. Causes. Constipation; presence of indigestible food ; collections of flatus; an abnormal amount of bile discharged into the intestines; lead poisoning; syphilis; chronic malaria ; rheumatism; hysteria. Symptoms. Romberg thus describes a paroxysm : " There are attacks of pain, spreading from the navel over the abdomen, alter- nating with intervals of ease. The pain is tearing, cutting, pressing, most frequently twisting, pinc/iing, accompanied by peculiar bear- ing-down pains. The patient is restless, and seeks relief "in changing his position and in compressing the abdomen; his surface maybe cold and his features pinched. The pulse is small and hard. The abdomen is tense, whether puffed up or drawn inward. There are DISEASES OF THE INTESTINAL CANAL. 103 often nausea and vomiting, and desire for stool. There is usually constipation, but sometimes the bowels are regular or even too loose. Duration from a few minutes to several hours, relaxing at intervals. The attack ceases suddenly, with a feeling of the greatest relief, although some soreness remains for a few days." Lead colic is always preceded by symptoms of lead poisoning, to wit: slate-colored skin, dark gums showing a blue line, heavy breath, with sweetish metallic taste, obstinate constipation, impaired appetite, slow pulse, and contracted abdominal walls. Diagnosis. Gastralgia differs from colic, in the pain being in the epigastric region and associated with disorders of digestion. In hepatic colic, or the passage of gallstones, the pain is in the hepatic region, attended with soreness over the gall bladder, and retching and vomiting, followed by jaundice and the presence of bile in the urine. In nephritic colic, the pain follows the course of one or both ureters, shooting to loins and thigh, with retraction of the testicle of the affected side, strangury, and bloody urine. In uterine colic, the pain is in the pelvis, and associated with men- strual disorders, in fact, a dysmenorrhoea. In ovarian colic or neuralgia, pain or pressure over the ovaries, with hysterical phenomena. Inflammatory disorders of the abdomen differ from colic by the presence of fever and tenderness on pressure. Prognosis. Most favorable. Death is the rarest termination possible. Treatment. Relief of pain is the first indication, and is best ac- complished by a hypodermic injection of morphines sulphas, gr. l /6- l /i (0.011-0.022 Gm.), which has tho additional advantage of relaxing the spasm, thereby favoring the action of purgatives, which should soon follow. One of the best in colic, no matter from what cause, is masses hydrargyrum, gr. v-x (0.3-0.6 Gm.), or hydrargyri chloridum mite, gr. ]/ z (0.03 Gm.) every half hour until four or five grains are taken, followed by a mild saline cathartic. After the relief of the pain and free action of the bowels, the cause of the attack should be ascertained and corrected, to prevent future suffering. For lead colic, morphina sulphas for the pain ; oleum ricini or magnesii sulphas, Z\ (4 Gm.) every hour, for the constipation, and 104 PRACTICE OF MEDICINE. potassii iodidum, gr. v-x (0.3-0.6 Gm.) after meals, or syrupus acidi hydriodici, f^j-iv (4-15 Cc.) after meals, diluted, to eliminate the metal from the system. Excellent results often follow a free or several small venesections in lead poisoning. Gratifying results in attacks of lead colic have been reported from tumblerful doses of oleum olives, repeated until some six ounces (180 Cc.) have been used. It is said to be curative in lead poisoning, in daily doses of two ounces, continued for some time. CONSTIPATION. Synonyms. Intestinal torpor ; costiveness. Definition. A functional inactivity of the intestinal canal, either due to atony of the muscular coat, causing lessened peristalsis, or to a deficiency of intestinal and biliary secretion ; characterized by a change in the character, frequency, and quantity of the stools. Causes. Dyspepsia; character of the food; habits of the patient, as sedentary habits and neglecting calls of nature ; diseases of the stomach and liver; malaria; lead poisoning ; syphilis. Symptoms. In the normal condition the majority of persons have one stool each day, although it is not to be considered abnormal if more or less than that number occur. The bowels are moved every three ox four days, with great straining and distress, the/ace often flushed, the cerebral vessels full ; leaving an uneasy sensation in the rectum. Or in other cases the bowels may be relieved once a day, but the stool is small and hard, causing great distress, and tenesmus, or teaz- ing. Another group of cases rx&ve frequent stools during the day, small and non-formed, due to retained hardened feces acting as an irritant upon the rectum. The change in the character of the stools is soon followed by symptoms of dyspepsia, headache, mental torpor, vertigo, palpitation on exertion, and in many cases with great distention of the abdomen. Prognosis. Death never results from functional constipation. Treatment. The successful treatment depends upon the removal of the cause and the hearty co-operatio7i of the patient. First, the patient must have a regular hour each day for going to DISEASES OF THE INTESTINAL CANAL. 105 stool, and must remain a sufficient time to permit a thorough evacua- tion of the bowels, assisting, until habit of daily stools is formed, by a warm water injection. Second, the diet must be carefully regulated, as concentrated foods increase the costive habit, so that those predisposed should eat bulky foods, much vegetables and fruits. Third, purgative mineral waters or cathartic medicines are to be used with caution, their reckless administration often causing more injury than benefit. Fourth, either of the following formulae, aided by the enforcement of the above rules, will give good results : R. Ext. nucis vomicse, g r - X .016 Gm. Ext. belladonnse alco., g r - X * 01 ^ Gm. Ext. aloes aqua., gr. ss .032 Gm. Pulv. rhei, gr. j .065 Gm. Olei cajuputi, TT\, j .06 Cc. M. In pill, at bedtime ; and after a week, every second or third night. R • Resina podophyl., Ext. physostig. , Ext. belladonnae alco. , Alomi, aa gr. X aa .016 Gm. In pill, every night, or second or third night. R. Ext. cascarae sagradoe fid. , . . . TT\,xx 1.3 Cc. Glycerini, tt\xx 1.3 Cc. Syr. sarsaparillse, V(\xx 1.3 Cc. Hour after meals, or once a day, as indicated. All cathartics and purgatives are improved by the addition of a small amount of sulphur praecipitatum. One of the very best purgatives is an early morning dose of magnesii sulphas (Epsom salts). Another excellent tonic purgative is aloinum, gr. yi-% (0.008-0.016 Gm.), after meals. Success often follows an enema of glycerinum, f^j-iv (4-1 5 Cc), or a suppository of glycerinum. Electricity to the abdomen is worth a trial ; one pole over abdomen, the other at anus, using either galvanism or faradism. Kneading the abdomen is frequently of benefit. 10 106 PRACTICE OF MEDICINE. DIARRHCEA. Synonyms. Enterorrhoea ; alvine flux ; purging. Definition. Frequent loose alvine evacuations, without tenes- mus; due to functional or organic derangement of the small intes- tines, produced by causes acting either locally or constitutionally. Causes. Those acting locally, such as indigestion, indigestible food, impure food and water, irritating matters or secretions poured into the bowels, or entozoa, cause the flux by a direct irritation of the mucous surface. Attacks of diarrhoea due to constitutional derangement may be secondary to such diseases as tuberculosis, fiyamia, albuminuria, typhoid fever, or disturbances of the functions of other organs, giving rise to vicarious fluxes. Atmospheric changes, as well as a sudden mental shock, will often produce an attack of diarrhoea in those predisposed. Forms. Acute and chronic. Symptoms. Acute diarrhoea presents itself in several varieties, the result of the particular cause. Feculent diarrhoea. A few hours after meals the patient feels colicky pains and flatulency, with a desire for stool. There is often nausea, coated tongue, but seldom vomiting. The pain is generally relieved by the purging which ensues. The stools have a feculent character, are of brown fluid, containing faeces, often offensive, the color becoming lighter after four or five evacuations. Constitutional symptoms are wanting. This form is the result of overeating, eating too rapidly, or indi- gestion of different forms, or worms in the intestinal canal, and patients generally recover in a day or two. Lienteric diarrhoea. In this form there is, with the frequency of evacuations, a want of assimilation of food, which passes through the intestines more or less unaltered. The stools are frequent, mucous or serous, more or less covered with bile, mixed with undigested food. In this form the patients emaciate rapidly, owing to the deficient assimilation, the digested portions of the food being hurried on by the increased peristalsis of the irritated bowel. It is usually subacute in its course. Bilious diarrhasa. The stools are frequent, green or yellow, with DISEASES OF THE INTESTINAL CANAL. 107 scalding sensations at the anus and griping pains in the abdomen. Excessive biliary secretion is the irritating cause. Any of the above forms may pass into chronic diarrhoea by exciting permanent diseases of the intestines. Diarrhoea due to constitutional causes will be mentioned when speaking of those conditions. Chronic diarrhoea results from repeated attacks of the acute form. or is the result of some cachexia. The sympto?ns, so far as the stools are concerned, are much the same as in the acute disease, except they are paler, whence it has been termed white flux ; in addition, dyspeptic symptoms, aphthous condition of the mouth and tongue, flatulency, colic, einaciation, and ancemia. The appetite is at times capricious, again impaired. Exacerbations result from indiscretions in diet and from the sudden onset of damp weather. Prognosis. Favorable in feculent a.nd bilious forms; unfavorable in lienteric and chronic forms when emaciation begins. Diarrhoea occurring as a symptom, the prognosis is controlled by the original disease. Treatment. Acute diarrhoea. If the tongue is heavily coated, the breath fetid, and the stools not excessive in number, it is well to clear the intestinal canal with a laxative such as oleu?n ricini or a saline. For children between one and two years of age : R. Pulv. ipecac, gr. ss .032 Gm. Pulv. rhei, gr. X _ K .016-.022 Gm. Sodii bicarb., gr. ss-ij .032-. 13 Gm. M. Every four hours until the character of the stools changes. As a rule, however, the stools have become so frequent when ad- vice is sought that the time for laxatives has passed, and someone of the following combinations is indicated : R. Salol, gr. xx-xxx 1.3-2. Gm. Bismuth subnit. , 3] 4- Gm. Sacch. lac, 3J 4- Gm - M- Ft. chart. No. x. SlG. — One every two or three hours, reducing the dose for children Or— R. Bismuthi salicylat, gr. xxx 2. Gm. Morphincesulph., gr. j .065 Gm. M. Ft. chart. No. vj. SlG. — One every three hours. 108 PRACTICE OF MEDICINE. Or the following modification of " Squibb's diarrhoea mixture": R . Tinct. opii deodorat., f^iv J 5- Cc. Tinct. camphorae, f.^i y J S' Co Tinct. capsici, fgij 8. Cc. Chloroformi pune, f 7, iss 6. Cc. Spts. vini gallici, f^j 30. Cc. Vini pepsini, ad fjiij ad 90. Cc. M. Sig. — One teaspoonful, p. r. n. Or the following, which I have always found successful : R. Tinct. opii deodorat., f ^ iv 15. Cc. Spts. chloroformi, f^ij 8. Cc. Acid, sulphuric, dil., fjfj 30. Cc. Vini pepsini, q. s. adfjiij ad 90. Cc. M. SiG. — One teaspoonful in water after each stool. For the bilious form : R . Hydrargyri chlor. mitis, .... gr. y% .008 Gm. Sodii bicarb., gr. ij .13 Gm. Pulv. opii, g r - X - ol6 Gm. M. In powder, every two or three hours, until eight powders are used, followed by large doses of bismuthum and pepsinum. In all acute forms restricted and regulated diet are imperative, pure milk with liquor calcis being the most suitable. In adults, an opium suppository often checks a flux that is uninflu- enced by opium internally. In lienteric or dyspeptic diarrhoea a carefully regulated diet and either of the following combinations : 1£ . Pepsini glycerit., f^j 30. Cc. Liq. potassii arsenit., t^xx 1.3 Cc. Tinct. opii deodorat., f ^ ij 8. Cc. Aq. chloroformi, ... q. s. ad fjiij ad 90. Cc. SiG. — One teaspoonful at meal-time. Or— I£ . Papoid gr. xx 1.3 Gm. Bismuth, subnit., 3J 4. Gm. M. Ft. chart. No. x. Sig. — One at meal-time. Chronic diarrhoea. Bismuth, gr. xxx-xl (2-2.6 Gm.), in milk, every four hours; Hope's camphor mixture, f]fj (30 Cc), every four DISEASES OF THE INTESTINAL CANAL. 109 hours ; or cupri sulphas, gr. T ^ (0.005 Gm.), ext. opii, gr. T ^ (0.005 Gm.), every four hours ; or argenti nitras, gr. l /e (0.01 Gm.), ext. opii, gr. ^(0.011 Gm.), every five hours; may all be used with more or less success ; when dry tongue and great flatulency use : R . 01. terebinthinse, f z j 4. Cc. 01. amygdal. express., f3 ss I 5- Cc. Tinct. opii, fzij 8. Cc. Mucil. acacise, f z * v J 5- Cc. Aq. lauro-cerasi, f|> ss I 5- Cc. M. SlG. — f 3 j every three or four hours, diluted. The diet should be nutritious in character, and moderate stimulants are indicated. Activity of the skin and kidneys should be encour- aged. All varieties of intestinal catarrh or diarrhoea are benefited by a few days' rest in bed and daily hot baths. CATARRHAL ENTERITIS. Synonyms. Intestinal catarrh ; acute diarrhoea ; inflammation of the bowels. Definition. A catarrhal inflammation of the mucous membrane of the small intestines ; characterized by fever, pain, tenderness, and looseness of the bowels. When the catarrh is limited to the duode- num it is termed duodenitis, and there is some jaundice. Pathological Anatomy. There first ensues hyperemia of the mucous membrane and intestinal glands, manifested by redness, swelling, and azdema ; this is followed by increased secretio?t, and an overgrowth and desquamation of the epithelium, together with a copi- ous generation of young cells. As a result of the hyperaemia, rupture of the capillaries and extravasation of blood often occur. The swollen glands show a strong tendency to ulcerate. This catarrhal process may involve the entire tube or be limited to portions of it. If the catarrhal changes extend to the ileum, the solitary and Peyerian glands show swellings that might be mistaken for the changes of typhoid fever. Causes. A specific virus seems probable in some cases. Per- haps a ptomaine poisoning. Improper and indigestible food ; summer HO PRACTICE OF MEDICINE. temperature and exposure to cold and wet, while perspiring. Swal- lowing fish-bones, cherry-stones, unmasticated kernels of nuts, etc. Symptoms. Begins with languor, followed by chilliness and fever, the temperature ranging at io2°-io3°; this is followed by pain, colicky and paroxysmal in character, situated above the umbilicus, localized tenderness, and loose evacuations. Nausea and vomiting often occur. The bowels are at first constipated, followed by per- sistent diarrhoea ; the stools contain but little fecal matter, are yellow ox greenish-yellow in color, mixed with undigested food ; if the stools are numerous, they become whitish and watery, the so-called " rice- water" discharges. No blood in the stools. The appetite is im- paired, and this, with the want of assimilation and great waste, soon produce extreme weakness and emaciation, which is always more marked in children. I have frequently noted a peculiar abdominal eruption in severe cases of intestinal catarrh, occurring as isolated dark-red spots, larger than those of typhoid fever, lasting, each, twenty-four hours, disappearing on pressure and with the decline of fever. Duration. In mild cases, four or five days; severe cases con- tinue, more or less marked, for a week or two. Diagnosis. From colic, by the absence of tenderness and fever, and presence of constipation and its paroxysmal character. From typhoid fever, by the absence of prodromes, characteristic step-like temperature record, characteristic eruption, enlarged spleen, and peculiar character of the stools. For points of distinction from dysentery or peritonitis, see those affections. Prognosis. Favorable, if early and proper treatment is em- ployed. Treatment. Rest the bowels by a restricted diet, such as milk and lime-water, or weak mutton or chicken soups, with well-boiled rice added. Keep the patient quiet in bed, a difficult matter in the case of children. For adults, opium is the remedy, in doses to control the symptoms; mild doses do well with — li . Ext. opii, gr. x /i-)/ 2 .016-.032 Gm. Camphone pulv., gr. iij .2 Gm. M. In pill, every three hours. DISEASES OF THE INTESTINAL CANAL. Ill Or— R. Tinct. opii deodorat., ..... Yf\x .6 Cc. Liq. potassii citrat., f^ij 8. Cc. M. Every hour until opium effect. The strength and the frequency of administration of either of these formulae must be governed by the severity of the attack. Salol, gr. j-iij (0.065-0.2 Gm.), alone or combined with bismuthi salicylas, gr. x-xv (0.6-1 Gm.), every few hours, is often of value in intestinal catarrh, although my experience is more favorable to opium. If vomiting is annoying, all other treatment must be discontinued until it has been controlled, the following being usually efficient : Jt . Hydrargyri chlor. mite, .... gr. ^ .008 Gm. Sodii bicarbon., gr. ij .13 Gm. Sacch. lac, gr. ij .13 Gm. M. Give every hour or two, dry, on tongue. For children : R . Tinct. opii deodorat. , TT\J .06 Cc. Bismuth, submit., gr. v .32 Cc. Mist, cretse, fgj 4. Cc. M. Every two hours, for a child of one year. If the disease shows the least tendency to linger, the acid treatment should be substituted, one of the best formulae being " Hope's Cam- phor Mixture." The following, which I have used with much success in the insane wards of the Philadelphia Hospital, where, at times, we see a good deal of intestinal catarrh, and which I have named " Mis- tura enterica," is generally satisfactory: 5c. Spts. camphorse, f^j 30. Cc. Acid, sulphurici dil., f<|i ss 45- Cc. Tinct. opii deodorat., f Ij 30. Cc. Tinct. capsici, f^ ss *5- Cc. Spts. chloroformi, f.! s s 15- Cc. Spts. vini gallici, . . q. s. adf^vj ad 180. Cc. M. SiG. — One to two teaspoonfuls, well diluted, every three or four hours. Locally. Poultices, warm fomentations, such as a turpentine stupe, or ung. belladonna or oleum camphoratce, are agreeable. 112 PRACTICE OF MEDICINE. CROUPOUS ENTERITIS. Synonym. Membranous enteritis. Definition. A croupous inflammation of the mucous membrane of the small intestines ; characterized by tenderness, paroxysmal pain, moderate fever, and the formation and discharge at stool of membranous shreds or casts. Causes. A disease of adult life. The female sex more liable than the male, and neuralgic, nervous, hysterical, or hypochondriacal subjects are more subject to it than are other types. A peculiar state of the nervous system seems necessary to its pro- duction. It is not a frequent disease. Pathological Anatomy. A subacute inflammation of the small intestine, during which the mucous membrane becomes covered with a whitish or grayish-white, firmly adherent, membranous deposit, cemented together by a coagulable exudation, and prolonged by rootlets from the under surface into the intestinal follicles. Symptoms. Begins by feverishness, feeling of soreness and dis- tention of the abdomen; these are followed by pains of a colicky character, severe and depressing, felt around the umbilicus, asso- ciated with tenderness, continuing for half an hour, an hour, or longer, and after a longer or shorter interval occurring again ; these pheno- mena continue for a day or two, when looseness of the bowels with distressing pain and tenesmus occur, the stools containing mucus, with or without blood, and shreds of membrane or cylindrical casts of the bowel. Great relief follows the discharge of shreds, although a feeling of rawness or soreness persists for a few days. Preceding the local manifestations of the disease are attacks of hysteria, hypochondriasis, neuralgia, nervousness, or excitability. The paroxysms recur at intervals of a week or two, or after several months ; as long an interval as three years between attacks is recorded. Diagnosis. Peritonitis may be suspected until the characteristic stools occur. Dysentery is excluded when the shreds and casts of membrane ap- pear. Prognosis. Favorable as to life, but one of the most difficult of diseases to eradicate. DISEASES OF THE INTESTINAL CANAL. 113 Treatment. The diet is an important factor, and preference should be given to coarse articles instead of to liquids. For the pain and suffering, opium in some form is indicated, the most effective being a hypodermic injection of morphince sulphas. For constipation during a paroxysm, an emulsion of oleum ricini with terebinthina is of benefit. Constipation must always be avoided. To prevent a return of the paroxysm, either liquor potassii arsenilis, nvj-ij (0.06-0.12 Cc), before meals, or hydrargyri chloridian corro- sivum, gr. ¥ x ¥ (0.001 Gm.), three times a day, with a course of oleum morrhuce, seems to answer in the majority of cases. Prof. Da Costa speaks highly of pix liquida in some form, as an alterative to the mucous membrane. CHOLERA MORBUS. Synonyms. Sporadic cholera ; English cholera ; bilious cholera. Definition. An acute catarrhal inflammation of the mucous membrane of the stomach and intestines, of sudden onset ; charac- terized by violent abdominal pains, incessant vomiting and purging, cold surface, rapid, feeble pulse, spasmodic contractions of the muscles of the abdomen and extremities, and prostration. Causes. A disease of summer and early autumn, climatic influ- ence being an important factor. Its prevalence during certain seasons seems to indicate a specific cause. Irritants of all kinds, unripe fruits and vegetables, and fermentation of food. Probably a ptomaine poisoning. Pathological Anatomy. Cases in which death has occurred within a few hours present no pathological changes. Generally, however, the gastro-intestinal mucous membrane is congested' and denuded of epithelium; the solitary and Peyerian glands are swollen and prominent. The blood is thick, and dark in color; the kidneys are enlarged and congested; and in prolonged attacks there are appearances of granular changes in the muscular system. Symptoms. Onset sudden and violent, and, unfortunately, gen- erally after midnight, with chilliness, intense nausea, vomiting, and purging, accompanied with distressing burning or tearing abdominal pains or colic. The vomited inatter at first consists of the ordinary 114 PRACTICE OF MEDICINE. contents of the stomach, and the stools of ordinary faeces, but soon the discharges by vomit and stool are liquid, whitish, or of a green or yellowish tint ; if the attack is severe or protracted, the discharges are of the " rice-water'" character. The patient is rapidly emaciated and redttced in strength, the body shrinks, the surface is cold and covered with a clammy sweat, and the pulse is small and feeble, hitense thirst is present, and when drink is given it is at once rejected. Aggravating the distress of the patient are severe cramps of the muscles, and especially those of the calves, and of the flexors of the thighs, forearms, fingers, and toes. Termination. Mild cases often terminate favorably without treat- ment, the patient able to be around in a day or two, although weak. Severe cases, the vomiting and purging cease after some hours, but the patient remains weak, with irritable stomach and bowels for a week or two. Grave cases, the true cholera type, recover from the prostration very gradually ; reaction coming on slowly and usually passing into a typhoid condition of some weeks' duration.' Diagnosis. Asiatic cholera and cholera morbus are easily con- founded during an epidemic of the former, and there are no positive points of discrimination, unless the comma bacilli of Koch are proven to be always in the true cholera stools. Irritant poisons, such as tartar emetic, elaterium, or other sub- stances, cause vomiting and purging, similar to cholera morbus, and are only discriminated from it by the clinical history and cause. Prognosis. In the majority of cases favorable. The mortality is about five per cent. Treatment. At once, regardless of the cause, a hypodermic in- jection of morphines sulph., gr. Y%-)A, (0.008-0.022 Gm.), and atropines sulph., gr. jfa (0.00054 Gm.), to be repeated in half an hour if no improvement; for patients who object to the hypodermic method, opium in some form by the mouth or rectum, giving the preference to the liquid preparations. Camphora and opiu?n combined often act well, or the "enteric mixture" mentioned on page 1 11, and if much depression, small doses of brandy or dry champagne. The intense thirst must not be gratified by the use of liquids, unless very hot, but small pellets of ice by the stomach are grateful. DISEASES OF THE INTESTINAL CANAL. ]15 If the vomiting and purging- continue, make use of — R . Bismuth, submit, gr. xx 1.3 Gm. Acid, carbol., gr. ]/§ .01 Gm. Glycerini, 1T\, XX 1.3 Cc. Aquse, . . f^iv 15. Cc. M. Every hour, in water. If the vomiting is so severe that no opportunity occurs for the medicament to come in contact with the gastric mucous membrane, an enema of chloral, gr. x-xv (0.6-1 Gm.), in some demulcent with tinctura opii deodorati, ttlx-xx (0.6-1.2 Cc), acts often like magic in quieting the distress of the tortured patient. The closer the case approaches the true cholera type, the more severe are the muscular cramps, and their treatment demanded. Prof. Da Costa suggests — R. Chloral, 3'iv 15. Gm. Ung. petrolei, ^j 30. Gm. M. To be rubbed over the affected muscles. Dr. Bartholow suggests — R . Chloral, giij 12. Gm. Morphinse sulph. , gr. iv .26 Gm. Aquae, f|j 30. Cc. M. . SlG. — Twenty minims, hypodermically, repeated p. r. n. Locally, sinapis, in the form of poultices of the dry powder, should be applied to the abdomen, or terebinthina stupes, or the hot-water bag. The after treatment depends upon the symptoms, generally an acid mixture and a regulated diet, with tonic doses of quinina sulphas, are indicated. ENTERO-COLITIS. Synonyms. Inflammatory diarrhoea ; ulcerative entero-colitis. Definition. A catarrhal inflammation of the lower portion of the small — ileum — and the upper portion of the large intestines, with a great tendency to ulceration of the intestinal glands if the catarrh becomes chronic ; characterized by moderate fever, nausea, vomiting, diarrhoea, swollen abdomen, pain, and emaciation. A common dis- ease of childhood. Causes. Improper and indigestible food ; summer temperature ; impure air; uncleanliness ; exposure to cold and damp air. 116 PRACTICE OF MEDICINE. Most commonly a disease of childhood. Forms. Acute and chronic. Pathological Anatomy. Acute variety ; hyperemia, swelling, oedema, and softening of the mucous membrane of the lower portion of the small and the upper portion of the large intestines, with hyper- plasia of the intestinal follicles, their excretory follicles enlarged and tumid, readily distinguished as grayish or blackish points in the mid- dle of the glands ; the patches of Peyer are also enlarged, tumefied, and project above the level of the surrounding mucous membrane, the orifices of the follicles appearing as dark points ; these patches often have an ulcerated appearance, but upon closer examination ulcers are not discovered. Chronic variety ; the thickening and infiltration have extended to the submucous and muscular coats, followed by induration of the tissues, so that the walls of the intestines are often abnormally rigid. Ulceration occurs, which extends through the entire thickness of the membrane. "These ulcers, when isolated, are from one to one and a half lines in diameter, oval or circular in shape, and either have sharp-cut edges, as though the piece of mucous membrane had been cut out with a punch, or the mucous membrane bounding them is undermined." The small ulcers often coalesce, so that large, irregu- lar ulcerated patches are formed, having for their base the submucous or muscular coats, and have a grayish-white color. The mesenteric glands are enlarged, but seldom, if ever, undergo ulceration. Symptoms. Acute form ; may develop slowly, with restlessness and fretfulness, or suddenly with feveris hness, toss of appetite, thirst, nausea, moderate vomiting, and abdominal pain ; or diarrhoea may be the first indication of illness. Regardless of the character of the onset, the stools should present the characteristic appearance ; they are semi-fluid, heterogeneous, greenish, acid, mixed with yellowish frag- me7its of ordinary faeces, and undigested casein, termed the " chopped spinach " stools. The abdoinen is enlarged and tender. An irregular temperature record may occur with increased frequency of the pulse. Emaciatio7i is marked in proportion to the severity of the symp- toms ; in marked cases the child is reduced to a condition of the greatest debility within a few days.. Chro7iic form, or ulcerative entero-colitis, usually follows the acute form, the character of the symptoms being less severe, but decidedly DISEASES OF THE INTESTINAL CANAL. 117 persistent : the strength fails, the temper is very irritable ; the com- plexion grows dark, sallow, and unhealthy, the skin dry and harsh, and, in consequence of the marked emaciation, either hangs in folds around the shrunken limbs or is drawn tightly over the joints*; the abdomen is enlarged and tender, the stools numbering from six to a dozen during the day and night, consisting of the products of an im- perfect digestion mixed with mucus, serum, pus, and oftentimes blood, having a semi-fluid consistency, and an extremely offensive odor. Ulcerative stomatitis is a frequent complication adding to the dis- comfort of the patient. An irregular temperature record may occur with increased frequency of the pulse. Duration. Acute form, from ten days to about two weeks, sub- siding gradually ; chronic form, from one to two or three months, or even longer. Diagnosis. The acute form can hardly be mistaken for any other condition, if the characteristic stools and other abdominal symp- toms are present. The chronic form has been frequently mistaken for the diarrhoea of tuberculosis, an error that can hardly occur if a physical examination of the chest has been made, as well as micro- scopical examination of the stools. Prognosis. Always a very serious malady, and proves fatal if it attacks the weak during midsummer, or when surrounded by unfavor- able hygienic conditions ; in vigorous children, who have passed through their first dentition, the prognosis is quite favorable. Treatment. For the acute form, restricting the amount of food for the first few days is of importance. Fresh, pure air, cleanliness, and rest are also of great importance. Any one of the following formulae may be used with advantage : R. Salol, gr. ij .13 Gm. Bismuthi subnit., gr. v .32 Gm. Ft. chart. SiG. — Such a powder every two hours. Or— %. . Hydrargyri chlor. mite, . . . . gr. ss .032 Gm. Pulv. ipecac. , gr. ss .032 Gm. Pulv. opii, gr. ss .032 Gm. Crete prseparat , gr. xx 1. 3 Gm. M. Ft. chart. No. xij. SiG. — One every two or three hours, to child of one year. Many cases do well with pulvis kino comp., others with minute 118 PRACTICE OF MEDICINE. doses, frequently repeated, of acidum lacticu?n, and many others with bismuthi subniiras , gr. x-xv (0.6-1 Gm.), in milk, every few hours. The following is a good combination : R. 'Bismuthi subnit., ^iij 12. Gm. Tinct. kino, f 5iss 45. Cc. Tinct. opii camphorat., . . . . f Jiss 45. Cc. Mist, cretse, ^ iij 90. Cc. M. SiG. — Tablespoonful every few hours. Locally, warmth to the abdomen, with mustard, turpentine stupes, or the spice poultice, made as follows : cloves, allspice, cinnamon, and anise seeds, each half an ounce (15.6 Gm.), pounded (not powdered) in a mortar, and placed between two pieces of coarse flannel about six inches square and quilted in ; soak this for a few minutes in hot brandy or hot whisky and water, equal parts, and apply to the abdo- men, heating again as it becomes cool. Chronic entero-colitis. Few conditions will tax the skill and patience of the physician to the same degree. First and foremost the diet must be carefully regulated. Milk alone, or predigested, or with lime-water, in the majority of cases is the best article of diet. Should it disagree, then recourse must be had to some of the prepared foods, such as Mellin's, Horlick's, Ridge's, Blair's prepared wheat, Liquid Peptonoids, or Eskay's albuminized food, or other prepared foods, often the one agreeing with one patient will not agree with another. After caring for the diet, then the hygiene of the patient requires attention. Cleanliness, such as daily warm baths, often adding with advantage sea-salt. Rest in bed for an hour or more after meals if the patient cannot be kept continually in bed. The air of the room should be fresh and pure. Among drugs may be mentioned bisfmithum and pepsinum or sali- cinum. Or — \i . Argenti nitrat., gr. j .065 Gm. Acid, nitric, dil. rr^xv 1. Cc. Mucil. acacire, f,^ ss l S- Cc. Aq. cinnamomi, ad f^iij ad 90. Cc. M. Sig. — Teaspoonful, diluted, every three or four hours. Or— R. Acidi carbolici, gr. T \,-l .005-. 008 Gm. Tincturae iodi, Iir\j— ij ' .06-. 12 Cc. Aquae menthae, f ~j 4. Cc. M. Si<;. — Every three or four hours. DISEASES OF THE INTESTINAL CANAL. 119 Or— R. Tinct. calumbae, f^iij I2 - Cc. Liq. ferri nitratis, Ttlxxx 2. Cc. Syrupi zingib. , .... q. s. adf^iij ad 90. Cc. M. SiG. — One or two teaspoonfuls, according to age, every three or four hours, diluted. Or— R. Quininae muriat. , gr. xxv 1.6 Gm. Acid, tannici, gr. x .6 Gm. Syr. limonis, f 3 ij 8. Cc. Aq. chloroformi, ad f 3 iij ad 12. Cc. M. Sig. — Teaspoonful every two hours. CHOLERA INFANTUM. Synonyms. Choleriform diarrhoea ; summer complaint. Definition. An acute catarrhal inflammation of the mucous membrane of the stomach and intestines, together with an irritation of the sympathetic nervous system, occurring in children during their first dentition ; characterized by severe colicky pains, vomiting, purg- ing, febrile reaction, and prostration. Cause. Age. There is no other disease of the intestinal canal showing the evidence of infectious origin so strongly as typical attacks of cholera infantum. Bad hygiene, or, as it is now entitled, "civic malaria"; continuous high temperature ; improper food ; dentition; constitutional, as in the feeble, delicate, nervous, or irritable. Pathological Anatomy. Resembles closely, if not identical with, the phenomena of catarrhal gastritis and enteritis, together with a powerful irritation of the fibres of the sympathetic nervous system. Symptoms. The onset is sudden in a child previously well, or in a child suffering from a bowel affection. Begins with vomiting, purging, abdominal pain, fever, rapid pulse, and intense thirst. The vomited matter is partly digested food, sero-mucus, and finally bilious, and is accompanied with distressing retching. The thirst is a marked phenomenon of the disease, and ice and water will be taken incessantly, although rejected only a few moments after. The stools are first partly faecal, but soon watery or serous, soaking ]20 PRACTICE OF MEDICINE. the clothing, leaving a faint greenish or yellowish stain ; their odor is musty, at times fetid ; their number is from ten to twenty in the day. Pains precede the vomiting and purging, colicky in char- acter. The fever begins at once, the temperature varying from ioi°to 105 , with morning remissions. The pulse is rapid and feeble, ranging from 130 to 160 beats. These symptoms continue but a few hours, before rapid wasting ensues, the body shrinks, the eyes are sunken and partly closed, the mouth partly open, the lips dry, cracked, and bleeding. The child, at first irritable and restless, passes into a semi-comatose condition, the pulse becoming more and more feeble ; the surface has a clammy coldness, the contracted pupils not responding to light, and the stupor deepens, death soon following, or the symptoms slowly ame- liorate, convalescence being slow and tedious. Diagnosis. The entero- colitis or inflammatory diarrhoea of child- hood is constantly being mistaken for cholera infantum. The symp- toms of the former are : gradual onset, with frelfulness, loss of appe- tite,, feverishness, nausea, and moderate vomiting, soon followed by diarrhoea, the stools being semi-fluid, greenish, mixed with yellowish particles of faeces and undigested casein, with a sour odor, the "chopped spinach" stools, the abdomen distended and tender, moderate fever and thirst, and having a duratio?i of about two weeks. Prognosis. Difficult to predict the result, and so care must be exercised in giving a prognosis. The duration of the choleraic symp- toms is short, under five days, but relapses are common, and the sequelae are protracted. Treatment. — The result of any mode of treatment for true cases of cholera infantum is unsatisfactory. Holt urges attention to the toxic nature of the disease, and suggests following indications for treatment : Empty stomach and intestines by stomach washing and intestinal irrigation ; neutralize the cardiac and nervous poison by hypodermics of morphia and atropia ; supply the fluid drain by hypodermoclysis of normal salt solution, and its intestinal use, and reduction of temperature by the graduated cooling bath and ice-cap to the head and bold stimulation. Change of air of the greatest benefit. Restricted diet, and particularly for first few days, using brandy, TT^v-x (0.3-0.6 Cc), in barley water at hourly intervals. For the vomiting, large doses of bismuthum ; or chlotal, gr. j-iij DISEASES OF THE INTESTINAL CANAL. 121 (0.065-0.21 Gm.), by mouth in demulcent, or double the amount by the rectum, or one of the following : R • Bismuth, subnit. , 5jij 8. Gm. Acid, carbolici, gr. j .065 Gm. Mist, acaciae, Aq. menth. pip., aa f t ^j aa 30. Cc. M. SlG. — Teaspoonful every half-hour, hour, or two hours. Or^- R . Hydrargyri chlor. mit, . . . gr. 2V - 00 3 Gm. Bismuth, subnit., gr. ij-v -^--S Gm. M. SlG. — A powder every half hour. Good results are reported from bismuthi salicylas, gr. ij (0.13 Gm), with sugar of milk every hour or two, or salol, gr. j-ij (o 065-0.13 Gm.), every two or four hours. If the fever is high, sponging with alcohol and water, the cold pack, or the cool bath can be used first, gradually reducing its tem- perature, and afterwards using stimulants. For degression, regulated nursing, and feeding every two hours, and water or ice to quench the intense thirst, and cognac brandy, tt\,v-x (0.3-0.6 Cc), every hour or two, in water, by mouth or in warm enema. Locally : over epigastrium, mustard or a spice poultice, or turpen- tine stupes. If the nervous symptoms become aggravated, small dose of potassii bromidum or valerian, which " reduces the reflex excitability, motil- ity, and sensibility," is indicated. ACUTE DYSENTERY. Synonyms. Colitis ; ulcerative colitis ; bloody flux. Definition. An acute inflammation of the mucous membrane of the large intestines ; either catarrhal or croupous in character, followed in some cases with ulceration, characterized by fever, tormina, tenes- mus, and frequent, small, mucous, and bloody stools. It occurs either sporadically, endemically , or epidemically. Four clinical forms are described : acute catarrhal ; amcebic or tropica] ; croupous or diphtheritic ; chronic dysentery. II 122 PRACTICE OF MEDICINE. Causes. Sporadic, endemic, or catarrhal dysentery prevails most extensively in the summer and early autumn months. All forms of colitis are of bacterial origin. Sudden atmospheric changes, such as hot days and cool nights. Malaria has some connection with its causation. Errors in diet not a cause. The drinking water may be the means by which the poison gains entrance to the system. Amoebic or tropical dysentery, characterized by the presence in the stools of the Amceba coli (Losch) or Amoeba dysenterica (Councilman and Lafleur). This variety is often epidemic in the tropics. Croupous or diphtheritic 'dysentery is often epidemic ; frequently occurs as a terminal event in acute and chronic diseases. The causes are much those of the acute catarrhal form, acting upon a depressed system. The Amoeba coli may be seen in the stools. Dysentery is not contagious, but is infectious. Pathological Anatomy. Catarrhal dysentery ; congestion, swelling, and oedema of the mucous membrane and submucous tissue of the large bowel, with an over-production of mucus ; the fol- licles are enlarged, from retention of their contents, the result of the swelling ; the congested vessels often rupture ; the mucous mem- brane softens in patches, and is detached, forming ulcers. Recovery follows, if the destruction of tissue is small, smooth cicatrices, minus gland structure, marking the site. Amoebic or tropical dysentery, the lesions are also in the large intes- tines and sometimes in the lower portion of the ileum. Abscess of the liver is a frequent complication. "The lesions consist of ulceration, produced by preceding infiltra- tion, general or local, of the submucosa, the general infiltration being due to an oedematous condition, the local to multiplication of the fixed cells of the tissue. In the earliest stages these local infiltrations appear as hemispherical elevations above the general level of the mucosa. The mucous membrane over these soon become necrotic and is cast off, exposing the infiltrated submucous tissue as a grayish-yellow, gelatinous mass, which at first forms the floor of the ulcer, but is subsequently cast off as a slough." (Osier.) Croupous or diphtheritic dysentery begins with intense congestion, swelling, and oedema of the mucous and submucous tissue, with extravasations of blood and the whole mucous membrane covered with a firm, fibrinous exudation ; the mucous membrane softens and sloughs, leaving large ulcers and gangrenous spots. If recovery DISEASES OF THE INTESTINAL CANAL. 123 occur, large cicatrices form, which narrow the calibre of the intestinal tube. The mesenteric glands enlarge, soften, and abscesses form in them ; the liver becomes the seat of small abscesses, from embolic obstruc- tion of the radicles of the portal vein ; the heart muscles are flabby and more or less fatty. Symptoms. Catarrhal form begins gradually, with diarrhoea, loss of appetite, nausea, and very slight fever, which continues for two or three days, when the true dysenteric symptoms develop, to wit, pain on pressure along the transverse and descending colon, tormina or colicky pains about the umbilicus, burning pain in the rectum, with the sensation of the presence of a foreign body and a constant desire to expel it, or tenesmus ; the stools for the first day or two contain more or less faecal matter, but they soon change to a grayish, tough, transparent mucus, containing more or less blood and pus ; during the tormina, nausea and vomiting may occur; the urine is scanty and high-colored ; the number of stools varies from five to twenty or more in the twenty-four hours. The duration is about one week, the patient being much emaciated and enfeebled. Amoebic form begins gradually as the catarrhal form, or gradually as an increasing diarrhoea. Soon the stools become characteristic of the variety of the attack, being frequent, bloody, mucoid, but very fluid ; as the disease progresses, the stools become yellowish-gray and liquid, containing mucus, sometimes bloody. The number of stools varies from six to a dozen or more in a day. Actively moving amcebce are found in the stools, disappearing as the stools become formed. Fever may or may not be present, or may come and go. Abdominal pain and tenesmus are present in the majority of cases. The loss of flesh and strength is marked. Abscess of liver and lungs are frequent and grave complications. Duration from six to twelve weeks ; recovery tedious, owing to anae- mia and loss of flesh. In every endemic or epidemic of dysentery a number of amoebic cases will occur. During the past three years I have seen probably two hundred cases of dysentery, beginning as catarrhal, but in the midst of the endemic a number of amoebic cases occurred, the con- valescence long outlasting the catarrhal variety. The croupous or diphtheritic form sets in suddenly, the stools being 124 PRACTICE OF MEDICINE. more frequent, containing more blood and pus, with patches of mem- brane, even casts of the bowel, together with more or less gangrenous mucous membrane ; nausea, vomiting, and great prostration, cold skin, feeble pulse, and emaciation with anxious expression, the odor surrounding the patient being fetid. The occurrence of this form as a termination of Bright's disease, lung and heart diseases, must be borne in mind. The duration of the grave symptoms is three or four days, when collapse and death occur, or slow convalescence begins, continuing for weeks. Chronic Dysentery. This is really a continuation of the acute disease, the symptoms continuing the result of the ulcerated mucous membrane, or the cystic degeneration of the glandular elements of the large gut (Woodward). Rarely, dysentery develops subacutely, and thus is almost chronic from the beginning. There is seldom a characteristic stool, little colicky pain, and little or no tenesmus, but a progressive loss of flesh with loose bowels, the stools containing mucus, little or no blood, undigested food, and are frothy. The number varies from two to a dozen in a day. Acute exacerbations are frequent. Duration, often months or years. Complications. Peritonitis ; hepatic abscesses ; phlebitis of the intestinal veins ; -intestinal perforation. Diagnosis. Enteritis lacks the tenesmus and characteristic stools. Peritonitis, when idiopathic, shows higher temperature, greater tenderness, and constipation. Chronic dysentery is difficult to distinguish from chronic diarrhoea. Prognosis. Catarrhal form favorable, save in those debilitated. Amoebic form : the mortality is higher than in catarrhal form, and in favorable cases the convalescence is slow. Croupous form: the prognosis is always grave, for if recovery does occur, the bowel may be crippled from loss of structure, or from nar- rowing of its calibre, the results of cicatrices. Treatment. Keeping in mind the following dictum of Osier, no case of dysentery, however mild, should be lightly considered : " Dysentery is one of the four great epidemic diseases of the world. In the tropics it destroys more lives than cholera, and it has been more fatal to armies than powder and shot." The patient should be confined to bed in even the mildest attack, and the stools removed at once and disinfected. In fact, the bed-pan DISEASES OF THE INTESTINAL CANAL. 125 or other vessels should constantly contain a solution of ferrous sul- phate (copperas) sufficient to cover the expected stool. The diet to be of the most nourishing yet bland character, adding stimulants if much prostration. The most frequently used drug, and in many cases by far the best, is opium, alone or combined with one or more astringents : R . Ext. opii, gr. ss .032 Gm. Plurubi acetat., gr. ij .13 Gm. Every two hours. Or— R . Pulv. opii, gr. ss .032 Gm. Plumbi acetat., gr. ij .13 Gm. Pulv. ipecac, g r - X ,01 ^ Gm. Every two hours, until character of stools change. I have frequently seen the character of the stools change within twenty-four hours with the following, which I call Mistura enteric a, viz. : R. Acid, sulph. dil., f g ss 15. Cc. Tinct. opii deodorat, f t ^j 30. Cc. Spts. camphorae, f^j 30. Cc. Tinct. capsici, f~% (0.005-0.01 1- 0.016 Gm.), provided no counter-indication to its use exists, or using at the same time frequent doses of caffeines citrata, gr. iij (0.2 Gm.). 186 PRACTICE OF MEDICINE. The following combination has given excellent results in a number of cases when the patient was able to swallow : &. Sparteine sulphat., gr. iv .265 Gm. Pilocarpine hydrochlor., .... gr. j .065 Gm. Infus. digital. , f^ij 60. Cc. M. SiG. — Teaspoonful every half hour, hour, or two hours until effect. Spiritus glonoini added to the above combination is valuable. If patient is unable to use the medicine by stomach, the same drugs can be used by the hypodermic method, using digitalinae cryst. : rjt . Digitalinae cryst. , gr. -^V .001 Gm. Pilocarpine hydrochlor., . . . . gr. J4 .016 Gm. Sparteine sulph., gr. y z .032 Gm. Aquedestil., rr\xv . I. Cc. M. Sig. — As dose p. r. n. Or— i£ . Pilocarpine nitrat., gr. ij .13 Gm. Unguent, petrolei, ....... f t ^j 30. Gm. M. SiG. — Apply (rubbed) bis die over kidneys. I have never observed the alarming symptoms of depression men- tioned by some observers from the careful use of pilocarpus. The production of free diaphoresis alone must not mislead, for unless the sweat contains urea or its products it is only depressing, and the clinical fact is that in uraemia the eliminating function of the skin as well as of the kidney is in abeyance. The convulsions are rapidly controlled by inhalations of chloroform (although the after symptoms are badly influenced by the drug), or the internal or rectal administration of full doses of chloral, or by a free venesection. Indeed, venesection is too much neglected in condi- tions of coma and uraemic convulsions. It not infrequently happens that upon opening a vessel the blood does not flow, or but a few drops slowly flow from the wound. If this obtains it is almost immediately changed by a hypodermic injection of amyl nitrite, rt\,v (0.3 Cc.) with spiritus anvnonice aro?naticus t TT^xv (i Cc). Diuresis is promoted by infusum digitalis, dry or wet cupping, poultices over the loins, and hot compresses of infusum digitalis over abdomen, pilocarpus rubbed over the kidneys, or caffeince cilrata, or sparteines sulphas, or spiritus glonoini. The injection of the nor- mal salt solution, 3j : Oj (4 Gm. : 473 Cc), into the bowel every DISEASES OF THE KIDNEYS. 187 hour or two, and by hypodermoclysisinto the loose connective tissue, promotes diaphoresis and diuresis. Excellent results have been ob- tained in uraemia with scanty urinary secretion and in other condi- tions with scanty urine with diuretin (a mixture of salicylate of soda and theobromin) in gr. xx-xxx (1.3-2 Gm.) in an ounce of water every two or four hours. Catharsis is best promoted by elaterium, gr. T V~i (0.005-0.008 Gm.), or an Epsom salts enema : ]£ . Magnesii sulph., Jfij 60. Gm. Glycerini, %] 30. Cc. Aquae bul., . giv 120. Cc. M. As enema. The febrile reaction does not call for antipyretics. It is one of the nervous phenomena of uraemia, and is controlled by the means employed to eliminate the poison. If symptoms of collapse develop, with cold, clammy skin, feeble, rapid pulse, and superficial respirations, at once administer atrofiin ss 2 - Cc. Mucil. acacias, f§ ss x 5- Cc. Misce et adde while stirring, Tinct. ferri chlorid., ^^ 1V 1 5- Cc. M. Liq. ammonii citrat. (B. P.), ad 13 iv ad 120. Cc. Sig. — One to two teaspoonfuls every two, three, or four hours, diluted. Prof. Da Costa reports a lessened proportion of cardiac compli- cations with ammo7iii bromidum, gr. xv-xx (1-1.3 Gm.), every four hours. I much prefer ammonii salicylas, gr. x-xv (0.6-1 Gm.), in simple syrup, well diluted, every four to six hours. Subacute attacks and lingering cases are favorably influenced by cinckonidincz salicylas, gr. v (0.3 Gm.), every four hours, or — r£ . Lithii salicylatis, gr. xv-xx 1.-1.3 Gm. Syr. zingiberis, f^j 4. Cc. Aq. lauro-cerasi, fgj 4. Cc. M. Every four hours. Or— R. Potassii iodidi, ^iv 5.3 Gm. Sodii salicylatis, %'w 15. Gm. Elix. cinchonas, f^iss 45. Cc. Infus. gentianas, f ^ iss 45. Cc. Aquae destil., f 3J 30. Cc. M. SlG. — Dessertspoonful every three or four hours, diluted. Good results are reported from the use of salol, gr. v-x (o. 3-0.6 Gm.), every four hours, from aminonii hydrochloras, gr. xv-xx (1— 1.3 Gm.), every four hours, and from salipyrin in solution, every four hours ; R. Salipyrin, giij 12. Gm. Glycerini, f^iij I2 - Cc. Syr. aurantii, f.^ v j 2 4- Cc. Aquas destil., adf^vj ad 180. Cc. M. SlG. — Tablespoonful, well diluted. Whichever plan, acidum salicylicum, salicylates, alkaline, or fer- rum, is adopted, quinince sulphas, gr. xv (1 Gm.), per day, should also be used. Pain and restlessness should be controlled by opium in some form, in full doses, or atropine sulphas, gr. -^ (0.0008 Gm.), hypodermic- ally. 224 PRACTICE OF MEDICINE. For the hyperpyrexia, quinince sulphas, gr. xxx-lx (2-4 Gm.), repeated p. r. n., with the cold bath or wet pack. Locally, the affected joints should be wrapped in cotton-wool or flannel, saturated with a solution of linctura opii, one part, and liq. plumb, subacetat. dil., two parts, or olei gaultheritz, fgj (4 Cc), with lin. saponis comp., f^iij (o/rCc), or — R. Sodii bicarbonatis, :fij 60. Gm. Tinct. opii, f.3 ss *5- Cc. Aquae bul., 6ij 960. Cc. M. Dr. Bartholow finds the application of blisters an effective method. He says : " I have small blisters, the size of a silver dollar, placed around the joint, leaving an interval between for succeeding applications. It is by no means so painful and disagreeable as it appears at first sight. The blisters remarkably relieve the pain, bring about a more alkaline condition of the blood, and render the urine less acid, or bring it to neutral, or even to alkaline." If the disease shows a tendency to linger in one or more joints, such joints should be immediately placed in the hot-air apparatus. MUSCULAR RHEUMATISM. Synonyms. According to location : cephalodynia ; lumbago ; torticollis ; pleurodynia. Definition. An affection of the voluntary muscles, inflammatory in character, either acute or chro7iic ; characterized by pain, tender- ness, and stiffness of the affected muscles. It is never complicated with cardiac disease. Causes. A disease of adult life. One attack predisposes to an- other. Almost always due to cold or damp, or direct draught of cold air. Gout increases the tendency to attacks. Pathological Anatomy. The true nature of muscular rheu- matism is not yet determined. Virchow suggests a " hyperemia of, and scanty serous exudation between, the muscular striae, and in chronic cases inflammatory proliferation of the connective tissue." Symptoms. The first attack is generally acute. Onset rather sudden, with pain in the affected muscles, with slight tenderness, and considerable stiffness and difficulty of move?nent, by which also the pain is increased. ACUTE GENERAL DISEASES. 225 The suffering may be severe and constant, or only on motion. Spasm of the affected muscles may occur. Objective symptoms are wanting, except it is evident that the patient keeps the affected muscles as quiet as possible. Fever is absent. The pain may pre- vent sleep. Duration, acute form, about one week. Chronic variety returns fre- quently, and finally becomes constant and aggravated when the weather is damp. Varieties. It may affect any or all of the voluntary muscles, but its most frequent and important varieties are : 1. Cephalodynia. Situated in the occipito-frontal muscles. Dis- tinguished from neuralgia of the trifacial, or occipital nerve, by pain on both sides of the head, excited or aggravated by the movements of the muscle and by absence of disseminated points of tenderness. The muscles of the eye may be affected, and movements of that organ excite pain. If the temporal and masseter muscles are attacked, mastication excites pain. 2. Torticollis. Wry neck, or stiff neck. Situated in the sterno- mastoid muscles. Generally limited to one side of the neck, toward which side the head is twisted, great pain being excited on attempting to turn to the opposite side. Rheumatism of the muscles of the back of the neck, cervicodynia, may be mistaken for occipital neuralgia. 3. Pleurodynia. Situated in the thoracic muscles, and may be mistaken for pleuritis, or intercostal neuralgia, from which it is differ- entiated by the absence of the diagnostic features of each. Pain is excited by forced breathing, coughing, and sneezing. 4. Lumbodynia or lumbago. Situated in the mass of muscles and fasciae, which occupy the lumbar region. Most common variety. Usually affects both sides. It may set in rapidly, and become very severe. Motion of any kind aggravates the pain, often becoming very sharp or stabbing in character. It is sometimes complicated with acute sciatica, when the suffering is agonizing. Diagnosis. The different varieties may be mistaken for any of the following ailments, to wit : trifacial, occipital, or intercostal neu- ralgia, pains of progressive muscular atrophy, neuritis, syphilis, metallic poisons, or painful affections of the loins, arising from calculi or gravel in the kidney. A careful examination of the history is usually sufficient to arrive at a correct diagnosis. 20 926 PRACTICE OF MEDICINE. Prognosis. Difficult to eradicate, and in chronic cases to amelio- rate, but is not dangerous to life. Death never results. Treatment. Rest is the first indication. This is accomplished in pleurodynia by firmly strapping the affected side with broad strips of plaster, extending from mid-spine to mid-sternum. The /^^/application to the affected muscles of hot poultices, made of two-thirds pilocarpus leaves and onz-\ki\xdi flax seed meal, changing them every two hours, is the most rapidly successful treatment in acute cases. Internally, antipyrin, gr. x-xx (0.6-1.3 Gm.), repeated in several hours, or ammonii hydroc Moras, gr. xv-xx (1— 1.3 Gm.), every three hours, or sodii salicylas, gr. xv-xx (1— 1.3 Gm.), every two or three hours, are each of value. Prof. Bartholow declares that lithii bromidum is almost a specific in muscular rheumatism. For the pain and consequent sleeplessness, use — R . Pulv. ipecac, et opii, gr. x .6 Gm. Potass, nitrat., gr. v-x .3-.6G111. M. SiG. — In powder, morning and night. Or, hypodermically, at the seat of pain, morphines sulphas, gr. yi- % (0.008-0.016 Gm.), and atropines sulphas, gr. -fa (0.0008 Gm.), p. r. n. In attacks where the disease is limited to a few muscles, the follow- ing liniment is valuable : R. 01. gaultherise, giss 6. Cc. Spirit, vini rectif., . . . • ■ ■ . f^ij 60. Cc. M. Sic*. — Thoroughly rub into affected part. In all forms, but more particularly in lumbago, a few dry cups over the seat of the pain give immediate relief. Wonderful results have followed the use of the hot-air apparatus in acute and subacute lumbago. Chro?iic cases : Rest, flannel worn next to the skin, stimulating and anodyne liniments, mild galvanism, dry heat, as ironing over the affected part with a common flat-iron, a piece of paper or towel being placed next to the skin. Internally, potassii iodidum, ammonii hydrochloras, sulphur, guai- acum or arsenicum variously combined. ACUTE GENERAL DISEASES. 227 RHEUMATOID ARTHRITIS. Synonyms. Arthritis deformans ; rheumatic gout (?). Definition. A destructive disease of the joints, accompanied with but slight fever, without suppuration ; progressive in character, causing nearly symmetrical enlargement and deformity of various articulations. Causes. The neuro-trophic theory, as advocated by Mitchell (J. K.) and supported by Charcot, is accepted as the predisposing cause. Among the exciting causes are bad hygiene, exposure, injury, prolonged lactation, frequent pregnancies, menopause, grief, tuber- cular diathesis, and following attacks of articular rheumatism. More common in women than men. A disease of middle life. Pathological Anatomy. It is not rheumatism, as the blood contains no lactic acid. It is not gout, as uric acid is not found in the blood nor urate of sodiwn in the joints. At first rheumatoid arthritis is attended with hyperemia of the affected synovial membrane and increase of the synovial fluid. Soon the capsular ligament becomes irregularly thickened, the synovial fluid decreasing. If the process continue, the internal ligament is destroyed, thus allowing dislocation to occur. The interarticular fibro-cartilages ulcerate and disappear, as do the cartilages covering the ends of the bone, the ends of the bones becoming smooth and eburnated, and often greatly enlarged. Symptoms. Either acute or chronic, the latter more frequent. Acute form, involves several joints at the same time, and is attended with slight pyrexia. Chronic form slowly involves one joint, which seemingly soon recovers, and is attacked again, and may never recover, but grows progressively worse. The joint slowly enlarges, is painful, movement exciting neuralgic pains along the limb. Soon the articulations become rigid or slightly movable after prolonged attempts, are more or less distorted and flexed, with nodules (Heberden's nodosities) on the sides or ends of the distant phalanges. Redness and tenderness are wanting. The muscles of the affected limb waste, giving the joint a greatly hyper- trophied appearance. Crepitation is distinct after ulceration has destroyed the cartilage. 228 PRACTICE OF MEDICINE. The hands are first involved, the disease spreading symmetrically from articulation to articulation, until in severe cases every joint is deformed. Diagnosis. Chronic articular rheumatism is often confounded with rheumatoid arthritis ; but the former lacks the marked structural changes and the progressive involvement of joint after joint. Gout differs from rheumatoid arthritis by the presence of deposits of urate of sodium in the joints, the ears, tips of fingers, and the bursae over the olecranon process of the elbow, the presence of uric acid in the blood, and the decided history of acute paroxysms. Gonorrheal rheumatis?n, so-called, has symptoms akin to rheu- matoid arthritis, but the history of urethral suppuration clears up the diagnosis. Paralysis agitans, when pronounced, might be confounded with rheumatoid arthritis if the examination were limited to the joints; but the whole history, such as the tremor, the gait, etc., should pre- vent error. Prognosis. If early treatment be instituted, the disease may be held in abeyance for several years. After pronounced structural changes have begun, the malady is incurable, although it may remain stationary for a long time. Treatment. If treatment be instituted before serious structural lesions have occurred, the author has seen benefit in many cases by the following plan : Oleum morrhuce carefully and thoroughly rubbed into the affected joints three times a day, with the internal use of lithii citras effervescentes, Z] (4 Gm.), three times a day, and the following tonic mixture : R. Massse ferri carbonat., gr. v .3 Gm. Liquor, potass, arsenit., .... rr^v .3 Cc. Vini xerici, f^j 4. Cc. A quae distill., f 3J 4. Cc. After meals, well diluted. I have had some success from painting the joints when painful with the following combination, using at the same time guaiacol carbonat., gr. v-x (0.3-0.6 Gm.), three times daily : R. Guaiacol, I part Tinct. iodi, 6 parts. M. Sig. — Paint over joints twice daily. ACUTE GENERAL DISEASES. 229 Complete recoveries are reported from the long-continued adminis- tration of small doses of liquor potassii arsenitis. Attention to diet and hygiene are most important and valuable. When structural changes have destroyed portions of the joint, pallia- tive treatment is the chief indication. GOUT. Synonyms. Podagra, gout in the foot; chiragra, the hand; gonagra, the knee. Definition. A constitutional disease, usually inherited ; charac- terized by the sudden occurrence of a paroxysm of severe pain and swelling in one of the smaller joints, — the great toe usually, — with the presence of uric acid in the blood, and the deposit of the urate of sodium in the structure of the joint. Causes. Predisposing : inherited, male more than female — women after menopause. Exciting; malt liquor and wine drinking; large consumption of animal food ; lead poisoning ; winter season. When an inherited tendency, may begin early in life; when an acquired tendency, after thirty-five years. The pathological cause consists in the presence of an excess of uric acid in the blood in the form of urate of sodium. Pathological Anatomy. Gout is characterized by the deposit of urate of sodium from the blood into the structure of joints and tissues that are not very yascular. The deposit is associated with signs of inflammation — to wit : hypersemia, redness of the surface, with swelling and effusion in and around the affected joint. The surfaces of the joint are incrusted with chalk-like masses, consisting of urates, which become greater with each attack, finally causing great deformity. The deposit usually begins in the metatarso-phalangeal joint of the great toe, but other and many joints are soon affected. The deposits may also be found in the knuckles, eyelids, and car- tilages of the ear. " Crystals of urate of soda are deposited in the tubules and intra- tubular tissues " of the kidneys — " gouty kidney " — and may be seen by the naked eye, the kidneys becoming small, granular, and fibrous. 230 PRACTICE OF MEDICINE. Hypertrophy of the left ventricle and of the arteries, ending in atheromatous changes, are results of gout. Symptoms. Acute gout is rare in the United States. It occurs in paroxysms ; one year's interval between the first and second attack ; six months usually between the second and third, after which it may occur at any time. Prodromes usually precede the paroxysm for several days, to wit, acid dyspepsia, constipation, headache, and lassitude. The paroxys?n begins suddenly, between midnight and 2 A. M., with acute pain in the ball of the great toe, which becomes red, hot, swollen, and so sensitive that the slightest touch cannot be borne. The veins are filled, the foot, ankle, and leg swollen, and the limb the seat of sudden spasmodic contractions, which increase the suffer- ing ; slight relief is afforded by elevating the limb. Associated with the local symptoms are chill, fever, quickened pulse, thirst, coated tongue, constipation, and scanty, acid, high-colored urine, which de- posits, on cooling, a heavy brickdust sediment. Towards daylight the symptoms ameliorate, to return again at sun- down, the severity gradually lessening, until the fourth or fifth day, when convalescence is established, the patient, as a rule, feeling better than before the attack. Chronic Gout. Either the result of acute attacks or with a greater number of joints being attacked. The paroxysms occur at any time, but develop slowly, with less pronounced local and general symptoms. Deposits are noticed, the joints becoming hard, knobby, and often distorted. The deposit's or chalk stones (urate of sodium) occur about the joints, tendons, and bursse, and helix of the ear. Diagnosis, An error cannot occur if the history of the case can be obtained, to wit : hereditary tendency, age, sex (females rare, until menopause), mode of living, character of symptoms, and presence of the characteristic deposits. Prognosis. Acute gout rarely fatal ; is prone to return, but much depending upon the mode of living. Chronic gout decidedly shortens life. The most serious signs are those indicating advanced renal disease, with non-elimination of uric acid. Gout influences unfavorably the prognosis from acute diseases or injuries. Treatment. For the acute paroxysms, at once, vinum colchici ACUTE GENERAL DISEASES. 231 radicis, gtt. xv-xx-xxx (1-1.3-2 Cc), every two hours, well diluted, either alone or in combination with a potassium salt, or sodiisalicylas, gr. xx (1.3 Gm.), every two to four hours, well diluted, until relief or ringing in the ears occurs. While the acute symptoms of gout are not so rapidly relieved by sodii salicylas as are those of acute rheu- matism, still it is an invaluable remedy and is rapidly succeeding colchicum. After the decrease of the acute symptoms, lessen the dose, but continue the remedy for some time. Dr. Bartholow recommends the following pill : Be. Colchicine, gr. -£§ .0013 Gm. Ext. colocynth. comp., gr. ss .032 Gm. Quininae sulph., gr. lij .2 Gm. M. Every two or three hours. For the pain, hypodermic injection of morphines sulphas, and wrapping the inflamed joint in cotton-wool saturated with liq. plumb, subacetat. dil. and tinctura opii. The use of morphia in acute gout must be with caution, as many subjects have more or less contracted kidneys. The diet must be restricted to milk and non-acid fruits, raw or cooked. The drinking of several ounces of water, hot or natural, every three hours, is most useful. For subacute or lingering cases, and in chronic gout, potassii iodi- dum is valuable. U . Potassii iodidi, £ij 8. Gm. Vini colchici radicis, f ^ iv 15. Cc. Aquae destil., fjjiiss 75. Cc. M. SiG. — Teaspoonful, well diluted, after meals and at bedtime. For chronic gout, regulated diet, free action on the secretions, and lithii cilras effervescentes, Z) (4 Gm.), three or four times a day, well diluted with water ; and perhaps a course of quini?ia, ferrum, and arsenicum. To prevent paroxysm, keep secretions acting by the free use of pure water or a good alkaline water, such as Buffalo lithia or Farm- ville lithia water, or Saratoga Vichy. The diet is of the greatest importance, and should consist chiefly of vegetables and fruit, excepting tomatoes and strawberries, lemons and oranges ; fresh meat must be discontinued for a time ; oysters, fish, and soups may be used sparingly. Alcoholic and malt liquors 232 PRACTICE OF MEDICINE. are contraindicated, as are tea and coffee ; milk should replace ail the above. No eggs or dishes containing eggs ; no pastry, hot bread, or cakes; no sweetmeats, spices, or condiments. Systematic exercise, especially walking, is of great advantage. Cold bathing with caution, while the vapor or Turkish baths are of benefit. Changing from a cold to a warm climate in winter, and the use of flannel underclothing, are strongly recommended. DIABETES MELLITUS. Synonyms. Glycosuria ; melituria. Definition. A chronic affection characterized by the constant presence of grape sugar in the urine, an excessive urinary discharge, and the progressive loss of flesh and strength. Causes. Most common in males. More frequent in the Hebrew than the Christian. Rare in negroes. Occurs at all ages, but most frequently between twenty-five and fifty years. It is often hereditary. Disorders of the nervous, hepatic, and renal systems. Excessive use of farinaceous food and malt liquors. Sexual excesses. The exact pathology of diabetes mellitus differs in different cases, and in the present state of knowledge no exclusive view can be adopted. Still, there are reasons for believing that, in a large pro- portion of cases, the nervous system is primarily at fault, though the character of the lesions may differ. Pavy believes diabetes mellitus originates in the nervous system, and probably as a vaso-motor paralysis. Disease or extirpation of the pancreas is followed by diabetes, and it is claimed the pancreas secretes a glycolytic ferment. Pathological Anatomy. None peculiar to diabetes is yet recognized. Hyperemia and hypertrophy of the liver and kidneys are gener- ally present, the result of increased functional activity. Various organic changes are found in the pancreas. The changes in the lungs peculiar to phthisis are often found in very chronic cases. The changes in the nervous system are not fully determined. Symptoms. Clinically, cases differ greatly in their course and severity ; one class presenting slight symptoms and a chronic course; another class having marked local and constitutional symptoms and ACUTE GENERAL DISEASES. 233 running an acute course. The symptoms of a typical case may be arranged under the following heads : Urinary Organs and Urine. Micturition more frequent and the urine increased 'in quantity. Pain over the region of the kidneys. The quantity of urine may amount to 4, 8, 12, 20, or 30 pints in twenty-four hours. It is usually pale, clear, and watery, having a sweetish taste and odor, the specific gravity ranging from 1.025 to 1.050. It ferments rapidly if kept in a warm place. It yields grape sugar to the usual tests, the amount present varying from an ounce to two pounds in the twenty-four hours. The urea and uric acid are increased. Albumin may be present. The increased passage of a large quantity of saccharine urine causes a constant itching, burning, and uneasy sensation at the prepuce, along the urethra, and at the neck of the bladder; in females, itching and eczema of the vulva are common ; in children, incontinence of urine is frequent. Digestive Organs. An almost constant symptom is thirst, with a dry and parched condition of the mouth. At times the appetite is excessive, again absent. The breath may have a sweetish odor, the tongue irritable, red, and often cracked. Dyspeptic symptoms are common, and occasionally vomiting. The bowels are constipated, the stools pale and dry. At times diarrhoea may occur. The patient complains of feeling very weak, languid, and of sore- ness and pai7i in the limbs ; there is more or less emaciation, a harsh, dry skin, the countenance distressed and worn. The mind is often greatly altered ; depression of spirits, decline in firmness of character and moral tone, with irritability, are present. Sexual inclination and power are greatly diminished. Defects of vision are present. The blood and various secretions contain sugar. Complications. Pulmonary phthisis ; Bright's disease ; defects of vision from atrophy of the retina or the formation of a soft cataract ; boils and carbuncles, and chronic skin affections, such as psoriasis and eczema. Course. The clinical history varies in different cases. In the majority of instances the course is chronic, lasting for years, the symptoms beginning insidiously, and becoming progressively worse, with, at times, decided remissions. Occasionally the disease runs an acute course, death occurring within four or five weeks. 234 PRACTICE OF MEDICINE. Termination. The majority of cases ultimately prove fatal, the symptoms markedly changing, the urine and sugar diminishing 'in quantity, the occurrence of albuminuria, disgust for food and drink, and the development of hectic fever and colliquative diarrhoea. The fatal result usually arises from gradual exhaustion from blood- poisoning, leading to stupor, ending in co7nplete coma, or occasionally to delirium or convulsions, or from complications. Rarely death occurs suddenly from urcemic convulsions or uramic coma. Diagnosis. Diabetes mellitus only exists when grape sugar is permanently present in the urine. " It is not the quantity, but the persistence of sugar which constitutes diabetes." With grape sugar in the urine, associated with more or less in- crease in the urinary flow, it should be mistaken for no other affection. From Bright' 1 s disease, by the absence of dropsy, and of tube casts in the urine, and the constant presence of sugar in the urine ; but the amount of albumin in the urine is never so great or constant in dia- betes mellitus as in Bright's disease. From diabetes insipidus, by the absence of sugar in the blood and urine, and the larger quantity of urine voided in polyuria. Simple glycosuria differs from diabetic glycosuria in that the amount of sugar in the urine is not constant, — at one time being pres- ent, at another absent, — the amount of urine voided is never in excess of health; simple glycosuria is a disease of the aged; diabetic glyco- suria usually appears under fifty years. Simple glycosuria often results from the inhalation of chloroform, the excessive use of chloral, and in the insane, also from excitement, or as one of. the results of injuries to the head. Prognosis. Most unfavorable as regards a cure, it being fairly questionable if complete recovery has ever occurred in a typical case. Still, decided amelioration may take place in the symptoms, and the progress of the malady be greatly retarded. The younger the patient, the more rapid the fatal termination. Treatment. Impress upon patients the importance of a strictly regulated diet. Prohibit or restrict the consumption of such articles as contain sugar or starch, especially ordinary bread or flour, sugar, honey, potatoes, peas, beans, rice, arrowroot, cracked wheat, oat- meal, turnips, beets, corn, and carrots, prunes, grapes, figs, bananas, pears, apples, and liquors of all kinds, whether distilled or fermented. ACUTE GENERAL DISEASES. 235 The main diet should be of animal food, including meat, poultry, game, and fish. A moderate amount of fluids should be allowed, and in a majority of cases milk will prove beneficial, although, theoretically, contraindi- cated. Tea, coffee, and cocoa, without sugar, may be allowed in moder- ation, glycerin or saccharin being used as a substitute for the sugar. Regulated exercise is of importance. The patient should wear flannel, and have two or three warm baths every week, or an occa- sional Turkish bath. Therapeutical treatment. It is difficult to estimate correctly the action of any drug in this disease, for, as is well known, a proper modi- fication of the diet will alone produce the most marked improvement. Opium exercises an influence over the excretion of sugar, but the effect is not always maintained. Pavy strongly urges the use of codeina in doses of gr. ss-iij (0.032-0.2 Gm.), three times a day, gradually increased. "The use of morphines hydrochloras, gr. j (0.065 Gm.), daily, or pulvis opii, gr. iij-v (0.2-0.3 Gm.), daily, is a favorite prescription. Prof. Da Costa suggests the use of ergota, which has decreased the urinary discharge and the quantity of sugar in a number of cases. Prof. Bartholow has met with an apparent cure by ammonii carbonas. Uranii nitras, gr. iij (0.2 Gm.), three times daily, will often markedly reduce the urine and sugar, and sodii salicylas, gr. xv (1 Gm.), three times daily, will markedly control the formation of sugar. Liquor bromini arsenitis, TT^iij-v (0.2-0.3 Cc), three times a day, often gives good results. Dickinson remarks that " strychnina is, of all remedies, the most constantly useful." Potassii bromidmn, 3j (4 Gm.) during the twenty-four hours, is strongly urged. The fol- lowing remedies are recommended by different observers — to wit: pepsinwn, liquor potassii arsenitis, iodum, potassii iodidum, acidum lacticum, glycerinum, quinina, and tine tura cannabis indices. Cures are reported from pulvis jambul seeds, gr. v-x (0.3-0.6 Gm.), three times daily. Also methylene blue, gr. viij (0.52 Gm.), per diem. The evidence in favor of the majority of these drugs is far from satisfactory. For diabetic coma, alkalies are particularly indicated. Sodium carbonas subcutaneously, or by intravenous injection, watching closely the effect on pulse and heart, as recommended by Stabel- man. The use of large quantities (quarts) of the normal salt solution by means of hypodermoclysis, and slowly thrown into the large bowel, is a most valuable aid to elimination. Use also inhalations of oxygen and diuretics and fluids to promote elimination of toxic products. 236 PRACTICE OF MEDICINE. Symptomatic treatment is mostly called for. For emaciation and anaemia, ferritin and oleum morrhuce ; for sleeplessness and restless- ness, morphi?i. fever heat. II. Stage of solidification Percussion dullness ; bron- Rusty-colored sputum; of lung tissue (red chial respiration ; bron- dyspnoea ; cough ; high hepatization). chophony. fever with marked even- ing exacerbations and morning remissions. III. Stage of softening The same physical signs as Chills; prostration, etc.; (gray hepatization). in the second stage, un- purulent or brownish less large abscesses have sputum ; generally high formed. temperature. Terminations. Asthenic cases recover within two weeks. When purulent infiltration supervenes, the disease pursues a tedious course of several weeks' duration, with a low exhaustive fever. If death occur during the first or second stages, it is usually the result of ^.collateral oedema of the uninflamed lung, or cardiac, failure and inipaired nerve force. If abscesses occur, there are exhausting sweats, frequent cough, with a large amount of yellowish-gray, at times blood-streaked, expectoration. Gangrene of the lungs is a rare termination ; it is associated with symptoms of collapse, the expectoration of a blackish, foetid charac- ter, with the physical signs of a pulmonary cavity. Diagnosis. (Edema of the lungs may be confounded with the first stage of pneumonia, but the subsequent history, its presence on both sides, and the waterish expectoration and absence of chill and pain and the physical signs of pneumonia soon determine the diagnosis. Pleurisy is oftener confounded with pneumonia than any other dis- ease, the points of distinction between which will be pointed out when discussing that affection. Complications. Acute pleuritis is a frequent complication of croupous pneumonia, occurring as often as from ten to twenty-five per cent, of cases. The more acute localized pain, the greater em- barrassment of respiration, and the usual physical signs of effusion are the evidences of a pleuro pneumonia. Endocarditis is a common complication, showing irregular but protracted temperature record, with chills and sweats and great embarrassment of the respiration. DISEASES OF THE LUNGS. 325 Capillary bronchitis is a rare but dangerous complication. Peri- carditis, rheumatism, and gout are rare complications. Prognosis. Depends upon the extent of the inflammation, the dangerous features of croupous pneumonia being cardiac failure, the result of an endo- or myocarditis or of embarrassed respiratory circu- lation, and the rapid tissue waste, associated with extreme fever (105 ), resulting in impaired nerve force. Double pneumonia has a very grave prognosis, but it is not nearly so frequent as was at one time supposed. The coexistence of pleuritis adds to the gravity of the prognosis, although not so fatal as generally supposed. Pneumonia of drunkards almost invariably terminates fatally. Typhoid pneu- monia, pneumonia of the aged and in the insane, and the so-called bilious pneumonia, purulent infiltration, abscesses of the lungs, and gangrene, all give a grave prognosis. Treatment. If pneumonia be regarded as a constitutional malady with a local lesion, then the consolidated lung no more calls for treat- ment than does the intestinal ulcer of typhoid fever, but the general condition of the patient is to govern in the management and not the local changes in the thorax. A simple pneumonia attacking persons previously in good health requires no more active treatment than any of the so-called self-limited diseases, provided only that the extent of the disease be moderate, and there be no complication. The much-discussed question of venesection is now a settled prob- lem in the affection ; if we bleed, it is " not because of pneumonia, but in spite of pneumonia" Called to a case in the first stage or early in the second stage, who has been vigorous and otherwise healthy, with a high temperature, 105 or more, with frequent pulse, one hundred and twenty beats or more, or a slow, full pulse showing cardiac oppression, flushed surface, and marked dyspnoea, a copious bleed- ing is indicated, and the same may be said when symptoms of collat- eral oedema threaten; this is bleeding for symptoms and not for the disease per se. There is no remedy which can exert a favorable influence upon the pneumonic process. Many cases recover without, and many cases in spite of, treatment. When treatment is instituted, be guided by the fact that you are not to treat pneumonia, but a patient with a pneu- monia. At the onset, if venesection is not indicated, relief of the pain may 326 PRACTICE OF MEDICINE. follow the use of dry or wet cups. If the tongue be coated and the gastro-intestinal canal deranged, a calomel purge is indicated. R. Hydrargyri chloridi mitis, . . . gr. ij .13 Gm. Sodii bicarb. , gr. iv .26 Gm. Pulv. ipecac, gr. j .065 Gm. M. Ft. chart. No. iv. Sig. — One every two hours, followed in two hours after last powder by mild saline. Action on the skin and kidneys by refrigerant mixtures or small doses of Dover's powder is valuable. The administration of the arterial sedatives, aconitum and veratrum viride, are recommended by Drs. Da Costa arid H. C. Wood. In pneumonia of children the use of small, frequently repeated doses of tinctura aconiti in the early stage is most useful. Poultices are of slight value, but the use of home-made mustard plasters, weakened with flour, is useful in all stages. If the heart be weak from the onset, either of the following are valuable : digitalis, caffeines citraia, nitro-glycerinum , spartei?i t or strycJi7iina. Indeed, it seems a good practice to administer strychnina in full doses from the onset. Quinines sulphas, gr. ij-v (0.13-0.3 Gm.) every three or four hours, is always valuable. Second Stage. It is at this period of a severe attack of acute pneu- monia that two prominent indications for treatment arise — heart insuffcie?icy and high temperature. To sustain the heart is one of the most important indications, for experience shows that cardiac failure is responsible for a large num- ber of deaths in this affection. Strych?iince sulphas, gr. 3V-2V (° °° 2 - 0.003 Gm.), repeated every few hours by mouth or by the hypodermic method, or caffeines citrata, gr. ij-v (0.13-0.3 Gm.) every four hours, or tinctura strophanthus, n\,v-x (0.3-0.6 Cc.) every three hours, are valuable cardiac tonics in pneumonia. The availability of digitalis and nitro-glycerinum depends upon a careful study of the pulse. If the tension is low, the result of relaxation of peripheral blood vessels, — vaso-motor paralysis, — digitalis in full doses is indicated ; but if the tension is high, with embarrassed right heart, nitro-glycerinum every hour or two, with spiritus ammonii aromaticus , is the indication. Alcoholic stimulants judiciously employed are most efficient means for preventing or overcoming the cardiac failure. The amount can DISEASES OF THE LUNGS. 327 only be determined by a careful study of each case, as a few ounces in the twenty four hours may answer in one, while another may require eight or ten ounces. It is well to begin with small doses, increasing or decreasing as its effects are good or bad. The indi- cator of the heart 's condition is the pulse. In the aged, the feeble, or in those accustomed to the use of alcohol, stimulation is indicated from the onset. Other indications would be a frequent, feeble, irregular, or intermitting pulse ; a dicrotic pulse ; delirium, muscular tremor, and subsultus ; immediately following crisis, and the period of collapse. To reduce the temperature is at times an important indication. If the fever is under 103 F., cool sponging with alcohol and water, or water alone, is sufficient. If the temperature is above 104 F., anti- febrin, gr. v (0.3 Gm.), may be used every three hours until a reduc- tion occurs. Strychnines sulphas, or caffeines citrata, may be added to each dose. Phenacetin or acetanilidum are also valuable, and considered less depressing, but it is to be remembered that a temper- ature under 104 is as normal to pneumonia as the dyspnoea or the rusty sputum, and so use antipyretic drugs with caution. The use of the cold pack or of cold baths for reducing the temper- ature in acute pneumonia has not given the success expected. Dr. Mays strongly advocates the use of ice bags to the chest in pneumonia. He says: "Very often it is found that the application of the ice to an affected spot is immediately followed by a marked lowering of the temperature and improvement in the physical signs in the part." I am able, from an experience of five years, to endorse this statement. For dyspnoea and pain, a hypodermic injection of m or phince sul- phas, repeated p. r. n. The dyspnoea is often relieved by inhalations of oxygen, but do not expect too much from oxygen as there is some additional factor besides the mechanical one of consolidation of the lung producing the dyspnoea, for the consolidation is just as marked immediately after the crisis, while the dyspnoea is wonderfully relieved. The diet must be of the most nutritious but easily digestible char- acter, and given at periods of every three hours, watching that the food is assimilated. A distended stomach and abdomen is danger- ous. Strong black coffee throughout the disease is valuable. Third Stage. The treatment is a continuation of that of the second stage, with the addition of the following valuable combination : 328 PRACTICE OF MEDICINE. I J . Ammonii chloridi, gr. v-x -3~.6 Gin. Strychnine sulph., gr. Jj .003 Gm. Aquae chloroformi, f gj 4. Cc. vSyr. prun. virg., f 3 iij 12. Cc. M. Sig. — Every three hours, diluted. Many cases are favorably influenced by an expectorant from the onset of the disease. Co?ivalescence. Nutritious diet, quinine sulphas in tonic doses, ferritin, together with a good blood-making wine or a good prepara- tion of malt. If the consolidation shows a disposition to linger, blisters may be used. The various symptoms other than those particularly mentioned are to be met, as they arise, by their proper remedies. For typhoid pneumonia, purulent infiltration, abscess of the lungs, or pneumonia in drunkards, the weak, or the aged, quinince sulphas, ferrum, nutritious diet and bold stimulation, and the free use of ammonii carbonas or spiritus ammonia aromaiicus, caffeines citrata, and strychnine sulphas, — these last two being respiratory and car- diac tonics, — are the indications. Sleeplessness is an annoying symptom frequently requiring treat- ment. Balfour, of Edinburgh, advocates chloral. With strychnines sulphas it is safe and satisfactory. The same can be said for trional with strychni?icz sulphas. The so-called antiseptic treatment of acute pneumonia is still under trial, and no definite opinion can be expressed concerning it. CATARRHAL PNEUMONIA. Synonyms. Broncho-pneumonia; lobular pneumonia; capillary bronchitis (?). Definition. An acute catarrhal inflammation of the bronchioles and alveoli of the lungs, characterized by fever, cough, dyspnoea, copious expectoration, and great depression. Causes. From an extension of a bronchial catarrh downward; following the eruptive fevers, especially measles ; complicating whoop- ing cough. Persons of the rickety or scrofulous diathesis, in whom there is a greater irritability of the epithelial elements, are particularly predisposed to this form of pneumonia on slight exposure ; emphy- DISEASES OF THE LUNGS. 329 sema ; diseases of the heart ; most frequently seen in childhood and old age. The inspiration of particles of food and mucus in the last stages of low diseases — the aspiration or deglutition pneumonia — is of the catarrhal variety. Bacteriological investigations seem to indicate that broncho-pneu- monia is due to more than one germ, although the diplococcus pneumoniae is the most frequent etiological factor. Pathological Anatomy. Hyperemia of the mucous membrane of the bronchi, extending to the connective tissue of the bronchioles and accompanying arterioles and to the alveoli, with swelling and succulence of these tissues, accompanied by an abnormal sec?~etion and an immense production of young cells from the proliferation of the bronchial and alveolar epithelium, admixed with a yellowish, creamy, mucoid material, which blocks up the bronchioles and air cells. The affected parts first have a reddish-gray, soon changing to a yellowish-gray, color, due to the rapid metamorphosis of the newly developed cells. If the fatty change be completed, absorption takes place and the consolidation is removed; if it remain incomplete, the cells atrophy, the little mass becoming caseous, and the disease passes into a chronic state. The bronchial tubes also participate in the disease ; the walls be- come thickened, from a hyperplasia of the connective tissue {peri- bronchitis}, and their calibre is often dilated. Symptoms. Catarrhal pneumonia begins as a catarrhal bron- chitis. It may be either acute, subacute, or chronic in its course. J* cute variety : Its onset is announced by a gradual rise of tem- perature to io2°-io3° F., the febrile phenomena assuming a typical remittent character, with rapid, laborious, and shallow breathing, as shown by the widely dilated nares and violent action of all the acces- sory muscles, while the insufficient distention of the lungs is shown by the great recession of the lower part of the chest walls and sinking in of the intercostal spaces. The inspiration is short and imperfect, the expiration noisy and prolonged; the pulse is frequent, 100-120 or more, and somewhat compressible ; the cough, which, during the bronchitis, was loose, now becomes short, hacking, dry, and painful, soon followed by more or less copious muco-purule?it expectoration ; the appetite is impaired, bowels somewhat loose, urine scanty, high- colored, and the surface frequently covered with a more or less profuse perspiration. 330 PRACTICE OF MEDICINE. The subacute and chronic varieties have the same general symp- toms, but the duration is longer and the exhaustion greater. The progress of catarrhal pneumonia is sometimes, although not often, a very acute one. The disease may prove fatal in a few days, especially if it attack feeble children ; in such the countenance be- comes pale and livid, the lips bluish, the eyes dull, and a restlessness giving place to apathy, and a continually augmented somnolence. Resolution, when it occurs, is by lysis, several weeks elapsing before complete recovery. Percussion. Dullness, scattered in patches, over both lungs, the intervening healthy lung often giving a more or less hollow or tympanitic note. Auscultation. Vesiculobronchial breathing, changing to moist bronchial breathing, associated with small bubbling (sub-crepitant) rales. As the disease progresses toward resolution, the rales become larger (large bubbling) and more numerous. If pneumonic phthisis result, physical signs indicative of that condition are soon evident. Sequelae. Attacks of catarrhal pneumonia complicated with atelectasis, or collapse of the lobules, when recovery occurs, are fol- lowed by emphysema of the lungs. If the catarrhal products which fill the alveoli and bronchioles and intervening connective tissue do not rapidly undergo complete fatty metamorphosis and consequent absorption, pneumonic phthisis re- sults. Diagnosis. Ordinary bronchial catarrh differs from catarrhal pneumonia by the absence of dyspnoea, fever, and dullness on per- cussion, and the presence of the large bubbling rales, and also by the subsequent history of the two affections. Croupous pneumonia is a unilateral disease ; catarrhal pneumonia is bilateral and diffused over both lungs — the former a self-limited disease, the latter having no fixed duration. Acute tuberculosis at its onset is characterized by the presence of a capillary bronchitis, a differentiation being possible only by a study of the clinical history and course of the two maladies and the presence or absence of the tubercular bacilli. (Ede7?ia of the lungs is a bilateral disease associated with a short, dry cough, and dyspnoea, but lacks the previous catarrhal history and high temperature of catarrhal pneumonia. Prognosis. Fully one-half of the cases of true catarrhal pneu- DISEASES OF THE LUNGS. 331 monia terminate fatally. The prognosis must be guarded in scrofu- lous or rachitic subjects, or those enfeebled by other diseases, for, unless prompt resolution can be effected, it will terminate fatally early, or develop pneumonic phthisis. Have seen cases continuing up and down for eight and ten months, and finally make a good recovery. Treatment. Confinement to bed is paramount, although the position of the patient is to be frequently changed. The diet must be of the most nutritious character, administered at frequent intervals : milk, eggs, chicken, beef, mutton and oyster broths are the most suitable articles. The steady use of brandy or whiskey throughout the attack is of importance, regulating the amount by the age of the patient and the severity of the attack. Locally a weak mustard plaster followed with a cotton-batting jacket is valuable. Poultices are of little use. The febrile symptoms and early cough are often modified by the following mixture : Be. Potassii citratis, gvj 24. Gm. Spts. setheris nitrosi, f 5 iv 15. Cc. Tinct. opii camphorat. , f 5 iv 15. Cc. Liquor, potassii citratis, ... adf^vj ad 180. Cc. M. Sic — Dessertspoonful every three hours. Early in an attack, in children with high temperature, tinctura aco7iiti, in small, frequently repeated doses is valuable. If the fever persists, a combination of phenacetin or antifebrin with camphor or digitalis is useful. The ice bags or poultices are as strongly urged for broncho- pneumonia as for croupous pneumonia, and in sthenic cases should be given a trial. For the catarrhal process, the air of the apartment should be main- tained at an even temperature and moistened by disengaging the vapor of water in it. The following combination is of great utility in nearly all cases, regulating the dose in accordance with the age of the patient : R • Ammonii carbonat Ammonii iodidi, Mucil. acacire, . Syr. glycyrrh., . Syr. prun. virg., SlG. — Every three hours • gr. v ■ S v - v_x . q. S. ad fg iv ad •3 Gm. .3- .6 Gm. q. s. 4- Cc. 15. Cc. ich pleasanter way of administering the ammonia salts is in 332 PRACTICE OF MEDICINE. capsules, each containing about two and one-half grains of each salt with an aromatic oil. Terpinum hydras acts remarkably well in many lingering cases. The spiritus ammonii aromaticus in either chloroform or cherry-laurel water makes an excellent mild, stimu- lating expectorant. For C07ivalescence, nutritious food, ferri iodidum, quinines sulphas, and oleum morrhucE. Locally : repeated application of mustard poultices or turpentine stupes, followed by cotton j acket. If the inflammatory processes tend to become chronic, scattering blisters should be used. PULMONARY TUBERCULOSIS. Synonyms. Phthisis pulmonalis ; phthisis ; consumption ; pneu- monic phthisis ; tubercular phthisis. Definition. An infective disease, caused by the bacillus tubercu- losis, the lesions of which are characterized by nodular bodies called tubercles or diffused infiltrations of tuberculous tissue, which undergo caseation or sclerosis, and may finally ulcerate, or, in some situations, calcify. (Osier.) Clinical Varieties. I. Acute miliary tuberculosis; II. Pneu- monic phthisis ; III. Tubercular phthisis ; IV. Fibroid phthisis. Cause. It is now generally accepted that all varieties of pulmon- ary consumption are due to the active presence of the bacillus tuber- culosis, discovered by Koch in 1880. The lung tissue must be in a receptive state, as the bacilli may be present in the respiratory tract without the development of the disease. Any condition that lowers the tone of the general system renders the tissues susceptible to the changes produced by the tubercle bacilli. These will be enumerated in speaking of the clinical varieties of the disease. ACUTE MILIARY TUBERCULOSIS. Synonyms. Acute phthisis; galloping consumption. Definition. An acute infective febrile affection, due to the rapid eruption in various parts of the body, but especially in the lungs, of miliary tubercles ; characterized by high fever, rapid pulse, hurried DISEASES OF THE LUNGS. 333 respiration, pains in the chest, cough, profuse expectoration, and rapid prostration. Causes. In the majority of cases it is the result of an auto-infec- tion, arising from either an active or latent tuberculous focus. Cases develop in which no cause can be assigned. Often follows measles, whooping-cough, variola, and influenza. Most frequent between puberty and middle life. " That the gray granulation is deposited throughout the body under the influence of certain conditions of irritation, it is necessary that a peculiar vulnerability of the constitution exist — in other words, that it be of the scrofulous type." Clinical Forms. General or typhoid, pulmonary and cerebral. The cerebral will be described in the section on nervous diseases. Pathological Anatomy. Pulmonary form. " The gray granu- lation or miliary tubercle consists of a fine reticulation of fibres, with a mass of epithelioid cells and granules, and often having a giant cell for its centre." The deposit is generally over both lungs and the bronchial tubes, and is followed by hypersemia, increase of secretion, having a viscid and adhesive character, and the destruction of all the tissue with which it comes in contact. Deposits also take place in the brain, pleurae, intestines, peritoneum, and kidneys. General or Typhoid. — Symptoms. Gradual progressive weak- ness, with loss of appetite ; dry, clean tongue ; costive bowels, flushed cheeks ; fever, irregular in type, and rapid, feeble pulse. Rarely the temperature reaches 103 F., to 104 F., associated with a mild delirium. The respirations are increased with slight or no cough, and little or no expectoration. Often the symptoms of a diffused bron- chial catarrh of the smaller tubes are present. As the symptoms continue the prostration increases, cyanosis develops, the patient growing stupid, gradually deepening into coma and death. Diagnosis. The symptoms of acute phthisis point to an acute general infection, and the disease is apt to be mistaken for typhoid fever. The points of difference are the absence of the typical typhoid, or step-like, temperature record, the characteristic eruption, and the diarrhoea. The. differential diagnosis can be more readily determined by the Widal test and the diazo-reaction in the urine. Prognosis. Recovery is the rarest termination. 334 PRACTICE OF MEDICINE. Treatment. Expectant and symptomatic. Pulmonary Form. Symptoms. The onset is usually sudden, with a chill or chilliness, followed by fever, io2°-io4° F., rapid, dicrotic pulse, 120-140, cough, with scanty, glairy sputum, increased respiration, 30-50 per minute, pain in the chest, hot skin, dry tongue, deranged digestion, and great prostration, the severity of the symp- toms rapidly increasing, with evidences of cyanosis, the sputum becoming more abundant and often rusty in color, with more or less frequent attacks of hcemoptysis, soon followed by headache, vertigo, sleeplessness, often delirium, coma, and death. If deposits have occurred in the meninges or the intestines, symp- toms of these affections are superadded. Percussion. The percussion resonance is normal until consider- able deposits have occurred, when it is either slightly impaired or even slightly tympa?iitic. With the development of cavities the am- phoric percussion note is present. Auscultation. Often little change in the vesicular murmur, but diffused rales of bronchial catarrh, or vesiculo-bronchial breathing, associated with large and small, moist or bubbling rales, soon followed by bronchial and brcncho-cavernous breathing, with large and small, moist and circumscribed gurgling rales. Duration. Acute phthisis usually terminates fatally in from four to twelve weeks. Rarely of several months' duration. Diagnosis. Commonly mistaken for typhoid fever with lung complications, an error that is readily made unless a close study of the history, symptoms, physical signs, and sputum be made. The Widal test may assist in determining the diagnosis. Treatment. There are no means of retarding the progress of this malady. Loomis says : " Morphia in small doses — -fa of a grain (0.003 Gm.) hypodermically every six or eight hours — has, in my hands, been more satisfactory in staying the progress of the disease, prolonging life, and keeping the patient comfortable than any other plan." Dr. McCall Anderson claims that subcutaneous injections of atropine sulphas check the exhausting sweats, and that quininas sulphas, digitalis, and opium reduce the temperature, and if they fail, ice-cloths to the abdomen will accomplish the desired result. The various symptoms should be met as they occur, the patient at the same time being supplied with large quantities of stimulants, and full doses of strychninae sulphas and arsenicum. DISEASES OF THE LUNGS. 335 PNEUMONIC PHTHISIS. Synonyms. Chronic catarrhal pneumonia ; catarrhal phthisis ; caseous pneumonia ; caseous phthisis. Definition. A form of pulmonary consumption characterized by the destruction of the pulmonary tissue resulting from the action of the bacillus tuberculosis, causing the caseation or cheesy degeneration of inflammatory products in the lungs, and the subsequent softening and destruction of the caseous matter, with greater or less destruction of the pulmonary tissue ; characterized by hectic fever, cough, shortness of breath, purulent expectoration, and more or less rapid prostration. Causes. The predisposing factor in the etiology of pneumonic phthisis is a strumous or scrofulous diathesis, or a condition of lowered health, the result of various unfavorable hygienic influences. The exciting causes are : the irritation produced by the presence of the bacillus tuberculosis and a catarrhal pneumonia in any portion of the lung, but especially at the apex ; inflammation occurring about a blood clot ; inhalation of irritant particles occurring in such occu- pations as weaving, grinding, mining, milling, cigar-making, and the like. Many cases of pneumonic phthisis can be traced to an attack of influenza a year or so before in individuals having the peculiar diathesis. Pathological Anatomy. When a pneumonia terminates in resolution, the inflammatory products are absorbed by first undergoing a fatty metamorphosis. If the fatty metamorphosis be incomplete, the cells are atrophied and undergo the caseous degeneration, which con- sists in the absorption of the watery parts, the fatty degeneration of the cellular elements, and the granular disintegration of the fibrinous material, so that ultimately a soft, solid mass is produced, yellowish in color, having the appearance of cheese. The destructive changes are thus described by Niemeyer: " Cells, the products of inflammation, accumulated in the alveoli and minute bronchi, crowd upon each other, becoming densely packed, and thus by their mutual pressure they bring about their own decay, as well as that of the lung textures, by interfering with their nutrition, the alveolar walls being also themselves damaged by the inflammatory process." The position of the catarrhal pneumonia resulting in the above 336 PRACTICE OF MEDICINE. changes is usually at the apex or under the lower inner scapular re- gion, but it may occur at any portion of the lungs, or a whole lung becomes infiltrated, and undergoes the cheesy degeneration (phthisis florida). As in croupous pneumonia, so in pneumonic phthisis is there in- volvement of the overlying pleura of tubercular character in the latter disease. Rarely rupture of lung and pleural structure occur, causing tubercular pneumohydrothorax. Symptoms. Pneumonic phthisis occurs in three forms — the chronic, the subacute, and the acute. Chronic form. The origin is rather insidious, the individual being susceptible to "colds," or " catarrhs," on the slightest exposure; gradually a persistent cough, with the expectoration of muco-pus, is established, each severe cold being accompanied with chill, fever, pain in the chest, and either slight hemorrhages or blood streaked sputa. Finally, the catarrhal symptoms become persistent, with morning chills, evening fevers, and rather profuse night-sweats, dis- tressing cough, profuse muco-purulent sputa, containing the bacilli, great weakness and exhaustion, loss of appetite and feeble digestion, the symptoms growing persistently worse, death occurring from exhaustion after one or two years' duration. Subacute variety. History of an acute attack of pneumonia of one or two weeks' duration, followed by a decided improvement, but not complete recovery. After a lapse of some weeks or months symp- toms of pulmonary softening beg'm , destroying the lung structure and forming cavities, accompanied by chills, fever, night-sweats, emaci- ation, cough, muco-purulent and blood-streahed expectoration contain- ing the bacilli, the patient dying from exhaustion within a year. Acute variety, the so-called phthisis florida, runs a rapid course, beginning either as a croupous or catarrhal pneumonia, involving the whole of one or part of both lungs, associated with rapid loss of flesh and strength, high but variable temperature, io3°-io5° F., with remissions, profuse night-sweats, shortness of breath, severe cough, profuse, purulent, and blood-streaked sputa containing the bacilli, loss of appetite, and feeble digestion, the patient succumbing in a few weeks or months from exhaustion. A decided remission in the local and general symptoms of the acute variety may occur, the disease afterward pursuing a more chronic course. DISEASES OF THE LUNGS. 337 Inspection. Shows deficient respiratory movements of the dis- eased portion of the lungs. Palpation. Increased vocal fremitus over the consolidated lung tissue and cavities. Percussion. The percussion note varies from a slight impair- ment of the normal note at either apex to dullness, and when cavities are formed, associated with scattered points of the tympanitic or hollow note. If the cavities communicate with a bronchial tube, the cracked-pot or cracked-metal sound is elicited. If the cavities are filled with pus, the percussion note is dull. If the pus be expelled, the tympanitic or cracked-pot sound returns. Auscultation. The vesicular murmur is unimpaired in those parts free from disease; it \§ feeble or indistinct if many bronchioles are obstructed; and is harsh or blowingM the bronchioles are nar- rowed. The inspiratory sound will be jerking, and the expiratory sound prolonged and blowing when the lung has lost its elasticity. Associated with the impaired vesicular murmur is Vifine, dry, crack- ling sound (crepitation), appearing at the end oj 'inspiration. If bron- chitis be associated, large and small moist or bubbling rales are also heard during respiration. When cavities form, either bronchial or broncho-cavernous respira- tion is heard, associated with more or less distinct gurgling rales. If the cavity be free from pus and have rather firm walls, the breathing is more amphoric in character. Diagnosis. Catarrhal bronchitis has many points of resemblance to pneumonic phthisis. The subsequent course of the latter, with the high temperature, prostration, emaciation, sputa containing bacilli, and physical signs will prevent error. Acute fibrinous and catarrhal pneumonia, often after a course of two or three weeks, show the bacilli and yet are not recognized as tuberculosis. It is a safe rule of practice to suspect tuberculosis and examine daily for the bacilli in all cases of pneumonia that show the least tendency to linger, and particularly where there are chills and a remittent temperature record. Prognosis. Acute variety, the phthisis florida, usually terminates fatally within a few months. The subacute and ch?'onic varieties may, under judicious treatment and favorable hygienic conditions, be arrested, the caseous matter partly expectorated and partly absorbed, leaving more or less loss of 29 338 PRACTICE OF MEDICINE. structure, cicatricial tissue supplying its place, which after a time contracts, causing more or less retraction of the chest walls. Cases not properly treated, either from carelessness or poverty, succumb after a year or two. TUBERCULAR PHTHISIS. Synonyms. Tuberculosis; consumption; incipient phthisis; chronic phthisis ; chronic ulcerative phthisis. Definition. A chronic pulmonary disease caused by the bacillus tuberculosis, resulting in the deposition of tubercle in the lung structure, which in turn undergoes ulceration and softening which results in a septic infection, characterized by progressive failure of health, fever, cough, dyspnoea, emaciation, and exhaustion. Causes. Hereditary and acquired susceptibility to the influence of the bacillus tuberculosis. It is questionable if an individual is born with pulmonary tuberculosis, but makes his advent with tissues that are a congenial soil for the growth and ravages of this wide-spread germ. Amongst the acquired causes are syphilis, alcoholism, chronic nephritis, certain occupations, and living in damp, overcrowded, dark, and badly ventilated locations. Debility following an attack of influenza predisposes to the deposition of tubercle. Pathological Anatomy. Tubercle is a grayish-white, translu- cent, and semi-solid granulation, about the size of a millet-seed, most commonly deposited in the walls of the bronchioles, or around the small blood-vessels, — a peri-arteritis, — exciting alow form of inflam- mation, the result of its own death. The masses of tubercle soon undergo softening (cheesy transformation) ; the lung structure is sec- ondarily affected, undergoing softening, which results in more or less destruction of the tissue, whence cavities are formed. The inflammation may extend to the small arteries, causing hemor- rhage. The deposit of tubercle is generally at one of the apices, and " once present in an apex, the disease usually extends in time to the opposite upper lobe ; but not, as a rule, until the lower lobe of the lung first affected has been attacked. Lesions of the base may be primary, though this is rare." Depositions may also occur in the brain, intestines, and liver. DISEASES OF THE LUNGS. 339 The pleura is usually the seat of a chronic inflammation (dry pleurisy, tubercular), resulting in the obliteration of the pleural cavity. Symptoms. The symptoms correspond closely to the stages of deposition, of softening, septic infection, and of the formation of cavi- ties. The development is insidious , with increasing dyspepsia and ancemia, the loss of appetite, distress after meals, and feeling of weakness, often misleading the patient and physician for some time until the occurrence of an irritable heart, a slight, dry, hacking cough, referred to the throat or stomach, scanty, glairy expectoration, gradual loss of weight, impaired muscular strength, pallid appearance, and a more or less copious hcemoptysis. Pain, sharp in character, below the clavicles, is often present. These symptoms are characteristic of the development of the disease. The beginning of softenifig is announced by increased cough, freer expectoration, showing under the microscope the bacilli, dyspnoea in- creased on exertion, morning chills, evening fever, night-sweats — the so-called hectic fever, diarrhoea, increased emaciation and weakness, the patient, however, continuing very hopeful. With the formation of the cavities the cough is more aggravated, with profuse and purulent expectoration, at times containing yellow striae, the amount depending upon the number and size of the cavi- ties ; haemoptysis is not common at this stage ; the pulse rapid and weak, increased hectic, burning of the soles and palms, copious night-sweats, greater debility and emaciation, with oedema of the feet and ankles, denoting failure of the circulation, death soon following from asthenia, the mind clear and hopeful to the end. Inspection. First stage, often shows slight depressions in the supra-clavicular, and at times in the infra-clavicular regions. Palpation. Second stage, the vocal fremitus is slightly increased at both or either apex. Percussion. First stage, slight hnpairment of the normal per- cussion resonance can sometimes be elicited at both or either apex. Second stage, the resonance is impaired, and may be even dull. Third stage, dullness with circumscribed spots of the amphoric, or tympanitic or cracked-pot sound. Auscultation. First stage, inspiration jerky, expiration pro- longed, the pitch higher than normal, the inspiration associated with crackling rales at both or either apex. 340 PRACTICE OF MEDICINE. Second stage, vesico-bronchial breathing, associated with sub-crepi- tant and large and moist or bubbling rales. Third stage, broftchial, broncho-cavernous, and cavernous respira- tion, associated with large and small moist or bubbling, and localized gurgling rales. Bronchophony in its various degrees is associated with the second and third stages of tuberculosis. Complications. Tubercular diseases of the brain, larynx, pleura, intestines, and peritoneum ; perineal abscess leading to fistula, endo- carditis, and myocarditis. Diagnosis. The early diagnosis of tubercular phthisis rests mainly on the history, together with the symptoms and physical signs. In the first stage it is often mistaken for dyspepsia, anaemia, malarial fever, or disease of the heart ; if the bacilli can be found in the sputum, the diagnosis is settled. Prognosis. In the main unfavorable, although under proper treatment, change of climate, and like favorable conditions life may be prolonged for years. FIBROID PHTHISIS. Synonyms. Chronic interstitial pneumonia ; cirrhosis of the lungs ; Corrigan's disease. Definition. A hyperplasia (thickening) of the pulmonary con- nective tissue, resulting in atrophy and degeneration of the vesicular structure, associated with bronchial inflammation ; characterized by cough, profuse expectoration containing the bacillus tuberculosis, fever, emaciation, and ultimately death by asthenia. Causes. Hereditary predisposition ; inhalation of irritants and associated with certain occupations, such as stone cutting, grinding, etc. Following lobar pneumonia ; chronic bronchitis ; alcoholism ; syphilis; chronic nephritis. Pathological Anatomy. In addition to the pneumonic changes in the lung structure, there is developed a reparative or fibrous process resulting in thickening of the bronchial mucous membrane and dila- tation of the air tubes. Hyperplasia of the pulmonary connective tissue, resulting in the compression and consequent destruction of the vesicular structure, which is assisted by the contraction of the newly DISEASES OF THE LUNGS. 341 formed tissues. Sooner or later catarrhal pneumonia results, the product undergoing the cheesy degeneration, cavities being formed, and as a result of the long-continued suppuration, tubercular deposi- tions occur, hastening the destruction of the lung tissue. Prof. Da Costa has reported a number of cases of "grinders' phthisis," in whose sputum was found the "bacillus tuberculosis," and in whose family history there were no traces of consumption. Symptoms. The course is chronic, beginning as a bronchial catarrh, worse in winter, better in summer, when, after several years, the cough becomes more continuous, the expectoration freer and muco-purulent, containing the bacilli tuberculosis in large numbers. Gradually hectic fever develops, with night- sweats, dyspnoea, and rapid emaciation, soon followed by oedema of the fee,t and ankles, the result of failing circulation, death occurring by asthenia. Inspection. Depression of the chest walls. Percussion. Impaired resonance, followed by dullness, with ir- regular spots of amphoric or tympanitic percussion note over the points of depression. Auscultation. First stage, vesiculo- bronchial, or harsh respira- tion, associated with large and small moist or bubbling, rales, followed by bronchial, broncho-cavernous, and cavernous respiration, with cir- cumscribed gurgling rales. Diagnosis. Beginning as a bronchial catarrh, slowly progressing, with the remission of the symptoms during the summer months, finally becoming progressively worse, the discovery of the bacilli in the sputum, with the formation of cavities, and symptoms of asthenia, are the chief points in the diagnosis. Prognosis. The duration of fibroid phthisis is most protracted, six to twelve years being the average duration ; death, however, is the inevitable termination. Prof. Da Costa has records of one hundred deaths from " grinders' consumption " whose average life was twelve years from the develop- ment of the signs of the disease. TREATMENT OF PULMONARY TUBERCULOSIS. Can pulmonary tuberculosis be prevented ? To a great extent, yes, as in a large proportion of cases the infection of the system is the result of contagion or the ingestion of food containing the germs in those having the inherited or acquired phthisical diathesis. It is 342 PRACTICE OF MEDICINE. now known that tuberculosis is very common in the cattle whose flesh forms so large a portion of the food of man. Were it not for the protection given by cooking, the history of this disease would be a sadder one than it is. But the milk is not often cooked. May not the great increase in tuberculosis be caused by the use of cows' milk ? The bacilli once found in the sputum, can the unfortunate host be cured ? While I have never seen a case of marked incipient phthisis cured, in the broad acceptation of the term, I have repeatedly seen life pro- longed for a number of years, and the deposition of tubercle long delayed by a change of climate early in the history of the case, warm clothing, life and exercise in the open air short of fatigue, and sys- tematic bathing with a nutritious plan of dieting. If the diet is ar- ranged in accordance with the appetite, the latter will gradually increase, but should it not, it may be stimulated by such bitters as strychnines sulphas, nicx vomica, ignatia amara, Colombo, or gentian. For a number of years I have been in the practice of placing in- cipient cases of tuberculosis upon what I term " up and down " doses of strychnines sulphas, and often with a success that is amazing. A formula is given of — R. Stryckninse sulph., gr. iv .26 Gm. Aq. chloroformi, vel Ess. pepsini, f^ij 60. Cc. M. SlG. — Ten minims equal gr. Jj (0.0025 Gm.). Mode of using : Five drops three times daily for one week, then ten drops three times daily for a week, then fifteen drops three times daily for a week, then twenty drops three times daily for a week, then fifteen drops, then ten drops, then five drops, and so on week after week for months and years. The symptoms are to be met as they arise, and drugs are not to be used simply because the patient has the physical signs of beginning phthisis. For the general debility and malaise that accompanies the early stages of the malady, any one or a combination of the follow- ing drugs, exercising care that they in no way interfere with the appetite : Guaiacol, rr^iij-v (0.2-0.3 Cc.) for adults, and ™Jj-iij (0.12- 0.2 Cc.) for children, four times daily, in either sweetened water, milk, or meat broth, or wine ; oleum morrhucz, ferri iodidum, hypophos- DISEASES OF THE LUNGS. 343 phites, strychnines arsenias, gr. ^V" sV (0.001-0.002 Girt.) after meals, or a combination of arsenicum and digitalis : R. Acidi arseniosi, gr. j .065 Gm. Digkalini (Merck's), gr. j .065 Gm. M. Ft. pil. No. xxx. Sig. — One after meals. For the cough and expectoration, creosote, rt\j (0.06 Cc.) in milk, water, or whiskey three times daily, gradually increasing the dose a minim a day until stomach toleration. In the pneumonic variety the attempt should always be made to remove the caseous matter by absorption and expectoration. The following prescriptions will sometimes prove successful : &. Ammonii carb., . gr. v Ammonii iodidi, gr. v-x Aq. chloroformi, f^ij Syr. prun. virg., ........ f^ij 8. Cc. M. Every five hours, diluted, alternating with Liq. potassii arsenitis, Ttlv Mass. ferri carb., gr. v Vini xerici, f zj Aquae, q. s. ad fjss 15. Cc. M. In the tubercular variety the early dyspeptic symptoms are wonder- fully relieved by the following : 3 Gm. 3-. 6 Gm. 8. Cc. 8. Cc. 3Cc. .3 Gm. 4 . Cc. 15 Cc. R . Pepsini cryst., gr. ij Acidi hydrochlorici dil., . . . . TTVxv I Glycerini, ... lTl x x I Succi limonis, l^xv I Aquae aurantii flor. , . . . . adfz,ij ad 8 Sig. — With meals, diluted. 13 Gm. Cc. 3 Cc. Cc. Cc. M. It is in this variety of consumption that every means should be employed to improve the general health. Improvement may often follow the long continued moderate use of alcoholic stimulants, the amount being only such as will increase the appetite and improve the digestion. If rise of temperature, flushed face, or dyspeptic symptoms occur, discontinue the stimulants at once-. Be sure of the diagnosis before resorting to alcohol. For the fibroid variety, to prevent the hyperplasia of the connective tissue, hydrargyri corrosivum chloridum, polassii iodidum, or aurii et sodii chloridum, are recommended. Oleum morrhutz is of benefit. 344 PRACTICE OF MEDICINE. For the gastric symptoms, which are often so severe as to seriously interfere with assimilation, either bismuthum, gr. xx (1.3 Gm.) before meals, or arsenicum : R . Liquor, potassii arsenitis, . . . TTLxxx 2. Cc. Tincturae nucis vomicae, . . . f 3] 4. Cc. Aquae chloroformi, . . . . adf^ij ad 60. Cc. M. Sig. — Teaspoonful before meals, diluted. For the fever, unfortunately, but little can be accomplished with drugs. If, however, it exceeds 101 F., an attempt should be made to reduce it. The " Niemeyer pill " is usually recommended, its formula being — R . Quinince sulph., gr. j .065 Gm. Pulv. digitalis, gr. ss .032 Gm. Pulv. opii, g r - X - OI 6 Gm. Pulv. ipecac, g r - X - OI ^ Gm. From a very considerable experience with this "famous " pill, I can recall few cases in which it has proven of the least benefit. The following is much more effectual : R. Quininae sulph. gr. x .6 Gm. Quininas muriat. , ...... gr. x .6 Gm. Pulv. opii et ipecac, gr. iij .2 Gm. Ft. capsul. No. ij. Sig. — One capsule five hours and the other three hours before the decided rise of temperature. In a few instances the temperature has been favorably influenced by antifebrin, gr. v (0.3 Gm.), in tablets, at one, three, and five o'clock each afternoon, or acetanilidum, gr. v (0.3 Gm.), at the same hours. If sweating occur, add to each five-grain tablet agaricin, gr. ^u (0.002 Gm.). Many patients prefer cool sponging, adding alcohol, vinegar, or bay-rum to the water, and there is no doubt that sponging will promptly reduce the temperature two or three degrees. For the cough the following may give relief: R. Codeince sulphat., gr. y^-Yz .022-032 Cm. Acidi hydrocyanici dil., rr\,ij .12 Cc. Syr. tolu, f£j 4. Cc. M. Sig. — Several times a day. DISEASES OF THE LUNGS. 345 Or— R. Codeinae, gr. iv .26 Gm. Acid, hydrochlor. dil., ^3 SS 2 - Cc. Spirit, chloroformi, f^iss 6. Cc. Syr. limonis, f^j 30. Cc. Aq. lauro-cerasi, adf^iv ad 120. Cc. M. Sig. — A teaspoonful, repeated when cough is troublesome. If diarrhoea develop, bismuthum, gr. xx-xxx (1.3-2 Gm.) every three or four hours, with rest in bed and mustard to the abdomen ; or R. Cupri sulphat., gr. iss (0.1 Gm.); ext. nucis vomicae, gr. iij (0.2 Gm.) ; pulv. opii, gr. vj (0.4 Gm.). M. et ft. pil. No. xij. Sig. — One every three or four hours ; or R . Liquor, potassii arsenitis, rr^xxx (2 Cc.) ; tincturse opii deodorat., f^iss (6 Cc.) ; liquor pepsini, ad f^ij (60 Cc). M. Sig. — Teaspoonful at meal time. For night-sweats, atropine sulphas, gr. -^ (0.001 Gm.) at bed-time, or agaricin, gr. -fa-fa (0.003-0 006 Gm.) at bed-time, adding small doses of morphina if it cause loose stools. Camphoric acid, gr. xx- xxx (1.3-2 Gm.), about two hours before the expected sweat, the time of administration is important, as the drug is rapidly eliminated and it has the additional advantage of causing no ill or disagreeable effect. It is best given dry on the tongue, or in cachets. It is claimed that sulphonal, gr. v-x (0.3-0.6 Gm.), at bed-time, controls the night-sweats and also produces a quiet, refreshing sleep. For hemoptysis no one remedy is comparable with atropines sulphas, gr. ^tj~ ioo ~gV (Q-00032-0.00065-0.001 Gm.), repeated pro re nata ; or nitro-glycerinum, one per cent, solution, Tt\j (0.06 Cc), every fifteen minutes for a few doses, often acts promptly. Beginning in December, 1890, a large number of cases of incipient tuberculosis were treated in the wards of the Philadelphia Hospital with Koch's tuberculin. The treatment was negative in every case. In the fall of 1892 ten cases of early tuberculosis were placed under treatment with Kleb's tube7-culocidin. Its action is different from Koch's tuberculin in that it never excites the febrile reaction of the latter. The results were also negative, although for several months the patients seemed free from the bacillus. The diet must be of the most nutritious and easily digestible character. If oleum morrhua or petrolatum can be assimilated, either should be used for a long time. The hygiene of the patient is of the utmost importance, and, as it is a struggle for life, no means should be left untried to gain the victory. 30 346 PRACTICE OF MEDICINE. DISEASES OF THE PLEURA. PLEURITIS. Synonyms. Pleurisy ; " stitch in the side." Definition. A fibrinous inflammation of the pleura, either acute, subacute, or chronic in character, occurring either idiopathically or secondarily; characterized by a sharp pain in the side, a dry cough, dyspnoea, and fever. It may be limited to a part, or may involve the whole of one or both pleural membranes. Causes. Idiopathic pleuritis is said to be due to cold and expo- sure, to injuries of the chest walls, or the result of muscular exertion. Tuberculosis is the cause in a few instances. Secondary pleuritis occurs during an attack of pneumonia, pericardi- tis, rheumatism, variola, scarlatina, measles, Bright's disease, tuber- culosis, or puerperal fever. Chronic pleuritis follows an acute attack, or is the result of tuber- culosis, Bright's disease, cancer, or alcoholism. Pathological Anatomy. The ordinary course pursued by an inflammation of a serous membrane is hyperemia followed by exu- dation of lymph, the effusion of fluid, its absorption, and the adhesion of the membranes. The first or dry stage of pleuritis is a hyperaemia or diffused irreg- ular redness of the membrane, with little specks of exudation. The second stage is characterized by the copious exudation of lymph, more or less completely covering the membrane, giving it a dull, cloudy, or shaggy appearance. If the inflammation ceases at this point, it is termed dry pleuritis. The third, or stage of effusion, is characterized by the pouring out of a semi-fibrinous liquid, more or less completely filling and distending the pleural cavity, and floating in the fluid are fibrinous flocculi, blood, and epithelial cells. Absorption of the fluid and more or less of the exudative lymph soon occurs, the unabsorbed portion becoming organized, forming adhesions which obliterate the pleural cavity. The effusion, if on the right side, pushes the heart farther to the left; if on the left side, the heart is displaced to the right, the impulse DISEASES OF THE PLEURA. 347 often being seen to the right of the sternum. The lungs are also compressed and displaced upward and against the spinal column, and, on removal of the fluid, expand again, except in cases of chronic pleuritis, when the functional activity of the pulmonary structure is more or less permanently impaired. Chronic pleuritis results when the fluid is not absorbed or when it is effused into the cavity in a slow and insidious manner. The mem- brane is irregularly thickened, with firm adhesions, fluid being found in the meshes; depressions of the thoracic walls also occur. The fluid may be serum, pus {empyema), or pus and blood. Open- ings may form, through which there is permanent discharge, either externally (fistulous empyema) or into the bronchi, or, rarely, into the bowels. Symptoms. Acute variety : Begins with a chill, followed by a sharp, lancinating pain (stitch) near the nipple or in the axilla, aggra- vated by coughing and breathing, associated with slight tenderness on Pressure. The respirations zxerapid and shallow, 30-35 per minute ; a short, dry, hacking cough ; mo&eraXQ fever ; compressible pulse, 90- 120. With the effusion of liquid the dyspnoea becomes aggravated, the cough more distressing, the cardiac action embarrassed, \hz coun- tenance wearing an anxious expression, the patient usually lying on the affected side. With the absorption of the fluid the symptoms gradually ameliorate, convalescence being more or less rapid. Subacute variety : Begins insidiously after cold, exposure, and fatigue in those enfeebled. Patients usually complain of a sense of weariness, shortness of breath, aggravated on exertion, evening fever, followed by night-sweats, short harassing cough, none or very scanty sputum; the pulse is small, feeble, but frequent, 100-120 beats per minute. The characteristic pain in the side is usually wanting. Chronic variety : Irregular chills, fever, night-sweats, dyspnoea, palpitation, embarrassed circulation, with more or less prostration. Inspection. First stage, deficient movement of the affected side, on account of the pain induced by full breathing. Second stage, bulging or fullness of the affected side, with oblitera- tion of the intercostal spaces and displacement of the cardiac im- pulse. Palpation. Second stage, vocal fremitus feeble or absent over the site of the effusion, exaggerated above the site of the fluid. Rarely, fluctuation may be obtained. 348 PRACTICE OF MEDICINE. Percussion. First stage ; may be slightly unpaired. Second stage • dullness or even flatness over the site of the effusion ; ty?npajiitic percussion note above the fluid. Auscultation. First stage; feeble vesicular murmur over the affected side, the patient breathing superficially, to prevent the pain ; a friction sound, slight and grating or creaking, becoming louder as the exudation of lymph increases, limited usually to the angle of the scapula of the affected side, rarely heard over the entire side, accom- panies the respiratory movements. Second stage ; feeble or absent vesicular murmur on the affected side, depending upon partial or complete compression of the lungs by the fluid. Above the fluid puerile breathing, and just at the upper margin of the fluid a friction sound may be heard. The vocal resonance \s diminished or absent over the site of the fluid and markedly increased above, cegophony being present at the upper margin of the fluid. With the absorption of the fluid the vesicular murmur gradually returns, associated with a moist friction sound. Diagnosis. Acute pneumonia is often mistaken for the effusion stage of pleurisy. The points of distinction are : in pneumonia there is the pronounced chill, high fever, and characteristic sputa, bronchial breathing, exaggerated vocal fremitus and resonance, and no displace- ment of the heart, the reverse occurring in pleurisy. Enlargement of tJie liver may be mistaken for pleurisy with effu- sion, the chief point of distinction being that, in enlargement of the liver, the superior line of dullness is depressed upon full inspiration, while in pleurisy with effusion inspiration does not modify the loca- tion of the dullness. Prognosis. Idiopathic pleurisy usually terminates in recovery within three weeks. Pleurisy the result of constitutional causes has its prognosis modified by the condition with which it is associated. Empyema, unless the result of a diathesis, terminates favorably. Double pleurisy is unfavorable. The etiological factor of tuberculosis must always be borne in mind in making a prognosis in pleurisy, whether acute or chronic. Treatment. At the onset, in plethoric patients, wet cups over the affected side ; if great dyspnoea, severe pain, and high arterial tension, even venesection, and in anaemic or weak persons, dry cups, follow- ing the use of either wet or dry cups with poultices or turpentine DISEASES OF THE PLEURA. 349 stupes. The severe pain is promptly relieved by the hypodermic in- jection of morphince sulphas, over its site, repeated as indicated, or the frequent use of small doses of pulvis ipecacua7ihce et opii. In the very early stages of pleurisy the disease maybe cut short by sodiisalicylas, gr. xv-xx (i— 1.3 Gm.), well diluted every three or four hours. In the stage of effusion excellent results follow the use of the salicylates. After effusion has begun, ex trac turn pilocarpi Jluidu7n,V(\ j xv (1 Cc), every two or three hours, or in drachm doses every other day for a week or two, after which twice weekly ; or — R. Pota^sii acetat., gr. xxx 2. Gm. Infus. digitalis, f^ij 8. Cc. M. Every three or four hours. Bowditch, of Boston, for years has advocated early aspiration in pleural effusion. If after three or four days no impression is made on the effusion by drugs, aspiration should be employed and table- spoonful doses of liquor fei'ri etammonii acetatis (Bashatns mixture) administered every four hours, and an early morning dose of mag- nesii sulp/ias, ^ss-j (15-30 Gm.) well diluted. The effusion of pleuritis is rapidly removed by the method of treat- ment suggested by Prof. Matthew Hay, of Scotland, consisting in the use of a concentrated solution of saline cathartics : " Order the patient to take nothing after the evening meal, and then an hour or so before breakfast the salt is given dissolved in as little water as possible. Usual dose from 3iv-vj (15-24G1T1.) to ^j-ij (30-60 Gm.) magnesiisul- phatis to an ounce or two of water, no fluids to be used after the dose ; this usually produces from four to eight watery stools, without pain or discomfort, and also acts as a diuretic." The essence of the " Hay method " consists in getting the concen- trated solution into the intestines at a time when the fluid contents are scanty. If the effusion is uninfluenced by the above-named means, use potassii iodidum, gr. xv(i Gm.), every four hours, well diluted, with flying blisters over the affected side, or unguentum hydrargyri in the arm-pits, groins, and over the site of the effusion. In double pleuritic effusion, evacuate the fluid at once with the aspi- rator, and use the potassium and digitalis mixture mentioned above. Chronic pleurisy. If the effusion be still serous, it is often absorbed 350 PRACTICE OF MEDICINE. by the internal use of potassii iodidum, alternating with "Bas/iam's mixture" and blisters, the secretions being watched. If, however, the liquid is pus {empyema), the aspirator should be used at once, the patient placed upon " Basham 's mixture," stimulants, and quinince hydrochloras. Usually, however, within a very few days after aspiration, another accumulation of pus will have taken place. Should this occur, the purulent pleurisy should then be treated as an abscess, an incision being made between the fifth and sixth ribs, the pus evacuated, a drainage-tube introduced, and an antiseptic dressing applied. If the tendency to pus secretion still remains, the pleural cavity must be washed out with an antiseptic solution, the constitutional treatment being continued. HYDROTHORAX. Synonym. Dropsy of the pleura. Definition. The effusion of fluid into the pleural cavities (bilat- eral), the result of a general dropsy from renal or cardiac disease. Pathological Anatomy. More or less clear serous fluid in both pleural sacs, compressing the lung. No signs of inflammation are present. Symptoms. Following dropsy of the abdomen occurs dyspnoea, with signs of deficient blood aeration, both lungs being compressed. Palpation. Absent vocal fremitus over the site of the fluid. Percussion. Dullness over the site of the fluid. Auscultation. Absent vesicular murmur over the site of the fluid. Diagnosis. Easily determined by association of the symptoms with a general dropsy. Prognosis. Controlled by the cause producing the general dropsy. Treatment. Depending upon the condition causing the dropsy. Dry cups over the chest afford relief. If the symptoms of non- aeration of the blood are severe, the fluid should be at once evacuated with the aspirator. PNEUMOTHORAX. Synonyms. Air in the pleural cavity ; hydropneumothorax. Definition. The accumulation of air in the pleural cavities, with the consequent development of inflammation of the membranes; DISEASES OF THE PLEURA. 351 characterized by sharp pain, followed by rapidly developing dyspnoea and cough. Causes. Generally the result of tuberculosis, causing perfora- tion of the pleura. Perforation may take place from the pleura into the lung, in connection with empyema or abscess of the chest wall. Direct perforation from without, by laceration of a fractured rib or severe contusion. Pathological Anatomy. The gas in the pleural cavity consists of oxygen, carbon anhydride, and nitrogen in variable proportions. It may fill the pleural sac completely, compressing the lung, or is sometimes limited by adhesions. The gas tends to excite inflamma- tion, the resulting effusion being either serous or purulent. Symptoms. Symptoms of pneumothorax, the result of perfora- tion, are sudden or sharp pain in the side, intense dyspnoea, attended with symptoms of collapse, coldness of the surface, and cold sweats. The above symptoms, in many instances, follow a severe or violent paroxysm of coughing. In severe cases there is never a moment's cessation of the acute pain and distressing dyspncea, causing orthop- ncea from the onset until death. Inspection. Enlargement of the affected side, the intercostal spaces being widened and effaced or even bulged out so that the surface of the chest is smooth. Respiratory movements of the affected side are diminished or absent. Percussion. Immediately after the rupture the percussion note is hyper-resonant, or even tympanitic or amphoric in quality. If the amount of air in the pleural cavity becomes extreme, there is dullness on percussion, associated with a feeling of great resistance or density. When effusion of blood occurs, dullness is observed over the lower part of the chest, hyper-resonant or tympanitic percussion note over the upper portions of the chest, these sounds changing as the patient changes position. Auscultation. The normal vesicular murmur may be diminished or absent. The typical amphoric respiratory sound is heard when the fistula is open, usually associated with a metallic echo. Metallic tinkling, or the bell sound, is sometimes distinctly pro- duced by breathing, coughing, or speaking, after the development of inflammation of the pleura. The vocal resonance may be diminished or absent, or, rarely, it may be exaggerated, with a distinct metallic echo. 352 PRACTICE OF MEDICINE. After the development of inflammation in the pleura, suddenly shaking the patient gives rise to a splashing sensation, the succussion sound, if both air and fluid are present in the pleural cavity. Prognosis. When occurring as the result of tuberculosis, the prognosis is extremely unfavorable ; rarely, the fistulous opening is closed by inflammatory action ; the case then becomes one of chronic pleurisy. Treatment. At once a hypodermic injection of morphince sul- phas, which relieves the severe pain and somewhat modifies the dis- tressing dyspnoea, followed by the evacuation of the fluid and air with the aspirator. If the fistulous opening be closed by inflammatory action, the case resolves itself into one of chronic pleurisy, the treatment indicated for that affection plus the treatment of tuberculosis, being the indication. DISEASES OF THE CIRCULATORY SYSTEM. The methods employed in making a physical examination of the heart are : I. Inspection. II. Palpatio?i. III. Percussion. IV. Aus- cultation. Inspection indicates the exact point of the cardiac impulse, and the presence or absence of any abnormal pulsations or any change in the form of the pracordium. Normally the impulse is visible only in the fifth interspace, midway between the left nipple and the left border of the sternum, its area covering about one square inch, most distinct in the thin, while often barely seen in the very fleshy ; often displaced downward by full in- spiration and elevated by complete expiration. Disease may alter the position and area of the impulse. The position of the impulse is moved to the right by left pleuritic effusions ; downward by cardiac hypertrophy or pulmonary emphy- sema ; upward by a pericardial effusion. The area of the impulse is changed and enlarged by pericardial adhesions, cardiac dilatation or hypertrophy. • DISEASES OF THE CIRCULATORY SYSTEM. 353 Palpation confirms the observations of inspection, and also deter- mines the force \ frequency , and regularity of the cardiac impulse. The force of the impulse is diminished by cardiac dilatation, fatty and fibroid degenerations of the heart, emphysema, pericardial effu- sion, and adynamic diseases. The impulse is increased by cardiac hypertrophy, during the first stage of endocarditis and pericarditis, functional cardiac disturbances, and sthenic inflammations. Percussion will determine the boundaries of the superficial and deep cardiac space, the so-called prcEcordium. It is essential that the upper, lower, and two lateral boundaries of the pericardial region be memorized, to wit : superior boundary, the upper edge of the third rib ; the lower boundary is a horizontal line passing through the fifth intercostal space ; the left lateral boundary is about or a little within a vertical line passing through the nipple, the linea mammalis ; and the right lateral boundary is an imaginary vertical line situated one- half an inch to the right of the sternum. These boundaries vary some- what in health, but are sufficiently accurate for all practical purposes. The superficial cardiac space represents that portion of the heart uncovered with lung ; it is triangular in form, its apex being the junc- tion of the lower border of the left third rib with the sternum, its area not exceeding two inches in any direction. The superficial space is increased by cardiac hypertrophy, dilata- tion, or pericardial effusion. Diminished at the end of full inspiration or by emphysema. The deep cardiac space represents that portion of the heart covered by lung, and extends from the upper border of the third rib to the lower edge of the fifth interspace, and from half an inch to the right of the sternum to near the left nipple. It is increased by hypertrophy or dilatation of the heart, left pleuritic effusion, and apparently increased by consolidation of the anterior border of the investing lung. Auscultation indicates the character of the normal cardiac sounds and the point at which they are heard with greatest intensity, and should be thoroughly familiarized if abnormal sounds are to be fully appreciated. The ear or stethoscope applied to the praecordium distinguishes in health two sounds, separated by a momentary silence — the short pause, and the second sound followed by an interval of silence — the long pause. 354 PRACTICE OF MEDICINE. The first sound, corresponding to the contraction of the heart — the systole — is louder, longer, and of a lower pitch and a more booming quality than the second sound, and has its point of greatest intensity at the cardiac apex or a little to the left. It corresponds closely in time to the pulsations as felt in the carotid or radial arteries. The second sound is shorter, weaker, and higher in pitch than the first sound, and has a clicking or valvular quality, having its point of greatest intensity at the second right costal cartilage and a little above, and corresponds to the closure of the aortic and pulmonary valves. The sound made by the closure of the tricuspid valves is best isolated at the ensiform cartilage ; the sound made by the closure of the pulmonary valves, at the third left costal cartilage. The following table, giving the phenomena and time of normal cardiac movements, will assist in recalling the physiology of the heart : Systole of the heart, or ventricular systole. Action of Heart. Ventricles contracting, auricles dilating. Auriculo-ventricular valves (mitral and tricuspid) sud- denly close and remain closed during the whole time of the first sound. Semilunar valves (aortic and pulmonary) open ; movement or locomotion of heart causing the impulse or apex beat. Blood rushes out from the ventricles into aorta and pulmonary artery, and di- lates these vessels and their extensions (arterial system). Blood flows slowly into the auricles from the vena cava and pulmonary veins. The pulse felt in different arteries from one-thirtieth to one-eighth of a second later ^ than impulse. Sound and Pause. First car- diac sound > (systolic dull and prolonged Time in One- tenths of the Heart's Beats. ) !- About four- tenths of the heart's beats, or twenty- four-sixtieths of a second. DISEASES OF THE CIRCULATORY SYSTEM. 355 Diastole of the heart, or ventricular diastole. Action of Heart. Ventricles dilating and re- ceiving blood from auricles. Auricles dilating and receiv- ing blood from veins. Auriculo-ventricular valves (mitral and tricuspid) open. Dilated pulmonary artery and aorta recoil and sud- denly close the semilunar valves (aortic and pulmonic), which remain closed during the whole of the second sound and the interval of silence. Ventricles and auricles still continue to dilate — viz. , receive blood. Near the close of this period the auri- cles, being fully dilated (filled with blood), suddenly con- tract and complete the dila- tation of the ventricles. Sound and Pause. Time in One- tenths ok the Heart's Beats. Second About three- cardiac tenths of the sound heart's beats (diastole) or eighteen - short and sixtieths of sharp. a second. Period of silence or rest. About three - tenths of the heart's beats, or eighteen- sixtieths of a second. The extent of surface over which the cardiac sounds are heard varies, according to the size of the heart and the condition of the adjacent organs for transmitting sounds. The cardiac sounds may be altered in intensity, quality, pitch, seat, and rhythm, or they may be accompanied, preceded, or followed by adventitious or new sounds, the so-called endocardial or cardiac ?nur- murs. The intensity is increased 'by cardiac hypertrophy, irritability of the heart, or consolidation of adjacent lung structure. The intensity is diminished \>y cardiac dilatation or degeneration, during the course of adynamic fevers, emphysematous lung over- lapping the heart, or pericardial effusion. The quality and pitch of the first sound may be sharp or short and of higher pitch when the ventricular walls are thin, or have under- gone beginning fibroid change, the valves being normal ; its pitch 356 PRACTICE OF MEDICINE. and quality are also raised during the course of low fevers. The second sound becomes duller and lower in pitch when the elasticity of the aorta is diminished or the aortic valves thickened. Either or both sounds have a more or less metallic quality in irritable heart and during gaseous distention of the stomach. The seat of greatest intensi'y of the cardiac sounds is changed by displacement of the heart, pleuritic effusion, pericardial effusion, and abdominal tympanites. The rhythm is often interrupted by a sudden pause or silence, the heart missing a beat, or the sounds are irregular, confused, and tumul- tuous, the result of organic changes in the cardiac muscle, valves, orifices, or vessels ; or a reduplication of one or both sounds of the heart may occur. The adventitious cardiac sounds or murmurs are of two kinds : those made external to the heart, as pericardial, exocardial, or frictional murmurs, and those made within the cardiac cavity, endocardial 7nurmurs. Pericardial murmurs, or friction sounds, are made by the rubbing upon one another of the roughened surfaces of the pericardial mem- brane during the early stages of inflammation. The sounds have a rubbing, creaking, or grating character, and are differentiated from a pleural friction sound by their being limited to the praecordium, synchronous with every sound of the heart, and not influenced by respiration. They are distinguished from an endocardial murmur by their super- ficial rubbing, creaking, or grating character, and by not being trans- mitted beyond the limits of the heart, either along the course of the vessels, or to the left axilla or back. Endocardial murmurs are of two kinds — to wit : organic and func- tional. Functional endocardial or blood murmurs are the result of changes in the normal constituents of the blood. Their character is soft, they are heard most distinctly at the base to the left of the sternum, during the systole, are not transmitted beyond the limits of the heart, either to the left axilla or the back, and they are associated with general anaemia. Organic endocardial murmurs are produced by blood currents pur- suing either a normal or an abnormal direction. In health there are two direct blood currents upon each side of the DISEASES OF THE CIRCULATORY SYSTEM. 357 heart — to wit : the current from the left auricle to the left ventricle, the mitral direct current; the current from the left ventricle to the aorta, the aortic direct current; the current from the right auricle to the right ventricle, the tricuspid direct current ; and the current from the right ventricle to the pulmonary artery, the pulmonic direct cut rent. When, from disease, the valves are not properly closed, the blood is allowed to flow back against the direct current, producing abnormal blood currents — to wit : when the mitral valve is incompetent, the blood flows from the left ventricle back into the left auricle during the cardiac systole, producing the mitral regurgitant or indirect current ; when the aortic valves are incompetent, the blood is permitted to flow from the aorta into the left ventricle during the cardiac diastole, producing the aortic regurgitant or indirect current ; when the tricus- pid valves are incompetent, the blood flows from the right ventricle back into the right auricle during the systole, producing the tricus- pid regurgitant or indirect current ; when the pulmonary valves are incompetent, the blood flows from the pulmonary artery into the right ventricle, producing the pulmonic regurgitant or indirect current. The mitral direct current occurs during the contraction of the left auricle, or just before the first sound of the heart and immediately after its second sound. The aortic direct current is produced by the contraction of the left ventricle, and occurs with the first sound of the heart. The tricuspid direct curre?it occurs during the contraction of the right auricle, or just before the first or immediately after the second sound. The pulmonic direct current is produced by the con- traction of the right ventricle, occurring during the first cardiac sound. The mitral direct or presystolic murmur occurs before the first sound of the heart and immediately after the second sound. It is caused by a narrowing of the mitral orifice, has a blubbering quality, well imitated by throwing the lips into vibration by the breath, of a low pitch, and it has its seat of greatest intensity at the cardiac apex, and is not transmitted to the left axilla or to the base of the heart. The mitral regurgitant or systolic murmur occurs with the first sound of the heart, resulting from the failure of the mitral valves to close the mitral orifice during the systole, in consequence of which the blood flows back, or regurgitates into the left auricle. It is usually of a blowing or churning character, and has its seat of greatest in- tensity at the cardiac apex, being well transmitted to the left axilla and inferior angle of the left scapula. 358 PRACTICE OF MEDICINE. The aortic direct murmur occurs with the first sound of the heart. It is caused by a narrowing of the aortic orifice, has a rough or creak- ing character, is of high pitch, having its seat of greatest intensity in the second intercostal space, to the right of the sternum, and is well transmitted over the carotid artery. The aortic regurgitant 7>iurmur occurs with the second sound of the heart, and is caused by the failure of the aortic valves to close the aortic orifice during the diastole, permitting the blood to flow back or regurgitate into the left ventricle. It is usually of a blowing or churning character and of low pitch, having its seat of greatest in- tensity over the base of the heart, and is well transmitted downward toward or below the cardiac apex. It is the only organic murmur heard in the left side of the heart which occurs with the second sound of the heart. The tricuspid di}'ect murmur occurs before the first sound of the heart and immediately after the second sound. It is caused by a nar- rowing of the tricuspid orifice, has a blubbering quality, and is low in pitch, having its seat of greatest intensity near the ensiform carti- lage. This murmur is exceedingly rare. The tricuspid regurgitant murmur occurs with the first sound of the heart, the result of the failure of the tricuspid valves to close the tricuspid orifice during the systole, thus allowing the blood to flow back or regurgitate into the right auricle. It is usually of a blowing or soft, churning character, having its seat of greatest intensity at the ensiform cartilage. This murmer is also very infrequent, and occurs mostly when the right ventricle is considerably dilated, and without the existence of any valvular disease. The pulmonic direct murmur occurs with the first sound of the heart. It is generally connected with congenital lesions. It occurs at the same instant that the aortic direct murmur occurs, and is dis- tinguished from the latter by its not being transmitted into the carotid artery, whereas the aortic direct murmur is always thus transmitted. The pulmonary regurgitant murmur occurs, like the aortic regurgi- tant murmur, with the second sound of the heart. This murmur is exceedingly rare, and its presence is only positively differentiated from the aortic regurgitant murmur by the absence of aortic lesions and symptoms. DIbEASES OF THE CIRCULATORY SYSTEM. 359 ACUTE PERICARDITIS. Definition. An acute fibrinous inflammation of the pericardium ; characterized by slight fever, pain, precordial distress, and disturbed cardiac action and circulation. If the inflammation be limited to the parietal or visceral layer, or to a part of either, it is termed partial or circumscribed pericarditis; if it involve the whole of both surfaces, it is termed general or diffused pericarditis. The inflammation may be primary or secondary. Causes. Primary pericarditis resulting directly from cold and exposure or injuries is rare. Secondary pericarditis follows, or is associated with, rheumatism, influenza, scarlatina, variola, puerperal fever, tuberculosis, septicaemia, . Bright's disease, gout, scurvy, and diabetes. It is frequently associated with pneumonia and pleuro-pneumonia, particularly in alcoholics. Pathological Anatomy. The same as of serous membranes in other situations. The morbid changes maybe seen as (i) acute plastic or dry pericarditis (frequently tubercular) ; (2) pericarditis with effusion, sero-fibrinous, hemorrhagic, or purulent. Hypercemia of the membrane, most marked on the visceral layer, followed by the exudation of lymph scattered in irregular patches, giving it a rough and shaggy appearance {dry pericarditis), followed by the effusion of a sero-fibrinous fluid, with flocculi floating in it, and at times mixed with blood. Rarely, the fluid is purulent. The fluid and lymph undergo absorption with resulting adhesions identical with those described under pleurisy. Symptoms. Acute pericarditis may be well marked and still present none of the characteristic subjective symptoms. It usually begins with rigors, fever of the remittent type, frequently nausea and vomiting, precordial distress and tenderness, acute shooting pains, in- creased by breathing and coughing ; dry, suppressed cough ; increased cardiac action, and sometimes violent palpitation. An attack of peri- carditis secondary to an existing disease presents no marked symp- toms other than those mentioned to indicate its onset. Attacks of nausea and vomiting occurring during the course of rheumatism, pneumonia, pleurisy, and nephritis should call attention to the heart. Duration of this early stage, from a few hours to a day or two. 3G0 PRACTICE OF MEDICINE. Effusioii stage : The symptoms of this stage are in keeping with the amount and rapidity of the effusion : precordial oppression, tendency to syncope ; dyspnoea, sometimes amounting to orthopncea ; dysphagia, hiccough, nausea and vomiting ; feeble, irregular pulse; sometimes either melancholia, delirium, or acute maniacal excitement. Absorptio?i is generally rapid, the heart remaining " irritable " for a long time after. If instead of absorption the fluid accumulates and life is not destroyed, the pericardial sac becomes dilated, chronic pericarditis resulting. Inspection. Early stage, excited cardiac action is evidenced by the impulse. Effusion stage, feeble, undulatory, or absent impulse ; its position displaced upward, or, rarely, downward; bulging of the praecordium and protruding abdomen if effusion be large. Palpation. Early stage, excited or tumultuous impulse ; peri- cardial friction fremitus rare. Effusion stage, feeble or absent impulse, and if present, its position is changed. Percussion. Early stage, normal. Effusion stage, cardiac dullness, enlarged vertically and laterally, and, if considerable fluid, of a triangular shape, with the base of the triangle on a line with the sixth or seventh rib, extending fiom the right of the sternum to the left of the left nipple, narrowing as it pro- ceeds upward to the second rib, or above, which represents the apex of the triangle. The shape of the dullness is sometimes altered by changing the position of the patient. Auscultation. Early stage, excited cardiac action, and usually afriction sound (exoca.rd'ia.1 murmur) synchronous with cardiac sounds and uninfluenced by respiration, but often increased by pressure with the stethoscope. Effusion stage, cardiac sounds feeble and deep-seated at the cardiac apex, becoming louder and distinct toward the cardiac base. The friction sound is sometimes heard at the cardiac base. If absorption occur, the above signs gradually give place to the normal, the friction sound returning, of a churning, or clicking, or grating character, gradually disappearing. Diagnosis. Endocarditis is often confounded with pericarditis, the points of distinction between which will be pointed out when dis- cussing that affection. DISEASES OF THE CIRCULATORY SYSTEM. 361 Cardiac hypertrophy or dilatation is sometimes confounded with pericardial effusion ; the differences between which will be pointed out when discussing those affections. Hydropericardium may be mistaken for pericardial effusion ; see that affection. Prognosis. Controlled by the severity of the inflammation, causes, and coexisting affections. There is no doubt but that peri- carditis with slight effusion is frequently overlooked. If slight effusion, favorable. Death has quickly occurred when a large quantity of fluid has been rapidly effused, the patient being really drowned in his own fluid. Adherent pericardium is a frequent sequela. Treatment. Perfect rest in bed with absolute mental quiet. Death has followed neglect of this precaution, and particularly during the stage of effusion. The important indications for treatment are to limit the inflamma- tory action and quiet the heart in the first stage, and to promote absorption and prevent cardiac failure in the second stage. Local applications in the early stage are most valuable ; for vigor- ous patients, the application of leeches or wet cups to the prsecordium, followed by the application of ice poultices or iced compresses ; in the feeble, dry cups in the praecordium, followed by poultices. For the gastro-intestinal symptoms calomel is indicated, and it may have a beneficial effect on the inflammatory action : R. Hydrargyri chloridi mitis, . . gr. y^ .022 Gm. Sodii bicarbonat. , gr. ij .13 Gm. Sacchar. lactis, gr. ij .13 Gm. Dry on tongue every two hours until free action. The late Dr. Pepper said the " following combination is often very acceptable" : R • Pulv. digitalis, Mass. hydrargyri, . . . . aa gr. x aa .6 Gm. Pulv. opii, gr. v .3 Gm. Quininse sulph., gr. xxx 2. Gm. Ft. mass et div. in pil. No. xx. Sig. — One pill three or four times daily. In young, vigorous patients, early in the disease control the excited cardiac action by small doses of aconitwn or veratrum viride ; in the 31 362 PRACTICE OF MEDICINE. adult, aged, or feeble using digitalis ; in all cases qui?iincz sulphas or hydrochloras is indicated. Avoid all cardiac sedatives in secondary cases save those following rheumatism. If pain is severe during the pre-effusion stage, pulvis ofiii et ipe- cacuanha or morphintz sulphas may be cautiously used. Effusion stage : As the effusion progresses, the free administration of alkalies — to wit : ammonii carbonas, gr. v (0.3 Gm.) every two hours, with liquor ammonii acetatis, or potassii acetatis, or potassii carbonatis, with quinince sulphas or hydrochloras, nutritious liquid diet and stimu- lants, being cautious with the use of cardiac sedatives or tonics. If the pericarditis is secondary, the general treatment of such con- dition must be continued. If the effusion has a tendency to linger, blisters to the prascordium and potassii iodidum should be used, and if the symptoms of oppres- sion are marked or the effusion linger, paracentesis is indicated. Dr. Roberts, in his monograph, gives an account of sixty cases of para- centesis with twenty-four recoveries. He advises that the tapping be done in the fossa between the ensiform and costal cartilages on the left side, or in the fifth left interspace near the junction of the sixth rib with its cartilage. Dr. Tyson recommends the use of a blister as soon as the diag- nosis is determined. He says : " There is no other disease in which I am so satisfied of the efficiency of a blister ; it helps to prevent effusion and also to promote the absorption of effusion." The diet must be nutritious and easy of digestion throughout the disease. If evidence of cardiac failure, use strychnince sulphas, gr. ^ (0.0025 Gm.), hypodermically. three or four times daily. CHRONIC PERICARDITIS. Synonym. Adhesive pericarditis. Definition. A chronic inflammation of the pericardium, with either distention of the sac by fluid or adhesions of the pericardium (adherent pericardium) ; characterized by impaired cardiac action and disturbances of the circulation. Causes. Almost always the result of an acute attack. The line of demarcation between the acute and chronic forms is not sharp. Pathological Anatomy. If the effusion be absorbed, the peri- cardial surfaces are agglutinated by several layers of lymph, which DISEASES OF THE CIRCULATORY SYSTEM. 363 increase the thickness of the membranes half an inch or more, and the outer surface of the pericardium becomes adherent to the chest walls. If the fluid is not absorbed, it may progressively accumulate, dis- tending the sac in all directions, displacing the diaphragm and inter- fering with the functions of the surrounding viscera, or a low grade of inflammation supervenes, the fluid becoming purulent (empyema of the pericardium), the disease terminating fatally after a variable period. As much as eight to ten pints of fluid have accumulated in the sac. Symptoms. Precordial pain and distress ; irregular, feeble car- diac action ; dyspnoea, aggravated by movement, and disturbed circu- lation. An agglutinated pericardium seriously increases the danger from an attack of any pulmonary inflammation. Inspection. If the effusion be present, bulging of the praecor- dium and displacement of the impulse. If adhesions are formed between the pericardial surfaces as well as with the chest walls, inspection reveals depression of the firczcordium, narrowing of the spaces, increased extent but displaced impulse, un- influenced by deep inspiration, and recession of the intercostal spaces {systolic dimpling) and epigastrium with every systole of the heart, the result of the adhesions. Palpation. If effusion, displaced, feeble, or absent impulse ; if adhesions, displaced and tumultuous impulse ; occasionally a peri- cardial fremitus is distinguished. Percussion. If effusion, the dullness has more or less the char- acter described for acute pericarditis. If adhesions, the cardiac dullness is but slightly modified. Auscultation. If effusion, cardiac sounds feeble and deep-seated at the apex, louder and more distinct at the cardiac base. If adhesions, cardiac sounds are heard with equal distinctness in their several positions, associated with a rough friction sound (exo- cardial murmur). Treatment. If effusion, blisters to the praecordium, with potassii iodidum to hasten absorption, the patient being supported by nutritious diet, quinines sulphas, ferrum and stimulants, and perfect quiet. If these means fail to remove the fluid, or if the fluid be purulent, para- centesis should be performed at once. 364 PRACTICE OF MEDICINE. If adhesions of the pericardium have resulted, the application of blisters to the praecordium, with the administration of potassii iodidum, alternating with ferrum and quinince hydrochloras, are indicated, with nutritious diet, stimulants, and perfect quiet. HYDRO-PERICARDIUM. Synonym. Pericardial dropsy. Definition. The accumulation of water in the pericardial sac, minus inflammation ; characterized by prascordial distress, disturbed cardiac action, dyspnoea, and dysphagia. Causes. Usually a part of a general dropsy ; Bright's disease; sudden pneumothorax ; pressure of an aneurism or other mediastinal tumor ; disease or thrombosis of the cardiac veins. Pathological Anatomy. The fluid may range in quantity from an ounce to one or two pints, and is of a clear, yellowish or straw- colored serum, at times turbid or bloody, and of an alkaline reaction. If the amount of fluid be large, the sac is dilated, its walls thinned by the pressure, and has a sodden appearance. Symptoms. Dropsy of the pericardium is so generally associated with hydrothorax or dropsy of the pleurae that the symptoms are but an aggregation of those attending upon that condition — to wit : dis- tu?'bed cardiac action, dyspncea, dysphagia, dry cough, and feeble cir- cu!atio7i. The physical signs are exactly those of the stage of effusion of pericarditis, minus a friction sound. Diagnosis. Pericarditis with effusion and hydro-pericardium present nearly the same signs and symptoms, a differentiation being possible only by a history of the case and the symptoms of the attack. Prognosis. Controlled entirely by the cause. Treatment. Depends upon the cause of the attack. If the amount of fluid in the pericardial sac be great, paracentesis will give relief. ACUTE ENDOCARDITIS. Synonyms. Valvulitis ; exudative endocarditis. Definition. An acute fibrinous inflammation of the serous mem- brane lining the cavity of the heart and particularly its valves, in DISEASES OF THE CIRCULATORY SYSTEM. 365 severe cases the chordae tendineae being involved, resulting in changes in the valves or orifices of the heart, or both ; characterized by cough, dyspnoea, disturbed cardiac action, nausea, vomiting, and more or less marked febrile reaction. Acute endocarditis occurs in two distinct forms : plastic or simple exudative endocarditis ; ulcerous or diphtheritic endocarditis. Causes. Usually secondary to acute articular rheumatism (par- ticularly in young people), pleuritis, pneumonia, pericarditis, Bright's disease, scarlatina, influenza, and diphtheria. Rarely attacks of endocarditis are due to a gonorrhoea. The association of acute endo- carditis and chorea is frequent. While as yet no specific micro-organism has been discovered, the view is gaining, however, that it is a microbic affection. Pathological Anatomy. Inflammation of the endocardium is usually limited to the left side of the heart after birth, during fcetal life the reverse being the case. The inflammation is limited or espe- cially marked at the valvular portions of the endocardium, owing probably to the presence of fibrous tissue beneath the membrane in these situations, and to the strain which falls upon the valves during the performance of their functions. Hypercemia from congestion of the vessels beneath the membrane, with considerable swelling of the valvelets, the result of an exudation of lymph and serum beneath and on the free surface of the membrane covering the valves and chorda iendinece, resulting in the roughening of the surfaces and the agglutination of the mitral valves to each other, and of the aortic segments to the walls of the aorta, or the pro- liferation of the endocardial connective tissue, forming the nuclei of the so-called warty excrescences or vegetations, their size being increased by the deposition of fibrin from the blood on its passage through the orifices. These vegetations may be detached by friction, giving rise to emboli, which may be washed by the blood current to the left side of the brain, or into the kidneys and the spleen. In the ulcerative variety a process of softening takes place in the fibrinous deposits, leading to ulcerations and perforations. Symptoms. The affection is usually masked by the course of another disease until disturbances of the circulation direct attention to the heart. The onset is often by increase of temperature, pi'czcordial distress, 366 PRACTICE OF MEDICINE. short cough, slight dyspnoea, more or less persistent vomiting ; increased cardiac action, often rapid and tumultuous, with throbbing carotids and noises in the ear. As the inflammation progresses, the cardiac action and pulse decline in frequency, with more or less congestion of the lungs and venous stasis. Auscultation. Shows a change in the character of the sounds or the development of murmurs at the various orifices, the character and points of distinction between which will be pointed out when discussing valvular diseases of the heart. Duration. Between one and three weeks. Diagnosis. Unless it is a rule of practice to always auscult the heart, many cases will pass unobserved or undetected. Pericarditis is distinguished from endocarditis by the character of the physical signs. In pericarditis the murmur or friction sound is heard with either cardiac sound, is near to the ear, and influenced by pressure of the stethoscope, besides being associated with more or less alteration in the size and shape of the cardiac dullness, and is not transmitted, while in endocarditis the murmur takes the place of or is associated with the cardiac sounds, and is transmitted to points beyond the praecordia, with the absence of change in size and form or increased dullness on percussion. If embolism occur, a new set of symptoms develop ; embolism of the kidneys causes sudden, deep-seated lumbar pain, with albumi- nuria and even haematuria'; embolism of the brain, sudden palsies and sudden disturbance of consciousness ; of the spleen, sharp pain and tenderness in the splenic region ; of the skin, petechial or purpuric spots. Prognosis. Acute endocarditis is not very dangerous to life, hence a favorable prognosis may be given ; regarding the ultimate results of valvular lesions, however, the prognosis is grave. Treatment. Absolute rest in bed. At the onset leeches or wet cups to the praecordium, followed by ice, or, what may be preferable to the patient, poultices. The excited circulation should be controlled by aconitum,veratrum viride, or digitalis, each of these drugs having their particular indi- cation. The free administration of such alkalies as ammonii carbonas, potassii acetas or carbonas, until the urine is decidedly alkaline, may prevent permanent changes in the valves or orifices. DISEASES OF THE CIRCULATORY SYSTEM. 367 If alkalies fail and the inflammation shows a tendency to linger, good results are often obtained by a slight hydrargyrum impression. If signs of oppressed circulation appear, the hands becoming blue, the face and extremities cedematous, -with congestion of the lungs, the free use of ammonii carbonas, spiritus ammonii aromaticus , nitro- glycerinum, digitalis, strophanthus , hypodermic injections of strych- nines sulphas, and stimulants are indicated. No drug equals airopince sulphas in oedema of the lungs, no matter what the cause. The free use of ammonii carbonas will often prevent or break up heart clots. After the acute symptoms have subsided, more or less absorption of the exuded lymph has followed the free use of potassii iodidum. During the entire course of the affection the diet should be of the most nutritious but digestible character. MALIGNANT ENDOCARDITIS. Synonyms. Ulcerative endocarditis ; septic, mycotic, and diph- theritic endocarditis. Definition. An acute, septic inflammation of the lining mem- brane of the heart, with a strong tendency to ulceration ; characterized by depression o f the vital forces with more or less cardiac distress. Causes. The specific micro-organism has not yet been deter- mined. Frequently complicates pneumonia. Associated with ery- sipelas and septicaemia. Rarely associated with acute rheumatism. Cases have been reported associated with or following influenza. Gonorrhoea is a rare cause. Pathological Anatomy. The changes are those of acute en- docarditis up to the development of the thickening of the endocar- dium lining the valves, and the development of the vegetations. Instead of the poison spending its force and the chronic condition obtaining, a process of softening, ulceration, development of abscesses and perforation of leaflets follows, resulting in loss of structure, gen- eral septic infection, and the development of emboli, which lead to infarctions, with their results in either brain, kidney, spleen, eye, or skin. Symptoms. Vary greatly, but always associated with constitu- tional signs of sepsis — a typhoid state, such as headache, restlessness, varying delirium with coated, dry tongue, sordes on teeth and lips, 368 PRACTICE OF MEDICINE. nausea, vomiting, loose or disordered stools, enlarged spleen, albumin in urine, and an irregular temperature record, varying from ioo° to 104 F. or higher, associated with rigors and profuse sweati?ig. The cardiac action is rapid, irregular, and weak — a compressible pulse. In the notes of twelve cases observed in the Philadelphia Hospital are the following symptoms : attacks of prolonged dyspnoea with par- oxysms of intensity, or a slightly quickened respiration with parox- ysms of dyspncea occurring every few days in patients with hectic temperature record. In four cases the paroxysms occurred three times daily, with respirations under twenty-five between the parox- ysms, for three weeks preceding death. Usually the respirations are so oppressed that the recumbent position is impossible for long periods. Another frequent symptom is marked cyanosis, either transient or lasting for days before the end. A frequent symptom of ulcerative endocarditis is a peculiar fades, indicative of a sense of impending danger, great anxiety, or terror. If embolism occur, there are superadded symptoms varying with the organ affected. If the brain, rapidly developing palsies with disorder of consciousness ; if the kidneys, deep-seated lumbar pains with haematuria or disordered urinary flow ; if the spleen, pain and tenderness of the splenic region with increase of temperature record. Auscultation. The booming, muscular, first sound is superseded by a feeble, irregular cardiac pulsation. Generally, a murmur may be detected. Diagnosis. One of the most difficult in medicine. Remember- ing the diseases with which malignant endocarditis may occur, and particularly pneumonia or sepsis, and the dyspncea, the cyanosis, the facies, and the temperature record, it may be possible to detect the disease much more frequently than formerly. Prognosis. Unfavorable. Recovery the rarest termination. Treatment. Entirely symptomatic. Nutritious diet, quinince sulphas, ferrum, alcohol, strychnine sulphas, strophanthus, caffeina citratra, and digitalis. For the cyanosis, large, frequently repeated doses of nitro-glycerinwn. Local application seems only to distress the patient, unless it be an emplastrum belladonna. DISEASES OF THE CIRCULATORY SYSTEM. 369 CHRONIC ENDOCARDITIS. Synonyms. Sclerotic endocarditis; interstitial endocarditis; chronic valvular disease. Definition. Alterations in the cardiac valves or orifices, render- ing the former incapable of properly closing the orifices, or causing the narrowed orifice to interrupt the blood current in its normal move- ment. The lesions are of two kinds : obstructive and regurgitant. An obstructive lesion, termed also stenosis, is a narrowing of the orifice, thereby obstructing the onward passage of the blood. A regurgitant lesion, termed also insufficiency , is such alteration in the valves as permits a portion of the blood to flow backward instead of onward, the true direction of the blood current. Varieties. I. Mitral regurgitation. II. Aortic regurgitation. III. Tricuspid regurgitation. IV. Pulmonary regurgitation. V. Mitral obstruction. VI. Aortic obstruction. VII. Tricuspid obstruction. VIII. Pulmonic obstruction. Causes. The great majority of cases are the result of an attack of acute endocarditis following rheumatism, chorea, or the infectious diseases. A chronic endocarditis from the onset may be caused by alcoholism, syphilis, gout, or excessive muscular labor. Chronic Bright's diseases are also exciting causes. Professor Da Costa has clearly established the development of aortic disease in early life by overwork and strain of the heart. In the elderly, chronic endocarditis is the result of atheromatous or fibroid changes. MITRAL REGURGITATION. This form of valvular disease is also termed mitral insufficiency, and is the most frequent variety of valvular heart disease. Pathological Anatomy. The most common conditions ob- served are more or less contraction and narrowing of the tongues of the valves, with irregular thickening and rigidity ; atheroma or calci- fication of the segments ; laceration of one or#more segments ; adhe- sion of one or more segments to the inner surface of the ventricle ; thickened and stiffened or rupture of the chordcs tendinea, and also contraction and hardening of the musculi papillares. As a result of the regurgitation or leakage of the blood back into 32 3T0 PRACTICE OF MEDICINE. the left auricle, there is a dilatation of the auricle, followed by slight cardiac hypertrophy. Ventricular hypertrophy occurs after a time from the increased number of the cardiac contractions. Symptoms. Insufficiency of the mitral valves soon leads to car- diac hypertrophy, to compensate for the diminished amount of blood sent onward by the ventricular systole. This condition causes quickened and strong pulse with some shortness of breath on severe exertion. When the " compensation ruptures," there occurs precor- dial distress, cough, dyspnoea ; feeble, soft, rapid, irregular pulse ; finally, from weakened cardiac action, may result pulmonary conges- tion, with cedematous limbs and general cyanosis, the abdominal cavity filled, liver congested, urine scanty and albuminous, the patient dying " drowned in his own fluid." Inspection. Cardiac impulse (apex-beat) displaced to the left and downward. In children and youths, bulging of the praecordia and increased Cardiac impulse. Palpation. Displaced cardiac impulse, early stage being forcible and diffused ; as compensation fails, impulse feeble or absent. Percussion. Transverse and vertical cardie dullness increased. Auscultation. Systolic blowing or churning murmur, audible in the mitral area, propagated to the apex, left axilla, and under the angle of the scapula, either occurring with or taking the place of the first sound of the heart, the second sound being markedly accen- tuated. Prognosis. So long as the compensating hypertrophy can be maintained, the prognosis is not unfavorable; when dilatation super- venes, however, the patient soon perishes, either from congestion of the lungs or dropsy and exhaustion. AORTIC REGURGITATION, Termed also aortic insufficiency, occurs next in frequency to mitral insufficiency. Pathological Anatomy. The valves or segments adhere to the walls of the aorta, or a segment is lacerated or may be perforated, or, more commonly, the segments are shrunken, deformed, and rigid, permitting the regurgitation of the blood. These deficiencies in the valves are usually associated with more or less dilatation of the orifices. The inability of the aortic valves to completely close the aortic DISEASES OF THE CIRCULATORY SYSTEM. 371 orifice at the proper moment allows the blood that should go onward to flow back into the left ventricle, and the normal flow of blood from the left auricle continuing, causes overfilling of the ventricle, which results in a dilatation of its cavity, and the extra effort of the ventricle to empty itself results in hypertrophy of the walls. In no other con- dition does the dilatation and hypertrophy of the cardiac walls reach such a degree. The older writers named this enormous enlargement of the heart " cor bovinum." Symptoms. There are no characteristic symptoms so long as the insufficiency is compensated by just enough hypertrophy of the ventricular walls, but as the muscular growth increases, the symptoms are those of marked cardiac hypertrophy — to wit : forcible cardiac action, headache, tinnitus aurium, congestion of the face and eyes, with pulsating vessels, even small ones pulsating that before were not visible to the eye ; pulsations of the retinal vessels can be recognized with the ophthalmoscope ; the receding pulse, which is particularly characteristic — forcible impulse but rapidly declining, called "water- hammer " pulse and also the " Corrigan pulse." As soon as there is the slightest failure in the compensation, the cardiac action becomes excessive and distressing with palpitation, causing anxiety and fear upon the part of the patient. When "compensation ruptures," dyspnoea, increased on exertion, cough, cyanosis, hepatic enlargement, congestion of the kidneys, with scanty, albuminous urine, ascites, and dropsy develop either gradually or rapidly, calling for prompt medication. If mitral insufficiency is now superadded, general venous stasis and death rapidly occur. Precordial pain is usually present in aortic disease. It may be a sensation of constriction in the cardiac region, or sharp, shooting pains extending to the arms — anginoidal attacks. Inspection. Forcible cardiac impulse. Palpation. Strong, full cardiac impulse. Percussion. Cardiac dullness increasing transversely and verti- cally. Auscultation. First sound, forcible ; second sound, replaced or associated with a churning, rus/iing, or blowing murmur of low pitch, distinct at the second right costal cartilage, but most distinct at the junction of the sternum and the fourth left costal cartilage, trans- mitted downward toward and below the apex. Prognosis. The one valvular disease most likely to occasion 372 PRACTICE OF MEDICINE. sudden death ; still, so long as the compensating hypertrophy remains intact, compatible with quite an active life. TRICUSPID REGURGITATION. Pathological Anatomy. This form of valvular insufficiency is either associated with right-sided cardiac dilatation from pulmonary obstruction, or is the result of mitral disease. The tricuspid orifice is dilated in the majority "of cases ; occasion- ally the segments of the valves are contracted or adherent to the ventricle. Symptoms. Venous stasis with its various consequences, and especially pulsation of the jugulars, synchronous with the cardiac movement, and, finally, general venous pulsation, especially of the liver, pulmonary congestion, engorgement of the kidneys, and dropsy. These symptoms are superadded to those of the affections with which tricuspid insufficiency is always associated. Inspection. Diffused, wavy, cardiac impulse ; jugular pulsation synchronous with the cardiac movement, uninfluenced by respiration, also more or less prominent hepatic pulsation. Palpation. The cardiac impulse extended, but feeble. Percussion. Dullness on percussion, extending to the right and below the sternum. Auscultation. The first sound is accompanied by a blowing murmur most intense at the junction of the fourth and fifth ribs with the sternum, distinct over the xiphoid appendix, becoming feeble or lost in the left axillary region ; often associated, however, with a mitral systolic murmur. PULMONIC REGURGITATION. Pathological Anatomy. Insufficiency of the pulmonary valves is of rare occurrence, but when present, the changes correspond more or less with those described for aortic regurgitation. Symptoms. Those of dilatation of the right side of the heart and consequent pulmonary congestion — to wit : dyspnoea, deficient aeration of the blood and cyanosis, distention of the superficial ves- sels, palpitation of the heart, precordial distress, sudden suffocative attacks, and dropsy. Percussion. The cardiac dullness extending to the right of the sternum. DISEASES OF THE CIRCULATORY SYSTEM. 373 Auscultation. A loud, blowing murmur associated with the second sound of the heart, most distinct at the junction of the third left costal cartilage and the sternum. Prognosis. Death results, sooner or later, from dropsy and exhaustion. MITRAL OBSTRUCTION. Mitral obstruction or stenosis is not so frequent as regurgitation, and is very often associated with the latter. Pathological Anatomy. Mitral stenosis is caused by deposits around the orifice, the result of endocarditis, or else the segments of the valves are "glued together by their margins," leaving but a funnel-shaped opening, the so-called "buttonhole" mitral valve. Vegetations on the valves lead to more or less obstruction to the blood-current. Symptoms. Hypertrophy of the left auricle results from obstruc- tion at the mitral orifice, followed in time by dilatation, the symptoms of stenosis being unobservable until the " compensation ruptures," or until dilatation becomes excessive, when occur irregular, small, and feeble pulse, dyspncea, cough, bronchorrhcea the result of bronchial congestion ; dilatation of the right side of the heart, soon leading to general venous stasis, dropsy, and death. Inspection. Normal until auricular hypertrophy, when an undu- latory impulse is observed over the left auricle. Palpation. When cardiac dilatation occurs, a diffused, feeble, and irregular cardiac impulse is felt near the xiphoid appendix. Auscultation. First sound normal in character, but often irreg- ular in rhythm. The second sound normal. A blowing, sometimes rasping, sound is heard, immediately after the second sound of the Tieart ceases, and immediately before the first sound begins — a pre- systolic murmur, heard most distinctly in the mitral area, lessening in intensity toward the cardiac base. The cardiac sounds are all more or less enfeebled if cardiac dilatation occur. Prognosis. The prognosis is controlled by the duration of the hypertrophy. Under favorable circumstances, mitral stenosis is compatible with a long and rather active life. AORTIC OBSTRUCTION. Pathological Anatomy. Stenosis of the aortic orifice is caused by the projection of the valves inward, and their becoming rigid 374 PRACTICE OF MEDICINE. and thickened, or atheromatous or calcareous, so that they cannot be pressed back by the blood, but remain constantly in the current of the circulation. Occasionally the valves are covered with fibrinous masses, the opening into the artery being thus more or less com- pletely closed, or the segments may be adherent by their lateral surfaces, leaving a central opening, which may be so contracted as to permit the passage of only the smallest probe. Aortic stenosis is nearly always a disease of advanced life, and is associated with the arterial changes of age. Aortic disease is not nearly so often of rheumatic origin as mitral diseases. Symptoms. Hypertrophy of the left ventricle rapidly super- venes upon aortic stenosis, and so long as the cardiac hypertrophy is just sufficient for compensation, there will be no subjective symptoms, many cases of stenosis being discovered when the individual is ex- amined for insurance or other reasons. The pulse is small, slow, and hard. When, however, the compensatory hypertrophy begins to fail, the supply of blood to the brain is insufficient in many cases, and pallor, with attacks of vertigo, syncope, or slight epileptiform seizures occur; finally, as dilatation of the left ventricle and incompetence of the mitral valve result, there occur pulmonary congestion, dyspnoea, and general venous stasis, the pulse soft and feeble. Palpation. Lowered cardiac impulse, strong in the early stage, feeble when dilatation occurs. Percussion. The cardiac dullness is increased vertically, the transverse dullness being but slightly increased. Auscultation. The first sound of the heart is replaced or asso- ciated with a harsh, raspitig sound, whistling at times, having its greatest intensity at the junction of the second right costal cartilage with the sternum, transmitted along the vessels ; the murmur may sometimes be heard a short distance from the patient. Usually, aortic stenosis is associated with more or less aortic regur- gitation, whence a double murmur occurs , having its greatest intensity at the base of the heart, the so-called to and- fro, or see-saw murmur. Prognosis. So long as compensation is maintained the condi- tion of the patient is comfortable, if a quiet life be followed. When the compensation is ruptured, the usual symptoms of dilatation, venous stasis, and dropsy soon ensue. DISEASES OF THE CIRCULATORY SYSTEM. 375 TRICUSPID OBSTRUCTION. This condition is one of the rarest affections of the heart, and if it ever does occur with or following an attack of endocarditis, the anatomical changes are similar to those of mitral obstruction. This condition soon leads to auricular dilatation ; venous stasis rapidly supervenes, associated with venous pulsations similar to those de- scribed when speaking of tricuspid regurgitation. PULMONIC OBSTRUCTION. Pathological Anatomy. Always a congenital malady, the changes consisting in " constriction of the pulmonary artery, un- closed foramen ovale, unclosed ductus Botalli, stricture at the ductus Botalli, with hypertrophy of the right cavity and frequent association with tuberculosis of the lungs." Hypertrophy of the right ventricle may ensue, the walls becoming almost as thick as those upon the left side. Those in whom these congenital defects in the cardiac structure occur are otherwise weak, develop slowly, have flabby tissues, soft bones, and seem poorly nourished. Symptoms. The hypertrophy which often ensues may keep life apparently comfortable for some time, but sooner or later " compen- sation ruptures," when cough, dyspnoea, cyanosis, and death occur. Prognosis. The duration of these congenital affections is short, usually from a few days to a few months ; although several well- authenticated cases record a much longer duration. DIAGNOSIS OF VALVULAR DISEASES. In making a differential diagnosis between the various forms of valvular disease of the heart, strict attention must be paid to the points of greatest intensity at which the several murmurs are heard. A murmur occurring with or taking the place of the first sound of the heart — the ventricular systole — heard most distinctly at the apex, transmitted to the left axilla, and to the inferior angle of the scapula, signifies mitral regurgitation — a mitral systolic murmur. A murmur occurring with or taking the place of the first sound of the heart, with its point of greatest intensity at the xiphoid appendix, signifies regurgitation at the tricuspid orifice — a tricuspid systolic murmur. 376 PRACTICE OF MEDICINE. A murmur heard with the first sound of the heart, high-pitched, rasping or grating in character, with its point of intensity greatest at the second right costal cartilage, signifies obstruction at the aortic orifice — an aortic systolic murmur. A murmur heard with the first sound of the heart, soft in character, with its point of intensity most distinct at the junction of the third left costal cartilage with the sternum, signifies obstruction at the pul- monic orifice — a pulmonic systolic murmur. A murmur occurring immediately after the second sound of the heart, and immediately before the beginning of the first sound of the heart, signifies obstruction at the mitral orifice — a presystolic mitral murmur. A murmur heard with or taking the place of the second sound of the heart, most distinct at the second costal cartilage, to the right of the sternum, and well transmitted toward the apex or below, signifies insufficiency or regurgitation at the aortic orifice — an aortic regurgi- tant or diastolic murmur. Although eight distinct valvular murmurs have been described as occurring in the heart, those on the right side are of rare occurrence, and hence of little clinical importance. If a murmur be heard with the first sound of the heart, it is almost certainly aortic obstructive or mitral regurgitant ; and if heard with the second sound, it is probably aortic regurgitant. A presystolic mitral murmur is also of comparatively rare occurrence, the force with which the blood passes from the left auricle into the left ventricle being, under ordinary circumstances, insufficient to excite sonorous vibrations. Functional or anceynic murmurs may be confounded with the va- rious forms of valvular disease of the heart. The chief points of dis- tinction between them are, that an anaemic murmur, which is always heard at the base of the heart, is always systolic in time, not trans- mitted away from the heart, and is soft in character, low in pitch, and of variable intensity, now being heard, now entirely absent. Treatment. There is no special plan of treatment for each form of valvular disease. Prof. J. M. Da Costa says : " I hold that the precise valve affected is not, with our present resources, the keynote to the treatment of valvular heart disease. We are to take as indications : I. The state of the heart-muscle and of the cavities. 2. The rhythm of the heart-action. 3. The condition of the arteries and veins and DISEASES OF THE CIRCULATORY SYSTEM. 377 of the capillary system. 4. The probable length of existence of the malady and its likely cause. 5. The general health. 6. The second- ary results of the cardiac affection." A good rule in practice is that if the apex-beat is not displaced, the cardiac dullness is not increased to the right of the sternum, and dysp- noea is absent, medication is not indicated and even maybe injurious. The important point to bear in mind in the treatment of valvular disease of the heart is that it is associated either with cardiac hyper- trophy or dilatation, and the treatment, if any at all be required, is directed toward this secondary condition. If compensation be com- plete, attention to the condition of the bowels, kidneys, and digestion, with some general directions as to exercise, are all that is required. If the hypertrophy become excessive, it is best controlled by either aconitum, veralrum viride, or spiritus glonoini. If dilatation have occurred, the heart's action weak and feeble, the circulation impeded, and venous stasis has followed, digitalis, caffeines citrata, strophanthics, or sparteines sulphas, with more or less active purgation, is indicated. If fatty degeneration of the heart result, the indications are for car- diac rest, strychnines sulphas, stimulants, strophanthics, or spiritus glonoini, and attention to the excretions. If the cardiac rhythm is disturbed, add belladonna or lithii bromi- du??i to whatever other plan of treatment is being used. If the capillary circulation is weak, strophanthus and nitro-glycer- z/z^;/z(gIonoinum) act better than digitalis, which latter has the power of contracting the arterioles. Any of the secondary results of the valvular affection are to be treated according to the particular indications. CARDIAC HYPERTROPHY. Definition. An overgrowth or increase in the muscular tissue which forms the walls of the heart ; characterized by forcible impulse, over-fullness of the arteries, diminished blood in the veins, and accel- erated circulation. Causes. Obstruction to the outflow of blood, resulting from valvular disease of the heart ; emphysema ; Bright's disease ; arterio- fibrosis ; functional over-action ; excessive use of tobacco, tea, coffee, or excessive muscular action. 378 PRACTICE OF MEDICINE. Varieties. I. Simple hypertrophy ■, or a simple increase in the thickness of the cardiac walls ; II. Eccentric hypertrophy , increase in the cardiac walls and dilatation of the cavities, causing a dilated hypertrophy ; III. Concentric hypertrophy, increase in the cardiac walls with decrease of the cavities, a very rare form. Pathological Anatomy. Hypertrophy of the heart is usually limited to the left side, the ventricles more commonly than the auri- cles, the latter dilating. The shape of the heart is altered by hypertrophy ; if the right ven- tricle, the heart is widened transversely and the apex blunted ; if the left ventricle, the heart is elongated and, as a rule, the cavity is dilated ; if both ventricles are hypertrophied, the heart has a globular shape. From increase in weight the heart'may sink lower during the recumbent position, thereby lessening the area of cardiac dullness, but during the sitting or upright posture it sinks lower in the chest and to the left, causing more or less prominence of the abdomen. The increase in the size of the organ is a true increase or hyper- trophy of the muscular tissue, and not a hyperplasia. The tissue is firmer and the color brighter and fresher than when the size of the organ is normal. The cor bovi?ium of the old writers is an enormous hypertrophy of the heart with dilatation of its cavities. Symptoms. Depend upon the amount of hypertrophy. The most common are increased and forcible cardiac action, the arteries becoming fuller, the veins less full, and the circulation accelerated ; pul- sating carotids and aorta, headache, often vertigo, frequent epistaxis, congestion of the face and eyes, tinnitus auriwn, dyspnoea on exertion, dry cough, restless nights, with more or less jerking of the limbs ; oc- casional praecordial pains shooting toward the left axilla ; full, firm, bounding pulse, and pulsations in the superficial arteries. A sphygmographic tracing shows the line of ascent vertical and abrupt, but the apex is rounded, and the line of descent is oblique, unless there is more or less insufficiency of the valves. Inspection. Often fullness or prominence of the prascordium, with distinct impulse. Palpation. The impulse is felt one or two intercostal spaces lower down and to the left, and is stronger and more or less diffused — the heaving impulse. Percussion. The area of cardiac dullness is increased vertically DISEASES OF THE CIRCULATORY SYSTEM. 379 and transversely upon the left side of the sternum, unless the right ventricle is also hypertrophied, when the cardiac dullness is increased to the right of the sternum. Auscultation. If simple hypertrophy without any coexisting changes in the valves or orifices, the first sound has a loud and some- what metallic quality, the second sound being strongly accentuated. Sequelae. Cerebral hemorrhage ; miliary cerebral aneurisms ; dilatation of the heart ; fatty changes in the cardiac tissue. Diagnosis. Hypertrophy of the heart can scarcely be mistaken for any other disease if a careful study of the physical signs be made. Prognosis. When the result of valvular disease, the hyper- trophy is said to be compensatory. If the result of Bright's disease, emphysema of the lung, or if occurring late in life, or associated with atheromatous degeneration of the vessels, the prognosis is unfavorable. When the result of functional over-action in the strong and robust, a further enlargement can often be prevented by active and persistent treatment. Treatment. The indications are, if the hypertrophy be exces- sive, to lessen the force and number of the cardiac pulsations and to remove the cause whenever possible. The former indications are best met by the persistent use of tinctura aconilim small doses, Tr\j-ij (0.06-0.12 Cc), three times a day, or tinc- tura verairi viridis, li\j— ij (0.06-0.12 Cc), three times a day, and at the same time keeping the bowels, kidneys, and the skin acting freely. A certain amount of hypertrophy is beneficial in chronic valvular disease, and drugs should not be administered simply because a car- diac murmur is discovered on auscultation. The habits of the patient are to be corrected, all laborious or active exercise to be restricted, the patient to be in the recumbent posture several hours during the day if possible, the diet being restricted, avoiding all forms of stimulants, such as liquors, tobacco, tea, and coffee. Cases of cardiac hypertrophy associated with Bright's disease are often relieved by digitalis, the cardiac distress being secondary to the kidney disease, for which the digitalis is used. There is no doubt that in rare instances cardiac pain follows the use of digitalis, which is probably due to the firm and powerful car- diac contractions produced by digitalis ; such cases do better with caffeincB citrata or stropha7ithus. 380 PRACTICE OF MEDICINE. Cases of cardiac hypertrophy associated with anaemia should, in addition to digitalis and rest, be placed upon a course oiferrum. DILATATION OF THE HEART. Definition. An increase in the size of one or more of the cavities of the heart, characterized by feebleness of the circulation, terminat- ing in venous stasis, cyanosis, oedema, and exhaustion. Causes. Over-exertion in those of feeble resisting powers, as youths or soldiers, as first pointed out by Prof. Da Costa; chronic valvular disease; emphysema; chronic bronchitis; gout; Bright's disease ; alcoholism ; syphilis. Varieties. I. Simple dilatation, the cavities being enlarged, the walls normal. II. Active dilatation, corresponding to eccentric hypertrophy ; the cavities being enlarged and the walls increased in thickness, the so-called " dilated hypertrophy." III. Passive dilata- tion, the cavities being enlarged and the walls thinned or stretched. Pathological Anatomy. The right side of the heart is far more frequently involved than the left side. The shape of the organ is altered, depending on the part affected. The weight of the organ is, as a rule, increased, as hypertrophy almost always accompanies or precedes dilatation. The muscular tissue is generally pale, mottled, and softened, and under the microscope presents evidences of degeneration. The orifices also participate, and especially the auriculo-ventricular orifice, result- ing in the valves becoming incompetent to close the orifices, and this latter effect is added to by the removal of the basis of the papillary muscles a greater distance from the orifice, in consequence of the extension of the wall. When the auricles dilate, the large venous trunks opening into them unprotected by valves commonly participate in the dilatation, and may become greatly enlarged. The passive congestion of the organs that follows the feeble circu- lation produces changes in their structure. Symptoms. Those associated with enfeebled circulation — to wit : Feeble pulse, veins distended, arteries emptied ; headache, aggravated by the upright position ; attacks of syncope, cough, with any of the fol- lowing phenomena of venous congestion; of the lungs, dyspnoea; liver, jaundice ; stomach, dyspepsia; intestines, constipation; kid- neys, scanty, often albuminous, urine ; brain, dullness of the mind DISEASES OF THE CIRCULATORY SYSTEM. 381 and vertigo, often relieved by a copious epistaxis ; and, finally, dropsy, beginning in the lowerextremities, the patient dying from exhaustion. Great relief often temporarily follows any of the above symptoms under treatment ; sooner or later, however, the venous stasis produces the final symptoms noted. Inspection. Veins of the surface distended and enlarged ; in- distinct cardiac impulse, often diffused and wavy ; if associated with tricuspid insufficiency, there is pulsation of the jugular. Palpation. Feeble and irregular fluttering, but heaving impulse. Percussion. Cardiac dullness extended transversely, and espe- cially increased on the right side. Auscultation. If no valvular lesion accompany the dilatation, the cardiac sounds are weaker than normal, the first sounds having a sharper quality than normal ; if accompanied by valvular lesions, cardiac murmurs are present. Diagnosis. Hypertrophy of the heart shows increased cardiac dullness, and is a disease of powerful cardiac action, while dilatation is an affection of feeble action associated with dropsy. Pericardial effusion has many points of resemblance to cardiac dilatation, but it begins suddenly, associated with some acute malady, and while the heart sounds are indistinct or feeble at the apex, they both have their normal qualities at the cardiac base, while dilatation of the heart has a chronic history, results in general venous stasis, the cardiac sounds being of the same intensity over the entire prascordium. Prognosis. Unfavorable, death resulting from gradual exhaus- tion, or suddenly by cardiac paralysis if there be some undue excite- ment. With careful living life may be prolonged for years. Treatment. Dilatation of the heart is incurable. In all cases there are two important indications : The first to maintain the general nutrition of the patient, and the second to control or prevent all irregular or violent cardiac action. The first is accomplished by a generous diet, moderate exercise, with bitters to increase the appetite and ferrum to improve the blood, and, in a majority of cases, the more or less free use of a good red wine. The second indication is met by the observance of strict rules in regard to exercise and such heart tonics as digitalis in powder, tinc- ture, or infusion, or a combination like the following : R. Tincturce nucis vomicae, . . . . f,^ss 15. Cc. Tincturae digitalis, f5ss 15. Cc. M. Sig. — Fifteen to twenty drops after meals, in water. 382 PRACTICE OF MEDICINE. Drs. Hare and Coplin have demonstrated by careful research that the prolonged use of digitalis actually increased the development of the normal heart muscle. Strychnines sulphas, gr. ■£% (0.0025 Gm.), three times daily, is a valuable cardiac tonic ; the same may be said of caffeines citrata, gr. j-iij (0.06-0.2 Gm.), three or fcnir times daily. Sparteines sulphas is a powerful cardiac tonic, particularly of service in the dilating heart of Blight's disease. The faictura strophanthus, alone or in combina- tion with digitalis, is valuable. Extractum convallariae fluidum is not always reliable. Morphincz sulphas in small doses, particularly when compensation is failing and the dropsy becomes great and is associated with marked cyanosis, hypodermicalry, as suggested by Prof. Bartholow, " often acts like magic in restoring the circulation." The following pill is often of great advantage : R. Ferri reduct. , gr. j-ij .065- 13 Gm. Quininse sulph., gr. j — ij .065-.13 Gm. Pulv. digitalis, gr. j .065 Gm. Morphinae sulph. , g r - 2? •°° 2 5 Gm. M. SiG. — Three times a day. An excellent combination is the following : R . Tinct. digitalis, ......... f^iss 6. Cc. Tinct. cacti grandiflor., . . . . f^j 30. Cc. • Caffeinae citrata, ....... ^j 4. Gm. Tinct. card, comp., .... adf^iv ad 120. Cc. M. SiG. — Teaspoonful, diluted, three or four times daily. The bowels, skin, and kidneys should be kept in action, using, if needed, purgatives, diaphoretics, and diuretics. The following combi- nation, suggested by Dr. J. M. Anders, is satisfactory in many in- stances : R. Caffeinae citrata, ^j 4. Gm. Strychninae sulph., gr. y$ .022 Gm. Sparteinae sulph. , gr. ij .13 Gm. M. Ft. capsulae No. xij. SiG. — One every three or four hours. Or the following excellent diuretic pill : R. Pulv. scillac gr. xxx 2. Gm. Pulv. digitalis, gr. xxx 2. Gm. Caffeine citrata, gr. xxx 2. Gm. Hydrarg. chlor. mitis, gr. v .3 Gm. M. Ft. pilulae No. xxx. SiG. — One three or four times daily. DISEASES OF THE CIRCULATORY SYSTEM. 383 If pulmonary congestion develop, dry cups, digitalis, cajfeina, atro- phia, and stimulants. For cardiac asthma, dry cups, morphines sulphas, hypodermically, or spiritus cztheris compositus (Hoffman's Anodyne). For hepatic congestion, blue mass or podophyllin. For dropsy, dry cups over the kidney digitalis with potassii acetas, with scoparius and juniperus, and pulv.ja lap ce comp., 5j-ij (4-8 Gm.), in water, before breakfast. If the dropsy is uninfluenced by the above means, success will follow the use of hydrargyri chloridi milis, gr. iij (0.2 Gm.), guarded with pidves opii, gr. ^ (0.005 Gm.), three or four times a day. The treatment of cardiac dilatation and cardiac failure by baths and systematic exercise has excited much interest and discussion re- cently, with the result of its indorsement in proper cases. Exercise is employed in one of three plans or, rarely, a combination of these plans : (i) passive exercise and massage (Swedish or Ling plan) ; (2) movements with limited resistance (Schott plan, but really a modifi- cation of the Swedish); (3) method of climbing (Oertel). The baths to be those of the Nauheim (saline) natural waters. A number of American and English clinicians report good results with artificial Nauheim baths. This system of cardiac treatment is associated with regulated diet and the use of some cardiac tonics, and business rest. ACUTE MYOCARDITIS. Synonyms. Carditis ; abscess of the heart. Definition. An inflammation of the muscular tissue of the heart, by extension from an inflamed pericardium or endocardium, or sec- ondary to pyaemia; characterized by pain, feeble circulation, symp- toms of blood-poisoning and collapse. Causes. The result of endocarditis or pericarditis ; pyaemia ; typhoid fever; emboli of the coronary arteries. Pathological Anatomy. Discoloration and softening of the cardiac substance and the infiltration of a sero-sanguineous fluid, fibrinous exudation and pus, leading to the formation of abscesses in the muscular structure of the heart. The disease leads to the formation of either a cardiac aneurism or 384 PRACTICE OF MEDICINE. to rupture of the walls of the heart. If recovery occur, cicatrices or depressed scars may mark the site of a former abscess. Symptoms. The clinical evidences of inflammation of the car- diac muscles are very obscure. If, during the course of one of the maladies mentioned, there are developed precordial pain, irregular and feeble cardiac action, cardiac dyspnoea, pyrexia of a low type, with symptoms of blood-poisoning and a tendency to collapse, or the symptoms of the so-called typhoid stale, myocarditis may be suspected. Diagnosis. The existence of myocarditis can scarcely ever be anything but a presumption, the signs being all negative rather than positive. If during the course of rheumatism, pyaemia, puerperal fever, typhoid fever, pericarditis, or endocarditis, symptoms of cardiac failure appear suddenly, associated with signs of blood-poisoning and collapse, inflammation of the cardiac muscle may be suspected. Prognosis. The course of acute myocarditis is very rapid, death being the usual termination in from three to five days. Chronic myocarditis pursues a very latent course. Treatment. Largely symptomatic. Perfect rest of mind, gen- erous diet, free stimulation, and the administration of quinince sul- phas, ferrui7i, and spiritus cEtheris nitrosi — a nitrite. CHRONIC MYOCARDITIS. Synonyms. Fibroid heart ; chronic interstitial myocarditis ; fibrous myocarditis ; chronic carditis ; cardio-sclerosis. Definition. A slowly developing hyperplasia of the interstitial connective tissue of the heart, leading to induration of its substance ; characterized by shortness of breath on slight exertion, attacks of tachycardia, prsecordial pain, disordered circulation, and vertigo. It is proper to state that many cases present no symptoms whatever. "Causes. The most frequent cause is sclerosis of the coronary arteries, leading to imperfect blood supply to the cardiac muscles. Among other frequent causes are diseases of the kidneys, alcohol- ism, excessive use of tobacco, syphilis, secondary to pericarditis, en- docarditis, and acute myocarditis. There is, undoubtedly, often an inherited predisposition to fibroid changes in the vessels, in which cases the causes named would act as exciting causes. DISEASES OF THE CIRCULATORY SYSTEM. 385 It is a disease of the aged, save in those instances resulting from hereditary predisposition or from excesses. The old saying, " A man is as old as his arteries," is applicable to this disease. Pathological Anatomy. The heart is enlarged and dilated. The morbid changes may be diffused, or limited to the walls of the left ventricle, the papillary muscles, and the septum. There is always more or less atheromatous deposit or changes in the aorta. All cases show atheroma in one, more, or all of the coronary arteries. Com- plete closure of one coronary artery, if produced suddenly, is usually fatal. On section, the cardiac wall cuts with a distinct resistance. The changes in the heart wall are an " overgrowth of the interfibrillar con- nective tissue, with development of fibrous tissue. These changes may be uniformly distributed through the substance of the heart when some intoxication, as by alcohol, or some general disturbance of the cardiac nutrition, has led to the myocardial disease ; or they may be seen in circumscribed areas when embolic or thrombotic occlusion of branches of the coronary arteries has occasioned anaemic infarction and subsequent sclerosis. In either case the microscope reveals masses of wavy fibrous tissue between the muscular bundles, and often slow degeneration or atrophy of the fibres themselves " (Pepper). The terminal branches of the coronary arteries are narrowed and sclerotic to the point of obliteration, particularly in cases resulting from syphilis. "Aneurism of the heart is commonly due to localized cardio- sclerosis. The inelastic fibrous tissue gradually gives way before the intracardial pressure, and saccular dilatation results " (Pepper). Atheromatous changes are often found in other than the coronary vessels, particularly the aorta. Various degenerative changes occur in other organs, the result of disturbed circulatory action. Symptoms. The great majority of patients having chronic myo- carditis present no symptoms until an extra cardiac effort is called for. An early symptom is breathlessness on slight exertion, with either cardiac palpitation or a feeble, irregular pulse. Vertigo is frequent and distressing, increased by indigestion and costive bowels. An- ginal attacks (cardiac pain) or a sensation of constriction or pressure over the praecordium are frequent, often following some exertion or an 33 386 PRACTICE OF MEDICINE. attack of indigestion. The pulse-rate is often decreased in frequency in cases which present no other symptom. A frequent symptom is syncope, coming without warning or after sudden exertion, the result of sudden failure of the cerebral circulation. Among other periodical symptoms are cardiac asthma, pseudo- apoplectic attacks, and hepatic, gastric and nephritic disorders. As the fibroid changes progress, there develop progressive weak- ness, dyspnoea, insomnia, disordered digestion, and cerebral weak- ness, often showing itself as mania, delusional attacks, or dementia. Percussion. Increased praecordial dullness is usually present, due to the dilated hypertrophy. Auscultation. The first sound of the heart is valvular in char- acter, the booming or muscular quality having disappeared. Mur- murs are very frequent, the result of valvular disease. A very characteristic condition is the irregularity in rhythm and in force, one contraction being fairly forcible, another weak or feeble, and so on. Diagnosis. A proper appreciation of chronic myocarditis is one of the most important questions in clinical medicine. The term " Heart Failure" is the opprobrium of the profession, and yet chronic myocarditis is one of the great causes of cardiac failure during the prevalence of some over-exertion or in acute pneumonia, typhoid fever, and other like diseases. The points of value in arriving at a diagnosis are : a careful study of the first sound of the heart at the apex ; the character of murmurs if present, the condition of the arteries, the dyspnoea, the feeble, irregular pulse in patients past fifty years, and the occurrence of anginal attacks after exertion or mental worry. Prognosis. This is controlled by the habits of the patient. The disease is incurable, but life may be fairly comfortable for many years if care be exercised. Treatment. No remedy can remove the fibroid change. The indications are to promote the patient's nutrition, hold in check the progress of the fibrosis, and meet or prevent the symptoms as they arise. Constipation is often a troublesome symptom, and calls for such drugs as aloes or cascarce sagrada. For the general condition, ferrum, arsenicum, and the hypophos- p kites. For the breathlessness, spiritus glonoini (nitroglycerin, one per cent.), or spiritus cetheris nilrosi, or spiritus ammonia aromaticus. DISEASES OF THE CIRCULATORY SYSTEM. 387 For cardiac palpitation, potassii bromidum, lithii bromidum, or spiritus ammonia aromaticus. For cardiac weakness, strychnines sulphas, gr. -fa (0.0025 Gm.), three or four times a day, and if the pulse is frequent, tinctura digitalis, tt^x-xx (0.6-1.2 Cc), three times daily, or caffeines citrata, gr. iij (0.2 Gm.), after meals ; maintaining the recumbent position and re- moving all unfavorable associate symptoms, as constipation, scanty urine, and dyspepsia with flatulence. For the anginal attacks, hypodermic injections of morphines sul- phas, gr. y%-% (0.008-0.016 Gm.), or chlorodyne, ff\,x-xx (0.6-1.2 Cc), repeated as needed. For the syncopal attacks, the patient should be placed in bed and stimulants administered, often used by the hypodermic method, with mustard over the praecordium, and TTLJ-ij (0.06-0.12 Cc.) spiritus glonoini every couple of hours. An excellent combination for breathlessness, vertigo, and chest pains is : R. Lithii brotnidi, . ^vss 22. Gm. Spiriti glonoini, W\, xv j *• Cc. Liq. potassii citratis, . . q. s. ad f^viij ad 240. Cc. M. SiG. — Tablespoonful four times daily, diluted. The patient must lead a quiet life, refrain from mental worry, phy- sical over-exertion, and eschew tobacco and malt liquors. The diet must be plain and simple, with but little tea or coffee. In the elderly, a small amount of good whisky once or twice a day is valuable. FATTY HEART. Synonyms. Fatty degeneration of the heart ; chronic myo- carditis. Definition. A change in the muscular fibres of the heart, in which the transverse strise are replaced by granules and globules of fat; characterized by feeble cardiac action, venous stasis, and dyspnoea. Causes. Impaired nutrition in the elderly ; prolonged anaemia ; chronic gout ; alcoholism ; phosphorus poisoning ; cancer ; tubercu- losis and scrofula ; diseases of the coronary arteries. Pathological Anatomy. The distinction must be made be- 388 PRACTICE OF MEDICINE. tween a deposit of fatty tissue upon or around the heart, and the degeneration of its muscular tissue. The fatty metamorphosis may affect the whole organ, or the entire ventricular walls, or be limited to portions of them. If the degenera- tion be marked, the color is yellowish, the tissues soft and easily torn, and to the touch have a greasy feeling, oil being yielded on pressure. The microscopic changes are characteristic. The striae of the muscle are easily rendered indistinct by fat and oil globules, grad- ually becoming more and more obscured, and finally disappearing altogether, the fibres being replaced by fat granules. Symptoms. Those of weak heart, anaemia of organs, and venous stasis — to wit: feeble, iwegular, but slow cardiac action /com- pressible pulse, prcecordial distress, often aggravated by attacks of angina pectoris ; dyspnoea, aggravated on exertion, with anaemia of the various organs from the feeble propulsive power; if of brain, vertigo, swooning, or pseudo-epileptic attacks, especially marked on suddenly rising from a recumbent position ; if of lungs, dry, hacking cough ; if of gastro-intestinal tract, dyspepsia and constipation ; if of kidneys, scanty urine, at times albuminous, and finally dropsy, begin- ning in the lower extremities. A formidable symptom, causing much inconvenience as well as alarm to the patient, is what he will term his constant " sighing," the Cheyne-Stokes breathing — "A pause in the breathing, a complete suspension of the respiratory acts for a period of time (during which breathing might occur several times in the normal manner), then the resumption of respiration very feebly and slowly, and a gradual and progressive increase in the number and depth of respirations until the maximum is reached, and then again a gradual and progressive diminution in the same order, in the number and depth of the res- pirations, until another pause occurs " — the " oscillating respiration." Concomitant symptoms are atheromatous changes in the vessels, and the arcus senilis. Palpation. Weak cardiac impulse. Percussion. Not markedly changed unless preceded by enlarge- ment of the heart. Auscultation. First sound feeble, toneless, almost inaudible, the second sound being normal, unless changes in the valves are present. Diagnosis. Feeble cardiac sounds, with slow pulse, attacks of DISEASES OF THE CIRCULATORY SYSTEM. 389 cardiac asthma or Cheyne-Stokes breathing, with evidences of arcus senilis, make the diagnosis very certain. The question of fibroid heart must always be considered. Prognosis. Incurable, the affections pursuing a more or less chronic course. Life may be prolonged at times by treatment, but death finally results from exhaustion, or suddenly from cardiac paralysis or rupture of the heart. Treatment. Incurable, there being no plan of treatment that can restore the degenerated muscular fibre. Generous diet, very moderate exercise, stimulants, oleum morrhucs, and the " triple elixir " — elixir ferri, quinines, et strychnines, or the hypophosphiles. All the excreting organs must be kept active, so as to relieve the crippled heart as much as possible. To sustain the cardiac action, strychnines sulphas, gr. 3V-4V (0.002- 0.0015 Gm.), three or four times daily, is most valuable. Other drugs are caffeines citrata, sparteines sulphas, or tinctura nucis vomiccs. Digitalis is contra-indicated in advanced cases. For syncopal attacks, nitro-glycerinum {spiritus glonoini), spiritus atheris nitrosi, spiritus ammonice aromaticus, or hypodermic injec- tions of estheris, cajnphora, or spiritus frumenti. The recumbent position for hours each day is a valuable means of resting a crippled heart. PALPITATION OF THE HEART. Synonym. Irritable heart. Definition. A functional disturbance of the heart ; characterized by increasing frequency of its movements and more or less irregu- larity of the rhythm, with a strong tendency toward hypertrophy. Causes. Over-exertion, " the heart-strain " of Da Costa ; dyspep- sia ; uterine diseases ; excesses in tea, coffee, tobacco, alcohol, or venery ; moral and emotional causes, grief, anxiety, and fear. Symptoms. Usually palpitation of the heart has a sudden onset after some one of the causes mentioned, with precordial oppression or pain ; rapid, tumultuous beating, the impulse being visible through the patient's clothing ; dyspnoea, anxiety, and a sense of choking or fullness in the throat, the recumbent position being impossible; vertigo, faintness, flashes of light, the pulse full and strong or feeble, the face 390 PRACTICE OF MEDICINE. flushed or ft ale, the patient having a feeling of anxiety with a sense of impending danger and a fear of sudden death. These attacks are paroxysmal, lasting from a few moments to several hours, or a day, the patient often voiding a large quantity of limpid urine after the paroxysm has subsided, when there is a strong tendency to sleep. Diagnosis. Irritability of the heart is differentiated from the various forms of cardiac disease by the absence of all the physical signs mentioned as occurring in those conditions. Prognosis. If early and properly treated, favorable. Treatment. The first point in the treatment of irritability of the heart is to remove the cause ; the next, to prevent the recurrence of the attacks of palpitation. The majority of cases do well after a few doses of either spiritus Getheris cojnposiius (Hoffman's anodyne) or spiritus ammonii aromati- cus, or a combination of digitalis and belladonna. Permanent relief is often afforded by a combination of potassii bromidum and veratrum viride. Trional, gr. x-xv (0.6-1 Gm.), three times daily, is often use- ful. If the patient be anaemic, excellent results follow the prolonged use of the elixir ferri, quinines, et strychnine?. Locally, emplastrum belladonncE to the praecordium affords relief. The acute attack is often wonderfully benefited by ice over the praecordium. TACHYCARDIA. Synonyms. Rapid heart ; quick heart ; paroxysmal rapid heart. Definition. Paroxysmal rapid cardiac action, minus or with sub- jective symptoms, the result of excessive cardiac rapidity. Causes. Tachycardia is one of the " crises " of cerebral or spinal diseases. Menopause. Neuritis of the pneumogastric nerve ; chronic myocarditis ; neurasthenia ; chronic gastritis ; excessive use of to- bacco (?) ; a variety of petit mal (?). Pathological Anatomy. No characteristic lesions. There may be paralysis of the inhibitory fibers of the vagus, an irritation of the accelerators of the sympathetic, or reflex action from some lesion in the cardiac wall or elsewhere. Symptoms. The paroxysm is sudden in its onset, with or without " warnings " — if these latter, they are in the shape of vertigo, ringing in the ears, and a sense of impending danger. The cardiac DISEASES OF THE CIRCULATORY SYSTEM. 391 action is increased to 150, 175, 200, rarely 250 beats per minute. The pulse is small, weak, easily compressible, and often irregular, with carotid pulsation (which indicates the emptiness and low tension of the artery, as in aortic regurgitation). The respiration is slightly increased; rarely there is dyspnoea. The surface is at first pale, but soon becomes flushed. The expression is anxious and denotes suffer- ing. There is a feeling of precordial constriction, with more or less smothering. Rarely, there are no subjective symptoms. . The duration is from a few minutes to hours, or days. The attack usually ceases during sleep, but if it does not, the rapidity of the pulse continues during the disturbed sleep. Auscultation. The first sound is clear and ringing, but not strong and booming. The second sound is weak and lacks the val- vular quality of the normal. A murmur is often heard at the apex. Diagnosis. The differentiation between tachycardia and palpi- tation is to be made, as also the rapid heart of valvular disease and of irritable heart. The chief point is that in tachycardia the attack is paroxysmal, and the number of pulsations exceeds the rapid heart of other conditions. Prognosis. It is often an unfavorable symptom of some central lesion. If it develop in patients suffering from chronic myocarditis or atheroma of vessels, the fatal result may be sudden. Treatment. For the paroxysm, the application of ice to the prae- cordium, conjoined with a hypodermic injection of morphines sulphas, gr. ]/e (0.011 Gm.), and atropines sulphas, gr. T ^ u (0.00065 Gm.), and rest in bed. A few large doses of digitalis should always be tried. Tinciura belladonna, potassii broinidum, lithii bro7nidu?n, strontii bromidum, or camphorcs monobromas are often valuable ; remember- ing that which answers in one case or attack may be useless in another. Trional, gr. xxx (2 Gm.), seems to rapidly control a paroxysm. An ice bag over the prsecordium has cut short an attack. The arrest of attacks of tachycardia is reported from compression of the vagus in the neck. Nothnagel reports the case of a patient who could cut short an attack by a full and deep inspiration. Rosenfeld succeeded in cutting short an attack in four cases by having " the patient squeeze his own arms and elbows into his sides, and at the same time forcibly compress his abdomen." After the paroxysm , nutritious diet, avoidance of alcohol, tobacco, tea, and coffee, and a course of arsenicum, strychnina, or potassii iodidum. 392 PRACTICE OF MEDICINE. BRADYCARDIA. Synonym. Brachycardia. Definition. A paroxysmal or permanent slowness in the cardiac action. It is agreed that bradycardia begins with a pulse reduced to at least forty beats per minute. Causes. Often associated with organic nervous diseases. It is a symptom of such cardiac diseases as fibroid and fatty heart and atheroma of the coronary arteries. It frequently occurs during convalescence from infectious diseases, such as diphtheria, pneumonia, typhoid fever, erysipelas, and rheu- matism ; uraemia, lead-poisoning, anaemia, and chronic alcoholism are often causes. Balfour says : " Many, if not most, of the sufferers from bradycardia are epileptics." Symptoms. Slow action of the heart is the chief symptom, varying from 40, 30, 20, to 10 or 8 beats per minute. The pulse is weak, small, and slow. As results of the slow cardiac action are vertigo, noises in the ears, syncopal attacks, and rarely convulsions. The onset may be either sudden or follow " warnings." Auscultation. The first sound is soft and feeble, and often the second sound is not heard. As a rule, with reduction in the number of contractions is an in- crease in their force, and this not obtaining in bradycardia determines its central origin. Diagnosis. A feeble cardiac contraction, with less than forty beats per minute, determines the diagnosis. Prognosis. Sudden death a very frequent termination. The cause controls the prognosis. Treatment. So long as the slow cardiac pulsations are sufficient to supply the requirements of the economy, medication is not needed; when, however, the reverse obtains, resort to rest in the re- cumbent position, heat to the praecordium, and the use of such reme- dies as atropines sulphas, caffeines citrata, strychnines sulphas, spiritus glonoini, or spiritus ammonia aromaticus. Often the emergency is so great as to call for the hypodermic use of the selected drug. Digitalis is contra-indicated. Between the paroxysms, such reme- dies as improve the general health and prevent the progress of the central or exciting cause. DISEASES OF THE CIRCULATORY SYSTEM. 393 ARRHYTHMIA. Synonyms. Arrhythmia cordis ; irregularity of the pulse. Definition. A lack of cardiac rhythm, or irregularity in the car- diac pulsations. It is a symptom rather than a disease. Causes. Valvular diseases ; myocardial diseases ; cardiac dilated hypertrophy ; atheroma of coronary arteries and aorta ; excessive use of tobacco, tea, or coffee ; flatulent dyspepsia. Neurasthenia, hysteria, and melancholia. Symptoms. An irregularity in cardiac action, either in the rhythm or the regularity of the force of the beats, or an intermission in the cardiac contractions. The sphygmograph gives the exact condition of the cardiac pulsa- tions and should always be used in cardiac diseases. Other symptoms that may be present are due to the condition pro- ducing the arrhythmia. Diagnosis. An examination of the pulse, auscultation of the heart, and the use of the sphygmograph determine the arrhythmia. Prognosis. Depends upon the cause. In functional cases favor- able, in organic cases unfavorable. Treatment. Rest of mind and body, regulated diet, and atten- tion to the secretions. Tinctura nucis vomica, strychnines sulphas, and digitalis are each useful. In functional cases the bromides are valuable. ANGINA PECTORIS. Synonyms. Neuralgia of the heart ; breast-pang. Definition. Paroxysms in which there occur sharp cardiac pains, extending usually into the left shoulder and down the left arm, ac- companied by a feeling of constriction of the thorax and a strong fear of impending death. Causes. Often hereditary ; associated with chronic cardiac changes, disease of the coronary arteries or calcification of the valves ; the excessive use of tobacco (?) ; syphilis ; according to Trous- seau, it is a form of masked epilepsy, and may alternate with true epileptic attacks. Often associated with hysteria (?). 394 PRACTICE OF MEDICINE. Pathological Anatomy. A disease of the arteries, ossification and occasionally obliteration of the cardiac arteries, producing car- diac ischaemia. "The pathological changes which stand in a causative relation to the attacks are those of the cardiac plexus of the phrenic and of the pneumogastric nerves. Pressure of enlarged lymphatics, inflamma- tion of parts of the cardiac plexus, with changes in the coronary arteries, seem to be most constant." Symptoms. A paroxysmal affection, the attacks occurring irreg- ularly ; in the interval entire absence of symptoms, or the symptoms of the organic disease causing the paroxysms. " The patient suddenly sits up in his bed ; with a cry of horror in- dicates the sense of pain at the praecordium. The pain is of great intensity, but is of a cold and sickening character ; the chest is fixed, the breathing quickened, and the hand placed over the praecordium finds that the heart's action is slight and enfeebled. The face wears a look of horror, pale and slightly leadened ; a cold sweat breaks out upon the forehead ; worse than the pain is the feeling of fearful sick- ness and depression. The poor patient gasps, 'I shall die! Ishall die ! ' and sometimes his short but concentrated sufferings in a few moments end in-death " (Sansom). The attack ends suddenly with vomiting, or great flow of urine. The unpleasant sensations of these patients during an attack, and the nervous disorder associated with it, slowly bring about a mental change. They are depressed and gloomy, sometimes suicidal, and often develop epilepsy. Attacks of angina in nervous women and children, the hysterical or pseudo-anginal attacks, come on gradually with distention of the abdomen, eructations of gases, excessive restlessness, flushed face, irritable pulse, diffused praecordial pain, and general hysterical phenomena. In a few cases the pain is absent, but all other symptoms are present — the " angina sine dolore " of Gairdner. Balfour claims that pain is not an essential part of the disease. He has probably never experienced an attack of true angina pectoris. Diagnosis. The points to be remembered are that the attacks are always paroxysmal, with long or short intervals, the patient hav- ing a sense of coldness, and frequently a cold sweat, the heart's action not increased, the chest fixed, and the breathing slow. DISEASES OF THE CIRCULATORY SYSTEM. 395 Prognosis. True angina pectoris is unfavorable, the patient, sooner or later, either succumbing during the paroxysm or from exhaustion, the result of the cardiac changes. Pseudo-angina is always favorable. Treatment. During the interval between the attacks an attempt should be made to remove the exciting cause or diminish its predis- posing influence. For the organic form, no one remedy is comparable with a long course of potassii iodidum, gr. x-xx (0.6-1.3 Gm.), three times daily, as the frequency and intensity of the attacks are often diminished and a fair number of cases are retarded, proving the axiom, " the iodides are the digitalis of the arteries." The efficacy of the iodides is greatly enhanced and the course of the disease favorably influenced by adding full doses of nitroglyeerinum. For the nervous form, all violent emotions and active physical ex- ercise are to be avoided, the diet regulated, and the excretions watched. Among the drugs that are useful are ferrum, arsenicum, strychnina, phosphorus, and zincum. If the cardiac action be weak, use stro- phanthus. Trousseau urges the administration of belladonna in continuous small doses, on the ground of the analogy of the affection to epilepsy. Quain states that a continuous current, the positive pole on the sternum and the negative pole on the lower vertebras, lessens the severity and frequency of the anginal paroxysms. For the attack, prompt relief follows the use of amy I nitras, rt^iij-v (0.2-0.3 Cc), inhaled at the instant, or morphines sulphas, gr. %-%. (0.016-0.032 Gm.), to which may be added with advantage atropines sulphas, gr. yi^ (0.00065 Gm.), hypodermically, or nitro-glycerinum, gr. A * g^ (0.00065-0.0013 Gm.), every hour or two. In many cases the use of gr. yi^- (0.00065 Gm.) of this powerful drug, three or four times a day for a long time, lessens not only the frequency, but the severity of the paroxysms. Chlorodyne, rtl,x-xv (0.6-1 Cc), repeated, often affords relief. Chloroformum has proven prompt, efficient, and harmless administered as suggested by Balfour — viz., "a half drachm (2 Cc.) is poured upon a sponge at the bottom of a wide- mouthed bottle, from which the patient may breathe ad libitum''' Dr. William Evans recommends sparteines sulphas, gr. }( (0.016 Gm.) three times daily, between attacks, to prolong the interval and lessen the severity of the paroxysms. Great care must be exercised with the diet that flatulency and con- stipation do not occur. 396 PRACTICE OF MEDICINE. ARTERIO-SCLEROSIS. Synonyms. Atheroma; arterio-capillary fibrosis (Gull and Sut- ton) ; endarteritis chronica deformans (Virchow). Definition. A chronic degenerative and inflammatory disease of the vascular system, resulting in an overgrowth of the con- nective tissues of the arteries, followed by calcareous deposits. The changes may extend to the capillaries and veins. As a result of the impairment of the arterial circulation, occur fibroid degenerations in other organs, resulting in loss of elasticity in the walls of the vessels, increase of arterial tension, narrowing of the calibre of smaller arteries, and impairment of the nutrition of the organs supplied. Causes. Old age, as "longevity is a vascular question, and has been well expressed in the axiom that "a man is only as old as his arteries " (Osier). Heredity is a factor, as arterial degenerations occur in some families at a very early age — thirty to forty years. Alcoholism, syphilis, and other excesses predispose to arterial changes. Lead- poisoning, diabetes, malaria, gout, and rheumatism. Chronic nephri- tis. More common in men than in women. Pathological Anatomy. The atheromatous changes are most frequent in the aorta. Rokitansky gives the relative order in which atheromatous degenerations occur as follows, aorta, splenic, femoral, iliac, coronary arteries of the heart, arteries of the brain, uterine, sub- clavian, brachial, ulnar, and radial. The internal surface of the affected vessels is irregularly thickened with either gelatinous and translucent, or dense and fibrous, or calcareous deposits or products. If the calcification is extensive, the vessel is changed into a hard, stiff tube. Often the surface of the thickening or deposit is destroyed, presenting the so-called "ather- omatous ulcers," which may be covered with masses of thrombus. The above conditions are the result of inflammatory change in the intima of the affected vessel. This appears three or four times as thick as normal, due to the swelling of its elements, the new growth of connective tissue and the deposit of round cells. Fatty degenera- tion of the inflammatory products results. The result of the changes in the arteries is a loss of their elasticity, thus hindering the propulsion of the blood current and raising the arterial tension, leading to hypertrophy of the left ventricle. The DISEASES OF THE CIRCULATORY SYSTEM. 397 changes finally involving the coronary arteries lead to alterations in the myocardium. If the intima of the smaller vessels be involved, the blood current to the organs supplied is lessened, resulting in a disturbance of their nutrition. Symptoms. Not always apparent. The symptoms vary with the arteries involved and the organs whose blood supply is lessened or cut off. Cardiac hypertrophy from the increased resistance to the arterial circulation. The peripheral arteries involved in the atheromatous changes can be determined by palpation, they having a hard, bony feeling, much like a whip cord. Attacks of vertigo, pseudo-apoplectic attacks, or spells of uncon- sciousness in the aged or those having superficial hardened arteries are generally due to changes in the cerebral vessels. Evidences of myocarditis and angina pectoris point to atheroma of the aorta and coronary arteries. Gangrene of the extremities in the old — senile gangrene — point to atheroma or thrombi, the result of the fibrosis. Palpation. Hard, superficial arteries, those at the wrist feeling like a string of beads, pulsating. The cardiac impulse is forcible in the early stages. Percussion. Increased precordial dullness, particularly over the left ventricle. Auscultation. In the early stages the first sound of the heart is prolonged, the second sound accentuated over the aortic cartilage. As the heart dilates and the walls become diseased, the sound be- comes feeble and often irregular and intermittent. Diagnosis. Only determined by a close study of the various symptoms and sequelae. Prognosis. Incurable. Treatment. Regulate the manner of living and the diet. Pre- vent constipation, and torpid liver and kidneys. No remedy can remove the fibroid changes, but a very considerable experience has convinced me that much comfort and prolongation of life follows the constant use several times a day for months and years of nitro-glyc- erinum, gr. -j-j^ (0.00065 Gm.), and long courses of potassii iodidian. 398 PRACTICE OF MEDICINE. ANEURISM OF THE AORTA. Varieties. I. Aneurism of the arch of the aorta. II. Aneurism of the thoracic aorta. III. Aneurism of the abdominal aorta. The arch of the aorta is divided by Gray into three parts — the as- cending, the transverse, and the descending. The ascending portion is two inches in length, arising from the left ventricle, on a level with the lower border of the left third costal cartilage, behind the left edge of the sternum. It ascends obliquely upward to the right to the upper border of the right second costo- sternal articulation. The transverse portion commences at the upper border of the right second sternal articulation, and, arching to the left and forward, passes in front of the trachea and oesophagus to the left of the third dorsal vertebra. The descending portion extends down- ward to the left side of the fourth dorsal vertebra. The thoracic aorta extends from the left lower border of the fourth dorsal vertebra, and ends in front of the body of the twelfth dorsal vertebra, at the aortic opening in the diaphragm. The abdominal aorta begins at the aortic opening in the diaphragm, descends a little to the left side of the vertebral column, and termi- nates over the body of the fourth lumbar vertebra, where it divides into the two common iliac arteries. Definition. A circumscribed dilatation of some portion of the aorta, the result of disease of the vessel wall weakening its resistance to the blood pressure. Causes. Those causing arterio-sclerosis are the chief causes. Exertion is an exciting cause. Aneurisms occur in early middle life rather than in old age, when the force of the heart has decreased. More common in men than in women. Pathological Anatomy. All aneurisms may be divided into two classes, dissecting and circumscribed. Dissecting A?ieurism — false aneurism — is the result of fatty changes in the internal and middle coats of the artery. The shape may be sacculated, fusiform, or cylindrical. A disease of the aged. Cir- cumscribed Aneurism may be true or false, depending on the rupture of the walls or not. It is a disease of middle life or under. Most frequent in men, usually a true dilatation. Syphilis is a very fre- quent cause. DISEASES OF THE CIRCULATORY SYSTEM. 399 ANEURISM OF THE ARCH. Symptoms. The onset is usually gradual, with evidences of arterio-sclerosis and failing health. Pain, either paroxysmal or constant, is a continuous symptom, with increasing dyspncea. The difficulty in breathing may be constant with exacerbations, or it may be remittent. Rarely dysphagia occurs. A slight cough from pressure on the laryngeal nerve, with more or less alterations in the voice, may be present. The pupils are dilated or contracted or are irregular, in some cases due to pressure on the sympathetic nerve. There is a gradual loss of flesh, disorders of the circulation, and a careworn expression of the face. Inspection. Negative until the appearance of a pulsating tumor. Palpation. A pulsation over the tumor, expansile in character (Corrigan's sign). If the aneurism is situated at the transverse portion of the arch, the left pulse and the left carotid are smaller and weaker than those on the right side. Tracheal tugging is a diagnostic sign (Page). " Place the patient in the erect position, with his mouth closed and chin elevated to the fullest extent. Then, on grasping the cricoid cartilage between the fingers and thumb and making gentle traction upward, the pulsations of dilated aorta or aneurism, if any exist, will be dis- tinctly felt, in most cases transmitted through the trachea to the hand." Percussion. Dullness, the extent depending on the size of the tumor. Dullness, other than cardiac, across the sternum is diagnostic of a mediastinal tumor. Auscultation. Over the tumor a murmur or bruit is usually heard, synchronous with the first sound of the heart. It is louder than the systole, lower in pitch, and of a blowing character. Diagnosis. If the tumor can be seen or felt, the diagnosis is made, its location being determined by a study of the physical signs. ANEURISM OF THE THORACIC AORTA. Symptoms. The most constant symptom is deep-seated thoracic pain, constant or paroxysmal. Dysphagia is a frequent condition. There is seldom dyspncea, and alteration of voice and pupils does not occur. 400 PRACTICE OF MEDICINE. Physical signs are usually wanting, and the diagnosis is rarely- made during life. I have seen three cases in which the only symptoms the patients complained of were pain of a deep-seated and boring character in the left shoulder, associated with a feeling of general fatigue. Death ensued in each of the three cases suddenly by a frightful hemorrhage from the mouth, death occurring in a few moments, and an autopsy revealed a thoracic aneurism pressing deeply in the upper left pul- monary lobe the size of a lemon, which had suddenly ruptured. ANEURISM OF THE ABDOMINAL AORTA. Symptoms. The chief and most constant symptom is pain at a circumscribed spot in the abdomen, or rarely diffused over the abdomen. Other symptoms depend upon the location of the aneurism, as they are the result of pressure. There is a gradual loss of health. Inspection. Usually negative unless the aneurism reach an enormous size. Palpation. A pulsating tumor in the abdomen to the left of the median line. The pulsation is synchronous with the first sound of the heart, and is expansile (Corrigan's sign) in character. Percussion. Dullness may be elicited if the tumor is large and the abdomen emaciated. Auscultation. Rarely a murmur or bruit is heard, systolic in time. Diagnosis. Abdominal aneurism and pulsating abdominal aorta may be mistaken for each other. The point of difference is, in the aneurism, the presence of the tumor with an expansile pulsation, while in pulsating abdominal aorta, the beating is like a pulsating cord, an up-and-down movement, not expansile. The condition of the patient is also important ; aneurism in males, at middle life, with changes in the vessels ; abdominal pulsation occurring in nervous women or effeminate men. Tumors located over the abdominal aorta may give rise to an ap- parent pulsation, causing them to be mistaken for an aneurism. The rule is, in all cases of abdominal pulsation, to place the patient in the knee-chest position ; if the tumor is aneurismal, the expansile pulsa- tion continues ; if not an aneurism but a cancer, impacted faeces, or other tumor, the pulsation at once ceases. DISEASES OF THE NERVOUS SYSTEM. 401 Prognosis of Aortic Aneurisms. Unfavorable. The duration of life after the development of the aneurism is from one to four years. Treatment. A persistent effort should always be made to pro- mote clotting in the sac and the contraction of the tumor. The so-called Tufnell's method is the most successful for this pur- pose, its aim being to diminish the force and rapidity of the circula- tion, and, if possible, to increase the fibrinous deposit. Its essential element is absolute rest of mind and body, and a restricted diet ; the patient is kept absolutely in bed day and night for at least three months, and placed on the following diet : Breakfast — two ounces of bread with butter and two ounces of milk; dinner — two or three ounces of bread, same amount of meat, and two to four ounces of milk or claret wine ; supper — two ounces of bread with butter and two ounces of milk. At the same time potassii iodidum is administered in increasing doses to the physiological limit. Galvano-puncture is said to do good in some cases ; two needles inserted into the aneurism are connected with the poles of a galvanic battery, and a weak current is passed through the tumor. The various symptoms are to be met with their appropriate reme- dies, always having in mind the condition of the arterial wall allowing the rupture and dilatation. DISEASES OF THE NERVOUS SYSTEM. The diseases of the nervous system will be described under the following headings : I. Diseases of the cerebral membranes. II. Diseases of the cerebrum. III. Diseases of the spinal cord. IV. Diseases of the nerves. V. General or nutritional diseases. VI. Mental diseases. 402 PRACTICE OF MEDICINE. DISEASES OF THE CEREBRAL MEM- BRANES. The brain is invested with two membranes — the dura mater and the pia mater, or pia-arachnoid. The dura lines the interior of the skull, and, in addition, supports and protects the brain. The falx is an extended process of the dura which extends into the longitudinal fissure ; the tentorium is a process of the dura separating the cerebrum and the cerebellum ; thefalcula is a process of the dura extending between the two hemispheres of the cerebellum. The blood supply for the dura is from the anterior, middle, and posterior meningeal arteries. The middle meningeal or medidural artery, a branch of the internal maxillary, is the largest of the three, and is the vessel usually involved in meningeal hemorrhage. The nerve supply (a mooted question) is undoubtedly received from the fifth or trigeminus pair of cranial nerves, irritation of which nerve supply may produce hyperesthesia, pain, reflex motor, and vaso- motor disturbances (Duret). The pia (which includes the arachnoid, after the suggestion of Tuke, and which Mills calls the arachiopia, ox pia arachnoid') is composed of two layers — the visceral layer and the parietal layer. This membrane is a vascular network held by connective tissue. The visceral layer of the pia (formerly known as the pia alone) closely invests the brain everywhere, dipping into the fissures and into the ventricles. The parietal layer (formerly known as the arachnoid) closely covers the dura in all its parts. The pia arachnoid is the nutritive covering of the brain, supplying a considerable section with blood. The vessels of the pia lie on the surface and are encased in perivascular sheaths composed of the denser portions of the membrane. These perivascular spaces are the lymph-canals accompanying the blood-vessels into the brain-sub- stance and communicating with the subarachnoid spaces or cisterns. The nerve supply of the pia arachnoid is still in dispute, the mem- brane being generally considered without sensation. This is proba- bly an error. DISEASES OF THE CEREBRAL MEMBRANES. 403 The Pacchionian granulations are always present in abundance " on the outside of the dura, on its inner surface, on the arachnopia, and within the superior longitudinal sinus and the parasinoidal spaces, or lacs sanguinis. They often indent the calvarium, and in rare instances they penetrate it. It is generally conceded that they are enlargements of the normal villi or tuft-like elevations of the parietal layer of the pia (arachnoid). Repeated attacks of meningeal hyper- emia probably assist in their development" (Mills). PACHYMENINGITIS. Synonyms. Meningitis ; hematoma of the dura mater. Definition. Inflammation of the dura mater ; when the external layer is primarily involved, it is termed pachymeningitis externa ; when the internal layer is primarily involved, it is termed pachymen- ingitis interna. Causes. Pachymeningitis externa is a surgical malady, resulting from fractures, penetrating wounds, and other injuries of the skull. Pachymeningitis interna is due to blows upon the head without injury to the skull, chronic alcoholism, scurvy, Bright's disease, tuber- culosis, and syphilis. Chronic internal otitis and suppurative inflam- mation of the orbit may cause it, and also inflammation in the venous sinuses the result of a thrombus undergoing suppurative changes. Following erysipelas, sun-stroke, and gout are recorded causes. Pathological Anatomy. Pachymeningitis interna. Hyper- emia of the membrane, followed by an exudation which develops into a membranous new formation, containing a great number of vessels of considerable size, but having very thin walls. Hemor- rhages from these new vessels are of frequent occurrence, which in- crease the size and thickness of the neo-membrane. The usual position of the neo-membrane or new formation is on the upper surface of the hemispheres, extending downward toward the occipital lobe. The changes in the adjacent portion of the brain are dependent on the size and thickness of the neo-membrane. Bartholow observed a case in which the " cyst " was half an inch in thickness at its thickest part, and it depressed the hemisphere corre- spondingly, the convolutions being flattened, the sulci almost obliter- ated, and the ventricle lessened one-half in size. 404 PRACTICE OF MEDICINE. In pachymeningitis syphilitica, the pathological lesion is in the form of gummatous tumors or masses which may degenerate and become either cheesy masses or be converted into a purulent-looking fluid. In old age the dura mater becomes thick, cartilaginous, and of a dull white color. The sheaths of the arteries are also thickened. Symptoms. Very obscure ; principally those of cerebral pres- sure. Cases of persistent headache, vertigo, photophobia, anorexia, insomnia, gradual impairment of intellect and locomotion, followed by delirium, and convulsions and coma, or by apoplectic attacks and paralysis, occurring in the aged, or those in whom some one of the causes of the affection are present, an inflammation of the dura mater may be suspected. Epileptic attacks (dural epilepsy) sometimes occur. Circumscribed painful oedema behind the ear and less fullness of the jugular of the corresponding side, the phlegmasia alba dolens en miniature of Griesinger, are indicative of thrombosis in the transverse sinus, as was first shown by Virchow. Diagnosis. Always problematical, as the symptoms are masked and so obscure that a positive diagnosis is impossible. In very many instances the condition was not discovered until an autopsy. Prognosis. Most unfavorable for either forms, although the course of the malady is usually slow. Surgical treatment in traumatic cases offers some hope. Treatment. Pachymeningitis externa is to be treated surgically. Trephining is indicated in some cases. It is claimed that benefit has followed a thorough course of potassii iodidum. In the great majority of cases, however, all that can be done is to treat symp- toms. ACUTE LEPTOMENINGITIS. Synonyms. Acute meningitis ; cerebral fever ; arachnitis. Definition. An acute exudative inflammation of the cerebral pia mater and arachftoid 7nembraties (pia arachnoid, or arachnopia), usually limited to the convexity of the cerebrum ; characterized by fever, vomiting, headache, delirium, and followed by symptoms of general collapse. Causes. During the course of the acute infectious diseases ; ery- sipelas ; associated with or a sequela of influenza and typhoid fever. Cerebral overwork ; prolonged wakefulness ; acute alcoholism ; ex- DISEASES OF THE CEREBRAL MEMBRANES. 405 posure to the sun ; syphilis ; blows on the head ; disease of the internal ear ; secondary to diseases of serous membranes. Most frequent in early adult life and in young children, and in males rather than females. " The micro-organisms found in meningitis are the pneumococcus, streptococcus pyogenes, intracellular diplococcus, the pneumo-bacil- lus, and a bacillus resembling that of typhoid fever " (Dana). Pathological Anatomy. The inflammatory changes may be limited either to the convexity or to the base of the brain, but more frequently both portions are involved. Intense hypercemia of both membranes, followed by a purulent and fibrinous exudation. The ventricles may be filled with fluid, com- pressing and flattening the convolutions. In twenty-five post-mortem examinations at the Philadelphia Hos- pital a meningo-encephalitis was present in fourteen. Symptoms. Keeping in mind the anatomy of the cerebral membranes and the extent of surface that may be involved in an inflammation, it will be seen how varied may be the symptoms of leptomeningitis. Prodromes : Headache, vertigo, cerebral vomiting, more or less feverishness, continuing from a few hours to one or two days, when occurs the Stage of Invasion : Onset with a chill, high fever, io3°-io4° ; a pulse 100-120; face flushed with congested eyes ; severe headache, most intense and continuous; ringing in the ears, photophobia, vertigo, the nausea aggravated ; projectile vomiting, with delirium ; general hyperesthesia to the touch. Stage of Excitation : General sensibility of the body, increased with sensitiveness to light and acuteness of hearing ; delirium furious, often resembling mania ; continual jerking of the limbs, oscillations of the eyeballs (nystagmus), -twitching of the muscles of the face, followed by powerful contractions of the flexor muscles, even to the extent of opisthotonos, and in children convulsions ; coated tongue, constipation and retracted abdomen. Duration, from one day to a week or two. The finger drawn across the surface leaves a red line, the tache cerebrate. Stage of Depression or Collapse ; the patient gradually becomes more quiet, the delirium subsiding, as well as the muscular agitation ; 406 PRACTICE OF MEDICINE. somnolence develops passing into coma, at times temporary conscious- ness, coma soon following again ; pulse irregular and slow, fever less ; various palsies, such as strabismus, ptosis, pupils uninfluenced by light, mouth drawn to one side, and urine and faeces involuntarily discharged. Death following either by convulsions or by deepening coma with cyanosis. Diagnosis. The characteristic symptoms indicating the existence of acute leptomeningitis are headache, vomiting, fever, and delirium, all developing rather rapidly. The headache is most persistent, and the vomiting not due to gastric trouble. The absence of any one of the four characteristic symptoms named above does not prove the absence of leptomeningitis, nor does the combination of delirium and fever alone determine the presence of meningeal disease. Cerebrospinal fever closely resembles acute leptomeningitis, the points of distinction between which are the first named occurring epidemically, associated with marked spinal symptoms and an eruption. Meningitis and abscess of the brain are apt to be mistaken for each other, the differential diagnosis being pointed out in the latter disease. The cerebral symptoms of rheumatism are differentiated from idio- pathic meningitis by the association of the joint trouble. Cerebral symptoms of typhoid and typhus fever have a close resem- blance to idiopathic meningitis, and are only determined by a study of the clinical history. In acute urce?nia the face is turgid, ©edematous, with puffiness of the eyelids ; in leptomeningitis the face is pale and no oedema; urae- mia has decided albuminuria ; it is slight or absent in leptomenin- gitis ; leptomeningitis has chills followed by fever ; uraemia has irregular temperature record, rapidly rising to 104 F.-106 F. and dropping to 99 F., to as rapidly rise again, and usually associated with convulsions. In delirium tremens the delirium is a busy one, the patient imagin- ing persons and animals around him, and is wild in his gestures and utterances ; the temperature is normal or subnormal, the skin wet and clammy. In leptomeningitis the delirium is mild but incoherent, the surface is hot and dry, and there is severe vomiting and head- ache. Prognosis. Not very favorable. If recognized early and treated, a fair number of recoveries occur, but it usually leaves the patient DISEASES OF THE CEREBRAL MEMBRANES. 407 subject to attacks of epilepsy or with a persistent headache, and more or less mental impairment. Blindness and chronic internal hydro- cephalus are rare results. Treatment. Keeping in view the course and general prognosis of leptomeningitis, it is questionable if any very active medication will abate the disease during any stage. Bed-rest, quiet, in a well-ventilated room, with elevation of the head, and the use of a nutritious liquid diet, with attention to all the secretions, which are markedly disordered, and the application of cold to the head for the intense headache, and meeting the symptoms as they arise in the different stages of the disease, is the safer way to manage the majority of cases of leptomeningitis. Attempts at abort- ing the malady are depressing to the patient in the later periods of the malady. In vigorous or sthenic cases, with high febrile reaction and exag- geration of the early symptoms, a more or less vigorous venesection, or the use of leeches behind the ears, to the temples, or in the nuchal region, followed by the application of cold and the internal use of full doses of extractum ergotce fluidum every couple of hours, may be used. The cerebral circulation may be markedly influenced by com- pression of the carotids. For the vomiting use chloral, gr. iij-v (0.2-0.3 Gm.), per mouth, di- luted with aquae menthae f^ss (15 Cc), repeated in half hour and p. r. n., or by enema in doses of gr. x-xv (0.6-1 Gm.). The most refractory vomiting, of whatever cause, will yield to a few doses of this drug. If the disease show a disposition to linger, small doses of hydrargyri chloridum mite or polassii iodidum are of benefit. Third stage : Free stimulation, nutritious food, ferri iodidum, and flying blisters. TUBERCULAR MENINGITIS. Synonyms. Basilar meningitis ; acute hydrocephalus. Definition. An inflammation of the leptomeninges (soft mem- branes), particularly the basal pia mater, attended with or due to the deposit of gray miliary tubercle ; characterized by gradual decline of the bodily and mental powers. Causes. Usually a secondary affection, a sequel to tubercular 408 PRACTICE OF MEDICINE. disease of some other organ. Most frequently occurs in children between two and six years of age, although numerous cases are reported occurring between twenty and thirty years; scrofulous (?) diathesis; inherited diathesis. The "gelatinous children of album- inous parents," as the phrase goes, possess a special susceptibility to tubercular meningitis. Pathological Anatomy. The deposition of tubercle usually occurs at the base of the brain. Depositions of grayish-white granules, of a translucent, somewhat gelatinous appearance — miliary tubercle, are distributed along the ves- sels of the pia mater, resulting in inflammation and the exudation of lymph, with the consequent thickening and opacity of the membranes. The cerebral tissue is not usually involved, although on section the lines indicative of blood-vessels are very much increased in number. The ventricles are distended by a clear, or milky, or even bloody serum. Tubercular deposits occur in the lungs, intestines, and, at times, in other organs. The presence of the tubercles alone may give rise to no symptoms until the exudative products of the resultant inflammation develop. Symptoms. The advent is either gradual and insidious, or with convulsions, in which cases the after progress is rapid. Prodro?nes : The child grows irritable, with loss of appetite, loss of flesh, swollen abdomen, constipation alternating with diarrhoea, irregular attacks of feverishness, with attacks of grinding the teeth during sleep, or sleeplessness. Headache occurs, as shown by the child, even when at play, suddenly stopping and resting its head on its hand or on the floor. Duration of this stage is from one week to a month or two. Stage of excitation : The onset is rather sudden, with obstinate vo?niting, severe headache, convulsions ; fever, io2°-io3° in the even- ing, falling to 99 in the morning; pulse soft and compressible, with irregular rhythm. On drawing the finger nail lightly over the surface a red line results, "the cerebral stain " of Trousseau. The symp- toms grow progressively worse with exaltation (hyperesthesia) of the special and general senses, the least pinch or even touch causing exquisite pain ; spas7nodic ?nove?nents of the muscles, with contraction and rigidity, at times opisthotonos. Duration of this stage is about two weeks to a month. DISEASES OF THE CEREBRUM. 409 Stage of depression, the result of the pressure of the exudation ; the pulse is slow and compressible, with irregular rhythm ; te?nperature depressed ; tendency to somnolence alternating with quiet delirium, mental stupor, continual movement of the fingers, as in picking up objects; convulsions from time to time, strabismus, oscillation of the eyeballs (nystagmus), followed by intervals of wakefulness, when the headache is excruciating, causing the peculiar, unearthly shrill cry or shriek, "the hydrocephalic cry," associated with contraction of the muscles of the face, as if suffering were experienced; finally collapse occurring with the " Cheyne-Stokes " respiration, the co?na deepening, followed by death, convulsions often ending the scene. Duration, from a day or two to two weeks. Diagnosis. Acute leptomeningitis and tubercular meningitis have closely analogous symptoms during the stage of excitation, but the history and clinical course of the two maladies determine the diagnosis. Prognosis. Unfavorable. Usual duration, three or four weeks after fully developed prodromes. If ushered in by convulsions, the duration is shorter. Treatment. Most unsatisfactory. No means of retarding the disease. Treat symptoms as they develop. Blisters, leeches, active purgation, pustulating ointments, potassii iodidtim, and hydrargyrum are all useless. I If the hereditary tendency be marked, nutritious food, oleum mor- hu<2,ferri iodidu?n, and quinina may somewhat delay the develop- lent of the affection. DISEASES OF THE CEREBRUM. To understand the symptoms in diseases of the nervous system, a clear and precise knowledge of the anatomy and physiology is neces- sary. Presuming this knowledge, only a very few of the most ele- mentary facts will be mentioned before discussing diseases of the brain and cord. 35 410 PRACTICE OF MEDICINE. The nerve-cell 'is the real foundation of the nervous system. It re- ceives its nourishment from the arterioles and the lymphatics, and is drained by the venules, as are other tissues, and is supported by the connective tissue. Each nerve-cell has two processes, the axis- cylin- der process and the protoplasmic process ; the three — the cell and the two processes — are known as the neurons, the nervous system being made up of neurons. The axis-cylinder processes conduct the nerve impressions or current from the cells, and is a continuation of the axis-cylinder of the nerve. The protoplasmic process conducts the nervous current or impressions into the cell, and it is through these processes and their collaterals that the cell is brought into communi- cation with all portions of the body. The nerve-cells — "the very inner citadel of nervous life" — are mainly set in the gray matter of the brain and the spinal cord, and the axis-cylinder processes and the protoplasmic processes run in bundles or collections in the white matter of the brain and spinal cord. The gray matter of the brain and spinal cord, or the nerve-cells, is found chiefly in the cortex of the cerebrum and the basal ganglia, the cortex of the cerebellum, in the horns of the spinal cord and the nuclei of the medulla oblongata, and all these masses of gray matter or cells are connected by nerves, or the white matter, each protected by connective tissue. The cells endow the nerves with their particular functions. A knowledge of the physiology of the nervous system is essential to understand the functions of the different masses of gray matter, or cells, and of the nerves, or white matter. Without a knowledge of the known centers of "localization " it is impossible to interpret the symptoms of diseases of the nervous system. A knowledge of the blood supply of the brain is of practical im- portance, and particularly for understanding the symptoms and path- ology of apoplexy and cerebral emboli. The external carotids on each side supply blood to the scalp, the skull, and the dura mater. The internal carotid artery on each side and the vertebral arteries supply the brain, pia mater, and the eyes. The internal carotid arteries divide into the anterior cerebral and the middle cerebral arteries. The vertebral arteries on each side give off the inferior cerebellar arteries, and then join and form the basilar artery, which redivides, DISEASES OF THE CEREBRUM. 411 forming the two posterior cerebral arteries, which, in turn, give off the posterior communicating artery. It is the uniting of these cerebral arteries by the anterior and posterior communicating arteries that forms the circle of Willis. From various portions of the circle of Willis and the beginnings of the anterior, middle, and posterior cere- bral arteries are given off six groups of vessels, which furnish the blood supply to the basal ganglia and the adjacent white matter, from which they derive their name, " the central arteries of the brain." The " central arteries " given off by the middle cerebral or Sylvian artery are of the most importance to the clinician. They are known as the lenticular-optic and the lenticular-striata arteries, and are usually involved in cerebral hemorrhage. The following centres have thus far been localized in the cortex — viz: the motor, vision, word-deafness, word-blindness, aphasia, agraphia, and muscular sense of pain and touch. The " mind " centre has been long considered as located in the frontal lobe, anterior to the motor area and the third frontal convolution, but of late the view is growing that for complete integrity of the mind the entire cortex must be intact, although lesions of the portions named produce mental symptoms only, while lesions of other portions of the cortex cause other disorders in which mental changes are more or less prominently observed. The many symptoms resulting from diseases of the brain can be placed in four groups : i. General symptoms of brain irritation. 2. General symptoms of brain pressure. 3. Symptoms of focal irritation or destruction. 4. Symptoms due directly to the pathological process. Symptoms of brain irritation, or hypersemia, are : headache, ver- tigo, vomiting, photophobia, mental irritability, insomnia, fullness or pressure over the brain, with scalp tenderness and noises in the ears. Rarely convulsive symptoms and delirium may occur. Symptoms of brain pressure are : headache, vomiting, mental dull- ness, and frequently some form of paralysis with contracted pupil and finally coma. Focal lesions depend upon their character: if irritative, convulsive or spasmodic phenomena if located in the motor area, and, if decided pressure or destructive lesions, paralysis, such as hemiplegia and aphasia. The symptoms of brain lesions due to the pathological process itself 412 PRACTICE OF MEDICINE. have few if any paiticular symptoms other than those due to the loca- tion except in abscess or gummata, when the constitutional symptoms of suppuration, such as chills, fever, sweats, and prostration, are added to other brain symptoms. CONGESTION OF THE BRAIN. Synonyms. Cerebral hyperemia ; cerebral congestion. Definition. An abnormal fullness of the vessels (capillaries) of the brain : Active, when arterial fullness ; passive, when venous full- ness; characterized by headache, vertigo, disorders of the special senses, and, if the hyperaemia be decided, convulsions. Causes. Active. Increased cardiac action, the result of hyper- trophy of the left ventricle ; general plethora ; excesses in eating and drinking; acute alcoholism; sunstroke; prolonged mental labor; diminished amount of arterial blood in other parts, the result of the compression of the abdominal aorta or ligation of a large artery, or the suppression of an habitual bleeding hemorrhoid, are examples. Passive. Dilatation of the right heart ; pressure upon the veins returning the cerebral blood. While congestion of the brain is not so frequent as was once sup- posed, the view that it cannot occur is disproven by the results fol- lowing the inhalation of a full dose of amyl nitris. The relief of head symptoms after a free epistaxis and the distress resulting if it does not occur is another instance. Pathological Anatomy. The post-mortem appearances are : Overloading of the venous sinuses and of the meningeal vessels, in- cluding the finer branches; the pia mater appears vascular and opaque ; the gray matter of the convolutions unduly red ; the convo- lutions may be compressed and the ventricles contracted, with the displacement of a corresponding amount of cerebro-spinal fluid. Long-continued or repeated congestions lead to enlargement and tortuosity of all the vessels, a moist and slimy condition (oedema) of the cerebral substance, and an increase in the sub-arachnoid fluid. Symptoms. "Rush of blood to the head" may be gradual or DISEASES OF THE CEREBRUM. 413 sudden in its onset, the symptoms aggravated by the recumbent posi- tion. Headache, with paroxysmal neuralgic darts, disorders of vision and hearing, buzzing in the ears and sparks before the eyes, con- tracted pupils, vertigo, blunted intellect, inability to concentrate the mind, irritable teinper, and curious hallucinations. The face is red, the eyes congested, and the carotids pulsating. The sleep is dis- turbed by dreams and jerkings of the limbs. If the attack be sudden (apoplectiform), sudden unconsciousness with muscular relaxation occur. Cerebral hyperemia in children often presents alarming symptoms, such as great restlessness, insomnia, night-terrors, gnashing of the teeth during sleep, vomiting, contraction of pupils followed by general convulsions. Any or all of these symptoms may continue more or less marked from an hour or two to a day, the child enjoying its usual health, after a sound sleep, save a feeling of fatigue. Prognosis. Mild cases terminate favorably in a few hours to a day or two, but show a strong tendency to recur. Severe cases (apo- plectiform) may terminate in health, but usually foretell cerebral hemorrhage. The passive form is controlled by the lesions giving rise to it. Treatment. Active form ; Remove the cause if possible. Elevate the head and apply cold, either cold cloths or the ice cap ; at the same time warmth to the feet. Leeches to the mastoid, or cups to the neck, or in the apoplectiform variety venesection, to diminish the intracranial blood pressure ; compression of the carotids, or ligatures about the thighs, have been recommended. An active purgation is indicated, either by oleum tiglii, or magnesii sulphas, by the mouth. The following enema is often valuable : R . Magnesii sulphatis, f, ij 60. Gra. Glycerini, f^j 30. Cc. Aquae bul., fjiv 120. Cc. M. Sig. — Administer slowly per rectum, with little force. In mild cases the application of an ice cap to the head, sinapis to the nucha, and potassii bromidum, gr. xxx-xl (2-2.6 Gm.), repeated, and the enema mentioned above, control the symptoms. Extraction ergotcE fluidum is strongly recommended, but its value seems to be overestimated. 414 PRACTICE OF MEDICINE. In severe cases, with forcible, overacting heart, to the above means must be added tinctura veratri viridis or tinctura aconiti. Passive form : Becomes a part of the treatment producing the stasis. CEREBRAL ANAEMIA. Definition. An abnormal decrease in the quantity of blood in the cerebral vessels ; general, when the diminished supply includes all the vessels ; partial, when the diminished supply is limited in area ; characterized by pallor, headache, vertigo, some loss of power, and, rarely, convulsions. Causes. Partial cerebral anaemia results from obstruction of a vessel, from embolism or thrombosis. General cerebral anaemia re- sults from hemorrhages, wasting diseases, during convalescence from severe attacks of fevers, sudden shock, feeble cardiac action, and general anaemia. Pathological Anatomy. The functional activity of the brain depends upon the quantity and quality of the blood circulating in the cerebral capillaries. Any decrease in the normal quantity or impairment in the quality produces the symptoms of cerebral anaemia. The brain is pale and milky in color, and on transverse section there are no bloody points ; the ventricles and perivascular lymph-spaces are well filled with fluid. In partial anaemia the local conditions differ somewhat from the above. Symptoms. Ge?ieral : Headache, relieved by the recumbent position ; vertigo, aggravated by exertion ; general pallor, and anae- mia with attacks of fainting ; when the general cerebral anaemia is sudden and decided, convulsions occur. Partial ancemia ; sudden loss of power of limited muscular area, gradually returning to the normal condition. Prognosis. Favorable in all cases save those the result of severe and repeated hemorrhages. Treatment. Regulated nourishment, with stimtilanls. A certain number of hours daily in the recumbent position is of advantage. When a tendency to attacks of swooning exists, alcoholic stimulants or spiritus a?nmonia? aromaticus and spiritus cetheris compositus every DISEASES OF THE CEREBRUM. 415 few hours or even the cautious inhalation of amyl nitris are indi- cated. To improve the quantity or quality of the blood — R. Tinct. ferri chlor., Tt\, xv *• Cc. Acid, phosph. dil., TT\,v .3 Cc. Liq. arsenici cbloridi, TT\^iij -2 Cc. Syr. limonis, f;5 ss 2 - Cc. Syr. zingiberis, . . . . q. s. ad fgij ad 8. Cc. M. Sig. — Every six hours, well diluted. Or— R. Strychninse sulph., gr. j .065 Gm. Quininae sulph. , gr. xlviij 3. 1 Gm. Acid, hydrochlorici dil., . . . f.^ij 8. Cc. Tinct. gentian, comp. , .... f.^iij 90. Cc. Tinct. card, comp., . q. s. ad f^vj ad 180. Cc. M. Sig. — Teaspoonful in water, after meals. CEREBRAL HEMORRHAGE. Synonyms. Apoplexy ; " a stroke." Definition. The sudden rupture of a cerebral vessel and escape of blood into the cerebral tissue, causing pressure and more or less destruction of the brain substance ; characterized by sudden uncon- sciousness, irregular, noisy respiration, and complete muscular relaxa- tion. Causes. Rare under forty years of age. The principal cause is disease of the vessels — the development of miliary aneurisms, or a chronic endarteritis with an associated cardiac hypertrophy ; heredi- tary tendency ; Bright's disease ; syphilis ; alcoholic and dietary ex- cesses, — chronic alcoholism is probably the most common cause. Apoplexy early in life is usually syphilitic. More frequent in the spring and autumn. Pathological Anatomy. The most common locations of cere- bral hemorrhage are the regions supplied by the " central arteries," the internal capsule, corpus striatum, and thalamus opticus ; less common, the cerebellum ; next in frequency the pons and medulla oblongata, and rarely on the convexity of the brain, termed menin- geal hemorrhage. Intracerebral hemorrhage is more common upon the right than upon the left side, and especially affects the region of the caudate 416 PRACTICE OF MEDICINE. nucleus, lenticular nucleus, internal capsule, and optic thalamus ; and particularly the outer border of the lenticular body, which is supplied by the striate artery, — the artery of cerebral hemorrhage. These lenticular striate arteries are branches of the Sylvian artery, and have no anastomoses. When the hemorrhage is large, the blood may break into the ven- tricles and pass by the iter from the third to the fourth ventricle. A recent clot is dark in color, and in consistency a soft, grumous mass, composed of coagulated blood and brain substance in varying proportions, at whose centre is the opening into the ruptured vessel. The £•/ or sarcoptes scabiei. The affection occurs at all ages and in every walk of life. Pathology. Scabies is an inflammation of the skin with the development of papules, vesicles, pustules, excoriations, and subse- quent crusting, the result of the ravages of the animal parasite, together with the irritation produced by the scratching of the patient. The parasite acarus, or sarcoptes scabiei, is a minute creature, barely visible to the naked eye as a yellowish-white, rounded body. The female is the most commonly met with ; the males are said to take no part in causing the affection, and so are rarely seen. They are said to die in about a week after copulation with the female. The female finds her way by boring through the horny layer into the mucous layer of the epidermis, and, being impregnated, begins at once laying her eggs and at the same time making her burrow. A variable number of eggs are deposited, usually about a dozen, after which she perishes in the skin. The ova hatch out in six or ten days. Symptoms. Scabies is an artificial dermatitis or eczema, accord- ing to the amount of irritation produced by the presence of the parasite and the traumatism resulting from the severe scratching of the patient. Immediately upon the arrival of the itch mite upon the skin it begins its work of burrowing, and very soon a burrow, or cuniculus, is formed, in which the eggs are deposited, and which also becomes the habitat of the female during the remainder of her life. The ova are hatched in about one week after their deposit, and at once begin to care for themselves and to burrow, resulting in the formation of as many additional cicniculi as there are active female mites. It is the presence of these burrowing parasites that constitutes the irritation resulting in the inflammation of the skin, characterized by the formation of minute papules, vesicles, and pustules, with more or less inflammatory indura- tion. Add to these the excoriations, scratch marks, Jissures, torn vesicles, and pustules with yellow and bloody crusts, caused by the scratching, and a picture of the fully developed disease is seen. The burrow, or cuniculus, as it is termed, is formed by the mite entering and making its way beneath the horny layer of the epidermis, which is raised, very much as a mole undermines the ground. It occurs as a slight linear elevation of the epidermis, varying from a 606 PRACTICE OF MEDICINE. half a line to four or five lines in length, and having an irregular or tortuous course. Its color is whitish or yellowish, speckled here and there with dark dots. At either end the cuniculus terminates as darkish points, the more prominent of which represent the parasite. The papules are the first inflammatory lesion, are numerous and of small size, and may be the extent of the disease. The vesicles are the next stage, varying in size and number, having an inflamed base, sometimes presenting cuniculi upon their summits. The pustules represent the completion of the inflammatory action, their size and number varying with the severity of the irritation. The intense itching, which is worse at night, results in excoriations, torn papules, vesicles, and pustules, followed by crustings, which after a time disguise the characteristic lesions. The regions of the body attacked are the hands, especially the sides of the fingers and the folds where they join the hands. After a time the wrists, penis, and mammae, and around about and upon the nipples, are invaded. Persons predisposed to eczema have this affection developed, in addition to the simple dermatitis, by the ravages of the itch mite. Diagnosis. A case of scabies seen before irritated by scratching presents no difficulty in diagnosis. The presence of the burrows always suffices for the diagnosis, but these are not always discover- able. The location of the eruption always points strongly to scabies. A history of contagion is of value. All doubt can be set at rest by the aid of the microscope. Prognosis. Always favorable, relapses only occurring when the treatment has been imperfectly carried out or when the individual has recontracted the disease. Treatment. Local measures are alone required in the treatment of scabies. The strength of the parasiticides must be controlled by the severity of the inflammatory symptoms present. If eczema com- plicate scabies, it is to be treated as an ordinary attack after the death of the itch mites. Scabies always succumbs to the following plan : The patient is to be thoroughly washed with soft soap and water, followed by a warm bath, after which cover eruption with tinctura benzoini, which imme- diately modifies the itching, or one of the following ointments is to be thoroughly rubbed into every portion of the body, especial attention being devoted to the hands, fingers, and other parts usually the seat of the disease : DISEASES OF THE SKIN, R . Styracis liquidis, fgij Ung. sulphuris, g ij-iv Ung. petrolei, ad Hjj ad SlG. — Apply after washing. (Bulkley.) Or— & . Sulphuris sublimat. , gj Balsam Peruviani, g ss Adeps, gj SlG. — For children. (Duhring.) Or— R . Creolini, gr. x Ung. petrolei, ^ ij SlG. — Apply thoroughly. G07 8. Cc. 16. Gm 3o. Gm 4. Gm. 2. Gm. 30. Gm. 0.6 Cc. 60. Gm. M. M. M. PEDICULOSIS. Synonyms. Phthiriasis ; morbus pedicularis ; lousiness. Definition. A contagious, animal parasitic disease of the head, body, or pubes, due to the presence of pediculi and characterized by the wounds inflicted by the parasite, together with excoriations and scratch marks. Varieties. Pediculosis capitis ; pediculosis corporis ; pediculosis pubis. Cause. The cause is the presence of the parasite, the result of contagion, direct or indirect. The view of " a spontaneous genera- tion " of pediculi is not accepted by the great majority of observers. Pathology. The lesion produced by the presence of the pediculi is a minute hemorrhage, caused by the parasite inserting its sucking apparatus, or, as it is termed, its haustellum, into a follicle, and obtain- ing blood by a process of sucking, and not by biting, as is generally supposed. The presence of the parasite in any great numbers brings about a peculiar irritable state of the skin, which gives rise to an irre- sistible desire to scratch, as a consequence of which the surface is markedly excoriated and lacerated. Symptoms. The symptoms which arise from the presence of the parasite in different localities are somewhat different, and call for separate consideration. Pediculosis capitis. This variety is caused by the presence of the pediculus capitis, or head louse. The ova, or nits, are readily recog- COS PRACTICE OF MEDICINE. nized at a distance. Their favorite seat is the occipital region, either upon the surface of the scalp or upon the hair. Their presence gives rise to considerable irritation, itching, and consequent scratching, re- sulting in the wounding of the scalp, with oozing of a serous or puru- lent fluid mixed with blood, which soon mats the hair and forms into crusts. In those predisposed to eczema the presence of the parasite will give rise to that condition. The general health is usually unaffected by the presence of the pediculi. Pediculosis corporis. This variety of the pediculosis is caused by the presence of the pediculus corporis, or body louse, or more properly termed the pediculus vestimenti, or clothes louse. Its color, when devoid of blood, is dirty-white or grayish, with a dark line around the margin of its abdomen. Its habitat is the clothing covering the general surface, remaining upon the skin only long enough to obtain sustenance. The ova are usually deposited in the seams of the cloth- ing, the lice being hatched within the week. Occasionally a few of the pediculi may be observed crawling about the surface, or in the act of drawing blood. As they move over the surface they give rise to an intensely disagreeable itching sensation, to relieve which the patient scratches, which in turn gives rise to the characteristic lesions of the affection. The lesions are numerous. The scratch marks are scattered here and there, either long and streaked, in other places short and jagged, the excoriations and blood-crusts varying in size from a pin-head to a split pea or even larger, with irregular-shaped pustules. In addition to the lesions resulting from the scratching are seen the primary lesions, consisting of minute, reddish puncta with slight areolae, the points at which the parasite has drawn blood. In cases of longstand- ing a brownish pigmentation of the whole skin may result from the long-continued irritation and scratching. The favorite site of the lesions are the back, especially about the scapular region, the chest, abdomen, hips, and thighs. Pediculosis is seen most commonly among the poorer classes, and especially the middle-aged and elderly. Pediculosis pubis. This variety of pediculosis is caused by the pres- ence of the pediculus pubis, or crab louse. Although having its seat of predilection about the pubes, it may also infest the axillae, sternal region in the male, beard, eyebrows, and even eyelashes. DISEASES OF THE SKIN. 609 They may be found crawling about the hairs, but more commonly hugging the surface closely. They infest adults chiefly, and occasion symptoms similar to those described in connection with other species. They are usually contracted through sexual intercourse, although occasionally they are present in cases in which they have not been communicated in this way, and where no explanation as to the mode of contagion can be suggested. The itching varies from slight to severe. Diagnosis. When violent itching exists in any case, without marked eruption, the possibility of the presence of pediculi should always be entertained, and if carefully sought after, are found. Prognosis. Favorable, if the treatment be thoroughly carried out. Treatment. Local measures alone are all that is necessary for the removal of the various forms of pediculosis. Pediculosis capitis. The most effective application to this variety is to thoroughly soak the head two or three times a day with ordinary petroleum or kerosene oil, and keep it wrapped in a cloth for twenty- four hours. At the end of this time the head should be thoroughly washed with soft soap and hot water, dried, and saturated with the official unguentum hydrargyri ammoniatum. If required, this entire procedure may be repeated, but usually any pediculi escaping the petroleum are destroyed by the unguentum. Pediculosis corporis. In this variety the habitat of the parasite being the clothing, they must be boiled or baked at a temperature sufficiently high to destroy their life. After this the clothing should be changed every day or two, carefully inspected, and if pediculi are seen, they must again be baked or boiled. It is folly to expect satis- factory results unless these directions are faithfully adhered to. For the irritation, itching, and excoriations, mild alkaline baths or lotions of acidum carbolicum are sufficient. Pediculosis pubis. The parts should be washed twice daily with soft soap and water, after which the thorough application of tinctura cocculus indiats, full strength or diluted, or a lotion of hydrargyri chloridum corrosivum or unguentum hydrargyri ammoniatum 01 unguentum hydrargyri (blue ointment), will be effectual. 5- INDEX Abdominal dropsy, 141 typhus, 22 Abscess, cerebral, 424 iliac, 129 of the heart, 383 of the liver, 153 perityphlitis 129 Acne. 574 artificialis, 575 disseminata, 574 indurata, 574 papulosa, 574 punctata, 534, 574 pustulosa, 574 rosacea, 576 sebacea, 531 tubercula, 574 vulgaris, 574 Acute articular rheumatism, 219 Bright' s disease, 168 diarrhcea, 109 gastric catarrh, 76 general diseases, 209 hepatitis, 153 meningitis, 404 nasal catarrh, 263 toxic gastritis, 78 uraemia, 183 yellow atrophy, 154 Addison's disease, 203, 584 Agraphia, 429 amnesic, 429 Ague, 39 brow, 39 cake, 39 dumb, 39 Albumin, tests for, 161 nitric-magnesian test, 161 Albuminuria, 169 chronic, 1 71 Alcoholism, 436 acute, 436 chronic, 443 Amygdalitis, 272 Amyloid kidney, 180 Anaematosis, 199 Anaemia, 195 Blaud's pill for, 198 cerebral, 414 England's pill for, 198 essential, 197 lymphatic, 202 of fatty heart, 199 progressive pernicious, 199 splenica, 201 Anatomy, morbid, 1 1 Aneurism of the abdominal aorta, 400 of the arch of aorta, 399 of the thoracic aorta, 399 Angina catarrhalis, 269 pectoris, 393 Anidrosis, 540 Anthrax, 571 Aorta, aneurism of the, 398 Aphasia, 429 Aphonia, 429 Aphthae, 69 confluens, 69 discrete, 69 Aphthous stomatitis, 69 Apncea, 14 Apoplexy, 415 capsular, 417 cortical, 417 crus-cerebri, 417 ingravescent, 416 611 612 INDEX. Apoplexy, serous, 446 Appendicitis, 129 Argyria, 584 Arrhythmia, 393 Arteries, Cohnheim's terminal, 421 Arterio- capillary fibrosis, 396 Arterio-sclerosis, 396 Arthritis deformans, 227 Artisans' cramp, 500 Ascaris lumbncoides, 137 Ascites, 144 Asthenia, 14 Asthma, 302 bronchial, 302 hay, 306 Kopp's, 286 Millar's, 286 spasmodic, 302 thymic, 286 Ataxia, locomotor, 467 Ataxic paraplegia, 470 Atheroma, 396 iodides in, 398 Atonic dyspepsia, 96 Atrophic paralysis of children, 458 Atrophy, chronic spinal muscular, 462 progressive muscular, 462 Atropia for hemorrhage, 315 Auscultation, 252 Da Costa's rules for, 252 Autumnal catarrh, 306 fever, 22 Bacillus, comma, 239 malaria, 39 of Eberth, 23 of Pfeiffer, 19 tuberculosis, 332 Bacteria of decomposition, 239 Bacteriology, II Barber's itch, 601 Basedow's disease, 495 Basham's iron mixture, 171 Bell's palsy, 483 Belt, hydropathic, 152 Beri-beri, 476 Bile, test for, 147 pigment, test for, 147 Biliary calculi, 149 Bilious cholera, 113 fever, 42,71 Bilious malignant fever, 48 remittent fever, 42 Biliousness, 151 Black-heads, 534 Bladder, catarrh of, 190 Blaud's pill, 198 Bleeders' disease, 204 Blepharospasm, 484 Blood, diseases of, 195 test for, 163 white cell, 201 Bloody flux, 121 Boil, 569 Bothriocephalus latus, 134 Bowels, inflammation of, 109 Brachycardia, 392 Bradycardia, 392 Brain, congestion of, 412 Brand's method, 30 Break-bone fever, 67 Bright's disease, acute, 168 chronic, 1 71, 1 75, 180 Bromidrosis, 537 pedum, 537 Bronchial catarrh, 290 dilatation, 299 hemorrhage, 313 Bronchiectasis, 298 Bronchitis, acute, 290 capillary, 293, 328 chronic, 298 croupous, 296 diphtheritic, 296 fetid, 298 fibrinous, 296 membranous, 296 peri-, 303 plastic, 296 secondary, 298 senile, 298 Broncho-pneumonia, 293, 328 Bronchorrhagia, 313 Bronchorrhcea, 298 Bronzed-skin disease, 203 Brow ague, 41 C^CUM, inflammation of, 127 Calculi, alternating, 188 biliary, 149 cutaneous, 535 hepatic, 149 INDEX. 613 Calculi, oxalate of lime, 1 88 phosphatic, 1 88 renal, 187 uric acid, 18S Callositas, 586 Cancer, gastric, 87 hepatic, 158 Cancrum oris, 75 Carbolic acid in tetanus, 499 Carbuncle, 571 Carbunculus, 571 Carcinoma, gastric, 87 of the liver, 158 Cardiac dilatation, 380 fatty degeneration, 387 hypertrophy, 377 paralysis, 213 valvular diseases, 369 Cardialgia, 94 Carditis, 383 chronic, 384 Catalepsy, 492 Catarrh, acute bronchial, 290 gastric, 76 nasal, 263 autumnal, 306 chronic bronchial, 298 gastric, 81 nasal, 267 1 contagious, 19 dry, 298 intestinal, 109 mucous, 298 of the bile-ducts, 147 of the bladder, 190 of the mouth, 68 of the rectum, 131 suffocative, 293 Catarrhal enteritis, 109 jaundice, 147 laryngitis, 274 nephritis, 167 pneumonia, 328 stomatitis, 68 tonsillitis, 269 " Catarrh sec" of Laennec, 299 Cephalic tetanus, 498 Cephalodynia, 224 Cerebral abscess, 424 anaemia, 414 congestion, 412 Cerebral embolism, 421 fever, 464 hemorrhage, 415 hypercemia, 412 softening, 416 thrombosis, 421 tumor>, 426 Cerebro-spinal fever, 35 neuroses, 484 sclerosis, 471 Cervico-brachial neuralgia, 480 Cervico-occipital neuralgia, 480 Cheyne-Stokes breathing, 388 Chicken-pox, 63 Child-crowing, 279 Chills and fever, 39 Chiragra, 229 Chloasma, 583 uterinum, 584 Chlorides, test for, 161 Chlorosis, 197 Cholera, 239 Asiatic, 239 bilious, 113 English, 113 epidemic, 239 infantum, 1 19 malignant. 239 morbus, 113 spasmodic, 239 sporadic, 1 13 typhoid, 239 Cholerine, 240 Chorea, 484 Huntington's, 485 post-hemiplegic, 485 Chromidrosis, 537 Chronic dyspepsia, 81 entero-colitis, 116 gastric catarrh, 81 gastritis, 81 nasal catarrh, 267 valvular disease, 369 Circular insanity, 514 Clavus, 587 Clinical history, 12 Cohnheim's terminal arteries, 42: Cold in the head, 263 Colic, hepatic, 149 intestinal, 102 lead, 103 614 INDEX. Colic, ovarian, 103 renal, 187 stomachic, 94 uterine, 103 Colitis, 121 ulcerative, 121 Coma, 14 ursemic, 183 Comedo, 534 Comedones, 534 Congestion, cerebral, 412 of the kidneys, 167 of the liver, 151 of the lungs, 316 spinal, 449 Congestive fever, 44 Constipation, 104 Consumption, pulmonary, 332 galloping, 332 throat, 288 Contagious fever, 1,1, catarrh, 19 Convulsions, uremic, 183 Cor bovinum, 371 Corns, 587 Corrigan's disease, 340 hammer, 442 sign, 89 Coryza, acute, 263 chronic, 267 Costiveness, 104 Cough, whooping, 308 winter, 298 Cow-pox, 63 Crisis, 13 Croup, catarrhal, 279 false, 279 membranous, 281 pseudo-, 286 spasmodic, 279 true, 281 Croupous bronchitis, 296 enteritis, 112 laryngitis, 281 pneumonia, 319 stomatitis, 69 Cyst, renal, 182 sebaceous, 536 Cysticercus bovis, 135 cellulosus, 134 Cystitis, 190 Cystitis, acute, 190 chronic, 190 Dandruff, 531 Dandy fever, 67 Death, 14 Delirium tremens, 438 Delusional insanity, 516 Dementia, 527 acute, 528 alcoholic, 529 apoplectica, 529 choreica, 529 chronic 529 epileptic, 513, 529 organic, 529 paralytica, 529 paretic, 521 partial, 530 primary, 530 secondary, 530 senilis, 530 syphilitica, 530 toxica, 530 Dengue, 67 Diabetes insipidus, 236 mellitus, 232 Diagnosis, 14 by exclusion, 14 differential, 14 direct, 14 physical, 244 Diarrhoea, 106 acute, 106, 109 bilious, 106 choleriform, 1 19 chronic, 106 feculent, 106 inflammatory, 115 lienteric, 106 mixture, Squibb's, 108 Diathesis, 12 Dilatation, bronchial, 299 cardiac, 380 gastric, 90 Diphtheria, 210 bronchial, 296 laryngeal, 213, 28 1 nasal, 213 Diphtheritic paralysis, 213 stomatitis, 70 INDEX. G15 Dipsomania, 439 Discharges, chopped spinach, 116 rice water, 1 10, 1 14 Disease, 9 acute, 13 Addison's, 203, 584 Basedow's, 495 bleeders', 204 Bright's, 168, 171, 175, 180 causes of, II chronic, 13 Corrigan's, 340 defined, 9 Duchenne's, 465 fish-skin, 590 flesh-worm, 138 Fothergill's, 479 functional, 9 Graves', 495 Hodgkin's, 202 Meniere's, 431 organic, 9 Parkinson's, 501 predisposition to, 12 subacute, 13 termination of, 13 Diseases, acute, general, 209 general or nutritional, 484 mental, 504 of the biliary passages, 147 of the blood, 195 of the bronchial tubes, 290 of the cerebral membranes, 402 of the cerebrum, 409 of the circulatory system, 352 of the intestinal canal, 99 of the kidneys, 159 of the larynx, 274 of the liver, 151 of the lungs, 316 of the mouth, 68 of the nasal passages, 263 of the nerves, 475 of the nervous system, 401 of the peritoneum, 140 of the pharynx, 269 of the pleura, 346 of the respiratory system, 244 of the skin, 531 of the spinal cord, 449 of the stomach, 76 Disorders of secretion, 531 Dizziness, 431 Dobell's solution, 54 Dropsy, cutaneous, 52 of the abdomen, 141 of the pleura, 350 pericardial, 364 peritoneal, 141 pleural, 350 Duchenne's disease, 465 Duodenitis, 109 Dysentery, acute, 121 chronic, 124 croupous, 121 epidemic, 122 nuclein in, 126 sporadic, 122 washing rectum in, 126 Dyspepsia, 96 acid, 97 atonic, 96 chronic, 81 drunkards', 81 flatulent, 97 hot water in, 78 intestinal, 99 irritative, 97 nervous, 97 Ecstasy, 492 Ecthyma, 568 Eczema, 542 acute, 543 ani, 555 aurium, 554 barbae, 553 capitis, 551 chronic, 545 erythematosum, 543 faciei, 552 fissum, 545 genitalium, 554 impetiginosum, 544 intertrigo, 555 labiorum, 552 madidans, 544 mammarum, 556 palmarum, 556 palpebrarum, 553 papillomatosum, 545 papillosum, 543 6] 6 INDEX. Eczema plantarum, 556 pustulosum, 544 rimosum, 545 rubrum, 544, 549 sclerosum, 545 squamosum, 545 unguium, 557 verrucosum, 545 vesiculosum, 544 Elixir, triple, 389 Embolism, cerebral, 421 Emphysema, 310 Empyema, 347 Encephalitis, acute, 424 suppurative, 424 Endarteritis chronica deformans, 396 Endocarditis, acute, 364 chronic, 369 diphtheritic, 365 malignant, 367 mycotic, 367 septic, 367 ulcerative, 367 Enteralgia, 102 Enteric fever, 22 Enteritis, catarrhal, 109 croupous, 112 membranous, 1 12 Entero-colitis, 115 Entero-mesenteric fever, 22 En tero ptosis, 92 Enterorrhcea, I06 Ephemeral fever, 1 7 Epidemic catarrhal fever, 19 cerebrospinal fever, 35 roseola, 58 Epilepsy, 486 Jacksonian, 486 Epileptic dementia, 513 imbecility, 513 insanity, 513 Erysipelas, 64 ambulans, 65 of the brain, 65 phlegmonous, 65 Erysipelatous dermatitis, 64 Erythema intertrigo, 541 simplex, 540 Erythematous stomatitis, 68 Hrythromelalgia, 481 Essential anaemia, 199 Etiology, II Eucalyptol in cystitis, 193 Exophthalmic goitre, 495 Exudative endocarditis, 364 Facial paralysis, 483 Farcy, 218 Fatty heart, 387 Favus, 593 Febricula, 17 Fever, 15 abdominal typhus, 22 autumnal, 22 bilious, 42, 76 remittent, 42 typhoid, 38 breakbone, 67 catarrhal, 19 cause of, 15 cerebral, 404 cerebro-spinal, 35 congestive, 44 contagious, 33 continued, simple, 17 dandy, 67 enteric, 22 entero-mesenteric, 22 ephemeral, 17 epidemic cerebro-spinal, 35 gastric, 22, 76 hay, 306 intermittent, 39 irritative, 17 jail, 33 lung, 319 malarial, 39 malignant intermittent, 44 remittent, 44 marsh, 42 Mediterranean, 48 nervous, 22 neuralgic, 67 periodical, 39 pernicious, 41 relapsing, 38 remittent, 42 rheumatic, 219 rose, 306 sailors', 48 scarlet, 51 ship, 33 INDEX. 617 Fever, simple continued, 17 spirillum, 38 spotted, 33 swamp, 39 thermic, 443 typhoid, 22 typho-malarial, 42 typhus, 33 winter, 319 yellow, 48 Fevers, 15 continued, 1 7 eruptive, 51 general treatment of, 16 periodical, 39 pernicious malarial, 44 primary cause of, 15 Fibrosis, arterio-capillary, 396 Fish-skin disease, 590 Floating kidney, 193 Folie circulaire, 514 Fothergill's disease, 479 Freckles, 583 Furunculosis, 569 Furunculus, 569 Gall-stones, 149 Gastralgia, 94 Gastric cancer, 87 carcinoma, 87 dilatation, 90 fever, 21, 76 hemorrhage, 93 neuralgia, 94 ulcer, 84 vertigo, 43 1 Gastritis, acute toxic, 78 chronic, 81 subacute, 76 toxic, 78 Gastrodynia, 94 Gastroptosis, 92 Gastrorrhagia, 93 General paralysis, 521 German measles, 58 Glanders, 218 Glenard's disease, 92 Glossitis, 73 Glottis, oedema of, 277 spasm of, 286 Glycosuria, 232 Glycosuria, simple, 234 Gonagra, 229 Gout, 229 rheumatic, 227 Gravel, 187 Graves' disease, 495 Green sickness, 197 Gripes, 102 Grutum, 535 H.EMATEMESIS, 93 Hematology, 11 Hematoma of the dura mater, 403 Hematuria, 188 Haemophilia, 204 Haemoptysis, 313 Hay asthma, 306 fever, 306 Headache, 434 Heart, anaemia of fatty, 199 dilatation of, 380 fatty degeneration of, 3S7 hypertrophy of, 377 irritable, 389 neuralgia of, 393 palpitation of, 389 rapid, 390 valvular diseases of, 369 Heartburn, 96 Heat exhaustion, 444 stroke, 443 Hemicrania, 434 Hemiplegia, 417 Hemorrhage, bronchial, 313 cerebral, 415 gastric, 93 meningeal, 418 pons, 417 renal, 188 ventricular, 417 Hemorrhagic diathesis, 204 Hemorrhcea petechialis, 206 Hepatic calculi, 149 cancer, 158 colic, 149 Hepatitis, acute, 153 general parenchymatous, 154 interstitial, 155 parenchymatous, 153 suppurative, 153 Hernia, strangulated, 132 6J INDEX. Herpes, 560 circinatus, 595 facialis, 560 gestationis, 561 praeputialis, 560 progenitalis, 560 tonsurans, 598 zoster, 561 Histology, II' Hives, 557 Hodgkin's disease, 202 Hooping cough, 308 Hydrocephalus, acquired, 446 acute, 407, 446 chronic, 447 congenital, 447 Hydropericardium, 364 Hydropneumothorax, 350 Hydrosis, 537 Hydrothorax, 350 Hyperemia, cerebral, 412 renal, 167 spinal, 449 Hyperemias of the skin, 540 Hyperidrosis, 537 local, 537 unilateral, 537 Hypertrophies of the skin, 583 Hypertrophy, cardiac, 377 Hypotonia, 469 Hysteria, 489 llystero-epilepsy, 492 Ichthyosis, 590 Icterus, 147 hemorrhagic, 154 Impetigo, 567 Incubation, period of, 13 Indigestion, 96 acute, 76 intestinal, 99 Inebriety, 436 Inflammation of the skin, 542 Influenza, 19 Insanity, 507 alternating, 5 T 5 chronic delusional, 520 circular, 514 delusional, 516 epileptic, 513 Kahlbaum's, 515 Insolation, 443 Inspection, 245 Intercostal neuralgia, 561 Intermittent fever, 39 tetanus, 497 Interstitial nephritis, 175 Intestinal colic, 102 dyspepsia, 99 indigestion, 99 obstruction, 132 parasites, 1 34 stricture, 132 torpor, 104 Intestines, diseases of, 97 Introduction, 9 Invagination, 133 Ipecacuanha in dysentery, 126 Iron lemonade, 196 Irritative fever, 17 Ischsemia, 195 Itch, 604 barber's, 601 Jail fever, 53 Jaundice, catarrhal, 147 malignant, 154 Kahlbaum's insanity, 515 Kakke, 476 Katatonia, 515 Kidneys, amyloid, 180 congestion of, 167 contracted, 175 diseases of, 159 floating, 193 gouty, 175 lardaceous, 180 movable, 193 sclerosis of, 175 small red, 175 wandering, 193 waxy, 180 white, large, 171 La Grippe, 19 Laryngeal phthisis, 288 Laryngismus stridulus, 286 Laryngitis, acute catarrhal, 274 croupous, 281 cedemalous, 277 spasmodic, 279 INDEX. 619 Laryngitis, tuberculous, 288 Larynx, diseases of the, 274 Law of parallelism, 220 Lentigo, 583 Leptomeningitis, acute, 404 spinalis, 452 Lesions, II Leucaemia, 201 Leucocytbemia, 201 Lichen simplex. 543 tropicus, 563 Lithsemia, 237 Lithiasis, 237 Liver, abscess of, 153 albuminous, 157 amyloid, 157 atrophy of, 156 carcinoma of, 158 cirrhosis of, 155 congestion, 15 1 diseases of, 15 1 gin drinkers', 155 hob-nailed, 155 hypertrophic sclerosis of, 156 lardaceous, 157 nutmeg, 156 sclerosis of, 155 scrofulous, 157 spots, 583, 603 torpid, 151 waxy, 157 yellow atrophy of, 154 Lock-jaw, 498 Locomotor ataxia, 467 Lousiness, 607 Lumbago, 224 Lumbo-abdominal neuralgia, 480 Lumbodynia, 224 Lungs, cirrhosis of, 340 congestion of, 316 consumption of, 338 gangrene of, 320 oedema of, 317 Lymphadenoma, 202 Lysis, 13 Malari/E oscillaria, 11 Malignant endocarditis, 367 intermittent fever, 44 jaundice, 154 ' remittent fever, 44 Mai, le grand, 486 Mai, le petit, 487 Malarial fever, 39 Mania, 507 acute, 508 delirious, 508 amenorrhceal, 509 asthenic, 509 chronic, 5 10 dancing, 509 delusional, 509, 516 erotic, 509 epileptica, 509 hallucinatory, 509 homicidal, 509 post-epileptic, 513 pre-epileptic, 513 puerperal, 510 reasoning, 520 recurring, 510 senile, 510 transitory, 510 Mania-a-potu,438, 509 Marsh fever, 42 Measles, 56 black, 57 false, 58 French, 58 German, 58 Mediterranean fever, 48 Megrim, 434 Melanaemia, 42 Melancholia, 504 agitata, 505 attonita, 506 chronic, 506 delusional, 516 hallucinatory, 505 hypochondriacal, 505 senile, 506 Melasma supra-renalis, 203 Melituria, 232 Membranous enteritis, 112 Meniere's disease, 432 Meningitis, 403 acute, 404 basilar, 407 cerebro-spinal, epidemic, 35 spinal, 452 tubercular, 407 Mensuration, 247 620 INDEX. Metastasis, 14 Migraine, 434 Miliaria, 563 alba, 563 rubra, 563 Milium, 535 Mitral regurgitation, 369 Mixture, Basham's iron, 171 Brown- Sequard's, for epilepsy, 488 Da Costa's muscular cramp, 114 enterica, ill ferro-salicylata, 223 Pepper's asthma, 304 Philadelphia Hospital epileptic, 488 Smith's tonic, 196 Squibb's diarrhoea, 108 Monomania, 520 Morbid anatomy, 1 1 Morbilli, 56 Morphina in acute unemia, 185 in cardiac dilatation, 382 Morphiomania, 510 Mouth, catarrh of, 68 diseases of, 68 white, 72 Movable kidney, 193 Mucus, test for, 161 Muguet, 72 Mumps, 209 Murmurs, aortic, 358 endocardial, 356 exocardial, 356 mitral, 357 pericardial, 356 pulmonic, 358 tricuspid, 358 Muscular rheumatism, 224 Myelitis, acute, 454 Myocarditis, acute, 383 chronic, 384 Myxcedema, 502 Nasal acute catarrh, 263 chronic catarrh, 267 passages, diseases of, 263 Nephritis, acute desquamative, 16 5 parenchymatous, 168 catarrhal, 167 Nephritis, chronic parenchymatous, 171 interstitial, 175 peri-, 182 pyelo-, 181 suppurative, 181 tubal, 168 Nephro-lithiasis, 187 Nephroptosis, 92 Nephrosis, pyelo-, 182 Nervous dyspepsia, 97 exhaustion, 493 fever, 22 prostration, 493 Nettle-rash, 557 Neuralgia, 479 cervico-brachial, 480 cervico-occipital, 480 dorso-intercostal, 480 intercostal, 561 lumbo-abdominal, 480 of stomach, 94 of the fifth nerve, 479 of the heart, 393 red, 481 sciatic, 480 Neuralgic fever, 67 Neurasthenia, 493 Neuritis, multiple, 476 simple, 475 Neuroses, occupation, 500 Noma, 75 Nomenclature, 10 Nuclein in dysentery, 126 Nymphomania, 509 Nystagmus, 484 Obstruction, aortic, 373 intestinal, 132 mitral, 373 pulmonic, 375 pyloric, 87 tricuspid, 375 Occlusion of cerebral vessels, 421 Occupation neuroses, 500 CEdema of glottis, 277 of lungs, 317 Oidium albicans, 72 Oinomania, 437 Oxyuris vermicularis, 137 Ozsena, 267 INDEX. 621 Pachymeningitis, 403 hypertrophic, 451 pseudo-membranous, 451 spinalis, 451 Pains, the girdle, 454 Palpation, 246 Palsy, Bell's, 483 shaking, 501 wasting, 462 Paragraphia, 429 Paralysis, 418 agitans. 501 alcoholic, 176. bilateral, 418 bulbar, 461 cardiac, 213 chronic progressive bulbar, 461 crossed, 418 diphtheritic, 213 essential, of children, 458 facial, 483 general, 521 glosso-labio-laryngeal, 416 infantile spinal, 458 of the insane, general, 521 o,f the tongue, 430 pharyngeal, 213 shaking, 501 spastic spinal, 466 unilateral, 418 wasting, 462 Paralytic dementia, 521 Paranoia, 520 Paraphasia, 424 Paraplegia, ataxic, 470 Parasites, intestinal, 134 Parasitic diseases of the skin, 593 Paresis, general, 521 Parkinson's disease, 501 Parotiditis, 209 metastatic, 209 Partial cerebral anaemia, 421 Pathogenesis, II Pathognomonic, 13 Pathology, 9 Pediculosis, 607 capitis, 607 corporis, 608 pubis, 608 Peliosis rheumatica, 206 Pemphigoid purpura, 207 Pemphigus, 565 Peptic ulcer, 84 Percussion, 247 auscultatory, 251 respiratory, 251 Perforating ulcer, 84 Pericarditis, acute, 359 chronic, 362 . dl 7> 359 Pericardium, adherent, 328 hydro-, 329 Peri-nephritis, 182 Periodical fevers, 39 Peripheral neuritis, 475 Peri-proctitis, 131 Peritoneal dropsy, 141 Peritonitis, 140 Peri-typhlitis, 1 29 Pertussis, 308 Pharyngeal paralysis, 213 Pharyngitis, acute catarrhal, 269 erysipelatous, 270 exanthematous, 270 fibrinous, 270 gangrenous, 270 phlegmonous, 270, 272 Phosphates, tests for, 161 Phosphoridrosis, 537 Phthiriasis, 607 Phthisis, 332 acute, 332 caseous, 335 catarrhal, 335 chronic, 338 fibroid, 346 florida, 336 incipient, 338 laryngeal, 288 pneumonic, 332, 335 pulmonalis, 332 tubercular, 332, 338 Physical diagnosis, 244 signs, 12 association of, 263 Pill, Blaud's, 198 Da Costa's, for hemorrhage, 315 England's, 198 Gross's neuralgic, 482 Moussette's, 482 Niemeyer's, 344 Pilocarpus for spreading erysipelas, 66 622 INDEX. Pilocarpus for mumps, 210 Pityriasis, 531 versicolor, 603 Pleurisy, 346 Pleuritis, 346 chronic, 347 Pleurodynia, 225 Pleuro-pneumonia, 319 alcoholic, 322 apyretic, 322 aspiration, 323 Pneumonia, bilious, 322 caseous, 335 catarrhal, 328 chronic catarrhal, 329, 335 interstitial, 340 croupous, 319 lobar, 319 lobular, 328 traumatic, 323 typhoid, 322 Pneumonitis, 319 Pneumothorax, 350 Podagra, 229 Poliomyelitis anterior acuta, 45 S chronic, 462 Polydipsia, 236 Polyuria, 236 Posterior spinal sclerosis, 467 Predisposition, 12 acquired, 12 inherited, 12 Prickly heat, 563 Primaiy delusional insanity, 516 Proctitis, 131 peri-, 131 Prodromes, 13 Professional neuroses, 500 PiT.gr.osis, 14 Progressive muscular atrophy, 462 pernicious anarinia, 199 Pseudo-tabes, 476 Psoriasis, 579 circinata, 580 diffusa 580 guttata, 580 gyrata, 580 nummularis, 580 of the mouth, 74 of the tongue, 74 palmar s, 5S0 Psoriasis, plantaris, 580 punctata, 580 unguium, 580 Psychalgia, 504 Pulmonary engorgement, 316 oedema, 317 tuberculosis, 332 Pulse, Corrigan, 371 irregularity of, 393 receding, 371 Purging, 106 Purpura, 206 hemorrhagica, 2c6 simplex, 206 urticans, 206 Pus, test for, 163 Pyelitis, 181 Pyelo-nephritis, I Si Pyelo-nephrosis, 182 Pyloric obstruction, 90 stenosis, 90 Pyrosis, 96 QUININA in trichinosis, 140 in typhoid fever, 26 Quinsy, 272 malignant, 210 Rales, 258 Reactions of degeneration, 459 Rectitis, 131 Rectum, catarrh of, 131 washing out the, 126 Regurgitation, aortic, 370 mitral, 369 pulmonic, 372 tricuspid, 372 Relapsing fever, 2^ Remittent fever, 42 Renal calculi, 187 colic, 187 cyst, 182 Respiration, Cheyne-Stokes', 388 oscillating, 388 Respiratory system, diseases of, 244 Rheumatic fever, 219 gout, 227 Rheumatism, acute articular. 219 gonorrhfeal, 221 hyperpyrexia of, 220 INDEX. 623 Rheumatism, inflammatory, 219 muscular, 224 Rheumatoid arthritis, 227 Rhinitis, acute, 263 chronic, 267 Rhinophyma, 577 Ringworm, honeycombed, 593 of the beard, 601 of the body, 595 of the scalp, 598 Rontgen or X rays, 14 Rosacea, acne, 576 Rose, the, 64 Rotheln, 58 Round-worms, 137 Rubella, 58 Rubeola, 56 Satlors' fever, 48 Salisbury steaks, 83 Sand, renal, 188 Scabies, 604 Scall, 542 Scarlatina, 51 Scarlet fever, 5 1 Schonlein s disease, 207 Sciatica, 480 Sclerosis, amyotrophic lateral, 462 ant ero lateral, 470 cerebro-spinal, 471 disseminated, 47 1 hepatic hypertrophic, 156 of the liver, 155 posterior spinal, 467 primary lateral, 466 spinal, 465, 471 Scorbutus, 205 Scurvy, 205 Sebaceous cyst, 536 Seborrhoea, 531 capitis, 532 faciei, 532 oleosa, 532 sicca, 532 Secondary processes, 13 Secretions, disorders of, 531 Shaking palsy, 501 Shingles, 561 Ship fever, 33 Sick headache, 434 Sickness, green, 197 Sign, Corrigan's, 89 Signs, 13 physical, association of, 263 Silver nitrate in phlegmonous erysip- elas, 67 in purpura hemorrhagica, 208 Skin, hyperemias of, 540 inflammations of, 542 Smallpox, 59 Smith's, Dr. A. H., tonic, 196 Sore throat, acute, 274 Sounds, in disease, chest, 255 in health, chest, 253 normal cardiac, 353 Spanemia, 195 Spasm, histrionic, 484 of the glottis, 286 Spasmodic croup, 279 tabes dorsalis, 466 Spastic spinal paralysis, 466 Spinal hyperemia, 449 irritation, 493 meningitis, 452 sclerosis, 465 Spinalis pachymeningitis, 451 Spotted fever, 33 Sprue, 72 St. Anthony's fire, 64 St. Vitus's dance, 484 Stomach, cancer of, 87 diseases of, 76 neuralgia of, 94 spasm of, 94 Stomatitis, aphthous, 69 catarrhal, 68 croupous, 69 diphtheritic. 70 erythematous, 68 follicular, 69 gangrenous, 75 parasitic, 70 simple, 68 ulcerative 70 vesicular, 69 Stonepock, 574 Stricture, intestinal, 132 Strychnin a in phthisis, 342 Succussion, 262 Sudamen, 539 Sudamina, 539 Sugar, test for, 164, 165 624 INDEX. Summer complaint, 119 Sunstroke, 443 Swamp fever, 39 Sycosis parasitica, 601 Symptoms, 12 Syncope, 419 Synocha, 17 Syringomyelia, 474 Tabes dorsalis, 467 Tachycardia, 390 Taenia saginata, 134 solium, 134 Tapeworm, armed, 134 unarmed, 135 Temulentia, 436 Test for albumin, 161 for bile, 163 for bile pigment, 164 for blood, 163 for chlorides, 161 for Ehrlich's diazo-reaction, 166 for indican, 166 for mucus, 161 for phosphates, 1 61 for pus, 163 for sugar, 164, 165 for urates, 1 60 for urea, 160 Tetanilla, 497 Tetanus, 498 Tetany, 286, 497 Tetter, 542 Thermic fever, 443 Throat, acute sore, 274 consumption, 288 putrid sore, 210 Thrombosis, cerebral, 421 Thrush, 72 Tic-douloureux, 479 Tinea circinata, 595 favosa, 593 furfuracea, 531 kerion, 599 sycosis, 601 tonsurans, 598 versicolor, 603 Tinkling, metallic, 261 Tone, bandbox, of Bamberger, 304 Tongue, strawberry, 52 Tonsillitis, acute, 272 Tonsillitis, catarrhal, 269 Tormina, 102 Torticollis, 225 Toxic gastritis, 78 Trance, 492 Treatment, 14 abortive, 14 expectant, 15 palliative, 15 preventive, 14 restorative, 15 Tremens, delirium, 438 Trichinae, 138 spiralis, 1 38 Trichinosis, 138 Trismus, 498 Trousseau's diuretic wine, 171 Tubbing in typhoid fever, 30 Tubercular meningitis, 407 Tuberculosis, 338 acute miliary, 332 Tuberculous laryngitis, 288 Tumor, phantom, 492 sebaceous, 536 Tumors, abdominal, 89 intra-cranial, 426 Turpentine in purpura, 208 Tympanites, chronic, 146 Typhlitis, 127 Typho-malarial fever, 42 Typhoid fever, 22 Typhus fever, ^^ Ulcer, duodenal, 86 gastric, 84 perforating, 84 Ulcerative colitis, 121 stomatitis, 70 Ulcerosa gingivitis, 70 Uraemia, acute, 183 * morphina in, 185 Uraemic coma, 183 convulsions, 183 intoxication, 183 Urates, test for, 160 Urea, test for, 160 Uric acid diathesis, 237 test for, 1 60, 161 Uridrosis, 537 Urine, 159 hysterical, 303 INDEX. 625 Urine, normal color, 159 constituents, 159 quantity, 159 reaction, 159 Urticaria, 557 Vaccination, 63 Vaccinia, 63 Valvular diseases of the heart, diagnosis of, 375 Valvulitis, 364 Varicella, 63 Variola, 59 Verruca, 588 Verrucktheit, 520 Vertigo, 431 auditory, 431 aural, 431 gastric, 431 nervous, 431 senile, 431 stomachic, 82, 431 Vesicular emphysema, 310 Voice in disease, 261 in health, 254 Vomit, black, 49 coffee-ground, 49 369 Waddle, the, 467 Warburg's tincture, 46 Wart, 588 venereal, 589 Wasting palsy, 462 Water blisters, 565 cancer, 75 Wen, 536 Wheals, 558 White blood, 201 cell blood, 201 mouth, 72 Whooping-cough, 308 Widal reaction, 27 Wilson's, Erasmus, tonic, 533 Winter cough, 319 Worms, round, 137 seat, 137 tape-, 134 Xeroderma, 591 Yellow fever, 48 Jack, 48 Zona, 561 Catalogue No. 8. August, 1899. CLASSIFIED SUBJECT CATALOGUE OF MEDICAL BOOKS AND Books on Medicine, Dentistry, Pharmacy, Chemistry, Hygiene, Etc., Etc., PUBLISHED BY P. Blakiston's Son & Co., Medical Publishers and Booksellers, 1012 WALNUT STREET, PHILADELPHIA. SPECIAL NOTE. — The prices given in this catalogue are absolutely net, no discount will be allowed retail purchasers under any consideration. This rule has been established in order that everyone will be treated alike, a general reduction in former prices having been made to meet previous retail dis- counts. Upon receipt of the advertised price any book will be forwarded by mail or express, all charges prepaid. We keep a large stock of Miscellaneous Books, not on this catalogue, relating to Medicine and Allied Sciences, pub- lished in this country and abroad. Inquiries in regard to prices, date of edition, etc., will receive prompt attention. Special Catalogues of Books on Pharmacy, Dentistry, Chemistry, Hygiene, and Nursing will be sent free upon application. 4S-SEE NEXT PAGE FOR SUBJECT INDEX. Gonld's Dictionaries, Page 8. SUBJECT INDEX. JJ®- Any books not on this Catalogue wewill furnish a price for upon application. SUBJECT. PAGE Alimentary Canal (see Surgeiy) 19 Anatomy (see Miscellaneous).. 14 Anesthetics 3 Autopsies (see Pathology) 16 Bacteriology (see Pathology).. 16 Bandaging (see Surgery) 19 Brain 4 Chemistry 4 Children, Diseases of 6 Clinical Charts 6 Compends 22, 23 Consumption (see Lungs) 11 Dentistry 7 Diagnosis 17 Diagrams (see Anatomy, page 3, and Obstetrics, page 16). Dictionaries 8 Diet and Food (see Miscella- neous) 14 Dissectors 3 Domestic Medicine 10 Ear 8 Electricity 9 Emergencies (see Surgery) 19 Eye 9 Fevers ., 9 Gout 10 Gynecology 21 Hay Fever 20 Heart 10 Histology 10 Hospitals (see Hygiene) 11 Hygiene 11 Insanity 4 Latin, Medical (see Miscella- neous and Pharmacy) 14, 16 Lungs 12 Massage 12 Materia Medica 12 Medical Jurisprudence 13 Microscopy 13 Milk Analysis (see Chemistry) 4 Miscellaneous 14 Nervous Diseases 14 SUBJECT. PAGE Nose 20 Nursing 15 Obstetrics 16 Ophthalmology 9 Osteology (see Anatomy) 3 Pathology 16 Pharmacy 16 Physical Diagnosis 17 Physical Training (see Miscel- laneous) 14 Physiology 18 Poisons (see Toxicology) .* 13 Popular Medicine 10 Practice of Medicine 18 Prescription Books 18 Railroad Injuries (see Nervous Diseases) 14 Refraction (see Eye) 9 Rheumatism 10 Sanitary Science 11 Skin 19 Spectacles (see Eye) 9 Spine (see Nervous Diseases) 14 Stomach (see Miscellaneous)... 14 Students' Compends 22, 23 Surgery and Surgical Dis- eases 19 Syphilis 21 Technological Books 4 Temperature Charts 6 Therapeutics 12 Throat 20 Toxicology 13 Tumors (see Surgery) 19 U. S. Pharmacopoeia 16 Urinary Organs 20 Urine 20 Venereal Diseases 21 Veterinary Medicine 21 Visiting Lists, Physicians'. {Send for Special Circular.) Water Analysis (see Chemis- try) 5 Women, Diseases oi 21 The prices as given in this Catalogue are net. Cloth binding, unless otherwise specified. No discount can be allowed under any circumstances. Any book will be sent, f>ottf>aid. u-frnn receipt of advertised ■{ vice. SUBJECT CATALOGUE OF MEDICAL BOOKS. 3 #3* All books are bound in cloth, unless otherwise speci- fied. All prices are net. ANATOMY. MORRIS. Text-Book oi Anatomy. 2d Edition. Revised and Enlarged. 790 Illustrations, 214 of which are printed in coiors. Just Ready. Cloth, $6.00 ; Leather, $7.00 ; Half Russia, $8.00 '* Taken as a whole, we have no hesitation in according very high praise to this work. It will rank, we believe, with the leading Anato- mies. The illustrations are handsome and the printing is good."— Boston Medical and Surgical Journal. Handsome Circular of Morris, with sample pages and colored illus- trations, will be sent free to any address. BROOMELL. Anatomy and Histology of the Human Mouth and Teeth. 284 Illustrations. #4 50 DEAVER. Surgical Anatomy. A Treatise on Human Anatomy in its Application to Medicine and Surgery. 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Just Ready. $7.00 MANN. Manual of Psychological Medicine and Allied Nervous Diseases. Their Diagnosis, Pathology, Prognosis, and Treatment, including their Medico-Legal Aspects ; with chapter on Expert Testimony, and an Abstract of the Laws Relating to the Insane in all the States of the Union. Illustrated. %Z-°° REGIS. Mental Medicine. Authorized Translation by H. M. Bannister, m.d. $2.00 STEARNS. Mental Diseases. Designed especially for Medical Students and General Practitioners. With a Digest of Laws of the various States Relating to Care of Insane. Illustrated. Cloth, $2.75; Sheep, #3.25 TUKE. Dictionary of Psychological Medicine. Giving the Definition, Etymology, and Symptoms of the Terms used in Medical Psychology, with the Symptoms, Pathology, and Treatment of the Recognized Forms of Mental Disorders, together with the Law of Lunacy in Great Britain and Ireland. Two volumes. $10.00 WOOD, H. C. Brain and Overwork. .40 CHEMISTRY AND TECHNOLOGY. 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A Synopsis of the British, French, German, and United States Pharmacopoeias and the chief unofficial Formularies. 12th Edition. Just Ready. $2.00 SKIN. BULKLEY. The Skin in Health and Disease. Illustrated. .40 CROCKER. Diseases of the Skin. Their Description, Pathol- ogy, Diagnosis, and Treatment, with Special Reference to the Skin Eruptions of Children. 92 Illus. 3d Edition. Preparing. IMPEY. Leprosy. 37 Plates. 8vo. $3.50 SCHAMBERG. Diseases of the Skin. 99 Illustrations. Being No. 16? Quiz-Compend? Series. Cloth, .80; Interleaved, $1.25 VAN HARLINGEN. On Skin Diseases. A Practical Manual of Diagnosis and Treatment, with special reference to Differential Diagnosis. 3d Edition, Revised and Enlarged. With Formulae and 60 Illustrations, some of which are printed in colors. $2.75 SURGERY AND SURGICAL DIS- EASES (see also Urinary Organs). CRIPPS. Ovariotomy and Abdominal Surgery. Illus. $8.00 DEAVER. Surgical Anatomy. 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Injuries and Diseases of the Jaws. 4th Edition. 187 Illustrations. $4-5o HEATH. Lectures on Certain Diseases of the Jaws. 64 Illus- trations. Boards, .50 HORW1TZ. Compend of Surgery and Bandaging, including Minor Surgery, Amputations, Fractures, Dislocations, Surgical Dis- eases, and the Latest Antiseptic Rules, etc., with Differential Diagno- sis and Treatment. 5th Edition, very much Enlarged and Rear- ranged. 167 Illustrations, 98 Formulae. Clo., .80 ; Interleaved, $1.25 20 SUBJECT CATALOGUE. JACOBSON. Operations of Surgery. Over 200 Illustrations. Cloth, $3.00; Leather, $4.00 JACOBSON. Diseases of the Male Organs of Generation. 88 Illustrations. $6.00 LANE. Surgery of the Head and Neck, no Illustrations. 2d Edition. Just Ready. $5-oo MACREADY. A Treatise on Ruptures. 24 Full-page Litho- graphed Plates and Numerous Wood Engravings. Cloth, $6.00 MAYLARD. Surgery of the Alimentary Canal. 134 lllus. $7.50 MOULLIN. Text-Book of Surgery. With Special Reference to Treatment. 3d American Edition. Revised and edited by John B. Hamilton, m.d., ll.d., Professor of the Principles of Surgery and Clinical Surgery, Rush Medical College, Chicago. 623 Illustrations, over 200 of which are original, and many of which are printed in colors. Handsome Cloth, $6.00; Leather, $7.00 " The aim to make this valuable treatise practical by giving special attention to questions of treatment has been admirably carried out. Many a reader will consult the work with a feeling of satisfaction that his wants have been understood, and that they have been intelligently met." — The American Journal of Medical Science. ROBERTS. Fractures of the Radius. A Clinical and Patho- logical Study. 33 Illustrations. $1.00 SMITH. Abdominal Surgery. Being a Systematic Description ot all the Principal Operations. 224 lllus. 6th Ed. 2 Vols. Clo., $10.00 SWAIN. Surgical Emergencies. Fifth Edition. Cloth, $1. 75 VOSWINKEL. Surgical Nursing. Second Edition, Revised and Enlarged, in Illustrations, fust Ready. $1.00 WALSHAM. Manual of Practical Surgery. 6th Ed., Re- vised and Enlarged. With 410 Engravings. $3-oo WATSON. On Amputations of the Extremities and Their Complications. 250 Illustrations. $5-5o THROAT AND NOSE (see also Ear). COHEN. The Throat and Voice. Illustrated. .40 HALL. Diseases of the Nose and Throat. Two Colored Plates and 59 Illustrations. $2.50 HOLLOPETER. Hay Fever. Its Successful Treatment. $1.00 HUTCHINSON. The Nose and Throat. Including the Nose, Naso-Pharynx, Pharynx, and Larynx. Illustrated by Lithograph Plates and 40 other Illustrations. 2d Edition. In Press. MACKENZIE. Pharmacopoeia of the London Hospital for Dis. of the Throat. 5th Ed., Revised by Dr. F. G. Harvey. $1.00 McBRIDE. Diseases of the Throat, Nose, and Ear. A Clinical Manual. With colored lllus. from original drawings. 2d Ed. $6.00 POTTER. Speech and its Defects. Considered Physiologically, Pathologically, and Remedially. $1.00 URINE AND URINARY ORGANS. ACTON. The Functions and Disorders of the Reproductive Organs in Childhood, Youth, Adult Age, and Advanced Life, Considered in their Physiological, Social, and Moral Relations. 8th Edition. $1.75 MEDICAL BOOKS. 21 ALLEN. Albuminous and Diabetic Urine. Illus. $2.25 BEALE. One Hundred Urinary Deposits. On eight sheets, for the Hospital, Laboratory, or Surgery. Paper, $2.00 HOLLAND. The Urine, the Gastric Contents, the Common Poisons, and the Milk. Memoranda, Chemical and Microscopi- cal, for Laboratory Use. Illustrated and Interleaved. 5th Ed. #1.00 JACOBSON. Diseases of the Male Organs of Generation. 88 Illustrations $6.00 MEMMINGER. Diagnosis by the Urine. 2d Ed. 24 Illus. $1.00 MORRIS. Renal Surgery, with Special Reference to Stone in the Kidney and Ureter and to the Surgical Treatment of Calculous Anuria. Illustrated. $2.00. MOULLIN. Enlargement of the Prostate. Its Treatment and Radical Cure. 2d Edition. Illustrated. In Press. MOULLIN. Inflammation of the Bladder and Urinary Fever. Octavo. Just Ready. $1.50 THOMPSON. Diseases of the Urinary Organs. 8th Ed. $3.00 TYSON. Guide to Examination of the Urine. For the Use of Physicians and Students. With Colored Plate and Numerous Illus- trations engraved on wood. 9th Edition, Revised. $1-25 VAN NUYS. Chemical Analysis of Healthy and Diseased Urine, Qualitative and Quantitative. 39 Illustrations. $1.00 VENEREAL DISEASES. COOPER. Syphilis. 2d Edition, Enlarged and Illustrated with 20 full-page Plates. $5.00 GOWERS. Syphilis and the Nervous System. 1.00 VETERINARY. ARMATAGE. The Veterinarian's Pocket Remembrancer. Being Concise Directions for the Treatment of Urgent or Rare Cases, Embracing Semeiology, Diagnosis, Prognosis, Surgery, Treatment, etc. 2d Edition. Boards, $1. 00 BALLOU. Veterinary Anatomy and Physiology. 29 Graphic Illustrations. .80; Interleaved, #1.25 TUSON. Veterinary Pharmacopoeia. Including the Outlines of Materia Medica and Therapeutics. 5th Edition. $2.25 WOMEN, DISEASES OF. BYFORD (H. T.). Manual of Gynecology. Second Edition, Revised and Enlarged by 100 pages. With 341 Illustrations, many of which are from original drawings. $3 00 BYFORD (W. H.). Diseases of Women. 4th Edition. 306 Illustrations. Cloth, $2.00 DUHRSSEN. A Manual of Gynecological Practice. 105 Illustrations. $ I -5° LEWERS. Diseases of Women. 146 Illus. 5th Ed. $2.50 WELLS. Compend of Gynecology. Illustrated. .80; Interleaved, $1.25 FULLERTON. Nursing in Abdominal Surgery and Diseases of Women 2d Edition. 70 Illustrations. ii.50 22 SUBJECT CATALOGUE. COMPENDS. From The Southern Clinic. " We know of no series of books issued by any house that so fully meets our approval as these ? Quiz-Compends?. They are well ar- ranged, full, and concise, and are really the best line of text-books that could be found for either student or practitioner." BLAKISTON'S ? QUIZ-COMPENDS? The Best Series of Manuals for the Use of Students. Price of each, Cloth, .80. Interleaved, for taking Notes, $1.25. 4®~ These Compends are based on the most popular text-books and the lectures of prominent professors, and are kept constantly re- vised, so that they may thoroughly represent the present state of the subjects upon which they treat. 4Sf The authors have had large experience as Quiz-Masters and attaches of colleges, and are well acquainted with the wants of students. 4£g* They are arranged in the most approved form, thorough and concise, containing over 6oo fine illustrations, inserted wherever they could be used to advantage. >9®* Can be used by students of any college. >8S~ They contain information nowhere else collected in such a condensed, practical shape. Illustrated Circular free. No. I. POTTER. HUMAN ANATOMY. Sixth Revised and Enlarged Edition. Including Visceral Anatomy. Can be used with either Morris's or Gray's Anatomy. 117 Illustrations and 16 Lithographic Plates of Nerves and Arteries, with Explanatory Tables, etc. By Samuel O. L. Potter, m.d., Professor of the Practice of Medicine, Cooper Medical College, San Francisco ; late A. A. Surgeon, U. S. Army. No. 2. HUGHES. PRACTICE OF MEDICINE. Part I. Sixth Edition, Enlarged and Improved. By Daniel E. Hughes, m.d., Physician-in-Chief, Philadelphia Hospital, late Demonstrator ot Clinical Medicine, Jefferson Medical College, Phila. No. 3. HUGHES. PRACTICE OF MEDICINE. Part II. Sixth Edition, Revised and Improved. Same author as No. 2. No. 4. BRUBAKER. PHYSIOLOGY. Ninth Edition, with new Illustrations and a table of Physiological Constants. Enlarged and Revised. By A. P. Brubaker, m.d., Professor of Physiology and General Pathology in the Pennsylvania College of Dental Surgery ; Adjunct Professor of Physiology, Jefferson Medical College, Philadelphia, etc. No. 5. LANDIS. OBSTETRICS. Sixth Edition. By Henry G. Landis, m.d. Revised and Edited by Wm. H. Wells, m.d., Instructor of Obstetrics, Jefferson Medical College, Philadelphia. Enlarged. 47 Illustrations. No. 6. POTTER. MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. Sixth Revised Edition (U. S. P. 1890). By Samuel O. L. Potter, m.d., Professor of Practice, Cooper Medical College, San Francisco ; late A. A. Sur- eeon. U S. Army. MEDIGAL BOOKS. 23 PQUIZ-COMPENDS ?— Continued. No. 7. WELLS. GYNECOLOGY. By Wm. H. Wells, m.d., Instructor of Obstetrics, Jeffersorj College, Philadelphia. 150 Illus- trations. No. 8. GOULD AND PYLE. DISEASES OF THE EYE AND REFRACTION. A New Book. Including Treatment and Surgery, and a Section on Local Therapeutics. By George M. Gould, m.d., and W. L. Pyle, m.d. With Formulae, Glossary, Tables, and m Illustrations, several of which are Colored. No. 9. HORWITZ. SURGERY, Minor Surgery, and Bandag- ing. Fifth Edition, Enlarged and Improved. By Orville Horwitz, b. s-, m.d., Clinical Professor of Genito-Urinary Surgery and Venereal Diseases in Jefferson Medical College ; Surgeon to Philadelphia Hospital, etc. With 98 Formulae and 71 Illustrations. No. 10. LEFFMANN. MEDICAL CHEMISTRY. Fourth Edition. Including Urinalysis, Animal Chemistry, Chemistry of Milk, Blood, Tissues, the Secretions, etc. By Henry Leffmann, m.d., Professor of Chemistry in Pennsylvania College of Dental Surgery and in the Woman's Medical College, Philadelphia. No. 11. STEWART. PHARMACY. Fifth Edition. Based upon Prof. Remington's Text-Book of Pharmacy. By F. E. Stewart, m.d., ph.g., late Quiz-Master in Pharmacy and Chemistry, Phila- delphia College of Pharmacy ; Lecturer at Jefferson Medical College. Carefully revised in accordance with the new U. S. P. No. 12. BALLOU. VETERINARY ANATOMY AND PHY- SIOLOGY. Illustrated. By Wm. R. Ballou, m.d., Professor of Equine Anatomy at New York College of Veterinary Surgeons ; Physician to Bellevue Dispensary, etc. 29 graphic Illustrations. No. 13. WARREN. DENTAL PATHOLOGY AND DEN- TAL MEDICINE. Third Edition, Illustrated. Containing a Section on Emergencies. By Geo. W. Warren, d.d.s., Chiet ot Clinical Staff, Pennsylvania College of Dental Surgery. No. 14. HATFIELD. DISEASES OF CHILDREN. Second Edition. Colored Plate. By Marcus P. Hatfield, Profes- sor of Diseases of Children, Chicago Medical College. No. 15. HALL. GENERAL PATHOLOGY AND MORBID ANATOMY. 91 Illustrations. By H. Newberry Hall, ph.g., m.d., late Professor of Pathology, Chicago Post-Graduate Medi- cal School. Second Edition. No. 16. DISEASES OF THE SKIN. By Jay T. Schamberg, m.d., Instructor in Skin Diseases, Philadelphia Polyclinic. With 99 handsome Illustrations. Price, each, Cloth, .80. Interleaved, for taking Notes, $1.25. In preparing, revising, and improving Blakiston's ? Quiz-Com- pends ? the particular wants of the student have always been kept in mind. Careful attention has been given to the construction of each sentence, and while the books will be found to contain an immense amount of knowledge in small space, they will likewise be found easy reading ; there is no stilted repetition of words ; the style is clear, lucid, and dis- tinct. The arrangement of subjects is systematic and thorough ; there Is a reason for every word. They contain over 600 illustrations. / Morris' Anatomy^* Second Edition, Revised and Enlarged. 790 Illustrations, of which many are in Colors. Royal Octavo. f Cloth, $6.00; Sheep, $7.00; Half Russia, $8.00. From The Medical Record, New York. '• The reproach that the English language can boast of no treatise on anatomy deserving to be ranked with the masterly works of Henle, Luschka, Hyrtl, and others, is fast losing its force. During the past few years several works of great merit have appeared, and among these Morris's "Anatomy" seems destined to take first place in disputing the palm in anatomical fields with the German classics. The nomencla- ture, arrangement, and entire general character resemble strongly those of the above-mentioned handbooks, while in the beauty and profuseness of its illustrations it surpasses them. . . . The ever-growing popularity of the book with teachers and students is an index of its value, and it may safely be recommended to all interested." *** Handsome Descriptive Circular, with Sample Pages and Colored Illustrations, will be sent free upon application.