COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 23286 RC79 .D74 Pract)ce ol medicine RECAP rW- ;^W-v. KC79 P7t Columbia ®nit)er^itj) mtlieCtipoflmigoi* College of ^fjpjsicians; anb burgeons; Hitrarp Pr. Jerome R Web sier Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/practiceofmediciOOdoub The Students' Quiz Series. A series covering the essential subjects of a thorough medical education, arranged in form of question and answer. By qualified teachers and examiners in New York. Illustrations wherever desirable. Priced at uniform loiu rate of §1.00, excejjt double numbers on Anatomy and Surgery, which are priced at $1.75 each. ANATOMY {Double Number)— By Feed. J. Brockway, M, D., Ass't Demonstrator of Anatomy, College of Physicians and Surgeons, New York, and A. O'Malley, M.D., Instructor in Surgery, New York Polyclinic. SI. 75. PHYSIOLOGY— By F. A. Manning. M.D., Attending Surgeon, Manhattan Hospital, N.Y. $1.00. CHEMISTRY AND PHYSICS— By Joseph Steuthers, Ph. B., Columbia College School of Mines, N.Y., and D. W. Ward, Ph.B., Columbia College School of Mines, N.Y. Sl.OO. HISTOLOGY, PATHOLOGY AND BA(5- TERIOLOGY— By Bexxett S. Beach, M.D., Lecturer on Histology, Pathology and Bacteriology, New York Polyclinic. 81.00. MATERIA MEDICA AND THERAPEU- TICS— By L. F. Waenee, M.D., Attend- ing Physician St. Bartholomew's Dispen- sary, N.Y. §1.00. PRACTICE OF MEDICINE-By Edwin T. DouBLEDAY, M.D., Member N.Y. Patho- logical Society, and J. D. Nagel, M.D., Member N. Y. County Medical Associa- tion. .?1,00. SURGERY {Double Number)— By E. A. Sands, M.D., .Assistant Demonstrator of, Anatomy, College of Physicians and Surgeons, N. Y. SI. 7.5. GENITO-URINARY AND VENEREAL DISEASES— By Chas. H. Chetwood, M.D., Yisiting Surgeon, Demilt Dispen- sary, Department of Surgery and Genito- urinary Diseases, New York. $1.00. DISEASES OF THE SKIN— By Chaeles C. Eansom, M. D., Assistant Dermatolo- gist, Vanderbilt CUnic, N. Y. $1.00. DISEASES OF THE THROAT, NOSE, EYE AND EAR— By Feank E. Miller, M.D., Throat Surgeon, Vanderbilt Clinic, N. Y , Assisted by James P. MacEvoy, M.D., Throat Surgeon, Bellevne Hospital, Out-Patient Department, New York, and John Bates, M. D., Assistant Surgeon, Manhattan Eye and Ear Hospital, New York. §1.00. OBSTETRICS — By Charles W. Hayt, M. D., House Physician, Nursery and Children's Hospital, New York. $1.00 GYNECOLOGY— By G. W. Beaten ahl, M.D., Assistant in Gynecology, Vander- bilt Clinic, N. Y., Assisted by Sinclaie TouSEY, M. D , Assistant Surgeon, Out- Patient Department, Roosevelt Hospital, New York. §1.00. DISEASES OF CHILDREN— By C. A. Ehodes, M. D., Instructor in Diseases of Children, N. Y. Post-Graduate Medical College. $1.00. LEA BROTHERS & CO.. PUBLISHERS, PHILADELPHIA. Th^ Students' Quiz Scries. PRACTICE OF MEDICmE. A MANUAL FOR STUDENTS AND PRACTITIONERS. BY EDWIN T. DOUBLED AY, M. D., Attending Physician New York Hospital, Out-Patient Department, and Member New York Pathological Society, AND J. DAKWIN NAGEL, M. D, Adjunct to the Department of Nervous Diseases of the New York Polyclinic ; Visiting Phy- sician to the French Hospital; Member New York County Medical Association. SERIES EDITED BY BERN B. GALLAUDET, M.D., Demonstrator of Anatomy, College of Physicians and Surgeons, New York; Visiting Surgeon Bellevue Hospital, New York. PHILADELPHIA : LEA BROTHERS & CO. Entered according to Act of Congress, in the year 1892, by LEA BROTHERS & CO., In the Office of the Librarian of Congress, at Washington. All rights reserved. ■Westcott & Thomson, William J. Dornan, Stereotypers and Electrolypers, Philada. Printer, Philada, PREFACE. This volume is only intended to embody briefly the main facts known in regard to the diseases treated of. It is a compilation from various authors, and has been writ- ten in the form of question and answer for the convenience of students. Theories regarding the origin of diseases have been avoided as much as possible, and none but English words have been used where it was possible to avoid the foreign equivalent. The principal authorities consulted are Fagge, Charcot, Striimp- fel, Niemeyer, Bennett, Flint, Delafield, Gowers, and various hos- pital reports. E. T. DOUBLED AY, J. DABWIN NAGEL. CONTENTS. PAGE Infectious Diseases: Typhoid Fever; Typhus; Eelapsing Fever; Scarlet Fever (Scarlatina) ; Measles ; Eoseola ; Sraall-Pox ; Vario- loid ; Varicella ; Erysipelas ; Diphtheria ; Dysentery ; Cholera ; Dengue ; Yellow Fever ; Epidemic Cerebro-spinal Meningitis ; Hydrophobia ; Mumps ; Trichinosis ; Whooping Cough .... 17 Diseases of the Eespiratory Organs: Coryza; Acute Pharyn- gitis ; Acute Tonsillitis ; Acute Catarrhal Laryngitis ; Croup ; Acute Bronchitis ; Chronic Bronchitis ; Asthma ; Pulmonary Emphy- sema ; Pleurisy ; Tubercular Pleurisy ; Pneumothorax ; Hydro- and Hsematothorax ; New Growths of the Pleura ; New Growths in the Mediastinum ; Foetid Bronchitis ; Bronchiectasis ; Stenosis of the Trachea ; Stenosis of the Bronchi ; Pulmonary (Edema ; Pneumonia; Croupous Pneumonia; Pulmonary Tuberculosis; Interstitial Pneumonia ; Gangrene of the Lung ; Embolism of the Lungs ; Brown Induration of the Lung ; Tumors of the Lung . . 47 Diseases of the Heart 75 Diseases of the Circulatory System : Acute Endocarditis ; Chronic Endocarditis; Myocarditis; Hypertrophy and Dilatation of the Heart ; Fatty Heart ; Angina Pectoris ; Tachycardia ; Pericarditis ; Hydropericardium ; Hsemopericardium ; Pneumopericardium . . 75 Diseases of the Vessels : Endarteritis ; Aneurism of the Aorta ; Thoracic Aneurisms (not Aortic) ; Aneurism of the Abdominal Aorta 86 Diseases of the Digestive Organs 89 Diseases of the Mouth : Stomatitis; Ulcerations of the Mouth ; Gloss- itis ; Leucoplasia 89 Diseases of the (Esophagus : Q^^sophagitis ; Dilatation of the (Esopha- gus ; Stenosis of the (Esophagus ; Cancer of the (Esophagus ; Rup- 5 b CONTENTS. PAGE ture of the (Esophagus ; Spasm of the (Esophagus ; Paralysis of the (Esophagus 91 Diseases of the Stomach: Acute Gastritis; Chronic Gastritis ; Phleg- monous Gastritis ; Gastritis caused by Poisoning ; Gastric Ulcer ; Cancer of the Stomach ; Hemorrhage of the Stomach ; Dilatation of the Stomach ; Nervous Dyspepsia 95 Intestinal Diseases : Catarrhal Enteritis ; Cholera Morbus ; Typhlitis and Perityphlitis ; Perforating Duodenal Ulcer ; Tubercular En- teritis ; Cancer of the Intestine ; Chronic Constipation ; Intestinal Parasites 102 Diseases of the Peritoneum : Acute General Peritonitis ; Acute and Chronic Local Peritonitis ; Chronic General Peritonitis ; Tuber- cular Peritonitis ; Carcinoma of the Peritoneum ; Hydroperi- toneum Ill Diseases of the Liver : Catarrhal Jaundice ; Biliary Calculi ; Abscess of the Liver (Suppurative Hepatitis) ; Cirrhosis of the Liver ; Acute Yellow Atrophy of the Liver ; Pernicious Jaundice ; Cancer of Liver and Bile-Ducts ; Echinococcus of the Liver ; Congestion of the Liver ; Hypertrophy of the Liver ; Fatty Liver ; Amyloid Liver ; Suppurative Pylephlebitis ; Thrombosis of the Portal Vein ' 115 Affections of the Spleen : Embolism ; Enlargement of the Spleen ; Waxy Degeneration and Tuberculosis ; Tumors of the Spleen 125 Diseases of the Pancreas: Hypertrophy and Atrophy; Hypersemia and Anaemia ; Acute Primary Pancreatitis ; Acute Secondary Pancreatitis ; Cancer of the Pancreas ; Ecchymoses into the Pancreas 126 Diseases of the Urinary Organs : Acute Congestion of the Kidneys ; Chronic Congestion of the Kidneys ; Passive Con- gestion of the Kidneys; Acute Degeneration of the Kidneys; Chronic Degeneration of the Kidneys; Parenchymatous Nephritis; Acute Diffuse Nephritis ; Chronic Diffuse Nephritis ; Suppurative Nephritis ; Tubercular Nephritis ; Tumors of the Kidney ; Renal Colic ; Perinephritis ; Glycosuria ; Diabetes Insipidus ; Hsematuria ; Hsemoglobinuria ; Chyluria 127 Diseases from Disturbance of the Blood-forming Func- tions : Simple Anaemia ; Chlorosis ; Pernicious Anaemia ; Leuco- cythaemia ; Pseudo-leucocythaemia (Hodgkin's Disease); Addi- son's Disease 140 CONTENTS. 7 PAGE Geisterat, Diseases: Acute Articular Kheumatisni; Subacute Rheuma- tism ; Chronic Rheumatism ; Gout ; Arthritis Deformans ; Scurvy ; Purpura Hseraorrhagica ; Haemophilia 145 DISEASES OF THE NERVOUS SYSTEM. Diseases of the Peripheral Nerves 152 Disturbances of Sensation : Anaesthesia of the Skin ; Neuralgia ; Neur- algia of the Trigeminus; Intercostal Neuralgia; Mastodynia, or Neuralgia of the Mammary Gland ; Sciatica ; Articular Neuroses ; Cephalalgia 152 The Reflexes, and How to Test Them 157 The Disturbances of Motion : Paralysis ; Muscular Spasm ; Writer's Cramp (Graphospasm) 159 Neuritis and its Varieties 165 Neuroma 167 Vaso-Motor and Chronic Disturbances : Hemicrania (Migraine) ; Pro- gressive Facial Hemiatrophy ; Exophthalmic Goitre 167 Diseases of the Spinal Membranes: Acute Spinal Meningitis; Chronic Spinal Meningitis; Meningeal Apoplexy 170 Diseases of the Spinal Cord : Disturbances of Circulation ; Spinal Apoplexy ; Functional Disturbances of the Spinal Cord ; Trauma- tism of the Spinal Cord; Concussion of the Spine; Caisson Dis- ease ; Pressure Myelitis ; Myelitis ; Disseminated Sclerosis ; Loco- motor Ataxia (Tabes Dorsalis) ; Amyotrophic Lateral Sclerosis ; Progressive Muscular Atrophy of Spinal Origin ; Pseudo-hyper- trophy of the Muscles ; Erb's Form of Juvenile Hereditary Mus- cular Atrophy; Spastic Spinal Paralysis; Acute and Chronic Poliomyelitis ; Acute Ascending Spinal Paralysis ; New Growths of the Spinal Cord and of its Membranes ; Cavities and Fissures in the Spinal Cord ; Unilateral Lesion of the Spinal Cord 173 Diseases of the Medulla Oblongata : Progressive Bulbar Paraly- sis; Hemorrhage into the Medulla and the Pons ; Embolism and Thrombosis of the Basilar Artery ; Acute Bulbar Paralysis; Com- pression of the Medulla 191 Diseases of the Brain 191 Diseases of the Cerebral Meninges : Hsematoma of the Dura Mater ; 8 CONTENTS. PAGE Purulent Meningitis ; Tubercular Meningitis ; Thrombosis of the Cerebral Sinuses 191 Diseases of the Brain-Substance : Disturbances of Circulation ; The Localization of Cerebral Diseases ; Aphasia and Allied Affec- tions; Cerebral Hemorrhage; Embolism and Thrombosis, fol- lowed by Cerebral Softening ; Abscess of the Brain ; Tumors of the Brain ; Cerebral Syphilis ; Chronic Hydrocephalus 198 Nervous Affections without Discoverable Anatomical Basis : Epilepsy; Chorea (St. Vitus's Dance) ; Paralysis Agitans (Shaking Palsy) ; Tetany ; Tetanus ; Athetosis ; Hysteria ; Neurasthenia . . 207 PRACTICE OF MEDICmE. INFECTIOUS DISEASES. What are infectious diseases? Diseases in which the morbid condition is produced by a poison taken into the body from without. What are the varieties of infectious diseases ? (1) Miasmatic, when the micro-organism hves and grows outside of the body, and is taken in by prolonged contact; (2) contagious, when the micro-organism Hves within the body, and is ehminated in a form to affect other bodies ; (3) unclassified cases, when the micro-organism can live either within or without the body. Give the varieties of infectious diseases according to their ap- pearance. (1) Sporadic, cases which occur in an isolated and scattered manner; (2) endemic, cases which appear to be confined to certain localities ; (3) epidemic, cases which attack many individuals suddenly, and when the disease rapidly spreads to other localities. How can contagion be transmitted? Through inoculation or contact (syphilis, gonorrhoea), through the sur- rounding atmosphere (typhus), by means of articles of clothing (scarla- tina), through food or water (typhoid), through excreta (tuberculosis), or by means of other infected bodies. What does the degree of contagiousness depend upon ? On the strength of poison, mode of application, constitution and state of health of the individual, hygienic surroundings, climate, season of the year, and locality. What is the nature of a contagium ? Each infectious disease is supposed to have its separate morbific agent or poison. This poison is capable of propagating and exciting this_ one disease, and no other. This specific poison is called contagium, virus, ferment, or micro-organism. 2— P. M. 17 18 INFECTIOUS DISEASES. What are the modes in which infectious diseases manifest themselves ? By local and superficial disturbances (gonorrhoea) ; by local, followed by constitutional, disturbance (syphilis) ; by general disturbance, fol- lowed by local lesions (typhoid). What measures should be taken to prevent and limit the spread of infectious diseases ? Isolation of patient, proper ventilation of the room in which the pa- tient is confined, removal from the room of all articles not absolutely necessary ; and thorough disinfection of the room and all articles which may have been brought in contact with the patient. TYPHOID FEVER. What is typhoid fever? An infectious disease whose special characteristics are lesions in the lymphatic glands of the intestines, mesentery, and spleen, and a roseolar eruption on the abdomen or chest. What is the cause of typhoid fever ? A specific, organized, pathogenic poison, appearing as a short rod- shaped bacillus with ends rounded off, generally found in colonies (foci) and multiplying by spores. The bacilli are propagated through sewer- gas, drinking-water, food, and dejections. The germs are introduced through the alimentary canal. When is typhoid fever most common as regards age and time of year ? Between the ages of fifteen and thirty-five years, and during the months of August to November. Give the pathological changes of typhoid fever? In the intestines Peyer's patches and the solitary glands are first en- larged and swollen, from irritation and inflammation caused by deposits of the typhoid virus. On the ninth or tenth day the infected glands ulcerate. If the case progresses favorably, they begin to cicatrize about the twenty-first day. The process of cicatrization generally lasts about two weeks. What are the most serious dangers to be feared from typhoidal intestinal ulcerations ? Extensive sloughing of the infected glands, causing septic general peritonitis or hemorrhage into the peritoneal cavity. Give the general course of the stage of incubation. It lasts two to three weeks ; symptoms are ver}^ indefinite ; the patient has anorexia, headache (generally frontal), general pains, chilly sensa- TYPHOID FEVER. 19 tions, 9,iid a feeling of languor. Occasionally he also has nausea, slight epistaxis, and slight fever. What are the symptoms of the stage of development ? The above symptoms increase rapidly in severity ; the skin is hot and dry, thirst is marked, and the evening temperature rises progressively ; the tongue is dry, and shows a brown or dark-j^ellow coating on both sides of the median line, pulse is accelerated and generally small and soft, the area of splenic dulness is increased, and. there may be gurgling and ten- derness over the abdomen on pressure, particularly in the right iliac fossa. Tympanites is often observed. Epistaxis and bronchial catarrh are frequently present. Diarrhoea or constipation may exist. Give the symptoms of the active stage of the fever. This stage lasts through the second, and sometimes through the third, week. Fever is from 102°-104° R ; generally coma or delirium is pres- ent ; slight bronchitis ; abdomen somewhat swollen and tympanitic ; gen- erally more or less tenderness in the right iliac region exists ; also in most cases a number of small pale-red isolated spots appear (size of a flea-bite). These increase in number, but for the first twenty-four hours disappear temporarily on pressure. The pulse is soft, frequent, and often dicrotic. Give the symptoms of the stage of decline. In simple cases this stage begins at the end of the third week. The fever declines, the greatest fall being in the successive morning tempera- ture. General symptoms decrease, and the patient's convalescence begins. What are the most frequent complications and sequelas of typhoid fever ? Inflammation of the peritoneum from perforation, caused by sloughing intestinal ulcers, and of the mesenteric glands or vermiform appendix ; sometimes also by softening and rupture of the spleen. Inflammation of the parotid, sublingual, or cervical glands. Nephritis, cystitis, orchitis, broncho-pneumonia, or inflammation of the membranes of the brain also occurs. Phlebitis of the saphenous, popliteal, or other veins of the ex- tremities, and also suppurative inflammation of the middle ear or the larger joints, are frequently seen. For what diseases would typhoid fever be most liable to be mis- taken ? The various forms of malarial fever, tuberculosis, meningitis, pneu- monia in old people, or central pneumonia. What is the prognosis of typhoid fever ? Perfectly favorable prognosis can never be given. It depends on the severity of the infection, the constitution of the patient, and on the com- plications. The average number of deaths is about 10 per cent. 20 INFECTIOUS DISEASES. What is the treatment of typhoid ? A specific treatment for typhoid is unknown. It is mostly sjTnpto- matic. The sick-room should be well aired. Diet should be liquid, con- sisting chiefly of milk. Some give meat broths and beef tea from the middle of the second week on, and stimulants should be given as called for by the condition of the patient's pulse. Cold water or cold tea may be given in large quantities. The treatment by cold baths is frequently emploj^ed. The patient is put in a bath of 90° F., which is cooled gradually to 73° F. This may be done three or four times a day, as necessary. Great weakness or severe complications, as peritonitis, con- traindicate this treatment. Sponging with alcohol or wrapping in a wet sheet is frequently employed to reduce the fever. The drugs most frequently used are naphthaline, antipjTine, the salicylates, bismuth, muriatic acid, and minute doses of calomel. These drugs are used either for their antipyretic or antiseptic action. For weak heart alcohol, digitalis, and strychnine are given. In hemorrhage and peritonitis ice over the abdomen, the cold coil, and internally opium and other astringents and narcotics. For diarrhoea the astringents, either by the mouth or by the rectum. Great care should be taken to disinfect all vessels used by the patient, the clothing, bedding, and excreta. TYPHUS. What is typhus fever? A continued fever running a definite course, attended with great pros- tration of the nervous and vascular systems, and characterized by a dis- tinct macular eruption. Give its etiology. It is generated by a specific poison whose nature is unknown. It is directly contagious. The predisposing causes are — a low physical condition of the organism, overcrowding, and want of cleanhness. It is most common between the ages of twenty and forty years. What are the pathological changes ? The blood is clotted, serum exudes into the cavities, the body decom- poses rapidly, maculas persist, the voluntary muscles are softened, the membranes of the brain are inflamed, and the internal organs are con- gested. Describe the stage of incubation and invasion. The stage of incubation lasts from nine to twelve days. There may be chilliness, restlessness, and general malaise. The stage of invasion is generally sudden. There is pronounced rigor, marked depression and exhaustion ; violent muscular pains ; sometimes vertigo, stupor, and de- RELAPSING FEVER. 21 lirium, ^ The temperature rapidly rises, often reaching 106° F. It is generally constant, with shght morning remissions. The skin is gen- erally hot and dry ; there is catarrh of the bronchial and nasal mucous membranes. The urine is scanty and high-colored, and the pulse is soft, frequent, and compressible, and sometimes dicrotic. Describe the stage of eruption. This lasts from the third to the seventh day. The eruption is either a subcuticular mottling or distinct maculae, which appear first on the back of the wrist and epigastrium, and persists to the end of the period of eruption. The spots are distinct, irregularly rounded, superficial ; at first pinkish, then darkish in color. At first they disappear on pressure. These spots disappear from the fourteenth to the twenty-first day of the disease. During the period of eruption all general symptoms increase in severity ; prostration is very marked and the urine becomes albuminous. What are the symptoms of the stage of decline ? All constitutional symptoms suddenly decrease on the fourteenth or twenty-first day of the disease. Temperature falls, the skin becomes moist, the tongue loses its dry appearance, delirium ceases, and con- valescence begins. What are the complications and sequelae ? The complications are those of infective fever ; sequelae are rare. What is the prognosis ? Prognosis is generally favorable, as the mortality is only 1 in 15, and relapses are rare. Coma, cardiac failure, extreme prostration, very high fever, severe cerebral symptoms, suppression of urine, and abundant erup- tion are generally indications of a fatal termination. What is the treatment? Treatment should be symptomatic, as no remedy is known to cut short the disease. Also extreme care should be taken to let the patient have an abundance of fresh air. RELAPSING FEVER. What is relapsing fever ? An acute specific disease of a very infectious nature. Give its etiology. It is caused by a micro-organism, which is a spirillum of a thread-like form, and which is found only in the blood at the time of the febrile paroxysms. Predisposing causes of the disease are overcrowding, want of cleanliness, and insufficient food. Men are more frequently attacked than women. It is most common between the ages of twenty and forty. 22 INFECTIOUS DISEASES. What are the pathological changes ? There are no characteristic changes. What is the stage of incubation ? From five to eight days. Prodromal symptoms are exceptional. What are the symptoms of the stage of invasion ? There is a sudden chill, violent headache, great lassitude, total loss of appetite, marked pains in the extremities, a rapidly-rising temperature, often reaching 106° F., a hot and dry skin, a dry and thickly-coated tongue, and the skin is of a peculiar yellow hue. Give the symptoms of the height of the disease. All the symptoms of the stage of invasion, except the temperature, increase in severity. The spleen and liver are found enlarged on percus- sion. The pulse is very quick and thready, and there is marked hyper- sesthesia of the muscles. These symptoms last from five days to a week. Give the symptoms of the stage of decline. The temperature lessens, attended with profuse sweating; general symptoms grow less, and patient improves rapidly. What is the further course of the disease ? In from five to seven days a second attack similar to the previous one occurs. Often afterward there is a third attack, and during the inten^al the objective symptoms disappear, with the exception of the persistence of the splenic tumor. What is the prognosis? The majority of cases recover, unless complications occur. ^ The mor- tality is 1 in 20. The most common complications are affections of the eye. Jaundice is generally a fatal symptom. What is the treatment? Treatment \& m2cm\y ^ym]}iom2X\Q. AntipjTctics are needless. Good nursing and proper food are the principal things to be regarded. From what should relapsing fever be differentiated ? Cerebro-spinal meningitis, typhoid fever, typhus, acute miliary tuber- culosis, pernicious malarial fever, yellow fever. SCARLET FEVER (SCARLATINA). ^S'^/Ti. -Scarlatina ; Red rash. What is scarlet fever? An acute disease characterized by a peculiar eruption appearing on the skin and the mucous membrane of the bronchi and throat. SCARLET FEVER. 23 What is the cause ? Infection occurs by direct contact with the poison. The specific poison is unknown, but the virus keeps it power for many months. The disease occurs most frequently between the ages of two and ten years. What are the period and symptoms of incubation ? Period of incubation is from four to seven days ; pi{)dromata are not marked. What are the symptoms of the period of invasion ? It begins with a sudden chill and rapid rise of temperature, difficulty in swallowing,_ or a feeling of stiffness in the throat. If the patient is young, there is usually vomiting of a projectile character, and marked cerebral symptoms, such as disturbed sleep or delirium and convulsions. What are the symptoms of the stage of eruption ? The cerebral disturbance increases ; temperature rises to 103°-105° F., and at the end of the first twenty-four hours an eruption appears on the neck,_ face, and chest. This eruption consists of numberless small red points, crowded together, which soon unite' into a general difi"use, scarlet-colored erythema. This disappears on firm pressure during the first twelve hours of its appearance. The inflammation of the throat increases, and the typical eruption is generally seen on the roof of the mouth and in the pharynx. The tonsils and cervical glands are enlarged and painful. The rash extends over the after parts of the body, persisting for three or four days, during which time the general symptoms continue severe. Describe the stage of defervescence. Eruption begins to fade on the portions of the body where it first ap- peared, at the end of the first or the beginning of the second week. The rash disappears, and the epidermis exfoHates in shreds. Conva- lescence is usually slow. What are the most frequent complications and sequelae ? The swelling of the_ throat often takes on a croupous character. Parenchymatous nephritis frequently occurs at the end of the second week or subsequently. Abscess of the cervical lymphatic glands or of the parotid gland is also a frequent complication ; suppurative inflamma- tion of the middle ear^ and purulent rhinitis also occur. Pneumonia, pleurisy, and endocarditis are less frequent sequelse. What are the variations seen from the typical eruption ? Eruption may first appear in a papular, vesicular, or hemorrhagic form or resembling the eruption of measles. 24 INFECTIOUS DISEASES. From what should scarlet fever be diagnosticated? From the infectious diseases attended bj^ eruption, such as typhoid, measles, and chicken-pox, and from the eruptions caused by irritant food or drugs. What is the prognosis? Prognosis is always uncertain, as complications are common and liable to occur at any time ; the disease is most fatal in very young children and adults. Prognosis also depends on the prevailing type of the disease. What is the treatment? In ordinary cases give liquid diet ; keep the room cool ; keep the skin and mouth clean ; the skin should also be greased by some form of fat ; the patient should wear flannels. For the sore throat a simple gargle or carbolic-acid spray may be used. Abscesses should be immediately opened when pus forms, and treated on general surgical principles. For the nephritic complications alkalies and a large amount of fluid by the mouth may be given. No form of treatment to cut short the fever (of any value) is known. The patient must be kept in bed for at least ten days after all symptoms subside. For otitis the ear should be sjTinged frequently with boracic-acid solution. Antipyretics for the fever and hypnotics for the restlessness should be used as indicated. MEASLES. Syn. — Rubeola; Morbilli. What is measles ? An exanthematous disease of a comparatively benign nature, charac- terized by a peculiar eruption of extreme infectiousness. What is the etiology of measles ? It is caused by a specific poison the details of whose transmission are unknown. It is very contagious and occurs in epidemics. Describe the stage of incubation. There are no special prodromata of this stage, but it is supposed to last for about ten days. There may be slight elevations of temperature during this period. Describe the period of invasion. Temperature suddenly rises to 102-104° F. ; there is marked coryza, with abundant nasal secretion ; more or less conjunctivitis and catarrh of the upper portion of the respiratory tract. There is also mild headache, restlessness, loss of appetite, and sometimes mild sore throat. This lasts from three to four days. Describe the period of eruption. The mucous membrane covering the hard and soft palate is reddened. MEASLES. 25 The eruption generally begins on some portion of the face, and rapidly spreads over the entire body. It frequently appears in all parts in thirty- six hours. The eruption consists of papular spots about the size of the head of a pin, surrounded by a pale-red, slightly elevated border ; the spots often become confluent and assume a crescentic form, with limited portions of normal skin intervening between the patches of eruption. With the appearance of the eruption the temperature generally rises somewhat, and the catarrhal symptoms persist. Describe the stage of defervescence. In from two to three days after the appearance of the eruption there is usually a rapid decline of temperature. The eruption begins to fade and the catarrhal symptoms diminish. Desquamation begins to take place in small scales. If no complications occur, convalescence goes on progressively. What variations occur in the typical form of eruption ? The spots may remain entirely separate and distinct, or they may be- come as confluent as in scarlatina. The eruption may assume a vesicular form or become hemorrhagic (black measles). What are the complications? Complications are generally exaggerations of the normal symptoms : serious eye disease, otitis media, marked inflammation of the throat, nose, or larynx may appear. A mild bronchitis frequently takes a severe form or results in broncho-pneumonia at the height of the disease or during convalescence. Dysentery and nephritis occasionally occur as complications. Pertussis, or tuberculosis in those who have the predis- position, are frequent sequelae. From what should measles be diagnosticated? From rbtheln, scarlet fever, typhus, chicken-pox, small-pox, the erup- tion of syphilis when attended with fever, and the eruptions caused by various drugs. What are the prognosis and treatment ? Prognosis is very favorable, but will depend greatly on the absence of pulmonary comj^lications. The treatment is symptomatic. Patients should be kept in a darkened room on account of photophobia; the eyes, nose, and mouth should be frequently washed with boric-acid solutions ; for severe eye trouble an ointment of yellow oxide of mercury is best ; cocaine spray for the hacking cough. The treatment of croupous and pulmonary complications is that generally employed in these diseases. Sponging the patient with lukewarm water and greasing the skin add to his comfort. Especial care should be taken to keep those aff"ected with tubercular or pulmonary complications away from the patient. 26 INFECTIOUS DISEASES. ROSEOLA. Syn. — German measles; False measles. What is roseola ? A disease characterized by an eruption somewhat similar to measles and attended with slight constitutional sj^mptoms. Describe the course of the disease. The period of incubation lasts two to three weeks. After a period of fever lasting a few hours the eruption appears. Fever is always slight : the eruption consists of circular pale-red slightly elevated spots, somewhat smaller than those of measles, and the spots are not apt to become con- fluent. The soft palate is inflamed at the beginning. There is usually no desquamation ; occasionally there is slight catarrh of the mucous mem- branes, similar to that of measles. Complications and sequelae are rare. What are the prognosis and treatment ? Prognosis is favorable. Treatment is similar to that of measles. SMALL-POX. Syn. — Variola. What is small-pox ? An acute infectious disease, characterized by a peculiar eruption, which is general all over the body, and by a marked febrile movement. What is the etiolgy ? The specific organism is unknown. Before the discovery of vaccina- tion the mortality was much greater than at present. Predisposition is universal, but is diminished by vaccination. The mode of transmission is uncertain. The poison apparently exists in the blood, in the contents of the eruption, in the scabs, in the excretions, and the exhalations. Describe the stage of incubation. It lasts from ten to fourteen days ; prodromal symptoms are slight or absent. Describe the stage of invasion. It is ushered in suddenly with a rigor, fever, headache, intense pain in the back, and the temperature rises rapidly, often reaching 104° F. The constitutional symptoms are generally severe : there may be dry tongue, stupor, or delirium, quick pulse, vomiting sometimes of a projec- tile character, diaiThoea, marked enlargement of the spleen, and albumin- ous urine. Describe the stage of eruption. On the second or third day after invasion the initial eruption appears, which is either as a diffuse or macular erythema or a hemorrhagic erup- SMALL-POX. ' ^T tion Tipen the hypogastrium and inner surface of tlie thighs. This lasts for three daj^s ; then the temperature generally falls and the characteristic eruption appears. It begins on the face and scalp, afterward extending to the trunk and arms, and lastly the legs. This regular eruption is papular in form, feeling like small shot under the skin, and on the second day after the appearance of the papules a vesicle forms upon their points. The vesicle grows larger, and by the sixth day becomes umbili- cated ; this becomes pustular on the eighth or ninth day. On its top the pustule presents a slight depression surrounded by a red border. With the eruption on the skin analogous signs develop along the mucous tract, but the eruption upon the mucous membranes rapidly takes on an ulcerative form. With the appearance of the eruption all constitutional symptoms abate somewhat, but with the appearance of suppuration the fever again rises and delirium often develops. On the twelfth to the thir- teenth day the pustules dry up, yellow scabs form, the swelling of the skin subsides, and the local skin exhales a characteristic odor, and con- stitutional symptoms gradually ' disappear and convalescence begins. Where the skin has been destroyed the characteristic scars are left. What are the varieties of small-pox ? In very mild cases the symptoms are very obscure ; in other classes of cases these suppurative papules may be so near together as to give the skin the appearance of a continuous area of suppuration (confluent form). Occasionally the papules are hemorrhagic, with abundant ecchymoses in the skin and mucous membranes (black small- pox). A few cases develop general hemorrhages in the initial stage. These cases are^ always followed by quick death. What is the differential diagnosis? It should be differentiated from typhus, the papulai' form of measles, syphihs, and the exudative erythemata. What is the prognosis ? During the initial stage it is uncertain. If the first symptoms are mild, prognosis is " favorable. Age, constitution, and alcoholic habits have marked influence. The confluent variety is generally, and the hemorrhage variety is almost invariably, fatal. Mortality averages about ] in 3, and death usually takes place between the eighth and the thir- teenth days. . What is the treatment as regards prophylaxis ? Vaccination, isolation, and disinfection. What is vaccination ? Inoculation with humanized vaccine virus. The operation is performed by making a few incisions in or scraping off" a small bit of the integument, 28 INFECTIOUS DISEASES. and introducing the lyniph. On the third or fom-th day after this the spot and the surrounding tissue become red and swollen. On the seventh_ or eighth day vaccine vesicles become well developed on the spot of inoculation. They become purulent in a few days ; then dry up, leaving a scar behind. Revaccination should be performed every fifth or sixth year. What is the treatment? Treatment is purely symptomatic. For the fever, cool baths and sponging ; for headache or delirium, hypnotics and ice-bag ; for the pus- tular eruption, antiseptic pastes and covering the face with a mask and the hands with gloves. Applications made to the skin should be fre- quently changed. For the eruption on the mucous membranes cooling and disinfectant lotions should be frequently used. Violent nervous symptoms always require the constant use of narcotics. What are the complications and sequelae? (Edema of the glottis, pneumonia, pleui'isy, pericarditis, or the various forms of endocarditis have been observed. A suppurative tonsillitis and suppurative inflammation of the salivary and cervical lymphatic glands occasionally occur. Erysipelas is not infrequent. Ophthalmitis, some- times resulting in permanent blindness, is not very infrequent ; occa- sionally orchitis, ovaritis, acute nephritis, or inflammation of the synovial membranes of the joints, attended with serous or purulent exudation, occur. Disseminated mj^elitis occasionally follows the disease. Mul- tiple subcutaneous abcesses, either as a comi^lication or sequela, are not infrequent. VARIOLOID. What is varioloid ? A milder form of variola, which is most often obsei*ved in those whose susceptibility to the poison has been diminished by vaccination. What is the difference between the courses of varioloid and variola ? In varioloid the primary' fever is less ; the number of pocks is smaller ; the course of the eruption is shortened and modified ; the eruption is ir- regular and often begins on the trunk ; the pocks often undergo resolu- tion before reaching a pustular stage ; and pitting is slight or absent. General symptoms are not severe, secondary fever is absent, and desicca- tion may begin on the eighth or tenth day. What is the treatment? The treatment is the same as for small-pox ; grave complications are exceptional. VARICELLA. — ERYSIPELAS. 29 VARICELLA. aS'?/;i.— Chicken-pox. What is varicella? A disease generally occurring in children, characterized by a definite course and a peculiar vesicular eruption. The disease is contagious and epidemic. Describe the appearance of the eruption. The eruption consists of smooth, transparent, lenticular, or irregular vesicles, appearing generally on the face or trunk. The vesicles gen- erally disappear without pustulation. Describe the course of the disease. The stage of incubation lasts from thirteen to seventeen days ; there is then a chilly sensation when the eruption begins to appear ; there is generally full development of the eruption by the end of thirty-six hours. On the appearance of the eruption there is fever, but generally consti- tutional symptoms are slight. Coryza is frequently present. In a few days the vesicles heal very rapidly, and complications are rare. What are the prognosis and treatment? Prognosis is favorable. Treatment for the disease is unnecessary, ex- cept general precautions as to exposure to draughts. ERYSIPELAS. What is erysipelas? An inflammation of the skin excited by the presence of a specific micrococcus (Fehleisen), and recognized by redness, swelling, and pain of the affected parts, and also by its spreading gradually and distinctly by direct extension. What is its etiology? A form regarded as belonging to the province of medicine is generally called idiopathic. It is supposed that the micrococcus must have a primary point of entrance. The disease generally manifests itself on the forehead or scalp, and usually starts at the junction and spreads from there to the face. The characteristic micro-organism is a chain-forming micrococcus. The disease is most frequent in adults, and is seen oftener in women than in men. Direct contagion seems exceptional. One at- tack apparently predisposes toward others. What is the course of the disease ? Shght rigors and sudden slight or great elevation of temperature, anorexia, headache, or a feeling of fulness in the head. These symp- toms are often attended with sore throat. A circumscribed red spot appears on the skin, which is somewhat elevated; this is swollen, 30 INFECTIOUS DISEASES. smooth, shiny, and red; it rapidly extends at various points of the circumference of the inflamed area. There is a marked hne of demar- cation between the healthy and the infected tissues. This process rarely invades the trunk. When the spreading process ceases, the in- flammatory process becomes milder and stops. Sometimes vesicles or bullae form on the skin involved ; rarely the infected tissues become gan- grenous. Much branny desquamation follows the subsidence of the disease. The inflammation generally lasts one week, but is often pro- tracted. The attack is frequently preceded by gastric or intestinal de- rangements. What are the complications and varieties ? and what is the diagnosis ? Local complications, with the exception of inflammation of the nasal and conjunctival membranes, are rare : other complications which may occur are bronchitis, pneumonia, and pleurisy, and in young adults en- docarditis, arthritis, herpes, and urticaria frequently occur. Meningitis may occur in any case from extension of the inflammation. As regards varieties of medical erysipelas, various authors divide it, according to the character of the disease, into simple, miliary, oedematous, and gan- grenous. It should be diagnosed from lymphangitis, cellulitis, acute eczema, scarlet fever, the acute roseola of syphilis, eruptions from drugs, rhus- poisoning, shingles (facial). What are the prognosis and treatment? The prognosis in healthy persons is favorable. It depends greatly also on the age of the patient. Alcoholics give an unfavorable prognosis. The treatment is mainly directed to supporting the vital forces of the patient and reducing the discomfort caused by the inflammation of the diseased parts. Locally, the inflamed parts can be sprinkled with powdered starch or smeared with a coating of vaseline, carbolized oil, or olive oil. A coating of collodion, mixed with various antiseptic drugs, has often been of benefit. The application of resorcin ointment is followed by good results. For the fever, cold sponging or cold baths, but the antipyretics are rarely necessary. For internal treatment camphor and the tincture of chloride of iron are frequently used, and the heart should be carefully watched, and its action kept up by digi- talis, strychnine, and stimulants in proper doses. In patients past middle life constipation is to be avoided. DIPHTHERIA. What is diphtheria? An acute infectious disease, characterized by an inflammation of the pharynx, posterior portion of the mouth, the upper air-passages, and the formation of a false membrane which extends into their tissues. DIPHTHERIA. 31 What is the etiology ? The contagion is believed to be associated only with the false mem- brane, but probably it is given off also in the breath. Direct contact predisposes to the disease. The poison has great tenacity. The disease is most frequent between the ages of two and seven years, but is occa- sionally met with up to adult life. Unhygienic surroundings form a favorable soil for the propagation and preservation of the virus. It is undecided whether the infection is first local and then constitutional, or vice versa. "What is the pathology? The disease is distinguished by the formation of a grayish-white, firm, elastic membrane, appearing as a fibrinous exudation over the infected parts. This can occasionally be easily lifted off, but generally it clings tightly to the mucous membrane, leaving a new bleeding surface when attempted removal is made. Microscopical examination shows it to be a firmly-organized membrane in which there are many colonies of micro- organisms. What are the course and symptoms of the disease ? The period of incubation is generally brief, lasting from two to five daj^s. The invasion begins with general malaise and headache, a tem- perature of 100°-102° F., pain on swallowing, and deep redness of the soft palate, tonsils, and fauces. The tonsils are swollen, and upon their inner surface and that of the soft palate, uvula, or fauces small gray spots of membrane appear. In severe cases this membrane spreads in a few hours. Over these parts there is considerable swelling, and also of the lymphatic glands around the jaw. The fever, as a rule, rapidly increases, and general symptoms of severe sickness, such as great pros- tration, total anorexia, and a rapid, full, and compressible pulse, become marked. If the case is a severe one, the patient's countenance has a peculiar drawn, pallid appearance. In ordinary cases these symptoms persist for from seven to ten days, when the fever subsides, general symptoms decrease, the membrane is exfoliated, and convalescence begins. At the beginning there is generally coryza or slight laryngitis, with the development of a harsh croupy cough. Restlessness is marked, and more or less dyspnoea super\'enes from blocking up of the air-pas- sages, or partial paralysis of the laryngeal muscles, caused by the false membrane. As a rule, the dyspnoea increases as the disease progresses, unless portions of the membrane are expectorated or swallowed. If this does not occur, in children or young persons coma or mild convulsions, followed by death, generally rapidly supervene. In some cases the fever never reaches a high point. The patient shows signs of general weakness, followed by coma and death, and the cough and dyspnoea are not marked. This type of the disease is often accompanied by the con- tinuous flow of a foetid greenish liquid from the mouth or nasal passages. In some cases dyspnoea is not marked. The patient is unable to breathe 32 INFECTIOUS DISEASES. through the nose, the false membrane being confined to the nasal pas- sages and upper portions of the naso-pharynx. The face has an ashy- gray appearance, which may precede the fatal termination for naany hours. The urine is scanty, often high-colored, and contains a variable amount of albumin. What are the complications? Extension of the membrane into the larynx or bronchi is common. Secondary pneumonia often develops, and general infection of the sys- tem through absorption of the poison also occurs. Sloughing of the tissues, caused by the false membrane, sometimes occurs, and also the infectious process may spread through the Eustachian tube to the middle ear, causing abscess of the part. Congestion of the kidney or desquama- tive nephritis is often a comphcation. Rarely endo- or pericarditis ensues. What are the most frequent sequelae? Paralysis of the laryngeal, or, less frequently, of other muscles, is liable to come on in from one to two weeks after, sometimes cyanosis, and in rapidly-fatal cases the inflammation ceases. This is due to degenera- tion of the peripheral nerve-endings. From what should it be diagnosed? From follicular tonsillitis and croupous tonsillitis, also from the initial stage (sore throat) of scarlet fever, and from acute laryngitis and bronchitis in young children. What is the prognosis ? The prognosis is unfavorable. It will greatly depend upon the condi- tion of the throat and the extension of the membrane downward. The mortality is greatest in cold and damp seasons. What is the treatment ? Attempts should be made to destroy the membrane by means of sprays, washes, or gargles, as the case may require. The drugs most frequently used are solutions of nitrate of silver (1 : 20), corrosive sub- limate (I : 2000), hsterine (1 : 8), trypsin (1 : 4), and other antiseptics. The nasal cavity should be frequently swabbed out with an antiseptic solution. Where the membrane has been removed the ulcerating sur- face left should be dusted with a powder of iodoform, lactic acid, or some other disinfectant and healing application. Externally, cold in the form of ice-cloths or the ice-pack is generally appHed to the neck. _ Internally, tinct. ferri chloridi and some of the preparations of strychnina are fre- quently used. Antipyretics are used as seem necessary. _ Continued stimulation by means of alcohol and the drugs which stimulate the heart should always be made in small quantities, to be increased as the case requires. If spasm of the larynx occurs from any (paralytic or mechanical) cause, tracheotomy or intubation is imperative. For the DYSENTERY. 33 paralysT§ following this disease nerve-stimulants, attention to the general health of the patient, and the use of electricity are indicated. DYSENTERY. What is dysentery ? A sporadic and epidemic disease affecting the colon, and characterized by frequent movements, generally containing blood and much mucus. The movements are accompanied by great griping and tenesmus. What is the etiology ? It is produced by a pathogenetic poison. The infection is at first local. It is most common in tropical countries, where many constitutional dis- eases are followed by so-called secondary dysentery. It is not directly contagious. What is the pathology? It is generally a croupous inflammation of the colon, but the disease may be confined to the rectum and sigmoid flexure. In severe cases the disease extends as far as the lower part of the ileum. In milder cases the formation of a croupous membrane is rare. What is the course of the disease ? The most pronounced symptoms are intestinal. At first the fever is slight. There is a feeling of discomfort in the abdomen, the bowels are irregular, followed by slight diarrhoea (two to six stools daily). In a few days the stools become very frequent (ten to sixteen), with a constant desire to evacuate the bowels, attended with tenesmus and burning feel- ing in the rectum and around the anus. The patient then has a pallid, drawn appearance ; the stools become very scanty, sero-mucous, and with bits of mucous membrane, necrosed tissue, and coagula of blood in them ;_ generally, bad odor of the dejecta is not marked. Sometimes there is considerable pain on micturition, and violent attacks of colic, vomiting, and hiccough. These symptoms last a week or ten days, when, if the patient should recover, the fever grows less, frequency of move- rnents decreases, and a very slow convalescence begins. Frequently the disease becomes chronic, when all sj'mptoms cease with the exception of the frequency of movements. In severe cases sudden collapse is liable to occur. Mention the most frequent complications and sequelae. Abscess of the liver from absorption of septic material into the portal system is the most frequent. Peritonitis, general or local, with or with- out perforation caused by intestinal ulcer, also occurs. Inflammation of various joints or cutaneous abscesses are less frequent, 3— P. M. 34 INFECTIOUS DISEASES. What are the prognosis and treatment ? Prognosis is generally good, but is much influenced hy the age of the patient. Treatment. — The patient should be isolated and his stools disinfected. When the patient is seen in the beginning of the disease a laxative, as ol. ricini, or an emetic, may be of good effect. In cases where the dis- ease is established, enemas of starch containing laudanum and some astringents, and the use of suppositories containing some preparation of opium, are indicated. Ipecac in large doses is of benefit. Special atten- tion should be paid to feeding the patient frequently and in small quan- tities by the most easily digested foods. For cardiac weakness camphor, ether, chloroform, and the rapidly-acting stimulants are used. CHOLERA. What is cholera? An epidemic disease, characterized by vomiting, purging, accompanied with painful griping and spasms of the muscles of the abdomen and calves of the legs, and generally attended with coldness of surface and extreme collapse. It usually occurs in epidemics, but in certain parts of the world (India) it is endemic. It sometimes spreads from its en- demic home in India in other directions, but mostly westward. Great epidemics appeared in Europe in 1817-, again in 1830. In 1888 the dis- ease spread and became epidemic in France, Italj^, and the Spanish Peninsula. Slight epidemics have occurred in this country, the last one occurring in 1866. What is its etiology? It is caused by a specific micro-organism (Koch's comma bacillus). This is found in the intestines. It has the appearance of a short, thick, bent bacillus, which grows into long spiral threads, and it is tenacious of life, as it will live in a temperature as high as 100.4° F. The bacilli- are found in the dejecta of cholera patients, and, owing to the lack of cleanliness, generally in all materials surrounding them or with which ih&Y have come in contact. The poison always follows the routes of hu- man travel, and is not transmitted by the air, but it must be swallowed to cause disease. Grastric derangements, excessive heat, a lack of per- sonal cleanliness, predispose to cholera. The disease is rarer in children than in adults. What is its pathology ? The intestines are reddened. The mucous membrane is swollen. There is transudation of a large amount of mucus into the cavity of the bowel. Later on, the lining membrane presents a diphtheritic appear- ance, with patches of necrotic tissue. The muscles are contracted. The liver and spleen are pale. The blood is thickened and disorganized. The spleen is generally not enlarged. In the brain the membranes are congested and the puncta vasculosa are prominent. CHOLERA. 35 Whatsis the course of the disease? The period of incubation is supposed to be usually about three days. The invasion is always sudden. The patient has sudden colicky attacks. Diarrhoea sets in, accompanied by rigidity and cramp-like contraction of the abdominal muscles and the muscles of the legs, which are rapidly followed by symptoms of collapse. In other cases the invasion is slower, lasting from a half hour to several hours, and beginning with slight diarrhoea, which becomes worse, and in the course of twenty-four hours the disease assumes its typical character. Occasionally these symptoms of slow invasion may last for a week, and the patient generally has nau- sea and slight vomiting. The temperature in the stage of invasion is elevated, and the pulse is full, quickened, and compressible. This stage is followed by that of evacuation. The movements become much more frequent, and consist of a whitish or brownish fluid ; urinating of a watery, semi-solid fluid occurs ; there are great thirst, marked contraction of the muscles of the abdomen and legs, subnormal temperature, a rapid and feeble heart, with a weak, thready pulse, often imperceptible in the ra- dials, a cold clammy surface of the body, and a drawn, masked appear- ance of the face. Partial or total suppression of the urine generally accompanies this stage. This stage may last from ten to fifteen hours. The patient may die or go into the stage of collapse. In the stage of collapse the vomiting and purging continue. The heart's action becomes very feeble. The skin has a dusky hue. The body has a shrunken appearance, and the temperature remains very low. Thirst becomes very excessive. The intellect generally remains clear throughout, unless the patient becomes delirious in the stage of invasion. This stage generally lasts not over twenty-four hours. Should the patient still live, the stage of reaction sets in ; evacuations become less frequent ; vomiting ceases ; pulse returns to the radials ; cyanosis diminishes, and the temperature rises above normal. This stage is often interrupted by relapses, which are, as a rule, fatal. In some cases an eruption develops, the so-called choleraic erythema. What are the complications? Complications are generally fatal. ^ The most common areerj^sipelas, pneumonia, acute nephritis, meningitis, pyasmia, or diphtheritic inflam- mation of the mucous membrane of the various organs. What is the diagnosis ? Diagnosis is easily made, as a rule, in epidemics. ^ At other times it must be diagnosed from cholera morbus, acute poisoning, and, in tropical countries, from cases of severe malarial disease. In cases where the dejecta can be bacteriologically examined the diagnosis can be confirmed. What is the prognosis ? Prognosis is always uncertain, even if the symptoms are mild. The mortality, as a rule, varies from 50 to 75 per cent., according to the 36 INFECTIOUS DISEASES. severity of the epidemic. Those of middle age generall}^ seem to stand the disease better than j'ounger or older persons. Intemperance, the results of previous constitutional disease, or bad hj^gienic conditions affect the prognosis. The duration of the disease may be very short (two hours) or extend to several weeks, but in fatal cases death usually takes place on the second or third day. What is the treatment? Isolation and disinfection of the dejecta are of primary importance. Individuals living in an infected area should pay great attention to per- sonal cleanliness and moderation in the use of food and stimulants. The patient should be bathed several times daily in a disinfectant solution. This procedure may also be used for the hands and clothing of the attendants. In the first stage enemata of opium and tannin, with stimu- lants, are most frequently given. The patient should be kept very quiet and wrapped in hot blankets. In the algid stage champagne, hypoder- mic injections of morphine, ether, or camphor are much used. As regards the food, thin porridge or mush only should be given. Small pieces of ice in the mouth are used to counteract the thirst. During the stage of collapse mild external stimulation and cardiac stimulants as necessary are indicated. During the stage of reaction careful nursing is most import- ant, and arising symj)toms must be treated as they occur. Malarial Diseases. What are malarial fevers ? A group of fevers the poison of which originates in the soil and is communicated to persons, but cannot be transmitted from one person to another. What is the etiology ? The poison is probably localized in certain places, but is endemic at times in most parts of the world : a warm climate and permanent damp- ness of the soil seem to favor its development. The organism causing the disease is apparently a micrococcus, most frequently found in the serum of the blood or in the white corpuscles during the paroxj^^sm. Liability to the disease is universal. What are the varieties? Intermittent fever, pernicious intermittent fever, remittent fever, chronic malarial cachexia, and the so-called masked intermittent. Describe intermittent fever. It is characterized by a short febrile movement ; or there may be a prodromal stage of headache, general malaise, and pain in the muscles ; or it may begin with a marked chill. These symptoms persist, and are quickly followed by shivering, generally nausea and vomiting, coldness of the skin, and rapid pulse. The internal temperature rises. In from MALAEIAL DISEASES. 37 half im hour to two hours the shivering ceases, the skin becomes hot, the'ejfternal temperature rises rapidl.y (103° to 105° F. ) ; there is severe pain in the back and head ; the pulse is rapid, and vomiting may con- tinue. This lasts from two to twelve hours. The patient then breaks out into a profuse sweat. Temperature rapidly falls, the constitutional symptoms cease, and the patient generally falls asleep. These attacks may reoccur at intervals of twenty-four hours (quotidian), but it is more common to see the attack reoccurring once every forty-eight hours (tertian type). Exceptionally, the attacks only reoccur every third, fourth, or fifth day. The febrile movement, and also the duration of the various stages, differ much in different cases. In children these attacks are fre- quently not ushered in by a chill, but vomiting is generally marked. What is pernicious intermittent fever? A severe type of malarial fever, mostly seen in tropical countries, and generally preceded by several attacks of the ordinary form. The symp- toms are similar, in the beginning, to those of simple intermittent, but vomiting is more marked and often assumes a hemorrhagic form. Jaundice is developed, and the patient generally becomes unconscious. This stage occurs from the third to the eighth day of the attack. The pulse becomes very rapid, weak, and thready; the temperature falls until it is slightly above the normal, or may become subnormal ; and there are sometimes twitchings of the muscles of the face and arms. Frequently in these cases there is delirium, which is followed by stupor and coma, lasting from thirty-six to forty-eight hours. This type of the disease is very fatal. What is remittent fever ? A form of malarial fever in which the temperature continues high (102°-104°F.), without total intermission, for a period of from four to seven days. There is generally a considerable decrease in the tempera- ture either every morning or every evening. The symptoms are those of cases of intermittent, but the chill is not, as a rule, so marked, and the stage of fever persists for a longer time. Gastric, nervous, hemor- rhagic, or other symptoms may predominate. The attack generally lasts from five days to a number of weeks. What is malarial cachexia ? A constitutional condition sometimes found in those living in malarious districts. It is due to slight or severe, often-recurring, attacks of malarial fever. It is characterized by a peculiar sallowness of the complexion, general muscular weakness, anorexia, vertigo, sweating on slight exertion, pains in the joints or muscles, cardiac palpitation, and often marked diarrhoea or constipation. Occasionally nervous symptoms, as muscular twitchings or insomnia, are marked. There may also be a regular fever. What is masked intermittent fever ? A form of malarial fever in which fever, as a symptom, is absent, but 38 INFECTIOUS DISEASES. other malarial sj^mptoms recur from time to time. These are chiefly neuralgic, and aiFect the cutaneous terminations of the nerves. The attacks last a variable time, but are generally of short duration (half an hour to eight hours). What is the diagnosis ? The diagnosis at first is often very difficult. A history of previous at- tacks or of the patient having lived, or living, in a malarious district, can often be of much assistance. Especial care should be taken to differentiate it from pj^aemia, acute endocarditis, acute tuberculosis, the first stage of scarlet fever, yellow fever, and erj^sipelas. Malarial fever is often mis- taken for the first stage of typhoid. What is its pathology? The liver is enlarged and congested. The spleen is swollen and soft, except in chronic cases, when it is often of very firm consistency and contains a large amount of dark fluid blood. There are no other path- ognomonic symptoms, but general congestion of the internal organs is found. In the pernicious form of the disease the blood in the larger blood-vessels is often found disorganized. What is the prognosis ? The prognosis depends mostly on the constitution of the patient, the number of previous attacks, and the type of the disease. The ordinary iPorm of intermittent is very rarely fatal of itself, but many successive at- tacks predispose to other constitutional disorders. The pernicious form is generally fatal when it occurs in tropical climates among those not ac- climated. What are the complications and sequelae? Muscular rheumatism, various digestive disorders due to the chronic congestion of the liver and spleen, hemorrhoids, acute nephritis, endo- carditis. What is its treatment? Quinine has always been considered almost a specific in the milder forms. Alcoholic stimulants, in combination with quinine, are extensively used to prevent attacks. The general custom is to first give an hepatic stimulant (calomel), and follow this, in from two to four hours, with a dose of ciuinine, to be repeated as seems proper. The hepatic stimulant is generally given about three hours before the chill is expected in cases of intermittent. Pilocarpine, given hypodermically (gr. ^) or by the mouth, has been used to cut short the chill. As a prophylactic War- burg's tincture in 3j or 5ij doses is highly esteemed. This remedy is also much given in the periods between the paroxysms. In the per- nicious forms of the disease the paroxysm should be prevented by the immediate use of quinine (hypodermically). The paroxysm itself is best treated by the use of opium, chloroform, and also alcoholic stimu- TYPHO-MALAEIAL FEVER. — DENGUE. 39 lants "iHternally ; heat to the body externally, and in the sweating stage the use 'of atropine and small doses of morphine are beneficial. Almost all cases of pernicious intermittent will require nourishing by the rectum. In all cases of malarial fever, especially where the attacks recur, the pa- tient should remove from the malarial district. In malarial cachexia arsenic, strychnine,^ cod-liver oil, and the various tonics should be used. In the hemorrhagic forni the general treatment, with the additional use of haemostatics, is indicated. Typho-malarial Fever. What is typho-malarial fever ? A malarial fever in which typhoidal symptoms predominate. Describe the symptoms. There is a marked febrile movement of a remittent character, accom- panied by severe abdominal pain, but especial tenderness, and gurgling in the right iliac fossa is absent. The tongue is often dry and furred in the centre. The pulse is small, rapid, and generally hard, and toward the beginning of the second week the patient becomes lethargic and has marked symptoms of the typhoidal state. What are the prognosis and treatment ? The prognosis will depend greatly on the locality in which the case occurs. The mortality is much smaller than in typhoid. General treat- ment is the same as that of malarial fever, and other symptoms should be treated as they arise. DENGUE. Syn. — Breakbone fever. What is dengue ? A disease occurring in the southern portion of this continent. It is especially characterized by sharp pains along the thighs and legs, and general soreness all over the body. It is also found in tropical and semi- tropical countries. Most authorities consider it to be both contagious and infectious. It is rarely fatal, and has no pathognomonic lesions. Describe its course. It begins suddenly with pain and stiffness in the muscles and joints. The pain is increased by motion, and there is a rapid but not very high rise of temperature. The pulse is frequent, and headache is sometimes marked. Pain increases for two or three days, and other symptoms become worse. Generally on the fifth day the pain diminishes or dis- appears, but it may recur. The temperature falls. At this time an eruption sometimes appears which takes the form of erythema, urti- caria, or umbiliform spots. This is usually attended with itching of the 40 INFECTIOUS DISEASES. skin. Serious nervous symptoms, sucli as delirium, are rare. Swelling of tlie l3^mpliatics often occurs. What is the treatment ? No treatment to abort the disease or limit it is known. Treatment should be directed toward improving the general condition of the patient and to general symptoms as they arise. YELLOW FEVER. What is yellow fever? An acute infectious disease of an epidemic nature, but endemic in small areas of country in tropical regions. What is its etiology? It is supposed to be caused by a specific micro-organism. It attacks strangers more frequently than those acclimated in the countries where it occurs. The mortality also is very much greater among foreigners than natives. Favorable conditions for its development are — high tem- perature, low barometer, dirty personal habits, and foul water. The specific poison is probably transmitted through the atmosphere, clothing, or fomites. Susceptibility to the disease seems to be universal, but the colored race appears to suffer less than the white. One attack generally secures immunity from subsequent ones. What is the pathology? ' There are no pathognomonic lesions, but the hepatic cells are generally found swollen and broken down, the tissue of the liver is yellow, and the blood is disorganized. There is jaundice of the skin, and often of other tissues. The changes of hemorrhagic nephritis are often found. What are the symptoms? The period of incubation lasts from one day to three weeks. Invasion is mostly sudden, but occasionally headache, sleeplessness, delirium, ver- tigo, nausea, and vomiting appear as prodromata. In cases of sudden invasion the patient is attacked with one or more chills or convulsions. There is a rapid rise of temperature (102°-105° F. ). The face is flushed. There are marked headache, pain in the back, and often constipation and vomiting. The pulse may be full and moderately rapid (80-100) or abnormally slow. Occasionally there is delirium. The urine is scanty. These symptoms last from two to six days, when the fever declines and the stage of calm begins. Then the temperature and pulse are about normal, and the pains disappear. In some cases convalescence some- times begins from this stage. Other cases go on to the third stage, in which there is marked vomiting of disorganized blood (black vomit). The patient is dull and apathetic, and the disorganized blood escapes into the tissues. The surface temperature is subnormal. The pulse is soft and compressible. Blood appears in the stools and urine, and may EPIDEMIC CEREBRO-SPINAL MENINGITIS. 41 exude from the mouth and nose. Stupor becomes more marked. The skin assumes a yellow hue (hemorrhagic jaundice). Cases which pass into the third stage generally end fatally. Where recovery takes place the convalescence is usually rapid. Occasionally cases are met with where the patient walks about until overcome with the severity of the disease. What is the diagnosis ? At the commencement of the disease diagnosis is not always easy, but the presence of other cases of yellow fever in like locality will be of great help. It should be distinguished from the severer forms of malarial fever, remittent fever, and jaundice of hepatic origin. What is the prognosis? The prognosis depends greatly on the severity of the epidemic and the early appearance of the so-called black vomit. What is the treatment? The disease cannot be aborted, but quarantine of the patient and thorough disinfection are necessary. In the beginning of the disease absolute rest and hot mustard foot-baths may be used. Opium will re- lieve the pains somewhat. For the fever cold sponging or the free in- gestion of small pieces of ice is of benefit. For the partial suppression of urine dry cups and diuretics are used. Alcoholic and other stimu- lants are given as necessary, and liquid food should be administered in small quantities at frequent intervals. For the cerebral symptoms the ordinary hypnotics are used. Black vomit should be combated by ab- solute rest for the stomach, mild counter-irritation to the epigastric re- gion, and fixation of the abdominal muscles by a broad pad. EPIDEMIC CEREBRO-SPINAL MENINGITIS. What is cerebro-spinal meningitis ? An infectious disease, characterized by inflammation of the membranes of the brain and spinal cord, and often accompanied by an eruption on the skin. What is its etiology? The first epidemic accurately observed occurred at the beginning of this centurj^ Sporadic cases occur occasionally. It is not known how the disease is transmitted, and it is not directly contagious. It is most commonly seen in childhood and young adult life, and is more frequent in winter and spring than at other seasons. What is its pathology? There is an exudative inflammation of the membranes of the brain and spinal cord, which closes up the cavities between the membranes, 42 INFECTIOUS DISEASES. and may even extend into the ventricles. Sometimes the inflammation extends to the substance of the brain, in which case it takes the form of a cerebral abscess. The micro-organism of the disease is a diplo- coccus. What is its course? The severity of cases difi'ers very materiajly. The most malignant cases only occur during the course of an epidemic. (1st) Should the case take on the malignant form, it begins with a sudden chill and rapid rise of temperature, quickly followed by uncon- sciousness, deep stupor, and death within a few hours. In ordinary cases prodromata are rare. The invasion, as a rule, is sudden ; there are either slight or severe chills. Headache is intense, and mainly in the back of the head. There are stiiFness and pain of the cervical muscles, and sometimes retraction of the head at this stage of the disease. But the fever varies greatly in intensity. The pulse is frequent, but afterward becomes abnormally slow. There are general muscular pains, but these are often succeeded by pain and some swelling in the joints. Delirium and great prostration from the commencement are sometimes present. The stage of invasion is followed by symptoms due to affection of the brain and spinal cord, such as headache, at first localized,_ then general and severe, and either continuous or intermittent ; also pain in the nape of the neck, caused by the spinal meningitis, and tenderness along the spine. Sometimes opisthotonos, drowsiness, _ delirium, restlessness, or insomnia, followed by stupor alternating with delirium, occurs. In children convulsions often take place, and contractions of the voluntary muscles frequently occur in all cases. (2d) Symptoms of a localized nervous character, such as strabismus, nystagmus, pupils at first contracted and afterward dilated, photophobia, contraction of the facial muscles and occasionally those of the jaw, then very acute hearing, followed by deafness, tinnitus aurium, cutaneous hyperaesthesia, and exaggerated cutaneous reflexes. All these sj^mp- toms result from implication of the roots of the various nerves or pressure upon them due to effusion. In cases where these symptoms are due to neuritis, they are often followed by hemiplegia, paraplegia, torticollis, aphasia, or blindness. (3d) Symptoms resulting from the constitutional infection most fre- quently seen are such as herpes, erythema or purpura, slight jaundice, polyuria or glycosuria. Where the patient survives any length of time the pulse becomes abnormally slow. The fever is very irregular, and rapid emaciation and great prostration occur. The_ skin is dusky and the tongue dry. There are often a muttering delirium, retention of urine, and involuntary discharge of faeces. The duration of the disease is generally from seven to twenty-one days, but convalescence in almost all cases is slow and tedious and in- terrupted by sequelae. HYDROPHOBIA. 43 What is the prognosis? Where patients live to the second or tliird week of the attack the prognosis is usually favorable, but relapses ma}' occur from exciting causes. Epidemics in which eruptions of the skin are common are gen- erally attended with the greatest mortality. From what should it be diagnosed? From tubercular meningitis and from other acute eruptive diseases which may be ushered in with cerebral symptoms, also from croupous pneumonia complicated by meningitis. It may occasionally be con- founded with spurious hydrocephalus. What are the more common sequelae? Persistent deafness, affections of vision, chronic hydrocephalus, mental impairment, hemiplegia, paraplegia, aphasia, and acute endocarditis. What is the treatment? The patient is to be put abed, and none but liquid diet allowed. In young adults of full habits moderate bleeding in the first days of the disease is sometimes of benefit. Blisters on the nape of the neck or ice on the head or along the spine ma,y be used. Internally, fluid extract of ergot and potassium iodide, with bromides, chloral, or some prepara- tion of opium to quiet the cerebral symptoms. Special treatment for the fever is rarely necessary. For heart failure alcohol, strophanthus, digitahs, and caffeine are given. For the vomiting minim doses of carbolic acid, with or without drop doses of tincture of iodine, also sodium bicarbonate and oxalate of cerium. Special care should be taken to prevent the rectum or bladder from becoming overloaded. HYDROPHOBIA. What is hydrophobia? A disease caused by inoculation with the virus of a rabid animal. What is its etiology? The poison is supposed to be contained in the saliva or blood of a rabid animal. In a large proportion of those bitten the parties escape infection, as they never exhibit the disease. The incubation period is generally from three to six months in duration, although it may vary greatly. What is its pathology? There is a congestion of the membranes of the brain and of the sub- stance of the spinal cord, with an increase in the amount of the cerebro- spinal fluid. There is also a degeneration of the ganglionic cells of the chord. 44 INFECTIOUS DISEASES. What is its course ? It generally begins with malaise, headache and general uneasiness, painful sensations in the cicatrix if there is such, and a marked aversion to liquids. In one or two days the hydrophobic stage begins. Tonic spasms of the pharyngeal muscles, of the respiratory muscles, and of those of the trunk and extremities. The convulsions are reflex. They are especially excited by attempts at swallowing. The convulsions last from a few minutes to half an hour. There is great mental excite- ment, sometimes delirium or mania. Great thirst and marked saliva- tion. The pulse is very full. Temperature is somewhat increased. This stage lasts from one to three days, when death occurs after violent convulsions or is preceded by a stage of paralysis and coma. Recovery hardly ever occurs. What is the diagnosis? The diagnosis is generally easy. The disease should be distinguished from traumatic tetanus and poisoning by the alkaloids, causing acute neurotic symptoms. What is its treatment? All wounds should be cauterized. Inoculation with attenuated virus (Pasteur) is much used. The treatment of the acute attack consists in mitigating the patient's sufferings by the use of narcotics and antispas- modics. MUMPS. Syn. — Parotitis. What is parotitis? An acute specific disease of an infectious nature, characterized chiefly by inflammation of one or both parotid glands. What is its etiology ? It generally occurs in epidemics in children or young males. It is directly contagious. The incubation period is about two weeks. What are its symptoms and its course ? There may be lassitude, slight headache, constipation, and a feeling of stiffness of the jaws for one or two days. Then one of the parotid glands begins to swell. The swelling rapidly increases, with oedema of the tissues surrounding it, although abscess rarely forms. The local dis- comfort is moderate and the fever generally slight. In men this disease is frequently complicated by swelling of the testicles, and in women by swelling of the breasts. What is the treatment ? Patients are to be kept abed and protected from draughts. Pain from the tension of the skin over the gland, caused by the swelling, is much TRICHINOSIS. 45 relieved by greasing with vaseline or painting witli iodine, with the ap- plication of an ice-bag. The diet should be liquid, and the bowels should be kept open by mild aperients. TRICHINOSIS. What is trichinosis ? A disease caused by the ingestion of meat infected with trichinge, and characterized by symptoms due to the development of the parasite in the system. What is its etiology? The encapsuled parasite, on being brought into the intestinal tract and there subjected to the action, of the digestive juices, is liberated. It proliferates, and migrates into the muscles, where it generally becomes encapsulated. When the muscle trichinae reach the stomach they be- come intestinal trichinae in from two to three days. The uteri of the females contain the ova, and the embryos are born seven days after ingestion. What is its pathology? The only characteristic change is found in the muscles. This consists in the presence of trichinae. These are found most frequently in the diaphragm, the intercostal, laryngeal, and pharyngeal muscles, and also in the muscles of the calf and biceps. The fibrillae of the muscles are often found in a granular condition, containing molecules of fat, and encapsulated therein the round worm, curled in a spiral form. The intestinal mucous membrane is sometimes hemorrhagic. What is its course ? After the ingestion of infected material the patient has a feeling of pressure in the stomach, attended with nausea and vomiting. These symptoms occur in from two days to three weeks. There is generally diarrhoea, but ^occasionally obstinate constipation is met with. In the second week severe muscular pains come on ; the muscles frequently are swollen and tender. The patient by preference lies motionless. Mastica- tion, respiration, and deglutition are generally difficult. Occasionally there is general oedema, cutaneous eruptions, or free perspiration. Fever is generally absent or slight. In cases where the fever is marked the patient frequently rapidly passes into a typhoid condition, followed by death. Painful contractions of the muscles of the foot are often met with. What is its treatment? Narcotics and poultices for the relief of pain, and cathartics in the early stage of the disease, are indicated. Kectal alimentation may be 46 INFECTIOUS DISEASES. necessarj", owing to difficulty of deglutition. Other treatment is symp- tomatic. WHOOPING COUGH. Syn. — Pertussis. What is whooping cough ? A contagious disease, characterized by a peculiar violent, convulsive, and strangulated cough, occurring in paroxysms. What is its etiology? It generally occurs with epidemics of measles. The contagion is sup- posed to be carried by the air from the secretions of the mucous mem- brane of the throat and nose. It is rare in adults. What are its symptoms? The incubation period is uncertain : it begins with a catarrhal condi- tion of the conjunctivae and nasal mucous membranes, attended by cough. This cough is at first dry, but afterward becomes of a moist character. This stage lasts from two days to three weeks, and is fol- lowed by the spasmodic stage. The cough now occurs in paroxysms and begins abruptly : it consists of a number of short, quick, spasmodic, expiratory puffs, followed by a lono-, shrill inspiratory sound. During the paroxysmal attack the patient is often cyanotic, and slight hemor- rhages from the naso-pharyngeal membrane maj^' occur. Sometimes the paroxysms are followed b}^ vomiting, or in young children by convulsions. The paroxysms vary in frequency, from fifteen to as many as thirty times in the twenty-four hours. This stage lasts from three weeks to three months. Between the paroxj'sms the patient often appears per- fectly well ; other general sj^mptoms in this disease are rarely marked. What are the complications and sequelae? The most frequent complications are pneumonia, emphysema, subacute bronchitis, tuberculosis, diarrhoea. Sequelae are not marked, but extreme prostration and protracted emaciation are most frequent. What is its treatment ? There is no specific treatment. Isolation is of doubtful efficacy. In the treatment of the disease fresh air is of the utmost importance. In- halations of carbolic acid, turpentine, or vapor of benzoin preparations are used. Internally, quinine, belladonna, and hypnotics are given. In cases where the paroxysms are especially severe chloroform ov ether may be administered if extreme care is used. Insufflation of quinine or boric acid is often of benefit. DISEASES OF THE RESPIRATORY ORGANS. 47 DISEASES OF THE RESPIRATORY ORGANS. OORYZA. Syn. — Cold in the head. What is coryza ? A catarrhal condition of the mucous membrane of the nasal cavities, frontal sinuses, and of the naso-pharj^nx. What is its etiology ? It is the result of exposure to cold or to chemical, vegetable, or me- chanical irritants. According to some observers, certain forms of it are contagious. It also appears as a complication to many diseases. What are its symptoms? In mild cases the symptoms are local only. The secretion from the nasal mucous membrane is at first scanty ; later on this becomes more abundant and watery. The nasal cavities are closed, and there is swell- ing of the mucous membrane. In children this condition is accompanied by dyspnoea. The sense of smell is diminished or abolished. The flow of mucus from the nasal cavities causes superficial dermatitis and ex- coriation of the upper lip, attended by some pain. In cases where the inflammation of these mucous membranes spreads to adjoining parts the symptoms are more severe. Headache becomes marked, and con- junctivitis, pharyngitis, or a mild form of laryngitis may develop. The temperature is generally but slightly influenced, but in severe cases may reach 103° F. at the beginning of the attack, when there is also chilli- ness, a general sense of weakness, and a soreness of all the muscles of the body. These symptoms last from two days to a week, and a steady convalescence commences. In elderly people or in those weakened by previous severe constitutional diseases there is danger of chronic bron- chitis from extension of the inflammation. What is the treatment? If the secretion is abundant, inhalations of the vapor of terebene, carbolic acid, iodine, and ammonia together, or iodine alone, often give relief. Where the disease assumes a subacute form, the use of astrin- gent sprays or astringent and sedative snufls is indicated. Internally, the ammonium salts, small doses of tartar emetic, or tincture of aconite, frequently repeated, are of benefit. Complications, either laryngeal or pulmonary, are to be treated as they arise. ACUTE PHARYNGITIS. Syn. — Sore throat. What is sore throat? An inflammation of the pharynx, limited to the mucous membrane, and attended by redness and swelling. The affected parts are at first 48 DISEASES OF THE RESPIRATORY ORGANS. dr}', and afterward covered with a thick coating of glairy mucus. Oc- casionall}", the surface of the tonsils is mottled with small white patches, due to the collection of coagula or mucus thereon. What is its etiology? Some persons seem to be much more liable to the disease than others. It is very common in young people, and recurrent attacks are frequent. The chief causes are exposure to cold, the inhalation of irritating gases, and unaccustomed and long-continued use of the voice. Sedentary habits and poor ventilation are predisposing factors. What are its symptoms? Difficulty in swallowing, a feeling of general malaise, and slight fever. At first a feeling of itching and dryness in the throat, followed hj a tendency to expectoration, due to increased activity of the salivary glands. What is its treatment ? Treatment consists in the use of astringent and antiseptic gargles and sprays of a like character. Insufflation of mild alkalies, bicarbonate of soda, etc. is beneficial. ACUTE TONSILLITIS. What is acute tonsillitis? An acute inflammation of the tonsils, which may assume various forms of intensity'. What is its etiology? It generally occurs in one of three forms — either catarrhal, follicular, or suppurative. The catarrhal and follicular forms are caused by ex- posure to cold or the inhalation of irritant material. The suppurative form is found most frequently in those of a rheumatic diathesis. What is its pathology? In the catarrhal form there are swelling of the mucous membrane and excessive secretion from the mucous glands. In the follicular variety the whole tonsil appears red and swollen, and dotted over its surface with numerous small white points, which cannot be brushed ofi". On pressure around these points a small plug of cheesy material exudes from the lacunae. In the suppurative form the tonsil at first is univer- sally enlarged and resistant to pressure; the surface is intensely con- gested ; later on the substance of the tonsil is apparently fluctuating, and frequently a round white spot appears on its surface.^ In suppura- tive tonsillitis complicating infectious diseases the tonsil_ may become necrotic. All forms of the disease may afl"ect both tonsils. What are the symptoms? The symptoms difi"er greatly according to the form of the attack. In ACUTE CATARRHAL LARYNGITIS. 49 the Qata"i;i'lial form fever is slight or absent, difficulty in deglutition is slight, and cough is not marked. In the follicular form there may be considerable difficulty in swallowing. Fever ranges from 100° to 102° F. There is general malaise, a feeling of soreness ; also headache and constipation. Cases of this character generally last from three days to a week. In the suppurative parenchymatous form, the so-called quinsy sore throat, the attack is generally ushered in by a chill, a marked rise of temperature, 101°-104° F., and much difficulty in swallowing. The other constitutional symptoms are also marked. On examining the throat the affected tonsil or tonsils are seen as a large, hard, red swell- ing. Where the disease is unilateral, this is often great enough to en- croach upon the base of the uvula and force it to the opposite side. There are generally pain and stiffiiess of the muscles of the jaws, and the patient is forced to breathe through the mouth, owing to the partial closure of the naso-pharynx by the swelling. Headache is not often marked, but anorexia and constipation are always leading symptoms. The pulse is quick, full, and tense. All these symptoms increase in severity up to, from the seventh to the tenth day of the disease, when the inflammation results in resolution or abscess. Recurrent attacks, every year, of this parenchymatous form are very common. What is the prognosis ? In all forms of the disease the prognosis is favorable, except in cases complicating severe constitutional affections. What is the treatment? The treatment of the catarrhal form is the same as that for acute pharyngitis. In the follicular variety the same general plan of treat- ment may be used, but also touching the inflamed lacunae with a solu- tion of nitrate of silver (10 gr. to ^j) or the solid stick of lunar caustic, or with compound tincture of benzoin, is of great use. In the suppurative form an hepatic stimulant, followed by a saline aperient, should be given at first. The strength of the patient is to be kept up by moderate stim- ulants and concentrated food. Locally, hot poultices about the neck, with astringent and antiseptic gargles, may be used in the first stages of suppuration. As soon as pus appears the tonsil should be opened. High temperature may be combated by antipyretics. ACUTE CATARRHAL LARYNGITIS. What is acute catarrhal laryngitis ? An acute inflammation of the mucous membrane of the larynx. What is its etiology ? It is generally caused by taking cold or by direct mechanical or gaseous irritants, and it often complicates other diseases. 4— P. M. 50 DISEASES OF THE RESPIRATORY ORGANS. What are the symptoms ? The s3'mptoms differ greatly with the variety of the disease. In mild cases there are a slight febrile movement, partial loss of voice, and an occasional hoarse, barking cough. In these cases pain in the larynx and dyspnoea are generally slight. In the more severe cases, and generally in those which occur in children, there are chilly sensations, slight ano- rexia, partial or total loss of voice, considerable dyspnoea and pain in the larynx, and a barking, stridulous cough, paroxysmal in character. In all cases the mucous membrane of the larynx is more or less red and swollen, at first dry, and afterward covered with white tenacious mucus. The attacks usually last from a few days to two weeks, and are liable to recur. What is the differential diagnosis ? The disease is liable to be confounded in children with croup, and also with scarlet fever (with marked throat symptoms) and diphtheria. It should be distinguished from croup by the difference in temperature, the attacks sometimes occurring in the daytime, the absence of cyanosis, and dj^spnoea being slight ; from scarlet fever it may be distinguished by the redness and swelling of the mucous membrane of the fauces and tonsils, also by the high temperature and severe constitutional symptoms at the beginning of the attack ; from diphtheria it is often impossible to make the diagnosis in the earlier stages of the disease, but a history of chill, extreme prostration, difficulty in swallowing, and high temperature ought to lead one to suspect diphtheria. What is its treatment? All injurious causes should be removed ; the patient should be kept in a room of even temperature, and have plenty of warm demulcent drinks. The inhalation of hot steam, or of steam combined with the vapor of antiseptic or astringent drugs, gives much relief Poultices or hot compresses to the neck may be used. In children at the beginning of the attack an emetic may prove of benefit. Narcotics where the paroxysms are severe may be used with caution ; also in such cases, when attended with cj^anosis, ether in stimulant doses (by inhalation) is often followed by good results. CROUP. What is croup? A disease of childhood, characterized by an acute inflammation of the larynx and trachea, generally accompanied by the formation of a fibrin- ous exudation on the affected parts. What is its pathology? The mucous membrane of the larjmx, trachea, and occasionally the upper bronchi, is swollen and hyperaemic, and contains a great number of leucocytes. It is covered by a membrane consisting of coagulated CROUP. — ACUTE BRONCHITIS. 51 fibrin, wtiicli can, as a rule, be readily stripped off from the underlying mucous membrane. What are its symptoms? The disease often begins insidiously. There is slight difficulty of res- piration, which becomes more marked at night. There may be slight cough and hoarseness of the voice, with moderate fever. In two or three days the symptoms of obstruction, due to exudation in the air- passages, develop, and at night there are intense paroxysms of cough- ing, attended with dyspnoea and cyanosis. The fever then increases somewhat, the cough becomes stridulous, and often a whistling sound is heard with inspiration. In a variable time (two to seven days) the cough becomes looser, and portions of the detached false membrane are often ex- pectorated. In cases which have a fatal termination the end is preceded by increasing cyanosis ; the voice is generally lost or sinks to a whisper ; all the auxiliary muscles of respiration are called into play ; and the patient succumbs to the want of oxj^gen. In many cases there is a temporary improvement in the symptoms, often followed by a more severe and frequently fatal attack. From what should it be differentiated? From acute catarrhal and croupous laryngitis or tracheitis, from the initial stage of scarlet fever when attended by severe throat symptoms, from diphtheria, and from acute follicular tonsillitis ; also from thecroupy, bark- ing cough of young children with intestinal irritation. Whooping cough may be mistaken for this disease in its initial stage. Close observation of the patient for twelve to twenty-four hours will prevent any false diagnosis. What is its treatment? Patients subject to this disease should be warmly, but not too heavily, clothed. Indoors they should not be subjected to sudden changes of temperature. The internal treatment of the attack is often begun by giving an emetic of hot water, s.vrup of ipecac, or mustard and water, followed afterward by doses of the bromides, repeated at frequent in- tervals. For the local congestion and spasm of the larynx the applica- tion to the throat of hot cloths or sponges wrung out in hot water and mustard seems to give the greatest relief If the attack should last a number of daj^s, the patient must be fed on liquid diet, and generally alcoholic stimulants are found necessary. Should cyanosis develop, the inhalation of oxygen gives relief, but this improvement is generally but temporary. In cases of marked laryngeal obstruction intubation or tracheotomy may become necessary. ACUTE BRONCHITIS. . What is acute bronchitis ? A catarrhal inflammation of the bronchial tubes. 52 DISEASES OF THE RESPIRATORY ORGANS. What is its etiology ? It appears most common in early or advanced age, and the more fre- quent predisposing causes are pernicious habits, chronic pulmonary or cardiac disease, a debilitated condition of the system, living in a damp climate, and certain occupations. The predisposition to the disease varies greatly. The most common exciting causes are catching cold, the extension of the inflammation from the mucous membrane of the larynx, or direct irritation from mechanical or chemical agents. It is frequently a symptom or comphcation of infectious diseases. What is its pathology? The changes are found in the trachea and in the large and medium- sized bronchi. The mucous membrane is red and swollen, at first dry and afterward covered with a glairy mucus. Owing to the swelling of the mucous membrane the lumen of the bronchi is narrowed. Exten- sion to the bronchioles is rare. What are the symptoms? The symptoms vary with the age of the patient. In mild cases in adults there are cough with scanty expectoration, a feeling of tightness over the front of the chest, and general malaise. This class of cases generally lasts one week. In severe cases, in adults, the cough is more marked, and is attended with copious mucous expectoration, sometimes streaked with blood. The attack is attended with slight dyspnoea, and the general symptoms are quite marked. These cases last about two weeks, but sometimes become chronic where the disease occurs in old people. There is much prostration, accompanied by some rise in tem- perature, which is very apt to be irregular. Both inspiration and expi- ration are much impeded. The cough is very troublesome, being at first dry, and afterward attended by the expectoration of large quantities of white glairy mucus. Delirium is sometimes present, and there is pro- gressive loss of appetite and strength, attended by emaciation. The pulse is quick, small, and feeble. Should there not be improvement in two weeks, the disease often ends fatally. In young children, owing to the bronchi taking up a large part of the lungs, an inflammation of the mucous membrane of these tubes gives rise to great dyspnoea. These cases, as a rule, are preceded by inflammation of the mucous membrane of the upper air-passages. In severe cases there may be convulsions, high fever, and rapid pulse. The attacks generally last two weeks, but in- fants, especially those with unhygenic surroundings, often succumb early to the attack. What are its physical signs ? The physical signs differ greatly, according to the age of the patient and the time the examination is made. As a rule, vocal fremitus is unchanged in children. There may be slight dulness on percussion, and in old people this sign is often marked over the bases of the lungs pos- CHRONIC BRONCHITIS. 63 teriorly {bypostatic congestion). The voice is unchanged, and also the breathing, though in severe cases expiration is somewhat prolonged. With both inspiration and expiration large and small moist sibilant and sonor- ous rales are heard. The number and intensity of these rales will depend greatly on whether the examination is made just before or after a parox- ysm of coughing. From what should it be diagnosed? From whooping cough, pneumonia, acute tuberculosis, and the various forms of laryngitis. Pleurisy is occasionally mistaken for this disease. What is the prognosis? Prognosis will depend greatly on the age of the patient. In those in the prime of life it is rarely fatal, except as a complication of infectious diseases, heart disease, or where the hj^gienic surroundings are bad. It is often fatal in infants or the aged, and a guarded prognosis should always be given in these cases. What is its treatment? At the commencement of the attack free action of the skin should be encouraged by hot drinks, saline diaphoretics, or Dover's powder in small doses. Should the patient be robust and the attack begin in a severe form, moderate bleeding may be used. Tightness across the chest is often much relieved and expectoration increased by the application of flaxseed-meal poultices to the chest. Internally, the expectorants, com- bined with sedatives or antispasmodics if the cough is annoying, may be used. Also for dyspnoea or the dry cough medicated vapors give great relief Where the disease occurs as a complication of infectious diseases or heart affections, and also when occurring in old people, the free use of stimulants is necessary. Antipyretics are rarely needed. CHRONIC BRONCHITIS. What is chronic bronchitis ? A catarrhal inflammation of the bronchial tubes of a chronic cha- racter. What is its etiology ? It frequently follows repeated attacks of the acute form. It also often complicates the gouty or rheumatic diathesis, and is very frequent in old people. Heart disease and other chronic disturbances of the circulation dispose toward it. What is its pathology? There is a continuous excessive secretion from the mucous glands of the bronchi. As a result of this the glands and surrounding tissue be- come hypertrophied, and the walls of the bronchi thicken and their calibre is decreased. 54 DISEASES OF THE EESPIRATORY ORGANS. What are its symptoms? In mild cases there is only occasional cough and expectoration of frothy mucus, unattended by constitutional disturbance, with the excep- tion of slight fever. There may be a constant feeling of weight over the chest, but dj^spncea is not marked. In the severer cases the cough is often paroxj^smal, and is worse in the morning and evening. The expectoration is profuse and muco-purulent in character. Fever of a mild type is usually present, but is irregular. There is slight constant or spasmodic dj'spnoea. What are its physical signs? The vocal fremitus and voice show no marked changes. The percus- sion note is normal, but sometimes there is a comparative dulness at the bases of the lungs posteriorly, xlll over the chest are heard whistling rhonchi with coarse and moist rales. Vesicular murmur shows no marked changes, but expiration is prolonged. What is its prognosis ? Owing to the course of the disease being generally very long, a guarded prognosis should always be given. The disease itself is rarely fatal, but elderly people often succumb to intercurrent affections. What is its diagnosis? It may be mistaken for tuberculosis, emphj^sema, or the bronchor- rhoea due to chronic cardiac disease or chronic disease of the liver and kidneys. What is its treatment? As the disease occurs most frequently in winter, the patient should go to a suitable climate if possible. During the attack the patient should be kept in a room of an even temperature, and if expectoration is scant}^ the air should be kept moist by means of aqueous vapor. Poultices at night over the chest will often relieve the tightness and sense of weight. Internally, the various salts of ammonia, the alkalies, and iodide of pot- ash are extensively used. Inhalations of steam medicated by the addi- tion of oil of turpentine, terebene, tincture of iodine, or the tincture of benzoin may be employed. The pneumatic cabinet has been exten- sively used. ASTHMA. What is asthma? A spasmodic contraction of the bronchi. What is its etiology ? Theories as to its origin differ greatly. Some say it is due to a sudden swelling of the mucous membrane of the bronchi, and others to a tonic spasm of the muscles of the smaller bronchi. There may be an heredi- PULMONARY EMPHYSEMA. 55 tary. pre^disposition to it. Diseases of the pharynx or nose and the in- halation of certain odors can produce it. It is frequently a complication of bronchitis of old people, advanced heart disease, or of nephritis in various stages. What are its symptoms? In its typical neurotic form it attacks the patient suddenlj^, and chiefly at night. The patient awakes with a feeling of oppression and discom- fort, and has to gasp for air. Both inspiration and expiration are diffi- cult, and the auxiliary muscles of respiration are called into play. The pulse is markedly quickened, and is either full and bounding or small and thready. Fever is absent or very slight. In severe cases there is sometimes slight cyanosis, but a pinched expression of the face and blue- ness of the lips are frequent. The attack may last from a few hours to several days. What are its physical signs? The vocal fremitus is somewhat increased, also the vocal resonance. On percussion there is a deep wooden sound, inspiration and expiration are both prolonged, and the vesicular murmur is accompanied by sibilant and sonorous rales. What is its diagnosis ? It may be mistaken for spasm of the glottis, pseudo-angina pectoris, or very rarely for spasmodic croup in adolescence. What is its prognosis? The prognosis^ as regards the attack itself, is favorable. Attacks are very liable to recur, and complete immunity from them is rare. What is the treatment? Patients should, if possible, live in a locality where experience teaches them they are free of attack. For the attack iodide of potash in large doses, nitro-glycerin, quinine, the bromides, or belladonna may be used. For the relief of the spasm inhalation of the iodide of ethyl or the smoke from burning stramonium, hyoscyamus, pyridine, or saltpetre are of benefit ; and internally, the narcotics, lobelia, quebracho, grindelia, or hyoscyamus, in small and frequently repeated doses. PULMONARY EMPHYSEMA. What is pulmonary emphysema? An abnormal dilatation of the air- vesicles of the lungs, often attended with intra-coUapse of the walls of neighboring vesicles. What is its etiology ? The most common predisposing cause is loss of elasticity of the walls of the pulmonary vesicles, attended by increased extra- or intravesicular pressure. The exciting causes are pressure on the walls of the vesicles, 56 DISEASES OF THE RESPIEATORY ORGANS. due to chronic disease of the heart or other diseases, causing obstruction of the pulmonary circulation, or else sudden excessive dilatation of the alveoli, with rupture of their walls. This is due, in most cases, to for- cible inspiration, such as occurs in asthma, and as the result of various occupations in which the respiratory organs are brought into excessive and. prolonged action. What is its pathology? In old people this condition is often found as a natural result of the general decay and atrophy of the organs. The lungs, instead of having a bright-red color, present graj^ish spots in places. On pressure of the lung-substance a crackling sensation is felt, and on section small cavities are seen. What are its syinptoms ? The disease is a very chronic one in its development, and is secondaiy to other diseases. The symptoms attending it are those of the compli- cating affection. From the lack of oxj-genating surface due to the de- struction of the air-cells, there is dyspnoea, especially marked on exer- tion, and cyanosis. The affection is often attended by a hacking cough and an expectoration of mucus streaked with blood, and hemoiThages small in quantity. The urine is generally scanty in quantity, and con- tains a large amount of urates. Patients with this affection generally suffer from chronic constipation. What are its physical signs ? On inspection the upper portion of the chest is seen to be very broad (barrel-shaped), vocal fremitus is decreased, and the percussion note is high-pitched (hyper-resonant), and at the base of the lungs has a wooden character. On auscultation the vesicular murmur is feeble, and expira- tion is generally attended by whistling rhonchi of a dry character. In- spiration is short and expiration prolonged. The heart-sounds are often faint and distant, but the second sound is frequently accentuated. From what should it be diagnosed ? From asthma in its various forms, and the dyspnoea caused by chronic cardiac, nephritic, or hepatic disease. What is the treatment? Owing to the nature of the disease it cannot be cured. Treatment should be directed to allaying the symptoms. PLEURISY. What is pleurisy ? An inflammation of the mucous membrane covering the surface of the lunsfs and hnins; the internal wall of the chest. PLEURISY. 57 What. is its etiology? I'he most frequent cause is exposure to wet and cold. It also occurs as a complication in pneumonia, where the inflammation spreads to the surface of the lung. In cases where tubercular deposits or neoplasms are situated on the surface of the lungs, local pleurisies often result. Traumatism and extension of inflammation from neighboring parts are a frequent cause of the disease. In cases of general blood-poisoning this membrane, in common with other serous membranes, is very liable to inflammation. What is its pathology? It takes one of three forms : there may be effusion of serum alone, of serum and fibrin with resulting adhesions, and of serum, fibrin, and pus in the cavity bounded by the pleura. The pleura is of a dull-red color and covered here and there with patches of white fibrinous exuda- tion. Threads of fibrin extend from the costal to the pulmonary pleura, and in the pleural cavity a quantity of fiuid may be found, vary- ing according to the type of the disease. This fluid may be serous, sero- purulent, or hemorrhagic in quality. In some cases the effusion of serum is very slight, and becomes rapidl}^ organized, these constituting the so-called cases of dry pleurisy. What are the lesions of dry pleurisy ? The inflammation begins in the costal pleura and extends to the pul- monary pleura opposite. As a rule, only a circumscribed area of the pleura is involved. This area is coated with a thick layer of fibrin. What are the causes of dry pleurisy ? It is caused by direct irritation of the pleura from injury, cold, exten- sion of inflammation from neighboring parts, blood-poisoning, and from various other causes, and often occurs as a complication of severe consti- tutional affections. What are its symptoms? There are slight cough, accelerated breathing, and a stabbing pain in the sid-e, especially marked on deep inspiration. This is generally felt in one axillary line or under the angle of the scapula. This pain is often so severe as to apparently cut short the breath. The temperature ranges from 99°-101° F. The pulse is somewhat accelerated at the beginning of the attack. Headache (frontal) is generally present, but is not severe, and malaise is not marked. What are its physical signs? Pulmonary signs are normal, except over the affected area. Over this space vesicular murmur is often feeble, and with both inspiration and expiration a friction murmur is heard. At the first this murmur is soft in quality, but as the disease progresses it becomes harsh and loud, and is heard with inspiration and expiration. As the attack subsides the 58 DISEASES OF THE RESPIRATORY ORGANS. friction murmur resembles the moist rales of capillary bronchitis, but is heard on both inspiration and expiration, and is not changed in quality by forced breathing or coughing. What is the duration of dry pleurisy ? In almost all cases the exact duration of the attack cannot be fixed, as many cases are unattended hy pain or general symptoms. Where the disease is well marked the attack generally lasts from seven to twelve daj's. What is the treatment? Most cases require no treatment except keeping the patient in an even temperature. In the more severe cases poultices or counter-irritants may be applied to the aifected part. Narcotics in small doses may be necessary to relieve the cough or pain in the side. Fixation of the chest by means of plaster straps is of value. What are the lesions of pleurisy with effusion ? In pleurisy with eifusion the inflammation is more extensive than in the dry form, and sometimes the pleuree of both sides are involved. The pleural membrane is covered with a thick coating of fibrin, but there is also a large effusion of serum. In many cases this effusion of serum causes more or less compression of the lung. Adhesions between the costal and pulmonary pleura are much more extensive and frequent after pleurisy with effusion than after dry pleurisy. What are its causes? The causes are the same as those producing the dry form. What are its symptoms? The symptoms are similar to those of dry pleurisy, but generally more severe and acute. The disease begins with chilly sensations or a marked rigor, and a temperature of 100°-102° F., with general muscular pains and prostration. The marked pain at the end of inspiration is often absent, but the cough is more frequent and is dry in character. As the disease progresses more or less dyspnoea develops, and should the lesion be on the left side there may be cardiac palpitation and irregularity, due to the displacement of the heart. What are the physical signs? When the disease commences the physical signs are similar to those of dry pleurisy. As the effusion takes place, at the level of the fluid and below, there is absence of voice and vesicular murmur, and vocal fremitus and flatness on percussion occur above the level of the fluid. The percussion note is generally tympanitic, and the vesicular murmur has an exaggerated broncho-vesicular note. In subacute or chronic cases of pleurisy with effusion the affected side often appears the more promi- nent. On recovery flatness on percussion often persists over the affected lunof. PLEURISY. 59 Wh^t is the duration of the disease ? The disease always lasts a number of weeks, and is often protracted for a long time. Where it occurs as a complication of other diseases it sometimes ends fatally. Most cases recover with a damaged pleura, w^hich forms a favorable nidus for the development of phthisis. What is its treatment? In the acute stage, externally, poultices and counter-irritants may be used with narcotics for the relief of pain. Where the disease is uni- lateral, strapping the chest with adhesive plaster gives great relief. The bowels should be kept open and the heart stimulated where neces- sary. After the acute symptoms have subsided the use of saline cathartics and diuretics is indicated to reduce the effusion. During con- valescence especial attention should be directed to building up the gen- eral condition of the patient, remembering the possibility of heart failure on exertion. After recovery some form of athletic exercise, to increase the expansive power of the lungs, and thus reduce the probability of phthisis, is indicated. What are the lesions of empyema ? Only one side of the pleural cavity is, as a rule, aifected. The pleura is coated with fibrin containing many pus-cells, and its cavity contains a variable quantity of purulent serum. Generally the amount of effusion is sufficient to compress the lung of the affected side. What are its causes? The causes are similar to those leading to the other forms of pleurisy, but this form occurs more frequently in patients who are phthisical or have been living in unhygienic surroundings. What are its symptoms? If it follows pleurisy with effusion or the dry form, the symptoms are those of that form ; but where it begins as a purulent effusion, the attack is ushered in by a marked chill. The temperature rapidly rises often to 104° F., and there is a feeling of weight in the affected side. Dyspnoea is quite marked and prostration is extreme. The beginning of the attack is also generally attended by sweating. These symptoms persist for a w^eek ; then loss of appetite becomes marked, and there is progressive loss of flesh and strength. After the first few days pain (pleuritic) is either absent or very slight, the patient has attacks of sweating at ir- regular intervals, and the temperature is very variable (pyaemic). In cases where the disease progresses without operative interference the general symptoms become more marked and the patient dies of exhaus- tion, generally attended by coma and apncea, which is often preceded by a typhoid condition. What are its physical signs? The physical signs are those of pleurisy with effusion, but the dulness 60 DISEASES OF THE RESPIRATORY ORGANS. on percussion and loss of vesicular murmur is often more marked, and the inspiratory movement of the chest is less noticeable. What is its prognosis ? The prognosis is always uncertain. It is most favorable in children and young adults who are operated upon early in the course of the disease. In very young children, in adults over thirty years of age, and in all cases where the disease occurs as a complication of other diseases the prognosis is unfavorable. From what should it be diagnosed ? From pneumonia, acute phthisis, abscess of the liver, and acute pleu- risy, particularly on the right side, with effusion. What is the treatment ? Aspiration should be tried first, but if the purulent fluid reaccumu- lates, a free incision with resection of a rib should be made and drain- age established. This incision is made preferably in the posterior axillary line at the level of the sixth rib. TUBERCULAR PLEURISY. What is tubercular pleurisy? A localized tubercular inflammation of the pleura which usually affects a portion or the whole of the pleura of one side. This is often secondary to tuberculosis of the adjacent parts. What are the pathological changes? The pleural membrane appears bright-red in color and mottled with small white spots of tubercular tissue, and the pleural cavity contains more or less bloodstained purulent fluid. What are its symptoms? The initial symptoms resemble those of pleurisy with effusion, but fever is more marked. The fever often has an intermittent character, and the attacks are followed by sweating. The patient, instead of im- proving, slowly becomes worse, and finally succumbs to the disease. What are the physical signs? The physical signs are those of pleurisy with eff'usion, to which are often added the graver signs of empyema. What is the treatment? Treatment locally should be directed to the alleviation of pain. The general treatment is that of tuberculosis. PNEUMOTHORAX. 61 . "/. PNEUMOTHORAX. What is pneumothorax? A collection of air in the pleural cavity. What is its etiology ? Usually caused by penetrating wounds of the chest, by the perfora- tion of a tubercular pulmonary cavity into the pleura, or by a perforating abscess of any of the surrounding organs. What is its pathology? The lung is retracted and compressed against the upper and inner part of the pleural cavity. If this condition has lasted many hours, the surface of the pleural membrane is covered by a layer of glairy lymph, and a small amount of eifusion may be found at the base of the pleural cavity. Should the patient live a longer time, the surface of the pleura may be covered by fibrin, and the pleural cavity is more or less filled with serous or sero-purulent fluid. What are the symptoms ? The onset is very sudden ; generally there are symptoms of profound collapse. The patient is either pale or cj^anotic, breathing is short and quick, and severe pain is felt in the side. On forced inspiration the movement of the affected side is hardly noticeable. Should the pneu- mothorax be caused by empyema or abscess of the lung perforating into the pleural cavity, there will be marked expectoration of pus. A hack- ing cough, attended by the expectoration of frothy mucus, is generally present. What are its physical signs? The percussion note is loud and deep, extending beyond the limits of normal lung percussion. Should the perforation be on the right side, the normal area of liver dulness is decreased, respiratory murmur is ab- sent, and amphoric breathing is generally present. Vocal fremitus is diminished or absent. Usually we get splashing sounds (succussion) if the patient is shaken with the ear applied to the chest. What is the result of pneumothorax ? In many cases death ensues in a few hours, especially where the per- foration of the pleural cavity is external. Where the perforation is that of the pulmonary pleura, recovery sometimes occurs, but the patient gen- erally succumbs to the underlying disease. What is its treatment? For severe pain morphia should be used, and if the pneumothorax is followed by large eifusion, aspiration may be necessary. Beyond this t7'eatment is governed by the causes of the pneumothorax. 62 DISEASES OF THE RESPIRATORY ORGANS. HYDRO- AND H^MATOTHORAX. What is meant by hydro- and hsematothorax ? An eifusion of serum or sero-sanguineous fluid into the pleural cavity. What is their etiology? They ma.y be caused by obstruction of the venous circulation, by malignant disease of the- pleura, or by traumatic laceration of the pleural or pulmonary blood-vessels. What are the symptoms? The symptoms are those of pleurisy with effusion, and their severity will depend on the amount of fluid in the pleural cavity. What is the treatment? The eiitire treatment should be directed to removing the primary cause. Where the effusion is caused by cardiac disease, or in cases where it is caused by chronic nephritis or cirrhosis of the liver or by congestion of the venous circulation, such remedies as indicated for these causes should be used. In cases of tuberculosis or carcinoma of _ the pleura temporary relief may be afforded by aspiration, although this is only a palliative measure. In all cases medicines which increase the ex- cretion from the kidneys, skin, and bowels are of benefit. NE"W GROWTHS OF THE PLEURA. What new growths are met with in the pleura ? Almost all neoplasms met with in the pleura are secondary. They are generally nodules due to either carcinoma, sarcoma, or tuberculosis. What are the diagnosis, prognosis, and treatment? Diagnosis is difficult unless the primary lesion is well marked. Prog- nosis is unfavorable. Treatment should be symptomatic. NEW GROWTHS IN THE MEDIASTINUM. What tumors are met with in the mediastinum? In the anterior mediastinum sarcomata are sometimes met with, mostly in youth or early adult life — more rarely carcinomata or lympho- mata. What are the symptoms ? They are those due to compression of the neighboring structures, such as dyspnoea, pain, paral.ysis, disturbances of deglutition, and hydrotho- rax due to compression of the pulmonary veins. On physical examina- tion dulness of the anterior portion of the chest is sometimes found. Care should be taken not to confound these tumors with aneurisms of the aorta. FCETID BRONCHITIS. BRONCHIECTASIS. 63 What are their prognosis and treatment? Prognosis is unfavorable, and treatment is symptomatic. FCETID BRONCHITIS. What is foetid bronchitis ? A form of bronchitis in which the secretion of the mucous membrane has a marked foetid odor, due to putrid decomposition of the excreted mucus. What is its etiology ? It may be an accompaniment of chronic bronchitis (especially of old persons), of bronchiectasis, of gangrene of the lung, or of pulmonary tuberculosis. What are its symptoms? They are those of the disease which causes the foetid mucous excretion. What is its diagnosis? Care should be taken to diagnose it from ozaena or croupous stomatitis. , In cases which are caused by gangrene of the lung microscopic exami-' nation of the sputum will show pulmonary tissue. In cases of bronchi- ectasis or pulmonary tuberculosis physical examination will show the cause. What is its treatment? It is that of the originating cause. BRONCHIECTASIS. What is bronchiectasis ? A dilatation of one of the larger bronchial tubes. What is its etiology? There is an inflammation of the mucous membrane of the bronchial tube, followed by its erosion or necrosis, and extension of this process to the underlying tissues of the wall of the tube. The paroxysms of cough- ing cause a dilatation of the weakened and thinned wall of the tube. In what conditions is this disease most frequently found? Phthisis, chronic purulent bronchitis, emphysema, and extensive ad- hesion of the lung to the chest-wall, due to dry pleurisy. What are the varieties of bronchiectasis ? (1st) Cylindrical, where a bronchial tube is uniformly dilated: this may be secondary to bronchitis, emphj^sema, whooping cough, or other diseases attended by long-continued and forcible attacks of coughing. 64 DISEASES OF THE RESPIRATORY ORGANS. In these cases the dilatation of the bronchial tube is long continued and gradual ; the excreted mucus is thin and quite abundant. (2d) Saccular, where a portion of a bronchial tube is dilated, almost entirety on one side : this dilatation generallj^ occurs gradually, although it may occur suddenly from an ulceration of the bronchial membrane. It is usually caused by the ulcerations of phthisis. What are the physical signs ? In the cylindrical variety numerous small moist rales are heard on auscultation over the area of the affected tube. In the sacculated variety the physical signs resemble those of a tubercular cavity. Where the bronchiectasis is deep-seated in the lungs the physical signs are very indefinite. What are the symptoms ? The Rijmptonis are principally those of the primary disease, but there is a large amount of expectoration of thin glairy mucus, and in the sacculated form the sputum may be muco-purulent. The sputum is very abundant, and is expectorated in paroxysms of coughing. What are the prognosis and treatment ? Both prognosis and treatment are dependent on the primary cause of the lesion. STENOSIS OF THE TRACHEA. What is meant by stenosis of the trachea ? A contraction of the calibre of the trachea. What is its cause ? It may be caused by disease in the vicinity of the trachea, such as enlargement of the thyroid gland, arterial aneurism, tumors of the mediastinum, swelling of the lymphatics or other growth in this neigh- borhood, or by disease of the trachea itself, such as polypi, carcinomata, syphilitic cicatrices, or inflammation resulting from foreign bodies or acute irritants. What are its symptoms? If the stenosis is slight, there is only a feeling of discomfort and slight dyspnoea ; if more marked, dyspnoea is very distressing, expiration is prolonged, breathing is stridulous, and the pulse is generally increased in frequency. Cough is generally present and aggravated by slight ex- ternal causes. What are its prognosis and treatment ? Prognosis and treatment depend upon the exciting cause. STENOSIS OF THE BEONCHI. — PNEUMONIA. 65 . " '. STENOSIS OF THE BRONCHI. What is meant by stenosis of the bronchi ? A narrowing of the calibre of a bronchus. What is its etiology? It occurs more often in the right than in the left bronchus, and is gen- erally caused by the presence of a foreign body ; it may be caused by aneurism of the aorta, enlarged heart, or the pressure of tumors. What are its symptoms? _ There are generally dyspnoea and a whistling sound all over the affected side. On inspiration this side does not dilate as much as the other. What are its prognosis and treatment? Prognosis and treatment depend on the primary cause. Where the trouble is caused by a foreign body, removal may be attempted. When not relieved, the lesion is often followed by emphysema or lobular pneumonia. PULMONARY CEDEMA. What is pulmonary oedema? A congestion of the lungs caused by the exudation of the albuminous fluid constituents of the blood into the alveoli and lung tissue, and gen- erally attended by an abnormal excretion of bronchial mucus. What is its etiology? It is a complication of other diseases causing congestion of the lung, and is often caused by the gradual onset of heart failure preceding death. What are its symptoms? Marked dyspnoea, accelerated respiration, and cyanosis of the face, with large, coarse rales all over the chest, are the most marked symptoms. There may be frothy expectoration. Percussion note, as a rule, is normal. What is the treatment? Remedies are almost invariably powerless, as oedema is usually a sign of approaching death. In the few cases where it is caused by temporary heart failure the volatile stimulants, with counter-irritation or cupping of the chest, may be of benefit. PNEUMONIA. What is pneumonia? An inflammation of the pulmonary tissue. 5— P. M. 66 DISEASES OF THE RESPIRATORY ORGANS. What are the two principal forms of pneumonia ? Bronchial pneumonia, also called catarrhal or lobular pneumonia, and croupous pneumonia, also called lobar pneumonia. What is the etiology of catarrhal pneumonia ? It generally occurs as an extension of a bronchitis. The secretion accumulates in the bronchioles and alveoli; fungi collect, and set up decomposition in the sputum. This process gives rise to pneumonia. Inhalation into the bronchi of particles of food often acts as an exciting cause of this form of pneumonia. It also often follows infectious dis- eases, and is most frequent in children and old people. What is the pathology of catarrhal pneumonia ? The walls of the bronchi are inflamed, thickened, and infiltrated with cells, as is also the surrounding tissue ; the pulmonary alveoli are in the same condition, and their cavities are fiUed with fibrin, pus, and epi- thelium. The inflammation is found in circumscribed scattered areas, and the pulmonary blood-vessels are engorged. What are its symptoms? In young infants there are fever, prostration, frequently coma and rapid breathing. Owing to the age of the patient, physical signs are generally indefinite, but the disease is fatal as a rule. In older children and adults the beginning of the pneumonia is often obscured by sj^mptoms of the primary disease ; in children there are sometimes convulsions. The respirations are frequent (forty to sixty a minute) ; there are considerable restlessness and frequent, painful cough. The face is pale, the pulse rapid, and the temperature ranges from 104° to 105° F. There is often a feeling of heaviness in the chest, but rarely any pain, unless the inflam- mation extends to the pleura and sets up a pleurisy. What are the physical signs? The signs in general are those of a diff'used bronchitis. On ausculta- tion small and medium moist rales are heard : there are sometimes bron- chial breathing and bronchophony. The percussion note is sometimes dull or tympanitic over the affected areas. What is the prognosis ? ♦ The 'prognods in children is alwaj^s bad. Severe cases succumb in from two to fourteen days. Most cases are protracted, and may die from exhaustion or development of tuberculosis. What is the treatment? Prophylaxis is only limited to the prevention of bronchitis in infec- tious diseases and the prevention of the extension of it when it occurs. When signs of catarrhal pneumonia develop, poultices or dry cups to the chest may be used. In children emetics at the commencement of the disease are sometimes of benefit, Narcotics may be used where pain CROUPOUS PNEUMONIA. 67 is marked, but great care must be used in their emploj'ment ; where con- vulsions occur antispasmodics (particularly bromides) are indicated; stimulants may be used in moderation, and the dose will depend on the condition of the vascular system. In convalescence the various tonics are of benefit, associated with change of climate. The muriate of ammo- nium is always of benefit, especially in small, frequently repeated doses where the disease occurs in children. Where the stronger alcoholics are not borne by the stomach, champagne is indicated, especially in older people ; the most easily assimilated food only should be administered. CROUPOUS PNEUMONIA. Syn. — Lobar pneumonia ; Lung fever; Pleuro- pneumonia. What is croupous pneumonia? It is a primary acute inflammation of the lung tissue. What is its etiology ? It is supposed to be caused by a specific pathogenic germ called the diplococcus pneumoniae. A certain constitutional state of the body seems to predispose to it ; also excess in the use of alcohol ; and some chronic diseases may act as a predisposing cause. It sometimes follows exposure to cold or traumatism. It is most frequent between the ages of eighteen and forty. What is its pathology ? In fatal cases the affected portion of the lung is dark-red on section, and small gray points of fibrin project from the bronchioles. It does not crepitate on pressure, and a portion of the affected lung sinks when immersed in water. On microscopic examination the alveoli and smaller bronchi are filled with a hemorrhagic coagulable exudation which con- tains large numbers of white blood-cells and pneumococci, and the mucous membrane of the neighboring larger bronchi is congested. Should a fatal result occur early in the disease, the red color will be most marked on section of the affected portion of the lung. Should the patient live until the fourth day or later, the section of the affected lung will show more or less of the gray points of so-called hepatization. The disease generally affects one or more lobes — is more frequent on the right than on the left side. Where resolution occurs the products of inflammation exuded into the alveoli soften down and are absorbed by the lymphatics, and to a certain extent by the blood-vessels. What is the course of the disease ? The disease generally begins suddenly with a marked chill, followed by a feeling of fever and weight in the affected side ; occasionally these symptoms are preceded for a few daj^s by a feeling of malaise, loss of appetite, and headache. After the chill the temperature rises pro- gressively, ajid there is often severe pain on inspiration. If the pneu- 68 DISEASES OF THE RESPIRATORY ORGANS. monia is situated at the surface of the lung and gives rise to pleurisy, the breathing is shallow and accelerated ; the pulse ranges from 90-130, and the temperature generallj^ rises to 103° F. or more. Painful cough is generally present, attended by tough, bloody, muco-purulent expec- toration, which soon becomes rusty in color. These symptoms last from twenty- four to sixty hours. Then the temperature remains high ; there are anorexia, often delirium, and vomiting. Constipation is marked. The respirations are from 30 to 60, and the pulse from 100 to 160, small and quick ; the tongue is dry, with a typhoidal coating. The urine is diminished from the commencement of the disease, and from the second day onward frequently contains a large amount of uric acid and more or less albumin. The chlorides are diminished. These symptoms, as a rule, last from the third to the ninth day, when, if recovery takes place, they rapidly diminish ; the fall of temperature is sudden as a rule ; occa- sionally it is gradual. The crisis generally occurs on from the fifth to the eighth day, when the temperature often falls to subnormal. Recovery from the disease is generally rapid, but may be protracted, owing to complications. All the symptoms of pneumonia may be masked where it occurs as an intercur- rent affection or is complicated by other diseases. Where the disease originates at the root of the lung or where it occurs in the aged or in alcoholics, many of the marked acute symptoms are often wanting. What are the physical signs? On inspection no change in the chest is seen except in cases compli- cated with large pleural effusion, when the affected side may be the more prominent. The respiration is accelerated, and the affected side moves less than the other. On percussion the note is at first somewhat dull, and later on tympanitic or wooden in character. On auscultation, at first large and small or crepitant rales are heard over the affected area ; as consolidation progresses the breathing loses its exaggerated vesicular character and becomes loud, sharp, and bronchial. Should the case go on to resolution, large moist rales are heard on auscultation, and the breathing regains its vesicular character. Voice over the affected area is high-pitched and bronchial, and bronchophony is generally present. Vocal fremitus is increased. What are the most frequent complications ? In almost all cases pleurisy occurs as a complication. Other frequent complications are endo- and pericarditis, congestion of the liver, nephri- tis, cerebral congestion, or a meningitis. What is the diagnosis? The disease is most frequentl.y mistaken for pleurisy with effusion ; also it may be mistaken for acute bronchitis attended with little expec- toration, but this only in the earlier stages. PULMONARY TUBEECULOSIS. 69 What-^s the prognosis? Prognosis should alwaj^s be guarded. The disease when it occurs in old people or in those of alcoholic habits is generally fatal ; in other cases, if the patient lives until the sixth day, prognosis should be favor- able unless complications should ensue. What is the treatment? Many authorities believe the disease may be aborted at its commence- ment by large doses of calomel or quinine. After acute symptoms of pneumonia develop the treatment is mainly symptomatic. Should there be pain from complicating pleurisy, hot poultices, mustard plasters, or dry cups applied to the side will give relief. Where cough and pain are both severe, morphine, hypodermically, would be of most benefit. In all cases of pneumonia narcotics should be used with great caution, espe- cially where there is any symptom of cardiac weakness. In plethoric individuals bleeding to a moderate extent, six to ten ounces, is sometimes found useful in the commencement of the disease. For high tempera- ture quinine, in 10 to 15 gr. doses, or phenacetin, 5 grains every three hours, are most used. Stimulants are always indicated, and the amount to be given will depend upon the condition of the heart and whether the patient has a previous alcoholic history. Digitalis or other cardiac stim- ulant should be used when the heart is weak and in cases where heart failure is threatened. Aromatic spirits of ammonia and ether in small doses internally are of great benefit. The diet should consist of con- centrated liquid food. Where delirium is a marked symptom, opium in large doses may be used, provided the action of the heart is carefully watched. PULMONARY TUBEBCULOSIS. Syn. — ^Phthisis; Consumption. What are the varieties ? This classification is made according to the occurrence of the physical signs and rapidity of progress of the disease : acute miliary tuberculosis and chronic miliary tuberculosis. What is its etiology ? The disease is caused by a bacillus, which fact was first demonstrated by Koch in 1881. These bacilli are small, rod-like bodies, with a length of one-fourth to one-half the diam.eter of a red blood-corpuscle. The bacillus may be introduced into the body through the inhalation of dry sputum of a person affected with tuberculosis, or by the use of utensils which have been used by a tuberculous person. A weakened condition of the body predisposes toward tuberculosis, and the disease is often met with in members of the same family. It is most frequent between the ages of fifteen and thirty years. 70 DISEASES OF THE RESPIRATORY ORGANS. What is the pathology? The changes due to tuberculosis may occur in anj^ organ of the body, but are most frequent in the lungs. It is characterized by the formation of small nodules in the peribronchial tissue. In these nodules are found colonies of bacilli and large so-called giant-ceUs, which m&y contain the bacilli. The nodules themselves consist of a caseous material, which, not being furnished with blood-vessels, is of poor vitality, subject to death and subsequent softening. Should many nodules, situated close together in the neighborhood of a bronchus, soften, they will cause obliteration of the bronchiole, collapse of the alveoli, and the formation of a tuber- cular cavity. In some cases these cavities heal, and are replaced by cica- tricial tissue. In a few cases the tubercular nodules are infiltrated with lime salts, and further progress of the disease is aiTested by their calci- fication. In acute, rapidly-progressing cases the tubercular infection frequently spreads to the intestines or membranes of the brain, and the disease is quickly fatal, owing to involvment of these organs. What are the symptoms and causes of the disease ? Symptoms will differ according to the seat of the disease. In cases where the disease is rapid and many tubercles soften at once, pulmonary cavities are formed, giving their physical signs. In other cases, where the tubercles are scattered through the lungs and do not coalesce, all symptoms and physical signs may not be marked. As a rule, the disease begins slowly, and is attended with slight cough, expectoration, pain in the chest, and shortness of breath. After a few weeks there are marked loss of appetite and consequent emaciation, pallor of the skin, and a general feeling of weakness. The temperature begins to be above normal at night, and there is chilliness, followed by sensations of fever and night-sweats. At this time cough becomes a more marked s^niip- tom. The temperature is often considerably elevated without giving subjective sjinptoms of heat to the patient. All these sjTiiptoms con- tinue for a greater or less period of time, together with progressive emaciation. In quite a number of cases there is a standstill for some years. In all cases pain in the side is due to the violent contrac- tions of the muscles in coughing or to a dry pleurisy caused by man.y tubercles being situated on the surface of the lun^s. Cough is always a marked symptom, but the amount of expectoration attending it differs greatly in the various cases. Where softening and the formation of cavities occur, expectoration is very profuse and muco-purulent in charac- ter. Where the cough is very severe the sputum is frequently streaked with blood, but where a cavity is formed ulceration into a blood-vessel may cause more or less coughing up of bright-red blood, (haemoptysis). As a rule, haemoptj^sis occurs without anj^ previous warning, although it is sometimes preceded by a feeling of oppression. Dj^spnoea is rarely marked unless the patient has had a number of attacks of dry pleurisy (then due to pleuritic adhesions). In all cases of phthisis the action of the heart is tumultuous. The second sound of the heart is generally PULMONARY TUBERCULOSIS. 71 markedly accentuated, and frequency of respiration is usually above the normal. What are the physical signs? The pulmonary signs of the disease are most frequently found at the apices of the lungs. Over the infected areas the percussion note is dull and expiration prolonged, vocal fremitus is increased, and more or less fine and coarse rales are heard, particularly at the end of inspiration. Should softening with the formation of cavities take place, the voice and breathing are bronchial or the amphoric percussion note is tympanitic, and loud bubbling or coarse rales are heard over the situation of the cavity. In cases where recovery takes place the afiected side is generally somewhat retracted, the percussion note is dull, and the vesicular mur- mur is feebler than on the normal side of the chest. Breathing often still has a bronchial character. In almost all cases the pleura is more or less involved, and we have the physical signs of pleurisy added to those of phthisis. Occasionally the pleurisy involves the pericardium, causing more or less displacement of the heart. In cases of disseminated miliary tuberculosis all marked physical signs may be wanting. Marked dul- ness on percussion above the clavicle is often a symptom of commencing phthisis : in some cases auscultation in the axilla will show rales if none are heard in other parts. What are the most frequent complications? Pleurisy, pneumothorax, tuberculosis of the larynx, pharynx, stomach or intestines, or nephritis. What are the diagnosis and prognosis ? The diagnosis is always easy where the tubercular bacilli are found in the sputum. In cases where there is marked softening or where cavities have been formed the diagnosis is also easy. The disease in its early stages may be confounded with typhoid fever, malarial fever, diabetes, simple angemia, or chronic bronchitis, with acute exacerbation or malig- nant neoplasm of the lungs. In the majority of cases the prognosis is unfavorable, but the duration of the disease cannot be foretold. In a few cases recovery takes place. What is the treatment? The patient should be isolated and have plenty of fresh air and the most nourishing food. All excretions should be disinfected. Internally, creasote and cod-liver oil, with the iodides, have proved to be of most benefit. For symptomatic treatment inhalations of iodoform or as- tringent and narcotic vapors often relieve the cough. Sponging and the use of phenacetin and extract of hyoscyamus internally are of benefit for high temperature and night-sweats. In cases where pleuritic pain is marked counter-irritation of the chest and narcotic treatment are indicated. When haemoptj'sis occurs the patient should be given absolute rest in a supine position, with an ice-bag to the chest, and gallic acid and other 72 DISEASES OF THE RESPIEATORY ORGANS. astringents and narcotics internally. For the loss of appetite tonics are always indicated. In all cases where practicable the patient is to be re- moved to a dry climate at a moderate altitude. INTERSTITIAL PNEUMONIA. Syn. — Fibroid phthisis. What is interstitial pneumonia ? A disease characterized by a slow increase of the interstitial tissue of the lungs. What are its causes ? Any prolonged irritation of the lung tissue causes a chronic congestion of the lungs, attended with proliferation of the connective-tissue cells. The most frequent exciting causes are the inhalation of irritating vapors or small particles of foreign bodies, and the case may be accordingly named stone-cutter's phthisis, miner's phthisis, etc. What is the pathology? The peribronchial interstitial tissue is much increased, as are also the number and size of the interstitial cells between the vesicles. As a con- sequence of this the calibre of both bronchioles and vesicles is diminished. On section there is more resistance on cutting the lung tissue, and the tissue has a paler appearance, than normal. It may be gray or black, according to what the irritant material has consisted of. This discolor- ation is generally found in nodules. What are the symptoms? The symptoms are those of chronic bronchitis, sometimes complicated with symptoms of emphysema. The symptoms and course of the disease are progressive unless the patient is removed from the exciting cause. What are the prognosis and treatment? Treatment in all cases is symptomatic. Prognosis as to complete re- covery is bad. As to partial recovery, the prognosis would depend on whether the patient can be placed in proper hygenic surroundings or not. This disease often furnishes a suitable nidus for the development of tuberculosis. GANGRENE OF THE LUNG. What is gangrene of the lung ? The decomposition and death of a certain portion of lung tissue. What are its causes? It is caused by the entrance of the bacteria of putrefaction into the lung : these bacteria may be carried there by the inhalation of foreign substances or particles of food, and also by the inhalation of mucus or EMBOLISM OF THE LUNGS. 73 muco-pus in cases of ulceration of the mouth, pharynx, or larynx. Oc- casionally it is caused by ulceration extending from the pleura or neigh- boring organs into the lungs. Rarely an embolus infected with bacilli causes gangrene of the lung. The disease occurs most frequently at the lower lobes, especially at the right side. What is its pathology? The affected portion of the lung is discolored and often gray in color. If the disease has existed for any length of time, it is changed into a soft, pultaceous, foul-smelling mass, and bronchial ectasic cavities are found in the neighborhood of the necrosis. What are the symptoms? The symptoms are those of foetid bronchitis. Expectoration is gen- erally profuse, and a microscopic examination of it shows portions of the parenchymatous tissue of the lungs. Fever is marked and pyaemic in character. The physical signs are often obscure. It is often compli- cated^ by pleurisy or pneumothorax, and intestinal irritation is often a prominent symptom from swallowing the infected sputum. Dyspnoea is rarely marked. The pulse is often accelerated. What is the diagnosis ? Diagnosis should be made" from foetid bronchitis, bronchiectasis, and perforation of the lung, from empyema or malignant disease starting in the neighborhood of the lung, mediastinal or visceral. What is the prognosis? The prognosis will depend on the underlying disease and the strength of the patient. It is always very grave, but some cases recover. What is the treatment? The treatment is mainly symptomatic. Antiseptic inhalations, the best of food, and hygienic surroundings are very necessarj^ EMBOLISM OP THE LUNGS. What is meant by embolism of the lungs ? A plugging of the pulmonary artery or one of its branches. What is its etiology? Secondary, generally speaking, to an inflammation of the valves of the heart or the valves of the large arteries, this inflammation is productive of an accumulation of fibrin in the diseased parts. The force of the blood-current detaches particles of fibrin and carries them into the pul- monary circulation, where they are unable to pass a vessel of smaller diameter than their own. As a result of this an area of pulmonary tissue is deprived of its blood-supph^ It is most frequently found as a result of endocarditis, pyaemia, endarteritis, and diseases attended with 74 DISEASES OF THE RESPIRATORY ORGANS. an increase of fibrin in the blood, accompanied by feeble circulation, and of puerperal fever. What is the pathology ? The area of the lung from which the blood has been cut off is gene- rally wedge-shaped, with its small end toward the root of the lung. It is dark-purple or brown in color, according to the length of time it has existed, except in cases where the embolus or infarct has contained septic matter. In these latter cases the embolic area may be gray in color, and show signs of abscess, or even the greenish softening of gangrene if the patient has lived long enough for this change to take place. In size the embolic area or infarctions vary greatly. On section the affected area of pulmonary tissue is firmer than in other portions, does not crepitate, and sinks in water. Microscopic examination shows the blood-vessels to be filled with disintegrated blood-cells, fibrin, and leucocytes, which latter are also found in the lung tissue in the immediate neighborhood of the embolic area. What are the symptoms ? The symptoms depend greatly on the size and situation of the embolus. Where a very large blood-vessel is occluded, death may be instantaneous or preceded for a few moments by intense and sudden dyspnoea ; in cases where the embolus is smaller, especially where complicating cardiac valvular disease exists, there may be a slight feeling of depression in the chest and a sudden cough with bloody expectoration. Where the em- bolus is very small acute symptoms are rarely present. If the embolus is large, there are dulness on percussion, crepitant rales, and bronchial respiration over the affected spot. Should it be situated near the surface of the lung and not immediately fatal, the physical signs of acute pleurisy will be found. Fever is rarely present, but may exist if the trouble is caused by a septic embolus followed by abscess or gangrene. What are the prognosis and treatment ? The prognosis depends greatly on the causative disease and on the severity of the symptoms immediately following the embolism. Treat- ment is symptomatic, but in all cases perfect rest (supine position) should be insisted upon. BRO'WN INDURATION OF THE LUNG. What are the etiology and pathology? Prolonged engorgement of the pulmonary vessels, such as occurs in heart disease, causes the lungs to assume a brown color and become hard and dense, as is seen on section. The capillaries are dilated and all por- tions of the connective tissue are increased in quantity and become thickened. The walls of the blood-vessels are generally thickened, but degenerated. The alveoli become diminished in size. DISEASES OF THE HEART. 75 What' are the symptoms ? As a consequence of the diminution of the size of the alveoh, the dyspnoea in case of heart disease is augmented, cough is present, and often large pigmented cells are expectorated. On phj^sical examination high-pitched inspiration with prolonged expiration is heard. The symp- toms of chronic bronchitis are often added to the others. What is the treatment? Treatment should be directed to relieve the pulmonary congestion and the alleviation or cure of the primary disease. TUMORS OF THE LUNG. Cancer occurs in the lung, but is generally secondary. Secondary sar- coma occurs but rarely. Echinococcus cysts and syphilitic gummata also occur. Treatment is symptomatic. In rare cases surgical inter- ference may be admissible. DISEASES OF THE CIRCULATORY SYSTEM. Diseases of the Heart. ACUTE ENDOCARDITIS. What is meant by acute endocarditis ? An acute inflammation of the lining membrane of the heart. What are the etiology and pathology? Any particle of irritating material circulating in the blood-current may settle upon the walls of the heart or the surface of the valves and pro- duce an inflammation. This condition is most frequently found in cases of rheumatism, tuberculosis, septicaemia, pyaemia, the acute infectious diseases, and the puerperal state. The inflammation of the endocardium may be very rapid, and cause ulceration if the irritating material is septic in character, or the inflammation of the endocardium may take on a longer and milder course if the irritating material is non-septic. The endocardium appears thickened and often nodular. When the process occurs on the valves, it is generally found near their free edges ; in the acute form these thickenings break down and give rise to ulcerous patches. Where the valvular form occurs in adults, it is most common in the aortic and mitral valves. Valvular endocarditis is the most fre- quent cause of embolism. What are the symptoms ? Mild cases of acute endocarditis often give rise to no symptoms^ except slight oppression in the chest and dyspnoea on exertion. As the disease generally occurs as a complication, the symptoms are often masked by those of the predominant disease. When occurring in the course of rheumatism, pyaemia, or other acute exanthemata, it generally begins 76 DISEASES OF THE HEART. with palpitation, (l3'spnoea, and pain in the cardiac region. The pulse is accelerated, full, and strong. Fever, if present, may show a slight in- crease ; the face is flushed and wears an anxious expression. In cases of ulcerative endocarditis the face may be pale and drawn and the pulse rapid, small, and wiry. Respiration is accelerated, and frequently there are anorexia and acute gastric disturbance : other existing symptoms are generally due to an accompanying disease. What are the physical signs ? The superficial area of cardiac dulness is often apparently increased ; the apex-beat is generally much intensified, except occasionally in cases of septic endocarditis. At the situation of the apex-beat or over the aortic valves a loud blowing, systolic murmur is present. In rare cases this murmur appears to be diastolic in point of time. In the aortic valvular type the murmur is often propagated into the subclavian area. What is the prognosis? The acute ulcerative form is always fatal. The acute non-septic endo- carditis generally assumes a chronic form, and xyrognosis depends upon the severity of the symptoms of the causative disease. High fever, cerebral symptoms, or hemorrhage is alwaj^s of grave import. What is the diagnosis ? Physical examination of the heart is the greatest factor in the dia- gnosis, and great care should be taken not to confound the malignant form with cases of acute meningitis, acute miliary tuberculosis, or typhoid fever. The non-septic form must be differentiated from simple cardiac palpitation, asthma, or acute gastro-enteric disturbance. In all cases the diagnosis will be much facilitated by considering the primary disease. What is the treatment? In the septic form little can be done for the disease itself. In the non- septic form complete rest in the supine position must be insisted upon, and cold applications should be made to the region of the heart. For iiTcgular cardiac action digitalis may be used. For dj^spnoea counter- irritants to the chest and morphine or hyoscyamus internally are best. For sudden cardiac failure the difiusible stimulants, such as ether, cam- phor, or ammonia, should be given either internally or by inhalation. The diet should consist of concentrated liquid food in small quantities, given at frequent intervals. CHRONIC ENDOCARDITIS. What is chronic endocarditis ? A chronic inflammation of the lining membrane of the heart, usually situated upon the valves. What is its etiology? It may follow on the acute form, but often runs a chronic course from CHRONIC ENDOCARDITIS. 77 the start. The most frequent exciting causes of it are recurrent attacks of rheumatism, arthritis deformans, or repeated irritation of the endo- cardium from chemical or mechanical influences, alcoholism, nicotine- poisoning, syphilis, or immoderate muscular exercise. Chronic nephritis is sometimes followed by endocarditis. It may occur at any age, but is most commonly noticed between the ages of eighteen and forty. What is the pathology? In the mural form the endocardium is thickened, whitish in color, and projects slightly in hypertrophied areas. In the valvular form the endo- cardium is at first thickened, and this thickening is often followed by calcification or ulceration and subsequent contraction of the valves. Where the process occurs on the free edges of contiguous valves an ulceration takes place. It may be followed by adhesion of the affected part. As a result of these processes insufficiency or stenosis of the valves takes place. In cases where the body has not attained its full physical development the insufficiency of the valves is compensated for by an increase in the size of the heart-cavities, also in the amount and power of the heart-muscle. Where the disease occurs in those of adult life, the cavities of the heart dilate, but there is not sufficient increase in the cardiac muscle to compensate for the dilatation. As a result of this there is engorgement of the venous system. What are the physical signs? The most common form of valvular endocarditis is insufficiency of the mitral valve. In these cases at each systole of the heart there is some regurgitation of blood into the auricle, and this, meeting another current of blood, produces a loud, blowing murmur. This is heard most dis- tinctly at the situation of the rebound — that is, the situation of the apex- beat. This murmur may be transmitted around the side of the chest or over the situation of other cardiac openings. In these cases there is gen- erally enlargment of the area of cardiac dulness, most marked on the left side. In long-continued cases of mitral disease the area of dulness of the right side is much increased. The second sound is often accentu- ated, but the pulse is large, firm, and generally regular. The apex-beat is diffused over a large space. Mitral stenosis is often associated with, and generally follows, mitral insufficiency. Owing to the stiffness and thickening of the leaves of the valve, and often to adhesion between two contiguous leaves, the blood is forced through with difficulty, and is accompanied by a murmur. This murmur is diastolic or presystolic in character, not very loud, and gene- rally transmitted to the base. The second sound is very sharp or redu- plicated. The murmur is most distinct over the situation of the mitral valve, and also the situation of the apex. The pulse is very small and irregular. The area of cardiac dulness is generally universall}^ enlarged, and, on the left side of the chest over the cardiac space, this area is sometimes permanent. 78 DISEASES OF THE HEART. InsujQ&ciency of the semilunar valves may arise from inflammation of the heart or the blood-vessels. As a result of it the blood regurgitates dui'ing diastole into the left ventricle, and causes a murmur, which is heard loudest at the upper portion of the sternum. This murmur often has a musical pitch, and is sometimes transmitted to the apex. The left ventricle is much dilated and the apex-beat displaced. The enlargement of the ventricle often causes a bulging visible on inspection, and the area of cardiac dulness is found to be increased by percussion. Visible arte- rial pulsation in the larger, and sometimes in the smaller, arteries is often marked, and the murmur is often transmitted along them. The radial pulse is of a jerky character. Stenosis of the aortic valves is not very common. Hypertrophy of the left side of the heart is marked, and the cardiac pulsations are slow and weak. The murmur heard in this form of disease is low, and most distinctly heard in the second intercostal space at the time of systole, and is transmitted to the right. Insufficiency of the tricuspid valve occurs, as a rule, with other valvu- lar aiFections. The area of cardiac dulness is increased, particularly over the situation of the right ventricle. Along the course of the jugulars a venous pulse is visible, and often pulsation may be felt in the hepatic veins. A sj^stolic murmur is heard at the sternal extremity of the fifth rib on the right side or over the lower portion of the sternum. Stenosis of the tricuspid valve rarely occurs, except congenitally. The murmur accompanying it is diastolic or presystolic, and is heard most distinctly over the situation at the third costo-sternal junction of the left side. Insufficiency of the pulmonary valves is accompanied by the ph3^sical signs of hypertrophy of the right side of the heart and a diastolic mur- mur in the region of the pulmonary valves. This form of valvular endo- carditis is not often met with. Pulmonary stenosis is generally a congenital disorder. General venous engorgement, attended with cyanosis, is a marked symptom. On physi- cal examination, inspection and percussion show hypertrophy of the right side of the heart, and a systolic murmur is heard over the heart. This murmur is most marked in the >second left intercostal space. Most patients affliicted with this disease generally die before their fifth year. The physical signs of all these valvular aiFections may appear in com- bination, but, as a rule, the symptoms of one affection will predominate over the others. What are the subjective symptoms, complications, or sequelae ? Dyspnoea, increased on exertion, and caused partially from congestion in the pulmonary circulation and partially from obstruction in the circu- lation of the heart, occurs early in the disease. ^ Palpitation after men- tal or physical strain, and occasional pain of a piercing character in the cardiac region, generally exist. Also there are generally vague pains in the shoulders and all over the body, headache, and slight disturbances MYOCARDITIS. 79 of digestion. The action of the heart becomes irregular, and there is often sudden acceleration of the heart-beats without apparent cause. In cases where the action of the heart is habitually weak a venous stasis is a prominent symptom, and the skin assumes a cyanotic appearance. This is often accompanied or followed by oedema of the eyelids or ankles, and in advanced cases by general dropsy. Rarely embolism or throm- bosis in the smaller arteries, with the resulting symptoms, takes place. Occasionally mental derangement arises from this cause. In all cases where the disease is advanced chronic congestion of the liver, spleen, and kidneys occurs, with the resulting appearance of albumin and bile- pigment in the urine, and digestive disturbances due to interference with the portal circulation. What are the prognosis and treatment? A definite prognosis can never be given. In cases where the com- pensating hypertrophy is efficient the disease may last for a long time and give little inconvenience. Any occupation involving physical exer- tion increases the danger. Cases of aortic insufficiency appear to run the longest course. Many cases of mitral disease also run a very slow course. The disease cannot be prevented, but may be often mitigated by great care during attacks of acute rheumatism and by preventing the recur- rence of such attacks. Where the disease is developed exertion of all kinds should be prohibited. If the compensation is not efficient, digitahs may be used, but the pulse should be watched very carefully, especially on account of the cumulative action of the drug. Caffeine and its prep- arations, convallaria, sparteine, and strophanthus also act well for the oedema. Rest, massage, and diuretics are of benefit. In case of marked ascites paracentesis may be necessary. For the dyspnoea morphine, acetate of lead, the preparations of ammonium, counter-irritants, and mild purges are most frequently used. For the palpitation the applica- tion of cold to the praecordium and the internal administration of the bromides or narcotics give most relief MYOCARDITIS. What is myocarditis ? An inflammation of the cardiac muscle, followed by increase of the interstitial elements and degeneration of the muscular elements of the heart. This degeneration is due to the contraction of the new connective- tissue formation. What are its etiology and pathology? The predisposing causes are chronic alcoholism, syphihs, mental over- exertion, and cardiac strain due to dilatation of the aorta. As a rule, the valves are not implicated in the process, but the coronary arteries show atheromatous changes. As a result of the diminished supply of 80 DISEASES OF THE HEART. blood the muscular elements of the heart are degenerated. On section the heart-muscle is found of a grayish color ; the walls are firm, but thinner than normal ; the cut surface of the heart presents a marked resistance to the finger. On microscopical examination the interstitial cells are found much increased in number and size, and the muscular elements are smaller than normal, and often contain minute oil-globules or small opaque spots. What are the symptoms ? The symptoms are similar to those of valvular endocarditis, with the exception of absence of the murmur. Arhythmia is more frequently found in myocarditis than in endocarditis. The disease generally begins with palpitation and dyspnoea, which gradually increase ; sooner or later symptoms of systemic, circulatory, or digestive disturbance take place. The area of cardiac dulness is generaUy enlarged, and occasionally a soft blowing, systolic murmur is heard over the base of the heart. In the course of the disease the patient is liable to attacks of extreme dyspncea or sudden sharp pain over the cardiac region. In all cases of myocarditis a sudden acceleration of the heart-action without an apparent exciting cause is often a prominent symptom. From what should it be diagnosed ? From valvular cardiac disease, anaemia in adults or seniles, fatty heart, cardiac neurosis and hypertrophy^, and dilatation of the heart following diseases of the abdominal viscera. What is the treatment ? Treatment necessarily is only palliative. Only moderate exercise and a moderate amount of easily-digested food should be indulged in. Medi- cal treatment, per se^ is of little value. In cases of sudden heart failure ammonia, ether, or other cardiac stimulants may be used. In well- marked cases the use of strophanthus, digitalis, scoparius, or convallaria is of benefit where the patient can take it sj^stematically under the care of the attending physician. HYPERTROPHY AND DILATATION OF THE HEART. What are hypertrophy and dilatation of the heart? An increase in the thickness of the cardiac walls and of the capacity of one or all of the cavities of the heart. What is the etiology? These cardiac changes are generally caused by extreme physical exer- tion, by over-indulgence in food or alcoholic stimulants, and occasionally by congenital predisposition. Sudden dilatation of the heart sometimes occurs in the course of acute systemic affections. FATTY HEART. 81 What. IS the pathology? The heart is increased in size and the cardiac walls are abnormally thickened. There is an increase in the capacity of the cardiac cavities. Upon minute examination the sarcous elements seem to be increased in size and number. What are the symptoms? The disease may exist for a long time without producing any marked symptoms^ but physical examination will generally show an increase in the area of cardiac dulness, and sometimes a soft blowing murmur over the base of tlje heart, due to insufficiency of some of the valves. In almost all cases the symptoms are those of chronic endocarditis or myo- carditis. The course of the disease is very slow, and disturbances of digestion, with the exception of constipation, are rarely marked. What is the treatment? Treatment \^ palliative, and must be directed to improving the patient's general condition and the administration of cardiac tonics. As long as compensation is efficient the patient will do well, provided he avoids sudden over-exertion. Care should be taken in the use of digitalis in all cases where the symptoms are not urgent. PATTY HEART. What is fatty heart ? A change in the muscular fibres of the heart, resulting in the replace- ment of the muscular elements by molecules of fat, and also generally attended by a deposition of fat between the bundles of muscular fibres. What is its etiology? It often accompanies prolonged cases of acute infectious disease. It also occurs in cases of chronic disease of the liver and kidneys or other diseases which by their continuance cause a strain of the heart-muscle. What is its pathology? As it is generally associated with dilatation, the size of the heart is ap- parently abnormal. The muscular portion often has a yellowish color, and on microscopic examination many of the sarcous elements are found to be replaced by molecules of fat. What are the symptoms and treatment? The symptoms^ of fatty heart itself are very indistinct, but it is gen- erally accompanied by dyspnoea or slight pain in the cardiac region. On physical examination the area of cardiac dulness is generally found enlarged, and the intensity of the second sound exceeds that of the first. In almost all cases of fatty heart there are physical signs of fatty de- posits in other organs. Treatment is mainly symptomatic. Moderate cardiac stimulants may 6— P. M. 82 DISEASES OF THE HEART. be employed with care and regular phj^sical exercise is often of benefit. As regards diet, all foods tending to increase the deposition of fat in the viscera should be avoided. ANGINA PECTORIS. What is meant by angina pectoris ? A sudden pain or spasm referred to the pericardial region, often ex- tending to the left shoulder, and piercing in character. What is its etiology? It may occur as a complication of any cardiac disease, but it is most frequently found in cases of fatty degeneration of the coronary arteries. What are its symptoms ? It is characterized by a sudden sharp pain in the prgecordial region, often extending down the left arm, and attended with the mental sensa- tion of impending death. The pulse is frequent, and irregular as to both force and frequency. The action of the heart is tumultuous ; respiration is irregular and often gasping in character ; the expression is anxious, and the face covered with a clammy sweat. The attacks generally last from a few moments to half an hour. What is its treatment ? During the attack inhalations of amyl nitrite, chloroform, or ether may give relief Counter-irritants and hypodermics of morphine or atropine should be used. As palliative treatment electricity or nitro- glycerin internally is sometimes of benefit. Prognosis is always un- favorable. TACHYCARDIA. What is meant by tachycardia ? A nervous affection of the heart, characterized by a great increase in the number of heart-beats, paroxysmal in character. What is its etiology? Angemia and plethora or over-indulgence in food or alcoholic liquors may cause it. It sometimes accompanies cardiac valvular disease. A senile condition is a predisposing factor. What are the symptoms? The paroxj^sms generally follow acute dilatation of the stomach from the ingestion of too much food or liquid. The patient is pale and nervous, but no dj^spnoea is present. The heart-action is much increased, and murmurs (hasmic) are often heard over the situation of the great vessels. The cardiac sounds are arhythmic in character. PERICARDITIS. 83 What is its treatment ? Tonic treatment is generally of benefit. Cardiac sedatives should be given between the attacks, and all excitements, mental or physical, avoided. PERICARDITIS. What is meant by pericarditis ? An inflammation of the membrane covering the heart and lining the pericardial sac. What is its etiology ? It is rarely of primary origin. It may follow diseases of the blood of septic origin, or inflammation of the pericardial cavity from the exten- sion into it of tubercular deposits or new growths. It also occurs as a complication of constitutional diseases or may be caused by external in- juries. What is its pathology ? The inflammation may be circumscribed or diffused over the entire lining membrane. As a rule, both surfaces of the pericardium are coated with an exudation which is serous, fibrinous, hemorrhagic, or purulent in character, with which the pericardial sac may be more or less filled. The exudation increases where the disease has existed for some time, adhesions form between the walls, and often the heart shows signs of muscular degeneration. What are the symptoms? Generally acute pericarditis occurs in the course of Bright' s disease, acute rheumatism, the acute infectious diseases, or as a result of the ex- tension of inflammation from neighboring parts. There are pain and tenderness in the cardiac region and irregular action of the heart. Oc- casionally the praecordial pain is very .severe. Headache and coma some- times occur, and also rigors. Fever is present, but its degree often de- pends upon the primary disease. There is dyspnoea, but the amount of it is generally proportionate to the distension of th* pericardial sac with fluid. Respiration is accelerated, and the skin is pale and cj^anotic. A short hacking cough is occasionally present. The pulse is quick and often irregular. What are the physical signs? On inspection the praecordial area is often abnormally prominent, and the apex-beat, although seen in the normal situation, is very faint. On percussion the area of cardiac dulness is greatly increased, dependent upon the amount of effusion. The area of dulness may change with the change in position of the patient. On auscultation the heart-sounds are generally heard very faintly, with accentuation of the second sound. Over the 84 DISEASES OF THE HEART. base a fine friction murmur is heard. On auscultation, should the steth- oscope be pressed upon the situation of the apex-beat, an exocardial friction sound is heard with both systole and diastole. In cases of chronic pericarditis there may be retraction of the left side of the chest, specially marked at the cardiac systole, due to adhesion of the two pericardial surfaces. There is diminution of the pulse on in- spiration, and the exocardial friction sound is likewise heard. From what should it be diagnosed ? It may be mistaken for cardiac neurosis due to anaemia or other wast- ing disease, myocarditis, aortic or mitral stenosis, or dilatation of the aorta. What is the prognosis ? In acute idiopathic cases recovery often occurs, but where the disease complicates other troubles, or where the effusion is very great, ])rognoSLs is very grave. Pericarditis occuring in the course of tuberculosis or neoplasms is always fatal ; also where the disease occurs as a result of the extension of inflammation from neighboring organs the lesion is often fatal. Chronic cases often last a long time, but sooner or later terminate in death, owing to increasing interference with the heart's action and the resulting changes in that organ. What is the treatment? When the disease occurs as a complication of rheumatism, acute rheumatic treatment is of the most benefit ; absolute rest should always be insisted upon ; cold applied to the pericardial region is of value. In cases of weak heart digitalis or other cardiac stimulants should be used. Morphine or other narcotics should be given to ensure rest, and in the first stages of the disease tincture of aconite or veratrum in drop doses, frequently repeated, will be of benefit ; but the i3atient must be kept constantly under observation. The diet should be of the most nourish- ing character, given often and in very small quantities. In cases of rai3id or great amount of efiusion aspiration of the pericardium may be necessary. This should be performed with the patient reclining : the needle should be inserted through the skin in the interspace between the fourth and fifth ribs, an inch and a half to the left of the sternum. The skin should then be pulled outward, and the needle pushed into the pericardial cavity. Care must be exercised to always have a vacuum in the aspirator, and to withdi'aw the point of the needle into the trocar as soon as it has penetrated the pericardial sac. Also, should there be any dyspnoea or a sudden failure of the pulse, no more fluid should be with- drawn. In cases of purulent pericarditis, where aspiration has not pi'oved of benefit, continuous drainage in vacuo may be necessarj'', or as a last resort resection of the rib with permanent opening of the peri- cardium. HYDEOPERICAEDIUM. — PNEUMOPERICARDIUM. 85 HYDROPERICARDIUM. What is meant by hydropericardium ? An increase in the normal amount of the jpericardial fluid, without any inflammation of the pericardium itself. This fluid is generallj^ al- buminous in character. What are the causes, signs, and treatment ? It is secondary to other diseases attended by venous stasis or anaemia. The area of cardiac dulness is increased, but there is no friction sound. There may be a weak heart-action or dyspnoea, depending upon the amount of the efiusion. Prognosis and treatment will depend upon the causative disease. H^MOPERIOARDIUM. What is meant by haemopericardium ? An accumulation of blood in the pericardial sac. What are the causes, signs, and treatment? It is caused by the bursting of small blood-vessels in neoplasms, in- volving the pericardium, from the bursting of aneurisms, or from direct injuries to the pericardium and heart. The signs are those of an accu- mulation of fluid in the pericardium. Treatment will be directed to the primary trouble. PNEUMOPERICARDIUM. What is meant by pneumopericardium ? The presence of air in the pericardial sac. It follows direct wounds or perforation of the pericardium caused by the extension of ulceration from the neighboring organs. What are the symptoms? They are the same as those of hydropericardium, but cardiac dulness is often absent, and a succussion sound is heard with the movements of the heart ; also the pulse becomes suddenly weak and urgent dj^spnoea occurs. What is the treatment ? Treatment should be symptomatic, tending to increase the comfort of the patient by position and stimulants. 86 DISEASES OF THE VESSELS. Diseases of the Vessels. ENDARTERITIS. Syn. — Arterio-sclerosis ; Atheroma. What is meant by endarteritis? A degenerative change in the interior and middle coats of the arteries, with a consequent thickening, followed by ulceration and the formation of thrombi. What is its etiology? It is chiefly met with in people over forty years of age. The alcoholic habit, sj^philis, gout, lead-poisoning, and nephritis also predispose to it. The disease usually affects the arteries, but occasionally the veins are also affected. What is its pathology? The cells of the lining coat of the artery are degenerated, and a de- posit of gelatinous, and later on calcareous, material takes place in them. The thickened affected areas break down and ulcerate, and the fibrin of the blood is deposited upon them, giving rise to thrombi. _ The elasticity of the arterial walls is lost, and they sometimes give way in places, caus- ing small aneurisms to form. Owing to the loss of elasticity of the arteries an extra pressure is put upon the heart, and it in consequence becomes hypertrophied. As a result of these changes large organs are often found in a state of fatty degeneration, due to disturbances of nu- trition. What are the symptoms ? On inspection the superficial accessible arteries are found to give a hard, incompressible sensation to the touch, andthey seem to follow a more tortuous course than is normal. On phj^sical examination there are generally found the signs of cardiac hypertrophy and the second sound is accentuated. There are also often found the weak cardiac sounds of myocarditis, due to sclerosis of the coronary arteries. ^ The symptoms vary according to which arteries are most affected — viz. in the brain there may be hemorrhage from rupture of the diseased vessel, or cerebral softening, due to partial or complete occlusion of the blood- vessels, due to thrombi. In the kidneys there will be signs of chronic diffuse nephritis, with a decrease of the blood-supply. When the ar- teries of the heart are mainly affected there is a slow, hard, weak pulse, sometimes dj^spnoea, and often oedema of the extremities. The pulse is often irregular. In all cases there are generally more or less headache and tendency to somnolence. Attacks of vertigo often occur. Ternperature may be subnormal. The lesion is frequently attended by gastric and in- testinal dyspepsia. The patient may live for many j^ears with the dis- ANEURISM OF THE AORTA. 87 ease, the principal danger being formation of thrombi and consequent occlu&ion of an important artery. What is the treatment? Treatment is purely symptomatic, but particular attention should be paid to abstain from alcohol and over-feeding, and to keeping the heart in its best condition by means of suitable cardiac tonics. ANEURISM OP THE AORTA. What is aneurism of the aorta ? A dilatation of a portion of the aorta, due to degeneration of the in- ternal coat of the arterial wall, and rarely having an injury as an exciting cause. What are its etiology and pathology ? Violent exercise, syphilis, gout, and lead-poisoning predispose to it. The dilatation varies greatly in size and shape. The eroded portion of the arterial wall is generally covered by several consecutive layers of coagulated blood, which often causes a narrowing of the lumen of the aorta. The ascending portion of the arch is that most commonly aiFected. According to shape of the sac and degree of dilatation these aneurisms are generally called cylindrical, fusiform, sacculated, or dissecting. What are its symptoms ? On inspection, if the aneurism be near the thoracic wall or have caused absorption of the bony parts, an abnormal pulsation is often visible. If it is in the descending portion of the arch, this is sometimes seen in the back ; a distinct swelling is also seen over the situation of the aneurism. On percussion there is dulness over the dilated artery. On auscultation a peculiar loud blowing murmur of a systolic character is generally heard. The pulse may be uneven in the radials, and signs of dilatation of the left ventricle are often present. The large veins of the neck are frequently dilated ; a purring thrill is often evident on pres- sure. There may be more or less dyspnoea, loss of voice, difficulty in breathing, pain in the arms or intercostal spaces, and dysphagia. These .S3^mptoms are of course due to pressure on the neighboring nerves and organs. In cases of aneurism of the transverse and descending portion of the arch a sharp boring pain in the back over the situation of the first two dorsal vertebrae is often present, due to pressure on and erosion of the vertebrae. What is the prognosis ? Prognosis is fatal, but patients sometimes live for a few years after it is discovered. Sudden death may occur from rupture into the pericardial sac or any of the neighboring passages. Death also occurs from pressure on the trachea or nerves of the heart, and in rare cases from increasing weakness. 88 DISEASES OF THE VESSELS. From what should it be diagnosed ? From mediastinal tumors, from h3'pertrophy of the sternum or costo- sternal articulations, and from bronchial and pulmonary growths. What is its treatment? Obliteration of the sac has as yet been unsuccessful : absolute rest in a supine condition, restricted diet, and large doses of iodide of potash have been followed by the best results. Acupuncture and galvano-punc- ture and the introduction of fine wire into the sac to favor coagulation have been tried. Opiates may be given for the relief of pain ; in cases of rupture nothing can be done. THORACIC ANEURISMS (NOT AORTIC). Where do these most frequently occur? In the innominate, common carotid, and first portions of the sub- clavian arteries. What are the diagnosis, symptoms, and treatment ? All symptoms and diagnoses are similar to those of aneurism of the arch of the aorta, only differing in the fact that in aneurism^ of the sub- clavian and carotid arteries the swelling, pulsation, and thrill are mani- fested earlier in the disease than in cases of aortic aneurism. The syinjjtoms due to compression of neighboring nerves or organs are the same as those of the aortic form. As regards treatment, if systemic it is the same as that of aortic aneurism. Locally, ligature of the common carotid or of the external and internal carotid, and also of the second or third portion of the subclavian, has sometimes proved of temporary benefit. ANEURISM OF THE ABDOMINAL AORTA. What is aneurism of the abdominal aorta ? A dilatation somewhere in the course of the aorta from the dia- phragm to its bifurcation at the fourth lumbar vertebrae. What are its etiology, pathology, and symptoms? Its etiology and pathology are the same as those of all other^ aortic' aneurisms, it is most frequently found near the coeliac axis. It is gen- erally fusiform in character ; occasionally it is saccular, but often the dila- tation is more marked on one side of the median line. As a rule, all symptoms are caused by compression of the neighboring organs. _ On physical examination inspection shows pulsation above the umbilicus (but this is rare). On auscultation a blowing murmur synchronous with the pulse is heard : occasionally on deep palpation a marked tumor over the situation of the aorta is manifest, but this symptom is often absent. Disturbances of digestion, such as gastric or intestinal dyspepsia, or slight jaundice, are generally found. Occasionally pressure on the DISEASES OF THE DIGESTIVE ORGANS. 89 plexus in the neighborhood of the aneurism may cause attacks of appar- ent hepatic or renal colic. Owing to pressure on the renal veins and those leading to the liver the urine is generally scanty, of high specific gravity, and shows an excess of indican. What is its diagnosis? It may be mistaken for abdominal growths overlying the aorta, for chronic dilatation of the stomach, or for accumulation of faecal matter in the transverse colon ; but expansile pulsation felt on palpation is of most diagnostic value. What is its treatment ? General treatment is the same as that of aortic aneurism. Local treat- ment by means of galvano-puncture or the introduction of foreign bodies into the sac (Loreta) has been followed by better results than in cases of aortic aneurism. A permanent cure has never been obtained ; therefore the prognosis is always very grave. DISEASES OF THE DIGESTIVE ORGANS. Diseases of the Mouth. STOMATITIS. What is stomatitis? An inflammation of the membrane covering the cavity of the mouth. What is its etiology? It is most commonly caused by mechanical and chemical irritants, such as scratches from the sharp edges of carious teeth or the ingestion of ir- ritating, alkaline, or acid solutions ; it also often occurs from the ingestion of mercurial preparations or from the extension of inflammation from the neighboring cavities. Want of cleanliness in the mouth is the most marked predisposing cause. What is its pathology? The mucous membrane lining the mouth is intensely red and swollen, especially that of the alveolar processes. It may be covered in patches or generally with mucus or muco-pus in the most severe cases ; there are spots of ulceration, frequently covered by a false membrane. The tongue is coated on its upper surface with a layer of new cells, mucus, and pus which contains large numbers of bacteria. The papillae are very promi- nent and enlarged. What are the symptoms? There is generally loss of appetite ; the breath is offensive, owing to decomposition of retained secretions. Patches of ulceration in children are often seen on the buccal mucous membrane, and in adults along the alveolar process surrounding the base of the teeth. The gums are red 90 DISEASES OF THE DIGESTIVE ORGANS. and swollen and bleed easily. The secretion of the salivary glands is much increased, and the lymph-glands and the submaxillary and parotid regions are often enlarged. Pain on deglutition is often marked, and in cases of the disease in children there may be more or less rise of tempera- ture. At the onset of the disease there is often a feeling of heat and dry- ness in the mouth. What is its treatment ? Strict attention to cleanliness of the mouth is of most importance. The condition of the bowels should receive careful attention, and saline cathartics may be used for this purpose. The diet should consist of the most easily digestible foods, given in moderate quantities. Locally in mild cases a mouth-wash of tincture of mjn-rh is often sufficient. In cases attended by ulceration or the formation of fibrinous membrane fre- quent swabbing of the affected parts with compound tincture of benzoin or with solutions of nitrate of silver (10-;-20 grains to ^j) is of benefit. In slight cases the milder antiseptic solutions, locally applied, will effect a cure. ULCERATIONS OF THE MOUTH. What are the causes ? Syphilis, gastric disturbance, and acute irritants. What is the treatment? The ulcer should be swabbed with a solution of 10-20 per cent, chromic acid in water, then washed off, and a mild antiseptic mouth-wash (1 : 100 carbolic acid, saturated solution of boracic acid, thymol 1 : 300). GLOSSITIS. Syn. — Inflammation of the tongue. What is its etiology? The acute form is caused by traumatism or it occurs as a complication of acute septic inflammation of the neighboring parts. _ The chronic form is often limited to a portion of the tongue, and is induced by long-continued irritation from sharp points of the teeth or other me- chanical irritants. In the chronic form there is often an ulceration of the hypertrophied portion. What is its pathology ? The tongue is very much swollen, often to double its size, is dark in color, and is covered with a thick purulent coating. _ In the acute form it often presents a glazed appearance. In the chronic form the affected portion of the tongue is enlarged, darker in color than normal, and on section the parenchymatous elements are found increased both in number and size. DISEASES OF THE (ESOPHAGUS. 91 What are its symptoms ? Owing to the excessive swelHng of the tongue the patient is obhged to keep the mouth open, from which the end of the tongue protrudes; saHvation is marked, and also enlargement of the cervical and sublingual glands. There may be great pain, and talking and deglutition are very difficult ; mastication is often impossible. The face is cyanotic, and con- siderable dyspnoea is present. The pulse is quick and small, but the amount of the fever generally depends on the exciting disease. The under surface of the tongue is often eroded, due to its continued pressure against the teeth. What is its treatment? In the acute form incision into the dorsum gives the most prompt relief The local use of small pieces of ice may give comfort. After- treatment is the same as that of stomatitis. LEUCOPLASIA. What is leucoplasia? A limited hyperplasia of the superficial epithelium of the tongue and cheeks, producing spots of a dull-white appearance. What are its cause and treatment? It is chronic in character, and gives rise to little discomfort, and, as it is limited in area, little importance is generally attached to it. The spots may disappear, but soon the original area is again invaded. Excessive use of tobacco seems to act as a predisposing cause. Occasionally fissures appear on the aifected portions of the tongue. Care should be taken to diagnose this condition from the mucous patches of syphilis. Treatment seems to be of little benefit, but the constant use of anti- septic mouth-washes — particularly carbolic acid — is recommended. Diseases of the (Esophagus. CBSOPHAGITIS. What is oesophagitis? An inflammation of the mucous membrane and underlying tissues of the oesophagus, which may be of a catarrhal, croupous, or purulent nature. What are its etiology and pathology? All forms of this disease generally occur as complications or extensions of other diseases. The catarrhal form is usually produced by an irritant of a chemical or mechanical nature or by venous congestion due to ex- ternal pressure. If acute, the epithelium of the mucous membrane is thrown oif very rapidly, and this is attended by a large amount of excre- tion. If the disease becomes chronic, slight thickenings of the mucous 92 DISEASES OF THE DIGESTIVE ORGANS. membrane may form in places, and slight oesophageal ulcers are some- times found. The croupous and diphtheritic forms usually occur as extensions of these processes from the pharynx or upper air-passages. The purulent form is generally caused by the irritation of strong acids or the presence of foreign bodies. It also occurs as a result of extension of inflammation from the pockmarks of variola. The pus accumulates in the submucous layer of the oesophagus and narrows the passage; occasionally the mucous membrane sloughs away over the affected por- tion, leaving large ulcers. In cases of recovery the healing of these ulcers frequently gives rise to stricture. What are the symptoms and treatment ? Constant pain is only marked when the disease assumes a severe form. More or less pain on swallowing is alwaj^s present. The pain may be referred to between the shoulder-blades or over and below the thjToid cartilages. Fever and acceleration of pulse are generally slight, but in- tense thirst is often a prominent symptom. In some cases all solid food is regurgitated. In all cases care should be taken not to confound this disease with those caused by external pressure on the oesophagus. The disease is treated symptomatically. If a foreign body has caused the affection, an effort should be made to remove it. ^ In cases of chemical irritants their proper antidotes ought to be administered. In all cases liquid diet is advisable, and this is best given through a soft stomach- tube. For the pain small hypodermics of morphine should be used. The swallowing of small particles of ice and the application of cold ex- ternally often give much comfort. DILATATION OF THE (ESOPHAGUS. What is dilatation of the oesophagus ? A sac-like enlargement of a portion of the oesophagus. What are its etiology and pathology? It frequently follows stricture near the cardiac orifice of the stomach. The muscular wall of the oesophagus becomes more or less para^-zed, and dilatation of the passage soon causes chronic catarrhal inflammation of the mucous membrane of the oesophagus. Pressure from an enlarged gland in the neighborhood of a weakened spot in the muscular layer of the oesophagus, external injuries, causing pressure upon the same, and obscure causes, also give rise to it. The enlargement, when circum- scri]3ed in the form of a diverticulum, often increases rapidly until the pouch becomes enormous in size. The most frequent seat of the affec- tion is at the junction of the pharynx and oesophagus, on the posterior wall of the latter. The walls of the affected portion are frequently thickened. The thickening is apparently due to increase of the mucous and submucous layers, giving rise to the appearance of a rupture through the muscular coat of the oesophagus. STENOSIS OF THE OESOPHAGUS. 93 What are the symptoms and treatment? If the dilatation is slight and uniform, the symptoms may be those of only slight gastric dyspepsia. Should the dilatation be sacculated, there is more or less increasing difficulty in deglutition. Owing to food lodg- ing in the pouch, regurgitation is often present. Frequently a small portion of food is left in the diverticulum and decomposes, giving rise to a foul odor of the breath. In cases where the pouch is very large the dis- tension of it by food may cause compression of the lumen of the oesoph- agus and gradual starvation. Where the dilatation is due to traction from the adhesion to bronchial glands,_ painful deglutition is generally marked. Pain is felt at a certain point in the course of the oesophagus, and should these glands soften down, ulceration and perforation of the oesophagus frequently occur. In these cases regurgitated food or Hquid is often mixed with pus and streaks of blood. In the mild forms the disease may last for years. Dyspnoea and disturbance of the circulation are always present in advanced cases. Treatment is directed chiefly toward supporting the vital forces of the patient, and in many cases rectal alimentation may be necessary. Where the dilatation is due to stricture, treatment is the same, with the addi- tion of that for the stricture itself. STENOSIS OF THE (ESOPHAGUS. What is meant by stenosis of the oesophagus ? A contraction of the lumen of the oesophagus. What are its etiology and pathology? It may be caused by carcinoma or sarcoma of the oesophagus, by the contraction of cicatrices following ulcers of the oesophagus, by compres- sion caused by tumors external to the oesophagus, and by pressure from aneurisms or from hypertrophy of the walls of the oesophagus following chronic inflammation. It is most commonly met with in the lower third of the passage, above the constricted portion. The mucous coat is usually hypertrophied and the lumen increased, due to the increased ex- ertion of forcing food through the obstruction. Below the contraction the walls are often thinner than normal. What are the symptoms ? The symptoms at first are very indefinite. In mild cases deglutition is but shghtly interfered with, but this gradually becomes more difficult, especially as regards swallowing solids. The difficulty and slight pain felt on deglutition are generally referred by the patient to a point beneath the manubrium. After a time regurgitation of food begins, and this frequently takes place some hours after meals.^ Should the constriction be marked, there is progressive emaciation, with the attendant signs of approaching starvation. The passage of an oesophageal bougie will often confirm the diagnosis. 94 DISEASES OF THE DIGESTIVE OEGANS. What are its prognosis and treatment? Prognosis will depend greatly on the primarj^ cause of the stricture. Where the stricture is due to ulceration caused by the passage of foreign bodies or chemical irritants the case may be improved, but in the majority of patients the disease gradually progresses to a fatal issue. Medical treatment is limited to feeding the patient through a stomach-tube or the rectum and the frequent and systematic passage of a flexible bougie. Should these measures be of no benefit, the case should be refeiTed im- mediately to a surgeon. CANCER OF THE CE3SOPHAGUS. What are the etiology and pathology of cancer of the cesophagus ? It is quite frequently met with, and is caused by continued irritation of the mucous membrane. It is generally situated in the lower or middle thirds of the oesophagus, and surrounds it in a ring-like manner. The new growth on examination is found to consist of the elements of scirrhous or medullary cancer, and to spring from the submucous layer. What are its symptoms? It generally occurs in people of advanced age. In a few cases symp- toms are not marked, but the patient shows progressive emaciation and exhaustion. In other cases the symptoms are those of stenosis of the oesophagus, which gradually increase in severity, but the thoracic and oesophageal pains are more severe, the emaciation more rapid, and the cachexia more marked than in non- malignant stenosis. When vomiting occurs the ejected matter may contain cancer-cells. What are the treatment and prognosis? Treatment can only be directed to the relief of painful or urgent symptoms. The disease is incurable, the patient succumbing to it in a year or a year and a half Surgical measures for the extirpation of the growth have been tried without success. RUPTURE OF THE CESOPHAGUS. What are the causes, symptoms, and treatment ? The disease is a rare occuiTcnce. It most frequently is caused by the softening of cancerous growths or ulcers which have weakened the wall of the oesophagus. The attack is frequently preceded by nausea and vomiting, and during this act a sudden severe pain is felt along the course of the oesophagus. Symptoms of collapse, as a pale face, cold perspiration, and feeble pulse, occur. Emphysema of the neck fre- quently takes place, and should the perforation be into any of the large blood-vessels, there is vomiting of blood. Death rapidly ensues. DISEASES OF THE STOMACH. 95 ' • ' SPASM OF THE OESOPHAGUS. What are its etiology, symptoms, and treatment ? It is due either to central disorder of that portion of the nervous system governing the parts or to local irritation caused by the ingestion of irritant poisons. It is characterized by an inability to swallow on effort. Care should be taken to diagnose from permanent constriction by means of etherizing the patient and passing the oesophageal bougie. Treatment will be directed to the primary cause of the disorder. PARALYSIS OF THE CESOPHAGUS. What are the causes and treatment ? It is quite rare, and follows diphtheria or disease of the nerves sup- plying the constrictors of the oesophagus. Treatment will be directed to the primary disease where the cause is ascertainable. If of diphtheritic origin, injections and the internal use of strychnine have proved of benefit. Diseases of the Stomach. ACUTE GASTRITIS. What is acute gastritis? An acute inflammation of the mucous membrane of the stomach. What are its etiology and pathology? It is due to injury of the mucous membrane caused by the ingestion of too hot or too cold food, or from mechanical or chemical irritants. All patients with fever, or weak, anaemic, or badly-nourished persons, are predisposed to it. It is of very frequent occurrence, brief in duration, and generally ends in recovery. The mucous membrane of the stomach is swollen and dark-red in color, and covered with a coating of thick, glairy mucus from excessive secretion of the mucous glands. What are the symptoms ? It begins with general malaise, anorexia, and a slight nausea. The sense of taste is diminished or totally lost. The patient has chilly sen- sations, is nervous, and often experiences great thirst. A feeling of pressure in the region of the pit of the stomach is often present. The breath has a foul odor, the tongue has a thick coating, and eructations of gas take place. There may also be headache or vertigo. Constipa- tion generally prevails, and the urine is high colored. Fever is usuallj^ slight, but may be marked in cases due to the ingestion of irritants. Vomiting is present, and the vomited material is first that of the ingested food, followed by bile and mucus. In children vomiting and high fever are marked symptoms, and there is often great restlessness at night, and occasionally there is delirium. 96 DISEASES OF THE DIGESTIVE OKGANS. What is the treatment? Grreat care must be given to the diet to prevent recurrence in those predisposed. At the onset of the attack an emetic of mustard and water, hot water, or in children syrup of ipecac, is advisable. Should the disease have existed for some daj^s, this should be followed by the administration of a carthartic. The diet should be restricted, and also the amount of fluid allowed. For the pain in the epigastriun and vom- iting counter-irritants to the pit of the stomach, small doses of opium, and small pieces of ice internally give relief The fever, except in chil- dren, rarely requires active measures. In such cases, hot baths, followed by small doses of phenacetin or the bromides, have a good effect. CHRONIC G-ASTRITIS. What is chronic gastritis? An inflammation of the mucous membrane of the stomach, which runs a chronic course. What is its etiology? It may follow repeated attacks of acute gastritis, or may be caused by improper diet or constant irritation fi'om ingestion of alcohol : chronic in- terstitial hepatitis, which produces congestion of the portal circulation, is also a frequent cause. Chronic gastritis is often associated with phthisis and cancer of the stomach. What is its pathology ? The mucous membrane of the stomach is dark brown in color and in- creased in thickness. The gastric glands are enlarged, and the inner surface of the stomach is coated with whitish mucus. What are the symptoms ? As the gastric juice is diminished in quantity, fermentation is apt to occur, causing irritation of the mucous and submucous layers. As a result of this, peristalsis is less vigorous than normal ; there are marked eructations of gas, and often pain in the pit of stomach. Anorexia and bad taste in the mouth are generally present. Owing to distension of the stomach marked prominence of the epigastric region often exists. In old cases there are nausea and vomiting of partly- digested food dur- ing the day, and vomiting of a watery, sour-tasting material in the morn- ing. If the disease extend to the intestines, constipation, passing of intestinal gas, progressive emaciation, impairment of general nutrition, and attacks of vertigo occur. The patient also becomes hypochondriacal. Cases differ much in severity, and may last months or years. In those long continued, ulcerative hemorrhage of the stomach may occur. What is the treatment ? The regulation of the diet is of primary importance. All spii'ituous GASTRITIS CAUSED BY POISONING. 97 liquors, spiced dishes, coarse vegetables, fatty foods or much of the car- bonaceous foods, should be prohibited. A milk diet with alkaline waters to drink is excellent. Meals should be eaten frequently, and should be small in quantity. As regards drugs, the use of carbolic acid or tincture of iodine in drop doses, or of salicjdic acid in 10-grain doses, will be of benefit in preventing fermentation. Washing out of the stomach twice or three times a day by means of a stomach-pump or siphon will often cure mild cases. Occasionally the essence of pepsin, pancreatine, or hydrochloric acid may be necessary to aid digestion. Should the epigastric pain and attacks of vomiting cease, the use of bitter tonics will hasten the cure. The use of various " test- meals,'' to ascertain the amount of gastric secretion and the form of food which is most easily digested, often shows the line of treatment to be fol- lowed in the case in question. PHLEGMONOUS GASTRITIS. What is phlegmonous gastritis ? A purulent inflammation of the submucous membrane of the stomach, gradually extending to all the other layers. What are its etiology, symptoms, and treatment ? It is very rare in occurrence, and sometimes complicates the various diseases of pyaemic origin. The symptoms are those of acute gastritis added to symptoms of pyaemia. It is usually fatal, on account of the primary disease. Narcotics should be given for pain, ice for the thirst, and stimulation for weak pulse or general prostration. GASTRITIS CAUSED BY POISONING. What is the effect of poisoning on the stomach ? After the ingestion of strong caustics the mucous membrane of the stomach is often softened, from the chemical action. After the inges- tion of acid poisons there may be softening or charring of the mucous membrane. Should a mineral poison be taken, the symptoms are not so immediate, but soon the symptoms of acute gastritis set in, attended by apparent paralysis of the stomach. In all cases there are generally cough and dysphagia, arising from the injury to the throat and oesophagus. There are also severe pain in the epigastrium, spreading over the ab- domen ; bloody vomiting, generally attended with purging ; a small, fre- quent pulse and other signs of collapse. What is the treatment? Treatment consists in the prompt use of emetics, followed by the proper antidotes. 7— P. M. 98 DISEASES OF THE DIGESTIVE ORGANS. GASTBIO ULCER. What is gastric ulcer? A localized inflammation of the mucous membrane of the stomach, causing a loss of the mucous and submucous tissue in the aifected spot. What is its etiology? It is caused bj^ an impairment of circulation in some spot of the sur- face of the stomach, and as a consequence of this the acid gastric juice, not being counteracted by the alkaline blood, attacks the part and pro- duces softening, followed by erosion. This often occurs in cases of phthisis, anaemia, alcoholism, or as a result of embolism. It is most frequently met with between the ages of eighteen and twenty-eight, and is more frequent in females than in males. What is its pathology ? The ulcer differs in size, but usually presents sharp borders and ex- tends through to the muscular layer of the stomach. It is generally single and situated on the posterior wall of the pyloric extremity. Should recovery take place and the ulcer be situated near enough to the p3^1oric orifice of the stomach, contraction of the cicatrix may cause stricture of the pylorus. In cases where the ulcer extends through the muscular coat an inflammation of the neighboring tissues is frequently set up, causing peritonitis or adhesions of the surrounding parts. What are the symptoms ? In a few cases no marked symptoms are present during life. In others sudden hemorrhage from perforation of a blood-vessel, or peritonitis from perforation of the stomach, first draws our attention toward the disease. Generally the case begins with slight disturbance of digestion, a feeling of fulness in the epigastrium, eructation of gases, and pain in the epigastrium of a sharp and intermittent character. This pain may be diffused over the region of the stomach or localized. The attack of pain only lasts a few hours, but is often attended by tenderness on pres- sure. There are generally frequent attacks of vomiting, which are unac- companied by blood unless a blood-vessel has been eroded. In these cases nausea is almost constant, and the patient vomits blood of a dark color or blood and food mixed. Constipation is generally present, and the stools frequently contain disorganized blood. Where perforation occurs the patient is seized with a sudden severe pain, quickly followed by all the symptoms of acute general peritonitis. Appetite is either un- impaired or irregular as to amount. Pulse and temperature are not affected, as a rule, by the disease. Should the ulcer perforate into the pleura or invade the liver, collections of pus in one organ or the other will give their typical symptoms. What is the diagnosis ? Careful attention to the history of the case will be of great assistance. CANCER OF THE STOMACH. 99 In cases where blood has been ejected, if it comes from the stomach it will usually be dark in color, acid in reaction, mixed with food, and clot- ted. This is not true of blood ejected from the lungs, unless it has been swallowed and retained in the stomach for some time. If hsematemesis has not occurred, the diagnosis will always be difficult, but especial care on physical examination should be taken to ascertain the presence of a tumor, which either might be an aneurism or cancer of the stomach or faecal masses in the transverse colon or fatty tumor pressing upon the walls of the stomach. What is the treatment? The principal treatment is careful regulation of the diet. This should consist of the most nutritious liquids, such as milk, meat soups, or ex- tracts of beef Internally, small doses of bismuth subnitrate, nitrate of silver, or morphine may be given. In obstinate vomiting counter-irrita- tion to the epigastrium, drop doses of carbolic acid, or tincture of iodine give relief. In obstinate cases rectal alimentation exclusively may be necessary. In all cases absolute rest should be insisted upon. CANCER OP THE STOMACH. What is cancer of the stomach ? A malignant growth of a primary or secondary nature, affecting the walls of the stomach, and generally situated at the pjdoric end or along the lesser curvature. What is its etiology? The primary cause is unknown, but some believe that the tendency to it is hereditary. It is most frequent between the ages of fifty and sixty, and more frequent in women than in men. The cicatrix of a gastric ulcer often seems to serve as a starting-point. Irritants, errors in diet, and the abuse of alcohol are said to predispose toward it. What is its pathology ? It apparently begins in the mucous laj^ers, and then spreads through all the otlTer layers of the stomach. It may have the soft or scirrhous form. Rarely the form of nodular infiltration is found. In the soft variety the disease is often complicated by the presence of ulcers. What are the symptoms? It begins, as a rule, with the signs of gastric dyspepsia, to which are added progressive emaciation and cachexia. The patient generally com- plains of a fulness in the stomach after meals ; occasionally cardialgia, eructation of gases, and vomiting. Should the disease have advanced to any degree, the vomited matters consist of decomposed food and blood of a coffee-ground appearance. Physical examination in almost all cases reveals the presence of a tumor in the epigastrium. This tumor varies much in size. There is also detected a marked dilatation of the stomach. 100 DISEASES OF THE DIGESTIVE ORGANS. Emaciation and gastric symptoms increase progressively, and in advanced cases there may be secondary deposits in the other abdominal organs or enlargement of the lymphatic glands. In the ulcerative form of cancer peritonitis or hepatitis may be caused by perforation of the gastric wall. The disease lasts from a few months to two years, but always terminates fatally. Temperature and pulse are generally unaffected by the disease. What is the diagnosis? It sh'ould be diagnosed from cancer of the liver, pancreas, omentum, and transverse colon by the difference in the situation of the tumor and the general feeling of hardness in the epigastrium ; also by the character of the vomit and the possible presence of cancer-cells (if of the soft variety) in it. It may be simulated by extensive ulcer of the stomach, and the cancerous cachexias by profound or pernicious anaemia. What is the treatment? An easily-assimilated, nutritious diet should be given, and where pos- sible the stomach should be washed out regularly, and the patient's strength supported by tonics. In the early stages of a few cases opera- tive interference may prolong hfe. HEMORRHAGE PROM THE STOMACH. Syn. — Haematemesis. What is its etiology? The most frequent causes are gastric ulcer, gastric cancer, or cirrhosis of the liver. Haematemesis also occurs as a result of thrombosis in the portal system or from the bursting of a varix or aneurism into the stom- ach. Less frequently it occurs in blood diseases, such as scurvy, purpura haemorrhagica, or leukaemia, more rarely as a result of acute j^ellow atrophy of the liver, traumatism, or the irritation due to strong corrosive poisons or foreign bodies. In the newborn it is sometimes met with in the affection called melaena neonatorum. What are the symptoms? The patient has a feeling of oppression in the region of the stomach. The face is pale, the skin cold and moist, the pulse small and frequent, and nausea is generally present. There may be syncope. In many cases the blood is all discharged through the bowels. In some cases the symp- toms mentioned are followed by violent vomiting of effused blood. This blood is often dark and clotted, but its appearance often varies with the cause producing the hemorrhage. The attack of bleeding itself is rarely fatal. What is the treatment? At the time of the hemorrhage the patient should be placed flat upon the back, with the feet slightly elevated, absolute rest be enjoined, and cold applied externally to the epigastrium. Ice in small pieces may be DILATATION OF THE STOMACH. 101 given' by the mouth, and hypodermic stimulation or small doses of mor- pKine hypodermically in cases where collapse occurs. After the acute symptoms pass off a purge should be administered to remove the re- mainder of the blood from the stomach and intestines. Other treatment will be that of the underlying disease. DILATATION OP THE STOMACH. What is dilatation of the stomach? An abnormal expansion in the capacity of the stomach. What is its etiology? It is most frequently caused by obstruction at the pyloric orifice of the stomach, and is generally due to a new growth or cicatrix of an ulcer in this situation. Pressure from external tumors may also compress the pylorus. It is also sometimes caused by habitual over-eating or the in- gestion of very large quantities of fluids. What is its pathology? The muscular fibres seem to be at first increased, but as the constric- tion becomes marked dilatation and apparent thinning of the gastric walls take place. Owing to the food being retained in the stomach for a long time, it decomposes, and causes chronic inflammation of the mu- cous membrane. What are the symptoms ? The symptoms are mainly those of chronic gastritis, but the vomiting which takes place brings up a very great quantity of semi-digested food, some of which has often been eaten three or four days previously. In a few cases there may be protuberance of the epigastrium or of the lower ribs, caused by the distended organ, and occasionally the peri- staltic movement can be felt. More or less emaciation is present. Con- stipation exists, and the urine is small in amount. What is the treatment ? In mild cases not dependent on malignant origin dietetic measures, with the use of the various digestive agents, may effect a cure. In more pronounced cases systematic washing out of the stomach (lavage) by means of a flexible bougie is of great benefit. The solution used may contain bicarbonate of soda or salicjdic acid or some alkaline water. Where the disease is caused by marked constriction of the pylorus sur- gical measures will be necessary. A diet limited to dry bread is often given. NERVOUS DYSPEPSIA. What is nervous dyspepsia? A disturbance of the gastric function, due to a nervous condition, and not dependent upon any perceptible change of structure. 102 DISEASES OF THE DIGESTIVE OEGANS. What is its etiology? Sudden excessive mental emotions, long continued or often repeated, or melancholia, hysteria, and the first few months of pregnancy, often give rise to it. What are the symptoms? The symptoms are those of acute gastritis, such as anorexia, nausea, vomiting of mucus and bile, epigastric pain, and increased peristalsis. To these are added the symptoms of the underl^dng disease. What is the treatment? The patient should be encouraged, a full diet allowed, a change of surroundings ordered where feasible, and cold-water sponging adminis- tered. A bitter tonic is sometimes of benefit, but internal remedies should be used with caution. Other treatment would be that of the causative disease. Intestinal Diseases. CATARRHAL ENTERITIS. What is catarrhal enteritis? An acute inflammation of the intestinal membrane, general or limited in extent. , What is its etiology ? It may be caused by improper food, ingestion of poisons, chemical or mechanical irritants. It often accompanies severe infectious diseases or obstruction to the circulation in the liver, respiratory organs, or peri- toneum. What is its pathology? The inflammation occurs most frequently in the large intestine. The mucous membrane is red and swollen, secretion is increased (sometimes it is purulent), the glands are enlarged and occasionally ulcerate. In chronic cases there is an atrophy of the mucous membrane. What are the symptoms? Diarrhoea is the most frequent symptom. At first the movements have a faecal appearance, but this gradually changes to a green color and more liquid consistence. This latter is due to increased peristalsis, on account of which the food does not stay long enough in the large intes- tine to consolidate. Large quantities of offensive gases escape from the bowels, and there are gurgling noises in the intestines, due to this cause. Abdominal pains of a paroxysmal, colicky character are present. There are slight fever, loss of appetite, sometimes vomiting, and if the disease exists a length of time the general health is much impaired. Should INTESTINAL DISEASES. 103 tlie enteritis he situated high up in the small intestine, diarrhoea may be absent, but there is frequently catarrh of the stomach, and the stools contain hyaline mucus and particles of undigested food. Jaundice often occurs in these cases. Where the enteritis is situated in the large intes- tine, the stools are very thin, and may consist entirely of mucus and pus. The abdomen is tender to the touch, especially along the course of the colon. In cases of catarrh of the rectum the passages are preceded by severe pain, burning and cutting sensations, and spasms of the sphincter. The stools consist mostly of mucus mixed with blood and pus, and there is a constant desire for evacuation. The acute form of enteritis may be- come chronic, especially in children, but the chronic form occasionally occurs primarily. The symptoms are those of acute enteritis, but fever is not as marked and the emaciation is more pronounced. A cachectic appearance is generally seen, and mucous casts of the intestinal tubes often appear in the stools. Mental depression is also a frequent symp- tom of the chronic form. Attacks of acute enteritis last from two to ten days. The chronic form frequently lasts for years, the patient gen- erally dying of exhaustion. What is the treatment of catarrhal enteritis ? In the mild acute cases rest, milk diet, and warm applications to the abdomen are all that are necessary. If the attack has been caused by irritants, such as indigestible food or irritant poison, a cathartic given early in the disease is advisable. This should be followed by the use internally of astringents, such as acetate of lead, tannic acid, tincture catechu, etc. For pain and increased peristalsis small doses of opium internally are best. In cases of excessive colic hot poultices to the abdo- men and morphine hypodermically are advisable. Should the disease be mainly situated in the large intestine or rectum the frequent use of large enemas, 2 to 3 pints of a solution containing vegetable astringents or disinfectants, gives much comfort. For the tenesmus, suppositories of opium combined with belladonna or hyoscyamus have a beneficial effect. In chronic cases the diet should be carefully regulated, and consist of the most easily digested food. Internally the astringent tonics should be administered, and externally electricity and massage should be used. Where practicable it is well to send the patient for a course of treatment at one of the mineral baths. CHOLERA MORBUS. What is cholera morbus? A disease occurring generally in the summer season, frequently epi- demic, and chiefly characterized by an intense, acute catarrhal inflamma- tion of the mucous membrane of the stomach and intestines. What is its etiology ? It is chiefly a disease of infancy and childhood, especially among those 104 DISEASES OF THE DIGESTIVE ORGANS artificially fed, but is also met with in young adults. The disease is prob- ably produced by a specific micro-organism, but the ingestion of unripe fruit or indigestible food seems to act as an exciting cause. What is its pathology? The mucous membrane of the intestines and stomach is swollen and of a dark-red color, but these changes do not correspond to the severity of the symptoms. Venous congestion of the pia mater is also often found. What are the symptoms ? The attack begins suddenly with pain in the abdomen, excessive vom- iting, and diarrhoea, the discharges frequently being almost liquid ( ' ' rice- water") in appearance. There are cramps in the muscles, and, though the skin may feel cool and moist, the temperature of the hody^ is high. There is restlessness, often delirium, in children. The pulse is small, weak, and quick, and the face pale. ^ In fatal cases death is preceded by coma. Convalescence in children is very slow. What is the treatment? At the beginning of the attack a good dose of calomel may be given ; afterward opium for the relief of pain and to check the diarrhoea, and a milk diet. In cases where collapse occurs, hot baths and alcoholic stimu- lants, either by the mouth, rectum, or hypodermically, will be necessary. Counter-irritation in the form of mustard plasters or electricity often re- lieves the cramps in the extremities. When convalescence is estabhshed a change of air is very beneficial, and often prevents a recurrence of the trouble. TYPHLITIS AND PERITYPHLITIS. What are typhlitis and perityphlitis? Typhlitis is an inflammation of the caecum which may produce ulcer- ation of the mucous membrane, or extend through the thickness of the entire wall and cause inflammation of the surrounding tissues. Peri- typhlitis is an inflammation of the connective tissue surrounding the caecum and the vermiform appendix. What is its etiology? In a few cases cold and wet seem to be the exciting cause. ^ In other cases traumatism gives rise to the disease. More frequently inflamma- tion within or around the caecum arises from irritation caused by accu- mulated faeces, especially when lodged in the appendix and containing seeds, small pieces of shell, or other hard bodies. The retained faeces sooner or later produce inflammation, ulceration, and sloughing. ^ Occa- sionally perforation occurs, causing perityphlitis or a general peritonitis. TYPHLITIS AND PERITYPHLITIS. 105 Perit>'phlitis also may develop as a secondary inflammation in acute dis- cases-^rheumatism, typhus, etc. What is the pathology ? The mucous membrane of the caecum is at first swollen and dark-red in color, but is soon destroyed by sloughing. An ulcer is formed which may heal and cicatrize, or may extend and perforate the caecum or ap- pendix, causing a perityphlitic abscess. This abscess may break under the colon, peritoneum, or descend down to the thigh and point there. What are the symptoms? It may begin slowly with constipation, a dull pain in the right iliac fossa, and repeated attacks of intestinal catarrh, or it may begin sud- denly. The patient complains of sharp pain in the region of the caecum ; there may be vomiting, mucoid or bloody passages from the bowels, loss of appetite, accelerated pulse, and fever. The pains extend over the right lower portion of the abdomen, and are increased on even moderate pressure. On examination we find the abdomen slightly swollen and tympanitic, and there is a prominence as of a sausage-shaped tumor in the region of the caecum. This is due to an accumulation of faeces and inflammation of the caecal wall. In some cases the process stops at this stage. Large masses of foul-smelhng faeces are evacuated, and in a few days the patient is on the way to recovery. Usually, unless active measures are employed, the inflammation spreads, takes on a purulent character, and the peritoneum becomes involved. Then ten- derness and swelling are more general, the right leg is kept bent to re- lieve tension, and later all the symptoms of collapse appear. In perityphlitis similar symptoms are present, though the tumor is less clearly felt. Should the formation of an abscess take place, there is often fever of a septic type, with signs of fluctuation at the afl"ected spot. The abscess may break externally or into the colon, in which cases re- covery often occurs. Should it break into the peritoneum, general peri- tonitis takes place, generally ending in death. What are the diagnosis and prognosis ? It must be diagnosed from rapidly-growing new growths of the kidney and ovary, and from abscess due to caries of the vertebrae or neighbor- ing bones. A favorable termination is common, but if abscess forms the result will depend on its early recognition and suitable treatment. What is the treatment? At first an attempt to remove the faecal masses by means of strong cathartics or large high enemata may be made. An attempt should also be made to hmit the inflammation by means of opiates internally and the application of ice or the cold coil to the affected part. Should suppu- ration take place, interference by surgical means should be immediately resorted to. 106 DISEASES OF THE DIGESTIVE OEGANS. PERFORATING DUODENAL. ULCER. What is its etiology ? It is generally due to the same causes as ulcer of the stomach. It sometimes follows extensive burns of the skin. It is more common in males than females. What is its pathology ? It is usually found in the upper horizontal part of the duodenum. The ulcer starts as a local necrosis, followed by a disintegration of ne- crosed tissue through the action of the gastric juice. Contraction of a resulting cicatrix may cause constriction of the gut. In appearance it resembles the round gastric ulcer. What are the symptoms? Sometimes there are no premonitory symj^toms until perforation takes place or a blood-vessel gets eroded and causes hemorrhage. In other cases precursory sjonptoms consist of gastric fulness after eating and tenderness on pressure over the situation of the duodenum. The gen- eral health often remains good. In cases of perforation an acute peri- tonitis is set up. These symptoms may persist a variable length of time. What is its treatment? It is well to keep the patient quiet and put him on a milk diet, and give large quantities of alkaline waters and bismuth. Narcotics may be used for the relief of pain. TUBERCULAR ENTERITIS. What is tubercular enteritis ? An affection of the intestines, generally secondary, and characterized by a caseous degeneration of the intestinal follicles and lymph-glands, followed by ulceration. What are the etiology and pathology? It usuallj^ develops in long-standing cases of pulmonary tuberculosis from the swallowing of the sputum. Primary cases originate from in- fected food. The tubercular process begins mostly in the ileum, affect- ing the lymph-glands and follicles. The glands are swollen and hard, but later they become yellow and soft, breaking down and causing tuber- cular ulcers. These ulcers vary in size and spread in the circumference of the intestine. The ulcer may cicatrize or break through the intestinal wall, causing peritonitis. On microscopical examination the affected portion of the gland is seen to be filled with round tubercle-cells crowded together, and colonies of bacilli are found in the edges of the ulcers. What are the symptoms and treatment? In the secondar}'^ form the symptoms are not pronounced, excepting CANCER OF THE INTESTINE. — CONSTIPATION. 107 diaiTlioea accompanied or preceded by pain. In tlie primary form, especially in children, there is general emaciation, development is re- tarded, diarrhoea comes on in attacks. The abdomen is prominent, and the enlarged mesenteric glands can (sometimes) be felt. The pulse is accelerated, and generally small. There is slight elevation of tempera- ture, except at night, when fever may be marked and night-sweats are frequent. Ti'eatment. — A great deal of out-door life, a generous and easily- digested diet, and change of surroundings are beneficial. Astringents and opiates may be given for the relief of the diarrhoea and pain, though the diarrhoea is, as a rule, uncontrollable. Internally the use of anti- septics is sometimes followed by improvement. CANCER OF THE INTESTINE. What are its etiology and pathology? It is usually primary, and does not occur so frequently as cancer of the stomach. It is most frequently found in the rectum, and is a disease of middle-aged or old people. It occurs very frequently in the colon. All three forms of cancer may be met with in the intestines. The new growth usually surrounds the intestinal tube, and occasionally it breaks down, causing cancerous ulcers. These ulcers may perforate into the peritoneum and surrounding organs. What are the symptoms and treatment? The symjjtoms^ as a rule, are very obscure. Defecation becomes painful, and constipation is present, which becomes more and more marked. The abdomen becomes prominent, and marked cachexia is developed ; emaciation is rapid ; the patient finally succumbs to the disease. When situated in the rectum the signs are more distinct. The hard cancerous nodules can be felt ; the sphincter ani, when involved, be- comes paralyzed ; and there is a constant discharge of mucus and blood, and, if ulceration is present, of pus. When the growth causes constric- tion of the intestine, the faeces are passed in small round lumps or in the form of ribbons. The cancer, if ulcerating, may perforate into any of the neighboring organs. The affection may run a very slow course, but is always fatal. A few cases are benefited by operative interference. Opiates will have to be given for the relief of pain. The constipation may be partially removed by attention to diet, the use of saline laxatives internally, and enemata of hot water administered through a soft-rubber rectal tube. Where the growth is situated low down the judicious use of a whalebone bougie is often of benefit. CHRONIC CONSTIPATION. What is understood by the term chronic constipation ? An impairment of the peristalsis of the intestines, characterized by 108 DISEASES OF THE DIGESTIVE ORGANS. irregular and infrequent discharge of faeces. It is a complication espe- cially of wasting diseases, and is also brought on from lack of exercise and small amount of food taken. It also occurs in the course of chronic peritonitis and diseases of the brain and spinal cord, causing inhibition of the intestinal nerves. Kareh^ the affection appears without any ap- parent systemic cause, and in these cases there are hypochondriasis and other nervous disturbances. Cases are generally difficult to treat, as patients rarely persistently follow a physician's advice. Small amounts of food should be given, frequently repeated, or large quantities when mechanical irritation is required : strong purgatives are contraindicated, as the habit requiring their use is easily developed. Mild laxativesmay be employed with care. If the cause of the condition can be ascertained, this of course would require the needed remedies._ Strj^chnine, bella- donna, cascara in required dosage often prove effective. Externally the use of massage and faradization of the abdomen, when systematically employed, frequently effect a cure. INTESTINAL PARASITES. TAPE-WOEMS. These worms are found in the intestines in three varieties : first, the long or chain tape-worm {Tcenia solium) ; second, the broad tape-worm [BotJinocephalus latus)\ third, the {Tcenia mediocanellata) , which is thicker than the Tcenia soliujii. What is the etiology of tape-worm ? The Tcenia solium^ when mature, is from ten to twenty feet long, and of a yellow-white color. The joints near the head are round, and then flatten as they form the body. The head is round, 3V o^ an inch in diam- eter, surrounded by four cup-like round suckers. The neck is slender, J an inch to 1 inch in length, to which is attached the body, consisting of hundreds of joints or links. The hnks nearest the neck are very small, but gradually increase in size, and are nearly quadrilateral in shape. The mature links have, in the male, a sHght projecting penis in the side, while in the female a uterus with branches along the middle of the link is found. The ovarj contains the Qgg, in which is lodged the embr\o with its six booklets. The blood-vessels run along the side of the joint. This worm is chiefly found in the small intestine, where the head_ clings to the mucous membrane. The mature links are often cast off with the faeces, and, being deposited on herbage, etc. , are eat^n by animals, and thus re-enter the stomach. The Tcenia mediocanellata resembles the T. solium^ but its links are broader and thicker. The head has four suckers, but no beak nor hooks. The uterus is much more branched than that of the Toeiiia solium. The undivided segments often move after being passed with the faeces. It is found chiefly in Germany, and is due to eating raw beef. The Botlirioceplialus latus has no suckers nor beak on the head, but INTESTINAL PARASITES. " 109 only- two slit-like openings. It is ten to twenty-five feet long, and has thousands of joints, which are broader than they are long. The neck is very thin and slender. The uterus has many branches, and the sexual opening is in the middle of the abdomen. The eggs are oval and the embryo ciliated. It develops in fresh water, where it is eaten by fish and subsequently by man. It is found in certain European countries only. What are the symptoms of tape-worm ? Often there are no symptoms at all, except the occasional presence of tgenia- links in the stools. ' In some cases there are nausea and vomiting, an increase in the flow of saliva, and paroxysms of sharp abdominal pain, loss of appetite or abnormal hunger, diarrhoea alternating with constipation. Hypochondriasis and progressive emaciation gradually develop. In children and young adults reflex symptoms are often caused, such as tickling of the nose, dilatation of the pupils, choreic movements, and frequently eczema. What is the treatment ? Treatment is directed to killing or benumbing the head of the worm and causing its expulsion. Patients should be given a mild laxative, and then made to fast for twelve hours : one of the anthelmintics may be then given, of which one of the best is filix mas, to be followed after twelve hours more of fasting by a large dose of calomel or one of the saline cathartics. During the treatment all movements should be care- fully inspected for the head of the worm. After-treatment will consist of tonics and a generous diet. EOUND-WOEMS (ASCARIS LUMBRICOIDES). What is the history of round-worms ? The ascaris is cjdindrical in shape, from six to twelve inches in length, pointed at both ends, and of a pink color. The sexes appear in diff"erent individuals. The head has three lips set with teeth. There is a long tail, straight in females and curved in males. The females have large ovaries containing millions of eggs, the males having long seminal tubes, with a small penis at the end of the tail. These worms are found mostly in the small intestine, and are often very numerous. In vomiting they may be brought up with vomited matter, and they sometimes enter the bile-ducts and peritoneum. The disease is seen most frequently in children. What are the symptoms and treatment? As a general rule, the presence of these worms gives rise to^ no symp- toms. Occasionally abdominal pain and reflex symptoms, like itching of the nose or even slight spasms, are caused by their presence. When present in great numbers they may simulate an intestinal obstruction. 110 DISEASES OF THE DIGESTIVE ORGANS. They occasionally enter the bile-ducts, causing the symptoms of catarrhal jaundice, and in rare cases the formation of abscess. Doses of santonin, gr. j-iv, combined with calomel, are the remedy most frequently em- ployed. OXYUEIS VERMICULARIS (PIN-WOEM). What is the history of pin- worm ? The oxyuris is a small, thin, round worm, the females being more nu- merous and larger than the males. We find them mostly in the lower portion of the intestines, chiefly the rectum, where they sometimes cover the whole mucous membrane like a thick coating. The eggs are laid in the rectum, and, amongst those of uncleanly habits, may be transmitted from the fingers of one man to another. The female sexual apparatus is near the head, the male penis near the tail end. What are the symptoms and treatment ? When high up in the intestines there are no symptoms. When in the rectum they cause a constant itching and burning, especially in the even- ing and during the night. There is a constant desire of defecation, the stools having a great deal of mucus from irritation of the rectum, and containing numbers of pin-worms moving about. The worms often crawl from the anus into the vagina of children, setting up irritation and leading often to rubbing of the parts and masturbation. Internally, santonin, followed by cold enemata, is often sufficient to dislodge the worms. In obstinate cases a plain enema, followed by one containing a good quantity of tannic acid, often effects a cure. The general health rarely requires special attention. ANCHYLOSTOMUM DUODENALE. What is the history ? This worm was first noticed among the inhabitants of Italy and Egypt. It is small, the female being larger than the male. The head has a cup- like mouth provided with six teeth, and the animal lives in the manner of the leech, by withdrawing the blood from the mucous membrane of the intestine. When present in large numbers profound ansemia is pro- duced. The eggs develop in water, and the drinking of impure water or its introduction into the sj^stem is a cause of the trouble. What are the symptoms and treatment? We have to deal with a gradual progressive general anaemia, without symptoms of systemic affection. The anaemia may finally end in death if the disease is not recognized in time. The fasces should be examined in all suspected cases. For treatment we may use the ordinary anthelmintics. DISEASES OF THE PERITONEUM. Ill • •'• TRICHOCEPHALUS DISPAE (WHIP-WORM). What is the history ? It is one to two inches long, the male being the longer, with a spiral tail. The female is straight, with the lower part studded with eggs. It is found mostly in the caecum, and hardly ever gives rise to any symp- toms. Diseases of the Peritoneum. ACUTE GENERAL PERITONITIS. What are its causes? It most frequently occurs as secondary to some other inflammation of the abdominal viscera or to traumatism. The involvement of the peri- toneum occurs from extension of the inflammation in the puerperal state or from rupture of the gall-bladder or of the hepatic ducts, or from the rupture into the peritoneal cavity of hepatic, ovarian, or other abcesses. It also sometimes occurs in the course of Bright' s disease or from expo- sure to cold. What is the pathology ? The peritoneum is at first reddened, and its surface is soon covered with a layer of fibrin, or fibrin and pus containing large numbers of leucocytes. The cavity of the peritoneum contains more or less sero- purulent fluid, and there are adhesions between its opposing surfaces. The intestines are always much distended by gas. What are the symptoms? The disease may come on gradually, when there is abdominal pain and soreness, followed by the general symptoms. When the dis- ease comes on suddenly, it is ushered in by a chill, and there is marked pain of a burning or lancinating character over the abdomen. Acute pain is produced by deep inspiration, and the respirations are usually shortened, but increased in frequency. Movements of the body or acts of coughing and sneezing cause intense pain. The abdomen is tense, tympanitic, and very tender on pressure. The patient lies on his back with the legs flexed. Vomiting generally exists, sometimes of a stercoraceous nature. The bowels are generally constipated. The tem- perature is markedly raised, and the pulse is small, wiry, and much accel- erated. The face generally has a characteristic drawn appearance ; the intellect remains clear. Retention of urine exists in some cases. What is its treatment? Treatment consists of rest in bed, cold externally to the abdomen, and the use internally of repeated small doses of calomel or vSulphate of mag- nesia and small doses of opium. The diet should be liquid, and consist 112 DISEASES OF THE DIGESTIVE ORGANS. of concentrated food, given frequently and in small quantity. The use of alcoholic stimulants may be necessary. Where opium is used the amount given in each dose should be regulated by the eifect of the pre- vious dose. In fatal cases the disease generally lasts from fiv^ to six days. ACUTE AND CHRONIC LOCAL PERITONITIS. What is its causation? It is caused by extension to the peritoneal surface of inflammation of an organ, as in ulcer of the stomach, the intestines, liver, gall-bladder, spleen, urinary bladder, and the uterus and its appendages. It also occurs as a complication of the inflammation caused by neoplasms in the abdominal organs. It frequently runs a chronic course. What is its pathology ? The aff"ected portion of the peritoneum is reddened, and the exudation in many cases is chiefly fibrinous. There are often adhesions, and in the acute form encapsulated collections of pus. In chronic cases contraction of the adhesions often gives rise to displacement of some of the viscera. What are the symptoms? The symptoms are those of a general peritonitis localized, and where the disease exists over the spleen, stomach, or liver a friction sound can sometimes be made out by auscultation. When it occurs in the neigh- borhood of the uterus the patient is very subject to recurrent attacks. What is the treatment? Treatment is that of the general form. In all cases of peritonitis anti- septics should be rigidly adhered to. CHRONIC GENERAL PERITONITIS. What is the etiology? It often follows an attack of acute peritonitis. In other cases the chronic inflammation, attended by thickening of the peritoneum, is a result of chronic inflammation of some of the abdominal viscera, at- tended by serous eifusion into the peritoneal cavity. Occasionally it results as an extension of chronic inflammation of the coating of the stomach. What is the pathology? The peritoneum is thickened, and the adjacent surfaces are often joined together by threads of new-formed connective tissue. The abdominal cavity contains more or less fluid, which may be serous, sero-fibrinous, or sero-purulent in charactei'. TUBERCULAR PERITONITIS. 113 What are the symptoms? Where the disease follows the acute form the local abdominal symptoms become less, but do not wholly disappear. Disturbances of digestion still persist, and there is generally occasional vomiting. The action of the bowels is irregular. As the disease progresses the patient loses weight and shows the other symptoms of anaemia. On physical exami- nation the abdomen is found to be distended, and, the patient being placed on his back, the percussion note in the region of the umbilicus is tympanitic and in the lumbar region dull. On percussion over the lumbar region an impulse is felt in the corresponding part of the oppo- site side. The disease is attended with slight elevation of temperature above the normal, but the pulse is often small and accelerated. What is the treatment? Treatment will consist of regulation of the functions of the liver and intestines. Should ascites be marked, aspiration might become neces- sary. Treatment can only be palliative, as the patient finally dies with exhaustion. Treatment directed to the primary cause should always be employed. TUBERCULAR PERITONITIS. What are its etiology and pathology? It is caused by a localized tubercular inflammation of the peritoneum. This tubercle tissue may be disseminated in the form of miliary tubercles, scattered nodules, or flat plaques on the surface of the peritoneum. There is generally a large quantity of serum in the abdominal cavity. The disease is frequently secondary to tubercular inflammations in other organs of the retro-peritoneal glands. Occasionally it seems to be a primary affection. What are the symptoms? The symptoms are those of chronic peritonitis, which shows a pro- gressive course. The abdomen is much distended ; its walls are resist- ant to pressure, and apparently much thickened ; and a large amount of fluid, as determined by percussion, is often present in the abdominal cav- ity. On aspiration the effused fluid is frequently found to be more or less hemorrhagic in character. What is the treatment ? General ti^eatment is that of pulmonary tuberculosis, but the opening of the peritoneal cavity and its thorough washing out are sometimes fol- lowed by temporary improvement. The disease is fatal. CARCINOMA OF THE PERITONEUM. What are its etiology and pathology? It is generally secondary to cancerous growths in other parts. It occurs in the form of colloid cancer or of hard nodules, which are com- 8— P. M. 114 DISEASES OF THE DIGESTIVE ORGANS. posed of connective-tissue stroma, enclosing cavities containing epithelial cells. There may be manj^ small tumors or one large mass. The peri- toneum is generally thickened ; there is also thickening of the omentum, and the intestines are matted together by adhesions. The disease occurs in persons over forty years of age. What are the symptoms and treatment? The symptoms are those of a slowly increasing chronic peritonitis. There are disturbances of the digestive functions, progressive loss of flesh and strength, and the development of a marked cachexia. Where the tumor is single it is often to be observed on palpation and percus- sion. In the early stages of the disease treatment by operative inter- ference may be of benefit. Other treatment will be symptomatic. The disease is fatal. HYDROPERITONEUM. Syn. — A.scites. What is its causation ? It occurs as a symptom of other diseases. It may be a local transuda- tion into the peritoneal cavity or a symptom of general dropsy. It occurs with chronic inflammations of the peritoneum or as a result of pyle- phlebitis (of the portal vein). It also occurs in cases of interstitial or syphilitic hepatitis, and in cases of abscess, cancer, or other tumors of the liver. In conjunction with general dropsy it occurs in Bright' s dis- ease, in compensating valvular lesions of the heart, in chronic indura- tion, and in other chronic diseases causing an hydraemic condition of the blood. What is its pathology? The fluid generally consists of yellowish serum. When caused by new growths it is often darker in color, caused by staining with blood. The specific gravity is from 1004 to 1020. The fluid generally contains about 2 per cent, of albumin. On the removal of fluid from the body it is found to contain flbrinogen, and often coagulates spontaneously. Karely the fluid is of a milky color from pressure or rupture at the large chyle-vessels. This is also true in a few cases of cancer or tubercle of the peritoneum. What are the symptoms ? Efi"usion generally takes place without pain, tenderness, or local sub- jective symptoms. Enlargement of the abdomen is first noticed, and increases rapidly. Then there are sjanptoms caused by pressure of fluid on the abdominal organs. There is often oedema in the lower extrem- ities, and the functions of the abdominal organs are impaired by com- pression. There may be more or less dyspnoea fi'om the forcing upward of the diaphragm. The superficial abdominal veins are abnormally DISEASES OF THE LIVER. 115 ppominent, and where the ascites is caused by diseases of the Uver jaundice is often marked. The urine is scanty, and high in color. Fever is absent, but the pulse is accelerated and generally feeble. What is its diagnosis ? Physical examination shows the distension (with patient on back) to be symmetrical. The line of tympanitic resonance will differ with the position of patient. When opposite sides of the abdomen are percussed, below the level of the fluid the wave of fluctuation is felt. The with- drawal of a small portion of the fluid by means of the hypodermic syringe, and its examination, will often settle the diagnosis. This con- dition may be mistaken for enlarged bladder, pregnancy, or cystic tumors of the abdominal organs. What is the treatment ? Treatment will be directed to the primary cause and removal of the fluid. For the latter purpose the administration of hydragogue cathar- tics and the salines and vegetable diuretics is indicated. Should the distension be sufficient to cause great distress or signs of heart failure, aspiration or tapping must be resorted to. Diseases of the Liver. CATARRHAL JAUNDICE. What is catarrhal jaundice ? A catarrhal inflammation of the biliary ducts, preventing the flow of bile into the intestines and causing a yellow discoloration of the tissues and fluids of the body, due to absorption of biliary pigment by the blood and its deposition in the various tissues. What are its etiology and pathology? Causes producing gastro-duodenal catarrh may also induce inflamma- tion of the mucous membrane of the bile-ducts. It is also caused by irritants of a chemical or mechanical _ nature ; by congestion of other abdominal organs, especially hyperaemia of the liver, as in cancer ; and by an infection whose character is undecided at present. The common duct contains mucus; its mucous membrane is 1-eddened and swollen, and its lumen is narrowed or completely occluded. Above the occlusion there is dilatation of the duct and its branches, often extending into the liver. What are the symptoms ? The disease is usually preceded by malaise, anorexia, nausea, slight vomiting, and other symptoms of gastro-intestinal catarrh. As soon as obstruction occurs, there are signs of reabsorption of bile into the lymph- atics, and thence into the blood. The conjunctivae become yellow, and 116 DISEASES OF THE DIGESTIVE ORGANS. soon the skin and the mucous membranes become similarly stained. There is itching of the skin, often attended bj^ urticaria. The heart's action is abnormally slow and ftill. Occasionally hemorrhages into the skin take place. There are general languor, pain in the muscles, and a feeling of weakness. The stools of the patient have a white clay color, from absence of bile. Owing to the same cause the food decomposes rapidly in the intestines and the stools have an offensive odor. Con- stipation is present, due to a lack of peristaltic action. Owing to the impairment of digestion, proper absorption is prevented and emaciation ensues. The urine is dark in color from the presence of biliary pig- ments, as is shown by the chemical reactions. Sometimes albumin and hyaline casts are found in the urine. The temperature naay be subnor- mal. On phj^sical examination the area of splenic and liver dulness is found increased. The hepatic area is tender to pressure, and a tumor projecting below the ribs can often be felt, which is due to a distended gall- bladder. All these sjTiiptoms may last one to three weeks, and gradually disappear, but occasionally they become chronic. What is the treatment ? In mild cases rest and light food, with the exclusion of fats, are suffi- cient. In pronounced cases the alkaline carbonates or phosphate of soda, in moderate doses frequently repeated, should be given internally ; saline carthartics should be used for the constipation. Massage and faradization of the gall-bladder have been lately used. Large cold-water enemata are also advocated. BILIARY CALCULI. What are biliary calcuU? Concretions of small or large size found in the bile-ducts or gall-blad- der. What is their etiology? The origin of bile-stones has not been definitely determined. The principal causes of their formation are retention of bile and consequent inspissation, and also an acid reaction of the bile and a consequent abnor- mal deposits of lime salts. Calculi are more frequent in women than in men, especially in the aged. The excessive consumption of nitrogenous foods and fat, combined with sedentary habits, gout, obesity, or disease of the liver or ducts, predisposes to the formation of calculi. The stones may be as small as a seed or as large as a hen's egg, assuming the shape of the gall-bladder. There may be a number of small stones filling up the gall-bladder, and they generally produce a mechanical irritation of its mucous membrane. The stones vary in color from white to brown, and often present various strata. When recently formed they are very brittle, but become harder with age. Chemically, they consist of choles- terin and biliary pigment, mixed with lime and magnesium salts. The BILIARY CALCULI. 117 centre. of tlie stone is usuall}^ the hardest portion, and consists of Hme salts and pigment. The very small biliary concretions may also be found in the liver and small ducts. Calculi may be present for a long time without causing structural change in the organ, but the sharp edges of the stones occasionally cause inflammation of the mucous membrane sur- rounding them, followed by ulceration, and finally perforation of the bladder or duct. Hepatic abscesses may arise from this cause, or par- tial or complete closure of the ducts with subsequent jaundice. What are the symptoms? Occasionally the calculi, whether in the liver or gall-bladder, are pro- pelled into the common duct to be voided into the intestines. The pas- sage of the larger calculi gives rise to marked symptoms. There is a sudden attack of sharp pain of a cutting nature, which follows the line of the common duct and may radiate over the rest of the abdomen and toward the right shoulder. This pain is not preceded by premonitory symptoms, but often follows a hearty dinner. The pain is paroxj^smal ; the abdominal muscles are tense ; the pulse is small, quick, and hard ; the skin cold ; there are nausea and vomiting, and rarely severe chill or even convulsions. The attacks may last from a few hours to a few days. The pain gradually subsides as the calculi slip into the intestine. These attacks are sometimes followed by jaundice. The attacks may not come on for years or may be frequently repeated. Should a calculus become permanently lodged in the ducts, the sharp pain lasts for several days, and is followed by a dull, constant pain, while the occlusion may give rise to jaundice or dropsy of the gall-bladder. If a calculus causes ul- ceration, we have symptoms analogous to ulceration of the vermiform appendix. In these cases at first there may be no symptoms, but when the peritoneum becomes afiected there are symptoms of local peritonitis, and should there be perforation of the wall of the duct, these are fol- lowed by symptoms of general peritonitis, caused by the escape of bile or calculi into the abdominal cavity. Rarely perforation takes place ex- ternally or into the duodenum. Intestinal obstruction may be caused by the impaction of large calculi in the intestines. What is the diagnosis ? This aifection must be difierentiated from intestinal colic, renal colic, cardialgia, and neuralgia of the abdominal nerves. The diagnosis will be based chiefly on the nature of the onset and character of the pain, on the presence of gall-stones in the stools, and on jaundice. Most cases end favorably in complete or partial recover}^ What is the treatment? During the colic the inhalation of chloroform [pro re nata) and the use of large doses of opium internally are of greatest use. A hot bath or hot poultices over the liver are often of benefit. For the severe vomit- ing, ice, the bromides, or opium may be used. Where collapse occurs' stimulants in large doses are necessary. After the colic has passed mild 118 DISEASES OF THE DIGESTIVE ORGANS. laxatives for the removal of the calculus maj" be given. To prevent the new formation of calculi, alkaline mineral waters, phosphate of soda, chloroform, and turpentine interna^ have all been used, as solvent powers have been claimed for them. Should the calculus become im- pacted in the ducts or intestine, surgical interference may be necessary. ABSCESS OF THE LIVER (SUPPURATIVE HEPATITIS). What is suppurative hepatitis? A suppurative inflammation in the liver, with subsequent disintegra- tion of the liver- cells and the formation of one or more abcesses. What is its etiology ? It is caused by the entrance of bacteria into the liver by way of the bile-duct after inflammation of the duct of a suppurative character, or by way of the vena cava. The bacteria may be carried by means of the circulation from the focus of inflammation in distant parts of the system. Direct exciting causes are wounds of the liver, ulceration or gangrene of the abdominal organs, or inflammation and thrombosis of the veins. The disease is primary in tropical countries. What is the pathology ? The blood-vessels surrounding the infected spot are filled with mi- crobes. The new cells and the cells of the parenchj^ma are seen to be disintegrating and softening, and thus an abscess is formed. This ab- scess sometimes extends in every direction, and may open into the sur- rounding organs or externally. If the abscess is quite small, its contents may be absorbed. In cases of recovery a dense cicatrix is found at the site of the abscess. What are the symptoms ? As hepatic abscess is a complication of many diseases, the symptoms are often indistinct. In pyaemia there may be numbers of very small abscesses without giving rise to any symptoms. In typical cases of ab- scess there are tenderness on pressure and a dull pain in the right hypo- chondrium, due to tension on the capsule of the liver or to a complicat- ing perihepatitis. Pain in the right shoulder is also present. On exam- ination the area of hepatic dulness is found to be enlarged, and if the abscess is very large we maj'' even get a sensation of fluctuation. Jaun- dice occurs in some cases. Elevation of temperature is a constant symp- tom, except where there is a chronic encapsulated abscess. Many cases begin with a chill, followed by high temperature and subsequent sweat- ing ; and these symptoms frequently occur at varjdng intervals. An- orexia is marked ; there is a progressive loss of flesh. What is its prognosis? When occurring in pyaemia the disease is always fatal. If due to cal- culi, the abscess may disappear after passage of the calculi. Occasion- CIRRHOSIS OF THE LIVER. 119 ally perforation takes place into the neighboring cavities, setting up a suppurative inflammation, as general peritonitis, empyema, or purulent pericarditis. Should perforation into the stomach occur, vomiting of pus takes place. Where perforation in the intestine occurs, the movements will contain a large amount of pus. Almost all cases terminate fatally. What is the treatment? Cold compresses externally and the use of calomel or emetics inter- nally are recommended. The use of quinine and stimulants is called for to relieve the chills and fever. Operative interference is advisable as soon as the diagnosis is established. If the careful introduction of a fine aspirating needle shows the presence of pus, operative measures will be indicated. CIRRHOSIS OF THE LIVER. Syn. — Interstitial hepatitis. What is cirrhosis of the liver ? A chronic inflammation of the fibrous covering and interstitial tissue of the liver, which results in the production of new connective-tissue ele- ments and atrophy of the parenchyma. What are its etiology and pathology? The most frequent cause is the excessive use of alcohol, causing im- pairment of the nutrition of hepatic cells and their consequent disinte- gration. It also occurs from obscure causes, as a result of infectious dis- eases and syphilis. It is more common in men than in women. In the first stage the liver is increased in size, the surface is smooth, and the capsule slightly thickened. The interstitial connective-tissue elements are much increased. In the second stage the liver becomes pale and hard, and is diminished in size from the shrinking of the new connective tissue. Its surface is often irregular and covered with nodules, due to the gradual changing of new connective tissue into the cicatricial form. The border of the liver becoming thin and indurated, its substance is hardened and dark. What are the symptoms? The first symptoms are those of congestion of the liver, often preceded by symptoms of gastric disturbance, as a sense of fulness in the epigas- trium, eructations of gas, nausea, and vomiting. Marked symptoms develop when the portal system becomes interfered with from the con- traction of new connective tissue. Ascites, more or less marked, is found, and the area of splenic dulness is enlarged. Symptoms of chronic gastric and intestinal catarrh begin, frequently accompanied by hemor- rhage from the stomach and intestines and the formation of hemorrhoids. Jaundice, though not a constant symptom, is often present. The area of hepatic dulness is decreased, and the nodules on the surface of the 120 DISEASES OF THE DIGESTIVE ORGANS. organ may sometimes be felt. Emaciation is progressive. The existing ascites is often complicated by oedema of the lower extremities. Fever is absent and the pulse is small. The frequency of respiration is in- creased from compression of the lungs and diaphragmatic interference, due to ascites. The urine is dark in color and contains an excessive amount of urates ; the specific gravity is high. In cases of long stand- ing there is often marked enlargement of the abdominal veins, due to interference with the portal circulation. The disease is chronic and may last for years, usually ending fatally. Death may be caused from ex- haustion, due to disease itself or to hypertrophy of the heart or chronic inflammation of the kidneys or meninges. Hepatic syphilis, chronic obstruction of the portal circulation, due to calculi, etc. , or chronic tuber- cular peritonitis, may be mistaken for this disease. What is its treatment? The diet should be limited, easily assimilated, and all alcoholic stimu- lants forbidden. Saline purgatives may be used to relieve the conges- tion. The internal administration of iodide of potash in large doses is sometimes followed by good results. Where there is marked distress from ascites, paracentesis must be resorted to. ACUTE YELLOW ATROPHY OF THE LIVER. . What is acute yellow atrophy of the liver ? An acute fatty degeneration of the liver which may be primary or secondary, attended with a yellow discoloration of the organ. What are the etiology and pathology? It is most frequentl}^ seen in women, especially during pregnancy, but occurs with typhoid fever, puerperal fever, septicaemia, and phosphorus- poisoning. In the primary form the patient is attacked suddenly, and the disease rapidly ends in death. As it is sometimes endemic, some authors have considered it infectious. The liver is diminished in size, the capsule is contracted, and the organ is soft The surface is yellow and the interior red and yellow. On microscopic examination the he- patic cells are found fatty, degenerated, and many of them have disap- peared, leaving blood-vessels and connective tissue. The blood-vessels are found enlarged and congested, giving the mottled red appearance. In many cases the spleen is enlarged and affected with fatty degenera- tion, and the same change is found in other organs. Ecchymoses into the skin and mucous membranes are often present. Examination of the blood frequently shows the presence of leucin and tjrrosin. What are the symptoms? The attack may come on suddenly or there may be prodromata. Pro- dromic s.ymptoms are — loss of appetite, fulness in the epigastrium, head- ache, nausea, vomiting, and slight jaundice. At the onset of the dis- ease there are headache, insomnia, and often delirium and convulsions of CANCER OF LIVER AND BILE-DUCTS. 121 au epileptic nature. This stage is followed by stupor, coma, and death. The jaundice is very marked, and the urine of a deep color, caused by the presence of the bile acids. Fever is very high. The pulse is fre- quent and the tongue dry. The faeces and the urine are passed involun- tarily. There may be bloody vomiting and bloody stools. The urine often contains leucin and tyrosin crystals, and the amount of urea is greatly diminished. On physical examination the area of hepatic dul- ness is much diminished in size, and there is tenderness on percussion over the right hypochondrium. The area of splenic dulness is greatly increased. The duration of the disease is from a few days to a few weeks. What is the treatment? Treatment is entirely symptomatic. PERNICIOUS JAUNDICE. What is pernicious jaundice ? A chronic obstruction of the bile-ducts, followed by sudden develop- ment of acute nervous symptoms and ending in death. What are the etiology and symptomatology? When chroriic retention of bile occurs in any affection of the liver, there is a sudden development of symptoms resembling those of acute yellow atrophy. These consist of delirium, convulsions, high fever, sub- cutaneous and submucous hemorrhages, and coma. Some claim the infection to be due to the retention of bile in the blood. Others, that it is produced by the presence of bile-producing elements in the blood, act- ing like an acute poison. Still other authorities think that from absence of proper assimilation cerebral anaemia develops, producing the above group of symptoms. It is invariably fatal, and treatment consists in quieting the delirium. CANCER OF LIVER AND BILE-DUCTS. What are its etiology and pathology? It is rarely primary, but is often secondary to cancer of the intestinal organs. The cancerous growths are usually scattered over the liver, and are varying in size. In extensive carcinomata the liver becomes very much enlarged. The nodules may be firm or soft, or white or reddish in color, and have a depression in the centre. Rarely the infiltration ap- pears to be diffuse instead of nodular. The primary form is more com- mon than cancer of the bile-duct or gall-bladder. The disease occurs between the ages of forty and sixty, and heredity appears to have a causative relation to it. What are the symptoms? If the portal veins or bile-ducts are not compressed, the symptoms are 122 DISEASES OE THE DIGESTIVE ORGANS. very indistinct : there are pain in the hypochondrium, radiating to the shoulder, a feehng of pressure in this region, and on examination an irregular enlargement of the liver, giving flat resonance on percussion, is found. Where the carcinomatous cachexia is developed and the abdom- inal fat is wanting, the enlarged nodules may often be seen or felt on forcing the liver down by deep inspiration. Ascites and jaundice gradu- ally come on as a result of the compression, and symptoms of gastric and intestinal catarrh develop. The urine is sometimes scanty and is dark in color. The diagnosu of cancer fi"om benign tumors, echinococci, or abscess of the liver is often difficult. The disease, as a rule, lasts a few months and ends in death. What is the treatment? It consists in the relief of pain and the administration of artificially digested foods. ECHINOOOCCUS OF THE LIVER. What is echinococcus ? A small tape-worm, the young brood of a mature worm. It has three or four joints, and develops from ingestion of eggs which occur in drink- ing-water containing the excrement of animals affected with taenia. The shells of the eggs are dissolved in the stomach, the embryo is liberated, and, penetrating the stomach, is carried by the blood into different organs. When the embryo is deposited in an organ, a cyst enclosing it is devel- oped, which is surrounded b}^ a capsule of connective tissue. The C5'st swells to a large vesicle containing a large colony of immature taeniae, each having four suckers and six booklets. These cj^sts may have daughter cysts, and thus enlarge, sometimes in the organ invaded, to an enormous size ; but finally the echinococcus dies, and the contents of the cyst become absorbed or calcified. Occasionally the sac bursts, setting up inflammation in the neighboring parts. What are the symptoms? Echinococci may remain in the liver for years without causing symp- toms. If large, there is a feeling of pain and oppression in the right hypochondrium, more or less dyspnoea, ascites, or jaundice from com- pression. The liver is enlarged, firm, and smooth ; the spleen is also congested. Emaciation is rapid until death comes on. Occasionally fluctuation at the site of the cyst can be detected. The sac may rup- ture, and its contents be emptied externally or into the pleural cavity, abdominal cavity, intestines, bile-ducts, or vena cava. When this takes place an acute inflammation is set up. The aspirator is useful for diagnosis in doubtful cases. CONGESTION OF THE LIVER. — AMYLOID LIVEE. 123 What is the treatment? Iodide of potash and mercury have been used internally, but surgical interference as soon as practicable gives the best results. CONGESTION OP THE LIVER. Give the causes and symptoms of congestion of the liver. Active congestion arises from blows over the region of the liver ; from increase of blood-pressure in the portal veins after immoderate eating or drinking ; from ingestion of irritating food or infectious matter ; and occasionally from the stoppage of bleeding from hemorrhoids or the uterus. Passj^ve congestion may result from cardiac disease or from acute or chronic pulmonary affection. On examination the liver is found more or less enlarged. It is dark on section, and pigmented, and often there are scattered yellow spots, due to fatty infiltration. In many cases the only symptoms are a feeling of fulness in the hepatic region and an increase in the area of normal liver dulness on percussion. In more severe cases there may be jaundice from the compression of the bile-ducts, and the symptoms of gastro-intestinal dyspepsia. Treatment consists in the regulation of the diet, mild systematic exer- cise, and the use of saline waters. In most cases the cause of the con- gestion is apparent, and treatment can be directed to it. HYPERTROPHY OP THE LIVER. What is hypertrophy of the liver ? A slow enlargement in the size of the liver which sometimes occurs in the course of chronic malarial fever, diabetes, rachitis, or chronic poisoning by alcohol. The condition rarely gives rise to any marked symptoms. PATTY LIVER. What is fatty liver? An infiltration with fat between and in the liver-cells, causing an in- crease in the size of the organ. It may occur with general obesity, with cancerous diathesis, rachitis, chronic tuberculosis, and chronic alcoholic poisoning. The condition itself may last for a long time without impair- ing the function of the organ. Symptoms are not marked. AMYLOID LIVER. What is amyloid liver? A waxy degeneration of the organ, usually a symptom of general amy- loid affection. It occurs with tuberculosis, syphilis, or long-standing sup- puration from any cause. The liver is much enlarged and the liver-cells are atrophied and degenerated. The spleen, kidney, and intestines are 124 DISEASES OF THE DIGESTIVE ORGANS. usually the seat of amyloid degeneration at the same time. Treatment will be directed to the cure or alleviation of the original disease. SUPPURATIVE PYLEPHLEBITIS. What is suppurative pylephlebitis? A purulent inflammation of the portal vein and its branches. What are its etiology and pathology? It is usually secondary to purulent inflammation of the organs, espe- cially perityphlitis, gastric ulcer, hepatic or splenic abscesses, dysentery, and, in the newly born, infection from suppurative inflammation of the umbilicus. The wall of the portal vein is thickened and infiltrated with pus containing large colonies of bacteria. A septic thrombus forms, spreading upward and downward. This breaks down, and particles of it are carried to other organs, forming secondary abscesses. What are the symptoms and treatment? In addition to the pysemic or other symptoms, caused by the original -disease, there maybe epigastric pain, radiating downward or laterally. As soon as a thrombosis develops symptoms of obstruction appear. The spleen is enlarged, ascites is rapid, and jaundice occurs. When the em- boli are carried into the liver, abscesses develop, and if there have been no pysemic symptoms they now appear. The fever is very high, and chills occurs at frequent intervals, followed hy marked perspiration. The pulse is small, hard, and rapid. Delirium and coma soon come on. A'^omiting and a diarrhoea of a bloody character are frequently noticed. The urine is diminished in amount. The patient soon dies with all signs of collapse. The relief of pain by the administration of narcotics and the use of heat externally is all that can be done for treatTnent. THROMBOSIS OF THE PORTAL VEIN. What is thrombosis of the portal vein ? A chronic adhesive inflammation of the portal vein and branches, with the production of a thrombus within the vein. What are the etiology and pathology? It is usually secondary, and due to compression from cirrhosis, syphilis, and new growths. The thrombus which is formed is at first soft and red, but soon becomes hard and friable. Pieces of it are easily carried off by the circulation, and cause a blocking up of the smaller veins. What are the symptoms and treatment? The symptoms are those of obstruction, and may develop slowly or rapidly. If the thrombus is large, the spleen is enlarged, ascites develop, and gastro-intestinal irritation, due to secondary venous stasis, is noticed. AFFECTIONS OF THE SPLEEN. 125 The, abdominal veins become enlarged, but all symptoms may abate if proper collateral circulation is established. When the disease is of long standing the liver may be somewhat diminished in size. The patient may survive for years or die from some intercurrent affection, like the plugging of a cerebral artery, etc. Prognosis is bad, and treatment can only be symptomatic. Affections of the Spleen. EMBOLISM. What are the causes, symptoms, and treatment? It results from emboli being detached fi-om the left side of the heart in endocarditis or aortic aneurisms, and carried into the arteries of the spleen. As many of these arteries are terminal ones, infarctions result. Should the embolus be of a septic nature, abscess occurs. These splenic abscesses often reach a very large size. Non-septic emboli give rise to no marked symptoms, but their results in the form of limited cal- cification, cheesy degeneration, or cicatricial contraction are sometimes observed after death. Sudden enlargement of the spleen, attended with pain and tenderness in the left hypochondrium and occurring in the course of endocarditis, will give rise to a suspicion of splenic embolism. Should the patient also exhibit p^^aemic symptoms, exploration with an aspirating needle will frequently confirm the diagnosis. The treatment of splenic abscess is similar to that of the liver. ENLARGEMENT OF THE SPLEEN. What are the causes and symptoms? Acute enlargement of the spleen occurs in diseases causing obstruction in the portal circulation, and it also occurs frequently in the course of the infectious diseases and yellow atrophy of the liver. Chronic enlarge- ment of the spleen results from repeated malarial attacks or from chronic obstruction of the portal circulation. This is most frequently due to chronic interstitial hepatitis and also chronic valvular cardiac diseases. It also occurs in the course of leucocythaemia, or Hodgkin's disease. En- largement of the spleen is not attended with much pain or tenderness, but where it is extreme there is a sense of uneasiness, due to the in- creased weight of the organ. This condition may be ascertained by palpation and percussion. Ti'eatment is that of the causative trouble. W^AXY DEGENERATION AND TUBERCULOSIS. What are the causes and symptoms of waxy degeneration ? It exists as a concomitant of waxy degeneration of other organs, and is observed in two forms ; the limited (sago spleen) and the diffuse 126 DISEASES OF THE DIGESTIVE ORGANS. variety. In the limited form the Malpighian corpuscles, and in the dif- fuse form the splenic pulp, are affected. The organ is enlarged whollj^ or in part. Tuberculosis of the spleen exists as a secondary deposit of either miliary granulation or cheesy collections of tuberculous material. The disease is seen in acute miliary tuberculosis of adults and in tuber- culous disease affecting children. The organ is more or less enlarged, but other local symptoms are absent. TUMORS OF THE SPLEEN. Neoplasms occur secondarily to their occurrence in other organs. Hydatid tumors have been observed, and also gummata. Cancer occurs secondarily to that of the liver or other abdominal organs. Treatment is the same as where they occur in other organs, except that operative interference has rarely been followed by good results. Diseases of the Pancreas. HYPERTROPHY AND ATROPHY. Hypertrophy is mostly due to enlargement caused by neoplasms within the gland. Atrophy results from diabetes or chronic diseases or from pressure upon the gland by tumors in the neighboring organs. HYPEREMIA AND ANEMIA. Hyperaemia is caused by increased blood-pressure, due to chronic disease of the heart, lungs, or liver. Anaemia is observed as a result of general ansemia, marasmus, or after great hemorrhage. ACUTE PRIMARY PANCREATITIS. What are the causes, pathology, and symptoms? It is an acute inflammation of the pancreas. The excessive use of tobacco, alcohol, or mercury seems to predispose to it. It is more com- mon in males than in females. The gland is found to be enlarged with hemorrhages scattered over its surface and through it, and the blood- vessels are congested It begins with deep-seated pains of a colicky character over the region of the pancreas. There are restlessness, nausea, vomiting, constipation, and considerable fever. Jaundice is absent. Within a few days the pain becomes intense, the pulse rapid, small, and weak, the extremities cold, and collapse, followed by death, takes place as a rule. In a few cases abscess in the substance of the pancreas has occurred, which, bursting into the peritoneum, sets up a peritonitis. The treatment is symptomatic. DISEASES OF THE URINARY ORGANS. 127 . '/. ACUTE SECONDARY PANCREATITIS. What are the causes, pathology, and symptoms? It follows infectious diseases, and consists of a parenchymatous in- flammation of the organ. The gland is swollen, reddish in color, and filled with granulations. Diagnosis between this affection and affections of neighboring organs is difficult. The symptoms are those of acute pancreatitis. CANCER OF THE PANCREAS. What are the symptoms and treatment? The disease occurs in the primary form, and is usually situated in the head of the pancreas. The surrounding tissues often become involved. When the new growth is small, diagnosis is difficult. As it increases in size a tumor may often be felt in the epigastrium. The patient is usually advanced in years, and begins to lose flesh and strength rapidly. There are dull pain in the epigastrium, nausea, and often the sjmiptoms of intestinal dyspepsia. Should the tumor press upon the bile-duct or portal vein, jaundice or ascites may occur. The stools are frequently light in color, and show the fats to be in an undigested state. The disease lasts from six to twelve months, and is fatal. Treatment is limited to the alleviation of pain with narcotics and the administration of artificially digested food. ECCHYMOSES INTO THE PANCREAS. These generally occur in fat people as a result of chronic congestion, due to venous stasis of surrounding organs. If slight, they give rise to no symptoms. If extensive, they may be fatal, in which case death occurs suddenly. DISEASES OF THE URINARY ORGANS. ACUTE CONGESTION OF THE KIDNEYS. What is acute congestion of the kidney ? A sudden increase beyond the normal in the amount of blood con- tained in the kidney. What are its causes? It is caused by the ingestion of poisons, by injuries or surgical opera- tions, and by vaso-motor paralysis. It also frequently occurs in the course of chronic nephritis or in degeneration of the kidney. What is its pathology? The kidneys are enlarged, have a dark-red color, and small hemor- rhages beneath the capsule are often found. 128 DISEASES OF THE URINARY ORGANS. What are its symptoms? Sj^mptoms, referable to the trouble itself, are those of a slight cold, attended by rise of temperature and a feeling of heaviness across the loins. The urine is diminished in quantity, the specific gravity is gen- erally increased ; it is high-colored and usually contains blood. Albumin is present, and it may contain hyaline or blood casts. What is its treatment? Where the disease is due to the ingestion of irritant drugs their use should be immediately stopped. Rest, poultices applied to the region of the kidney, and abundance of diluent and mucilaginous fluids are indicated. CHRONIC CONGESTION OF THE KIDNEYS. What are its causes? It is due to an increase in the blood-pressure of the kidneys, such as is caused by a valvular endocarditis, pulmonary emphj^senia, tumors press- ing upon the renal veins, or other diseases causing chronic obstruction to the renal circulation. What are the pathological changes ? The kidneys are generally normal in size, but their weight is increased. The surface is smooth and red, and they seem harder than normal on section. On microscopical examination the smaller blood-vessels are found to be dilated, their walls are thickened, and there is an increase in the amount of coimective tissue in the kidneys. What are the symptoms? Symptoms referable to this trouble are confined to changes in the urine. The urine is generally diminished in quantity, and the specific gravity is variable. A trace of albumin is often present, but casts are generally absent. What is the treatment? Treatment will be that of the primary disease, but great care should be taken to regulate the action of the heart. PASSIVE CONGESTION OF THE KIDNEYS. What is the cause ? , Any condition of the system which causes venous stasis, such as chronic inflammation of the liver, heart, or lungs. What is its pathology? The organs are enlarged, their consistence is increased, they are of a dark-red color, the surface is vsmooth, and the capsule is not adherent. CHRONIC DEGENERATION OF THE KIDNEYS. 129 Whalb.are the symptoms? The symptoms^ in general, are those of diseases caused by increase in the general venous pressure, the most marked of which is oedema of the lower extremities. Sj^mptoms due to the disease itself are found in the condition of the urine. The quantit}^ of urine is diminished, its specific gravity increased, the color is high, and it contains a moderate quantity of albumin. A precipitate of urates is mostly apparent on allowing the urine to stand, and hyaline casts are found on microscopic examination. ACUTE DEGENERATION OP THE KIDNEYS. What are its causes? _ It occurs as a result of tho, poison of infectious diseases and the inges- tion of mineral poisons. It also follows the destruction of extensive portions of the surface of the skin. Fatty degeneration is often com- bined with this form. What is its pathology? The kidney is often enlarged, and the cortex is thickened and of an opaque grayish color. The surface is smooth and the capsule is adhe- rent. On microscopical examination the epithelial cells of the con- voluted tubes are found to be swollen and filled with granular material. In the fatty fomi these cells are also seen to contain fatty molecules, and on close examination the cortex is pale and presents yellowish streaks. AVhere the disease is due to mineral poisons hemorrhages are often pres- ent in the substance of the kidney. The glomeruli are found to be unchanged. What are the symptoms and treatment? All symptoms^ except a diminished quantity of urine, sometimes high in color, are referable to the primary cause of the lesion. Treatment should be directed to the primary cause. CHRONIC DEGENERATION OF THE KIDNEYS. What are its causes? Long-continued disturbance of the circulation, due to chronic endo- carditis or dilatation of the heart, chronic poisoning by alcohol, or other chronic diseases attended by disturbances of nutrition. What are the pathological changes? The kidneys are increased in size, the surface is smooth, the cortex is thickened and pale in color, and the pyramids are red. On microscopical examination the epithelial cells of the straight tubes are seen to be swollen and granular or fatty. The capillaries are frequently dilated, and the tubes obstructed by casts, 9— P. M, 130 DISEASES OF THE URINARY ORGANS. What are the symptoms? Symptoms due to the disease itself are progressive loss of flesh and strength and anaemia. In eases where there is partial or complete sup- pression of urine there inn.y be delirium, convulsions, or coma due to chronic anaemia. The quantity of urine is very variable. The specific gravity is frequently slightly below the normal, but albumin and casts may be present in small quantities. What is its treatment ? Treatment is directed toward the amelioration or cure of the primary disease, to regulating the circulation, and to improving the general health. PARENCHYMATOUS NEPHRITIS. Syn. — Acute exudative nephritis; Tubal nephritis; Desquamative nephritis. What are its causes? The disease sometimes occurs from exposure to cold or in the course of local epidemics. It also occurs as a complication of the acute infec- tious diseases, and of peritonitis, dysentery, er3^sipelas, diabetes, and pregnancy. What is its pathology ? The kidneys are generally enlarged, the cortex is thick and white, and occasionally the whole kidney appears reddish in color. On microscopical examination white blood-cells are found in the tubes or in the stroma. The renal epithelium is opaque in color or infiltrated with fat, and the tubes contain casts. In severe acute cases pus is also found in the tubes and pelvis of the kidney. What are the symptoms? In mild cases symptoms are indefinite, except the change in the urine. In more severe cases there are shght fever, anorexia, lassitude, nausea, and occasional vomiting. In the very severe cases there are also head- ache, insomnia, delirium, stupor, and convulsions. The heart's action is often feeble and irregular ; the pulse is accelerated. Slight dropsy is often present. The urine is diminished in quantity, high in color, the specific gravity is unchanged, and it contains albumin. On micro- scopic examination it is found to contain casts, red and white blood-cells, and renal epithelium. What is the prognosis? Almost all cases recover, but a few run into the. chronic form of nephritis. What is the treatment? Eest, fluid diet, and the use of narcotics to keep the patient quiet. ACUTE DIFFUSE NEPHRITIS. 131 The- bowels should be kept open by small and frequently repeated doses of saline cathartics. Cupping over the lumbar region and the use of hot-air baths are often beneficial. In cases of weak heart the use of cardiac stimulants is indicated. ACUTE DIFFUSE NEPHRITIS. What is meant by acute nephritis? An increase in both the connective tissue and parenchymatous cells of the kidney, constituting a disease which runs a rapid course. What are its causes? It occasionally occurs as a primary disease, but more frequently com- plicates or_ follows scarlatina, diphtheria, or other infectious disease. It is sometimes caused by the ingestion of a poisonous dose of alcohol or irritant drugs. What is its pathology? The kidneys are enlarged, the cortices thickened, and the cut surface of the kidney may be mottled, red and white, or universally red in color. On microscopical examination the connective-tissue cells are found to be increased, and there is also an increase in the size of the cells lining the glomeruli. The growth of these cells is often seen to be sufficient to press upon the vessel tufts. What are the symptoms? The invasion of the disease is often sudden : there are headache, restlessness, insomnia, general convulsions, and nausea, sometimes vom- iting, and increased cardiac action, coupled with arterial tension. These symptoms may increase in severity, and shortly be followed by delirium, coma, and death, or the disease may pursue a slow course, the symptoms gradually lessening or complete intermissions taking place. In this last set of cases the disease takes a chronic form, dropsy is often present, and the urine is diminished in quantity. Its specific gravity is normal or increased, and it also contains albumin, blood, and epithelial and blood casts. What are its prognosis and treatment ? Prognosis is always grave, because, should the patient survive any length of time, the disease is very apt to become chronic. What is its treatment ? Rest abed, stimulation of the action of the skin by means of hot-air baths, or, in cases where the heart is in good condition, hot vapor-baths are of benefit. Dry cupping or the application of poultices over the kidneys is often of great benefit. An abundance of water where thirst exists, and the use of hydragogue cathartics in cases attended by dropsy, are indicated. In this form of nephritis stimulating diuretics are of little 132 DISEASES OF THE URINARY ORGAIS^S. value. The diet should be of the most nutritious and easity assimilated character (such as eggs, oj^sters, milk, cream). Where the disease occurs in old people or alcoholic subjects cardiac stimulants, as digitalis, stro- phanthus, or caffeine, must be used. CHRONIC DIFFUSE NEPHRITIS. What is chronic diffuse nephritis ? An inflammation of all the tissue-elements of the kidneys, running a chronic course. What are its causes? It frequently follows previous acute or subacute trouble of the kidneys, and also occurs as a complication of syphilis or chronic phthisis. In a few cases the disease is apparently excited by frequently repeated in- dulgence of alcoholic stimulants. What are the pathological changes? The kidnej'S differ very materially in size. The capsule is adherent. The surface is often roughened or nodular. On section the cortex is found thickened and white or gray in color. On microscopical examina- tion the cortical tubes are often seen to be dilated, and the epithelium lining them has undergone fatty or waxy degeneration. The cavities of the tubes are often filled with casts, and there is also found an increase in the interstitial tissue of the kidney. What are the symptoms? In almost all cases the symptoms are referable to the primary disease. In many cases dropsy is present. Attacks of insomnia and frontal head- ache often occur. The patient is frequently anaemic, and there may be dyspnoea. In a small number of cases muscular twitchings, followed by coma, due to partial or total suppression of the urine, occur. The pulse is generally accelerated, small, and hard. The urine is increased in quantity. The specific gravity is low, but there is generally a well- marked trace of albumin. On microscopical examination hyaline or granular casts are found. The disease is often attended by complica- tions, such as hy{)ertrophy or dilatation of the heart, endocarditis, peri- carditis, bronchitis, cirrhosis of the liver, or chronic gastritis. What is the treatment? General treatment consists in regulation of the diet and use of small doses of opium or bichloride of mercury. Where the dropsy is ex- cessive diuretics or cathartics may be necessary. In cases of high arterial tension or threatened uraemia small doses of nitro-glycerin, fre- quently repeated, and hot-air baths, are of most benefit. What is the prognosis? Prognosis as regards recovery is bad, but life may be prolonged in some cases for many years by proper treatment. SUPPURATIVE AND TUBERCULAR NEPHRITIS. 133 SUPPURATIVE NEPHRITIS. What is suppurative nephritis ? An acute inflammation of one or more kidneys, attended by the formation of small or large abscesses. What are its causes? Direct injuries to the kidney occasionally cause it, but the most fre- quent causes are pyaemia, due to malignant endocarditis or venous thrombi. Occasionally the disease occurs in one kidney without assign- able cause. Suppurative nephritis also follows the extension of inflammation from the bladder or urethra. What is the pathology ? The kidney is enlarged, and small yellowish-white spots are observ^ed on its surface. These spots consist of accumulations of purulent mate- rial. Streaks of grayish purulent material are observed along the course of the pyramids. Colonies of bacteria are always found in the diseased portions. The pelvis of the kidney also contains collections of purulent material, and may be distended. What are its symptoms? It generally begins with chills and a rise of temperature. The fever is of an irregular character. The patient loses flesh and strength, becomes ansemic, and nausea and vomiting may be present. There is more or less pain over the region of the kidneys. Should the disease run a chronic course, there may be a tumor over the region of the affected kidney. The urine is diminished in quantity or suppressed. Its specific gravity is increased, and it contains a small amount of albumin, with blood and pus. The urine may also contain broken-down elements of kidney tissue. What is the prognosis? In cases due to malignant emboli or occurring in old people the prog- nosis is fatal. Cases due to idiopathic abscess generally run a chronic course, and sometimes recover under treatment. What is the treatment? The treatment is surgical — i. e. incision and removal of the kidney if necessary. TUBERCULAR NEPHRITIS. What are its causes? The presence of tubercle bacilli in the kidney, causing the formation of tubercle tissue, new connective tissue, and frequently accompanied by the formation of abscess. 134 DISEASES OF THE URINARY ORGANS. What is its pathology? The changes are frequentlj^ limited to only one kidney, generally the left. It is also often secondary to tubercular inflammation in other por- tions of the genito-urinar}^ tract. The kidney is generally more or less infiltrated with pus ; there are masses of cheesy material, and an increase of the connective tissue between these masses. The mucous membrane of the pelvis and calyces is similarly affected. A large portion of the kidney may be replaced by the new tissue, which sometimes becomes calcified. What are its symptoms? There is generally fever of a hectic type, attended by night-sweats and a quick, small pulse. Loss of health and strength is progressive, though frequently slow. Pain and tenderness over the affected kidney generally exist. The urine usually shows little change, except on microscopical examination. The changes are the presence of blood, pus, epithelium, and shreds of tissue. Occasionally the tubercle bacillus can be found by proper means. What is the treatment? Treatment is that of pulmonar}'- phthisis and the complications which may exist. What is the prognosis? A few cases recover. The majority result fatally, though the course of the disease is often very chronic. TUMORS OF THE KIDNEY. What are the most frequent tumors of the kidney? Sarcoma and adenoma. What is their pathology? They originate in the kidney or its pelvis. The sarcomata are fre- quently of large size, are of firm consistence, and consist of embryonal connective tissue, with mucous or muscular tissue generally present in variable amounts. They most frequently occur in infancy or childhood. The adenomata are tubular or papillary in type, and often malignant. What are the symptoms? The presence of a tumor over the region of the kidney, pressure upon which causes more or less pain, and the cachexia which is found existing with the presence of malignant tumors. The urine frequently contains blood, though this is not a constant symptom. What is the treatment? Removal of the tumor by surgical means. BENAL COLIC. 135 / '. RENAL COLIC. What is renal colic ? An attack of pain, caused by the presence of a calculus in the pelvis of the kidney or the passage of such calculi through the ureter. What are the pathological causes ? Inflammation of the mucous membrane of the pelvis of the kidney or any condition of the system, such as gout, rheumatism, or that produced by a sedentary life, which causes the production of an abnormal quantity of uric acid, oxalate of lime, phosphates, or of cystine, may give rise to the production of the stone. On examination the stone is found in the pelvis of the kidney, in the ureter, or in the bladder. The stone may consist of uric acid or of a uric-acid centre surrounded by a shell of the other constituents of the urine which are able to be precipitated. On section the stone frequently presents the appearance of concentric layers. What are the symptoms ? The passage of minute stones (sand and gravel) is generally attended by only a feeling of discomfort. Should the stone be larger and become loose in the pelvis of the kidney, its passage into the ureter, and from thence to the bladder, is attended by a sudden severe pain in the loin and side of the abdomen of the affected kidney. The pain often runs down the inner surface of the leg of the affected side and into the scrotum. There is retraction of the testicle, which may occasionally be swollen and painful. Should the attack be severe, it is often attended by vomiting, fainting, and, rarely, general convulsions. The pulse is short and quick, and there is slight fever in severe cases. The urine is generally passed frequently in small quantities, and may contain blood. If the attack has been caused by the passage of a nuniber of small stones, these symptoms will recur with periods of intermission. Most attacks only last for a few hours under treatment. What is the treatment ? Treatment is directed to the rehef of pain and the hastening of the passage of the stone. Hot hip-baths, poultices over the kidneys, and small hypodermics of morphine will often cure the attack. Should the attack persist or recur, the use of inhalations of ether or chloroform for the relief of pain may be necessary. What is the prognosis ? Most patients have recurrent attacks of colic, and prognosis will de- pend on whether the stone lodges in the ureter, passes into the bladder, or is ejected with the urine. In all cases where there are symptoms of the retention of the stone in the bladder or ureter the prognosis is grave, as the treatment is necessarily surgical. In cases where there are sjnnp- toms of a retained stone in the pelvis of the kidney the prognosis is also grave. 136 DISEASES OF THE URINAEY ORGANS. PERINEPHRITIS. What is perinephritis? - An inflammation of the connective tissue around the kidney, generally leading to the formation of an abscess. What are the pathological changes ? The kidney is surrounded by an abscess, which may extend into the muscles of the back or into the cavities of the neighboring viscera. The kidney is often itself compressed by the surrounding pus and the seat of small abscesses. What are the causes? It is generally produced by an extension of chronic inflammation of neighboring parts, such as caries of the spine or pelvic cellulitis. It sometimes complicates acute infectious diseases, as small-pox and typhoid and typhus fever. It may also be caused by direct injury to the lumbar region. What are the symptoms? The disease is generally ushered in by chills and a febrile movement. Pain and tenderness over the lumbar region are quite constant, as is also nausea. The patient is somewhat prostrated, remains in bed on his back, and lies with the thigh of the afibcted side flexed, as movement of it gives pain. In a few days a swelling in the lumbar region, caused by the increase of the abscess, often appears. Should the abscess per- forate the surrounding viscera, symptoms due to this accident will be added to those due to the formation of the abscess itself What is the treatment? In the earlier stages of the disease small doses of sulphate of magnesia or calomel internally, and the application of continuous cold to the lum- bar region, may be employed. Should the formation of pus be sus- pected, exploration with the hypodermic needle or aspirator is called for. Should pus be found, an immediate operation is necessary. What is the prognosis? In cases where the abscess is detected early and operated upon, recovery sometimes occurs. Where the abscess perforates the pleura, colon, or bladder the disease generally runs a chronic course, accompanied by waxy degeneration of the viscera and followed by death. Where the abscess penetrates the peritoneum the prognosis is always fatal. GLYCOSURIA. Syn. — ^Diabetes mellitus. What is glycosuria? A presence of sugar in the urine. GLYCOSURIA. 137 What is its etiology? It may be temporary or permanent. It is often caused by certain poisons, and is frequently present, temporarily, in the course of acute infectious diseases, functional disorders of the liver, cerebral apoplexy, concussion of the brain, and pregnancy. The disease is twice as com- mon in men as in women, and generally affects young and middle-aged adults. What is its pathology? The nature of the disease is obscure. In some cases the pancreas is found to be small, the liver fatty, and the kidneys show the changes of chronic nephritis. Changes in the blood-vessels of the medulla have also been noticed. What are the symptoms? The onset of the disease is generally slow and gradual ; patients have a feeling of lassitude and unnatural thirst, and pass an abnormally large quantity of urine, which contains sugar. There is progressive loss of flesh and strength, with disturbance of the functions of the digestive tract. These symptoms may last for a long time, and be complicated by furunculosis, nephritis, gangrene of the extremities, or cataract. Should a fatal termination occur, the symptoms of diabetic coma may be as fol- lows : After exertion the patient feels suddenly weak, the skin is cold, the pulse feeble ; he becomes comatose, and dies in a few hours. Or there may be sudden headache, dizziness, stupor, coma, and death ; or for a few days the patient complains of weakness, loss of appetite, slight drowsiness, and abdominal cramps, which symptoms are followed by rest- lessness, delirium, dyspnoea, cyanosis, and feeble heart-action. Coma comes on in a few days, followed by death. What is the treatment? Regulation of the diet and mode of life is most important. No sugars or starches should be eaten. The use of wines or liquors should also be avoided. In regard to drugs, the preparations of opium, combined with the^ use of alkalies, are most frequently used. Sulphide of calcium, 1 grain four times a day ; solution of bromide of arsenic, 10 minims three times a day ; and jambol in powder, 10 grains three times a day, may be used. What is the prognosis? A few cases recover completely, and in the majority of cases the dis- ease can be controlled and the patients have fair health for a long time. Prognosis will depend somewhat on the age of the patient, children doing very badly. 138 DISEASES OF THE UEINARY ORGANS. DIABETES INSIPIDUS. What is diabetes insipidus ? A disease characterized by the passage of large quantities of urine with a low specific gravity. What is its etiology? It is not due to disease of the kidneys, and its causes are unknown. It is more common in males than in females, and usually occurs in young adults. What are the symptoms? The patients pass large quantities of urine of low specific gravity. They have great thirst, attended by disturbances of digestion and symp- toms of hysteria. What is the treatment? Attention to the diet, which should consist principally of nitrogenous food. The use of ergot and gallic or the mineral acids is often followed by marked benefit. The disease usually runs a chronic course, but is rarely if ever fatal. H.^MATURIA. What is hsematuria ? The presence of blood in the urine. What is the etiology? In tropical countries it occurs as a symptom of the presence of the distoma-worm in the vessels of the bladder or those of the portal system. The condition also occurs as a symptom of acute and chronic Bright' s disease, pyelitis, cancer of the kidney, renal congestion, tubercular in- flammation of the kidney, and, rarely, as a sj^mptom of hemorrhagic infarction of the kidney. The ingestion of certain drugs may also give rise to a bloody appearance of the urine (false heematuria). In hemor- rhage occurring from the bladder pure blood is passed after micturition. The urine does not pass freely, and the presence of calculus or vesical tumor may often be determined b,y surgical examination. In cases of hemorrhages from the ureter there are often signs of impacted renal calculus. If examination shows the presence of blood-casts, the dia- gnosis of nephritic hsematuria is rendered certain. What is the treatment? Internally the use of haemostatics, as acidum tannicum, ergot, iron, or alum, and externally the use of the ice-bag over the bladder and kidneys, are followed by good results. HEMOGLOBINURIA. — CHYLURIA. 139 . ','. HEMOGLOBINURIA. What is hgemoglobinuria ? An affection characterized by the presence of the coloring matter of the blood in the urine, with the absence of blood-corpuscles. What is the etiology ? A pathological condition of the blood. ^ It occurs in the course of scurvy, purpura haemorrhagica, hemorrhagic small-pox, typhoid fever, measles, and scarlet fever. It has also been observed as a result of' phosphorus-poisoning. Exposure to cold seems to be often an immedi- ately exciting cause. What are the symptoms? The attacks generally come on in the late fall or winter ; they are paroxysmal in character, and may be more or less severe. Jaundice occasionally occurs. The patient is attacked by a well-pronounced chill, lasting half an hour or longer, . and followed often by fever and sweating. During or following the chill the urine voided is of a dark-red color. Microscopic examination shows the presence of brownish-colored sedi- ment in the urine, consisting of granular matter, but the absence of red corpuscles. Granular and hyaline casts are also often observed. After the paroxysm the urine becomes clearer, and in twenty-four hours is normal. What is the treatment? During the paroxysm rest in bed, internally hot drinks with some alcoholic stimulant, and heat externally to the surface, are advised. Be- tween the paroxysms a mild and uniform climate, with the use of chalyb- eate tonics and a generous diet, may prevent future attacks. CHYLURIA. What is chyluria? A disease characterized by the passage of urine resembling milk. What is its etiology? It is most frequently found in tropical countries, and is sometimes associated with hgematuria. In some cases chyluria is apparently caused by the presence of a parasite. This parasite is a worm y^- of an inch in length, found most frequently in the blood and urine examined at night. This worm is called the filaria sanguinis homines. After death vast numbers of these worms are found in the cortical and pyramidal portions of the kidney. What are the symptoms? Attacks generally occur without any appreciable _ exciting cause and without premonition. The chyluria occurs intermittingly, and the at- 140 DISTUEBANCES OF THE BLOOD-FORMING FUNCTIONS. tacks are as irregular as the duration and occurrence. In very severe cases there are lumbar pains, a feeling of lassitude, and other sjinptoms of phj^sical exhaustion. What is the treatment? Ergot, gallic acid, 1 to 2 drachms to be given in twenty-four hours, and spirits of turpentine, 5 f^, t. i. d. , have been used. Large draughts of astringent infusions may be of benefit. DISEASES FROM DISTURBANCE OP THE BLOOD-FORMING FUNCTIONS. SIMPLE ANEMIA. What is simple anaemia? A disease characterized by decrease in the number of the cellular ele- ments of the blood, which tends to recovery under suitable treatment. What is its etiology? It often occurs associated with chronic diseases. It is also seen as a result of confinement in ill-ventilated rooms. Women are more subject to it than men. It also results from the action of certain poisons, such as zinc, lead, phosphorus. What are the symptoms? The symptoms are very varied. Those pertaining to the nervous sys- tem are mental depression, mental irritability, a feeling of lassitude and incapacity for muscular exertion, functional palpitation of the heart, neuralgias in various situations, and occasionally hj^sterical phenomena. The respirations are often increased in frequency, and dyspnoea may be present. As a result of non-assimilation of food, nausea, and even vom- iting after meals, epigastric pain, and eructations of gas, are often seen. The urine is light in color and of low specific gravity. The amount is frequently increased. The mucous membranes are pale, and the surface of the body is generally cool. On auscultation the action of the heart is found to be feeble and often irregular. At the base of the heart a systolic murmur is often heard, and in the neck is heard a continuous murmur known as the venous hum. Examination of the blood will fre- quently prove whether the anaemia is benign or pernicious. What is the treatment ? Besides the treatment of the causative disease where it is ascertain- able, patients should be given plenty of fresh air and out-door exercise. The body should be sponged daily and well rubbed. The bitter tonics before meals and the use of artificial digestants are necessary in cases with gastric dyspepsia or catarrh. Food should be of the most nutri- tious quality, and care must be exercised not to give too much at one meal. The preparations of iron are always of benefit. The powdered CHLOROSIS. — PERNICIOUS AK^MIA. 141 lactate of iron seems to be the best form of administration in cases of children or young women. CHLOROSIS. What is chlorosis? A form of anaemia in which there is a reduction in quantit}^ of haemo- globin in the red corpuscles, with or without a diminution in their number. What is its etiology? It occurs most frequently in girls between the ages of fourteen and twenty-four years. It shows itself as a persistent simple anaemia. The cause is often obscure, but js evidently connected with the development of the sexual system. Patients affected with simple anaemia, when they are subjected to great mental shock or are victims of masturbation, often develop chlorosis. What are the symptoms? The sympto7iis are those of a very marked simple anaemia, and to these are often^ added choreic symptoms or attacks. Also perversion of the appetite is often shown by a craving for non-nutritious substances. What is the treatment? General treatment is the same as that of simple anaemia. Encour- aging the patient with hopes of complete recovery and occupying the patient's mind with congenial tasks are important elements in cure. PERNICIOUS ANEMIA. What is pernicious anaemia? A disease characterized by the symptoms of simple anaemia, but hav- ing added to them fever, marked heart murmurs, hemon'hages into various tissues of the body, and progressive exhaustion, attended with various abnormal changes in the blood. What are the etiology and pathology? The etiology in many cases is obscure. Many observers regard it as an intense simple anaemia. Conditions of life leading to prolonged inanition predispose to it. Endemic influences also have a causative relation to the disease. It is somewhat more frequent in women than in men, and is generally observed between the ages of twenty and forty. The red corpuscles are reduced from the normal number from one-tenth to one-third. The percentage of haemoglobin may also be decreased. Large corpuscles are often observed in the blood, but smaller white cor- puscles are often observed in abnormal numbers. The blood coagulates less perfectly than in health. Fatty degeneration of the myocardium, of the hepatic cells, and of the renal epithelium has been observed. In 142 DISTURBANCES OF THE BLOOD-FORMING FUNCTIONS. the long bones the normal j^ellow marrow often 'has a red appearance, due to granular matter and nucleated red corpuscles. In a few cases the medulla of the bones presents a greenish appearance. Small extrava- sations of blood are often found in the retina, the meninges of the brain, and the serous membranes. What are the symptoms? The onset is often gradual. There is a feeling of lassitude and anorexia, with slight chilly sensations. These symptoms are followed by nausea and vomiting and shght epistaxis. The patient at times has an anxious look, but may not have the pallor of simple angemia. Occasionally emaciation sets in early in the disease, and is progressive. Attacks of a regular fever soon develop, and are frequently attended by severe epistaxis or hemorrhages from the gums or serous membranes. An impairment of vision from retinal hemorrhages is usually observed. Examination of the heart shows the presence of a loud systolic murmur over the base. The duration of the disease is from four weeks to several months. Most cases end fatally. What is the treatment? Treatment is the same as that of simple anaemia ; but especial care must be taken to administer concentrated foods, and the patient should be kept quiet in a sunny room with an even temperature. LEUOOOYTH^MIA. What is leucocythaemia ? A chronic disease of the blood characterized by an excess of white corpuscles and a diminution of the red corpuscles in the blood. What are the etiology and pathology? The causes are very obscure. A disturbance of function of the splenic or Ijmiphatic glands has some relation to the production of the disease. It occurs in three forms — the splenic^ lymphatic^ and medullary. These forms are usually combined with each other. On examination the blood is often opaque and paler than normal. There is great diminution in the number of red corpuscles. A considerable increase of the white cor- puscles above normal is found. The corpuscles may contain granular or molecular fat. The spleen is enlarged and the capsule is often thickened. On section it presents a mottled appearance from the presence of Mal- pighian bodies as whitish dots or infarctions of a dark-red or yellowish color. On microscopical examination the elements of the spleen are found to be increased in size and number. In cases involving the lym- phatic system many lymphatic glands are found to be larger or smaller than normal, and their color is gray or reddish gray. The microscope shows an increase of lymphoid cells in the substance of the glands. The PSEUDO-LEUCOCYTH^MIA. 143 same -mcrease of lyiiiplioid cells is sometimes found in the pharyngeal tonsil, the tonsils, and the solitary glands of the intestine. In the bones the changes are usually found in the marrow of the ribs, the sternum, and the vertebrae. The marrow has a reddish or greenish appearance, and is of a soft, pulpy consistence. In a few cases the marrow is of a dark-red color and of a gelatinous consistence. The diameter of the long bones may be found increased beyond the normal, but this is due to encroachment of the medulla upon the hard outer portion of the bones. The kidneys are frequently enlarged. What are the symptoms? The disease comes on very slowly. General lassitude, gastric dyspep- sia, and disinclination to exertion are often prese'nt for a considerable period. Pallor of the face and mucous membranes takes place, and phys- ical examination at this time will often show tenderness over the spleen and marked enlargement of that organ. Swelling of the lymphatic glands occurs, especially of those of the neck and axilla. The mesen- teric glands are also sometimes enlarged. Dj^spnoea occurs, and is often exaggerated by the enlargement of the liver or spleen. Ascites or hy- drothorax occurs sooner or later in most cases. The action of the heart is much increased and a haemic murmur is often audible at the base of the heart. The temperature is generally raised, especially in the even- ing. Hemorrhages from the mouth, nose, throat, pharynx, or the intes- tinal organs are frequent symptoms. As a result of gastro-intestinal disturbances diarrhoea is a frequent sj^mptom ; jaundice rarely occurs. This disease lasts generally two years, but it may run a rapid course or be prolonged for a long time. It occurs most frequently between the ages of twenty and fifty years. What is the treatment? Internally the use of quinine, ergotin, iodide of potassium, and ex- ternally cold douches and faradization of the abdomen, have been recom- mended. No other remedies beyond general tonic treatment have seemed to be of any value. PSEUDO-LBUCOOYTH^MIA (HODGKIN'S DISEASE). What is pseudo-leucocythsemia ? _An affection in which blood-changes similar to those in leucocythae- mia occur, but unattended with an increase of the white corpuscles of the blood and accompanied by marked swelling of the lymphatic glands. What are its etiology and pathology? It generally occurs between the ages of ten and thirty years ; the ex- citing causes are obscure. The lymphatic glands of the neck or abdo- men are frequently enlarged, the increase being due to a proliferation of the lymphatic cells and of the cells of the reticular network. The swollen glands are grayish or yellowish-white in color ; where many neigh- 144 DISTUKBANCES O^ THE BLOOD-FOEMING FUNCTIONS. boring glands increase in size, they may coalesce and form a firm, hard mass. If the glands are subcutaneous, the skin over them is generally freely movable. The afi"ection often first attacks the cervical glands. The spleen is generally enlarged, but not so much so as in cases of leuco- cythsemia. In the kidneys and liver nodules composed of lymphoid tis- sue are often present, and these nodules may be formed in other organs of the body. What are the symptoms? The glandular enlargement comes on slowly, and is attended by a feel- ing of lassitude, a quick, feeble pulse, anorexia, nausea, and occasionally vomiting. These initial symptoms are followed by progressive exhaus- tion, submucous or subcutaneous hemorrhages, progressive anasarca, due to the anaemic state of the patient ; and symptoms referable to pressure caused by the enlarged glands, as dyspnoea, due to enlarged peribronchial or mediastinal glands ; dysphagia, due to lymphomatous growths in the throat or enlargements of the lymphatic glands around the oesophagus ; aphonia or persistent cough, due to pressure of enlarged glands on the larynx or laryngeal nerve ; irregular cardiac action, due to pressure on the pneumogastric nerve. The disease may last from a few weeks to many years. Prognosis is always grave. What is its treatment? The treatment is, internally, the use of arsenic alone or combined with iodide of potash ; externally, the application of iodine or of hot poultices to the superficial glands gives some relief. The injection of enlarged glands with carbolic acid, iodine, or nitrate of silver is sometimes employed. In cases of enlarged glands, threatening life by their local pressure, the ex- cision of the gland by surgical measures will often be followed by tem- porary relief. ADDISON'S DISEASE. What is Addison's disease ? A disease characterized by a pigmentation of the skin, constitutional disturbances, and changes in the suprarenal capsules. What are the etiology and pathology? The etiology is obscure, but may be due to some disturbance of a func- tion of the sj^mpathetic nerve. The skin has a dusky or yellowish-brown hue, especially on the parts most exposed to the air. The suprarenal capsules are found imbedded in a mass of fibrous tissue, their connective tissue is increased in amount, and the stroma is often changed to a case- ous mass containing large Ij^mphoid cells. The mesenteric glands in the neighborhood of the suprarenal capsules are often enlarged and the seat of cheesy degeneration. Examination of the blood generally shows a diminution of the red blood-corpuscles. ACUTE ARTICULAR RHEUMATISM. 145 What are the symptoms ? The symptoms come on slowly, and begin with a feeling of lassitude, very slight dyspnoea, and slight cardiac palpitation on exertion ; these are followed by feeble heart-action, anorexia, nausea, and vomiting. There are also muscular pains in the loins and across the abdomen ; the weak- ness increases progressively, and frequently the vomiting becomes per- sistent ; the bowels are generally constipated, but diarrhoea may set in at at the end. The discoloration of the skin comes on gradually in the course of the disease. The disease is progressive and ends in death, sometimes preceded by coma or convulsions. Care should be taken to diagnose this from the cutaneous discoloration caused by skin diseases and drugs. What is the treatment ? Treatment is simply symptomatic. GENERAL DISEASES. ACUTE ARTICULAR RHEUMATISM. What is acute articular rheumatism ? A disease characterized by fever and enlargement, redness, and pain of one or more joints of the body. What is its etiology ? An especial disposition to the disease as a predisposing cause. It oc- curs in all ages, and a primary attack is often followed by others. Sup- pression of the functions of the skin, owing to the action of cold, seems to be the immediate exciting cause of an attack. What is the pathology ? The affected joints are swollen, reddened, and tender ; the normal amount of synovial fluid in them is increased, and it is often turbid, from the presence of flocculi of fibrin. _ Inflammation of other serous or mucous membranes is often observed, as inflammation of the pericardium or en- docardium. What are the symptoms? Occasionally pain and a soreness of the joints precede the acute symp- toms. There is a sudden attack of pain in some of the joints. This may be ushered in by a chill, but fever is always present. The affected joints become enlarged, very tender on movement, and the skin over them hot and reddened. Pressure on the afi"ected joints causes much pain. In some cases the large joints are affected simultaneously or in quick suc- cession. In other cases the disease is limited to a single joint for a longer or shorter time. The joints most frequently affected are the knee, ankle, wrist, shoulder, and hip, less frequently the elbow and the small joints of the hands and feet. There is generally sweating at night, and often 10— P. M. 146 GENERAL DISEASES. miliary vesicles appear on the neck or chest Anorexia is present, the tongue is coated, and the saliva acid. Constipation generally is present. The urine is diminished in quantity, very acid, high in color, and con- tains a large excess of urates. In many cases the inflammation attacks the lining or enveloping membrane of the heart, in which cases symptoms of endo- or pericarditis are added. In a few cases, owing to very high temperature or other causes, delirium occurs. The duration of an acute attack varies greatly, but the average is about three and a half weeks. The disease of itself is rarely fatal. What is the treatment ? Salicylic acid and the salicylates are most frequently used in the treat- ment of the disease. For the relief of pain in the inflamed joints small doses of opium internally and bathing the joints with a saturated solution of bicarbonate of soda give relief. Alkalies combined with soluble salts of iron are often given with benefit. In the use of salicylic acid or the salicylates in large doses the patient should be carefully watched for the cumulative action of the drug. In cases where the articular pain is very distressing, immobilization of the joints by means of well-padded splints is advisable. SUBACUTE RHEUMATISM. What is subacute rheumatism? An attack of rheumatism which lacks the intensity of the acute form, runs a longer course, and is often attended with remissions and exacer- bations. The symptoms are those of a mild attack of acute rheumatism, and treatment is similar. CHRONIC RHEUMATISM. What is chronic rheumatism? A rheumatic inflammation of the joints, generally following a subacute attack and running a chronic course. What are the symptoms and treatment ? The affection does not shift from joint to joint, as in cases of acute rheumatism. The affected joints are tender and painful to the touch, somewhat enlarged, and their surfaces reddened. Motion is painful, and often attended with a grating sensation in the joint. Fever is generally absent, and the tendency to cardiac complications is slight. In the course of time the affected joints often become stiff and ankylosed. For treatment internally the preparations of guaiacum, iodide of potas- sium, arsenic, or colchicum, singly or combined, give the best results. Local treatment of infected joints is important. Between the attacks of pain massage and counter-irritation of the affected joints are useful. If attacks of pain come on, immobilization of the joints, with the local ap- plication of heat, gives relief Attention should be paid to the general GOUT. 147 health' and having the patient wear warm under-clothing, as sudden changes in the weather seem to have a causative relation to the attacks. GOUT. What is gout? A disease resembling rheumatism which may occur in an acute, sub- acute, or chronic form, and is characterized by an excessive formation of urates in the body and the symptoms caused by their presence, chiefly in the joints. What are its etiology and pathology? Heredity is one of the great factors in the production of gout ; it is a disease principally occurring in adult life or subsequently. Exposure to cold or over-indulgence in food or stimulants occasions attacks in those predisposed to the lesion. Men are said to be more liable to the disease than women. Cases of acute gout are most frequently observed in the spring and fall. The pathological characteristics of the disease are de- posits of urate of sodium in the form of white chalk-like incrustations upon the free surface and in the substance of the articular cartilages. These changes in early stages of the disease are found in the smaller joints. Later the deposits may occur in the larg^ joints or in the tissues surrounding them. The affected joints are enlarged, the external surface is often red, and frequently the deposits (tophi) external to the joint break through the skin. In old cases the articular cartilages are often eroded, giving rise to marked crepitation on movement. The kidneys are usually small in size, the capsule is adherent, and the surface of the kidney granular ; white lines are seen in the pyramidal portion of the kidney, due to the deposit of urate of sodium. This is found both within the tubes and the interstitial tissue. What are the symptoms? The disease may come on suddenly or slowly. In acute gout there is sudden pain, often coming on at night, in one of the small joints. This maybe preceded by cardialgia, eructations of gas, and mental depression. The pain is generally of a boring character, attended with throbbing in the affected joint.^ More or less elevation of temperature is present ; the affected joint rapidly becomes swollen ; the skin covering it is red and shining, and excessively tender to_ touch. These symptoms often sub- side during the day, to return again in one or more nights. The joints of the great toe are those most frequently affected, but in prolonged at- tacks other joints are often imphcated. The bowels are generally con- stipated. Urine is high-colored, scant in amount, and overloaded with an abnormal amount of urates and phosphates. The perspiration is very acid, and erythema may be present from irritation of the skin. In sub- acute gout all these symptoms are present, but are less severe, and the attack is generally of longer duration. Should the symptoms persist for many weeks, the disease must be regarded as chronic. 148 GENERAL DISEASES. Chronic gout begins with recurrent attacks of acute gout, though some- times the disease comes on slowl}'^ and assumes the chronic form from the first. In this form the fever, intense pain, heat, and redness of the af- fected parts are frequentl}^ wanting. The general health is often im- paired, and sj'mptoms of gastric dyspepsia exist. The affected joints are enlarged, have solid or semi-liquid chalk-like deposits within or around them, and tend to become stiffened and ankylosed. Deformity of the joints is also a marked symptom. Deposits of urate of sodium are also noticed in the ear, the eyelids, or various portions of the extremities. The shoulder- and hip-joints are rarely affected. Acute exacerbations often occur in the course of the chronic form of the disease, and these are frequently excited by injudicious use of particular kinds of foods or stimulants. Occasionally the gouty diathesis manifests itself by various disorders of the functions of the viscera. These consist of sudden attacks of pain in the stomach, attended with nausea and vomiting, or of sudden general colicky pains (in the abdomen), with diarrhoea ; and to these are often added an irregular action of the heart, cough, dyspnoea, and neuralgic pains in the main nervous trunks. The urine in these chronic and anomalous forms of this disease is gen- erally abundant, normal in color, and deposits but little sediment. It may contain a trace of albumin, but casts are generally absent unless the dis- ease is of long standing. What is the treatment ? For the acute attacks hot poultices to the affected part, and internally the use of alkalies in combination with colchicum, may be used. The salts of lithia are also often given. For the relief of the pain small doses of opium, combined with hyoscyamus, belladonna, or aconite, are indi- cated. The diet should be restricted, nitrogenous food being excluded during the acute attack. Large draughts of hot water, frequentl}'' re- peated, are of use as a diuretic. In the chronic form local treatment of the affected parts is of little value. The diet should be nourishing and adequate for purposes of nutrition. All highly-seasoned food and wine should be excluded. Internally, iodide of potash and colchicum, with the free use of alkaline mineral waters, are recommended, ARTHRITIS DEFORMANS. What is arthritis deformans ? A chronic disease dependent upon an abnormal condition of the blood, resulting in a partial destruction and deformity of the joints, unattended by the constitutional sj^mptoms occurring in either chronic articular rheu- matism or gout. What are the etiology and pathology? The remote causes are obscure. The disease may occur at all ages, SCURVY. 149 but is commonly observed in middle life, and oftener in women than in men. Exposure and hardships are often exciting causes. The patho- logical changes occur in all parts of the joints. The articular extremi- ties of the bones become enlarged, owing to a growth of new cartilaginous and osseous tissue. The cartilaginous articular extremities of the bones are often absorbed, particularly in their centres. The normal villous outgrowths of the synovial membrane are much increased in size and number, and may be changed into cartilaginous or osseous tissue. The pedicles of these nodules often break, and the nodules remain as for- eign bodies in the articular cavity. The ligaments surrounding the joint become much thickened, owing to deposits of cartilage in them ; the bones are often rendered immovable. Dislocations or subluxation of the joints may occur from the absorption of the ligaments and artic- ular cartilages. Where the joints have become immobile the muscles attached to them are often atrophied from lack of use. On microscop- ical examination there is found a proliferation of large cartilage-cells around the edges of the joints and in the ligamentous tissue surrounding them. After the disease has existed for a short time the synovial fluid is very much decreased in quantity or may be entirely wanting. What are the symptoms and treatment ? The progress of the disease is slow, but the smaller joints may be first aifected. Chalky deposits in the joints are wanting, and there seems to be no liability to pericarditis or endocarditis. Fever is absent, and there is little constitutional disturbance. The appetite and digestion, as a rule, are but little affected. The affected joints are enlarged and painful, es- pecially on motion. Crepitation is generally present, but the skin cov- ering the affected joint is not red or shiny. As the disease progresses the joints become disturbed and their motion impaired. In this disease the larger joints are frequently affected first, and in the smaller joints those of the fingers are often affected previously to those of the toes. The disease is also unattended by the paroxj^sms and acute exacerbations characterizing gout. The urine often does not contain an excess of uric acid. The treatment must be mainly symptomatic and directed to check the progress of the disease, as the deformity of the joints is incurable. A nutritious diet and a building up of the system by iron and other tonics are most important. The remedies used for chronic rheumatism and gout are of little value. Iodine, hot baths, and passive motion applied to the affected parts are useful. The use of hot mineral and mud-baths is often beneficial. SCURVY. What is scurvy? A disease characterized by extravasations of blood into the skin and serous membranes, and "the presence of ulcerations in various portions of the body. 150 GENERAL DISEASES. What are the etiology and pathology ? It is supposed to be caused by the want of vegetable acids in the diet- ary of the patient. It is more prevalent during the winter than in the summer, and is most frequently seen in those whose constitution is much run down. The composition of the blood is changed, and some ascribe the change to the lack of the potash salts. Extravasations of blood often appear before and after death beneath the skin and also between the bundles of muscular fibres. The tongue, the gums, and the buccal mucous membrane are often swollen and frequently ulcerated. Ulcerations some- times occur on the inner surface of the synovial membranes, and the synovial fluid may be tinged with blood. Ecchymoses are frequently observed on the surface of the serous membranes. The spleen is enlarged, and the heart, liver, and kidneys may be in a condition of parenchymatous or fatty degeneration. "What are the symptoms and treatment ? The patient usually complains of general weakness and disinclination to exertion ; an angemic appearance is present, and anorexia becomes marked. These symptoms become progressively worse. The gums are swollen and have a spongy appearance. Hemorrhages are frequent from them, and also from the nostrils, vagina, and intestines. The breath is generally offensive. Ecchymoses appear spontaneously on the skin, and are frequently caused by the slightest blow. The skin is dry and rough. An oedema of the lower extremities or the face soon takes place. There is palpitation and dyspnoea on exertion, and a systolic angemic murmur is frequently heard over the base of the heart. The urine is scanty and high-colored. Fever is generally absent. The pulse is soft and com- pressible, but its rate varies greatly in different cases. Disturbance of the mental faculties does not occur, but obstinate insomnia is frequently present. Muscular pains in the lumbar region and lower extremities are frequently observed. Death occurs in some cases from heart failure, due to over-exertion ; in other cases from hemorrhage into the meninges or into the pericardial or pleural cavities, or from exhaustion, due to re- peated and profuse hemorrhages into the outlets of the body. Where the disease is recognized early and proper treatment can be given, the cases generally recover. The prevention of the disease by the use of fresh acid fruits is very important. Where the disease is established easily-digested nutritious food and the internal use of the bitter tonics, mineral acids, and the preparations of iron are indicated ; the salts of potassium should also be given in small doses. For the ulcerations, antiseptics, and if in the mouth astringents added, give relief. PURPURA HEMORRHAGICA. What is purpura haemorrhagica ? A disease characterized by extravasations of blood into the skin and mucous membranes. HAEMOPHILIA. 151 What are its etiology and pathology? The causes are obscure, but the hemorrhage seems to depend upon an abnormal condition of the coats of the capillary vessels, due to vaso-motor disturbance. There is also some morbid change in the blood. The ex- travasations may consist of petechias or large ecchymoses. They re- semble those occurring in scorbutus, but extravasations into the muscles, the joints, and viscera are uncommon. What are the symptoms? The disease is most apt to occur in the summer or autumn. It some- times begins insidiously with gradually increasing mental depression and physical weakness, and then comes the appearance of the hemorrhagic spots on the body, followed by more or less profuse hemorrhage from the mucous membrane of the nose, mouth, or intestinal tract. In other cases the disease begins with fever, headache, a quick, rapid pulse, loss of appetite, and an increasing prostration. There is also pain in the back, hmbs, and joints. The larger joints frequently swell in a manner similar to that of acute rheumatism. In the more severe cases hem- orrhages from the mucous membranes occur ; the patient becomes anae- mic in appearance, and may die from exhaustion. This aflection is sometimes seen as a complication of infectious diseases (typhus, typhoid, meningitis). What is the treatment? General treatment consists of a nutritious diet and the internal use of small doses of wine and of tonic remedies, such as dilute sulphuric or hydrochloric acid, and the tincture of the chloride of iron for the arrest of the hemorrhages. Gallic acid or ergot internally is recommended. HAEMOPHILIA. What is meant by haemophilia ? A liability to excessive bleeding, occurring either idiopathically or as the result of very small or insignificant lacerations. The disease seems to be hereditary in many cases, but it will sometimes skip a generation in the family so aifected. Men are oftener affected than women. The disease may show itself directly after birth by bleeding from the umbili- cus, but the diathesis is generally first manifested during or shortly after dentition. It will occur from the slightest wounds, and also take place without assignable cause from the nostrils, and sometimes from the bronchial tubes, stomach, intestines, and kidneys. _ The blood seems to be less coagulable than normal, and the inner lining membrane of the arteries has been found to be very thin. Some disorder of the vaso- motor nerves seems to be a factor in the production of the disease. The treatment consists of tonics and haemostatics internally, and the use of styptics in cases of hemorrhage locally. DISEASES OF THE NERVOUS SYSTEM. DISEASES OP THE PERIPHERAL NERVES. DISTURBANCES OF SENSATION. Sensation may be diminished or absent (anaesthesia) or increased (hyperaesthesia). In anaesthesia a strong irritation produces a weak reaction or none at all ; in hyperaesthesia a weak irritation produces an exaggerated reaction. We have special nerve-fibres for the tactile sense, which is measured by means of objects applied to the skin ; the sense of locality, tested by means of a compass, the two points of which are applied to the skin ; the sense of pressure, tested by the application of weight to different parts of the skin ; the sense of temperature, tested by means of tubes filled with hot and cold water ; the sense of pain, tested by means of a pin ; and electric sensation, tested by means of the electric current. We also distinguish muscular sensibility, or the power to judge of our motions without the aid of our eyes. We find anomalies of all these sensations in the various nervous affections. ANESTHESIA OF THE SKIN. What is anaesthesia of the skin ? A partial or complete absence of _ sensation over a certain area of the cutaneous surface, due to interruption in the conducting power of the sensory nerves. What are the etiology and pathology of anaesthesia ? The sensory nerve-fibres, after reaching the spinal cord, pass through the posterior columns (and the " columns of Groll " ) of the opposite side to the medulla and the internal capsule, and the centre is situated in the posterior third of the posterior limb of this capsule. Anaesthesia may be due to affection at the cutaneous end of the nerve (chills, narcotics, ether, injury, local disturbance of circulation), or to affection along the track of the nerve (traumatism, inflammation, new growths), or to affec- tion in the spinal cord (locomotor ataxia, inflammation, new growths), or to affection of the cerebrum (hemorrhages in the internal capsule, hj's- teria, effect of anaesthetics on the brain). Anaesthesia may also be caused by infectious diseases, and sometimes by syphilis. What are the symptoms of anaesthesia ? The patient may notice that in some part of his skin sensation is not normal. He does not feel the pressure of his clothing, small objects drop 152 neuralgia! 153 from'tis hand, as he does not feel their presence, although in cases of hj^steria the anaesthesia may be extensive without the patient being con- scious of it. It may be combined with a feeling of pain or of numbness or trophic disturbances. Voluntary motions are executed with ease, but become more difficult when the eyes are closed. Anaesthesia is rarely an independent affection, but mostly a symptom of other diseases of the nervous system. The prognosis therefore depends on the causative dis- ease. The patient is liable to receive injuries, scalds, burns, and cuts without being aware of the injury. In aneesthesia of the trigeminus nerve the face is usually bloated and the temperature on the affected side is somewhat lower than that of the other, the tongue loses its power of taste on the anterior two-thirds, and ulcers easily form on it from bites that are not felt. What is the treatment of anaesthesia ? If we can discover the primary cause of anaesthesia, we must try to remove that. If the cause is obscure, we may use with good effect a faradic or galvanic current, especially in cases of hysteria. Massage or rubbing with various liniments is very useful. The affected parts should be protected against injury. The use of strychnine internally is advised. NEURALGIA. What is neuralgia ? Pain occurring in the course of nerves and in their area of distribution. The pain has remissions and intermissions, and is due to some morbid affection of the nerves of sensation or their spinal or cerebral centres. What are the etiology and pathology of neuralgia ? The cause is unknown in most cases, although it is probable that we have to deal in many cases with an inflammatory affection of the nerve- tissue. It occurs more frequently in women past the middle age, in those of a neurotic tendency and in an anaemic condition. Exposure to cold, mechanical irritants, tumors, aneurisms, pressure on the bones, and wounds lead to neuralgia. Infectious diseases and various poisons and gout may also be causative. What are the symptoms of neuralgia ? In some patients an attack of neuralgia is preceded by a chilly feeling and slight pains. When acute, there is a burning or violent tearing sen- sation in the course of the affected nerve, increased on exertion. The pain may cease for a time, to recur with renewed vigor. There is gene- rally anaesthesia of the skin in the affected region, but occasionally we meet with hyperaesthesia, and along certain points the pain is always more intense [points doulourenx). There are also vaso-motor symptoms in the form of pallor or congestion of the affected part. Various erup- tions and changes in the color of the hair may also occur, and when the attacks are prolonged we have symptoms of interference with the general 154 DISEASES OF THE PERIPHERAL NERVES. nutrition. The attacks may recur at regular intervals or not return for a long time. What is the treatment of neuralgia ? If dependent on anaemia or other general causes, we must try to cure the constitutional complaint. Nutritious food, tonics, etc. restore anae- mic patients rapidly. In malarial, syphilitic, or gouty subjects we use the constitutional treatment. In mild cases we may use counter-irritants. Gralvanic electricity seems to be very beneficial, especially the descending current, beginning with a mild current and gradually increasing _ its strength. Internally, quinine in large doses, arsenic, bromides, ergotine, aconite, potassium iodide, and phenacetin are recommended. In severe forms the use of opium cannot be dispensed with, but we niust be very cautious in its use. External applications in the form of ointments or embrocations are of slight temporary benefit. _ In cases where no remedy seems to be of value a neurectomy — an excision of a part of the diseased nerve — may be necessary. Sometimes neurotomy — a section of the dis- eased nerve — or stretching of the nerve is practised. Baths are of ben- efit to some patients, especially in sciatic neuralgia. NEUBALGIA OF THE TRIGEMINUS. What are the cause and symptomatology of trigeminal neural- gia? A sudden chilling, cold, or malarial infection, affections of the teeth or cranium, constant strain of the optic nerve, may induce neuralgia of the fifth pair. The attacks of intense pain along the course of the trigeminus may come on without any special cause or after an excitement of a physical or mental nature. The circulation becomes interfered with, and the face, at first pale, becomes red. Herpes may appear along the course of the nerve, while salivation or lachrymation are often prominent symptoms. According to the branch aff"ected, we have (a) ophthalmic neuralgia, of a supraorbital or frontal nature, with pain on pressure along the course of the nerve ; (6) supramaxillary, chiefly along the infraorbital nerve ; and (c) inframaxillar}^, chiefly along the inferior dental nerve. The attacks may be very mild or very severe, and are sometimes sudden and epilep- tiform in character. What are the diagnosis, prognosis, and treatment of trigeminal neuralgia ? Differentiate from periostitis or osteitis, migraine or toothache. Chronic cases are hard to cure, recent cases are quite amenable to treatment. Look always for the cause, and try to remove it. The application of electricity is beneficial. Internally, quinine, arsenic, gelsemium, aconite, opium, may be employed. In obstinate cases operative interference is advisable. INTERCOSTAL NEURALGIA. — SCIATICA. 155 • .'• INTERCOSTAL NEURALGIA. What is the etiology of intercostal neuralgia ? Affection of the vertebrae, ribs, the spinal cord, and aorta may be at first manifested by nem-algia of one or more of the intercostal nerves. But it may develop independently, and in anaemia after exposure to cold. It is more common on the left side, and occurs mostly in the nerves situated in from the fifth to the ninth intercostal space. What are the symptoms and treatment of intercostal neural- gia? The pain is usually very severe, especially on movement of the inter- costal muscles. With the pain, as a rule, an herpetic eruption appears along the course of the affected nerve, which is supposed to be due to an extension of the inflammation from the nerve-ends to the skin. Pain on pressure is most marked near the vertebral, the sternal end, and the mid- dle of the nerve. The affection is very obstinate, and may last long after the eruption has disappeared. In recent cases we may use counter-irritants, and in the more chronic cases electricity and anodynes are indicated. For herpes a protecting ointment is sufficient. MASTODYNIA, OR NEURALGIA OF THE MAMMARY GLAND. This occurs in women at the time of puberty, and is a painful affection of the intercostal nerves supplying the mammary gland. Little is known about the affection, except that it is very obstinate and very difficult to treat. Applications of heat and electricity may be resorted to. SCIATICA. What is sciatica ? A neuralgic affection of the sciatic nerve, characterized chiefly by pain along the course of this nerve. What are the etiology and pathology of sciatica ? It occurs frequently, and is more common in males than in females. It is most often observed between the ages of forty and fifty years. The gouty and those affected with muscular rheumatism are more liable to the disease. Muscular over-exertion, wet and cold, mechanical pressure from tumors, habitual constipation, and caries of the spine are all ex- citing causes. The sheath of the nerve is the part usually affected : it is swollen and red, and shght ecchymoses are noticed along its course. Some- times the inflammation extends to the nerve itself. What are the symptoms of sciatica, and their treatment ? If sudden in its development, the patient experiences a lightning-like pain shooting down from the sciatic notch, along the posterior surface of 156 DISEASES OF THE PERIPHERAL TCERVES. the thigh and the outside of the leg to the foot. These parox3^sms are repeated on the shghtest exertion, but after a while the^^ become constant and dull, worse at night. There is pain on pressure above the hip-joint, at the sciatic notch, the middle of the thigh, behind the knee, below the head of the fibula, behind the external malleolus, and on the dorsum of the foot. Abnormal sensations, anaesthesia, hypergesthesia, and parges- thesia, are noticed along the course of the nerve. The muscles become slightly atrophied, and may give abnormal electrical reaction. Herpes zoster is sometimes observed along the course of the nerve. The affec- tion may last a few weeks or be prolonged for years. It should be differ- entiated from psoas abscess, lumbago, locomotor ataxia, and nervous coxalgia. If dependent on some exciting cause, attempt to cure that. Absolute rest to the limb, heat, and counter-irritants, electricity (a strong descending cun-ent), and massage are generally of benefit. Internally, narcotics, mercury, lithia, may be given. Injections of cocaine or osmic acid are recommended. Nerve-stretching and cautery may be tried. ARTICULAR NEUROSES. What are articular neuroses ? Severe and painful diseases of one or more joints, without discoverable anatomical cause and due to affection of the nerves supplying these ar- ticulations. What is the etiology of neuralgia of the joints ? The pains are not as paroxysmal as the ordinary neuralgic pains. We mostly meet these affections in the hysterical, especially young women, and they are often provoked by slight injuries, not serious enough to af- fect the joint itself What are the symptoms of neuroses of the joints ? Immediately after a slight accident or some time later the patient complains of a constant pain in one of the joints, which is'increased on ex- ertion or by mental excitement. Pressure or sudden janing cannot be borne. Locomotion is painful, and the patient is unable or unwilling to move for weeks and months. The leg or arm is rigid, and either ex- tended or flexed. The kriee- and hip-joint are most often affected. Diagnosis is rendered easy by the fact of absence of swelling and a general healthy appearance of the patient. If contracture is marked, examination under an anaesthetic is advisable. What is the treatment of articular neuroses ? Electricitj'' and massage, with cold douches, are of benefit. ^ No local applications should be made. Try to treat the mental condition of the patient, and to induce daily attempts at walking. Tonics may be given if the patient is anaemic. CEPHALALGIA. 157 CEPHALALGIA. What is cephalalgia? Habitual headache, probably due to disturbances of circulation and nu- trition. What are the etiology and pathology of cephalalgia ? It is a very common affection, but little is known as to its pathology and causes. The irritation may be in the brain-substance, but is com- monly supposed to be situated in the meninges. Strong as well as anae- mic subjects are liable to the disease. After prolonged mental drain or physical exertion, headache is liable to follow. Rheumatism, the ex- cessive use of tobacco or alcohol, chronic constipation, are predisposing causes. It sometimes appears to be idiopathic and also hereditary. It may last for months or a lifetime, occurring in repeated attacks. What are the symptoms and treatment of cephalalgia ? The attacks of headache occur after mental emotion or physical exhaus- tion or without assignable cause. The pain is either general, all over the head, or limited to a certain area, being of a sharp, burning character as a rule. _ Nausea, vomiting, perspiration, general malaise, may accompany the pain. Occasionally there is hyperassthesia of the skin along the seat of the headache. Our treatment must necessarily depend on the cause of the affection. If syphilis, anaemia, or rheumatism cause it, we must remedy these mala- dies. For neurasthenics, electricity and cold water ; for those mentally exhausted, rest, change of surroundings. Quinine, arsenic, bromides, coffee, and ergot are recommended ; but there is no sure cure. Elec- tricity and massage are of great benefit in many cases. If the pain is severe narcotics have to be resorted to. After cold, sod. salicylate will often relieve the headache. Lately antipyrine and phenacetin have come into use, with good success. Other Forms of Neuralgia. Neuralgias of the occipital, cervico-brachial, lumbar, genital, and rec- tal nerves are sometimes met with. Their etiology., symptoms^ course, and treatment are the same as those of the other neuralgias. THE REFLEXES, AND HOW TO TEST THEM. What reflexes do we test for in nervous diseases ? . For the cutaneous and tendon reflexes. What are cutaneous reflexes? Muscular action produced by irritation of the cutaneous nerves of sensation, not originating from central irritation. According to the man- ner in which reflexes are induced we get different results in different 158 DISEASES OF THE PERIPHERAL NERVES. parts of the body. By tickling, striking, or pricking the skin, or by ap- plying cold to it, we may produce muscular movements in a correspond- ing part of the body. In some diseases (hysteria, hydrophobia, poisoning by some drugs) there is an abnormal increase in the reflex action, and the muscles of the whole body iifespond to an irritation of a part of the cuta- neous surface. Two cutaneous reflexes are specially marked : the abdom- inal reflex, a contraction of the abdominal muscles by stroking the skin of the same side ; and the cremasteric reflex, a drawing up of one or both testicles by stroking the skin on the inside of the thigh or of the scrotum. All these reflexes are abnormally increased or diminished in some nervous affections. Disease of the peripheral cutaneous nerves of the reflex centre of the spinal cord may produce diminution of reflex movement. Loss of power of inhibition, increase in irritability of the skin, may pro- duce an increased muscular response to cutaneous irritation. What are tendon reflexes ? Muscular action due to a mechanical excitement of the tendons and fascia. They are most marked in the lower extremity, where we have the "knee-jerk," or patellar reflex, a contraction of the quadriceps mus- cle, following a quick blow on the ligamentum patellae while the leg hangs down passively; and the " ankle clonus," a violent tremor of the foot following a sudden flexion of the foot whereby th^ tendo AchiUis is stretched. We also get muscular contraction occasionally by suddenly striking the periosteum of the bones of the lower extremities or the fas- cia. Normally, there are no tendon reflexes in the upper extremities, but under abnormal conditions we get muscular contractions by a blow on the respective tendons. Muscular contraction may also be produced in some nervous aff"ections by a direct blow on the belly of a muscle. How is electrical diagnosis made? Both the faradic (induction) and the galvanic (constant) current may be used. One pole is applied to an indifferent point, while with the other direct excitement is produced by placing the pole on the muscle, or indirect^ by placing it on the nerve, and thus acting on the muscle. In applying the galvanic battery one pole is positive (anode), the other negative (kathode). If the current is weak, there ^ is no response ; if stronger, on closing the current, while the kathode is on^ the muscle or the nerve, there is a slight contraction, but none on opening it. When the current is still stronger, the contraction on kathode closure is marked, and slight on anode closure or opening. Using the strongest current, tetanus is produced on kathode closure, and contraction on anode closure, anode opening, and kathode opening. As an abbreviation the following terms will be used : Ka for kathode, An for anode, CI for closure, for opening, and C for contraction. The electric excitability of the muscles may be increased in tetany, pe- ripheral paralysis of recent origin, or diminished in bulbar paralj^sis, and progressive muscular atrophy. In some cases the quality of the electric PARALYSIS. 159 reaction becomes changed, and we have the so-called "reaction of degen- eration. ' ' In progressive paralysis there is a progressive diminution in the power of the nerve to conduct either faradic or galvanic currents. The muscle does not respond to the faradic irritation, but weak galvanic currents will produce strong, protracted contractions, the Ka CI C being as strong as the An CI C, or the An CI C may even be stronger than the Ka CI C. This is known as "the reaction of degeneration." In pro- tracted, incurable cases the electrical excitability soon diminishes or disappears, while in curable cases there is a gradual return to normal electric reaction. In some cases the reaction of degeneration is only partial. THE DISTUKBANCES OF MOTION. PARALYSIS. What is paralysis ? A loss of motor power in the voluntary muscles of the body. When this loss of power is complete, it is called paralysis ; when incomplete, paresis. Disease affecting the cortical gray matter or the motor centres produces paralysis. The motor fibres take their beginning in the region of the central convolutions of the cerebrum and the paracentral lobule, and pass through the internal capsule, its posterior limb, the crusta, and pons. Then after decussation in the medulla they progress through the opposite half of the lateral column and part of the anterior columns of the spinal cord to the motor ganglia of the anterior cornua. Thence they emerge as the anterior spinal roots, and pass to their peripheral endings. The injury along the track of the motor nerves may be localized in a certain spot, thus producing paralysis of a^ limited portion of the body (monoplegia). But when the injury occurs in the internal capsule, where the motor-fibres are collected, the affection usually involves one-half of the body (hemiplegia), it being the side opposite to the injured spot in the cap- sule. In the medulla the fibres for both sides of the body lie together, and injury at this spot produces complete paralysis. of both sides of the body (paraplegia). Lesions of the cord produce muscular paralysis of the parts supplied by the respective nerves emanating from the cord below the seat of lesion. Paralysis of an individual peripheral nerve is sometimes met with. What is the etiology of paralysis ? It is customary to divide paral3^ses, according to their cause^ into ana- tomical^ with a known anatomical basis as to their causation, and into functional.^ in cases in which there is no discoverable anatomical lesion. Any definite cause impairing the conducting power of the motor tract may produce paralysis, as inflammation, disturbances of circulation, new growths within the nervous tract or in the surrounding tissues, trauma- tism, the influence of poisons like lead and arsenic, infectious diseases due 160 DISEASES OF THE PEEIPHERAL NERVES. to poisoning from pathogenic products, inflammation of the nerve caused by exposure to cold. The causes of paralysis following attacks of hys- teria, sudden emotion, disease of the sexual organs and of the intestines, cannot as yet be explained from anatomical lesions. What are the symptoms of paralysis ? The patient complains of inability to perform certain motions. The affected sets of muscles after a while may or may not show atrophic changes. When there is no atrophy the lesion is usually between the cortex and 'the anterior cornua ; when atrophy occurs, the lesion usually is situated in the ganglia of the anterior cornua or in the peripheral motor tract. In these cases with the atrophy of the muscles there is also a corresponding atrophy of the nerves ( " degenerative atrophy '' ). The nerve-atrophy is demonstrated by changes in the normal electrical reaction. Passive motion may be easily performed, or resistance due to rigidity or shortening (contracture) of the muscles ( "spastic paralysis " ) may be met with. What are the different forms of paralysis met with ? {a) Paralysis of the Ocular Muscles may be due to affections of the peripheral or the central portion of the nerves. Direct injury, com- pression from tumors, thickened meninges, aneurism, exposure to cold, diabetes, acute diseases, locomotor ataxia, are among the causes producing it. The vision becomes double. If the oculo-motor nerve is affected, the upper eyelid droops, the pupil is dilated, the ej^e cannot move upward, downward, or inward. If the abducens is par- alyzed, the eye does not move outward. If the trochlear nerve is par- alyzed, rotation of the eyeball is irnpaired. With these symptoms there is often pain in the eye and in the supraorbital and frontal regions. The affection should be treated by means of weak electric currents, strych- nine, and iodide of potash if of syphilitic origin. (5) Paralysis of the Muscles of Mastication from an affection of the third branch of the trigeminus is of rare occurrence. If it is on one side, there is a difficulty in chewing ; if on both, chewing is impossible. The jaw hangs down and cannot be moved. The cure of this affection de- pends on the primary cause. (c) Paralysis of the Facial Muscles^ or Bell's palsy, is of rather com- mon occurrence, and is due to exposure to wet and cold, disease of the middle ear and the sphenoid bone, inflammation and enlargement of the parotid gland, tumors or inflammation within the brain or along the course of the nerve. The paralyzed half of the face is flat and without expression ; the eyelids cannot be closely approximated, and tears are constantly trickling over the cheek ; the corner of the mouth is droop- ing, and the saliva flows from it. On motion of the facial muscles the contraction of the sound side is more evident than usual. Speaking and chewing are difficult ; the soft palate and uvula are sometimes relaxed and drawn to the unaffected side ; the taste on the anterior two-thirds PAEALYSIS. 161 of the, tongue becomes dulled ; the secretion of saliva is diminished ; the hearing is abnormal The affection, as a rule, begins suddenly, and in mild cases there is simply a loss of muscular power, but no change in the taste or the electric excitability of the muscles. In more pronounced cases the electric reaction is slightly changed, and anode closure contrac- tion (An CI C) is greater than kathode closure contraction (Ka CI C). In the severe forms, with complete nerve and muscular degeneration, the electric excitability is lost, and after a time symptoms of motor irri- tation are noticed — tonic or spasmodic contractures and increased re- flex excitability. The mild cases last two or three weeks, the severe forms from four to six weeks ; the worst cases last for a long time, but may ultimately recover. Prognosis always depends on the primary lesion, and is good when the electric excitability is not altered within a week or two. Electricity, at first galvanic, then faradic, may be employed. Hypodermic injection of strychnia, nerve-stretching, massage, have been also resorted to. In- ternally, iodide of potash is given. [d) Paralysis of the Muscles of the Upper Extremities. — The following are the leading characteristics : Paralysis of Trapezius : elevation of the shoulder is imperfect, the scapula becomes rotated, the general contour of the neck is changed, noticeable on deep inspiration. Paralysis of Khomboids : the edge of the scapula stands slightly outward, and there is some rotation of the scapula ; when arm is raised, movement backward is weakened. Paralysis of Serratus Magnus : the scapula is slightly rotated, and on moving the arm a deep furrow is noticed between the scapula and the vertebrae. Elevation of the arm above the shoulder level is difiicult. It occurs often in men accustomed to lift heavy weights on their shoulder, and recovery is very slow. Paralysis of the Deltoid ; abduction of the arm is difficult ; the patient is unable to elevate the arm. There is usually pain in the shoulder. The muscle soon begins to atrophy, and the head of the humerus falls away from the acromion. Paralysis of Infraspinatus : outward rotation is lost, as well as in paral- ysis of teres minor. Paralysis of Teres Major and Subscapulars : inward rotation is lost. Paralysis of Latissimus Dorsi : adductio"h is impaired, and tjie humerus cannot be moved backward. Paralysis of Pectoralis Major and Minor : adduction of upper arm is lost or diminished ; the arm cannot be lowered against resistance. Paralysis of Brachialis Anticus and Biceps : when in supination, flex- ion of the forearm is interfered with ; when flexed, supination of forearm is lost. Paralysis of Supinator Longus and Brevis : flexion is usually accom- panied by supination, which Is very feeble, and accompUshed by other auxiliary muscles. 11— P. M, 162 DISEASES OF THE PERIPHERAL NERVES. Paralysis of Pronator Teres and Quadratus : pronation of forearm is lost. '"'"RadiaV^ Paralysis. — After compression, direct injury or cold, paral- ysis of muscles supplied by the musculo-spiral nerve may occur. When the triceps is paralyzed from the use of a crutch, etc. there is loss of ex- tension in the forearm. When the extensors in the forearm are para- Ij'^zed, the hand hangs down, adduction and abduction are difficult, flexion of fingers is impaired, the thumb is flexed and adducted ; flexion with the arm in position of pronation is difficult. Sensation is also impaired along the radial half of the back of hand and the fingers. In long- standing cases atrophy becomes pronounced. Ulnar Paralysis often occurs in progressive muscular atrophy or after traumatism or from pressure. Flexion of the hand and lateral motion are altered ; flexion of the fingers is imperfect ; adduction and abduction of the fingers are impossible, as well as adduction of the thumb. The proximal phalanges are extended, and the terminal are flexed, giving the hand a claw-like appearance {main en grippe). Atrophy of the interossei is marked. Sensation is lost over the portion supplied by the ulnar cutaneous branches. Median . Paralysis mostly follows injury. Pronation of the forearm is lost ; the terminal phalanges cannot be flexed ; the thumb cannot be flexed or circumducted. There are often trophic disturbances and loss of cutaneous sensibility along the distribution of the nerve. The cases may be mild or very marked. Most of the traumatic cases are not amenable to treatment. The primary cause should be removed if possible. A constant galvanic current, alternated with faradic applications, is of great benefit. Electricity must be kept up for quite a long time. Baths and local massage are great aids to the treatment. (e) Paralysis of the Diaphragm is but seldom met with, except in in- jury to the phrenic nerve or during attacks of hysteria. It may occur conjointly with other forms of paralj^sis in afl'ections of the cord or cer- ebrum. The respiration is thoracic and very rapid ; the abdomen does not change during inspiration or expiration-. Bronchitis often develops, during which coughing is difficult. If dependent on hysteria, recovery will take place ; in other cases it is doubtful. Faradization of the phrenic nerve is sometimes beneficial. (/) Paralysis of the Muscles of the Lower Extremity. — Paralysis of Gluteus Maximus and Minimus: abduction of the thigh is difficult. Groing uphill or rising from the sitting posture is difficult. Circumduc- tion, rotation inward, and walking are impaired. The toes are turned outward. Paralysis of Anterior Crural Nerve : flexion of the thigh and flexion of the trunk are impaired ; the leg, when flexed, cannot be extended. Walking is difficult, standing is possible if the knee is extended. Rising from the kneeling position is impossible. The patella easily becomes dis- located, MUSCULAR SPASM. 163 Paralysis of Obturator Nerve : adduction of thigli and rotation out- ward are impaired. The patient finds it difficult to cross the legs. Paralysis of Flexors of Knee: the knee cannot be bent, and locomo- tion is difficult. The leg is rotated either inward or outward, and the ligaments of the knee are unduly stretched. Paralysis of Extensors of the Foot : extension of the ankle is impaired, walking is difficult, standing on tiptoe is impossible. The foot is everted, the ankle lowered, and talipes calcaneus results. Paralysis of Peronei : the foot is inverted, the plantar arch is flat- tened. Paralysis of Flexors of Foot ; flexion, abduction, and adduction are impaired, and talipes varus soon develops. The treatment of all these affections is the same as for paralysis of the upper extremity. [g) Toxic Paralyses. — Lead paralysis occurs often in persons who have used articles prepared from lead. There is a primary de- generative atrophy of the nerve, followed by degeneration of the mus- cle, which are due to toxic action of lead upon the nerves or the spinal cord. The musculo- spiral nerve is the one usually afi^ected. Extension of the first phalanx of the middle, ring, index, and little fingers becomes impaired. The extensors of the thumb and wrist become involved. In some cases the deltoid and the biceps are also affected. It occurs on both sides of the body, and the atrophy soon becomes marked. Sensa- tion remains intact. On the gums, above the teeth, a characteristic blue "lead line " usually appears. Recovery occurs in most cases. Remove the cause, administer salines, iodide of potash. Electricity is of great value. Ether, alcohol, copper, zinc, and arsenic may also produce paralysis, but these forms are of comparatively rare occurrence. MUSCULAR SPASM. What is muscular spasm? A morbid movement of the muscles which is involuntary and due to motor irritation. The spasm may emanate from central irritation or may be due to peripheral reflex excitement. "What varieties of spasms do we meet with ? Spasms in general may be clonic (intermittent) or tonic (continuous). In epileptiform spasms the convulsions are clonic and extend over the whole body. In choreic spasms the movement of the muscles is either shght or very pronounced. In apoplexy we meet with rhythmical spasms of certain groups of muscled. Tremor (slight motions constantly follow- ing one another) is met with in a great many nervous diseases. A con- stant wave-Hke contraction of the small ^ fibrillar muscular fibres is ob- served in progressive atrophy. Athetosis (a succession of various move- ments in the arms, head, but especially in the fingers and hand) is ob- 164 DISEASES OF THE PERIPHERAL NERVES. served in some nervous affections of children or adults. In cataleptic rigidity the muscles are no longer under the influence of the will, but assume an}^ position given to them. If the tonic spasm affects the mas- seters, we call it trismus ; if affecting the muscles of the back, bending the bodj'' backward, it is called opisthotonus ; if attacking the whole bod.y, it is tetanus. Paradoxical muscular contraction is a slow tonic contraction caused by sudden approximation of the attachments of a muscle. Enumerate the different spasms met with. Spasm of the motor branch of the trigeminus : the masseters become very hard, the jaws are firmly brought together. This form of tonic spasm is called trismus, and may occur on one or both sides. Clonic spasm may be produced from reflex causes, and often lasts a long time. The affection should be treated by removing the cause, if it can be as- certained. Electricity is of great benefit. In tonic spasm we must often resort to artificial feeding. Narcotics may be used in severe cases. Clonic facial spasm maj'^ be produced by peripheral or central causes. We notice short, rapid contractions in the muscles supplied by the facial nerve, either on one or on both sides of the face. These come on in re- peated attacks or last continuously. Voluntary muscular action is not impaired. In some cases the spasm affects the ej^elids only, and is either clonic (blepharospasm) or tonic. The spasm may last a few weeks or a whole lifetime. Treatment is difficult. Best results are obtained from the use of electricity, applied daily for five or ten minutes. In- ternally, bromides and arsenic are given. Application of the Paquelin cautery is sometimes of benefit. Lingual spasms of a tonic or clonic nature may occur in hysteria or epilepsy, but rarely independently. Spasms in the muscles of the neck may occur as a result of caries or nervous affection. The head is drawn forward, backward, or sideways according to the muscle affected. When the sterno-mastoid is affected and the head is drawn to one side, the condition is called torticollis. Most cases become chronic, and are not easily amenable to treatment^ which consists]of electricity, the cautery, nerve-stretching, and application of narcotics. Mechanical support gives good results in some cases. Spasms of the muscles of the shoulder and the upper extremity may occur from reflex or central causes. Usually a whole group of muscles is affected ; more often the forearm and the fingers than the arm. We treat these spasms in the same manner as all other spasms. Spasms of the muscles of the lower extremity occur mostly in affections of the brain or cord. Tonic spasms (cramps) come on in the muscles of the calves of the legs after fatigue. When the reflexes are exaggerated, we sometimes notice a saltatory reflex spasm which consists of a violent movement of the leg following every attempt to touch the floor with the foot. It is mostly seen in hysterical persons. Spasm of muscles of respiration is always rare. If tonic, the dia- NEURITIS AND ITS VARIETIES. 165 phragm' •becomes immobile and there is a severe pain in its region. The clonic form (singultus or hiccough) is not uncommon, which is sometimes verj" persistent, especially when the phrenic nerve is affected. Electri- city and nervines are of benefit. WRITER'S CRAMP (GRAPHOSPASM). What is writer's cramp ? A disturbance of co-ordination in which the muscles of the hand, when to be applied to writing, are attacked by violent spasm, although the same muscles are able to perform their function when applied to any other ordinary action. It occurs in cases of excessive and long-continued ' application to wi'iting. What are the symptoms and treatment of graphospasm ? At every attempt at writing a spasm of the fingers occurs, making it impossible to hold the pen. In some the affection is of a clonic, tremu- lous nature, so that the words when wi-itten are very ihegible. Sensation is normal, except slight numbness in the fingers and some pain in the affected muscles.^ A cm-e is very difiicult, though many cases can recover when treated in time. Chorea and paralysis agitans sometimes also simulate graphospasm. Writing must be abandoned altogether. Mechanical appliances may help in the beginning. Change of suiToundings, sea- , baths, electricity, massage, and gymnastic exercises are of great value. Similar cramps have also been noticed in piano- and viohn-players, telegraphers, tailors ; in the tongue in cornet-plaj'ers ; in the lower ex- tremities in sewing-girls, ballet-dancers, professional athletes, etc. NEURITIS AND ITS YARIETIES. What is neuritis? An inflammation of the nerves of an acute or chronic nature. What are the etiology and pathology of neuritis ? Neuritis may be produced by injury to nerves, a violent muscular strain, exposure to cold, extension of inflammation from adjacent structures, general infectious diseases, rheumatism, syphiMs, cancers, etc. In some cases it appears to be idiopathic. In the acute form the vessels of the nerve become congested, exuda- tion occurs, the nerve appears swollen and red. In severer cases the medullary sheaths and axis-cylinders of the nerve-fibres undergo destruc- tion. These changes may take place along a considerable tract of the nerve or be Hmited to certain spots. The process of destruction may stop, and regeneration, partial or complete, may take place. The regen- eration consists in the restoration of the axis-cyhnder and in abundant formation of new connective tissue. In the chronic form the destruction is progressive from the beginning, advancing in many cases from the peripheiy toward the centre. 166 DISEASES OF THE PERIPHERAL NERVES. What forms of neuritis do we meet with ? (1) Neuritis following traumatism and inflammation is chiefly charac- terized by pain of a violent nature along the course of the affected nerve, which is also sensitive- to pressure. As a result of impaired nervous function anaesthesia and motor paralj^sis gradually develop, with subse- quent muscular degeneration. The skin is oedematous, and an herpetic eruption is often noticed along the course of the nerve. Recovery is the rule in these cases if the primary exciting cause can be remedied. Some- times an acute attack is followed by the chronic form. (2) Multiple neuritis is a successive or simultaneous affection of one or more groups of nerves. It is comparativeh^ rare with us, but more com- mon in the East, where it is called ' ' beri-beri. " It is supposed to be due to the presence of some poison affecting the nerves. The affection usually begins suddenly with fever, loss of appetite, headache, and pains. The pains are most marked in the extremities along the larger nerves. The joints become swollen, the patient "finds himself unable to move his legs very readily, and soon the paralysis extends to the upper extrem- ities. The reflexes are diminished or absent, and the reaction of degen- eration now becomes evident. The loss of muscular power produces a characteristic wrist- and foot-drop. Th« tingling fii'st noticed in the skin becomes a troublesome hjq^eraesthesia. Trophic disturbances (oedema, loss of hair and nails) may also come on in the later stages of the disease. The bladder and rectum retain their normal functions. As soon as the paralj^ic affection extends to the muscles of respiration death speedily occurs. In some cases the affection, at first acute, soon becomes chronic, and after a time gradual recovery takes place or it goes on to a slow, fatal termination. It has been noticed that in these chronic cases tuber- culosis often occurs as a complication. The affection should be differen- tiated from poliomyelitis. Recovery may take place even when the dis- ease is very far advanced. During the acute stage salicylates seem to be of benefit. For the pain we use narcotics and hot applications. In chronic cases change of air, baths, and electricity are of great value. (3) Alcoholic neuritis is a special variety of the chronic form of multi- ple neuritis, due to the toxic effect of alcohol on the peripheral nerves. This form is much more common in women than in men. It rarely be- gins acutely. There are usually prodromic symptoms consisting of vomiting, tingling, and pain in the extremities. The pain soon becomes severe, and inco-ordination of movements develops. The gait becomes staggering, the muscles give the reaction of degeneration, the reflexes are diminished or lost. The muscles soon atrophy, and anaesthesia over large areas becomes marked, though there may be tenderness on pressure. The affection is progressive as in multiple neuritis, unless the alcoholic habit is abandoned, in which case recovery usually takes place. The dis- ease resembles greatly locomotor ataxia. The treatment demands abstinence from alcohol, electricity, and the use of strychnine. VASO-MOTOR AND TROPHIC DISTURBANCES. 167 NEUROMA. What is neuroma? A morbid increase in the tissue-elements of the peripheral nerves. What varieties of neuromata do we distinguish ? False and true neuroma. False neuromata consist of a morbid increase in the connective tissue of a nerve-sheath, while true neuromata consist of an increase in the numbers and size of the elements of a peripheral nerve. The true neuroma consists of medullated or non-medullated nerve-fibres imbedded in connective tissue. They may be hereditary or due to traumatism and amputation. The true neuromata are often mul- tiple, and may give rise to no symptoms, or may cause a great deal of pain of an intermittent character, which is increased on pressure. When the conduction of the nerve-fibre is interfered with, anaesthesia and loss of power may develop. Reflex spasms of a tonic or clonic nature may also occur in the course of the disease. We sometimes are able to feel the little nodular growths, or when superficial we may see them. These nodules may be very sensitive or give no pain at all. The disease is very chronic in duration, but may eventually disappear. The diagnosis is often difficult, except when the new growths are superficial. Treatment consists in extirpation of the new growths. If too nume- rous, narcotics should be used for the alleviation of pain. Fibromata, sarcomata, myomata, syphilitic and leprous gummata, are frequently called false neuromata, and any of these may give the same symptoms as the true neuroma. VASO-MOTOR AND TROPHIC DISTURBANCES. It is generally assumed that there are two sets of nerve-fibres surround- ing the blood-vessels — the vaso-constrictors and vaso-dilators — but some deny the existence of the latter. The centre of the vaso-motor nerves is is in the cortex of the brain near the motor centre ; thence the nerve- fibres proceed to the medulla, through the lateral columns and anterior roots, to the sympathetic system. What varieties of vaso-motor disturbances do we meet with ? (1) Vaso-motor paralysis is characterized by an unnatural redness of certain parts of the skin, accompanied, as a rule, by a local elevation of temperature. This affection may accompany other neuroses or may occur independently from injury to the sympathetic nerves. The redness may be general or confined to one of the extremities. (2) Vaso-motor spasm is characterized by unnatural pallor and cold- ness of the skin, accompanied by stiffness, and sometimes by pain. When of long duration gangrene of the affected parts may develop. This is sometimes observed as a reflex result in those having their hands con- stantly in water (washerwomen). 168 DISEASES OF THE PERIPHERAL NERVES. The existence of tropliic centres is not proven. Some authoi-s claim that trophic disturbances are due to vaso-motor irritation, but it is prob- able that there is a trophic centre, for in injury to the nerves often the skin becomes glossy or an abnormal amount of pigment is deposited. Atrophy of the muscles and the appearance of bed-sores are also referable to tropliic disturbances. The nails in some nervous affections become dark and cracked, the hair is lost or turns white, and the trophic disturb- ance may even extend to the bones and joints. Associated with trophic disturbance we have disturbances of secretion in some neuroses. Sweat- ing may be increased, diminished, absent, or unilateral. The salivary and other secretions may also be increased or diminished. HEMIORANIA (MIGRAINE). What is hemicrania ? A peculiar variety of unilateral headache, associated with vaso-motor disturbances. What is the etiology of hemicrania ? ; It is more common in women than in men ; it is often inherited, and may last from puberty to menopause or during the whole lifetime. Men- tal emotion, phj^-sical or mental fatigue, constipation, a faulty digestion, seem to act as exciting causes. Very little is known as to the direct cause and location of the affection, but it is most likely situated in the meninges, and is due to some vaso-motor disturbance. What are the symptoms and treatment of hemicrania ? It comes on in distinct attacks, preceded usually by prodromata of vertigo, chills, malaise, uneasiness, etc. The pain when once beginning is continuous, mostly in the frontal, temporal, or parietal region, and is often of great intensity. The skin over the painful part is hyperses- thetic. There are loss of appetite, nausea, irritability, and bright spots before the eyes. The pain may be limited to one side (mostly the left). In the spastic form the affected side is pale, the skin is cool, the pupil is dilated, and the flow of saliva is increased. All these symptoms are de- pendent on u-ritation of the s^^mpathetic. In the paralytic form the af- fected side is reddened, hot ; the blood-vessels are dilated, the pupils are contracted. All these s3Tnptoms are due to paralysis of the sympathetic. Most attacks are not distinctly definable. They last a few hours or a day, and end with vomiting. 1^\\q prognosis is not very good, as the at- tacks are apt to recur in spite of treatment, which in many cases is with- out effect. Narcotics act badly. Nitrite of amyl in the spastic form, ergotine in the paralytic form, are sometimes of benefit. Bromides, arsenic, cannabis, salicylates, guarana, nitro-glj'cerin, caffeine, are also used. Cold baths, electricity, massage, are of value. PROGRESSIVE FACIAL HEMIATROPHY, ETC. 169 . V. PROGRESSIVE FACIAL HEMIATROPHY. What is progressive facial hemiatrophy? A progressive atrophy of the structures of one half of the face. What is its etiology? It is of rare occurrence, and belongs to early youth. It is slow in its progress, and has been noticed more in women than in men. What are the symptoms of facial hemiatrophy ? It begins in a small spot on the cheek or the chin, where the normal color changes to white or to brown. From this point the discoloration spreads, and the affected part begins to have a sunken appearance. The skin, the bone, and the muscles all begin to atrophy on one half of the face, sometimes involving the tongue and soft palate on the same side. The sensibility is normal, but the hair is thinned on one side. Sometimes the atrophy spreads to the structures of the neck and shoul- der. Occasionally only the skin and bones atrophy, while the muscles remain intact. The affection is probably due to some trophic change the nature of which has not j'^et been determined. What are the prognosis and treatment of facial hemiatrophy ? The affection is progressive and incurable, though the patients may be benefited by applications of electricity. Occasionally a marked hyper- trophy of one side of the face has been observed. EXOPHTHALMIC GOITRE. Syn. — G-raves's disease ; Basedow's disease. What is exophthalmic goitre ? A group of symptoms consisting chiefly of a swelling of the thyroid gland, a quickening of the pulse, and a protrusion of the eyeballs from their orbits. What is the etiology of exophthalmic goitre ? Little is known regarding its anatomical basis, but it is most likely due to a vaso-motor disturbance. It is often hereditary. Injuries in the nature of a concussion, mental emotions, pregnancy, and sexual disorders are among the exciting causes. It is more common in women who have reached maturity. What is the pathology of exophthalmic goitre ? As yet no definite pathological lesion has been found to explain all the symptoms of exophthalmic goitre. It is claimed to be due to a disturb- ance or a paralysis situated in the sympathetic nervous system. It must be still looked upon as a general neurosis. 170 DISEASES OF THE SPINAL MEMBRANES. What are the symptoms, prognosis, and treatment of exophthal- mic goitre? The pulse becomes rapid (100-160), but varies at diiFerent times, and is usually rlij'thmic. The pulsation in the carotids is marked. The heart itself is often hypertrophied and dilated. The swelling of the thyroid gland (goitre) comes on gradually, and is either slight or very large. It is soft, and pulsations can be distinctly felt. The protrusion of the eyeballs is slight or may be sufficient to cause entire dislocation from their sockets, though the sight is not affected. Besides these chief symptoms there is usually a general muscular tremor of greater or lesser intensity, headache, sleeplessness, vertigo, anxiety, and irritability. Occasionally there are an elevation of temperature and sweating on one or both sides of the body. Pigmentation of the skin, gangrene of vari- ous parts, may occur. Anaemia, d3^spncea, digestive disturbances arise sooner or later. The disease lasts for years, and recovery is not common. Rest, change of surroundings, tonics, electricity, belladonna, ergotine are of benefit. Extirpation of the goitre is dangerous. DISEASES OP THE SPINAL MEMBRANES. ACUTE! SPINAL MENINGITIS. What is acute spinal meningitis? An acute inflammation of the membranes of the spinal cord. What are the etiology and pathology of acute spinal meningi- tis? The inflammation may affect chiefly the dura mater or the pia mater or both. The inflammation is often secondary from extension of inflammation of the surrounding parts. It may complicate general in- fectious diseases, tuberculosis, septicgemia, and empyema. From caries an inflammation of the dura mater (pachymeningitis) often follows, while in general fevers it is the pia mater (leptomeningitis) that is usually attacked. If the dura mater is inflamed, it is red, thickened, and covered on its inner or outer surface with lymph or pus, and it may sub- sequently adhere to the bone. If the pia mater is inflamed, it appears congested and reddened, opaque and thick, and covered with lymph or pus. The space between the dura and pia mater may be filled with a purulent or semipurulent exudation. What are the symptoms of acute spinal meningitis ? No matter where the inflammation is situated, the general clinical symp- toms are the same. If there is a primary affection, the s^^mptoms of this disease will often precede those of the spinal affection. There is pain in the back, nausea, followed by chills, fever, and an increase of the pain, which, when the nerve-trunks are compressed from exudation, may radi- ate toward the distribution of these nerves. The pain is constant, and CHRONIC SPINAL MENINGITIS. 171 ig incl-eased on movement. The muscles of the back and neck become rigid, and may sometimes produce opisthotonos. The reflexes and sen- sations are increased. There may be retention of urine, constipation, headache, dehrium, dyspnoea, and Cheyne-Stokes respiration. The paralysis is progressive ; anaesthesia and the loss of reflexes are marked, and death may follow, but sometimes even severe cases recover, with or without the loss of muscular power. What are the diagnosis and prognosis of acute spinal meningi- tis? When the prinaary affection is severe, we may not be able to diagnose the spinal affection during life. Differentiation must be made from myelitis, meningeal hemorrhage, spinal hemorrhage, and rheumatism. The prognosis is very serious, especially in the severer forms of the affec- tion and when the primary disease is dangerous to hfe. What is the treatment of acute spinal meningitis ? Absolute rest, exclusion of sound and light, leeching and counter-irri- tation along the spine should be used. Hot baths may be given in the beginning. The use of mercury by inunction is of benefit. Sedatives are given for pain. If the paralysis is progressive, we. must use electricity and massage. CHRONIC SPINAL MENINGITIS. What is chronic spinal meningitis? A chronic inflammation of the spinal membranes. What are the etiology and pathology of chronic spinal menin- gitis? It hardly ever occurs as a primary affection. Secondarily, it follows acute attacks, epidemics, diseases of the cord and vertebrae of a chronic nature, concussion, traumatism, alcoholism, syphilis, and tuberculosis. The membrane is thickened and opaque ; the spinal fluid is increased in quantity. The nerve-roots are swollen, and afterward from compression they may undergo atrophy. Sometimes the inflammation extends to the cord itself, causing softening and disintegration. What are the symptoms of chronic spinal meningitis ? The symptoms correspond to those of the acute form, being less in in- tensity. There are pains in the back, mostly of a dull nature : the stiff"- ness in the muscles is not so marked as in the acute form of the disease. The pains along the distribution of the nerves may be severe ; hyper- aesthesia and abnormal sensations, followed by anaesthesia, are frequently present. The pain persists for weeks or months, the muscles atrophy, and the reflexes and sensation are completely lost. If the cord is com- pressed, the parts supplied by the affected nerves are paralyzed. 172 DISEASES OF THE SPINAL MEMBRANES. What are the diagnosis and prognosis ? We must differentiate from rheumatism, neuritis, progressive muscu- lar atrophy, locomotor ataxia, and spinal caries. Prognosis is best in cases following injury or syphilis, but in all cases it depends on the extent of the inflammation and its location. What is the treatment ? Absolute rest, a comfortable posture, and counter-irritants to the spine are essential. For the pain we give sedatives. Iodide of potassium and mercury are given internally where the disease is suspected to be of syphilitic origin. Tepid or cold baths, electricity, and massage in the later stages may be used. PACHYMENINGITIS OBRVIOALIS HYPERTROPHICA. What is hypertrophic pachymeningitis ? A chronic thickening of the dura mater, nearly always in the cervical portion of the spinal cord. What are its etiology and pathology ? The etiology is obscure : it may follow cold and excessive use of alco- hol. The dura mater becomes very thick fi'om a new growth of con- nective tissue, and the cord and nerve-roots become compressed, causing degeneration of nerve and muscles. What are its symptoms? There is severe pain in the cervical region, shooting down the arms. The fingers feel numb. This condition may last a few months, and is followed by paralysis, accompanied by atrophy of the upper extremities, chiefly noticed along the distribution of the ulnar or median nerve. The hand becomes extended from contracture of the extensors. _ As the com- pression of the cord advances there arises a spastic paralysis of the lower extremities, not accompanied by atrophy. What are the prognosis, diagnosis, and treatment? Recovery may take place, though most cases gradually advance to a fatal termination. We must differentiate fi'om tumors in the cord, lat- eral sclerosis, and caries of cervical vertebrae. The treatment is symptomatic : electricity, iodide of potash, and the Paquelin cautery are also of benefit. MENINGEAL APOPLEXY. What is meningeal apoplexy ? A hemorrhage of large or small extent into and between the mem- branes of the spinal cord. DISEASES OF THE SPINAL COED. 173 What are the etiology and pathology of meningeal apoplexy ? It may occur at all ages. Injury, great physical exertion, severe con- vulsions, diseases of the vertebrae, meningitis, infectious and septic fevers, and aneurism may produce it. Extradural hemorrhage is slight in ex- tent, and collects on the posterior surface. It mostly occurs in the cer- vical region. Intrameningeal hemorrhage sometimes fills up the whole space between the cord and the dura mater, causing compression of the cord. What are the symptoms of meningeal apoplexy ? They begin suddenly, but cause no loss of consciousness. When the hemorrhage is of slight extent the symptoms are not marked, but when the hemorrhage is more or less extensive we have symptoms of irritation in the sensory and motor branches of the corresponding parts, as follows : severe pain, neuralgia in the extremities, muscular tremor, and contract- ures. ^ If the hemorrhage is extensive, symptoms of muscular paralysis and disturbance of the bladder function may appear. An aifection called pachymeningitis interna haemorrhagica is sometimes met with, consisting of an encapsulated collection of blood on the inner surface of the dura mater, and occurring in the chronic insane and alcoholics. What are the prognosis, diagnosis, and treatment of meningeal apoplexy ? The prognosis is favorable when the blood is rapidly absorbed. Diag- nosis can rarely be made with certainty. We treat by employing abso- lute rest, local applications of ice, and bloodletting. In chronic cases electricity, baths, and iodide of potassium may be used. DISEASES OF THE SPINAL CORD. DISTURBANCES OF CIRCULATION. What disturbances of circulation in the cord are met with ? Anaemia, a temporary or permanent diminution in the blood-supply ; and hyperaemia, a temporary or permanent increase in the blood- supply. What are the symptoms of anaemia ? It usually is caused by a general narrowing of the arteries, as in chronic meningitis. If the diminution in blood-supply' is permanent, paralysis necessarily follows. If the anaemia is transient (from arterial spasm), tetanoid symptoms often develop, as also the so-called "intermitting lameness." If the anaemia of the cord is part of a general anaemia, the spinal sj^mptoms are not pronounced. There are dull pain and fatigue on slight exertion, and weakness which may increase to paralysis, Para- plegia may also result from anaemia, caused by excessive loss of blood. Attention to the general health is most important in the treatment of these cases. 174 DISEASES OF THE SPINAL CORD. What are the symptoms of hyperasmia ? Mechanical congestion may result from lying on the back. Active congestion may complicate many diseases, and may follow tetanus, strych- nine-poisoning, general disturbance of circulation, and coitus. The symp- toms are obscure, and cannot be diagnosed during life, except when so active as to cause inflammation. SPINAL APOPLEXY. What is spinal apoplexy? A hemoiThage into the • substance of the spinal cord of a primary or secondary nature. What are the etiology and pathology of spinal apoplexy ? Primary hemorrhage is rare, except after traumatism. Secondary hemorrhage may complicate myelitis, chronic alcoholism, sexual excess, tumors of the cord, and epidemic, meningitis. The extravasation may be slight or severe. Wheii large the substance of the cord is destroyed in the direction of the long axis. What are the symptoms of spinal apoplexy ? Most cases begin suddenly, though occasionally there are prodromata, as disturbances of sensation. When the hemorrhage is extensive, there is a rapid development of paralysis, most marked in the lower extremi- ties. There is also great pain in the back, paralysis of the bladder, anaesthesia, and change of reflexes — symptoms the occurrence of which will depend on the location of the hemorrhage. If the blood is absorbed, the paralytic symptoms gradually disappear, but often the symptoms persist and death ensues. What are the diagnosis, prognosis, and treatment of spinal apo- plexy ? We must differentiate from multiple neuritis, hemorrhagic myelitis, and meningeal hemorrhage. The danger to life is always great, but the prognosis is better when the hemorrhage is in the dorsal region. The treatment consists of absolute rest, ice to the spine, laxatives, and ergot. The paralysis is treated according to general principles. FUNCTIONAL DISTURBANCES OF THE SPINAL CORD. What are functional disturbances of the spinal cord ? A set of S3^mptoms resembling severe spinal disease, but having no known anatomical basis. What is the etiology of functional disturbances of the spinal cord? It is not known whether disturbance of the sensory tract or of the cir- culation is the basis of these troubles. Severe emotional excitement, mental exertion, excessive use of tobacco or alcohol, and onanism are TRAUMATISM OF THE SPINAL CORD. 175 among the exciting causes. Hypochondriasis also may lead to func- tional disturbances. What are the symptoms? They are slow in their onset, beginning with fatigue and weakness, pain in the back of a more or less severe character, numbness in the ex- tremities, sexual disturbances, and a number of general symptoms, due to the neurasthenic condition of the patient. There may be tenderness along the vertebrae. The reflexes and sensations are usually normal, but there may be coldness, sweating, and chilly feelings. The appetite is good as a rule. What are the diagnosis, prognosis, and treatment ? It is sometimes difficult to diagnose the affection from serious spinal disease except by thorough physical examination. Permanent recovery may ensue, but in some cases the affection, though never dangerous, continues all through life. Moral treatment is of chief importance. Proper diet, good exercise, electricity, cold baths, and tonics are of great benefit. TRAUMATISM OF THE SPINAL CORD. This is a lesion of the spinal cord due to mechanical injury. What is the pathology of traumatic lesion ? The extent of injury varies greatly according to the cause. There is usually hemorrhage, either outside or on the inner surface of the dura mater or the pia mater or into the cord itself, and with more or less laceration of the cord tissue. As a result of the effusion the cord usually softens ; the nerve-fibres waste away and degenerate in an ascending or descending manner. What are the symptoms of traumatism of the spinal cord ? The symptoms differ according to the seat of injury. There are usually marked motor and sensory disturbances, and occasionally sudden, com- plete paralysis of the upper or lower extremities. The bladder and rec- tum may be abnormal in their functions. There are pains and abnormal sensations. The temperature is often increased, the reflexes are dimin- ished. When the damage to the spinal cord is extensive death ensues sooner or later. The symptoms in some cases are very slight in the beginning, but increase in severity within a few days, or there may be a sudden increase in them a few months subsequently. In other cases the symptoms, at first marked, gradually abate, which is due to the absorp- tion of the blood-clot. What are the prognosis and treatment of spinal traumatism ? If the symptoms are slight we may expect a recovery, but we must always be cautious in our diagnosis of the extent of the lesion. 176 DISEASES OF THE SPINAL COED. The treatment is more surgical in the beginning. Absolute rest, ap- plication of ice ; trephining may be necessary. When paralytic symp- toms develop we treat them accordingly. CONCUSSION OF THE SPINE. What is concussion of the spine ? A severe jarring of the body, followed by a group of spinal sj^mptoms supposed to be due to some minute changes in the cord of an unknown nature. What is the etiology of concussion of the spine ? Severe concussions may result from railway accidents ( ' ' railway spine ' ' ) or violent bending of the body, fall from a horse, blow on the back, high jumping, etc. What are the symptoms of concussion of the spine ? In some cases the onset of the symptoms is sudden, due to a jarring of the brain as well as of the spinal cord — loss of consciousness, complete paralysis, small pulse, collapse, and within a few hours death. In others the severe symptoms are followed by gradual improvement, but it often takes years till the recovery is complete. There is a difficulty in loco- motion, weakness in the upper extremities, but the electric reaction is normal ; there are pain of varying degree and tenderness on pressure along the spine. Sometimes sensation is diminished as well as the re- flexes. Cerebral symptoms, like headache, dizziness, fainting, etc. , may be present or absent. Anomalies in the action of the bladder, rectum, and sexual organs may or may not occur. These symptoms may last for months or years. In other cases there are no special symptoms after the concussion, but within a few weeks or months there is a gradual devel- opment of spinal symptoms, combined with bulbar symptoms and cere- bral disturbances. These cases gradually get worse, although recovery may take place. What are the diagnosis and treatment of concussion of the spine ? We must be careful in differentiating concussion from neurasthenia or hysteria. In the treatment we advise rest, stimulants, electricity to counteract the shock to the system. In chronic cases electricity, potass, iodide, ergot, and strychnine, baths, change of climate best. CAISSON DISEASE. What is caisson disease ? An affection occurring in divers, in bridge-builders, and in all those working under water at a great depth. The symptoms develop on com- ing to the surface suddenly, where the atmospheric pressure is greatly PRESSURE MYELITIS. 177 lesseijBd. The affection is supposed to be due to the presence of gases in the blood, escaping thence into the nerve-structures, and causing an arrest of nervous function from pressure. What are the symptoms of " caisson disease " ? The symptoms usually occur on return to the surface of the water or a short time after. There are pains in the ears and joints, bleeding from the nose. The pulse is slow and strong ; vomiting often occurs. There is a disturbance of motor and sensory functions. Paraplegia or hemi- plegia may occur, usually beginning suddenly. Sensation may also be lost. In some cases recovery takes place within a few weeks ; in others a fatal termination rapidly ensues. Occasionally cerebral symptoms, like loss of consciousness, coma, and irregular breathing, have been noticed. Retention of urine, partial or complete, generally exists. What is the treatment of " caisson disease " ? As a prevention we should advise persons engaged in work under water to change gradually from a great depth to the surface, and not come up all at once. When the disease is once developed, it should be treated in the same way as an acute myelitis, which it resembles in its symptoms. PRESSURE MYELITIS. What is pressure myelitis? An inflammation of the spinal cord, due to compression of the cord from the presence of new growths and diseases of the vertebrae. What are the etiology and pathology of pressure myelitis ? Accumulation of masses of inflammatory products within the mem- branes, chronic caries in tubercular and other disease, new growths, aneurism, and cancer of the vertebrae may by compression of the cord produce paralj^sis of the parts below the seat of affection. It occurs in children as well as in adults. In tubercular caries of the vertebrae, hav- ing its seat most commonly in the dorsal portion, several vertebrae become diseased, and, being rendered softer, the healthy vertebrae compress them, and, pushing them toward the cord, the spinal canal is narrowed. From encroachment of the vertebrae the cord is compressed. The cord at this point is considerably narrowed and softened, of a flat, cylindrical, or indented appearance. The nerve-fibres are not destroyed, though their power of conduction is interfered with from pressure. Insome cases we find very little evidence of infiammation in the cord itself, though sometimes there is a disintegration of the axis-cylinders and the neuroglia and an increase in new connective tissue, while in other cases the symptoms of inflammation are very marked. In chronic cases the degeneration extends in an ascending or descending manner. What are the symptoms of pressure myelitis ? The symptoms depend on the degree of compression, its duration, 12— P. M. 178 DISEASES OF THE SPINAL CORD. and the amount of degeneration produced. In some cases caries may be present for a long time without ever involving the spinal cord. In other cases we first have the signs of the presence of a caries of the vertebrae, followed by slowly or quickly developing spinal symptoms. In these cases there is pain in the affected part of the spine, increased on exertion, and there is also pain shooting along the course of the com- pressed nerves. The pains are of a neuralgic character, and are constant or intermittent. There is hyperassthesia, and later angesthesia. The muscles become weak and atrophy ; the paresis increases, going on to paralysis if the affection is progressive. As to the reflexes, when the compression is above the reflex arc for the lower extremities, the tendon reflexes are greatly increased, as the inhibitory influences do not reach the reflex arc ; the cutaneous reflexes are not so markedly increased, and are often even diminished. There are sometimes trophic and circulatory disturbances. In severe cases the functions of the bladder and the rec- tum are interfered with. What are the prognosis and diagnosis of pressure myelitis ? In tumors (cancer, etc. ) the prognosis is always bad. In caries re- covery may take place, even in cases seemingly severe and hopeless, except when some complicating disease arises. We must differentiate this affection from subacute transverse myelitis, new growths within the cord, and extensive pachymeningitis. What is the treatment of pressure myelitis ? If it is due to spondylitis, we must treat that affection in the proper manner. Rest in bed, cupping, and counter-irritation of the spinal col- umn, especially the Paquelin cautery, electricity, the internal use of iodine, are all recommended. As to the other symptoms, we treat those as we do ordinary myelitis. Orthopaedic appliances are often followed by great benefit in suitable cases. MYELITIS. What is myelitis? An inflammation of the spinal cord. What are the varieties of myelitis ? If divided according to the mode of onset, we distinguish acute, sub- acute, and chronic myelitis. If divided according to the distribution, we have diffuse, transverse, disseminated, central, parenchjonatous, and interstitial myelitis. We shall divide the affection into acute and chronic myelitis. What is the etiology of acute and chronic myelitis ? The etiology is obscure. It is more common in males than in females, and heredity seems to have some influence. As exciting causes we have exposure to cold, great phj^sical or mental strain, sexual excess, injuries, MYELITIS. 179 concussion of the spine, hemorrhage into the cord, acute infectious dis- eases, syphilis, purulent inflammation of neighboring organs, sudden arrest of menses, lifting of heavy weights, alcoholism, and hydrophobia. What is the pathology of myelitis ? The cord in a certain spot is soft and flexible, the white matter is red- dish in color, the gray matter is indistinct. On microscopical examina- tion the nerve-tissue is found to be almost entirely destroyed, the axis- cylinders are swollen, the ganglion-cells show evidences of destruction. There is a marked increase in connective tissue, causing a great hardness in the affected part of the cord in long-standing cases. There are fatty cells and flat "spider cells" in great number between the meshes of neuroglia. The blood-vessels are dilated and thickened. Hemorrhages are noticed in various places. The seat of the affection is mostly in the dorsal portion of the cord. It usually extends in a transverse manner, and then upward and downward from the main focus. A complete softening and breaking down of nerve-tissue in the cord is very rarely met with. What are the symptoms of myelitis ? The symptoms differ greatly according to the seat and extent of the inflammation. They depend on interference with the function of the cord, and in the acute form may be accompanied by general symptoms of all acute inflammations — malaise, headache, fever, and loss of appe- tite. The motor symptoms are first to appear, though they may be preceded by tingling and burning sensations. There is a slight weak- ness in one or both legs, increasing even to complete paralysis, due to in- terruption pf conduction in the lateral or crossed pyramidal tract, where the fibres of voluntary motion are situated. If situated in the dorsal or lumbar part of the cord, the upper extremities remain free. If situated in the cervical region, paralysis of the upper extremity and respiratory muscles may occur. Associated with the motor paralyses there are also symptoms of motor irritation — spasmodic twitchings, painful cramps, ataxia, and sometimes convulsions. Sensation is impaired, but as a rule this occurs later on in the disease. At first there are symptoms of sen- sory irritation — numbness, pricking, formication. In chronic cases the sensation is diminished, but frequently it is entirely lost ; occasionally hypersesthesia has been observed. When the sensation is impaired the posterior columns, especially the posterior cornua of gray matter, are involved. The myelitis is about on a level with the line of dis- turbed sensation. The reflexes are diminished, normal, or increased according to the position of the lesion. If the fibres above the reflex arc are irritated, the reflexes are diminished, but if destroyed, the reflexes are increased, as the power of inhibition from above is not transmitted. The posterior column and anterior cornua of gray matter seem to be the seat of reflex conduction. In dorsal and cervical myelitis the reflexes are increased, while in lumbar myelitis they are diminished or 180 DISEASES OF THE SPINAL COED. destroj^ed in the lower extremities. Micturition is difficult and painful from the beginning, and there maj^ be complete retention of urine. Later on, from paralysis of the sphincter of the bladder, incontinence may oc- cur. Cystitis is very apt to complicate retention. These bladder symp- toms may complicate myelitis in any part of the cord, but mostly in affection of the posterior columns. At first there is constipation from diminution in the peristaltic movements of the intestines or from paresis of the abdominal muscles. Later the sphincter ani becomes paral3"zed, and the faeces are involuntarily passed. The sexual functions are also diminished or lost. The trophic disturbances consist of atrophy of the affected muscles, with or without degeneration, dry skin, and brittle nails ; vaso-motor disturbances are also noticed. If degeneration takes place, the lesion is situated in the anterior gray cornua or anterior roots. There is often an increase in the temperature of the affected part in the beginning, but when the paralysis is complete it may fall to subnormal. There may be an optic neuritis if the cervical portion of the cord is affected. Bed-sores occur in the later stages of the disease. Most cases are chronic in their course, lasting one or more years. Improvement and remissions occur, but recovery is rare. What are the diagnosis and treatment of myelitis ? We must differentiate it from compression of the cord, new growths, and sclerosis. If we can find an exciting cause, we should try to remedy that at once. If due to cold, a hot bath is of great benefit. If due to syphilis, antisyphilitic treatment should be employed, and in doubtful cases always resort to mercurial inunctions. The constant electric cur- rent, if not too strong, is of benefit. The galvanic may be alternated with the faradic current. Baths are of great service. If taken at home, the baths should be moderately warm, daily repeated, and followed by rub- bing. If the patient is in better circumstances, mud-baths or cold-water institutions may be tried. In recent cases dry or wet cupping along the spine, counter-irritants, hot-water bags, may be tried. Internally, ergot and strychnine have been used, but with little success. Mental and bodily rest, nutritious diet, and an easy posture are advisable. In cases of retention of urine we employ the catheter. If the pain is severe, nar- cotics must be resorted to. The skin should be kept absolutely clean. Nitrate of silver internally has sometimes given good results. Tonics should be employed in anasmic patients. DISSEMINATED SCLEROSIS. What is disseminated sclerosis? A chronic affection of the spinal cord and brain, due to a dissemina- tion of sclerotic patches in various parts of the central nervous sj^stem. What are the etiology and pathology of disseminated sclerosis ? Very httle is known as to its etiology. Heredity, syphilis, mental or LOCOMOTOR ATAXIA. 181 phygicaL over-exertion, may have an influence on the development of the sclerotic nodules. There are small gray nodules distributed all over the cord and brain, chiefly in the white substance. Each patch consists of connective tissue, with very few nerve-cells and a number of fat-cells. There is hardly ever any secondary destruction in the cord itself What are the symptoms of disseminated sclerosis ? According to the location of the patches the symptoms differ. The most constant symptom is a tremor resembling that of paralysis agitans, but in sclerosis, tremor occurs only with intentional movement, and is not regular in character, and is more marked in the upper extremities than in the lower. There are also a disturbance of speech and slight twitch- ings of the eyeball (nystagmus). Paresis does not occur until late in the disease. The tendon reflexes are greatly increased, especially in the lower extremities. The gait is usually dragging (spastic-paretic). Sen- sation and cutaneous reflexes remain quite normal. Associated with the spinal symptoms there are also cerebral symptoms — mental weakness, dementia, melancholia, apoplectic attacks, vertigo, and epilepsy. Trophic disturbances and affections of the bladder and rectum are unusual. The affection is very chronic in its course, lasting for years and ending in death. _ The above set of symptoms is not the exact type of disseminated sclerosis, as there are a good many varieties resembling any of the affec- tions of the spinal cord. Diagnosis is sometimes difiicult. What are the prognosis and treatment of disseminated sclerosis ? Prognosis is unfavorable. The treatm&it is that of chronic myelitis. LOCOMOTOR ATAXIA (TABES DORSALIS). What is locomotor ataxia? A disease characterized by a gray degeneration of the posterior col- umns of the spinal cord. What is the etiology of locomotor ataxia ? Heredity is not a permanent factor in its production. Syphilis is one of the most common causes, and is said to be the only cause, according to the view of some observers. Poisoning by ergot gives symptoms sim- ilar to locomotor ataxia. It is more common in men than in women (10 : 1), mostly in those of middle age. But it is sometimes met with in children, the victims of hereditary syphilis. What is the pathology of locomotor ataxia ? The pia mater is thickened, the posterior columns have a gray, trans- lucent appearance, and are atrophied ; the posterior cornua of gray matter and the posterior nerve-roots are atrophied. Under the microscope we can see that the nerve-fibres in the posterior columns have disappeared, and are replaced by new connective tissue. The degeneration is most 182 DISEASES OF THE SPINAL COED. marked in the lumbar portion of the cord, affecting there the middle and posterior portions of the posterior columns ; in the dorsal portions the whole of the posterior columns is usuall}^ affected ; while in the cervical portion mostl}^ the columns of Groll degenerate. The degeneration is usuall}" s\Tnmetrical in the two halves of the cord. The gray color is due to the disappearance of medullary sheaths. What are the symptoms of locomotor ataxia ? The symptoms show the same regularity in their appearance in aU cases, making the diagnosis of this affection comparatively easy. The prodromata consist of lightning-like pains in the lower extremities, numb- ness in the fingers, a sensation of constriction around the chest, and head- ache. These sjTuptoms may constitute the only evidence of locomotor ataxia, and last for years ; but sooner or later there are added absence of patellar reflex and an immobility of the pupil. The absence of patellar reflex (Westphal sj^mptom) is alwaj'S observed, and is due to a degene- ration of the centripetal portion of the reflex arc in the middle portion of the posterior column of the spinal cord. The immobility of the pupil (Argjdl-Robertson symptom) consists of immobilitj^ of the pupil to light, while accommodation of the pupil is retained, as can be proved by test- ing for distance of objects. As a rule, the pupils are contracted. There may also be a paralysis of the ocular muscles, either on one or on both sides, coming on rather suddenly and dependent on degeneration of the respective nerves. In some cases there is also an optic atrophy, which may begin quite early in the disease, ending with total blindness. There may also be a slight loss of cutaneous sensation. All these sj'mptoms may last for several months or years. The second or ataxic stage commences with disturbances of mobility. The disturbance of co-ordination (ataxia) is very marked, especially in the lower extremities. The gait becomes difficult and uncertain ; there is difficulty in rising or rapid turning. The patient feels as if he were walking on coal, and on closing the eyes the body begins to sway (Rom- berg's sj^mptom), especially when the feet are put together, which s\^mp- toms are due to a defect in controlling the muscles from impairment of sensation. Walking soon becomes very difficult, and ataxia may appear in the upper extremities also. The definite cause of ataxia has not jet been ascertained, but it is probably due to a lesion of the gray matter. The power of the muscles is usually preserved in locomotor ataxia. The electric excitement of the muscles and nerves remains normal, but the muscles soon become flabby from disuse. Sensation is changed from the beginning, and the lanci- nating pains are marked in all cases and come on in paroxysms. The pains are mostly in the legs, but also occur in the arms and head, the loins, the back, and the trunk. Herpes accompanies these neuralgic pains some- times. But soon anaesthesia develops. At first the tactile sense is inter- fered with ; then the senses of pressure and temperature are diminished or lost. The muscular sense is greatly interfered with, especially when the LOCOMOTOR ATAXIA. 183 controlling power of the eyes is temporarily taken away. Occasionally we meet with delaj^ed sensations, as is proved when the prick of a pin is only felt a few seconds after being applied. The cutaneous reflexes are normal in most cases. Difficulty in micturition is nearly always present, and cystitis may develop. In advanced cases there is incontinence of urine. Constipation is the rule, and is often marked. The sexual func- tions are diminished or abolished. This stage may last for many years, and may show a standstill, but it is usually progressive and advances to the third stage. The third or last stage is marked by a gradual change to the worse, and the patient is unable to leave his bed. Paresis, and even paralysis, may occur from extension of degeneration to the lateral p3Tamidal tracts of the cord. Anaesthesia of the lower, and sometimes of the upper, ex- tremities becomes marked. The joints (mostly the knee- and hip-joints) show on both sides of the body a painless swelling, from the presence of great quantities of serum. Spontaneous dislocation and fracture occur. Other trophic disturbances are rare, except bed-sores and peculiar per- forating ulcers of the sole of the foot. Death usually occurs from ex- haustion. There are often complications in other organs. There may be attacks of sharp pain, called "crises," coming on suddenly, in paroxysms. "Gastric crises "_ consist of violent pain in the stomach, vomiting, and vertigo, lasting a variable time. ' ' Intestinal crises ' ' consist of a very painful diarrhoea. ' ' Laryngeal crises ' ' are severe attacks of dyspnoea, due to a spasm of the glottis and associated with a severe par- oxysmal cough. ' ' Renal crises ' ' resemble attacks of renal colic. There are also rectal, urethral, and testicular crises, characterized by acute pain in the regions mentioned. Cerebral symptoms are sometimes met with in the last stage of the disease, as dementia and delusions. Occasionally the sense of hearing is lost from degeneration of the auditory nerve. What are the prognosis and diagnosis of locomotor ataxia ? The affection is usually fatal, though it may last for a great many years. The different cases show a difference with regard to their progress, although the characteristic symptoms are present in all with a varying degreeof intensity. The diagnosis of locomotor ataxia is somewhat difficult in the beginning, but comparatively easy when the characteristic symp- toms appear. In persistent "rheumatic pains," ocular disturbances, and gastric attacks we should always examine the reflexes. Vertebral caries compressing the cord, tumors of the cord, multiple sclerosis, alcoholic or tobacco neuritis, may simulate locomotor ataxia. What is the treatment of locomotor ataxia ? Any cause that may hasten the production of the disease should be removed, such as mental or physical exhaustion, exposure to cold, al- coholic excess, smoking. In most cases an anti syphilitic treatment should be begun at once — iodide of potash, mercurial inunctions, com- 184 DISEASES OF THE SPINAL CORD. bined with tonics and good food. In addition, arsenic, stryclinia, nitrate of silver, belladonna, ergot, and phospborus are recommended. The ascending electrical current, vapor-baths, cold baths, mud- andiron-baths are valuable adjuvants to internal treatment. Counter- irritation may be employed along the spine. Lately nerve-stretching and stretching of the spinal cord by means of an extension or suspension apparatus have been used with benefit in many cases. For the pain and the crises we use narcotics, antipyrine, bromides, etc. The other symptoms are treated according to general rules. AMYOTROPHIC LATERAL SCLEROSIS. What is amyotrophic lateral sclerosis? A degeneration of the whole pyramidal tract of the spinal cord, com- bined with atrophy of certain nerve-centres in the medulla. What are the etiology of amyotrophic lateral sclerosis, and its pathology ? The etiology is very obscure. Exposure to wet and cold and great physical exertion are supposed to act as exciting causes. It has been more common among females between twenty- five and fifty j^ears of age than among males. Both pyramidal tracts are symmetrically sclerosed, as well as the large cells in the anterior gray cornua. Sometimes the degeneration extends as far as the internal capsule. Certain nerve-cen- tres (the hypoglossus and vagus accessory) in the medulla also degen- erate, the process also extending to the periphery. The muscles greatly atrophy, and sometimes wholly disappear. What are the symptoms of amyotrophic lateral sclerosis ? The affection usually manifests itself in the arm at first. There is an increasing weakness in one arm, which after a time extends to the other. The muscles become markedly atrophied, especially on the extensor side. The atrophy is not hmited to one group of muscles, but seems to occur en masse. The power to move the arm is soon totally lost. Electric reaction is normal in the intact muscular fibres, but reaction of de- generation is noticed when the atrophy is extreme. The arm shows a characteristic paralytic deformity: it lies close to the body, the fore- arm is semiflexed and pronated, the hand is semiflexed, and the fin- gers are bent upon the palm. The affected muscles are in a marked state of contracture. Sensation is normal, but the tendon reflexes are greatly increased. The atrophy and contracture afterward extend to the lower extremities ; the gait becomes spastic and paretic, but soon paraly- sis supervenes. The speech becomes indistinct, swallowing is difficult, the tongue becomes atrophied, and general nutrition suffers. Death finally ensues from difficulty in respiration. The bladder and rectum usually retain their normal functions. PEOGRESSIVE MUSCULAR ATROPHY. 185 What are the diagnosis, prognosis, and treatment of amyotrophic lateral sclerosis? Mj^elitis, tumors in the spinal cord, may for a time simulate this affec- tion, but the course is, as a rule, a typical one. The prognosis is bad, the disease being fatal within a few years. The treatment should be symptomatic. PROGRESSIVE MUSCULAR ATROPHY OF SPINAL ORIGIN. What is progressive muscular atrophy? A slow wasting of the muscles, beginning in a limited manner and ex- tending to all voluntary muscles. What is the etiology of progressive muscular atrophy ? It is more common in males than in females, being usually an affection of adult life. Heredity may play some part in its development. Mental excitement, exposure to wet and cold, injury to the spinal cord, concus- sion, syphilis, lead-poisoning, acute infectious diseases, may act as excit- ing causes. What is the pathology of progressive muscular atrophy ? The affected portion of the spinal cord (usually the cervical portion is first affected) is softer and smaller than normal in the region of the an- terior cornua ; the ganglion-cells have mostly disappeared ; the anterior roots and motor fibres of the peripheral nerves and the muscles supplied by them are atrophied. The atrophy of the muscles may be simple or degenerative. What are the symptoms of progressive muscular atrophy ? The prodromata consist of aching and loss of strength in the affected portions, mostly the upper extremity. The atrophy is first noticed in the small muscles of the thumb ; the ball of the thumb becomes flat, and the thumb is in close apposition to the second metacarpal bone. Soon the interossei atrophy, and the palm of the hand is sunken, and the fingers assume a claw-like appearance from the action of the extensors. Next the muscles of the forearm or those of the shoulder waste away, and the same change takes place in those of the trunk. Those of the neck are rarely implicated. Movements with the arms become difiicult, and when the diaphragm or the intercostal muscles become affected respiration is interfered with. A fibrillar twitching of the affected muscles is noticed early in the disease. The electric excitability may be lost or show a re- action of degeneration. Trophic and vaso-motor disturbances, as men- tioned in the sections on these subjects, may occur. The tendon reflexes are always absent. The sensation remains normal ; the bladder and rectum do not lose their functions. Atrophy of the muscles of the leg is much rarer, and less marked when it does occur. The face and tongue usually escape the atrophy. The process is very slow, and it may be years 186 DISEASES OF THE SPINAL CORD. before the muscles that are supphed from the medulla begin to atrophy. When their nuclei are attacked we have all the symptoms of a chronic bulbar paralysis. What are the diagnosis, prognosis, and treatment of muscular atrophy ? The diagnosis is sometimes difficult, on account of an excessive develop- ment of fat during the course of the disease, masking the muscular atrophy. The disease must be diiFerentiated from amj^otrophic lateral sclerosis. The prognosis is bad, as it always ends fatally, though it may be pro- longed for a good many j^ears. The treatment is symptomatic. General healthy suiTOundings, proper food, massage, electricity, may prolong life. (It is claimed by some authors that injections of strychnine can arrest the disease permanently. ) The two following diseases are now presented, to contrast with the preceding. PSEUDO-HYPERTROPHY OP THE MUSCLES. What is pseudo-hypertrophy of the muscles ? A morbid condition limited to the muscles, and not dependent on a lesion of the central or peripheral nervous system. What are the etiology and pathology of pseudo-hypertrophy of the muscles? It is an affection almost wholly limited to youth, and showing in many cases a congenital predisposition. Male children are more liable to be attacked than female. There is a decided atrophy of the muscles, as in chronic progressive muscular atrophy, but this atrophy is concealed by a great increase in fatty tissue. What are the symptoms of pseudo-hypertrophy ? It is gradual in its onset. The child has difficulty in walking fi*om weakness in the muscles of the back, trunk, and lower extremities. The gait is waddling ; the abdomen is very prominent ; the spinal column shows a decided forward curve in the lumbar region ; the legs are raised with difficulty ; and the toes droop. Sooner or later the movements in the upper extremities become interfered with. The muscular groups show a great increase in volume from superabundant development of fat, but occasionally there is no pseudo-hypertrophy. Reaction of degen- eration is never noticed. Sensation is normal, and the functions of the bladder and rectum are preserved. In some cases mental weakness has been noticed. What are the prognosis and treatment of pseudo-hsrpertrophy ? The affection advances steadily, and usually terminates fatally from respiratory disturbance or some other intercurrent disease. The treatment is purely symptomatic. SPASTIC SPINAL PARALYSIS. 187 ERB'S FORM OF JUVENILE HEREDITARY MUSOU- ' • ' LAR ATROPHY. This is a form of muscular atrophy hereditary in some families, and attacking chiefly the female members of the familj^ What are the symptoms of hereditary muscular atrophy ? In nearly all cases certain sets of muscles atrophy, while others remain perfectly normal. Those mostly attacked are the pectorales, trapezius, latissimus dorsi, serratus magnus, rhomboidei, sacro-lumbalis, and lon- glssimus dorsi. The muscles of the arm and forearm withstand the effect of the disease for quite a long time. In the lower extremities the glutei, quadriceps, peronei, and tibialis anticus are first to suffer. The func- tions of the respective parts are soon interfered with, slowly progressing till the loss of function is complete. Sensation, as a rule, is not inter- fered with, and reaction of degeneration is absent. In some cases the atrophy is chiefly hmited to the face. Examinations of the peripheral nerves and the spinal cord have failed to give any evidence of patholog- ical changes. What are the prognosis and treatment of Erb's form of atrophy? The prognosis is not favorable, as the disease slowly but persistently progresses toward complete paralysis and death. The treatment is purely symptomatic. SPASTIC SPINAL PARALYSIS. What is spastic spinal paralysis? A gradually increasing paralysis, progressing from below upward, with muscular tension, reflex contractions and contractures, a decided increase of tendon reflexes, with absence of disturbance of sensation, of vesical, rectal, sexual, and mental derangement or of trophic changes. What are the etiology and pathology of spastic spinal paraly- sis ? It occurs mostly between the ages of twenty and fortj^ Heredity, syphilis, concussion of the spine, exposure to wet and cold, acute dis- eases, or congenital causes may produce this form of paralysis. The anatomical lesion consists of a sclerosis of the lateral columns. What are the symptoms of spastic spinal paralysis ? The most prominent symptoms are motor paralysis and decided increase in tendon reflexes. At first the patient notices a weakness in the legs, increasing very slowly. The tendon reflexes, especially in the lower ex- tremities, are greatly exaggerated. There are reflex contractions, causing soon rigidity and even contractures. There may be reflex spasms in the muscles. Soon motion becomes decidedly disturbed, the gait becomes stifi" and paretic, and there is a tendency to walk on the toes — the 188 DISEASES OF THE SPINAL COEB. ' ' spastic-paretic gait. ' ' In some cases the motor disturbances are hardlj^ noticeable, while the tendon disturbances are alwaj^s marked. Other spinal s3^mptoms, as a rule, are entirely absent. The disease is ver}' slow in its progress, and may last many years, gradually attacking the chest and the upper extremities. What are the diagnosis and treatment of spastic spinal paraly- sis? Chronic hydrocephalus, transverse myelitis, compression of the spinal cord, multiple sclerosis, and locomotor ataxia may resemble this form of paralysis. It is treated as chronic myelitis. Warm baths are very beneficial for the spasms. ACUTE AND CHRONIC POLIOMYELITIS. What is poliomyelitis? An atrophic spinal para^^sis, occumng mostly in children. What are the etiology and pathology of poliomyelitis ? It occurs mostly — and according to some authors exclusively — among children. It is noticed more in warm weather, and seems to show an infectious nature. The anterior gray cornu of one side is usually affected, being changed to sclerosed tissue. The atrophy extends through the anterior nerve-roots to the periphery and thence to the muscles. What are the symptoms of acute and chronic poliomyelitis ? The acute form is sudden in its onset, as a rule. High fever or chills, general malaise, pain all over the body, decided cerebral symptoms, like delh'ium or convulsions, and clonic contractions, generally usher in the disease. These prodromata may last a short while or several weeks, after which the paralysis is noticed, being extensive as a rule, and affecting one, two, or all the extremities, and sometimes the muscles of the trunk. The general paralysis soon disappears, being left permanently only in one or the other extremity, chiefly in one leg. Thecerebral and other symp- toms completely disappear, the general condition becomes normal, and the loss of motion in the extremity is the only trace left of the disease. The paralyzed part atrophies rapidly, the reaction of degeneration be- comes noticeable after a few weeks, and sometimes the extremity shows a partial arrest of development. The tendon and cutaneous reflexes are absent, sensation is normal, but trophic disturbances soon appear. ^ After a while contractures and subsequent deformities of the extremities ap- pear. In adults the disease is very rare, but it difl"ers little from that de- scribed above. The onset is sudden ; the paralj^sis quickly follows, afifect- ing single groups of muscles or one-half or the whole of the body. The subacute and chronic forms diff'er from the acute form in the less rapid ACUTE ASCENDING SPINAL PARALYSIS. 189 dev.dopment of paralysis, beginning with weakness, tenderness on pres- sure, parassthesia, and then followed by paralysis, which becomes sta- tionary for a long time, but may ultimately show signs of recover}^ What are the diagnosis, prognosis, and treatment of poliomye- litis? We must differentiate the acute form from certain cerebral diseases, hereditary muscular atrophy, and spastic spinal paralysis. In adults it sometimes resembles neuritis. The prognosis in the acute stage is somewhat doubtful. The paralysis often improves, and recovery is known to have occurred, but prognosis in this respect is unfavorable if the paralysis shows no decided change within the first few months. In adults the recovery is more frequent. The treatment during the acute symptoms consists of ice to the head, counter-irritants along the spinal column, tepid baths for the fever, and calomel internally. Electricity kept up constantly, sometimes for years, may prove of great benefit in the chronic cases. Massage, gym- nastics, passive motions, baths, greatly aid us in preventing contractures. Internally, tonics, iodide of potash, and strychnine may be used. Ergo- tine and atropine subcutaneously have been used with success. ACUTE ASCENDING SPINAL PARALYSIS. What is acute ascending paralysis ? A paralysis beginning in the lower and rapidly extending to the upper extremities, not based on any known anatomical lesions. The functions of the bladder and rectum are always normal. What are the etiology and pathology of ascending spinal paral- ysis? It occurs more frequently in males than in females — between twenty and forty years. Exposure to cold, alcoholism, infectious diseases, trau- matism, and septic diseases act as exciting causes. The affection is sup- posed to depend on an infective agent of an unknown nature. What are the symptoms of ascending spinal paralysis ? Prodromata of malaise, pain in the head, tingling in the extremities, are sometimes noticed. These premonitory sj^mptoms, as a rule, are fol- lowed by a sudden appearance of paresis in one or both legs. The weakness soon spreads to the arms, the thorax, and the diaphragm. The reflexes are diminished or lost. Sensation is diminished, but elec- trical excitement remains normal in most cases. The vaso-motor dis- turbances and sweating are sometimes marked. The paresis soon pro- gresses to paral.y,sis, and, respiration becoming interfered with, death follows more or less rapidly. The temperature during the course of the disease is usually increased considerably, and in some cases an albumi- nuria has been observed. 190 DISEASES OF THE SPINAL COED. What are the diagnosis, prognosis, and treatment of ascending paralysis ? We must diiFerentiate it from multiple neuritis. The prognosis^ as a rule, is unfavorable, the affection terminating fatally within a few days or a few weeks. Occasionally there is an arrest of the symptoms. Galvanism and counter-irritants along the spine are useful. Internally, iodide of potash, mercury, and ergot are given. Inunctions of mercury are often used. NE^W GROWTHS OF THE SPINAL CORD AND OF ITS MEMBRANES. Tumors may appear in the spinal^ cord or membranes, giving rise to different symptoms according to their seat. What varieties of new growths do we meet with ? Most commonly gliomata, also tubercles, syphilomata, and mj^xomata. In the meninges, carcinoma, sarcoma, fibroma, lipoma, myxoma, and gum- mata have been found. Cysts or collections of pus may also give symp- toms of a morbid new growth. The tumor may be single or multiple, and sometimes two varieties are found blended in one tumor. What are their common symptoms ? Nearly all tumors show their presence with the appearance of symp- toms of compression, such as shooting pains and motor weakness, which latter is soon increased to paralysis. The symptoms are at first confined to one side of the body, as a rule, but later greatly resemble diffuse chronic myelitis, becoming general. According to the seat of the morbid growth, the symptoms appear in correspondingly different parts of the body supplied by the compressed nerve. What are the prognosis and treatment of tumors of the cord and membranes ? The prognosis, as a rule, is unfavorable. Most cases end fatally after a shorter or longer period. .. ^ The treatment is symptomatic and, in selected cases, surgical. CAVITIES AND FISSURES IN THE SPINAL CORD. What is the pathology of cavities and fissures in the spinal cord ? Cavities may originate from a dilatation of the central canal (hydromy- elus), or they may form within the substance of the cord (syringomyelia). The cavity, as a rule, extends only over a small portion of the cord. Most of the cavities and fissures arise from congenital causes, but occa- sionally from pressure of tumors and extravasations. What are the symptoms? These vary according to the location of the cavity. Some cases pre- DISEASES OF THE MEDULLA OBLONGATA. 191 sent.lio symptoms during life. When the cavity is extensive the symp- toms are very complex, and diagnosis can hardly ever be made. What are the prognosis and treatment ? The affection is chronic in duration, and always ends unfavorably. The treatment is that of chronic myelitis. UNILATERAL LESION OF THE SPINAL CORD. "What is unilateral lesion of the cord ? A group of symptoms due to a unilateral affection in a part of the spinal cord. What are the etiology and symptomatology of unilateral lesion ? It is caused by direct injury, inflammation, and compression from tu- mors. As the sensory fibres of one side of the cord are at every level decussating and passing to the other side of the body, while the motor fibres pass on the same side to the periphery, it is evident that in uni- lateral lesion we have loss of motion on one side, and loss of sensation on the other corresponding side of the body. On the paralyzed side sen- sation is usually abnormally increased, with the exception of the mus- cular sense, which is diminished. Corresponding to the level of the lesion in the spinal cord there is a slight anaesthetic zone above the paralyzed part. The reflexes are increased, and the temperature is usually higher on the paralyzed than on the anaesthetic side. Micturi- tion and defecation are disturbed, and there are shooting pains in the affected parts. What are the prognosis and treatment of unilateral lesion ? Prognosis and treatment entirely depend on the primary affection. DISEASES OF THE MEDULLA OBLONGATA. PROGRESSIVE BULBAR PARALYSIS. What is progressive bulbar paralysis ? A progressive disintegration of the nuclei in the medulla oblongata. What are the etiology and pathology of progressive bulbar paralysis ? The etiology is obscure. Cold, emotions, traumatism, and physical exertion may act as exciting causes. The affection is usually found in middle-aged men. The nuclei of the nerves which act on the atrophied muscles are found under the microscope to have undergone degenera- tion or to have completely disappeared. The connective tissue is in- creased ; the nerve-fibres, and subsequently the muscles, also atrophy. 192 DISEASES OF THE MEDULLA OBLONGATA. What are the symptoms of progressive bulbar paralysis ? The symptoms appear gradua'%, and may be preceded by prodromata of general pain. As a rule, the disease is first manifested by a difficulty in articulation. The difficulty lies in pronouncing the letters that are uttered with the aid of the tongue (alaha). The tongue itself becomes flabby and atrophies ijrogressively, and soon becomes completely para- lyzed. The power of speech and of deglutition is lost. With the tong-ue the lip becomes affected too, and the labial sounds are pronounced with difficulty. The face assumes a thin aspect from atrophy of various mus- cles of expression. When the muscles of the pharynx and larynx be- come paralyzed deglutition and resiDiration are interfered with. Food may enter the larynx, producing pneumonia. The reflexes, as a rule, are diminished or absent, but occasionally an increase in the tendon reflexes of the muscles of the face is met with. OccasionaDy the mus- cles of mastication are also attacked by the atrophy. The reaction of degeneration can only exceptionally be demonstrated, as only portions of the affected muscles atrophy. Sensation always remains normal. Salivation occurs in most cases, as well as vaso-motor distm-bances. ^ Occasionally other nuclei may be attacked in the medulla, producing symptoms different fi'om those just given. In some the ocular muscles are affected, while in others both sides of the face are symmetrically at- tacked. But these forms are very rare. What are the prognosis, diagnosis, and treatment of bulbar paralysis ? The course of the disease is very protracted, although there may be a temporary arrest of the symptoms. It lasts several years, and, as a rule, ends fatally. Differentiation should be made from slowly-developing tumors of the medulla, thrombosis and hemorrhage in the medulla, and bilateral cerebral affections. There is a great similarity in the patho- genesis and course of this affection and of progressive muscular atrophy and amyotrophic lateral sclerosis. Gralvanization is successful in some cases in aiTCsting the progress of the disease for quite a long time. A proper and careful nourishment should be given. In other respects the affection is treated symptomati- cally. HEMORRHAGE INTO THE MEDULLA AND THE PONS. What are the etiology and pathology of hemorrhage into these parts? It occurs more often than in the spinal cord, but less often than in the brain. It is probable that preceding the hemorrhage there is alwaj^s some disease of the blood-vessels. Cardiac disease, nephritis, and alco- holism act as predisposing, and injury and local inflammation as exciting, causes. The pathological appearance is analogous to that of cerebral hemorrhage. EMBOLISM AND THROMBOSIS OF THE BASILAR ARTERY. 193 What .are the symptoms of hemorrhage into the medulla and the pons? The symptoms^ as a rule, develop suddenly. Occasionally there are prodromata of headache and spasms, followed by dizziness or loss of consciousness. The patient may die if the hemorrhage is extensive. In most cases bulbar paralysis of large or small extent follows. The tongue, the pharynx, the face, and the extremities may be paralyzed. The paralysis is usually unilateral, the upper and lower extremitj^^ on one side being affected and the face on the other side, because of the decus- sation of the facial nerve-fibres above the pyramids. Sensation is rarely interfered with, except when the pons is affected. Yaso-motor and re- spiratory disturbances may also present themselves, and an elevation of the temperature and a quickening of the pulse are sometimes noticed. What are the prognosis and treatment ? Prognosis is favorable if symptoms of absorption present themselves. The treatment is symptomatic. Rest, iodide of potash, and galvaniza- tion are of great benefit. EMBOLISM AND THROMBOSIS OF THE BASILAR ARTERY. What is the etiology of embolism and thrombosis ? The medulla and pons derive their chief blood- supply from the basilar artery. An occlusion in any of the branches of the artery may produce a softening in these parts and a subsequent bulbar paralysis. Thrombosis is usually a result of a disease of the artery, while embolism may follow heart disease. The pathological condition is analogous to softening of the cerebrum from embolism. Wha.t are the symptoms of embolism and thrombosis ? As soon as the occlusion takes place in the artery there may be an apoplectic attack or a sudden development of paralysis. If the patient survive, the subsequent symptoms are those of hemorrhage into the medulla, with decided bulbar symptoms. What are the prognosis and treatment? If circulation is not restored to normal, death usually ensues. The treatment is symptomatic. ACUTE BULBAR PARALYSIS. What is acute bulbar paralysis? An affection characterized by an acute development of marked bulbar symptoms. What are the etiology and pathology of acute bulbar paralysis ? It is very rare in occurrence, and little is known regarding its etiology. 13— P. M. 194 DISEASES OF THE BRAIN. The pathology is probably based on an acute inflammation of the me- dulla. What are the symptoms of acute bulbar paralysis ? There maj^ be prodromata of headache and vague pains all over the bod3% followed, as a rule, bj^ decided bulbar symptoms, such as interfer- ence with deglutition, the speech, and the respiration. The temperature, as a rule, is elevated, the pulse is rapid. The extremities are attacked in only very few of the cases. What are the prognosis and treatment of acute bulbar paraly- sis? Death occurs in most cases within a short time from interference with respiration. The treatment consists of alleviation of painful sj^mptoms. COMPRESSION OF THE MEDULLA. What is the etiology of compression of the medulla ? Injuries may cause a sudden compression, followed by instant death. Disease of the bones and structures surrounding the medulla, tumors, and aneurism may produce gradual compression. What are the symptoms of compression of the medulla ? The symptoms are due to pressure on the nerve-tracts, causing an in- terruption in their conduction. No exact rules can be drawn up as to the manner of manifestation of the different symptoms. The bulbar S3Tnp- toms are most pronounced, but cerebral symptoms may also appear later on in the disease. What are the prognosis and treatment? The ]jrognosis, as a rule, is bad. The treatment is like that of bulbar paralysis. DISEASES OF THE BRAIN. Diseases of the Cerebral Meninges. HEMATOMA OF THE DURA MATER. What is haematoma of the dura mater ? An accumulation of effused blood met with on the inner surface of the dura mater. What are the etiology and pathology of haematoma of the dura mater ? Hemorrhagic effusions of the dura mater are usually extensive. The disease may complicate diseases of the heart, lungs, or kidne3"S, infectious PURULENT MENINGITIS. 195 diseases, alcoholism, anaemia, and is more common in men than in wo- men. It often follows traumatism, and has been noticed in paral3^sis of the insane. In milder cases there is usually found a thin encapsulated layer of clotted blood ; in chronic cases there are, as a rule, several suc- cessive layers. The collection of the blood is found most commonly in the parietal region or at the base of the brain. What are the symptoms of haematoma of the dura mater? If the effusion is slight there are no marked symptoms, as a rule. The onset of the hemorrhage is usually sudden in the more pronounced cases : a sharp pain in the head, followed by stupor or coma, a slow pulse, and sometimes a contraction of the pupils. The subsequent symp- toms depend upon the size and the location of the effused blood. If in the neighborhood of the motor region, there is paresis, paral3^sis, or muscular twitching on the opposite half of the body. If the effusion spreads to the other side of the motor region, there may be general par- alysis from a compression of the cortical motor-centres. In some cases the muscles of one-half of the face may be paralyzed or aphasia is pro- duced. If the effusion be very extensive, death soon follows. Improve- ment, and even complete recovery, can take place when the blood-clot is absorbed, but it is a characteristic of dural hemorrhages that they show a tendency to frequent recurrence. What are the prognosis, diagnosis, and treatment of hsematoma ? The affection is very protracted as a rule, but recovery maj^ occur. The diagnosis is not easily made, and the symptoms may be completely obscured by the primary disease. Constant application of ice to the head, bloodletting, and drastic purges are old-fashioned methods, but may be of benefit. If paralj^sis fohows, we must treat that accordingly. In case of recovery we must carefully guard against a recurrence of the attack. PURULENT MENINGITIS. What is purulent meningitis ? A purulent inflammation of the cerebral dura mater or pia mater. What are the etiology and pathology of purulent meningitis ? It occurs rarely on the dura mater, but more often on the pia mater. If primary, it is due to a specific micro-organism. The secondary form follows diseases of the cranium, inflammation of the ear, traumatism, inflammation of the cranium, the infectious diseases, pneumonia, and systemic septic diseases. The pathology is that of cerebro-spinal men- ingitis. The convexity is the part usually attacked. The brain in most cases becomes secondarily affected. What are the symptoms of purulent meningitis ? If the affection be primary, it is ushered in mostly by a chill and a 196 DISEASES OF THE BRAIN. rise of temperature. The head aches greatlj'^, and soon the pain be- comes violent. Vertigo, delirium, or coma may be added. In addition there may be sj^nptoms referable to an irritation of the cranial nerves, such as nj'stagmus, trismus, disturbance of hearing or sight, and fibrillar twitchings in the muscles. The head is drawn back, and occasionally there are also convulsions. The pulse is usually rapid and the tempera- ture high. Yomiting has been noticed in many cases. Constipation and diminution in the quantity of urine are the rule. In secondary cases the onset of the disease may be wholly obscured by the primary affection. What are the prognosis, diagnosis, and treatment of purulent meningitis ? The affection lasts but a few daj^s, and is nearly always fatal. Differ- entiation must be made from typhoid, septic diseases, uraemia, and general tuberculosis. The treatment is S3Tnptomatic. As a prophylactic measui'e purulent affections of the ear, etc. should be promptly attended to. TUBERCULAR MENINGITIS. What is tubercular meningitis ? An inflammation of the pia mater of a tubercular nature. What are the etiology and pathology of tubercular meningitis ? The affection, as a rule, is not primary, but follows other tubercular diseases, such as phthisis, tubercular pleurisy, tubercular disease of the joints, and tubercular glands. It is more common in children than in adults. Heredity is one of the predisposing factors. The pia mater is more or less covered with miliary tubercles and is the seat of inflamma- tion. As a result of the inflammation the pia mater is covered with a serous exudate. If the exudation is large, the brain is found to be compressed. Secondary tubercular inflammation of the brain and spinal cord may also be found. The part usually affected is the pia mater at the base of the brain. What are the symptoms of tubercular meningitis ? The symptoms of the primary affection precede and often obscure those of the meningitis. The beginning of the tubercular process in the meninges is usually announced by the development of severe headache, vomiting, and restlessness. Soon the headache increases, and delirium may supervene. The patient is restless, can hardly be roused, and moans if headache be severe. If the motor-centres are irritated, there are muscular twitchings, occasionally convulsions, paresis, or paralysis. The eyeball and ocular muscles may also show evidences of an irritation of the nerves supplying them: there may be strabismus, nystagmus, THEOMBOSIS OF THE CEREBKAL SINUSES. 197 slow reaction of the pupils to light, etc. The reflexes are at first in- creased, but soon become diminished. The temperature may show a constant slight elevation or a variation. The pulse, at first slow, becomes rapid later on. The respiration is rapid as a rule, and may assume the Cheyne-Stokes character (a pause in the breathing, followed by slight inspirations, which grow deeper and deeper, then diminish gradually till the respiration stops again). There is constipation, and an impairment of general nutrition becomes marked, and death finally ensues from general marasmus and paralysis. In children the prodromal symptoms extend over a long space of time. Besides the headache, they complain of pain in the chest and abdomen. The child soon becomes comatose, occasionally emitting a loud scream (the "cephahc cry"). Convulsions are more common in children than in adults. The other symptoms are analogous with those in adults. What are the prognosis, diagnosis, and treatment of tubercular meningitis ? The prognosis i^ bad, although some authors claim that recovery is possible. Differentiation should be made from purulent meningitis, septic disease, and uraemia. Ice to the head, bloodletting, mercurial inunctions may be tried. In- ternally, a strong purgative, iodide of potash, and alcoholic stimulants are given. For pain and delirium narcotics should be employed. THROMBOSIS OF THE CEREBRAL SINUSES. What are the etiology and pathology of thrombosis of the sinuses ? Thrombosis in the cerebral sinuses is always a grave affection. Phthisis, cancer, general marasmus, and acute specific diseases act as predisposing causes ; suppurating disease of the cranial bones, erysipelas, and mastoid abscess act as exciting causes. The longitudinal sinus is the one mostly affected. The thrombus, when extensive, may cause hyperaemia in the meningeal and cerebral veins, and subsequent extrava- sation of blood. What are the symptoms of thrombosis in the cerebral sinuses ? When slight, the symptoms are not noticeable. When severe and occurring in children, there is a sudden development of hemiplegia, attended with convulsions and muscular twitchings. In adults there may be prodromata of headache, delirium, and visual disturbances, followed by hemiplegia. When the thrombus begins to suppurate there are symptoms of septic infection. The paral3^sis may be permanent or transient, depending on the absorption or elimination of the clot. 198 DISEASES OF THE BRAIN. What are the prognosis and treatment? The prognosis is not very favorable, especially when septic symptoms develop. The treatment is symptomatic. Diseases of the Brain-substance. DISTURBANCES OF CIRCULATION. What disturbances of circulation do we meet with in the brain ? Anemia and hypergemia. What are the causes and symptoms of anaemia ? Temporary or permanent diminution in the blood-supply of the brain may be caused by cardiac weakness, mental excitement, and general angeniia. Certain drugs, like chloroform (when inhaled), may also cause cerebral ansemia. The sipnptoms are known as the ' ' fainting spell." Dizziness, ringing in the ears, spots before the ej^es, nausea, and occasionally vomiting, precede the loss of consciousness, which may last a variable time. The face is pale, the pulse small, and the body is covered with a cold perspiration. In cases of general angemia the drowsiness is constant and the patient complains of an obstinate headache. What are the causes and symptoms of hypersemia ? Temporary or permanent increase in the blood-supply of the brain may be caused by the chronic use of alcohol and tobacco, by mental over- exertion, and by chronic plethora. The si/mptoms of cerebral hyper- gemia ("rush of blood to the head ' ' ) begin with a sense of warmth in the head. The face is red, the arteries in the neck are strongl3^ pulsating. The patient complains of violent headache and tinnitus. In some cases stupor follows, while in others an attack of mania may be brought on. The attack may last a few minutes or longer, dependent on the exciting cause. What is the treatment of cerebral anaemia and hyperaemia ? In ansemia, rest, the horizontal position, mild stimulants, and cold douches ; in hyper«3mia, rest, elevation of the head and shoulders, cold to the head, foot-baths, and strong purgatives or bloodletting. Try to remove the cause. THE LOCALIZATION OF CEREBRAL DISEASES. What is localization? The inference of the locality of an affection from the symptoms it produces. THE LOCALIZATION OF CEREBRAL DISEASES. 199 Where are the various centres located in the brain ? The upper tliird of the central convolutions contains the_ centre for the movements of the leg of the opposite side. The middle third of the central convolutions contains the centres for the movements of the arm of the opposite side. The upper part of the lower third of the central convolutions contains the centre for the muscles of one-half of the face, and the lower part contains the centre of the muscles of the lips and tongue. The frontal convolutions contain no motor-centres in their upper two- thirds. The lowest frontal convolution on the left side contains the cen- tre of speech. The parietal convolutions have no motor-centres, but are said to con- tain the centres of the cutaneous and muscular sensation. The occipital convolutions (especially the cuneus) contain the cortical centre for visual sensations, a lesion here producing hemiopia (only one- half of the field of vision being perceived), and occasionally a loss of visual memory. The temporal convolutions (especially the uppermost) contain the cen- tre of hearing of the opposite side. The anterior part of the lobe con- tains the centre of smell. The centrum ovale contains the fibres of the various cortical centres ; consequently injury may cause analogous symptoms, as an injury of the cortical portions: hemiplegia, hemianopia, word-deafness, aphasia, and monoplegia. The central ganglia (caudate nucleus, lenticular nucleus, and thalamus opticus), when injured, produce temporary hemiplegia or hemianses- thesia. The posterior portion of the thalamus also contains the centre for part of the optic nerve. The internal capsule contains in its posterior limb the pyramidal tract, and injury produces complete hemiplegia on the opposite side of the body. The posterior extremity of the internal capsule contains the sen- sory tract, and injury produces hemiansesthesia, and sometimes loss of the special senses. The anterior pair of corpora quadrigemina contain the fibres of the optic nerve, and injury to both causes total blindness. The crura cerebri contain the pyramidal tracts, the sensory fibres, and the nucleus of the third nerve. The pons Varolii contains the motor-fibres of the opposite side of the face, arm, and leg, and the nuclei of the fifth, the sixth, and the third nerve of the same side. The medulla oblongata contains the cardiac and respiratory centres, the nuclei of the hypoglossal, spinal accessory, and glosso-pharyngeal nerves, and the motor-fibres for the opposite side of the body. Affection of the cerebellum produces uncertainty of gait (ataxia) and a marked vertigo. Affection of the crura ad pontem produces forced positions and forced movements. 200 DISEASES OF THE BRAIN. APHASIA AND ALLIED AFFECTIONS. What is aphasia? Loss of speech, either from inabihty to revive voluntarily the word- images (amnesic aphasia) or from inability to execute the co-ordinative movements necessary for the pronunciation of a word (ataxic aphasia). What are the symptoms of aphasia ? In amnesic aphasia the patient is aware of the nature of the object, but is unable to pronounce its name, as he has forgotten it. This amne- sia may be partial, when only part of a word is forgotten, or complete, when the whole word is forgotten. In ataxic aphasia the patient is per- fectly well able to recollect the name of an object, but is unable to pro- nounce it, as the power to transfer the word-image into sound is absent. The ataxia may be complete, when the patient can utter only separate sounds, or partial, when words are only slightly mispronounced, and when some certain words cannot be pronounced at all. What other allied affections are to be met? Monophasia, when a patient's whole vocabulary consists of one word ; paraphasia, when words are confounded ; sensory aphasia, or word-deaf- ness, when a word does not call up the corresponding image ; agraphia, an inability to wi'ite down the thoughts ; alexia, an inability to read the wi'itten words ; amimia, an inability to perform pantomimic movements to aid in the expression of words ; apraxia, an inability to recognize sur- rounding objects for what they are. What is the localization of aphasia and its treatment ? The centre for speech is situated in the third left frontal convolution. Word-deafness is probably due to injury to, or disease in, the first left frontal convolution. The treatment consists of persistent exercise in spfeaking and language. CERBBBAL HEMORRHAGE. What is the etiology of cerebral hemorrhage ? HemoiThage into the brain-substance is almost always due to an affec- tion of the walls of the large or small cerebral arteries (miliary aneurism), producing rupture and subsequent hemorrhage. The veins are rarely affected. The aneurism may affect the larger arteries or the minuter arteries, and the miliary aneurisms are alwaj'S abundant in number. It occurs mostly in persons over fifty years old, and is more common in men than in women. It is sometimes hereditar3^ Syphilis, gout, and the alcoholic habit predispose to its occurrence. Disease of the heart, violent mental or bodily exertion, combined with an elevation of arterial tension, may cause a ruptm'e of a cerebral artery. Pernicious anasmia, septicaemia, severe infectious diseases, and direct injury maj^^also be pro- ductive of cerebral hemoiThage. Hemorrhage is most frequently met CEREBEAL HEMORRHAGE. 201 witla -in the corpus striatum, from rupture of one or the other middle cerebral artery or of one of its branches, and hardly ever occurs in the cortex. What is the pathology of cerebral hemorrhage ? When the hemorrhage is extensive the surrounding parts are com- pressed. The effused mass is surrounded by a wall of torn cerebral tis- sue, and the blood-clots are mixed with broken-down nerve-tissue and fat-cells. The parts surrounding the clot are softened. The clot is some- times absorbed, and leaves in its place a cyst filled with serum. Occa- sionally the absorption is complete, and only a scar is left to indicate the seat of lesion. The blood-vessel, before the rupture, is usually found in an atheromatous condition. What are the symptoms of cerebral hemorrhage ? In most patients the onset is sudden. In some there are prodromata of headache and a feeling of tension, due to a disturbance of the arterial circulation. When the hemorrhage takes place there is usually hss of consciousness. The nearer the hemorrhage to the cortex, the more pro- nounced are the symptoms. If the hemorrhage is extensive, the patient falls suddenly into a deep coma, and it may soon prove fatal. If the hemorrhage is slight at first and gradually increases, the symptoms cor- respondingly grow worse : the patient at first is delirious, then one arm, one side, and finally the wJioJe body, become paralyzed, and unconscious- ness, even death, may ensue from paralysis of the cardiac and respiratory centres. In most cases the symptoms begin with a loss of consciousness. The face is red, the pulse is full and slow, the respirations are slow and deep ; the temperature, at first subnormal, becomes elevated. The head and eyes are sometimes persistently fixed in one direction, mostly toward the injured side. The jJwpzY.s are contracted, dilated, or normal. The paralysis may not be noticeable at first during the comatose state, as the patient lies perfectly motionless, but in some instances there is a tonic rigidity of the muscles when the hemorrhage is located in the lateral ventricle, or there are epileptiform convulsions when the hemorrhage occurs near the cortical motor-centres. The urine is suppressed or invol- untarily passed, and usually contains a slight percentage of albumin. Sensation seems to be retained to a greater or less degree. In some cases the deep coma is followed by death ; in others the clot in the brain is gradually absorbed and there is a slow return to consciousness. Occasionally relapses from renewed hemorrhages occur. In mild cases, instead of the deep coma, there are only headache, faint ness, nausea, and vomiting. The damage resulting from cerebral hemorrhage de- pends on the location of the clot. In some cases the resultant symp- toms are only temporary if the blood-clots become absorbed. In other cases the injury is permanent, as a destruction of brain-tissue from con- stant pressure of the clot may follow. 202 DISEASES OF THE BRAIN. In most cases the apoplectic attack is followed bj' hemiplegia of one- half of the bod}^ opposite to the seat of injury : one side of the face ap- pears flatter than the other ; the corner of the mouth on the well side is drawn over ; the eyelids close imperfectly on the paralyzed side ; the tip of the tongue when protruded points toward the paralyzed side, and ar- ticulation may not be complete ; the soft palate appears more flabby on the paralyzed side, and the uvula deviates to one side or the other ; the shoulder on the paralyzed side is lower than on the sound side ; the chest on the afl"ected side does not expand as freely as the other side ; the upper and the lower extremity on the paralyzed side are totally immovable, or only certain groups of muscles are affected, or the affected limbs are simply paretic. The tendon reflexes are exaggerated, the shin reflexes are diminished. Sensation is normal except when the internal capsule is involved, in which case there is also hemiopia. In many cases the paralyzed parts gradually regain their functions within a few weeks, but restoration is not always complete._ The lower extremity is first to improve, the arm following later. The improvement gradually goes on for a few months, but after the sixth month improve- ment seems to come to a standstill and the paralyzed muscles become contracted. Occasionally involuntary movements have been observed in the paralyzed parts (post-hemiplegic chorea). Reaction to electricity is usually normal. Trophic and vaso-motor disturbances and swelling of the joints may occur when the disease is of long duration. The general nutrition remains good, and only rarely do mental symptoms manifest themselves. What are the diagnosis and prognosis of cerebral hemorrhage ? Cerebral embolism, nreningitis, and ursemic coma greatly resemble cerebral hemorrhage. The prognosis is favorable if the patient survive the primary shock. We must be guarded in giving a prognosis as to ultimate favorable re- covery. What is the treatment of cerebral hemorrhage ? At the time of the occurrence of the shock rest, elevation of the head and shoulders, ice to the head, are advisable. If there is congestion, bleeding is beneficial ; if the pulse is weak, stimulants should be ad- ministered. The subsequent symptoms are treated on general thera- peutic principles. For the pain and restlessness morphine is given. For the paralysis, after it has shown no signs of improvement, elec- tricity, especially galvanism, may be used. Iodide of potash, ergot, and strj^chnia are also in use. The various bathing-places may aid in the restoration to health. If we can detect the predisposing cause of the hemorrhage, the patient should be guarded against any recurrence of the attack. EMBOLISM AND THROMBOSIS. 203 ' Embolism and thrombosis, follo^a^ed by cerebral softening. What are the etiology and pathology of embolism and throm- bosis ? A plug may be carried by the arterial circulation into the brain, where it is arrested by an artery smaller than the plug (embolism), or a clot may form within the cerebral jfrtery at a certain spot (thrombosis). Em- holism may be caused by disease of the heart, a morbid affection of the vascular system in any other part of the body, or a general septic disease. Thrombosis arises from a local disease of the wall of the cerebral artery, causing a roughening of its surface and a subsequent deposition of fibrin. Severe constitutional illnesses, like typhoid and cancer, syphilitic endar- teritis, and arterio-sclerosis, are productive of thrombosis, which in its turn may cause embolism, or vice versa. If an embolism or thrombosis occur, the circulation is often re-estab- lished in the afiected_ part of the brain through the formation of col- lateral branches ; but if this fails to take place, the tissues are deprived of their blood-supply and are transformed into a soft mass, which often assumes a reddish or yellowish tinge from the blood-corpuscles present. This degeneration takes place within a few clays, and if collateral circula- tion be established by that time, the nerve-tissue may be restored ; but if not, the destruction is permanent. The soft mass may be absorbed and a cyst or a cicatrix take its place. The artery most commonly affected is the middle cerebral. If the embolism is of septic origin, the local affection in the cerebral artery may be followed by a sup- purative disease of the brain. What are the symptoms of cerebral embolism and thrombosis ? Embolism, as a rule, gives the same symptoms as cerebral hemorrhage, and, according to the size of the artery involved, the shock ma}^ be mild or severe ; but it is rarely as long continued as the shock of cerebral hem- orrhage, and the pulse is not so slow, on account of an absence of com- pression. The symptoms disappear as soon as the circulation is re- established, but if softening occurs the symptoms are identical with those following cerebral hemorrhage. Thrombosis is generally slow in its onset, and coma occurs after the thrombus has lasted for some time. In their further course the symp- toms of thrombosis are like those of embolism. Cerebral hemiplegia, with or without aphasia, is the most common sequela of thrombosis or embohsm, as the middle cerebral artery supplying the internal capsule is generally the seat of affection. What are the diagnosis, prognosis, and treatment? Embolism and hemorrhage greatly resemble each other, but in embo- lism the occurrence is more common in young people than in old, the shock is less severe, and there is nearly always, some preceding consti- 204 DISEASES OF THE BRAIN". tutional disease. A sudden rupture of an abscess may also resemble embolism. The prognosis and treatment are the same as in cerebral hemorrhage. ABSCESS OF THE BRAIN. Synonym. — Suppurative Inflammation, of the Brain. What are the etiology and pathology of cerebral abscess ? Abscess of the brain is usuallj^ produced bj^ inj\uy to the brain, sup- purating disease of the cranial bones, the middle ear, and the nasal cavity, pysemia, and suppurating disease of the heart. Occasionally it seems to be of idiopathic origin, in which case it is probably due to the entrance of a septic micro-organism. The abscess may be small or large. The pus is of a greenish color, and mixed with broken-down nerve-tissue. The cerebral tissue surround- ing the abscess is usually softened from the pressure of pus. A large abscess situated near the cortex may produce a suppurative inflamma- tion of the meninges. Occasionally the abscess becomes encapsulated, preventing an extension of inflammation. What are the symptoms of abscess of the brain ? Abscesses of small size or of slow development may not manifest their presence by any symptoms. The onset of cerebral abscess resembles that of acute meningitis — by delirium, headache, and high fever. In acute cases these initial symptoms are followed by loss of consciousness, coma, and death ; occasionally acute cases change into chronic. In chronic cases the primary symptom consists of a chill, persistent head- ache in the region where the abscess is situated. Vomiting, irregular fever, mental dulness, and optic neuritis may also be present. Accord- ing to the locality of the abscess there may be difi"erent focal sj^mptoms, which were described in the section on Localization. The duration of the affection may be weeks or months, and occasionally even years. What are the prognosis and diagnosis of abscess of the brain ? The disease is nearly always fatal. Occasionally the abscess becomes encapsulated, giving rise to no further sjaiiptoms. Cerebral tumor greatl}?^ resembles in its sjmiptoms cerebral abscess, but in tumor fever is usually absent, as is also optic neuritis. Purulent meningitis may also give sj^mptoms similar to cerebral abscess. What is the treatment of cerebral abscess ? In case diagnosis is absolutely certain and the localization from the focal sjTnptoms approximately exact, the surgical procedure of trephin- ing is of great value. If operation cannot be resorted to, the treatment is purely symiDtomatic. . ABSCESS OF THE BRAIN. 205 rmiORS OF THE BRAIN. What forms of cerebral tumors are met with ? Nearly every variety of tumor may be found in the brain, but the most common growths met with are those of a tubercular or syphilitic origin. Tubercles occur mostly during youth, while syphilitic gummata generally afflict adults. They -may be single or multiple, and are usually situated in the cortex and in the cerebellum. Gliomata are also of fre- quent occurrence, originating in the connective tissue surrounding the nerve- elements. Carcinoma and sarcoma have also been found to occur in the brain in some rare cases. Men are more subject to the develop- ment of cerebral tumors than women. What are the symptoms of cerebral tumors? Most of the new growths originate in the meninges, and by compress- ing a certain part of the brain they produce their symptoms, such as severe and persistent headache, usually generalized, but occasionly local- ized at the situation of the tumor; an impairment of the memory; som- nolence, apathy, and sometimes dementia ; vomiting ; a slow, irregular pulse (between 50 and 60) and vertigo ; optic neuritis and disturbances of vision ; insomnia and loss of flesh and strength. Besides these gen- eral symptoms, cerebral tumors also produce local symptoms, either as a result of direct destruction of brain-tissue or as a result of pressure upon the brain-tissue. The most common seat of the different tumors is at the base of the brain, where they cause compression of the various nerve-trunks and subsequent paralysis of the muscles supplied by these nerves. The paralyzed muscles always give the reaction of degenera- tion, showing that the paralysis is peripheral and not central. When the tumors are situated in the cerebral hemispheres, hemiplegia usually develops, but always very slowly. In general the local symptoms always depend upon the locality of the seat of the tumor. As to the nature of the cerebral tumor, those most commonly found are glioma or syphilitic or tubercular growths. A general tubercular tendency or a syphilitic his- tory points to a tubercular or syphilitic tumor. In young people with no syphilitic history the new growth is likely to be tubercular ; in adults with no phthisical history the new growth is likely to be syphilitic. _ If the tumor follows a carcinoma or sarcoma elsewhere in the body, it is most likely of a malignant nature. Glioma or tubercle occurs mostly in the cerebellum and pons ; syphiloma mostly in the cortical substance or the base of the brain ; sarcoma mostly outside the brain-substance. Oc- casionally cysticerci originating from taenia solium are found in the brain, giving rise to epileptiform convulsions or other symptoms according to their situation. What are the duration, prognosis, and diagnosis of cerebral tumors ? Most tumors are slow in their development, and the symptoms increase 206 DISEASES OF THE BRAIN. graduallj^ the disease lasting for months and years, terminating usually in death, except in syphilitic growths, and occasionally in tubercular growths. G-liomata sometimes give rise to hemorrhages, followed by an apoplectic shock. Abscess, softening from embolism and thrombosis, sclerosis, localized meningitis, and chronic hydrocephalus may be mis- taken for cerebral tumors. What is the treatment of cerebral tumors ? Whether there is certainty about the tumor being sj^philitic or not, it is always safe to resort to antisyphilitic treatment in strong doses. Ar- senic lias been used with success in some cases of tubercular growth. If the tumor is not amenable to syphilitic treatment, the affection must be treated s^Tuptomatically. Sui'gical operation has been resorted to in some instances. CEREBRAL SYPHILIS. What is the etiology of cerebral syphilis ? The symptoms of cerebral syphilis belong to the tertiary stage of the disease, usually a good many years after the initial syphilitic symptoms have disappeared. Both sexes are equally liable to be attacked by the disease. Hereditary syphilis sometimes manifests itself by cerebral symptoms. Syphilis may produce a circumscribed tumor, a disease of the arteries, or a general sclerotic infiltration of the brain. The tumors (gummata) are small, yellowish in color, cheesy in the centre, and, if originating in the dura mater, spread to the brain-tissue. The arterial disease causes a thickening of the blood-vessels, a narrowing of their lumina, and thus produces thrombosis. What are the symptoms and diagnosis of cerebral syphilis ? The symjjtoms of cerebral gummata are the same as those of tumor, and have already been enumerated. When Syphilis is diffuse it re- sembles multiple sclerosis in its symptoms. The memory and speech become impaired by degrees, the motor powers are lost, and after a long, protracted iUness the patient finally ^dies. What are the diagnosis, prognosis, and treatment of cerebral syphilis ? Tumors, cerebral softening, hemorrhage, sclerosis, and parah^sis of the insane resemble cerebral syphilis. Prognosis is favorable when treatment is resorted to early. Mercurial inunctions should be used very fi-eely, and iodide of potash must be given in large doses. Tonics and good nutrition are combined with these remedial agents. NERVOUS AFFECTIONS. 207 CHRONIC HYDROCEPHALUS. What is chronic hydrocephalus ? A dropsical effusion occurring in the ventricles of the brain. What are the etiology and pathology of chronic hydrocephalus ? Hj^clroceplialus may be primar}^, without known cause, or secondarj^, following meningeal inflammation or the compression from tumors. The affection seems to be hereditary in some families. It is of rare occurrence in adults. The head is enlarged, sometimes to an enormous size, the cranial prominences bulge out, the cranial bones become thin- ner and flattened out, the fontanelles are widely separated, the ventricles are greatly distended with a colorless fluid of a low specific gravity. What are the symptoms of chronic hydrocephalus ? Occasionally hydrocephalus is apparent immediately at birth, but in most cases the head begins to swell a few weeks after birth, the increase being very rapid. The enlargement is usually symmetrical ; the sutures are separated, and sometimes fluctuation can be detected through the fontanelles. The face is small, and the head, being heavy, easily falls forward or backward. The child is very slow in intellectual develop- ment. Symptoms of motor disturbance and motor irritation arise sooner or later, but sensation nearly always remains perfect. What are the prognosis, diagnosis, and treatment ? Most children gradually succumb to the affection, although a tempo- rary or permanent arrest of the symptoms is possible. In cases not well marked the affection may be mistaken for rachitis. The treatment is symptomatic. Occasionally surgical means have been resorted to, but with no decided success as yet. NERVOUS AFFECTIONS WITHOUT DISCOVER- ABLE ANATOMICAL BASIS. EPILEPSY. What is epilepsy ? A nervous affection characterized by chronic convulsive attacks, not due to brain disease, and accompanied by loss of consciousness. What are the etiology and pathology of epilepsy ? It is an hereditary affection in many cases. A neurotic tendency or alcoholic habits in parents is apt to produce epilepsy in the offspring. Bodily or mental excitement, anaemia, febrile diseases, injury to the head, or in a reflex manner injury to the peripheral nerves, parasites, ovarian or uterine diseases, may produce epilepsy in those predisposed to this affection. No decided anatomical change has as yet been found in the brain or 208 NERVOUS AFFECTIONS. nerves of epileptics. The convulsions are probablj^ dependent upon in- termittent irritations of tlie cortex cerebri from temporary cerebral anaemia. What are the symptoms of epilepsy ? Inmost cases the affection begins in early youth. ^ The attack may not be repeated for years or may recur daily. Alcoholism, sexual excess, fatigue, ovarian disease, pregnancy, often determine the frequency of the attacks. In some the attacks are diui*lial, in others nocturnal, and may not be noticed for a long time. The characteristic paroxysm is usually ushered in by the prodromal ' ' aura. ' ' The aura may be sensoini (beginning with parsesthesia in the arm, in the leg, or in the stomach, an unpleasant odor, an appearance of color-spots before the eyes, a buzzing in the ears, or with a pecuHar taste in the mouth) ; it may be motor (beginning with muscular twitchings or aphasia) ; it may be vaso- motor (beginning with cold and warm sensations, a flushing of the face, or a profuse perspiration) ; or the aura may be psychical (consisting of mental excitement, vertigo, or confusion of ideas). This aura may last a few seconds or a few hours, and is usually followed by the convulsive stage (grand mal). The convulsions begin suddenly. The patient falls down, loses consciousness, and often utters a peculiar piercing cry. The convulsions at first are tonic. The body is bent backward, the teeth are firmly closed, the fingers are clenched over the thumb, the extremities are rigid, breathing stops, the face is cyanotic, and the pupils are dilated. This tonic convulsion lasts a few seconds, and is succeeded by clonic convulsions. Beginning in the facial muscles, the contractions extend to the muscles of the eyeball, the tongue, the 7ieck, the arms, and the legs. The tendon reflexes are exaggerated, the cutaneous re- flexes are absent. This stage lasts a few minutes, and is succeeded by coma, which gives way to a quiet sleep, lasting sometimes for a few hours. Headache, exhaustion, a sore tongue from biting it during the clonic spasm, and pain in the muscles are apt to_ follow the attack. In some patients the attacks are much milder (petit mal). ^ These attacks are rarely preceded by an aura, and instead of convulsions there is a simple transitory faintness or somnolence. .Occasionally violent epileptic spasms are succeeded by an epileptoid condition in which the patient suffers from temporary mental derangement. ^ Different patients may present any number or variety of epileptic seizures. Between the at- tacks the epileptics seem to be quite well. After attacks lasting a good many years the intellect is apt to become permanently deranged and various cerebral disorders may develop. What are the prognosis and diagnosis of epilepsy ? In rare instances are epileptic paroxysms followed by death. The af- fection may last a lifetime, and even after having been an-ested for a long time some sudden exciting cause may bring on a recurrence of the CHOREA. 209 paro^5^.sms. Epileptiform seizures may also occur from cerebral tumors, abscess, multiple sclerosis, and hysteria. What is the treatment of epilepsy ? Bodily and mental fatigue, alcoholic and sexual excess, should be for- bidden. A plain, nutritious diet, proper exercise, and attention to hy- gienic rules are important. Internally the bromides are used pre-eminently, in large doses and continued over a long period. If bromides fail, vale- rian, belladonna, arsenic, etc. may be tried. Cold sponging and the galvanic current may do some good. During the seizure nitrate of amyl, ether, or chloroform may be employed. The patient should always be encouraged, as the mind seems to exert a great influence on the produc- tion of spasms. CHOREA (ST. VITUS' S DANCE). What is chorea? An irregular spasmodic contraction of a clonic kind of the voluntary muscles, ceasing during sleep, and but slightly under the control of the will. What is the etiology of chorea ? It occurs mainly among children, and girls are more often attacked than boys. Mental excitement, articular rheumatism, and infectious diseases act as predisposing causes. It is sometimes induced by imita- tion. What are the symptoms of chorea ? The onset of chorea is gradual, and occasionally it is preceded by pro- dromata of restlessness or rheumatic pains. Sooner or later character- istic muscular contractions occur in different groups of muscles, which contractions and movements are independent of the will. These twitch- ings may affect any group of muscles, but are most common in the arm, which is moved and contorted in every possible manner. These muscu- lar contractions may be very mild or very severe, and occasionally the whole body is attacked by violent movements, causing a rapid loss of flesh and strength from inability to take food properly. The affection appears in most cases only on one side of the body. Sensation and re- flex action are normal, and even excessive movements do not seem to fatigue the patient. Some patients exhibit irritability of temper, rest- lessness, or peevishness. Whst are the prognosis, diagnosis, and treatment of chorea ? Most cases recover after lasting for a few weeks or a year. Occasion- ally death follows the very severe cases. Relapses after apparent recov- ery may occur. Athetosis, paralysis agitans, saturnine and other tremors, may resemble chorea. 14— P. M. 210 NERVOUS AFFECTIONS. Absolute rest, Fowler's solution, bromides, baths, and electricity are of benefit. PARALYSIS AGITANS (SHAKING PALSY). What is paralysis agitans? Continuous and involuntary tremors, attacking various muscular groups ot* the body, increased by emotion or attempt at movement, and ceasing during sleep. What is the etiology of paralysis agitans? The affection does not occur with great frequency, and belongs more to old age than to j^outh. Traumatism, violent emotion, acute fevers, may act as exciting causes in those predisposed to the disease. What are the symptoms of paralysis agitans? The affection is manifested at first by a trembling, beginning in the hands and extending to the arms, the legs, and sometimes to the whole bod}^ The tremor consists of rapid, uniform oscillations, and arises from motor irritation. The trembling is continuous, but is less violent when body and mind are in repose than when the patient is in a state of men- tal or bodily excitement. The muscles become rigid and shortened ; the head becomes flexed ; the body is bent forward ; the arms, the fingers, and the thumb are flexed ; and the legs are bent. Movements soon be- come impaired, and the extremities show some stiffness on motion. The muscles become paretic, but the reflexes and the functions of the bladder are not interfered with. When the patient is pushed forward ( ' ' pro- pulsion "), he has to keep on running to avoid falling ; in bed he cannot voluntarily change his position. What are the prognosis, diagnosis, and treatment of paralysis agitans ? The affection may last many years, and may be temporarily cured, al- though it always ends in death. Multiple sclerosis greatly resembles paralysis agitans. The treatment is symptomatic : internally arsenic, bromides, ergot may be tried. Electricity may do some good. TETANY. What is tetany ? An intermittent form of tetanus, characterized by paroxysms of tonic convulsions in certain sets of muscles. What is the etiology of tetany ? _ It occurs mostly among children and young people, and women, espe- cially nursing women, are more liable to be attacked than men. Acute TETANUS. 211 diseases, exposure to cold, extirpation of a goitre, may be followed by paroxysms of tetany. What are the symptoms of tetany ? The typical paroxysm is usually preceded by a sensation of weakness and pain all over the body. After a few minutes or hours the convul- sions follow, beginning in the upper extremity and extending to the lower, as a rule. The flexors are most prominently affected, and the hands and toes show most markedly the tetanic condition of the flexor muscles. The muscles are hard and firm, and remain so while the attack lasts, which may be for a few minutes or a few hours. Sensation and mental functions as a rule are not impaired. When the attack has passed away the patient feels comparatively well, except that the periph- eral nerves are very sensitive to electrical and mechanical stimulation. The frequency of the attacks varies in different cases. Trousseau has demonstrated that a new paroxysm can be brought on by pressure on the larger arteries and nerves. What are the prognosis, diagnosis, and treatment of tetany ? The prognosis is favorable, and the paroxysms, after lasting for a few weeks, gradually cease. Ergotine in poisonous doses may give symptoms of tetany. Galvanic electricity is of great benefit. Internally, sedatives may be used. TETANUS. What is tetanus? Persistent, involuntary, and painful contractions of various groups of voluntary muscles ; the paroxysm may yield in intensity in one group, while continued in others. What are the etiology and pathology of tetanus ? It is more common in the tropics than in moderate climates, and occa- sionally appears as an epidemic. It may follow exposure to cold or in- jury. Occasionally infants are attacked by tetanus. The affection is believed to be due to a specific micro-organism. What are the symptoms of tetanus ? There may be prodromata of headache and malaise, especially in cases following exposure to cold. After a few days, or, in traumatic cases, after a few weeks, the muscles of the face, jaw, and neck become rigid, the stiffness extending to the muscles of the back and abdomen. The patient is unable to open the mouth on account of the trismus of the nias- seters ; the whole body is in a position of opisthotonos, but the arms may remain freely movable. Occasionally there are exacerbations of the paroxysm, during which the affected muscles become still more tense. Sensation as a rule is normal, but the rigid muscles cause a great deal of 212 NERVOUS AFFECTIONS. pain. The cutaneous reflexes are increased. The stiffness of the tho- racic muscles may cause dj^spnoea, and, expectoration being difficult, there may be an accumulation of mucus, causing subsequently pneumonia. The pulse is small and rapid ; the temperature soon becomes elevated, and remains high after death. The intellect remains clear throughout the disease. In the mild forms the paroxysms are slight, of short dura- tion, and may go on to recovery. Severe cases are rapidly followed by death from inability of the patient to take proper nourishment and from respiratory difficulties. Occasionally tetanus attacks only the muscles of the face and head, and is combined with spasms of the pharynx and oesophagus. What are the diagnosis and treatment of tetanus ? Strj^chnine-poisoning, acute meningitis, and hydrophobia may all pro- duce symptoms resembling tetanus. If the affection follows exposure to cold, large doses of the salicylates may be employed. Narcotics and sedatives may allay the severity of the spasm. Curare has sometimes been used with good results. Rest and a liquid nourishment are essential. In traumatic cases great care should be given to the injury. ATHETOSIS. This is an involuntary movement of a group of muscles, due to an irri- tation of the motor-centres. The movements may be in any set of mus- cles, but most commonly affect the hand, the fingers being constantly separated, extended, flexed, and approximated. These movements in- crease in rapidity with mental excitement. Their exact causation is unknown, but they may complicate some of the general nervous diseases, as epilepsy, hemiplegia, etc. HYSTERIA. What is hysteria ? A complex disturbance of all the cerebral functions of a chronic nature, and not dependent upon any visible anatomical derangement, but inti- mately associated with psychical exciting causes. What is the etiology of hysteria ? Females after the age of puberty are much more frequently attacked by hysteria than males. Violent emotions of a sudden or protracted nature are chief causes for the development of hysteria, especially in those of a neurotic nature. It is often hereditarj^ in some families, and anything tending to weaken the nervous system is instrumental in the production of hysteria. Diseases of the female sexual organs, by de- pressing the spirits of a woman, often cause the development of this af- fection. HYSTERIA. 213 ,What are the symptoms of hysteria ? The appearance and behavior of hysterical persons often betray their malady. They are irritable, emotional, and subject to extreme expression of their feelings. Their will-power is weak, but they are often talented and persons of genius. They are usually of a weak constitution, and are always complaining of all kinds of aches and ills. In the worst cases emotional disturbances are often followed by convulsions resembling epilepsy (''hystero-epilepsy "), but consciousness is not completely lost, sensation is not abolished, and the movements are much more elaborate than in true epilepsy. The convulsions may be confined to the muscles of respiration or to an isolated group or to a single muscle. The patient may have fits of crying or laughing, or of a constriction of the oesopha- gus or pharynx. The attacks may last from a few minutes to a few days. Violent emotions may also be followed by paralysis of the voluntary muscles, dependent on an inhibition of the will-power to move the affected part. The lower extremities are most often attacked, and rigid contrac- ture of the muscles may follow. Sudden aphonia, from paralysis of the vocal cords, has been noticed in many cases. Some patients exhibit a complete or partial anaesthesia, but hemiansesthesia is characteristic of most cases of hysteria. The skin, mucous membrane, and the deeper structures on the affected side all show a complete anaesthesia, as do the organs of special sense situated on the same side, and the muscular sense on this side is also in abeyance. In some cases, instead of anaesthesia or in conjunction with it, there is a great deal of hyperaesthesia and pain in certain parts of the body. The ovaries are very sensitive to pressure, as are several of the vertebrae and some parts of the cranium. Vaso- motor disturbances in the superficial or deep structures are often observed. The stomach may be the seat of nervous affections, and hemorrhages from various parts of the body may cause some apprehension. Swal- lowing of air may produce symptoms of peritonitis or a tumor, but under an anaesthetic these symptoms vanish. There are disturbances of the sexual function and of the urinary secretion. Hysterical angina may also follow mental emotions. In the most pronounced cases ( ' ' grande hysterie ' ' ) the attacks of hysteria begin with epileptiform convulsions, and are followed by peculiar contortions and a great variety of " attitudes of passion. ' ' Delirium and hallucinations may follow these attacks. Hysterical subjects are also brought with great ease under hypnotic influences. The different cases display the greatest variety of manifestation re- garding the severity of the symptoms, and no two cases are identically alike in their appearance. What are the prognosis, diagnosis, and treatment of hysteria ? Some cases recover permanently, but most patients show a tendency to relapse. A great many organic and other diseases may be simulated by hysteria, and only experience can aid in making a differential diagnosis. 214 NERVOUS AFFECTIONS. The proplij^axis consists of a proper bringing up of a child display- ing hj'sterical tendencies. Hj^steria must be treated as a disease, and attention should be paid to every sjanptom, as indifference on the ■ part of the physician will render the patient worse. The patient must be removed from all exciting influences and moral treatment should be adopted. In cases of paralysis the affected part should be well ex- ercised and the will-power of the patient strengthened. Electricity and massage, with cold sponging, are good adjuvants. Contractures may be remedied by thorough massage and constant exercise of tlie parts. In aphonia strong electric shocks to the vocal cords often bring back the voice. During the convulsion the patient should be put in the horizontal position, and a good drenching with very cold water will probably bring him back to a normal condition. The anaesthetic parts should be stroked with the faradic brush. In cases with general hj^sterical symp- toms nerve-tonics and moral influence should be applied. A good many remedies have been recommended for internal use. Valerian, bromides, asafoetida, and many other things have been used with varying results. If an organic disease be at the foundation of the affection, we must en- deavor to remedy that. NEURASTHENIA. What is neurasthenia? Nervous exhaustion, due to an impaired vigor of the brain or spinal cord, or of both. What is the etiology of neurasthenia ? Any influence weakening the central nervous system is apt to produce neurasthenia. In people with neurotic tendencies sexual abuse, mental overwork, and anxiety may produce neurasthenia. What are the symptoms of neurasthenia ? The patient complains of a constant feeling of pressure in his head, associated sometimes with hypersesthesia and pain. Mental work can- not be performed with ease ; the patient is troubled with insomnia, and cannot pursue his former occupation with the same facility. He is easily exhausted by any muscular exertion, and from lack of exercise appetite is lost and constipation is apt to follow. There may be vague pains all over the body, and if the patient has a hypochondriacal nature he soon avoids the society of others, and in brooding over himself gradually grows worse. What are the prognosis, diagnosis, and treatment of neuras- thenia ? It is never fatal, and complete recovery may take place, but relapses are very common. Hysteria and grave cerebral affections may resemble neurasthenia. In NEURASTHENIA. 215 hypoohondriacal patients a sympathetic assurance that improvement is taking place often restores health. Diet is very important. Obese people should be reduced, thin people fattened. Stimulants must be interdicted as well as all mental work. Electricity, massage, passive or active movements, baths, and douches are very beneficial. Internally, tonics should be given. Narcotics should be avoided, and the insomnia is best treated by improvement of the general health. INDEX. A. Acute ascending spinal paralysis, 189 bronchitis, 51 diagnosis, 53 pathology, 52 physical signs, 52 symptoms, 12 treatment, 53 catarrhal laryngitis, 49 symptoms, 50 treatnaent, 50 gastritis, 95 treatment, 96 pharyngitis, 47 symptoms, 48 treatment, 48 tonsillitis, 48 treatment, 49 Addison's disease, 144, 145 Amyotrophic lateral sclerosis, 184 Ansemia, 140 pernicious, 141, 142 simple, 140 Anaesthesia, 152 Aneurism, aorta, 87 Aneurisms, thoracic, 88 abdominal aorta, 88 Angina pectoris, 82 Aorta, aneurism, 87 Apoplexy, meningeal, 172, 173 spinal, 174, 175 Appendicitis (see Perityphlitis), 104 Arthritis deformans, 148, 149 Articular neuroses, 156 Ascites, 114 Asthma, 54 physical signs, 55 symptoms, 55 treatment, 55 Athetosis, 212 P. M. B. Basilar artery, embolism and throm- bosis, 193 Biliary calculi, 116 Breakbone fever, 39 Bronchi, stenosis of, 65 Bronchial pneumonia, 66 Bronchiectasis, 63 Bronchitis, acute, 51 chronic, 53 foetid, 63 Bulbar paralysis, progressive, 191, 192 acute, 193 c. Caisson disease, 176, 177 Calculi, biliary, 116 symptoms, 117 Cancer, of the intestine, 107 oesophagus, 94 stomach, 99 Carcinoma of the peritoneum, 113 Catarrhal enteritis, 102 treatment, 103 Cephalalgia, 157 Cerebro-spinal meningitis, 41 cause, 42 diagnosis, 43 treatment, 43 Chicken-pox, 29 Chlorosis, 141 Cholera, 34 complications, 35 diagnosis, 35 symptoms, 35 morbus, 103 pathology, 104 symptoms, 104 treatment, 104 217 218 INDEX. Chronic brouchitis, 53 diagnosis, 54 physical signs, 54 symptoms, 54 treatment, 54 constipation, 107 Chyluria, 139, 140 Cold in the head, 47 Consumption (see Pulmonary Tuber culosis), 69 Coryza, 47 Croup, 50 diagnosis, 51 symptoms, 51 treatment, 51 Croupous pneumonia, 67 physical signs, 68 treatment, 69 D. Dengue, 39 Diabetes insipidus, 138 Dilatation of the oesophagus, 92 symptoms, 93 treatment, 93 Diphtheria, 30 complications, 32 diagnosis, 32 etiology, 31 pathology, 31 symptoms, 31 treatment, 32 Disseminated sclerosis, 180, 181 Disturbances, motion, 159 sensation, 152 trophic, 167, 168 vaso-motor, 167, 168 Dry pleurisy, 57 physical signs, 57 symptoms, 57 treatment, 58 Dysentery, 33 treatment, 34 Dyspepsia, nervous, 101 E. Electrical diagnosis, 158 Embolism of the lungs, 73 Emphysema, 59 physical signs, 59 pulmonary, 55 symptoms, 59 treatment, 60 Endarteritis, 86 treatment, 87 Endocarditis, acute, 75 chronic, 76 Enteritis, catarrhal, 102 tubercular, 106 Epidemic cerebro-spinal meningitis, 41 Erysipelas, 29 diagnosis, 30 treatment, 30 varieties, 30 Exophthalmic goitre, 169, 170 F. False measles, 26 Fatty heart, 81 Foetid bronchitis, 63 o. Gangrene of the lung, 72 pathology, 73 symptoms, 73 treatment, 73 Gastric ulcer, 98 Gastritis, acute, 95 chronic, 96 phlegmonous, 97 toxic, 97 German measles, 26 Glossitis, 90 Glycosuria, 136, 137 Gout, 147, 148 Graphospasm, 165 H. Hsematuria, 138 Hgemoglobinuria, 139 Hsemopericardium, 85 Haemophilia, 151 Heart, diseases of, 75 dilatation of, 80 hypertrophy of, 80 Hemicrania, 168 Hepatitis, suppurative, 118 interstitial, 119 Hodgkin's disease, 143, 144 Hydromyelus, 190 Hydropericardium, 85 Hydropei'itoneum, 114 Hydrophobia, 43 cause, 44 diagnosis, 44 INDEX. 219 Hydi'optObia, treatment, 44 Hydrothorax, 62 Hypertrophy and dilatation of heart, 80 Hysteria, 212, 213 I. Infectious diseases, 17 contagion, 17 manifestation, 18 prevention, 18 varieties, 17 Interstitial pneumonia, 72 Intestinal parasites, 108 anchylostoma duodenale, 110 ascaris lumbricalis, 109 bothriocephalus latus, 108 oxyuris vermicularis, 110 taenia mediocanellata, 108 solium, 108 trichocephalus dispar. 111 J. Jaundice, catarrhal, 115 pernicious, 121 K. Kidneys, 127 acute congestion, 127 symptoms, 128 treatment, 128 chronic congestion, 128 degeneration, 129 symptoms, 13Cf treatment, 130 passive congestion, 128 symptoms, 129 tumors, 134 Laryngitis, acute, 49 catarrhal, 49 Leucoplasia, 91 Liver, abscess of, 118 acute yellow atrophy of, 120 amyloid, 123 cancer of, 121 cirrhosis of, 119 congestion of, 123 echinococcus of, 122 fatty, 123 hypertrophy of, 123 the ! Lobar pneumonia, 67 Lobular pneumonia, 66 Locomotor ataxia, 181 symptoms, 182 treatment, 183 Leucocythsemia, 142, 143 Lung, brown induration, 74 symptoms, 75 treatment, 75 fever, 67 tumors, 75 M. Malarial diseases, 36 intermittent fever, 36 malarial cachexia, 37 masked intermittent fever, 37 pernicious intermittent fever, 37 remittent fever, 37 Mastodynia, 155 Measles, 24 differential diagnosis, 25 eruption, 24, 25 treatment, 25 Mediastinum, new growths of, 62 Medulla, compression, 194 diseases of, 191 hemorrhage, 192 Meningeal apoplexy, 172, 173 Meningitis, cerebro-spiual, 41 Migraine, 168 Morbilli, 24 Motion, disturbances of, 159 Mouth, ulcerations of, 90 Mumps, 44 Muscular atrophy, Erb's, 187 spasm, 163, 164 Myelitis, 178-180 ' due to pressure, 177, 178 Myocarditis, 79 diagnosis, 80 treatment, 80 Nephritis, 130 acute diffuse, 131 chronic diffuse, 132 parenchymatous, 130 suppurative, 133 tubercular, 133 pathology, 134 symptoms, 134 treatment, 134 220 INDEX. Nervous dyspepsia, 101 Neuralgia, 153, 154, 157 intercostal, 155 mammary glaud, 155 trigeminus, 154 Neurasthenia, 214 Neuritis, 165, 166 Neuroma, 167 Neuroses, articular, 156 New growths of the pleura, 62 of the spinal cord, 190 o. (Esophagitis, 91 (Esophagus, cancer of, 94 dilatation of, 92 paralysis, 95 rupture, 94 spasm, 95 stenosis of, 93 P. Pachymeningitis cervicalis liyper- trophica, 172 Paralysis, 159, 160 different forms of, 160-163 Parasites, intestinal, 108 ♦Parotitis, 44 Pancreas, 126 anaemia, 126 atrophy, 126 cancer, 127 ecchymoses, 127 hypersemia, 126 hypertrophy, 126 Pancreatitis, 126, 127 Pericarditis, 83 diagnosis, 84 treatment, 84 Perinephritis, 136 Peritonitis, acute general, 111 local, 112 chronic general, 112 local, 112 tubercular, 113 Perityphlitis, 104 pathology, 105 symptoms, 105 treatment, 105 Pernicious jaundice, 121 Pertussis, 46 Pharyngitis, acute, 47 Phlegmonous gastritis, 97 Phthisis (see Pulmonary Tuberculosis), 69 Pin-worms, 110 Pleura, new growths of, 62 Pleurisy, 56 pathology, 57 varieties of, 57 dry, 57 tubercular, 60 with effusion, 58 physical signs, 58 symptoms, 58 treatment, 59 Pleuro-pneumonia, 67 Pneumonia, 65 bronchial, 66 catarrhal, 66 croupous, 67 forms of, 66 interstitial, 72 lobar, 67 lobular, 66 Pneumopericardium, 85 Pneumothorax, 61 Poliomyelitis, 188 Portal vein, thrombosis of, 124 Pressure myelitis, 177, 178 Progressive facial hemiatrophy, 169 muscular atrophy, 185 Pseudo-hypertrophy, muscular, 186 Pseudo-leu cocythsemia, 143, 144 Pulmonary emphysema, 55 pathology, 56 physical signs, 56 symptoms, 56 treatment, 56 cedema, 65 tuberculosis, 69 diagnosis, 71 etiology, 69 pathology, 70 physical signs, 71 symptoms, 70 treatment, 71 varieties, 69 Purpura hsemorrhagica, 150, 151 Pylephlebitis, suppurative, 124 R. Eed rash, 22 Eeflexes, tests for, 157, 158 cutaneous, 157 tendon, 158 Relapsing fever, 21 INDEX. 221 Eelapsirig fever, course, 22 differential diagnosis, 22 symptoms, 22 treatment, 22 Eenal colic, 135 Rheumatism, 145 acute articular, 145, 146 chronic, 146 subacute, 146 Eoseola, 26 Eound-worms, 109 Eubeola, 24 Eupture of the oesophagus, 94 S. Scarlatina, 22 Scarlet fever, 22 cause, 23 complications, 23 eruption, 23 symptoms, 23 treatment, 24 Sciatica, 155, 156 Sclerosis, disseminated, 180, 181 Scurvy, 149, 150 Small-pox, 26 complications, 28 differential diagnosis, 27 prophylaxis, 27 treatment, 28 vaccination, 27 varieties, 27 Sensation, disturbances of, 152 Sore throat, 47 Spasm, muscular, 163, 164 Spastic spinal paralysis, 187 Spleen, 125 embolism of, 125 enlargement of, 125 tuberculosis of, 125 tumors of, 126 waxy degeneration of, 125 Spinal apoplexy, 174, 175 cord, 173 cavities and fissures, 190 concussion, 176 disturbances of circulation, 174 new growths, 190 traumatism, 175 unilateral lesion, 191 meningitis, acute, 170, 171 chronic, 171, 172 173, Stomach, cancer of, 99 dilatation of, 101 hemorrhage from, 100 Stenosis of the bronchi, 65 of the oesophagus, 93 of the trachea, 64 Stomatitis, 89 Syringomyelia, 190 T. Tabes dorsalis, 181 Tachycardia, 82 Tape-worms, 108 Tetanus, 211 Tonsillitis, acute, 48 Trachea, stenosis of, 64 Trichinosis, 45 Trophic disturbances, 167 Tubercular enteritis, 106 pleurisy, 60 Tuberculosis, pulmonary, 69 Typhlitis, 104 Typhoid fever, 18 complications, 19 symptoms, 19 treatment, 20 Typho-malarial fever, 39 Typhus fever, 20 eruption. 21 symptoms, 20, 21 treatment, 21 u. Ulcerations of the mouth, 90 V. Vaccination, 27 Varicella, 29 Variola, 26 Varioloid, 28 Vaso-motor disturbances, 167 Vessels, diseases of, 86 w. Whip-worms, 111 Whooping cough, 46 Y. Yellow fever, 40 diagnosis, 41 treatment, 41 , LEA BROTHERS & COS LIST OF THE Leading Medical Text-Books h-FH-f— H— f-^+ ^natom^, IDictionarics. Gray's Anatomy— 12th Edition. Colors or Black. Anatomy, Descriptive and Surgical. By Henry Geay, F, R. S., Lecturer on Anatomy at St. George's Hospital, London. Edited by T. Pickering Pick, F. R. C.S., Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Royal College of Surgeons of England. A new American from the eleventh enlarged and improved London edition, thoroughly revised and re-edited by William W. Keen, M. D. , Professor of Surgery in the Jefferson Medical College of Philadelphia. To which is added the second American from the latest English edition of Landmarks^ Medical and Surgical, by Luther HoLDEN, F. R. C. S. In one imperial octavo volume of 1098 pages, with 685 large and elaborate engravings on wood. Price of edition in black : Cloth, 16.00 ; leather, $7.00 ; half Russia, $7.50. Price of edition in colors : Cloth, $7.25 ; leather, $8.25 ; half Russia, $8.75. The most popular work on anatomy ever written. It is sufficient to say of it tliat this edition, thanks to its American editor, sur- passes all other editions. — Journalofthe Amer- ican Medical Association, December 31, 1887. Gray's Anatomy is the most magnificent work upon anatomy which has ever been pub- lished in the English or any other language. — Cincinnati Medical News, Nov. 1887. As the book now goes to the purchaser he is receiving the best work on anatomy that is published in any language. — Virginia Medi- cal Monthly, December, 1887. Gray's standard Anatomy has been and will be for years the text-book for students. The book needs only to be examined to be per- fectly understood. — Medical Press of Western New York, January, 1888. Dunglison's Medical Dictionary. MEDICAL LEXICON; A Dictionary of Medical Science : Containing a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Phar- macology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence and Dentistry, Notices of Climate and of Mineral "Waters, Formulae for Officinal, Empirical and Dietetic Preparations. "With the Accentuation and Ety- mology of the Terms, and the French and other Synonymes, so as to constitute a French as well as an English Medical Lexicon. By Robley DuNGLisoN, M. D., Late Professor of Institutes of Medicine in the Jeffer- son Medical College of Philadelphia. Edited by Richard J. Dunglisox, M. D. In one very large and handsome royal octavo volume of 1139 pages. Cloth, $6.50 ; leather, raised bands, $7.50 ; very handsome half Russia, raised bands, $8.00. Hoblyn's Medical Dictionary. A Dictionary of the Terms Used in Medicine and the Collateral Sciences. By Eichaed D. Hoblyn, M. D. Eevised, with numerous additions, by Isaac Hays, M. D., late editor of The Amer- ican Journal of the Medical Sciences. In one large royal 12mo. volume of 620 double-columned pages. Cloth, $1.50 ; leather, $2.00. It is the best book of definitions we have, and ought always be upon the student's table. — Southern Iledical and Surgical Journal. Foster's Physiology— New (Fifth) Edition. Text-Book of Physiology. By Michael Fostee, M. D., F. E. S. , Prelector in Physiology and Fellow of Trinity College, Cambridge, England. New (fifth) and enlarged American from the fifth and revised English edition, with notes and additions. In one handsome octavo vol- ume of 1072 pages, with 282 illustrations. Cloth, $4.50 ; leather, $5.50. The appearance of another edition of Foster's Physiology again reminds us of the continued popularity of this most excellent work. There can be no doubt that this text- book not only continues to lead all others in the English language, but that this last edi- tion is superior to its predecessors. It is evident that the author has devoted a con- siderable amount of time and labor to its preparation, nearly every page bearing evi- dences of careful revision. Although the work of the American editor in former editions has been by the author largely adopted in a modified form in this revision, much was still left to be done by the editor to render the work fully adapted to the wants of our American students, so that the American edition will undoubtedly continue to supply the market on this side of the Atlantic. The work has been published in the characteristic creditable style of the Lea's, and owing to its enormous sale is offered at an extremely low price. — The Medical and Surgical Reporter^ January 9, 1892. Chapman's Physiology. A Treatise on Human Physiology. By Heney C. Chapman, M. D. , Professor of Institutes of Medicine and Medical Juris- prudence in the Jefferson Medical College of Philadelphia. In one hand- some octavo volume of 925 pages, with 605 fine engravings. Cloth, $5i50 ; leather, $6.50. Dalton's Physiology— Seventh Edition. A Treatise on Human Physiology. Designed for the use of Students and Practitioners of Medicine. By John C. Dalton, M. D., Professor of Physiology in the College of Physicians and Surgeons, New York, etc. Seventh edition, thoroughly revised and rewritten. In one very handsome octavo volume of 722 pages, with 252 beautiful engrav- ings on wood. Cloth, $5.00 ; leather, $6.00. From the first appearance of the book it has been a favorite, owing as well to the author's renown as an oral teacher as to the charm of simplicity with which, as a writer, he always succeeds in investing even intri- cate subjects. It must be gratifying to him to observe the frequency with which his work, written for students and practitioners, is quoted by other writers on physiology. This fact attests its value, and, in great measure, its originality. It now needs no such seal of approbation, however, for the thousands who have studied it in its various editions have never been in any doubt as to its sterling worth. — Ntto York 3fedical Jour- nal, October, 1882. |3[)2sic0, diemiatrg. Draper's Medical Physics. Medical Physics. A Text-book for Students and Practi- tioners of Medicine. By John C. Deapee, M. D., LL, D., Professor of Ohemistry in the University of the City of New York. In one octavo vol- ume of 734 pages, vpith 376 vroodcuts, mostly original. Cloth, $4.00. Simon's Chemistry— Tliird Edition. Manual of Chemistry. A Guide to Lectures and Labora- liory work for Beginners in Chemistry. A Text-book, speciq^lly adapted, for Students of Pharmacy and Medicine. By W. Simon, Ph. D., M. D., Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and Professor of Chemistry in ^e Maryland College of Pharmacy. New (third) edition. In one 8vo. volume of 477 pages, with 44 woodcuts and 7 colored plates illustrating 56 of the most impor- tant chemical tests. Cloth, $3.25. Among the many works on chemistry offered for the use of the medical student, there is probably none that outrivals Dr. Simon's work in practical arrangement and thoroughness. A special feature of the book, and one that deserves the greatest praise, is the presence therein of the beauti- ful colored plates representing fifty-six chemical reactions. To say that they are splendidly and artistically executed hardly does them justice. They must convey to the mind of the student lasting impressions of the color changes that he has noted in his experiments in the laboratory, and the perusal of this work must recall them vividly to recognition. The many cuts are well selected, and the make-up of the book leaves nothing to be desired. As a student's manual this work is of the highest order, — The 3fedical News, February 20, 1892. Fownes' Chemistry— Twelfth Edition. A Manual of Elementary Chemistry ; Theoretical and Practical. Embodying Watts' Physical and Inorganic Chemistry. By Geokge Fownes, Ph. D. New American, from the twelfth English edi- tion. In one large royal 12mo. volume of 1061 pages, with 168 illustra- tions on wood and a colored plate. Cloth, |2.75 ; leather, $3.25. Attfield's Chemistry— Twelfth Edition. Chemistry, General, Medical and Pharmaceutical; Including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. By John Attfield, M. A., Ph.D., F. I. C, F. E. S., Etc., Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. A new American, from the twelfth English edition, specially revised by the Author for America. In one handsome royal 12mo. vol- -ame of 782 pages, with 88 illustrations. Cloth, $2.75; leather, $3.25. Cl)emi6tr2, J3l)armocg, ®l)era|jeutics, illaUria illebica. Bloxam's Chemistry— Fifth Edition. Chemistry, Inorganic and Organic. By- Chaeles L. Bloxam, Prof, of Chemistry in King's College, London. New American from the fifth London edition, thoroughly revised and much improved. In one very handsome octavo vol. of 727 pages, with 292 illua. Cloth, ^2.00 ; leather, $3.00. Remsen's Theoretical Chemistry— New (4th) Ed. Principles of Theoretical Chemistry, with special ref- erence to the Constitution of Chemical Compounds. By Iea Kemsen, M. D., Ph. D., Professor of Chemistry in the Johns Hopkins University, Baltimore. Fourth and thoroughly revised edition. In one handsome royal 12mo. volume of 325 pages. Cloth, $2.00. Just ready. Parrish's Pharmacy— Fifth Edition. A Treatise on Pharmacy : Designed as a Text-book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. By Edwaed Paeeish, late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. Fifth edition, thoroughly re\i£ed, by Thomas S. Wiegand, Ph. G. In one handsome octavo volume of 1093 pages, with 256 illustra- tions. Cloth, ^5.00 ; leather, |6.00. Stille & Maisch's National Dispensatory— 4th Ed. The National Dispensatory. Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in the Pharmacopoeias of the United States, Great Britain and Germany, with numerous references to the French Codex. By Alfeed Stille, M. D., LL. D., Professor Emeritus of the Theory and Practice of medicine and of Clinical Medicine in the University of Penn- sylvania, and John M. Maisch, Phae. D., Professor of Materia Mcdica and Botany in Philadelphia College of Pharmacy, Secretary to the Amer- ican Pharmaceutical Association. Fourth edition revised, and covering the new British Pharmacopoeia. In one magnificent imperial octavo vol- ume of 1794 pages, with 311 elaborate engravings. Price in cloth, $7.25 ; leather, raised bands, $8.00; half Eussia, $9.00. \*2%2S work will he furnished with Patent Beady Reference Thumb-letter Index for $1.00 in addi- tion to the price in any of the above styles of binding. "We thinR it a matter for congratulation j neither the physician nor the pharmacist that the profession of medicine and that of can do without the latest text-books on pharmacy have shown such appreciation them, especially those that are so accurate of this great work as to call for four editions and comprehensive as this one. The book within the comparatively brief period of is in every way creditable both to the au- eight years. The matters with which it thors and to the publishers. — New York 31ed' deals are of so practical a nature that icaZ Jo«rna/, May 21, 1887. Maisch's Materia Hledica— New (5th) Ed. Just Ready. A Manual of Organic Materia Mediea ; Being a Guide to Materia Mediea of "the Vegetable and Animal Kingdoms. For t'ae nse of Students, Druggists, Pharmacists and Physicians. By John M. Maisch, Phar. D., Professor of Materia Mediea and Botany in the Phil- adelphia College of Pharmacy. New (fifth) edition, thoroughly revised. In one very handsome 12mo. volume of 544 pages, with 270 engravings. Cloth, $3.00. Just ready. Hare's Practical Therapeutics— Second Edition. A Text-Book of Practical Therapeutics; With Especial Reference to the Application of Remedial Measures to Disease and their Employment upon a Rational Basis. By Hobaet Amory Hare, B. Sc, M. D., Professor of Materia Mediea and Therapeutics in the Jefferson Medical College of Philadelphia ; Secretary of the Conven- tion for the Revision of the United States Pharmacopoeia of 1890. With special chapters by Des. G. E. de Schweinitz, Edw*ard Martin, J. Howard Reeves and Barton C. Hirst. New (2d) and revised edition. In one handsome octavo vol. of 650 pages. Cloth, $3.75 ; leather, $4.75. This work has received the rare distinc- of drugs and diseases in alphabetical order, tion among medical works of reaching a according to their English names; and a second edition six months after its first ap- dose list of drugs oflacinal and unofficinal. pearance. Many new prescriptions have In addition to the general index, a copious also been inserted to illustrate the best and explanatory index of diseases and rem- modes of applying remedies. Among other edies has been appended which will render features of this practically helpful treatise the contents easily accessible.— TAe Medical which will make reference to it convenient Age^ July 10, 1891. and profitable, are the arrangement of titles Brnnton's Therapeutics and Mat. Med.— 3d Ed. A Text-Book of Pharmacology, Therapeutics and Materia Mediea ; Including the Pharmacy, the Physiological Action and Therapeutical Uses of Drugs. By T. Lauder Brunton, M. D., D. Sc, F. E S., F. R. C. P., Lecturer on Materia Mediea and Therapeutics at St. Bartholomew's Hospital, London, etc. Adapted to the U. S. Phar- macopoeia by Francis H. Williams, M. D , of Harvard University Medical School. Third edition. Octavo, 1305 pages, 230 illustrations. Cloth, $5.50 ; leather, |6.50. No words of praise are needed for this work, for it has already spoken for itself in former editions. It was by unanimous consent placed among tue foremost books on the sub- ject ever published in any language, and the better it is known and studied the more highly it is appreciated. The present edition contains much new matter, the insertion of which has been necessitated by the advances made in various directions in the art of therapeutics, and it now stands unrivalled in its thoroughly scientific presentation of the modes of drug action. No one who wishes to be fully up to the times in this science can afford to neglect the study of Dr. Brunton's work. The indexes are excellent, and add not a little to the practical value of the hook.— Medical Jtecord, May 25, 1889. |3rttctice of Mchitine, Lyman's Practice— Just Ready. The Principles and Practice of Medicine. For the Use of Medical Students and Practitioners. By Heney M. Lyman, M. B , Professor of the Principles and Practice of Medicine, Eush Medical Col- lege, Chicago. In one very handsome octavo volume of 925 pages, "with 170 illustrations. Cloth, $4.75; sheep, $5.75. Just ready. The author has undertaken to present in this volume not only the results of his long experience as a practitioner and teacher, but to make it. representative of the latest state of knowledge in its department. The work is assured of wide use as an unsurpassed guide for the student and likewise for the practitioner. Flint's Practice— Sixth Edition. A Treatise on the Principles and Practice of Med- icine. Designed for the use of Students and Practitioners of Medicine. By Austin Flint, M. D., LL. D., Professor of the Principles and Prac- tice of Medicine and of Clinical Medicine in Bellevue Hospital Medical College, New York. Sixth edition, thoroughly revised and rewritten, by the Author, agisted by William H. Welch, M. D., Professor of Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., Professor of Physiology, Bellevue Hospital Medical College, New York. In one very handsome octavo volume of 1160 pages,^ with illustrations. Cloth, $5.50; leather, $6.50. No text-book on the principles and prac tiee of medicine has ever met in this country with such general approval by medical stu- dents and practitioners as the work of Pro- fessor Flint. In all the medical colleges of the United States it is the favorite work upon Practice; and, as we have stated be- fore in alluding to it, there is no other medi- cal work that can be so generally found in the libraries of physicians. In every state and territory of this vast country the book that will be most likely to be found in the oflQ.ce of a medical man, whether in city, town, village, or at some cross-roads, is Flint's Practice. We make this statement to a considerable extent from personal observa- tion, and it is the testimony also of others. An examination shows that very considera- ble changes have been made in the sixth edition. The work may undoubtedly be re- garded as fairly representing the present state of the science of medicine, and as reflecting the views of those who exemplify in their practice the present stage of pro- gress of medical art. — Cincinnati Medical News, Oct. 1886. Hartshorne's Essentials— Fifth Edition. Essentials of the Principles and Practice of Medi- cine. A Handbook for Students and Practitioners. By Heney Harts- HOKNE, M. D. , LL. D. , lately Professor of Hygiene in the University of Pennsylvania. Fifth edition, thoroughly revised and rewritten. In ona royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75;, half bound, $3.00. An indispensable book. No work ever very useful to students especially. These exhibited a better average of actual practical essentials are most valuable in affording the treatment than this one; and probably not means to see at a glance the whole literature one writer in our day had a better opportu- of any disease, and the most valuable treat- nity than Dr. Hartshorne for condensing all ment.— Chicago Medical Journal and Ex- the views of eminent practitioners into a aminer, April, 1882. 12mo. The numerous illustrations will be practice of Mehidnc, ^istoiogg, |)atl)oIo92. Fothergiirs Handbook o! Treatment— 3d Edition. The Practitioner's Handbook of Treatment ; Or, the Principles of Therapeutics. By J. M. Fothergill, M.D., Edin., M.R.C.P., LoND., Physician to the City of London Hospital for Diseases of the Chest. Third edition. In one 8vo. vol. of 661 pages. Cloth, $3.75 ; leather, $4.75. Flint's Auscultation and Percussion— Fifth Edition. A Manual of Auscultation and Percussion ; Of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. By Austin Flint, M. D., LL. D,, Professor of the Principles and Practice of Medicine in Belle vue Hospital Medical College, N. Y. Fifth edition. Edited by James C. Wilson, M. D., Lecturer on Physical Diag- nosis in the Jefferson Medical College, Philadelphia. In one handsome royal 12mo. volame of 274 pages, with 12 illustrations. Cloth, $1.75. This little book through its various edi- tions has probably done more to advance the science of physical exploration of the chest than any other dissertation upon the sub- ject, and now in its fifth edition it is as near perfect as it can be. The rapidity with which previous editions were sold shows how the profession appreciates the thorough- ness of Prof. Flint's investigations. For students it is excellent. Its value is shown both in the arrangement of the material and in the clear, concise style of expression. For the practitioner it is a ready manual for re (erexice.— North American Practitioner^ Jan- uary, 1891. Gibbes' Histology and Pathology. Practical Pathology and Morbid Histology. By Heneage Gibbes, M. D., Professor of Pathology in the University of Michigan, Medical Department. In one very handsome octavo volume of 314 pages, with 60 illustrations, mostly photographic. Cloth, $2.75. This is, in part, an expansion of the little work published by the author some years ago, and his acknowledged skill as a practi- cal microscopist will give weight to his in- structions. Indeed, in fulness of directions as to the modes of investigating morbid tis- sues the book leaves little to be desired. The work is throughout profusely illustrated with reproductions of micro-photographs. We may say that the practical histologist will gain much useful information from the book.— 2%« London Lancet, January 23, 1892, Green's Pathology and Morbid Anatomy— 7tb Ed. Pathology and Morbid Anatomy. By T. Heney Geeef, M. D., Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hos- pital Medical School, London. Sixth American from the seventh revised English edition. Octavo, 539 pages, with 167 engravings. Cloth, $2.75. It is better adapted to the wants of gen- microscope. The fact that it is so generally eral practitioners than any work of the kind employed as a text-book by medical students with which we are acquainted. The cuts is evidence that we have not spoken too much exhibit the appearances of pathological in its favor. — Cincinnati Medical News, Octo- Btructures just as they are seen through the ber, 1889. Patl/oIo92» ^istologs, Sacteriologa- Payne's General Pathology. A Manual of General Pathology. Designed as an Intro- duction to the Practice of Medicine. By Joseph F. Payne, M. D., F. R. C. P., Senior Assistant Physician and Lecturer on Pathological Anatomy, St. Thomas' Hospital, London. Octavo of 524 pages, with 152 illustrations and a colored plate. Cloth, $3.50. in those diseases now with reasonable cer- tainty ascribed to pathogenetic microbes. In this department he has been very full Knowing, as a teacher and examiner, the exact needs of medical students, the author has in the work before us prepared for their especial use what we do not hesitate to say is the best introduction to general pathology that we have yet examined. A departure which our author has taken is the greater attention paid to the causation of disease, and more especially to the etiological factors and explicit, not only in a descriptive man- ner, but in the technique of investigation. The Appendix, giving methods of research, is alone worth the price of the book, several times over, to every student of pathology. — Si. Louis Med. and Surgical Jour., Jan. 1889. Klein's Histology— Fourth Edition. Elements of Histology. By E. Klein, M. D., F. R. S , Joint Lecturer on General Anatomy and Physiology in the Medical School of St. Bartholomew's Hospital, London. Fourth edition. In one 12mo. volume of 376 pages, with 194 illustrations. Limp cloth, $1.75. ^ee Stu- dents^ Series of Manuals, page 30. Abbott's Bacteriology. The Principles of Bacteriology : a Practical Manual for Students and Physicians. By A. C. Abbott, M. D., First Assistant, Lab- oratory of Hygiene, University of Pennsylvania, Philadelphia. In one 12mo. volume of 259 pages, with 32 illustrations. Cloth, $2.00. Just ready. On reading this manual of Dr. Abbott, any one familiar with the subject will readily recognize the fact that the book is not merely a compilation from other works, but one giving evidence of the originality of the author, as well as complete knowledge of the practical details of bacteriology. His "scheme for the study of an organism" furnishes an excellent guide to the student. Of equal importance is the chapter on disin- fectants, antiseptics and skin disinfection. It will form a valuable addition to the litera- ture of laboratory technique and bacterio- logical investigation.— 2%6 Therapeutic Ga- zetie, May 16, 1892. Senn's Surgical Bacteriology— Second Edition. Surgical Bacteriology. By Nicholas Sexn, M. B., Ph. B., Professor of Surgery in Rush Medical College, Chicago. New (second) edition. In one handsome octavo of 268 pages, with 13 plates, of which 10 are colored, and 9 engravings. Cloth, $2.00. Coats' Pathology. A Treatise on Pathology. By Joseph Coats, M. D., F. F. P. S., Pathologist to the Glasgow Western Infirmary. In one very handsome octavo volume of 829 pages, with 339 beautiful illustrations. Cloth, $5.50; leather, $6. 50. IXcxvom anh Mtntai IHiseaeca, Surgery. Gray on Nervous and Mental Diseases. A Practical Treatise on Nervous and Mental Dis- eases. By Landon Caeter Gray, M. D.. Professor of Diseases of the Mind and Nervous System in the New York Polyclinic. Shortly. T^HIS work is devoted purely to the practical aspedts of nervous and mental -*- diseases, especial care being taken to present the fundamental knowledge essential to a grasp of its subjects and to cast everything in the clearest possible form. The series of illustrations are rich and unique, embracing a large num- ber of photographic engravings of exceptional vividness and interest. By the employment of a style at once concise and clear, and by careful arrangement, the author is enabled to include an exposition of a vast and important subject in a condensed and convenient form. It will be an admirable work for the student as well as for the practitioner. Ross on Nervous Diseases. A Handbook on Diseases of the Nervous System. By James Eoss, M. D., F. E. C. P., LL. D., Senior Assistant Physician to the Manchester Eoyal Infirmary. In one octavo volume of 725 pages, with 184 illustrations. Cloth, $4.50 ; leather, $5.50. This admirable work is intended for students of medicine and for such medical men as have no time for lengthy treatises. In every part this handbook merits the highest praise, and will no doubt be found of the greatest value to the student as well as to the practitioner. — Edinburgh Medical Journal, Jan. 1887. Roberts' Modern Surgery. The Principles and Practice of Modern Surgery. For the use of Students and Practitioners of Medicine and Surgery. By John B. Egberts, M. D., Professor of Anatomy and Surgery in the Phila- delphia Polyclinic ; Professor of the Principles and Practice of Surgery in the Woman's Medical College of Pennsylvania ; Lecturer in Anatomy in the University of Pennsylvania. In one very handsome octavo volume of 780 pages, with 501 illustrations. Cloth, $4.50 ; leather, $5.5^. This work is a very comprehensive man- ual upon general surgery, and will doubtless meet witn a favorable reception by the pro- fession. It has a thoroughly practical charac- ter, the subjects are treated with rare judg- ment, its conclusions are in accord with those of the leading practitioners of the art, and its literature is fully up to all the ad- vanced doctrines and methods of practice of the present day. Its general arrangement follows this rule, and theauthor in his desire to be concise and practical is at times almost dogmatic, but this is entirely excusable con- sidering the admirable manner in which he has thus increased the usefulness of his yfor]s..—3fedical Record, Jan. 17, 1891. ErMsen's Surgery— Eighth Edition. The Science and Art of Surgery; Being a Treatise on Surgical Injuries, Diseases and Operations. By John E. Eeichsen, F.E.S. , F. R. C. S., Professor of Surgery in University College, London, etc. From the eighth and enlarged English edition. In two large 8vo. volumes of 2316 pages, with 984 engravings on wood. Cloth, $9.00 ; leather, $11.00. Ashhurst's Surgery— Fifth Edition. The Principles and Practice of Surgery. By John^ AsHHimST, Je., M. D., Barton Professor of Surgery and Clinical Surgery in the University of Penn'a; Snrgeon to the Penn'a Hospital, Phila. Fifth edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 1144 pages, with 642 illos. Cloth, $6.00 ; leather, $7.00. A complete and most excellent work on Burgery. It is only necessary to examine it to sete at once its excellence and real merit either as text-book for the student or a guide for the general practitioner. It fully considers in detail every surgical injury and disease to which the body is liable, and every advance in surgery worth noting is to be found in its proper place. It is un- questionably the best and most complete single volume on surgery, in the English language, and cannot but receive that con- tinued appreciation which its merits justly demand.— Southern Fraciiiioner, Feb. 1890. Druitt's Modern Surgery. Manual of Modern Surgery. By Robeet Deuitt, M. R. C. S., etc. Twelfth edition, thoroughly revised by Stanley Boyd, M. B., B. S., F. R. C. S. In one 8vo. volume of 965 pages, with 373 illus- irations. Cloth, $4.00 ; leather, |5.00. Bryant's Surgery— Fourth Edition. The Practice of Surgery. By Thomas Beyant, F.E.C.S., Snrgeon and Lecturer on Surgery at Guy's Hospital, London. Fourth American from the fourth and revised English edition. In one large and very handsome imperial octavo volume of 1040 pages, with 727 illustra- tions. Cloth, $6.50 ; leather, $7.50. Wharton's Minor Surgery and Bandaging. Minor Surgery and Bandaging. By Heney R. Whae- TON", M.D., Demonstrator of Surgery and Lecturer on Surgical Diseases of Children in the University of Penna. In one very handsome 12mo. volume of 498 pp., with 403 engravings, many being photographic. Cloth, $3.00. This new work must take a first rank as soon as examined. Bandaging is well de- scribed by words, and the methods are illus- trated by photographic drawings, so to make plain each step taken in the application of bandages of various kinds to different parts of the body and extremities — including the head. The various operations are likewise described and illustrated, so that it would seem easy for the tyro to do the gravest amputation. The various established opera- tions are described in detail. Hence this work becomes a most valuable companion- book to any of the more pretentious treatises on surgery, where simply the general advice is given to bandage, amputate intubate, operate, etc. For the student and young surgeon, it is a very valuable instruction book from which to learn how to do what may be advised, in general terms, to be done. — Virginia Medical Monthly, October, 1891, Holmes' Treatise on Surgery. A Treatise on Surgery; Its Principles and Practice. By Timothy Holmes, M. A., Surgeon and Lecturer on Surgery at St. George's Hospital, London. From the fifth English edition, edited by T. Pickering Pick, F. R. C. S. In one octavo volume of 997 pages, with 428 illustrations, aoth, |6.00; leather, $7.00. Surgerg. Treves' Operative Surgery. A Manual of Operative Surgery. By Feedepjck Treves, F. R. C. S., Surgeon and Lecturer on Anatomy at the London Hospital. In two octavo volumes containing 1550 pages, with 422 original engravings. Complete work, cloth, |9.00; leather, $11.00. Just ready. We have no hesitation in declaring it the best work on the subject in. the English language, and indeed in many respects the best in any language. We feel called upon to recommend the book so strongly for the excellent judgment displayed in the arduous task of selecting from among the thousands of varying procedures those most vrorthy of description ; for the way in which the still more difficult task of choosing among the best of those has-been accomplished ; and for the simple, clear, straightforward manner in which the information thus gathered from all surgical literature has been con- veyed to the XQdk^Qx,—Annals of SurgerVi. March, 1892. Smith's Operative Surgery. The Principles and Practice of Operative Surgery. By Stephen Smith, M. D., Professor of Clinical Surgery in the University of the City of New York. Second and thoroughly revised edition. In one very handsome octavo volume of 892 pages, vrith 1005 illustrations. Cloth, $4.00; leather, $5.00. It can be truly said that as a handbook will its readers, no matter how unusual the for the student, a companion for the sur- subject, consult its pages in vain Its com- geon, and even as a book of reference for the pact form, excellent print, numerous illustra- physician not especially engaged in the tions, and especially its decidedly practical practice of surgery, this volume will long character, all combine to commend it. — Bos- hold a most conspicuous place, and seldom ton Medical and Surgical Journal, May 10, '8S» Hamilton on Fractures and Dislocations. A Practical Treatise on Fractures and Dislocations^ By Frank H. Hamiltoist, M. D., LL. D., Surgeon to Bellevue Hospital, New York. New (eighth) edition, revised and edited by Stephen Smith, A. M., M. D., Professor of Clinical Surgery in the University of the City of New York. In one very handsome octavo volume of 832 pages, with 507 illustrations. Cloth, $5.50; leather, $6.50. It i8 pre-eminently the authority on frac- tures and dislocations, and universally quoted as such. The additions it has re- ceived by its recent revision make it a work thoroughly in accordance with modern prac- tice, theoretically, mechanically, aseptically. The more one reads the more one is im- pressed with its completeness. The work has been accomplished, and has been done clearly, concisely, excellently well. — Boston. Iledical and Surgical Journal, May 26, 1892. Stimson's Operative Surgery. A Manual of Operative Surgery. By Lewis A. Stimson^ B. A., M. D., Professor of Clinical Surgery in the Medical Faculty of the University of the City of New York. Second edition. In one very hand- some royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. Stimson on Fractures and Dislocations. A Treatise on Fractures and Dislocations. In two handsome octavo volumes. Vol. I. , Feactuees, 582 pages, 360 beautiful illustrations. Vol. II., Dislocations, 540 pages, with 163 illustrations. Complete work, cloth, $5.50] leather, $7.50. Either volume separately, cloth, $3.00 ; leather, $4.00. The appearance of the second volume f and Dislocations. The volume on Fractures marks the completion of the author's origi- nal plan of preparing a work which should present in the fullest manner all that is known on the cognate subjects of Fractures assumed at once the position of authority on the subject, and its companion on Disloca- tions will no doubt be similarly received. — Cincinnati Medical News, May, 1888. Norris & Oliver on the Eye— In Press. A Text-Book of Ophthalmology. By William F. NoEEis, M. D., Clinical Professor of Ophthalmology in University of Penna., and Chaeles A. Olivee, M.D. In one octavo volume of about 800 pages, richly illustrated with engravings and colored plates. In press. TN PEEPAEING this volume the authors have had in view the needs of -*- students, physicians and specialists. Its concise and clear style, its completeness and the beautiful series of illustrations will at once render it a favorite work with all classes for whom it is intended. Nettleship's Students' Guide tc tbe Eye— 5th Ed. Diseases of the Eye. By Edwaed Nettleship, F.K.C.S., Ophthalmic Surgeon at St. Thomas' Hospital, London. Surgeon to the Koyal London (Moorfields) Ophthalmic Hospital. Fourth American from the fifth English edition, thoroughly revised. With a Supplement on the Detection of Color Blindness, by William Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College. In one 12mo. volume of 500 pages, with 164 illustrations, selections from Snellen's test-types and formulae, and a colored plate. Cloth, $2.00. It was primarily intended for the use of students, and supplies their needs admir- ably, but it is as useful for the practitioner. It does not presuppose the large amount of recondite knowledge to be present which seems to be assumed in some of our larger works, is not tedious from over-conciseness, and yet covers the more important parts of clinical ophthalmology. — Ntw York Medical Journal, December 13, 1890. Burnett on the Ear. The Ear ; Its Anatomy, Physiology and Diseases. A Practical Treatise for the use of Medical Students and Practitioners. By Chaeles H. Buenett, A.M., M.D., Professor of Otology in the Philadel- phia Polyclinic ; President of the American Otological Society. Second edition. In one handsome octavo volume of 580 pages, with 107 illustra- tions Cloth, $4.00 ; leather, $5.00. Dr. Burnett has fully maintained his rep- ! bution to aural surgery, not only on account utation, for the book is replete with valuable I of its comprehensiveness, but because it con- information and suggestions. The revision j tains the results of the careful personal has been carefully carried out, and much | observation and experience of this eminent new matter added. Dr. Burnett's work I aural surgeon, — London Lancet, Feb. 21, 1885. must be regarded as a very valuable contri- | ilrinar^^ bencreal, Skin. Roberts on Urinary Diseases— Fourth Edition. A Practical Treatise on Urinary and Renal Diseases, including Urinary Deposits. BySiE William Roberts, M. D., Lecturer on Medicine in the Manchester School of Medicine, etc. Fourth American from the fourth London edition. In one handsome octavo of 609 pages, with 81 illustrations. Cloth, $3.50. The peculiar value and finish of the book are in a measure derived from its resolute maintenance of a clinical and practical character. It is an unrivalled exposition of everything which relates directly or in- directly to the diagnosis, prognosis and treatment of urinary diseases, and possesses a completeness not found elsewhere in our language in its account of the different affections. — The Manchester Medical Chroni- cle, July, 1885. Jackson on the Skin— Just Ready. The Ready-Reference Handbook of Skin Diseases. By George Thomas Jackson, M. D., Professor of Dermatology, Women's Medical College, New York Intirmary. In one 12mo. volume of 450 pages with 50 illustrations. Cloth, $2.75. Just ready. This volume is devoted to the art of dermatology, to the practice of this department of medicine in its latest development. No attempt has been made to discuss debatable questions, and pathology and etiology do not receive as full consideration as symptomatology, diagnosis and treatment. The alphabetical arrangement of the different diseases has been adopted as conducive to the greatest possible convenience in use. The pages are illustrated with a large number of engra^dngs, many being photographic and vivid reproductions of actual cases. A handsome lithographic frontis- piece adds to the beauty and usefulness of a volume for which a wide recog- nition is assured. Culver & Hayden on Venereal Diseases. A Manual of Venereal Diseases. By E M. Culver, M. D., Pathologist and Assistant Attending Surgeon, Manhattan Hospital, New York, and J. K. Hayden, M. D , Chief of Clinic Venereal Depart- ment, Yanderbilt Clinic, Col'ege of Physicians and Surgeons, New York. In one 12mo. volume of 289 pages, with 33 illustrations. Cloth, |1.75. Hyde on the Skin— Second Edition. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. By J. Nevins Hyde, A.M., M.D., Prof, of Dermatology and Venereal Diseases in Rush Med. College, Chicago. Second edition. In one handsome octavo volume of 676 pages, 2 colored plates and 85 beautiful and elaborate illus. Cloth, $4.50; leather, $5.50. His treatise is like his clinical instruction, into his book all the best of that which the admirably arranged, attractive in diction past years have brought forth. The pre- and strikingly practical throughout. No scriptions and formulse are given in both clearer description of the lesions of the skin common and metric systems. Text and is to be met "with anywhere. Dr. Hyde has illustrations are good, and colored plates of shown himself a comprehensive reader of rare cases lend additional attractions. — Med- the latest literature, and has incorporated ical Press of Western New York, June, 1888. (Sgnecologs* Tbomas & Munde on Women— Sixth Edition. A Practical Treatise on the Diseases of Women. By T. Gaillaed Thomas, M. D., LL. D., Emeritus Professor of Diseases of Women in the College of Physicians and Surgeons, New York, and Paul F. Munde, M. D., Professor of Gynecology in the New York Poly- •cliQic. New (sixth) edition, thoroughly revised and rewritten by Dr JMunde. In one large handsome octavo volume of 824 pages, with 347 illus- trations, of which 201 are new. Cloth, $5.00; leather, $6.00. Probably no treatise ever written by an tion and scholarly and scientific statement American author on a medical topic has must remain what it long has been, a stand- heen accepted by more practitioners, as a ard text-book both for practitioner and stu- standard text-book, or read with pleasure dent, at home and abroad, and an enduring and profit by more medical students than pride to American gynecologists. — 27te Thomas on the diseases of women. This Brooklyn Medical Journal^ March, 1892. Tolume in classic excellence, elegance of die- | Davenport's Non-Snrgical Gynaecology— New Ed. Diseases of Women, a Manual of Non- Surgical