C\G ^\^s OInlumbta HmurrHttg tn tljr (Ettg of N^m fork ^poattph fan .!to.!rfi...C.^....Q!^v\>r.h .er. Digitized by tine Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/essentialsofpriOOhart ESSENTIALS Z^^^^^^,^ OF THE „.__^ PRINCIPLES AND PRACTICE OP MEDICIITE. A HANDBOOK FOR STUDENTS AND PRACTITIONERS. BY HENRY HARTSHORNE, A.M., M.D., LATELY PROFESSOR OF HYGIENE IN THE UNIVERSITY OF PENNSYLVANIA, AND PROFESSOR OF HYGIENE AND DISEASES OF CHILDREN IN THE WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA; EDITOR OF AMERICAN EDITION OF " REYNOLDS' SYSTEM OF MEDICINE," ETC. FIPTH EDITION, THOROUGHLY REVISED AND IMPROVED. ^rt^ |{tt«W mi %m\i-^tm )fk%M\n%. PHILADELPHIA: HEiTRY C. LEA'S SOl^r & CO, 1881. c^. Entered, according to the Act of Congress, in the year 1881, by HENRY C. LEA'S SON & CO., In the Office of the Librarian of Congress. All rights reserved. ^ J. FAOAN t BON, ELECTROTTPERS, PHILAD'A. Xr^ a* TO THE FIFTH EDITION QINCB the publication of the last edition of this work, in 1874, medical knowledge and thought have received addi- tions such as, fully set forth, might occupy several volumes. If it should seem a hopeless task to present a summary of the most important of these within the compass of a few score of pages, such an endeavor appears, nevertheless, to be called for by the purpose and antecedents of this volume of " Essen- tials." It has therefore been undertaken ; with what approx- imation to success, my readers must judge. Several liundred brief additions have been made throughout the work ; a num= ber of new subjects have been written upon, especially in con- nection with the pathology of the Nervous System ; the illus- trations have been considerably added to, and a large number of new and carefully selected formulae for the administration of medicines have been introduced. An account is given, also, for the first time, of the method of prescribing according to the Metrical system ; and a section is added upon Eyesight, its Examination and Correction. While thus endeavoring to do justice to all real medical improvement and progress, it appears necessary for me still to remain in the minority upon a few subjects of current opinion. Especially, it does not seem to me that the time has arrived for Clinical Medicine to surrender at discretion to Physiological Therapeutics. Whatever of valuable suggestion IV PEEFACE. or explanation may rightly proceed from the physiological or toxicological laboratory, the true field of decision in Experi- mental Medicine must, according to my belief, always lie in clinical observation and experience. Some farther remarks upon this topic, which has latterly become one of prominent importance, are ventured upon near the close of the Introduc- tion. The besetting medical error of almost all periods, the nimia diligentia, doing overmuch, was, about the middle of this cen- tury, put aside for a time, by an era of scepticism in therapeu- tics, logically followed by inert expectancy Now we have, under new theories, a revival of heroic medication ; with the use of drugs, especially narcotics and stimulants, capable of great usefulness, but also of misuse, as serious as ever befell the lancet, calomel, or antimony in former times. Through all, however, true science must in the end prevail. References to authors cited in this book have, through accu- mulation, become somewhat cumbrous. I have, nevertheless, concluded to retain most of them ; believing that instruction may be derived from even so partial a record of the recent history of medical observation and opinion. Although still having to regret many imperfections, I trust that my readers, to some of whom I send greeting as far off as Japan, may find the work, thus revised, more serviceable than hitherto, in facilitating their acquaintance with the most important facts and principles of Practical Medicine. H. H. Geemantown, Philadelphia, August, 1881. CONTENTS. INTRODUCTION: Systems of Medicine PAGE . 13 PART I. PRINCIPLES OF MEDICINE. SECTION I. GENERAL PATHOLOGY. MoEBiD States of the System 2 6 Fever 26 Toxaemia 2Y Anasmia 31 Plethora 32 Oacliexia 32 MoEBiD States of Oegans . 44 Hypertrophy .... 44 Atrophy FARE . 45 Irritation . 46 Inflammation . . . . 47 Chronic Inflammation 54 Degeneration . . . 65 Morbid Growths . . 56 Neuropathology . . 60 Modes of Death . . . 66 SECTION II. SEMEIOLOGY. 1. Symptomatology. Digestive System Circulation . . Respiration . . Skin .... Secretions . . Motor Apparatas Sensory Apparatus Psychical Functions General Vital Condition 1* 67 67 69 73 74 75 93 94 97 98 2. Physical Diagnosis . . 98 Inspection 98 Mensuration and Palpa- tion 99 Spirometry . . . . . 100 Percussion 101 Auscultation . . . .103 Exploration of the Heart 110 Exploration of the Abdo- men 115 V VI CONTENTS, Diagnosis of Diseases of "Women 116 Laryngoscopy . . . .119 The Ophthalmoscope . . 121 The Sphygmograph . .124 Temperature in Disease . 128 Pneumatic Aspiration . 133 Inspection OF THE Dead Body 134 Medioo-Legal Examina- tions 137 SECTION III. GENEEAIy THERAPEUTICS. Classification of Kemedies 138 Balancive Measures . . 139 Antiphlogistic Treatment 141 Febrifuge Treatment . .151 Supporting Treatment . 154 Calmative Treatment . 163 Antidotal Treatment . . 164 Alterative Treatment . 169 Medioal Electricity . .171 Hydropathy 175 Hot- Air Baths . Movement-cure. . . 175 . . 177 . . 177 Inhalation and Atomiza- tion 179 Hypodermic Medication . 183 Transfusion of Blood . .. 187 General Conclusions and Maxims 191 SECTION IT NOSOLOGY. Classification of Diseases 192 Phlegmasia 192 Zymoses 192 Cachexise 193 Neuroses .193 Ataxias 193 PART II. SPECIAL PATHOLOGY AND PRACTICE. Affections of the Eespiea- TOET System 194 Pneumonia 194 Cirrhosis of the Lung , 200 Pleurisy 201 Abscess of the Lung . . 206 Gangrene of the Lung . 206 Emphysema of the Lung 207 CoUapse of the Lung . . 207 Bronchitis 208 Asthma 210 Bronchial Dilatation . Chronic Nasal Catarrh Laryngitis .... Aphonia Laryngismus Stridulus Croup Pleurodynia .... Intercostal Neuralgia Thoracic Myalgia . . Phthisis Pulmonalis . . 214 . 215 . 217 . 218 . 219 . 220 . 226 . 227 . 227 . 227 CONTENTS. VU PAGE Affections of the Heart AND Acuta 239 Pericarditis 239 Endocarditis .... 242 Valvular Disease . . . 244 Dilatation of the Heart .. 24G Hypertrophy of the Heart 247 Fatty Degeneration of the Heart 248 Sudden Death in Heart Disease 249 Angina Pectoris . . . 250 Exophthalmic Goitre , . 250 Palpitation 252 Cardiac Exhaustion . . 253 Aneurism of Thoracic Aorta 253 Aneurism of Abdominal Aorta 255 Affections of the Alimen- tary System 257 Stomatitis 257 Tonsilhtis 260 Pharyngitis 261 Retropharyngeal Abscess 262 Stricture of (Esophagus . 262 Gastritis 263 Chronic Gastritis . . . 264 Anti-emetic Remedies . 265 Ulcer of the Stomach , .266 Cancer of the Stomach . 267 Dyspepsia 268 Constipation .... 272 Enteritis 273 Peritonitis 275 CoHc 277 Common Remedies in Colic 288 Obstruction of the Bow- els 284 Cholera Morbus . . . 287 Diarrhoea 289 Cholera Infantum . . . 291 Dysentery 294 PAGE Hemorrhoids .... 297 Fissure of the Anus . . 300 Prola])sus Ani .... 301 Affections of the Liver . 301 Acute Congestion . . . 301 Chronic Congestion . . 302 Hepatitis 303 Abscess of the Liver . . 303 Jaundice 305 Acute Yellow Atrophy . 307 Pigment Liver . . . .308 Cirrhosis 309 Fatty Liver 310 Waxy Liver 311 Syphilitic Liver . . .312 Cancer of the Liver . . 312 Hydatids of the Liver . 313 Tubercle of the Liver . 313 DUatation of the Gall- bladder 314 Affections of the Spleen . 314 Affections of the Kidneys AND Bladder 315 Renal Congestion . . .315 TJrfBmia 315 Nephritis 316 Bright's Disease . . . 317 Lithiasis 323 Diabetes Insipidus . . 325 Diabetes Mellitus . . .326 Hydronephrosis . . , 329 Pyonephrosis .... 330 Cancer of the Kidney . 330 Tubercle of the Kidney , 331 Amyloid Kidney . . . 331 Hydatids of the Kidney . 332 Cystitis 333 Retention of the Urine . 334 Enuresis 335 Affections of the Brain AND jSTertous System . . 335 Inflammation of the Brain 335 Hydrocephalus .... 340 Brain Exhaustion . . . 340 vm CONTENTS. PAGE Ramollissement . . . 342 Ophthalmia 343 Otitis ....... 346 Apoplexy 348 Spinal Meningitis . . . 353 Softening of the Cord . 353 Spinal Irritation . , .354 Cerebral and Spinal Sclerosis 355 Paralysis 360 Locomotor Ataxy . . . 368 Athetosis 370 Infantile Paralysis . . 371 Epilepsy 372 Catalepsy 375 Heatstroke 376 Insomnia 377 Night-terrors .... 378 Convulsions 379 Chorea 382 Aphasia 384 Tetanus 384 Hydrophobia .... 387 Hysteria 390 Hystero-Epilepsy . . . 391 Neuralgia 392 Delirium Tremens . . . 395 Methomania 397 Insanity 398 Hemoeehages 400 Epistaxis 401 Hemorrhage from the Mouth 402 Hemoptysis 402 Pulmonary Apoplexy . 408 Hgematemesis .... 403 Hsematuria 404 Hemorrhage from the Bowels 404 Vicarious Hemorrhage . 404 Uterine Hemorrhage . . 405 Deopsioal Affections . . . 405 Acute General Dropsy . 406 Ascites 406 Ovarian Dropsy . . . 406 PAGE Zymotic Diseases .... 409 Variola 409 Varioloid 411 Vaccination 411 Varicella 414 Scarlatina 415 Measles 419 Rotheln 420 Mumps 422 Hooping-Oough . . . 422 Diphtheria 424 Glanders ». 431 Influenza 432 Dengue 432 Malarial Fever .... 433 Intermittent . . . 438 Eemittent . . . .439 Pernicious. , . . 445 Prophylaxis of Malarial Fever 447 Typho-Malarial Fever . 448 Yellow Fever .... 449 Eelapsing Fever . . . 455 Oerebro-Spinal Fever . 457 Typhus Fever . . . .461 Typhoid Fever .... 464 Plague 473 Erysipelas 474 Flood Fever of Japan . 475 Puerperal Fever . . . 476 Cholera 478 Diatheses 497 Rheumatism .... 497 Gout 502 Scurvy 505 Scorbutic Dysentery . . 506 Syphilis 507 Constitutional Syphilis . 609 Syphilizatiou . . . .511 Gonorrhoea 512 Scrofula 513 Rickets . . . ... . 515 Spinal Caries .... 516 Coxalgia 517 An£emia 518 CONTENTS. IX Pernicious AnaBmia . .519 Chlorosis 521 Beriberi 522 Mjxcedema 523 Leucocythfemia . . . 524 Hodgkin's Disease . . . 525 Pya3rnia; Septicfemia. , 526 Thrombosis ; Embolism . 528 Mucous Disease . . . 530 Angeioleucitis . . . .530 Whitlow 531 Onychia; Onyxis . . . 631 Carbuncle 532 Addison's Disease . . . 533 Goitre 534 Diseases of the Skin . . . 536 Exanthemata .... 536 Papulfe 537 Vesicul89 538 Bulte 541 Pustulaa 542 Squamae 543 Maculae 547 Hypertrophiaa .... 547 Tubercula 549 Haemorrhagiae .... 554 Neuroses 555 Parasiticae 556 Syphilida 560 Poison -Vine Eruption . 561 PACE Chilblains 561 Burns and Scalds . . . 562 Unclassified Affections . 562 Amenorrhcea .... 562 Dysmenorrhoea. . . . 564 Menorrhagia .... 565 Leucorrhcea 566 Irritable Uterus . . . 566 Ulcers of the Uterus . . 568 Uterine Tumors . . .569 Prolapse of Ovaries . . 578 Spermatorrhoea . . . 574 Entozoa 576 Cestoid Worms .... 577 Trematode Worms . . 579 Neraatoid or Round Worms 580 Epizoa 585 Poisons 585 Bites of Serpents . . . 589 Asphyxia 590 Eyesight, its correction , 592 Formula 601 Medicines referred to . . 601 Miscellaneous .... 624 Explosive Pharmacal Compounds .... 643 Metrical Prescriptions , 644 Aliments 648 Disinfectants 653 Index of Diseases and Formula 655 General Index 657 ILLUSTRATIONS. FIG. PAGE 1. Yellow Tubercle ... 36 2. Gray Tubercle .... 36 3. Tul)erc]e Corpuscles . . 36 4. Multinucleated Cell . . 37 5. Miliary Tubercles ... 38 6. Apex of Tuberculous Lung 39 7. Cicatrix of Lung ... 40 8. Giant Cells 43 9. Hypertrophy of Heart , 45 10. Pus Corpuscles ... 52 11. Bands of Lymph ... 53 12. Fatty Infiltration ... 56 13. Cancer Cells .... 57 14. Colloid Cancer .... 58 15. Colloid Cancer .... 58 16. Myeloid Sarcoma ... 58 17. Colloid Cancer .... 59 18. Lateral View of Brain . 64 19. Inner Sui'face of Hemi- sphere of Brain . . 64 20. Psycho-motor Centres . 65 21. Foreign Bodies in Urine 77 22. Urea 80 23. Uric Acid 80 24. Carbonate of Calcium, and Hippuric Acid . 81 25. Oxalate of Calcium . . 81 26. Oxalate of Calcium . . 81 27. Crystals of Tyrosin . . 82 28. Crystals of Leucin . . 82 29. Nitrate of Urea ... 84 30. Urates 85 31. Urate of Sodium ... 85 32. Urate of Sodium ... 86 33. Urate of Ammonium . 86 34. Triple Phosphate ... 87 35. Cystine 87 FIG. PAGB 36. Vaginal Epithelium . . 88 37. Epithelial Cells ... 90 38. Uric Acid Calculus . . 92 39. Mulberry Calculus . . 92 40. Area of Hepatic Dulness 101 41. Anterior Thoracic Re- gions ...... 104 42. Posterior Thoracic Re- gions 105 43. Pneumothorax . . . 106 44. Normal Position of Heart 110 45. Distended Pericardium . 112 46. Diagram of Heart's Ac- tion 113 47. Auricular- Systolic Mur- mur 114 48. Ventricular-Systolic Mur- mur 114 49. Ventricular-Diastolic Murmur ..... 114 50. Sims' Speculum . . .117 51. Sims' Depressor . . . 118 52. Fergusson's Speculum . 118 53. Sims' Copper Sound . .118 54. Emmet's Silver Probe . 118 55. Sponge Tent . . . .119 56. Laryngoscope .... 120 57. Laryngoscopic Drawing 120 58. Laryngoscopic Drawing 120 59. Ophthalmoscope . . . 122 60. Tubercle of Choroid . . 122 61. Choked Disk .... 123 62. Marev's Sphygmograph 124 63. PnW Tracing . . . .125 64. Radial Pulse Tracing . 126 65. Tracing of Healthy Pulse 126 66. Radial Pulse Tracing . 126 xu ILLUSTRATIONS. FIG- PAGE 67. Pulse of Aortic Eegurgi- tation 126 68. Pond's Sphygmograph . 127 69. Pulse in Thoracic An- eurism 128 70. Pulse in Thoracic An- eurism 128 71. Pulse in Bright's Disease 128 72. Typical Ranges of Tem- perature . . . .130 73. Temperature in Hectic Fever 132 74. Pneumatic Aspirator . 133 75. Apparatus for Trans- fusion 188 76. Red Hepatization . .195 77. Red Hepatization , .198 78. Gray Hepatization . . 196 79. Pleuritic Effusion . . 202 80. Vesicular Emphysema . 207 81. Dilated Bronchi . . .214 82. (Edema of Glottis . . 217 83. Trachial False Mem- brane 221 84. Bronchial False Mem- brane 222 85. Durham's Canula . , 224 86. Bryant's Oanula . . .225 87. Pericarditis, with Lymph 240 88. Thickening of Mitral Valve 244 89. Atheroma of Aortic Valve 245 90. Diagram of Cardiac Murmurs .... 246 91. Fatty Degeneration . . 248 92. Rupture of Heart . . 249 93. Exophthalmic Goitre . 251 94. Aneurism of Aorta . . 254 95. Aneurism of Aorta . . 255 96. Ulcer of Stomach , . 266 97. Perforating Ulcer of Stomach 267 98. Sarcinse 270 99. Gall-stones .... 280 100. Calculi in Gall-bladder . 281 101. Cholesterin Tablets . . 281 102. Intussusception . . . 284 103. Fatty Liver . ... 310 PIG. PAGE 104. Renal Hyperaemia . . 316 105. Renal Cysts .... 317 106. Casts in Bright's Disease 318 107. Granular Kidney . . . 319 108. Renal Epithelium . . 320 109. Waxy Casts . . . ,321 110. Sugar Fungus. . . .328 111. Miliary Aneurisms . . 349 112. Cerebral Hemorrhage . 350 113. Spinal Sclerosis . . . 355 114. Lumbar Sclerosis . . 356 115. Sclerosed Patch . . .357 116. Advanced "Wasting Palsy 366 117. Pseudo - hypertrophic Paralysis .... 367 118. Hystero-epilepsy . . . 392 119. Vaccination Scratches . 413 120. Temperature in Yellow- Fever 451 121. Cerebro-spinal Fever . 458 122. Ulceration of Peyer's Glands 467 123. Syphilitic Teeth . . .510 124. Blood in Leucocythsemia 525 125. Thrombosis in Saphena Vein 528 126. Embolus of Pulmonary Artery 529 127. Bronchocele .... .534 128. Elephantiasis Arabum . 548 129. Acarus Folliculorum . 550 130. Acarus Folliculorum . 550 131. Group of Acari Follicu- lorum . . . . 551 132. Acarus Scabiei — Male . 557 133. Microsporon Furfur . . 558 134. Hairs from Tinea Ton- surans 560 135. Hodge's Pessary . . .568 136. A. H. Smith's Pessary . 568 137. Echinococcus Hominis . 577 138. Taenia Solium . . . .578 139. Trichocephalus Dispar . 581 140. Trichina in Muscle . . 582 141. Encysted Trichina . . 583 142. Trichina, Magnified . . 583 143. Orthoscopic Glasses, , 598 144. Diagram to show Astig- matism 600 THE PRINCIPLES AND PRACTICE OF MEDICINE. INTRODUCTION. SYSTEMS OF MEDICINE. BEFOEE Lord Bacon, and before, in fact, all others whose writings have come down to us, Da Vinci, the architect, painter, and engineer, proclaimed, in the first half of the six- teenth century, that in the study of natural truth we must con- sult experience., experience rather than reason. " Those," said he, "who in the study of the sciences do not consult nature, but authors, are not the children of nature ; they are only her grand- children." "Nature begins from the reason and ends in expe- rience, but we must take the reverse course, — begin from the experiment and try to discover the reason." "Theory is the general, but experiments are the soldiers.'''' Not that these were the first utterances in all time in favor of the value of observation and experiment in acquiring a knowl- edge of nature ; but only that now, for the first time, these began to be the governing ideas of science and philosophy. Aristotle was a naturalist, although still more emphatically a dialectician ; Leucippus and Democritus founded a school whose dependence was almost exclusively on the evidence of the senses ; and even Cicero, who paid little attention to natural science, wrote this wise sentence : ''Praistat naturae voce doceri, quam ingenio suo sapere." But it is especially interesting to us to recall the fact that most clearly, perhaps, of all the ancients, was this reliance upon nature enunciated, and most practically was it exemplified, by Hippocrates of Cos. He asserted again and again in his works that " nothing should be affirmed concerning the nature of man until after having acquired a certainty of it by the aid of the senses." And, although this may seem very obvious indeed to us, yet it is a familiar fact that the great intellects of 2 13 14 INTRODUCTION. antiquity, from the sages of the Vedas and from Pythagoras and Plato downward, had more confidence in the tnath-compelling powers of their own reason ; and even Hippocrates himself often forgot his own maxims, and became dogmatic beyond his knowl- edge. It is not my purpose here to go into any historical discussion of philosophy, which would be inappropriate in this place. Nor will I attempt to crowd into a few pages the history of medicine itself. But it appears to me that I cannot better occupy space, in this introduction, than by endeavoring to place before the mind of the reader such a succinct view of the most essential phases and mutations of medical opinion, in times past and present, as will enable us to apprehend all that bears upon the aspects and prospects of the theory and practice of Medicine. In the midst of the multitude of authors who have written upon medicine, in every age which has possessed a literature, the number of cardinal ideas, of distinctive methods, opinions, or principles, has not been great. Those who may be considered to have been original thinkers or leaders in medical philosophy • have been few ; or, if we cannot refuse to a larger number the credit of originality, yet that of actual novelty is not often theirs, as they have merely started anew an idea, a principle, a system, or theory, which had long ago its propounders, its advocates, and its opposers, although it may have been again forgotten. Yet, few as these essential ideas have been, it will be impos- sible to do more than mention them, as it were, in catalogue at present. A work, for example, might be, and more than once has been, written upon the doctrines of Hippocrates, and of the writings classed under his name alone. Suffice it for us to recollect that the leading idea of this greatest of physicians was reliance upon and observation and imitation of nature. Yet he theorized upon health and disease, upon the four elements and the four humors, and his system has, therefore, been styled Dogmatic. To him, also, is traced the principle of medication by contraries ; ra havria Tuv kvavTLuv kariv 'irjuara. The greatest value of the Hippocratic writings undoubtedly consists in their numerous and admirable descriptions of the symptoms of disease, and of the relations of symptoms to prognosis. The study of hygienic laws and influ- ences also received from his school much attention. Contrasted with the Hippocratic reflective or dogmatic method of studying nature, was the more detailed and less systematic plan of the contemporaneous Cnidian school. Later, with Philinus and Serapion of Alexandria, the distinctly Empirical method was promulgated, in which observation, and this alone, especially as to the use of remedies, was urged. No reasoning about why or how^ but only what^ engaged the minds of these industrious men ; whose materials thus accumulated only too fast for their limited powers of classification. Their most elegant writer was Aretaeus, who is not always credited to them, but whose descriptions of disease have seldom been equalled, even down to our own day. It is less easy to characterize, in a few words, the school curi- S Y S T E M S (> F M E D I C I N E . ] 5 ously called Mvtlunlist, which orif^inatod with the opinions of Clcoplianlus of Alexandria, and of Asclepiades the liithynian, the friend of Cicero, and was estahlishcd hy Themison, their disciple, at Rome. Disniis.sing the expectant study of the course of diseases inculcated h}' Hippocrates, whicli they laughed at as a "meditation upon death," and denying his theory of "coctiou" and "crisis," tht^y dogmatized in a diflereut way upon the changes occurring under disease in the condition of the solid structures of the hody, and in the movement of its atomic com])onents. Making hut two essentially different pathological states, the "laxum" and the "strictum," they simplified the theory of medicine very much. Chielly, however, was Asclepiades dis- tinguished for the moderation of his practice ; rejecting complex, violent, and perturhatory remedies, and aiming, as he said, to cure " tuto, cito, et jucunde." A somewhat complicated course of alterative treatment is, however, ascrihed to his successors by Crelius Aurelianus, under the name of the " metasyncritic circle." The most judicious as well as one of the most learned of phy- sicians was Aulus Cornelius Celsus. He selected from the opin- ions and practice of his predecessors and contemporaries those of the greatest soundness ; so that, not having propounded any exclusive dogma, nor yet being limited l)y the narrow results of observation alone, he may be justly styled eclectic; or, as that term has been made odious of late by the usurpation of a set of pretenders, episynthetic, or comprehensive^ might be a preferable title. Galen, less carefully selective, although undoubtedly an ad- mirable man, excellent practitioner, and learned writer, renewed and added further strength to the hypothetical as well as the practical views of Hippocrates. From this time but little of original force appeared in medical literature until after the period of sevei-al centuries of mediteval darkness had been broken in upon by the revival of learning and intellectual activity, in the fifteenth and sixteenth centu- ries. In this revival it was natural that much recourse should be, at first, had to the treasures of the ancients. Plato and Aristotle divided the newly-revisited realm of philosophy, while Galen, as the exponent of Hippocratic doctrine, almost monopolized that of medicine, until Da Vinci, Telesius, Csesalpiuus, Campanella, and Bacon established the inductive method of observation and experiment, most obviously necessary for advancement in the physical sciences, of which medicine is one, — one, too, which, as Lord Bacon expressed it, had been previously "more labored than advanced." C/temisi)'!/, which had already received much attention from the Arabians, and which, under the fascination of alchemy, had reached valuable discoveries— which, in fact, in the hands of Albertus Magnus, Eoger Bacon, Basil Valentin, Isaac Hollandus, and others, had performed wonders, and, in the trumpetings of Paracelsus, had made still more extraordinary pretensions — chemistry was now ripening into a great science. In the seven- 16 INTRODUCTION, teenth century its influence upon physiological and pathological theory much increased, and the practice of medicine could not fail to be consequently affected. By Sylvius, of Amsterdam and Leyden, and by Thomas Willis especially, a school of CJiemiater, iatro-chemists, or chemical physicians, was instituted. Following the discovery by Harvey of the circulation of the blood, in the investigations of Sanctorius and Borelli, of Pisa, mechanics likewise found a place in the study of the functions of the body, in health and disease. An latro-meclianical school may be thus said to have existed, to which the distinguished Senac, physician to Louis XIV., among others, contributed, in a work of great ability. Boerhaave, JDrofessor at Leyden, endeavored to combine these, the chemical and mechanical modes of studying the body and its disorders, into an ingenious but complex ecrectic system of his own ; which his influence, as a man of genius, and one of the first of modern clinical lecturers, enabled him to extend far and wide. It was rather a dogmatical than an empirical eclecticism. The latter was admirably exemplified in the writings of Sy- denham, who has been well called the modern Hippocrates. Certainly there was a great resemblance between the methods of the Greek and English fathers of medicine. At the beginning of the seventeenth century there grew up, in the University of Halle, two opposing theories : the Animmn, or psycho-vitalism of Stahl, and the Solidism and neuro-pathol- ogy of Hoffmann. Stahl's doctrine was, in brief, that the soul of man governs health and disease. An expectant or do-nothing practice naturally followed from such a view. Hoftmann taught a less simple scheme ; but that part of it which seemed to the renowned and learned Cullen, the nosologist of Edinburgh, to be the most worthy of his adoption, was his appreciation of the importance of the nervous system in the production of the phe- nomena of disease. But the most brilliant of the meteors that have crossed the horizon of medical science, not disappearing, indeed, any of them, without leaving some solid precipitate of knowledge, was the Sthenic system of John Brown, of Edinburgh, the pupil, friend, rival, and enemy of Cullen. All life, according to this bold and able, although too reckless dogmatist, depends upon stimulation; all disease upon too much or too little excitement, causing direct or indirect debility. Ninety-seven cases of sickness out of a hundred, in his thera- peutics, require stimulation for their relief or cure. Wonder- fully simple this ! Haller's doctrine of the irritability of organic tissues was, very possibly, its source ; but so nearly akin was it to the great idea of vitalism, dimly seen by Pythagoras, an- nounced by Hippocrates, but lost for ages until revived and dis- torted by Yan Helmont and Stahl, and afterwards rendered more positive by J. Hunter and Bichat — so near was it to this imperishable idea, that Brown's theory, thus supported at once by ancient philosophy and modern discovery, had an unprece- dented influence upon medicine. All theories, and theorists, during and since his time, unless we except the discreet vitalism SYSTEMS OF MEDICINE. 17 of Barthez, of MontpcUier, have reflected or refracted, with various modilications, the Brunonian ray. What have we had since, in fact ? liasori, in Italy, adopted Brown's pliysiological basis, but considered that excita1)ility and excitement were multiple, and unequally distributed, in disordered states, in different organs ; and, moreover, tliat over-excitement was nmch more frequent, and demanded more attention in prac- tice tlian Brown had supposed. Hence arose his sedative or " contro-stimulant" method, by large bleeding and tartar emetic ; so famous once, especially in the treatment of inflammatory afiec- tions of the chest, Broussais, in France, proceeding upon the same original basis, saw in local irritation and inflammatio)i, mostly of the alimentary canal, the scat and centre, the fans et origo of the dynamic or excitational error which caused all diseases. His practice varied from both Brown and Rasori ; his whole object being to calm and allay the central irritation by diluents, demulcents, local de- pletion, and counter irritation, avoiding all heroic treatment. In this country, which can hardly be said to have had a system before Rush, that noble and independent mind was also influenced by the Brunonian radiation ; although a still different view of pathology and therapeutics resulted from his reflections and ob- servations. The " unity of disease" was, with him, a favorite idea. Although his strong good sense did not allow this to ex- clude from his appreciation remedies and modes of treatment not easily reconciled with such a scheme. Rush evidently leaned much toward the opinion that all acute diseases were but different "states of fever ;" for the mitigation of most of which the lancet was the potent and indispensable remedy. In this he resembled Rasori rather than Brown or Broussais. Even earlier than the universal dissemination of the teachings of the latter, the dis- tinguished successor of Rush, Dr. JSTathaniel Chapman, of Phila- delphia, claimed and afforded evidence that he had first taught the theory of the local origin of fever, in irritation of the alimentary canal ; but he did not allow it to modify his practice in the same manner as Broussais. A part of the practice of Brown has, under the teachings of the late Dr. Todd, of London, constituted a medi- cal " fashion" of the day, as an almost undiscriminating alcoholic stimidism. Now, let us look back. Who have been the laTp6-iTpo(ptjTai., the great leaders in medical speculation, the reformers and deformers of medical practice? The list is not a long one, although its scope of time reaches over two thousand years. Let me hazard their enumeration. Hippocrates, Serapion, Asclepiades, Celsus, Syl- vius, Harvey, Borelli, Sydenham, Boerhaave, Stahl, Hoffmann, Haller, Cullen, Avenbrugger, Brown, Jenner, Hunter, Bell, Bichat, Barthez, Pinel, Rasori, Rush, Laennec, Broussais, Louis, Liebig, Yirchow, Brown-S^quard. And what have been their essential ideas, stripped of all their complexities and environments? Naturalism, empiricism, eclec- ticism, humoralism, soUdism, chemicism, mechanicism, neuro-pa- thologij, stimidism, plilogisticism, pyrexism, vitalism, and of recent date cellular pathology and physiological therapeutics. I leave 2* B 18 INTEODUCTION. out of the list the Thomsonian extravaganza of thermalism, and the Hahnemannic homoeopathism, as, however serious may have been their detrimental 'effect upon the welfare of the public at large, they have scarcely influenced the progress or present status of medical science, either for good or evil. Hy natiiralisni I mean dependence upon nature, and systematic imitation, in practice, of. her spontaneous curative processes. We have already referred to this as the leading Hippocratic idea. It was rejected by the early Methodists, practically repudiated by Cullen, and systematically excluded by Kush. More recently it has been conspicuously illustrated and defended in the lucubra- tions of Sir John Forbes, following those of Dr. Bigelow, of Bos- ton, upon "Nature and Art in Disease ;" to the former of which the sobriquet of "Young Physic " has been applied. " Expectancy" is a term now frequently used, to dignify what amounts sometimes to absolute inertness of practice ; upon an idea, latent or declared, that all medicines are impotent, and that active interference with the self-limitations of disease is never justified by science. This is but a reaction, certainly extreme, from the 2^olyphar'm,acy and hypertherapy of the past. Empiricism is strict adhesion to experience ; the accumulation of means of treatment simply by observation and experiment, independently of physio-pathological reasoning. Tlie most favor- able example of this among the ancients, was Areteeus ; of dis- tinguished moderns, Sydenham, Laennec, and Louis. Eclecticism or episythetism is, of course, the selection or combi- nation of what is deemed best in several methods, as, in practice, of means or measures, some of which have been obtained by mere observation, and some from physiological reasoning or deduction. Celsus afforded the most beautiful early example of this ; it has been exemplified, although at the same time, somewhat paradoxi- cally, derided, in our own period, by Trousseau, of Paris. All of the other systems which I have named are phases of nationalism^ which is the proper antithesis of Empiricism. Solidism, first broached perhaps by the ancient school of Ascle- piades, with its laxum and strictum, was urged to its farthest limit in the mechanicism of Borelli, and in the neuro-pathology of Hoff- mann, Cullen, and Henle. It was taught in Philadelphia for twenty-five years by Professor N. Chapman. Humoralism, the older view, which saw in changes of the fluids all that was essential in disease, pervaded the system of Galen, and the G-alenists of the fifteenth and sixteenth centuries. The chemists generally have had a natural leaning towards it. In this country it was represented at one time by Dr. Hosack, of New York. A very distinguished example of it has lately been known and respected in England, in the lamented Eobert Todd, of London. Cfiemicism was boldly inaugurated by Sylvius De Lebo, in the seventeenth century, but has received its ripest contributions in the two last decades ; especially from Liebig and the other chemi- cal physiologists, Lehmann, Moleschott, etc. Meclianicism, as an exclusive system of physiological or patho- logical reasoning, was never permanently established, its influ- SYSTEMS OF MEDICINE. 19 ence, as affordino; even a predominant l)ias, having been always confined to a few thinkers during a brief period. Neurn-patholngi/ has had a more important place ; dividing with a modified humoralism the domain of medical theory, even down to the present hour. We can never dismiss tlie consideration of the nervous centres and their communicating nerves from the study of tlie human functions, healtliy or morbid. So that, al- though it is decidedly an error to say, as some liave done, that man is all brain, or tliat the "nervous mass" is the animal, yet the nervous system must be made prominent in all medical in- quiries. Enough has been said already to explain the nature and pow- erful influence of the Brunonian theory of excitement, or of sthenia and asthenia, which I have named under the title of stimulism. It was one step towards the application to pathological and med- ical truth of dynamic physiology, that study of the forces of the living body, in connection with the constantly acting forces of external nature, which is now, or soon, destined to rule supremely, not as excluding, but as guiding our investigations of the chemical and mechanical changes both of the solids and of the fluids. Life is not merely excitation ; but normal excitation is one of the requisite conditions of the performance of all the functions of the body, not even excepting that of growth and development itself ; since to this a certain degree of heat at least is essential, Rasori was, moreover, right in saying that excitement is not a xmit for the whole body, but may be unequal in its different parts ; and, moreover, that excess of excitement of one or more organs or functions is as frequently present in acute diseases as the reverse. So, too, Broussais made a just amendment of the same scheme, to a certain extent, in noticing the sympathetic and secondary efi'ects of local irritation ; although he, as well as our Chapman, undoubtedly exaggerated the relative importance of irritation of the stomach and intestinal canal. We need not pause for a moment over the Stahlian theory of the organic soul or autocrateia ; although very lately a view much like it has been again taken, by Laycock and Morell, under the cognomen of the " unconscious soul ;" and in biology, under that of "plastidule soul," by Haeckel. A recent phase of revolution in the scientific basis of medical opinion, has been that which, in the language of its most emi- nent leader, Virchow, of Berlin, we may designate as cellular pathology. Associated in similar, although not quite identical views, have been Prof. Bennett, of Edinburgh, and Dr. Addison, of London. It has been a favorite idea with the physiologists of our period that, in the general law of organic cell-genesis, the fact that every living being, human, animal, and vegetable, springs from a globoid germ-cell, while most of the separate tissues also have the cell for their first starting form ; that in this we have the great central radical fact of physio-pathology, out of which (as in physi- cal science out of the Newtonian law of gravitation) all truth in 20 INTRODUCTION'. the history of the animal organization, and tlius in medicine, must grow. But Dr. Bennett, an earnest teacher of molecular physi- ology,^ denied that to the cell doctrine can be awarded such a place or potency; as it is not a universal law, but has its manifest exceptions. Dr. Beale, also, a leading British authority in his- tology, insists upon some essential modifications in Virchow's theory. It does not belong to me to discuss this point here ; but, as it bears largely on the theory of medicine, I will merely say that if there he one fact or idea which more than any other is the gravi- tative centre of all truth in physiology, pathology, and medicine, it is that of the peculiar agency and supremacy in the body of the life-force., and of its intimate relations with the other physical forces f of its being, in fact, capable of degrees of life temperature, like those of heat temperature, in the body as a whole, and in its various parts and organs ; of its manifesting attributes or laws, like the other forces or phases of impetus and molecular movement in nature ; which must be much more patiently and thoroughly studied than they have yet been, before we can be said to under- stand the human economy, even so well as astronomers now do the solar and sidereal systems. This brings us towards the conclusion of our inquiry. "We have been examining, in this brief manner, several schemes of rational- ism. But as the use of facts and ideas in the practice of medicine is our standpoint, we must now ask, Is rationalism available for the treatment of disease? Is physiology perfect? How much of it is positive? We are compelled to answer — Physiology, and with it necessarily pathology, is one of the least matured, because one of the most complex of the sciences. What would be said, then, were a man to undertake to repair a watch, when he had never seen its works in motion, and had n.o proven knowledge of the mode of action of nearly all its machinery? If he should find on trial, that hanging it up, or laying it down, or shaking it when it stopped, or keeping it warm or cold, promoted its good time-keeping — very well ; let him do so. But if, in this state of uncertain knowledge, he should seize and alter, with fingers or forceps, the delicately arranged and complicated wheels and springs, would not the chances be that he would do more mischief than good? Nor would reasoning about possible or probable watches, theories in chronometry, avail him much towards the medication of the particular timepiece in his hands. Yet this is our position, as physicians, regarding the present relation of physiology and pathology to the actual treat- ment of disease. It seems, therefore, only a slight over-statement of Trousseau's that nationalism in medicine leads only to absurdities. We might easily confirm Trousseau by other authorities, early and late. Stahl spoke of the materia mediea of his time as a "stable full of otfal." Sydenham complains that practice was "pestered with too many eminent remedies. " It is said that when 1 Clinical Medicine, Introductory Lecture. 2 See Grove, Carpenter, and others, on the Correlation of Physical and Vital Forces ; Tnman, Foundation for a New Theory and Practice of Medicine; Chambers, Renewal of Life, etc. SYSTEMS OF MEDICINE. 21 Sydenham was asked by Sir R. Blackmore what book to begin his medical studies witli, he replied Don Quixote. Biehat denounced the vasjjue theories of medication prevalent in his day, and dciclared that hut little was really positive in our knowledge of the action of remedies. Pinel had so little conlidi'uce in therapeutics that his only study of disease was for a naturalistic classification: "Given a certain malady — to find its place in the nosological system." Laennec considered physiology and pathology "vain amusements of the mind." Says Lebert, "We cannot yet, unhappily, con- struct therapeutics on the basis of scientific medicine ; and with the best intentions in the world we can regard the greater part of its precepts but as the result of emi)iricism." But, some may exclaim, this is treason 1 This would remove the practice of medicine from science altogether, and leave it at the mercy of Paracelsus, and Cagliostro, and the old women ! Not so. "We have only to turn back to the grand platform of Bacon, on which all modern science is built, to see that to found the practice of medicine on ohservation is to make it eminently scientific. What science can do without empirical observation ? Can physics, or astronomy, or chemistry V ISTone of them. How irrational, then, to attempt to reason out, a priori, therapeutics, or to place it upon any other principal basis than clinical observa- tion ! Blind, uninstructed, unsystematic empiricism is a bane to society, and a disgrace to the human intellect. ^ But scientific empiricism constitutes the most rational practice attainable, while physiology is imperfect. What is most wanted now, is more jjositivism in medicine ; more exact observation of clinical and therapeutical facts. It is otherwise in most of the natu- ral sciences. Agassiz, one of the great leaders in science, re- marked that thought and generalization are now esipeciaWy required amongst naturalists ; who are in danger of being buried among their multitudinous detailed facts, as knights of old, sometimes, were borne down by the vv^eight of their own armor. But it is not so in our science. Medicine needs more fact and less theory. I could sustain these positions by argument, by citation, and by example ; but we have no room. The proposition must be barely stated, that the most complete knowledge possible of a disease will never alone inform us, what will be the effect upon it of any remedies, until experience has put them to the test. The tv/o blades of the scissors of practical medicine are, diagnosis and clinical proof; physiology and pathology may, perhaps, be com- pared to the handles ; but to the former, rather than to the lat- ter, belongs at present the chief function of guidance in our action. Our total ignorance of the modus operandi of any agent does not in the least interfere with its availability in the treat- ment of disease, when that treatment has been proved to be suc- cessful. We do not know — nor does the chemist require to know — why sugar is sweet, or sulphuric acid sour ; or why the latter will redden litmus, while an alkali will render turmeric brown. 1 1 advise no one to imitate the follies of Cato the Censor ; who, while he forhado his son ever employing a physician, yet dosed his own wife to death, attempted to reduce dislocations by repeating magical words, and wrote a book, in which he recommended cabbage as a sovereign remedy for many diseases. 22 INTRODUCTION. It is no more necessary^ although it would be interesting, to know how bitters improve the appetite, or iodide of potassium cures syphilitic rheumatism. "We may use opium to produce sleep, or lull pain, although we know little more than Moliere's doctor — " opium facit dormire, quia est in eo virtus dormitiva." It was, in fact, as was long ago observed, " only after men had found remedies, that they commenced to reason upon them." The most remarkable treasures of medicine have been discovered almost by accident, and have obtained their place in the materia medica often against the protests of the theorists. Opium is one of the oldest of drugs. Iron is nearly as ancient. Mercury was a contribution of the alchemists. Arsenic and colchicum appeared first as secret remedies. Iodine (in burnt sponge) and sulphur were popular and domestic before they were professional medi- cines. And did not the French Academy formally denounce tar- tar emetic ? Did not all the schools disbelieve in cinchona, be- cause it neither sweated, puked, nor purged ? And Jenner, who drew the idea of vaccination, by a most sagacious induc- tion, from a popular tradition of the country, against what strong theoretic opposition did his noble discovery have to estab- lish itself ! Nolens volens, then, we have to acknowledge our indebtedness, in therapeutics, to empirical observation. But it is the vocation of the true physician to make it scientific. To know that two cases of disease are really alike, and not onlj'^ apparently so, in order for the application to them of the same remedies ; to make accurate comparison of the virtues of different modes of treatment, avoiding the " post hoc propter hoc " fallacy ; and to appreciate the conditions and circumstances which modify the actions of medicines, as they do the course of diseases ; these are tasks which enlist the highest faculties of ixnalysis, as well as of obser- vation. Moreover, medicine is progressive. Even an incompleted phy- siology may suggest safe and proper experimentation. For good diagnosis we need pathology ; for pathology, physiology is indis- pensable. We do not admit, then, with Laennec, that these beautiful sciences are but "vain amusements." We look for- ward to the day, when the laborious and intelligent culture they are now receiving, will be repaid by a tenfold harvest, x^ractieal as well as abstract. The time may come, when the why and how of therapeutics may be largely as well as accurately ex- plained. But practical medicine, having its crying necessities, cannot wait for such an era ; let it use its facts, and not be mis- led by false expectations,^ Yet, we must remember, that it is the facts, not of the experi- ence of an individual, which most of all is " experientia fallax," but of the aggregate experience of the whole profession, in all time, that constitute the body of therapeutical science ; which should, as Dr. Todd has said of pathology, be reviewed and reconsidered 1 " When there is no certain knowledge of a thing, a mere opinion about it cannot discover a sure remedy." " Medicine ought to he rational ; but should draw its methods from the evident cause ; all the obscure being removed, not from the attention of the artist, biUfiom the practice of the art." — Celsus, Treatise on Medicine. SYSTEMS OF MEDICINE. 23 from time to time ; Imt which can never be abandoned or rejected. It is not well, then, to call the great ph3^sicians, our predecessors, as Dr. Bennett has done, " blind guides." Rather may we, with the late Dr. Alison, believe that a disagreement between a newly- broached pathology and the practical experience of all time is a much better reason for setting aside the new pathology than the old practice. Just now (1881) a form of medical rationalism is particularly in vogue, under the guise of jjhi/siohyical or experimental thera- peutics. Since its principal reliance is the application to the treatment of disease of inferences drawn from the eflfects of drugs upon living animals, it may be called, without injustice, the system of toxico-therapy. That experiments with medicines upon animals may have very consideral)le suggestive value, there is no doubt. The error here, as in regard to the kindred subject of vivisection in connection with normal physiology, consists in overrating its comparative authoritij ; as if it were, instead of a subordinate method, supreme above all others. Objections to its being permitted to rank higher than, or equal to, clinical obser- vation (the true experimental medicine) are, briefly, these : first, the frequent differences between the effects of the same agent upon man and upon animals, as well as amongst animals them- selves ; and, secondly, the great importance of differences in the action of drugs in states of health and states of disease, whether of men or animals.^ We may sum up the substance of the foregoing remarks, by asserting that the therapeutical methods or principles upon which we may deal with, the treatment of disease are essentially three :^ the natural, hygienic, or expectant ; the specific, or purely empirical (including the tentative) ; and the conditional (including the perturbative or alterative). Of the first two quite enough has been said. Of the last it will suffice to say that it is the most of all open to suggestion from positive physiology and enlight- ened pathology. It comprises the rational treatment of diseased conditions of the body, for which no direct or specific remedy has been discovered ; a part of medicine of very great importance, but in which the greatest variation has necessarily occurred in the past, and continues yet to exist. This is the debatable ground, upon which tournament upon tournament and crusade after crusade have been fought ; the world at large looking on sometunes with more amusement than profit. The lesson of these petty wars, however — pre-indicated clearly by the old clas- 1 A clear account of the former of these difficulties may be cited with advantage from an extreme advocate of " physiological therapeutics," Prof. H. C. Wood. In his Treatise on Therapeutics, Materia Medica, and Toiicology (2d edition, p. 423), while discussing the calomel question, this writer says: "The canine diet and digestion are sodiiferent from the human, that it is to be expected that medicines acting upon the digestive apparatus will influence dogs differently from man." Hence, experimental evidence must be "all laid aside when we desire to study the question as to the cholagogue action of remedies upon man ; and our conclusions must be based solely upon clinical evidence." Without laying aside any of the facts concerning experiments upon ani- mals, we may unhesitatingly apply the concluding words of the above sentence gen- ernl/j/ ; by saying that whatever suggestions or explanations may be contributed by physiology and toxicology to practical medicine, its final conclimoiis upon the treat- ment of disease should always be based upon clinical evidence alone. ■■i Lordat. See Kenouard's Hist, of Medicine. 24 INTRODUCTION. sical writers upon medicine — has been at last tolerably well learned : Not to do harm when we are unable to do good; the reversal of the old maxim, " melius anceps quam nullum remedium," be- cause, in the restoration of a patient from disease, the physician is not the only nor even the stronger agent, nature being the principal, he only the accessory. ^ Some have given credit for this medical gospel to distinguished recent writers, as Dr. Bige- low and Sir John Eorbes ; but they are revivers of the doctrine only, not its discoverers. Hippocrates distinctly recognized the self-limitation of many diseases. Td Kpivd/ueva koL to. KSKpifiiva apTiug fii] KLVEELv /iTjSe veuTepoTToieEiv, iii]Te (pap/xaKETjai p.rjr'' alloiULv ipEdLGfioiaiv^ alV kav.^ So also did Asclepiades, notwithstanding the protest of his sect against Hippocratism, when he said that the best cure for a fever is the fever itself.^ So did Sydenham* and others who wrote long ago. We may, perhaps, safely divide the progress of historical medicine (as to its predominant tendencies) into three great periods. 1. Indefinite^ often heroic, always venture- some tentative practice ; lasting from archaic times down to near themiddle of our nineteenth century. 2. Under a somewhat de- spairing reaction from this has come the era of medical scephasm, minimism^ expectancy; which qualities characterize much of the ordinary practice of to-day. 3. Following this, it may be hoped, will yet come the scientific medicine of the future: definite in its facts, clear in its indications, positive in its therapeutic measures ; in accordance with a well-ascertained knowledge of the body, in health and disease. And now, although Dr. Bennett, of Edinburgh, predicted the "approaching downfall of empirical practice," yet his co-laborer. Dr. Todd, of London, urged in his last words the importance of its support in clinical research ; and the philosophic medical his- torian, Renouard, seconding the eflforts of Louis, the founder of the numerical method, andlfollowed by the lamented Niemeyer, Sir W. Jenner,^ and others, has foretold the coming triumph of rational empiricism or inductive medicine. We may well believe that this prophecy will yet be fulfilled. iChomel. 2 Aphorism 20, Section 1st. ^Cselius Aurelianus. 4" To imagine that nature always needs the aid of art is an error, and an unlearned error, too." 5 " It is to the experience of the mass of the profession that we look for the final establishment of doctrine, and of rules of practice."— fAe Practical Medicine of To-Bay, 18G9, p. 7. PART I. PRINCIPLES OF MEDICINE. SECTION" I. GENERAL PATHOLOGY. DISEASE may be defined as a perversion either of the functions or of the structure of the body or of any of its parts. It is, in other words, a deviation from the normal physiological state or action of the organism, under the disturbing influence of morbid causes. The seat of disease may be In the constitution: e. g., secondary syphilis ; scrofula. In special tissues: e. fir., mollities ossium. In particular apparatus: e. g., dyspepsia ; neuralgia. In individual organs : e.g., pleurisy; cirrhosis; hydatids. In the blood: e. (/., anaemia ; scorbutus ; typhus. Of course disease may be, and generally is, not limited to what is to be regarded as its principal or original seat. For example, in cholera, while its cause, no doubt, acts first upon the blood, the ganglionic system also is affected, as well as the stomach and bowels, etc. Morbid states of the system : — Eever ; Toxaemia ; Anremia ; Plethora ; Cachexia ; Depression ; Exhaustion. Morbid states of organs : — Hypersemia ; Hyperfesthesia ; Hypertrophy ; Inflammation ; Atony ; Exhaustion ; Atrophy ; Degeneration. Of the above, the most important general or systemic morbid 3 25 26 GEXERALPATHOL,OGY, states may be included under fever, toxaemia, and cachexia ; con- stituting a sort of "■ tripod " of systemic disease. A similar tripod of the most frequent and important local dis- orders may be established, of irritation, inflammation, and atrophy. GEWEKAL PATHOLOGY OF AFFECTIONS OF THE SYSTEM. FEVER. In using the term fever, as applied to a morbid state of the system, we must remember that the same word is also used as a part of the designation of several complex diseases: as typhus fever, yellow fever, remittent fever, etc. This double use of the word is unfortunate, but cannot now be avoided. Symptoms of Fever. — Increased heat of the whole body; Dryness of the skin, mouth, etc.; Diminution in hulk of the excretions ; Muscular debility ; Frequency of the pulse ; Functional disturbance of stomach, brain, etc. Heat is the most essential characteristic of the febrile state, having given name to it in all languages. Notwithstanding the scantiness in quantity of the stools, urine, and perspiration in fever, it has been shown by Virchow, Yogel, Bocker, Parkes, Jenner, and Plammond, that the actual amount of solid matter excreted^ especially by the kidneys, is generally in- creased. We have, in the heavy, offensive odor of the breath, evi- dence that it, too, contains an excessive amount of decomposing organic material. It is highly probable, also, that much excremen- titious matter is, during fever, retained in the blood. It has been observed, that if a local inflammation, as pneumonia, occurs during the febrile attack, the excess of secreted solids disappears until the inflammation has passed. Dr. C. Anton Errald, as well as Ley- den and Frankei,^ upon the basis of numerous careful observations, asserts that the amount of carbonic acid excreted is always in- creased during fever.^ Ammoniacal matter, also, is present in the breath exhaled, in sufficient amount to form (Fothergill) crystals of chloride of ammonium when a glass slide moistened with hydro- chloric acid is held under the nostrils. Brattlcr^ ascertained a close correspondence between the amount of urea passed in the urine and the temperature ; "the greater the amount of urea, the greater the temperature. " When perspiration is absent, there is evidently, also, a dimin- ished loss of heat from the body, which, of course, promotes its accumulation. This is very important. This increase of the disintegration of the substance of the body is, at present, one of the most prominent and interesting phenom- ena connected with the pathology of fever. The whole subject, however, is surrounded by obscurity, notwithstanding the fact that 1 Cen trail )latt, f. d. Md. Wissenshaft, Sept. 28, 1878. 2 Philadelphia Medical Times, September 20, 1873; translated from Archiv fUr Anatomie, Physiologie, etc. ^Uuoted by Murchison, in his work on Fevers. TOXiEMIA. 27 the symptomf; and aspects of the febrile state have been familiar ever since man became a prey to disease. On the basis of the facts observed and scrutinized at the present tinic!, I think we may venture to throw out a comprehensive theory of fever. Thus — its ess(!ntial phenomenon is increased heat of the body ; this bein)scrved in experimental inflammation : " traumatic interference, disturbance of circulation, exudation of fluid and morphological constit- uents, disturbances of nutrition, now formation." INFLAMMATION. 51 osseovis, cnrtilafjinous, or vascular tissue, or into epithelium, etc. (rarely into muscular or nervous tissue), or its degeneration into pus, or (jranule cella^ exudation (/ranulcs, etc. The rapid resorption of a moderate amount of exuded lymph constitutes the resolution of an intlammation. Its development is also a form of resolution, but with modifi- cation of the condition, dimensions, etc., of the i:>art. This is, in some instances, merely restorative. The degeneration of the exudation results in its being throvm off, as pus, or finalh/ absorbed , in the form of molecular exudation- granules. Whether immediate absorption, development, or suppurative or granular degeneration shall occur in any particular case of inflammation will depend — 1. On the state of the blood ; 2. On the seat of the inflammation ; 3. On the degree of inflammation. (See Paget's' experiments as to the influence of the state of the blood on the lymph of vesication. ) As to the seat of the attack, genercdly, serous and synovial tis- sues (pleural, peritoneal, arachnoid, articular) are most subject to (ulhesive inflammation, i.e., with the exudation of fibrinous lymph. Mucous tissues seldom exhibit this, being more prone to su2)purative inflammation. (Exceptions in croup, dipMlieria, etc.) Parcnchi/matoua tissues, as those of the lungs, liver, etc., when inflamed, may suppurate, or the lymph exuded may degenerate into exudation granules, and be finally absorbed. The degree of the inflammation exercises an important influ- ence. The greater its intensit}^ or severity (i.e., the more de- cided and extended the local lesion of nutrition and the concentric hypercnnia), the further will the lymph exuded be removed, in its primary chax-acter, from that transuded iu the natural state of the part, and the more will its subsequent changes differ from those of normal nutrition and development. Degeneration may affect both the fibrinous and the corpuscular portions of inflammatory lymph. The fibrinous part is subject to — 1. Drying into horny concretions (as on the valves of the heart, from endocarditis). 2. Feitty softening. 3. Liquefactive degeneration. Both of these last contribute, no doubt, to the process of sup- puration. Calcareous and pigmental degeneration are also de- scribed as occurring in it occasionally, but they are less important. The corpuscular portion of lymph may also undergo — 1. Withering and drying (as in scrofulous inflammation of glands). 2. Conversion into gramde cells (inflammatory globules of Gluge), hy fatty degeneration. 3. Calcareous, or 1 Surgical Pathology, Phil, ed., p. 220. 52 GENERAL PATHOLOGY. 4. Pigmental degeneration. 5. Host commonly, degeneration of the lymph-cells into pus- cells ; the whole of the lymph being transformed into pus. Pus is a greenish-yellow, creamy fluid, consisting, under the microscope, of the liquor puris and pus-cells or corpuscles. Tlio latter are definite cell forms, larger than blood or lymph cor- puscles, somewhat more irregular, and often containing several nuclei. Their characters, however, are not invariably distinctive; as might be anticipated, from their being merely transformed or degenerated lymph, blood, of Fig. 10. epithelial corpuscles ; or, in a wound or ulcer, cells of granulation. The assertion of Cohnheim,! ^f 33erlin, that pus-corpuscles are white blood-cells which have em- igrated through the un- broken walls of the blood- vessels, should not be finally accepted without very full confirmation. Professor Koster, of Utrecht, thinks he has obtained similar re- sults. Professor K. Balogh,^ of Pesth, after great care, failed to confirm them ; and the same is reported by Feltz and Picot. Lebert, Strieker, Caton, Woodward, and others find their observations to accord with them. If the fact of migra- tion (Recklinghausen) of the colorless corpuscles be granted, it does not follow, as Strieker has shown,^ that all pus-cells are of this origin. Some, most probably, are, as before taught by Paget and Virchow, of local origin. Strieker announces his discovery of the divisio7i of the "nomadic cells or pus-corpuscles." It has, perhaps, also, not yet been proved to be quite impossible, that what Cohnheim believes to be emigrating corpuscles, may be nuclei of the capillary walls, which, as described by Beale* "are at definite intervals, often on alternate sides of the tube," and, according to his opinion, " may give origin to the white corpuscles." Chemically, pus may be approximatively tested by its solubility in liquor potassce. Suppuration is either circumscribed (as in abscess), diffusive (in erysipelas), or superficial (in leucorrhoea, etc.). The effects of inflammation upon the part or organ involved are Enlargement ; Degeneration ; Induration i ; Ulceration ; Softening ; Mortification. A. Pus Corpuscles (magnified 350 diame- ters). B. Same made transparent with acetic acid. a. Cell wall. b. Nucleus, c. Nucleolus. (After Lebert.) 1 Virchow, Archiv. Band 40, s. 38. 2 Brown-Sequard's Archives de Physiol., etc., 1869. 3 Studien aus dem Instit. fur experiment. Pathol., 1869. See, also, a paper by Dr. S. H. Chapman ; Am. Journal of Medical Sciences, October, 1872. 4 Microscope in Practical Medicine, 1867, pp. 165, 166. INFLAMMATION, 53 We thus see that very different or even opposite results may- follow from different deqrces or kinds of inflammatory action. Specific inrtammatiohs require merely to be mentioned here. They are, chiefly, scrofulous, erysipelatous, rheumatic, gouty, diphtheritic, exanthematous, syphilitic, gonorrhoeal. These are distinguished from ordinary inflammation and from each other in that— 1, each exhil)its a peculiar pMn of morbid process ; 2, each depends upon a peculiar cause; 3, the effects of the said cause are irrespective of its quantity mostly \ 4, they are especially diffusible from one part of the body to another ; 5, they sometimes exhibit definite stages of the morbid process (e. g. primary and secondary syphilis); G, they are nearly all, in a more strict sense than other inflammations, self -limited \ the morbid process dying out after a certain time. (This last statement applies especially, if not only, to exanthematous, diphtheritic, rheumatic, gouty, and gonorrhoeal inflammations ; hardly to the scrofulous, erysipelatous, and syphilitic.) It maybe questionable whether erysipelatous inflammation is a truly specific process •, as reason has been shown for believius; that its peculiar character may be owing to the tissue which it chiefly affects ; viz., that of the lymphatic system. Fig. 11. Bands of Lymph in Peritonitis. The post-mortem appearances of inflammation are important. They can be generalized, so as to avoid, to a great extent, the necessity of their reiteration in connection with the description of particular diseases. It is, at the same time, necessary for the student to familiarize himself with them, in their local manifes- tations, by availing himself of every opportunity for autopsic study. A part which has been inflamed will exhibit after death some, or perhaps all, of the following signs : 54 aENEEAL PATHOLOGY. Bedness ; Coagulable lymph ; Enlargement of Pus ; blood-vessels ; " Softening ; Tumefaction ; Induration, The redness of inflammation must be distinguished with care from — 1st, hypostatic injection, or cadaveric settling of blood in the lowest parts, by gravitation ; and 2d, physiological redness, as of the stomach during digestion, the ovaries during menstruation, etc. Inflammatory redness is usually more unequal than either of the above, and is stellated, or in streaks and patches. Enlargement of the blood-vessels of a part may occur as the result of a chronic affection, different from acute inflammation. This sign, therefore, is to be interpreted with great caution. The same is true of tumefaction (general swelling of the part). Softening, if not cadaveric (as when the body has been long defunct), may have been produced by chemical action, as in poisoning by corrosive sublimate, etc., by acute and rapid inflam- m,ation, or by slow, non-inflammatory degeneration. Induration may also follow either acute inflammation, or slow, atrophic degeneration. Sclerosis is the term now commonly applied to it, especially in connection with morbid affections of the cerebro-spinal system. The presence of bands or membranes of coagulable lymph is indisputable evidence of inflammation having occurred in the part. But it is not easy, in all cases, to determine with certainty whether such formations are old or new. The existence of pus is a still stronger sign of the recent exist- ence of inflammation ; but, occasionally, instances occur in which pus, produced by inflammation in one part, is conveyed (as in phlebitis) by the veins, etc., and deposited in another. This, al- though a rare event, is possible at least. Clearly, therefore, no one of the above post-mortem signs of inflammation is sufficient alone. Several of them together will make the diagnosis certain. Bedness and enlargement of hlood-vessels, with lymph or pus, and softening or slight induration of tissue, will leave little or no doubt in any case. The variations in the appearance of different organs and por- tions of the body, in fatal cases of inflammatory disease, are not such as to interfere with the correctness and availability of this general description. CHRONIC INFLAMMATION. The term "chronic inflammation," as commonly applied, is a misnomer. Although the cases so designated exhibit more or less redness, heat, swelling, and pain, yet they are wanting in exudation; without which, pathologically, there is no inflamma- tion. There is also, in the same cases, only a partial stasis or none; and the hyperoimia is less intense and less strictly concen- tric than in acute inflammation. The characteristics of this state, for which a new term is wanted, are — 1. Enlargement of the blood-vessels of a part (chronic hyper- semia), with the flow of a large amount of blood through it. DEGENERATION. 56 2. Exaggeration of the sensibility of the part (hypersesthesia) and morbid irritability. 3. Deficient or irregular functional power. 4. Unusual proneness to acute or subacute attacks of actual inflammation. For this familiar combination of pathological elements I pro- pose the name hyperaemaestliesia. It has, with some, boon usual to designate it by the term "irritable," in connection with the name of the particular part aflected, thus — Irritable uterus ; Spinal irritation ; to which I would add — Irritable eye (chronic ophthalmia) ; Irritable stomach (chronic gastritis) ; Irritable brain, etc. Erythromelalgia is a descriptive name applied to an unusual affection of the extremities (nearly always the feet) observed and reported upon by Graves, Vulpian, Weir Mitchell,^ Launois,^ and others. Its signs are, burning pain, bright red flushing of the feet, turgescence of the blood-vessels, and violent arterial pulsa- tions, with local increase of temperature. It is clearly a condi- tion of active hyperKinia, with hypercesthesia. (According to the erroneous current ideas of vaso-motor physiology, it is called by authors an instance of vaso-motor paralysis; which I hold to be precisely opposite to the truth. Consistently with such a view, symmetrical gangrene is said'' to result from " peripheral vascular spasm ;" a veritable reductio ad absurdum.) DEGElSTERATTOlSr. Degeneration has been already defined as qualitative atrophy ; i. e., a substitution, under decline of the organic force incessantly active in nutrition and repair, of abnormal for normal structure and material. The forms under which this occurs are— Fatty degeneration ; Calcification ; Pigmental degeneration ; Fibroid, colloid, and amyloid degeneration ; Liquefactive and corpuscular degeneration. Amyloid degeneration has been described by Yirchow and others as occurring in the brain, spleen, liver, etc. It consists in the conversion of tissue into a substance which is made reddish-brown by iodine, instead of yellow, as the healthy tissues would be. It is also characteristically stained of a violet color by methyl-aniline (methyl green). Hyaline degeneration of the vessels and substance of the lym- 1 Am. Journal of Med. Sciences, July, 1878. , 2 Paralfsie Vaso-Motrice des ExtreinitJs, ou Erythromelalgie. Paris, 1880. 8 Am. Journal of Med. Sciences, April, 1881, p. 539. 66 GENERAL PATHOLOGY. Fig phatic glands has been described by Wieger (1880). A translu- cent substance is formed, very slightly colored by iodine, but deeply stained by carmine. In regard to these alterations it may be stated (see PageVs Surgical Pathology) that 1. They are changes such as may be observed naturally occur- ring, in one or more parts of the body, at the approacn of the natural termination of life. 2. The new material is of lower chemical composition than that normal to the part ; i. e., it is less removed from the inor- ganic state : as fat, gelatin, calcareous matter, etc. 3. In structure, it is less developed ; being crystalline, granu- lar, simply globular, etc. 4. In function, it is less powerful. 5. In nutrition, it is less active and capacious. 6. Generally^ although not ahoays, constitutional debilitation precedes, and (we may infer) institutes the local alteration of structure. 7. Inflammation or other local disease niay, by impairing the nutrition of a part, cause it to degenerate. The form of degenerative disease which has received the most attention from pathologists is fatty degen- eration. This has been carefully studied, as it occurs in the heart, arteries (atheroma), brain, muscles, bones, liver, kidneys, and morbid products. It must be distinguished carefully from mere fatty accumulation or adiposity. Our knowledge of the facts concerning de- generative disease, and of the share which it claims in the domain of structural pathol- ogy, once almost entirely usurped by in- flammation, is among the most important of the acquisitions of the medical science of the last half century. MORBID GROWTHS. Tumors, and morbid growths benign and malignant, which may be best classified as forms of structural degeneration or vitiated nutrition, I leave, at present, except to state the following classification (Cornil and Ran- vier, Bristowe): — Connective-tissue tumors ; viz., Fibroma, of fibrous tissue. Lipoma, of fatty material. Myxoma, of mucous tissue. Cartilaginous tumors, Chondromata. Osseous tumors, Osteomata. Nervous tumors, Neuromata. Muscular tumors, Myomata. Vascular tumors, Angiomata. Fatty Infiltration of MuS' cle (magnified). AtORRID GROWTHS. 57 Glandular tumors, Adenomata.^ Embryonic tissue tumors, Sarcomata. Syphilitic tumors, Gtimmata. Alveolated epithelial tumors, (Jardnomata. Cancer or cfmi»o»iaf;illsitndcr the notice and care of the medi- cal practitioner, when it attacks parts or organs within any of the great cavities of the body. There is no essential impropriety in classing, pathologically, all malignant growths' together as cancerous ; their subdivisions being clinical or surgical. (By malignant, we mean prone to Fig. 13. Cells of Cancer of Tongue. unlimited increase : disastrous in effect or result ; and difficult or impossible of arrest or cure.) Cancers may, then, be divided simply into Scirrhus, or hard cancer (fibro-carcinoma) ; Colloid, or gelatiniform (alveolar) cancer ; Encephaloid, or brain-like (medullary) cancer.^ Each of these contains, as its anatomical elements, fibres, fluid, or semi-fluid jelly, and cells. Scirrhus is composed mainly of a fibrous or filamentous tissue, with little fluid, and comparatively few cells. It never becomes encephaloid, nor does encephaloid cancer ever become scirrhus. 1 Lymphomala. - Tubercle is not a growth, but rather an abortion of tissue. 8 Other names are used, as epitheUal, melanoid, osteoid, hcrmaloid, myeloid, and villous cancer, enchondroma, round-celled, spindle-celled and giant-celled sarcoma, etc. 68 GENERAL PATHOLOGY. Colloid cancer has a variable amount of fibrous tissue, arrayed as a matrix (compared often to the structure of an orange), con- FlG. 14. Fig. 15. Colloid, exterior. Interior of Colloid. taining a jelly-like substance ; cells also may be found in it, but in less proportion. Encephaloid cancer is (so to speak) the highest development of Fig. 16. Myeloid Sarcoma. (Virchow.) carcinomatous formation. It consists of a fibrous matrix, con- taining an abundance of abnormal, multiform cells, and a pecu- liar fluid. MORBID GROWTHS. 69 When a cancer, of either type originally, is based upon and in- cludes bony structure, it constitutes osteosarcoma. If it develop itself upon the skin, or other epithelial tissue, or, wherever occur- ring, display similar structure, it may be called epithelioma. If its location involve especial vancularitij and hemorrhage, it assumes the form and name of fmvjus lurmalodea. The pain of cancer (which is not always present) appears to depend upon the exten- sion of the disease to a tissue well endowed with nerves. The cells, tibres, and tluid ' of cancer are all abnormal. Cancer-cells are of various shapes, resembling gland-cells, but larger, averaging about y^^jg- of an inch in diameter. But are these forms heterologous; i. c, different from anything normal or natural to the body? Are they, so to speak, inipAanta- tions, or distortions? I believe, fully, that the latter is the correct view. The "cancer-cells" are no longer held by micrologists to be pathognomonically distinctive ; they are homologous with Colloid Cancer. (Rindfleisch.) other cells found in the body. Yet, they are such forms ns do not normally belong to the part; being produced by morbid alteration or perversion of its natural elements; especially the epithelial elements. They are, moreover, crowded together abnormally, in the meshes of an imperfectly and irregularly distributed connective tissue ; and with a great number of nuclei^ often large in proportion to the cells. Classen's opinion (1870) that cancer always originates in a morbid development of migrated leucocytes (white blood-corpuscles) is extremely unlikely to be correct. The view of Thiersch (1865) I The milky or creamy "cancer-juice," which emulsifies with wator, is considered highly characteristic by many observers. The malignily, or proneness to Increase, and extend destructively, of a tumor, is generally in proportion to its succulence or juici- ness. The lawless mmmer of gj-owth of cancer-cells, compared with the regular apposition of those of the same part when healthy, is very important. 60 GENERAL PATHOLOGY, and Waldeyer (1867), ascribing cancerous growths to a modifi- cation in the cell-multipUcation of ordinary epithelium, is more probable. This view is favored also by Rindfleisch ; who, how- ever, admits as one mode of growth of epithelial cells, their deri- vation from wandering formative cells, in contact with existing epithelium.' The most rational theory of cancer is dynamic. The disease consists in a morbid tendency ; a tendency to enormous and un- healthy growth of a formation which is, at the same time, vascular and sensitive, showing subserviency, although under perversion^ to the physiological laws of the organization. The origin of cancer in most cases, is constitutional ; it is fre- quently hereditary. A cancerous cachexia is recognized in very many cases ; its most obvious sign is a peculiar sallowness of the skin. It follows much more rapidly upon cancers of the viscera than upon those of external parts. Genuine cancer may always be expected to return after removal — although exceptions occur, and it has occasionally been known to undergo spontaneous degeneration. The order of choice which cancer exhibits, as to the parts it attacks, is (Rokitansky) as follows : — Uterus ; Liver ; Testicle ; Mamma ; Bones ; Ovary ; Stomach ; Skin; Tongue ; Rectum ; Brain ; (Esophagus, Lymph-glands ; Eye; Colloid cancer, in particular, prefers the Stomach, rectum, peritoneum. Scirrhus, the Mamma, stomach, intestines. Micephaloid may occur in any organ ; it alone attacks the Liver, kidney, lung, testicle, eye, lymph-glands. NBURO-PATHOLOGY. The pathology of the nervous system is, itself, an extensive field, of which the merest coup d^ceil is possible here. For the purposes of pathological study, we must remember that the anatomical elements of the nervous apparatus are — 1, gray, vesicular ; and 2, white, tubular ; and 3, gray, gelatinous nervous substance ; the first being arranged in ganglia, the latter two in nerves and commissures. Physiologically, the functions of the ganglia (nerve-centres, and, probably, impressible peripheral ganglionic expansions also) are, to receive, reflect, accumulate (generate?) and distribute nerve-force. The sole function of nerves and commisswes is, to transmit or con- duct it. As a whole, we may state the otfices of the nervous apparatus to be as follows : — lit is a proposition not yet proven, that " wandering leiicocytes" take part in tlie formation of any tissue whatever. I believe it to be extremely doubtful. NEURO-PATHOLOGY. 61 Excito-mntor ; Internuncial, i. c, Excito-sccrctory ; Sympathetic and Sensory; Synergic (co-ordinative); Voluntary motor; Psychical, i. e., mental. The forms of disorder to which this apparatus is liable, are 1. Anaesthesia; i. c, that condition in which the patient re- mains without cognizance of impressions made on a surface which is normally sentient. This may result, a, from disease of the ner- vous expansion at the surface; h, from disease or injury of the conducting nerve, somewhere on its track ; c, from disease of the cerebral sub-centre of sensation (sensorium). The thalami are believed by physiologists gencu-ally to be the aggrec/aUve centres of sensation ; and local lesion (apoplectic clot, tumor, softening, etc.) in or near them is frequently associated with hemiplegia, etc. The paralysis is (iommonly observed (from decussation of the nerve iibres in the medulla oblongata and cord) on the side opj)osite to that on wr.icli the lesion has occurred. 2. Subjective impressions and sensations; i. e., those which affect the consciousness of the individual without the action of any external or •peripheral cause. These subjective impressions may be divided into — a, those which are central in their origin, as when disease of the thalamus causes neuralgia of the fifth pair of nerves ; and 6, those whose origin is intermediate ; as, when in- flammation of the slirath of a nerve, or disease of the spinal axis, gives rise to pain referred by the patient to the termination of the nerve. Subjective hypersBsthesia, or perversion of sensibility or psychi- cal impressibility, maybe, in its causation (as regards the nervous apparatus), either functional ^ or organic ; and the difference be- tween these is often practically important. 3. Muscular Paralysis ; or that condition in which a central volition (or an excitation equivalent to it) fails to produce its normal effect of muscular contraction. Of this defect, also, the pathological origin may be, as to its seat, either peripheral, inter- mediate, subcentral (in the corpora striata or cerebellum), or central (in the convolutions of the cerebrum). Muscular as well as sensational paralysis dependent on an affection of the brain, occurs usually (not invariably) on the opposite side to that of the encephalic lesion. Scarcely ever is palsy confined exclusively to sensation or to voluntary motion — altbough the proportion of im- pairment of the two functions may vary considerably in particular cases. Both kinds are occasionally re/?ex (Brown-Sequard). In- vestigation is now being industriously made into the pathogeny (morbid origination) of motor as well as of sensory paralysis, by means of — 1, minute anatomical dissection; 2, comparison of lesions found after death with symptoms occurring during life ; 3, vivi- sectory experiynentation. To my judgment it appears, that the "net result" of experimentation upon the brain and spinal cord of living animals during the last twenty years, has been to throw 1 FiincUonal nervous disorder results fjenerally (Todd) from an abnormal state of thfl blood. See a valuable lecture ou Hyperiesthesia, by Dr. C. Handfield Jones : Brit. Med. Journ., Sept. 30, 1871. 6 62 GENERAL PATHOLOGY. the whole subject into inextricable confusion. While a quite different estimate of it prevails generally in the profession, it is admitted by several excellent authorities that normal and morbid anatomy^ taken together with the study of the healthy and dis- ordered performance of functions^ afford at present the most reliable information required by the physician for his guidance.^ 4. Involuntary contraction of voluntary muscles, or Convulsion. Only very local, and usually transitory spasmodic affections are (unless reflex) peripheral in their origin. Usually, convulsive affections are accounted for by functioaal excitement of the motor centres ; the causation of which is made up of three elements, in variable proportion, viz. : a, morbid irritability of the spinal excito-motor apparatus itself; 6, imperfect control over the subordi- nate nervous centres by the brain, from an abnormal condition of the latter ; c, the disturbing influence of a peripheral irritant — as, tension of the gums in teething, worms in the bowels, un- digested food in the stomach, etc. The three forms of spasmodic disturbance to which the muscles are liable under a morbid alteration of innervation, viz., the tonic, choreic, and clonic, are illustrated respectively in tetanus, chorea, and epilepsy. Modifications of these are seen also in spastic spinal paralysis, locomotor ataxia, and paralysis agitans (shaking palsy). Hughlings-Jackson has shown that chronic localized convulsions (affecting a few muscles only), as well as localized paralysis, usually result from localized lesion of the opposite hemisphere of the brain — most generally a tumor. 5. Excito-secretory action (Longet, Campbell) becomes morbid under conditions like those which produce convulsion ; for ex- ample, the diarrhcea of infants, so common at the time of dentition. A subject of great interest, ahnost neglected until within the last dozen years, is that of the effects of various agencies, through the nerve-centres, upon the blood-vessels. But while the vaso- motor nerves are now recognized, and their special relation to the ganglionic or sympathetic system is beginning to be appreciated, much confusion on this subject still pervades physiological and medical hterature. A further important pathological subdivision exists as to the method of origination of those functional disturbances of the nervous system to which we have been alluding. The source of any of the above forms of nervous disorder, hypersesthesia, anaesthesia, muscular paralysis, or convulsion, may be (when not purely local) either — 1. Central organic disease ; 2. Blood-perversion, or defective nutrition ; 3. Purely sympathetic disturbance. It is far from easy, in many cases, to mark the diagnosis petween these different modes of causation of nervous symptoms ; wut, when the decision has been made in any iustance, the prog- nosis is most favorable in the last case ; less so in the second ; and most unfavorable in %\ie, first, i. e., when the symptoms have their origin in an actual organic lesion of au important nerve-centre. 1 To justify the above expressions, let any one compare the earlier and later dicta of Pr. Brown-Sequard, one of the most eminent of living experimental physiologists. NEURO-PATHOLOGY. 63 6. Neurasthenia is a torm convoniontly applied (Beard) to a general deficiency of tone ;ind strenij;th in the nervous system ; producing symptoms variously affecting either the organic, sen- sory, muscular, or psychical functions. If the first of these be most involved, we have nervous dyspepsia, occasionally diarrlicea, or vrmiithifj ; amenorrJiopd, dysmenorrhoea, or menorrhagia; perhaps retention of urine, etc. When the sensory apparatus exhibits the results of neurasthenia, neuralgia is tlie most common symptom ; sometimes, however, ancesthesia occurs instead, or functional poraZ- ysis of special sensation; e. g., blindness or deafness. In the mus- cidar apparatus, the same condition produces a tendency to con- vulsions, general or local. Psychical symptoms of neurasthenia are extremely various in both sexes. In females, all of the above disorderly conditions and actions have been commonly grouped together, under the term hysteria. But they occur in men and boys also, under circumstances sustaining the view that in either sex the relation to the reproductive system is rather accidental than essential. Special terms have been invented to apply to some of the mental peculiarities of neurasthenic subjects ; as anthropophohia^ dread of society ; agoraphobia, a fear of crossing large open spaces ; thanatopjhohia., an excessive apprehension of death ; to which might be added ergopjhohia, or morbid shrinking from active eflbrt of every sort, etc. But these expressions add very little to definiteness of description. Undoubtedly, neuras- thenia bears an increasingly large part in the diseased states with which the physician has to deal in the artificial life of modern society, especially in great cities. Cattses of neurasthenia are chiefly as follows : sexual or sensual excesses or abuses ; very large use of tobacco; continued "worry," i.e., fretting and wearing care about business, domestic, political, or other affairs ; too laborious brain-work, with insufficiency of sleep ; social dissipation, with the same effect of deficiency of rest ; unhygienic habits of bodily and mental inertia, typified by the corset, the veil, the novel, and the sofa. Predisposition to nervous debility, with some or all of its attendant ailments, is, be3^ond question, often hereditary. It is promoted, sometimes, by inheritance of the gouty constitution. No more interesting question has been latterly discussed in neuro-pathology, than that of the localization of brain-lesions. Physiological experiment and pathological anatomy have contrib- uted many facts concerning it ; in the former field, through the labors especially of Fritsch, Hitzig, Terrier, Schiff, Nothnagel, Carville, Duret, Burdon Sanderson, Brown-Srquard, Lussana, Yulpian, Munk, Tamburini, Dupuy, and Lauterbach ; in the lat- ter (morbid anatomy), by those of Dax, Bouillaud, Broca, Hugh- lings-Jackson, Charcot, Bouchard, Pitres, Brun, Lupine, Mey- nert, Huguenin, Mills, and others. Space cannot be given here for a full statement upon this sub- ject.' My own view upon the physiological inquiry is this : that aU that has been proved is, the functional association, in some 1 See a summary account of it by the author, in Reynolds' System of Medicine, Ameri- can edition, Vol. I., p. 916 el seq. 64 GENERAL PATHOLOGY. manner, not yet fully determined, of certain regions of the cortex of the cerebral hemispheres with diiferent groups of muscles ; that this relation is probably connected particularly with emo- FiG. 18. Lateral View of Brain, showing Fissures and Convolutions. Fig. 19. Inner Surface of Hemisphere, showing Convolutions and Fissures. a, superior frontal fissure ; b, inferior frontal ; c, fissure of Rolando ; d, fig- sure of Silvius; e, interparietal; /, fronto-parietal ; g, parieto-occipital ; h, first temporo-sphenoidal ; i, second ditto ; j, inferior ditto ; k, occipito-tem- poral; Z, calcarine ; m, hippocampi. A, superior, or first frontal convolution ; B, second ditto ; C, third ditto ; D, ascending frontal; E, ascending parietal ; F, superior parietal ; Fj, prcecuneus; G, supra-marginal; G-^, gyrus angularis, or pli courbe; H, first temporo- sphenoidal ; I, second ditto ; J, third ditto ; K, fusiform lobule ; L, lingual lobule ; M, gyrus fornicatus ; Mj, gyrus hippocampi ; Mg, uncus gyri fornicati, or subiculum cornu Ammonis; N, cuneus. (From Bristowe.) NEU UO-PATHOLOGY. 65 tiondl expression; Terrier's phrase, '■'■psycho-motor " centres, bcine: thus most appropriate ;' while, under organic disease or injury of the same regions, the motor functions which are directly con- trolled by the lower sensori-motor centres (thalamus, corpus stri- atum, pons, medulla oblongata, etc. ) are often perturbed or im- paired by reflex action or synqjatky. Goltz has removed the whole of the ^'- motor zone" of the cortex cerebri in animals, without paralysis of motion following. Fig. 20. Lateral View of Brain, showing Ferrier's Psycho-motor Centres. I, centre of lateral movements of head and eyes, with elevation of eyelids and dilatation of pupils ; II, extension of arm and hand ; III, complex move- ments of arm and leg, as in climbing, swinging, etc.; IV, movements of leg and foot as in locomotion ; V, movements of lips and tongue, as in articula- tion ; VI, depression of angle of mouth ; VII, elevation of angle of mouth ; VIII, supination of hand and flexure of forearm; IX, centre of platysma, retraction of angle of mouth ; X, movements of hand and wrist; XI, centre of vision; XII, centre of hearing; XIII (Fig. 20), centre of touch; XIV (Fig. 20), centre of smell and taste. (From Bristowe.) The most considerable amount of pathological evidence in regard to cerebral localization of function, is that which points to the third anterior frontal convolution of the left hemisphere, as the seat of language. Many cases have been observed in which a lesion of that part of the cortex cerebri has been found to accom- pany right hemiplegia (paralysis confined to the right half of the body) and apjhasia (see Aphasia^ later in this volume). But the whole subject, both of the physiology and the pathology of the brain, is rendered more difficult by the very close interconnection, in structure and function, existing amongst its different parts ; making it often almost or quite impossii)le to separate from each other the direct and indirect effects of injury or disease. An 1 Ferrier, however, claims a more positive motor function for these " centres" than appears to me to be warranted by the facts ; especially in view of the results of Goltz'a, Dupuy's, and Tamburini's experiments. 6* E 66 SEMEIOLOGY. immense amount of care and labor will still be necessary, before accuracy of diagnosis in aflFections of the brain can be based upon a complete and exact pathology. Some further attention will be given to cerebral localization, in connection with the special pathology of the Brain and Nervous System, in Part II. of this book. Localization of diseases affecting the spinal marrow has, of late years, through clinical observation, aided by autopsic study, ac- quired considerable definiteness. Romberg, Duchenne, Lockhart Clarke, Charcot, Tiirck, Westphal, Erb, Gowers, Moxon, Seguin, and Hamilton have especially contributed to this result. Anatom- ical names are now commonly given to diseases of the spinal marrow : as, posterior spinal sclerosis^ for locomotor ataxy ; lateral spinal sclerosis, for spastic spinal paralysis ; anterior poliomyelitis, for infantile paralysis ; disseminated or multiple cerebrospinal scle- rosis,^ etc. MODES OF DEATH. Death may occur — 1st. By asthenia ; the dynamic force of the system being ex- hausted or destroyed, so that the heart ceases to beat ; as in death from old age, lightning-stroke, poisoning by prussic acid, etc. Syncope (fainting) simulates or threatens this. 2d. By anaemia ; the blood being rendered insufficient for life ; as from hemorrhage after labor, surgical injuries, bursting of an aneurism, etc. 3d. By apnoea, or asphyxia ; that is, arrest of respiration, either from disease of the lungs, obstruction of the air-passages, defi- ciency or impurity of the air. 4th. By coma; the brain (medulla oblongata) being made inca- pable of sustaining innervation ; as in apoplexy, opium poison- ing, etc. Sudden death may occur from Apoplexy ; Valvular heart-disease (especially mitral); Rupture of the heart (or syncope) in fatty degeneration ; Bursting of an aneurism, or abscess, within the thorax, or of an aneurism within the abdomen ; Suffocation ; Violent shock or alarm, producing fatal syncope. SECTION II. SEMEIOLOGY. I. RATIONAL SYMPTOMATOLOGY. II. PHYSICAL DIAGNOSIS. Rational symptoms and physical signs are distinguished (some- what arbitrarily) thus: a rational symptom is a sign of disease which is obvious to the patient himself or to the practitioner with- out close inspection. A physical sign is one determined by exam- 1 See Part II. for the special pathology of these affections. SYMPTOMATOLOGY. 67 ination into the properties and material conditions of the organs of the body ; as by palpation, auscultation, percussion, etc. Symptoms guide us, generally, hy yhysioloyical inference; physi- cal signs, by anatomical necessity. Symptoms and pliysical signs together contribute to diagnosis ; t. e., tlie knowledge of the character of the morbid process or state in a given case ; the answer to the question, "Wliat is the matter ? " Prognosis is the anticipation of the progress and results or ter- minations of disease. The essential elements of prognosis are, a knowledge of the cause or causes of disease present ; of tlie condi- tio^i of the organs; and of the general vital state, or degree of vital force of the system. Prognosis depends, therefore, upon diagnosis ; but is governed, in a majority of cases, chiefly by those rational symptoms which indicate the organic energy of the patient, and the kind and rate of change .that his system is undergoing. SYMPTOMATOLOGY. Symptoms, or rational signs, are — Local, or constitutional ; Idiopathic (primary), or secondary ; Premonitory (prodromata) ; Critical ; Pathognomonic (characteristic). "We examine the symptoms of disease as connected with the digestive, circulatory, respiratory, tegumentary, secretory, motor, sensory, and psychical apparatus. SYMPTOMS CONNECTED WITH THE DIGESTIVE STSTEBI. The tongue may be natural, pale, cold, red, furred, brown, black, cracked, or fissured. It is pa^e, in anaemia. Cold, in collapse, as of cholera, etc. Hed, in scarlatina, stomatitis, sometimes in gastritis. Furred, in indigestion, gastro-hepatic catarrh, fever, etc. Brown or blacky cracked or fissured, in low fevers : as typhus or typhoid. Protruded with difficidty, in low fevers, and in apoplexy ; to one side, in paralysis. The?)ia»ne>v>/'cZeam«(/of the tongue during convalescence should also be noticed, as affording prognostic indications. The teeth are covered with sordes in low febrile states. They are loosened by severe salivation. Their raind decay shows some impairment of constitution ; but this is unfortunately very common. The gums are swollen, soft, and spongy, and prone to bleed, in scurvy. A blue line along the gums is observed in lead poisoning. A red line along their edge is sometimes noticed in phthisis. Swelling and soreness of the gums, with tenderness of the teeth, and a coppery taste, occur in salivation. Increased flow of saliva gives name to this effect of mercury on 68 SEMEIOIiOGY. the mouth. Jaborandi often produces it, without any action upon the gums. Iodide of potassium occasionally does so. Deficiency and thickness or viscidity of the saliva occur gener- ally during fever ; and often also in chronic diseases, especially of the throat and stomach. The taste is morbidly Bitter^ in hepatic derangements, dyspepsia, etc. ; Sour^ in gastric indigestion; Saltish^ in phthisis pulmonalis, haemoptysis, etc. ; Putrid^ in gangrene of the lungs. Appetite is generally deficient (anorexia) in disease, especially of an acute character. Excessive appetite (bulimia) is not often important; sometimes it occurs in nervous affections, in diabetes^ and in persons having worms in the alimentary canal. Perverted appetite is one of the, symptoms of chlorosis, hys- teria, etc. Thirst is excessive in tioo opposite conditions: high fever and low collapse. Difficulty of swallowing^ [dysphagia] may result from — Inflammation of the fauces, tonsils, or pharynx ; Spasmodic constriction of the throat ; Stricture of the pharynx or oesophagus ; Obstruction by a foreign body, tumor, etc. ; Betro-pharyngeal abscess; Paralysis, as after diphtheria ; General debility, as in the moribund state. Nausea and vomiting may occur from — Indigestion: egesta,^ partly digested food, mucus, etc.; Colic: eg. ditto, bile, etc.; Sea-sickness: ditto, ditto; Pregnancy: eg., mucus, food, etc. ; Gastritis: eg., abundant and altered mucus, etc. ; Hysteria: eg., gastric and biliary secretions, more or less altered ; Cholera morbus: eg., gastric and biliary secretions, diluted; Cliolera maligna: eg., copious watery fluid (rice-water) ; Bilious fever: eg., altered mucus, bile, etc. ; Yellow fever: eg., (advanced stage) black vomit; Ulcer of stomach: eg., mucus, lymph, blood; Cancer of stomach: eg., ditto, with cancer-cells, fibres, etc.; Disease of the brain: eg., not peculiar in character; BrighVs disease of kidney: eg., not peculiar; Strangulated hernia: eg., stercoraceous (fecal) ; Poisoning: as by tartar emetic, arsenic, etc. Sarcince, or microscopic, wool-sack like vegetable parasites are occasionally found in matters vomited, in cases of disease of the stomach. Epithelial cells, starch granules, torulse (also vegetable), and vibriones, are often discovered by the microscope. 1 Egesta, matters thrown out. SYMPTOMS CIRCULATORY SYSTEM. 69 SYMPTOMS CONNECTED WITH THE CIRCULATORY SYSTEM. Palpitation or disturbed action of the heart may depend upon — Pericarditis or endocarditis ; Hninrtroplui of the heart;- Chronic valvular disease; Exophthalmic goitre; Ancemia; Nervoiis irritability (nervousness); Disoixler of the brain ; Dyspepsia. The pulse should be examined when the mind and body of the patient are as tranquil as possible. It is most rapid in the stand- ing posture, less so when sitting, slowest in the recumbent posi- tion. Dr. Guy asserts it to be most rapid in the morning. It is increased in force and frequency by exercise, food, and emotional excitement. The pulse of the female is slightly more rapid, as a rule, than that of the male sex. It diminishes in rapidity from infancy to old age ; but in very aged people it again becomes somewhat accelerated. In obscure cases we should examine the pulsation of other arte- ries beside those at the wrist ; and should especially observe the character of the impulse of the heart. Absence of pulsation in a particular artery is often important as a sign of embolism.^ In adults, the average number of beats in health is, for the male, 70 ; for the female, 75. Infancy, 120 to 100. Middle Hfe, 75 to 65. Childhood, 100 to 90. Old age, 70 to 60. Youth, 90 to 75. Decrepit age, 75 to 80. We judge by the pulse (inferentially) of the force of the heart's action, of the force of the arterial impulse, of the excitability of the nervous system, of the fulness of the blood-vessels, and of the tone and physical condition of the arteries. The pulse in disease may be natural, or strong, weak, firm, yield' ing, full, small, bounding, compressible, rapid, slow, quick, jerking, hard, soft, tense, gaseous, corded, wiry, thready, imperceptible, regu- lar, irregular, intermittent, dicrotous. Not considering it necessary here to define each of these terms, it may be i-emarked that an important difference exists between a rapid pulse and a quick pulse, and between one that is merely full and large and one that is strong. The pulse of fever is characterized by moderate acceleration, with variable increase of force in the beat. It is most rapid in relapsing fever, scarlet fever, and puerperal fever. The pulse of inflammation (with constitutional excitement) is not only accelerated, but hard or tense, and commonly full. What- ever may be said to the contrary, this character of the pulse is, in acute inflammations, of great consequence as one indication for treatment; although, of course, it must not be depended on alone. ^ Bee Embolism, in Part II. 70 SEMEIOLOGY. The pulse of nervous irritation is usually quick, and variable in rapidity and force, under excitement or repose, A jerking^ abrupt pulse is associated (Stokes, Corrigan) with deficiency of the aortic valve of the heart. ' The pulse oi extreme debuity is nearly always (as in the dying state) very rapid and very small, or " thready," A pulse of 150 or 160 in an adult is nearly always a fatal sign. Slowness of the pulse is most marked in compression of the hrain (as from fracture of the skull, apoplectic clot, or hydro- cephalic effusion) and in opium poisoning. Exceptionally, it is met with under other circumstances. In one case, I have known the pulse to be but 20 in the minute (temporarily) from func- tional disorder of the heart. Irregularity of the pulse is occasionally congenital; sometimes it comes on with old age. It is of the least importance in young children. It may be a transient symptom, accidental, as it were, during the progress of an acute malady; or at the commencement of convalescence, as from remittent fever. It is directly related to the nature of the disease, in certain cases of disease of the heart, and in meningitis (inflammation of the membranes of the brain) during the stage of effusion. Dr. B. W. Richardson has laid stress upon the frequency with which mental depression is a cause of irregularity of the heart's action. The dicrotOTis or double pulse is observed especially during con- tinued fevers, either typhous or typhoid. It is explained in some cases, at least, by a loss of muscular tone in the arteries, so that the arterial impulse is separated from that of the ventricles by a perceptible (though slight) interval. The state of the capillary and venous circulation often affords signs of disease. Torpor of the circulation is marked by slowness in the return of the blood after it has been displaced by pressure; for instance, upon the cheek or back of the hand. The veins of the hand or arm may be similarly examined with advantage ; as in cholera, pernicious intermittent, low continued fever, etc. The venous circulation is affected not unfrequently in heart disease: e. g., pul- sation of the jugular veins, from valvular disease involving the right side of the heart; cyanosis, or hlueness, from imperfect sepa- ration of the arterial from the venous blood,- etc. A network of enlarged superficial abdominal veins is sometimes seen in cirrhosis of the liver. Pulsation of the veins does not always depend upon disorder of the heart. The author has seen three cases in which jugular pul- sation was evidently the result of local irritatimi, exaggerating the muscular activity resident in the organic muscle-fibres of the vein. The blood itself is perhaps the most important of all subjects of inquiry in connection with disease. Little, however, as yet, is known of its morbid changes. The principal facts are, that — In anaemia, there is deficiency of haemoglobin and corpuscles ; In plethora, an excess of red corpuscles ; In leucocythmmia, an excess of the colorless corpuscles ; In pseudo-leukaemia, deficiency of red corpuscles ; 1 Galabin has shown (Medico-Chirurgical Transactions, 1876) that occasionally this pulse results from relaxation of arterial tension. SYMPTOMS — CIRCULATORY SYSTEM, 71 In inflammation^ and in chlorosis^ excess of fibrin ; In antidpation of suppuration, excess of colorless corpuscles ; In gout, excess of uric acid ; In rheuyvatism (probably), excess of lactic acid; In (malarial) mekmo'.mia, excess of free pigment; In jauyuUce, excess of biliary matter ; In advanced BrighVs disease, excess of urea, etc. (urajmia) ; In diabetes, excess of sugar ; In malignant cholera, deficiency of water and salts; In relapsing fever, spirilla (minute organisms) ; In yellow fever, granulation of white corpuscles. These peculiarities require minute inspection, with the aid of the microscope or of chemical reagents. To the eye, differences sometimes exist which may be instructive; e. g., as to the bright red or very dark color of the blood ; as to the magnitude, form, and firmness of the clot, the rapidity of coagulation, etc. Counting' the blood-corpuscles is important in the diagnosis of leukcemia (leucocythsemia) and pseudo-leiikcemia, progressive per- nicious avcemia, etc. The principle employed was first devised by Vierordt ; it con- sists in making a definite dilution of a measured quantity of blood, and counting the corpuscles in a known volume of that dilution. Cramer, Potain, Malassez, Hayem, Nachet, and Gowers have modified Vierordt's process. Gowers gives the following account of his improvement upon Hayem's hcemacytometer^ His apparatus consists of " 1. A small pipette, holding exactly 995 cubic millimetres. 2. A fine capil- lary tube, holding 5 cubic millimetres. 3. A small glass jar, in which the dilution is made. 4. A cell, exactly one-fifth of a millimetre deep, the floor of which is ruled intenth of a millimetre squares. Whatever solution is employed, the corpuscles are, more or less, changed by it. One which answers very well is a solution of sulphate of soda of a specific gravity of 1025. "A pipetteful of the solution is placed in the mixing vessel. Five cubic millimetres of blood are drawn into the capillary tube from a drop in the finger, and then blown into the solution. The two are well mixed by a glass rod; a drop of the dilution is placed in the centre of the cell, the covering glass is applied and secured by springs, and the slide is placed on the stage of the microscope. The lens is then focussed to the squares. In a few minutes the corpuscles have sunk on to the squares. The number in ten squares is then counted." Multiplying the average number for a square, of these ten micrometric squares, by 10,000, we obtain the number of corpuscles for a cubic millimetre of blood. In healthy blood, Vierordt and Welcker found this number to be 5,000,000 ; of which from 5,000 to 15,000 are white or colorless corpuscles. In leukcemia and pernicious anaemia the red and white corpuscles are both diminished in number ; but in leuki38mia the white corpus- cles are notably increased in number beyond the normal propor- tion. Cases of this last affection not rarely show as many as 1 white corpuscle to 3 of the red. In Hodgkin's disease (pseudo- 1 Reynolds' System of Medicine, American edition, Vol. III., p. 520. 72 SEMEIOLOGY. leukaemia) the alteration of the normal proportion is very seldom, if ever, so great. In cases of lingering prostration, cZots may form in the heart or large arteries before death. After very rapid malignant dis- eases, the blood is sometimes found uncoagulable. Hemorrhag'e from different parts of the body is often impor- tant as a symptom, but requires to be interpreted with care. Its consequence varies much with its quantity, and the source of the blood thrown out. Thus, in epistaxis, or bleeding at the nose, the flow may result from — Mechanical injury ; Congestion of the Schneiderian membrane; Congestion of the brain; Typhoid fever ; Hemorrhagic diathesis; Suppressed menstruation. This variety of hemorrhage is, however, most frequent during childhood and early adolescence. In haemoptysis, or spitting of blood, the source of the hemor- rhage may be the — Gums; Posterior nares; Throat (e. g., ulcerations, etc.); Bronchial mucous membrane; Lungs ; Stomach. In the last case, being vomited into the mouth, it is properly called hsematemesis. Sometimes it requires care to determine what is the source of blood coming from the mouth. We must notice what are the symptoms preceding the hemorrhage; and the manner of its ejection, whether by coughing or vomiting, etc., as well as tlie appearance of the blood, wliether mixed with food, gastric fluid, etc. True pulmonary haemoptysis may arise from — Active congestion of the lungs ; Passive congestion, from heart disease; Tubercular phthisis; Hemorrhagic diathesis; Vicarious monthly flow, in the female ; Mechanical injury, as fractured rib, etc. ; Rupture of aortic aneurism.^ Haematemesis, or vomiting of blood, may be — Hysterical ; Ulcerative ; Cancerous ; Vicarious, etc. "Uterine hemorrhage, other than the normal menses, may be — 1 Dr. Baelz, of Japan, has reported cases of hasmoptysis from the presence in the lungs of a minute gregarinoid parffsi^e. Epistaxis has, in like manner, been sometimes caused by a small parasite in the nasal cavities ; pentastoma iosnioides. SYMPTOMS llESPIRATOKY ORGANS. 73 Cnnrjestive ; Ulcerative ; Cancerous; as well as, in tho prerjnant female, placentaL technically called "unavoidable hemorrhage;" that of abortion.; or after parturitvm. Hemorrhage from the bowels may be connected with— Hemorrhoids, or piles ; Dysentery ; iflceration of the bowels; Intussusception ; Cancer of rectum, etc. ; JRupture nf aneurisrii ; Hemorrhagic diathesis ; Typhoid or yellow fever ; Vicarious menstruation. Haematuria, or bloody urine, may result from — Mechanical injury of the bladder, prostate gland, or urethra; Itenal inflammation; Calculus ; Hemorrhagic diathesis ; Passive senile congestion of the kidneys ; Scarlatina. SYMPTOMS CONNECTED WITH THE RESPIRATORY ORGANS. The normal, average rate of breathing in the adult, while at rest, is sixteen or eighteen respirations in the minute. In fever it is much accelerated. In extreme narcotism it becomes slower than natural. In some cases of fatty degeneration of the heart it is sighing and interrupted. Dyspnoea, or difficulty of breathing, when great, is called orthopnoea, from the erect posture required by the patient. Cer- vical respiration, i. e., auxiliary action of the muscles of the neck, occurs in cases of great exhaustion, or of obstruction of the respiratory function by disease. Dyspnoea may be caused by — Chlorine or other irrespirable gases in the air; Morbid change of the blood, as in cholera ; Laryngeal or tracheal obstruction, as in croup, etc. ; Bronchial spjasmodic constriction, as in asthma ; Bronchitis; pneumonia; pleurisy ; pjhthisis; Heart disease; aneurism of thoracic aorta; Cancer within the chest ; hydrothorax ; ascites. Coughing may depend upon a variety of causes, the nature of which may often be concluded upon from its character. Thus, usually, Cough is dry and hollow, or hacking, when nervous or sym- pathetic ; Dry and tight, in early bronchitis ; Soft, deep, and loose, in advanced bronchitis ; Hacking, in incipient phthisis pulmonalis ; Deep and distressing, in confirmed consumption ; Short and sharp), in pneumonia ; 7 74 SEMEIOLOGY. Barking and hoarse, in early or spasmodic croup ; Whistling, in advanced membranous croup ; Paroxysmal, and whooping, in pertussis. Expectoration is— Mucous, in catarrh, and early bronchitis ; Purulent, in severe and protracted bronchitis ; Busty, in early and middle stages of pneumonia ; Bloody and muco-purulent, in phthisis ; nummular and heavy, etc., in advanced phthisis ;^ Putrid, in gangrene of the lung. The temperature of the breath is increased during the febrile state. It is lowered, sensibly, only in aggravated prostration ; as in the collapse of cholera. Coldness of the breath is an almost certain prognostic of dissolution. The odor of the breath is rarely perfectly agreeable except in the healthy infant or child. It is very heavy at the commence- ment of fever ; sour during indigestion ; offensive, often, from decayed teeth ; rotten, in gangrene of the lung. Hiccoug'h (singultus) is produced by a spasm of the diaphragm. It may depend upon indigestion, nervous disorder, or exhaustion. It is serious in prognosis only when the last (exhaustion) is present or is anticipated. Stertorous respiration, from relaxation of the velum palati, results from cerebral oppression ; the cause of which may be apo- plexy, fracture of the skull, dead drunkenness, or narcotism by opium, etc. SYMPTOMS CONNECTED WITH THE TEGUMENTART APPARATUS. The skin is hot and dry during the presence of fever. Moisture is almost always a favorable sign. The exceptions are, the profuse colliquative sweats of phthisis, etc., and the cold and clammy perspiration of extreme prostra- tion. Coldness of the skin, or inequality of temperature, is always more or less unfavorable. Emaciation is often an important sign. It generally occurs in severe chronic diseases, but is sometimes rapidly brought on in acute affections ; e.g., diarrhcea or dysentery. The changes which occur in the adipose tissue, and in the plumpness and roundness, or flabbiness and shrunken appearance of the surface of the body, are often extremely rapid in children. The color of the skin varies much in disease. Thus, the face is — Pale, in anaemia, syncope, etc. ; Flushed, in fever, congestion of brain, etc. ; Cheeks brightly flushed, in hectic fever ; Forehead and eyes flushed, in early stage of yellow fever ; Purple or livid, in low continued fever ; Yellow, in jaundice, bilious fever, yellow fever ; Sallow, in chlorosis, dyspepsia, cancer ; Bronzed, in Addison's disease ; 1 Microscopic examination discovers portions of disintegrated lung-tissue in the expec- toration of phthisical patients; arched and anastomosing fibrils of pulmonary and bronchial elastic tissue, with abrupt or square fracture. SYMPTOMS — URINATION. 75 Blue, in the collapse of cholera, and in cyanosis ; Black, almost, in asphyxia, and I'rom large internal use of nitrate of silver. Eruptions upon the skin are characteristic of certain diseases. Their description belongs to Special Patholog}'. (See Part II.) SYMPTOMS CONNECTED WITH THE SECRETIONS. These must always be considered along with othei- explanatory symptoms ; and the character of the discharges should never be overlooked. Thus, Constipation may denote — Tor])or of the muscular coat of the bowels ; Deficient secretion of the liver, or intestinal glands ; Defective innervation, from spinal or encephalic disease ; Siriciure of rectum or colon ; preynancii ; cancer ; Intussusception, strangulated hernia, etc. ; Symxjathetic disturbance from fever, etc. ; Diarrhoea and Dysentery will be considered in another depart- ment. It may be mentioned, however, that in di/sentery the dis- charges contain blood, mucus, lymph (in small quantity), and, when ulceration has occurred, pus. In diarrhoea they are either fecal, mucous, bilious, or serous^the last being of importance, especially in the diagnosis of cholera. Symptoms Connected with Urination. Djisuria, or difficult urination (strangury). Ischuria, retention of urine. Enuresis, incontinence. Diuresis (diabetes), excessive discharge of urine. Iforbid character of the urine itself. The average quantity of urine passed by a healthy adult in twenty-four hours, is from thirty to fifty ounces — greatest in the winter. In reaction to test-paper, the urine is normally acid; redden- ing litmus, or restoring to turmeric its yellow color after it has been made brownish-red by an alkali. The color of healthy urine is that of amber. The average specific gravity of human urine (water being 1000) is 1017-24 ; containing about twenty grains of solid matter to the ounce. Deviation, to a certain extent, from any or all of the above standards as to quantity, reaction, color, and weight, is quite compatible with ordinary health ; but a very decided and per- sistent deviation is a proof of disease. Retention of urine may be caused by — Deficiency of contractile pjower in the bladder ; Spasmodic constriction of the vesico-urethral muscular fibres ; True stricture of the urethra ; Enlargement of the prostate gland ; Calculus in the bladder or urethra ; Percussion and palpation, as well as catheterism, are some- times necessary to determine the fact of retention of urine. 76 SEMEIOLOGY. Suppression of urine, from inaction of the kidneys, is a most serious symptom under all circumstances. If long continued, it becomes fatal by uroemic poisoning — coma, and often convulsions, preceding death. Partial suppression of urine occurs, sometimes transiently, in cholera, scarlet fever, etc. Excessive urination is frequently present in hysterical cases — the water being pellucid, and of low specific gravity (diabetes insipidus). The influence of cold and of diuretic medicines pro- duces a similar watery excess, mostly with little increase in the solids of the urine. Diabetes mellitus is, however, a more important affection ; in which the urine is not only excessive in quantity, but heavy, and loaded vnth sugar. For the accurate estimation of the changes occurring in the urine in disease, scientific skill is requisite. To pursue original investigatio^is upon the subject, considerable practical knowledge of analytical chemistry, and of the use of the microscope, is indis- pensable. But for the application of the conclusions of pathologi- cal chemists and micrologists to diagnosis, a much more moderate amount of skill will suffice. There is wisdom in the remark of Dr. Todd [Clin. Led. on Urinary Organs, etc., p. 73), that, "while it is clearly a duty not to neglect any means of observation and investigation, it is desirable that you should be as little as possi- ble dependent on means which are not always at hand, and which it does not fall to the lot of every eye and hand to use with equal readiness and skill. "^ I shall state, on this principle, only the most important and available points in urinary pathology and diagnosis. Allowance must always be made, or correction obtained, for the variation the urine undergoes in the course of the same day. It may be divided conveniently into the uriiia sanguinis, urina chyli, and urina potus : the first being that after a night's rest, the second that after dinner, the third after a very light meal with fluid, as tea. All of these should in each case be examined and compared.^ The questions in regard to any given specimen of urine are, as to its general appearance, specific gravity, acidity or alkalin- ity, the chemical or microscopical character of its sediments, and the effects of reagents upon the clear fluid. General appearance. If clear, after standing a few hours, note the color. Deep-colored transparent urine, of high specific gravity, indicates excessive metamorphosis of tissue. In jaun- dice, the urine is generally very yellow, and sometimes as dark as porter. If the urine be opaque, it is either white or dark. White opaque urine contains either mucus, or pus, or undissolved earthy salts, or all of these together. Mucus floats more distinctly in a separate cloud than pus ; purulent urine is generally opaque throughout, 1 A similar remark has been made by Virchow, in reference to "naked-eye pathol- ogy." He asserts that almost always microscopical appearances may be anticipated by a careful and skilful examination with the unaided sight. 2 It is well also (in some cases at least) to avoid the complication of urethral di.scharges, by having the first ounce or two passed into a ditferent vessel from that which is to receive the urine to be retained for examination. SYMPTOMS — URINATION. 77 and of a creamy yellow color at bottom. Pus can, however, be more readily diHuscd by agitation than mucus. Purulent urine is oftenest acid; mucous uriiu;, generally alkaline. Pus contains albumen, as shown by testing ; mucus does not. Acetic acid coagulates mucus, not pus. Dark-colored opaque urine is most frequently tinged with blood, Fig. 21. Foreisrn Bodies in Urine. a. Cotton fibres ; b. Flax fibres ; c. Hairs ; d. Air-bubbles ; e. Oil globules ; /. Wheat starch ; g. Potato starch ; h. Rice starch ; i, i, i. Vegetable tissue ; k. Muscular fibres. giving it a pinkish or brownish hue. The latter color prevails especially in cases of passive hemorrhage from the kidney — the former in fresh hemorrhage from the bladder, or active renal hem- 7* 78 SEMEIOLOGY. orrhage. Urine may also be dark from the presence of bile (as in jaundice), or of purpurin ; also, from carbolic acid poisoning. For biliary coloring matter (biliphain, cliolepyrrhin) a good test is (Gmelin's) the addition of nitric or, better, nitroso-nitric acid, drop by drop, to a little of the urine on a white dish. It will become pale green, violet, pink, and yellow, in succession. Or (Heller's) shake a little solution of albumen (white of egg) with the urine, and then add a slight excess of nitric acid ; if bile be present, the coagulum will be dull green or bluish. Or (Cunisset) add half its bulk of chloroform to "the urine ; the yellow coloring matter will be carried down. Pettenkofer^s test for the biliary acids (rarely present in urine) consists in the addition (after separating albumen, if it be present in the urine, by coagulation and filtration) to the fluid, of a grain or two of white sugar, and then, drop by drop, two-thirds of the volume of strong sulphuric acid. If bile be present, a very dis- tinct and characteristic violet-red color will be produced, which is intensified by heat. Strassburg, of Bremen, modifies this by dipping a slip of filtering paper into the urine, to which a little cane sugar has first been added. The slip is then withdrawn and dried. On applying to it a drop or two of concentrated sulphuric acid by means of a glass rod, and holding the paper up to a strong light, a violet color appears. MarechaVs test for bile is tincture of iodine, allowed to trickle, a drop at a time, down the side of a test-tube containing the fluid to be examined. A green color will, if biliary coloring matter be present, appear just below the portion reddened by the iodine. This test is probably as reliable as any other. Purpurin is, probably, a morbid modification of the coloring matter of urine, derived, originally, from that of the blood. Some pathologists believe it to be one of the indications of disease of the liver. It frequently accompanies deposits of urate of ammo- nium. Urine containing purpurin is pink or purple, not unlike bloody urine in appearance. As tests — liquor potassse makes purpurin greenish-brown; car- bonate of potassium, yellow. Alcohol will dissolve purpurin from an evaporated extract of urine, receiving and retaining its color. Hydrochloric acid added to urine containing purpurin will, if heat be applied, give it a lilac or decidedly purple tinge. Late authors make little mention of purpurin. Tyson^ states the normal coloring matters of the urine to be urohoematin (uro- phain) and uroxanthin (indican) ; abnormal, besides foreign mat- ters from food or drink, the coloring principles of the blood (altered) and uroerythrin (Heller). Excess of urohcematin may occur in fevers, or whenever the urine is much concentrated ; also in jaundice and in chronic dis- eases of the liver. Heller's test for urohsematin is, pouring a fine stream of the urine from a height of four inches into a small quantity of pure colorless sulphuric acid. A deep garnet-red coloration results from the admixture. (Diabetic sugar, how- ever, and also uroerythrin, give the same reaction.) 1 Practical Examination of Urine, Philadelphia, 1875, p. 57. SYMPTOMS — URINATION. 79 Excess of uroxanthin ovindican has been observed in a number of diseases : cancer of the liver, cancer of the stomach, phthisis, tabes mesenterica, Addison's disease, spinal and renal affections, etc. Heller's test for it is, dro])pin U Af , 117 8. The exploring needle. 9. Auscultation and percussion. 10. The microscope. Space is not allowed in this work to treat of many particulars concerning those methods. ,Thc student is referred, in regard to them, and for full information uppn all the surgical diseases of women, to the treatises of Thomas, Sims, Simpson, Hewitt, Churchill, Hodge, Meigs, Bedford, Byford, Agnew, Atlee, Barnes, Emmet, and others, on the general subject or on the different departments of Gynaecology. Besides the vaginal touch, himanual palpation and the speculum are the most important means available for the detection of uterine affections ; e. g., displacements, ulcerations, tumors, etc. In cases of abdominal enlargement, the following is a compact statement (Jovini) of the method of diagnosis "by exclusion:" " First, exclude pregnancy, uterine and extra-uterine ; then consider whether or not there may be an immense deposit of fat on the abdominal walls. You do this by lifting up the skin between your hands. Next think of tympanites. When you have gone thus far, decide by palpation whether the tumor is liiiid or solid. If it is solid, it is in all probability either a fibroid of the uterus, an enlarged liver, or enlarged spleen. If it is fluid, it is either ascites, an ovarian cyst or fibro-cystic tumor of the uterus, a distended bladder, hydatids of some of the viscera, pyonephrosis, or abscess. The most common forms of abscess are abscess in the neighborhood of the ileo-csecal valve, abscess the result of pelvic cellulitis, and abscess from disease of the pelvic bones. " When you reach the point Fig. 50. of diagnosis of a fluid-tumor, you are then justified in as- pirating the case and exam- ining the obtained fluid by the microscope." For exploratory aspiration, in the abdomen or elsewhere, the common hypodermic syringe will usually answer very well. The Speculum. Cylindrical (see Fig. 53) and valvular forms of the speculum are used. Both have their ad- vantages and inconveniences. Some have two, others three or four valves or movable portions. They are employed not only for inspection of the uterus and vagina, but also for the application of probes, Sims's Speculum, medicaments, etc. Sims's spec- ulum is used with the aid of a depressor. Thomas has modified it so as to fix the depressor in connection with the blade. 118 SEMETOIiOGY. The position of the patient preferred for the introduction of Sims's speculum is semiprone; so as to allow the abdominal viscera to gravitate forward. Fig. 51. Siras's Depressor. Fig. 52. Fergusson's Speculum. The Uterine Sound. This is a firm rod of metal, of such a size and curve as to enter readily the uterine cavity. It requires skill and much care to use it safely. Very serious accidents are endangered by an over- violence with it. As stated by Thomas, the facts which may be determined by it are these : — 1. The capacity of the uterus. 2. The existence of growths within it. 3. Deviations of its canal. 4. Displacements, as discriminated from tumors. 5. The existence of endometritis. 6. The mobility of the uterus. FiG. 53. Sims's Copper Sound. Fig. 54. y^ZZ. Z) Emmet's Silver Probe. Dilating Tents. These are commonly made either of sponge or of the sea-tangle (laminaria digitata). For the former a good clean sponge is cut THE LARYNGOSCOPE. 119 into conical pieces from two to three and a half inches in length, and with bases varying from the width of the little finger to that of a walnut or an egg. Each piece may be dipped in a weak solu- tion of carbolic acid, salicylic acid, or oil of cloves, in glycerin ; then saturated with mucilage of gum Arabic ; a wire is next passed through its centre, and it is tightly wrapped from apex to base with strong cord. Then the wire is taken out and the sponge is allowed to dry. After that the cord is removed and another cord is passed through the sponge and sewed fast to its ai)ex. Dr. A. H. Smith prefers a sponge tent with a large point, cylindrical to its end ; before introduction, to be covered with moistened soap, coated with salicylic acid. Fig. 55. Sponge Tent. The advantage of the sea-tangle tent is that it affords no ani- mal matter to decompose and produce fetor or irritation. Several small tents are better than one large one.^ Some German practitioners (Landau^) recommend, instead of sea-tangle, the tupelo (root and stem of nyssa aquatica) for tents ; asserting that they expand more uniformly, and to a greater extent, while almost free from tendency to produce septic infection. Dilatation of the uterus by tents is not free from danger. Tetanus and peritonitis have sometimes followed their employ- ment. The tent ought never to be left in the uterus more than twelve or, at the longest, twenty-four hours ; and the patient ought to remain in bed during that time and for one or two days afterwards. The Laryngoscope. Instrumental aid in examining the interior of the larynx was first thought of by Levret, in 1743. Laryngoscopic mirrors were devised by Dr. Babington, of London, in 1829. Bozzini, 1804; Senn, of Geneva, in 1827 ; Selligues, Paris, 1832 ; Baumes, Lyons, 1838 ; Liston, 1840 ; Avery, 1844 ; Garcia, 1854, and about the same time Jacobi, of New York, gave attention to the same sub- ject. Tiirck, of Vienna, applied mirrors anew to diagnosis in 1857 ; but shortly afterwards Czermak pursued laryngoscopy with so much acuteness and energy as to have associated his name with it pre-eminentlj'. 1 SurKical-instruraent makers prepare sea-tangle tents for the use of practitioners. " Sammlung Klin. Vortrage, No. 187, 1831. 120 SEM BIOLOGY. The apparatus required is a laryngeal mirror, an illuminating mirror, and a tongue depressor. Glass or polished metal may do for the mirrors. The laryngeal mirror may be round or square, preferably the former, and about an inch or less in diameter. It should be Fig. 56. JSTWt — ' = Laryngoscope. attached at an obtuse angle ("120° to 125°) to a stem, which may be fastened into a slender handle so as to be drawn out or pushed in. The illuminating mirror is larger (from 3 to 12 inches in diam- eter) and concave, to concentrate reflected light. It may be held by a handle in the operator's mouth, or fixed by a band to his forehead, or, best, as used by Semeleder, perforated in the mid- dle and fastened to the bridge of a pair of spectacles (with or Fig. 58. Laryngoscopic drawing, showing the Vocal Cords drawn widely apart, and the position of the various parts above and below the Glottis during quiet inspiration, g. e. Glosso-epi- glottidean Folds, u. Upper surface of Epiglottis, l. Lip of Epiglottis, c. Cushion of Epiglottis. ?;. Ventricle of Larynx, a. e. Ary-epiglottidean Fold. c. W. Cartilage of Wrisberg. c. S. Capitulum Santorini. com. Arytenoid Commissure, v. c. Vocal Cord. V. b. Ventricular Band. p. v. Processus Vocalis. cr. Cricoid Car- tilage. ^ Rings of Trachea. (Mac- kenzie.) without the glasses) so as to rest before one of the eyes and be looked through. The laryngeal mirror is introduced (after being warmed to pro- Laryngoscopic drawing, showing the approximation of the Vocal Cords and the position of the various parts in the act of vocalization. /. i. Fossa Innominata. h.f. Hyoid Fossa, c. h. Cornu of Hyoid Bone. c. W. Carti- lage of Wrisberg. c. S. Capitulum Santorini. a. a. Arytenoid Carti- lages, com. Arytenoid Commissure. p. V. Processus Vocalis. (Mac- kenzie.) THE OPHTHALMOSCOPE. 121 vent condtmsfition of moisture) so that its bacl< pushes the uvula upwards and 1)aekwards, its lower edL!;e presses upon the posterior wall of the pharynx, and its stem rests in the angle of the mouth. Sunlight, horizontal (morning or evening), is the best for laryn- goscopy, but artificial light, as of a good lamp, may suffice. The diJficAilU/ of the operation is produced by the irritability of the fauces and larynx. Few can allow of a successful examina- tion on the first attempt ; practice makes tolerance. To hasten this, bromide of potassium has sometimes been given. The fre- quent insertion and retention for a while of the finger of the patient or of an instrument in the fauces accustoms the parts to pressure. Holding ice to the throat just before the examination also lulls sensibility. Momentary use of ether spray has been resorted to for the same purpose. By laryngoscopy, tumors, ulcerations, inflammatory changes, etc., iin the larynx may be inspected, topical applications made, and surgical operations performed, with a precision not otherwise possible. Rhinoscopy is the examination, in a similar manner, of the posterior nares. It requires merely a smaller mirror (less than three-fourths of an inch in diameter) than for laryngoscopy, and at about a right angle to its handle. The otoscope (for the ear), and endoscope (for the urethra), etc., are instruments for surgical diagnosis, not demanding description here. The Ophthalmoscope. Not only for ascertaining the state of the eye in various disor- ders of vision, but also to aid in diagnosticating affections of the hrain^ this instrument has acquired importance in recent times. Essentially perfected by Helmholtz (1851), it was brought forward especially by Grafe (1860), and has had minor improvements made in its use by Liebreich, Anagnostaki, Zander, and others. It con- sists of a concave circular mirror about two inches in diameter, perforated by a small hole at the centre, with which is used also a biconvex lens of two or three inches focal length. The following account of the mode of its employment is from Zander : " In order to effect a satisfactory examination of the eye with the ophthalmoscope it is essential to have a good light. Artificial light, as that from an oil or gas lamp, is practically the best. In preparing the patient for an examination the pupil should be dilated by atropia, a small quantity of a solution containing one- twentieth of a grain of the alkaloid to the ounce of water having been applied to the eye several hours before. The room being darkened and the patient seated, the lamp should be placed near the head of the patient, on the same side as the eye to be exam- ined, so far back as to leave the cornea in shadow. It is also important that the flame, the eye of the patient, and the eye of the observer should be all at the same level. The observer now takes the concave mirror in the hand that is on the side towards the lamp, places its edge against the superior margin Oi" his orbit, and looks through the perforation at the eye to be examined ; he then causes the mirror to turn a little on its vertical axis, until 11 122 SEMEIOLOGY. the inverted image of the flame is cast upon the eye under exam- ination, the pupil of which will then return a more or less intense reddish or whitish glow. For Fig. 59. a general inspection of the re- fracting media, it will be suffi- cient to look at the eye from different directions, and cause it to make slight movements upwards, downwards, and to either side. If no diseased conditions be apparent, the observer proceeds to examine the inverted image of the fun- dus. For this purpose he takes a biconvex lens of 2''^ or 3^^ focal length, in the thumb and index of his free hand, rests his little finger upon the forehead of the patient, and brings the lens in front of the examined eye, so that the light from the mirror, passing through the lens, will be concentrated upon the pupil. The actual inverted image of the fundus wiU now be formed betwixt Fig. 60. Ophthalmoscope. Representation of the appearances seen with the Ophthalmoscope in a case of Tubercle of the Choroid, a. Tubercle in the Choroid, b. Artery of the Retina, c. Veins of the Retina, d. Optic Disk. (Bouchut.) the lens and the eye, and in the focus of the former ; and to ren- der it visible, the observer must usually move his head somewhat further back. The first object to be sought within the eye is the entrance of the optic nerve. Sometimes before its white surface becomes visible, darker streaks may be seen traversing a bright THE OIMITIIAT.MOSCOPE. 123 rod _c;ronn(l. Those will bo the vessels that proceed from the entrance itself, and by foUowitiij; one of them, in tlu; din^ction of its increasing thickness, towards the inner and infc^rior parts of the eye, by movemonts of the observer and mirror in the opposite directions, the wliite surface of the optic disk will presently bo perceived. After insi)ection of the nerve surface, attention should next be directed to the vessels, to observe whether they present a normal condition at their place of enti-ance, to note their course over the white disk, and their conduct at and after passing to the red background. After the vessels, should be observed the trans- parency of the retina, its relations to the choroid ; and then the observer should return to a more careful and accurate study of the entrance of the nerve. Lastly follows the inspection of the refractory media, the vitreous body, the crystalline lens, the cor- nea, and then that of the iris." Tiirck first called attention to retinal signs of brain disease, in 1858. Von Graefe, in 18G0, pointed out the existence, in dilier- ent cases, of two conditions : that of engorgement of the intra- ocular end of the optic nerve [stasis papillcej or choked disk, and Fig. 61 . Choked Disk. (After Liebreich.) that of inflammation of the optic nerve, descending from menin- geal inflammation {descendiny optic neuritis). In ninety-five per cent, of brain tumors (Bouchut, Ogle, Earnest Hart, Allbutt, Ilughlings-Jackson, Annuske, Reich, Longstreth, Norris,' Shakes- peare) one or other of these appearances exists. Yet, as some marked cases of brain tumor have been shown (Becker, Schweig- ger) to be entirely without ophthalmoscopic signs, the most cer- tahi value of their frequent coincidence appears to be negative. 1 riula. Med. TiiiiL's, Aug. 30, 1S79. 124 SEMEIOLOGY. That is, ivhen tumor of the brain is suspected hut not proven^ the total absence of ophthalmoscopic changes lessens greatly the probability of its existence. Among the abnormal appearances shown by the ophthalmo- scope, involving the eye itself, one of the most interesting is the cupped depression of the optic nerve-disk, in connection with the morbid tension of the eye-ball in acute glaucoma. Accompanying this sign, we have evidence of undue tension on palpation of the bafi, with marked redness from increased vascularity, severe pain, and rather sudden loss or impairment of vision. Atrophic degeneration of the optic nerve may be ophthalmo- scopically shown in many cases of locomotor ataxy ^ multiple cerebro- spinal sclerosis, chronic alcoholism, and nicotism (tobacco poisoning). In some instances such a degeneration is the occasion of heredit- ary loss of sight. The Sphygmograph. H^risson, about 1833, supported by Magendie, attracted much attention at Paris by his sphygmometer ;^ this was a mercurial tube, ending in an excavated hemisphere of ivory or steel, with a sub- jacent membranous portion made to rest upon an artery. 2^^ext came, for the visual study of the pulse, the kymographion of Lud- wig ; afterwards, King's improvement upon it by the use of a lever ; then the sphygmograph of Vierordt, and afterwards, that of Marey. The instrument of the latter is, undoubtedly, at the same time the simplest and the most accurate. It consists essentially of a very delicately adjusted lever, one end of which rests upon an upright, which, by a rounded, surface, Fig. 62. Sphygmograph applied to the Arm. presses on the radial artery at the wrist ; while its free end sus- tains a pen, whose point is placed in contact with a strip of paper, kept in steady motion by clockwork.'^ Each beat of the pulse, therefore, magnified by the lever, is registered in a waving line upon the paper. Some observers prefer a smooth point acting upon smoked glass for the registration. 1 1 have before me a copy of a translation of Hfirisson's memoir presented to the French Institute, published in Philadelphia in 1835, by Dr. J. G. Nancrede. 2 Few of our instrument makers yet construct the sphygmograph. One may be im- ported from Paris for about $40. Otto & Reynders, of Now York, manufacture the im- proved instrument of Dr. E. Holden. Pond's sphygmograph, also, is now made in this country. THE SPHYGMOGRAPH. 125 -4 Much phj'siological as well as pathological interest attaches to this mode of demonstration of arterial action. It has l)een care- fully studied 1)v a number of able observers, especially Wolff, Naumann, Onimus and Viry, Bunion Sanderson, Anstie, B. W. Foster, and E. Holden.' Our present concern with it is in regard to its diagnostic use. The marking of the normal or liealthy pulse presents in regular succession the following parts: 1. An ascending line or summit wave; 2. A slight depression, or notch, rising very soon into a secondary wave ; 3. A deep impression, or great notch ; 4. A second great ascension ; 5. A descending line. All authorities are not quite agreed as to the explanation of each of these por- tions of the curve; which admit, moreover, of some variations compatible with health. The following is probably the correct view. 1, The first ascension or summit-wave follows immediately upon the full commencement of the ventricular S3'stole, as a " pressure- wave " (Weber), or vibratile impulse communicated to the column of blood in the vessels. 2. The secondary wave coincides with the closure of the auriculo-ventricular valves, and the forward impetus of the blood under the total pressure of the systole. 3. The "great notch" ( Wollf) is due (Naumann, B. Sanderson) to the rebound of blood under the arterial contraction ; the reflux which closes the aortic valves. It is sometimes called the aortic notch, 4. The second main ascension follows the closure of the semilunar valves of the aorta, the arterial systole then taking its full effect. 5. A descending line attends the subsidence and in- termission of the pulse.^ By variations from Fig. 63. these usual characters of the sphygmographic marking, evidence is given in regard to changes in — 1. The force of the heart's ac- tion. 2. The tension of the arteries. 3. The ex- istence of obstructions, anywhere, to the move- ment of the blood. The p^j^g Tracins. permanent record ob- « Primary Wave; 6 Tidal Wave;- c Dicrotic tainable by meansof the Wave; d Fourth Wave; e Aortic Notch. instrument gives great (Fiulayson.) advantage for the com- parative study of diflerent cases. Hence, hospital men, espe- cially, should value the sphygmograph. In old age^ the pulse-mark has generally a nearly vertical but sometimes broken ascent, a rounded or fattened summit, deti- 1 Prize Essay on the Sphygmograph, 1873. Room yet exists for further investigation of the same subject in other modes. See a paper by the author, Am. Journal of iMi'd. Sciences, July, 1868, p. 2SS. 2(iahibin has asserted a complictifhif! effect in the sphygmographic pulso-record to bo due to the oscillation of the instrument; but this view is not well sustained. 11* 126 SEMEIOLOGY. ciency in the dicrotism or second (arterial) ascent; often a sudden fall after the primary cardiac wave. In aneurism of either of the great vessels, the sphygmograph affords much assistance in diagnosis. It shows a loss of force in Fig. 64, Fig. 64. Pulse-tracing of Radial Artery, somewhat deficient in tone. Fig. 65. Firm and long Pulse of Vigorous Health. Fig. 66. Pulse-tracing of Radial Artery, with Double Apex. the pulse on the side of the aneurism, with lessening of dicrotism ; and, particularly, a difference in the radial pulse-mark of the two sides of the body. Aortic regurgitation is attended by a vertical ascent of the first wave, ending in a point. This alone, however, is not, as Marey and others for a time supposed, decisive ; since functional dis- turbance of the heart may produce the same effect. There is, in aortic regurgitation, a notable suddeness in the fall that fol- FiG. 67. Pulse of Aortic Regurgitation. (Finlayson.) lows the pointed ascent ; a collapse of the artery, without the dicrotic vascular rebound or second ascending wave. An ohlique line of the first ascent generally occurs in obstruction of the aortic valves. Mitral regurgitation gives indication of a small, irregular, ( THE RPITYGMOGRAPH. 127 usually dicrotic pulse ; easily modifiecl by compression of the artery. Variations in the fulness and pressure of the arterial system, under difterent causes, will produce corresponding: changes in the sphygmographic markings. ^ This is very quickly shown when the pulse is registered while under the influence of inhaled vapors ; c. J/., nitrite of amyl. In acute diseases accompanied by fever, Wolff and others have described some characteristic sphygmo- graphic alterations ; which, however, require further analysis. It is stated that, in fever, instead of the three-pointed (tricrotous) pulse, a tendency to dicrotism exists ; sometimes to a single wave or monocrotism. When the aortic notch is deepened moderately, so as not to reach the line of the base of the pulse-curve, it is said to be hiipodkrolous. If it reach that line in its descent, perfecthj dicrotmis. When it goes below it, it is hyperdicrotous. Changes of temperature are asserted to accompany these variations ; the highest degree, above 104°, being found usually with the last. Anstie has recorded, also, the effects of alrohol Fig. 68. on the pulse as shown by the sphygraograph. He determined that, when it acts as a helpful stimulant, in typhoid states, the pulse is made slower, and ex- cessive dicrotism is re- duced. When alcohol acts as a narcotic, it acceler- ates the pulse and in- creases dicrotism. Always, a want of uni- formity and regularity in the pulse-marks, or sud- den or great changes in their character, will be significant of morbid states, which may often be of serious importance. Still it would, in the case of the sphj'gmograph, as in that of other instru- ments, be a great mistake to allow it to supersede the use of the more simple and constantly available modes of diagnosis. The taciiis eruditus must keep its plac'% as indispensable to every skilful physician. Other sphy^mograpic instruments besides Marey's have been invented and used i Mahomed, Ilolden ^. Pond's ^ sphygmograph, especially, has met with considerable favor. 1 London Practitioner, April, 1S79, p. 298. Pond's Sphygmograph. 128 SEME 10 LOGY. Dr. Hawksley^ has devised a " stetho-sphygmograph," by which may be observed and recorded not only'ijeculiarities or Fig. 69. Eight Radial Pulse in a case of Thoracic Aneurism. (Finlayson.) Fig. 70. Left Radial Pulse, in same. (Finlayson.) Fig. 71. Pulse in a case of Bright's Disease. (Finlayson.) modifications of the circulation, but at the same time their rela- tions to respiration. Combination has also been effected between the sphygmograph and the cardioyra-ph (for record of movements of the heart). Marey arranged this upon the "tambour" method, with air as the medium of transmission. Others^ have employed water for the same purpose, with similar, if not greater, success. TEMPERATURE IN DISEASE. The thermometer (De Haen, 1754, Wunderlich, J. Davy) is a useful aid in diagnosis and prognosis, making exact that infor- mation which every physician constantly obtains by the touch. It is especially valuable in the clinical study of febrile disorders, as, since Galen, fever is essentially defined by the words "pre- ternatural heat." The axilla is the best part for examination of temperature. Some, however (Finlayson), prefer the rectum. In children, this is probably better. The instrument should be kept there 1 Lancet, December, 18, 1869 2 K-eyt, New York Medical Record, Oct. 30, 1880, p. 479. TEMPKUATURE IN DISEASE. 129 from three to five minutes at a time. Normally, in the armpit, the temperature averai^es ^)P>.rp Fahr.,' with a range in health (Davy) from 99° to 97.9-2.0 It is about 1° hi.gher in trop- ical than in temperate climates. In the temperate, it is higJieat on waking in the early mori,iing ; lowest at midnight. In tropi- cal regions, it is Irnvest in the early morning, and highest during the day.- It is one or two degrees higher in children than in adults ; but in children during health, according to Finlayson, it is less in the evening than in the morning. A rise of temperature, in disease, of 1° Fahr. corresponds, as a rule, with an increase of the pulse of eight to ten beats per minute. The thermometer in the axilla may, in some febrile cases, mark 100°, 108°, even 112°. It has been found highest in scarlet fever, yellow fever (Dowler), and tetanus. Dr. H. C. AVood, found it lO'.P in the axilla of a man dying with heat- stroke, and nop in his abdomen after death. Wunderlich records the temperature of 112.55° in tetanus at death, and 113.56° after death. The most extraordinary excess of bodily temperature has been reported by J. W. Teale,'^ as occurring in a case of injury of the spine by a fall. As tested by eight different thermometers, it ranged for seven weeks above 108°, and during a number of days fluctuated between 116° and 122°. But for the concurrent testi- mony of several medical witnesses, this account would appear incredible. Dr. Donkin has recorded cases of fever, pneumonia, inflamed stump of limb, and pyonephrosis, in which temperatures occurred as high as 112°, 113° 115°, and 117°. All these patients recovered. In intermittent fever, during the paroxysm, even when the patient shivers and feels cold to himself, his heat by the ther- mometer is usually above the natural degree. " When* the temperature is increased beyond 98.5° it merely shows that the individual is ill ; when it is raised as high as 101°- 106°, the febrile phenomena are severe ; if above 105°, the patient is in imminent danger ; with 108° or 109° a fatal issue may with- out doubt be expected in a comparatively short time. "A person, yesterday healthy, who exhibits this morning a temperature above 104° Fahr., is almost certainly the subject of an attack of ephemeral fever or of ague ; should the temperature rise to or beyond 106.3°, the case will certainly turn out one of some form of malarious fever. It cannot be typhoid fever. " A patient whose temperature rises during tlie first day of ill- ness up to 105° or 106° Fahr., certainly does not sufter from typhus or typhoid fever. In a patient who exhibits the general typical signs of pneumonia, but whose temperature never reaches 101.7° Fahr., it may be concluded that no soft infiltrating exudation is present in the lung. "If a patient suffer from measles, and retain a high tempera- 1 Aitken states it as 98.4°; Wunderlich, 98.6°; my own observation gives it 98 5°. F. Finlayson asserts the existence of greater variability of temperature in children. 2 See Aitkcn's Science and Practice of Medicine, 4th ed., vol. i., p. 39. 8 London Lancet, March 6, 1875. * Aitken, op. citat., vol. i., p. 44. I 130 SEMETOLOGY. tOiC THCOtMiH OOi 2 g --, r- :« 1 » ' <: , — =: -= -n ^_ — s»> ^^ "^ < IE [^ > < -=: > -- •• § < > 111 <; ♦'-,^ .;, 3 5 I > *T~~~- lv» a: vS \- r^- =, < '■ K ► o z "'- -<. ^ u. o " < ^ 2 '-- .. K , I> e k. > < •< ""v . > <^ L'' f> '■ --- <; t> ":• p» ■""- ---- > V, ■» > ^■^ ,,^ ^ CO El O 05 00 t^ CD O OS 05 OS O^ o aj •9 1=1 I? OJ o3 QJ p "cl O .2 a §3 :2 S3 -S ©•■^ 13 3. ^ j> 1, -S S^ a3 S 0-2-2 £o:§ g <^ a 2 -^ s-i aS I '=' =s S six °= T, "^-^ g 03 O CD'S a <^ IK'S H s =*■ 2 . O 13 (u tn C S H a a hi fl TEMPERATURE IN DISEASE, 131 ture after the eruption has faded, it may be concluded that some coniplicatinij; disturbance is present. " In typhoid fever, a temperature wliich does not exceed any evening 103.5° indicates a i)robaljly mild course of the fever. 105'^ in the evening, or 104° in the morning, shows danger, in the third week. In pneumonia, a teniperature of 104° and upwards indi- cates a severe attack. In acute rheumatism, a temperature of 104° is always an alarming symptom, foreboding danger, or some complication such as pericardial inflammation. In jaundice, otherwise mild, a rise of temperature indicates a pernicious turn. In a puerperal female, an increase of temperature shows approaching pelvic inflammation. In tuberculosis, an increase of temperature shows that the disease is advancing, or that untoward complications are setting in.^ "A fever temperature of 104° to 105° Fahr., in any disease, indicates that its progress is not checked, and complications may still occur." Certain diseases have been found to have typical ranges or daily fluctuations of temperature throughout their course ; so that their " diflerential diagnosis" may be thus assisted materially. This has now been determined, especially in malarious fever, relapsing fever, typhus, typhoid, smallpox, scarlatina, measles, rheumatism, pyaemia, pneumonia, and acute tuberculosis. Dr. Da Costa has observed that, in some cases at least, cancer is attended by a lowering of temperature. The same assertion has been made by others in regard to dia- betes mellitus. Dr. B. W. Richardson found that tlie narcotism produced by hydrate of chloral is always accompanied by reduc- tion of temperature. Alcohol produces a moderate effect of the same kind. Dr. Bourneville has shown that a considerable fall occurs in ursemia.'^ Dr. Ogle reports the decided lowering of the temperature in cases of phthisis, under fifteen and twenty-grain doses of sulphate of quinine.* Many observations make it appear that large doses of quinine greatly lower the temperature. Sali- cylic acid and oil of eucalyptus also have a similar effect. Bella- donna and coftee increase the temperature. Dr. Nieden observed the temperature to be reduced after an injury of the spinal cord. During the collapse of malignant cholera, in moribund cases, the temperature of the breatli has been found to be as low as 80°, or even 70°. Recover}^ has seldom been known from any disease when the temperature in the axilla has fallen below 90° Fahr., except in alcoholic poisoning ; in which Bathurst Woodman has several times seen recovery after that degree had been reached.* Ursemic coma, also, is attended by low temperature. Dr. I. Alvarado, of Mexico, has made a study of the relations between the 1 The statement (S. Ringer) that rise of temperature alivays attends the deposition of tubercle is not exact. Wiiuderlich, Roser, Herard, Cornil, Jenner, and otliers, have sliown many exceptions to it. In Brit. Med. Journ., April 5, 1873, a case is reported as occurring under the care of Sir W. Jenuer, in wliicli fatal acute tuberculosis occurred u-Hliont any pyrexia. 2 Sec Ham/t, Lancet, .Tan. 4, 1873. 3 London Lancet, July 6, 1872. * Dr. Mendelson found a temperature of 90° F. in the rectum ot a half-starved insane patient in the N. Y. Hospital, in April, 1881; he recovered under stimulation with nutriment. 132 SEMEIOLOGY. temperature and the pulse^ in health and disease, which may, when completed, be of value in diagnosis and prognosis.^ Fig. 73. 1 f 1 -1 1 NO -^ i ^ „o I03°- ■ i ■ HtcT.C| j 1 'jPH'Hl siiS.; , 1 -r-pr40 .in9°-_L ! vxm N iBBMiinBrMia imniiiiiinin 93° ''\- VHUWI 1 1.I- / ! '- ' ' 1 '4 \ ■■^.:.f . ,/S^ ■ ,r37°| 1 - .. . Diurnal range of Temperature in Hectic Fever. (Finlayson.) In relapsing fever,^ the heat rises quickly in the first stage, reaching 104° or 105° on the second day ; fluctuating then until the day before the defervescence, when it attains its highest point ; sometimes 107° or 108°. Then it sinl-;s rapidly, as the other symp- toms subside, down to 98°, or even less. When the relapse occurs, about the fourteenth day, the heat again increases to 104°, 105°, or more ; to descend as rapidly as before, when convalescence begins. In continued fevers, the temperature is generally less high in the morning than in the evening. In typhus, however, not unfre- quently it falls a little towards night. ^ Stability of temperature from morning to evening is a good sign ; on the other hand, if a high temperature remains stable from evening till the morning, it is a sign that the patient is getting or will get worse. When the temperature begins to fall from the evening to the morning, it is a sure sign of improvement ; but a rise of tempera- ture from the evening till the morning is generally a sign of getting worse. Inequalitij of temperature in different parts of the body is sometimes quite important ; especially in chronic diseases of the nervous system. By means of very delicate instruments, varying temperatures of different portions of the head (Broca, 1877, Lombard, Bert, Amidon, L. C. Gray, Mills) have been noted in some cases.^ A difference has been observed also (Peter) in regard to temperature, between peritonitis with effusion and ascites of non-inflammatory origin ; and in pleurisy, when the effusion is actively increasing, and when it is undergoing absorp- tion ; also (Broca) between cerebral embolism (with lessening of 1 Phila. Med. Times, May 22, 1880, p. 435. - Observations on Relapsing Fever, by Dr. J. S. Parry, Am. Journ. of Medical Sciences, October, 1870. 3 J. W. Miller. Brit, and Foreign Medico-Cliirurg. Review, October, 1868. < Phila. Med. Times, March 13, 1S80, p. 308. PNEUMATIC A S P 1 11 A T I O N . 133 warinth in the temporal regions) and acute cerebral or meningeal inflammation. Convalescence from disease docs not begin until the normal temperature of the body returns, and maintains itself unchanged through all periods of the day and night. PNEUMATIC ASPIRATION. Dr. Bowditch, many years ago, commenced the use of a fine "capillary" trocar and canula, which, as well as the grooved needle of Trousseau, have now long been in common use for the careful exploration of any of the cavities of the body, supposed to contain fluids. Dr. H. P. Walker,^ of New York, proposed the employment of the hypodermic syringe for the same purpose in diagnosis. M. G. Palletan, in 1831, devised an instrument for the same object. But the attention of the profession has been espe- cially given, since 1859, to the "pneumatic aspirator" of Dr. Georges Dieulafoy, of Paris. By tliis, it is claimed, the greatest possible safety and convenience are obtained for exploration (and also withdrawal of fluid) in pleuritic and pericardial efiusions, cysts in various regions, abscesses of the liver, hjalrarthrosis, retention of urine, strangulated hernia, etc. Dr. W. Pepper (1874) has em- ployed it for the local treatment of cavities in the lungs in phthisis; and Dr. Howe, of New York, for transfusion of blood. The spe- cial claim of Dr. Dieulafoy, besides that of the fineness of his hol- low needles, consists in the use of the "previous vacuum," i. e., a chamber in his instrument exhausted of air before the introduction of the hol- low needle into the j)art to be explored or drained. The application of the instrument is thus described :^ — " The aspirator being ready, that is to say, the previous vacuum being made, the needle is introduced sharply at the spot pointed out. Before the needle has penetrated a centimetre into the tissue, that is, as soon as its opening is no lon- ger in contact with the external air, the stopcock connected with the needle is opened, and the vacuum is thus formed in the needle itself. This needle, carry- ing the vacuum with it, is slowly, very slowly, pushed in the direction of the bladder, until the urine flowing over the glass index shows that the bladder is pierced. Owing to this proceeding, and having the previous vacuum at our com- mand, we know the precise moment the fluid is reached." While this apparatus and method appear to involve a real Fig. 74. Pneumatic Aspirator of Dieulafoy. 1 See T. Gaillard Thomas, on Diseases of Women. Phila. ed., 1872, p. 663. "Treatise on Pnoumatic Aspiration, etc., by Dr. G. Dieulafoy. Philada. ed., 1873. Tlie instrument has been improved upon by I'otain, Steurer, and others. 12 134 SEMEIOLOGY. improvement, capable of great utility in many cases, it must not be supposed that their employment is absolutely with- out danger. A few instances of fatal result, following even the introduction of the hollow needle into an articulation,^ have enforced the necessity of caution with it. Local anaesthesia, by Richardson's spray-producer, with ether or rhigolene, has some- times been employed to obviate the pain caused by the opera- tion. It is not certain whether this will lessen or increase the danger of subsequent irritation. INSPECTION OF THE BODY AFTER DEATH. In conducting post-mortem examinations, with a view either to pathological study or medico-legal investigation, order and method are of great importance. The three great cavities — the head, the chest, and the abdomen — should always be examined, whether suspicion of disease in them exists or not. First, however (the autopsy being made from twelve to thirty-six hours after death), we should note the external appearance of the body ; its size, weight, conformation, color of the slcin, etc. (In cases of suspected violence, even abra- sions should be minutely described.) To examine the Head, an incision should be made through the scalp, across the top of the head, from ear to ear — the two flaps thus formed should be reflected, the one over the forehead, the other over the occiput. The nature of the attachment of the occipito-frontalis muscle to the bone beneath is such as to allow very easily the loosening of the scalp. The cranium (calvaria) is now to be removed by means of a small saw. For the purpose of holding the head firmly during the use of the saw,. Dr. T. A. Demme has furnished, as a substitute for the craniotome of Lund, of London, a cranium-holder, which en- ables the operator to make a section of the skull in any direction. It consists simply of a bar of iron, curved like the letter U, at each extremity of which two drill screws are placed, which, when forced down upon the bone, holds the bar firmly in situ, and enables the examiner to control the head. The legs of the instrument, for use, are placed upon the lateral portions of the skull, over the squamous portions of the temporal bones. The section of the cranium with the saw should be made through its outer table, completely around the head— from be- fore, oackward, from below the frontal protuberances to the squamous portion of the temporal bone, and from behind forward, from the occipital protuberance to the squamous portion of the temporal bone, meeting the line just described. The shape of the piece thus cut out enables it to be maintained in its proper position when the parts are readjusted. It is removed by the aid of an elevator, or chisel and hammer, fracturing the inner table of the skull by strokes so applied as not to i)ierce the brain. The dura mater is next to be cut through, on each side of the superior longitudinal sinus; after which, dividing the falx cerebri, 1 See Irish Hospital Gazette, Jan, 15, 1873. POST-MORTEM EXAMINATIONS. 135 the brain may be raised carefully with the hand placed under its anterior portion. The internal carotid artery, and cranial nerves, etc., are now to be severed by tlie knife, and finally, the vertebral arteries and spinal cord. Tlie brain itself may then be taken out and inspected, by slicin<^ it from the upper part downward, in successive horizontal layers. Both before and after its re- moval, the amount of Uqu'ul present should be carefully noted ; measuring it, if excessive, by the aid of a pipette or small syr- inge and graduated glass. Instead of horizontal, many pathol- ogists prefer oblique (vertico-transverse) or longitudinal vertical sections through the hemispheres, on each side of the great lon- gitudinal fissure. Modern neurologists insist much on the ex- amination of the "psycho-motor " and " psycho-sensory" zones. (See Part I., Neuropathology), as well as the thalamic corpora stri- ata, and internal and external copsufe.s. There seems to be patho- logical importance in distinguishing, in what was formerly de- scribed en masse as the corpus striatum, two parts ; the anterior, intraventricular portion, the nucleus caudatus; and posteriorly, the extra-ventricular portion, nucleus lenticulatus. Between the caudate nucleus and thalamus above, and the lenticular nucleus below and without, is the internal capsule, of white fibrous ner- vous matter ; a portion of the cms cerebri. Outside of the len- ticular nucleus is the white fibrous external capsuled To examine the Spinal Colunm, an incision should be made from the occipital protuberance to the extremity of the os coccygis. The deep muscles of the back should then be loosened from their attachments, so as to expose the laminse and spinous processes of all the vertebrae. With the chisel and mallet, or saw, we must cut through the arches of the vertebrae on each side, close to their articular processes.^ After thus opening the spinal canal, the cord is to be exposed by dividing the dtira mater through its whole length. To examine the Neck, an incision should be made through the skin, extending from above the hyoid bone to the upper part of the sternum. Avoiding penetration of the large veins of the neck, the parts to be examined may be carefully dissected, and if desirable, removed from the body. The thyroid gland, larynx, and its appendages, tongue, pharynx, oesophagus, blood-vessels, and nerves of the neck, may be thus viewed. To examine the Chest, two incisions are desirable ; the one from the root of the neck, in front, to the extremity of the ensi- form cartilage ; the other at right angles to this, across the mid- dle of the thorax. The cartilages of the ribs are to be cut through, with a strong knife, at the lines of junction with the ribs. The ensiform cartilage, being drawn outward, is to be de- tached from the soft parts, the knife being held close to the sternum. 1 An interesting subject for minute investigation is the question whether the fibres of the internal capsule constitute a direct continuous connection between the cortex of the cerebrum and the spinal cord, — or communicate only by means of the ganglionic masses at the base of the brain. Pathological evidence favors the former answer to this ques- tion; but physiological'analogy is against it, and I am not aware that it has yet (1881) been positively settled by anatomical deiuonstration. - Dr. Satterthwaite's modification of Brunett's chisel has great convenience for ex- posing the spinal canal. See N. Y. Med. Record, May 8, 1880, p. 520. 136 SEMETOLOGY. The stemo-clavicular articulation may now be opened, and the sternum with the costal cartilages raised from its position — a cautious use of the knife being made to remove the adherent soft parts. The thoracic viscera are now exposed, and may be drawn out with care, and inspected in detail. The heart should be removed first, after opening the pericar- dium by a vertical incision, and ascertaining the presence or absence of adhesions, effused fluid, etc. The apex is then to be raised, and the great vessels at the " root " of the heart divided at a short distance from its base. Laying the heart upon a board, as nearly as possible in the position it occupies in a recum- bent body, the auricles and ventricles may be carefully laid open. The right auricle may be opened by cutting through its middle portion, betwen the entrances of the vence cavce. The left auricle may be entered by an incision commencing near the left superior pulmonary vein. The right ventricle should be laid open by a deep incision from the base to the apex, beginning near the septtim at the base. The left ventricle is to be opened by a similar deep incision from the base to a point not far from the apex. Especial care is needed in dividing the parts near the orifices of the aorta and pulmonary artery, so as to examine the condition of their valves. Scissors are convenient for this part of the inspection. In examining the mitral and tricuspid valves, care must be taken not to confuse appearances by a promiscuous division of the membranous ct^sps, as well as of the columnce carnece and char dee tendinece. The lungs may be placed first in water to determine whether they will float or not (the lungs of a still-born infant, which has never breathed, will, unless from some extraordinary cause, sink in water). The same may be done with portions of the lungs after they have been cut for examination. Incisions for this purpose should be made, vertically and transversely, through"^ each pulmonary lobe. The bronchial tubes may be best divided with long-bladed scissors, cutting towards the lungs. To examine the Abdomen, make a crucial incision ; the one branch extending from the sternum to the pubes, passing to the left of the umbilicus ; the other transversely across the middle of the abdomen. Care must be taken, in making these incisions, not to injure the subjacent viscera. Before removing the stomach or any portion of the intestines, ligatures should be placed above and below the part that is to be separated. When — as is always desirable, if possible — both of the large cavities of the trunk are to be opened, a single incision, extend- ing from the top of the sternum to the symphysis pubis, may be made. The weight of organs, altered by disease, is sometimes an im- portant point. The following are normal weights of the prin- cipal organs in healthy adult subjects : MEDICO-LEGAL EXAMINATIONS, 137 Male. Female. 49J oz. 44 oz. . 1 oz. 4 dr. 1 oz. 4 dr. [ right, 24 oz. •. (left, 21 " 17 oz. 15 " . 11 oz. 9 " . 63 " 45 " 6 " 5 « . . 5i " 5 " . . 1 to U dr. Brain Spiual cord Lungs Heart Liver Spleen Kidney Ovary In every case incision through the skin should be made, as far as practicable, only in those parts which are usually covered by the clothes of the deceased. It is generally advisable, when the abdomen or thorax has been opened, to fill the cavities with bran or sawdust. After the examination has been completed, the edges of the divided integument should be brought together, and re- tained in apposition by the common continued suture.^ MEDICO-LEGAL EXAMINATIONS. In cases of suspected poisoning, the following practical direc- tions are given by Professor Reese, of the University of Pennsyl- vania, to be observed by those who have charge of post-nwrtem examinations : 1. Ascertain whether the individual has labored under any previous illness, and how long a time had elapsed between the first suspicious symptoms and his death ; also the time that had elapsed after death before the inspection is made. 2. Note all the circumstances leading to a suspicion of murder or suicide, such as the position and general appearance of the body, and the presence of bottles or papers containing poison about his person or in the room. 8. Collect any vomited matters, especially those first ejected, and preserve them in a clean glass jar, carefully stoppered and labelled. The vessel in which the vomited matters have been contained should be carefully inspected for any solid (mineral) matters which may have sunk to the bottom or adhered to the sides. If no vomited matters be procurable, and vomiting has taken place on the dress, bedclothes, furniture, etc., then portions of these must be carefully preserved for future examination, 4. Before removing the stomach, apply two ligatures beyond 1 The examiner should wash his hands with the utmost thoroughness after an autopsy, for his own sake as well as that of others, especially patients to be visited. If the subject examined died of a disease capable of contagion or infection (in which category erysipelas, puerperal fever, and diphtheria must be included) some disinfectant should be used. I prefer Labarraque's solution of chlorinated soda for this purpose. A fluidounce of it may be poured slowly over the hands above a basin of warm (or hot) water, in which they should then be washed. If this is followed by a vigorous scouring with castile soap and water, very little danger of conveying disease will remain. An abrasion upon any part of the hand should forbid its being used in an autopsy, or, at least, being brought in contact with the internal cavities of organs. If a puncture or incision of the examiner's hand occur during the operation, the proper thing (however disagreeable) is to wash and suck it immediately, and then keep it out of all contact Willi the body. Not a few lives have been sacrificed by neglect of these precautions. 12* 138 GENERAL. THERAPEUTICS. each extremity, dividing between each pair, so as to prevent the loss of any of the contents. 5. If the stomach be opened for inspection, this should be per- formed in a perfectly clean dish, and the contents collected care- fully in a graduated vessel, so as to properly estimate their quan- tity. [I^ote here, also, the presence of blood, mucus, bile, or undigested food.] These contents should be preserved in a per- fectly clean glass jar, securely stoppered, covered over with blad- der, and sealed. The contents of the duodenum should be collected and preserved separately. 6. Carefully inspect the state of the throat, oesopJiagiis, and windpipe for the presence of foreign substances, and for marks of inflammation or corrosion. 7. Observe the condition of the large intestine, especially the rectum: the presence of hardened feces would indicate that purging had not very recently taken place. 8. Note any morbid changes in the lunys, as congestion, inflam- mation, or eflusion ; in the heart, as contraction, flaccidity, pres- ence of a clot ; and the condition of the contained blood. 9. Examine the state of the brain and spinal marrow, and, in the female, the condition of the uterus, ovaries, and genital organs. [Poisons have sometimes been introduced into the vagina.] 10. Along with the contents of the stomach and duodenum, the viscera that are to be reserved for chemical analysis are tlie stomach and duodenum (to be kept separate from the others), the liver and gall-bladder, spleen, kidney, rectum, and urinary bladder with its contents. Sometimes, also, a portion of the hlood may be required for the examination. 11. As the legal authorities wiU rigorously insist upon proof of the identity of the matters alleged to be poisonous, it is of the greatest importance to preserve such matters from all possible contamination by incautious contact with a surface or vessel which is not absolutely clean. Avoid the use of colored calico or paper for wrapping up the specimens. When once the suspected articles are deposited in the hands of a medical man, he must preserve them strictly under lock and key, and confide them only to a trusty agent for transportation. Many cases are on record where the chemical evidence failed simply from a want of power clearly to establish the identity of the matters analyzed. Actual testing for poisons in cases of suspected criminality ought to be undertaken only by those whose chemical knowledge and skill are considerable. SECTION m. GENERAL THERAPEUTICS. Eemedies have been classified, for the study of Materia Medica, in a manner which is sufficiently well adapted to the present state of that science. I propose the following classification, from the standpoint of GENERAL THERAPEUTICS. 139 the practitioner, i. e., according to the indications of treatment, or objects proposed. Thus regarded, remedies may be studied as — Anodyne and calmative; e. y., opium; ether; chloroform; aco- nite ; Ijydrocyauic acid ; hydrate of chloral. Protective; e. {/., demulcents; surgical dressings. Balancive ; c. y., cold to an over- vascular part ; pediluvia ; blood- letting. Economic ; rest; astringents ; retarders of tissue-metamorphosis. Eliminative; e. y., purgatives; iodide of potassium, etc. Antidotive; e. y., liydr. ox. of iron for arsenical poisoning; ant- acids; cinchonization in intermittent. Alterative; e. r/., nitrate of silver in scarlatinal sore throat ; arsenic in skin diseases ; electricity in cancer, etc. Recuperative ; stimulants ; tonics ; chalybeates ; oleum mor- rhute ; travelling. An elaborate work might, of course, be written upon the topics just enumerated. It is appropriate to our purpose, only to state them ; dwelling, presently, upon another yet more brief classifi- cation, of the modes of treatment 7nost freqicently called for, in the management especially of acute and subacute aftections. First, a few words upon balancive measures. These constitute a very large part of therapeutics ; one of the most constant ele- ments of disease, and especially of acute diseases, being a dis- turbance of the proptortion of circulation, nutrition, innervation, and action in diflerent parts. For example: when one "takes cold," what has occurred? Chilling the surflxce, as by damp air, has checked perspiration, contracted the superficial blood-vessels, causing congestion of inte- rior organs, and partial contamination of the blood, from retained excretory matter. What, then, is the "indication" or pointing of nature ? Clearly, it is to restore the lost balance ; by warmth to bring on perspiration (unless fever occurring demand another method); purgatives and diuretics, with plenty of water, to relieve the blood of its morbid excess of excreta. Again, in flatulent colic, unequal distension and spasmodic contraction of a bowel occur, from gaseous accumulation or the presence of irritating ingesta. Aromatics, such as ginger ; stim- ulants, as hot water or whisky ; or anodynes, as camphor or opium, by a diffusive action on the whole surface of the affected intestine, and upon its innervation when they are absorbed and reach the gangUa, will renew a proportionate contraction (peri- staltic) of the muscular coat, and remove the pain, Yery often, gentle friction, pressure or kneading the abdomen, or external warmth all over it, will have a similar balancive eftect. Laxatives for deficient movement of the bowels, astringents for excess of the same ; cold to a too hot head, and mustard and hot water to cold feet, are all balancive means. So is the familiar and always safe use of n mustard-plaster to the skin, over any part of body which suffers pain. Pain denotes a morbid innervation from some cause. Apply something which, like mustard, causes a strong impression in a dilferent place, not too remote, and tlie 140 GENERAL THERAPEUTICS. "eiTor loci" of nerve-tension (or debilitation,^ as the case may fee), is done away witli — the balance is restored. Notice may be here taken, briefly, of a "method" in thera- peutics, extending the balancive principle systematically — called the "neuropathy" [gangliotlierapy) of Dr. John Chapman. The origin of this is really to be credited to the vivisections of Bernard and Brown-Sequard,'^ and conclusions based upon them, especially by the latter. The experiment of most importance in this connection has been the section of the sympathetic nerve in the neck of a rabbit ; which was found to be followed by dilatation of the blood-vessels of its ear. It was concluded from this and other facts similarly obtained (all traumatic or pathological, as, indeed, are all facts of vivisection), that to increase the amount of blood and sensibility in any part of the body, you must paralyze, partially or temporarily, its sympathetic ganglion. To diminish its vascularity and sensibility — you should excite its vasomotor nerve-centre. Dr. John Chapman systematized the use of these principles, by the application of elastic bags, containing ice, or hot water, along the spine ; so as to act upon the ganglia located thereupon, and, through them, to aflfect the viscera, both palliatively and cura- tively, in disease. "He considers that ice applied along the spine increases the general circulation, stops the cramp of voluntary and involuntary muscles, proves an effective remedy in epilepsy and other convulsive affections, cures sea-sickness, restrains the sickness of pregnancy, arrests diarrhcea, recovers patients from the cold stage of cholera, and, finally, promotes menstruation. On the other hand, heat along the spine lessens the general circulation, overcomes congestion in all parts of the body, lessens fever, restrains hemorrhage, and lessens or arrests the menstrual flow." If the. phiisiological theory of Brown-S^quard, above mentioned, were true, the therapeutical process of Chapman, deduced from it, might be justified. I deny the truth of the one, and, a pjriori, have no belief in the validity of the other. Clinical experience, however, must decide the claims of the practice. It must be remembered, that a pjractice may prove beneficial, whether the theory which suggested it be correct or not. Hot and cold applications to the spine must make (especially when alter- nated, as Brown-Sequard proposed for bed-sores) a strong impres- sion on the whole system ; this may prove a rapidly alterative impression in certain cases of disease. Should this prove so, the use of such means should be adopted, just as, and so far as, ex- perience shows it to be useful. JSTo such utility of applications whose explanation may be reached in many different ways, can make the theory above cited seem, to the present writer, other than erroneous. The modes of treatment most frequently called for, in ordinary medical practice, may be designated as — 1 RadclifFe " On Epilepsy, Pain, and Paralysis ; " Inman, op. citat. 2 See his Lectures on the Nervous System, p. 205, etc. See, also, a discussion of the experiment mentioned, in the author's Prize Essay on the Arterial Circulation.. GENERAL THERAPEUTICS. 141 The antiphlogistic ; The supporting ; The febrifuge ; The antidotive ; The alterative treatment. Under the first head, the antiphlogistic ' {i. e. the treatment of inflammation), we place — Rest ; position; Tartar emetic ; Digitahs; Cold applications ; Nitrate of potassium ; Ergot ; Venesection ; Ipecacuanha ; Mercury ; Local depletion ; Veratrum viride ; Opium ; Purgation ; Diet ; Aconite ; Counter-irritation. The necessity of rest during active inflammation of any organ is a rule without exception. A choice of position is often dictated by the sensations of the patient. AVhen one of the extremities is inflamed its elevation is advised, in order to allow the blood to return from the overloaded vessels. Cold applications are very important in the treatment not only of inflammation, but of active hypermmia or congestion (e. ert Jackson preceded him ; and so had Cirillo of Naples, De Hahn (Breslau, 1737), Samoilowitz (Moscow, 1771), and others. Indeed, in tetanus, and sometimes in fevers, even Hippocrates, Galen, and Avicenna used cold affusion or the cold bath. What is there new under the sun? FE15RIPUGE TREATMENT. 153 parox3sm of irritative or roactivc fever, but also to those of longer duration, under toxaeniic (zymotic) causation; as exan- ihemalous (rubeolar, scarlatinal, variolous) or continued (typhus, typhoid) fevers. An exception is believed by many to exist, in the case of autumnal, malarial, periodical fevers, i. e., interndttent, remittent^ and pernicious (co'ngestivej ; in which, interference by the antidntal remedy, cinchona or its alkaloids, is considered safe at all times, and sometimes necessary before the sul)sidence of fever. But I believe this exception to be only partial, since care- ful recorded experience has given rise to the conclusion' that quinine is S(!ldom necessary during the heir/lit of the exacerbation of either type of malarial fever, and that in large doses at that period it may do harm. It is, I consider, the best practice gen- erally, in the treatment of autumnal remittent fever, to wait iiiitil the febrile stage has passed its climax, and its symptoms have beytm to decline — the urgency of the case, and all its circumstances, then, guiding the practitioner as to how soon, as well as how largely, the special remedy must be introduced. It is needful, however, in this connection, to refer to the appro- val by Sir Thomas Watson of the use of opium in the hot stage of intermittent fever; as well as the employment, with reported success (Squire), of quinine in the pyrexia of scarlet fever, and of the same remedy in full doses in pyoemia, by Dr. Fordyce Barker and others. In Germany, quinine is often much given during fever, to reduce the tenqjeratnre. Antipyretic treatment, of a very positive and active kind, is much in vogue at the present day. Its chief weapon, besides immersion in cold baths, consists in the administration of fifteen or twenty- grain doses of quinine; or, of corresponding amounts of salicylic acid or resorcin. Without recent personal observation of this last practice, I am convinced, by the results of a careful trial of quinine in typhoid fever in the Pennsylvania Hospital (Dundas's treatment) many years ap;o, and by the reports of the compara- tive mortality where antipyretic measures have been vigorously pushed, that it is an uncertain, if not a hazardous method of medication. Such an impression of quinine upon the nervous centres as is necessary to abate the high temperature of (non- malarial) fevers, is too powerful to be likely, on the whole, to benefit the progress of those maladies. Exception does not seem yet to be proved to the rule, that typhoid and typhus fevers can- not he '•'■ jugidated,'''' being typically self-limited diseases', but must be carefully conducted, with very little interference, to th^ir close. Sir William Jenner,'^ in an admirable summary of the results of experience in the treatment of typhoid fever, has given the weight of his authority to the non-acceptance of this heroic and abortive " antipyretic " practice. Moreover, it is extremely important that the indication for elimination of excreta in all acute febrile maladies (e. g., scarlet 1 See Medical Statistics of United States Army, 1839-54. * Address before Birmingham Medical Institute ; Lancet, November, 1879, p. 715. See, for testimony against the cold-bath treatment fBiermer, Lindworm. Lichtenstein, Wiin- derlich, Griinshaw, Pepper, Peters) a paper by F. Allport. M. I)., N. Y. Med. Record, No- vember, 1879, p. 414. Bristowe, also, has proiiounced against it. 154 GENERAL. THERAPEUTICS. fever, measles, small-pox, etc. ) should not be neglected. Early opening of the bowels, and free action of the skin and kidneys are of the greatest consequence in such affections. "When diarrhoea is present, it should be merely held in check (not, usually, sup- pressed) with much caution. I have more than once known death to result from premature locking up of the secretions, by opium, etc., in acute febrile disorders, which, probably, otherwise might have done well. Of medicines which, without undue depression, tend to refriger- ate the system in fever, acids, vegetable and mineral, as well as their salts, have long been commended by experience. Citric and acetic acids, even when combined (as in solutions of citrate of potassium or acetate of anamonium) are the general favorites for this purpose. In continued fevers (typhus and typhoid) hydro- chloric, nitric, and nitro-muriatic acids are often of great service. In connection with this clinical experience may be mentioned the suggestive fact, that physiological experimentation (Gaskell, Lancet, Sept. 18, 1880) has shown the direct influence of acids to be depressive of the action of both the heart and the arteries, while alkalies have the reverse, or a tonic eftect. It is a matter of general remark, that patients scarcely ever die during the hot stage of any kind of fever. In the most intense form of malarial poisoning, called pernicious fever, the danger exists in the extreme depression of the cold stage; if fever comes on, the patient is comparatively safe for the time. The supporting treatment is that adapted to states of prostra- tion or deoility. General weakness of the body (when not a congenital defect) occurs under three forms — Exhaustion ; Depression ; Oppression. We are familiar with the first, exhaustion, as the effect of over- exertion, loss of sleep, deficiency of food, excessive discharges, etc., and as following acute, or constituting a pa7't of chronic disease. The second, depression, is to be discriminated from exhaustion, as resulting, not from expenditure or waste of the material or forces of the body, but from interference with their normal activity by some disturbing cause. To use a mechanical illustration, exhaustion' is the running down of the clock; depression the arrest of the iziipelling movement of the weights or spring, by which its wheels are kept in motion. Oppression, then, may be compared to the obstruction of the machinery by some foreign body, or by some mechanical disar- rangement among the wheels, which clogs their action until it is removed or corrected. Exhaustion and depression have their chief seat in the nerve- central sources of dynamic force ; oppression, in the circulation of the blood, or in some subordinate organs or functions. This distinction, however recondite in theory it may seem to be, is of high practical importance. This will be seen on consideration of the remedies used and required in the different forms of debility. SUPPORTING TREATMENT. 155 Supporting measures may be classified as — 1. Stimulant; 2. Analeptic (recuperative, restorative). Under the first head we rank the preparations o[ ammonia and alcohol, etc., as usually employed. Under the second are included generous diet, tonics, clialybeates, cod-liver oil, chanije of air, etc. Now the first of these (stimulants) are adapted especially to acute prostration or depressio^i; the second class (analeptics), to c/iroJiic prnstrrdion or exhaustion. Oppression or cowderfeit debility generally requires neither, being benefited by very different treat- ment. A minyling or blending of these states is of course possible ; and then a union of measures is right, to meet the conjoined indi- cations. Oppression (simulating depression) is every day illustrated by the condition of a patient in the early stage of any of even the mildest acute disorders ; as catarrh or bronchitis, indigestion, tonsillitis, measles, etc. In all of these cases, especially where fever is developing, the patient is very iveak ; not only as to his muscular apparatus, but in the performance of all the animal and organic functions. But stimulation, for such a condition, in per- sons of ordinary constitutional vigor and soundness, would be generally inapjpropriate, often injurious, sometimes dangerous. A more serious degree of oppression occurs in some cases of visceral congestion, particularly of the lungs or brain ; and in violent spasmodic affections of the alimentary canal, with consti- pation of the bowels. Urcemia, from inaction of the kidneys, presents another case of oppression, in which even a fatal result may occur. Counterfeit debility or oppression, then, to recapitulate, may occur in — The first stage of all acute diseases; The febrile state; Indigestion or dyspepsia; Congestion of the brain, lungs, etc. ; Obstruction of the bowels; Urcemia. The first of these instances is to be treated usually by measures which promote reaction in the mildest manner. More doubt exists, however, if the cold stage itself be intense or profound — as in pernicious intermittent — constituting a depression under toxeemic influeiice. Of this, a word or two presently. The febrile oppression is to be managed simply ]jy those pallia- tive measures mentioned already under the head of febrifuge treatment. That of indigestion is usually temporary or occasional only ; and gives way under the use of antacids, carminatives, blue pill, etc. Violent congestion of the brain or lungs occurring in a person of previously good constitutional strengtli (although it may produce the most absolute debility, which, especially in the case of pid- monarg congestion, masks tlie cause of the disorder i, calls, if the diagnosis be clear, for counter-irritation and the local or general 156 GENERAL THERAPEUTICS. abstraction of blood. In doubtful cases a tentative plan may be pursued ; abstracting but a minimum quantity at first, being en- couraged to repeat and enlarge the depletion only if the result be favorable. Constipation, producing oppressive debility, is of course to be met by agents calculated to unload the bowels ; antispasmodics, anodynes, etc., being also indicated if colic exist, and be not relieved by laxatives alone. In absolute (mechanical) obstruction of the bowels, as intussusception or internal strangulation, the treatment now generally adopted is, to depend ^ upon opium and rest, avoiding purgatives. Urcemia demands all the means within our power to restore the action of the kidneys ; and to aid them in their eliminating duty by favoring the cutaneous transpiration and secretion. I have already said that mixed cases of oppression and depres- sion occur, in which the indications of treatment are, to a certain extent, obscure and doubtful. Such are, the cold stage of perni- cious (congestive) intermittent, the incipiency of the algid or collapsed state of epidemic cholera, etc. It is clear that reaction is here to be brought about, if possible ; and that external stimulation, by powerful rubefacients, frictions, etc., is altogether appropriate ; but, however authoritatively rules may have been laid doAvn, it is not so certain, in every case, whether alcoholic stimulation or venesection would afford the better result, or whether some cases might not be benefited by both com- bined. The incompatibility supposed to exist between bloodletting and stimulation is in fact nut intrinsic but circumstantial. Hold- ing distinctly in our minds the principle that the object of blood- letting is to balance the quantity, consistency, and distribution of the blood, and 7iot to reduce the strength of the patient, it is far from impossible that the balancive action, especially of local bloodletting, may be called for in a case in which the forces require to be sustained at the same time by "supporting' treat- ment." To borrow an illustration (Billing), the one is like taking part of the load from the cart, the other, whipping the tired horse up the hill. Personal experience and judgment, however, are indispensable to the application of these, or of any analogous principles, to cases in regard to the management of which the profession has been, but we may hope will not be always, divided. The recent tendency of medical practice has been quite too much in the direction of over-stimulation. Depression is exemplified in the state produced by — Severe injuries; e. g., railroad accidents, extensive burns, etc. Mental shocks; e. g., terror or great grief. Withdrawal of accustomed stimulation; e. gf., delirium cum tre- more.^ Intense toxaemia; e. g., pernicious intermittent, etc. (see above). Gouty spasm, of the heart or stomach, etc. 1 Unless clear indication exists for a surgical operation to relieve ihe obstruction. 2 It is not intended, of course, to indicate that all cases of delirium tremens ai'e referable to this cause. AN A LKPTICS. 157 Stiniulalion by alcohol, ammonia, ether, opium, camphor, tur- pentine, capsicum, etc., is needed, with greater or less urg(!ncy, and in larger or smaller doses, in all of these conditions ; always bearing in mind tlie prol»atiility of 7-eac<(0*i and avoiding, as far as possible, tlie exaggeration of this reaction into fever. Dr. Lidell' remarks that "'the physician's success in saving or prolonging life in cases of jjulmonary tui)erculosis, chronic bron- chitis, chronic (jueumonia, chronic pleurisy, chronic abscess, ver- tebral caries, chlorosis, leuktemia, scrofulous adenitis,'^ ague cachexia, syphilitic cachexia, infantile marasmus, and many other debilitating diseases, will largely depend upon his ability to prevent the occux-rence of thrombosis ' in some part of the venous system." Ammonia is urged as meetuig this indication, as well as that of pure stimulation. The prostration of t)/))hus fcvn\ in a majority of cases {rtot in all)^ and that of typhoid fevrr, in a minority of cases, requires especially after the height of the fever has passed, alcoholic stimu- lation, as well as sui»port by concentrated liquid nutriment (beef- tea, milk), at short intervals. The instances of these fevers afford a sort of intermediate gradation between what I have called acute and chronic debihty. In regard to the latter (the debility of convalescence, chronic disease, etc.), certain principles are agreed upon b}^ all physicians, on the ground of experience, confirmed by the deductions of phys- idlogical science. We shall ilrst brieily consider some of these, and then one or two debatable points akin to those already alluded to. The two most important and familiar results of clinical experi- ence in the treatment of debility, are, the superiority of the pure vegetable bitters in stomachic and digestive weakness, and of iron in anaemia (spanremia). The influence of qninia andcinchonia in nervous debility is equally assured. The confidence of many physicians is strongin the utility of the mineral tonics (zinc, cop- per, arsenic, and silver salts) ' in debility with nervous sjrmptoms ; e. (/., chorea, hysteria, etc. I believe this confidence to be deserved, to a considerable extent ; but some of the diseases in which these medicines are given (e. g., epilepsy) will in many instances baffle all treatment. The use of strychnia in certain cases of paralysis is also well established ; although requiring much care and discrimination. Some practitioners (Coujiland, Gulstonian Lectures, 1881) make considerable use of arsenic in obstinate anajmia. Cod-liver oil holds, at the present time, a very high place in the list of analeptics. All medical observers are not of one opinion in regard to its value ; but most of them believe it (on the basis of experience in practice) to be the best and most reliable, whei'e it is tolerated, of all recuperative medicines, not only in consumption, but in other wasting diseases. The theory of the mode of action of cod-liver oil as an analeptic 1 Am. .Tournal of Med. Sciences, July, 1874. ^Glandular inflammation. a Coagulation of blood in a vein. * Salts of mnnt^nnrxe (^ phosphate and sulphate) are valued by some physicians as very aseful in ansemia and debility. 14 158 GENERAL THERAPEUTICS. is an interesting subject. Dr. Bennett's view of phthisis was that the error of liseinatosis, from which tubercle results, consists in an excess of albumen in the blood, with a deficiency of oil ; so that, in the process of cell-formation, the first step of which is believed (Ascherson) to be the investment of oil globules with albu- minous envelopes^ an imperfection exists fatal to the subsequent development of the cell, and ohliging it to abort. But the debili- tation of the digestive and assimilative functions in phthisis renders it impossible by ordinary food to supply the desiderated oleagin- ous matter to the blood. Cod-liver oil is fatty matter which, by the assimilating action of the liver, following the process of digestion, is prepared for immediate absorption and appropriation by the blood, for purposes of nutrition. This rationale of its influence is, although not demonstrable, much more probably correct than that which refers it to the presence of iodine, phos- phorus, or any other special ingredients which it may contain. Allusion to the more lately introduced dugong oil (Holt), shark oil, etc., would be more proper in connection with the subject of materia medica than here. The phosphates and h3rpophosphites have attracted a great deal of attention. I do not consider the question settled as yet, as to their comparative value. My impression, however, is, that the phosphate of iron is the best of them all, and that they will be found secondary and inferior to cod-liver oil. Still, a combi- nation of hypophosphites often proves useful in improving appe- tite and digestion. Within a few years renewed attention has been given (Gubler, Hammond, Baumetz, S. E. Percy,^ Eouth) to the effects of phos-' phorus (not in the state of phosphoric acid) in exhaustion of the brain and nervous system ; as, e. g., from over brain-work or worry, or from venereal excesses. Chemical analysis shows a diminished amount of phosphorus in the brains of aged people, and still more in those of idiots. There is reason to believe that it is also lessened especially in cases of softening of nerve centres. Phosphorus is safe in doses of /g grain, in oil or in powder with some farinaceous substance.^ Amorphous phosphorus is the least irritating, and therefore most safe. Phosphide of zinc is often given, in pill, in gr. -^^ to gr, } doses. What is the proper place of alcoholic beverages or prepara- tions in the treatment of chronic debility, such as that of phthisis, etc. ? This important question opens a discussion, only the main elements of which can be noticed in this work. In the first place, the theory of the action of agents called stimulants was formerly almost always misstated in authorita- tive treatises. It lias been commonly laid down that "one of the laws of all stimulation, whatever may be its degree, is, that it is followed by a defjression proportionate, at least approxi- mately, to the previous exaltation of the function or functions excited." The true law is this : that all stimulation which is excessive 1 Prize Essay on Phosphorus, etc., Trans. Am. Med. Assoc., 1872. » See Routh on Overwork and Premature Decay, etc., 1873. ATiCOTTOT.. 159 is followed by a depression corresponding to the excess; while all that merely excites any function up to par (to use a familiar expression), i. r., to or toward its normal activity, does, so far, only good, with no rrsnUiiuj dcl)ilitation, however it may fail, from want of other conditions, to sustain the organ or system at the point desired. To deny this would be to ignore some of the most obvious physiological facts. Heat is a stimulant to life force ; oxygen to all th(^ active functions ; blood is an excitant as well as fofxl to all the tissues it reaches ; and all those impres- sions upon the exterior of the body which give rise to instinctive or automatic actions are stimulants, without any necessary ulterior depression. Nor do I see how the use of stimulants in any supposable case of disease could be rationally justified, if we practicdllji admitted the force of the law as above stated ; sin(;e, if, after every dose of aia excitant, the patient should sink as far hclow the condition for which he was treated, as the intended remedy raised him for the moment above it, of course a mere osciUation, and no advantage, must be the result.^ This, however, is theory, which has not largely governed practice on this subject. Another interesting physiological question — " does alcohol contribute to the material or to the force of the economy, or only excite some of its organs to exhaustive action?" — has been the topic of able and learned disquisitions. I venture the opinion that it may do either of the three, or neither^ according to the circumstances and the quantity of its administration. When there is scarcity offood^ or difficulty of digestion, alcohol may contribute to the needed material; its carbon, hydrogen, and oxygen going to repair the adipose tissue at least, and to economize albuminous substances.'^ When there is excessive exertion, alcohol may sustain the flagging forces of the system. When given in viere excess, as with the intemperate, it excites to exhaustive action, organic if not motor ; even when the bloated body shows increase in quantity of material, its quality being more or less degenerate. Parkes, Richardson, and others have shown that alcohol, given during health, produces a wasteful consumption of force, by ac- celerating the heart's action. In a word, then, the phrase "accessory food " is a happy one. When unnecessary, as in full health, alcohol is injurious precisely in proportion to the quantity used ; and the same is true in. disease, when the quantity given is disproportionate. This is the important practical precept. Alcoholic stimulus should never be taken in quantities which produce circulatory or cerebro-nervous disturbance or suj^er-excitation. If this rule be observed, not only will it be a valuable supporting agent in phthisis and other complaints, but no dipjsomaniaj (methomania) or morbid thirst for it will arrive, thai terrible disease always growing out of excess. Upon this principle, in the use of alco- 1 Some recent writers have ahjured the term " stimulation," and the idea commonly attached to it, altogether; particularly as applied to the effects of alcohol. Although made excusable by an error in the now prevailing vaso-motor physiology, this innova- tion in the use of language tends only to confuse the judgment and paralyze practice. - Dr. Wilks, of Guy's Ho.spital, London, has given carefully-obtained evidence that alcohol, under some circumstances, acts as food. See Lancet, Jan. 27, 1872. 160 GENERAL THERAPEUTICS. holic beverages in cases of ordinary debility, tlie common table doses are, medicinally speaking, too large. Alcohol, in advanced or advancing consumption, in low fever, and in other analogous cases, when used in due proportion, is useful — 1. By its direct excitanl/supporting power. 2. By aiding the enfeebled stomach to digest a larger supply of food. 3. By tending to retard tissue-metamorpliosis. This last action is one which alcohol has been shown (Booker, Hammond) to have, under some circumstances, at least, in com- mon with other agents, used as medicines or luxuries ; coffee, tea, morphia, quinia,' etc. I have alluded to it in our classifica- tion of remedies, under the head of " economic medicines." It is not supposable, however, that the retardation of the change of tissue in the body is always beneficial. It may, espe- cially in febrile disease, when accumulation of effete matter in the blood and organs is a present evil, be injurious. It is probable, however, that in low fevers, when oxidation is going on excessively, alcohol yields carbon and hydrogen as fuel for the "•combustion" which takes place under the depression''* of life-force ; thus economizing the materials of the blood and tis- sues. This may explain the entire absence of "toxic" effects of alcohol when given in typhus, in regulated, but often consid- erable quantities. When more is given than can he consumed by oxidation., then symptoms of alcoholism occur. The lowering of temperature under the use of small or mod- erate doses of alcohol in low fevers, may be accounted for in two ways : 1, by its combustion generating less heat than that of other materials in the blood and tissues whose place, in oxidation, it may take ; 2, by its energizing influence upon the ganglia, through which the vital control over excessive waste and combustion may be restored or promoted. Admitting, then, the frequent utility of alcohol, we are pre- pared, most of all from clinical observation, to condemn without hesitation or qualification the practice introduced by the late Dr. Todd, of London (foreshadowed by that of the famous Dr. Brown of the last century), of giving alcohol as the remedy or proper medicine " for all acute diseases." Enough for our present pur- pose to cite some impartial testimonies as to the results of that practice. 1. The physician whom Dr. Todd intrusted with the task of analyzing his own records of hospital practice^ asserts, that the mortality from fever in the hospital attended by Dr. Todd was in a marked degree greater than that of any other fever hospital in Great Britain. 2. Statistics of the London Hospital* more recently published, 1 Kerner, Eanke, and Strassburg have shown that quininization diminishes by one- half the excretion of urea and uric acid. 2 Lowering of vital energy being attended by increased activity of ordinary chemical change. 3 British and Foreign Medico-Chirurg. Review, October, 1860, p. 331. i British Med. Journal, Dec. 9, 186£t STIMULTSM, 161 show a large Increase, since 1858, in the use of stimulants in that hospital, and, with it, a closely coincident ratio of increase in mor- tality. 3. Drs. Gairdner' and Kussell have shown, in the Glasgow Fever Hospital, that even typhus may be treated, with excellent results, almost entirely withoiit alcohol. Stimulism, as we may call the theory and practice of Dr. Todd, since followed by many others, confomids three distinct propositions : 1. That all disease is debility; 2. That all debility should be treated by the use of stimulants ; 3. That alcohol is always the best stimulant. Granting, with some qualification, the hrst of these, wc emphatically deny the truth of the second and third. It is a practice which, like many other specialisms., will have its day. It is already subsiding in most places. Says Dr. J. Matthews Duncan,'^ " This practice was derived from London, and I hope London will have the honor of putting an end to it." 8ir W. Jenner's rule in treatment of typhoid fever* may well have a wider extension: ''to abstain from giving alcohol if, in the case before me, I douht the wisdom of giving it ; and when there is a question of a larger or smaller dose, I, as a rule, i)rescribe the smaller." In a large "Temperance Hos- pital" in London, alcohol is, practically, omitted in the treat- ment of all cases of disease. This is an extreme which my own experience agrees with that of the profession generally in not believing to be a safe example in therapeutics, nor one demanded by the interests of temperance. When used with proper judg- ment and caution, alcohol may be administered with as little danger of subsequent habits of excess as any other powerful med- icine. But such caution is of great consequence. The following classification of the "genuine effects of stimula- tion," when properly used as to time and dosage (remembering the often opposite effects of small and large d.oses), is from Anstie.* "I. Relief of pain. II. Removal of muscular spasm, tremor, or convulsion. III. Reduction of undue frequency of the cir- culation. lY. Reduction of excessive secretion. Y. Removal of general debility, or of special fatigue of muscles, brain, or digestive organs. Yl. Removal of delirium or maniacal excite- ment, and production of healthy sleep. YIL Support of the organism in the absence of ordinary food. YIII. Local increase of nutrition where this is deficient." From the same writer comes also the following terse summary of the stimulating agencies most available therapeutically. "1. Quickty digested and nutritious /ood. 2. Opium in doses of one or two grains; or morpjhia (sulphate, etc.) a quarter to half a grain. 3. Carbonate and chloride of ammonium in doses of five and ten grains respectively. 4. Alcohol, in doses just too small to produce flushing of the face or sweating of the brow.*" 5. Chloroform, inhaled (in the proportion of about two per cent, to the bulk of atmospheric air) for a short time ; or taken inter- 1 British Med. Journal, Aug. 22, 1868. 2 Lancet, Oct. 30, 1880. 3 Ibid., Nov. 15, 1879. * On Stimulants and Narcotics, pp. 112, 113. 5 It is singular that Headland (On the Action of Medicines, last edition) does not include alcohol in his list of stimulants. It is, with him, an " inebriant narcotic." 14* L 162 GENERAL THERAPEUTICS. nally, in doses of a few drops, 6. Certain fetid gum resins. 7. Many aromatic volatile oils. 8. The bitters, pure and aromatic. 9. Counter-irritation, as it is called ; stimulation, as it should be termed, through ttie skin." Hypodermic injection of powerful stimulants is sometimes used in cases of threatening collapse. Ether^ has been so employed, 15 drops being thrown in under the skin at a time. Ammonia has been similarly administered, in so strong a solution as equal parts of aqua amraonise and water ; a fluidrachm being injected at once^ into a vein. Whisky or brandy may be resorted to under like circumstances ; when (for example, from exhausting hemorrhage) life is endangered by prostration not reached by stimulants administered by the mouth or rectum. Under the now accepted opinion that digitalis is a "heart tonic," it (or digitalin) is sometimes used by hypodermic injec- tion, in cases of "flagging heart ; " and atropia as a stimulant to the respiratory function. Dr. Karel, of St. Petersburg, within a few years, obtained the attention of the profession to the treatment of dyspepsia, chronic nervous affections, etc., by an exclusive diet of skimmed milk. Dr. Donkin followed him, giving in Bright's disease and other chronic diseases six or seven pints of skimmed milk daily, for weeks together, without any other food. Dr. S. Weir MitchelP reports favorably of the alterative influence of this treatment in obsti- nate disorders of the stomach. He begins with one or two table- spoonfuls of the milk on rising, and every two hours through the day. Increasing the quantity in a few days, the maximum amount of two quarts daily is mostly attained without great inconven- ience, although some long constantly for other food. I cannot see anythiug in this practice but a purely empirical dernier ressort in troublesome cases of chronic disease. As such, however, it is now on trial by many physicians. My experience convinces me that, in ninety-nine cases in a hundred, unskimmed is better than skimmed milk, for the sick or well. In diabetes mellitus, however, skimmed milk may be preferred. Desiccated blood (Le Bon,* 1875) is said to be capable of skil- ful preparation so as to preserve its hoemoglobin, and to answer a good purpose as a recuperant. Dr. Andrew Smith, of New York, and others report favorably of its action in anaemic cases. The subject of the treatment of debility, acute and chronic, must not be dismissed without one further remark, upon the im- portance of rest in cases of exhaustion from over-exertion. The popular truism, that exercise is beneficial to health., has been often abused by applying it universally to invalids or valetudinarians. The one remedy for the immediate effects of over-exertion is abso- lute and prolonged repose. The time required for recuperation, after cerebral over-fatigue, may be counted rather by months than by weeks or days ; and it is quite possible for irreparable mischief to be done to the brain or 1 Verneuil, Journal de Med. et de Cliirurg. Pratiques, March, 1877. 2 Griswold, N. Y. Med. Record June 7, 1879. 3 Phila. Medical Times, Oct. 15, 1870, et seq. * Comptes Rendus, 1875. See Journal de Thgrapeutique, Nov. 25, 1880. CALMATIVE TREATMENT. 163 spinal marrow by neglecting too long the demand of nature for rest. With many others, the author must acknowledge indebt- edness to the late Prof. Jackson, of the University of Pennsylva- nia, for the judicious empliasis of his teaching upon this point. It is an important hygienic and therapeutic law, that exercise, to be beneticial, must be proportionate to the strength of the individual ; and must never be carried to the extent of great fatigue or temporary exhaustion. Calmative treatment has always been regarded as of impor- tance in allections of the nervous system ; not only for the relief of suffering, but to arrest the waste of irritation. Opium, cam- phor, valerian, and assafoetida are the oldest and most commonly appreciated medicines of this class. Warm and tepid baths and ablutions, simple or medicated (especially with salt or alcohol), have always been favorite adjuvants. Bromide of potassium has come largely into use within a few years (Locock, 1852), as a sedative to reflex exdtability of all the surfaces, or rather of the centres, of the body. In sleeplessness, ejnlepsi/, hysteria, and spermatorrhoea, it has seemed to be particu- larly valuable. I have always found it to act mildly and safely in twenty-grain doses. Tliirty or forty grains at a single dose may be safe in an adult generally. Dr. Da Costa has pointed out that the bromide adds to the beneficial effects of opiates, given with or after it. Bromide of sodium is very similar in its effects, and agrees better with some feeble patients. Bromide of calcium does not generally set so well u^Don the stomach. The sedative action of the bromides when locally applied, in solution, is some- times valuable. Bromo-camphor (Schwartz) is said to act as a useful calmative in 2 to 5 grain doses. It must be remembered, however, that the continuance of any of the bromides in large doses may cause bromism; a condition of general debility, with abdominal pain, fetid breath, salivation, nausea, vomiting, or purging, an eruption like acne, anaesthesia of the skin, dilated pupils, dimness of sight, unsteadiness in walking, drowsiness and lowness of spirits. Organic disease of the kidneys is considered to contraindicate the use of the bromides. Hydrate of chloral has, since its introduction by Liebreich, of Berlin, taken a leading place among hypnotic or sleep-producing medicines. It appears to be nearly as certain in its action as opium, with less unpleasant after effects ; but to be not so power- ful in the relief of pain. As a-xx^antispasmodic, under various circumstances, it has proved etficacious.^ Some tendency to depression of vital energy is observable under the influence of considerable doses of chloral hydrate. This is especially as- serted as of importance in contra-indicating its employment when the respiratory function is impaired. What I have seen of 1 Hydrate of chloral is soluble in water, alcohol, ether, chloroform, and fatty sub- stances. Dosf, 15 to 30 grains. Much larger doses are given, but are not unattended by danger. Death has, in a number of instances, followed excess in its use. Chloral hydrate, being pungent and acrid, should be considerably diluted when taker. ; but tlie scihition should always be freshly prepared, as it does not keep well. Alkalies are incompatible with it." Dr. Kidd has reported its acting well by enema when, given by the luouth, it disturbs the feeble stomach. 164 GENERAL THERAPEUTICS. its use, however, gives me the impression that (as regards small doses^ at least) the danger of this has been rather over-rated.' Probably the chief danger attends its depressing influence upon the heart and general circulation. Persons habituated to its use for a considerable time l^ave sometimes died suddenly after taking not more than 60 or 70 grains at once ; as if the vascu- lar (or vaso-motor) system had been previously enfeebled by it.^ Dr. Edward Hartshorne has found chloride of ammoniimi^ in 15 or 20 grain doses, to exert a tranquillizing influence not unlike that of the bromides. Under the head of antispasmodic calmatives may be named nitrite of amyl; the inhalation of which is now often resorted to for the' arrest or prevention of paroxysms of epilepsy, angina pectoris, etc. It must be used with care ; inhaling at first only a few drops at a time. The sign of its action is flushing of the face. It may be carried about the person in well stopped small vials ; each vial containing not much more than a single dose, as what is left after breathing is nearly inert. Some practitioners, to avoid spilling, have the vial fix'st filled witli cotton, which is then saturated with the nitrite. The dose of it may be gradually increased, when it is inhaled repeatedly. Jamaica dogwood (piscidia erythrina) is one of the later narcot- ics, from whose action upon animals a useful role as an anodyne is hoped for, but not yet (1881) safely ascertained. Eri/throxylon coca, of South America, has been long known as a popularly used nerve-stimulant in its native country. Although getting latterly under trial, its precise uses in practical medicine are not yet well defined. Its action is more like that of coffee and tea than that of opium. (Dose of fluid extract, f5ss to f5ij-) Antidotal treatment is a topic of great interest. Its idea is probably the oldest in medicine. Specifics have always been looked upon as the magna bona of therapeutical science. Unfor- tunately, however, their number, instead of increasing, has diminished under the inexorable scrutiny of modern investiga- tion. Yet, there is room for hope that they may again positively increase, with the diligent application of enlarged means of observation and discovery. In the widest extension of the term, antidotive remedies may be classified thus : — Positive antidotes ; ^ . Chemical palliatives ; ' Chemical antidotes; Antacids ; Antitoxics ; Antilithics, Parasiticides. Constructive antidotes ; Antiperiodics ; Antiscorbutics. Antisyphilitics ; 1 Ordylowski (Gazette des Hopitaux, Aug. 28, 1880) asserts that in a considerable num- ber of eases of phthisis, doses of 15 to 30 grains of chloral at bedtime promoted rest and strength, -without any bad symptoms in any of the cases. 2 A prominent symptom of chloral poisoning, however, is stupor (coma). See an article by Dr. H. H. Kane, in N. Y. Medical Record, Dec, 1880. ANTIDOTAL TREATMENT. 165 Tentative antidotal remedies ; Antiarth ritics; Antiseptics; Antirheumatics ; Antiziimotirs. The familiar use of antacids as palliatives in dyspepsia, etc., needs no remark. Nor have we occasion to dwell, here, upon antilithics ; i. e., solvents for urinary solids, prescribed on chemical principles ; as alkalies for excess of uric acid or the urates, mineral acids for excess of phosphates or oxalates. The subject of chemical antidotes for poisons belong to Toxi- cologi/. (See Part. II.) Anthelmintics are best treated of in the department of Prac- tice of Medicine. (Part II.) Antipsorics, or specific remedies for scabies (itch), arc repre- sented generally by sulphur; which, although not at all the only agent capal)le of destroying the morbific acarus (sarcoptes), is the most cimvenient. Other cutaneous parasites (nosophyta) are also destroyed, but with less certainty, by preparations of mer- cury, etc., called parasiticides. Of "constructive antidotes," the most important are the alka- loids of cinchona, applied to the treatment of malarious affections (antiperiodics). Medical men are divided upon the question whether quinia arrests intermittent fever, etc., by antagonizing (chemically) the organic poison itself in the system,^ or (physi- ologically) by caus^ing such an opposite impression upon the nervous centres as is capable of subverting the condition on which \ the periodical or paroxysmal affection depends. The last is the prevailing view. But, in either aspect, the cure of autumnal fevers and allied affections occurring under malarial influence (neuralgias, etc.), by cinchonization, is properly called specific treatment ; as — 1. No other remedies (yet discovered) have the same power. 2. These remedies have no such control over any other diseases {e. g., typhus and typhoid fever, yellow fever). The second proposition is asserted with positiveness, notwith- standing the now common, but still experimental, use of quinine in full doses in typhus and typhoid fever, and its frequent admin- istration in yellow fever. Dr. E. B. Baxter, of London {Practitioner, Nov., 1873), reports a series of experiments showing the antiseptic power of quinia, quinoidine, cinchonidine, and cinchonia ; the comparative action of these alkaloids in this respect (and their control over the migratory movements of the colorless blood-corpuscles), being relatively proportionate to their antiperiodic and curative power. The power of quinine to destroy minute fungoid vegetative organisms has been asserted by several observers. So has that of the active principle of eucalyptus globulus. This accords especially with the "fungous" or "disease germ" theory of malarious causation. In stating that no other medicines, yet discovered, have the 1 Bence Jones found in human blood a fluorescent material, in small amount, not improl)al)ly supposed to be identical with quinia; Drs. E. Rhoads and VV. Pepper also ascertained a deliciency of this "animal quinoidine" to exist inpatients suffering under malarial disease.— See Penna. Hospital Eeports, 1868, p. 269. 166 GENERAL THERAPEUTICS. same power, I mean, to a degree or with a certainty at all com- parable to that of the cinchonic alkaloids. The nearest approach to this is afforded by arsenic and the sulphites. It is, however, a remarkable and important fact, that, when the recurrence of the paroxysms of intermittent fever has been allowed for a long period (ckronic intermittent), and the system of the patient has become debilitated and anaemic, quinine will only interrupt, but will not cure the disease. Iron is, then, the remedy. Opinion is divided as to the value or necessity of mercury as an antisyphilitic. In the primary disease I am a full believer in its importance ; against which its frequent abuse furnishes no argument. In secondary syphilitic affections, especially syphilitic rheumatism, iodide of potassium also exhibits decidedly specific powers. Antiscorbutics are most valuable as preventives of scurvy ; but will promptly relieve it, also, when it has occurred. All fresk vegetables belong prominently to this class ; certain plants not so used, as the cactus opuntia, are included in it ; the juice of lemons, limes, etc., is of service for the same end, and the neu- tral salts of potassium have been largely employed, with variable results. Tentative antidotal treatment — for diseases in which there is evidently (as a part, at least, if not the primary part of the malady) humoral disorder, such as gout, rheumatism, the exan- themata, etc. — affords a large field for study and ratiocination. The positive /acis, so far, are few; the hypotheses, legion. In gout, colchicum has long held, deservedly, a high place, as either an eliminative or an antidotal remedy. Most observers have given it the first title ;^ Dr. Garrod's experiments induced him to prefer the idea, if not the phrase of the latter. Alkaline salts of organic acids, as bicarbonate of potassium, sodium, or lithium (Garrod), or tartrate of potassium and sodium, and the alkaline earth, magnesia, have also a large share of confidence in the treatment of gout. Experience satisfies me that this confidence is well founded. After all, however, so incomplete is any curative plan as yet devised, that a large margin is left for patience and opium. The same is true of rheumatism; especially in its distinctive form, of acute articular rheumatism, or rheumatic fever. Colchi- cum has been here also much given ; but in the absence of the gouty, diathesis,'^ hereditary or acquired, it will often, if not generally, dis- appoint. Alkaline salts are, with many, the favorite tentative anti-rheumatics. Lemon-juice also has been freely employed. 1 Colchicum has heen shown, by Krahmer and Hammond (Proceedings of Biological Department of Acad, of Nat. Sciences of Philadelphia, Nov. 1st, 1857), to increase the amount of the solids of the urine more decidedly than any other vegetable diuretic. 2 (iarrod insists on the diagnostic importance of the uric acid test for gout. It is easily applied, as follows : Take about f5jss of the serum from a blister, or from the blood drawn by venesection or cupping, and place it on a flat dish or watch-glass. Add to this fifteen drops of acetic acid, and place in it two or three threads of cotton. Allow the glass to stand in a warm room for one or two days, to evaporate. If the cotton fibres be then removed and examined microscopically with an inch object-glass, they will be found, if the serum contained uric acid, to be covered with its crystals, arranged somewhat as the crystals of sugar-candy form on a string. SULPHITES. 167 Phosphate of ntnmonium was for a hv'wf timo in vogue. Certain enfeebled cases, with free perspiration, will recover speedily und(U' quininiz<(li(in. Ikil in all these modes of treatment there is no spccijir certainty. Of projyi/Uiinin, as a remedy for rheu- matism, I liave had some experience, and liave found no basis for a favorable opiniim. First employed by Awenarius, of JSt. Peters- hurg, Drs. (raston, Diijardin Beaumetz, and Besnier have reported favorably of this remedy. Dr. Da Costa' has obtained good results with bromide of annnomum. .Strieker, in 1876, asserted rapid cures with saliajUc acid. Since then, Traube, S6e, Broadbent, Machigan and many others have obtained, by their published results, the general confidence of the profession in its value. (See l{hcum<(tism, Part II.) As it is capable of causing death when used in excess, moderation in dosage is necessary with it. Chronic rheumatism is not satisf\ictorily shown to be a humoral disease. Except in its si/'philitic form, when iodide of potassium will always relieve it, there is no specific for what is commonly known as chronic rheumatism. Of all medicines, I have found oil of cajuput (in 5 to 10 drop doses) do the most in mitigation cf its pains. Oil of turpentine is a more generally used remedy for the same purpose, and one often serviceable. The explanation of the action of these oils in such cases is very obscure and doubt- ful. Iodide of potassium, also, is largely given for chronic rheumatism. In syphilitic rheumatism, it is absolutely a specific remedy. In the management of the zymotic aflfections, the only great triumph of medical art has been one of prevention. Vaccination afibrds an instance of control over one of the most destructive and loathsome of pestilences, by the interference of the physician. As to the treatment, even of small-pox^ itself, when it has occurred, and of scarlet fever, measles, chicken-pox, hooping-cough, and mumps, we are forced to confess our powerlessness, except to con- duct the case, by the aid of palliative measures, to its natural and spontaneous termination. This is equally true of yellow fever. There is no specific yet known for this terrible disease. It is to be palliated, as it cannot he cut short. Nor have we any specific for epidemic cholera. Antispasmodics, at very short intervals of administration, and ice, with free ex- ternal stimulation, will conduct many cases to a successful close ; but this is not antidotal treatment. In the medication of zymotic atiections having, as a local symp- tom, infiammation of the mucous membranes, with unusual tendency to (septic) decomposition or disorganization — e. g., scarlatina, diphtheria, and pycemia — chlorate of potassium and other preparations of chlorine, as tincture of chloride of iron, have achieved a very widespread reputation. Benznate of sodium has, of late, with some, claimed a share of the same con- fidence. The tincture of the chloride of iron appears also to have an 1 Pennsylvania Hospital Reports, 18^9. ^Sarracenia has proved valueless upon fair trial. 168 GENERAL THERAPEUTICS. excellent effect (although we can hardly call it antidotal) in asthenic erysipelas. Antidiphtheritic power has been strongly asserted of lime-water^ locally applied, and of lactic acid.. Professor Polli, of Milan, in 1864 (following Ghaussier and Bielt of Paris), proposed the internal use of the sulphites of sodium, calcium, and magnesium, in toxsemic diseases, as antizymotics or antiseptics. The chemical rationale of their action is very plausible. Success has been asserted ^ for them in pyaemia, scar- let fever, diphtheria, intermittent fever, cattle-plague, etc., and in glanders in the horse. As a tentative practice these remedies have seemed wortby of careful trial ; although, especially in the United States army during the late war, the amount of positive evidence in their favor has not been very large. Science should suggest remedies for experience to prove; em- piricism may thus be made rational, and rationalism in medicine may become practical. Even if disappointment attend a certain set of experiments, such a trial is fully justiflable in principle. The sulphites appear in the urine about twenty minutes after they are taken ; also in the sputa and saliva ; but they are gradu- ally changed in the system into sulphates. M. Carey Lea, of Philadelphia, in a paper published in 1865,'^ reported a series of careful experiments, in which he found evidence that when a small quantity of sulphite or bisulphite of sodium is taken, less than a hundred grains, it disappears by oxidation in the system ; but if large amounts be ingested, a considerable portion passes un- changed in the urine, and sulphurous acid may even be detected in the breath. Dr. Polli recommends especially the sulphite of magnesium as the most active and having the least taste. The dose is fifteen to thirty grains, in powder, dissolved in water or an aromatic vehi- cle, or in troches. He advises saturating the system with the medicine ; four or five drachms daily for an adult as a minimum. Pive to seven drachms of the sulphite of sodium are borne well. Its long-continued use may bring on oedema and diseases of de- bility ; otherwise, it shows no special influence on the system. Externally^ solutions of the sulphites, especially when mixed with a portion of glycerin, are recommended as applications to suppurating surfaces, to sloughing and ulcerated parts, and in erysipelas. Sulphites of calcium and magnesium are somewhat caustic. In septaimia from wounds, etc., Polli administers thirty grains of the sulphite of magnesium, every two hours, internally. Carbolic acid has also come under extensive trial, as an anti- zymotic, both externally and internally used. Dr. Shoemaker, of Ohio, amongst others, reports excellent success with it, given internally in small doses, in scarlet fever. Dr. Ernest Sansom^ uses in scarlet fever and other allied diseases, the sulpho-carbolates of sodium, potassium, and other bases ; especially sulpho-carbo- late of sodium, five or ten grains every four hours. iSee Amer. Journal of Med. Sciences, Oct., 1863; and later numbers of the same Journal. 2 Am. Journ. Med. Sciences, Jan., 1865, p. 84. 3 Lancet, Jan. 15, 1870. AliTERATIVE TREATMENT. 169 Silicate of sodium is asserted by Dubreuil' and Champouillon^ to have powerful antiseptic properties, especially available locally, in ozoena, catarrhal bronchitis (by atomization of its solution), and cytitis with accumulation of decomposing secn^tion. Salicylic acid, iodoform, and bcnzoale of sodium are now under abundant trial, in the treatment of many disorders. Their antiseptic properties are only a part of those contributing to their value, not yet wholly dcit'rnfuKHl in therapeutics. Of benzoatc of sodium (rec- ommended byLetzerich in dii)hth('ria, and by several practitioners in scarlet fever) the minimum dose for an adult is five grains ; some physicians (Klebs, vScluiler) give it or the benzoate of mag- nesium to the amount of 5J in a day. Klebs and Krocsak advise inhalation of its solution (from 2 to 5 per cent, in water) two or three times daily. Its administration in phthisis will be referred to hereafter in another place. One of the latest introduced (1880) of anti-zymotics is resorcin; whose eftects have not yet been thoroughly investigated.^ En resumr, we may say that all endemic, epidemic, infectious, and contagious diseases are naturally self-limited ; and that, so far, we have only reached a certainly curative treatment for one class — viz., intermittent, remittent, and pernicious (classed to- gether as malarial) fevers ; and a preventive treatment for another, small-pox. While, therefore, for yelloAV fever, scarlatina, pertussis, etc., we are without the possession of any specific or antidotal treat- ment, the palliative plan is the one for us to pursue. All attempts, by violent measures, to cut short either of these diseases, while they fail to attain that object, will endanger the patient by lowering his forces and thus promoting the victory of the depres- sive toxsemic cause. Yet, I repeat, we are not to abandon or reject the hope that observation and cautious experim-ent, guided by the lights of advancing science, may enable us hereafter to discover remedies as potent in the management and control of scarlet fever, yellow fever, and cholera, as quinine is in that of ague, or vaccination in the prevention or salutary modification of small-pox. Alterative treatment is distinguished, in our classification, it may seem arbitrarily, from the antidotive. All antidotes may be said to be alterative, but all alterative medicines are not anti- dotal ; as the latter expression implies at least the iwohahle, if not the known existence of a material cause, against which the antidote is to act. Yet the distinction is not one upon which we can insist, although it appears convenient. The term alterative is by no means a mere apology for ignorance ; it involves an important therapeutical principle, viz., the sup- planting or displacing of a morbid impression, condition, or pro- cess in the body, by the safer impression and counteraction of a medicinal agent. The influence of the latter, physiologically 1 Gaz. Medicale de Paris, No. 49, 1872. ^Gaz. Hebdomadaire, No. 8, 1873. Loltmann and Roteuhofer, of Breslau, have used it with advantage iii cholera in- fantum. Lyon Med., Feb. 20, I881. 15 170 GENERAL THERAPEUTICS. speaking, ma}'^ be, per se, abnormal ; yet, having a sanative pur- pose, it is therapeutic. This principle may be sufficiently illustrated by allusion to two or three examples. In the peculiar and often violent inflamma- tion of the throat in scarlatina, the free application of a strong solution of nitrate of silver to the part will almost invariably arrest (if used early) the morbid local process; converting it, at all events, from a specific and dangerous into a simple and mild phlo- gosis. So may the early and powerful impression of the solid nitrate of silver, or other caustic, upon the surface of the penis affected with chancre, supplant the venereal process, and leave in its place a benignant ulcer. When erysipelatous inflammation is spreading like a conflagra- tion from part to part, a blister, or tincture of iodine, etc., will sometimes succeed in forming a cordon sanitaire, by inducing its own milder irritation in advance of the disease. The most essential part of the treatment of chronic diseases of the skin, is either alterative or antidotal. Parasitic affbctions, as scabies, favus, mentagra, etc., require the destruction of the epizoon or epiphyte by an antidote. Othei's, as eczema, lichen, impetigo, lepra, etc., when at all obstinate, are all generally treated in the same manner essentially, to whichever class the disease may belong. Why ? Because the principle is the same in all — the alterative principle. The abnormal, perverted nutri- tion of the cutaneous tissue, whether it be deeply or superficially affected, is (apart from antiphlogistic or sedative treatment, called for in certain cases) to be subverted, by a decisive change in all its conditions ; and, speaking boldly, it is little matter what change, so it be considerable. Any means which will hurry the removal of the old diseased skin, and favor the immediate construction of a new layer, will be curative, whether it be only soap, water and frictions, mercurial ointment, chrysophanic acid, vesication, or the actual cautery.' And the same principle explains and jus- tifies the internal use of arsenic and mercury in the management of so many very diverse forms of cutaneous disease — the indica- tions for alterative medication being the same in all. The administration, for long periods, of minute doses of pow- erful alterative medicines, in the treatment of chronic affections which resist other management, is less common now than formerly, on account of the explosion of some old hypotheses connected with it. It is very possible that in this, as in some other medical reforms, we may have gone too far. Agents which tend with any degree of constancy to increase the rate of metamorphosis of tissue in the body, are few. Mercury appears to have this effect ; and its alterative power may to a con- siderable extent be due to this. It is well known that most of the diuretics given for the removal of dropsical accumulations (a treatment often carried to an irrational excess), increase only the 1 Dr. Hughes Bennett, in the treatment of cutaneous diseases, relied mainly (London Practitioner, Vol. I.) on the beneficial influences of waiei' and oil; in affections with moist secretions, water ; in those which are dry, scurfy, or scaly, oil. Of course, how- ever. Prof. Bennett assigned some value to other applications, as adjuvants. ET.ECTRICITY. 171 fluid secretion of the kidneys, affecting little or not at all their solid excreta. But there is good reason to believe that potassa and soda, and some of their compounds, as well as iodine and mercury, do hasten the disintegration of tissue. Iodide of potas- sium has been shown by Melsens to be in this way ellminatire of lead, laid up in some organ (probably the liverj, removing it in the shape of iodide of lead. If any possible measures, beyond attention to hygiene and repose can benefit cases of oi-ganic degeneration, we may hope for advantage from the combination of tonics or analeptics with alter- atives. Dr. Chambers (on Dlyestion and its Derangements) remarks thus : — "In Bright's disease, I know of no treatment so advantageous as that which unites alteratives (that is, hquefacients of tissue) with those restorers of blood par excdlence, iron and animal food. " Iodide of iron or iodide of potassium at the same time with cod- Hver oil, may afford an example of this sort of medication in its simplest form. Its object is to favor the rapid removal of old tissue, and the formation of good new structure in its place. AVhatever produces a powerful impression, not immediately destructive upon the system, may act alteratively, and some- times beneticially, in chronic disease. Change of air, scene and circumstance often- exemplifies this. Electricity, perseveringly used as an alterative, in certain cases of paralysis and other neuroses, does more good than any- thing else. The ancient Eomans used the shock produced by the torpedo (electrical fish) for the cure of paralysis and gout ; and the natives of Western Africa apply the sihiriis in a similar way, in baths, for the treatment of sick children. Pivati, of Venice, 1740, and after him De Haen, Winkler, Manduyt, and NoUet, employed statical electricity as a remedy. G-alvani (1790) and Volta introduced new means, which have since been exten- sively used. Faraday discovered the induced currents in 1831. At present, while it is clear that electricity must be capable of powerfully influencing the human system, om* knowledge of its uses is far from complete. Rash experimentation with it may do harm ; but all its appliances may be so graduated as to admit of the mildest and most cautious tentative practice. Three agencies are included under the term electricity : 1. Static or frictional electricity, of the machine of glass and rub- ber. 2. Galvanic or Voltaic ^ electricity, the current of the bat- tery, of metals with acid solutions, etc. 3. Faradization, by induced and interrupted currents, electro-magnetic or magneto- electric. Frictional electricity is least in use. It is best employed by placing the patient on an insulated stool (with glass legs or feet) and charging him from either a plate or a cylinder machine ; then withdrawing the electricity by a pointed metallic conductor, if a mild and general effect is wanted, or by a round one of some 1 In strict justice, tliis ought to be called Voltaic electricity. Galvani was the earlier discoverer iu the field of animal electrical phenomena ; but Volta first discovered and demonstrated the origination of electrical currents from chemical action. 172 GENERAL THERAPEUTICS. size to produce sparks and a locally stimulant effect. Dr. Arthius, of Paris, has written a work (1873) upon the therapeutic uses of statical electricity. Voltaic or galvanic electricity is developed by chemical action. A battery consists of a series of plates of two materials (copper, zinc, silver, carbon, etc.), in alternation, and a liquid in contact with both which acts more upon one than on the other. Daniell's and Smee's batteries are especially recommended. Althaus pre- fers a modification of Daniell's, in which, with copper and zinc plates, a solution of sulphate of copper is used as the liquid. This will run for six months without cleaning ; with cleaning, for a much longer time. The size of the cups determines the quantity of the current of electricity ; the number of cups, its intensity. Quantity is especially powerful for chemical action ; intensity, for overcoming the resistance of a slowly conducting medium. The direction of the current, through the wire or wires connecting them outside of the liquid, is, in ordinary batteries, from the copper (or platinum, silver, or carbon) to the zinc ; the former being the positive and the latter the negative pole. Dr. Hammond^ prefers the direct to the induced current. His apparatus consists of a series of plates of perforated zinc and copper or copper gauze, soldered in pairs, with flannel between the elements. They are moistened by pouring strong vinegar upon the top, so that it runs through the perforations. Faradic or induced electrical currents are usually obtained in either of two modes : 1. By galvanic electricity (from chemical change) acting upon iron ; making it magnetic during the closure of the circuit, which is interrupted momentarily by a vibrating spring. A current is thus induced, in one direction at the moment of closing, and in the opposite at the opening of the con- nection. 2. By causing a magnet or its keeper of iron to revolve so as alternately to approach and recede from contact. A helix or coil of wire, wound around the magnet, will then have an induced current at the moment of approach and at that of sepa- ration. This (magneto-electric) is more convenient than any other apparatus ; but some authorities claim greater power for electro-magnetism in therapeutics. It has been shown also that the constant galvanic current (as of Daniell's, Grove's, Bunsen's, or Smee's batteries)^ has a more extended or general stimulant or alterative efiect ; while the interrupted (faradicj current is more powerful locally. Proof of the difference between the two may be obtained by ajDplying them in succession to the face. The continued current jDroduces a flash of light by its influence upon the retina. The interrupted causes the muscles to contract in proportion to its force. The action of a voltaic or galvanic battery may be readily interrupted, by alternately lifting and replacing one rheophore,^ while the other is retained in contact 1 Quarterly Journal of Psychol. Medicine, etc., July, 1867, p. 62. 2 The Leclanche cell is now a favorite with many practitioners. 3 Bheophore, " current bringer ;" i. e., the metallic disk, moistened sponge, brush of fine wire, or other arrangement (provided with handle) used to apply electricity to any part at the will of the operator. Bheophores are constructed for introduction into the rectum, bladder, etc. For such use, all but the end of the conductor should be insulated by being surrounded by gutta-percha or india-rubber. ELECTRICITY. 173 with the surface of the body. Renuik has expressed the grctitcst contidencc in the continuous current ; especially that which is constiint in strength. lie uses from 15 to 30 of Daniell's cells (mo(lilied), weii^hini; S pounds each. He asserts that the down- running curriiut acts niost^ upon the sensory nerves, and the up current upon those of motion ; and that while interrupted cur- rents take elfect almost alone upon the muscles, con.stant cur- rents act upon the nerve-centres themselves. Hiflelsheim and Onimus have extended Remak's investigations. It has been shown (E. AVeber, Matteucci, Erb)^ that a constant current may be made to take effect upon the brain and spinal marrow. Kiihne and others have also found, by the aid of the microscope, distinct action of the constant current upon organic cells and protoplasm ; a ciiange of form of the cell sometimes resulting, which has been called cell-ietamis. Duchenne, of Bologne, asserts, as the conclusions derived from his experience, the following : " In man, whatever may be the direction of the currents, or the degree of vitality of the nerves they traverse, the same results are always produced when the conductors are applied to any part over the course of the nerves, — namely, muscular con- tractions and sensations. " Various changes in the current-direction produce no appre- ciable influence over the sensibility, or capability of voluntary muscular contraction, in man." On the basis, however, mainly of Dubois Reymond's experi- ments, other electricians insist that a current towards the centres of the body stimulates the sensory nerves, while it lessens the ■ excitability of the motor nerves ; and that a current /rwn the cen- tres out to the periphery stimulates motor, and acts as a sedative to sensory nerves. Pereira says, " In paralysis of sensation only, the current should be direct or centrifugal. In paralysis of mo- tion, it should be inverse or centripetal. In paralysis of both sensation and motion, the vibrating current (faradization) is peculiarly appropriate ; for by this the sensitive and motor nerves are alternately excited, while the one current promotes the restoration of the excitability, which may have been lessened by the preceding current." Hitzig, Brenner, Chauveau, De Watteville, Benedict, and Russell Reynolds,'^ all sustain the above quoted judgment of Duchenne, as to the absence of specific differences, practically available, according to the directinn of the current applied ; while the locality of the application is of the greatest importance. It does not appear to be proved that either poZe, as such, has pecu- liar "anodyne or stimulant" powers, as some have supposed. As a general rule, it may be said, that the continuous voltaic (galvanic ) current tends to produce a tranquillizing effect upon spasmodic over-action ; while the interrupted faradic current is 1 Budge and Waller have reported remarkable observations upon the "centrum cilio- spinale," in relation to the action of the iris. See M. Meyer, Medical Electricity, transL by Hammond, p. 77. 2 Cited by Dr. L. Carter Gray, N. Y. Med. Rec, August, 1879. 15* 174 GENERAL THERAPEUTICS. especially stimulant to enfeebled and atrophied muscles, and to a sluggish circulation. For the use of frictiorial (machine) electricity, whose effects are most like those of the faradic current. Dr. Bartholow rec- ommends the Toepler-Holtz machine as most efficient and reliable. Dr. Moritz Mayer ^ lays down the following as the best estab- lished facts. 1. Electricity is a stimulus. 2. It increases the sup- ply of blood to the irritated part. 3. It augments also its temperature, and tends to increase its volume. 4. It enhances the contractile energy of the vascular walls. 5. It counteracts the secondary changes occurring in inactive nerves and muscles. 6. It is capable of aiding in the restoration to nerves and mus- cles of their lost functional power. 7. It is capable of develop- ing a supplementary function in muscular fibres not yet par- alyzed. Dr. G. M. Beard recommends the use, in many chronic affec- tions, of " central galvanization ; " the negative pole being placed at the pit of the stomach, and the positive pole applied success- ively to the head, over the sympathetic and pneumogastric in the neck, and to the spine ; the whole of the central nervous system being thus brought under the influence of the current. The precautions needful in employing electricity as a remedial application are — 1. Always to begin with it very gently, watching carefully its effects ; contiiming it therefore at first but for a few minutes at once. The hand o/ the operator is the gentlest and best electrode for sensitive or irritable parts. To use it, of course the electric- ity must pass through the operator's body. This mode, however, is not commonly resorted to. 2. To be especially careful in its use at or near the great nerve centres, as the brain and spinal marrow. 3. Avoid using it, even locally, during the existence of an inflammation or acute irritation of the spinal marrow or brain. The idea which Dr. Radclifte has especially advocated, of using galvanism, e.g., in neuralgia, or convulsions, with such force as to partially or temporarily paralyze a disordered nerve-centre, is, I am sure, unsound in theory and very unsafe in practice. I would not think of resorting to such a measure in any conceivable case. The affections in which electricity, in various modes of appli- cation, has been found most positively and frequently serviceable are paralysis (especially hysterical, reflex,'^ infantile) and lead palsy, aphonia and diphtheritic paralysis of the throat ; neuralgia., chronic rheumatism, exophthalmic goitre, angina pectoris, amenorrhoea, sup- pression of lactation, obstruction of the bowels, lead colic, cancerous or other tumors, eczema, herpes, prurigo.^ In surgery, galvano- puncture is resorted to for aneurisms, etc. In treatment of asphyxia, narcotic coma, etc., its powerful stimulation is some- 1 Medical Electricity, p. 372. 2 See Mitchell, Morehouse, and Keen upon Wounds of Nerves, etc. * In one case I have known it to appear to retard the progress of piilmonai-y pMiisis for a considerable period. HYDROPATHY. 175 times an irnportant moans of saving life. Applied to nncuriam of the thoracic aortn^ tlu; ol)joct is to produce coiij^ailation of blood in the tumor. The best mode of operating is as follows : two sharp platinum needles coated with gutta-percha an; successively plunged into the tumor, gver which the skin has first been benumbed with ice or spray of ether or rhigolene. The needles having been connected with a voltaic battery, tlie current is gradually increased to its full strength and continued so for several minutes, after which the needles are withdrawn. Crussell, Spencer Wells, and Hannnond rejjort gi'cat success in causing the healing of indolent ulcers and bed-sores by mild, constant currents. Dr. Hammond's method is the following : "A thin silver plate, no thicker than a sheet of paper, is cut to the exact size and shape of the bed-sore; a zinc plate of about the same size is connected with the silver plate by a line silver or copper w^ire six or eight inches in length. The silver plate is then placed in immediate contact with the bed-sore, and the zinc plate on some part of the skin above, a piece of chamois-skin soaked in vinegar intervening. This must be kept moist, or there is little or no action of the battery. Within a few hours the effect is perceptible, and .in a day or two the cure is complete in the great majority of cases. In a few instances a longer time is required." The use of electricity in diagnosis will be alluded to in another part of this book. Hydropatliy (hydrotherapy^ is an example of a most valuable agent misapplied by exclusivism, which is always quackery, — that is, it is quackery to deny the virtues of other remedies, no matter how long or well established, in extolling those of one made the sole prmacea of practice. Bathing (local and general), douches, and even packing in the wet sheet, are, if used with judgment, potent alterative and often sanative means. Almost hopeless chronic cases of nervous disorders, dyspepsia, chronic rheumatism, etc., may sometimes have their languid vitality aroused by the revolutionizing action of such processes. The danger is of unprofessional and ill-judging abuse of an agency of such power. Hot-air baths have of late years attracted attention. M. Fillet (1764), Fordyce, Blagden (1775), and others, proved, as Chabert the "Fire King" also illustrated, that a dry-air heat above that of boiling water can be borne by the human body with safety. Within a few years the use of the hot-air bath, similar to that of the calidarium of the ancient Romans, has been intro- duced for remedial purposes. It is misnamed the "Turkish Bath," as the latter includes a vapor bath at a temperature below 100°. Erasmus Wilson, the dermatologist, Urquhart, and others, have, upon personal experience, lauded the virtues of the hot-air bath. The requisites are a heated metallic surface (a common stove will do) to warm the air of the apartment, and an adjoin- ing convenient water bath, with warm or cool water, to plunge into after or alternately with the air bath. 176 GENERAL THERAPEUTICS. TJrquhart thus speaks of its use in health: "When I come back to it after its absence and the use of other baths, even the best, it is like getting ^n the back of a thorough-bred after hav- ing to ride a cart-horse. It is of service at every moment, and at all temperatures. You come in from a journey, say before dinner ; you go in not heated, when it may stand at 120° ; you dress at that charming temperature, with streams of hot or cold water, or the tank to revel in. So, also, you may dress in the morning. My regular practice, when not requiring it for health's sake, is to go in on getting up and on going to bed, dressing and undressing there ; five to ten minutes suffice to bring on the flow of perspiration. After that a plunge in the cold water, and you come out fresh, glowing with a sense of cleanliness, health, and strength, which no other operation can convey to the body. You are then indifferent to the heat of summer and the cold of winter." Copious perspiration and the thorough removal of the effete cuticle, as well as'of all foreign impurity, from the surface of the body are the obvious and direct effects of the hot-air bath. Depuration and functional balance of the excretory processes are thus promoted, while the stimulant influence of heat, so often useful in cases of depressed vitality, is obtained. Renewal of the nutrition of the skin must also be more rapid under such a process. The temperature is made to vary between 120° and 200° ; 130° to 140° is a good standard. The diseases in which the hot-air bath has been tried with favorable results, in cure or palliation, are, especially, acute and chronic rheumatism, lumbago, sciatica, neuralgia, gout, dropsy, catarrh, influenza, throat affections, diarrhcea, dysentery, slug- gishness of circulation, disorders of the liver, scrofula, incipient phthisis, Bright's disease, ague, obstinate skin diseases, chorea, mania ; also, it is said, even cholera and hydrophobia. Hot sand-baths have been used in London by Dr. Conradi^ and others to promote perspiration and relieve congestion of the internal organs. Mustard Bathing, — Dr. S. Kewington, of England, ascertained by experience in his own person that the extensive and continued application of mustard to the body is a powerful tranquilizer of nervous excitement and means of restoration of the balance of a disturbed circulation. Use of the same remedy with a number of patients has confirmed its value. One mode of its application is as follows : Two handfuls of powdered mustard are tied in a cloth and placed in hot water, then squeezed in the hand until the strength of the mustard has been extracted. A thick towel long enough to reach around the loins is then wrung out of this infusion, wrapped round the body, and covered with a large piece of oiled silk or gum-elastic cloth. Another plan is that of the mustard bath, — that is, an ordinary warm bath into which have been thrown five or six handfuls of mustard. In maniacal excitement^ particularly, these applications have been found usefully sedative. SleexAessness^ from any cause, may be so treated, as well as hysteria, etc. It may be expected that 1 Med. Times and Gaz., October 19, 1872, p. 150. MASSAGE. 177 such a process will be useful also in promotinjif reaction in cases of internal congestion; porliapsf in the chill of pernicious fever, in "spotted fever," and in the incipient collapse of cholera. Movement-cure {kinesipathy) is the name for a kind of practice (Taylor) founded upon the- teachinf^^s of Ling, of Sweden, con- sisting of 2J«.s.su'e exercise of the muscles, for the purpose of im- proving the circulation, innervation, and reparative nutrition of diseased and enfeebled organs. Although an elaborate system of particular movements upon a gM«.s?-physiological rationale has been devised and adapted to each kind of chronic local or general disorder, careful examina- tion of the treatise of an authority upon the subject convinces me that this is all surplusage. What remains to be true is that where active exercise is not practicable, systematic frictions and passive movements of all parts of the body are very useful in its stead. What is added to this by the specialist is, faith on the part of the patient and perseverance in the attendant, — two things which, without extraordinary processes, explain much and ac- count for many cures. Massage is the term applied to systematic rubbing and knead- ing the muscles and other accessible parts of the body. It is an ancient practice, common even among some savage nations. The lomi-lomi of the Sandwich Islands^ is of this character. It is familiar to the Brahmins in India, and is traced as far back as to the Egyptian priests, before Hippocrates. It is now used especially in cases of general and nervous debility, in which mus- cular exercise is not to a sufficient extent obtainable. Dr. S. AVeir Mitchell" thus describes this procedure : "An hour is chosen midway betAveen two meals, and the patient lying in bed, the manipulator starts at the feet and gently but firmly pinches up the skin, rolling it lightly between his fingers and going carefully over the whole foot ; then the toes are bent and moved about; in every direction, and next, with the thumbs and fingers, the little muscles of the foot are kneaded and pinched more largely, and the inter-osseous groups worked at with the finger-tips between the bones. At last the ankles are dealt with in like fashion, all the crevices between the artic- ulating bones being sought out and kneaded, while the joint is put in every possible position. The leg is next treated, first by surface-pinching and then by deeper grasping of the areolar tissue, and last by industrious and deeper pinching of the large muscular masses, which for this purpose are put in a position of the utmost relaxation. The grasp of the muscles is momentary, and for the large muscles of the calf and thigh both hands act, the one contracting as the other loosens the grip. In treating the firm muscles in front of the leg, the fingers are made to roll the muscles under the cushions of the finger-tips. At brief intervals the manipulator seizes the limb in both hands, and lightly runs the grasp upwards, so as to favor the flow of venous blood-currents, and then returns to the kneading of the muscles. 1 K^rdhoff: Northern California, Oregon, and the Sandwich Islands, 1874. 2 Fat and lilouU, and How to Make Them, p. 52. M 178 GENERAL THERAPEUTICS. The same process is carried on in every part of the body, and especial care is given to the muscles of the loin and spine, while usually the face is not touched." At first this is continued for but lialf an hour at once ; gradu- ally it is increased to an hour daily or every other day. After each rubbing the patient should have at least an hour's absolute repose. Dr. Mitchell advises the use of cocoa oil or vaseline to lubricate the parts rubbed. My belief is that more stress might be placed upon this inunction, as itself an important portion of the treat- ment. The ancients resorted largely to anointing for sanitary and remedial (as well as religious) purposes. Their wisdom in this has been too much neglected. Cod-liver oil inunction in scrofulosis of children, and in some obstinate forms of skin dis- ease, has decided therapeutic value. Although but little oil may be absorbed through the skin, it has been proved that the ten- dency to emaciation may be arrested or abated by inunction. One of the drawbacks in the use of massage is that so much depends on the judgment, dexterity, and tact of the rubber (masseur or masseuse). Dr. Mitchell's advice to disregard such symptoms as increased nervousness and even loss of sleep, fol- lowing the daily massage, is, as I know from observation, not safe. Average professional rubbers sometimes do harm instead of good. The constant oversight of the medical adviser is neces- sary; and there are some cases of neurasthenia in which this method does not prove advantageous. It is likely to do good par- ticularly in paralysis^ chronic rheumatism^ and sprains of the joints. Electro-massage is sometimes practised, by the use of a metallic brush of fine wire, connected with a battery. Under any treatment, however, we must not encourage sanguine hopes in instances of organic degeneration, the origm of which is so generally to be found in a failure of systemic vital power. The physician will do much for his patient if he can persuade and instruct him to adapt his living to the actual condition of his physical resources, so that, whether his malady be Bright's disease of the kidney, diabetes mellitus, cirrhosis of the liver, locomotor ataxy, or fatty or other organic disease of the heart, he may economize both the material and the force of his system by such a regimen of diet, exercise, and excitement as his state requires. With such management, it often happens that valetudinarians live longer than those who, with sound constitutions, are less watchful against causes of disease, and less prompt in taking warn- ing from the slightest symptoms or approaches of ill health. Nor need we look upon the failure of medicine to arrest the process of organic degeneration as a subject of very humiliating discouragement. As death is the. natural result of life, in the human organism as in every other material form, this partial death occurs, also, under physiological laws ; and, if it be rela- tively premature in certain instances, we may believe that this, too, may be traced to a near or remote causation in perfect harmony with the highest interests, moral and physical, of man. * INHALATION AND ATOMIZATION. 179 1NIIAI.ATION AND ATOMIZATION. Although the ancient Egyptians had some knowledge of the effects of" drugs whose vapors were inhaled, and Hippocrates, Cralen, and other Roman physicians, as well as, later, the Ara- hians, so employed them, they were afterwards long lost sight of. Bennet, of London, in the seventeenth century, seems to liave heen the first in modern times to use inhalations systematically. The earliest proper instrumental inhaler was probably that of Dr. John Miulge, an English physician, invented and applied in 171)9. St. John Long, the charlatan, used lai'ge inhalers, from which a number could breathe at once, Bocrhaave and Von Swieten, in the early part, and Beddoes at the end, of the eigh- teenth century, employed medicated inhalations. Scudamore, in 18:50, issued a work upon the subject which had a wide circu- lation. Since that time, an immense amount of experimentation has been made, to ascertain what local effects upon the lungs and air-tubes, and what action upon the system at large, might be ol)tained by vapors brought in contact with the highly absorbent respiratory membrane. Most important of all, of course, was the discovery of gaseous anoesthcsia by Sir Humphrey Davy, and the subsequent practical application of it by Wells and Morton. Ether, chloroform, nitrous oxide, and bichloride of methylene now take their places not only as alleviators of pain during oper- ations and in parturition, but, also, as occasionally valuable aids to the physician in medical cases. Extreme neuralgic pain is sometimes relieved by the inhalation of ether or one of the other anaesthetics. Convulsions are not unfrequently so treated ; and, in those at least of a hysterical or merely irritative character, with good success. Angina pectoris is often relieved by breath- ing a few drops of nitrite of amyl. For medical as well as surgical use, chloroform is the most prompt, quiet, and effectual anesthetic. In cases of disease, it does not need to be so given as to produce the total relaxation of profound anaesthesia. Can its use be justified, in view of the fact that a considerable number of deaths have been traced to it ? Without space to discuss this point, I may say that observation of the use of chloroform in a method employed by some of the sur- geons of the United States army during the civil Avar, has modi- fied my previous apprehension of it. The great necessity is, as Dr. Sansom' has shown very fully, the dilution of the chloroform with abundance of air, and its gradual introduction. Most meth- ods exclude air too much. That which I have alluded to above is, letting the chloroform fall, dnq) hy drop, upon a handkerchief spread singly over the face of the patient. An instrument is used for dropping, which will allow only one drop to pass at once. I believe that, with this or any other mode of abundant dilution and slow inhalation of it, watching momentarily its efiects, chlo-- roform is safe, in an immense majority of cases. Anaesthesia from chloroform cannot with safety be produced in less than five or six minutes. 1 On Chloroform ; its Action and Administration. 180 GENERAL THERAPEUTICS. Ether excites some persons too much to be generally relied upon in medical case^. Two or three parts of ether with one of chloroform make a mixture often used with advantage. Dr. Sansom prefers one part of chloroform to one or two of absolute alcohol. Dr. B. W. Richardson combines ether with bichloride of methylene. Nitrous oxide, although experimented upon by Davy and used by "Wells before ether, has only of late come to be highly appreciated for practical use. Its applications by inha- lation in disease remain to be tried and studied. The same is true of bromide of ethyl. Compressed air (Waldenburg) and oxygen gas are now considerably employed for inhalation in con- sumption. Some practitioners believe the chief benefit to result from mechanical expansion of the air-cells of the lung. Apart from the " anaesthetics, " it cannot be said that great success has ever been obtained in the cure of diseases by inhala- tion. Palliation of pulmonary and bronchial or laryngeal irri- tatioH, or diminution of excessive expectoration, as by simple vapor of water, tar-vapor, or that of infusion of hops, opium, etc., has been often realized. "With other aims and agents, dis- appointment has generally predominated. For ordinary inhalation, very simple apparatus will suffice. For instance, a wide-mouthed jar or bottle, with a cork in it ; the cork pierced by two glass tubes, one straight, and reaching to near the bottom of the bottle ; the other short, and bent out- side of the cork. The bottle is to be not quite filled with the liquid (more or less heated according to its volatility) ; the bent tube not reaching its surface, the other conveying air into it from beyond the cork. Even this is not necessary, at least in the case of liquids used with water. We may employ these by pouring boiling water into a convenient vessel of any kind, the medica- ment being added to it, and then covering the vessel with a towel, holding the mouth and nostrils under the edge of the lat- ter. Hops in infusion, stramonium leaves, laudanum, etc., may thus be used. Of laudanum, e. g., twenty or thirty drops may be put into a pint of water, for a very worrying cough. Smoking is a primitive method of inhalation. Tobacco, so employed, some- times relieves in asthma ; but cigars of stramonium leaves, or of paper saturated with nitrate of potassium, are more effectual in the paroxysms of the same disorder. Continuous inhalation is sometimes desirable. For this, Dr. W. Eoberts's small and light metallic box may be used. It is perforated in front and behind, and filled loosely with tow, into which the desired liquid is poured for inhalation. It may then be fixed by elastic bands over the ears, and worn for some time without inconvenience. Curschmann has devised a similar respirator made of vulcanite, with a rim of soft India-rubber. A simple glass or metal tube will answer for a shorter period. Dr. Pepper employs a tube enlarged near its lower end, in which pumice-stone is placed to receive the material for inhalation. Dr. Andrew H. Smith's insufflator is sometimes convenient to introduce powders into the larynx. It consists of a small wide- mouthed bottle, through whose cork are passed two tubes, each bent at right angles. To one is attached a rubber hand-ball ; INHALATION AND ATOMIZATION. 181 the other is placed near the orifice of the glottis. When the medicated powder has been put into the bottle, the compression of the hand-ball will blow the powder out through the other tube into the throat. Extremely minute division or atomizahon of liquids, introduced into the air-passages, has been latterly often substituted for inhala- tion. It was first devised by Sales-Girons. Under the natural fascination of novelty, and the imposing appearance presented by instrumental appliances, it is quite probable that a degree oir enthusiasm has existed about it, more than will be permanent. Still it is an important addition to our means of treatment of affections of the throat, and, perhaps, of some of those of the lungs. Referring the reader to special works' upon it for details, I must give only the briefest account of atomization or nebu- lization. The essential idea of it is, the forcing of a fine jet of liquid against a solid body or a strong current of air, so as to convert it at once into diffused spray. Bergson, for instance, employed the tubes used for odoratnrs^ that is, to spread perfumed liquids in the air. Two glass tubes with minute orifices are fixed at right angles to eacli other, so that the end of the upright tube is near and opposite to the centre of the orifice of the horizontal tube. The upright tube being immersed in the liquid to be nebulized, air is forcibly blown through the horizontal one. The current of air, passing over the outlet of the tube communicating with the liquid, rarefies the air in the latter, causing a rise of the liquid in the tube, and its very minute subdivision (atomiza- tion, nebulization, pulverization), as it escapes. Silver tubes may be used instead of glass, but they are harder to keep clean. Glass ones may be cleaned with hydrochloric acid solution, aided by a bristle to remove obstructions. The form of the tubes may be varied, so as to allow of their application to any part of the body. Richardson's spray-producer (designed for local refrigeration) is constructed upon a similar principle. It consists of a gradu- ated bottle, through whose cork passes a double tube ; that is. a tube within a tube. The inner one reaches to near the bottom of the bottle, below, and above near to the extremity of the outer tube. The latter has entering it, above the cork, another tube connected with "hand bellows" — i. f., two elastic bags, the one nearest the bottle (protected by silk network) acting as an air- chamber, and the furthest one being compressed by the hand, to produce a jet of air into the bottle and tube. Siegle contrived an apparatus for the application of steam-' power to atomization. The tubes being arranged upon Bergson's principle, a small boiler is connected with the horizontal one, and in the boiler steam is generated by the heat of a spirit lamp. The jet of steam from the horizontal tube nebulizes the liquid drawn up from the vertical tube immersed in a vessel containing it. Various modifications of this have been made.^ Though the 1 See Da Costa on Inhalation. - Gemrig, of Philada., Dr. W. Reed, of Boston, and Codman and Shurtleff, of Boston, furnish improved forms of apparatus for atomization. 16 182 GENERAL THERAPEUTICS. Steadiness of action of the steam apparatus must be a great advantage, for many purposes the hand-ball atomizer is more available. For full effectiveness of any method of inhalation in chronic or subacute cases, the patient must have the instrument at his own house, learn its management, and use it with regularity for a sufficient time. This of course limits very much the employment of such medication. The first inhalations should always be short, and with warm water only, to inure the patient to their use. The distance of the mouth from the tubes may vary from six inches to two feet. When prepared for it, one may inhale "medicated spray" for ten minutes at a time ; breathing deeply if we wish the liquid to reach the remoter air-passages. It should never be done after a hearty meal ; and the patient should remain in-doors for a while after the operation. Proof has been obtained that atomized liquids inhaled do, some- times at least, pass down into the trachea ; constantly, into the larynx. It is probable, indeed almost certain, that a certain portion may even reach the lungs. As to their application, trial has been and is now being made of this process, especially in croup, diphtheria, oedema of the glottis, catarrh, chronic laryn- gitis, hooping-cough, asthma, pulmonary hemorrhage, and phthisis. False membrane has been asserted by Kiichenmeister, Biermer, Geiger, and others, to be dissolved, or at least removed from the throat, by inhalation of hot lime-water. Dr. Geiger's method is to make the patient breathe the vapor arising from hot water poured on unslaked lime. Lactic acid is said (A. Weber) to have the same power. From Dr. Da Costa's monograph upon inhalation I cite the following conclusions as indicating the results of experience upon the subject: — ^ "That in most acute diseases of the larynx, and still more so in acute disorders of the lungs, the value of inhalations of atomized fluids, save in so far as those of water may tend to relieve the sense of distress, etc., and aid expectoration, is very doubtful ; though in some acute affections, as in cedema of the glottis and in croup, medicated inhalations have strong claims to consideration. " That in certain chronic morbid states of the larynx, particu- larly those of a catarrhal kind, and in chronic bronchitis, they have proved themselves of great value. " That in the earlier stages of phthisis, too, they may be of decided advantage, and that at any stage they may be a valuable aid in treating the symptoms of this malady. " That their influence on such affections as hooping-cough and asthma is not satisfactorily proven. " That they furnish a decided and unexpected augmentation of our resources in the treatment of pulmonary hemorrhage. " That they require care in their employ ; and that in acute « Op. citat., p. 40, HYPODERMIC MEDICATION. 183 affections we should consider whetlier, as tlioy have to be used frequently to be of service, the ])atient's strenf^th justifies the disturbance or the annoyance their frequent use may be." DOSES YJJli INHALATION.' Alum 10 to 20 grains. Tannin 1 to 20 " Perchloride of iron . . . . ^ to 2 " Nitrate of silver 1 to 10 " Sulphate of zinc 1 to 6 " Chloride of sodium . . . . 5 to 20 " Chlorinated soda i to 1 drachm. Chlorate of potassium . . . . 10 to 20 grains. Chlorate of ammonium . . . . 10 to 20 " Watery extract of opium . . . i- to ^ " Eluid extract of conium . . . 3 to 8 minims. " " hyoscyamus . . 3 to 10 "■ Tincture of cannabis indica . . . 5 to 10 " Lugol's solution of iodine . . . 2 to 15 " Fowler's solution of arsenic . . . 1 to 20 " Tar-water 1 to 2 drachms. Oil of turpentine 1 to 2 minims. To these may be added, carbolic acid (Marcet) 1 or 2 grains, or creasote, 1 or 2 drops, in phthisis ; and lactic acid (15 to 20 drops in half an ounce of water), in croup. Also, nitrite of amyl^ 2 to 5 drops; in puerperal convulsions, angina pectoris, etc. HYPODERMIC MEDICATION. Apparently upon a suggestion contained in Yalleix's work on Neuralgia, Dr. Alexander Wood, of Edinburgh, in 1843, experi- mented successfully with the injection of anodynes under the skin of parts affected with neuralgic pain.^ Dr. Kursak, of Vienna, disputes priority with him. Mr. Rynd, of Dublin, followed him after about a year. Local effects, only, seem to have been clearly recognized by these gentlemen. C. Hunter, in 1858, proved that general effects upon the whole system are pro- duced, in whatever part of the body the injections are made. Since 1855, however, many medical men have studied the sub- ject; especially Behier, Lorent, Eulenberg, and Nussbaum, abroad, and Ruppaner and Bartholow in this country. The prac- tice has now become common. It has been amply proved that hypodermic injection of medic- inal substances is ordinarily entirely safe ; more rapid, certain, and exact in its effects, in proportion to the amount, than medi- cation by the mouth ; that it requires one-third or one-half of the quantity necessary when given by the stomach, and produces less complicated and generally less inconvenient results. The medicines principally used in this way are narcotics, sed- atives, nervine tonics, and stimulants. It is in diseases or symp- toms affecting the nervous system that the greatest number of 1 From Da Costa. - In 1S:>9, Drs. I. Taylor and Washington, of New York, made subcutaneous injec- tions with an Ancl's syringe, after first incising ttie skin. 184 GENERAL THERAPEUTICS. The injection of medicines into the cellular tis- sue beneath the skin may be made. Generally -, In Cerebral. Spinal. and Sympatlietic nerve-cases, inflammatory affections, etc. successful cases has been reported. Pain, most of all, is speedily conquerable by it. Hunter lays down the indications for it thus ; — " When the immediate and decided effect of the medicine is required. "Where medicines administered by the usual methods fail to do good. " Where the effect of a medicine is required, and the patient refuses to swallow. "Where, from irritability of the stomach, or other cause (such as idiosyncrasy, etc.), the patient cannot take the medicine by the stomach." The following Table is slightly modified from Hunter's : — Locally f 1. Caustics for nsevi, aneurisms, etc. with ... (2. Anodynes, for local neuralgia. Insomnia. Melancholia. Mania. Delirium tremens. i Hystei'ia. I Chorea. [ Central neuralgia. ' Kheumatism. Tetanus. Hydrophobia. Retention of urine. Convulsions. Epilepsy. 'Peritonitis. Pericarditis. Dysentery. Ophthalmic surgery. Malarial fever. Gangrene. Dysmenorrhoea. Colic. Cholera. Sea-sickness. Cancer. Ulcer of stomach. Intussusception. As antidote f For opium, bella- \ donna, etc. f With or after chloro- Ansesthetic ) fon^ q^ gther in ( operations. The instrument most approved is a small glass syringe, holding about half a fluidrachm, and graduated for drops or minims, with a tube for puncture, of tempered steel, or of silver with a gold point. The end of the tube must be small and sharp, and kept very clean.' Graduation of the cylinder is not necessary, as it is ^ Dr. E. Cutter, of Woburn, Mass., has had made a syringe (of ahiminiiim alloy) so compact as to be carried easily in a pocket case. This is furnished by Shepard & Dud- ley, William Street, New York. Celluloid syringes also are made. HYPODERMIC MKDTCATION, 185 easy to measure the amount to be taken up by it. Not much pain is usually produced ; but sometimes it is quite severe. If the dose of the medicinal agent be not too large, the only danger (unless in an erysipelatous patient) is of a circumscribed inflam- mation. Kepeated injectidns should not be made at exactly the same spot. Apart from special local indications, the best places for injection are the arms, the back, the abdomen, the thighs, and the calves of the legs. In operating, draw the skin tense with the forefinger and thumb of the left hand, and pass the point of the tube (first well oiled) quickly and steadily through it. Then push in, not rapidly, the desired amount of the fluid ; and withdraw it without rotating it. Avoid subcutaneous veins ; the puncture of one of them may give an excessive action of the medicine. Intravenous injection, however, is sometimes purposely employed, with proportionate doses. . The agents most used are salts of morphia, atropia, strychnia, and quinia. For anodyne purposes. Dr. Buppaner prefers liquor opii compositus, of which one hundred drops are equal to a grain of sulphate of morphia. Many use the ordinary solution- of mor- phia (gr. j of morph. sulph. in fgj) or Magendie's (gr. xvj in fgj). Doses (for adults) are as follows : — Sulphate of morphia Acetate " " Sulphate of atropia Sulphate of strychnia . Sulphate of quinia Hydrochlorate of quinia Jaborandi, fluid extract Pilocarpin Ergotin .... Tinct. digitalis Aconitia Apomorphia . gr. i-i gr. jh—is gr. Sff— tV gr. i — iv gr. I— iii f3ss-f3j gr. l-k gr. i — V gtt. V — X gr. 2(JtJ — TTTT gr. i\—i Practitioners find it best to make always a, fresh solution of sul- phate or acetate of morphia^ for hypodermic use. Possibly from decomposition and the growth of fungi in the liquid, old prepa- rations are more likely to be followed by abscess. Strongly acid and strongly alkaline liquids are alike unsuitable. Quinine is frequently dissolved in glycerin for subcutaneous injection. It is apt to give considerable pain, however. Kobner advises using the hydrochlorate (muriate) of quinia for this pur- pose, its dose being smaller than that of the sulphate, as it con- tains more quinia in the same bulk. Among the diseases in which palliation or relief of suffering is often important by means of this method of treatment, are espe- 1 Anstie and some other British practitioDers have preferred the acetate of morphia, freshly prepared. Five grainsof the acetate are dissolved, with uminrmof acetic acid, in a fluidrachm of hot distilled water. Two minims of this will be a dose to begin with. Vachell and White have proposed the following: Acetate of morphia, 20 grains; dis- tilled water, 140 minims; acetic acid, 5 minims. T. & H. Smith advise meconic acid instead. Drasche, Rosenthal, and ("onstantin Paul recommend glycerin, instead of water, for hypodermic injections. Adrian prefers distilled water with twenty per cent. of glycerin. Pellets for hypodermic use are now made. They keep well, but are less easy to graduate in dose than solutions. 16* 186 GENERAL THER APE lTTICS. cially neuralgia, hysteria, palpitation of the heart, cancer, and ulcer of the stomach. A case of the latter affection is recorded in which for weeks or months the patient was only able to retain food upon the stomach after the disposition to vomit had been allayed by a hypodermic injection of morphia. Curative effect from anodynes so employed has been asserted in cases of delirium tremens, mania, and tetanus; from quinine (two to four grain doses) in intermittent fever. Tentative use of the same mode of practice is justifiable in cholera, hydrophobia (woorara), poisoning (as the injection of morphia for belladonna poisoning, and the converse), croup (apo- morphia), violent hooping-cough i^atropia), pernicious fever, spot- ted fever, etc. That the operation is always without inconvenience to the patient is not true. Not only pain, but local inflammation and even suppuration may sometimes be induced. Odevaine, in India, reports three cases of tetanus following the hypodermic injection of quinine. {Indian Med. Gazette, April, 1871.)^ But many patients, suffering painful complaints, have had a hundred or more injections made in different parts of the body, without any disadvantage, and with great relief. A hahit of hypodermic injection of morphia has often been formed ; exhibiting the same power over the will of the indi- vidual as tliat experienced by the opium-eater. Hydrate of chloral is sometimes used by hypodermic and also (Bucquoy) intravenous injection, especially in tetanus. It should be diluted considerably (ten grains to the ounce) to prevent local irritation. Intravenous injection of aqua ammonice (half a flui- drachm with the same or twice the amount of water) has been resorted to for stimulation in cases of exhaustion ; also, to antag- onize the poisoning of snake bites (Halford). Ether (15 drops at once) has been given for the same purpose by hypodermic injection. Whisky and brandy may be introduced hypoder- mically in cases of collapse, in half drachm doses. Strong cojfce has also been so used, and in opium poisoning, 20 or 30 drops at a time. Woorara (curara) has been injected, with asserted suc- cess, in two or three cases of hydrophobia. This powerful agent has also been hypodermically applied in the treatment of epi- lepsy. Acetic acid injected into cancerous tumors is said to have some power to cause them to shrink and cease growing. I pro- pose the use of alcohol upon the same indication. I am not aware of its having been thus employed ; but Politser^ has so treated polypi of the ear with success. Creasote may do good in like cases. Apomorphia (grs. -j\ to 5^) when injected under the skin, pro- duces a powerful emetic effect. It has been used with advantage in membranous croup. It is so depressing as to require caution. Camphor (2 or 3 grains, dissolved in ten times its weight of 1 other cases of tetanus following hypodermic injections are mentioned in the Lon- don Lancet, Dec. 16, 1876, and July 6, 1867; and Brit. Med. Journal. Nov. 1, 1879. It would seem that a peculiar state of system must be present, predisposing to tetanus in such cases. 2 Wiener Med. Wochensehrift, Nov. 31, 1880. TRANSFUSION OF BLOOD. 187 almond oil) has been found, when subcutaneously injected, bene- ficial in calming excitement and promoting sleep in lunatics and hysterical patients. Ergot (or its extract, called ergotin) has been much used of late years, hypodermically, to produce contraction of blood-vessels and other involuntary muscular tissues ; as in the treatment of hem- orrhages^ fibroid tumors of the uterus^ enlargement of the spleen^ etc. Of ergotin (which, as commonly prepared, is not the pure alka- loid, but a watery extract) Bartliolow' says, from one to five grains may be injected at once ; best, freshly dissolved in distilled water, and then passed through a filter. Of the fluid extract of ergot, from five to ten minims may be injected at a time ; for serious hemorrhages, yet larger doses. It may be thus emplo5'ed in epistaxis, haemoptysis, uterine hemorrhage, aneurism of the aorta, etc. (It should not be pushed so far as to cause spasmodic closure of the sphincter of the bladder and retention of urine.) Pilocarpin, hypodermically injected, is the most powerful of sudorifics, increasing also largely the secretion of saliva, and promoting the action of the kidneys. Hypodermic alimentation has been tried in a few cases. Dr. J. T. Whittaker,'^ of Cincinnati, succeeded in keeping a patient suffering with gastric ulcer alive for several days at a time by subcutaneous injections of beef extract, milk, and cod-liver oil. Menzel, Peres, Strieker, and others had before experimented simi- larly upon animals, and Krueg successfully with olive oil upon an insane patient.* Atropia is sometimes hypodermically injected in states of great prostration, as a ''respiratory stimulant ;" and digitalis (or digi- talin) to "support a flagging heart." TRANSFUSION OF BLOOD. In states of extreme debility, as from copious hemorrhage after parturition or surgical injuries, tlie introduction of fresh blood into a vessel has been occasionally practised almost from ancient times. It was performed for the benefit of Pope Innocent YIII. near the end of the fifteenth century. Sir Christoplier Wren wrote a paper upon its practicability, for the Royal Society, in 1657. Not much later. Lower in England, and Denys in France, experimented with it ; the latter with two successful cases in human subjects. Har- wood, Blundell, Waller, Martin, and others afterwards called attention to the same practice.* Several methods have been employed ; the oldest, the transfusion of blood from an artery^ directly into a vein of the arm of the patient. In 1872, Prof. Esmarch performed arterial transfusion twice. Kolomnin, of Russia, after ten trials, prefers injecting defibrinated blood into the peripheral end of tite radial artery.^ Mediate transfusion of 1 Materia Medica and Therapeutics, p. 277. Squibb's preparation is probably the best. 2 The Clinic, Jan. 22, 1876. 3 Revue des Sciences Medicales, Jan., 1876, p. 106. *In 1861, Dr. Martin published a statement of forty-five successful instances of trans- fusion, out of fifty-seven cases of its performance. See N. Y. Med. Record, April 1, 1874. In all, 126 successful cases had been reported down to July, 1874, and probably as many or more have occurred since that time, successful so far as the immediale result of the operation is concerned. 6 Transactions of the Society of Kussian Physicians, 1879-1880. 188 GENEEAli THERAPEUTICS. venous blood has been most often used ; the blood being received into an instrument, from which it is again injected into a vein or (Albanese, Auter, Kolomnin, Asche) into an artery (radial or posterior tibial). On theoretical grounds, defihrinated blood has been much favored, especially in order to prevent inter- ference with the operation by coagulation. It would appear, however, to be a defensible opinion that unwhipped natural blood, promptly (though not too rapidly) transfused, will better afford favorable conditions for recuperation. Introduction of air during the operation has been regarded as its chief danger ; speedy death has been ascribed to this accident in several cases. Kobin and Feltz have explained this by capillary embolism. But Ore found, experimentally, that a small amount of air may be injected into the femoral vein of a dog without injury. While precautions are necessary to exclude air, tliis risk need not stand in the way of transfusion. Altogether, it is probable that Aveling's method of immediate Fig. 75. Dr. Aveling's Apparatus for Transfusion. transfusion from vein to vein is the best. The instrument for this consists of a small india-rubber tube, about a foot long, with a bulb at the centre ; the ends being furnished with canulas for introduction into the veins. The movement of the blood is facili- tated by pressure upon the bulb. The quantity of blood trans- ferred has varied from four to twelve or more ounces ; probably from four to six or eight ounces will always suffice. It may be sufficiently well estimated in direct transfusion, by the time occu- pied. Three or four minutes will do when blood flows from vein to vein ; half a minute to a minute, if from artery to artery. Behier^ saved the life of a woman with twenty drachms; using Moncocq's apparatus, by which, at each turn of the rack, five grammes of blood are introduced. Dr. J. W. Howe (JV. Y. Med. Itecord^ April 1, 1874) has found Dieulafoy's aspirator, modified for the purpose, to serve in transfusion with great convenience. 1 Eevue Scieniiflque, March 7, 1871. TRANSFUSION OF BLOOD. 189 Dr. B. E. Fryer, U. S. A., has added a second bulb to Aveling's apparatus, for more convenient manipulation of the blood, which requires some force of pressure to secure its transmission {N. Y. Med. Itecord, April 15, 1874). Dr. T. G. Morton {Am. Journal of Med. Sciences, July, 1874) reports success in four cases with the use of defibrinated blood. He has a vessel in which the blood can be kept warm, by being surrounded by hot water, while awaiting use. Some practitioners prefer to omit the bidb of Aveling's appa- ratus. Others (McDonnel) recommend the employment of a funnel into which defibrinated blood is poured, to be conducted to the vein through a rubber tube ending in a cauula. On the question of choice between the use of unmodified and that of defibrinated blood, B. W. Richardson is among those who urge the latter ; Barnes and A. Flint, Jr., as well as Howe and Mon- cocq, the prompt use of unaltered blood. During the operation it is advisable (MacEwen^) to have the patient's arm elevated, to lessen the probability of air entering the vein when it is opened and when the blood is introduced. For the same reason, when a syringe is used, a small portion of blood may be forced out after it has been filled, the nozzle being slightly inclined upwards. The purpose of the operation is of course to sustain life until the emergency which threatened exhaustion is overpassed, and normal sanguification in the patient is renewed. Transfusion of blood has been so far chielly employed in cases of hemorrhage from any cause, and, in a few cases, for the col- lapse of cholera. Plasse, Proegler, and others, however, have resorted to it, with at least apparent temporary advantage, in advanced phthisis.'^ Experiments of the same kind, with lamb's blood, made at Dresden, by Drs. Oehme, Stetzner, Hirschfeld, and Bischofl', have not sustained the expectation that much benefit can be thus effected in phthisis. Immediately after the operation, in several instances, shivering, vomiting, and even convulsions followed ; a day or two later, hsematuria. All these symptoms soon disap- peared ; but the patient was left with his malady about as before. Landois, Ponfick, Panum, and Kuster have strengthened the evidence against the employment of any kind of blood except that of man ; that of other animals being apparently dangerous in proportion to the quantity introduced. Dr. Hodder, of Toronto, in 1850, used intravenous injection of strained 7nilk in three cases of cholera, in collapse. Two of these patients recovered. Dr. J. W. Howe, of New York, in 1874, injected fgvi of goat's milk fresh from the animal into the cephalic vein of a patient having phthisis. During the following year Dr. T. Gaillard Thomas^ injected fgviijs of cow's milk, freshly drawn, into the median basilic vein of a woman exhaust- ed after the removal of a large abdominal tumor. She rapidly 1 London Lancet, 1880. " Fhila. Med. Times, May, 1874. See, also. Vie Lamm-blui Transfusion beim Menschen, by Dr. Oscar Hasse, Nordbausen : Die Transfusion des Blutes, by Dr. Franz Gesellius ; and an article by Dr. H. M. Madge, Brit. Med. Journal, Jan. 10, 1874. » Amer. Journal of Med. Sciences, Jan., 1876, p. 61. 190 GENERAL THEE APEUTICS, recovered. Drs. Howe and Dupuy proved by experiments upon dogs that milk an hour or inore removed from the cow has fatal eft'ects ; it must be fresh and alkaline to be successful. For cer- tainty of its alkalinity, a small amount of carbonate of sodium or ammonium may be added. Not more than eight fluidounces of milk should be injected at once ; four or five ounces may suffice. The funnel and canulated rubber tube are preferred for its introduction. By April, 1878,^ Dr. Thomas had operated in this way seven times upon human subjects ; with no bad effects in any instance, and in several cases with prolongation of life. Meldon,^ of Dublin, has injected milk in ten cases ; four of these are reported as thus cured of pernicious ansemia. Drs. J. H. Brinton and C. T. Hunter of Philadelphia have also had suc- cessful cases ; in all to October, 1879, twenty-two cases were recorded.* Wulfsberg^* Demetre-Culcer^ and Schafer^ object to the trans- fusion of milk, on the basis of results obtained in experimenting on animals. Theoretically, also, they point out as important the absence of hcemoglobin from milk, the diiference of milk corpus- cles from those of blood, the danger of capillary embolism, and of bacteria or other "septic organisms" being introduced with milk. Against these objections stands the success of the opera- tors above mentioned, in so considerable a number of cases ; giving encouragement to the hope of Dr. T. G. Thomas, of a use- ful future for intravenous lacteal injection. Ponfick,' Bizzozero and Golgi* have obtained promising results with the transfusion of defibrinated blood into the peritoneal cav- ity. After experimenting with animals, Ponfick resorted to this practice with three hospital patients. Slight feverishness and abdominal tenderness occurred, but soon passed away. The apparatus used was an india-rubber tube, to one end of which a glass tube was attached, and to the other a pen-pointed canula, which could be closed with a tap. First filling the whole tube with defibrinated blood, the canula was pushed through the abdominal wall, the tap opened, and the blood poured into the peritoneal cavity. From 220 to 350 grammes (7 to nearly 9 ounces) were injected at one operation, without pain or great discomfort. Immediate increase of the red blood corpuscles in the blood of the subject of transfusion was ascertained, and this lasted more than a week. Absence of danger to the brain, lungs, or heart is urged on behalf of this procedure. Of course there is a possibility of peritoneal inflammation ; and the value belonging to the operation will have to be finally determined by more extended experience. The inconvenience attending all modes of transfusion is likely to cause them to be reserved very much for extreme emergencies. (On Pneumatic Aspiration, see p. 112.) 1 N. Y. Med. Record, April, 1878. 2 Lancet, April, 3, 1880. 8 Medical Press and Circular, October, 1879. * Lancet, Dec. 7, 1878. B These de Paris, 3 Mai, 1879. sTransac. of Obstet. Society of London, 1879. 1 Medicinisch Rundschau, 1879. p. 876. 8(Jentralblatt f. Medicin. Wissenschaft, Dec. 20, 1879. THERAPEUTIC MAXIMS. 191 GENERAL CONCLUSIONS. The following may, in recapitulation, be stated to be the most general desiderata in the management of all diseases: — ■Rp f f ft, in all acute diseases ; iteSb I ^^ jj^ ^Y\ cases of exhaustion. P , fa, of the j^mV?s and solids ; ijaiance | ^^ ^f ^^^q activity o[ functions. T>T 1 VI J v f a, due removal of exci'ch'ons: Normal blood-change | ^' ^^^^^^^^ of movhid poisons. q „_„_* S ^1 i^ fiii asthenic cases ; Dupport ^ j^^ j^j^ ^^^g^ siages of sthenic cases. THERAPEUTIC MAXIMS. 1. All pathology is but the physiology of organic perturba- tions. 2. Never interfere actively in disease without a distinct object. 3. Act only upon scientific reason, or well-defined experience. 4. Treat the cause of disease whenever it is possible. 5. Watch always, and treat, when requisite, the condition of the patient. 6. Avoid, especially, routine treatment according to the names of diseases. 7. Use no violence with self-limited diseases. I believe that a sound "theory of medicine" may be approxi- mated in a single para:^rapli, thus : — Physiological optimism characterizes the aggregate tendency of all the forces of the living organism, under the influence of life- force. But, the best possible result in a given case may, from its conditions and circumstances, fall far short of health. Medicine, then, is to favor or supply those conditions which, under natural laws, alloiv or promote the best result. In aiming to fulfil this duty, the art of healing must always depend, in part, upon empirical observation (which every branch of knowledge requires) and in part upon deductive science. But in both alike, the physician is, or should be, "naiwrce minister et inttrpres.''^ 192 ■ NOSOLOGY. SECTION IV. NOSOLOGY. Diseases were by Cull en classified as locales, pyroses, eachexise, and neuroses (local diseases, fevers, cachectic diseases, and nervous aftectious). The advances made in pathology since Cullen's time require some modification of this arrangement, while retaining its princi- ple. I propose, therefore, that diseases be sub-divided as — Phleg'inasiae : inflammations. Zymoses : zymotic diseases. Cachexise : cachectic affections. Neuroses : nervous disorders. Ataxias : unclassifiable diseases. The following list is intended to present only the most important diseases of each class : — Phlegmasiae : Laryngitis ; G-astritis ; Tracheitis ; Enteritis ; Bronchitis ; Dysentery ; Pneumonia ; Peritonitis ; Pleurisy ; Hepatitis ; Endocarditis ; Nephritis ; Pericarditis ; Meningitis ; Stomatitis ; Cerebritis ; Pharyngitis ; Myelitis. Zymoses (diseases produced by a morbid poison ; enthetic) : Only produced by contact or inoculation — 1. Primary Syphilis ; 3. Hydrophobia ; 2. Gonorrhoea; 4. Vaccinia. Eruptive — contagious — 1. Variola ; 4. Morbilli (measles) ; 2. Varioloid ; 5. Eotheln ; 3. Varicella ; 6. Scarlatina. Contagious — not eruptive — 1. Parotitis Contagiosa (mumps) ; 2. Pertussis (hooping-cough). Generally epidemic or endemic — 1. Typhoid Fever ; 6. Plague ; 2. Typhus ; 7. Cholera ; 3. Cerebro-spinal Fever ; 8. Endemic Dysentery ; 4. Puerperal Fever ; 9. Influenza ; 5. Erysipelas ; 10. Diphtheria. NOSOLOGY. 193 Endemic, occasionally epidemic — 1. Yellow Fever ; 2. Relapsing Fever ; "Malarial;" endemic — 4. Intermittent ; Kemittent ; Cachexiae : 1. Diatheses (general cachexiae): Always chronic — 3, Dengue, Pernicious Fever. a. SpaiicTemia (ansemia); h. Hemorrhagic Diathesis ; h. Chlorosis ; i. Tuberculosis ; c. Leucocythpemia ; j. Diabetes ; d. Pseudo-leukeemia ; k. Lithiasis; e. Pernicious Anaemia ; I. Secondary Syphilis ; /. Melanremia ; m. Addison's Disease ; (J. General Dropsy ; n. Exophthalmic Goitre. Acute Oi* subacute— u. Scurvy; d. Septaemia ; 6. Gout ; e. Pyaemia ; c. Eheumatism ; /. Mucous Disease. 2. Local cachexia} (degenerations): Cancer ; Bright's Disease (of the Kid- Various Tumors, Cysts, ney); etc.; Fatty Degeneration of the Goitre ; Heart ; Cirrhosis (of the liver, Other organic Degenera- etc.); tions. Skin diseases, viz.: Exanthemata (urticaria, Hypertrophiae (elephanti- roseola); asis, etc.); Tubercula(molluscum, etc.); Papulae (lichen, etc.); Vesiculae (herpes, etc.); Hemorrhagise (purpura); Bullae (pemphigus, etc.); Neuroses (prurigo); Pustulae (impetigo, etc.); Parasiticae (scabies, etc.); Squanuc (psoriasis, etc.); Syphilida. Maculae (fuscedo, etc.); Neuroses : Apoplexy ; Cerebro-spinal Sclerosis ; Paralysis ; Laryngismus Stridulus ; Epilepsy; Convulsions ; Catalepsy ; Neuralgia ; Hysteria ; Delirium Tremens ; Chorea ; Insanity ; viz. : Tetanus ; Mania ; Asthma ; Monomania ; Angina Pectoris ; Melancholia ; Locomotor Ataxy ; Dementia. Ataxiae (unclassifiable Diseases) : Hemorrhages ; Cholera Morbus ; Local dropsies (ascites, etc.); Colic ; Jaundice ; Diarrhoea ; Dyspepsia ; Worms, etc. 17 N PART 11. SPECIAL PATHOLOGY AISTD PRACTICE OF MEDICINE.^ HAVIITG endeavored, on our previous pages, to state, with brevity, what may be regarded as the essential principles of the science of medicine, we proceed to apply these to an account of the diseases to be dealt with in practice. Our purpose will be to give a brief and clear description of each disease, with its causa- tion, diagnosis, pathology, and treatment. The classification of diseases followed in the succeeding pages is chiefly clinical ; though based upon the pathological nosology already stated (Part I., Sect. TV.). Such an arrangement finds suflicient justification in its convenience. AFFECTIOKS OF THE EESPIEATORY ORGAN'S. PNEUMONIA. Definition. — Inflammation of the substance of the lung. Varieties. — According to its seat; single, double, lobular. According to causation ; idiopathic, from cold and wet ; traumatic, from injury ; caseous or tuberculous, in phthisis ; and typhoid pneumonia. Except in phthisis, we seldom meet with chronic pneumonia ; what is commonly called so being mostly induration following acute pneumonia as an efiect, not a continuation of it. Symptoms and Course. — A chill or stage of depression, followed soon by fever, with oppression in breathing, dull pain (not always present) in the chest, and sometimes short cough. Delirium is common. In children, vomiting frequently occurs. Temperature of the body is high, especially on the fourth or fifth day ; some- times, in the evening, reaching 104° or 105° Fahr. in the axilla. Secretions scanty, as in other febrile states. Urine containing an excess of urea, but deficient especially in the chlorides, in the middle period of the attack. Expectoration commences about the third day usually, the sputa being composed of mucus, lymph, and blood mixed together, making the rusty sputum of pneumonia. In this an excess of chloride of sodium will be found by testing with nitrate of silver. INOTE TO Paet II. — The letter F, followed by a number, in parenthesis, indicates a reference to a formula of that number, in the latter part of the book. See, also. Index of Formulae, at the end of the book. 194 PNEUMONIA 195 Fig. 76. The hcif^ht of the attack is generally reached between the fifth and the seventh day ; after which the temperature declines, and, in favorable cases, all the symptoms subside. In others, oppres- sion in breathing, and prostration increase ; cough deepens, and expectoration becomes more abundant, at last purulent. Death seldom occurs before the sixth, and may be as late as the twentieth day. Stages.— 1st. that of congestion or engorgement, and the com- mencement of exudation ; 2d, that of exudation and red hepati- zation ; ;kl, that of gray hepatization, softening, or purulent infiltration. Physical Signs.— These differ in the three stages. In the first they are, moderate dulness of resonance on percussion over the affected lung, and, on auscultation, after the first day or two, the fine crepitant rale. In the second stage, decided dulness on percussion, no rille, but instead, bronchial respiration and bronchophony ; with increased vocal fremitus. In the stage of softening or suppurative i n fi 1 1 r a- tion (gray hepatiza- tion), dulness on per- cussion, and coarse crep- itant or mucous rale. When resolution fol- lows the second stage, as in cases of recovery, the bronchial respira- tion gives way to re- turning fine crepitation (crepitus redux); and, then, the dulness of resonance on percus- sion also gradually dis- appears. Terminations. — Besolution ; death in the second stage from asphyxia ; death from exhaustion in the third stage ; recovery after the third stage (uncommon); abscess ; gangrene of the lung. Complications. — Pleurisy (pleuro-pneumonia) ; capillary bron- chitis ; tubercle ; inflammation of the liver ; endemic malarial fever. Sequelae. — The most frequent is that persistent consolidation of the lung called by some chronic pneumonia. Tubercular deposit, sometimes even acute phthisis, may follow pneumonia, in persons predisposed to it. Morbid Anatomy. — The loicer or middle lobe is almost always the seat of the disease. Should death take place (as it rarely does) in the first stage, the lung would be found somewhat swollen, dark-red, inelastic (splenization), and filled with blood or bloody serum. It would still float in water, though heavier than healthy lung. It is easily torn. In the second stage, of hepatization, the lung is no longer spongy, but presents considerable resemblance to the liver ; Eed Hepatization (magnified). 196 DISEASES OF ORGANS OF RESPIRATION. although a finger may be easily thrust through it. When entirely hepatized, it will not float in water, the air being dis- placed from the cells by the exudation of coagulable lyniph. The third stage consists in the Fig. 77. degeneration (in the absence of more favorable resolution by absorption) of the exudation. This occurs by granulation, soft- ening, and suppuration. Mostly the latter is infiltrated ; occa- sionally an abscess forms. In gray hepatization, the lung is sohd, impermeable to air, with a granite-like appearance of red and white points on section. It sinks in water, but is more easily torn, or crushed into a pulp, than in the second stage. Caseous pneumonia is now regarded by many as a frequent beginning of phthisis ; the exudation neither being absorbed (resolution) nor converted into pus, but undergoing a slow cheesy degeneration ; corresponding with what has been hitherto called " tuberculous infiltration." Fig. 78. Lung-tissue in Red Hepatization. >6 4 X <1^ / y Elements of Gray Hepatization. (Da Costa.) Chronic pneumonia, of authors, is rather a sequela of the inflam- matory affection ; consisting in induration or consolidation of the affected portion of lung, the exudation not undergoing, for a con- siderable time, either absorption or degeneration. It is not fre- quent, in the absence of tubercular deposition. This was, at least, the opinion of Laennec, sustained also by Grisolle, Chomel, Stokes, Niemeyer, and other authorities. Wilson Fox, however,^ identifies cirrhosis of the lung with chronic pneumonia. Walshe, 1 See Cirrhosis of the Lung, p. 200 of this book ; also, artiole on Chronic Pneumonia, in Reynolds' System of Medicine, Amer. Edition, Vol. II. PNEUMONIA. 197 Corrifjan, Bastian,Wilks, and others, regard pulmonary cirrhosis as a disLiuct aUcctiou. Diagnosis. — The only affections with which pneumonia is likely to be confounded are pleurisy, bronchitis, and phthisis. In children, collapse of the lung has been mistaken for lobular pneumonia. From pleurisy, pneumonia is known by the absence of the sharp pain belonging to the former, and by the crepitant rule and rusty sputa. From bronchitis, by the dulness on percussion, crepitant rale, bronchial respiration, and bronchophony. From phthisis, by its sudden onset, tine crepitation, and sputa, as well as by the acute violence of the attack. Latent pneumonia sometimes com- plicates fevers, etc. Prognosis. — Simple pneumonia, of one lung, in a young and previously healthy person, ought, under favorable circumstances and judicious treatment, always to be recovered from. In the aged, it is dangerous ; and double pneumonia is so at all periods of life, though good recoveries do occur. It is double in about one case in eight. Pathology and Nature. — Ordinary pneumonia is a phlegmasia; with the usual elements of general pyrexia or fever, local hyper- semia, and local exudation. As in other phlegmasise, the rela- tion of these to each other is not easily determinable. Is the local affection always the first thing, causing the fever, or is there a blood disease first, producing both the fever and the local affec- tion ? In traumatic pneumonia, it is plainly the former. In other cases, after exposure to cold and wet, we may suppose it to be both ; but the primary step of the actual inflammation is prob- ably the local disturbance in circulation, functional action, and nutrition. Causation. — As already intimated, cold, suddenly or partially applied to the body, especially to the chest, is the most common cause of pneumonia. But the previous state of the health, and especially, also, latent tubercle, may predispose to it. So, in cer- tain regions, does the influence of malaria. Some writers have latterly maintained that pneumonia is, ordinarily, a "fever" or self-limited constitutional disease (not a true phlegmasia or idiopathic local inflammatory affection). While there is no doubt at all that inflammation of the lungs frequently complicates malarial,^ typhoid, and other fevers, my belief is decided that the large majority of cases of pneumonia are simply inflammatory, as truly as pleurisy or other phlegmasice. The " pneumonic fever" theory seems to me to have influenced treat- ment disadvantageously. Treatment. — This remains to be a qucestio vexata. Having con- sidered already (General Therapeutics) the principles involved, my conclusions may be briefly stated. I am convinced by expe- rience that prompt and moderate "antiphlogistic" treatment may greatly lessen the danger of pneumonia, if not shorten its duration. Probably nine cases in ten would recover without the abstrac- 1 See La Roche on Pneumonia and Malaria. 17* 198 DISEASES OF ORGANS OF RESPIRATION. tion of blood ; the tenth might die for want of it. I believe that the mortality of pneumonia has increased in Philadelphia and elsewhere since bloodletting has been so g^erally abandoned.^ But bleeding from the arm, if resorted to, should be done but once; not later than the third or fourth day ; and it may be mod- erate in amount. Old persons and those of feeble system will neither bear nor require it. Cupping between the shoulders may, in many cases, take the place of venesection ; in some, it may follow this. The early administration of a vigorous purgative, as Epsom salts, or citrate of magnesium, is proper in the absence of any special contraindi- cation. Tartar emetic [F. 1]^ in the dose of one-eighth to one-quarter of a grain for an adult, every two or three hours, may be con- tinued during the height of the febrile stage. For this, as for bleeding, the indications are to be found not in the physical signs of pneumonia, but in the general condition of the system ; not in the crepitant rale, but in the hot skin, hard or else oppressed pulse, pain and dyspnoea, and more or less darkly flushed face. After the height of the attack, small doses of ipecacuanha [F. 5] may be substituted for the antimonial ; or nitrate of potassium [F. 4] , gr. X, every two hours. Some practitioners (as J. Lewis Smith)^ give, in place of antimony, tincture of veratrum viride, in small doses, watching its effects, and withdrawing it when the pulse has been sufficiently reduced. Murchison sometimes uses tincture of aconite, with liquor ammonii acetatis. Dr. Gehrun^, of Colorado [St. Louis Med. and Surg. Journ.., November, 1873), urges the importance of rest to the inflamed lung; which he endeavors to secure by passing a broad bandage around the chest, over a layer of cotton batting. Where but one lung is affected, the idea seems reasonable. A broad piece of adhesive plaster^ unilater- ally applied (Eoberts), will answer as well for the same purpose. Asthenic pneumonia requires a different treatment ; and the same will apply to the third or suppurative stage of all cases. Support may be required, in a few cases, even from the first ; by beef-tea, wine or spirits (best with nourishment, as in milk punch), quinine [F. 2], or ammonia [F. 3]. In hospital, I have known more than one case to recover under this plan alone; but they are the exceptions.* Some cases in which bleeding or cupping will be proper in the first stage before the fourth day, may require beef- 1 The late Dr. L. P. Gebhard, of Philadelphia, informed me, that in a large practice, of more than half a century, he had never lost a case of simple pneumonia; his treat- ment being (according to cases) " moderately antiphlogistic," as above described. Those ■who object to venesection in all cases of pneumonia, do so, almost invariably, on theo- retical grounds, without having tried it. Its occasional use is justified with almost equal unanimity, by those who have had experience with it. This was well brought out in a discussion of the subject at Richmond, Va., 1881 ; the "net result" of which was thus expressed by Dr. Martin, of Boston : " I trust that it may go out to the world that the American Medical Association sanctions the occasional use of the lancet, at least." 2 F., with a number, in brackets, refers to a formula in the collection at the end of the book. s On the Diseases of Infancy and Childhood: Philadelphia, 1870 * Dr. A. Patton, of Indiana, reports the treatment, by himself and others, of three hundred and nine cases of pneumonia, of all grades, with carbonate of ammonium ; ."5 to 10 grains every two hours, night and day ; little other treatment being used, The number of deaths was eight, or one in thirty-eight cases. — Am. Journ. of Med. Sciences, October, 1870, p. 374. PNEUMONIA. 199 tea in the second stage, and moderate stimulation later. A large blister over the aflected part is often useful about the fifth, sixth, or seventh day of the attack. Dr. A. Flint' considers that twenty-grain doses of quinine, given early, may abort some attacks of pneumonia. He believes also that, in any case, "if it does no good it does no harm;" and advises resorting to the use of quinine in all cases of pneu- monia. Supposing this to be allowable in many cases treated in hospitals^ 1 am by no means convinced that it will answer well in all cases met with in private practice. Dr. Everett (N. Y. Med. Kecord, Sept. 10, 1881) has treated cases successfully with continuous inhalation of cold aii\ brought through a tube from out of doors in winter. Varieties of Pneumonia. — When comphcated with pleurisy or bronchitis, no important modification of treatment is called for. Tuberculous pneumonia requires careful husbanding of the re- sources of the economy. Loss of blood is then rarely proper ; if at all, it must be local only, and in minimum quantity. The necessity for the analeptic treatment of the tubercular diathesis is paramount. Dry cups, blisters, and counter-irritant plasters, or tincture of iodine, croton oil or tartar emetic ointment exter- nally applied, are then suitable. Warm poultices, as of Indian or flax-seed meal, with or without the addition of mustard ; or carded wool, covered by India-rubber or oiled silk, kept on the chest day and night for a time, are often very useful, especially in children. Traumatic pneumonia, following an injury, is not common, except in army practice. It calls for no particular difference of treatment. Typhoid pneumonia is a term not always uniformly applied. It means, with some authors, inflammation of the lungs compli- cating typhoid fever ; others include under it all cases of asthenic pneumonia. More generally, however, it designates that form of the disease in which epidemic or endemic influence has impressed a peculiar character. Malarial regions especially exhibit this, in. the "winter fever "or typhoid pneumonia of our Southern States. Early and great debilitj^, out of proportion to the local symptoms, with a tendency to low delirium, and to remittence, mark this disorder. In treatment, it bears little or no depletion, hardly even, the reduction of excitement by tartar emetic or veratrum viride. Diaphoretics first, as [F. 6] ipecac, 2 grain, with, perhaps, the same amount of calomel and five or ten grains of nitrate of potassium, every three hours ; or liquor ammonii acetatis [F. 7] , or solution of acetate of potassium [F. 8] ; then quinine, when the need of a tonic is apparent, which may be very early ; with strong liquid nourishment, in a few cases stimulants, and moderate counter- irritation : these are the measures usually proper in typhoid pneumonia. After recovery from an attack of inflammation, the lung will be for some time more than usually susceptible to conditional changes. Exposure should, then, be carefully avoided ; and flan- nel ought to be worn next the skin. In winter a mild warming 1 Philadelphia Medical Times, June 3, 1880, p. 158, 200 DISEASES or ORGANS OF RESPIRATION. plaster, as of hemlock or Burgundy pitch, over the chest, wili give good protection. CIERHOSIS OF THE LUNG. Definition. — A slow, chronic affection, with cough and muco- purulent expectoration, not unfrequently hemorrhages, but with little or no wasting of the body ; in which, as ascertained after death, the lung involved is shrunken (sometimes to but one-fourth of its normal size), with obliteration of its air-vesicles, by conver- sion of the parenchyma into a fibroid material ; the bronchial tubes also being dilated, and the lung on the other side much enlarged. As physical signs, may be noticed high-pitched percussion reso- nance ; sometimes amphoric resonance over a much dilated bron- chial ramification ; occasionally, bronchophony ; on auscultation, feeble or absent respiratorj'^ sound at the apex of the afiected lung ; tubular respiration in various degrees elsewhere on the afiected side. Mucous rales are not uncommon. After several months , shrinking of the side of the chest affected occurs. The posi- tion of the heart is altered by the gradual shrinking of the lung ; the heart being, so to ^peak, moved toward that side. Synonyms. — Chronic pneumonia ; interstitial pneumonia; sclero- sis of the lung; fibroid plithisis. Pathology. — Difierent opinions have been the following : 1. That of Laennec, that the consolidation of the lung results from chronic catarrh, with accumulation of mucus and pressure of dilated bronchial tubes. 2. C. J. B. Williams' view, that it is a sequela of pleuro-pneumonia. 3. Charcot's and W. Pox's opinion, that it is identical with, or the result of, chronic pneumonia. 4. The judgment of J. Hughes Bennett, that it is a phase of tuber- cular disease, advancing towards recovery. 5. Corrigan's and Bastian's, that it is analogous to cirrhosis of the liver ; — the char- acteristic change being the interstitial growth or deposit of a fibroid tissue ; a fibroid substitution or degeneration, whether preceded or not by acute or chronic inflammation.^ Practically, tlie most important question in regard to cirrhosis of the lung is, as to its independence of tubercular deposit, and the tubercular diathesis. I believe that the occurrence of a true fibroid degeneration of the lung, independent of tuberculosis, has been proved ; but such cases are not frequent. Indications for the treatment of pulmonary cirrhosis are those of relief of the symptoms as they present themselves, along with hygienic management and general support of the energies of the system. For the cough, remedies applicable to chronic bronchitis will be in place ; including the inhalation of tar vapor, creasote, or (JSTiemeyer) spirits of turpentine. Iodide of potassium, and the external application of tincture of iodine, are advised with a view towards the dissipation by absorption of the deposited fibroid material. Of this, however, we cannot be sanguine in any case ; although retardation of the degenerative process is not improb- able. 1 See Bastian's article on Cirrhosis of the Lung, in Reynolds' System of Medicine, Amer, edition, VoL II, PLEURISY. 201 PLETJKISY. Definition. — Inflammation of the pleura. Varieties. — Single or unilateral, and bilateral or double ; upon the same side, unilocular, bilocular, or multilocular, idiopathic, traumatic, and secondary, e. y., tuberculous, or cancerous. Chronic pleurisy, so called, is merely the consequence of an acute attack. Symptoms and Course.— Generally, after a chill or cold stage, sharp pain in the side, impeded and accelerated respiration, short, sharp cough, and fever. The pain centres in the infra-manmiary or lower axillary region ; it is often intense, and is increased by a long breath, by coughing, pressure, or lying on the affected side. Dr. Peacock asserts ^ that in many cases the patient suffers only discomfort, with little pain and no fever. I have met with but one or two such instances, in which it may be a question whether the term pleuritis or that of liydrothorax should be applied. The pain and fever lessen after efiusion has occurred ; but the dyspnoea may then be increased. It is, after that period, most comfortable to lie on the diseased side, so as to allow of free breathing by the other lung. Acute pleurisy is often recovered from without any con- siderable efiusion. When the latter does occur, absorption mostly follows. If not, life is endangered by interference with respiration. At first serous, constituting one form of hydrothorax, the fluid may become purulent ; this is pyothorax or empyema. The term false empyema is given to a collection of pus in the pleural cavity from the rupture of an abscess in the lung. Pneumothorax is the accumulation of air in the cavity of the pleura ; hydro-pneumo- thorax, of water and air together. Both of these are most com- mon in tuberculous pleurisy, i. e., occurring in the course of a case of pulmonar}' phthisis. Stages. — In severe pleuritis there may be, 1, the adhesive ; 2, the effusive ; 3, the suppurative stage. In favorable cases the third stage is that of absorption. Physical Signs. — Of the first stage, deficient elevation of the ribs in breathing, feeble respiratory murmur on the affected side, and friction-sound. Second stage, dulness of resonance on percussion, bronchial respiration, bronchophony, sometimes cego^yhony. When the effusion becomes very copious, bulging of the side occui'S, with suppression of respiratory sound and of vocal resonance and vibration, and exaggerated or puerile respiration on the sound side. Displacement of the heart may take place if the effusion be on the left side ; of the liver if on the right. There is no physical sign by which empyema can be certainly distinguished from serous effusion ; but irritative fever usually accompanies empyema. Baccelli, of Rome, has pointed out^ that the thickness and heterogeiieous character of the fluid in empyema (presence of pus corpuscles, etc.) must produce greater interruption of the conduction of sound than when serous fluid only is present. This is observed in auscultation of vocal sounds ; which, as well as bronchial breathing, are (if Baccelli is right) not to be heard at 1 British Medical Journal, July 20, 1872. 2 London Med. Record, Aug. 15, 1876. 202 DISEASES OF ORGANS OF RESPIRATION. the base of a purulent effusion. There are, however, not a few cases in which vocal resonance may be heard (notwithstanding the presence of effusion) all over the chest^^but it is then muffled over the effusion. Above the seat of effusion, where the lung is condensed, it is apt to be louder than usual. Displacement of Heart by Pleuritic Effusion. "When the amount of fluid effused is not very great, there may be observed an in and out movement at the intercostal spaces,^ synchronous with the respirations. In some such cases, also, of a chronic character, even before retraction from absorption has begun, the measurement of the healthy side of the chest may be as large as, or occasionally even larger than, that of the side of the effusion ; yet the rounded shape of that side, with the other physical signs, will distinguish it upon inspection. Absorption following extensive effusion induces retraction and depression of the chest on that side, from the slow or imperfect expansion of the lung. Then return, first, bronchial respiration and voice, or segophony ; afterwards, gradually, the normal respi- ratory murmur. Sometimes, from adhesions of false membrane over the lung, permanent depression of the thorax on that side is left. During effusion, its fluid character as well as extent may be shown by percussion in different positions. Sitting up, it falls 1 Edinburgh Med. Journal, October, 1880. PLEURISY. 203 forward, and rises to a higher line in front ; lying on the back, the dulness, from gravitation, may fall much lower in the anterior region. Sometimes adhesions prevent this. Succussion, or sudden shaking of the chest of the patient, may produce an audible splashing, if the ear 'be upon or near the affected side. By ocular inspection and 'measurement, the changes in the amount of the effusion may be estimated from time to time. Terminations. — Pleurisy may sometimes be "nipped in the bud " at an early stage by appropriate treatment ; that is, prompt resolution of the incipient inflammation may be effected. The other terminations are, serous effusion, which may vary from an ounce or two to quarts, gradually absorbed altogether; the same, slowly and incompletely absorbed, leaving collapsed lung ; death, in double pleurisy, by asphyxia from excess of fluid ; and empyema, often, but not nearly always, fatal by slow exhaustion. Complications. — Pneumonia, tubercular deposit, inflammation of the liver (bilious pleurisy). Sequelae. — What authors call chronic pleurisy is the sequela of acute pleuritis. Its results and terminations have been above named. Morbid Anatomy. — In the early period, general redness and vascular injection of the pleura, with bands of whitish and more or less translucent or opaque coagulable lymph, causing adhe- sions of the pulmonary and costal pleura. Later, serous, san- guinolent, or purulent effusion, in variable quantity ; sometimes displacement of the heart, lungs, and liver, and bulging of the ribs and intercostal spaces. Diagnosis. — From pneumonia, pleurisy is known in the height of the acute attack, by the sharpness of the pain, the friction- sound, and absence of crepitant r<\le and of dulness on percussion. After effusion, especially by the change of the line of dulness with change of position, sitting and recumbent ; by the bulging ; and by the degree of diminution of vibration of the walls of the chest when speaking. From intercostal neuralgia, pleurisy is distinguished by the absence of fever and friction-sounds in the former, and the non- increase of the neuralgic pain upon inspiration. Congestion, in some rare cases, attend.s neuralgia ; the diagnosis is then more diflicult. In intercostal muscular rheumatism, there is slight increase of pain in breathing deeply, but also as much in moving the arms ; the pain is much less acute, and the attack is gener- ally without fever. Prognosis. — Pleurisy is rarely fatal ; though death may occur, from very abundant effusion in bilateral j)leuritis, or with empy- ema in the unilateral, through gradual exhaustion. Causation. — Exposure to cold and damp is the ordinary excit- ing cause of "idiopathic" pleurisy. Fracture of the rib, punc- tured wounds, etc., may cause traumatic pleurisy. In the course of phthisis, it not uncommonly occurs by extension of disease from the lung. Cancer of the chest may produce it in an analo- gous manner. Treatment. — In young and vigorous persons still more confl- 204 DISEASES OF ORGANS OF RESPIRATION. dence may be placed in early antiphlogistic treatment than in pneumonia. When high fever and constant severe pain occur, bleeding, in such patients, on the first, second, or third day, should be the general rule. Leeches or cups may follow, or be used instead of venesection in doubtful cases. Tartar emetic, after a free purge, may be given, ^ to | of a grain every two or three hours, with ^ to 1 grain of ojjium. Some practitioners add calomel, J grain to 1 or 2 grains every two or three hours. [F. 9.] I believe it may be generally omitted without risk. When fever subsides, or vomiting occurs, the antimony should be withdrawn; the opium and perhaps the calomel may be continued, while the pain lasts — carefully avoiding over-narcotism by the former and salivation by the latter. Dr. Anstie prefers the early hypodermic injection of acetate of morphia ; the side being then enveloped in a hot poultice. Dr. F. T. Roberts^ advises maintaining the affected side at rest by strapping it with wide strips of adhesive plaste,r. As soon as the heat of skin has considerably abated, if the pain continues, a large blister should be applied over the affected part. For the effusion^ diuretics, as squill [F. 10], juniper-berry infu- sion, or compound spirit of juniper [F. 11], acetate or bitartrate of potassium [F. 12], etc., may be used. Iodine, in Lugol's solu- tion, and iodide of potassium alone, are often advised. Anstie relied more on tincture of chloride of iron. Jaborandi (in drachm doses, four times a day) has been used with success by Crequy^ and Da Costa. Repeated blistering sometimes has excellent effect. Purgatives seem to be much less successful in removing pleuritic effusion than in carrying off that of ascites, or anasarca. They should be used, if at all, with caution, to avoid debilitation. Dr. Sutton, of the London Hospital, insists on the importance, as a rule, of rest in bed. When life seems to be threatened or the general health much impaired by exhaustion from dyspnoea, owing to large effusion not becoming absorbed, paracentesis, or puncture of the chest, is proper. This operation is now much more frequently performed, and at an earlier stage of pleurisy, than formerly. Anstie's rules (Reynolds' System of Medicine, article Pleurisy) for concluding upon it are these: Paracentesis should be performed "1. In all cases of pleurisy, at whatever date, where the fluid is so coj)ious as to fill one pleura, and begins to compress the lung of the other side ; for in all such cases there is the possibility of sudden and fatal orthopnoea. 2. In all cases of double pleurisy, when the total fluid may be said to occupy a space equal to half the dimensions of the two pleural cavities. 3. In all cases where, the effusion being large, there have been one or more fits of orthopnoea. 4. In all cases where the contained fluid can be suspected to be pus, an exploratory puncture must be made ; if purulent, the fluid must be let out. 5. In all cases where a pleuritic effusion occu- pying as much as half of one pleural cavity has existed as long as one month, and shows no sign of progressive absorption." In 1 Handbook of Theory and Practice of Medicine, 1873. 2 Bulletin Gen. de Therapeutique, March 30, 1875. PLEURISY. 205 the history of thoracentesis the names of Trousseau (1843), Bow- ditch, AUbutt, and Diculafoy have been most prominent. Dr. Bowditch has most frequently used Wyman's apparatus, which is a trocar, with a silver cannula, having a stopcock, and capable of being connected with a syringe by an intermediate piece, also having a stopcock, both cocks acting the same way. The opera- tion is performed while the patient is sitting up, if able, or lying over the edge of the bed. The puncture is made somewhere between the sixth and tenth ribs (Bryant prefers the sixth or^ seventh intercostal space ; Laennec, Stokes, and Walslie have advocated the fifth), just behind their angles ; making sure first of the position of the liver and spleen, so as to avoid them. Insert the instrument (rather quickly) near the upper edge of the lower rib, raising its point as it goes in.^ When the trocar is witiidrawn, the fluid may be gradually removed by the double- cocked syringe with safety to the slowly expanding lung. The operation may need to be repeated, even several times in the same patient. The occurrence of albuminous expectoration after thoracentesis has given rise to considerable debate in France.^ The grooved needle or exploring trocar (T. Davies) is often, used to ascertain the nature of the contents of the chest. Bla- chey, of Paris, prefers a very fine "capillary" trocar for the operation of thoracentesis. Dieulafoy's xmeumatic aspirator has attracted much attention. It does appear to be an improve- ment upon all apparatus so far employed for the same purpose ; reducing the danger of puncturing the cavities of the body to a minimimi. Suction should be stopped as soon as any distressing or very uncomfortable symptoms (stricture, violent cough, etc.) result. Yibert^ recommends the preliminary hypodermic injec- tion of morphia to prevent pain and syncope. When pus is pres- ent (empyema, pyothorax) in considerable amount, "drainage" may be resorted to. Following the grooved needle or trocar, a tine long iron probe, somewhat bent, is passed through to the lower and back part of the pleural cavity, against the intercostal space. Being felt there, an incision is made upon it ; a strong silk thread is passed through its eye, and then drawn through the first opening. After this, draw in a drainage tube of India- rubber perforated with many holes ; both of whose ends hang out and are to be tied together. Sometimes, by the tube, the cavity may be washed out, with water, or dilute astringent or antiseptic solutions. Dr. Bowditch latterly has expressed a preference for a free incision in an intercostal space, low down in the back, instead of tubular drainage, for empyema. Such an opening may be kept open with lint, as long as may be needful. Eoser, Konig, and Peltavy^ advise (and have practised with some success) resection of a portion of a rib (usually the sixth) for the radical cure of empyema. One advantage claimed for this operation is that it does away with the necessity for a canula ; so that the pleura is saved from the irritation liable to be caused by its presence. Yet practitioners of experience with 1 Dr. Leale, of Kew York, uses a scalpel and male catheter, instead of the trocar and cannla. - Lo Mouvement iNTedicale, 1873. 3 Journ. de Therapeut., Dec. 25, 1876. ^ Boiiiuer KJin. WochoDschrift, May 8, 1876. IS 206 DISEASES OF OIlGAI>rS OF EESPIR ATION. paracentesis are by no means all agreed upon the necessity of such an exsection. Washing out or "spraying" the pleural cavity in cases of empyema, with dilute solutions of carbolic acid, iodine, permanganate of potassium, has become a prom- inent point in its treatment with several practitioners (Fraentzel, Morgan,^ Eerguson, Lowe). In chronic cases of pleuritic effusion or empyema, the strength of the patient requires usually to be supported by good diet, and sometimes by tonics. This, in empyema, is often the most important part of the treatment. ABSCESS OF THE LUNG. In rare instances, inflammation of the lung, active or latent, may terminate in abscess. Before rupture, dulness on percus- sion, bronchial respiration, and dyspnoea proportioned to the size of the abscess, are present. When an opening occurs allowing the matter to escape into the bronchial tubes, the rather sudden commencement of purulent expectoration should attract atten- tion. Then the physical signs of a cavity are discoverable by percussion and auscultation ; amphoric or tympanitic resonance on percussion, cavernous respiration, metallic tinkling, etc., vary- ing with circumstances. As is the case with pleuritic empyema, pulmonary abscess may communicate externally by a sponta- neous opening. The principal importance of abscess of the lung consists in the possibility of mistaking it for phthisis. The points of difference will be alluded to in connection with that disease. PULMONAEY GANGRENE. This may occur in pneumonia from extreme violence of the inflammation, or from a depressed state of the system ; also from cancer within the chest, pysemia, etc. It is rare, but less so than circumscribed abscess of the lung. Except when very narrowly limited, pulmonary gangrene is always fatal. Its signs are, coarse, mucous rAle, taking the place of the vesicular murmur in the lower part of the lung ; with copious brownish and offensively fetid expectoration, dyspncea, and great prostration. In bronchitis, occasionally, temporary fetor of the expectora- tion and breath may simulate gangrene ; but transiently, and without the above-mentioned symptoms. The treatment of pulmonary gangrene must be, of course, sup- porting and antiseptic. Alcoholic stimulants, rather freely given, will be proper, with concentrated liquid food, as beef-tea. Sul- phite of sodium (ten grains in solution every three hours) may be tried ; or chlorine water, a teaspoonful or two every two or three hours ; or carbolic acid, one drop in solution every three or four hours. Inhalation of an atomized solution or emulsion of oil of eucalyp- tus is recommended for its antiseiDtic effect. 1 Lancet, March 5, 1881. COLLAPSE OP THE LUNG. 207 EMPHYSEMA OF THE LUNG. Fig. 80. Vesicular Emphysema. This is dilatation of the pulmonary air-cells of one or both lungs. It may accompany prolonged asth- ma, or may follow chronic bron- chitis. Sometimes it aids in pro- ducing dilatation of the heart. Its symptoms are dyspnoea, and when extensive, blueness of the lips, cyanosis, from interference with the circulation through the lungs ; in many cases wheezing respiration. There has been much contro- versy as to whether dilatation of the air-cells is produced by exces- sive distension during inspiration, or by obstruction to the expiratory movement. The experiments of Hutchinson have made it almost certain that the latter is the general rule ; but probably both modes of explanation may apply to different cases. The physical signs of emphysema are, bulging of the chest, increased clearness of resonance on percussion, and feeble inspi- ratory murmur with prolonged expiratory sound ; sometimes dis- placement of the heart or liver. It is most easilj^ mistaken for pneumothorax. But, in the latter^ the resonance on percussion is more tympanitic, the inspiratory murmur still feebler, or quite absent, and there is no prolonged expiratory sound ; besides which, the concomitants of pneumothorax usually serve to distinguish it. Pulmonary hydatids are rare and difficult of diagnosis, for an account of which the student may be referred to more extended treatises. Hydatids of the lungs are said to be not uncommon in Australia. Dr. L. D. Bird,^ of Victoria, claims to have cured a number of cases by tapping the cysts (mostly at the base of the lung), and then administering anti-parasitic medicines ; as bromide or iodide of potassium and kameela. COLLAPSF OF THE LUNG. In hooping-cough or in severe bronchitis, especially in children, obstruction of a considerable air-tube may lead to an exhaustion of air from the cells supplied by it, and a return of that poi-tiou of the lung to the unexpanded condition {atelectasis) of foital life. The same state may occur under other circumstances, from debil- ity. It was formerly always mistaken for lobular pneumonia. It is usually fatal, unless very much limited. Signs of it (often difficult of determination, however) are, mod- erate dulness on percussion, with absence of the murmur of respi- ration ; and, in some cases, an inward motion or recession of the lower ribs during the effort at inspiration. I London Lancet, July 1, 1871. 208 DISEASES OF ORGANS OF E ES PI R AT lOJST . BRONCHITIS. Definition. — Inflammation of the mucous membrane of the bronchial tubes. Varieties. — Acute and chronic ; general and capillary ; plastic, rheumatic, and syphilitic bronchitis. Symptoms and Course. — Systemic depression, followed by fever; tightness and soreness of the upper and anterior part of the chest ; cough, at first short, dry, and tight ; later, deeper and looser, with expectoration ; the latter being at first mucous, in rare instances pseudo-membranous, in severe cases at a late stage purulent. Cainllary bronchitis is marked by greater dyspncea and tendency to early depression and prostration. It is most common in young children and in the aged ; and is considerably more dangerous than ordinary acute bronchitis. Plastic or fibrinous bronchitis is more frequent in children than in adults, but is comparatively rare (Lebert) in the aged. Dr. Glasgow,^ of St. Louis, has found records of twenty-three Ameri- can, and more than a hundred European cases of this variety of bronchitis.^ It is certainly rare ; many practitioners of long and large experience having never seen a case. It is recognized simply by the expectoration of casts, more or less extensive, of the bronchial tubes. Most generally, it occurs in the chronic form. If the fibrinous exudation, Avhen formed, cannot be thrown off, the patient dies of dyspnoea. In a number of instances, however, attacks of the same kind have taken place repeatedly for years. Olironic bronchitis is often free from febrile symptoms ; the cough and expectoration, with slight dyspnoea, characterizing it. Stages. — Ordinary bronchitis may be divided in its progress into, 1st, the stage of diminviion of secretion ; and 2d, that of increase and perversion of it. Physical Signs. — ISo dulness on percussion, except in case of collapse of part of a lung from obstruction, or extensive capillary bronchitis ; sonorous rhonchus and sibilus, generally, though not quite always, on both sides of the chest ; varying from time to time, in seat, character, and loudness. In capillary bronchitis, extended mucous, crepitant or subcrepitant rMes, closely resem- bling the fine crepitation of pneumonia. Terminations. — Acute bronchitis may end in death from apnoea, in the first or second stage ; or in chronic bronchitis ; but most generally in recovery. Complications. — Asthma; pneumonia; bronchial dilatation; pulmonary collapse. Broncho-pneumonia is especially common in early life. Disease of the heart (especially of the left side) is, not rarely, attended by chronic bronchitis, as well as by attacks of pulmonary congestion. Morbid Anatomy. — General redness and congestive tumefac- tion of the bronchial membrane ; with more or less obstruction from mucus (in chronic cases pus), epithelium, and, rarely, casts of the tubes of plastic lymph. 1 Transactions of American Medical Association, 1879. 2 Reported by Peacock, Eiegel, Biermer, Lebert, and others. BRONCHITIS. 209 Diagnosis.— No difficulty exists except in distinguishing chronic bronchitis from phthisis. Absence of dulness on percussion and of the signs of excavation, are most important ; the expectora- tion also is whiter and of less weight in bronchitis ; and there is no distinct hectic fever. The temijerature does not rise to so high a degree in chronic bronchitis as in tubercular phthisis. Prognosis. — Acute bronchitis may be dangerous in old persons and young children ; seldom fatal in vigorous middle life. The capillary form is always most serious ; death taking place some- times from the tenth to the twelfth day. Acute fibrinous bron- chitis, according to Lebert, has a mortality of one in four or five cases. Chronic bronchitis is not often fatal, even by exhaustion ; but it may last an indefinite time, even many months. Causation. — Exposure to cold is the most frequent cause. In cer- tain employments, as needle-grinding, cotton-spinning, etc., solid particles inhaled cause bronchitis by meclianical irritation. Trans- ference of rheumatism occasionally induces it in the rheumatic diathesis ; and it is one of the possible manifestations of tertiary syphilis. The gouty element, also, may in exceptional instances be recognized in its production. Treatment. — Abortive treatment of a "cold on the chest " may sometimes be effected within the first twenty-four hours, by taking, at bedtime, a glass of hot lemonade, six grains of quinine, or ten grains of Dover's powder, after a warm mustard foot-bath. Should this treatment fail or be omitted, a brisk saline purgative should be given, of Epsom or Eochelle salts, or citrate of magnesium. Then, when the fever is high, cough very tight, and breast sore, tartar emetic may be advised, I to i grain every two or three hours [F. 1], with frequent draughts of flaxseed tea or some similar demulcent ; in some cases, leeches or cut cups to the upper part of the chest. A large sinapism over the upper sternal region will aid in giving relief; and so will friction with oil of turpentine. In milder cases, or where the strength of the stomach is doubt- ful, syrup of ipecacuanha, \ to \ drachm every two or three hours, will answer ; and it should be continued until the cough softens and the breathing becomes easier. Then syrup of squills [or, F. 13] may follow in fluidrachm doses, every three or four hours. Another excellent mild expectorant and palliative of bronchial cough is syrup of wild cherry bark^ in teaspoonful doses. When the cough is troublesome at night, I to 1 fluidrachm of paregoric [F. 1.5] may be added at bedtime ; or through the day, occasion- ally, if coughing be very violent or frequent. Opiates do the most good, however, after loosening of the cough with free expec- toration. When the fever has abated, and especially if dyspnoea continue, a blister may be applied over the sternum. In capillary bronchitis, or in the ordinary form in the aged and feeble, instead of tartar emetic, the more stimulating expecto- rants may be required, as senega, in decoction or syrup, chloride [F. 15] or carbonate of ammonium, with quinine and beef-tea, wine-whey, or whisky punch. Inhalation of .steam, alone, or from infusion of hops, sometimes soothes the air-tubes advan- tageously. 18* O 210 DISEASES OF OEGANS OF RESPIEATION, Dr. Bedford Brown,' of Virginia, in a number of cases in chil- dren, has found tlie early use of an emetic of ipecacuanha very serviceable ; a combination of ipecac and quinine being continued afterwards. Korrmann recommends muriate of apomorphia as an expectorant ; 3^,5 gr. for a child three years old. This is a rather large dose. Beck (Lond. Med. Record, April 15, 1881) advises ^^5 grain doses of the same medicine for a child under ten years of age. In children, especially, warm poultices^ as of mush and mustard, over the chest, are beneficial. Chronic bronchitis requires persevering use of counter-irrita- tion over the chest, by croton oil (3 drops with as much of sweet oil applied nightly till a papular eruption follows), painting with tincture of iodine, or plasters of Burgundy pitch, hemlock, etc., and alternation of stimulating and alterative expectorants, and tonics. Besides squill and senega, ammoniacum, copaiba [P. 17] , and chloride of ammonium [F. 16] are most frequently useful. Eucalyptol (dose, about minims) is an expectorant of consider- able i)ower. Grindelia rohusta^ of California, has lately acquired a similar reputation. Dose of fluid extract, half a fluidrachm. Dr. T. Clark (Practitioner, April, 1878), has reported good effects in chronic congh from, oxalate of cerium; five grains each morning, before rising. Others have preferred employing it in smaller doses, morning and night. It appears to act as a calma- tive, without disordering the stomach.'^ Dr. Lander Brunton asserts that carbonate of potassium tends to render bronchial expectoration fluid and abundant ; while nitric acid has the ojiposite effect, of diminishing its amount. These opposed indications may both occur at different periods in the same case. If the system be below par, quinine, iron, and cod-liver oil are important. "When secretion is very copious, inhalation of tar-vapor or of creasote should be tried. The former may be used by putting an ounce or two of tar in a cup over boiling water ; so as to diffuse the tar vapor through the chamber. Creasote, 20 or 30 drops, may be put into half a pint of boiling water, to be breathed from by means of an ordinary inhaler. Dr. J. A, LidelF uses by preference the atomizer, with a solution of one grain of carbolic acid in an ounce of water. "When medicine fails, change of air will sometimes entirely cure. Dr. Gi-reenhow* has pointed out that patients with chronic bronchitis generally do better when mucli out of doors, than when confined closely to the house. On Haemoptysis, see Semeioloyy ; also the article on Phthisis, and that on Memorrhayes. ASTHMA. Definition. — Paroxysmal and spasmodic dyspnoea. Varieties. — Idiopathic a,nd symptomatic; cZ^/sj3epf^■c asthma ; hay asthma. Symptoms and Course.— Every night, or once a week, month, 1 Am. Journal of Med. Sciences, October, 1870. 2 H. Cheeseman, N. Y. Med. Becord, June 12, ISSO, p. G64. 2 N. Y. Medical Record, July 1, 1872. * 0» Chronic Bronchitis, etc. London, 1869. ASTHMA. 211 or year, or at irregular intervals, the attack comes on. Most fre- quently it is iK'twcen one and three o'clock in the morning. Pre- monitory symptoms often are gn^at drowsiness, or wakefulness, headache, flatulence, itchins* under the chin, Dyspniwa then l)ecomes the charact(^ristic symptom. The sufferer sits or stands up, leaning forward, and labors to breathe. The chest is expanded to its utmost, by the accessory as well as principal inspiratory muscles. The countenance is anxious, with pallor, coldness, and, in severe cases, lividness of the face and hands. Perspiration is often copious, A wheezing sound accompanies respiration ; giving way finally, with relief, upon the expectoration of mucus, usually rather thick, and in pellets. The attack may pass over in a few minutes, or may last for hours ; or, with some remission, days or weeks. Where asth- matic symptoms are persistent^ as is not very uncommon, for years, some structural change in the organs of the chest must exist ; it is then symptomatic asthma. Physical Signs. — Inspection shows unusual elevation of the ribs and shoulders. Placing the ear on the chest, sonorous and sibilant sounds, loud but mostly small in calibre, are found to take the place of the respiratory murmur. These sounds change their locality frequently ; and they are usually douhle; i. e,, occur both with inspiration and with expiration. As the attack gives way with expectoration, the mucous rale is heard. Secretions. — At the beginning of the paroxysm, the urine is abundant and pellucid ("nervous urine") ; for some hours after the attack has ceased, it is more scanty, and deficient in urea and chloride of sodium. Complications. — Bronchitis ; puhnonary emphysema ; dilata- tion or hypertrophy of the heart. Diagnosis. — Laryngeal spasm may, without care, be confounded with asthma ; but the modification or arrest of the voice ought to distinguish the former. Violent bronchitis is known from it by the febrile condition. Angina pectoris, by the extreme pain, and localization of distress about the heart, Hydrothorax, by the dulness of resonance on percussion, and absence of rhonchus. Special exploration is necessary in each case to determine the presence or absence of pulmonary or cardiac complication. Prognosis. — Death almost never occurs during the fit of asthma. Those subject to it often live to old age. But dilatation of the pulmonary air-cells, and enlargement of the heart, may follow in protracted cases, breaking down the health. Pathology and Nature. — It has been made almost certain that asthmatic dyspnoea is owing to a spasmodic constriction of the smaller bronchial tubes, by tonic contraction, mostly reflex, of their involuntary muscular fibres. Perhaps the intercostal muscles and diaphragm may be sometimes involved, Savignac^ considers jjaraZ7/si6' (how paroxysmal?) of the bronchial muscular fibres more probable than their spasmodic contraction. This view is not likely to receive much support. Causation. — Asthma is hereditary in a majority of cases. Males 1 Bulletin Gonyral de TlijrapL'utique, Nuv. 30, 1867. 212 DISEASES OF ORGANS OP RESPIRATION. have it more often than females. It may occur at any age. Dr. Salter classifies cases according to their causation — 1, by agencies acting upon the lungs, as fog, smoke, fumes of various things, ipecacuanha, mustard, new hay, etc. ; 2, by reflex action, as irri- tation of the stomach from indigestion, loaded rectum, sudden emotion ; 3, by pulmonary or cardiac disease. Behind aU these there must be a predisposing peculiarity of constitution. Treatment. — During the attack, our aim is to give relief, by relaxing spasm. Ipecacuanha wine, with tincture of lobelia, one- quarter to one-half fluidrachm of each [F. 18] , every half hour until nausea or expectoration is produced, I have known often to act very well. Hoffman's anodyne, in one-half drachm or drachm doses, will sometimes do great good. Some practitioners advise hyoscyamus, musk [F. 19], hydrate of chloral, or hydrocyanic acid [F. 20]. Smoking tobacco relieves in some instances ; smok- ing cigarettes of stramonium-leaves in others. More still find comfort in breathing the air in which are burned papers which have been soaked in a saturated solution of nitrate of potassium. Inhalation of oxygen has been found beneficial by Demarquay, Andrew H. Smith, and others; and so has the respiration of compressed air. Inhalation of ether, nitrous oxide, or nitrite of amyl (three to five drops), may be carefully used in extreme cases. Hypodermic injection of morphia (Hirtz, Huchard) has sometimes given immediate relief. Dr. T. M. Eochester reports well of half-drachm doses of fluid extract of grindelia rohusta. Tincture of quebracho^ in teaspoonful doses, is recommended dur- ing the attack, by Berthold and others. As an adjuvant, the warm mustard foot-bath may be employed ; as well as sinapisms or dry cupping between the shoulders. Between the attacks, endeavor should be made to rectify diges- tion and its tributary processes, and to invigorate the nervous system. Some cases will require blue pill, nitro-muriatic acid [F. 21], chloride of ammonium or taraxacum, bitter tonics and mild laxatives, such as rhubarb, etc. Others need iron and qui- nine. Iodide of potassium is highly recommended by some; conium, cannabis indica, and arsenic in small doses by others. There is reason for giving trial to the bromide of potassium in obstinate cases ; most patients will bear from ten to twenty grains of this twice or thrice daily for weeks together without inconven- ience [F. 22]. Dr. Faulkner, of Allegheny City, Pa., has found remarkably beneficial results in asthma from painting with iodine (tincture) the tracks of the pneumogastric nerves in the neck ; from the thyroid cartilage to the upper borders of the clavicles. Dr. Eobson (British Medical Journal, April, 1880) has used with advantage nitro-glycerin; from one to three minims of a one per cent, solution at a dose. Pilocarpine hypodermically, succeeded well with Berkart (British Medical Journal, 1880, Yol. I., p. 960). Schajfi'er, of Bremen, has used with encouraging success the appli- cation of the induced electrical current to the throat (across the larynx and soft palate). A current is employed of sufficient strength to be decidedly felt by the patient. Dr. Yeo^ reports a case in which this treatment answered very well. 1 Lancet, November 13, 1880. ASTHMA. 213 Prophylaxis. — Ko disease is more curiously capricious in its causation tlian asthma. Some always have a paroxysm if they visit the sea-sliore ; others are more secure there than elsewhere. One cannot sleep on the first floor ; another does better there than higher up. Each must learn his own peculiarities and be gov- erned thereby. Dr. Whitehead, of Denver, insists, ^after large experience, that the climate of Colorado has a remarkable influence in promoting the amelioration and cure of asthma. Most remarkable are the annual attacks of asthma, hay fever, summer^ catarrh, autumnal catarrh, or asthmatic bronchitis, to which some individuals are subject. The symptoms are those of a violent cold, coming on generally either in June or in August. There are many persons who for years are obliged to arrange all their business for such an attack, which is punctual almost to a day. Some escape the paroxysm only by going to the sea-shore, and others to the mountains, before the expected time, and remaining there through the time during which it would have lasted. Dr. Sebastian, of Texas, mentions the case of a gentle- man who was enabled to escape his attacks by wearing a thick veil through the period of their expected return. This periodical aftection, however, is not incompatible with long life ; several of its victims have been known to survive their eightieth year; and one, at least, lived to be ninety-five. In a number of cases, the application to the nostrils of a sat- urated solution of sulphate of quinine has arrested the paroxj^sm in a day or two, several different years. Prof. Helmholtz, of Berlin, having been subject to "hay-fever," ascertained in 1868 that the secretion from his nostrils during the attacks contained a number of minute yibrio-like bodies, absent at other times. In view of the action of quinine in destroying infusoria, he applied a solution of it to his nostrils, with excellent effect. Drs. Frickhofer and Busch have obtained like results. (See a letter from Prof, Binz, of Bonn, to Prof. Tyndall, in Nature, May 14, 1874.) Dr. E. C. Seguin advises frequent use of a strong gargle of bromide of amynonium (5j or 5ij iii fSJ water) and a solu- tion one-fourth as strong as a wash for the nostrils. Dr. Fer- rier's^ treatment for common nasal catarrh is worth trying in this affection also, viz., by snuffing into the nostrils powder of suhnitrate of bismuth, mixed with a httle morphia and gum arabic. Dr. W. Moss, of Philadelphia, in his own case and in others, has found the hypodermic injection of morphia to give great relief. Dr. Hoover, of Ohio, shortened the duration of two cases by atomi- zation with solutions of chlorate or bromide of potassium with morphia. Prevention, however, is, in the case of periodical ca- tarrh, emphatically more attainable, as well as better than cure. As to localities almost certainly places of escape for those subject 1 American Journal of Medical Sciences, April, 1874. 2 See Experimental Researches, etc., by C. H. Blackley, M. R. C. S., London, 1873. Blackley believes pollen to be the usual exciting cause of this alfection. 8 Philadelphia Medical Times, May 13, 1«7C. 214 DISEASES OF ORGANS OF RESPIRATION. to it, the following is the report of Dr. Morrill Wyman, after care- ful investigation : "Long and varied experience with numerous individuals has proved that (in New Hampshire) the Glen, Gorham, Randolph, Jefferson, Whitefleld, Bethlehem village, the White Mountain Notch, Twin Mountain House, the high level about Franconia Notch, are all within the limits of safety. Other elevated tracts are safe : Mount Mansfield at Stowe, Vermont, and the Adiron- dacks are particularly safe, also the Ohio and Pennsylvania plateau, including the high range of southern counties in New York, from the Catskill Mountains to the western border of the state ; the plateau in these counties having an elevation of two thousand feet above the sea. The valleys of the rivers and lakes of the same state, at a lower level, are not safe. The Island of Mackinaw, and the country north of the great lakes in Canada, and beyond the Mississippi, at St. Paul, Minnesota, have a certain immunity, but not equal to that of the Lake Superior region. Farther west are large tracts which may be resorted to. South, the Allegheny Mountains at Oakland, and other elevated points, and Iron Mountain, on the Tennessee and North Caro- lina line, are unusually free. To the east, the elevated interior of Maine and its extensive lakes afford both pleasure and safety. Mount Desert is not free, but some of the islands about it are thought to give relief If the sea coast is preferred, the whole coast east of the St. John, thence quite around to Labrador, is open to the subjects of autumnal catarrh. Sufferers who actually pitch their tents in these favored regions, as a general rule, not only escape their enemy, but may find themselves at the end of the month with a vigor that nothing but living under canvas seems to give. Fig. 81. "The limits of the exempt regions are often narrow and very sharply defined." In asthmatic persons gener- ally, nothing is more impor- tant than prudence and regu- larity in diet and regimen. BRONCHIAL DILATATION. This (synonym, bronchiec- tasis), of which extreme de- grees are not common, is of interest chiefly because it is possible for it to be mistaken for phthisis. There are two forms, the tubular and the sac- cular enlargement. In either, slight dulness on percussion may occur from condensation of the lung around the expanded part. Sonorous rhonchus and coarse mucous r^le exist, the latter especially in the saccular form. In this, the signs are almost identical with those of tubercular excavation ; but they occur usually at the Dilated Bronchi. CHRONIC NASAL CATARRH, 215 middle or lower part of the lung, and are stationary, as they are not in tuberculization. Dr. Gairdner describes the formation of ulcerative excavations of the lung communicating with the inflamed bronchi as "bron- chial abscess." Cough, very troublesome, and attended by copious mucous or slightly purulent expectoration, is common in bronchial dilatation. The palliation of this symptom, with care of the general condition of the patient, is all that can be accomplished for it in treatment. CHEONIC NASAL CATARRH. This often troublesome affection is sometimes called naso-pha- ryngeal or post-nasal catarrh ; or, when attended by obstruction of the nostrils, oiasal stenosis; in cases of offensive discharge or odor, ozoena. It is most common in children ; not rarely in those of seem- ingly healthy constitution, but Avorst and most obstinate gener- ally in those of scrofulous habit, or who inherit syphilis. Mild cases exhibit merely an annoying constancy or frequency of mucous discharge, and more or less interference with nasal breathing. In others, however, there is painful irritation and copious discharge ; or there may be obstruction of one or both nostrils, almost absolute, with a dry state of the swollen Schnei- derian membrane, and an accumulation of thickened mucus in the posterior nares ; which becomes offensive from putrefactive decomposition. The respiratory portion of the lining membrane of the nostrils, compared (Kohlrausch, Kolliker, Bigelow) to the erectile structure of the penis,^ may undergo hypertrophy to such a degree as to be sometimes mistaken for polypus. It always differs from the latter, however, in the absence of a stem, and in the immobility of its mass. Worse yet, is the occasional extension of inflammation from the mucous membrane to the bones of the nose ; which may then sufier destructive caries. Sometimes (especially in syphilitic cases) this disorder, ending in necrosis, begins in the turbinated or other osseous structures. Ulceration of the lining membrane of tlie nose is not common, except in patients of syphilitic constitution. I have seen it, however, largely affecting the septum, in a case in which such a taint was quite impossible. JSTot unfrequently the antrum maxillare, on either side, or one or both of ih.Q frontal sinuses^ may be involved. In the last case, dull aching pain over the brow may be experienced. It is in the instances of extension to the maxillary and frontal cavities that the fetid discharge called ozoena is most apt to be met with. Not uncommonly, in such cases, no nasal discharge occurs ; whatever is secreted passes down into the pharynx ; bxit the odor may still be extremely unpleasant to the sufferer and to others. Predisposition to nasal obstruction appears to have, in some 1 Koe; N. Y. Med. Record, AprU 30, 1881, p. 486. 216 DISEASES OF ORGANS OF RESPIRATION. persons, an anatomical origin ; in a symmetrical growth of tlie bony structure of the nasal cavities.^ Usually, however (apart from strumous or syphilitic constitutions), chronic nasal catarrh is the result of repeated or prolonged exposure to changes of temperature, and especially cold and damp, such as abound in our American climate. Effects of this disorder, besides its direct annoyances, may involve loss of the sense ot smell; impairment o{ hearing (through extension to the Eustachian tube and middle ear) ; injurious modification of the voice; and the disadvantage of being obliged to breathe through the mouth. From the last named necessity, irritation and chronic troubles in the pharynx, larynx, or even lungs may result. Treatment. — First, we must ascertain the cause and nature of the affection. Is it simply idiopathic, or scrofulous, or syphilitic? Moreover, surgeons have often relieved ozsena by the removal of foreign bodies from the nasal cavities. Careful inspection of the nose must be made, by aid of a small bivalve speculum and the rhinoscopic mirror. (See Rhinoscopy^ under Semeiology, in Part I. ) But it is of great consequence, also, to have full information in regard to the constitutional history of the patient. Should there be any reasonable suspicion of syphilis, iodide of mercury ought to be advised, followed by iodide of potassium. Either of these alteratives may be given along with syrup or pills of iodide of iron. For the scrofulous diathesis, Lugol's solution, iodide of iron, iodoform, and cod-liver oil may be prescribed, suc- ceeding each other so as to impress the system through a long periodr Plenty of time is apt to be allowed in the treatment of chronic nasal catarrh ; which is often one of the opjprobria of medicine as well as of surgery. Local treatment, however, must not be neglected. It has become, of late, almost a special surgical department.^ The most general indication is cleansing, and when ozsena is present, deodorization and disinfection of the nasal cavities. For this, syringing is less effective than Weber's and Thudichum's nasal douche. This consists of a reservoir containing the selected fluid, to be held a little higher than the patient's head ; from it depends a quarter-inch-bore rubber tube, at the lower end of which is a nozzle, large enough to fill the orifice of the nostril. When the douche is administered, the ]Datient must breathe altogether by the mouth, and avoid swallowing. Then the fluid will enter by one nostril and pass out by the other. A simple funnel, or a bowl or pitcher with a siphon, will answer for the reservoir. The movement of the liquid may be controlled by raising or lowering the reservoir, and by compressing the lower part of the tube between the thumb and fingers. For simple cleansing, a solution of common salt in warm water (a teaspoonful in a pint) will be very suitable. Other lotions are employed, containing some of the following substances : alum, borax, boracic acid, chloride of ammonium, compound tincture 1 Harrison Allen ; Phila. Med. Times, Dec. 6, 1879, p. 120. 2 See Bosworth, on the "Throat and Nose;" Beverley Robinson, "Chronic Nasal Catarrh," etc. LARYNGITIS, 217 of benzoin, chlorate of potassium, nitrate of silver, sulphate of zinc, corrosive sublimate, tar-water, permanganate of potassium, chlorinated soda, hydrate pf chloral, iodoform, carbolic acid, salicylic acid, glycerin, etc. Anoth(u- mode of local medication of the nostrils is by atomiza- tion (see Part I.) with similar solutions. The hand-hall atomizer will suffice for the purpose. Many practitioners prefer insuffla- tion of powders; e. {/., tannic acid, bismuth, cubebs, or iodoform. Woakcs' and others use medicated pellets of cotton-wool, satur- ated with the preferred agent in solution with glycerin. [F. 340, 341, 34-2, 343, 344, 345.] Latterly, obstinate cases, in which hypertrophy of the mucous membrane over the lower turbinated bone obstructs the nostril, destructive local treatment is much in vogue. Escharotics may be used for this; as nitric, chromic, ov glacial acetic acid. The last named is probably the best for the purpose. When such applications have proved insufficient, removal of a portion of the obstructive mass may b^; perfornied by means of a snare-ecraseur, in principle like that used by Bryant and others for the excision of polypi from the nose. Jarvis' ecraseur^ has been found to work satisfactorily. Some practitioners prefer the galvano-cautery for a similar operation.^ Dr. Blackwood, of Philadelphia,* reports the successful employ- ment of induced elee;triciti/ in the treatment of chronic post-nasal catarrh. It must be applied with care, on account of the vicinity of the region to be dealt with to the base of the brain. Fig. 82. LARYNGITIS. Slight inflammation or congestion of the mucous membrane of the larynx is very common as the result of cold; its signs being hoarse- ness, with a dry, short, harsh cough and some soreness in drawing a breath. But simple acute laryngitis of severe grade is quite a rare affisction. When it occurs, there is fever, with hoarseness, "brassy" cough, distress- ing dyspnoea, and difficulty of swallow- ing. (Edema glottidis, or submucous etlusion of serum, constitutes the great- est danger in laryngitis ; the tumefac- tion obstructing respiration to a degree often fatal. This disorder is almost exclusively met with in adults. Early purging, the application of leeches, the internal use of ipecac, in doses just short of nausea, with mod- erate quantities of opium, and the fre- quent inhalation of the steam of boil- ing water, constitute the best treatment. (Edema of the Glottis. If dyspnoea become I Lancet, vol. i.. 1S80, p. 87G. 2 N. Y. Med. Record, April 30, 1881, p. 500. 3 Bosworth, N. Y. Med. Record, Nov. G. 1880, p. 510. 4 Monthly Review of Med. and Pharuiacy, January, ISSO, p. 8. 19 218 DISEASES OF ORGANS OF RESPIRATION. . decidedly serious, threatening asphyxia, tracheotomy is advised. Some account of tliis operation will be given in connection with croup. CEdema of the glottis may be produced immediately by the ingestion of boiling water, or of sulphuric or nitric acid, which has often accidentally happened. Chronic laryngitis, with ulceration, is a not infrequent attendant on phthisis. Some cases of the latter begin with it ; in others it occurs somewhat late in the course of the disease. An early sign in some cases of phthisis is (Seller^) an ashy-gray discolora- tion of the mucous membrane of the pharnyx and larynx ; along with pyriform swelhng of one or both of the aryteroid cartilages of the larynx. Syphilitic ulceration of the larynx is tolex'ably common, as a secondary symptom. This, as well as polypi or other tumors of the larynx, may be discovered, and treated by operation for removal, or with solutions of nitrate of silver, etc., through the aid of the laryngoscope. My confidence in the utility of very strong solutions of nitrate of silver in chronic inflammations of the mucous membranes, of the throat or elsewhere, has not increased, in fact has not been sustained, by what I have seen in practice. Dr. Horace Green and others made frequent use of it of the strength of sixty grains to the ounce. Except for ulceration, which may benefit even by the solid caustic, I believe that from four to ten grains in the ounce of water will do more good, in almost all cases, than the stronger proportions. Iodoform is a useful local application for ulceration of the fauces, threatening extension to the larynx. The application of nebulized liquids, by apparatus for atomiza- tion, is now in vogue in both acute and chronic laryngitis. Some remarks upon this have been made already, under General Thera- peutics (Part I.). Vapor of water containing laudanum, hops, or hyoscyanius, will probably do the most good in laryngitis. APHONIA. Loss of voice may be transient or permanent ; and either func- tional or structural in its origin. Especially in hysterical females, a nervous shock may produce a paresis or enfeeblement of the vocal jjower, lasting often for days together. I saw one such case in which a young woman could only speak in a whisper for more than three months. A choreic affection of the vocal appa- ratus is now and then met with ; stammering is, in fact, analogous to this ; depending on a want of command and co-ordination of the vocal muscles. Faradization, i. e., the use of induced electrical currents (as magneto-electricity), carefully applied, has sometimes cured ner- vous or hj'^sterical aphonia.^ I have known vesication of the back of the neck to be useful for it. Congenital dumbness, except in idiots, is due to deafness, making the learning of speech impossible, unless by a recently invented system of instruction by sight. 1 Phila. Med. Times, July 3, 1880. 2 Dr. Morell Mackenzie has pointed out that a shrill cough or the slightest dyspncua should forbid the u.se of electricity for aphonia. — The Pracliiioner, vol. ii. LARYNaiSMTTS STRIDULUS. 219 Organic or structural aphonia is caused by lesions of tlx; lar3mx, such as ulcerative destruction of tlie vocal cords, tumors, etc., which are to be diagnosticated by l;irynno.scop3\ Fcitjnc.d dunil)ne.ss is detectal)le 1)y careful watching, or, in the last i-esort, by etltcrizatinn. In the stage of early excitement, or when reviving from anaesthesia, the pretender will betray him- self by involuntary speech. The term di/sjihoni(i dcricorum has been applied to an affection of the throat not uncommon among clergymen and other public speakers, called b}' Dr. Horace Green "follicular disease of the pharyngo-lai'yngeal membrane." Its symptoms are soreness and irritation in the throat, with disposition to hawk and spit fre- quently, and hoarseness or partial loss of voice. On inspection, the fauces, pharynx, and glottis are found to be of a reddish granular appearance, with more or less enlargement of the mucous follicles, and, in severe cases, a muco-purulent secretion about the uvula. Sometimes, however, the membrane is dry. A conventional treatment for this affection has formerly been the application every day or two of a solution of nitrate of silver, with a brush or pi-obang. Saturated solution of tannin is also used for it. My belief is that, if these local remedies do not begin to relieve in a week or two, the frequent swallowing of small pieces of ice, or gentle gargling several times a day with ice-water, ma}'^ be substituted with advantage. Counter-irrita- tion over the throat, especially by croton oil, should, if necessary, be persevered in for a considerable time. Three drops of the oil (diluted with as much sweet oil for a delicate skin) may be rubbed over a limited space in front of the throat every night until a papular eruption comes out.^ Dr. J. W. Corson'^ asserts that relief will often be given when the voice has been suddenly lost, by slowly dissolving in the mouth and partially swallowing a piece of borax, containing three or four grains of the salt. Oil of eucalyptus is, latterly, a popular remedy for hoarseness. Many cases of this complaint are as much constitutional as local in origin. Where real dysphonia (difficulty or imperfection of vocalization) exists, liublic speaking or singing must be avoided, to allow the organs repose. Tonics and change of air may often prove the best measures of treatment. (For Aphasia^ see Dis- eases of the Brain.) LARYNGISMUS STRIDULUS. This is an infantile affection, consisting in spasmodic closure of the glottis, causing a stridulous or shrill whistling respiration. It is most apt to occur during dentition, but is not very common. Its onset issudden, and its duration bi'ief. Though exceedingly alarm- ing, it is seldom fatal. Of 52 cases recorded by Prof. Henoch, of Berlin, 33 were between 9 and 30 months of age, and 19 between 2 and 9 months. The treatment must be prompt ; producing derivation by slap- ping the back and limbs, and putting the feet into hot water, while 1 Patients should be cautioned, of couise, against allowing the oil to come near the eyes. I have known a severe ophthalmia to result from neglect of this. 3 N. Y. Medical Kecord, Jan. 1, lS7a. 220 DISEASES OF ORGANS OF RESPIRATION. cold water is applied to the head. Trousseau advised the applica- tion to the throat (better the nucha) of a sponge dipped in quite hot water. In severe cases mustard plasters (diluted with flour) may be applied to the chest and back. Some advise the momentary inhalation of chloroform ; others (Charon, Henriette) of ammonia. When life is really in great danger from prolongation of the spasm, tracheotomjr may be Justifiable. Dr. Polk,' of N'ew York, saved one child's life by the introduction of a JS'o. 8 silver catheter. Children who have laryngismus are generally aneemic ; requiring iron [F. 23] (perhaps bromide of potassium) and salt baths. CROUP. We understand by croup, an acute cynanche or angina, whose signs are, a hoarse cough— ditficult and audible respiration, and aphonia ; the seat of the disorder being the upper portion of the air-passages. Its place in nosology has been empirically or con- ventionally (rather than systematically) established. The identity of membranous croup with diphtheria, asserted by Dr. J. F. Meigs and many others, appears to me to be disproved, by a distinctness of history and pathology too signal to be put out of view. The one (croup) is a sporadic local inflammation, mostly sthenic ; the other (diphtheria) is an epidemic constitu- tional affection, with local symptoms ; mostly asthenic. As IS^ie- meyer^ points out, also, in croup the exudation is thrown out itxjon the epithelial surface of the mucous membrane, while in diphtheria it forms also within its stibstance. Of other authorities, we find among those holding the doctrine of the identity of membranous croup with diphtheria. Sir Thomas Watson, Hillier, George John- son, and Morell Mackenzie. On the other hand, the frequent occurrence of cases of inflammatory, pseudo-membranous croup not identical with diphtheria, is maintained by such writers as Spence, Squire, C. West,^ Hogg, Virchow, Hassenstein, Oertel, Oppolzer, ISTiemeyer, Trendelenburg, and Letzerich, abroad ; and G. B. Wood, A. Flint, J. Lewis Smith, Fordyce Barker, and Cohen, in this country. For brevity's sake, the following propositions may be ad- vanced :— 1. The pathological elements of croup are, a, spasm ; ft, hyper- semia or congestion ; c, inflammation, either ordinary or diph- theritic. The spasm affects especially the muscles whose action tends to close the rima glottidis ; but may involve also the muscular coat of the trachea itself. The hyperismia commences in the mucous membrane of the larynx or trachea, but often extends throughout the whole anterior cervical region. The inflammation may be located in a small portion of the same mucous membrane, or, it may extend downwards indefinitely into the bronchial tubes. 2. We may mentally distinguish between cases, in which the croupal dyspnoea results from simple spasm, from simple tumefac- l N. Y. Med. Record, June 19, 1880, p. 709. B Text-book of Practical Medicine (transl.,) vol. 1., p. 15. 8 Until recently ; not now (1881). CROUP. 221 tion, or from iiidaniniulion williout any spasmodic constriction of the glottis. But, in practice, the pathognomonic cough and breath- ing rarely attend such an isolation of one of these conditions. A certain number of cases, however, Fig. 83. occur, of purely spasmodic or nervous croup ; now and then substituting more general convulsions ; as when worms have been, apparently, an exciting cause. A purely inllammatory case is at least equally rare. In fatal pseudo-membranous cases, autopsic examination has repeatedly shown that the amount of false mem- brane was by no mi>ans sufficient, alone, to have occluded the larynx or trachea ; the result being due to the additional spasmodic contraction. 3. The most frequent form, common night croup, is pathologically characterized by spasm of the glot- tidcan ai)paratus, with congestion and tumefaction (transient in character), of the laryngo-tracheal mu- cous membrane. It is in these respects precisely analogous in nature to the asthmatic attack, whose seat is in the smaller air-tubes. There is no strongly marked line of sepa- ration between this form and the catarrhal croiq), or croupal catarrh, in which more or less active inflam- mation occurs, prolonging the existence of the symp- toms. _ _ 4. Looking, then, on the hypertemic state as simply pg^jgg Mem- intermediate, we may classify the cases of croup, as brane iu they ordinarily occur, clinically, as, 1st, those in which Trachea, spasm predominates; and 2dly, those in which inflam- mation is the dominant condition ; or, bearing in mind the above expressed qualification, into spasmodic and inflamma- tory cases. 5. Pseudo-membranous, or "true croup," does not generically dift'er from inflammatory croup ; of which it is only a grade or termination: i. e., any case of inflammatory or catarrhal croup may end in the exudation of coagulable lymph within the air- tubes. 6. Whether this shall occur or not, in any given case, depends, a, on the degree of the inflammation ; 6, on the state of the blood of the patient ; c, on the treatment. 7. It cannot be predicated on the ground of experience, that either vigorous and plethoric, or feeble and anaemic children, are especially prone to the membranous form or termination of inflam- matory croup. It may and does occur frequently in both. 8. The ordinaril}^ recognized signs for the diagnosis of inflam- matory from uon- inflammatory croup are sufficient, viz., the persistent duration of the croupal cough and voice — the (gen- erally) slow onset — the febrile sj'mptoms — and the stridulous inspiration, as the dyspnoea increases. 9. Inflammatory or true croup is, with the above inclusion (as always potentially membranous), not at all necessarily fatal, although highly dangerous. The presence of the false mem- brane itself does not inevitably determine a fatal result. Heart- 19* 222 DISEASES OF ORGANS OF RESPIRATION. Fig. 84. clot, from embarrassment of the circulation, has sometimes hast- ened death.' 10. In no disease does more depend on early treatment, which Is often prevented hy the insidious approach of the attack deluding the parents. The mortality of the dis- ease may thus in part be accounted for. 11. In the treatment of all forms of croup, relaxation and secretion are the two great desiderata. 12. In the spasmodic cases, emetics and antispasmodics (e. gf. , ipecacuan- ha, onion, assafoetida, or lobelia) will eftect these objects, especially if aided by the warm bath or foot bath. 13. In mild inflammatory cases, saline purging, gentle vomiting, and the use of demulcents, counter-irri- tation, and pediluvia will relieve. 14. In the more active cases, the loss of blood by the lancet, or by leeching, or by both, will be neces- sary, and should be early used.'^ 15. The most satisfactory emetic for employment in such cases is a combination of ipecac and alum [F. 24] ; the latter being used in half tea- spoonful doses in urgent cases, until emesis is produced. ISTor should the practitioner hesitate to compel re- peated vomiting at intervals, in des- perate cases. Better for a child to risk being sick for a month, than to die of cynanche (dog-choke, as the Greeks termed it). But the alum is unlikely to do harm. Turpeth min- eral is preferred by some. 16. Tartar emetic should not be used as an emetic in croup ; in sedative or expectorant doses, it may be advantageous. The same may be said of veratrum viride, pilocarpin, and apomorphia; each of which is greatly promotive of relaxation, but also of seri- ous depression. Cure has been effected in a desperate case, by the hypodermic injection of -^^ grain of hydrochlorate of apo- morphia. For a child the dose must be small, and its action must be watched before repetition. A case has been reported^ in which life appeared to be saved by the hypodermic injection of three drops of a one per cent, solution of sulphate of atropia. 1 B. W. Kichardson, Med. Times and Gazette, March, 1856. 2 Dr. F. Barker employs, instead, ii7ict. veratr. vivid, in one or two drop doses ; some- times combined with carbonate of ammonium, and followed by large doses of quinine in severe cases. — Am. Journal of Obstetrics, May, 1870. 2 De Ponteves; L'Union Miidicale, 1879. Bronchial False Membrane. CROUP. 223 17. Calomel [F. 25], freely administered, that is, a grain every hour or two, has the highest authority in its favor, in serious croup. 18. Nitrate of potassium has hoth experience and reason in its favor. ]^eing a solvent of lihrin, it may tend to prevent the exces- sive coagulability of the exudation. According to late theories, ammonia might do the same thing ; but the clinical or therapeutic antecedents of ammonia point otherwise. Of the lately asserted value of sulphur in croup, I have no experience. 3)r. Ozanam i-eports great success with bromine solution (one drop in an ounce of water), a few drops every hour ; using also the bromine water and bromide of potassium by inhalation with boiling water. 19. The great evil in membranous croup is the solidifying ten- dency of the exudation ; why should not, therefore, an abundant imbibition of liuids, even of water, do something towards counter- acting this y Inhalation of steam, from hot water poured upon unslaked lime, is eulogized by several writers. Glycerin, in tea- spoonful or half teaspoouful doses, is recommended by E. Ilarts- horne and others. Lactic acid, found by Bricheteau to be a powerful solvent of false membranes, has been applied locally, in solution, with success, by Dr. Dureau.^ Keeping the air warm (over 70°, some say 80° or 90°) and moist around the patient is advised by several practitioners. 20. No clear indication exists for the use of opium in the major- ity of cases of inflammatory or membranous croup ; although it may become useful, in cases which are protracted, or which are attended by a more than usual disposition to spasmodic symptoms. Tlie objection to it, in my mind, is, its tendency to diminish bron- chial (or tracheal) secretion; which, in croupal affections, we desire especially to promote. 21. Blisters are decidedly useful ; but they should not be left on long in croup, a superficial vesication only being desired. With Trousseau, a favorite application was a sponge or compress dipped in hot water and applied to the throat. 22. The application of a strong solution of nitrate of silver [F. 2G] to the fauces (and larynx, if possible), does good in many cases ; in the pre-exudative stage as a medicament ; in the exuda- tive, as a mechanical operation aiding to dislodge the membrane. 23. Iodide of potassium is too slow in its systemic action to be relied on ; and the same may be anticipated of the bromide ; although nothing should forbid their fair trial. 2-1. Tracheotomy or laryngotomy will, when performed early, succeed in a fair number of cases ; but in many of those cases it is impossil)le to know that they (as well as some in which it fails) might not have recovered without it. Few practitioners, there- fore, in this country, can demand the operation early ; and in the moribund state, the vascular congestion, from asphyxia, about the tbroat, renders success difficult, sometimes impossible. Upon the whole, therefore, the cases in which the operation may be expected to add to our hope in croup, are few\ In 1859, Bouchut, of Paris, introduced tubage (or catheter-like dilatation of the 1 Bulletin General Therapeutique, Sept. 15, 18GS. 224 DISEASES OF ORGANS OF RESPIRATION. larynx and trachea) instead of tracheotomy, at the same time publishing some statistics very unfavorable to tracheotomy. The Academie Imperiale de Medecine, however, decided ad- versely to the use of tubage as a substitute for tracheotomy. An instance of the successful employment of a common catheter was reported by Dr. Paton (Brit. Med. Journal, vol. i., 1881, p. 803). My own experience with tracheotomy has not been encouraging. "With Dr. C. West, who had but one recovery in sixteen cases, I am obliged to admit its success, in some otherwise hopeless instances ; especially in France, where Trousseau and others have operated earlier than in England or here.^ It is most often fatal in children under three years of age. Where there is reason to believe the membrane to extend into the bronchial tubes, it is of course in vain. The danger of hemorrhage, from dilated blood- vessels especially, is least if the operation be early. Dr. Aitken thinks that it ought always to be performed if no symptoms of amelioration follow active treatment, by "bleeding, emetics, the warm bath, and calomel purgation" steadily pursued for twelve or sixteen hours. The suggestion is a good one, that the opera- FiG. 85. Durham's Canula and Pilot. tion is most appropriate when the tendency to death is more hy con- tinuous apnoea than hy exhaustion."^ If delayed too long, the apnoea itself may iiroduce an irremediable condition. If performed, it should be deliberate, tying every vessel that bleeds, making a considerable opening in the upper rings of the trachea, and inserting a tube or canula^ of good size. Some 1 Nfilaton's first operation was successful; he then had twenty-three cases without one success. N. Y. Med. Record, June, 1869. From statistics published by Jacob! and others, it appears that of 1024 operations of tracheotomy, in Europe and this country, 220, or 21.48 per cent., have been followed by recovery. During the years 1861-1872 inclusive, there were performed in the department of Prof. Wilms, in Berlin, 330 tracheotomies on diphtheritic patients under 16 years of age. Up to 2 years of age there were 6 operations, and all died. In the ages of 2-3 years, there were 56 opera- tions, 15 recovered; 3-4 years, 69, 22 recovered; 4-5 years, 74, 18 recovered; 5-6 years, 57, 20 recovered; 6-7 years, 33, 15 recovered; 7-8 years, 21, 5 recovered; 8-14 years, 19, 8 recovered ; total, 103 recoveries (31-^ per cent.)— boys, 36§ per cent., girls, 24J per cent. In the first two years, and between the ages 11-14 inclusive (of each 6), not a case recov- ered. Successes under one year have, however, been reported. " Dr. G. Buchanan, Brit. Med. Journal, March 4, 1871. 3 F. Howard Marsh (Reports St. Barthol. Hosp., vol. iii.) asserts, after careful measure- ments, that the diameter of the trachea is, before two years of age, 10-40ths of an inch ; in the third year, ll-40ths; between this and the seventh year, 14-40ths. Acanulamay be 9-40ths of "an inch for a child under four years; ll-40ths between five and eight, and 12-40ths from that to twelve years of age. Durham's canula is probably the best now in use. Luer's silver canula, movable on the shield, is preferred by some; others use Leiter's hard-^'uhher canula. CROUP. 225 operators excise a small portion of one or two tracheal rings. Others, instead of a canula, use a leaden wire passed around the neck, its ends being hooked into the sides of the opening. A bivalve dilator (Trousseau's or Hutchinson's) sliould be inserted soon after the trachea is opened. R. W. Parker (Medico-Chirur- gical Transactions, 1879) advises that a feather sliould be used to clear the trachea of membrane before inserting the tube. Sometimes medicated solutions are tbus introduced ; as (Trous- seau) l)icarbonate of sodium, or persulphate of iron with glycerin, etc. In the adult, Arnott and others have used a curved trocar; Marshall Ilall, scissors. The use of chloroform or ether will facilitate the operation ; the danger from the inhalation is least when the vitality of the patient is not yet greatly reduced. Some have observed partial anaesthesia of the skin to be a sign of increasing asphyxia, such as indicates the propriety of the operation. lictraction of the chest-wall during inspiration is yet more significant of danger to life from failure of breathing. After trach(;otomy, the patient should be surrounded constantly with a warm, moist atmosphere. The canula should be witli- drawn in as few days as possible, upon the return of permeability of the larynx. The wound may then be treated with ordinary Bry nut's Cauula. A. Full length. B. Shortened. mild dressings, to exclude the air and heal it up. Yerneuil, Saint Germain, Ranse, Muron, and Boeckel have advocated trache- otomy with the actual cautery. Its especial advantage is said by them to be the division of the tissues exterior to the trachea., by means of a knife at a dull red heat, without the danger and delay of hemorrhage. They sometimes divide the trachea itself with a common bistoury ; separating the edges of the wound with a dilator to insert the canula. Another'method proposed (Reis- mann, 1879) for " bloodless tracheotomy" is, to introduce sutures through all the tissues along the sides of the incision made, before the trachea is opened. The fact that lime will dissolve false membranes has been largely applied to the treatment of croup ; by making the patient breathe the steam from boiling water poured over unslaked lime. Altliough the lime is not vofatile, some of its minute particles will be raised mechanically by agitation. Several successful cases of its use are reported. Prolmbly the absorption of the carbonic acid of the breath ma}^ partly explain the usefulness of lime. Kuhn, however, asserts that carbonate of potassium, given P 226 DISEASES OF ORGANS OF RESPIRATION. early, will prevent the formation of false membrane. Lactic acid (inhalation of a solution of 20 drops in half an ounce of water) has been used with success (Adolph Weber) in croup, ^ To sum up, I would begin the treatment of a case of inflamma- tory croup with a saline purgative. Then an emetic of ipecacu- anha ; which may have to be repeated. Leeching, and even venesection, will be useful in a robust subject if seen early. Between the times of emesis, there may be prescribed 1 grain of calomel with 5 grains of nitrate of potassium, every two hours ; in urgent cases every hour. In children over three years of age ri to jig grain tartar emetic may be added ; or one-drop doses of tincture of veratrum viride ; watching the effect produced. The warm bath, prolonged, may be used once or twice daily. Hot compresses, or cloths wrung out of cold water (which soon be- comes warm when applied) may be applied to the throat ; but a blister should follow in a severe case. Inhalation of steam from lime or lactic acid should be tried, early as well as late. Alum must be added to ipecac, if relief be delayed, Nitrate of silver siDonging, and catheterism or tracheotomy, are last resorts. The following conclusions are laid down by Dr. J. S, Cohen, in his monograph^ upon Croup and Tracheotomy : " 1, There are no insuperable contra-indications to trache- otomy in croup. "2. The administration of an ansesthetic for the purpose of controlling the child's movements is admissible in performing the operation ; but it should be used with great caution. "3. A careful dissection should be made down to the windpipe, and hemorrhage be arrested before incising it, whenever there is at all time to do so. "4, The incision should be made into the trachea as near the cricoid cartilage as possible, to avoid excessive hemorrhage, and subsequent accidents which might occasion emphysema, " 5. A dilator should be used, or a piece of the trachea be excised, whenever any difficulty is encountered in introducing the tube. " 6, The tube should be dispensed with as soon as possible ; or altogether if the case will admit of it. "7, Assiduous attention should be bestowed upon the after- treatment, especially that of the wound. A skilled attendant should be within a moment's call for the first twenty-four or forty-eight hours immediately following the operation," The diagnosis between inflammatory croup and diphtheria will be referred to hereafter, in connection with the latter disease, PLEURODYNIA. Synonym. — Intercostal Rheumatism. Symptoms, — Pain, generally i-ather dull, sometimes quite se- vere, oY one or both sides, oftenest on the left. It is increased by deep breathing or coughing, moving the arms or trunk. Diagnosis. — From pleurisy, it is known by the absence of fever, and of all modifications of the sounds heard upon percussion and auscultation, 1 Med. Times and Gazette, Jan. 22, 1870. 2 Philada., 1874. PHTHISIS PULMONALIS. 227 Treatment. — A lai-gc mustard plaster over the part ; friction with soa}) or volatile or some anodyne liniment ; dry or cut cui)s ; covering- the side with carded wool and oiled silk; a belladonna plaster ; a blister if obstinate as well as severe. INTEKCOSTAL NEURALGIA. Symptoms. — Severe lacerating pains between the sixth and ninth or tenth ribs, along the intercostal spaces ; frequently inter- mitting, or even regularly periodical. This aftection is most generally met with in ansemic patients, or in those who have been exposed to malarial intluence. Occasionally the paroxysms are attended by a sort of reflex pulmonary congestion, simulat- ing pleuro-pneumonia. Spinal tendeimc.^s is often present. Treatment. — A sinapism may be applied ; or ointment of aconite [F. 27], or of chloroform [F. 28], or veratria [F. 29], may be rubbed upon the side during the paroxysm. Should these not relieve, a small blister may be allowed to vesticate, and then one or two grains of acetate of morphia diluted with powder of gum arable may be applied to the surface ; or solution of mor- phia may be used hj hypndemdc injection^ half a drachm at a time being introduced by means of a syringe adapted to the purpose, over the part. General treatment, by iron, quinia, or ciuchonia, etc., will be determined by the condition of the patient. THORACIC MYALGIA. This term has been applied (Tnman) to an affection characterized by pain in the superficial muscles of the chest, mostly dependent upon ill-nourishment and overwork ; sometimes produced by con- strained positions of the body, or pressure ; as by a desk, or a soldier's belt, etc. Its treatment consists in the removal, if possible, of its cause ; with local warming or anodyne applications, and general invigora- tion of the system. PHTHISIS PTJLMONALIS. Definition. — Tuberculous or caseous consumption of the lungs. Varieties. — Acute, chronic, and latent phthisis. Symptoms and Course. — Consumption may begin after a severe acute bronchitis or broncho-pneumonia ; or, more gradually, with an apparently slight hacking cough ; or with a hemorrhage ; or with dyspepsia and general debility ; or with chronic laryngitis. Increasing, in most cases slowly, the pectoral and constitutional disorder becomes developed. We have, then, pains in the chest, frequent and severe cough, hemorrhage occasitmally (in about two-thirds of the cases) and pallor, acceleration of the pulse and elevation of the temperature, with the paroxysms of hectic fever, i. e., chills followed by fever with bright flush of cheek, but with- out headache ; emaciation, arrest of menstruation in the female, night-sweats, colliquative diarrlitea; finally, often, though not always, delirium ; and death, mostly by exhaustion, but some- times 1)}^ sullbcation. The spirits of the patient are apt to be cheerful, even hopeful of life almost to the last. Appetite is 228 DISEASES OF ORGANS OF RESPIRATION. variable, cligestioa usually not vigorous ; but to this there are exceptions. The following description of advanced phthisis is from the late Prof. ]Sr. Chapman : " The cheeks are hollow, the bones prominent, the skin arid, the nose sharpened aiid drawn, the eyes sunken, with the adnata of a pearl color, destitute of vascularity, the lips retracted, so as to produce a bitter smile, and the hair thinned by falling out, the neck wasted, oblique, and somewhat rigid or immovable, the shoulder-blades projected or winged, the ribs naked or exposed, with diminution of the intercostal spaces, and the thorax appa- rently narrowed ; the abdomen flat, the joints, great and small, seemingly enlarged from the wasting of the integuments, the nails livid and occasionally incurvated, the extremities oedema- tous ; the angular points on which the body rests, in several points protruded through the skin — the whole attended by a most afflicting cough, aphthae, sore throat, difflcult deglutition, and feeble, whispering voice, or entire extinction of it." The expectoration in phthisis is at first mucous or bloody ; later, muco-purulent and bloody, or else nummular; i. e., in roundish masses like coins, not floating perfectly in water ; or, al)undant and purulent. Dr. T. Thompson first noticed (1852) the appear- ance of a rather deep-red line along the gums as one of the signs of phthisis. Stages. — These are, 1. Incipient phthisis ; 2. The stage of con- solidation of the lung ; 3. That of excavation or vomicce ; 4. Ad- vanced or confirmed consumption. Piiysieal Signs.— The earliest indications upon physical explora- tion are, a sinking in under the clavicle upon the left side, with prolonged expiratory sound. Not long after, the evidence of con- solidation is, increased dulness over the apex of the lung upon percussion (not invariably, but generally upon the left side) with blowing or bronchial respiration, or interrupted jerking respira- tory murmur, and increased vocal resonance and vibration. Dry crackling follows, with mucous or coarse crepitant rale. When softening of tubercular deposits occurs, moist crackling and gurgling become very distinctive signs. The presence of a vomica is shown by cavernous respiration and bronchophou}^ or pectoriloquy. Percussion-resonance over a cavity will be dull if its walls be thick, and amphoric if they are thin and tense ; if thin and relaxed, the bruit depotfeU or cracked-pot sound. On percussion over a cavity when the patient's mouth is shut, the sound produced may be of a lower pitch than when the mouth is open. Pneumothorax and hydro-pneumothorax, i. e., dilatation of the pleural cavity and compression of the lung by air, or air and liquid together, with perforation of the lung, are not uncommon results of tuberculization, although possible without it. Of pneu- mothonix, the percussion-resonance is tympanitic ; respiratory murmur is lost. Hydro-pneumothorax may give t3"mpanitic reso- nance above, v/ith metallic tinkling on auscultation, and dulness below. Physical and Microscopical Peculiarities.— Temperature has PHTHISIS PU I.MON A LIS. 229 been found to be a diagnostic aid in phthisis. It is asserted that there is a continued elevation of the heat of the hodi/ in all cases in which tubercle is being dcpofjited ; that this may occur for weeks before any local physical sign is discoverable ; and that the rise in the heat of the body varies, during the progress of the case, with the greater or less activity of the tuberculization. It has been shown, however, that exceptions to this general rule do occur ; and it is not certain whether the elevation of temperature is not due really to a concomitant irritative or sub-inliammatory process, rather than to the simple deposit of tubercle. This last is the most probable view. When expectoration is copious, some micrologists aver that diagnosis may be aided by its minute characters ; arched and anastomosing fragments' of pulmonary fibrous tissue, and tuber- cular corpuscles, being discerned. But it is not proven that the former are thrown off only in phthisis ; and the latter may be absent or obscure in character in an otherwise clear case. Nie- meyer regarded the presence of elastic fibres in the sputa as a sure indication of consumption. Dr. Fenwick, of London, detects minute portions of lung-tissue by boiling the expectoration a few minutes with its bulk of solution of caustic soda (gr. xv in f § j of distilled water), and adding cold water, in a conical vessel. The sediment is then examined with the microscope. Terminations. — The cicatrization of vomicae, and the cessation of tubercular deposition, have, although exceptional, been often found to occur ; and so have the cornification and calcification of unsoftened tubercle. Recovery from phthisis may in such cases be expected to take place, as the arrest of the local disease attends the presence of a favorable constitutional state. Death from consumption may come by asthenia or by apnoea. The first is most common. Suffocation or apncea may follow— 1, from hemorrhage ; 2, rupture of a large vomica ; 3, pulmonary OBdema or hydrothorax ; 4, excessive secretion or bronchorrhoea, beyond the power of expectoration. Complications. — Pleurisy is a frequent concomitant of phthisis. Tubercular peritonitis is much more rare. On account of its dura- tion, however, pulmonary consumption may be accidentally com- bined with various affections not specially kindred with it. Asthma is particularly not apt to be conjoined with phthisis. Diagnosis. — It is from chronic bronchitis, cancer of the lung, pleuritic effusion, bronchial dilatation, and pulmonary abscess that phthisis requires the most care in discrimination. Chronic bronchitis is not common except in old persons ; its expectoration is thinner, v/hiter, and not nummular nor bloody ; there is no hectic, although there may be emaciation ; and there are none of the special physical signs of phthisis. Cancer of the lung exhibits a marked dulness of resonance on percussion on one side, with blowing respiration, unless a bron- chial tube be obstructed, when there is no respiratory sound. There is severe and almost constant pain in the chest. The pecu- 1 Dr. J. G. Richardson calls attention to the sqwire fracture of these fragments as being distinctive. 20 230 DISEASES OF ORGANS OF RESPIRATION. liar auscultatory signs of tubercular disease are absent ; while the sallow, cachectic aspect of cancer, and the concurrent existence of carcinomatous tumors somewhere in the body, generally make the case clear. In "chronic pleurisy," as pleuritic effusion is often called, the dulness on percussion is at the lower part of the chest ; the side is expanded, unless after the fluid is absorbed ; respiratory murmur and vocal vibration are suppressed ; and the general symptoms, as irritative fever and wasting, are not so extreme. Bronchial globular dilatation may give auscultatory signs exactly like those of a tubercular cavity; but there is no haemoptysis nor emaciation, nor much loss of health. The expectoration mfiy be as copious as in consumption; but the matter is more liquid, and pus much more diffused in it. The cough is more constant than in phthisis. Abscess of the lung is to be distinguished from phthisis by its history, generally following recognized pneumonia ; its seat mostly at the base of the lung ; its physical signs decreasing instead of increasing ; and, as with cancer, the affection being confined alto- gether to one lung. The extension of the signs to both lungs is important in most cases in the diagnosis of phthisis. Dr. Walshe states that caseous infiltration is more likely to occur either at the base, or in the middle portion of the lung than is the case with tuberculization.^ Syphilitic disorder sometimes affects the lungs and bronchial tubes, with a condition almost undistinguishable from ordinary consumption. The previous existence of venereal disease, and periosteal nodes upon the clavicles, with the slower progress of the decline, will help to enlighten us. Prognosis. — Phthisis is certainly one of the most destructive of diseases. In no case can recovery be anticipated ; but it does occur, as every physician must have witnessed. I have seen a num- ber of such recoveries ; generally from the incipient stage, but also even where vomicae, emaciation, and night-sweats had occurred. Dr. A. Flint has recorded the history of sixty-two cases of resto- ration from consumption. Cruveilhier said of phthisis, long ago, "Prevent inflammation, and you will cure your patient." Her- ard and Cornil have lately asserted nearly the same opinion. Under improved hygiene and medical treatment, the mortality from phthisis appears to be declining. Without referring to sta- tistics (the nomenclature connected with which in past times would be a source of doubt, as chronic bronchitis, etc., were once called consumption), I am convinced that fewer people die of phthisis now than thirty years ago, in Philadelphia. The duration of phthisis varies greatly, being least, as a general rule, in the youngest subjects. Eighteen months to two years is the most frequent period. But in some instances life is prolonged under it for twenty, thirty, or even forty years. Dr. C. T. Williams^ found the average duration of 198 cases, under favorable circumstances for treatment, over seven years ; 1 Treatise on Diseases of the Lungs, 4th edition, 1871. 2 Lancet, January 21, 1871. PHTHISIS PULMONAI^IS. 231 and of 802 still living, the average continuance of the disease was more tlian eight years. It is probable tliat, in cases not cured, the hygienic and therapeutic measures now employed increase the length of life much beyond what was possible thirty or forty years ago. In the United States, however, the deaths from phthisis still constitute about 25 per cent, of the whole mortality from all diseases. Acute phthisis, or galloping consumption, may end life in from six weeks to three months. This sometimes follows pneumonia. Its symptoms differ from those of ordinary consumption chiefly in their rate of progress. Softening of the tubercle and the forma- tion of cavities do not always occur to any extent, apnoea being caused by extensive diffusion or infiltration of the tuberculous or caseous deposit through the lungs. In any case of consumption, the state of the general system is of primary import in prognosis. When the patient is gaining in weight and strength, and fever and night-sweats diminish or dis- appear, there is hope, for a time at least. Spitting of blood (when consumption is proved to exist already) does not increase the un- favorable aspect of the case. Rapid emaciation, chills, hectic, swelling of the feet, and diarrhoea are always discouraging ; as, of course, are, also, all signs of increase in the local pulmonic affection. Causation. — Hereditary taint of constitution^ is general ; inde- pendent origination of phthisis the exception. From 18 to 35 years is the time of life most subject to it ; but it is now and then met with even in children, and frequently in the aged. Statistics in Europe and in this country show some proportion between the mortality from consumption and nearness to the sea-level ; the lowest lands having the greatest total amount of it. High, dry, and equable climates and situations, even though cold, are most exempt from it. It is not a disease of the Arctic regions, and there is more of it in Tennessee than in Illinois. The views of Oppolzer, jS'iemeyer, Yirchow, and others, con- cerning the frequent origination of consumption in "caseous pneu- monia" or broncho-pneumonia, or bronchitis, and the declaration that tubercle is absent in a large number of cases, even of fatal consumption, have received, as they deserve, critical examination by the profession. I believe it not safe to accept so great a modi- fication of pathological doctrine as they involve ; although the occasional occurrence of scrofulous phthisis without characteristic tubercular deposits may be (as indeed it has long been) admitted. If we accept the opinion of many pathologists, recent as well as older, that caseous softening is the customary change (Virchow, Waldenburg) which true miliary tubercle undergoes, it would seem quite supposable that the absence of true (so-called) tuber- cle in a number of cases in the lungs of those who have died of phthisis may be explained by the process of softening and trans- formation having had time to be completed. Among the predisposing causes of consumption is congenital 1 Even those who advocate the new views (resorption, or infection) of the uaturo of consumption mostly admit a " vulnerability " which is inherited. 232 DISEASES OF ORGANS OF RESPIRATION. stenosis (contraction) of the pulmonary artery (Farre, Gregory, Louis, Traube, Frerichs, Lebert). Dr. A. Flint,^ analyzing 670 cases of phthisis in private and hospital practice, concludes as follows : "Pneumonia and bron- chitis have very little if any causative influence in developing this disease ; and there is no clinical evidence of haemoptysis having such an influence. ISTor is there evidence to sustain the hypothesis which attributes miliary tuberculosis to absorption of morbid pro- ducts in different parts of the body. The doctrine is sustained that pulmonary tuberculosis is eminently a diathetic disease ; i. e., one arising from a constitutional determining agency." Allusion has been made in a previous part of this book to what I believe to be the untenable theory of the existence of a specific virus (Cohnbeim, Martin) productive of tubercle. (See General Path- ology ; Tuberculosis. ) individually, and in families, all causes that depress vitality pro- duce consumption ; but most of all impure atmosphere.'^ Sedentary employments and exhausting excesses, with foul air, make large cities very productive of it. In constitutions having the proclivity towards it, tuberculization may be brought on by any reducing disease, especially such as involves the breathing organs ; as measles, bronchitis, or pneumonia. Dr. Copeland^ considers that phthisis may be communicated^ by the emanations from the lungs and skin of a patient ; and hence urges that consumptive mothers should not nurse their infants ; and that healthy persons should not sleep with consumptives. Parks, Budd, and others, confirm this opinion ; which was held also by Morgagni, Laennec, Andral, and Sir James Clark. Dr. R. Payne Cotton, of the Consumption Hospital, Brompton, England, with extended opportunities for observation, denies it.* If proved, it is not a spjecific contagion., but extension of decay hy contact with decaying tissue. Drs. W. H. Webb^ and E. Holden,® in papers upon this topic, give references showing an affirmative opinion in regard to the communicability of phthisis to have been expressed by Galen, Cullen, Ileberden, Morgagni, Laennec, Andral, Bright, Addison, Copeland, Drake, Dickson, Budd, Walshe, Beale, Bowditch, Flint, Stille, Da Costa, and others. Dr. Holden obtained, in answer to circulars of in- quiry, two hundred and fifty replies from leading physicians in different parts of the United States. Of these, one hundred and twenty-six afiirmed their belief that consumption is communica- ble. The judgment of Sir T. Watson is no doubt well expressed ; who, while denying that phthisis is contagious, would still, "for obvious reasons, dissuade the occupation of the same bed, or even the same sleeping apartment, by two persons, one of whom was known to labor under pulmonary consumption." Treatment. — Hygienicmanagementis, decidedly, more important 1 New York Medical Record, 1873. 2 Dr. MacCormac, of Belfast, has rendered service to the profession hy especially en- forcing this. Dr. Bowditch, of Boston, U. S., and Dr. Buchanan, in England, have like- wise shown the great importance of dampness of situation as a promotive cause of phthisis. 3 On Consumption and Bronchitis, London, 1866. i Brit. Med. Journal, Aug. 31, 1873. fi Amer. Journal of Med. Sciences, April, 1878, p. 426. 6 Ihid., July, 1878, p. 14.5. PHTHISIS PUI.MONALIS. 233 to the consumptive than mctlicine. The following precepts are well laid down by Dr. B. W. llichardson : — 1. A supply of pure and fresh air for respiration is constantly required hy the tuberculous patient. 2. Daily exercise in the open air is impcrativelj^ demanded by the tuberculous patient. 3. It is important to secure for the patient a uniform, sheltered, temperate, and mild climate to live in, with a temperature about 00° and a range of not more than 10° or 15° ; where, also, the soil is dry and the drinking-water pure and not hard. 4. The dress of the tuberculous patient ought to be of such a kind as to equalize and retain the temperature of the body. 5. The hours of rest should extend from sunset to sunrise. G. Indoor or sedentary occupation must be suspended ; but out- door employment in the fresh air, even in the midst of snow, has been and may be advantageous. 7. Cleanliness of l)ody is a special point to be attended to in the hygienic treatment of tuberculosis. 8. Marriage of consumptive females, for the sake of arresting the disease by pregnancy, is morally wrong and physically mis- chievous. Dr. Hermann Weber asserts, upon experience, that prolonged residence in elevated localities is curative of phthisis. Altogether, the analeptic principle is now universally adopted for the treatment of consumption. The diet must be nourishing ; a "generous" regimen; and tlie same indication is to be followed in the employment of medicines. There has been discovered, as yet, no specific to arrest tubercu- losis. But cod-liver oil and alcohol, and, in lesser potency, iron, quinine, and other tonics, in a certain number of cases do mani- fest an important conservative and restorative influence ; and palliation of symptoms, as pain, cough, loss of rest, may greatly help the comfort of the patient. My confidence in the frequent value of cod-liver oil is based chiefly upon observation. Three individuals in one family, for example, under my care, notwith- standing a well-marked family tendency (shown by the previous death by phthisis of three sisters, their mother, and uncle), recovered from incipient consumption under the use of the oil. Other cases, much more commonly, have life prolonged by it. Unfortunately, however, in quite a considerable number of per- sons the stomach turns against cod-liver oil. When that is the case, it is in vain to urge it. It may be taken in the froth of porter or ale, or after rinsing the mouth with brandy, which may also follow it. Some dislike it less when saltecl. Ammonia added to the oil lessens its taste ; but I have not tried the com- bination extensively. Addition of ■walnut (or other) catsup ^ will disguise its taste quite effectively. The gelatinous capsules make it much less disagreeable to swallow; but less than two or three table spoonfuls of the oil daily will hardly suflice. It can always be taken best in cold weather [F. 30, 31, 32]. Dr. B. W. Foster, on theoretical grounds, has proposed the addition of 1 Pharmaceutical Journal, 18SI. 20* 234 DISEASES OF OEGANS OF RESPIRATION. etlier to cod-liver oil, to promote its digestion by the pancreatic secretion. Dr. Van den Corput, of Brussels' gives, with asserted advantage, boluses of cod-liver oil saponified by hydrate of lime. A bitter tincture, as of bark (Huxham's), columbo, or gentian, will lessen the disagreeableness of the oil, while adding to its tonic effect. Carre, Lemoine, and Bouchut have found^ cod-liver oil bread very available, especially for children. Every pound of bread may contain about five tablespoonfuls of oil, and six spoon- fuls of milk. The taste is said to be thus very much disguised. Alcohol, though variouslj'^ estimated by different physicians, is, in my view, well established as a remedial or at all events a sup- porting agent of value in consumption. ISTot to be used in excess, nor ever to produce excitement in any degree ; but simply as a roborant ; an addition to the diet and a supporter of the strength of the invalid. The dose must, therefore, be proportioned toliis condition ; and it ought usually to be small. Whisky is preferred by many ; but ale, lager beer, and wine suit different patients best. A little, two or three times daily, will be much better than a full drink at one time. I would always begin with very small quantities — say two or three teaspoonfuls of whisky, or half a glass or even less of wine, or half a tum- blerful of ale or beer. To do good, the stimulant should not quicken the pulse^ flush the face, or be felt to affect the head. Kept under such restrictions, even when increased to meet great pros- tration, I have never known any hankering after excess to be caused by it. One patient of mine, with phthisis, would some- times, when temporarily much reduced, take more than half a pint of whisky daily for a time ; and then as his strength rallied, would diminish the amount to almost none, without any difficulty or longing for more. "VVe have heard of advantage accruing from the "raw beef and brandy " treatment for consumption ; but I am doubtful of its possessing any very special virtue.^ When it can be done, alcoholic stimulus is best given with nourishment, as in milk, or beaten up with a raw egg, etc. Koumiss, a fermented drink, made from mare's or cow's milk, is a popular remedy of the Tartars, adopted to some extent by the Russian physicians. Beef-tea, as a concentrated nutrient, is very useful when digestive power is low, at any stage of phthisis. One lady under my care, who, with tussieula, heemoptysis, and emaciation, had greatly the appearance of incipient consumption, and who could not retain cod-liver oil upon her stomach without loss of appetite, was put upon the daily use of a pint of strong beef-tea,* for several weeks together, with no medicine but a mild expectorant. She recovered, and has since married and become a mother. 1 Med. Times and Gazette, Nov. 26, 1870. 2 Bulletin de Therapeut., 1873. 3 The possibility of parasites being taken into the body with raw beef is exemplified by a case reported by Dr. Leidy, in which taenia mediocaneliata was evidently thus introduced. 4 The mode of preparation of beef-tea is not unimportant. I prefer the following: Cut up a pound of good lean beef into small pieces, pour upon it half a pint or a piut of cold water, and let it stand two hours beside the fire. Then boil it 20 minutes or half an hour. Take otf all the scum and oil-drops, carefully ; but do not filter or strain it unless through a coarse sieve. It should have a rich brown color; and with salt is agreeable to the taste. PHTHISIS PULMONALIS. 235 The phosphates and hypophosphitos of calcium, etc., have been suHicieiitly ti-icd to prove tlieir inferiority to cod-liver oil. My own experience with them, in the wards of the Episcopal Hos- pital in this city, as well' as in private practice, has been dis- couragin<,r ; and I believe the best phosphate for analeptic use to be phosphate of iron. Dr. Henry lilanc {Lmuxt, June 13, 1874) insists on the value of the phosphate of calcium, given at the same time with the juice of raw meat ; the phosphate being always taken at meal times. Chlorate of potassium has, I think, failed under fair trial, although a few (as Dr. E. J. Fountain, of Iowa) still confide in it. Glycerin will not take the place of cod- liver oil ; nor has any oil been shown to be capable of doing so. Ilrrard and Sankey have used arsenic in small doses ; Dr. Mou- tard-Martin' considers it a valuable remedy in phthisis. Dr. \V. M. Logan, of Cincinnati, reports'* the recovery of ten out of twenty-four cases, treated with thirty or forty drop doses of nitric acid (after meals) along with tincture of chloride of iron ; besides hygienic measures, and in some cases,cod-liver oil. Drs. Blacque, of ^Paris, and Griffith and Milton' of Bradford, Pa., assert the cure of a number of cases under the use of crude j)etroleum (dose 3 or 4 drops). Dr. Inman, of Liverpool, and others, recommend frequent wimction witli oil. In 1879, henzoate of sodium was urged, especially in Germany (Kroczak, Klebs), as a valuable medicine in phthisis, when used by inhalation. Conflicting evidence, however, soon threw its usefulness into great doubt ; as may be expected with regard to any special "remedy " for such a disease. Maltine, or Malt Extract, is largely used in some German hos- pitals, instead of cod-liver oil ; and a number of American prac- titioners place a high value on it. It remains, I think, to be proved that it can compare favorably with cod-liver oil as a recuperant. Where expectoration is copious and fluid, I believe creasote, internally given, to be a useful medicine. Bouchard and Gim- bert* found it to exert an evidently beneficial influence in 54 cases out of 93. It increases the appetite, and probably tends to retard the softening process in the lungs. It may be given in cod-liver oil, — with an aromatic or bitter tonic, as comp. tinct. of gentian. Iron, especially the iodide [F. 33] and the tincture of the chlo- ride, are frequently suitable ; and so may be quinine, nux vomica [F. 34], or the simple bitter tonics. But the patient must not be worried and disgusted with much medicine,* whatever depresses ai^petite is likely to do more harm than good. For this reason, expectorants require discretion in their use. Those of a nauseous kind must be very sparingly prescribed in phthisis. The syrup or fluid extract of wild cherry [F. 35, 36] is one of the most suitable. Squills will do when loosening 1 Bulletin General Therapeutique, Nov. 15, 1868. 2 Consumption : its Pathology and Treatment; Philadelphia, 1871. 3 N. Y. Med. Kecord, July 2, 1881, Consumption is said to be rare in the oil region of Pennsylvania. ^ Gazette Hebdomadaire, Nos. 31 and 33, 1877. 236 DISEASES OF ORGANS OF RESPIRATION. effect is particularly required. Ipecac and tartar emetic are too depressing to the stomach for the consumptive. Sometimes, at a late stage, carbonate of ammonium will be useful as a stimulant. Anodynes and calmatives are almost always wanted as the case advances, to soothe the wearisome cough, and to give rest at night. Lactucarium, hyoscyamus, hydrate of chloral, and finally opium, or morphia, in some form, will be important sources of comfort to the patient, and may economize his strength. Mazza recommends cyanide of potassium in small doses. Hsemoptysis, when not large in amount, requires only quiet- ness, for the time, with little or no special medical treatment. Should much blood be raised, the patient ought to be kept in bed, with the shoulders somewhat raised ; and only iced milk and beef essence, or beef-tea, should be given for food. Gallic acid, in ten grain doses every two or three hours, will then be an available styptic medicine. Ergot, however, is preferred by many (Anstie). The poiDular remedy of holding salt in the mouth may be of some temporary use in hemorrhage. Slowly melting and swal- lowing ice will probably do more good. If nervous disquietude exist, it may be allayed by an opiate at night. The colliquative sweats seldom demand treatment, they being the result rather than the cause of debility. Oxide of zinc has been much used for them. Belladonna is found (Frantzel) ^ to reduce the amount of perspiration. Atropia (S. Ringer) prob- ably has the greatest control over it of all drugs. Ablution with brandy or whisky and alum may be practised if sweating is very excessive. Diarrhoea may require to be held in check, by simi^le astringents and opiates, especially in enemata. If pleurisy or peritonitis supervene as a complication, the local inflammation must be treated in view of the general condition. Depletion is out of the question at an advanced stage. Dry cups, small blisters, and opium are all that we can use in the treatment. For the variable pains in the chest in the course of the disease, mild or moderate counter-irritation, by warming or belladonna plasters, tincture of iodine, or croton oil, may be used. It is not, however, to be said that the name or character of phthisis should in all cases rule out local depletion in the incipient stage. In one of three cases in a family (already alluded to) who recovered, notwithstanding a strong inherited tendency to consumption, from a condition threatening it, a great relief and improvement followed the early application of two dozen leeches to the side ; it was (to borrow an expression of Dr. Condie's) at the time an acute tuberculous pneumonia. Yet such cases are exceptional. The pervading indications in phthisis are economy and recuperation. Niemeyer's suggestion that the identification of phthisis with caseous pneumonia should lead us to put all con- sumptives, in the early febrile stage, to bed, and bleed or cup them, could not be approved as a rule of practice, even if his pathological views should be accepted. 1 Virchow's Arehiv, Ixviii. 1. PHTHISIS PULMONALIS. 287 Inhaldtinn has often been tried in phthisis. Not onnmorating agents which liave siuninarily failed, I believe that tlie best hope attaches, in this way, to inhalation of the vapor of on^asote or of carbolic acid. These agents-are styptic, and by coagulating albu- men and all)uniinoid material maybe expected to aid in arresting the softening and destructive process in the lung. At least, we might hope that this would (Cursclimann has found it to do so) lessen excessive and exhausting expectoration. Dr. Marcet' I'cports favorably of the use, by inhalation, of carbolic acid, one or two grains to the ounce of water. Dr. G. II. Ma(;kenzie'' has recorded excellent eflects produced in a marked case by the con- tinuoiis inhalation of creasote ; great diminution of expectora- tion resulting, with abolition of the night-sweats, and improve- ment in appetite and strength. Dr. Cheron'* asserts the value, especially in slowly progressing cases, of inhalation of the vapors of oxygenated essences ; as that of the laums camphnrm^ cedar, chamomile and eucalyptus. Oxygen is given by inhalation in the practice of some physicians ; and so have been conqjressed air and very dilute nitrous oxide gas. I have no positive knowledge of their results. Transfusion of lamh''s Wood has been tried in Germany, with doubtful advantage.'^ Assistant Surgeon Wood, U. S. A., has reported a case of recovery following transfusion of four ounces of human blood. Injection of a pulmonary cavity with alterative solutions (as tincture of iodine, carbolic acid, permanganate of potassium) has been proved, by Berkart, Koch, Mosler, Thomp- son, W. Pepper,^ and others, to be safe, if a hollow needle (Dieulafoy's) or capillary trocar and canula be used; and, in some instances, the effects have appeared to be beneficial. Jn cases manifestly progressing towards death, such a practice seems worthy of trial ; with the hope of promoting the cicatrization of cavities. Dr. J. H. Hutchinson has shown {Phila. Med. Times, Ma}'^ 30, 1874) that even Hippocrates recommeuded puncture of the chest in phthisis ; the idea of it being revived by Baglivi (1723) and Ramadge (1836). Hastings and Stork practised it about 1845. Prof. J. H. Bennett {Reynolds'' s System of Medicine, article. Phthisis) asserts that, as might have been expected from the nature of the disease, such measures have uniformly and totally failed. Change of climate is often proposed for the benefit of the con- sumptive. In an early, or middle, or even a stationary advanced stage, it may be of important advantage. When to forbid, or advise it, may be a very delicate question. More will depend upon the rate of progress than upon the period of the case. But the patient must have strength enough to travel, and must be not too dependent upon his home comforts, or he may be made worse instead of better. It is cruelty to banish one who is already on the verge of the grave to die in a strange place among strangers. Yet I have known life to be prolonged from 1 Practitioner, November, 18G8. 2 Lancet, May 14, 1881. 3 Gaz5 Similar observations have been made concerning cases occurring amongst soldiers (as at the Hospital at Nctley, England). But it is very improbable that any such i)redominance of this mode of causation exists in ordinary civil life. The following points may be added in regard to its clinical his- tory (see Stokes on the Heart and Aorta) :— 1. The effects of the aneurismal pressure may vary from time to time ; much more thfin they do in cancer. 2. The aneurismal impulse may be even stronger than that of the heart ; but a feeble impulse in some instances attends a large aneurism, 3. Destruction of one or more vertebra; from absorption under pressure (as shown by autopsy) is not uncommon. 4. Phthisis is often associated with aneurism of the aorta. ABDOMINAL AOETIC ANEURISM. Of this, the signs and symptoms are — deep-seated severe pain (occasionally intermitting) in the back and abdomen, increased by certain movements ; unaccompanied by fever, but resisting all treatment ; later, muscular spasms of the lower limbs, displace- ment of the liver, and the manifestation of a pulsating abdominal tumor, felt upon palpation, over which there is dulness of reso- nance upon i^ercussion. The higher up the aneurism, the more severe are the pains and other symptoms of disturbance. Aneurism of the aorta may, without careful examination, be confounded with aortic pulsation v/ithout tumor (common in dys- pepsia, etc.), or with neuralgia, rheumatism of the bowels, colic, worms, disease of the liver, caries of the spine, psoas abscess, or cancer. Only the discovery of a distinctly puhating tumor ^i<^« 95. (not a tumor moved by subjacent pulsation) can establish the pres- ence of aneurismal disease. An additional sign of value is a local- ized "bruit" or aortic murmur heard along the course of the spine.' The treatment of either thora- cic or abdominal aortic aneurism is usually not hopeful. Hi/gienic measures maj' retard decline, and careful self-management may avert a sudden catastrophe ; that is mostly all. Exertion and ex- citement must, of course, be pro- hibited altogether. Dr. Sibson urges the importance of limiting the amount of fluid taken by the patient, to a pint daily ; in order to lessen the volume of the blood, Aortic Aneurism, and thus reduce the pressure upon the sac. Tufnell insisted upon entire rest, with low diet, for mouths together. The medicine most in favor for aneurism 1 W. Moore, iu Dublin Quarterly Journal of Medicine, August, 1869. 256 DISEASES OF ORGANS OF CIRCULATION. of the aorta with leading practitioners is iodide of potassium (ISTelaton, Balfour). Excellent effects are ascribed to it in a number of reported cases. Electro-puncture (Ciniselli, 1846) has succeeded, in a few instan- ces, in curing, and in a greater number, temporarily relieving, aneurism of the thoracic aorta. It is applicable only to cases in which the aneurism approaches closely to the wall of the thorax. It may then be performed without danger. Petit ^ advises not delaying it (after other treatment has failed) until an external tumescence has formed ; statistics showing the best results when that event has been anticipated. For galvano-puncture, a battery of moderate intensity may be employed. Two sharp needles of platinum, steel, or soft iron are prepared by coating them, except the points, with gutta-percha, varnish, or gum. Many practitioners'^ connect one needle with the positive, and the other with the negative, pole of the battery. Dujardin-Beaumetz,^ Dreschfeld,* and others, prefer to attach them only to the positive pole ; the circuit being completed by connecting the negative pole with a metallic plate or moistened sponge applied either near the aneurism or on another part of the body. Pain may be dimin- ished by freezing the sMn over the aneurism, with pounded ice or ether spray. Then the needles may be plunged into the tumor, and the electrical current may be gradually increased, and continued for twenty or thirty minutes at a time. The operation may be repeated after an interval of weeks or months. The prevailing theory of the beneficial action of electricity is that it produces or promotes coagulation of blood within the aneurismal sac. Petit ^ has collected 114 cases of galvano-puncture for thoracic aneurism, in which amelioration was effected in 69 instances. In 61 cases more or less aggravation of the symptoms resulted. The greater number of patients obtained by its means relief or diminution of pain and dyspnoea, with increase of appetite and ability to sleep. While scarcely any actual cures seem to have been effected by this method of treatment, the amount of bene- fit appears to be quite sufficient to justify it in cases which con- tinue to grow worse, notwithstanding the employment of iodide of potassium and rest through a long period. Dr. Headland Greenhow reports'* the entire cure of a case occurring in an able-bodied seaman, aged 28, by pressure (con- tinued, at intervals, for three or four hours at a time) with Lis- ter's tourniquet upon the aorta above the tumor. Drs. Murray, Moxon, and Durham (in 1864 and 1872) have reported two other successful cases, under the same treatment. Dr. S. P. Speer had two recoveries under gallic acid internally, with iron.' AOETIC STENOSIS. This term, meaning contraction of the aorta, applies strictly to cases of very rare occurrence, unless amongst still-born children, iL'Union Medicale, Aug. 1, 1880. 2 Pepper, N. Y. Med. Record, Nov. 13, 1880. 3 Bulletin Gen. de Therapeutique, July 15, 1880. ' 4 Lancet, Oct. 12, 1878. 5 L'Union Medicale, Aug. 21, 1880. 6 British Med. Journ., June 14, 1873. ? Med. and Surg. Reporter, March 28, 1874. STOMATITIS. 257 or those dying early in life. Occasionally, however, instances are met with, cspccisilly in subjects under age, presenting the following signs : a murmur in t!ic aortic region, and extending from this more or less distinctly over the chest ; feehleness or absence of pulsation in the arteries of the lower extremities ; imperfect growth of the extremities and of the genital organs ; dilatation of the intercostal and other superficial arteries ; ten- dency to passive congestions, for instance, of the hands, feet, lips, and ears. Such persons are not likely to attain to long life ; but examyjles have been known of their surviving for a number of years after the evidences of this malformation liave been discovered.' The oriijin of aortic stenosis may be a simple defect of develop- ment ; or the organization of a c?oi, or thrombus, during foetal or infantile life ; or an ivflammation of the aorta, followed by its constriction, or partial obstruction by bands of lymph. No treatment can exert any influence upon a true aortic steno- sis. Warning must be given to the patient that his constitution unfits him for great or sudden exertion, or strong excitement. AFFECTIONS OF THE ORGANS OF DIGESTION. STOMATITIS. Defillition. — Inflammatory disease of the mouth. Varieties. — 1. Simple stomatitis. 2. Aphtha. 3. Thrush. 4. Inflamed ulcer or canerum oris. .5. Gangrene of the mouth. 6. Mercurial sore mouth or salivation. 7. Nursing sore mouth. 8. Scorbutic disease of the mouth. Simple Stomatitis.— From taking very hot or corrosive liquids into the mouth, it may become inflamed ; this condition being shown by redness, swelling, soreness and heat of the tongue, gums, lining membrane of the cheeks, palate, and fauces. Cor- rosives (as sulphuric acid or creasote) may whiten the mucous membrane superficially. The course of such an affection is generally simple and brief- recovering in a few days under mild treatment. Glossitis, how- ever, or inflammation of the tongue, may be more obstinate and serious. I have seen the tongue so swollen as to protrude from the mouth for more than a week, too large to return. Slight ulcerations and fissures often occur in simple stomatitis, increasing the soreness and pain ; and increase in the flow of saliva is common. Treatment. — In the beginning, holding ice, iced gum-water or flaxseed-tea frequently in the mouth, or, if a corrosive agent be the cause, almond oil or dilute glycerin [F. .50], will soothe the irritation. In violent glossitis, leeches may be applied to the swollen tongue ; even free incisions may be called for to relieve its swelling ; later, solution of alum (5ij in f^vj of water) or sul- phate of zinc (gr. j in fgj) may be used as a wash. Remember that such articles ought not to remain in contact with the teeth, the enamel of which they may impair. 1 r:. F. lugalls, N. Y. Med. Record, Sept. 4, 1880, p. 255. 258 DISEASES OF ORGANS OF DIGESTION. Follicular iiiflainmation of the mouth is recognized by small red elevations over the tongue, soft palate, etc. This is common in infants during dentition ; as well as in adults of deficient gen- eral health. It requires no specialty of treatment. Aphthae, — These are small ulcers, with whitish surfaces, follow- ing a vesicular eruptive inflammation of the mouth. The ves- icles are small, round or oval, of a pearly appearance, and con- tain serum.' They break in a few days, leaving a sore white ulcer, with redness around it. They may be scattered or con- fluent. Fever may attend the latter, with disorder of the stomach. Though not common in the earliest infancy, children sometimes liave this disease, but less often than adults. Decaj'ed teeth may produce it. On the whole, it is to be considered rare. Its duration is generally a week or two, but confluent cases may last a month, and have occasionally been fatal. Treatment. — The constitutional condition may require cooling laxatives or saline diaphoretics, and gastric irritation may call for antacids, as bicarbonate of sodium or magnesium. Chlorate of potassium should be given, 5 to 20 grains four times daily. Locally, at first, flaxseed tea or gum-water, or a solution of glycerin in rose-water, may be frequently applied. When ulcera- tion occurs, a powder, consisting of equal parts of prepared chalk and pulverized gum arable [F. 51], may be dusted or laid over each of the ulcers, several times a day. Some prefer a mixture of glycerin and prepared chalk, of the consistence of a soft paste. A wash of borax, myrrh [F. 52] , alum, sulphate of zinc [F. 53], or acetate of lead, may also be applied. If the ulcer prove severe or obstinate, strong solutions of sulphate of zinc (15 grs. in fgj of water) or nitrate of silver (20 grs. in foj), or solid sulphate of copper, may be used to toudh the ulcerated surface every day or two. Thrush: Muguet. — This is much more frequent in infancy. Its peculiarity is, the occurrence, after a day or two of diffused inflammation, of a number of small whitish points within the mouth, which coalesce and form patches of a whitish curd-like exudation (often confounded with aphthce). In bad cases it may become brownish. This may fall off and be renewed, more than once. The mouth is hot, the stomach disordered ; vomiting and diarrhoea may occur, with some fever. The attack lasts from one to two or three or more weeks ; being seldom dangerous except in children otherwise in poor health. It sometimes attacks adults. Nature. — The specific nature of the curd-like exudation appears to be connected with a microphytic (minute vegetative) growth, to which the name of oidium albicans has been given. Treatment. — Experience favors the internal administration of chlorate of potassium [F. 54] in all severe forms of sore mouth. In the absence of a rationale by which its special applications might be definable, I would employ it in thrush as well as in aphthae, etc, A child under five years of age may take from one to five grains of the chlorate, in solution, several times daily. iDr. J. Worms asserts the discharge of aphthous vesicles and ulcers to he sebaceous. He, therefore, regards apbthse as a sort of acne of the mucous membrane. STOMATITIS. 259 As a laxative, magnesia wiJl be suitable. Feeble cases may require quinine, beef-tea, whisky and milk, in quantities propor- tioned to condition and age. Locally, at first, we may use flaxseed or gum arable emulsion — then glycerin and rose-water (one part to four or five), borax in solution ("2 drachms in 4 ounces) or in powder, equal parts witli sugar— and later, tincture of myrrh in water (fS^s in fgij), alum in solution, or sulphate of zinc, or muriatic acid with honey and water (acid, hydrochlor. ^j, mellis velsyrupi f5J, aquai fgij) ; the latter being applied carefully with a camel's-hair pencil, occa- sionally. Cancrum Oris.— Canker of the mouth is characteristically ulcer- ative, from the commencement. It begins on the cheeks, gums, or lining of the lips ; but may reach the fauces. The ulcer is grayish or j^ellowish-white, with an inflamed border and environs ; the cheek may swell from it externally. It is quite painful. Saliva flows freely, and the odor of the breath is offensive. Fever is often present. The complaint may last for several weeks or even months ; but it is almost never fatal. It is most common in children, from two to six years of age. Treatment. — Besides general measures, adapted to the condition ofthejjdtient, the same local applications, mentioned as appropriate in dificrent forms of sore mouth, may be used. Direct touching of the ulcer with a strong solution of sulphate of zinc (gr. xv vel XX in fgj), or with the solid bluestone (sulphate of copper) twice daily, will do the most for its cure ; especially with the interme- diate " dressing" of powdered chalk and gum arable, and occa- sional washing with glycerin and rose-water. Gangraena Oris. — Extreme inflammation or ulceration, in the mouth as elsewhere, may end in gangrene ; but this affection is peculiar, and may be unconnected with any severe inflammation. A morbid state of the system seems to predispose to it. It occurs mostly in children, but has been met with in adults. There is, at first, an ash-colored ulcer, most often on the gums, or inside of the cheek. If the latter, it is accompanied by swelling. Spreading, it assumes a sloughing character ; the breath grows fetid ; acrid fluid is discharged, with copious salivation ; other ulcerations are formed, the bones of the face are affected with necrosis, and the teeth fall out. Penetrating the cheek, mortifi- cation may go on rapidly, reaching sometimes even the ethmoid bone. Low fever and prostration attend these local changes ; later, diarrhcea, colliquative perspirations, and death. The only well-marked promotive causes of this very serious disease are, bad air (especially crowd-poison) and insufficiency of food. When treated early, it is often quite manageable ; but after extensive sloughing has occurred, the prognosis is bad. Treatment. — Early, I should always try the chlorate of potas- sium. Quinine and tincture of chloride of iron [F. 56] will be re- quired on account of the tendency to prostration. Beef-tea and wine whey, or brandy or whisky punch, pro re nata, are called for, by the same indication. To the part, at first, the astringent lotions, mentioned already, may be applied. When the gangrenous condition becomes pro- 260 DISEASES OF OEGANS OF DIGESTION. nounced, a solution of liquor sodse chlorinat. in glycerin (f^j in fgij) may be applied frequently. Solution of ereasote in glycerin, or in water (gtt. iij togtt. xx infgj) may meet the same purpose ; or permanganate of potassium (gr. x in fgj) ; or chloride of zinc (gr. j in fgj) ; or sulphite of sodium (5j in fgj) ; or bromine (5ss in fgij). Mercurial Sore Month. — Salivation is made known in its approach, by a " coppery " taste, soreness of the gums, tender- ness of the teeth when pressed together, with redness and swell- ing of the gums, and a broad white line just beyond their edge. The tongue also may swell. The flow of saliva increases greatly ; the cheeks and even throat may grow sore and painful ; the breath offensive. Ulceration of the gums takes place in severe cases, with loss of the teeth. Even sloughing may follow, approaching the state of things in gangrcena oris. Difficulty of swallowing may be so great as to threaten starvation ; and irri- tative fever may result from the local disorder. Treatment. — Moderate salivation will always pass away in a few days, spontaneously. A good mouth-wash for it is brandy or whisky and water, one part of the former to four of the latter ; alum may be added to it [F. 59] , or a little tincture of myrrh. Ulcers or sloughs should be treated as in other varieties of stomatitis. Opium may be called for, at least at night (e. g. , Dover's powder 10 grains at bedtime), by the distress of the system. Milk diet, or some other liquid nourishment, must be given during the diffi- culty of deglutition. In good practice, at the present day, no physician ever seriously salivates a patient. BTurses' Sore Moutli. — Women who suckle children, and some- times those who are advanced in pregnancy, are liable to ulcera- tive stomatitis. It begins with small, hard, painful swellings on the tongue and cheeks, which ulcerate and are attended by a great deal of local, and sometimes constitutional irritation. When the infant is weaned, the affection subsides soon. Treatment. — Chlorate of potassium has in this complaint a spe- cial curative power. 20 grains of it may be given three or four times daily. Iron, quinine, etc., and full nourishment, may be required in subjects of obvious debility. Local treatment, such as has been given for cancrum oris, etc., will also have its utility. Scorhutic mouth affection will be dealt with in another part of the book — under Scurvy. TONSILLITIS. When severe, this is commonly known as quinsy. Soreness of the throat in swallowing, with pain or swelling of one or both tonsils, and fever, are its symptoms. Unless relieved in a few days, the pain becomes very constant and throbbing, dysphagia is extreme, and, when the patient begins to be seriously alarmed, a tonsillar abscess breaks or is o^Dened by the physician, and recovery soon follows. In a very few instances, bleeding after the incision (or after excision of the gland) without wounding the artery, has been troublesome, and even dangerous to life. We PHARYNGITIS. 261 must supposo hrvmnpMlia (constitutional predisposition to hem- orrhage) to account for sucli events. Treatment. — A dose of citrate or sulphate of magnesium, or other cooling aperient, should be given the first day. Then, wine of ipecac, twenty drops every three hours, with frequent draughts of flaxseed tea or flaxseed lemonade. If the swelling, heat, and pain of the throat are great, ai)pl}^ (in an adult j from 20 to 30 American leeches to it. Then, or instead, in mild cases or feeble subjects, poultice with flaxseed meal, to which lard and laudanum have been added ; bathing, when the poultice is changed, with liniment of ammonia, or soap liniment to which aqua ammonite has been added. If still severe, and not certainly suppurating, a small blister may be applied, or the part may be painted with tincture of iodine. When an abscess is evidently forming, poul- tices will be better, until it is ready to open from within. Lancing the suppurated tonsil requires care not to wound the internal carotid artery. The point of the lancet should be directed towards the middle, not to the outside of the throat. ISTot unfrequently, especially in children, repeated attacks of non-suppurating inflammation of the tonsils will leave them incon- veniently enlarged. Sometimes persevering use of astringent gar- gles, or touching daily with strong solution of tannin or nitrate of silver, will make them shrink to the normal size. If not, excision of a part of the tonsil may be proper. With Fahnestock's, or any other guillotining instrument, the operation is easy and safe ; at all events, if it be not attempted to remove the whole gland, which is not necessary. Should hemorrhage occur, it may be suppressed by applying to the part, on the end of a short stick, a pad of lint which has been soaked in solution of persulphate, or tincture of perchloride, of iron ; aided by the application of ice to the outside of the thi'oat.' Ehrmann has reported a case in which (without any operation) the spontaneous rupture of a tonsillar abscess was followed by hemorrhage so severe as to require ligature of the carotid artery.^ PHARYNGITIS. Slight sore throat is among the commonest of affections, requir- ing for its treatment only mild gargles (as alum in flaxseed or sage tea), demulcents (flaxseed or gum arabic or slippery elm infusion), or laudanum and water, one part to eight, fomentation with vola- tile liniment or spirits of turpentine, and a dose of some saline cathartic, with slo2) diet. With children who cannot gargle, finely powdered alum may be blown into the fauces and throat, through a tube or quill, more readily than in any other way. Chronic pharyngitis is often a much more troublesome, though not dangerous disorder. The mucous membrane becomes perma- nently hypersemic, almost granulated ; with either abnormal dry- ness or a thickened secretion ; and constant soreness. In the treatment of this, all the difterent astringent, demulcent, and alterative applications may be tried — sometimes with little suc- 1 Lidon reports a case where, from abnormal tendency to bleeding, the hemorrhage obliged him to tie the carotid artery. This must be a very rare accident. 2 Centralblatt fur Chirurg., No. 34, 1379. 262 DISEASES OF ORGANS OF DIGESTION. cess. When nitrate of silver, tannin [F. 60] , sulphuric and mu- riatic acids, sulphate of zinc and acetate of lead have been found to fail, it may happen that ice, or gargling frequently with ice- water, will prove more useful. Counter-irritation, with repeated small blisters, tincture of iodine, or croton-oil, is always a suitable and important part of the treatment of chronic inflammation of the throat. Ulcerated Sore-throat. — This may be idiopathic, syphilitic, or tuberculous. The second is most common. The treatment in the first variety consists in the local applica- tion of bluestone or, lightly touched, solid nitrate of silver to the ulcers, if within reach. The syphilitic will require also iodide of potassium [F. 61] internally (gr. v velxter die); the tuberculous, tonics, generous diet, and cod-liver oil. Iodoform, in powder (applied with a moistened camel's-hair pencil), is an excellent local detergent and alterative for ulcerated sore throat. RETEOPHARYNGEAL ABSCESS. This most often follows fever as a sequela ; but it is altogether rare ; least so in children, in whom, however, it is liable to be overlooked. Of 144 cases reported by Bokai, of Pesth, 134 occurred under four j^ears of age. Of these, 32 were scrofulous, and 10 rachitic. The affection is shown to the careful observer by dysphagia and dyspncBa, much increased by the recumbent posture ; yet not, as in croup, increasing rapidly from day to day, or disappearing in a short time. There is also stiffness of the neck, and swelling on one or both sides of it. In such circum- stances a finger passed over the tongue into the pharynx may find a firm projecting tumor occupying its posterior and lateral walls. It may prove fatal by asphyxia, or by preventing the patient from swallowing food. When diagnosticated in time, the matter may be let out by opening the abscess with a lancet through the pharyngeal wall. In an adult, a trocar will be safer, the head being rapidly bent forward after the operation, to pre- vent suffocation by the discharge suddenly entering the air-pass- ages in breathing.^ If there be doubt as to the nature of the tumor, aspiration (Dieulafoy) will aid the diagnosis. . STRICTURE OF THE (ESOPHAGUS. This is uncommon. Its principal causes are, if structural, cor- rosive poisons, swallowed ; or ulceration of the throat, involving the oesophagus, and contracting upon cicatrization. Functional stricture may be spasmodic, as in hysteria. Dysphagia, not other- wise accounted for, and obviously low down in its seat, or the rejection of food partly swallowed, may lead to a suspicion of stricture ; and examination with a bougie will fix the diagnosis. For the structural affection I know of no appropriate treatment except dilatation with bougies made for the purpose, applied for a short period, oiled, once or more daily. Elias,^ in one case, suc- cessfuUyperformedgastrotomy ; making anartificial gastric fistula. 1 Aberlin, Schmidt's Jabrbucher, No. 5, 1872, 2 Deutsche Med. Wochens., No. 25, 1880. GASTRITIS. 263 GASTRITIS. Simple gastritis, in ah acute form, is very rare. I have mot ■with but one case of it, in a woman who was kicked over the stomach by her husband. Corrosive poisons almost always in- volve the intestinal tube with the stomach. The most common form of "idiopathic" r^astric inflammation is "gastro-hepatic catarrh, " or "a biUous attack, " in which the stomach, duodenum, and liver are all somewhat involved. Signs of stomachic inflammation are, epigastric pain and ten- derness on pressure, rejection of all food and drink, jactitation, and fever ; the pulse, however, being kept down by the impres- sion made upon the circulation by constant nausea. Post-mortem evidences of gastritis are — redness, browner or deeper and more livid than natural, and dotted, stellated, or arborescent, rather than difiused ; moreover, not confined to dependent parts ; enlargement of blood-vessels ; in acute cases, softening of the mucous membrane ; in more lengthened ones, either softening or hardening and thickening ; abundance of thickened mucus ; rarely, coagulable lymph ; almost never, pus. Gastro-hepatic catarrh (Chambers) may follow any of the causes of indigestion, or exposure to cold and wet. There is nausea, or vomiting of greenish-yellow fluid, generally not copi- ous, but very acrid ; headache and dizziness ; constipation of the bowels, and fever. In the treatment of this, magnesia is a good quieting stomachic and cathartic ; many patients will be relieved as soon by a bottle of solution of citrate of magnesium. Ice, melted in the mouth and swallowed slowly, will give com- fort. Rest and abstinence from food as nearly as possible may, with the above, generally complete the cure in two or three, or not mau}^ more days. The best preventive or abortive of a "bilious attack" is blue pill^ timely administered. Let the first nausea, constipation, and headache be met by giving at bedtime two or three grains of blue mass in pill (the '■'■lang syne'''' portion was from six to twenty), followed in the morning by a teaspoonful or two of Husband's magnesia. If the bowels are free, bicarbonate of sodium may be better than magnesia ; the eighth part of a teaspoonful at a dose. Chloride of ammonium, in 15 or 20 grain doses, proves the best medicine for some such cases. Sick headache is usually a modification of the above, the sympathetic cephalalgia being especially severe. In some per- sons it is periodic. The treatment above mentioned for gastro- hepatic catarrh, with rest in bed, will be adapted to a majority of cases of it. Oil of turpentine^ in moderate doses, has been said (W. Begbie) to be remedial for it. Dr. Kennion' advises a solu- tion of bisulphide of carbon, applied to the temples or behind the ear, for a short time. Citrate of caffein (3 to 5 grains at a dose) is highly recommended by several practitioners. Acute softening of the stomach is described by a few French and other writers, as a rapidly prostrating and dangerous aftec- tiou in children, sometimes epidemic. Its symptoms are said 1 Brit. Med. Journal, June 13, 1868. 264 DISEASES OF ORGANS OF DIGESTION. to be, at first, those of simple gastritis ; then, with or without diarrhoea, great agitation, prostration, want of sleep, insensibility — and death in one or two weeks from exhaustion. I have never met with any such case. An irregular fever with gastric irrita- tion (gastric fever or infantile remittent) once had a regular place in the nosological catalogue among fevers. It appears to me to be scarcely uniform enough for so special a designation or consideration. Acute dilatation of the stomacli has been reported upon espe- cially by Dr. C. Hilton Pagge.^ It is very rare. Its symptoms are those of severe abdominal disease; particularly, profuse vomiting. As physical signs, we have rapidly increasing, unsym- metrical distention of the abdomen (largest on the left side), and a widely extended tympanitic resonance over the dilated region. In treatment, evacuation of the stomach by aid of the stomach- pump appears to be indicated ; with continued rest to the organ, nourishment being afforded by enemata. Subacute Gastritis of Childreii.— In the older books on medi- cine, and still by a few authors (e. g.. Dr. F. P. Porcher,^ of Charleston, S. C. ), this has been called gastric remittent, or infan- tile remitteyxt fever. Its symptoms are those of irritation of the stomach, with fever, which has a more or less regular daily remission, almost always in the morning. Its treatment requires rest, diet of milk with, lime-water, barley, or rice-water ; mild laxative medicine's ; gentle abdominal counter-irritation, as by spice- plasters ; and refrigerant diaphoretics, such as small doses of sweet spirits of nitre, acetate of ammonium, etc., during the febrile exacerbations. CHEONIC GASTEITIS. "While the same doubt as to the pathological correctness of the name (indicating inflammation) exists in the case of this disease as in other "chronic inflammations" (see General Pathology), an affection of some distinctness of character, commonly called by the above title, is often observed. With the greatest brevity, we may indicate its symptomatology by contrasting it with that of atonic dyspepsia. In Chronic Gastritis. In Atonic Dyspepsia. Much epigastric tenderness. Little orno epigastric tenderness. Pain increased by active exer- Pain not increased by exercise, cise or stimulating food. lessened by stimulating food. Vomiting usually. Vomiting rarely. Eructation of gas rarely. Eructation of gas commonly. Chronic gastritis is apt to be obstinate, but not dangerous to hfe. Treatment. — Counter-irritation over the epigastrium by re- peated vesication, will be useful. Internally, nitrate of silver [P. 62] , in pill, beginning with gr. J, with gr. I of opium, and increas- ing in a few days or a week, gradually rising to 1 gr. thrice daily, with a proportionate quantity of opium, I believe, upon experi- 1 Guy's Hospital Reports, vol. xviii., 1873. s Am. Jour, of Med. Sciences, January, 1881, p. 46. ANTI-EMETIC REMEDIES. 265 ence, to be the most valuable "medicine. Subnitrate of bismuth [F. 03] is for the same condition lauded by some. Most impor- tant is a hland-dk't; lime-water and milk, arrowroot, tapioca, sago, jellies, cracker soaked in ice-water, etc., in small quantities at short intervals. Ice will often quench thirst to better advan- tage, without disturbing the stomach, than water. The skim- hiilk regimen (Karell) may be adapted to some cases of this disease.^ Feeding by the rectum is indispensable in bad cases; beef-tea, defibrinated blood, eggs, milk, arrowroot, fruit, jellies, etc., may be thus administered. ANTI-EMETIC REMEDIES. Yomiting is so frequent and troublesome a symptom, in many diseases besides inflammation of the stomach, as to demand much practical study from the physician. For this reason, though quite in deviation from systematic routine, I here intro- duce an enumeration of the most available medicines used for the relief of the symptom of vomiting — the selection among them depending upon the judgment of the practitioner as to the real cause of that symptom. At the same time it is clear that many of these remedies prove useful for vomiting when produced by very diflerent and almost opposite causes ; the symptom, as such, rationally demanding medication when we are uncertain or in search of its cause. Ice. Cinnamon-water. Lime-water. Infusion of cloves. Mineral water. Hydrocyanic acid. Elfervescing draught. Chloroform. Champagne. Hydrate of chloral. Brandy. Nitrate of silver. Paregoric. Oxide of silver. Solution of morphia. Subnitrate of bismuth. Aromatic spirit of ammonia. Oxalate of cerium. Comp. tinct. of cardamom. Enema of laudanum. Comp. sp. of lavender. Spice poultice. Bicarbonate of potassium. Sinapism. Belladonna plaster. Bicarbonate of sodium. Blister ; surface being dressed Magnesia. with acetate of morphia (gr. Camphor. ij, with gum acacise, gr. x). Calomel, small doses. Ice-bag to the spine. Blue pill. Hypodermic injection of mor- Creasote. pliia. [See F. 64, 65, 66, 67, 68, 69, 70.] For sea-sickness, the ice-bag to the spine is said to be sometimes remedial. In my own experience of this affection, iced efferves- cent (carbonic acid) water has given more relief than anything else. Hydrate of chloral internally, inhalation of nitrite of amyl (C. Clapham, Western Lancet, June, 1876), 3 drops at once, and morphia by hypodermic injection over the epigastrium, are re- ported upon favorably in its treatment. Surgeon Cory, of the Australian Mail S. S. Co., found nearly always successful, a mix- 1 See an article by S. W. Mitchell, M. D., Thiladelphia Med. Times, March 15, 1871. 23 266 DISEASES OF ORGANS OF DIGESTION. ture of bromide of potassium and hydrate of chloral, taken effer- vescing with citrate of magnesium. In the vomiting of pregnancy, bromide of potassium has been found very serviceable. ^ tJLCER OF THE STOMACH, This serious affection is rare after the middle of life. It is most often met with in feeble systems, especially in women, Sirmptoms. — Dull, sickening pain in the stomach, extending to the back, with localized tenderness on pressure. The pain is in- creased by motion, and by food, especially by hot food, or by sugar. Vomiting occurs, not copious, but rather frequent. Vomiting of blood is an important sign ; it is impossible to be certain of the existence of an ulcer in the stomach without it. The amount of blood thrown up at once may be very small. Fig, 96 I'i. »,u{\. Ulcer of Stomach, It is often difficult to diagnosticate gastric ulcer from chronic gastritis, as well as from cancer, caries of the spine and aortic aneu- rism. No hsematemesis, however, is met with in the first, third,'- and last ; and a tumor, at some period, will make known cancer. So will angular deformity demonstrate spinal caries. Perforation, causing peritonitis, and copious hemorrhage, are the most dangerous terminations of gastric ulcer. The signs of the former are, abdominal swelling and diffused pain, with collapse. One instance has been reported (Chiari, Viemifi, 1880) of the rup- ture of a perforating ulcer of the stomach into the left ventricle of the heart. Treatment.— Bland diet is very important. Arrowroot, tapioca. 1 Copeman's method of treatment of the vomiting of pregnancy is, to dilate the cervix uteri by insertion of the index finger. Dr. Baldwin, of Ohio (Ohio Med. Eecorder, Aug., 1879), reports the immediate relief of an obstinate case in this way. _ Dr. J. S. Warren, of New York, has had great success with Fowler's solution of arsenic, in drop doses, upon an empty stomach. 2 Unless (improbably) an aortic aneurism should communicate with the stomach. CANCER OF THE STOMACH. 267 sago, corn-starch, rice, eggs, and linic-walcr and milk arc suital)lc. Beef or mutton tea (concentrated) will be better for feeble patients than solid food. liectal alimentation will sometimes be indispensable, to aflbrd the stomach complete rest. Milk, Fio. 97. eggs, beef- tea, defibrinated blood, &c., will answer; but it is well to add pepsin to such ma- terials, so as to approach gastric digestion as nearly as possible. Nitrate of silver, in pill with opium [F. 02] ; oxide of silver, in 1 or 2 grain doses ; iodoform in one grain pills ; and subni- trate of bismuth, may be given with the hope of promoting cicatrization of the ulcer. Opium alone, in pill, or lauda- num, etc., or conium or bella- donna, as anodynes, when the pain is severe. When hemor- rhage is threatening,^ ice, crea- sote ( ^ drop to 2 dropsl, tannic or gallic acid, acetate of lead, oil of turpentine (small doses), tincture of chloride of iron, ammonio- ferric alum. H3'podermic injection of morphia has been used with advantage, especially to check vomiting, in this affection. Perforating Ulcer of Stomach. CANCER OF THE STOMACH. Seirrhus of the pylorus is the most common form ; occasionally the cardiac orifice is the seat of cancer. It is a frequent form of cancer; of 9118 cases of cancer in Paris in four years, 2303 aftected the stomach. The usual symptoms are pain, in rare in- stances absent or nearly so, often excruciating ; epigastric tender- ness, about in proportion to the pain ; vomiting of food, mucus, and " coftee-grounds," or mixed blood and mucus, almost never pure blood ; acidity or other symptoms of indigestion ; fetid breath ; decided constipation ; emaciation, and cachectic, almost jaundiced, sallowuess of complexion ; sometimes irritative fever. The diagnosis is made nearly certain by the discovery of a tumor ; not absolutely so^as the tumor may be fibroid, and not malig- nant. Cancer of the stomach seldom occurs before forty years of age. Its duration averages about a year ; it seldom reaches two years. The i)atient commonly dies by slow starvation, the stomach be- coming incapable of digesting and transmitting food. No treatment can avail for the cure of such an affection. To nourish by concentrated articles of diet, as beef-tea, milk, etc., and to allay suffering by judicious use of anodynes, will be all that we can do. Kussmaul's method of washing out the stomach daily with a solution of bicarbonate of sodium, may prove an 1 The same remedies may be used with advantage for hsematemesis from other causes. 268 DISEASES OF ORGANS OF DIGESTION. important measure of relief. Dr. J. H. Hutchinson^ has reported a case in which, by this means, vomiting was arrested, and the patient was enabled to take and retain food. Bectal feeding may sometimes be necessary. In 1881, Billroth removed a cancerous pylorus by excision, and the patient recovered.^ Soon afterwards, however, he repeated the operation on two other patients, both of whom died.^ Chloral may be particularly recommended for trial ; as, in some cases of cancer of other parts (uterus, breast, etc.), Drs. C. Paul and Martineau have found hydrate of cliloral to exercise an especially favorable influence.* C'kian turpentine (Clay) has been put (1880) under extensive trial for various forms of cancer. The general report is against its efficacy. Cancer of the Duodenum^ Ccecum, Bectunt, a,nd Omentum are much more rarely met with. Their possibility must always be remem- bered in considering the diagnosis of abdominal tumors.^ DYSPEPSIA. Although denied a special place in nosology by recent writers upon diagnosis, clinical experience calls for a separate recognition of this as a disease, complex in its pathology, and diverse in its symptoms. Of the latter only a very general account can here be given. Symptoms. — The patient /eeZs his stomach all the time, though not nearly always with pain. Wli-en the latter occurs, it is often in the breast, causing suspicion of pectoral disease. Little or no tenderness on pressure exists, nor is there much nausea, nor vomiting. The mouth is clammy, or has a sour or bitter taste. The complexion is more or less sallow. The bowels are costive, and stools deficient in color. Other frequent symptomatic affec- tions are cardialgia (heartburn), pyrosis (waterbrash), hypochon- driasis, palpitation of the heart, headache, and disorders of the senses, as diplopia (seeing double), etc. Dyspepsia is not a dangerous, but is frequently a very obstinate disease. Pathology. — The functional disturbances above enumerated have their seat, more or less prominently, in different parts of the digestive apparatus ; in the alimentary mucous membrane, gland- ular, muscular, or ganglio-nervous organs. The distressing gastro- intestinal irritation, cardialgia, pyrosis, etc., are located in the mucous membrane. Defective action of the liver and enteric glands produces constipation, with its consequences ; imperfect secretion of the gastric juice and pancreatic fluid impairs the whole process of digestion. So does atony of the muscular coat of 1 Phil. Med. Times, May 27, 1876. Dr. Hutchinson found that the best way to effect this was by the use of Tkudiehum's douche. An ordinary stomach-tube was introduced into the stomach, and, by means of a rubber pipe attached to a bottle held above the patient's head, the solution passed into the stomach by its own gravity. While the tubes were still full, the bottle was depressed below the level of the patient's body, and the rubber tube was detached from the bottle. By the syphon thus made, the fluid passed out, emptying the stomach. 3 Wiener Med. Wochenschrift, Feb. 5, 1881 ; Med. Times and Gazette, March 5, 1881. Pean had performed this operation, 1829 ; but his patient died. ^Allgemeine Wiener mediciuische Zeitung, March 15, 1881. 4 Lancet, March 14, 1874. 6 Dr. D'Arpen, of Elba, has reported the apparently curative effects, in cancer of the rectum, of enemata of gastric juice. Lancet, March 18, 1871. DYSPEPSIA. 269 the stomach ; while deficient power of the peristaltic intestinal contraction is perhaps Die most common cause of constipation. Possibly the presence of torulm {saccharomycefi) may increase the formation of acetic and lactic acid from farinaceous and saccharine food, in some cases. Insufficient or perverted innervation may originate or intensify any or all of these morbid states and actions. Sometimes this is so oliviously primary and predominant, as to jus- tify the use of the term, in certain cases, of " nervous dyspepsia. " Causation. — Most briefly, we may assert the cause of dyspepsia to be, either one or several of the following : too much food, or too little food ; imperfect mastication, and hurry in eating ; too little exercise ; too much fatigue ; excessive study, or emotional excite- ment ; inordinate use of ardent spirits, opium, tobacco, coffee ; or of medicine out of place. Treatment. — This involves regimen^ as well as medication ; the first is most important. The meals should be regular, and with sufficient time allowed ; and all the food should be simple as well as nutritious ; variety being obtained rather by having a change from day to day, than by a number of dishes at each meal. Some dyspeptics are obliged to eschew variety, and confine themselves to a routine of beef, mutton, and stale bread. Caution should be used not to blame, unjustly, particular articles as "disagreeing," when everything disagrees, because of the state of the stomach. But a sensible person will be able mostly to ascertain what things' agree best with his digestion ; and others should not be taken. Most persons, even of feeble digestion, can eat beef, mutton, chicken, turkey, oysters (not fried nor raw, but roast, panned, stewed or steamed) ; with stale bread ; bran bread occasionally, as more laxative ; crackers, boiled rice, tomatoes, and young and tender beets. When weak enough to require any stimulant, sherry, or Madeira wine, or ale, or in the feeblest, whisky, in small doses, will agree best at dinner. Let Dr. N. Chapman's precept be here rcm'embered, "whatever we grant, let it he sparing- ly.''^ Advise, for example, Italf a wineglassful of Madeira or sherry, or half a tumblerful of ale, or one or two teaspoonfuls of brandy or whisky, at or after dinner.^ For breakfast and supper, tea will be the best drink for refreshment ; milk for nourishment ; although some persons do not digest milk with ease. Coffee I have so often known to produce dyspepsia, that I would forbid it altogether ; notwithstanding its toleration by some highly respectable authorities. Cocoa is too rich for most dyspeptic stomachs ; some find it acceptable. Fruit, especially when fresh, as a general rule is useful ; peaches, in season, are so with few exceptions. Stewed fruit also is excellent for laxative effect. Preserves, cakes, and pies must be avoided. If a full meal can- not be taken without discomfort, it will be better to appease hunger or sustain strength by a small and simple "bite " between meals. Idleness and emptiness, as well as repletion, in the stomach promote disorder. Dr. Brown-Sequard has proposed to ' The author must dissent strongly from Dr. Anstie's opinion, that even a perfectly healthy aflult will receive benefit from the use of at least an ounce of alcohol, in some form daily. Perfect health, I believe, is best maintained with none. The careful experi- ments of Drs. Parkes, Richardson, and others fully sustain this opinion. 23* 270 DISEASES OF ORGANS OF DIGESTION. treat obstinate cases of dyspepsia by administering very small quantities of digestible food, at very short intervals. Sometimes, in desperate cases, this may be temporarily important ; but it must soon become inconvenient and tiresome, if, as he advises, the intervals be made so short as fractions of an hour. Exercise, daily, in the open air, is very important to the dys- peptic. So is bathing, to maintain Fig. 98. healthy action of the skin, with which the stomach sympathizes. " But active exercise ought not to g be taken just before or just after a <& ** meal. "After dinner sit awhile." ® Mental states and nervous im- ^ pressions are of great consequence. Q Anxious occupation, or harassing _ ffl responsibility, may increase greatly ® ^ the difficulty of recovery. Thus ^ * ^ ® * ^^ travelling, or resorting to watering- * places, with release from care, may Sarcinae. assist the cure. The medical treatment of dys- pepsia involves a number of indications, not always exactly the same. Especially are tonics^ laxatives, anta/iids, and other palli- atives and alteratives, apt to be required. Tonics. — Pure vegetable bitters, as gentian [F. 72, 73] , quassia, and columbo, are most suitable as direct stomachics. Chiretta is a favorite with some. Oxide of silver has had one or two enthusiastic advocates. Where nervous debility is prominent, and particularly in cases of long standing, extract of nux vomica [F. 71], or strychnia in very small doses (one-fortieth to one-thirtieth of a grain) will often do more good than any other medicine. Iodide of iron, in aneemic cases, may be given. Laxatives. — Khubarb has been, time out of mind, the standby for habitual constipation [F. 75, 76, 77] . If it be insufficient alone, or lose its effect, compound extract of colocynth, aloes, or resina podophylli may be added, in pill. Senna, magnesia, and sulphur may be used occasionally, for special indications. Saratoga, Chel- tenham, Yichy, and Hunyadi Janos (half a wineglassful or more at a dose) waters are found sometimes to have excellent regulat- ing effects. Antacids. — After meals, a pinch of bicarbonate of sodium (gr. v to gr. x) or half as much bicarbonate of potassium, or a dessert- spoonful of lime-water, will, in cases of acidity, contribute much to the comfort of the patient. Carbonate of^ magnesium and aromatic spirit of ammonia are preferred by some ; and charcoal has useful absorbent powers. Sulphite and hyposulphite of cal- cium or sodium, for antiseptic effect, may also be given to allay the after symptoms of indigestion. Alteratives. — In the commencement of the treatment of a case of dyspepsia, in which derangement, and commonly inaction, of the liver is most generally present, experience fully justifies the moderate use of blue pill. I prefer to give it in fractional doses, in such a case, say gr. i thrice daily for a week [F. 74] . Occa- DYSPEPSIA. 271 sionally it may require to be -repeated, at intervals; but should never be pushed to salivation. Nitro-muriatie acid, in 3 or 4 drop doses, acts as a mild tonic both to the stomach and the liver; and may well follow blue mass, when hepatic torpor is believed to exist. The same indication may be met, with less certainty, by taraxacum. Nitric acid is lauded by some practi- tioners. Leube urges hydrochloric acid instead. Chloride of ammonium acts very well with some ''bilious" patients. Among the agents shown by Corvisart, Blondlot, Lehmann, and Bernard to increase the secretion of gastric juice, were alkalies, common salt, diluted alcohol, ether, ipecacuanha, and nitrate of bismuth. Fepsin^^ when pure and fresh, may be of considerable service; and so may lactopeptine, and Savory's essence of pepsin and pancreatin. Bouchut praises an extractive of the pojxtya plant, of Java and S, America, as a sort of vegetable pe])sm. Ingluvin, from the gizzard of the fowl, is said by some practitioners to have simitar effects to those of pepsin. English practitioners make considerable use in dyspepsia of "liquor pancreaticus" (containing the pancreatic ferment trypsin), along with a small quantity of bicarbonate of sodium to prevent its action from being arrested by the gastric acid in the stomach (W. Eoberts). Cardialgia seems to depend mainly upon acidity, aggravated perhaps by butyric fermentation. Aromatic spirit of ammonia, tincture of ginger, and camphor-water, as well as the antacids above named, may be given tor it ; or chloroform, in 5 or 10 drop doses [F. 78]. Gastrodynia is a technical name for stomach-ache, common in dyspeptics. Carminatives are appropriate for it ; one of the best of these is oil of cajuput, 5 drops at a dose, on a lump of sugar. Spirits of camphor, compound spirits of lavender, compound tincture of cardamom, and essence of ginger, are among the most popular preparations for its relief. A mouthful of very hot water will sometimes quell the pain. Pyrosis (water-brash) is best treated by mild astringents ; as oil of amber, catechu, krameria, ammonio-ferric alum [F. 80], creasote {j- drop or J drop doses) [F. 81], tincture of chloride of iron. Dr. Lawson considers the sulphites to be almost infallible in the treatment of pyrosis. For hiccough, which is an occasional symptom of either acute or chronic indigestion, hydrate of chloral has been found' to be a useful remedy. After all, the dyspeptic may be able to do the most for his own cure. In the words of the late Prof. N. Chapman, "If he be 1 Dr. Chambers, of London, speaks well of " Boudault's pepsin," obtained from the sheep's stomach. Dr. Pavy, of London, states that a large part of Boudault's pepsin is inert. Glycerin extract of pepsin is said by some good authorities (Natur^ 18/0) to be active and stable. Br. L. Beale asserts that pepsin can be obtained in an effective state by quickly drvin a gruel of it, to be mixed in equal parts with milk. Meigs and Pepper highly recommend gelatin food (see Di£tary Prepurntionti, at the end of the book). After the first stage, many children will require small quantities (drops, not drachms) of brandy or whisky (preferably with their food) for support. Kjellberg ' asserts that cncmata of from four to eight grains of hydrate of chloral, with one drop of laudanum, in a dessert-spoon- ful of liquid (as starch or mucilage) will often arrest the vomiting. In the early stage, if the head continue to be hot and stupor be threatened, a, few leeches behind the ears, and the application of cold water, upon a light cambric handkerchief, to the head, may sometimes be proper. Such a stage, however, does not often last long. The tepid or even cool bath (Comegys '■^), also, may do excel- lent service, repeated every day. Dr. J. L. Smith sometimes keeps down the temperature with Kibbee's fever cot. Later, the two difficulties are, to check the diarrhoea, and to overcome the rejection of food by the stomach. For the bowels, astringents are' then called for; especially logwood, blackberry root, geranium, krameria, aromatic syrup of galls ; aided in serious cases by paregoric in small quantities by the mouth, or even the injection into the bowels of one, two, or three drops of laudanum with starch. Sometimes acetate of lead injections (from one to three grains, with starch) may be needed for the same intent. Acetate of lead with acetate of morphia, in muci- lage with cinnamon-water, makes a useful combination in obsti- nate cases. Nitrate of silver, in ^V of a grain doses, thrice daily, has sometimes an excellent effect]^ Dr. H. L. Byrd advises sul- phite of sodimn; 1 or "2 grain doses. Dr. Boardman Reed^ has obtained good results with small doses of corrosive sublimate. Dr. J. L. femitli gives morphia and quinine hypodermically. Protracted summer complaint aflbrds scope for perseverance and contrivance in finding food available for the child. Well-made beef-tea agrees with most children. Frozen beef-tea (proposed by Dr. H. B. Hare, of Philadelphia) is especially likely to be accept- able. Raw beef scraped or rasped fine, has been found to answer the purpose best with some. But all medical treatment may fail in some cases of cholera infantum, which will speedily recover on being removed from the city to the country. The immediate effect of a salubrious air is often surprising and delightful. Prophylaxis. — This is very clear and simple. A child under five years of age ought never to be kept in the close-built parts of a large city, in our climate at all events, through June, July, and August, if it can be helped. Next to a residence for the summer in a high and open country, will be the benefit of frequent excur- sions or visits ; riding or sailing ; or even, if nothing else be pos- 1 Amer. Practitioner, June, 1880. 2N. Y. Med. Record, June 29, 1876. 3 Phila. Med. Times, Jan. ai, 1880. 25* 294 DISEASES OF ORGANS OF DIGESTION". sible, being carried daily into the squares or parks of the city. The proposition to have estabhshed summer camps, outside of each of our large cities, as places of refuge for the children of the poor during the hottest weather, is a very reasonable one. Im- mense good has been done in Philadelphia, New York, and Balti- more by children's sanitaria at the seaside or elsewhere out of town, and by the " country week " charity, by which poor infants are boarded (with their mothers if necessary) for a week or two at a time in the country during hot weather. A decided reduc- tion in the annual summer infantile mortality of those cities has already been effected by these and kindred improvements. DYSENTERY, Definition. — An inflammation of the large intestine, involving the muscular as well as the mucous coat. Varieties, — Acute and chronic ; sthenic and asthenic ; endemic or epidemic ; bilious ; ulcerative ; strumous or tuberculous. Symptoms, — Pain in the lower half of the abdomen, with sore- ness or tenderness on pressure or motion ; frequent disposition to go to stool, with small and bloody or blood-marked muco-fecal or mucous passages, sometimes containing shreds of lymph or false membrane ; tendency to strain (tenesmus) with griping (tormina); fever in most acute cases. Severe and protracted cases maybe considered as going through, first, the inflammatory, and second, the ulcerative stages. Simple acute dysentery is commonly sthenic, or open, active, and inflammatory, without early or great tendency to prostra- tion. Endemic or epidemic dysentery (the first name is the more correct) is generally asthenic. In this form fever may be absent, brief, or of a typhoid character. Vomiting is not rare in this, as it is in the ordinary acute form. Coldness and debility come early. Sometimes, in malarial districts, dysentery, like all other mala- dies, may be intermittent ; with daily or tertian exacerbations and intervals. Morbid Anatomy. — Redness, turgescence, thickening, soften- ing, ulceration, suppuration, and occasionally pseudo-membranous deposits, are, after death from dysentery, found, in various de- grees, in the rectum, colon, caecum ; chiefly in the lower bowel. Pigment deposits have been found especially in scorbutic dysen- tery, in the villi of the small intestine, and in the patches of Peyer ; giving the peculiar " shaven beard " appearance of that affection. The hemorrhage which makes the typical bloody stools, is due to the congested and inflamed mucous membrane being constricted, in the tenesmus, by spasmodic and irregular con- tractions of the muscular coat. Abscess of the liver is not very uncommon. Chronic dysentery presents nearly always ulceration of the rectum or colon, or both. The discharges in this may become almost entirely muco-purulent. Causation. — Predisposition to dysentery is common in the latter part of summer ; in Philadelphia and its neighborhood, from the middle of August to the end of September, especially. Relaxa- DYSENTERY. 295 tion from heat, with sudden exposure to cold and wet, may pro- duce an attack. 80, often, will indigestible food ; as unripe fruit. Bad drinking-water is another cause. At any season and locality such agencies may produce simple acute dysentery. But in certain regions it becomes at times endemic. This is particularly noticed in many localities having considerable elevation, not subject to malarial fevers, but within a short distance of ague districts ; dysentery upon or among the hills, while intermittent and remittent occur in the adjoining or subjacent valleys and meadow lands. Prognosis.— Either form of dysentery may be fatal; but the endemic and asthenic type is much the more dangerous. The other, with good early treatment, is generally quite manageable. When allowed to become chronic and ulcerative, the doubtfulness of recovery is much greater. Bilious dysentery, that is, the form in which disorder of the liver is a prominent feature, the dis- charges presenting an excess of more or less altered, irritating bile, is more intractable than ordinary simple dysentery. Scor- hutic dysentery (such as was seen during the Crimean war, and in the Chickahominy region of Virginia during the civil war in this country) is frequently fatal. Treatment. Simple acute form. — isTow and then we may find a robust patient who will require to be bled during the first, active stage of dysentery. Much more often, leeches over the abdomen, where the tenderness is greatest, will be suitable. After these, warm poultices, of flaxseed meal, mush, etc., may be put on. Later, in obstinate cases, a large blister in the same region. At the very start, the old practice of beginning with a dose of castor oil, with ten or fifteen drops of laudanum, will do very well. If left for a day or two, it had, as a rule, better be omitted. Then the first prescription, in a mild or moderate case, may be of blue mass with ipecacuanha. After one or two days (sooner in an urgent case), camphor may be added, in pill. ISText, we may substitute, for the blue pill, opium; afterwards, omit the ipecac, con tinning the opium and camphor, pi'orenaia. Some practitioners (Curci') assert that chloral does more good in dysentery than opium. If the disorder be still not checked, we must resort to acetate of lead, with opium, or in solution with acetate of mor- phia [F. Ill, 112, 113, 114]. Perfect rest is indispensable to prompt recovery from dysen- tery ; there is no disease in which this is more important. The diet must be bland ; as rice-water, arrowroot, or other fari- nacea ; chicken-water, or beef-tea in the feeblest cases. When thirst is intense, iced rice-water, or beune-leaf tea, or infusion of slippery-elm bark, may be used as a drink ; or, during the active stage, ice in substance may be taken slowly. Encmata are very important in dysentery. First, of flaxseed- tea as a demulcent (two or four ounces at once) ; the same with laudanum ; or laudanum with starch [F. 115] . In decidedly sthenic, inflammatory cases, injection into the bowel of ice-water or finely powdered ice ^ may be resorted to ; taking care that the 1 Practitioner, October, 1879. 2 Bodo Wenzel ; Berliner Klin. Wochenschrift, Dec. 1, 1873. 296 DISEASES OF ORGANS OF DIGESTION. effect be kept short of chilling the patient. In chronic cases, or obstinate acute ones, acetate of lead may be given by enema, with laudanum in mucilage. So may sulphate of zinc and nitrate of silver. Mseder has used with advantage enemata of alum^ four teaspoonfuls to a pint of water. I have seen some remarkable cures of chronic dysentery by the use of an enema containing ten grains of sulphate of zinc, forty drops of laudanum, and four ounces of flaxseed tea. Such an injection may be painful at the time, and would be too irritating, except in an ulcerative case of considerable standing ; for which it should be reserved. Solution of tannic acid, in water or in glycerin, will be worthy of trial for a similar purpose. Dr. Morse, ^ of San Francisco, reports success in chronic dysentery with injections of a solution of Labarraque's chlorinated soda (one part to twenty of water), two or three pints at a time. Asthenic, endemic form. — In this there will be need of the earlier use of opium, and often of quinine and stimulants. ISTo leeching, or little, is likely to be well borne, and ipecac may be prohibited by the occurrence of vomiting. "When it can be taken in small doses (not more than J a grain every 3 hours), I believe it to be a valuable remedy. "When malarial influence is obvious, and most of all in the intermittent form, quinia or cinchouia will be the remedy, to which others are adjuvants [F. 117]. Hope''s mixture will be more likely to do good in this, the adynamic, than in the simple acute form. (K. — Acid, nitric, f 5j ; tinct. opii, gtt. xl ; aquse camphorse, foviij ; dose, a tablespoonful. ) In India, the pods of the mangosteen {Garcinia mangostana) have been found to furnish an extract serviceable in dysentery. Bilious Dysentery. — As a distinctive variety, this is not uncom- mon, and, if it last over ten days, it may be very hard to cure. Ordinary anti-dysenteric medication will not be inappropriate to it, but may disappoint much more than it is apt to in simple acute cases. Without having a very satisfactory recollection of the results of treatment of such cases in my own experience, I should trust most to the withholding of mercurials in the first stage, the gradual introduction of one of them in the second week, the appli- cation of a blister at the same period over the liver, and, besides opium, etc., as required for a stringent eflect, the administration of chloride of ammonium, or nitro-muriatic acid. Of course the chemical incompatibility of this acid with lead must be remem- bered ; but this will not interfere with saturnine injections while using the acid by the mouth. Some physicians treat dysentery, with asserted advantage, by the internal administration of small doses of sulphate of magne- sium or sulphate of sodium. Dr. L. D. Harlow uses the follow- ing : Sulphate of sodium, 1 drachm ; laudanum, 40 drops ; cinna- mon-water, 4 fluidounces ; mix, and give J a fluidounce every three hours. This mode of treatment must, I think, be best suited to the early stage of rather sthenic cases. If abscess of the liver occur as a complication of dysentery, it may require surgical treatment. (See Hepatitis^ later in this book.) 1 California Medical Gazette, Sept., 1868. HEMORRHOIDS, 297 Scorbutic dysentery may require the use of opiates and astrin- gents, as in the other forms ; but anti-morhutic diet is apt to be the most important portion of its treatment. HEMOBRHOIDS. Definition. — Piles ; tumors at the verge of the anus or within the rectum. Varieties. — External and internal ; varicose and fibrous ; dry and bleeding. Symptoms. — At first, weight and fulness in the rectum ; sore- ness about the anus ; pain, increased upon having a stool. The pain may extend up the loins, and down tlie limbs even to the feet. As intiammation increases, throbbing and aching may become almost constant. Swelling, and then the formation of one or more distinct tumors, occur. If without the anus, there may be every variety of pain fulness, aggravated at certain times. If internal, tlie prolapsus of the tumor during defecation, and its constriction or strangulation by the sphincter ani, cause great suffering ; often the tumor requires to be put back by the hands. Occasionally it cannot be returned, but undergoes mortification, and sloughs a way. Bleeding occurs from internal hemorrhoids. The amount may vary from a teaspoonful to a pint or more in a day. Cases are recorded by good authorities in which several pounds of blood have been lost in a single night. Commonly it is much less ; but may be enough to l>lanch and reduce the patient to the extreme of anjemia and debility. Anatomy. — Inspection shows external piles to be globate, hroad-])ased tumors at the verge of the anus, covered by thin integument ; livid in color when fresh, losing that hue when old ; tense and elastic to the touch, and very tender, at least during inflammation. The old idea that every hemorrhoid is a dilated vein has been corrected by observation. Piles consist of distended skin and connective tissue, with contained extravasation of blood, and deposit and organization of lymph, from local congestion. Internal hemorrhoids are descril^ed as chiefly of three varieties : 1st. Solid, round or pear-shaped, attached by a peduncle, smooth, and dull in color, composed of mucous membrane, connective tis- sue, and thickened veins. These bleed very little, if any. 2d. Broad-based, bright red, spongy tumors, villous on the surface, and bleeding readily arterial blood ; consisting of loose folds of mucous membrane, with hypertrophied connective tissue and enlarged capillary, small arterial and venous vessels. 3d. Florid, very vascular excrescences upon the mucous membrane, not of lai'ge size, but bleeding sometimes copiously. Complications and Sequelae. — These are, especially, ulceration, abscess, fistula, fissure of the anus, prolapsus ani, and sympa- thetic irritation of the urethra, bladder, prostate, or testicles in the male, or of the uterus and vagina in the female. Slougking of a strangulated hemorrhoidal tumor is considered by some to endanger life ; but my own observation of its occurrence would lead me to depreciate this danger. Certainly good natural cures thus occur. 298 DISEASES OF ORGANS OF DIGESTION. Moderate bleeding from inflamed hemorrhoids gives temporary relief. When habitual and not excessive, its sudden arrest may possibly j)romote some internal congestion — as apoplexy. Diagnosis. — Hemorrhoids may be mistaken for venereal excres- cences, or polypi of the rectum, or for prolapsus ani. The first are harder, more abru^jt in their elevation and margins, and of a quite difterent history ; in addition to which other marks of the syphilitic constitution exist. Polypi are of slower growth, and unaccompanied by inflammation, or, as a rule, by hemorrhage, and their surface is smoother than that of piles. Prolapsus ought to be easily made out, by examination discovering the structure of the everted mucous membrane. The source of bleeding from the rectum may sometimes be in doubt, as to whether it be hemorrhoidal or not. True hemorrhage from the bowels, other than from piles, is the result commonly of serious and obvious disease ; as typhoid fever, yellow fever, etc. Such flow of blood is itself painless, and the blood is dark, clotted, and variously mixed with fecal matter when passed, and the symptoms of piles are absent. Causation. — Hereditary predisposition sometimes exists. Hem- orrhoids are uncommon in either sex before puberty ; in females they are most frequent at the time of the cessation of menstrua- tion. "Warm and damp climates promote them, as in the East and West Indies, etc. The plethoric constitution is the most liable to them, especially with sedentary habits. Pregnancy is attended by them not unfrequently. Other causes are, long stand- ing, or sitting upon hard seats ; excessive venery or self-abuse ; over-stimulating diet ; misuse of purgatives, especially aloes ; ascarides, diarrhoea, dysentery, stone in the bladder. Constipa- tion of the bowels always predisposes to hemorrhoids. Treatment. — This must be both general and local; the former depending upon the constitutional condition, and the cause of the affection. The bowels must be regulated; neither over-purged nor allowed to be costive ; a soluble state is the most desirable. The bleeding of piles must be but cautiously interfered with, if it has been habitual, or if there be a tendency to apoplexy, gout, or insanity. The diet must be made to consist of digestible and unirritating food. Long standing and sitting, or rough riding, must be avoided ; although active exercise in the open air may be very advantageous. External piles may often be averted in the forming stage by attention to the bowels, along with the frequent application of the simplest unguents to the irritated and swollen part. Lard, tallow, cold cream, simple cerate, benzoated vaseline, or sperma- ceti ointment, will answer very well ; but the grease should be applied several times daily, and especially after a stool, so as to keep the part constantly soothed by it [F. 118, 119, 120, 121]. Dr. H. C. Wood^ recommends enemata containing chlorate of potassium and laudanum. The laxatives most approved for hemorrhoidal cases are rhu- barb, sulphur, and senna. The confection of senna is a very good 1 Phila. Med. Times, Dec. 6, 1879. HEMORRHOIDS. 299 preparation for such use. Map;nosia is irritant to piles ; and so are, thougli in less degree, the fealine catharti(;s. Aloes is stimu- lant to the sensibility of the lower bowel ; yet some practitioners (as Fordyce Barker) lind it. in moderate or small doses, especially with hyoscyamus, a useful alterative in hemorrhoids. Dr. D. Young thinks highly of ghjcerin for a similar eflect. Enemata are objectionable merely because of the mechanical pressure of the instrument. In internal hemorrhoids they are often decidedly serviceable. When piles arc inflamed, washing with cold water, or a cool sitz-bath, may relieve. ' Some patients prefer warm water or soapsuds under the same circumstances. "When bleeding is so considerable as to need to be checked, cold water injections, or liot water, solution of alum, or tincture of iron, may be employed. A piece of alum made into a smooth supposi- tory will sometimes do well. In really threatening hemorrhage the patient must lie still in bed. On the other hand, inflamed non-bleeding piles may require local depletion by leeches, or, as many prefer, cupping over the sacrum. Prolapsed internal hemorrhoids often have to be replaced by the hand. Oiling will of course facilitate such reduction. Astringent and sedative ointments, as of galls, tannin, carbon- ate of lead, creasote, or iodoform, with regimen and laxatives, may cure piles even of considerable standing. [F. 118, 119, 120.] But old and obstinate cases demand removal by operation. External hemorrhoids may be excised^ with curved scissors or a probe-pointed straight bistoury ; taking off no more integument than what covers the tumors. Fain during the operation maybe prevented (Coote) by the ether spray. Allingham^ employs a clamp. Good authority, also, pronounces touching carefully with nitric acid to be safe and successful. Internal hemorrhoids ought, when operated upon, to be re- moved always by ligature. Excision is dangerous, and has several times been fatal by hemorrhage. Some prefer cauterization with, nitric acid. In ligating hemorrhoids, it is best to apply a double ligature around the base of each tumor. Silk or hemp will answer ; Bushe's needle-receiver is a good instrument for the application. Colles, of Dublin, 1874,^ introduced the treatment of hemor- rhoidal tumors by injection with tincture of chloride of iron. In this country, first in the West,^ it has become common to inject carbolic acid; with reported success in many cases. Dr. Blackwood,* of Philadelphia, thus describes the operation : "I use crystallized carbolic acid, with enough glycerin (a few drops only) to render it fluid. Empty the bowel thoroughly the day before, and the rectum by enema an hour before operating. Do not inject during acute inflammation — a fit of the piles. Put the patient in bed. Anoint the mass of tumors, after their extrusion, with fresh olive oil or cosmoline, to prevent accidental caustic action on the adjoining parts, especially in females. Use a good glass 1 Diseases of the rectum, etc., 2d edition, 1873. 2 Dublin Journal of Med. Science, June, 1874. sPooley, Toledo Med. and Surgical Journal, Nov., 1877. . 27 314 SPLEEN. DILATATION OF THE GALL-BLADDER. This may be produced by obstruction of the gall-duct or the common bile-duct, or, more rarely, by a morbid formation of serous fluid within it, allied to a local dropsy. The diagnosis of this may be important, as it may be readily confounded with hepatic enlargement. It is to be distinguished from cancer by the great amount of jaundice (in most cases), the previous occurrence of gall-stone colic (also not invariable), and the more uniform and softer character of the swelling. From hydatids the same signs, except the softness of the tumor, are distinctive ; and hydatids grow much more slowly. For the treatment of dilatation of the gall-bladder, the remedies suitable for obstruction of the biliary ducts will be appropriate. Surgical interference is, in any case, bold practice ; unless, per- haps, by pneumatic aspiration. The operation of cholecystotomy (puncturing or incising the gall-bladder) for removal of gall-stones, has, however, several times been performed ; in a few instances with success. Although proposed by Petit (1733), and several others since, the first recorded example of it (except one men- tioned in Good's Study of Medicine^ 1855, without particulars) was that of Dr. Bartholow, in 1876. G. Brown, Marion Sims, W. W. Keen, Bryant, Lawson Tait, and Calhoun have followed ; the last three, with recovery of their patients.^ Perforation of the gall-bladder or gall-duct now and then occurs, from prolonged obstruction and dilatation. This must prove fatal (as in a case referred to upon a previous page) by the production of peritonitis, from the escape of bile into the peritoneal cavity. Gall-stones are alluded to under "Bilious Colic," ArrECTIONS OF THE SPLEEK. These are necessarily treated of at length in extended syste- matic treatises. It will be enough for our purpose to say a very few words of them. The spleen" is commonly enlarg'ed in inter- mittent, remittent, and typhoid fevers and in leucocythcemia ;. some- times, in pregnancy (Simpson). Rupture of the spleen, causing death, has been several times reported. Such an affection (i. e,, rupture of the spleen) could scarcely be diagnosticated during life. Enlargement of the spleen is readily ascertained by inspection and palpation. It often increases and diminishes, during and between the paroxysms of intermittent (ague-cake). iPiorry asserted its rapid diminution under cinchonization. Some prac- titioners have found it to diminish under hypodermic injections of ergotinj Faradaic electrization will also have a similar effect. Other affections of the spleen (inflammation, tubercle, hydatids, etc. ) are so generally difficult of diagnosis as to have chiefly a post-mortem interest ; and they present no clearly recognized 1 See papers on the subject by Dr. W. W. TCeen, Amer. Journal of Med. Sciences, January and April, 1879 ; and by Dr. C. W. Calhoun, of Turkey in Asia, in N. Y. Med. Becord, Jan, 29, 1881, p. 116. 2 Da Costa, Amer. Jour, of Med. Sciences, Jan., 1875. UR^.MIA. 315 indications for treatment. About forty cases have been reported * in which the spleen was removed entirely ; more than half of the patients recovered. AFFECTIONS OF THE KIDNEYS AND BLADDER. CONGESTION. Causation. — Under exposure to cold, overdoses of cantharidcs or turpentine, or the disturbance belonging to different inllamma- tory and febrile complaints, active renal congestion may occur. Pasdve congestion is more common in heart-disease, or pulmonary obstruction, as by pleuritic ellusion or emphysema, or when press- vire impedes the circulation in the renal veins or ascending vena cava, as in pregnancy or abdominal tumors. Symptoms.— Pain in the lumbar region, sometimes with tender- ness on pressure on each side of the spine. Scanty urination, the fluid being high-colored, sometimes bloody, or containing albu- men. Certain cases exhibit under the microscope fibrinous casts ; epithelial cells are commonly met with. Diagnosis. — It is only occasionally difficult to distinguish this condition from Bright's disease. Active congestion begins aln-uptly under a recognizable cause. Passive congestion shows a dependence upon some other organic affection, and although variable, is not progressive. They are thus distinguishable from advancing and more or less permanent disease of the kidneys. Treatment.— For active congestion, cupping the lumbar region is proper, abstracting blood in amount proportioned to the state of the patient. Purgation may follow, by castor oil or citrate or sulphate of magnesium. Then, the warm bath or hip-bath, con- tinued for some time. uk.i:mia. Definition.— The retention in the blood of the material which it is the function of the kidneys to excrete ; from the suppression of their action. Symptoms.— When well-marked, headache, dimness of vision, vomiting, diarrhoea, convulsions, and stupor; ending in fatal coma. The temperature of the body is generally above the normal degree. This aids in the diagnosis between ursemic coma and opfum poisoning ; in which the temperature is lower than natural. Pathology.— The question as to what is the immediate toxic agent in urjemia is not yet fully determined ; i. e., whether it is urea, or an ammoniacal educt from its decomposition in the blood. In the absence of demonstration of the latter, the former appears probable. A further view has been urged ; that it is unchanged creatin, creatinin, and other extractives, that contaminate the blood. (See BrighVs Disease.) The term iirinceynia is a safe one, not involving either of these 1 London iMed. Times and Gazette, Dec. 7, 18G7. This is less extraordinary than Prof. a. Simou's ease (Deutsche Kliuik, April, 1870), in which he extracted successively the left ovary, the uterus, and the left kidney ; and the patient recovered. See also Am. Jour. Mod. Sci., April, 1878, and April, 1879. 316 DISEASES OF KIDNEYS AND BLADDER, opinions. Traube has proposed the hypothesis that the ursemic symptoms, so considered, in Bright's disease, may depend upon oedema of the brain. Treatment. — This must vary with the circumstances of the production of the suppression ; but the great indication is to depurate the blood — by the kidneys, if they can be restored to action, and by the aid or substitution of the bowels and skin.' For this end, the warm bath, or the hot-air or warm vapor bath may be of great service. In acute sthenic cases, moderate vene- section will do good. So may cupping, hot poultices or counter- irritation by mustard or tincture of iodine over the small of the back. Dr. B. W. Richardson has especially urged venesection as the most hopeful remedy for uraemia. Saline cathartics, even hydragogues, may be given to such patients as have sti'ength to bear them ; as cream of tartar, Epsom salts, elaterium, or croton oil ; the last two most rarely. Lemonade drunk freely is often one of the best of diuretics. Others will be mentioned hereafter, in connection with Dropsy. Dr. A. L. Loomis has reported suc- cessful results in the treatment of ursemic convulsions with hypodermic injections of morphia.^ NEPHRITIS. In the present state of urinary pathology, it is common to merge the topic of inflammation of the kidney (except suppura- FiG. 104. Deposits from Urine in Renal Hyiiersemia. tive pyelitis) as distinct from active renal congestion — in Bright's disease. If this be questionable as a matter of pathological system, it has at least practically no disadvantage ; as the symptoms of nephritis are included in one or other of the affections named ; 1 There is reason to believe (Cyon) tliat tlie liver also aids in the separation of urea from the blood. 2 N. Y. Medical Record, August 1, 1873. BRIGHT .S DISEASE, 317 and so is its treatment. We may submit tliereforo to the usas;e of authority upon tliis point, without liesitation. The symptoms of acute 2)!/clitis (intlammation of tlic pelvis of the kidney) are essentially those of renal con!j;estion, intcnsilied ; with tenderness on pressure over tlu^ kidney, and fever, until suppuration is estab- lished ; then, purulent discharge for a variable time from the kidneys. (See ryonephrosis.) Before pus appears, blood, in small quantity, mucus, and renal epithelial cells may be found in the urine. A tumor in one of the lumbar regions may precede for a while the escape of pus. BKIGHT'S DISEASE. Definition. — Albuminuria, dependent upon structural change in the kidneys ; or, more cor- rectly, disease of the kidney, characterized usually by al- buminuria and dropsy. Varieties or Stages.— Au- thorities differ as to the dis- crimination of these. Bright believed there were three varieties. Dr. G. Johnson asserts two — the desquama- tive and non-desquamative nephritis. Frerichs con- siders them to be grades of the same affection, and admits three stages, essen- tially of hypereemia, exu- dation, and degeneration. Anatomically, we have the large, smooth, white kidnei/ ^the small, smooth kidney, the gran- ular uncontracted kidney, and thegranidarcontractedkidney. "We may safely follow Rob- erts, dividing Bright's dis- ease, first into acute and chronic. The latter is then divided into, 1. Cases which have lapsed from the acute state (smooth, white, generally large kidney) ; 2. Cases slow or chronic from the beginning (granular, red, contracted kidney) ; 3. Cases associated with waxy or amyloid degeneration of the kidneys. Causation. — Bright's disease is one-third more common in males than in females. The greatest number of cases occurs between the ages of 45 and 65. Acute Bright's disease is most often produced by cold and dampness ; next by scarlet fever, pregnancy, or violent intemperance. Malaria is also to be inctuded among its causes.^ The acute form is most common in early life. Chronic Bright's disease also is greatly promoted by exposure ^1 Renal Cysts (dilated tubules). 1 Busey, Am. Jour, of Med. Sciences, January, 1873. 27 318 DISEASES OF KIDNEYS AND BLADDER. to cold and wet ; it is caused, moreover, very often, by abuse of spirituous liquors. Other predisposing causes are gout, valvular disease of the heart, constitutional syphiUs, and affections of the bladder and urethra. Climate must have something to do with it ; as the ratio of deaths from renal disease to all deaths is, in London 1 to 49, Paris 1 to 226, Bombay 1 to 2800, and Genoa 1 to 4303.^ Symptoms. Acute Bright's Disease.— After exposure to cold, or a drunken fit, or scarlet fever, the patient is seized with chilli- FiG. 106. Casts, in Bright's Disease, a a. Epithelial Casts, b b. Opaque Granular Casts. ness, headache, nausea, vomiting, pain in the back and limbs, checking of perspiration, and oppression in breathing. Fever follows, and the face, trunk, and limbs become puffy with anasarca. Effusion may also occur into the pleura or peritoneum. The urine is scanty, heavy, acid in reaction, and dark in color, from the presence of blood ; and very albuminous. The disposi- tion to void it occurs more frequently than during health. The deposit from it, under the microscope, shows blood-corpuscles, loose renal epithelium, free nuclei, tube-casts, and shapeless masses of fibrin and debris. After one, two, or three weeks, or even a longer period, the attack proceeds to one of three terminations : recovery, death, or lapse into the chronic state. Death results through uraemia, or from secondary pneumonia, pleurisy, peritonitis, pericarditis — or hydrothorax, oedema of the glottis, hydrocephalus, or ascites. Probably two-thirds or more of the cases of acute Bright's disease recover. 1 See a paper by Dr. A. Flint, New York Medical Record, July 15, 1869. BTITGHTS DISEASE. 319 Treatment.— Cupping the " blanket " bath ; active purg- ing, as witli cream of tartar and jalap, or citrate of mag- nesium ; and dia[)horetics, as citrate of potassium, or liquor amnion, acetat. Mercury is not recommended. The diet should be liquid and simply nutritious. Chronic Bright's Disease. ^This approaclics so slowly as seldom to be detected until after the lapse of months or years. Gradual loss of strength, pallor or puffiness of the face, shortness of loins, hot water or hot-air or Incipient Gianular Degeneration of Kidney breath, and frequent disposition to urinate, are early signs of it. But they are not always present •, the denouement of the dis- ease may be by a convulsion, oedema of the lungs, amaurosis, or some violent local inflammation. Symptoms and signs of a well-marked case (not all present in every instance) are : albuminous urine, deposits of tul)e-casts and renal epithelium, dryness of skin, frequent micturition, espe- cially at night, general dropsy, or local effusions into the cav- ities, indigestion, ancemia, ursemic effects (headache,^ dizziness, impairment of sight,^ convulsions, coma, vomiting, diarrh(jea), enlargement of the heart, and secondary inflammations. Bron- chitis is especially common. The progress of the case is usually interrupted by exacerba- tions and intervals ; each fresh attack leaving the patient man- ifestly worse than before. Such attacks much resemble acute Bright's disease ; they are sometimes referred to known causes ; the intervals may last weeks, months, or even years. In prognosis, the tendency is always towards a fatal result. About one-third die of ureemic poisoning. A considerable num- ber die of local dropsical eft'usions. One-fifth from secondary pneumonia, pericarditis, or pleurisy. The rest, by exhaustion, from ansemia, indigestion, and anasarca, or the complications of apoplexy, cirrhosis, phthisis, intestinal ulcerations, etc. Diagnosis. — The presence of albumen in the urine, with dropsy, not of sudden origin or brief duration, is pathognomonic of this aftection. The tests for albumen, by heat and nitric acid, are readily applied. The microscope will show also free renal epithe- lium and tubular casts in the urine ; in advanced cases the casts are sprinkled with oil-dots. The solids of the urine, especially the urea, are reduced below the normal amount. 1 Occipital headache is (Seguin) one of the signs of uraemia. 2 Prof. J. Green, of St. Louis, has well described the ophthalmoscopic signs of albu- minous retinitis in Bright's disease. There are usually white stellate spots on the retina, with enlargement of the retinal blood-vessels. TUrck and others regard the affection of the retina as a fatty degeneration. Dr. Gouverncur Smith, of New York, remarks that dulness of hearing also occurs under similar causation, in some cases of Bright's disease. See Trans, of N. Y. Academy of Medicine, 1869. 820 DISEASES OF KIDNEYS AND BLADDER. Pathology. — Degeneration of the structure of the kidney (usually following interstitial inflammation) induces albumin- uria, by allowing the serum of the blood to pass almost un- changed through the cortical substance into the tubuU uriniferi. The deficiency of urea is due to the same impairment of secreting power. The smooth white, generally large, kidney is the result of fatty degeneration ; this either following an inflammatory attack, or being primarily a chronic atrophic affection. Dr. T. Grainger Stewart describes three forms of change : 1. The inflam- matory form, with three stages : a, that of inflammation ; &, fatty Fig. 108. Benal Epithelium, a, Normal, b, Atrophied, c, Fatty Degeneration, transformation ; c, atrophy. 2. The waxy or amyloid form, also with three stages : a, degeneration of vessels ; h, secondary changes in the tubes ; c, atrophy. 3. The cirrhotic, contracting or gouty form. Dickinson especially has shown the importance of the distinction into tubal, interUibal, and vascular disease. Dr. George Johnson has proved that in Bright's disease the coats of the small arteries in various parts of the kidney become thick- ened with hypertrophy. An early change in the arteries seems to be a part of most organic degenerations. Runeberg ^ suggests the occurrence of an abnormal permeability of the blood-vessels of the Malpighian tubes, as allowing the transudation of serum albumen. Sir Wm. Gull and Dr. H. G. Sutton^ advance the view that the affection of the kidneys is only a part of a morbid process going 1 Deutsche Archiv f. Klin. Med., vol. xxiv., p. 248. 2 Medico-Chirurgical TranxSactions, vol. Iv., 1872. B R I G II '1^ ' S DISEASE. 321 on in the general vascular system ; to which thoy c;ive the name "arterio-capillary lihrosis. " ' In tlie vessels of tlu; allected kid- ney, two kinds of clianalsy is recovered from. Iodide of potassium appears to act as an eliminant of the lead accumulated in the system. Ergot is asserted by some to be curative also. Faradaic electricity has been found decidedly beneficial ; used in moderate strength for a few minutes two or three times a day. (See Medical Electricity^ in Part I. , Sect. III. ) A milk diet is asserted by M. Peligot, an experienced glass man- ufecturer, to be preventive of lead poisoning in those exposed to it. Mercurial Palsy is occasionally met with in those who work with the metal. Mf)stly tremor is a predominant symptom. Early withdrawal from the influence of the cause, and the con- tinued use of the iodide of potassium, are the principal measures of treatment. Paralysis agitans, or shaking palsy, is a more or less constant involuntary and uncontrollable shaking of the hands, arms (sel- dom the head), and progressively of the whole body. Slight or moderate degrees of such tremor are common enough from general nervous debility. Extreme cases evince the wreck of the ccrebro- 31* 366 DISEASES OF BEAIN AND NEEVOUS SYSTEM. spinal system, and are therefore incurable. Since the study, by Charcot and others, of disseminated or multiple cerebro-spinal sclerosis, some cases are referred to that affection which formerly would have been included as examples of paralysis agitans. Two kinds of tremor are described ; one constant (that of paralysis agitans), and the other volitional, i. e., occurring only when some muscular action takes place under an effort of the will. The latter belongs to disseminated or multiple cerebro-spinal sclerosis. No absolutely certain demonstration of the morbid anatomy of paralysis agitans has yet been obtained ; and no especial treat- ment can be pointed out for it. Spastic Spinal Paralysis — Lateral Spinal Sclerosis. — This has been already sufficiently considered. (See Cerebral and Sjnnal Sclerosis.) Wasting Palsy (Cruveilhier's) — Progressive Muscular Atrophy. — A few of the muscles of one limb, or the voluntary muscles of the whole body, may lose their power, and then waste away almost to nothing. The shoulder and the ball of the thumb are frequent points of commencement for the palsy and atrophy. Insidious in its approach, the affection may last from six months to several years. It may end in recovery, in permanent arrest at Fig. 116. Advanced Wasting Palsy. a certain stage of the disease, or in death. Twelve months is the earliest recorded period for the occurrence of a fatal end. This is the result always when the trunk is invaded. After death, the spinal maiTOW has been examined in but a few cases. No lesion has been found in most of them ; in a certain number it has. Dr. J. Lockhart Clarke in one case^ found the diameter of the cord one-fourth less than the average. Joffroy, Hayem and Charcot assert the coincidence in several instances of pro- gressive muscular atrophy with degeneration of the anterior gray cornua of the spinal cord. Friedreich, Cohnheim, and Lichtheim have reported cases where no lesion of the cord or nerves was ascer- tained; but, considering the possible minuteness of such alterations under some circumstances, positive observations outweigh the negative, which may be exceptional. Our methods of inspection of nervous tissue are yet too imperfect for it to be pronounced that such an atrophic disease is ever independent of the nervous 1 Brit. Med. Journal, Dec. 7, 1872. PARAI.YSIS, 367 Fig. 117. centres. It may be the gawjlia which regulate nutrition that are most directl}^ in fault. A siuiilar remark may be made in regard to the patliology of progressive muscular sclerosis, the pseudo-hypertrophic muscular paralysis of Duchenne ; the singularity of which consists in the Rict that while some of the muscles are wasted, or at least weakened, enlargement afterwards occurs, in the same or in other muscles,' by morbid proliferation of connective-tissue ele- ments. Friedreich and Gowers believe this to be an idiopathic disease of the muscular tissue. The subjects of this affection are mostly young. Its progress is gradual and not painful. The muscles of the calves of the legs, lumbar region, and buttocks are especially often in- volved. The affected muscles are not con- tracted at any stage. For progressive mus- cular atrophy, the most hopeful treatment is by means of electricity. General Paralysis of the Insane.— Only a minority of insane persons have this affection. Difficulty of speech and general tremor char- acterize it, followed by the gradual loss of all mental, muscular, and sensory power. Delu- sions of an extravagant kind commonly attend it : whence some French writers have called it "folic ambitieuse." It is incurable. In diag- nosis. Dr. Bucknill has pointed out the signif- icance of the loss of electro-motor excitability in the muscles. In pathology, general paraly- sis, or paresis^ seems to be connected with a change in the cortical substance of the brain. Calineil, who first clearly described it (1825 ; ^ Bayle, 1822), believed it to be due to chronic Pseudo-hypertrophic inflammation ot the brain. More probably, its cause is a defect of nutrition ; a degenera- tion ; whether or not preceded by inflammation. Dr. Howden, of Montrose, has found granular degeneration of the nerve-cells in some cases.^ Granulations of the lining of the ventricles are asserted by M. Joire"' to be peculiar to general paralysis ; but Maudsiey, Bland ford. Shew, and Seguin* have found them in cases of mania and dementia. Allbutt has, by the ophthalmo- scope, detected atrophy of the optic nerves in nearly every case. Ludwig Meyer, of Giittingen (Virchow's Archiv, Aug., 1873), advocates the view that the essential affection is a chronic inflam- mation of the brain and its membranes ; involving the minute Paralysis, towe). (Bris- 1 See a careful analytical report of a ease of this affection by Dr. W. Pepper, Pliila. Med. Times, .Tune 15th, 1871. The researches of Lockhart Clarke have made it certain that wa.stiiii; palsy is essentially a central disease. 2 London Lancet, July 31, 1SG9, p. 1.57. 3 Hullotin do I'Acad. Iniperiale de Medecine, 1861. * Amer. Journal of Med. Sciences, July, 1871. 368 DISEASES OF BRAIN AND NERVOUS SYSTEM. vessels and interstitial material, not the nerve-cells. Palliative treatment only, and that which economizes the energies of the system, can be employed in this affection. For the relief of the occasional paroxysms of excitement, physostigma (Calabar bean) has been found rather particularly useful. Constitutional syphilis has probably a causative relation to some, but certainly not to nearly all cases of general paralysis. When there is room to suspect this, anti-syphilitic treatment ought to be tried for its relief. LOCOMOTOR ATAXY. Though recognized in its essential features by Sir Charles Bell, Matthew Baillie, Hufeland, and others, this affection has been better known since its especial study and designation by Duchenne (of Boulogne) not many years since. Dr. E. B. Todd called it ataxic paraplegia ; an older name, especially in Germany, was tabes dorsalis. Symptoms. — Pains generally first occur ; mostly in the limbs, sudden, variable, but often very severe ; "fulgurant," compared sometimes to toothache in the legs. Occasionally they are in the face or trunk ; and commonly they are aggravated by pressure, as well as by cold and wet. Strabismus and dimness of vision (amblyopia) are apt to be early symptoms. Loss of sensibility of the skin, or more deeply seated, especially in the feet, and after- wards in the upper extremities, follows. Insensibility to pain (analgesia) on pinching or pricking with a needle occurs in many cases. More rarely, there is local hypercesthesia^ or excessive tenderness to the touch. Betention or incontinence of urine come usually later ; spermatorrhoea often quite soon in the case. Impo- tence, in an advanced stage, is the general rule. The bowels are generally constipated ; though the patient may lose power to con- trol the act of defecation. The pulse is moderately accelerated. The stomach is subject to attacks of indigestion and vomiting. Sometimes a rheumatoid affection of the joints occurs. This may go so far (Charcot) as almost to destroy the ends of the bones, at the knee, shoulder, or elbow. Papular, or even pustular, eruptions are not rarely met with, perhaps increasing and remitting accord- ing to the severity of the lancinating pains. The tendon-reflex disappears (Westphal) early in locomotor ataxy. By it we mean the jerking of the leg and foot upward and for- ward when, one leg being crossed over the other in a sitting posture, a sudden blow is struck upon the tendon of the quadriceps femoris muscle, at its junction with the patella. In a healthy person, this is almost always observed. It is exag- gerated in lateral spinal sclerosis (spasmodic spinal paralysis). Analogous to it is the ankle-clonus. If the foot be flexed firmly by pressure upward on the sole, and the tendo Achillis be then briskly tapped, the foot at once undergoes flexion and extension, in rapid succession, for a considerable number of times. As this, like the tendon-reflex, is increased in cases of spastic spinal paralysis, it is to be expected that it would be diminished in locomotor ataxy ; but the constancy of this diminution has not beeii established. LOCOMOTOR ATAXY. 369 InactwiU/ of the pwpil (Argyll Robertson) under changes from light to darkness and the reverse, is anotlier not infrequent sign, in locomotor atax}^, of the diminution of retlex susceptibility. The pui)il may be either more or less than usually contracted under moderate light ; Init it responds sluggishly or imperfectly to stimulation of tlie contractile tissues of the iris. The ^KiOH/(! sign of this aifection is asynergia (Bazire), i. e., loss of co-ordination of the muscular movements of tlie lower limbs. The gait, in walking, is iDisteadi/ and insecure ; the limbs feel heavy and are easily fatigued. Each step, in an advanced case, is apt to be made with a sort of jerk forwards ; quite differ- ently from the slow and dragging movement of ordinary hemi- plegic paralysis. If the patient shuts his eyes, he is likely to fall down. A similar loss, of co-ordination in the ai*ms and hands is met with not unfrequently , but to a less extreme degree. Although Duchenne asserts the persistence of muscular power without loss in this disease, it is almost certain (Oppolzer, AUbutt) that it is more or less impaired from the beginning in every case. Prognosis. — It is a progressive disease, but of various duration ; from six months to thirty years ; average perhaps about seven years. Recovery is scarcely to be hoped for. Causation. — This is a disease of middle life, especially in males. Obscure in its origin, and perhaps, as Trousseau insisted, con- nected with hereditary predisposition, its main promotive causes appear to be, exposure to cold and wet, depressing mental influ- ences, and venereal excesses, particularly self-abuse, and syphilis. Morbid Anatomy and Pathology. — The posterior cohonns of the spinal cord are characteristically altered (^sclerosis of Charcot) in locomotor ataxy. With atrophy and degeneration of the nerve- filaments, inci'ease in the bulk of the connective tissues gives a gray and semi-transparent appearance to the structure ; espe- cially in the dorsal and lumbar portions of the cord. The posterior nerve-roots (Yulpiau) are similarly affected. So are, also, the cranial nerves, at first apparently at their peripheral ends, and progressively toward the centres. The 5th, 7th, and 8th pairs of nerves are not reported as having been found subject to the same lesions. Dr. James T3^son^ observed, in one case, softeningof the lumbar enlargemeni; of the cord, with partial sclerosis of the antero-lateral column, higher up. According to Erb, the sclerotic change probably begins in the external hwids of the posterior columns, and spreads thence further; the sclerosis of the /asacjfh' gracilcs (Goll's colunms) being a secondary degeneration. Simul- taneous involvement of the posterior gray horns and of certain por- tions of the lateral columns is inferred rather from clinical than from anatomical evidence. Examination of the ganglia and nerves of the sympathetic system has seldom been made in con- nection with this disease. Dr. Gull believes the brain to be frequently involved. Although physiological considerations suggest a cerebellar as well as spinal seat for this disorder, in which loss of muscular co-ordination is so prominent a symptom, this view does not seem 1 Phil, Med. Times, Jan. 31, 1874, p. 286. Y 370 DISEASES OF BEAIN AND NERVOUS SYSTEM. to be confirmed as yet by observation. The difflculty would appear to lie rather in the perceptive apparatus by which the natural stimulus of the motor centres is afforded and their func- tions maintained. Treatment. — Almost hopeless of cure, the life of a sufferer from this malady may be prolonged, and his discomfort lessened by the best hygienic management, as to food, atmosphere, clothing, and rest, aided by tonics, electricity (especially the constant current), and perhaps the careful use of strychnia, hypodermically (Drink- ard) or by the mouth. Dujardin Beaumetz^ recommends phos- phorus, in ^L grain doses, in almond oil (F. 252). Dr. S. Weir Mitchell advises rest as an important portion of the treatment.^ Althaus'^ asserts that he has "completely cured" two cases with drachm doses of liquid extract of ergot, three times a day, con- tinued for six or eight months. Dr. Mitchell has confidence in the advantage of rather large doses of iodide of potassium, for alterative effect. Debove, Langeubuch, Esmarch, and Erlen- mayer have performed nerve-stretching* (of the sciatic, radial, or median nerves) in several cases of ataxy ; with the effect not only of relieving the lancinating pains, but of at least palliating the other symptoms of the malady. ATHETOSIS. Hammond first applied this term in 1871 to an affection char- acterized by a constant, involuntary, and more or less regular move- ment of thefiyigers and toes, on one side or both. As an occasional phenomenon, it had been before noticed, by Charcot in 1853, and by Heisse in 1860. Charcot regards it as a variety of chorea. Gowers and McLane Hamilton do not admit that it requires clinical or pathological separation, as a distinct disease, from other affections of disordered movement, chiefly following hemi- plegia. There is no doubt that hemiplegia has preceded athetosis in most instances ; but not in all.^ Athetosis may be unilateral, or double (on both sides). If the former, it is nearly always upon the same side with the hemiplegia. Oulmont has written a short treatise** upon this affection. Cases of it have not been very often reported.^ In the autopsy of one, by Dr. Sturges, of London (the patient having died of phthisis), the following appearances were observed : the whole right hemi- sphere of the brain was distinctly smaller than the left ; atrophy of some of the convolutions had occurred, especially those of the frontal and parietal lobes ; the whole of the gray substance of the right corpus striatum, and nearly all of its white substance, was destroyed. In this case the regular movements of the thumb and fingers (alternation of clasping and pronation with supina- tion and extension) had, during life, occurred in the left hand alone. 1 Bulletin G6n. de Thgrapeutique, Jan. 15, 1868, el seq. 2 Am. Journal of Med. Sciences, July, 1873. 3 Ibid., October, 1878, p. 348. * Brain, January, 1881. 6 See London Medical Record, March 15, 1879. 6 Etude clinique sur I'Athetose, Paris, 1878. " SeeKevue Med. Tr. et Etrangere, Jan., 1879; and London Lancet, March 15, 1879. INFANTILE PARALYSIS. 371 INFANTILE PARALYSIS. Under this name is designated what Ilandfield Jones would call paresis (diminution, withcnit total loss, of jiower) of some of the nervous centres, extending so far as, in infancy, to arrest nutri- tion, as well as to abridge power in the limbs. Adams points out the following characteristics of the aflection: 1. The paral- ysis is usually partial, single muscles or groups of muscles only being allected. 2. Sensation in the paralyzed parts is generally perfect, or nearly so. 3. The bladder and rectum are conunonly not distinctly implicated. 4. The paralyzed muscles are not rigid at any stage. Dissipation or bad health in the parents will predispose to this disease in children. No violent symptoms attend the onset of the attack, although it sometimes comes on quite suddenly. There may be moderate fever ; in a few cases, convulsions. Nausea and vomiting are quite common. The sus- ceptibility to Faradaic electricity is less than normal. In fatal cases, Kosenthal, Duchenne, and Damascina have found an atro- phic malformation of the anterior cornua of the spinal cord ; with enlargement and thickening of the blood-vessels ; the latter being regarded as the primary change.^ Spinal congestion is thought by many observers (Heine, Fliess, Laborde, RadclifFe) to be an early condition in this disease. Roth, of Bale, Prevost, Vulpian, and. others, have proved that the typical lesion of this affection is myelitis of the anterior horns of the gray substance of the cord (anterior polmmjelitis). Barwell considers it charac- teristic that the loss of power comes on suddenly, without other premonitory or attendant symptoms. But, since paralysis does actually occur during infancy, sometimes with and sometimes without evidences of spinal congestion, there is need of some further addition to our terminology to make clear the discrimina- tion among such cases. {Lancet^ Feb. 24, 1872.) Duchenne con- siders that a disorder identical with "atrophic paralysis of youth " may occur even as late as forty-five years of age. Anton Frey also refers to a "temporary paralysis" of adults, similar to that of infants, consisting in acute myelitis of the anterior cornua of the cord. The attack, in adults, is described as commencing with feverishness, delirium, deafness, and sometimes convulsions. Generally its duration is but one or two months ; if more xjro- longed, the prognosis becomes unfavorable. Mostly, with care, this affection in infants tends to recovery. But want of knowledge or of attention may allow deformity to result from it; especially club-foot. " Talipes equinus " (in which the heel will not touch tlie ground), says Dr. Taylor,'^ "is the first, and simplest, and most natural sequence of the paralysis — the weight of the foot being all that is necessary to produce it — and no other form of talipes is likely to occur while the patient lies in bed. The bend- ing of the ankle outward (talipes varus) is the result of weight on a foot with a shortened tendo-Achillis ; bending inwards (talipes valgus) of the ankle is the result of weight partially overcoming the gastrocnemius, soleus, etc., and talipes calcaneus 1 Centralblatt f. d. Med. Wisensschaften, No. 11, 1872. 2 Infantile Paralysis, p. 83. 372 DISEASES OF BRAIN AND NERVOUS SYSTEM. (where the toes are raised so as to be unable to touch the ground at the same time with the heel) of weight entirely overcoming those muscles." The author just quoted concludes, from special experience, that all such deformities are preventable, by proper care as to the position and use of the limbs and muscles of all parts of the body during the paralytic or paretic state. The treatment of club-foot is a subject for surgical treatises. '^ In some cases fatt}^ degeneration of the muscles takes place to such an extent as to render the case almost or quite incurable. Brodie observed that a case is likely to recover, in which, when the child is lying on the back, there is power to draw the limbs up by flexing the thigh towards the body. Treatment of infantile paralysis should consist of general recuperative management, including tonics (strychnia in some cases, with caution) and cod-liver oil, salt bathing, passive exercise of the affected limbs, and galvanism ; especially the constant cur- rent. The latter must be very carefully conducted in children. Local application of heat is advised by Drs. Taylor and Hammond. The former prefers dry heat ; seating the child before a fire and thrusting its legs through a screen, so as to be thoroughly warmed for hours together. Dr. Hammond immerses the paralyzed limb in hot water at 140°-160°. The hot sancZ-bath might be employed. Dr. Dio Lewis has proposed for analogous cases a siin-hath. Dr. Jacobi^ recommends small doses of ergot, internally, in the early stage of the disease, when spinal congestion is believed to exist. This practice is now followed by many practitioners. EPILEPSY. Definition. — Periodical convulsions, with unconsciousness dur- ing the attack. Varieties. — Grand mal said petit vial of the Erench ; the latter is the eclampsia minor of some writers ; in which unconsciousness occurs with scarcely any convulsion. The term " Jacksonian epilepsy" (after Hughlings-Jackson, who has best described it)'* has been applied to unilateral or partial epilei^tic convulsions ; which may sometimes involve only a small group of muscles, as those of one side of the face, one hand, or one foot. Often, how- ever, these are followed, in time, by the more usual form of attack. Symptoms. — Premonition occurs in a minority of cases before a seizure ; headache, dizziness, terror, spectral illusions, or the epileptic aura. This is a creeping or blowing sensation, like that of a current of air or stream of water, beginning in a hand or foot, and extending toward the trunk. It (if it occur) imme- diately precedes the paroxysm. Then, sometimes with a scream, the patient falls down, and is violently convulsed. Foaming at the mouth, grinding of the teeth and biting of the tongue are common ; the face is flushed, the eyeballs roll, the pupils are unaffected by light, sometimes vomiting or involuntary urination or defecation takes place •, and respiration may be very laborious. 1 Adhesive plaster has been successively used for gradually rectifying congenital club- foot, in early infaucy. 2 N. Y. Medical Record, Oct. 1, 1870. 3 Reynolds' System of Medicine, American edition, Vol. I., p. 72. EPILEPSY. 373 Epilepsy is somclimos counterfeited. Among the best tests for a genuine case (I)clasiauve, Trousseau) is a deadly pallor, inime- dvately preceding the fall of the patient in the attack.' Iluppert (Virchow's Archiv, LIX., ?> and 4) asserts that albundnuria is a constant concomitant of epileptic attacks. The fit lasts on an average from five to ten minutes. The interval between the attacks may be from several months down to a few hours. Old cases may have two or three paroxysms daily. Tliey vary much even in the same individual. The condition after the attack is various. Generally, drowsi- ness or deep sleep follows it ; or headache, debility, ordelirium ; sometimes maniacal frenzy. Homicide has been committed in this state ; for which, of course, the person is not criminally responsible. Anatomy and Pathology.— Epilepsy is not often the immediate cause of death. Autopsies of epileptics (Schrceder van der Kolk) have shown changrs. especially in the pons and medulla oblon- gata ; dilatation of the blood-vessels and extravasations of blood being prominent. Exaggeration of reflex motor excitability, with loss of the controlling power of the braiu over the spinal axis, would seem to be part, at least, of the morbid condition. Marshall Hall's idea of "trachelismus," or temporary partial asphyxia from spasm of the muscles of the neck, has been exploded. Brown-Srquard's opinion of the importance of the aura, as indicating a peripheral irritation at its seat, has, after causing the tentative amputation of a few limbs, suffered the same fate. Perhaps as near an approach as can be now had to a true statement of the pathological nature of epilepsy is that of Hughlings-Jackson : that it is the consequence of "an irregular discharge of nerve-force occurriiig in any part of the gray mat- ter of the brain or spinal cord." Diagnosis. — From hysterical convulsions, which also may be periodical and violent, those of epilepsy are distinguished by the total loss of consciousness — which is partially retained during the hysterical paroxysm. Curability belongs much more to the latter than to tlie epileptic disease. Prognosis. — Few cases of genuine epilepsy recover. The younger the patient, and the longer the interval, the more hope. Life may last indefinitely with the disease. Gradually, in most cases, the mental faculties are impaired. Yet several great men have been epileptic: CiBsar, Mahomet, Petrarch, Newton, Peter the Great, Napoleon, Byron. Canon Liddou maintains the prob- ability that the Apostle Paul was subject to epileptic attacks. Causes. — Hereditary transmission of this disease is common. Intemperance, venereal excess and self-abuse, blows on the head, and fright, are among the most frequent exciting causes. Treatment. — During the paroxysm, when habitual, little or nothing is to be done. Place the patient so that he cannot strike his head or limbs against anything hard ; loosen the clothing about the neck to favor free resj^iration and circulation ; and insure fresh air about the patient ; that is all. An occasional 1 C. B. Radcliife ; Croonian Lecture, Lancet, April 12, 1873. 32 374 DISEASES OF BRAIN AND NERVOUS SYSTEM. convulsion requires treatment ; of that more will be said here- after. (See Convulsions.) To break up the recurrence of the fits is the problem, for which a vast number of remedies have been tried in vain. To name them would be to go over almost half the materia medica. Prominent, since nitrate of silver was abandoned as useless in this disease, have been belladonna, arsenic, valerianate of zinc, digitalis, and bromide of potassium. I have known valerianate of zinc to postpone the paroxysm for considerable periods. Begin- ning with one grain twice daily, it may be gradually increased to three or four times that amount. A case of recovery occurred under my knowledge in which rather large doses of digitalis were persevered in for several months. Bromide of potassium'^ is now the favorite medicine with many ; upon the evidence that it is a direct sedative to the excito-motor susceptibility of the medulla oblongata and other nerve-centres. From ten to twenty or thirty grains, twice or thrice daily, may be given, and continued for an indefinite length of time. Dr. Echeverria found it power- less in 104 out of 486 cases. ^ Bromide of ammonium (dose 10 grains) is spoken favorably of by some who have used it. Bro- mide of arsenic is the favorite remedy with Dr. Clemens, of Frank- fort-on-the-Main. {London Med. Becord, Feb. 15, 1877.) Dr. Hammond,^ latterly, prefers bromine itself (Bromine, 5j *? water, fgviij ; dose a teaspoonful, diluted). Bannister,* Spitzka, Jewell, and others, have observed that the arrest of epileptic convul- sions by bromides is, not unfrequently, followed by furious mania. This would suggest moderation in the use of the rem- edy ; especially after its controlling influence has been shown. Combining quinine with bromides (L. Carter Gray) has been found beneficial. Strychnia is lauded by AV alter Tyrrell, of Lon- don. Dr. Weidener, of Jena, reports the cure of a„case by the hydrate of chloral, given in full doses shortly before the times of the expected paroxysms. Drs. Echeverria and MacDonald have found coniwn to act beneficially.^ Dr. Pollock,® of Charing- Cross Hospital, cured one case, which had resisted bromide of potassium, with half-drachm doses of tincture of assafoetida three times a day. Many reports have been made of success in ward- ing off epileptic attacks by inhalation of nitrite of amyl. Fr-om two to five drops may be used at a time. Nitro-glycerin has recently been so employed (as well as for angina 'pectoris) ; one or two drops of a one per cent, solution in alcohol. So simple an expedient as pulhng the great toe forcibly, is said (Brown- Sequard) to often arrest an attack. General roborant treatment may sometimes contribute to the good efiect of special nervine remedies. Cod-liver oil was found 1 In this country, at least, the introduction of hromide of potassium as an anti-epilep- tic may be credited to Dr. C. E. Brown-Sijquard. It was first used in medical practice by Dr. Williams, in England, for treatment of enlargement of the spleen. 2 Philadelphia Med. Times, Nov. 23, 1872. 3 N. Y. Med. Record, .July 2, 1881, p. 21. i Ibid., p. 18. 6 Philadelphia Med. Times, April 15, 1871. The preparation used was, in some cases, the English suceus conii (from the green fruit), in 3^ ounce doses or more; in others, Squibb's fluid extract, from the fresh unripe fruits, in thirty minim doses. « Lancet, August 21, 1869. CATAT.EPSY. 375 to do so in a nitirked instance by Dr. Fairbaira,' of Brooklyn. W. Pepper advises continued rest in bed. Several instances are reported' of benefit from nerve-stretching (median and ulnar nerves) in epilepsy. Hambursin' has recorded the cure of six cases of long standing by the continuous use of large doses (ten drops twice daily, grad- ually increased to sixty or a hundred drops) of tincture of coc- c^dus Indicus, Dujardin Beaumetz and Planat also recommend it. Gowers and Uamskill have tried picrotoxin (active principle of cocculus Indicus) without satisfactory results. Gowers found cannabis Indica to do good in a few inveterate cases ; and some such also had the fits arrested by borax, ten or fifteen grains thrice daily, continued for a considerable time. Hypodermic injection of apomorphia (j^t^ grain) will (diort an epileptic attack, with some tendency to prolong the interval before its recur- rence. Self-management is very important to the epileptic. Temper- ance, with nutritious diet, as the disease is one of asthenia, is necessar3^ Regularity of the evacuation of the bowels is a sine qna non. Abundant exercise in the open air, short of exhaustion, often does good ; systematic gymnastics have even cured some cases. They are worth trying always. Avoidance of, or the extremest moderation in, sexual intei'course must be insisted upon. Self-abuse will make recovery impossible. Tobacco ought not to be used, unless by smoking only a single pipe or a segar or two in the day. Coffee has not been generally recommended ; but Dr. Echeverria, on the basis of extensive experience, asserts that coffee is beneficial to epileptics. It has been already implied that tracheotomy, suggested by Marshall Hall, and amputation of the limb in which Vhe aura is felt, are useless although severe measures in epilepsy.* A seton kept in the back of the neck is well worth trying in every case. I have known it to promote recovery. CATALEPSY. This is a periodical disease, in which the attack is marked by unconsciousness, and fixed rigidity of all or many of the volun- tary muscles. It is rare. The attack generally lasts but a few minutes. Sometimes, in lunatics, a semi-cataleptic state of the muscles is permanent. I am not aware of any special treatment appropriate for this aftection. Management like that suitable for the epileptic will be in place also in catalepsy. Both are now so well understood to be asthenic disorders, with impaired hcematosis (blood-mak- ing) as an important element, that all reducing measures are properly omitted in their treatment. This must be essentially tonic and analeptic or restorative. 1 N. Y. Med. Record, Dec. 11, 1880, p. 671. 2 Le Progr^s Medical, Feb. 5, 1881. s Bull, de I'Acadeinie Eoyale de Med. de Belgique, No. 2, 1880. ■» Another operation, cli/orUlccfonu/, practised by Baker Brown, of London, in certaia cases in females, has not met with favor in the profession. 376 DISEASES OF BRAIN AND NERVOUS SYSTEM, HEATSTROKE. Synonyms. — Sunstroke; Coup de Soleil; Insolatio. Two forms of heatstroke undoubtedly occur. In one the direct rays of the sun upon the head induce cerebral congestion; in the other exces- sive heat, often not under the immediate influence of the sun, affects the whole system with prostration, apparently from a hlood- change; the chemical operations of the economy being modified by heat in a manner incompatible with the vitality of the blood. Nerve and muscle-tissue are at the same time impaired. After death, Arndt has found the large veins generally distended with uncoagulated blood ; the heart contracted, the brain, liver, and kidneys anaemic but swollen with oedematous effusion. Symptoms. — G-enuine swistroke is commonly sudden. Falling unconscious, the head is very hot, the temporal arteries distended; the breathing is apt to be stertorous (snoring), the pulse full, gen- erally rapid, but in a few instances slow. In severe cases convul- sions may precede death. In heatstroke of the second variety (more common than the first), almost equal suddenness marks the attack. There is, however, no excessive heat in the head; the pulse is rapid and weak ; unconsciousness is less complete, and without stertor of the breathing; the whole condition resembles syncope rather than apoplexy. Causation. — It is remarkable that few cases of heatstroke occur in the country among farm laborers, and very few at sea, even in the tropics. Large cities afford nearly all the cases. In 'New York over 800 cases have occurred in a single week (1868). This looks as if the atmosphere had much to do with predisposing to it, at least by deteriorating the blood and lowering the resistance of the vital energy. In tropical climates the attack often occurs at night. It is almost always, in the case of heat-exhaustion^ those who have been fatigued by exertion in the sun or shade who are over- come. Drinking largely of cold water when thus exhausted in- creases the danger. Intemperate persons are particularly liable to heatstroke. Treatment. — For heat-apoplexy^ cupping or lee.ching the back of the neck or behind the ears should generally be the first remedy, after the application of ice or iced water freely to the head. The head and shoulders should be kept raised. A pur- gative enema should also be administered, and sinapisms applied to the lower limbs. Heat-exhaustion requires quite different treatment, in part at least. Cold water or ice should be applied to the head and body, and then sinapisms to the spine, epigastrium, and limbs, in turn. First cool the blood, and then excite physiological stimulation. Local depletion should be avoided. If syncopal symptoms be decided, ammonia may be for a few moments applied to the nos- trils, and, if the patient can swallow, aromatic spirits of ammonia may be given by the mouth, 10 drops every fifteen minutes at first, gradually increasing the interval. Mixed cases of course occur, demanding an intermediate or composite treatment. A. R. Hall, of India, has found the utmost benefit from the hypo- INSOMNIA. 377 dermic injection of sulphate of quinia in heatstroke.' Brown- Sdquard assorts the aduul cautery, with a liot iron momentarily applied, to be very serviceable. INSOMNIA. Definition. — Morbid wakefulness ; impossibility of sleep. Causation. — Apart from pain, or severe acute disease affecting the brain (as delirium tremens), insomnia may be brought on l)y intense or prolonged mental labor or emotional excitement. Ex- cessive use of strong coffee or tea, or belladonna, stramonium, or cannabis indica, may produce it. Pathology. — Only within a comparatively recent period (Dur- ham, Hammond) has the correct view been adopted, that during sleep the arterial circulation of the brain is at its minimum. In sleeplessness the most certain error loci is an erethism (morbid erectility) of the cerebral arteries, -which keeps their circulation full and prevents sleep. It is not possible to be sure that this is all, as the precise nature of brain-action and nerve-force is unknown. But this furnishes a basis for rational management. Treatment. — This must vary with the cause. The overworked brain of the professional, literary, or business man must be with- drawn from his employment. Irregularity of the circulation dependent upon general debility must be met by tonics and generous diet. Accumulation in the head must be diminished by such physical exercise as the strength will bear. Decided cerebral exhaustion is apt to be attended by such loss of nerve- force as will forbid much effort of any kind ; but milder cases of insomnia will be benefited by exercise. The brain should be especially allowed to rest from excitement near the usual hour for sleep. Hence a walk, or the use of dumb-bells, just before bedtime, will be suitable. If the stomach is empty, a little easily digested food, even late at night, will promote sleep, not- withstanding the familiar fact that heavy suppers induce wake- fulness or nightmare. A glass of lager beer at bedtime is, as my own experience has proved, one of the best of hypnotics. The warm bath or pediluvium, with cold to the head, will some- times be serviceable in abstracting blood from the brain. Posi- tion of the body is important. The sufferer from insomnia may often be very sleepy before lying down, yet after going to bed he becomes wide awake. Several jiersons in such case, to my knowledge, have found it best to recline with the head and shoulders raised. Thus, by gravitation, the flow of blood to the head is retarded and sleep is promoted. As medicines for simple insomnia, in the absence of pain, opium and other powerful narcotics are not appropriate. Hops, lactuca- rium, and hyosoyamus arc safer. Bromide of potassium, in 10 or 20 grain doses, is much used as a cerebro-vascular sedative [F. 1 Dr. Herbert Norris treated successfully, in the Pennsylvania Hospital (1868), four cases, in which restlessness was a prominent symptom, by the hypodermic injection of one-quarter of a grain of sulphate of morphia. Dr. Marino, of Palermo, asserts that ergothi, hypodermically used, is very efficacious in sunstroke. — Gazz. Clin, di Palermo, June, 187G. Tomlinson and Murphy report success with hydrochlorale of aiiomoriihia ; one-sixteenth of a grain producing vomiting and relief. — PractUioner, June, 1880. 32* 378 DISEASES OF BRAIN AND NERVOUS SYSTEM. 134], Its action appears to differ from tliat of morphia^ as it will not produce sleep by narcosis in a healthy person. It seems rather to relieve insomnia by allaying the local or general irrita- bility which causes or maintains it. Dr. Da Costa ^ has found the combination of bromide of potassium (40 grains) with opium or morphia to correct the unpleasant effects of the opiate, while it adds to its hypnotic power. Hydrate of chloral is a positive and valuable soporific. In 15 or 20 grain doses it seldom fails, and is rarely followed by any disagreeable after-effects. NIGHT-TEREORS. Dr. C. "West^ gives the following description of an attack which is not very uncommon, occurring in infants or children under ten years of age. "A child who has gone to bed apparently well, and who has slept soundly for a short time, awakes suddenly in great terror, and with a loud and piercing cry. The child will be found sitting up in its bed, crying out as if in an agony of fear, ' Oh, dear! oh, dear! take it away! father! mother!' while terror is depicted on its countenance, and it does not recognize its parents, who, alarmed by its shrieks, have come into its room, but seems wholly occupied with the fearful impression that has aroused it from sleep. Iii from ten minutes to half an hour, as the terror abates, it may become quiet at once and fall asleep ; but frequently it bursts into a fit of passionate weeping, and sobs itself to rest in its mother's arms. In some instances a quantity of limpid urine is voided as the fit passes off, but this occurrence is by no means constant. Usually the remainder of the night is passed in toler- ably sound sleep ; two attacks do not often occur in the same night." "Seizures of this kind may come on in a great variety of circumstances, and, according to the cause whence they have arisen, may continue to return for many weeks together, or may occur but a few times. As far as I have had the opportunity of judging, they are never the indications of primary mischief in the brain, but are alwa5^s associated with some disturbance of the intestinal canal, and more or less obvious gastric disorder. In the majority of cases constipation of the bowels exists." My experience with such cases confirms that of Dr. "West, as indicating that these attacks do not prove disease of the brain. But the nervous system of a child so affected must be morbidly susceptible ; and signs of indigestion, constipation, or irritation of the bowels are not always present. During the attack, the child should be at once gently lifted up from the bed, and either carried for a few moments or laid down in a different position. Washing the face softly with a rag dipped in cool or cold water may arouse thoroughly. If any medicine be suitable, it will be a teaspoonful or two of camphor-water. Care is needed to prevent the attacks. Violent exercise and mental excite- vient are almost as apt to bring them on as indigestion or consti- pation. The bowels should, however, be kept open, as by fluid extract of rhubarb, or senna, etc. Bromide of potassium is 1 Am. Journal of Med. Sciences, April, 1871, p. 359. 2 Diseases of Children, p. 210. TON vur,sioNS. 379 advised by Dr. S. Ringer iii obstinate recurrent attacks. Some practitioners prefer cbloral, in from tbree to six grain doses. To promote tranquil sleep, some one sbould remain witb tbe cbild, if timid, for a wbile after it goes to bed ; or a ligbt sbould ])e left burning low. A cbild liable tonigbt-terrors ougbt to be allowed to linisb its morning sleep undisturbed. Abundance of sleep is sedative to an over-excitable brain. Neglect of such precautions may convert a mere transitory functional disturbance into a serious attack of brain disease. CONVULSIONS. These may be classified as, principally, infantile, epileptic, parturient and puerperal, hysterical, and occasional convul- sions. During infancy, causes which in an adult would cause delir- ium produce convulsions ; excito-motor action having in early life the ])redominance, and being then less under the control of the brain. They are, usually, of less serious prognosis in the infant than in the adult. The exciting causes of infantile convulsions are numerous. Constipation of the bowels ; indigestion ; worms ; irritation of the gums in teething ; and excitement of the brain, as by fright, are the most frequent. Many acute and chronic diseases of infancy (c. r/., scarlet fever, meningitis, hooping-cough, etc.), have convulsions among their occasional symptoms or complica- tions. Sudden drying up of eruptions on the scalp may bring them on, also. Bouchut has shown that cerebral thrombosis (obstruction of the veins by coagula) is often the pathogenetic cause of convulsions in the chronic diseases of childhood. Premonition of a fit may be observed in a child's fret fulness, or restlessness, or gritting of the teeth in sleep. When a fit comes on, the muscles of the face twitch, the body becomes rigid at first, then in a state of jerking motion ; the head and neck are drawn backward, the limbs violently flexed and extended. Some- times these movements are confined to certain muscles, or are limited to one side. Nurses call by the name of " inward fits " cases in which the limbs move but little, but the countenance is aflected, tbe eyes are unnatural in expression, or roll spasmod- ically, and the body is more or less rigid. During a fit, con- sciousness is absent. The eye shows no sign of sight, though open ; a finger passed over it does not make it wink. The pupil is immovably contracted or dilated ; the ear is insensible even to loud sounds. The pulse is small and very frequent ; breathing hurried or labored ; skin wet with perspiration, often cold and clammy. After this condition has lasted a few minutes it mostly gives way. The child fixUs into a quiet sleep ; or it becomes con- scious and bewildered ; or gradually resumes its ordinary healthy state ; or dies in the fit. Sometimes one attack is followed by an- other, with intervals of conscious or unconscious quiet between, for many hours. These are the most serious cases, although recovery often happens even from them. Salaam convulsions, or nodding convulsions of infants (eclampsia nutans), are a rare form of disease, usually the precursor of epilepsy. 380 DISEASES OF BRAIN AND NERVOUS SYSTEM. Treatment.— Ascertain, if possible, the cause of the convulsion. If the gums are swollen, or have been tender and irritated, at the time of teething, lance them freely; dividing the gum with a sharp gum-lancet down to the coming tooth. This' practice, formerly universal, has been objected to by Trousseau, and scarcely sustained by Rilliet and Barthez. Marshall Hall strongly urged it, in accordance with the theory of reflex irritation, which explains the convulsions of abnormal dentition. Dr. C. "West says "'the circumstances in which the use of the gum-lancet is really indicated are comparatively few. " If this be true, I believe that they are, nevertheless, very impor- tant. Dr. A. Jacobi (Dentition and its Derangements, p. 171) testifies that he has seen, once or twice, the instant cessation of convulsions upon lancing the gums. Dr. J. Finlayson^ has collected reports of a number of fatal hemorrhages following the operation. Others assert injury to the growth of the teeth, cic- atrices, etc. All these objections do not, in my mind, outweigh the frequent and manifest advantage which I have seen in prac- tice, from clean, free incisions (not gouging or laceration) of the gums, when they are congested or inflamed, or when, with tension. without congestion, they are evidently a source of nervous irritation to the child. I have several times known a child, after the experience of relief obtained, asfc for the use of the lancet. In a very extensive practice, lasting for half a century, my father, the late Dr. Joseph Hartshorne, met with no accident from lancing the gums, and retained his confidence, to the last, in its frequent utility. If the bowels have not been moved, or if the abdomen be swollen and tense, give at once an enema, of castor oil, soap, and molasses [F. 141J, or some other laxative material, with warm water. When the head is hot, apply cold water all over it, by wet cloths, renewed every two or three minutes. If the fit lasts long enough for it, place the child in a warm bath ; sup- porting, of course, the head while the body is immersed. Then mustard plasters may be applied, to the back, epigastrium, and legs, at once, or successively.^ Bleeding from the arm is to be recommended only in a child of known vigor and fulness of system, the attack being severe, and not habitual. But a moderate amount of blood should be taken. Cupping the back of the neck, in doubtful cases, where time is allowed by a protracted fit, may be resorted to. Pressure upon one or both carotid arteries is said, by M. Favez, to have promptly succeeded in checking convulsions. Etherization, so much used by some practitioners in puerperal convulsions, requires certainly more caution in its use in infants. I regard it as justifiable in an obstinate case at any age ; watch- ing its effects. Dr. J. Lewis Smith uses with reported advantage rectal injections of hydrate of chloraU Convulsions of Pregnancy. — Probably about one pregnant 1 Obstet. Journal of Great Britain, December, 1873, and January and February, 1874. 2 The objections urged by Dr. Hammond and some others to this usual practice do not appear to me to be well founded. 3 N. Y. Med. Record, May 8, 1880, p. 522. CONVULSIONS. 381 woman in fifty has more or less albuminuria,' principally from the pressure of the womb upon the renal veins producing con- gestion of the kidneys. Ai)out one in ten of these will have epileptiform convulsions, either during gestation, while in labor, or after delivery. Pathology. — All convulsions of pregnant women are not uraimic; this has been proved. There are (putting aside in- stances of Bright's disease already existing) several conditions possible: 1. Urremia ; 2. Cerebro-spinal reflex irritation, of uterine origin; 3. Cerebro-spinal (apoplectic) congestion, con- nected especially with the bearing-down eftbrts of labor itself; 4. According to Traube, cerebral tedema and consequent ansemia. Treatment, — It is important, particularly during gestation : 1. That plethora should be avoided ; 2. That free action of the kid- neys, as well as regularity of the bowels, should be maintained. For the first, care of the diet is proper, that, in women of full habit, it be not too highly animalized or stiiiiulant. If head- ache, with a full, hard pulse, occur, a mild cooling laxative may be given ; if not relieved, cups to the nucha or bleeding from the arm will be a safeguard. When urination is not free and copious, even if no albumen appear in the urine, cream of tartar, a tea- spoonful or more every day or two, or acetate of potassium, may be a useful prophylactic, by favoring free excretion from the kidney. When convulsions actually occur, in the pregnant or puerperal state, the question is to be considered — are they reflex, ursemic, or simply congestive or apoplectic? When they come without previous signs of cerebral disturbance, in a woman of delicate and impressible nervous organization, "without much heat of head or snoring respiration, the pulse being rapid and feeble, it is probable that refleo: irritation is the nature of the case. Counter-irritation by dry cups to the spine and sinapisms to the epigastrium and limbs, and etherization, may be here used. Inhalation of nitrite nf amyl (a few drops') sometimes relieves.^ Where the convulsions are repeated, hydrate of chloral, in full dose, has been given (A. Milne). Conderau has found advantage in using a hypodermic injection of three-fourths of a grain of muriate of morphia, followed in a few minutes by a large dose (a drachm or more i of chloral hydrate. In convulsions beifore labor, Fordyce Barker combines the hypodermic use of morphia with the inhalation of chloroform. Dr. Fearu'' and others repoi't excellent results with large doses (half a drachm or a drachm of ISTorwood's tincture, or one-half as much of Squibb's extract) of veratrinn viride. This remedy, so powerfully depressing under ordinary circumstances, can surely be adapted only to sthenic cases ; especially in vigorous women, where the pulse is hard or firm as well as rapid. Some unfavorable results under its employment 1 A different reaction with oxide of copper and potassa has been observed in the albu- men of Hriifht's disease, from that of the albuminuria of pregnancy. aVV. F. Jenks, Philadelphia Med. Times, Aug., 1872. 8N. Y. Medical Kecord, March 16, 1874. Dr. Fearn's first paper on the subject was published in 1869. 882 DISEASES OF BRAIN AND NERVOUS SYSTEM, have been reported. Still, in desperate cases, it is well worthy of further trial. Brauu (1879) treated a case successfully with hypodermic injection of inlocarpin. When plethora has been present, and the head is hot, its vessels distended, the coma profound, with snoring respiration, and full, rather slow pulse, either ursemia or simple congestive apoplexy is to be concluded upon. In either case, but especially in the latter, bleeding from the arm, or by cups from the back of the neck or temples, will be advisable. Laxative enemata may be used also. After bleeding, if the convulsions be protracted, while the coma is less intense, careful inhalation of ether or chloroform may be tried ; but it is less hopeful here. The prognosis of the apoplecti- form convulsion is always one of great danger. The urcemic condition, if labor be survived, generally passes off spontaneously, soon after delivery. The signs commonly interpreted as indicating plethora during pregnancy are by some (Cazeaux) ascribed to hydrcemia, with (Frank, Munk) increased arterial tension. If this view be correct, as it may be, probably, with regard to some cases, we may still expect moderate venesection to be a useful mode of treatment ; only, the support of the patient ought to be afterwards provided for by strong, concentrated nourishment.^ Prof. J. Carson, in an elaborate article^ on puerperal eclampsia, asserted the belief that the tendency to convulsions during pregnancy depends upon " altered nutrition of the nervous centres." Upon the idea of "oedema of the brain" Jaquet, of Berlin, advises the wet pach (sheet wrung out of cold water) for diapho- resis. Occasional convulsions in adults, from whatever cause, should be studied and treated upon the same principles, essentially, as those just Ifiid down for the convulsions of pregnancy. Hysteri- cal convulsions will be considered under Hysteria. CHOREA. S3niOiiym. — St. Vitus''s Dance. Symptoms. — Irregular movements of the voluntary muscles, over which the wiU has but partial control. Walking, in severe cases, is difficult or unsafe ; the hands cannot be regulated enough to write or work ; speech may be affected ; the muscles of the face often twitch grotesquely. During sleep all these movements cease. The pupil is, in some cases, unnaturally dilated ; palpitation of the heart may occur ; and also constipa- tion and indigestion. The urine is of great density. A cardiac murmur is often heard on auscultation, which Sir Wilham Jenner affirms^ to be owing to irregular action of the muscular appa- ratus of the mitral valve ; sometimes with irregular contraction of the heart itself. Prognosis.— The mean duration of chorea is about four weeks ; but it may last for several months. Recovery, if the attack be 1 See Fordyce Barker on Bloodletting in Obstetric Medicine ; D. Appleton & Co., 1871. 2 Am. Journal of Med. Sciences, April, 1871, p. 405. SLancet, Nov. 5, 1870. CHOREA. • 383 uncomplicated, may always be anticipated. Dr. J. ^Y. Oslo, however, has reported the details of sixteen fatal cases.^ The so-called post-paralytic chorea (Weir Mitchell), hemichorca, or heniikinesis of Hughlini^s-Jackson, is a quite dillerent affection from ordinary chorea. It follows hemiplegia, in rare instances, and is often incurable. The occurrence of any form of paralysis, in a case which commences as chorea, is always a very unfavor- able sign ; although patients thus affected may often live for a long time. Complications. — Endocarditis and pericarditis have been ob- served in connection with chorea in a number of cases. Gen- erally, however, the affection of the heart precedes the chorea ; both probabl}' depending upon the same cause, rheumatism. Men- tal derangement sometimes accompanies chorea. Drs. Kirkes, Hughlings-Jackson, and Broadbent believe the disease to be often dependent upon embolism of the cerebral arteries ; especially those of the corpus striatum and thalamus. Paralysis complicating chorea increases greatly, of course, the seriousness of the case. Although it may be of the transient, hysterical form, yet the danger exists that it may be the result of organic lesion of the brain or spinal cord. Causation. — From six to sixteen, in both sexes, especially often in girls, chorea occurs. It is extremely rare in negroes. Nervous deljility is nearly always present before the attack. Fright is a frequent cause. Over-flitigue, or mental excitement, blows or falls may produce it. Rheumatic fever is sometimes followed by it. Treatment.— Good diet, salt-bathing, and systematic gymnastic exercises (light gymnastics or calisthenics) will suffice for mild cases. Where marked antemia exists, iron (citrate, phosphate [F. 142], or pyrophosphate, tincture of chloride, syrup of iodide) is important. Obstinate cases may be treated with Fowler's solution of arsenic, in small doses, gradually increased. Cimici- fuga has been a good deal used, perhaps with benefit. Cod-liver oil should be given if great debility exists. Gcdahar hean (physo- stigma) has been introduced as a remedy in chorea ; f3ss of the tincture, or from gr. j to gr. vj of the powder thrice daily. Dx*. C. West confides in the sulphate of zinc. Dr. Hammond has used the sulphate of 'manganese with success. Ether-spray applied to the spine, four or five minutes at a time, every day, is reported to have been curative in the hands of Dr. John Rose'-* and Per- roud of Lyons. ^ Bromide of potassium has been tried, without very much advantage. Chloral ought to be of service in this disease. Trousseau used strychnia ; if employed, it should be with great caution. Electricity has sometimes done good. It is well to separate a child having severe chorea from other children ; both because of the annoyance of their curiosity, and because sympathetic irritation sometimes extends the affection from one to another. This has been repeatedly observed. 1 Brit, and Foreign Medico-Chirurg. Review, January, 1868. - Lancet, Dec. 10, 1870. ■> l^hil. Med. News, February, 1870. 384 DI-SEASES OF BRAIN AND NEIiVOUS SYSTEM. APHASIA. Loss of speech may occur as one of the symptoms of disease of the brain, either functional and transient, or organic and irremovable. Such a loss of language is termed (Bouiilaud) aphasia. Importance has been given to it by the observations of Trousseau and others, and resulting speculations (Dax. P. Broca) as to the seat of the faculty of speech. Kot articulation, as in aphonia, but expression is, in this affection, wanting. The power to write words from memory, to convey meaning, is lost ; but, in some cases, at least, they may be copied correctly. ThinMng without ivords may go on in such instances ; as Lordat recorded, after recovery, in his own case. In certain cases, especially in hysterical persons, the loss of speech appears to be "spasmodic" or functional, without permanent disease of the brain. Hemiplegia of the right side has in a number of examples coin- cided with aphasia ; and, several times, also, autopsy has shown softening or other lesion of the left anterior portion of the cere- brum. On the suggestion of these facts a hypothesis has been based, that the site of the faculty of language is in the third anterior frontal convolution of tlie left hemisphere of the cere- brum. This is a very unphysiological supposition, in view of the symmetry of the cerebro-spinal axis throughout ; nor does this objection disappear even upon the conjecture that the "organ" upon the right side may exist always in an undeveloped state. A remarkable case has been reported,^ in which impairment of speech followed a severe injury of the right cerebral hemisphere. A number of instances of a similar kind, adverse to Broca's theory, have been collected by Dr. J. W. Ogle.^ Valvular lesion of the heart sometimes accompanies aphasia. Embolism is pos- sibly an occasional cause of it. Dr. H. C. Bastian^ divides the cases into aphasia, when the patient can think, but cannot speak or write ; aphemia, when he can tliink and write, but not speak ; and agraphia., when he can think and speak, but not write. Cases of aphasia are rare. I am not aware of any special measures of treatment for it pointed out as yet by experience. Dr. Osborne recommends (having succeeded with it in one case) teaching the patient to speak anew, as is done in infancy. While this can have no effect upon the cerebral lesion, it may much diminish, in some cases, at least, the inconvenience of the resulting symptoms. TETANUS. Definition.— A disease characterized by continued and intract- able tonic contraction of the voluntary muscles. Trismus is local tetanus or lock-jaw. Symptoms. — Stiffness of the muscles of the jaws commonly 1 Western Journal of Medicine, March, 1868. 2 London Lancet, March 21, 1868. See also Dr. Wadham's case, St. George's Hospital Reports, 1869 ; and one reported by Dr. Echeverria (N. Y. Medical Record, March, 1869), in which post-mortem examination revealed sclerosis of both third anterior frontal convolutions, without symptoms of aphasia having occurred. 3 Brit, and Foreign Medico-Chinirg. Rev., January and April, 1869. TETANUS. 385 begins the attack. This extends to the throat and neck, face^ trunk, and lastly to the limbs. Thouixh never ceasing entirely, the spasm of the muscle is paroxysmally increased. Sometimes opwUiotonos occui's, i. c, arching of the body upon the back and heels, the abdomen projecting ; or emprosUiotonos^ arching for- ward, the face approaching towards the toes. Pleitrosthotonos, or lateral curvature, is much more uncommon. Chewing food is impossible; swallowing nearly or quite so; respiration becomes very diflicult. The patient suffers dread- fully, and cannot sleep; but delirium scarcely ever occurs. Death in most cases takes place within a week. Varieties. — These are, 1. tetanus from cold (idiopathic), 2. traumatic tetanus (from an injury), and 3. trismus iiascentmni^ or tetanus of infancy. The first is least certain to be fatal. The third, tetanus oieonatorum, is rare in Philadelphia, some- what less so in the tenement houses of New York ; common in Iceland, the Hebrides, and some tropical countries. It was formerly not very uncommon among the negroes of the planta- tions of the Southern States. Its chief cause is dose, unsanitary living. Some foundling hospitals have suffered great mortality from it. The time for its occurrence is mostly within the first two weeks after birth ; and death usually occurs within two or three days. In symjjtoms, this form of tetanus differs from that of adults chiefly in the frequent occurrence of clonic spasms of the voluntary muscles, or of paroxysms of extreme rigidity. These are produced by slight causes ; as a sudden sound, a fiash of light, a breath of air. Recovery from the attack is scarcely to be looked for in any case. Yet recoveries have been reported ; by Drs. Gaillard and De Saussure, under treatment with can- nabis indica; by Dr. G. Troup Maxwell and others, with chloral. Dr. Osterlong, of Kentucky, has succeeded with injections of chloral into the rectum. CoUes, of Dublin (181S), called attention to evidence making it appear that inflammation of the umhilicus connected with the cord is a frequent local source of tetanic irritation at the time of birth. Sims (184G) published cases seeming to show that pressure of tJie occipjital bone upon the medulla oblonc/ata at the time of delivery produces trismus nascentium ; and that laying the child upon its side at once after birth may prevent the attack. But many cases of the disease have occurred in which neither Colles' nor Sims' mode of causation could be ascer- tained. While, therefore, each may have a considerable share in its production, neitlier can be regarded as universal or essential. Much the greater number of cases, after infancy, results from lacerated and punctured wounds ; but amputations and other operations may be followed by tetanus. Irritation (not inflam- mation) of tlie ends of sensitive nerves, transmitted to the spinal cord, produces the reflex spasm, whose general extension and continuance prove fatal. Strychnia, in poisonous doses, causes a very similar state. While there can be no doubt that the spinal marrow is the seat of tlie disease, no characteristic organic change has been found in it ; sometimes not even congestion. 33 Z 386 DISEASES OF BEAIN AND NERVOUS SYSTEM. Dr. Allbutt has recently^ reported softening of the cord in four traumatic cases. Causation.— This is principally included in the above ac- count. Treatment.— In two cases of tetanus which I have seen to re- cover, opium and brandy were the remedies used. A tablespoon- ful of brandy or whisky (to an adult) every two or three hours, with milk or beef-tea, and a grain of opium every three or four hours, may be given. The opium may be, if needful, increased to a grain every hour at night, and every two hours through the day. Beyond that I would not go. Hypodermic injections of morphia will answer the same purpose. Chloroform and other ansesthetics, by inhalation, have been tried, with variable effect ; nearly always without success. Bel- ladonna, conia, aconite, hydrocyanic acid, cannabis indica, tobacco, woorara, and quinine, are among the many medicines favored by different practitioners. Demme is said to have cured eight cases out of twenty-two with curara. Drs. E. Watson, of Glasgow, and Frazer, of Edinburgh, have used Calabar bean, one grain at a dose; or five drops of the tincture.^ In so des- perate a disease it is excusable to give them all further trial. Dr. Joseph Hartshorne used vigorous counter-irritation all along the spine, by the decoction of cantharides in turpentine (lini- mentum cantharidis). Lately chloroform has been locally used in the same way. Hammond advises the use of ice-bags to the back ; Sporer, a succession of hot-water compresses along the back. Per- roud, of Lyons, has employed successfully the application of ether- sxjray to the spine ; Demarquay, the hot-air hath. CJiloral has been emi^loyed, with recovery in some, though not in all cases, by Ver- neuil, Dufour, Denton, Lavo, Beck, Coryllos, Lewis, ^ and others. It has proved to be esiiecially beneiflcial in trismus nascentium. Prof. E. de Eenzi* draws the following conclusions from his observations of tetanus : 1. Light renders the tetanic contractions of animals and man more frequent and intense. 2. It can be demonstrated experimentally in animals, that ahsolute repose during the absence of all stimulus, retards the teta- nus and renders it less fatal. 3. Of three cases of severe tetanus, treated almost exclusively by absolute repose, two cases were cured. The patients were kept isolated in a dark room ; all noise or other stimulus or irri- tation was avoided, except such as was caused by the adminis- tration of food and beverage at long intervals. When, after severe local injury, the nerves of the part appear to be involved and tetanic symptoms occur. Key and Bryant approve of amputation. In 1845, Key performed this operation successfully on account of tetanus following unreduced disloca- 1 Med. Times and Gazette, Feb. 18, 1871. 2 Dr. W. W. Keen (Phila. Med. Times, March 1, 1871) gave the tincture of Calabar bean (physostigma venenosum) in doses of orae or two hundred minims, in a case in which recovery "occurred. Of 18 cases (collected by Dr. E. Watson) in which physostigma was used, 10 recovered. — Practilioner, September, 1869. 8 Am. Journal Med. Sciences, October, 1877, p. 420. 4 Gaz. Med. Ital. Lombard., January, 1875. H YD It OP HOB I A. 387 tion of the astracfilns, Sovoral other cases seem to justify the practice in anal()r. Ballard, of London, has given- statistics showing that while humanized virus aflbrda 978 successes for 1000 insertions, the best results with animal virus do not exceed 700 per 1000 insertions. Dr. II. Stevens, of the English Local Government Board, who has probably vacci- nated as many children as any one, declares that he has seen no ground for the opinion that humanized lymph has lost its true and original Jennerian character. It is at the same time possi- ble that many transits througli hvmian bodies may somewhat modify the virus. Renewal by inoculating healthy children, not too young, every now and then, from the udder of the cow, is to be recommended. Cattle with the cow-pox may be found in almost any agricultural neighborhood. As Dr. B. Lee'' has w^ell pointed out, the most reliable, often the most active virus, is that which has been recenthf humanized; especially if it be but one or a few removes from the cow-pock. In the absence of small-pox the second month of infancy will be time enough for vaccination. But under danger of exposure, a babe should be vaccinated at any time after birth. Matter only from healthy children ought ever to be used. While it is unlikely that any constitutional disease (as syphilis' or scrofula) will be so introduced, there should, in practice, be no room left for any doubt of the kind ; and some cutaneous diseases might certainly be transmitted. Unless on account of risk from exposure, the existence of an eruption of the skin, or any other indisposition of the child itself, may be a reason for postponing the operation. The excitement produced by it may aggravate an existing inflam- matory affection. Vaccination has often been blamed for the breaking out of eruptions, supposed to be transmitted, when their cause was really the state of system of the patient. For the operation, the outside of the arm, near the shoulder, is commonly selected. The exact method used is not important. A small wedge-shaped lancet, or even a sharp- pointed penknife will do. Various slides have Fig. 119. been contrived for the purpose. I prefer to cut ^ or push out a very small flap of the cuticle, ^; uncler which a thick paste, made by pressing ^; and mixing a portion of the scab with a drop ^^ of tepid water, may be inserted. Or, instead of the scab, a lancet charged with fresh lymph (arm to arm) may be employed. Or, to use the quill with dried lymph, dip it for a 1 Twelfth Report of the Medical Officer of the Privy Council, Appendix No. 7. Lon- don, 1S70. 2The Practitioner. February, 1S80. 3 New York Med. Journal, May, 1872. * At Rivalta, Italy, and Morbihan, in France, and in England, a number of cases of syphilitic disease (primary and secondary), following impure vaccination, have been reported ; the best instances by H. Roger and DepauCand by Jonathan Hutchinson of London. But West, Marson, Seaton, Loines, and others assert the alarm concerning it to be groundless, as the instances of it are excessively rare, and ahcnys preventable. In North Germany (Auspitz, Wiener Med. Wochenscrift, Jan. 25, 1873X only one or two examples of it occurred in twelve million vaccinations. 35* 414 ZYMOTIC DISEASES. moment in tepid water, and apply it to the abraded or incised part. The art of the operation is to pierce the skin without drawing enough blood to flow. Besides the flap it is well to scratch the skin and puncture it at a little distance, giving three chances of taking instead of one ; or several small scratches will do (Fig. 119). ]f o disturbance of the arm must be allowed for twenty minutes or half an hour afterwards. If it be successful, no sign of it is distinctly visible for two or three days. On the fourth day a decided small red pimple is to be seen and felt. This becomes a vesicle of some size on the fifth day ; it grows large and cylindrical, or hat-shaped, and by the tenth or" eleventh day is fully umbilicated, or depressed like a navel in the centre. Before that, about the eighth day, the bright red ring or areola forms around it. This fades after the eleventh day, and the vesicle dries up into a round and flat, but rather thick, mahogany-colored scab, which falls off about the nine- teenth day. All of these particulars are important, as showing the genuineness of the vaccination. So is the appearance of the cicatrix left ; which should be large in proportion to the vesicle, and dotted or marked with subdivisions. This is owing to the vesicle being composed of several small cells or compartments. Slight fever, with restlessness, is not unfrequently observed dm'ing the first few days after the vesicle appears ; but there is rarely anything requiring treatment. Re-vaccination. — Experience shows that a number of persons, after several years, reacquire the susceptibility to small-pox. As the only test of tliis is exposure either to the latter or vaccinia, the renewal of this, at least once after puberty, is always advisable. On the occasion of epidemic small-pox it may be repeated again and again. There is no pain of any consequence in the operation, nor danger, and if a genuine vesicle form, making a sore arm, that discomfort for a few days cheaply pur- chases immunity from the terrible disease, I have sometimes thought it possible that the system may be protectively affected by re-vaccination, even when no local effect or only a " spurious " sore follows. Certainly small-pox is extremely rare in re-vac- cinated persons,^ M. Danet, in an official report, insists that persons who have had small-pox should also be re-vaccinated. The virus from a second vaccination should not be relied upon for use. VAKICELLA. Synonym. — (Jliicken-X)OX. This is a mild exanthematous disease resembling small-pox or varioloid considerably. Hebra, of Vienna, asserted its identity with variola ; but this opinion is not well sustained by facts. After an incubation of four or five days from exposure to the contagion of one having it, pimples form, gen- erally scattered widely. In the second day they become vesicles 1 According to testimony obtained by a Medical Conference upon the subject of vac- cination at Paris, in 1870, the proportion of the re-vaccinated liable to variolous infec- tion is 2.33 per cent. Prof Corfield, of London, has stated (Nature, Oct. 16, 1873), that, of fifteen thousand cases of small-pox in the London hospitals during the last epidemic, only four presented j)roof of having been re-vaccinated. In 1880 (Buchanan) the death-rate per million in London from small-pox was 90 among the vaccinated against 3350 among the unvacciaated. SCARLATINA. 415 filled "with lymph. Two or tlircjo days more find them scabbing ; they dry and lall off soon, witjiout pitting, except in rare instances. There is little or no fever or other indisposition. The disease is attended with no danger to life, and requires only precautionary treatment, i. c, to avoid exposure to cold and wet, to keep the bowels regular, and, if needful, promote action of the skin by a diaphoretic, as neutral mixture or hq. ammou. acetat. The eruption of varicella differs from that of variola in coming out in successiv^e crops; in not suppurating or becoming umbil- icatcd ; and in not deeply involving the true skin. Inoculation has been found to foil in propagating it, and vaccination has no preventive power over it. Adults are very seldom affected with it, and it is more often epidemic than small-pox. SCARLATINA. Synonym. — Scarlet fever. "Varieties. — Scarlatina simplex, anginosa, and maligna. Symptoms and Course. — After an incubation usually of about five days from exposure to its cause, lassitude, anorexia, head- ache, pains in the back and limbs, mark the beginning of the attack. Soon these are followed by fever ; on the first day, very often, the throat is sore. On the second day, usually, a punc- tated red eruption appears on the face and neck, and in ten or twelve hours has covered the whole body. It is of a scarlet or, sometimes, a brick-red hue, uniformly diffused, with a swollen appearance and great heat, reaching by the thermometer lOo'^ or 106° Fahr. Occasionally miliary vesicles are seen. There is also a sense of burning and some soreness or irritation of the skin. The tongue has a strawberry-like look, from the projec- tion of enlarged red papillce through a whitish fur. The throat is very red and swollen, generally, with a hue not unlike that of the skin. Fever runs very high, with an extremely rapid pulse, great thirst, headache, perhaps delirium, costiveness, in some cases vomiting. Bad cases may have stupor. By the fifth day, mild examples of the disease show already an abatement. Most have passed the height of the pyrexia by the ninth ; although sequelce may protract the attack much longer. Malignant cases* may be fatal in a day or two, or even in less than twenty-four hours. Desquamation of the skin follows the fading of the erup- tion, often large masses of cuticle coming away at once. At this stage more or less decided albuminuria is common. Scarlatina Simplex. — In this the eruption comes out early and well, with moderate fever, little or moderate inflammation of the throat, and an even course throughout. Sometimes there is hardly any febrile disturbance ; the child may even play about without having to go to bed. Scarlatina Anginosa. — Here the violence of the disease falls upon the throat chiefly. The tonsils swell greatly, suppurating either early or late, or they are covered by pseudo-membranous deposit, white, gray, or dark-brown, whose coming away leaves an ulcerous surface, with in some instances an acrid, offensive discharge. The extension of the ulcerative inflammation may 416 ZYMOTIC DISEASES. I)ass the Eustachian tube to the tympanum, and may destroy the auditory apparatus so as to cause permanent deafness. After the rash has disappeared, abscesses in the neck may form and discharge, exhausting the patient. Scarlatina Maligna. — This term designates an overwhelming toxeemic impression of the morbid cause of the disease. Depres- sion in the first stage becomes intense, without reaction ; or, after the eruption has partly come out, it recedes, or grows livid in appearance ; or the brain is oppressed with coma. Coldness is sometimes present, or unequal temperature of different parts of the body, instead of the usually diffused febrile heat. The throat may be much or little affected. In some instances the patient seems almost as if struck by lightning, so sudden and deep is the general prostration. In this condition death may take place in a few hours. Otherwise, there is continued prostration, and hemorrhage from the stomach or bowels, or vomiting, or diar- rhoea threatens an untoward result. Sequelae. — Abscesses about the throat have been mentioned ; similar local affections may take place elsewhere after the attack. Ozsena is not uncommon ; neither is suppurative inflammation of one or more of the joints, or of the testicle ; nor vaginitis. Endocarditis or pericarditis may occur. So may paralysis ; either hemiplegia or paraplegia ; generally this is partial, and it is often slowly recovered from. Dropsy from arrested action of the kidneys, with imperfect action of the skin, is the most common, and in many cases the most serious of the sequelae of scarlatina. It comes most fre- quently within a week or two after desquamation has commenced. Mild cases are almost as likely to be followed by it as severe ones. Exposure to cold is the generally observable direct cause ; but cases happen in which no such exposui'e could have existed. Wagner, Biermer, Klein, and Putnani-Jacobi^ have found post- mortem proof of interstitial nephritis in several instances. Ana- sarca is the least dangerous though most frequent form of this dropsy. There may, instead or in addition, be ascites, hydro- thorax, or hydrocephalus. Albuminuria, and often hsematuria, may accompany either form. Diagnosis. — From measles, scarlet fever is known by the erup- tion coming out on the second day, without catarrhal symptoms, but with sore throat, and by its being of a brighter red color, and uniformly diffused instead of being in patches. Erom roseola, it is distinguished by the fever and sore throat, and by the rash in the latter being in irregular blotches, and of a damask rose color instead of a brick- or scarlet-red hue. Prognosis. — This is proverbially uncertain in scarlet fever. The simple form is, however, the least dangerous, and a very large majority of cases get well. The anginose is more threat- ening and serious. But the malignant variety, as its name indi- cates, is far the most so; recovery from it is the exception, although it does occur. I have known two cases of such recov- ery, one in which coma was complete for thirty-six hours. 1 N. y Med. Record, March 26, 1881, pp. 353-5, SCARr.ATINA. 417 Adults are, when afiected with scarlet fever, in somewhat greater danger than children, and sa, especially, are puerperal women. Causation. — Although most (not all) authorities agree that this disease is contagious, it is certainly very capricious or variable in its manifestation of this quality. That is, many persons who are exposed escape it. It is true that several children in a family often have it in immediate succession. But the escape of all but one is, so far as my observation has gone, as common. It rarely occurs twice in the same person. I remember but one or two instances of this in my own practice. It seldom occurs in infants under three months of age. Treatment. — Mild cases require no medication at all, other than to make sure that the bowels are well opened. If fever is high, after a saline cathartic (citrate or sulphate of magnesium or Rochelle salts), neutral mixture or eft'ervescing draught, or liquor of acetate of ammonium may be given. Sweet spirits of nitre may be added, in small doses (} to o fluidrachm for an adult, and proportionately less for a child) if the kidneys act slowly. Drinking cold water freely is to be encouraged, as it is demanded by thirst. If the throat be much inflamed, the fre- quent melting in the mouth of ice, in small pieces, will do good. Dr. Egbert:, of Pennsylvania,^ uses, instead, an ice-bay^ applied to the throat. This must require caution, not to allow the local impression of cold to become extreme. Venesection is prohibited now in scarlatina by nearly all writers. In the earl}^ part of my practice, I bled from the arm in six cases, all of which did remarkably well. They were examples of violent fever with abundant eruption, severe sore throat and headache, in children of good constitution. I do not advocate the practice, simply in deference to the common opinion of the profession. Certainly it should be always ruled out in asthenic cases, and in all unless at the early stage of the fever. Di-. Squire and others have reported well of the employment of quinine, in 5 or 10 grain doses, during the height of the febrile attack in scarlatina. For the sore throat, which is specific in character, besides the use of leeches externally, if the inflammation be great and the case sthenic, local alteratives may be used. An old and popular gargle is one of red pepper, vinegar, and water. More powei'ful in changing the character of the inflammation, I think, is a strong solution of" nitrate of silver (gr. xxx in f,3J) applied with a large hair pencil. When pseudo-membranous patches appear, with a tendency to fetor or ulceration,'-' muriatic acid, with honey, equal parts, may be applied in a similiar way ; or, diluted, used as a gargle. Sulphate of zinc (gr. xv to xx in fgj) is also a good application ; and so are solutions of creasote in glycerin ; of chlorinated soda ; and of permanganate of potassium. For the irritation of the skin connected with the rash, according to my experience the best relief is to be obtained by sponging "with cool or tepid water, two or three times a day. Inunction 1 Transactions of Penna. Med. Society, 1872. 2 Sir W. Jenner considers the danger to be increased by septic infection from absorp- tion of fetid material from the ulcerated throat. 2B 418 ZYMOTIC DISEASES. with lard, or glycerin, is preferred by some. Cold affusion is unnecessarily violent and troublesome. The diet in scarlet fever should be, as a rule, liquid, but need not be low, generally, in the sense of dilution or exclusion of animal material, unless in the first few days. Sooner than in most diseases, the tendency to debility is manifest. Then, milk, chicken-broth, mutton-tea or beef-tea, etc., will be suitable. At the same stage, some patients will require a tonic treatment, by quinine, or, as some prefer, nitric acid in small doses. Ilalignant scarlatina is a disease of terrible depression from the outset. Deficiency of reaction is one of its characteristics. To promote this, external stimulation is primarily important. The hot salt or mustard bath is a powerful agent for the purpose. Urtication, i. e., the direct application of fresh nettles, has been sometimes employed. Mustard plasters may be applied energet- ically ; and so may hot bottles, or bags of hot salt, etc. Inter- nally, ammonia, quinine, and cajisicura are the most prompt and reliable stimulants, although we may add to the same list, Hoffmann's anodyne, and brandy, whisky, or wine. Where a tendency to stupor exists free purging will be the main hope. Jalap is a convenient article for the purpose [F. 151] . The sulphite of sodium is still under trial in various zymotic diseases, as an antagonistic of morbid blood-changes. The dose for an adult may be about ten grains every two or three hours [F. 152]. Chlorine water, in fluidrachm doses for an adult (ten drops for a child of two years), is sometimes given in scarlet fever with a similar view ; and so is chlorate of potassium.^ Other modes of treatment for severe cases are, the use of tincture of chloride of iron freely ; of infusion of digitalis (L. P. Gebhard) ; of diluted acetic acid (5j to 5iv of the officinal acid in fgiv of water, the dose of the solution being a tablespoonful, sweetened, every few hours) ; of bromide of sodium ; and of diluted nitric acid. Carbolic acid, in one- or two-grain doses, diluted, has been used by Drs. Kempster, Bissell, Fuller, Shoe- maker, and Cleaver, with asserted beneficial efieets.^ Its dose' should be always small (1 grain), and given well diluted with water. Dr. E. Martin {Lancet, Jan. 8, 1876) has suggested the use of medicated ice, when children resist local applications to the throat ; as very often happens. A large test-tube may be nearly filled with the required solution, and then immersed in a mixture of pounded ice and salt. When it is frozen, a momentary dip of the tube in hot water will enable the cylinder to be turned out ; it can then be given to the child as ice. Of the sequelae of scarlet fever, each has its own indications for treatment. That of dropsy is the most frequently important. iSee Squire, on Te.mperaturo Variations in Children, 1871. deleaver, in Iowa Med. Journal, 1869. Dr. Kempster, of Utica, and Dr. A. M. Car- penter (Physician and Pliarmaeeutist, November, 1868), use carbolic acid, with glycerin and water, as a local remedy for the sore throat of scarlatina. 3 Read win (Pharmaceutical Journal, Oct., 1869), gives the following quantities as safe: for internal use, 1 grain of pure carbolic acid (crystals) in a fluidounce of water. _ As a gargle, 1 or 2 grains in an ounce of water. For injection, 1 grain to 4 ounces ; lotion, 15 grains to an ounce of water; liniment, 1 part to 20 of olive oil ; ointment, 16 grains to an ounce of lard. Some facts of experience, accidental and therapeutic, render it not improbable that carbolic acid may be safe iu larger than one-grain doses. MEASLES. 419 If, (luring desquamation, tlie kidneys show any threatening; of suppression or inaction, the greatest care of the state of the skin must be maintained. It is, indeed, a good rule of precaution, for fear of some carelessness and exposure, not to allow a patient recovering from scarlet fever to leave his chamber for three or four weeks at least, from the beginning of the attack, nor the house for four or five weeks. Lemonade as a drink, if the urine be scanty, may be freely used. Cream of tartar and acetate of potassium are approved in the same case as diuretics. Digitalis has tlie contidence of many. Quinine, in doses large enough to cinchonize, is reported very favorably of, in scarlatinal dropsy, by some practitioners. Pilocarpin may act powerfully, through the skin, but requires much care, for fear of depression. Dry cupping to the lumbar region, and the application there of a large mustard plaster, are measures suggested by the known congested state of the kidneys. Dr. C. West even bleeds from the arm upon the same indication ; a practice which I should hesitate to follow, after so exhausting a disease as scarlet fever. Pui-gatives must not be omitted when- diuretics fail ; the princi- ples governing their use being the same as in other varieties of dropsy. Prophylaxis. — Belladonna has been asserted to have a protec- tive power against the contagion or infection of scarlet fever. But the evidence in its favor does not appear to me to warrant our giving any contidence to it, or to any prophylactic. MEASLES. Sjnonym.—MorbilU. Formerly, with all writers, and still with many, rubeola is a synonym for measles. Some writers, however, designate by the name of rubeola only a hybrid or blending of measles with scarlatina. (See Botheln.) Symptoms and Course. — After an incubation of from ten to fifteen days from exposure to its contagion, the attack begins with a slight or obscure stage of depression, passing into fever. With this there are all the symptoms of a cold ; running at the nose, redness and watering of the eyes, and a cough. On the fourth day of the attack the rash begins on the face, and extends over the body and limbs. It is not so bright in color as the erup- tion of scarlet fever ; and is irregularly distributed in patches more or less crescentic in shape. By about the seventh day the rash begins to fade, and about the same time or before, the fever has begun to decline. Desquamation is much less extensive than after scarlatina. No such intensity of febrile movement, nor severity of any kind, as is common in the last-named disease, exists, except very rarely, in measles. Camp measles, during the late war in this country, sometimes assumed a typhous character, with a consid- erable mortality ; due to the conditions under which it occurred among the soldiers. Savages have sometimes suffered much from it ; as in the Fiji Islands in 1875, when from one-fourth to one-fifth of the popula- tion died of it. Under ordinary circumstances, unless in very 420 ZYMOTIC DISEASES. young children, measles seldom threatens life. Even in so devel- oped a country as Japan, however, as reported by Dr. D. B. Sim- mons, in 1861, 75,000 deaths occurred from it. Occasionally, the bronchitis may become capillary, or may be extended into broncho-pneumonia. Much less often, gastro-intes- tinal inflammation, with vomiting, abdominal pain, and dysenteric diarrhoea, may complicate the attack. Of 314 cases observed by Meigs and Pepper, 7 were thus affected ; but all of these recov- ered. Others have reported a few deaths resulting from this complication. The possible sequelae which are of the most consequence are, ophthalmia, diphtheria, chronic bronchitis, and phthisis. Yery severe inflammation of the eyes sometimes follows measles ; but blindness from this cause is rare. Diphtheritic sore throat is not infrequent, and may be fatal in children. Chronic bronchitis is common, especially when care is not taken during convalescence to avoid exposure. Phthisis, under the same circumstances, is to be apprehended only where the constitution suffers under a predisposition to tuberculaT disease. Causation. — ^Measles is one of the most contagious of diseases, beyond all doubt. Singularly enough, however, I once attended w^ith it one of a pair of twins at the same mother's breast, the other escaping it altogether. A second attack is exceptional, but not very rare.^ Treatment. — Beginning with a moderately active saline cathar- tic, diaphoretics, expectorants, and demulcents are next in place. On account of the possibility of diarrhoea, it is well to be careful with the use of strong purgative medicines in measles. Yet, on the other hand, the necessity of sufficient elimmation of excretions must be borne in mind. It is decidedly better, during the first few days, for the bowels to be freely moved than confined ; and, in checking excessive discharges, it should be remembered that accumulation of effete material in the blood renders the action of opiates more narcotic, and, in large doses, even dangerous. Syrup of ipecacuanha with neutral mixture (J drachm of the former, for an adult, with each tablespoonful of the latter) every two, three, or four hours, would be an average treatment for the first week ; flaxseed lemonade being freely used as a drink. After that, the continuance or relief of the bronchial symptoms must determine whether some other expectorant (as squills or wild cherry) shall follow. Debility may require tonics during con- valescence. ROTHELN :— HYBEID BETWEEN SCARLATINA AND MEASLES. Synonym. — German Measles. This, called Buheola by some, is not common, but is less rare now than formerly. I have seen a case in which the symptoms of the 1 Not long since, Dr. Salisbury, of Ohio, produced measles-like symptoms in several persons by exposing them to the influence of fungi growing upon damp straw. The identity of the affection with measles was not, however, shown. Drs. Hammond and Woodward, at Washington, repeated the same experiments without result. Some Brit- ish writers aver that rubeola notha is a distinct disease, and may be ascribed to straw- fungus. ROTIIELN. 421 two disorders were so nicely balanced that two physician? of similar experience pBonoui>ced it, the one scarlet fever, and the other measles. Dr. MaL,a-uder, of Olney, Maryland, has reported a case in which tlie two kinds of eruption coexisted on dillerent parts of the body of the same patient.' Dr. Murchison and others assert "German measles" to be an entirely distinct dis- ease, an attack of wliich afibrds no immunity from either measles or scarlet fever.'- If this be so, such a disease has been in former 3'ears little known in this country. Dr. J. Lewis Smith, in the Sanitarian for July, 1874, gave a ])rief account of its prevalence as an epidemic in New Yoi"k at that date. In IST."), thirti!en cases of it occurred at Haverford College, near Philadelphia. In these cases, the early general symptoms were mild ; malaise, headache, slight sore throat, loss of appetite, and debility. In two or three days, with some increase of fever, a rash appeared, having more the color of scarlet fever than that of measles, but dotted or miUary (sub-papular j in form. In some cases it became aluicst couLiiiuous, with a moderate amount of tumefaction of the limbs and general surface. In one instance the fauces exhibited a scarlet hue to the eye, although no feel- ing of soreness of the throat existed in that case. Catarrhal symptoms were not noticed in any of these patients. In some of them, the glands of the neck were swollen. None had a very high fever. The duration of the attack in each case was about a week ; and convalescence was rapid. No sequeliB were observed in any instance. During the summer of 1878 I saw three cases of rotheln with Dr. Macomber in Germantown, Pa. They closely resembled those above described. An interesting feature concerning them was, that they occurred in a period of transition between a con- siderable epidemic of scarlet fever and the most extensive x^rev- alence of measles ever known in the locality. In 1880-81, many cases of riitheln or rubeola (often inaccurately called roseola) were recognized by practitioners in Philadelphia.* Dr. I. Minis Hays'* observed the occurrence of this affection (in an institution) in fifteen persons who, within a year, had been the subjects of ordi- nary measles. Dr. Forrest,^ of Charleston, S. C, mentions the occurrence of a widespread epidemic of German measles in that city during the first four months of the year 1880. In the winter of 1880-81, there was a considerable prevalence of it in the city of New York ; and a number of cases in Chicago. Dr. D. B. Simmons, of Yokohama, asserts that rotheln or "rubeola Ger- manica" is quite common, as a mild epidemic, in Japan. In severity, the hybrid attack is generally more like measles ; although dropsy and albuminuria may follow it, as well as bron- chitis, etc. Its treatment requires no special consideration, being involved in what has been said of the two diseases of which it really seems to be a combination. 1 Med. and Surg. Reporter, July 16, 1881, p. 81. 2 See a Lecture by Dr. Liveinjj, March 14, 1874. 3 See a paper by Dr. L. A. Duliring, March 26, 1881. * Ibid. 6 Amer. Journal of Med. Sciences, April, 1881. 36 422 ZYMOTIC DISEASES. MUMPS, Synonjrms. — Parotitis contagiosa; Cynaiwhe parotidea. Symptoms and Course. — This is generally a mild affection, of a few days' duration. The parotid gland swells and becomes hot, painful, and tender to the touch. Some inconvenience in swal- lowing may result. There is little or no fever, but some general malaise ; and the attack is generally at an end within a week. Once in awhile an attack may be quite severe ; with high fever, delirium, etc. One or both parotids may be affected. There seems to be reason to believe that attacks may occur at con- siderable intervals, even of j^ears, involving first one gland and afterwards the other. Suppuration is rare ; I have seen it but in one case. The disease is undoubtedly contagious. Bouchut, in 1873, in a communication to the French Acad- emy, brought forward the remarkable assertion that parotitis is simply a salivary retention, due to catarrhal inflammation of the parotid duct. Diagnosis. — As the parotid gland, as well as other glands about the neck, may inflame from cold, septicsemia, or scrofula, it becomes sometimes a question whether a swelling in that region be mumps or not. When the parotid alone is affected, it is impossible to decide, unless direct exposure to another case of mumps be known. The parotid is, however, not apt to inflame under other causation, even from salivation by mercury, the submaxillary glands are much more liable to swell from that cause. The suddenness of the attack, and its brief duration, are generally quite diagnostic of mumps, as compared with scrof- ulous or other inflammations of glands about the neck. Complications. — Metastasis of mumps, to the mamma or tes- ticle, or even to the brain, occasionally occurs. Instances of the last-named complication have come to my knowledge. In either of the first two, a somewhat similar inflammation of the gland attacked takes place ; usually more protracted than that of the parotid. If the brain be the seat of the transfer of the morbid element or action, meningitis, or coma, may follow ; and even death is said thus to have resulted. Otherwise, mumps is free from danger to life. Treatment. — Care to avoid being chilled, lest metastasis or greater severity of the attack be produced, is important. No general treatment is necessary, nor does the patient usually need to remain in bed. Perhaps a mild laxative may be given on the first or second day. A poultice of flaxseed meal is a good local application for the gland. It may also be bathed night and morning with soap or volatile liniment. HOOPING-COUGH. Synonjrm. — Pertussis. Symptoms and Course.— After an incubation of about six days, the attack commences with symptoms much like those of acute bronchitis, including fever of variable degree ; soon showing its peculiar character. This is, a spasmodic and paroxysmal cough. For hours the patient may be apparently well, and then, often H O O P I N O - C O U O H . 423 with a premonitory sensation which leads the child to run to its mother or nurse, or, if at night, to sit up in bed, a fit of coughing begins, and lasts for several seconds or minutes. It consists of a rapid succession of sliort but violent expiratory efforts, witli scarcely any intervals of inspiration ; at the close of which, air is taken in by force tlirough tlie contracted glottis, making a whoop- ing sound, whence tlie name of tlie disease. All who have it do not whoop ; but the paroxysmal character of the cough is pathog- nomonic. Expectoration is copious, of thick mucus, sometimes even of lymph and pus. Vomiting occurs often during the spells of coughing. The child may become very much exhausted, even to a fatal end ; but unless from complication or previously feeble constitution, death does not very often occur. I never knew asphyxia to be fatal during the paroxysm, though it is sometimes threatening. One case has come to my knowledge in which death took place with apoplectic symptoms. Intense congestion of the eyes, from the violent coughing, is common. There may be many variations of severity in all the symptoms in the course of an attack. Dr. Gibb has found the urine saccharine in this disease. Ulceration under the tongue is common, but not universal. The duration of hooping-cough is seldom less than six weeks, although cases have ended within three weeks. Often it lingers for three or four months ; in one case I knew it to last a year. Complications.— Pneumonia, collapse of the lungs, and (as a sequela) phthisis, are the most likely to occur. Deafness from rupture of the membrana tympaui during the violent coughing, has been known. Sometimes the eyes become bloodshot from the same cause. Convulsions occasionally increase greatly the serious- ness of the disorder. I have known it (as above mentioned) to terminate with fatal apoplexy. Causation and Pathology. — There is no question of the con- tagiousness of hooping-cough. Generally it occurs but once in the same person ; but second attacks are not very rare. Like scarlet fever, measles, etc., it is much most often met with in children ; but this is merely from their susceptibility under expo- sure ; as adults also may have it. Belonging with the zymotic diseases, and caused by a specific morbid poison, the spasmodic nature of the cough points to the nervous system as in main part the seat of its action. Yet the expectoration, as well as early (and afterwards occasional) febrile symptoms, show that bronchial inflammation exists secondarily at least. The asserted discovery, by Letzerich,^ of a fungoid vegetation in the epithelium of the air-tubes, requires confirma- tion. Similar observations, however, are reported by Buhl, Hiiter, Tomasi, Oertel, and Nasilofl". Another view is, that the s])asmodic aftection may be produced by the pressure of enlarged bronchial glands upon the pneumogastric and recurrent laryngeal nerves. Treatment. — Mild cases need only care to avoid exposure to danii? and cold. After the first few days, if there be no fever nor 1 Quarterly Journal of Microscopical Science, April, 1871. 424 ZYMOTIC DISEASES. soreness of the chest, the patient need not be kept in the house in good weather. Indeed, he will cough least when most out of doors. When the cough, at first, is tight and painful, with little expecto- ration, syrup of ipecac or squills may be given. As soon as the spasmodic character of the cough declares itself with some vio- lence, the "milk" or the tincture of assafoetida may be given, with or without other expectorants, according to the case [F. 153]. Severe cases may be quieted by belladonna or musk ; but I have been especially satisfied with the effect of the fluid extract of hyoscyaraus, in the dose of from four drops in a child of ten or twelve years of age, down to a fraction of a drop at a time in a young infant [F: 154, 155, 156] . Atomizatwn of belladonna has been used with good success by Dr. Haynes.^ Coffee, hydrocyanic acid, bromide of ammonium (from two to twelve grains at once for a child), nitric acid, alum, clover-tea, chestnut-leaf i&Si (Unsicker, Davis) or fluid extract of the same, oxalate of cerium, and ben- zoic acid, are among the remedies often employed to allay the violence of the paroxysms. Application of strong solution of nitrate of silver to the larynx has some advocates. Dr. Gibb's preference is for nitric acid, given internally. Dr. De Cailhol, of St. Louis, has reported (1879) a rapid cure under the internal use of jaborandi. Dr. Bowles, of VirgUiia {Va. Med. Monthly^ March, 1881), asserts the benefit, in a severe case, of inhalation of (a few drops at a time) nitrite of amyl. Binz,'^ Dawson, and others assert decided advantage from qui- nine, in considerable doses, during the height of the disease. Hydrate of chloral is said by Drs. Lorey, P. B. Porter, and others, to be of great value in this affection.^ Inhalation of the steam of boiling water containing ammonia (f5J of strongest liq. ammon. in a gallon of water) is advised after the third week by Dr. J. Grantham [Brit. Med. Journal, Sept. 16, 1871). In protracted cases counter-irritation to the chest and back of the neck may be required. I once met with great relief upon the application of a small blister to the nucha. Tonics are also not unfrequently called for toward the end of the attack in a feeble child ; especially quinine or tincture of bark (Huxham's), iron, or cod-liver oil. There is very seldom need to restrict the diet in this disease, unless during the first week. Dr. W. S. King has reported several cases seeming to show that the air of gas-works, freely breathed, is curative of hooping- cough.* DIPHTHERIA. Synonyms. — Pseudo-membranous Angina; Putrid Sore Throat, Dijjhtheritis. History.— Though the name diphtheria (from 6c(f>depa, a skin or membrane) was only given to this disease by Bretonneau of Tours less than sixty years ago, it appears to have been described by Aretseus of Cappadocia as a .disease of Egypt, and was mentioned 1 Phila. Med. Times, April 25, 1874. 2 Am. Journal of Obstftrics, May, 1870. See also the same Journal, Feb., 1873. s New York Med. Journal, Aug., 1873. i Phila. Med. and Surg. Keporter, May and June, 1867. DIPHTHERIA. 425 also by Macrobius and Coelius Aurelianus amonf? early writers. Hecker gives an account of'its prevalence in Holland in WM ; Carnevale, at Naples, 1()2U ; Taniayo, at Madrid, called it (/arotiUo^ in 1622. Ghisi first clearly described the pseudo-membranous formation, at Cremona, 1740. In France Ohomel saw it in 1743-9 ; in Enj^land, Fothergill in 1754 ; Douglas of Boston, in this country, in 17:50 ; and Samuel Bard of New York, in 1771. Iluxham, Cheyne, Rosen, Albers, and Guersent also described it under different titles. Bret(mneau most fully made it out as a distinctive disease, in 182G. Since that time it has been recog- nized and treated of by nearly all medical authorities. Later epidemics of it have been principally those of Paris and Boulogne of 1855-7, passing to England in the latter year ; and of our own country beginning in California in 1856, and in the Eastern States a little later, gradually increasing in prevalence until 1860. Since that time it has rather declined in frequency, although still existing, and sometimes attended by great local ftitality. New York and Brooklyn have suffered severely with it. In one week in January, 1881, there were 168 cases in New Y'ork. During 13 weeks of the last quarter of the year 1880, Brooklyn had 1185 cases of dipbtheria, with 483 deaths.* It was terribly destructive in some parts of Russia in 1879-80 ; carrying off, in two or three towns, more than half of the children. Bre- tonneau, not unreasonably, supposes Washington and the Empress Josephine to have died of diphtheria. Stephanie, the beautiful queen of Portugal, and the Princess Alice, of Hesse (1879), were victims of it. Varieties. — 1. Simple ; 2. Croupous ; 3. Ulcerative ; 4. Malig- nant diphtheria. Symptoms. — Premonitory, but not distinctive, are general malaise^ slight sore throat, and swelling of the lymphatic glands behind the jaAv. Then, in the simple form, fever occurs, with headache, furred tongue, constipation, and difficulty of swallow- ing. On examination, a swollen and very red or purple appear- ance of the fauces will be observed, as well as of the palate and tonsils. Over one or both of the latter there may be seen, often as early as the second or third day, a whitish or yellowish-white membranous deposit. All the symptoms continue in this form from five to nine days, when, in favorable cases, convalescence follows. The croupous form has caused the greatest number of deaths, especially in children. This seems especially prone to follow measles or scarlatina. In it, after the same early symptoms as those above described, but sometimes with violence from the beginning, increase of discomfort in the throat is complained of. Then an abundant yellow or brownish leathery exudation is found to cover the tonsils and fauces, which, under the exuda- tion, are much swollen. Often quite early in the attack, the pseudo-membranous inflammation extends to the larynx. This is shown by the usual symptoms of croup ; the barking cough and voice, and difficult inspiration, becoming whistling or sibilant 1 Sanitary Engineer, Dec. 15, 18S0. 36* 426 ZYMOTIC DISEASES. when the obstruction to breathing is the greatest. A fatal ter- mination may occur by asphyxia in a very few days. This can only be averted by the detachment and expulsion of the mem- brane without its re-formation. The ulcerative variety is not common. When destruction of the palate and tonsils has attended it, with copious dark-colored and pulpy exudation, and some extravasation of blood, it has been mistaken for, and described as, gangrene ; whence the old name "putrid sore throat." The occasional existence of true gangrene cannot be altogether denied. Malignant Diphtheria. — At the commencement of this, there is, with intense headache, not unfrequently vomiting, which is uncommon in the milder varieties, and hemorrhage from the nose, mouth, stomach, or rectum. Great dysphagia soon exists, and enormous engorgement of the submaxillary, parotid, and cervical glands. The tonsils, pharynx, and palate are covered thickly with a leathery deposit, at first yellowish, but soon becom- ing ash-colored, brown, or almost black, and of an offensive odor. The tonsils may suppurate or even slough. The nostrils are also sometimes involved, being swollen, lined with false membrane, and emitting an acrid and" fetid discharge. Extreme prostration comes on at a more or less early period ; it may be from the first day. The pulse becomes very rapid, the face lividly pale, mor- bid heat of the skin being followed by clammy coldness. Coma often precedes death. The latter may take place in three, four, or five, occasionally in one or two days ; sometimes from the constitutional impression of the disorder before the local affec- tion has been fully developed. Special Symptoms and Comi^licatioiis.— Albuminuria is pres- ent in most severe cases of diphtheria, from an early time in the attack. A diphtheritic affection of the sMn has been now and then observed. A blistered or otherwise abraded surface will usually in the course of the disease be covered by false membrane. Pneumonia is an occasional and dangerous complication. Endo- carditis (Bouchut, Lagrave) is not rare, although its symptoms may be masked and overlooked. Heart-clot^ sometimes makes death certain, in an otherwise doubtful case. Sequelae. — These are especially long-continued debility, pa- ralysis of the soft palate, and paralysis elsewhere in various degrees. In this, deglutition, articulation, vision, and locomo- tion may be involved. A fatal result may occur after a few weeks, or recovery after a longer period ; sometimes from two to eight months. Morbid Anatomy. — The pellicle or deposit, formed upon the highly-injected and tumefied mucous membrane of the fauces and throat, constitutes the anatomical peculiarity of the disease. Minutely examined, the false membrane is found to vary from ^th to ^th of an inch in thickness, and to be fibro-laminated ; i. e., of layers of fibrinous network, including epithelial cells, and having on its free surface exudation corpuscles or " pyoid glob- ules," and granules; these forms appearing to be only stages of 1 J. F. Meigs, Am. Journal of Med. Sciences, April, 1864. DIPHTHERIA. 427 degeneration. No process of organization or development occurs in the mass ; it is aplastic. In some cases only a granular super- ficial infiltration of mucous membrane is observed, without even distinct filn-illation. The common deposit of diphtheria differs from the false mem- brane of simple inflammatory croup, and still more from the "coagulable lymph" of inflamed serous membranes, in being tliicker, more tough, yellower, and less capal)le of anything like organization.' (Dr. B. Sanderson asserts that he discovered evidence of development of the exudation in one or two speci- mens of the simple form of dii)htheria.) Pathology. — Excluding from the title of diphtheria all instances of accidental or merely inflammatory "'diphtheritic " or i)seudo- membranous formations, as they occur, for example, in croup and scarlet fever, we must admit that there is a special zymotic or "enthctic" disease, for Avhich the name is appropriate and should be reserved. It is a toxaimic or " dyscrasial " affection, in which the morbid change in the blood has its main and charac- teristic local manifestations in the throat.^ Ortel, Letzerich, and others have asserted the constant occur- rence of a microscopic organic formation (bacterium or micrococcus) in the throat in diphtheria. Other competent observers have failed to find any such organisms in well-marked cases, and have found them also in cases not diphtheritic ; hence concluding that although the coincidence of their presence with that of the disease is frequent, not being universal, it cannot be causative or patk- ogenc'tic. Drs. H. C. Wood and Formad, in their investigations (1880), found satisfactory evidence against the bacterial origin of diphtheria. Among those who continue to assert it, Talamon^ reports suc- cess in cultivating spores from diphtheritic membrane, and, with them, producing false membranes by inoculating rabbits and other animals. But the vexed question remains, whether only these spores were transferred from the seat of disease ; or whether their presence was coincident merely, or really causa- tive of the afi'ection. Causation. — Not doubting the existence of a special material cause, yet unknown except by its eflects, we can only say further that the disease is generally epidemic or endemic, with a special tendency to limited localization. It acts with intensity in con- fined centres ; as, a small village, a crowded school, a tenement house, a numerous family, inflicting therein often a terrible loss in proportion to the numbers attacked — a sort of domestic pestilence. Is diphtheria transmitted by contagion ? I am sure that it sometimes is so, although clearly not dependent upon that mode of propagation in its epidemic migrations. The certain examples 1 Bretonneau long since, and Dr. Sanderson a few years ago, imitated the diphthe- ritic exudation, by injecting oil of cantliarides into the throats of animals. The prin- cipal ditierence was in the manifest tendency to organization iu the cantharidal p.seiido- mumbrane. 2 Sir W. .Tenner considers the absorption of septic matter from tlie throat a cause of increased danger in diphtheria, as well as in scarlatina. 3 See Lancet, April 9, laSl. 428 ZYMOTIC -DISEASES. of its extending from one person to another are few ; but I have known of several such. Valleix, the celebrated French physi- cian, is said to have lost his life in this way. In 1880, Dr. San- ford B. Hunt, of Green Point, N. Y., died in consequence of blowing through a tracheotomy-tube, while operating upon a patient. The instance of the Princess Alice of Hesse, infected by kissing her sick child, has become historical. Such cases suggest precautions, which ought always to be enforced. Children are much more liable to diphtheria than adults. Climate and season do not seem to affect its pi'evalence. It often shows very decided preference for unhealthy places, where filth or crowd-poison abounds. Conveyance of diphtheria by milk has appeared to be proved in one or two instances at least. (See Lancet, Jan. 11, 18*79.) W. H. Powers traced this in an epidemic in Korth London. It has been suggested that possibly a disease of the cow, called ''garget," may have to do with its origination; but this whole subject requires further investigation. Diagnosis. — From scarlatina , diphtheria is distinguished by the absence of the eruption, and of the peculiar punctated or briek- dust-like flush of the throat, and "strawberry" tongue. That scarlet fever 'predisjposes to diphtheria, as a subsequent attack, is a well-established and not unimportant fact. With membranous croup, it is contrasted in the following man- ner. That disease is a sporadic and sthenic local phlegmasia, whose general symptoms are, as much as in any inflammation, dependent upon the local affection ; while diphtheria is a consti- tutional disorder, usually epidemic, in which the local symptoms are secondary. More directly, in practice, we may mark the commencement of the pseudo-membranous deposit, in diphtheria, about the tonsils and pharynx ; in croup, in the trachea or larynx. That of diphtheria rarely extends, in any case, below the larynx ; that of croup, not unfrequently even into the bronchial tubes. After the laryngeal complication or extension has occurred in diphtheria, the croupal sj'^mptoms are really the same as those of any other laryngeal obstruction, and thus are not different from those of croup. There is no albuminuria in croup, and the sequela of paralysis never attends recovery from it. Prom thrush, and aphthce, diphtheria is known by the deposit being much larger and thicker, never vesicular, and mostly duller in color ; and attended generally by more severe constitutional symptoms. Thrush begins in the mouth ; it is, moreover, much more uncommon in adults than diphtheria ; and is never epidemic. Prognosis.^ — Simxjle diphtheria is not very dangerous to life. The croupal form is decidedly so ; and the malignant is fatal in a large majority of cases. Insidiousness is a trait often belonging to the disease in children ; a name which has been applied by some, for that reason, is " creeping croup." Treatment. — No specific remedy having been discovered for this disease, we must be governed in our tentative treatment of it by our idea of its nature ; while concluding upon its therapeu- tics, finally, through experience. Nothing, it may be confessed, is very satisfactory, as yet, in the management of bad cases of D I P II T II E R r A . 429 it. All agree that it is not a mere local inflammation, but a sys- temic aflection primarily ; and that its type is most generally asthenic. Much dojiletion is therefore not to be thougbt of. I would never bleed from the arm in diphtheria. In simple, open cases, I liave used leeches to the throat, with seemingly decided advantage, within the first three days. Even their use, however, must be exeeptiDual. Moderate purgation, as with citrate of magnesium, or Kochclle salt, at the very beginning, is suitable in the simple and croupal, though perhaps not in the malignant form. Chlorate of potassium is a favorite medicine with many in this disease. My best results in bad cases have attended its early and free use. An adult may take twenty grains in solution every three hoiu's; I have given five grains every two hours to a child five or six years old [F. 156] . Such a treatment will not, of course, need to be continued for many days. Tincture of chloride of iron is relied upon by many ; from ten to twenty drops every three hours for an adult ; with or without the chlorate of potassium [F. 157]. Prof. Clar' uses sesquichlo- ride of iron in glycerin ; giving half-teaspoonful doses of a mixture consisting of twenty drops of "liquor ferri sesquichloridi " in two ounces of pure glycerin. Sulphate of quinine is also given, alone, or at the same time with the above remedies, by a number of practitioners ; say, of quinine, for an adult, a grain every two or three hours. Besides these, or instead of them, for internal use, permanga- nate of potassium has, after trial (C. Bell), the recommendation of some observers. A drachm of it may be dissolved in a pint and a half of water, a fluidrachm of this being taken every hour. Chlorine water is urged by others. It may be given in teaspoonful or even tablespoonful doses to an adult. Sulphite of sodium, ten grains every two or three hours, is worth}^ of trial in this as in other zymotic diseases : and carbolic acid likewise. Trideau recommends highly copaiba and cubebs.'- Guttmann's'^ treatment, with pilocarpine has attracted considerable attention. Dr. Wendt, of New York, has followed it, with reported success, giving to an adult half a tablespoonful every hour of a mixture containing half a gi-ain of muriate of pilocarpin in four ounces. After each dose the patient also took half an ounce of sherry wine to pre- vent depression. Copious expectoration resulted, and usually free perspiration. Guttmann's own prescription was from half a grain to a grain in an eight-ounce mixture, which also con- tained half a drachm of pepsin and a few drops of hydrochloric acid. He insists on the administration of wine after each dose of the pilocarpin, reducing the amount of wine, of course, as well as of the medicine, for children. It has been reasonably suggested that, for local as well as general effect, medicines should be given, in diphtheria, in small doses frequently repeated, rather than large doses at long in- tervals. 1 Practitioner, July 1, 1871. 2 Brit, and Foreign Medico-Chirurg. Review, October, 1868, p. 417. s Berlin. Kliu. Wochenschr., Oct. 4, 1880. 430 ZYMOTIC DISEASES. More heroic modes of treatment have been (1881) proposed and put on trial in diphtheria ; e.f/., by large doses of oil of turpen- tine, of bichloride, and of cyanide of mercury. A priori, there is much against such practice ; but here, as elsewhere, the only required test in medicine is experience. Concentrated liquid food must, as a rule, be given throughout an attack of diphtheria (milk, beef-tea, and very often wine whey or brandy or whisky punch), in small quantities at short intervals, according to the degree of prostration present. Local treatment is, by most physicians, regarded as very im- portant. Experience has shown, I think, that it ought not to be violent. Ice in small pieces, melted in the mouth slowly, is possibly as useful as any application. Muriatic acid and honey, equal parts, applied freely with a large camel's-hair pencil, or diluted with water and used as a gargle, I believe to be service- able. Creasote dissolved in glycerin [F, 158], lime-water, chlo- rinated soda dissolved in twenty parts of water, diluted carbolic acid, and permanganate of potassium (a drachm in a pint), make also appropriate gargles. M. Eevillout (Gazette des Hupitaux, 1874), on the basis of long experience, recommends pure lemon- juice for this purpose. Dr. Hotz,^ of Chicago, speaks highly of the application to the throat, with a brush, of a solution of a drachm each of carbolic acid and alcohol, with half a drachm of tincture of iodine and five drachms of water. Dr. J. Lewis Smith'^ uses the following : Acidi carbolici, gtt. v ; Liq. ferri sub- sulphat., f3ij ; glycerinpe, gj ; M. This is applied by means of a brush. Dr. Clark, of Oswego, eulogizes the use of the liq. ferri persulph. alone. Dr. J. L. Smith favors also the use of lime- water with the atomizer, e.g., acid, carbol., gtt. xxxij ; glycerin., f,5ij ; aq. calcis, fjvj ; if. Dr. H. Eeynolds^ has used with suc- cess equal parts of carbolic acid and glycerin, locally applied. J. A. E. Stuart, of Edinburgh,* reports the curative effect of powdered sulphur blown through a quill upon the patches of exudation. Ciattaglia, of Kome, asserts excellent results from the application of a solution of chloral in five times its bulk of glycerin. Iodoform (local application of the powder) ought to be tried in bad cases of diphtheria, on account of its admirable influence upon indolent ulcerations and inflammations. It might be blown, in small amount (its dose internally is about one grain), into the fauces through a quill or other tube. Benzoate of sodium (used internally as well as locally) is reported by Letzerich to have cured twenty-six out of twenty-seven cases of diphtheria.* Drs. Jacobi and Billington, of IsTcw York, insist on the impor- tance of frequently syringing out the throat, and the nostrils in nasal diphtheria, to wash away the offensive exudation and secretions. Simple tepid salt water will, according to Dr. Bill- ington,*^ answer for this, thrown in by means of a hard-rubber ear-syringe. Dr. W. W. Cleave,' of Louisville, recommends, after 1 New York Med. Record, Aug. 15, 1871. 2 Ibid., April 1, 1874. ^ Medical News, December, 1872. 4 Practitioner, April, 1879. 6 Berlin. Klin. Wochens., 1879, No. 7. 6 New York Med. Record, March 27, 1880, p. 335. 7 LouisTille Medical News, January, 1881. GLANDERS. 431 trial, the local application, with a mop, of o(7 of turpentine, which is said to penetrate tin; exudation and cause its separation. Dr. I. R. Page,' of Baltimore, states that 1)(; lias found fresh lemon- juice, applied upon a camel's-hair proljang, the most efl'ective agent to promote the removal of tlie membrane from the throat in diphtheria. Chloroform, similarlj- applied, is recommended hy Dr. Lathrop,' of New Hampshire. In a young child ice is sometimes the only local application possible without a struggle so disturl)ing as to make the benefit of it doubtful. Cold-water compresses may be applied outside of the throat in the early stage, while there is excess of heat. Later, flannel wrung out of hot water, to which an equal amount of spirits or vinegar has been added, will give more comfort. Inhalation of the steam of lime-water is worthy of continued trial in diphtheria, especially in the croupous variety ; or, the atomization of lime-water by the nephogene or some other appa- ratus constructed for the purpose. 1 am convinced that the eftbrt (which I have seen practised) to remove the patches of exudation by force, as by excision or actual cauterization, is to be deprecated, as likely to do harm rather than good. In treatment of the paralysis which sometimes follows diph- theria, strychnia is especially appropriate, but here, as elsewhere, it must be given with caution. GLANDERS. Synonym. — Equinia. Though not common in the human sub- ject, it is important to know that this afiection can be taken from the horse. It is said to occur either in the acute or the chronic form, generally the former. Symptoms and Course. — After an incubation of from two to seven days, with febrile symptoms, the nostrils become inflamed, and at the same time pains in the joints occur, like those of rheu- matism. Over parts of the body the skin becomes red in patches, which may grow dark and even gangrenous. Crops of pustules also appear, one after another, on the face and limbs. In the course of a week or so a muco-puruleut discharge comes from the nostrils, which are swollen, ulcerated, or gangrenous. The fauces, pharynx, larynx, even the lung, may become seriously involved. The face and eyes inflame and become (edematous. Throughout, fever of a low form continues, with great thirst, delirium or coma, a fetid odor from the skin, and diarrhoea. Death almost always occurs within three weeks, sometimes one or two weeks later. Chronic glanders is rare ; it is described as milder than the above, and much less fatal. Treatment. — This must be purely tentative. Most worthy of trial are carbolic acid and the sulphites, as sulphite of sodium, and bcnzoatc of sodium, with a supporting diet of milk, beef-tea, » New York Med. Record, May 7, 1881, p. 530. ■■^ Phila. Med. Times, May 22, 1881, p. 533. 432 ZYMOTIC DISEASES. etc. Locally, I would use creasote or carbolic acid dissolved in glycerin — dilute chlorinated soda and lime-water. INFLUENZA. Synonym. — Epidemic Catarrh. History. — Although, among persons exposed to the same weather, catarrhal affections are, of course, common at certain times, there is evidence that, apart from the conditions of humid- ity and temperature of the air, epidemic catarrh sometimes occurs as a zymotic disease. It is recorded as having been quite fatal in France in 1311 and 1403 ; in 1570 also it prevailed, and in 1557 spread over Europe and extended to America. It occurred again in 17-29, '43, '75, '82, 1833, '37, with notable violence. In the United States, one of the most remarkable epidemics, for extent, was that of 1843. Another was that of 1872, following nearly the course of the epizootic amongst horses of the latter part of that year. The local prevalence of influenza may occur at very irregular periods, and sometimes so mildly as not to be distin- guished from common sporadic catarrh. Symptoms and Course. — The ordinary symptoms of "a bad cold" are those of influenza, but the illness of the latter is some- what more severe, and prostration is generally greater. Of this there are all grades, however. Bronchitis, sometimes capillary, and pneumonia, are not rare complications. Old people are especially apt to be carried off by influenza. Its mortalit}'- is very small among persons in early or middle life. The duration of an attack is commonly from three to ten days. Causation. — The hypotliesis has been entertained, in conse- quence of the irritating eftect of ozone upon the air-passages, that an excess of it in the atmosphere may be the cause of influenza. But no facts raise this supposition beyond conjecture. Treatment. — Mild cases require housing, and little more. A warm mustard foot-bath at night, followed by a large draught of hot lemonade if there be chilliness, or the saiue taken cold if fever exist, and a dose of solution of citrate of magnesium or Eochelle salt or senna-tea in the morning, will generally suffice. Sweet spirit of nitre may be added to the night-draught if the skin be. dry and the urine scanty. Great prostration, especially in old people, may call for support by quinine and stimulants. Hot whisky punch is, for such a case, not out of place. The abortion of an attack of influenza is some- times practicable within the first day or two, by giving quinine, in four- or five-grain doses, thrice daily. Bronchitis or pneumonia, as complications, will require treatment as in other cases. DENGUE. Synonym. — Brealc-hone Fever. History. — ^Frequently in the Southern United States, occasion- ally in the N'orthern (at least Dr. Rush seems to have described it at Philadelphia in 1780), and in Egypt and the East and West Indies, this disorder has occurred. Some English writers regard it as a variety of scarlet fever ; naming it Scarlatina rheumatica. INTERMITTENT FEVER. 433 In Chai'leston (L'^.jO) there were 10,000 cases of it ; in the summer of 1K80, between '2000 and 3000 ; without any deaths. Symptoms and Course. — Usually after a chill, fever comes on, moderate in d(;, earlier stages there is little to distinguish the intes- tinal lesion from the corresponding process of ordinary enteric fever, except perhaps tiic; great tendency to the deposit of black pigment in the enlarged follicles. In the latter stages, certain peculiarities are often distinctive enough to enable the anatomist to recognize typho-malarial fever by the post-mortem appearances alone. The tumefaction in t3q)ho-malarial fever rises very grad- ually from the surrounding mucous memltrane, and attains a moderate degree of thickness (three to six lines) on the edges of the ulcer. In this it diilers materially from the ordinary typhoid ulcer, in which the enlarged patch rises abruptly from the mucous membrane in such a way that the summit is often larger than the constricted base, giving rise to the comparison made by Roki- tansky, who likens the shape of the tumefaction to that of fiat sessile fungi. The umbilicated depression, so frequent in the ordinary typhoid patches prior to ulceration, has never been observed in typho-malarial fever. The ulcer itself presents ragged, irregular edges, which are often extensively undermined in consequence of the erosion extending more widely in the submucous connective tissue than in the glandular tissue of the mucous membrane. This characteristic undermining of the edges is much more extensive in these than in ordinary typhous ulcers." Pathology. — Doubting not at all the presence of the malarial element, the question occurs, was the modifying "febrile" cause of the tj/phnus or of the ti/plioid character'? Granting, that is, that these are pathogenetically distinct, we should expect that the typhous or "crowd-poison " element must result from the circum- stances, as from those which have made typhus or "camp fever " the scourge of armies in Europe. Only, against this, we have the local lesion of the glands of Peyer and mucous membrane of the bowels, recalling enteric or typhoid fever. But — as, wdiere typho-malarial fever occurred, causes of intesti- nal irritation (bad water, deficient food, etc.) w^ere present — I am not satisfied that such an appearance (not, as we have seen, iden- tiad with that of typhoid fever) should exclude the idea of the zymotic action being that of the tyjihous cause. In that opinion, as a probability, not, of course, now demonstrable, I rest. Treatment. — From the above view of the hybrid and threefold nature of the disease, came its rational treatment. More qidnine than in typhus, more alcohol than in remittent, more fresh vcyetable food and fruit than in either. Experience justified this plan. In our hospitals in Philadelphia, few died from fever who were not moribund on their arrival from the seat of war. YELLOW FEVER. Only certain locahties have ever been subject to this disease ; and of those, most have had it but occasionally. It existed as 1 Op. cit., pp. 102-3. 38* 2D 450 ZYMOTIC DISEASES. far north as Boston in 1693 ; very rarely since, in any similar latitude. In New York, it occurred in 1068, 1702, 1743, 1795, 1803, and 1822 ; first in New Orleans, 1769. In Philadelphia, it first appeared in 1699 ; then in 1741, 1747, 1762, 1793, 1794, 1819, 1820, 1853, 1854, and 1855 ; the last visitations being to a very moderate extent. The worst epidemic in New Orleans, where it has been frequent (almost annual), was in 1853. Sanitary meas- ures, under G-eneral Butler's military rule, in 1862, appeared to avert it, in that city, amid circumstances which might have been expected to promote it. A very severe visitation of yellow fever occurred at Norfolk and Portsmouth, Virginia, in 1855. A still more destructive one devastated Memphis, Tenn., and Shreve- port. La., in the summer of 18'^3. In 1878 many places in the South suffered great mortality from it. In 1879, Memphis was almost ruined by it. Wise and liberal sanitary improvements, however, give a reasonable hope of its future exemption from such devastation, which has been strongly encouraged by its entire freedom from yellow fever in 1880.^ All the places which it has ever visited are upon the borders of the Atlantic Ocean, or its tributary waters, the Gulf of Mexico, and the Mediterranean Sea. Although with like climatic condi- tions, it is common in the West Indies and West Africa, but unknown in the East Indies, the eastern shores of Africa, and the Pacific .coast of America. Symptoms and Course. — With an abrupt beginning, or an indis- tinct cold stage, and pains in the back or limbs, commencing often in the night, a febrile stage occurs, of long average duration ; sometimes two or three days without remission. Violent cases have it shorter ; it may last only a few hours. The skin, at this period, is hot and dry. Thirst is extreme, the tongue is generally furred. Nausea and vomiting are common on the second day, with great epigastric tenderness. The bowels are costive ; if discharges occur they are very offensive. A flush of the forehead, with a fiery look of the eyes, is charac- teristic. Delirium is frequently present. Violent headache is nearly universal. The stage which follows this pyrexia is a sort of remission or intermission. All the symptoms abate except the epigastric ten- derness. The flush of the face and other portions of the skin is succeeded by yellowness, vyhich grows deeper as the disease advances. The pulse becomes slower, heat lessens, respiration becomes natural in frequency, the patient sits up and feels better. This state of things lasts for a variable time, averaging about twelve hours. Sometimes convalescence now takes place. Much more often a third stage succeeds, of prostration or collapse. Muscular debil- 1 The following places (recorded for possible future reference) in the Southern States ■were visited by the great yellow fever epidemic of 1878: Louisiana, Ngw Orleans, Plaquemine, Baton Rouge, "Morgan City, Hudson, Port Hudson ; Alabama, Mobile, Decatur; Mississippi, Vickstiurg, "Holly Springs, Canton, Ocean Springs, Pass Christian, Water Valley, Port Gibson, Grenada, Bay St. Louis, Friar's Point, Mississippi City, Spring Hill, Crystal Springs, Biloxi, Greenville, Hernando ; Tennessee, Memphis, Browns- ville, Chattanooga, German town, Paris, Grand Junction; Kentucky, Louisville, Hick- man ; Missouri, St. Louis ; Illinois, Cairo. Y E I. T. O W FEVER. 451 ^ i ^ /■) k b 6 y .. -i/-^ i- 10'i m 102 101 100 S9 58 S7 ~ — I E \- ^ i E -^ \ K E ' V i\i V i V E ity becomes great ; (ho pulse is rapid, irregular, and compressible ; the capillarycirculation sluggigji ; the skin deep yellow or bronzed ; the tongue brown ; the stomach excessively irri- Fig. 120. tal)le. It is at this time that the hlavk vomit oc- curs, which is pathog- nomonic of this fever. Hemorrhages may also occur from the mouth, throat, or bowels. The mind grows apathetic, or low muttering delirium exists. In bad cases, which are many, hiccough, clam- my sweats, convulsions, and involuntary dis- charges precede dissolu- tion. Death most fre- quently takes place on the Temperature in Yellow Fever. Recovery. fourth, fifth, or sixth day. "When there is reaction from the collapse, there follows a sec- ondary fever, of very variable duration, which may terminate in a tedious convalescence, an almost equally prolonged typhoid condition, or death by exhaustion. Black Vomit. — This has been found, upon chemical and micro- scopical examination, to consist essentially of blood, altered by action of the fluids of the stomach. It is usually acid to test- paper. The urine, in yellow fever, Is scanty and high-colored at the beginning, and especially deficient in amount from the third to the fifth day. About the fourth day it becomes cloudy and dei)osits a sediment. Granular tube-casts from the kidneys may be discovered in it on the fifth day. Blood and bile also may appear in it ; as well as large amounts of creatin or creatinin. Urea is apt to be below the normal quantity. Morbid Anatomy. — Congestion of the brain is common ; inflam- mation of the stomach also is usual. The liver is most frequently dry, pale yellow, and antemic ; but occasionally it is engorged. Fatty accumulation in the liver has been repeatedly observed ; and exudation into its substance is asserted. The spleen is little altered ; the kidneys are always congested. Crevaux, Guechet, and Gama Lobo have especially studied the morbid anatomy of yellow fever. During the year 1879, elaborate investigation was made concerning it, microscopically as well as macroscopically, b}^ Drs. Sternberg, II. D. Schmidt, Guiteras, Satterthwaite, and Woodward.^ Not only did they confirm the previous observa- tions of Alonzo Clark, T. H. Bache, Leidy, and Riddell, of fatty degeneration of the liver, but they found evidences of a similar change also in the brain, sympathetic ganglia, stomach, and kid- neys. Probably, in each of these organs, a stage of hypera^mia I Supplement No. 4, National Health Bulletin, 1880. 462 ZYMOTIC DISEASES. precedes the fatty alteration. Indeed congestion of most of the internal organs was found by Dr. Schmidt in a number of in- stances. Dr. Sternberg noticed, besides crenation of the red cor- puscles, a marked increase of highly refractive granules in the white corpuscles of the blood, taken during life from yellow fever patients. These he interpreted as showing a commencing fatty degeneration of the corpuscles. Drs. Joseph Jones and J. G. liichardson assert the observation of numbers of bacteria in the blood, urine, kidneys, etc., of cases of yellow fever. Drs. Schmidt and Sternberg did not find any such forms, except when the materials examined had been kept for some time after death. Diagnosis. — The only doubt likely to be entertained is as to its discrimination from bilious remittent fever. As already remarked, the latter is a disease of the country, in any warm quarter of the globe. Yellow fever is restricted geographically, and is seldom mSt with except in towns and near the sea or large rivers empty- ing into it. The order of stages in the two diseases is different ; remittent never has a pyrexia lasting over twenty -four hours without mitigation.. There is more epigastric tenderness in yel- low fever. The jaundiced hue of the skin is more commonly met with, and more decided, in that disease. Albuminuria and hemorrhages are usual in yellow fever ; not so in remittent. The black vomit, when it occurs, is decisive. Possibly, even probably, in a few localities, the combined causation of the two fevers may produce hybridity between them. Immunity for a lifetime after one attack, is common with yellow fever ; not at all with remit- tent. Prognosis. — This is a very dangerous disease, the deaths from it averaging about one for three cases. A long and moderate febrile paroxysm, without excessive irritation of the stomach, is favorable. So is the occurrence of secondary fever instead of collapse after the remission. Black vomit is almost (not quite) always a fatal sign ; suppression of urine is equally unfavorable. Some instances of the disease are called walking cases, because their early symptoms are slight, only the countenance and pulse betraying the danger, until near the end. Pathology and Causation. — There seems no room for doubt that yellow fever is a zymotic disease whose cause is generated only under certain local conditions. That cause must be itself material ; and, probahhj^ being slow and limited in transporta- tion, it is a microscopic vegetation. The local conditions observed are : 1. Continued high heat ; about 8U° for one or two months. 2. Excess of moisture in the air ; a high dew-point.^ 3. Vicinity to the sea, or to a large river emptying into the sea. 4. Organic, especially vegetable, matter in a state of decomposition. This is furnished not only by the offal, etc., of cities, but by decaying wharves and causeways (as at Norfolk, Ya.), and by newly upturned earth. Mobile was almost relieved of danger from yellow fever by paving the streets of the city with oyster shells. 1 This is not witliout exception. Matthew Carey relates that at Philadelphia, in 1793, the months of August and September, and much of October, were remarkably dry and sultry. , YELT^OW FEVER. 453 But it is very remarkfiblo, as already stated, that certain quar- ters, only, of the <2;l()l>e ever have this disease, though presenting all the above con(litions. It never visits the Paeilic coasts either of America' or Asia. Canton, Calcutta, Bombay, Alexandria, Constantinople, and Athens, have never seen it. Nor have any of the interior cities of either continent. It visits often the tropical islands of the Atlantic, the north coast of South Amer- ica, Vera Cruz, the West India Islands, New Orleans, Savannah, Charleston ; nccdsinnalh/ the western coast of Africa, llio Janeiro, Buenos Ayres,'' Bermuda, Natchez, Mobile, and other United States ports and cities, as far north as Boston and Providence ; also Gibraltar, Marseilles, and other places on the Mediterranean, as far as Sicily. It was very destructive in 1870 at Barcelona, in Sj)ain. The contcujiousncss of yellow fever, from person to person, is disproved by the immense preponderance of facts incompatible with it. A very few apparent examples of transmission by indi- viduals, if admitted to have occurred, are otherwise explained. Trdnsportation hy sJiiiJS is admitted, because a ship may carry a section, as it were, of a locality, with all its conditions and atmosphere. But, then, the port to which the ship goes must have all the conditions rife for the propagation of the disease, or its "germs " will not be maintained so as to cause an epidemic.* Naval surgeons of experience assert that only a foul ship can carry yellow fever. Moi'e will be said of this under the head of Prophylaxis. Treatment. — No specific has been found for j-ellow fever, and no abortive treatment. All kinds of remedies have been tried for this in vain ; especially bleeding, calomel, and quinine. I say in vain as to cutting it short ; but in palliating and conducting it through its stages with safety, those and other remedies may be of use. Bleeding is suggested by the relief often attending spon- taneous hemorrhages in its course ; but, as in other malignant affections, the cases for it must be well selected, the time early, and the amount moderate. Much the greater number will gain only by the application of leeches or cups to the epigastrium or back of the neck.' Many authorities approve of the use of calomel as a cholagogue cathartic, at least in a single dose (say of three or five grains), followed by a saline laxative, as citrate of magnesium, near the beginning of the attack. All the result of the use of quinine, of which I feel sure, is, that it is not likely to do good at any early stage, but only when prostration begins to appear ; and then in 1 A single instance of its occurrence on shipboard off the west coast of Soiith Amer- ica has been asserted. If so, no doubt it was a case of limited transporhuion by a vessel. 2 At Buenos Ayres, in 1871, the mortality from yellow fever reached, for a time, over 700 daily. 3 On the whole subject of yellow fever, see La Eoche's exhaustive treatise. ■» The followinc; may be regarded as a curiosity of medical history. Matthew Carey, in his account of the yellow fever of 1793 in Philadelphia, says: "The efficacy of bleed- ing in all cases not attended with putridity was great. The quantity of blood taken was, in many cases, astonishing. I)r. Griffiths was bled seven times in five days, and asi-ribes his recovery principally to that operation. Dr. Jlease, in five days, lost seventy- two ounces of blood, by which he was recovered when at the lowest stage of the dis- order. Many others were bled still more, and are now as well as ever they were."— A Short Account, etc., p. 25. 454 ZYMOTIC DISEASES. tonic or supporting, not cinchonizing, doses. It is undoubtedly of service during convalescence. Attention to the stomach is demanded by urgent symptoms. Ice, by the mouth, is refreshing and useful ; so is mineral water, or iced champagne, a little and often ; lime-vi^ater, charcoal water, and hot coifee have sometimes done service in arresting vomiting. A mustard or spice plaster over the epigastrium, or a blister dressed with acetate of morphia, may have an important effect upon the same symptom. During the hot stage, cold sponging to the face, body, and limbs will sometimes promote perspiration better than any other measure. Enemata of cold water (with care not to chill too powerfully) have been used for the same end. Dr. Miller, IJ.S.ISr., lias found the hot bath (114° Fahr.) especially service- able. On the other hand, Dr. F. Peyre Porcher,^ of Charleston, South Carolina, urges the application of ice-cold water to the head, hands, and arms, as long as there is a continuance of abnormal heat. In the collapse, stimulation will be needed, by wine, brandy, or whisky, etc., along with concentrated liquid food, in small amounts at short intervals. When the stomach is very irritable, nourishment may be given by the rectum. Experiments with antiseptic substances, as chlorine, the sul- phites, and carbolic acid, already made with other affections analogous to yellow fever, may be properly tried with it also. Dr. Eiddes, of Jamaica, reports very favorably of the sulphites. Prophylaxis. — Besides what has been said, the following state- ments will indicate the principles of prevention of this disorder: — 1. The infection of yellow fever is rarely diffused over regions of great extent ; mostly its immediate limits may be measured by fractions of a square mile. 2. The removal of the inhabitants of an infected spot will inevitably put an end to an endemic or epidemic of it. 3. Sanitary police may effectually prevent it (as at New Orleans in 1862 and 1873), and will mitigate it even after its outbreak. The immunity of Nashville in 1879, under good sanitation, but without quarantine, as reported by Dr. J. Berrien Lindsley, and the complete absence of yellow fever at Memphis, following great sanitary improvements, in 1880, are telling facts. 4. The material cause of yellow fever is never generated or multiplied in the bodies of those having the disease ; they may be taken anywhere without fear of communicating it, any more than well persons.^ 5. The germs of the disease are extremely seldom, if ever transported hyfomites; i. e., clothing, bedding, merchandise, etc. If they exist in any such material, tliey are certainly destructible by cleansing and disinfecting measures. 1 Trans, of S. Carolina Med. Association, 1872. 2 This was illustrated in Philadelphia in 1870, when, from local infection from a foul vessel, a number of deaths from yellow fever occurred at the Lazaretto; but none in the city, although several of the patients were ill there, having left the vessel before being taken sick. In other places similar instances, disproving the personal conta/- giousntiss of yellow fever, .have counted by hundreds, if not thousands. R E L A r S r N G FEVER. 455 6. A ship may carry yellow fever on board of it for a lenijth of time ((luriiiij; warm weather)', and to a great distance ; hut the disease will not spread far from the ship; at least unless local conditions add their propagating inlluence. 7. Thorough airing, cleansing, and disinfection of ships (espe- cially hy dry heat or superheated steam) vvill always deprive them of the power to generate or transport yellow fever. H. Against yellow fever, the true prophylactic method must he that of sanitary police; apart of which should be, the inspection, near ports liable to it, of all vessels arriving during warm weather.' 9. At the place of such inspection all foul vessels should be detained until cleansed, being first emptied of their passengers and cargo. The cargo also should be inspected, and, if unwhole- some, destroyed or disinfected. 10. 'No jjersonal detention whatever, other than of those ill, for necessary hospital treatment, should be imposed upon the pas- sengers or crews of vessels which have yellow fever on board. There are no facts which give reason for any such detention. RELAPSING FEVER. Prof. Aitken- thus defines this disease: "A continued fever, having a very abrupt invasion, marked by rigors, chilliness, and severe headache, vomiting, and often jaundice ; a white, moist tongue, epigastric tenderness, confined bowels, enlarged liver and spleen, high-colored urine, a frequent, full, and often bounding, pulse; pains in the baek and limbs, restlessness, and, occasionally, delirium. These symptoms abruptly terminate by an exceed- ingly copious perspiration between the fifth and the eighth day ; and after a complete apyrectic interval (during which the patient may be so well as to get up and walk about), an abrupt relapse supervenes on the fourteenth day from the first commencement. The relapse runs a similar course to that of the primary parox5'sm, and terminates between the third and the eighth day. In some cases a second, third, fourth, and even fifth relapse may occur. Death is apt to happen from sudden syncope, especially after the excessive perspiration ; or from suppression of urine and coma. No constant eruption and no specific lesion are associated with the fever." The temperature generall}^ rises to 104° or 105° F. on the second day, and reaches its maximum the day before the defervescence. Then, as the other symptoms subside, it sinks rapidly to about 98°. When the relapse occurs on or near the fourteenth day, the heat again rises to 10'4°, 105°, or more ; descending afterwards with convalescence. History. — Drs, Christison and Welsh first described relapsing fever in Scotland, 1817-18 ; Barker and Cheyne in Ireland about the same time. Kutty appears to have given an account of it in Dublin as early as 1789. In 1844, Dr. M. Clymer recognized it in 1 The substance of these conclusions was clearly advocated by Dr. G. Milroy, 1867, before the London EpidemioloL'ical Society. - Science and Practice of Medicine, Philadelphia ed., vol. i., p. 4.38. See on Relapsing Fever in Philadelphia, a valuable paper by Dr. J. S. Parry, in Am. Journal of Med. Sciences, October, 1870. 456 ZYMOTIC DISEASES. some Irish emigrants coming to the Philadelphia Hospital.^ Dr. Dubois reported the occurrence of a few cases in ITew York, mostly among emigrants, in 1847-8. In the same years it was epidemic in Glasgow, Edinburgh, London, and some parts of Ger- many, in 1855, in the Crimea, during the war; and since that time in Russia, and elsewhere on the European continent. Since 1856 it appears to have almost disappeared from Great Britain. During the summer of 1870, in New York and Philadelphia, hun- dreds of cases occurred in local "nests " of unsanitary conditions. In the Philadelphia Hospital, from April to November, 1870, 517 cases were admitted, with 80 deaths. Of this mortality (15.} per cent.) the greater part was amongst negroes; of whom 26 per cent., affected with relapsing fever, died ; of white patients, only 5 per cent.^ In Great Britain the deaths have been reported as about 1 in 40 ; in Russia, 10 or 11 per cent, of the cases. Diagnosis. — The most distinctive features of this fever are, the "crisis," from the fifth to the seventh or eighth day, and the relapse on the fourteenth, or, at all events, between the twelfth and the twentieth day. In its general symptoms it resembles, otherwise, remitting fever; but with less decided daily abate- ment and exacerbation of the febrile movement, and with greater severity of "rheumatic" pains in the joints and, muscles. The convalescence is slow, and is not unfrequently attended by a severe ophthalmia. Pathology and Causation. — It would seem that relapsing fever must be a specific disease. Associated in nearly all cases with circumstances of destitution in large cities, it has been called in Europe, "famine fever." Contagion is asserted of it by Prof. J. Simon, Dr. E. Harris, and others. Carter, Munch and Mots- chutkoffsky^ found that it could be inoculated by means of the blood taken during the febrile paroxysm. In the Philadelphia Hospital, in 1870, it did not spread to other inmates. Anatomically, it has been observed, in fatal cases, that the sjyleen is often enlarged to a greater degree than in any other fever. Dr. Hand, of Philadelphia, has found the red corpuscles gran- ulated and cranated ; besides (Cormack, A. Thompson) increase of white corpuscles. Dr. Obermeier, of Berlin, asserted the ob- servation of minute mobile filiform bodies in the blood in this disease, called spirilla. They have been found also by others, but not constantly. Dr. J. R. Lewis believes them not to be essential to the disease.* Treatment. — After a mild cathartic at the beginning, and, if headache be severe, a few cups or leeches to the back of the neck, cooling diaphoretics may be given, as solution of citrate of potas- sium or acetate of ammonium. After the crisis, quinine and mineral acids may be used, in moderate doses, at least until the relapse. It has been proved that this (the relapse) will not be prevented by any amount of quinine. Many patients will require 1 Fevers, etc., by Meredith Clvmer, M. D., Philadelphia, 3846, p. 99. 2 Philadelphia Med. Times. March, 1871. The total number of deaths in the city, reported to the Board of Health, was 162, of which 107 were of colored people. 8 Centralblatt fur die Med. Wissenschaft, 1875, xi., 193. * Lancet, Feb. 28, 1880. CEREBROSPINAL FEVER. 457 support, especially in the third week, by beef-tea, etc. ; some, also, alcoholic stimulation. CEREBRO-SPINAL FEVER. Sjnionyms.— Oerebro-.s'pma^ Mcn'mgith ; Spotted Fever; MaJig- nant Purimrir. Fever. The name adopted above is preferred by me, in the absence of sufficient prepond(!rance of authority or reason in favor of either of the; other names. The disease; is a fever, or systemic disorder ; not a mere local phlegmasia. It has no more claim to be called cerebro-spinal meningitis' than typhoid fever has to be called enteritis, or scarlet fever faucio-jjhctri/nyitis. Yet the term spotted (or petechial, Wood) fever is not fully justi- fied as distinctive — because only in a minority of cases it exhibits any eruption, and something like the same is also at times seen iu typhus. History,— Often obscurely described, this disease appears to have been known in France in DUO and 1482 ; over Europe, or parts of it, in 1503, '10, '16, '17, '28, '45, '59, (Sicily) '64, '68, (Paris) '69-'74. Inl5S0, it was at Rome, Venice, andMadrid, with great mortality; again over Europe in 1582; at Trent, 1591, Florence, 1592 ; at various places, 1616 and 1624. Sydenham described it in 1661. In 1661 and '93 it was in Italy ; and in England, 1698, 1710, 1741 ; in Prussia, 1704. Other years named for' it are 1720, '60, '61 ; 1757 and 1788. A well-known outbreak of it occurred at Geneva, 1805 ; one in the Prussian army, 1806-7; in Sicily, 1808; at Dantzic, 1811 ; Brest and Mayence, 1813-14 ; Grenoble, 1814, and the same year at Paris ; 1815 at Metz ; else- where in 1816 and 1823. Afterwards in Europe its historians (under the names mmingite cerehro-spinale fjjidemique^ cerebral tijphus, and tifo upoplettico tetanico) speak of it in 1832, '37, '39, '40, and almost every year till 1850, extending over many places in succession as far as Gibraltar and Algiers at the south, and Scot- land and Ireland at the north. From 1854 to 1861, in Sweden, jSTorvvay, and Holland. In North Germany and Russia, it is said to have prevailed in 1863-4-5 ; and iu Ireland, 1866 and 1867. In the United States, its first recorded visitation was in 1806, in Massachusetts. Then it gradually spread through the New Eng- land States, New York and Canada, from 1807 to 1812, when it had reached Philadelphia. After that it was met with at various places until 1820 ; but not with great frequency.^ BetAveen 1840 and 1850 it was epidemic in several of the Middle, Western, and Southern States (Kentucky, Indiana, Illinois, Michigan, Missouri, Tennessee) ; also in 1852 and 1858. Next we hear of it in 1862-3; most clearly in the descriptions of Dr. Gerhard,* in the latter 3fear, as it occurred in the neighborhood of Phila- delphia. Since that time (at which cases were seen especially II regret being oblisted to differ here from so liiffh an authority as Professor A. Stille. See his " Treatise on Cerebro-spinal Menin<;itis," Philadelphia, 1867. 2 Early American writers upan it were, North and Strong, I8U ; Gallop, 1815; Miner, 1825. STransaotions of the College of Physicians of Philadelphia, 1863. 39 458 ZYMOTIC DISEASES. at Frankford, Falls of Schuylkill, Manayunk, and l^orristown, but only a few in the city) it has been observed in a number of places in Pennsylvania, New York, Ohio, Indiana, Michigan, Missouri, Rhode Island, Vermont, Massachu- setts, Maryland, and the District of Columbia. Symptoms and Course. — The attack is nearly always sudden. Chilliness, terrible pain in the head, extending to the back of the neck, nau- sea and vomiting, are the earliest symptoms. Delir- ium follows ; ending not un- frequently in coma. Tetan- ic spasm or rigidity of the muscles of the back of the neck (and sometimes of the back and limbs), is common. Convulsions are much less so, but do occur, particularly in the young. Painful sensi- tiveness (hypersesthesia) of the whole surface of the body is present in most cases, when there is no coma. Loss of sight and hearing may take place during the middle period of the attack. The pulse is at first slow, then accelerated, but diminished in volume and strength. Respiration is slower than natural in most, but not in all cases. The tongue is usually at first white and moist ; sometimes natu- ral ; in prolonged cases it may become yellow or brown. The bowels are costive or natural. The skin has almost always at the beginning an abnormally low temperature. When reaction occurs it does not become very hot as a rule. Burdon Sanderson has found it as high as 102° to 104° in children. Near the time of death, Wunderlich has known it to reach 107°, 108°, 110°. Dr. J. Lewis Smith has found the temperature morbidly elevated in the rectum, when it was not so in the axilla. Dryness of the surface is most com- mon, although late in the attack profuse perspiration may occur. Often there is an herpetic eruption about the lips. In a minority of the cases, though varying in proportion in different epidemics, S20ots (petechise) appear, on the second or third day, or later ; on the neck, breast, or limbs ; seldom on the Cerebro-Spinal Fever. (J. Lewis Smith. CEREBRO-SPINAL FEVER. 459 face. They are of difierent dimensions, from tlie size of a pin's head to three-quarters of an' inch in diameter, and distinct ; but not elevated nor disappearin., Report on Cerebro-Spinal Meningitis. Chicago, 1866; J.J. Levick, M. D., "Report on Spotted Fever, so called," Trans. Am. Med. Assoc, 1866; A. Stillfi, M. D., Treatise on Cerebro-Spinal Meningitis, 1867. 39* 462 ZYMOTIC DISEASES. the heart is often noticeable ; sometimes so much so as to justify Dr. Stokes's diagnosis of " typhous softening." Hypostatic pneu- monia (i. e., beginning with passive congestion of the lungs pos- teriorly) is the most frequent complication of the fever. The duration of an attack of typhus is generally three weeks. The critical period is usually about the eleventh day; after which defervescence (the decline of the fever) may be looked for. Occa- sionally death may take place within five days, or recovery within fifteen from the commencement. Morbid Anatomy. — Absence of lesion of the solids has been repeatedly noticed. The blood is always altered during life; after the early stage it is less coagulable and darker in color than in health. Passive congestion in various organs is observed, as in the lungs, brain, liver, etc., but without anything characteristic. Patholog-y and Causation.— I^o disease affords more reason for pronouncing it a disease of the blood than typhus. Its cause, demonstrably in many cases, is ochlesis or crowd-poison; the effluvia from human bodies, accumulated, especially in cold weather, in small and ill-built dwellings of the poor, and most of all in filthy towns, ships, jails, or camps. Having been thus gen- erated, it becomes contagious ; one patient having, in his morbid emanations, the poisoning power of a whole crowd. Yet the contagion is not very strong ; many who are exposed, especially in well-ventilated places, often escaping the disease. In giving this account of it, candor requires me to add that the spontane- ous origin of typhus in any case, apart from direct, specific, per- sonal contagion, is denied by such eminent British authorities as Drs. W. Budd, Parkes, and others. Diag'nosis. — After the first two or three days (during which there may well be doubt as to its character) the only probable question will be between typhus and typhoid fever. All medical authorities are not yet agreed as to the non-identity of the two forms of slow continued fever.' A large majority, however, regard them as quite distinguishable during life, and separated pathologically by the absence in typhus of the morbid alterations of Peyer's glands, and those of the mesentery, characteristic of typhoid fever. I have many times seen typhus and typhoid cases in the same ward, lying side by side, and should feel confident of being generally able to diagnosticate them by the countenance alone. Under the head of Ti/phoid Fever the clinical differences will be enumerated. Prognosis. — Murchison states the mortality in the hospitals of Great Britain, from typhus^ to be one death in five cases, 1 Dr. J. Hughes Bennett, for example, maintained their identity; and some German writers call typhoid " abdominal typhus." The definite history of typhoid or " enteric " fever began witli Prost, of Paris, 1804. Louis, 1839, studied it elaborately, showing the constancy of the intestinal lesions. In 182.S, Dr. Enoch Hale, of Massachusetts, described two forms of continued fever. Dr. Gerhard, upon careful autopsies in the Philadelphia Hospital.announced evidence of the distinctness of typhus from the typhoid or " dothinenterite " of Louis in 1835. Dr. A. P. Stewart, of Glasgow, published similar conclusions in the same year ; and so did D. R Perry, of Glasgow, and Dr. John Reid, in 1836-7. In 1846, Dr. W. Jenner commenced an investigation into the subject, whose results most physicians have accepted as decisive. He concluded that typhus and typhoid fevers are clinically and anatomically distinct as well as dilTerent in causation. Dr. (Tairdnerhas recorded cases in which patients convalescent from typhoid fever have taken typhus upon exposure to its contagion. TYPHUS FEVER. 463 Cheyne and others in private practice have found it hut one in twenty or more. I have not seen many deatiis from it, in private or hospital pi'actice. Prohahly one in ten or fifteen would he a fair jreneral estimate. Bad siiins are, great feebleness or extreme rapidity of the i)ulse, ]n-ofound coma, hiccough, suj)pression of the urine, involuntary defecation. Pneumonia, complicating the attack, increases its danger, though I have known several recov- eries notwithstanding this. Treatment. — More than half the cases of typhus, according to my observation, require alcoholic stimulation, as well as concen- trated nourishment, after the fourth day. But not all the cases, as my own, among others, proved. I was bled on the second day, the diagnosis not beinii' made out; and leeched on the third day, freely, on the back of the neck; yet no alcoholic stimulus was i-e- quired, after the typhous nature of the attack was clearly shown; recovery following at the usual time. Drs. Russell and Gairdner ' have shown (in the Glasgow Fever Hospital) that typhus may be treated, in many cases, without alcohol. In nearly a thousand cases their mortality was about nine per cent. Dr. A. L. Loomis,- of New York, in 1S61-2, treated five hundred cases of typhus, in tentfi, without any alcohol. His mortality was one death in sixteen cases. At the same time, in Bellevue Hospital, under the large use of alcohol then prevalent, the mortality was one death in every six cases.'' Dr. Loomis very properly urges the importance of having patients with typhus placed in the purest and freshest atmo- sphere possible. The hospital tent will always be better for them than the hospital ward. We may begin the treatment of an ordinary case of typhus with a mild laxative — e. g. , a moderate dose of solution of citrate of magnesium on the second day. The diet at first may be of gruel, etc.; but very soon must milk and beef-tea or chicken or mutton-broth (or an alternation of these) be given in small quantities, at short intervals, to support the strength. Before the first week is out, half the cases will need wine in moderation; some, brandy or whisky. In the second and third week, more than half the cases will require steady support of a positive kind. In such cases, the proper routine is a tablespoonful of brandy or whisky punch (one part of spirit to three, two, or one of milk) every two, three, or four hours, and, the alternate hours, a table- spoonful or two of lieef-essence or beef-tea. Of medicines, quinine has had the most extended trial in typhus. It acts well as a tonic in 1- or 2-grain doses, four or five times daily, after defervescence has begun; i. e., after the tenth or twelfth day, usually. Dr. Dundas's plan of treating typhus early with large doses of quinine (renewed of later years with the view of reducing temperature) is, I am satisfied, after seeing some trials of it, futile and even unsafe. Mineral acids have acquired much reputation in typhus. Dr. 1 British Meaical Journal, Aupr. 22, ISGS. 2 N. Y. :Mcd. Record, May 21, 1881, p. 5G3. 3 At Bellevue Hospital, during the sprinc: of 1881, there were 273 cases of typhua fever, with 64 deaths. K. Y. Med. Record, Aug. 13, 1881, p. 190. 464 ZYMOTIC DISEASES. Flint advises dilute sulphuric acid; Huss, phosphoric acid. Mtro- muriatic acid I have known to produce an excellent effect in the depression of the middle stage. Large doses are not required; but the acid should be given several times in the day. Some prefer dilute nitric acid [F, 165, 166]. Chlorine ruaier is lauded highly by others. Sulphite of sodium and carbolic acid may be worthy of further trial. Co/fee, given by Gaillasse in typhoid fever, would seem a reasonable stimulant in a low stage of typhus also. But the great point of skill will be to determine when and how far to stimulate. Delirium favors the probability of its being needed ; especially a low, muttering delirium. Of course a very feeble pulse indicates it. On trial, when the pulse grows slower, the skin more moist, and the restlessness or delirium is quieted, the stimulus has done good, and should be continued. If, on the contrary, a more hurried or a harder pulse follow, with heat of head and dryness of skin, and wilder delirium or deeper stupor, it should be stopped, for a while at least, or, if given, be dimin- ished in amount, Catheterism may be needed for retention of urine. Inquiry and inspection should determine every day the state of the blaclder. Constipation, through the attack, may be overcome by enemata, or by small doses of oil, Eochelle salt, or other mild laxative. When the coma is very deep, a blister to the back of the neck may do good ; and so may sinapisms to the extremities. Great heat of the head may possibly, though rarely, render proper, especially in the first week, the application of cold water to the head. Sponging the whole body daily (best at night) with whisky and water, warmed, is extremely comforting and beneficial. Hypostatic pneumonia in typhus cannot be treated actively. Even abstraction of blood by cups is hardly ever to be ventured upon. Dry cups, between the shoulders, and a blister upon the breast, are about all the special treatment allowable. It is, how- ever, possible generally to prevent hypostatic pneumonia, by not allowing the patient ever to lie for many hours together upon his back. Let him be turned, once in a while, upon one or the other side. Prophylaxis. — Thorough ventilation is the only (but sufficient) security against the generation of typhus fever ; and this is capable also of almost disarming its contagion. TYPHOID FEVER. Synonyms. — Slow Nervous Fever; Common Continued Fevers- Enteric Fever; Abdominal Typhus (Pythogenic lever of Mur- chison). Symptoms and Course. — After a more gradual approach than that of any other fever, with languor and debility, anorexia and headache for several days, bleeding at the nose and a bronchial cough are almost pathognomonic early symptoms. The patient takes to bed, with fever of considerable violence. The face acquires a dark purple flush. He lies dozing, perhaps muttering, unless disturbed, all day; but is more or less wakeful and delirious at night. Hardness of hearino^ is common from the middle of the TYPHOID B'EVER. 465 second week. Swelling of the belly ( tympanites) comes on towards the end of the iirst week ; dtarrhoea about the same time. Rose- colored lenticular spots [laches rowjes)^ disappearing on pressure, are discovex'able, few in number, and on the abdomen only, toward the end of the second week ; they continue a week or two. Ten- derness on pressure in the right iliac region, with gurgling under the hand, generally exists. Sudamina over the chest are not unusual. The duration of the typhoid pyrexia is seldom, from the start, nmch less than two weeks, and it is often more ; the whole attack of typhoid fever may be protracted, as I have seen it, to two or three months. One month may be considered the average time, from taking to bed to leaving it convalescent. Late symptoms in sevei'e cases are, the dicrotous pulse, sub- sultus tendinum, retention (perhaps suppression) of urine, hemor- rhage from the bowels ; and, if death be imminent, hiccough, cold sweats, involuntary discharges. In protracted cases, great emaciation and bed-sores may super- vene. Even during convalescence, abscesses in various parts of the body may give trouble. These usually affect the glands or connective tissue, but may occasionally involve the long bones, lungs, liver, or spleen. Danger of perforation of the intestine, from deep ulceration of the glands of Peyer, exists always after the first week, until late in convalescence. Patients out of bed for a week or two have sometimes died from this cause. Dr. Harlan reports^ a case in which fatal perforation took place four months after the com- mencement of an attack of typhoid fever. Dr. Da Costa men- tions it as happening after seven months, from error in diet. The occurrence of perforation is recognized by symptoms of severe peritonitis, with collapse. The result of this is almost inevitably fatal ; the only recorded exception being reported by Prof. 6. B. Wood. I saw a case of suppurative peritonitis, opening exter- nally, which recovered, in the Philadelphia Hospital, several years ago ; but I was not able to learn the antecedents of the case. Temperature. — This has been made a special study in typhoid fever. The rise from 98.5° (the normal degree) is gradual, during the first four or five days ; reaching 104° on the evening of the fifth day ; sometimes 1U4:.5°. An attack of disease in which on the second day the heat in the axilla is as high as 104°, is not typhoid fever ; and the same exclusion applies if from the fourth to the eleventh day the temperature falls below 108°. A diflerence of 1° or 1.5° between morning and evening (greatest heat, the latter) is usual ; the reverse is not a good sign. The marked tendency to a morning fall and evening rise of temperature is almost pathog- nomonic of typhoid fever. Toward the end of the second week, lowering of the heat below 103° is always favorable ; persistence at a 104°, 105°, or 106°, shows a severe case ; the higher the worse. Sudden increase of temperature indicates a complicating inflammation ; as pneumonia. Discharges. — Liquidity of the stools is a characteristic of this disease, even if there be but one daily. Generally, after the mid- > Trans. Philada. Pathol. Soc, 1859. 2E 466 ZYMOTIC DISEASES. die of the first week, there are two or three passages, brownish with a slight yellowish tinge, every day. From the very begin- ning of the attack, the bowels are usually susceptible to the action of purgatives ; a teaspoonful of castor oil operating readily. Excessive diarrhoea, at a middle or late stage, not unfrequently adds to the prostration of the patient. Hemoi'rhage from the bowels, when it occurs, is most apt to be met with in the second or third week. The urine^ through the attack, is commonly scanty, high-colored, excessive in the amount of urea, deficient in the chlorides, and sometimes albuminous in severe cases. Complications. — Pneumonia, especially the hypostatic form (as in typhus), is the most frequent. It has been, by some writers, denied that true pneumonitis, anything more than passive conges- tion, occurs in these cases. But, in the analogous instance of typho-malarial fever, especially when the scorbutic diathesis was also present, I have seen, after death, more than once, suppura- tion as well as hepatization, confined altogether to the posterior portions of both lungs. I do not doubt the same happening in typhoid as well as in typhus fever. Inflammation of the brain may complicate typhoid, more often than typhus ; but it is not common. Peritonitis follows when perforation of the ileum takes place. Examples of its occurrence without that accident are said to have been, though very rarely, observed. Relapses. — Even after seemingly decided convalescence has taken place, a relapse may occur, with return of all the symp- toms of the disorder, including (Da Costa) the cutaneous eruption. The temperature "bounds, "In a relapse, almost at once to 103° or 104° ; returning, as in ordinary cases of the fever, in a zigzag man- ner to the normal degree, with convalescence. This second attack seldom lasts so long as the original one ; and death does not often result from it, unless perforation of the bowel takes place. Sequelae.— Prolonged debihty, or a very slow convalescence, is common. The mental faculties are sometimes enfeebled for weeks or months. Paralysis is an occasional sequela. Abscesses have been mentioned ; they may occur in the connective tissue, joints, lungs, liver, or spleen. Periostitis, followed by necrosis, of the tibia, femur, or humerus, may happen, though I have known of but two such cases. Perforation of the bowel may, as already stated, occur after convalescence has seemed to be established. Morbid Anatomy. — Omitting variable and merely occasional appearances, the parts characteristically affected in typhoid fever are, the agminated glands or patches of Peyer in the small in- testine, the mesenteric glands, and the spleen. Careful study of Peyer's glands, by many observers, has shown that, at first, the glands thicken and become elevated from one to three lines above the membrane around them. They are generally at this time, reddened ; but with variable depth of hue. Sometimes, after this, a sort of induration occurs ; in other instances, softening. Later, ulceration affects many, though not all, of the altered glands ; and this process may go on until, as above said, it may perforate all the coats of the intestine. This, however, is excep- TYPHOID FEVER. 467 tional. Tho healiiiij; of the ulcers by granulation is the general rule. Dr. Murchison has reported fatal cases of sloughing of the intestine without perforation.'^ The solitari/ dosed glands of the small intestine are also com- monly enlarged, and often softened or ulcerated. The mesenteric glands are almost uniformly enlarged, congested, and softened ; occasionally they suppurate. The r)msdcsj especially the recti ahdnminis^ in protracted cases, have been shown to undergo a granular, or sometimes a waxy or amyloid degeneration ; resulting, in the rectus, occasionally in rupture of its fibres. Pathology. — Typhoid fever is believed by most authorities to be a general or systemic disorder, with a characteristic second- ary local lesion in the intestines. How far the matter deposited in the patches of Peyer befoi'e ulceration is specific, is a question. Rokitansky and Carl Wedl have believed it to be peculiar — the former comparing it to that of encephaloid cancer, the latter to tubercle. I do not believe that there is anything propei'ly to be called specific in its nature. Latterly, however (1881), under the prevailing tendency to find a "contagium" for almost every disease, it is a very commonly taught doctrine that typhoid fever is eminently a specific dis- order. Klebs'^ asserts the discovery of its "microbes" or caus- ative micro-organisms. Eberth, Braulecht, and others have made similar observations.^ Such discoveries, however, require repeated verification by several observers before they can be accepted in science. Dr. G. B. Wood held the opinion that an inherent predisposi- tion to the disease exists in many persons, analogous to the tuber- culous, gouty, and rheuma- tic diathesis. This seems Fig. 122. very probable. Dr. H. Ken- nedy, of Dublin, has (1873) advanced a similar opinion. Another view is, that the affection of the intestine is primary ; and that the " ty- phoid " symptoms result from the absorption into the blood of morbid, putrescent material from the glands of Pe3'^er, producing a septcemid or ichorcemia. This view does not appear to me to be con- firmed by the usual order of events in the disease. Causation. — More room for doubt exists as to this in typhoid fever than in regard to any other common disorder. Depressing causes of all kinds seem to promote it ; foul air, Ulceration of Glands of Peyer. 1 Trans, of Pathol. Soc. of London, 1866, p. 130. 2 Archiv fur Exper. Pathologie, t. xii., p. 231, 1880. 8 Lancet, May 7, 1881. 468 ZYMOTIC DISEASES. removal from home, fatigue, anxiety, etc. Yet it will occur in the entire absence of all such causes. No locality limits it ; ail climates allow it; from the Arctic regions to those bordering upon the tropical ; from the cities of the East to the Rock}"^ Moun- tains. The "mountain fever" of hunters in the far West was found in the autopsies of Dr. Hammond to present the lesions of Peyer's and the mesenteric glands. buch universality is very much in the way of the "pytho- genic " theory of Murchison (i e., its reference always to foul air, as that of sewers), or that of Budd, that its only cause is a specific matter, passed from the bowels of those having it, and by water or air, conveyed into the systems of others. Contagion of this kind is, nevertheless, widely believed in now, especially in England. Some facts asserted (Flint, Canstatt, Budd, Watson) in proof of it are hard to explain without admit- ting such a mode of propagation (e. g.^ by the discharges of a patient getting into a well, etc., so as to contaminate drinking- water). Dr. Ballard has reported' instances in which it appeared to be propagated by the milk served by dairymen. The pans used for the milk appear to have been washed with .water exposed to contamination. A more extensive series of cases in the west end of London, in the summer of 1873, was traced to the same mode of propagation.^ Prof. I. Buckman asserts the observation of a peculiar "fungoid or confervoid" growth in water, contaminated by sewage or otherwise, and productive of typhoid fever. But the large majority of cases allow of no such explanation ; most of all those occurring in the open country. There is no doubt that typhoid and typhus fevers may coexist as epidemics ; sometimes affecting the same patient, the one fever shortly after the other (Gairdner); and occasionally together, as a hybrid disease. This may help us to account for some instances in which foul air has appeared to generate typhoid, and where the latter has seemed to be contagious. My own experience leads me to adopt the view expressed by Niemeyer, Anstie, and others, that "typhoid fever is certainly not contagious in tlie same sense as typhus is." Dr. Murchison-^ states that, in the Eever Hospital, in fourteen and a half years, with 2506 cases of typhoid fever admitted, only eight new cases originated in the hospital. Liebermeister has stated (1865) that he has never, in the hos- pitals of three cities visited by him during many years, seen a single patient, physician, or nurse attacked with typhoid fever, although cases of it were placed in the general wards. Dr. R. Bruce Low, of Yorkshire, England, has reported some striking facts showing the great probability, if not certainty, of the orig- ination of typhoid fever de novo in isolated localities.* Dr. S. S. Turner, of Dakota,^ writes thus: "The prairies of Dakota are very healthy. The air is exceptionally pure and invigorating. And yet typhoid fever is not unkfie^n here, ae 1 British Medical Journal, Nov. 26, 1870; Lancet, April 5, 1873. 2 Lancet, Aug. 16, 1873. 3 on Fevers, p. 428. 4 Philadelphia Med. Times, Dec. 18, 1880, p. 178. 6N. Y. Med. Record, April 30, 1881, p. 502. TYPHOID FEVER. 469 something entirely distinct from the indigenous mountain mala- rial remittent so called. An occasional ' sporadic' case is seen at military posts where the sanitary conditions are seemingly the best, and the general health entirely satisfactory. I have seen the same thing in commands living in tents upon the dry prairie, where the natural conditions were perfect, and the privy-sinks remote from the camp. These cases have furnished perfect clinical histories of typhoid, and where they have termi- nated fatally the pathological conditions were found to be typical, as specimens now in the Army Medical Museum will testify." Dr. Thorne Thome's so-called "crucial instance" of the extension of typhoid fever by drinking-water^ falls decidedly short of that character, since the presumed initial case was by no means certainl}' one of typhoid fever : all that is made clear in Dr. Thome's report is, that the man had diarrhoea, but was able to walk about and be at work. In a number of places in the country, suspicion has fallen, with reason, upon the too close proximity of pi-ivies, or foul drains, to drinking -wells, as a promotive cause of typhoid fever. More than twenty cases were thus directly accounted for in Germantown, Philadelphia, in 188U. At Zurich, Switzerland, in 1839 and 1878, epidemics of typhoid fever, with 440 cases in one instance, and about 500 in the other, followed immediately upon a musical festival. Investigation connected the disease with the use of bad veal, furnished by an innkeeper of the place. ^ All kinds of foulness no doubt promote typhoid fever. This I believe to be the true solution of the question, in regard to the influence of contamination of water by privies, sewers, etc. ; there being no sufficient proof of the now current opinion, that the disease depends upon a "specific infection" or " contagiura " passed from the bowels of a typhoid fever patient, which must in some manner get into the body of another to produce the disease. Dr. Austin Flint^ writes thus : " under ordinary circumstances it is not diffused by contagion;" "facts appear to show conclu- sively the spontaneous generation of the causative agent in the great majority of cases." Typhoid fever is rarest in old age ; not frequent in childhood ; most common between fifteen and thirty years. Few have it under ten or over forty; almost none beyond fifty. It scarcely ever (relapses apart) occurs a second time in the same person. Diagnosis. — From remittent fever, typhoid is known by the usual absence of vomiting and of sallowness of the skin, the slower onset, more protracted course, the hebetude or mental dul- ness and drowsiness, and the abdominal symptoms. Vomiting may occur in children. From typhus fever, the distinctive points* are as follows : — 1 Practitioner. June, 1879. 2 Journal de Medecine, June, 1S79. 3 Practice of Medicine, 4th edition, 1873, p. 883. * The credit of iiist establishing the non-identity of tvphus and tvphoid fever belongs to Dr. W. VV. Gerhard, of Philadelphia ; 1837. See note on p. 462. ' 40 470 ZYMOTIC DISEASES. In Tyiohus. In Typhoid. No epistaxis nor bronchitis ; Epistaxis and bronchitis ; Bowels constipated ; Diarrhoea ; Belly seldom tympanitic ; Tympanites, gurgling, etc, ; Miliary eruption, 5th to 7th day ; Lenticular rose spots ; Progress moderately slow ; Progress very slow ; Death often within ten days ; Death rarely within 14 days: Countenance dusky red ; Countenance purplish red'; Causation mostly obvious ; Origin obscure ; Anatomy not peculiar. Lesions characteristic. As Dr. J. W. Miller^ has pointed out, the duration of elevated temperature is, in typhus, rarely longer than eighteen days ; in typhoid, seldom less than twenty-one days, and often more than thirty. In typhus, also, the evening temperature is, not unfre- quently, lower than that of the morning ; in typhoid, the even- ing temperature is almost constantly higher than that of the morning. Cases called "febricula," or "irritative fever" (formerly " sy- nochus") are described by some writers, and met with once in a while in practice, which give a good deal of trouble in diagnosis. Some of these, probably most of them, are mild examples of typhoid fever. A few may be called walking cases : the patient being able to keep out of bed. Prognosis. — The mortality from this disease varies greatly under different circumstances. The possibility of perforation of the ulcerated bowel gives an element of uncertainty to every case. Probably one death in twenty cases will represent its average mortality. The favorable and unfavorable symptoms, other than those common to typhus or other febrile affections, have been indicated sufficiently already in our account of the disease. The state of the tongue, especially at the period of defervescence (end of second week, about), should alwaj^s be noticed, as it aids our observation of the abdominal symptoms in concluding upon the progress of the intestinal lesion. Hemorrhage from the bowels is so far at least an unfavorable sign, that it shows the intestine to be so deeply involved as to make perforation not improbable. Patients before robust may survive a quite large hemorrhage during typhoid fever. If, however, repeated, or occurring in a feeble subject, it presages danger of exhaustion. Treatment. — Self-limited as typhoid fever is, no cutting short of it is possible. We must conduct the patient through it as safely as we can. For this, very little medication, perbaps none, will suffice, with good nursing, in many cases. I have treated the disease with so little medicine, that it might be said to have been left to nature, supported by regulated liquid nourishment alone. Yet this is not always proper or safe. The course of treatment learned in the Pennsylvania Hospital many years ago, has been followed throughout my practice with generally successful results. My only deviations from it have 1 Brit, and Foreign Medico-Chir. Review, Oct. 1868, p. 464. TYPHOID FEVKR. 471 been in the direction of diminishing the amount of medicine given. It was, upon tl\c aveirage, as follows : — In the course of the lirst few days, if the bowels were costive, a teaspoonful of castor oil was given ; after that, no laxative. During the first week, while the fever was highest, the tongue furred and often dry, skin hot and without perspiration, small doses of blue mass with ipecacuanha were prescribed, with the view of favoring freedom of the secretions. Afterwards, or at the same time, sjiiritus mindereri (liquor ammonii acetatis) was given, a tablespoonful (diluted) every two or three hours, from noon till near midnight, as a diaphoretic. Liquid food is necessary from the first. Oatmeal gruel, toast- water, rice-water, the first three or four days ; then milk may be added, one or two tablespoonfuls every two or three hours. Less than half the cases of typhoid fever which I have seen have required' alcoholic stimulation at any stage ; not more than one- fourth of the cases need it before the middle of the second week, when the fever begins to decline. After that time, many require it, first in wine whey, half a wineglassful about every three hours ; later, when weaker, brandy or whisky punch ; — a tablespoonful of whisky, for instance, every four, three, or two hours, sometimes every hour, with the same or twice as much of milk. Sir W. Jenner's rule is undoubtedly a good one, "in typhoid fever to abstain from giving alcohol if, in the case before me, I doiM the wisdom of giving it ; and when there is a question of a larger or a smaller dose, I, as a rule, prescribe the smaller : the reverse of the rule in tj'phus fever. "^ Beef-tea is indispensable in nearly all cases, from the second week. It may alternate with punch, hour by hour. As in typhus, a patient prostrated with severe typhoid fever should be waked from sleep to take the required nourishment, night and day ; otherwise he may sink for want of it. Co/fee has been used as a stimulant by Guillasse, with asserted advantage. Quinine, I am satisfied, has no place as a curative of this fever. It is useful as a tonic after the critical period of the passing of the height of the fever ; not more than eight or ten grains (in one or two-grain doses) in twenty-four hours [F. 2]. 1 am not a believer in the validity of the "antipyretic" action of quinine, in continued fever, in twenty-grain doses ; and am glad to be able to quote the authority of Sir William Jenner to sustain my want of confidence in it. In the first ten days, headache and heat of the head may call for the application of cold to it ; sometimes for leeches to the temples or back of the neck. Dryness and heat of the surface of the body may be best allayed by sponging all over (one part only uncovered at a time) with tepid whisky and water. This opera- tion, done in the evening, will promote sleep. Dr. Drasche,- of Vienna, introduced the systematic use of cold water externally, to lower the temperature, which is morbidly increased in fever. Brand, Liebermeister, Ziemssen, Wilson Fox, and others have appUed this remedy extensively, and with reported success. • Lancet, Nov. 15, 1879. « British Medical Journal, Feb. 19, 1870. 472 ZYMOTIC DISEASES. Ziemssen's gradual method is the best : immersing the patient, when the heat is excessive, in a bath at 95° F., the temperature of which is gradually lowered ten or even twenty or more degrees, according to the efiect produced. In this way, morbid heat may he lessened, without shock or undue depression. On the whole, the mortality of typhoid fever does not seem to be lessened by its treatment with cold bathing. Eiess (1780) uses, instead, pro- longed lukewarm baths. ]!ianassein, of St. Petersburg, prefers cold enemata. Great tenderness of the abdomen may be treated by application of large poultices of hot mush, with which one-fourth or one-fifth part of mustard has been stirred. Diarrhoea being a symptom of the disease, it needs not to be checked unless the passages num- ber more than three or four a day, or are uncommonly copious. Then, a pill of tannic acid and opium (3 grs. of the former to gr. -4- of the latter), 2^to re nata — or small doses of paregoric or laudanum, will generally reduce it. Earely is it necessary to use laudanum and starch enemata, or to add acetate of lead to opium in iDill. Hemorrhage from the bowels is not apt to continue long, or to be often dangerous. If it should be so, astringents, as lead and opium, by enema or by the mouth, must be used. Shall we attempt to medicate the affection of the glands of Peyer? This also being symptomatic, its palliation only appears to be indicated. I am not satisfied that any special treatment for it is demanded in mild ordinary cases. But if, after the tenth or twelfth day, the defervescence does not take place, and restlessness is great, with abdominal tenderness, a dry tongue and considerable diar- rhoea, oil of turpentine is recommended by authority (Wood) and experience. The dose should be not more than ten drops four times daily in mucilage, with a few drops of laudanum. jSTitrate of silver is used instead by some. I have had no experience with it ; but I have often seen the good effects of turpentine. This seems to act as a local alterative to the ulcerated surface of the bowel. Pecholier, of Montpellier, gave creasote, 3 drops daily, diluted with lime-water and orange-flower water, to sixty hospital patients, with typhoid fever, as an "anti-zymotic" remedy. He asserts that it lightened and shortened the attack. Dr. W. Pep- per^ decidedly prefers nitrate of silver ; -} of a grain three or four times daily for an adult, in pill, or for children, in a mucilaginous mixture. When hemorrhage from the bowels occurs, it is very important to avoid increasing it by much movement or change of position. Enemata of cold water, with, in serious cases, the addition of astringents and opiates, will be likely here to do good service. Of course it is necessary that such enemata should not be of too low a temperature, or be repeated so frequently as to cause depression. Attention to the state of the bladder, day by day, to prevent or relieve retention of the urine, is important. Long-protracted cases may demand a great deal of care to avoid severe bed-sores. In anticipation of these, when threatened, frequent changes of 1 Plii]a.Med. Times, Feb. 12, 1881, p. 299. PLAGUE. 473 position should be made, and the parts should be bathed with whisky, spirits of canii)hor mixed with olive or lard oil, or soap liniment. The bed-elothes must be kept smooth under the person. Adjustment of pillows, with the addition of small ones made for the purpose, may do much. When a part is unavoidably pressed upon, it may be protected by a piece of kid spread smoothly with soap plaster, or adhesive plaster. Actual excoriations must be treated like ulcers — with simple cerate, lime-water, poultices, adhesive plaster, etc., according to their condition. PLAGUE. Of this oriental disease, now fast being extinguished, little need be said here. It was probably plague of which Thucydides gave account, at Athens during the 2d Peloponnesian war. Livy describes an epidemic, probably of plague, at Rome ; Procopius, in Egypt and Palestine, in the 6th century ; Boccaccio, at Flor- ence, in the 14th century ; and Defoe, in London, near the end of the 17th. Its last outbreak at Marseilles, in 1720, destroyed nearly half of the population. Before that time, it had occa- sionally reached Paris also, and some of the German cities. In 1828-29, it prevailedwith severity amongst the Russian soldiers in Bulgaria. In 1 876, it occurred at Bagdad, Hillah and other towns in Mesopotamia ; and in 1877-78, in scattered locahtiesin Russia. Early in 1879 it proved very destructive at Yetlianka and a number of other fishing villages extending for a hundred miles on both sides of the river Volga. All of these villages are described as having been in a very filthy condition. Early in 1881, a number of deaths from plague were reported as occurring in and near Bagdad. Plague is a zymotic aflection, allied to the fevers, of rapid course and great mortality. Its symptoms are debility, restlessness, fever, delirum, vomiting, hemorrhages, petechise, and glandular swellings, especially in the axilla, or carbuncles. Death often takes place in two or three days. Sometimes, how- ever, the case may last for two or even three or four weeks. The characteristic buboes occur in the axilla, neck or groin ; always originating in enlarged lymphatic glands. They vary in size from that of a chestnut to that of a goose's egg. Maturing toward the middle of the second week, when the fever has already begun to decline in favorable cases, many of them undergo resolu- tion ; others suppurate. Carbuncles are met with in not more than one-fifth of all the cases ; their appearance is usually later than that of the buboes. Appearing upon any part of the body, they are most frequent on the legs. They begin as red pimples ; the mildest form vesicles which burst and dry up ; the worst pass to a gan- grenous condition ; involving all the surrounding tissues. While plague is almost entirely a disease of hot or warm climates, its epidemics decline or cease at the height of the tropical summer. Plague was once thought to be the most contagious of diseases. Excellent reasons are given, however, for believing it not person-: ally contagious at all ; but locally infectious. Not quarantine, but sanitary police and hygienic improvements in the great cities (Cairo, in Egypt, for example) have almost put an end to it. 40* 474 ZYMOTIC DISEASES. In treatment of plague, diaphoretics, opiates, and mineral acids are best reported of. Polli's treatment with the sulphites might be tried in it with propriety ; and also that with carbolic acid, benzoate of sodium, etc., in small doses. ERYSIPELAS. Synonyms.^ — St. Anthony''s Fire ; Bose. Varieties. — Traumatic and idiopathic.'^ Symptoms. — These are both local and general. Sometimes the former and sometimes the latter appear first. Idiopathic erysipe- las generally begins with an ill-defined cold stage, followed by fever. The eruption most often commences on the face, with sore- ness to the touch, and redness ; which spread like a slow confla- gration, from part to part. This character of continuous diffusion or spreading is pathognomonic. Heat and moderate swelling attend the eruption. It may extend almost all over the body. It may also be superficial and transient, or the inflammation may involve the subcutaneous cellular tissue (especially on the limbs), causing suppuration and sloughing. The fever of erysipelas has no special features, nor has the disease any definite period of duration. When the scalp is the seat of the eruption, delirium is common, and inflammation of the brain, or fatal coma, may follow. Otherwise, the danger of the disease seems to be from suppression of the function of the skin, and exhaustion. Traumatic or secondary erysipelas com- bines the danger of the disease itself with that of the injury, abscess, or other local affection from which it starts. Sthenic and asthenic forms or types of the disease may be discerned, according to constitution and circumstances. Erysipelas is often destructive in surgical hospitals, as an endemic or infectious malady. Ventilation and cleanliness will do much towards its prevention. Absolute contagion is not proved of it ; but the theory of •' continuous molecular change " (Snowj applies very well to it. The immediate promotive cause of it would seem usually to be accumulation of effete material thrown off" from the human body in connection with inflammation. It appears most probable that erysipelas is, pathologically, a capillary li/mjjhangitis, i. e., inflammation of the minutely distrib- uted lymphatic vessels of the skin. Treatment. — ^As above remarked, erysipelas may be more or less sthenic or asthenic. Thus we may account for the diverse views and results of its treatment. It is very common now to treat erysipelas with free stimulation. Yet I do not remember ever to have lost a case of erysipelas, in which life was not already in serious danger from a previous injury— either in private or hospital practice. Nor have I, in more than a very few out of a large number of cases, found occasion to give any alcoholic stimu- lant whatever. I have commonly begun the treatment of an attack of the disease with a mild saline cathartic — as a small dose of Epsom 1 Billroth asserts tliat erysipelas always depends on morbid lymphatic absorption. This is doubtful ; since the degree in which the lymphatic vessels are involved varies mucli in diflFerent cases. FLOOD FEVER OF JAPAN. 475 salts, or one of Rocliellc sjiltor citrate of magnesium. Then blue pill with ipecac, if tlie stomach be good (gr. ■} of the former with gr. i or gr. \o( the latter, every three hours) and neutral mixture or Uquor ammonii acetatis. Asthenic cases appear to gain by the free use of iron — twenty drops of the tincture of the chloride every three hours. After C. Hamilton Bell, some ])ractitioners use tincture of chloride of iron in all cases of erysipelas. I am not convinced of the propriety of this practice. Dr. Da Costa generally gives quinine as well as iron. Locally, mild emollient applications are the best, unless as cordons sanitaires, or lines of demarcation. At the very start, lard, tallow, or cold cream may almost '' put out the fire" at once. Mucilage of slippery elm bark, or of flaxseed and diluted lead- water, are all that my experience justifies for application to the eruption itself. I would not try to suppress it. I think I have seen one death result in the practice of another physician from the attempt to do this with nitrate of silver over a large surface ; cerebral congestion and coma taking place. Solution of bisulphite of sodium has been used, internally and externally, with great asserted advantage. A solution of camphor in ether is said to have proved useful in some cases. Cavazzani' adds to this combination tannic acid (camphor and tannin, each 15 grains ; ether, 2 drachms). To head off the eruption is perhaps only worth while when, from the face, it is spreading to the head. Tincture of iodine, or strong solution of nitrate of silver, may, for this purpose, be painted in a line of half an inch in width ; or a narrow strip of fly blister may be put on. A seemingly heroic practice (Hiiter, 1874) is said to have been successful, viz., the hypodermic injection of a two-per-cent. solution of carbolic acid near the inflamed parts ; avoiding, how- ever, the most vascular tissues, for fear of carbolic acid poisoning. Rothe,.'^ of Altenburg, has made considerable use of the external application of carbolic solutions in erysipelas. Dr. Radclitte,^ of Washington, D. C, reports the history of a severe case in which such an application (carbolic acid, 5ij, with olive oil, giv, put on freely with a feather) appeared to do much good. When, in traumatic erysipelas, a limb is greatly swollen and inflamed, threatening destruction of the subcutaneous tissues, long incisions through the integument to relieve pressure and congestion may be justifiable. A milk diet is usually suitable in this disorder. FLOOD FEVEE OF JAPAN. This disease is said to prevail in July and August in flooded districts, aflecting about eight per cent, of those residing there. Beginning with rigor, fever follows, nearly continuous for about two weeks, with constipation, until the latter part of the attack, when diarrhoea may occur ; sometimes deafness and delirium ; 1 Lond. Med. Record, Nov. 15, 1876. a Deiitsch. Med. Wochenschr., .Tan. 22, 1881. 3 Phila. Med. Times, April 23, 1881. 476 ZYMOTIC DISEASES. temperature, from 101° to 104°. Characteristic of the disorder are swelling and tenderness of the lymphatic glands of the neck, axilla, and groin, and an eruption of large, flat, dark-red papules, with smaller lichenoid spots between them. The glands become tender about the second day, and the eruption appears on the sixth or seventh day of the attack. Fatal cases have high fever, copious bloody stools, maniacal delirium, and coma. The average mortality is about fifteen per cent, of those affected.^ I have, so far, met with no account of the treatment found best for this disease. PUEEPERAL FEVER. In the time succeeding confinement, liability always exists (besides the transient "milk fever" about the third day) to metritis^ and, more often, peritonitis; also, but with much less frequencj^, to that asthenic febrile affection, to which the desig- nation pwerperaZ/euer is best given. As this belongs rather to obstetric practice, I propose only a brief allusion to it. Beginning with a chill, its symptoms are fever, with an extremely rapid pulse, pain in the abdomen, and tenderness on pressure, or on motion, as in drawing up the knees ; tympanites, often ; a day or two later, vomiting, delirium, and tendency to collapse. Death may occur within a week ; and more than half the cases are fatal. Sometimes the pain and tenderness of the abdomen are slight or temporary only ; the general debility proceeding still to the fatal end. Autopsy shows, in much the larger number of cases, the mani- fest lesions of peritonitis ; serum, lymph, with extensive adhe- sions, or pus. In a few cases, however, these are absent entirely. Inflammation of the uterine veins and lymphatics has been met with. In causation, it is observed that nearly all the cases of this disorder (distinct from simple peritonitis of the lying-in room) take place in towns, or in hospitals, especially those which have surgical as well as obstetrical wards. Puerperal fever is many times endemic in such localities. Physicians have been beset with it, in some instances, in practice, as a "private pestilence ;" every woman attended by one practitioner, for months together, being attacked by it, when others have none of it. Hence we infer two or three things. One, that this fever has a material zymotic cause, which may be localized. Another, that the materies morbi seems to be con- veyable by hand from person to person. Although disputed by eminent authorities, the evidence preponderates in favor of this opinion. Some such evidence has come immediately to my own knowledge. Further, several morbid poisons appear, in the peculiarly susceptible, quasi-traumatic state of the womb and abdomen after delivery, to promote the disease. Erysipelas does so, or at least the conditions productive of erysipelas ; also, the typhus poison ; perhaps that of small-pox and scarlatina, etc.^ 1 Lancet, Jan. 10, 1880. 2 Dr. O. v. Manson described malarial puerperal fever in the Virginia Medical and Surgical Journal, 1855. rUERPERAL FEVER. 477 As to erysipelas, it presents a close and striking analogy with puerperal fever. Thus : Erysipelas is an acute febrile Puerperal fever is an acute feb- ciisease, occurring most often rile disease, most common in in surgical hospitals, in whicli lying-in hos])itals, in which a a peculiar diflusive inllamma- peculiar diffusive inflamma- tion is a prominent character- tion is a prominent character- istic ; the seat of this inflam- istic ; the seat of the inflam- mation being the slm, li/m- mation being the uterine phatics, and connective tissue. veins, lymphatics, and 2^^'^^''' toneum. Pathologically, some questions are not yet entirely decided. Is puerperal fever a special disease, with one specific morbid material cause or virus ? or is it a cachcemia, which any morbid poison has power to produce during the lying-in state ? or, again, is it an idiorhcemia, from absorption of foul matter from the cavity of the uterus by its semi-patulous sinuses ? or a pyaemia from inflammation and suppuration of the uterine veins V I am not ready to answer these questions. Perhaps the ichor- hcemic theory has the most of evidence at present in its favor ; adding to that the hypothesis of "continuous molecular change," alluded to already in another place. Dr. Ford3^ce Barker believes the disease to be a specific disease, entirely peculiar to the puer- peral state. Practically, sanitary measures of precaution are clearly indi- cated to prevent puerperal fever. One of these is personal. It has been well said that "an offensive post-partum vaginal dis- charge must not be permitted. It must be prevented by skilful management of the third stage of labor, by insuring efficient lochial drainage, and, if necessary, by washing out the utero- vaginal canal with antiseptic fluid." For this latter purpose, Dr. J. M. Duncan' prefers a solution of carbolic acid, 1 part in 40 (occasionally 30) of tepid or warm water. Lying-in hospitals, moreover, must be great evils, rather than benefits, unless they have the best possible situation, construction, and administra- tion. And no such hospital, or ward, should ever be under the same roof or in the same inclosure with a surgical ward or hos- pital. Moreover, in private practice, attendance on delivery by a physician who is visiting at the time a case of puerperal fever or of erysipelas is at the risk of the patient; if the danger of conveyance of the disease be removable, it is only so by the most careful and thorough cleansing and disinfection. The clothes should be changed, and the hands washed in strong solution of chlorinated soda or carbolic acid, before making such a transit from the one patient to the other. Several physicians in Phila- delphia always decline confinement cases under the circumstances named. Tlie treatment of puerperal fever has often proved unsatisfac- tory. I had intimate knowledge of the experimentation to which it was subjected in the wards of the Pennsylvania Hospital by 1 Lancet, Nov. 6, 1880. 478 ZYMOTIC DISEASES. the late eminent Drs. Meigs and Hodge, between 1845 and 1849. Venesection, purging, and mercurials, etc., were tried amply, and failed most signally. Quinine in tonic doses, with beef-tea, and, if collapse be threat- ened, alcoholic stimulation, has, though far from always success- ful, had at least better results. Leeching the abdomen freely, at the beginning of the attack, in the least asthenic cases, does in:iportant good. After the leeches, for a day warm poultices may be applied, then a large blister. Sulphites and carbolic acid may be worth trying in this disease. Behier, "Winckel, and Joulin' speak well of the application of ice, in a bladder, to the abdomen, continued until a reduction of the temperature has been obtained. Por the personal prophylaxis of puerperal fever, obstetricians of authority confirm from experience the reasonable view, that it is of great importance to empty the womb, and if possible the vagina, thoroughly, after child-birth. Good uterine contraction is indispensable as a safeguard. Washing out the vagina, within a few hours of delivery, with lime-water or solution of glycerin, may also be recommended for a similar end. CHOLERA.* Synonyms. — Epidemic, Spasmodic. Malignant^ Asiatic^ Indian Cholera; Cholera Algida ; Cholera Asphyxia ; Mordshi. Symptoms and Course. — Premonitory diarrhoea, mostly painless and watery, occurs in most, but not in all cases. Its duration varies from an hour or less to two or three days. The worst epidemics of cholera have been marked by some cases of fearful rapidity. In India, in a few instances, death has resulted, by collapse, in ten minutes. Commonly, the diarrhoea increases in frequency and copious- ness, and in a few hours vomiting commences. The discharges are colorless or "rice-water" like, and are spirted out with spas- modic force. The skin grows cold by degrees, and great debility comes on, with cramps in all the limbs usually. "The temper- ature in the rectum and vagina has been several times found to be higher than natural. Dr. D. AV. Parsons^ asserts a constant difference of about 8° between the axilla and the tongue ; the latter being the colder. If not checked, collapse arrives ; with intense thirst, oppression m breathing, loss of voice, disappearance of the pulse, suppression of urine, cold, hlue^ and shrunken skin, sometimes bathed in sweat, and, at last, cold breath ; ending in death. This occurs, on the average, in about eighteen hours. When reaction takes place, recoveiy may immediately become complete, or a low fever may supervene. The termination of this may be in death within a few days, or recovery in a week or two. 1 Am. Journal of Med. Sciences, April, 1871, p. 504. 2 See, for the fuller statement of the author's views upon this disease, his essay, en- titled "Cholera: Facts and Conclusions as to its Nature, Prevention, and Treatnient." Philadelphia, 1866. 8 Liverpool Medical and Surgical Reports, October, 1871. CHOLERA. 479 Appearances after Death.-:— /??Y/w^* Leloir, Annales de Dermat. et de Syph., No. 1, 1880, p. 69. 43* 510 DIATHESES. The affections belonging to secondary syphilis are, peculiar copper-colored eruptions, rupia especially ; warts about the gen- itals; ulcers of the throat; iritis; loss of hair (alopecia); affections of the testicle or uterus. These last, as well as periostitis and osseous tumors or nodes, cu- FiG. 123. taneous tubercles, gummata (soft, elastic tumors, found on the skin and the bones, and occasionally in the vis- cera), and chronic degen- erative inflammations of the brain, spinal marrow, liver, spleen, lungs, etc. , are often called tertiary syph- ilis. Jonathan Hutchin- son regards the secondary Syphilitic Teeth. Healthy Teeth. maladies as due to blood- changes; the tertiary, to al- terations of tissues. Although long ago suspected, Dr. T. Reade, of Belfast, first proved (1847) the syphilitic origin, in some instances, of certain nervous affections ; epilepsy, mania, hem- iplegia, amaurosis, loss of memory, cranial neuralgia, paralysis of sphincters ; all resulting from syphilitic disease affecting the nerve-centres.* General experience and opinion have asserted that constitu- tional syphilis is not transmissible by inoculation. Some modern experiments (Lee, Walker, Pelizarri) have placed this question again "sub judice." The following statements (Bryant) are now generally accepted: — " A health}^ woman marrying a man who has had syphilis, but who has lost all symptoms of it, may acquire syphilis through a blighted ovum, or a series more or less prolonged of stillborn children, the placental circulation between the foetal and mater- nal blood being the infecting medium. "A healthy woman, giving suck to a child the subject of hered- itary syphilis, may acquire the disease through some fissure of the nipple, the disease, locally and constitutionally, manifesting its presence with all the intensity of a primary inoculation. "Again, the secretion of any true syphilitic sore, chancre, mu- cous tubercle, whether of the mouth, nose, anus, vulva, or penis, is capable of transferring the disease ; and the syphilitic poison may probably be simply absorbed by the vessels of a part— p%s- iological absorption — without giving rise to any local affection. Hunter believed this, and Lane, Marston, and Lee have pub- lished observations that tend to support the theory." There seems no room to doubt that a child may inherit syphilis from a syphilitic father, even when the mother is perfectly healthy at the time of conception. In 1872, at Vienna, Dr. A. Lostorfer asserted his discovery of certain small shining bodies in the blood of syphilitic patients (after it had been kept several days) which are not present in the 1 See a paper by Dr. E. L. Keyes, N. Y. Med. Journal, November, 1870. SYPHII.TS, 511 blood of other persons. These " syphilitic corpuscles," so called, were, however, afterwards found by Strieker and others in patients suffering with various cachectic allectious. Treatment. — Mercury is available in the treatment of second- ary as well as of primary syphilis ; but its power over it is less absolute. After jnoderate trial of its impression (especially of the green iodide of mercury in ^- grain doses, twice daily), iodide of potassium may be given ; from ten to thirty grains thrice daily. This is an almost certain cure (I have never known it to fail) for syphilitic "■ 77ia«?)(at/sm " or bone pains with or Avithout nodes. Over ulcers of the throat, also, it has great power ; as well as over purely syphilitic affections of the nervous system. Such things, however, often do not stay cured ; they break out again, as may also the cutaneous eruptions ; requiring the same treatment over and over. In some amemic cases iodide of iron will do great good. Mercury and iron may be given together very well ; either the two iodides or the two percldorides. Donovan''s solution,^ internally, and mercurial ointment locally, are the only additional remedies among many proposed and often used, that 1 think it worth while to name in our brief considera- tion of this subject. Dr. F, Bumstead thinks very highly of mercurial inunction, along with the internal use of iodide of potassium. The oleate of mercury (Marshall) has become a favorite with some practitioners for external use. Of course, enfeeblement of the constitution of the patient may require the employment of generous diet, salt bathing, change of air, iron, quinine, or cod-liver oil. Syphilization. — Among the most remarkable curiosities of medical history is the attempt made to prevent, and even to cure, syphilis by inoculation with the syphilitic virus. Auzias Turenne, Sperino of Turin, Broeck of Christiania, and J. Z. Hall of St. Louis, Mo., have esj^ecially urged their assertions of success with this process. The immunity is said, like that of vaccination, to last for life. Out of place as it would be to discuss it here, it must be said that, after reading a good many pages of the evidence, pro and con, I do not find that positive proof enough has been afforded to overcome the strong a liriori improbability of its availability. It has been fairly tried by eminent authorities, such as Hebra, of Vienna,'-^ and abandoned. Also those who advocate it admit that it is a slow method of cure, as well as far from agreeable ; and as to its prophylactic use, few physicians, at all events, in this country, are likely to recommend it to their patients instead of avoidance of the cause of contamination. Jonathan Hutchinson, Bodet, Hardie, and others have recorded instances of the recur- rence of syphilis by a second inoculation in the same person. Kcebner, of Berlin, reports forty-five cases of this ; thirty-seven witnessed by others, and eight occurring under his own knowl- edge. 1 Liquor Hydrargyri et Arsenici lodidi. Dose, 3 to 5 drops. «See Phila. Med. Times, Oct., 1870, p. 11, 512 DIATHESES. GONOEBHCEA. Very few words must suffice us upon this topic, Gronorrhoea is a specific urethritis; in tlie female, also, vaginitis ; produced by impure sexual congress. Its symptoms are, pain and soreness, redness and swelling of the penis, with early and continued suppurative discharge. Burning pain on passing water, and chordee, or painful rigidity of erection, are the principal causes of suffering, while the patient is at rest. Walking about aggravates very much the soreness and pain. Urethritis, or balanitis (inflammation of the glans penis), may occasionally be brought on by contact with the matter of leucor- rhoea or the menstrual discharge. No perceptible difference exists in the symptoms in this case from gonorrhoea ; but the latter is more obstinate, and is itself directly contagious. Such non-specific urethritis is, moreover, a very rare disorder. The period of incubation of gonorrhoea is sometimes but a day ; seldom many days. Its duration is generally from ten days to three weeks. But a gleet, or chronic discharge, more or less muco-purulent without active inflammation, may be left behind, of indefinite continuance. Sy77ipathetic non-suppurating bubo may attend gonorrhoea ; so may also orchitis, or inflammation of the testicle. Gonorrhoeal rheumatism is sometimes met with, ascribed to a metastasis of the local affection to some of the joints. Pyaemia sometimes (P. Hewett) follows gonorrhoea, though very rarely. Treatment. — At first, during the height of the inflammation, rest in bed, low diet, Epsom salts, and free draughts of flaxseed tea, comprise the best treatment. It is true there is a period at the end of incubation, when the symptoms are just commencing, when abortive treatment may be practised ; as by a strong injec- tion of nitrate of silver (gr. vj to gr. x in fgj) into the urethra. This is a bold and uncertain measure, however. Kuchenmeister, of Dresden, asserts (1880) that lime-water (one part to four of water), repeated several times in a day, will safely abort gonor- rhoea. Dr. W. W. Cheyne ^ uses bougies of cocoa butter, mixed with iodoform and oil of eucalyptus (iodof. gr. v, ol. eucalypt. •"K. X ; butyr. cac. gr. xl). Other practitioners also employ bougies of butter of cacao, or gelatin and glycerin, with which diflferent remedies are incorporated; as gallic or tannic acid (gr. j), subnitrate of bismuth (gr. x. ), nitrate of silver (gr. i to |), acetate of lead (gr. i to gr. j ), sulphate of zinc (gr. J to gr.j), extract of belladonna (gr. j to ii). Bathing the penis frequently in warm water is very soothing to the pain and soreness. Chordee may be treated by that means, and by suppositories of opium and cocoa butter. A pill of cam- phor and belladonna (camphor five grains, ext. belladonnse half a grain) at bedtime will be useful in preventing chordee. As soon as the activity of the urethritis has subsided, injections may be used ; of nitrate of silver (gr. j to gr. iv in fgj), acetate or subacetate of lead (subacetate, gr. x in fgj), sulphate of cop- iBrit. Med. Journal, vol. ii., 1880, p. 124. RCROFTTT. A. 518 per (tcr. j in f,\j), sulphate of zinc {<^v. ij in f,\i), or chloride of zinc (i^r. j in f,\i). (xlycorin may be added to the water in eith(;r of these solutions with advantage. Glycerole of tannin [F. 205] is also a useful preparation. Copaiba and eubebs are, time out of mind, medicines for gon- orrluea. Without any specijic antidotal properties, they come in well, one after the other; first the copailta, and then the eubebs (in half-tiuidrachm doses of the former, in mucilage, and ten to twenty-grain doses of the latter), when the inflammation is sub- siding [F. 174, 175]. For yleet, which is often very annoying, local treatment, with regulation of the diet (avoiding stimulants and condiments), must be depended on. Injections, of the same character as those above alluded to, may be repeated. Should they fail, a bougie, smeared with an astringent ointment, should be introduced every day or two, and left in the urethra for ten or twenty minutes. Ointment of nitrate of mercur}^, of carbonate of lead, spermaceti ointment, and ointment of nitrate of silver, are all reconmiended. A flexible bougie, of cacao (cocoa) butter will irritate the least. Very obstinate cases have sometimes been cured by the introduction of solid nitrate of silver by the porte-caustique. Examination with the endoscope (introduced for specular exam- ination of the urethra) may detect the exact spot which is the seat of the irritation and discharge. Blistering the perineum is practised by some for gleet. Constitutional treatment by tonics may be called for when general relaxation maintains the com- plaint. SCEOFULA. Prof. Aitken^ defines (scrofulosis or) tuberculosis as follows : "A particular morbid condition of the system, attended [gener- ally] by a persistent increase of temperature, followed by a con- tinuous wasting of the body and the growth of a substance in various tissues and organs, especially" the lungs, to which the name of tubercle or tuberculous matter has been applied. These phenomena are associated with peculiarities of outward appear- ance during life, and liability to certain diseases termed scrofulous, such as swellings of lymj^hatic glands and of joints, carious ulcer- ations of bones, frequent and chronic ulcerations of the cornea, ophthalmia, abscesses and cutaneous pustular eruptions, persistent swelling and catarrh of the mucous membrane of the nose, and characteristic thickening and swelling of the upper lip, — lesions which, while they are distinguished by mildness of symptoms, are peculiarly persistent, and follow the application of exciting causes which would have no eflect on a healthy person." Scrofula is the term applied commonly to those of the above- named local aliections involving (most frequently in rather early life) the glands, bones, nose, ears, and eyes. The tubercular diathesis has been already sufficiently consiclered for our purpose 1 Science aud Practice of Medicine, vol. ii., p. 188. As remarked already under Gen- eral Pathology, this identification of tuberculosis with scrofulosis is not assented to by all pathologists. I believe, however, that it is essentially correct. 2H 514: DIATHESES, and space. (See General Pathology.) A very few words of a practical bearing must be added. ^ The causes of scrofula are, chiefly, hereditary transmission, and deprivation of pure air. The former is well known to all. Baude- locque, McCormick, and Greenhow, among others, have proved the latter most thoroughly. All depression of the system by low living, such as insufficiency of food and warmth, dampness, etc., will promote it. It has been imagined, not proved, that the syphilitic taint of constitution may glide into it. In treatment of scrofula in any of its forms, but particularly in chronic enlargements, with or without cheesy softening, of the lymphatic glands (of the neck, armpit, or groin), iodine has had general confidence [F. 176], It is not, however, infallible. Iodide of ammonium (dose 3 grains) is now coming under trial. Iodized milk (Hagar) is said to be very available ; one part of iodine dissolved in ten parts of alcohol, and mixed with ninety parts of fresh, warm cow's milk.^ The external application of iodine to tumors, scrofulous or other, "to produce absorption," will very frequently disappoint. I am not sure that it has, locally, any effect but as * stimulant or irritant. That may sometimes be useful. Mr. Furneaux Jordan asserts^ that counter- irritation by iodine, applied a short distance from the enlarged glands, as at the back of the neck, has, in his hands, never failed to be followed by their reduction. Dr. J. Lewis Smith advises the application to the enlarged glands of a rather weak ointment of iodine, to allow absorption without irritation. Mr. Henry Power, of St. Bartholomew's Hospital, London, has found extract of belladonna, internally, and the local application of atropia, important remedies in stru- mous ophthalmia, in children. God-liver oil is also an anti-strumous remedy of great power ; and one more readily taken by the young than by adults, gen- erally. Iron may be serviceable in many debilitated scrofulous eases. Sea bathing and sea air are among the best of remedies. Good diet is indispensable. The dietetic salt of Dr. Lankester, prepared by adding to common salt small quantities of phos- phoric acid, sulphuric acid, lime, potassium, and iron, may have some advantages, and is worthy of trial. The same may be said of ferruginous chocolate. Moleschott, of Turin (1878), has reported several years' favor- able experience with iodoform in promoting the removal of scrof- 1 Lymphadenoma, the adinie of Trousseau, pseudo-letikcemia, or " Hodgkin's disease " of the glands (Medico-Chirurg. Transactions, vol. xvii.), appears not to be identical with scrofula. " Hodgkin observed it first in the mesenteric glands, but any or all may be affected. In it the glands become very much enlarged, even to the size" of an egg, and apparently more numerous; they present a smooth external appearance, and have a soft semi-fluctuating elastic feel. On section the surface of the gland presents a smooth, bloodless, semi-transparent, loose, succulent structure; microscopically it is made up of glandular tissue and abundance of fibro-nucleated tissue ; it is of a tough, leathery consistence, and exudes a clear serous fluid ; the tumors are always free, each being separable from the others." (Bryant's Surgery.) Mycosis is a name given by some pathologists (Malassez, Gilot, Landouzy) to an affec- tion of the glands of a similar nature to this. See a case reported by Debove ; Le Mouve- meni Medicate, October, 1872. 2 Medical Press and Circular, Jan. 1.5, 1871. 3 Med. Times and Gaz., Aug. 20, 1870. RICKETS. 615 ulous glandular enlargements. lie prefers its local application (although giving it also iuteriially in one-grain doses), by means of a combination of one part of iodoform with fifteen of elastic collodion ; or an ointment of the same strength. This may be brushed over the glandular tumors with a eamel's-hair pencil at night, and washed off with soap and water in the morning. I have found hcnzocUcd vaseline a good vehicle for iodoform, lessen- ing although not destroying its unpleasant odor; which is also said to be removed by the addition to it of balsam of tolu, or by tincture of musk (Tt^' to §j). Massage, especially with oleaginous inunction, is likely to be beneficial in the more torpid scrofulous constitutions. (See brassage, in Part I., Section III.) Kapesser^ reports the beneficial use of regular periodic inunc- tion with soft soap in treatment of glandular enlargements. The Ioc((l treatment of so-called scrofulous affections is to a great extent surgical. Slowly softening glands may sometimes be cut out. Scrofulous periostitis, threatening caries, I have seen arrested by free application of cerate of carbonate of lead over the aftected bone. The legs are most frequently the seat of such disease ; but it may attack any of the long bones. Removal of diseased or necrosed portions is to be recommended rarely, unless they are loosened. Extensive resections should be very exceptional. RICKETS. Synonym. — Bachitis. Infants upon learning to walk show the cachexia to which this name is given, by yielding of the bones, with muscular debility, and general failure of nutrition. The bones are brittle from imperfect development ; the spine is apt to become curved and the limbs crooked. The occipital bone and ribs are apt to undergo irregular enlargement. The teeth are backward in coming, and fall out with early decay. Tender- ness of the surface of the body, and irritability of the nervous system, also exist. Laryngismus and convulsions are among the not uncommon symptoms. Dr. C. C. Ritchie'^ has shown that an important diagnostic sign between rickets and tuberculous disease is, that the increase of temperature, especially in the evening, common in tuberculosis, is absent in rickets. Rachitis does not appear to be hereditary. Its most frequent cause is insufficient or unsuitable food. '^ English medical authors speak of rickets as a very common disorder in Great Britain. It is certainly not so in America. Practitioners of large experience see very little of it. In nine years, endiiag with 1870, the mortality records of Philadelphia reported but two deaths from rickets. Meigs and Pepper* 1 Berliner Klin. Wochensclir., Feb. 11, 1878. 2 Med. Times and Gazette, Jan. 7, 1871. 3 See an elaborate paper l)y Dr. J. S. Parry, Am. Journal of Medical Sciences, April, 1872. See also the article " Rickets" by Professor Aitken, in Reynolds' System of Medicine, American edition. Vol. I. * Treatise on Diseases of Children, p. 631. 516 DIATHESES. remark, "we escape to a great extent the ravages of this fatal disease." Treatment. — Hygienic measures are of the first consequence. "Well-aired rooms, warm salt bathing, milk or beef-tea diet, cod- liver oil, iron, and phosphate, lacto-phosphate^ [F. 257j, or hypo- phosphite of calcium, all have their value. CARIES OF THE SPINE. Synonym, — PoWs Disease. In scrofulous children of either sex, between two and fifteen years of age, sometimes without, but oftener after, a fall, blow, or other mechanical injury, caries of the body of one, or occa- sionally two or three of the vertebrae may occur. The dorsal region is most frequently attacked. Symptoms. — Pallor, debility, pain in the abdomen,^ in sudden and severe paroxysms ; irritability of temper, stooping forward in walking, rigidity of muscles, a cautious, gliding gait, to avoid concussion of the spine ; loss of appetite, swelling of the belly, uneasy sleep, hurried or impeded respiration ; tenderness of the spine on pressure ; an angular deformity or backward projection of a portion of the spine ; paralysis in various degrees, abscesses of the back, discharging externally or by the lungs, bowels, vagina ; or, the pus entering the hip-joint. Treatment. — Dr. Henry G. Davis,^ of IS'ew York, claims, and I believe with reason, to have introduced an important improve- ment into the treatment of caries of the spine. Of the older methods, the best idea was rest to the back, with careful efforts at extension ; and, especially in this country by the late Dr. John K. Mitchell, support (by means of corsets) dependent upon attachments quite outside of the body. Dr. Davis, reasoning upon the fact that the bodies of the vertebrte are the seats of the destructive process, aims at separating these, throwing all the weight upon the oblique processes. The spine is relieved then by strengthening rather than extending it. An apparatus of Dr. C. F. Taylor carries out this and other rational principles of treatment very well. It is thus described :* "A broad band passes around the trunk low down, so low that in front it almost touches the thighs in sitting. It passes just above the pubes and entirely below the abdomen, so that the abdomen is sustained upward, instead of being, as in most instru- ments, pressed downward. There are two pieces or levers passing up the back, not over the spine, but each side of it, so that it is firmly held from lateral deviations. At the top is a cross-piece in the form of two T's with the small ends united. The object of this arrangement is that the straps may pass directly forward and around the arms, and thus prevent a great loss of force by 1 Dusart and Blache, Bull. Gen. de Therapeutique, July, 30, 1868 ; also, a paper by Dr. B. W. MacCready, New York Med. Journal, June, 1871. 2 Dr. B. Lee (Angular Curvature of the Spine, 1867) speaks of gastralgia as an initial symptom. 3 Conservative Surgery, 1867. Dr. Davis's first publication on the subject was in the Boston Medical and Surgical Journal, August, 1852. * Angular Curvature of the Spine, by Dr. B. Lee, p. 70. COXALGIA. 517 diacconal action ; and also that thoy shall toucth the person only whcn^ the pressure is needed', namely, on the forward part of the shoulders. At a part of the instrument opposite the seat of the disease, the point where we make our ful(;rum, the pads are placed. Tlu'S(^ are made of chamois skin, or Canton llannel, and- are tilled, not with cotton, which soon packs and becomes hard, but with lon-ij, elastic African or East Indian wool, which has no feltini^ qualities. Tiiese pads are removable when they become compacted. The shoulder-straps and bands around the hips are likewise provided with removable pads to protect the skin against pressure and abrasion. " It will be seen that the instrument, like the spine itself, acts like a double lever with a common fulcrum at the curvature ; this action is directly backward at the hips and shoulders, and directly forward at tlie middle of the back, or wherever the diseased part is located. . . . The instrument is provided with several hinges, stn}) hinges in frnut. but free to bend backwards, which allows the most unrestrained use of th.' muscles of the back . . . useful in causing the development of the spinal muscles instead of binding them up and causing their atrophy, as results from the use of instruments which prevent muscular action." Dr. Say re's name has become especially connected with the use of the jacket, made of bandages soaked in plaster of Paris, and fitted to the body by their application while the patient is sus- pended (so as to extend the spinal column) by the axilla and head in a framework constructed for the purpose. W. Adams, of London, Dr. B. Lee, and others have used, instead, a porous felt jacket, similarly applied. Di\ D. H. Agnew' prefers a jacket made of leather, strengthened by thin strips of steel. Constitutional treatment, by fresh air and sunshine, nourishing diet and cod-liver oil, iron, or other tonios, as well as purgatives (if required, as they are in most cases) must be added, of course, to mechanical means. Cures are thus sometimes efiected in cases once thought hopeless. Lateral curvature of the spine is very different, mostly depend- ing upon muscular weakness or inequality of development. Bad habitual positions often cause it. Training the subject of it to , icse his muscles properly, and thus develop and strengthen them, must be the leading idea in its treatment, apparatus here being quite secondary, though perhaps sometimes temporarily needful. COXALGIA. Synonyms. — Morbus Coxarius ; Hip-Disease. Though regarded, like spinal caries, as rather a " surgical " subject, a few words may not be out of place upon this theme also. Its etiology appears to be like that of disease of the spine ; a constitutional tendency, tubercular or scrofulous, acted upon in many, though far from all cases, by a local injury. Intiam- mation of the hip-joint occurs, in some instances acute and vio- ' Principles and Practice of Surgery, Vol. \:, 44 518 DIATHESES. lent, oftener active only at first and to a moderate degree ; not rarely insidious in approach. Symptoms of the most characteristic kind are, pain in the knee, without any other sign of disease about that part ; and a limping gait, the knee being bent, the child treading only on the toes of the affected limb. Spasmodic contraction of the muscles causes fixation.of the joint. Examining the hip-joint, it is found that pressing the head of the thigh-bone into it gives pain. Atrophy of the muscles over the hip may follow. G-eneral weakness and emaciation, with other symptoms of the scrofu- lous cachexia, usually attend. Suppuration in the joint, with chronic abscesses, ulceration of the cartilages, subluxation of the femur, and caries of the bones, with hectic fever and pro- gressive debility, occur in severe cases. Treatment. — Physick's celebrated treatment was, absolute rest of the joint by means of a carved splint, passive exercise in the open air, in a carriage, or, if a young child, in arms— and sys- tematic purgation with jalap and cream of tartar. To this, with less stress upon the not at all necessary purging. Dr. H. G. Davis has added the use of continued elastic extension of the limb, so as to relieve the joint of the pressure of the head of the bone in its socket, caused by the contraction of tlie muscles. This con- tinued elastic extension may be obtained in bed, by adhesive plaster strips, to which is suspended, by a cord and pulley, a weight, proportioned to the amount of power wliich the muscles display, and tested by the comfort secured by it to the patient. Out of bed, a splint may be applied, maintaining elastic exten- sion by a perineal band, best made of adhesive plaster, spread (as proposed by Dr. Davis) upon twilled material, and kept for a while before use, so as to lose its unctuous property and remain more securely in place. Another mode of treatment (J. C. Hutchison)^ is by extension of the joint, without absolute rest. This may be effected by placing a high-soled shoe upon the foot of the sound limb, and letting the patient walk about for two or three hours daily with crutches. Several practitioners, prefer along witli this, to secure the joint from much movement by a posterior splint, or silicate of sodium immovable bandage. Simple inflammation of the hip-joint may, of course, follow an injury; and may find relief in a comparatively brief time, from rest, with local antiphlogistic measures, as cups, a blister, etc. N^MIA. Something has been said upon this subject under General Pathology. The causes of anaemia are, most often, either, 1. Loss of blood, from disease or injury causing hemorrhage. 2. Excessive suck- ling in a mother, or wet-nurse. 3. Severe or protracted diar- rhoea, or (more rarely) leucorrhcea. 4. Typhoid or some other form of fever. 5. The malarial influence, sustained for a con- 1 Amer. Journal of Med. Sciences, January, 1879 ; Phil. Med. Times, May 7, 1881. AN JEM! A. 519 siderable time. G. Deficiepcy of food, light, warmth, or fresh air. Anreinic symptoms are pallor, slenderness of figure, dcbilit^^, nervous excitability, cardiac palpitation. Antemic murmurs in the heart and aorta have be(m mentioned under Semeiologij. In the treatment of antemia, (jood did., jmre ah% and irrm or cod-liver oil are the essentials. Of the preparations of iron, numerous as they are, I have found the most satisfactory results from the tincture of the chloride, tbe pill of the carbonate (Val- let's mass), the iodide (syrupus ferri iodidi), the phosphate, and in children, the citrate [F. 202, 20:5, 204, 205]. Goodhart, Fother- gill, and others bave observed that, as anteniia promotes dilata- tion of the heart, care must be taken with autemic persons, to avoid much exertion ; and, if symptoms of weak heart appear, digitalis may be given along with iron. Dr. Aitken speaks very higbly of the value of a combination designated as the "• syrup of the phosphates of iron, quinine, and strychnia." This form- ula will be given at the end of the book [see F, 213] . Progressive Pernicious Anaemia. — Under this name, Biermer, 1871, described a form of anaemia not accounted for by any of the ordinary causes of such a condition. Otherwise named, the same malad.y had been before mentioned by Andral (1823), Addi- son [idinpathic ansemia), Wilks, Zenker, and Wagner, Lebert has called it essential anaemia. Symptoms. — Mostly with a gradual approach, this affection is marked by extreme pallor, or a dusky yellowness of complexion ; debility ; impairment of digestion and irritability of the stomach ; palpitation of the heart; cardiac systolic murmurs and fremisse- ment cataire; dyspnoea and a tendency to fainting on slight exer- tion. Emaciation is not extreme ; it may be very moderate in proportion to the aneemia and debility. Swelling of the feet and legs is common at a late stage. Hemorrhages are apt to occur, from the nose, gums, bronchial raucous membrane, uterus, or under the skin {petechice, vibices, ecchymoses). Betinal hemor- rhages, producing blindness, have been observed (with the aid of the ophthalmoscope) in several cases. Toward the end of the attack, fever is almost always present. Morbid Anatomy and Pathology. — Biermer, Immermann,' and others have insisted that we should exclude from the list of cases of this disorder all those in which, after death, lesions are dis- covered such as are ordinarily known to be associated with anaemia ; as enlai-gement of the spleen, disease of the lymphatic glands, and morbid alterations of the marrow of the bones. This appears to me to be too arbitrary an exclusion. The question, hardly yet finally decided, is, whether there is a group of cases of progx-essive anaemia whose clinical history is sufficiently pecu- liar and constant for them to receive a distinctive nosological name ; and with this question, of course, that of their causation is closely connected. Fatty degeneration of the heart has been (first by Wilks) a num- ber of times observed. Changes in the marrow of the hones have 1 Ziemssen's Cyclopaedia of Medicine, article Progressive Pernicious An&emia. 520 DIATHESES. been found by Eichhorst, Gardner, Osier, Fede, Cohnheim, Pep- per,' Litten, and others. Eichhorst described as microcytes cer- tain minute nucleated red corpuscles in the marrow, sometimes also seen in the blood. Neumann's larger nucleated " embryonic corpuscles " were also seen in the marrow by Gardner and Osier, ■^ In some cases of idiopathic anaemia, however, Lepine, Burger, and Quincke have found the bone-marrow free from disease. Enlargement of both the spleen and the liver were reported in a marked case by Eosenstein.* Changes in the blood are, after all, most characteristic. It is, during life, paler and thinner than healthy blood. The number of the red corpuscles is reduced from one-fourth to one-twelfth of their normal proportion ; and they vary also in size, and often present irregularity of outline. The white corpuscles are not ahnormally increased; they may be even diminished. The vol- ume of the blood generally throughout the body is believed to be considerably lessened. Brigidi,* in one case, ascertained that the coeliac ganglia were morbidly altered, fatty and pigmentary degeneration having taken place in their nerve-cells. Causation. — No constant relation of this disease to sex has yet been established ; although pregnancy (especially rapidly repeated pregnancies) obviously predisposes to it. Nor is it certain that one age is more liable to it than another, except that it has scarcely been met with in persons under twenty years of age, and rarely in those of advanced age. Hemorrhages, exhausting acute or chronic maladies of various kinds, and prolonged mental anxiety or trouble, are among the most notable influences predis- posing to it. Yet, in a large number of instances, no such, or any other, sufficient causation can be ascertained for it ; espe- cially for the progressive and obstinate character which belongs to it. Diagnosis. — Pernicious anaemia resembles most, leucocythcemia (leukaemia), psewZo-Zezii-oemia or Hodgkin's disease, chlorosis, and Addison''s disease (melasma supra-renalis). From leucocythsemia those cases at least are clearly distin- guished in which tliere is enlargement neither of the spleen nor of the lymph-glands, tenderness on pressure of the sternum, ribs, or other bones, or actual increase of the number of the white blood^corpuscles beyond their normal proportion to the quantity of blood. From pseudo-leukEsmia we may separate pernicious anaemia by the absence of that general and persistent enlarge- ment of the lymphatic glands which belongs to Hodgkin's dis- ease. Pepper has expressed the opinion that pernicious anaemia is simply "myelogenous pseudo-leukaemia." Chlorosis is almost always an affection of females near the time of puberty. In it, as a rule, there are no dropsical effusions, no hemorrhages, and no fever. It is, moreover, nearly always sus- ceptible of improvement and cure under appropriate treatment ; 1 Amer. Jour. Med. Sciences, April, 1877. 2 Canada Med. and Surg. Journal, March, 1877 ; and Canada Journal of Med. Sciences, May, 1881. * Berliner Klin. Wochenschrift, Feb. 26, 1877. < Lo Sperimentale, May, 1878. CHLOROSIS. 521 lis potnicious ansemia is net. The latter is distinguislied from Addi.son's disease ])y the absence of bronze discoloration of the skin, the more extreme aniemia with less emaciation, the hemor- rhages, and the fever. Prognosis. — It has been held to be characteristic of this affec- tion to be extremely intractable, if not incural)le. While usually progressive, with a duration of from six weeks to six months, cases are recorded in which reynissions, lasting even for months, have given a deceptive hope of recovery.^ When pregnant women are attacked with pernicious anasmia, abortion is to be antici- pated, with death following not long afterwards. Treatment. — As the fatal ijemiciousness of this disease is only absolutely determined by the result, it is reasonable always to employ with perseverance those remedies and hygienic meas- ures which are most available and effective for enrichment of im- poverished blood, and renewal of the blood-making function. As already shown, the most important of these are, the admin- istration of iron, arsenic in small doses (Coupland), animal food (concentrated and liquid when digestion is weak), change of air, and, if the strength allows it, sea-bathing. Transfusion of blood has been repeatedly tried in cases of pernicious anaemia, mostly in vain. Dr. Austen Weldon- asserts the cure of four cases by the intravenous injection of milk. Dr. C. Cary^ obtained recov- ery in a case in which iron, etc., had failed, by transfusion of ojaly fgij of human blood, by means of Dieulafoy's aspirator. Parasitic anaemia has been studied by observei's in different parts of the world ; e. g. , amongst laborers in the construction of the St. Gothard tunnel. There the disease was traced to para- sites in the intestines.* Manson, in Amoy, China, Brisbane in Australia, and Wortabel in Syria, have found aneemia of a very severe degree to be produced by i\\Qfilaria sanguinis and bilharzia hiX'tnatohia.^ Sprue^ a sort of anaemic affection, with soreness of the mouth and diarrhoea, common in Java and to some extent in India, is probably of a similar pathogenetic nature. Ko specific treatment can be laid down for such affections until some mode of safe elimination or desti'uction of the infesting parasites can be devised. CHLOROSIS. Synonyms, — Clihro-anmmia ; Green Sickness. This affection of girls, about the age of puberty, is by some regarded as simple anaemia ; by others as a pathologically dis- tinct affection. Symptomatically, it is characterized by a pecu- liar waxy, yellowish, or greenish pallor of the face. The lips also are nearly colorless, and (as in common anaemia) the tongue is often pale. (Edema of the feet or of the face may occur, or a dark circle may appear around each eye. Weakness, nervous- ness, and palpitations exist, with somewhat lowered temperature 1 J. H. Hutchinson, Med. News and Library, Philadelphia, February, 1879. 2 Med. Press and Circular, October, 1879. 3 Buffalo Med. and Sure:. Journal, January, 1881. * Meissner, Schmidt's Medicinische Jahrbiicher, 1881. 6 Phila. Med. Times, June 4, 1881, p. .563. 44* 522 DIATHESES, of the body. A murmur (bruit de diahle) is often heard on aus- cultation in the region of the heart. Ringing in the ears, low- ness of spirits, and disturbed sleep are common. Digestion is impaired, and a morbid wppetite is sometimes present, as for coal- ashes, slate-pencils, chalk, earth, or, in other cases, strong acids. Neuralgia, affecting especially the abdominal parietes, or myalgia may occur. Menstruation is either absent (amenorrhcea), irreg- ular, or painful (dysmenorrhcea). The blood in chlorosis has been found deficient in corpuscles, and containing an excess of fibrin. One of the curiosities of medical history is the fact that crude theory led at one time to the employment of venesection in its treatment, to diminish the amount of fibrin, whose excess was supposed to constitute it an inflammatory disease. Virchow asserts the predisposition to it to depend mostly upon some congenital abnormity of the heart or the aorta ; especially often of the latter. The duration of chlorosis is variable. It may be protracted for years. It is perhaps never alone directly fatal. In treatment, measures adapted to anaemia are generally suit- able. Good diet, sea-bathing, change of air, light gymnastics, iron, bitter tonics, quinine (sometimes even strychnia or nux vomica in small doses) will all have their place. Certain cases do not bear iron well, from tendency to fulness of the head. Some even, chlorotic but not anajmic, need to be relieved of that symptom by the application of a few leeches or ..cut cups to the back of the neck. It is often best J;Qi) speak of ancient leprosy as a white scaly disease. It thus diflers decidedly from either kind of elephantiasis. The report of a Committee of the London College of Physicians* states that leprosy now exists in Egypt, Abyssinia, Algeria, Mo- rocco, Senegambia, Cape of Good Hope, Madagascar, Mauritius, Isle of Bourbon, Syria, Arabia, Persia, Bokhara, Cashmere, India, Ceylon, Java, Sumatra, China, Kamskatka, Australia, ^gean Islands, Crete, Cephalonia, Malta, Greece, Russia, Esthonia, Fin- land, Courland, Sweden, Norway, Iceland, coasts of North Italy and Southeastern France, other shores of the Meditei'ranean, 1 See Brit, and For. Medico-Chirurg. Rev., 1850, p. 71. - See Neligan's Treatise on Diseases of the Skin, edited by Dr. Belcber (Philadelphia ed., l'6i;, p. -289). 3 Med. Times and Gazette, Feb. 23, 1867. 46* 2K 546 DISEASES OF THE SKIN. delta of the Rhone, Spain, Portugal, Mexico, Brazil, West Indies, New Granada, Venezuela, Ecuador, and La Plata. It is said to be on the increase in the West Indies, and has been known recently in New Brunswick.^ A number of cases have occurred lately in the Sandwich Islands ; as well as at Key West, Florida. At New Orleans, a hospital for lepers was established in 1778. The disease exists in two forms : 1. Tubercular ; 2, Non-tubercular. Anaes- thesia of the skin is frequent in both ; and so is enlargement of nerve-trunks. It is hereditary. It may be congenital ; but generally begins about puberty. Bad diet, and other personal xmsanitary condi- tions, are most promotive of it. Hygienic improvements prevent or mitigate it. Medical treatment appears to be generally inca- pable of curing it.^ Qurjun (dipterocarpus) oil and chaulmoogra oil have been much used for it, both externally and internally, in India and elsewhere. Of chaulmoogra oil (gynocardia odorata) the dose at commencement is 5 minims. The bark of the lioang- nan, a vine of Cochin China (strychnos Gaultheriana), in 3-grain doses, is also said to be serviceable in the treatment of leprosy. Dr. Simmons, of Yokohama, Japan, uses for it copaiba, inter- nally and externally. E. Wilson^ gives the duration of tubercular leprosy as from ten to fifteen years; of the anaesthetic, fifteen to twenty years. Life may last under it for five, ten, or twenty years. It has no proved connection with syphilis; nor is there decisive evidence of its contagiousness. Segregation of the lep- rous does good, by preventing or limiting the marriage of lepers. Climate can have but little to do with its causation, as it prevails in places as remote and unlike as China and Norway; late writers asserting the identity of the Norwegian "spedalsked " with the leprosy of other places. Jonathan Hutchinson* reported to the Royal Medical and Chirurgical Society a well-marked case of leprosy in which recovery took place. He attributed her cure mainly to change of diet, especially the abandonment of fish. The first recorded case of inherited leprosy in the United States is said to have occurred in Nebraska, being reported by Prof. Hyde, of Chi- cago.'' Altogether, statistics of the Dermatological Society make it appear that, in 1880, there were between 50 and 100 lepers in tiie United States. Although not contagious in the ordinary sense, after getting a foothold in a place, it appears to increase in some manner, generally. In 1840, there was no leprosy in. the Sandwich Islands ;® having been brought thither since by the Chinese, in 1880, about one-tenth of the inhabitants were said to be lepers. 1 A pamphlet has been written by Dr. Brognat-Landre on its prevalence in Surinam. 2 Carbolic acid, externally applied, is asserted to have cured some cases. Oil of cashew- nut (Auacardium occidentale; has acquired some reputation in Trinidad, under the hands of Dr. Beauperthuy. 3 Lectures on Dermatology, Lancet, February and March, 1873. i Lancet, Feb. 15, 1879. 6 Chicago Med. Journal and Examiner, December, 1879. * This statement, however, has been lately denied by residents of those islands. HYPEliTKOPUI^. 547 ' MACULJE. Ephelis^ Vitilifjo, and Chloasma may be included under this term; perhaps better under that of Decolorationes. Ephelis ; lenthio. — Sunburn and freckles best correspond with these names, which, however, are by some authors extended further. Neither are of importance, unless in regard to api)ear- ance. For the removal of freckles (which often disappear spon- taneously with time) or the yellowish brown spots called chloasDia, or melasma, all applications may fail; dilute nitro-muriatic acid (fifteen to thirty drops in an ounce), left for some time in contact with the discolored spots, is more likely than anything else to take effect._ _ [See F. 373.] Vitiligo. — Literally veal-sMn. Unnatural whiteness from defi- ciency of coloring matter. When universal over tlie body (nearly always then congenital) it is albinismus. We see albinoes, some- times families of them, in all the races of mankind ; as well as among the lower animals. Leucoderma, Avhite skin, and le2ico- pathia, or white disease, are names given by some writers to both the general and the local affection. When local, vitiligo is seen mostly in rounded patches or spots, which slowly increase in size, though without regularity of shape. The head, chest, back, and thighs are the most frequent seats of them. The hairs on the parts involved become white ; or fall out, causing baldness— ca?(.'ii cantharidal collodion, lightly applied ; these are among the many applica- tions which may be used for the purpose, with generally successful results. As has been observed, tinea is seldom transmitted to a cleanly person ; at least with- out very close and continued contact. Chloasma Versicolor {Pityriasis Versi- color).— The parasite of this is raicrosporon furfur. The disease is recognized by the for- mation of dull, reddish-yellow spots of various size and shape, seldom numerous, on the front of the chest or abdomen. The same local applications may be used for it as for tinea ; besides the internal use of arsenic. Plica Polonica. — This is an affection of Y'fStWPBHP'P ^^® hairy scalp, endemic in Poland, Russia, iS^Si^B' and Tartary. The hair-follicles become dis- eased, and the hair is matted and glued together into felt-like masses. TrichopJiyton Tin ea^Tonsura'^s ^'^"^^''''^"■^ ^nd trichophyton sporuloides are the loaded with spores, parasitic vegetations described as found con- (McCallAuderson.) nected with it. The disease has not been seen in this country. Some dermatologists assert that it is nothing but eczema capitis, with seborrhoea and dirt ; but this is not probable. SYPHILIDA. Enough for our purpose and space has already been said of the general history of syphilis. Among its constitutional manifesta- tions cutaneous eruptions are very frequent. These are seldom vesicular, not very often papular ; most often squamous or scab- bing. Lepra and rupia, particularly the latter, are prominent among syphilitic affections, though both may occur independently of syphilis. All eruptions in persons of this diathesis are marked by a coppery color, which remains long, even after their cure ; by a disposition to ulcerate, perhaps only superficially; and by pref- erence in locality for the face, shoulders, and back. In the treatment of syphilitic eruptions, the diathesis must be 1 Duhring includes tinea eircinata and Hnea tonsurans together, as tinea tnchophytina. 2 Blention has been made on a previous page to the propriety of caution in the use of chrysophanic and pyrogallic acids. (See Psoriasis.) Hairs from a case of FKOST-BITE; CHILBLAIN. 561 met by our remedies. Iodide of mercury internally; after that, iodide of potassium, and, in feeble persons, cod-liver oil, perhaps iodide of iron ; locally, menuirial ointment (besides palliatives, if required, as in other eruptions) or the calomel vapor bath should be prescribed. Often such afl'ections will seem to be cured, but, after weeks or months, will retui'n again ; then the treatment should be renewed, and discontinued when they disappear. POISON-VINE ERUPTION. The common poison-vine^ [Bhiis toxicodendron), a species of swamp sumach, and one or two other plants more rarely, cause, by contact, in some persons, an inflamed vesicular eruption of considerable severity. The hands and face are its most common localities ; but it may come out on the lower limbs or about the anus and genitals. Its duration, when severe, may be from one to two weeks ; but it is often quite limited and of short course. In the treatment of this annoying but not dangerous attack, I have had a good deal of experience in my own person as well as with others. I have found much relief, and great effect in short- ening the course of the disease by reducing the inflammation, from Icad-water.earh/, freely, and frequently applied with a large camel's- hair pencil. It should not be put upon the openecZ vesicles, which it irritates ; but around them, upon the reddened skin. In the practice of Dr. E. Hartshorne, a successful remedy has been the fluid extract of serpentaria, painted directly upon the erupti(m. It seems to kill it at once. Oxide of ziuc ointment is sometimes very soothing to the eruption. Dr. Hatch, '^ of California, finds solution of sulphate of iron beneficial in this affection. Late experience with it (1874) has convinced me that the bicarbonate of sodium., in strong solution, applied early with a camel's-hair pencil, is especially efficacious. Its action (and that of lime- water, also sometimes useful) is explained by the fact, pointed out by Prof. Maisch, of Philadelphia, that the active principle of the poison-vine is an a.cid—toxicodcndric acid. Dr, Brandt,' of Indiana, recommends a saturated solution oi sulphite of sodium, constantly applied, Dr, Brown,'* U. S, N., asserts that bromine exercises a specific control over rhus poisoning. He dissolves bromine in olive oil or vaseline, 10 or 20 drops to the ounce, rubs this gently over the parts aftected three or four times a day, and washes the parts afterwards with soap. Lathering the seat of the eruption, with a soft shaving-brush, is very relieving to the itching and burning which attend it, FROST-BITE; CHILBLAIN. Gangrenous destruction of parts, especially of toes, not unfre- quently follows actual congelation. Short of this, exposure to 1 This somewhat resembles the Virginia Creeper, but is three-leaved. One variety of it is erect, not climbinfc. - California Med. Gazette, 1869 ; also Butler & Brinton's Half-yearly Compendium, part iv., p. 1.12. 3 N. Y. Medical Record, July 12, 1879. p. 46. Dr. Ward (same Journal, Aug. 21, 1879), advises liquor sotlce c/ilorina/re diluted with from 3 to 6 parts of water. * Boston Med. and Surgical Journal, 1879. 2L 562 UNCLASSIFIED AFFECTIONS. continued cold, especially when suddenly warmed again, may cause an erythematous inflammation, erythema pernio, already mentioned under that head. When the feet or other parts have been so chilled as to be almost frozen, gradual warming — for in- stance, at first rubbing them with snow — is proper as a preventive of frosting. In its treatment, cooling unguents, as Goulard's cerate, or lotions, as lead-water, may be first indicated, and then astringents, as alum-water, infusion of oak-bark, solution of chloride of iron, creasote ointment, etc. Cabbage leaves are a popular domestic remedy for chilblains. BURNS AND SCALDS. If half of the body be so burned or scalded as to arrest the functions of the skin over that extent of surface, death will always result. Collapse comes on from the terrible shock to the nervous system through the impression on the widely distributed cutane- ous nerves. The pulse is then very low, the body cold, and, com- monly, thirst is great. Sufiering is often, in a few hours, lost in apathy and prostration. The treatment for this prostrated condition must be stimu- lant as well as anodyne. Opium and whisky, or wine, should be given as freely as in any other condition of positive debility or exhaustion. For local treatment of burns, I believe that nothing is better than lime-water and cdl, equal parts (either linseed, olive, or lard oil), on cotton wadding, covered with oiled silk. Other remedies often used are, dry cotton (which sticks too close in deep burns], glycerin, rye-meal, starch powder, fresh lard, fruit jellies (Marin), carbolic acid,^ and molasses. To exclude the air seems to be the main indication. I have been disappointed in several trials of a saturated solution of sodium bicarbonate, which was much praised as a remedy for burns a few years ago. Soap-suds will do as much or more good. UNCLASSIFIED AFFECTIONS. AMENOREHCEA. A few words seem appropriate here u^ion some of those affec- tions of the sexual system which every practitioner must often meet with. Their full discussion belongs to books of a different kind. Especially at a distance from the large cities, a general practitioner will often have occasion to make his own diagnosis in such cases, and, perhaps, carry out his own treatment. In regard to the more serious operations of gynaecological surgery, much caution may very reasonably be exercised by any one whose opportunities have not enabled him to acquire the skill of the specialist. Upon these subjects, the works of Thomas, Barnes, Atlee, and Emmet may be especially recommended for study and reference. 1 In solution, 3lj in O.j of water ; ov 1 part to 7 parts of glycerin ; or else Lister's "carbolic oil," 1 ounce of carbolic acid in a pint of olive or linseed oil; or carbolized oxide of zinc oiutmeut, 1 part carbolic acid to 32 parts zinc ointment. AM EN oil KIKE A. 563 Amenorrhoea, or suppression of iho menstrual discharge in women, n\ay be either an interruption of it during its cjccurrence, or its lia1)itual non-appearance. The former is commonly the result of cold and wet, or of some nervous shock, to which the patient is exi)osed during the menstrual period. Habitual amenon-ha^a may occur with plethora, from disturb- ance of ovarian and uterine functions, or with ancemia and de- bility, or as a secondary effect of chronic disease, e. {/., phthisis. The greater number of cases is met with in ansemic females; but the opposite state is not very uncommon. Vicarious hemorrhages from the lungs, stomach, etc., sometimes accompany it. As bearing upon the treatment of amenorrhoea, the question always comes up, is the suppression of the menstrual flow the cause of other symptoms or morbid effects, or is the amenorrhea itself the effa-t of a morbid condition, the removal of which will restore this arrested function? It is to be said in reply, that sometimes the one and sometimes the other may be the case. In amenorrho'a with plethora, generally the interruption of men- struation may be found to be a primary, though perhaps not the sole, cause of disturbance of the system. In anaemic amenor- rhoea, most frequently the constitutional state is primary, and the restoration of general strength will be attended by the spon- taneous return of the function. Practically, then, we must, in any case, inquire into the gen- eral condition and history of the patient. If there is headache, increased by stooping, with a flushed face and full, strong pulse, the patient having previously been vigorous in health, taking blood from the lumbar region by cups, or, in clear cases, from a vein in the arm by the lancet, is indicated. Also purgatives ; at first, in a sudden attack, senna, or, if much heat of the system exist, citrate or sulphate of magnesium ; afterwards, when the amenorrhoea is obstinate, aloes. Hot mustard foot-baths, or warm hip-baths, and warm poultices to the breasts, every night, should be used in a case of sudden suppression of menstruation in the midst of its period. Tincture of aloes and myrrh is a favorite domestic emmenagogue ; a teaspoonful twice or thrice daily, in hot water. Tincture of rhubarb and senna (Warner's cordial) will, I believe, answer as well. Black hellebore, savin, senega, etc., are also resorted to for similar action ; but all emmenagogues are more uncertain even than diuretics. In many cases of amenorrhoea, a delicate and, in some, a diffi- cult question is, as to the possibilit}^ of the (physiologically) nor- mal cause of pregnancy being present to account for it. Most of all may this difficulty present, of course, in young single women, who may, unfortunately, have reason for concealment. Apart from the very clear ethical principle that a physician has no moral right to aid, in any way whatever, in producing an abortion, active emmenagogue treatment in the pregnant state is unsafe for the healtli of the subject of it herself. Medicine will fail to cause abor- tion in eight or nine cases in ten, unless it be so used as to produce a serious, often dangerous, effect upon the system of the patient. When we susjjcct pregnancy, then, mild measures only are in place — waiting for time to develop the nature of the case in full. 564 UNCLASSIFIED DISEASES. Anceniic amenorrhoea requires tonics; above all, iron. Other medicinal and hygienic roborant agencies may also be called in. Aloes, in small doses, repeated daily [F. 201, 202], occasional or periodical hip-baths, foot-baths, a,nd breast-poultices, especially near the time when the menstrual flow should occur — may in many cases be superadded. Strychnia, in one-thirtieth of a grain doses, is a favorite tonic in amenorrhoea with some practi- tioners. Galvanism, or statical electricity (of the friction-machine) is much resorted to by others. The spinal and pelvic regions should be the seats of application. DYSMENORRHtEA. Painful menstruation is habitual with some women for years together. Pregnancy not unfrequently cures the habit. The affection seems to be of two kinds or origins : 1, functional or physiological, and 2, mechanical dysmenorrhea. With the former, disorder of innervation and circulation occurs ; even the ovaries may participate in this. Some women suffer attacks of monthly ovarian irritation (ovarian colic), with fever. Ordina- rily, before menstruation begins, the subject of functional dys- menorrhoea feels ill, with pain in the back, perhaps headache, ' followed by pains, almost like labor-pains of the first stage, in the womb. That organ becomes palpably swollen and heavy, its pain being somewhat assuaged by compression by the hand through the abdominal wall. When free discharge comes on, relief is obtained. Sometimes a membranous cast, in one or more frag- ments, of the lining of the uterus, is expelled : constituting mem- branous dysmenorrhoza. The symptoms of mechanical dysmenorrhoea are not always strikingly different, but it is a more local affection. The direct cause of it is obstruction at the os or cervix uteri ; the external or internal os usually, if constriction be the trouble ; in the neck, when anteversion, retroversion, or lateral flexion produces it. On the indication of this causation. Dr. Simpson, of Edinburgh, some years since introduced the practice of dilatation of the os and cervix for the cure not only of dysmenorrhoea, but of sterility, dependent upon the same obstruction. A sponge-tent was used [F. 232] ; sometimes, more lately, the sea-tangle (laminaria digitata) instead. Dr. W. L. Atlee (1861) introduced a uterine dilator,^ which has been found to act well in many cases. Dr. Ellwood Wilson and Dr. Molesworth have made large use of similar instruments. Simpson and others, however, have pre- ferred incising the neck of the uterus with a hysterotome. Much discussion on this subject has transpired. I must refer upon it to works on special surgery and gynaecology ; particularly the works of Drs. Marion Sims and T. A. Emmet. It is observable, however, that Dr. H. B. Storer, the distinguished obstetrician of Boston, adheres to careful dilatation instead of incision. Drs. Tilt and H. Bennet, of London, and Drs. F. Barker and Emmet, of New York, also object to frequent hysterotomy. Whatever the cause of dysmenorrhoea in any case, the subject 1 Amer. Journal of Med. Sciences, April, 1871. MENORRHAGIA. 565 of it should always avoid being much on her feet for a day or two before her monthly time ; and should go to bed when the pain begins. Cloths wrung out of hot water, or spirits and hot water, may be placed upon the aljdomen, and renewed as they cool. Internally, spirits of camphor, with compound spirit of lavender and hot water (sweetened to taste) may bo given [F. 203] ; or if not relieved, paregoric in teaspoonful doses. Dr. Emmet advises large vaginal injections of liot water. Dr. Blackwood,' of Phila- delphia, has found electricity to give the best results. The ad- vantage of avoiding much exercise or fatigue just before the time of the expected menses ought to be impressed upon the patient. No medicine appears to have any important pro^jhylactic effect; unless it be iron in ansKmic patients. MENOKEHAGIA. Excessive menstruation may be of two kinds : 1, its occurrence too often ; 2, too great an amount or continuance of the discharge. Both very frequently occur together. Causes of menorrhagia are — general relaxation of system ; over-excitement of the genital apparatus ; thinness of the blood, hemorrhagic diathesis ; and over-fatigue, especially on the feet, promoting a descent of blood toward the pelvic organs about the time of menstruation. Ulcer- ation, cancer, or tumors of the uterus, as well as abortion and placenta prcevia, cause uterine hemorrhage, not properly to be called menorrhagia ; but metrorrhagia. This affection is much most common in the ansemic. Rest, iron, good diet, and astringents, internally and sometimes locally, are then the remedies for it. Tincture of chloride of iron is, liere, the favorite chalybeate. It may be given through the interval. During the attack, ammonio-ferric alum, in tive-grain doses, may be administered ; or tannic or gallic acid, three to five grains several times daily. The indiscriminate- use of iron, however, simply because of excessive menstrual discharge, is to be avoided. Sometimes, without ancemia, the disorder is due to uterine con- gestion ; and then, by promoting this, iron may increase the flow. For metrorrhagia, ergot may be required; f5ss of the fluid extract, or fpj of the wine every half-hour for several doses ; or hypodermic injection of ergotin, two or three grains at once, or 7j-JiT of a grain of atropia (Tacke). The patient must be kept still upon her back till the flow is controlled. Sometimes cold wet cloths (for a serious hemorrhage) have to be put upon the abdomen ; or an ice-water sponge, or half a lemon, or a syringe- ful of vinegar, or tannic acid solution, or of solution of tinct. ferri chlorid. (foss in fgviij) may be thrown into the vagina. Dr. Wooster, of California, uses injections of a solution of chromic acid; 15 grains in f5i of hot water, passed through a gum catheter, car- ried up to the fundus.^ Hot water alone" is much employed in recent practice. It should be at a temperature not below 110° nor above 120° Fahr. Dr. Matthews Duncan-^ injects tincture of iodine 1 Phila. Med. Times, Oct. 9, 1880. 2 Dr. Emmet credits Dr. Sims with the introduction of chromic acid as a local remedy in uterine diseases. Its use requires caution. 3 Med. Times and Gazette, August 7, 1S80. 48 566 UNCLASSIFIED DISEASES. into the uterus for threatening hemorrhage ; regarding it as safer than tincture of the chloride of iron. Dr. Barnes advises that, at the time of an injection into the uterus, an assistant should grasp that organ through the abdomen, to lessen the danger of the escape of the fluid through the Fallopian tubes. Plugging, with a tampon of cotton, lint, or sponge,^ in a few instances may have to be resorted to. Dr. T. G. Thomas prefers, for the application of a tampon in uterine hemorrhage, the preliminary distension of the vagina with Sims's duck-bill speculum. "Pieces of cotton soaked in water, pressed and flattened out by the fingers, each about the size of a very small biscuit, may be pressed into the vaginal cul- de-sac by means of forceps till this is filled. Then other pieces are packed firmly around the cervix until only the os is visible ; a smaller pad is then pressed firmly against or introduced within the cervical canal and the whole vagina is then filled to its lowest portion." In every case of severe or protracted menorrhagia, the practitioner must endeavor to be sure whether or not any malignant or other organic affection of the uterus is present. LETJCORRHCEA. Synonyms. — Fluor Alhus; the Whites. This is quite a common trouble of women. The mucous discharge may be either from the vagina, from the cervix, or from the uterine cavity. When from the glands of the neck of the uterus, it is apt to be glairy, like the white of an egg. Irritation of the organs, followed by relaxation, is its general cause ; but, often, relaxation alone seems capable of producing it. Procidentia or prolapsus uteri is a frequent source of it ; the descended uterus pressing upon the vaginal walls, causing morbid increase of secretion and exhalation from one or both. In treatment of leucorrhoea, tonics are often required ; iron, bitters, etc. Also astringents, by the mouth and locally ; those mentioned for menorrhagia will apply here also, but usually in less strength, for a longer time [F. 204, 205]. Vaginal, or in some cases uterine, suppositories also may be used. They may be made of cacao butter, or gelatin and glycerin, medicated according to each case. A suppository for the uterus should be cylindrical, of about the diameter of a goose-quill, two inches long, and weighing about fifteen grains. For the vagina, of course, it must be larger. If prolapsus or procidentia exist, a well-adapted pessary (gutta percha or India-rubber ring, or double horseshoe of similar light material), will, in a majority of cases, do good service. IRSITABLE TJTEKUS. This consists of a permanent and painful sensibility of the womb, especially of its neck ; often accompanied by increased frequency of pulse, a drj^, hot skin, and generally, in protracted cases, gastric and renal derangement. This disease comnionly occurs in the middle period of life, though it is sometimes met with in early youth. 1 Dr. T. E. Beesley contrived a light metallic conical plug or cork for the vagina; to be kept in place by a bandage. Gutta-percha might be adapted to the same purpose. TRRITART.E UTRRUS. 667 The local syniploins are pain in the lumbar and sacral r(!f;;ion3 extending down tlie tluLjli ti) Uic knee, and around the brim of the pelvis to the lowest part of the abdomen. Tiiere are also some erratic pains in the thorax and loins. The character of the pain is that of soreness ; slight pressure relieves it, but it is agjgravatcd by rough handling ; sometimes it is spasmodic, like that of abortion. The pain is incu-eased by excitement of any kind, by exercise, and sometimes by standing. Straining, either in defecation or urination, constipation, flatulence, and diarrhoea will aggravate it. A vaginal examination may prove the uterus to be either displaced or engorged, but not altered in form, size, or density ; extremely painful to the touch in the body as well as in the neck. Causes. — Among the predisposing causes may be placed, inju- dicious education, fashionable life, prolonged lactation, and tem- perament. Among the exciting causes, bodily exertion dm-ing menstruation, astringent injections, abortions, displacements, and sudden arrest of the menses in any way. Diagnosis. — From neuralgic dysmenorrhcea, by the constancy of the pain. From acute inflammation of the cervix, by the absence of heat, swelling, and throbbing; by the absence also of discharges, and by the slight changes of the cervix compared with the amount of suffering. Pathology. — Gooch considers it a permanently painful con- dition of the uterus, neither accompanied by nor tending to produce change in structure. Ashwell regards it as a modified inflammation, or, at least, closely allied to inflammation or con- gestion. Thomas names it "areolar hyperplasia," on account of the increased formation of areolar or connective tissue com- monly occurring in its course. This term omits, however, the recognition of the "irritability" which gave occasion for the name preferred for this affection by Hodge and others. Treatment. — Two indications present themselves, viz.: 1. To mitigate local suftering ; 2. To sustain and improve the general health. The first indication will be fulfilled by the use of ano- dynes, either by the mouth or rectum, or applied directly to the uterus itself; by the ai)plication of the nitrate of silver, and by anointing the cervix with anodyne unguents. The second indi- cation, by rest, exercise in a recumlDent posture, or, in some cases, on foot or horseback ; tonics, nutritious food, cold bath or the douche, and cheerful society. Scarifications of the neck of the uterus are highly recommended by some authors, especially when there is congestion. The introduction of a pessary is often followed by marked relief, if there be any descent of the womb. Dr. T. H. Buckler, of Baltimore, asserts advantage from dilata- tion of the cervix uteri by insertion of a male urethral bougie, left in for a number of hours at a time. This practice is founded upon the view that the cervical congestion and hyperplasia are owing to a strangulation of the veins of the uterus by an exces- sive action of its circular muscular fibres. It must certainly require care to avoid the eftects of direct local irritation, en- dangering inflammation (endometritis). 568 UNCLASSIFIED DISEASES. Fig. 135. In regard to pessaries, nearly all the best gynsecologists agree that they are often useful in sup- porting a prolapsed or displaced uterus. Hodge's horseshoe pess- ary (of light material) is frequently serviceable ; and so is a simple India-rubber ring pessary. The tact of the practitioner, as well as his knowledge of pelvic anatomy, must be exercised in selecting and adapting such an instrument for each case. Dr. M. A. Fallen^ pre- fers a soft-day pessary or "utero- vaginal rest." It is impossible for an external application of any kind to replace a dislocated womb ; yet there are not a few cases in which the real origin of the trouble is relaxation of the muscular parietes of the abdomen, and consequent tendency to descent of all of its contents. For this state of things a well- fitting abdominal bandage may afford a very useful support. I have known cases, not only of irritable uterus, but of severe nervous symptoms (in one instance epileptoid convulsions), to be essentially relieved by wearing, for months together, external abdominal supporters. Hodge's Pessary. Fig. 136. A. H. Smith's Pessary. Ulcers of the Uterus. — Much discussion has occurred as to the fitness of the application of the term ulcer to such "granular degenerations, erosions, or abrasions" as are observed about the OS and cervix of the uterus. The term is, however, thus applied by most gynaecologists.^ Thomas describes six varieties of cer- vical ulcerations : 1. Granular ; 2. Follicular ; 3. Inflammatory ; 4. Syphilitic ; 5. Corroding ; 6. Cancerous. Of these, the granular ulceration of the vaginal (exterior) surface of the cervix is the most frequent. Its symptoms are sometimes slight, in other cases quite grave. It is pi'oduced by 1 N. Y. Med. Record, June 19, 1880, p. 688. 2 Dr. Reamy, of Cincinnati (1880) in 8000 women examined, found (excluding syph^ iUtic and cancerous cases) but 19 instances of what he regarded as " true ulceration." UTERINE TUMORS. 669 all causes of uterine irritation or inflammation, as displacements; sexual (if)uscs; 2>'i'<'ssure ; iiijurics during parturition. In a serious case the sym])toms may be as follows : leucorrhcea^ sometimes bloody or puruUiuL; ^Kf/n and bloodt/ discharge after coition; menorrliagia ; j)ain on locomotion; constant pain in the hack and loins; generxxx. Dose, f5.j, in wine or brandy, p. r. n. Lini''- water is asserted by Dauvernc to give immediate relief to the pain caused by the stings of bees and wasps. Aqua nmmimifriwxW generally arrest the pain of bee-stings at once. 3 N'l.'iirc. Sept. .S, 1870 Th • .serpents were the very venomous tiger-snake and brown and l)lack snakes of Australia. 50 590 UNCLASSIFIED DISEASES. fatally venomous than those of Australia.^ Inspector-General C. J. Smith, ^ of Madras, has recorded the cure of a case of cobra poisoning, by the internal use of liquor ammonise, in half-drachm doses, diluted, taken repeatedly every ten or fifteen minutes. Dr. Fayrer has more confidence in artificial respiration, in bad cases, than in any other remedy ; but the cobra bite, esi^ecially in vascular parts of the body, is apt to be incurably fatal. So is that of the rattlesnake, and of the moccasin of the Southern States, about the face or neck ; as well as that of the phoorsa snake. ASPHYXIA. "Whether from drowning, breathing coal-gas in an unventilated apartment, or excessive inhalation of chloroform, etc., the treat- ment for suspended animation must be essentially the same in principle. First loosen everything about the neck. Draw the tongue forward and clear the mouth. Laying the patient upon the back, let both arms be raised (Sylvester) as far as possible above the head, and then brought down again ; this should be repeated at least fifteen or twenty times a minute. Pacini's method of drawing the shoulders upward, and Bain's of lifting and letting them down alternately, may be combined with Syl- vester's. Blowing into the mouth or nostrils, with or without a trachea-tube or a quill in the nostril, is available sometimes, especially in a child ; at the same time, when oxygen gas can be obtained (as, of course, it very rarely can), a jet of it may be used. Dr. Polk,^ of New York, in 1880, saved a child's life by intro- ducing into its larynx through the glottis a 'No. 8 silver catheter, and inflating the lungs by blowing through it ; an assistant alter- nating this with pressure upon the chest and abdomen to pro- mote expiration. Le Bon and Goyard* have found immersion in hot water effective in relieving the asphyxia of new-born infants. Passing a vial of solution of ammonia at intervals under the nostrils will aid to excite the nerve-centres. Rubbing the limbs and trunk vigorously, and chiefly towards the heart, to hurry the venous circulation, is useful. So, also, is the application of mus- tard, or friction with red pepper and brandy or whisky. Hot bottles may be applied to the feet and legs. Excessive heat will not be expedient before respiration is established ; but moderate warmth always promotes vitality. The application of a red-hot iron, momentarily, to the epigastrium or the back of the neck, for intensely stimulant effect, is not unreasonable in idea. Gal- vanism may be employed in any case of suspended animation. The extraordinary measure has recently been sometimes prac- tised, of forcibly dilating the anus and introducing the hand and forearm into the bowel, as far as the colon. The semi-lunar ganglia, it is believed, may be thus subjected to stimulation by contact. Atropia, hypodermically injected, as a "respiratory 1 In 1871, Dr. Halford received thanks from the Government of India for the intro- duction of this treatment; and the republication of his pamphlet, for distribution, was oflncially ordered. Of 939 cases of snake-bite treated in Bengal by the police, with ammonia, 702 are said to have recovered. 2 Brit. Med. Journal, Feb. 22, 1868. 3 N. Y. Medical Record, June 19, 1880, p. 710. * Le Courrier Medical, Jan. 22, 1881. ASPHYXIA. 591 stimulant " is recommendod by some authorities in asphyxia •, and digitalis, similarly used, as a "cardiac stimulant." The Executive Committee of the Life Saving Society of New York, consisting of Prof. Frank II. Hamilton, Prof. C. F. Chand- ler, and others, have issued the following series of rules for the treatment of persons rescued from tiie water in an insensible condition : — "Rule 1. — To drain ofl' water from chest and stomach: Instantly strip the patient to the waist. Place him face downward, the pit of the stomach being raised above the level of the mouth by a large hard roll of clothing placed beneath it. Throw your weight forcibly two or three times, for a moment or two, upon the patient's I)ack, over a roll of clothing, so as to press all tluids in the stomach out of the mouth. ^ "Rule 2. — To perform artificial breathing: Quickly turn the patient upon his back, the roll of clothing being so placed beneath as to make the breastbone the highest point of the body. " Kneel 1)eside or astride patient's hips. Grasp the fnmt part of the chest on either side of the pit of the stomach, resting your fingers along the spaces between the short ribs. Brace your elbows against your sides, and steadily grasping and pressing for- ward and upward, throwing 5^our whole weight upon your chest, and gradually increasing the pressure while you can count one, two, three. Then, suddenly, let go with a final push, which springs you back to your first position. Rest erect upon your knees while you. can count one, two ; then make pressure again as before, repeating the entire motions at first about four or five times a minute, gradually increasing to about ten or twelve times. " Use the same regularity as in blowing bellows, and as is seen in natural breathing, which you are imitating. " If another person be present, let him, with one hand, by means of a dry piece of linen, hold the tip of the tongue out of one corner of the mouth, and, with the other hand, grasp both wrists and pin them to the ground above the patient's head." Having witnessed, in two cases at Atlantic City, the insuffi- ciency of the above methods of producing artificial respiration, it has occurred to me that ahdomiwd insjoiration may perhaps be promoted, by vigorous traction upon the walls of the abdomen. I have had made an instrument for such action ; consisting of a large syringe or pump, about two inches in diameter and twelve inches long, attached to a metallic cup or bowl, six inches across at its outer edge. It is intended to be applied closely to the uncovered abdomen, so that, by strong traction with the pump, the viscera may be lifted and the diaphragm made to descend. I have not yet had opporti;nity to make trial of this method ; but it appears to me that it ought at least to answer the purpose of facilUating the action of the diaphragm. It may be readily com- bined with Sylvester's method, as above described.^ After-treatment. — After breathing has become natural, dry the patient briskly. Wrap him in blankets only and let him be kept 1 Of course violence must be avoided in such a procedure. 2 The same principle, of a6rfo»wno/ /r«cility, chronic or subacute jaundice^ etc. 22. Bromide of Potassium. R . — Bromide of Potassium, half an ounce ; Peppermint or Cinna- mon Water, or Pure Water, six fluidounces. Dose, from a dessert- spoonful to a tablespoonful. In insomnia, hysteria, spermatorrhcea, etc. 23. Citrate of Iron. R. — Citrate of Iron, two drachms; Orange-flower Water, five ounces and a half; Simple Syrup, half an ounce. Take from a teaspoonful to a tablespoonful thrice daily, before or after meals. For anaemic children. 24. Ipecacuanha and Alum. R. — Powder of Ipecacuanha and Powder of Alum, each half a tea- spoonful ; mis with water. Eepeat in ten minutes if it does not vomit. In threatening croup. 25. Calomel and Nitrate of Potassium. R. — Calomel, six to twelve grains; Nitrate of Potassium, one drachm ; Sugar, one scruple ; mix, and divide into twelve powders. Take one every three hours. In inflammatory croup. 26. Nitrate of Silver Solution. R. — Nitrate of Silver, five to ten grains; Eose-water, or Distilled Water, half a fluidounce ; dissolve. Apply with a camel's-hair pencil to the throat, in memiranotis croup, or scarlet/ever. 27. Tincture of Aconite Boot. R. — Saturated Tincture of Aconite Root, one teaspoonful. To be rubbed gently into the sMnfor neuralgia. 28. Cliloroform Liniment. R. — Chloroform, three fluidounces; Olive Oil, four fluidounces; mix. Pure chloroform, prevented from evaporating by oiled silk or a watch-glasie, acts as a strong rubefacient ; burning like mustard. 29, Ointment of Veratria. R. — Veratria, ten to twenty grains; Pure Lard, one ounce; mix. In severe neuralgia; applied to the part. FORMULA. 605 30. Cod-liver Oil. g.. — Cod-liver Oil, Syriip of Ginger, .ind Mucilage of Gum Arabic, each two riuidoimces; Oil of Cloves, six drops; mix. Take a table- spoonful tbree or four times daily. In wanting diseases. 31. Cod-liver Oil and Glycerin. R. — Cod-liver Oil and Glycerin, each tvvoHuidounces; Gum Arabic, two drachms; Oil of Bitter Almonds, two drops; Oil of Cloves, twelve drops. Take a tablespoonful thrice daily. 32. Cod-liver Oil and Glycerin., Iron., and Quinine. R. — Take of Citrate of Anuiionium, Iron, and Quinine, each ten grains; Cod-liver Oil and Glycerin, each two liuidounces; mix. Dose, a tablespoonful. 33. Iodide of Iron. R. — Syrup of the Iodide of Iron, half a fluidounce. Take twelve to twenty drops, in water, thrice daily. Ill ancemia, scrofula, etc. 34. Tincture of ISfiix Vomica. R. — Tincture of Nux Vomica, half a fluidounce. Take from ten to thirty drops, thrice daily. In nervous debility, aggravated dyspepsia, etc. 35. Wild Cherry and Lactucarium. R. — Syrup of Wild Cherry, and Syrup of Lactucarium, each two fluidounces; mix. Take a dessertspoonful or two, at night, or one or two teaspoonfuls in the daytime. In J'requent and troublesome cough; as iii jjhtMsis. 36. Hoffmann'' s Anodyne, Squills, and Morphia. R. — Syrup of Squills, a fluidounce and a half; Hofl'mann's Anodyne (Compound Spirit of Ether), and Solution of Mori)hia (one grain in the ounce), each a fluidounce; Camphor Water, and Mucilage of Gum Arabic, of each a fluidounce and a quarter; mix. Dose, from a tea- spoonful to a tablespoonful. In troublesome coughs. 37. Carbonate of Potassium and Nitre. R. — Carbonate of Potassium, and Nitrate of Potassium, each two drarhms and a half; Water, eight fluidounces; dissolve. Take a tablespo(mful thrice daily. In gouty attacks. 38. Digitalis, Squills, etc. R. — Citrate of Potassium, two hundred grains ; Tincture of Squills, two fluidrachms; Wine of Colchicum Root, one fluidrachm ; Liquor of Acetate of Ammonium, two fluidrachms; Infusion of Digitalis, two fluidounces; Pe])permint Water, enough to make eight fluidounces; mix. Take half a wineglassful thrice daily. In dropsical effusions. 51* 606 FORMULA. 39. Cream of Tartar and Dandelion. R. — Bitartrate of Potassium, an ounce; Extract of Taraxacum, half a drachm ; Decoction of Taraxacum, eight tiuidounces ; mix. Take half a wineglassful two or three times a day. In dropsy or jaundice. 40. Cider Mixture. B. — Bruised Juniper Berries, Mustard Seed, and Ginger, each half an ounce ; Bruised Horseradish and Parsley Root, each an ounce ; sound old Cider, a quart; infuse. Dose, a wineglassful thrice daily. In dropsy. 41. Acetate of Lead Pills. R. — Acetate of Lead, half a drachm; Opium, five grains; Conserve of Roses, or Crumb of Bread, a snfiicient quantity ; mix, and divide into twenty pills. Take one thrice daily, watching the effect. In hy2Jertrop)hy of the heart. 42. Digitalis. R. — Powder of Digitalis, twelve grains; divide into twelve pills. Take one thrice daily. In cases of over-ra2nd action of the heart. 43. Digitalis. R . — Tincture of Digitalis, half a fluidounce. Take ten drops thrice daily, in water. As above, 44. Yeratrum Viride. R. — Norwood's Tincture of Veratrum Viride, half a fluidounce. Take from two to five drops every three or four hours. If nausea or prostration follow, withdraw or diminish the dose. In hypertrophy of the heart, and inflammatory fever. 45. Colchicum and Magnesia. R. — Wine of Colchicum Root,one fluidrachm; Husband's Magne- sia, one drachm ; Peppermint Water, four fluidounces ; mix. Take a tablespoonful thrice daily. In gout and gouty rheumatism. 46. Colchicum and Alkalies. R. — Wine of Colchicum Root, one fluidrachm; Bicarbonate of Potassium, and Rochelle Salts, each two drachms and a half; Pep- permint Water, four fluidounces ; mix. Take a tablespoonful thrice daily. In gout and gouty rheumatism. 47. Hoffmann^s Anodyne., Ammonia., and Soda. R. — Bicarbonate of Sodium, four scruples; Aromatic Spirit of Ammonia, one fluidrachm; Compound Spirit of Ether, one fluidounce; Compound Tincture of Cardamom, three fluidrachms ; Camphor Water, and Mucilage of Gum Arabic, each a fluidounce and a quarter ; mix. Take a dessertspoonful or tablespoonful at once. In angina pectoris, or gout of the stomach or heart. FORMULA. 607 48. Warner^ s Cordial and Laudanum. R. — Tincture of Rhubarb and Senna, a tiuidounce- and a half; Syrup of (iinfj;er, tliree tluidrachnis; Laudanum, one fluidracliin ; mix. Take a teaspoontul at once, in-liot water. Jii angiiKi pectoris^ or spasmodic gout. 49. Chloroform-.! IIoffmann''s Anodgne, etc. R. — Chloroform, and Aromatic Spirit of Ammonia, each two fluidrachms; llotfmann's Anodyne, and Paregoric, each half an ounce; Mucilajre of Gum Arabic, half an ounce; mix. Take a tea- spoonful at once. In angina j)ectoris, retrocedent gout, etc. 50. Glycerin and Rose Water. R. — Glycerin, one part; Eose Water, five parts; mix. Use as a lotion for the skin, or a mouth-wash. 51. Prepared Chalk and Gum Arabic. R. — Equal parts of finely powdered Prepared Chalk, and Powder of Gum Arabic; mix. Ajyply to ulcerated places in the mouth. 52. Borax, Myrrh, etc. R . — Borate of Sodium, two drachms ; Powdered Myrrh, one drachm ; Water, six fiuidonnces; mix. Use as mouth-wash, or gargle. 53. Sulphate of Zinc and Rose Water. R. — Snlpbate of Zinc, from two to ten or twenty grains; Rose Water, a fliiidounce; dissolve. Use as a mouth-wash, with care, in severe eases. 54. Chlorate of Potassium. R. — Chlorate of Potassium, half an ounce; Water, six fluidounces; dissolve. Take a tablespoonful every three or four hours. In ulceration of the mouth or throaty diphtheria, etc, 55. Muriatic Acid and Honey. R. — One part of Hydrochloric Acid, and two parts of Honey; mix. To be applied to the throat in diphtheria, with a soft sponge, firmly fastened to a (probang) piece of whalebone. In diphtheria. 56. Tincture of Chloride of Iron. R. — Tincture of Chloride of Iron, half a fluidounce. Take from ten to thirty drops thi-ice daily, in water. In ancemia, diphtheria, menorrhagia, leucorrhcBa, asthenic ery- sipelas, etc. 57. Clilorinated Soda and Glycerin. R. — Labarraque's Solution of Chlorinated Soda, one fluidrachm; Bower's Glycerin, and Water, each two fluidounces ; mix. Use as mouth-wash, in gangrcena oris. 608 FORMULA. 58. Creasote and Glycerin. R. — Creasote, two or three drops; Bower's or Price's Glycerin, and Water, each half a iiuidounce ; mix. Use as mouth-wash, in cuncrum or gangrcena oris, or severe aphthm or thrush. 59. Alum, Brandy, and Water. R . — Ahim, one drachm ; dissolve in six fluidounces of Water ; add two fluidounces of Brandy. To wash the mouth in salivation. 60. Tannic Acid Solution. R. — Tannin, ten to thirty grains; Water, a fluidounce; dissolve. To he applied with a hair pencil, to enlarged tonsils, etc. 61. Iodide of Potassium. R. — Iodide of Potassium, one to two drachms; Cinnamon or Pep- permint Water, six fluidounces ; dissolve. Take a tablespoonful thrice daily. As alterative in syphilitic rheumatism, and in many other affec- tions. 62. Nitrate of Silver Pills. R. — Nitrate of Silver, five grains; Opium, two grains and a half; mix, and divide into tv/enty pills. Take one thrice daily. In chronic gastritis. 63. Subyiitrate of Bismuth. R. — Subnitrate of Bismuth, one to three drachms; divide into twelve powders. Take one three or four times daily, in water. In gastric or intestinal irritation. 64. Lime -Water and Milk. Mix together equal parts of clear Lime-water and good Milk. Take a dessertspoonful or tablespoonful of the mixture at once. To check vomiting, or give nourishment when the stomach is irri- table. 65. Effervescing Draught. Dissolve two drachms and a half of Bicarbonate of Potassium in four fluidounces of Water. Pour out, for administration, a tablespoonful of this solution, and add to it a tablespoonful of water. Then add a tablespoonful of fresh Lemon-juice ; or of a solution containing two drachms of Citric Acid in four fluidounces of Water. In fever with irritability of stomach ; also, in sea-sickness. 66. Cardamom and Potassa Mixture. R. — ^Bicarbonate of Potassium, one drachm; Compound Tincture of Cardamom, a fluidounce ; Syrup of Ginger, two fluidrachms; Orange- flower Water, enough to make four fluidounces ; mix. Take a dessert- spoonful at once. To relieve nausea and vomiting. FORMULAE. 609 67. Ammonia, Soda, and Morphia. R. — Bicarbonate of Sodium, four scrni)les; Aromatic Spirit of Ammonia, one Huidraclim; Solution of Morphia, two rtuidraclims; Cinnamon Water, encnigli to make four tluidouuces. Take one or two teaspoonfuls at once. Ihr vomiting. 68. Creasote, Soda, and Morphia. R. — Creasote, eight droi)s; Bicarbonate of Sodium, one drachm; Solution of ^forpbia, a tluidrachm and a half; Peppermint Water, enough to make four tiuidouuces ; mix. Take one or two teaspoonfuls at once. For vomitinrj. 69. Calomel Powders. R. — Calomel, two grains; divide into eight powders. Take one every two hours. For vomiting, etc, 70. S%iice Poultice. R . — Powdered Cloves, Ginger, and Cinnamon, each one or two tea- spoonfuls ; Wheat Flour, a tablespoonful ; Brandy, or Whisky, enough to make a mass moist enough to spread upon thin, soft liannel. Double the flannel over it, and apply it to the abdomen. In obstinate vomiting, etc. 71. Nux Vomica, Iron, and Quinine. R. — Pill of Carbonate of Iron (Vallet's Mass), two scruples (or Quevenne's Metallic Iron per hydrogen, one scruple); Sulphate of Quinia, one scruple; Alcoholic Extract of Nux Vomica, five grains; mix, and divide into twenty pills. Take one, thrice daily. In prolonged atonic dysj)epsia, general debility, or ganglionic cachexia. 72. Tincture of Gentian and Rhuharh. R. — Compound Tincture of Gentian, and Tincture of Ehubarb, each two fluidounces; mix. Take two teaspoonfuls before each meal. In dyspepsia. 73. Gentian and Bhid)arh Pills. R. — Extract of Gentian, and Powder of Ehnbarb Root, each half a drachm ; mix, and divide into twenty pills. Take one or two thrice daily. In dyspepsia, flahdence, or tendency to colic. 74. Gentian, Rhuharh, and Blue Mass. R. — Extract of Gentian, and Powder of Rhubarb, each half a drachm ; Blue Mass, four grains; .Oil of Cloves, four drops; mix, and divide into twenty pills. Take one three or four times daily for a few days. To prevent recurring bilious colic or sick headache. 75. Rhuharh Pills. R. — Rhubarb Root, and Castile Soap, each half a drachm; Oil of Anise, four drops ; mix, and divide into twenty pills. Take one or two as recjuired. For slight constipation. 20 610 FORMULJE. 76. Rhuharh and Colocynth. R, — Rhubarb, Castile Soap, and Compound Extract of Colocyntb, each half a drachm; mix, and divide into twenty pills. Take one or two as required. For constipation. 77. Bhubarb and Aloes, etc. R. — Rhubarb, two scruples; Aloes, one scruple; Extract of E"ux Vomica, four grains ; mix, and divide into twenty pills. Take one as required. For obstinate constipation. 78. Carminative Mixture. R. — ^Bicarbonate of Sodium, one drachm; Compound Tincture of Cardamom, one fluidounce ; Spirit of Camphor, one fluidrachm (or. Paregoric, half a fluidounce) ; Spiced Syrup of Rhubarb, half a fluid- ounce; Peppermint Water, enough to make four fluidounces. Take a teaspoonful at once. 79. Oil of Cajuput. R . — Oil of Cajuput, half a fluidrachm ; Compound Spirit of Lav- ender, half a fluidounce; Syrup of Ginger, twQ fluidrachms; Mucilage of Gum Arabic, enough to make two fluidounces. Take a dessert- spoonful at once. For flatule?it pain in the bowels ; also, in chronic rheumatism or gout. 80. Ammonio-ferric Alum. R. — Ammonio-ferric Alum, two scruples; Cinnamon "Water, four fluidounces ; dissolve. Take a tablespoonf ul every two or three hours. An excellent tonic astringent. 81. Creasote Pills. R . — Creasote, twenty drops ; Conserve of Roses for Extract of Gen- tian), one drachm ; mix, and divide into twenty pills. Take one every two, three, or four hours. As astringent, in hcematemesis, ulcer of stomach, etc. 82. Podophyllum, etc. R . — Resin of Podophyllum, two grains ; Fluid Extract of Rhubarb, and Fluid Extract of Senna, each a fluidounce ; Oil of Cloves, four drops ; Syrup of Ginger, half a fluidounce ; Mucilage of Gum Arabic, enough to make four fluidounces. Dose for an adult, a tablespoonf ul. For constipation. 83. Suppository of Soap. Cut a piece of good Yellow Soap to the shape, and rather less than the size, of the last joint of the little finger. Dip it in Castor Oil, Olive Oil, or Lard, and introduce it within the rectum. To act upon the bowels, instead of an enema. 84. Nux Vomica, Colocynth, and Soap. R. — Compound Extract of Colocynth and White Soap, each half a drachm; Extract of Nux Vomica, five grains; mix, and divide into twenty pills. Take one niglit and morning. For torpor of the bowels. FORMULiE. 611 85. Aloes, Bhuharh, and Belladonna. R, — Rlnib.irb and Aloes, each lialf a drachm; Extract of Bella- donna, three grains; Oil of Cloves, three drops; mix, and divide into twenty pills. Take one twice daily. Fo7- habitual constipaiion. 80. Calomel and Opium Pills, R. — Calomel and Opium, each six grains; mix, and divide into twelve pills. Take one every two, three, or four hours. In peritonitis, bilious colic, etc. 87. Bills of Opium and Ipecacuanha. R . — Powder of Opinin and Powder of Ipecacuanha, each six grains ; mix, and divide into twelve pills. Take one every three hours. In typhlitis. 88. Cerate of Carhonate of Lead. R . — Carbonate of Lead, two drachms ; Simple Cerate, one ounce ; mix. For external use in chronic ophthalmia, periostitis, hemorrhoids, etc. 89. Aromatics.1 etc., for Colic. R. — Aromatic Spirit of Ammonia and Spirit of Camphor, each a flnidrachm ; Tincture of Ginger, two fiuidrachms; Bicarbonate of Sodium, four scruples; Peppermint Water, enough to make four tluidounces. Dose, a tablespoonful, 90. Carminative Anodyne. R. — Spiced Syrup of Rhubarb, Compound Tincture of Cardamom, Paregoric, and Cinnamon Water, each a fluidounce ; mix. Dose, from a dessertspoonful to a tablespoonful. For crapulent colic. 91. Chloroform Mixture. R. — Chloroform, a fluidounce; Camphor Water, Peppermint Water, and Mucilage of Gum Arabic, each a fluidounce ; mix. Dose, from a teaspoouful to a dessertspoonful, repeated cautiously. For colic, etc. 92. Chloroform Paregoric. — No. 1. R. — Chloroform, Laudanum, Spirit of Camphor, and Aromatic Spirit of Ammonia, each a tluidrachm and a half; Creasote, three drops; Oil of Cinnamon, eight drops; Alcohol, two fluidrachms; mix. Dose, fn)m ten drops to half a teaspoonful, in water. //* cholera. 93. Chloroform Paregoric. — No. 2. R. — Chloroform, two fluidrachms; Spirit of Camphor, a tluidrachm and a half; Laudanum, a tluidrachm; Oil of Cinnamon, five drops; Alcohol, three and a half tluidrachms ; mix. Dose, ten drops to half a teaspoouful, in water. 94. Carminative for Infants. R. — Bicarbonate of Sodium, half a draclim ; Aromatic Spirit of Ammonia, half a Huidrachm ; Solution of Morphia, half a flnidrachm ; 612 FORMULAE. Syrup of Ginger, half a fluidounce; Camphor Water, enough to make two fluidounces; mix. Dose, a teaspoonful, repeated if nec- essary. In colic. 95. Podo2)hyUu'm^ BMibarh, etc. R. — Resin of Podophylhim, one grain; Simple Syrup of Rhubarb, a fluidounce ; Oil of Fennel, one drop ; mix. Dose, ten drops to a teaspoonful. For constipation in infants. 96. Castor Oil and Spiced Syrup of Bhuharh. Mix one tablespoonful of Castor Oil thoroughly with two table- spoonfuls of Spiced Syrup of Rhubarb ; administer immediately after mixture. This is the least disagreeable way of taking castor oil. 97. Castor Oil and Laudanum. To the above prescription, add ten, twenty, or thirty drops of Laudanum. Useful in incipient acute dysentery. 98. Assafoetida Mixture. Rub one drachm of Assafoetida gradually with four ounces of Water, until thoroughly mixed. Then add two fluidounces of Syrup of Ginger. Dose, for a child, a teaspoonful. 99. Magnesia and Ammonia Mixture. R. — Best Magnesia (Husband's or Henry's), a drachm; Aromatic Spirit of Ammonia, a fluidrachm ; Peppermint Water, four fluidounces ; mix. To be shaken before administration. Take a teaspoonful every half hour. In common summer cholera morbus. Half a fluidounce of Paregoric may be added to the above, if there is much purging. 100. Chloroform and Gamplior. R. — Chloroform, half a troyounce; Camphor, one drachm; the yolk of one &§g\ Water, six fluidounces. Rub the yolk in a mortar, first by itself, then with the Camphor, previously dissolved in the Chloroform, and lastly, with the Water, gradually added. This is the "Mixture of Chloroform " of the United States Pharmacopoeia. Dose, from a teaspoonful to a tablespoonful. 101. Spiced Rhiibarh and Magnesia. R. — Spiced Syrup of Rhubarb, half a fluidounce; Magnesia (Hus- band's), fifteen grains ; Cinnamon Water and Camphor Water, each two fluidrachms ; mix. Take in two doses, three hours apart. As a corrective in slight diarrhoea. 102. Chalk Mixture. R. — Prepared Chalk, two drachms; White Sugar and Gum Arabic, each a drachm and a half ; Tincture of Kino, two fluidrachms and a FOKMULiE. 613 half; Laudannm, twenty to forty drops ; Peppermint Water, enough to make six fluidounces; mix. Dose, a tablespoonful. In diarrhoea. 103. Cv.mphoT Mixture. R. — Compoiind Spirits of Lavender, a flnidmmce; Spirit of Cam- phor, a fhiidrachm; Laudanum, half a fluidracLm ; Sugar and Gum Arabic, each a drachm and a half; Cinnamon "Water, enough to make six fluidounces; mix. Dose, a tablcspoonful onco in three hours. In diarrhtta. lOi. Lead and Morphia Mixture. R . — Acetate of Lead, eight to sixteen grains ; Acetate of Morphia, one grain ; Gum Arabic, two drachms ; Cinnamon Water, enough to make eight fluidounces; mix. Take a teaspoonful every three or four hours. In obstinate diarrhoea. 105. Catechu, and Paregoric. R. — Tincture of Catecliu and Paregoric, each, half a fluidounce; mix. Take a teaspoonful every thi-ee or four hours, with water. In severe diarrhoea. 106. Tannic Acid and Opium. R . — Tannic Acid, thirty-six grains ; Powder of Opium, three to four grains ; mix, and divide into twelve pills. Take one every three or four hours. To check diarrhoea. 107. Calomel.! Soda., and Ginger. R. — Calomel, two grains; Bicarbonate of Sodium, one scruple; Powder of Ginger, twelve grains ; mix, and divide into twelve powders. Give one three or four times daily. In incipient cholera infantum. 108. Mercury with Chalk and Cinnamon. R. — Mercmy with Chalk, and Powder of Cinnamon, each twelve grains ; mix, and divide into twelve powders. Give one thrice daily. In the early stage of cholera infantum. 109. Ammonia, Bhubarb, and Paregoric. R. — Aromatic Spirit of Ammonia, twenty-five drops; Paregoric, half a fluidrachm to a fluidrachm; Spiced Syrup of Rhubarb, a fluid- ounce; Peppermint Water, enough to make two fluidounces ; mix. Give a teaspoonful every three hours. In cholera infantum. 110. Rhatany and Paregoric. R. — Tincture of Krameria, and Paregoric, each a fluidrachm ; Sugar and Gum Arabic, each half a drachm ; Cinnamon Water, diluted, enough to make two fluidounces ; mix. Give a teaspoonful every two, three, or four hours. To check the diarrhoea of cholera infantum. 52 614 FORMULA. 111. Blue Mass and Ipecacuanha. B . — Blue Mass, twelve grains ; Powder of Ipecacuanha, six to twelve grains; mix, and divide into twelve pills. Take one every three hours. In incipient dysentery. 112. Blue Mass, Ipecacuanha, and' Camphor. g.. — Blue Mass, eight grains; Ipecacuanha, six grains; Camphor, twelve grains; mix, and divide into twelve pills. Take one every three hours. In an early stage of dysentery. 113. Camphor., Ipecacuanha, and Opium. R.— Camphor, eighteen grains; Ipecacuanha, six grains; Opium, three or six grains; mix, and divide into twelve pills. Take one every three or four hours. In dysentery. 114. Acetate of Lead and Opium Pills. R.— Acetate of Lead, twelve to twenty -four grains; Opium, three to twelve grains ; mix, and divide into twelve pills. Take one every three or four hours. In dysentery. 115. Enema of Laudanum and Starch. Prepare half an ounce of Starch, thin enough to be drawn into a small syringe ; add from twenty to sixty or more drops of Laudanum, according to the case; mix, and inject into the bowel. In severe dysentery, retention of urine, very painful hemorrhoids, etc. 116. Enema of Sulphate of Zinc and Laudanum, To four fluidounces of Flaxseed Tea, made without boiling, add forty drops of Laudanum, and from four to ten grains of Sulphate of Zinc; mix, and inject into the rectum. In obstinate chronic dysentery. 117. Quinine, Ipecacuanha, Camphor, and Opium. R. — Quinine, two scruples ; Camphor, two scruples; Ipecacuanha, ten grains ; Opium, ten grains ; mix, and divide into twenty powders (or pills). Take one every three or four hours. In asthenic malarious dysentery. 118. Ointment of Galls and Opium, R. — Powder of Galls, two drachms ; Opium, ten grains; Lard, one ounce ; mix. Apply as ointment. Eor piles. 119. Spermaceti Ointment and Opium,. R. — Ointment of Spermaceti, Ointment of Rose Water (Cold Cream) or Glyceramyl, an ounce ; Opium, ten grains ; mix. To be used as ointment. For piles. 120. Belladonna Ointment. R. — Extract of Belladonna, a drachm; Spermaceti Ointment, an ounce; mix. Use as ointment. For painful piles. FORMULAE. 615 121. Tannic AcAd Wash. R. — Tannic Acid, twenty to thirty grains ; Water, six ounces; dissolve. To be injected (cooled with ice) into the rectum for Heed- ing piles. 122. Soda and Sweet Spirit of Nitre. R. — Bicarbonate of Sodium, three drachms; Sweet Spirit of Nitre, six Huidrachms; Peppermint Watei", enough to make six fluidounces ; dissolve. Take a tablcspoonful three or four times daily, //i uric acid gravel. 123. Benzoic Acid and Soda. R. — Bicarbonate of Sodium, two drachms; Phosphate of Sodium, half an ounce; Benzoic Acid and Gum Arabic, each two drachms; Sweet Spirit of Nitre, lialf a fluidounce ; Peppermint Water, enough to make six fluidounces; mix. Take from a teaspoonful to a table- spoonful, occasionally. Iti gravel. 124. Ojnum Suppositories. R. — Opium, one or two grains; Cacao (Cocoa) Butter, a suflacient quantity ; mix, and introduce into the rectum. For painful hemorrhoids, dysmenorrhoea, irritation of the bladder, etc. 125. Belladonna Suppositories. R. — Extract of Belladonna, one to four grains; Cacao Butter, a sufficient quantity; mix, and introduce into the bowel. Ihr painful hemorrhoids, etc. 126, Benzoic Acid. R . — Benzoic Acid, two drachms ; Cinnamon Water, six fluidounces ; dissolve. Take a tablcspoonful thrice daily. In irritation of the bladder, incontinence of urine, etc. 127. Groton Oil. R. — Croton Oil, four drops; Crumb of Bread or Conserve of Roses, a sufficient quantity to make four pills; mix, and divide. Take one every four hours, until they operate. As a powerful cathartic, in rare cases. 128. Lead-ioater for the Eyelids. To a fluidounce of pure River, Well, or Spring Water, add one drop of Goulard's Extract of Subacetate of Lead. Apply this with a earners- hair pencil, to the outside of the lids, frequently. 129. Alum Eye-water. R.— Two to four grains of Alum; Water, one fluidounce ; dissolve. Drop into the eye from a quill or a hair pencil, once or twice daily. 130. Collyrium of Nitrate of Silver. R. — Nitrate of Silver, two to four grains; Distilled Water, one fluidounce; dissolve. Apply to the inside of the lids with a hair pencil, or drop between the lids. 616 FORMULA. 131. Atropia Solution for the Eye. R . — Sulphate of Atropia, two to four grains • Water, one fluidounce ; dissolve. Drop into the eye once or twice daily. To dilate the pupil; as in iritis. 132. Lotion for the Ear. B- — Glycerin and Warm Water, each half a teaspoonful; mix. Pour into the ear from a teaspoon (in preference to a syringe) twice daily. Ear otalgia, or irritation of the ear. 138. Olive Oil and Laudanum. Mix half a teaspoonful of warm Olive Oil with five or ten drops of Laudanum ; pour it into the ear. For earache. 134. Bromide of Ammonium,. R. — Bromide of Ammonium, two drachms ; Water, four fluidounces ; Aromatic Spirit of Ammonia, one fluidrachm ; dissolve. Take a des- sertspoonful thrice daily. In hysteria, etc. 135. Besin of Jalap. B . — Eesin of Jalap, one scruple ; divide into three parts. Give one every four hours till they operate. An active cathartic. 136. Podophyllum Pills. R. — Eesin of Podophyllum, two grains; Turkey Ehuharb, eight grains ; Oil of Anise, two drops ; divide into eight pills. Take one or two at once. Cathartic and cholagogue. 137. Strychnia. R. — Sulphate of Strychnia, half a grain; Conserve of Eoses, six- teen grains; mix, and divide into sixteen pills. Take one or two thrice daily. Cautiously, in many cases of paralysis. 138. Stimulating Liniment, R . — Oil of Turpentine, Spirit of Camphor, Water of Ammonia, and Olive Oil, each two tablespoonfuls ; mix well together, for external application. In chronic rheumatism, bruises, sprains, etc. 139. Sassafras Liniment. R . — Oil of Sassafras, two fluidrachms ; Water of Ammonia, a table - spoonful; Camphorated Soap Liniment, three fluidounces ; mix. Eor swelling of joints, etc. 140. Cod-liver Oil. R . — Cod-liver Oil, twenty-four drachms ; Alcohol, twelve drachms ; Essence of Peppermint, twenty-four grains; mix. Take a dessert- spoonful thrice daily. In phthisis, chronic rheumatism, etc. FORMULi^. 617 141. Enema of Castor Oil, Soap, and Molasses. Mix togetlier a tablespoonfiil of Oil, and the same of Molasses, with a pint of warm Water, in wliich a little Castile or good yellow Soap has been dissolved. Inject into the rectum with a syringe. To empty the bowels promptly. 142. Pliosphate of Iron. R. — Phosphate of Iron, one drachm; divide into twelve powders. Take one thrice daily, in water. A good chalybeate tonic. 143. Assufoetida Pills. R. — Assafoetida, one drachm; divide into twenty pills. Take one every two or three hours. For hysterical nervousness. 144. Solution of Morphia with Valerian. R. — Solution of Siilphate of Morphia (one grain to the fluidounce), and Fluid Extract of Valei-ian, each one fluidounce; mix. Take one or two teaspoonfuls, as required. In delirium tremens. 145. Pills of Opium, Camphor, and Hyoscyamus. R. — Opium, four to eight grains; Camphor, twelve grains ; Extract of Ilyoscyamus, a scruple ; mix, and divide into twelve piUs. Take one every three or four hours ; or, one or two at night. ^ good calmative- 146. Gallic Acid. R. — Gallic Acid, two drachms and a half; Syrup of Cinnamon, four fluidounces ; mix. Take a dessertspoonful every two, three, or four hours. As astringent, in hemorrhages, diabetes, etc. 147. Oil of Turpentine Mixture. R. — Oil of Turpentine, two to four fluidrachms; Compound Spirit of Lavender, half a fluidounce ; Laudanum, twenty minims ; Sugar and Gum Arabic, each two drachms; Water, enough to make six fluidounces; mix. Take a tablespoonful at once. In hemorrhages, typhoid fever, etc. 148. Glyceramyl. Mix together two drachms of Starch, and two fluidounces of Bower's or Price's Glycerin, cold ; heat gradually to about 240° Fahr., stirring all the time ; then let it cool. A very soothing local emollient, 149. Neutral Mixture. R. — Citrate of Potassium, two drachms; Lemon Symp, half a fluid- ounce; Water, three and a half fluidounces; mix. Dose, a table- spoonful every two or three hours, with one of water, in fever. The lemon syrup may be omitted without disadvantage, 52* 618 F O R M U I. JE . 150. Spiritus Minder eri with Nitre. 5t. — ^Liquor of Acetate of Ammonium, three fluidouuces and a half; Sweet Spirit of Nitre, half a fluidounce ; mis. Take a tablespoonful every two or three hours, with a little water. In typhoid fever. 151. Jalap and Squills. R. — Kesin of Jalap, half a drachm to a drachm; Squills, twelve grains to a scruple ; mix, and divide into twelve powders. Take one at once. As cathartic, in cerebral congestion, hydrocephalus, etc. 152. Sulphite of Sodium. g.. — Sulphite of Sodium, two to four drachms; Mucilage of Gum Arabic, six fluidounces ; mix. Take a tablespoonful every three or four hours. In zymotic diseases, as glanders, etc. 153. Assafoetida and Expectorants. g^ .—Syrup of Ipecac, two fluidrachms and a half; Syrup of Squills, three or four fluidrachms ; Mixture of Assafoetida, enough to make two fluidounces ; mix. Give one or two teaspoonfuls at once. In hooping-cough. 154. Belladonna Mixture. g: . — Extract of Belladonna, one grain ; Mucilage of Gum Arabic, two fluidounces; mix. Give one or two teaspoonfuls thrice daily. In severe hooping-cough. 155. Fluid Ext't-act of Hyoscyamus. g. — Fluid Extract of Hyoscyamus, half a fluidrachm ; Orange- flower Water, or Camphor Water, four fluidounces ; mix. Give from a teaspoonful to a tablespoonful, every three or four hours. In severe hooping-cough. 156. Cfhlorute of Potassium. R. — Chlorate of Potassium, two drachms and a half; Peppermint Water, four fluidounces ; dissolve. Take a tablespoonful every three hours. In diphtheria, ulcerated sore mouth, etc. 157. Chlorate of Potassium and Chloride of Iron. ^ .—Chlorate of Potassium, two drachms ; Tincture of Chloride of Iron, one fluidrachm ; Simple Syrup and Peppermint Water, each two fluidounces ; mix. Take a tablespoonful every three hours. In diphtheria. 158. Creasote in Glycerin. Dissolve four to eight drops of Creasote in two fluidounces of Glycerin, diluted with an equal bulk of Water. Use as gargle. 159. Quinine Pills. R. — ^Divide twenty grains of Sulphate of Quinine into ten or twenty pills. Take one as required. For intermittent fever, etc. FORMULA. 619 ICO. Sulphate of Cinchonia Solution. R. — Siilp?iate of Cinclionia, forty-eight grains; Aromatic Siil|)l)uric Acid (Elixir of Vitriol), a tliiidrachm and a half; Compound Tinc- ture of Cardamom, halt' atlmdounco; Peppermint Water, enough to make four tluidounces. Take' a teaspoonfid or two as required. For intermittent fever, etc. IGl. SiiJpliate of Cinchonia Pills. R. — Sulphate of Oiuchonia, two scruples; divide into twenty pills. Take one as required. As a tonic, or for intermittent. 1G2. Quinine and Iron Pills. R. — Sulphate of Quinine, a scruple; Pill of Carbonate of Iron (Vallet's Mass), a drachm; mix, and divide into twenty pills. Take one three or four times daily. An admirable tonic, after intermittent, etc. 163. Capsicum Pills. R . — Powdered Capsicum, a drachm ; divide into twelve pills. Take one every hour or two. In the chill of pernicious fever. 164. Calomel, Quinine, Camphor, and Opium. R. — Calomel, Quinine, and Camphor, each eight grains; Opium, two grains ; divide into eight pills. Take one every half hour, hour, or two hours. In pernicious fever. 165. Nitro-muriatic Acid, Nitre, and Camphor Water. R . — Xitro-muriatic Acid, half a fluidrachm ; Sweet Spirit of Nitre, half a fluidounce; Camphor Water, five and a half fluidounces; dis- solve. Take a tablespoonful every two or three houi-s. In low fevers. 166. Nitric Acid. R. — Nitric Acid, forty drops; Water, eight fluidounces; dissolve. Take one or two tablespoonfuls every three hours. In typhus fever. 167. Guaiacum. R. — Tincture of Guaiacum, two fluidounces. Take a teaspoonful thrice daily, in water. Por chronic rheumatism. 168. Nitre, Sulpjhur, and Guaiacum. R. — Nitrate of Potassium, an ounce and a half; Sulphur, an ounce; Guaiacum, half an ounce; add two nutmegs, and a half pint of mo- lasses ; mix. Take a teaspoonful or two at night. For chronic rheumatisin. 169. Iodide of Mercury. R. — Green Iodide (Protiodide) of Merciuy, twelve grains; Con- serve of Roses, a scruple ; divide into twelve or twenty-four pills. Take one twice daily. In syphilis. 620 FORMULiE. 170. I)onovan''s Solution. B . — Liquor of the Iodide of Mercury and Arsenic, half a fluidounce. Take from three to five drops twice or thrice daily. In secondary syphilis, obstinate cutaneous eruptions, etc. 171. Injection for Gonorrhoea, R. — Sulphate of Zinc, four grains; "Water, two fluidounces; dis- solve. Use once daily. 172. Injection for Gonorrhoea. R . — Solution of Subacetate of Lead (Goulard's) half a drachm to a drachm ; Water, four fluidounces. Use once daily. 173. Injection for Gonorrhoea. R . — Chloride of Zinc, two grains ; Glycerin and Water, each a fluidounce; dissolve. Use once daily. 174. Copaiba Mixture. R . — Copaiba, half a fluidounce ; Compound Spirit of Lavender, two fluidrachms ; Sugar and Gum Arabic, each two drachms ; Peppermint Water, enough to make six fluidounces. Take a tablespoonful thrice daily. In gonorrhoea. 175. Cuhehs Mixture. R . — Oil of Cubebs, two drachms ; Sweet Spirit of Nitre, half a fluidounce; Sugar and Gum Arabic, each two drachms; Peppermint Water, enough to make six fluidounces ; mix. Take a tablespoonful thrice daily. In gonorrhcea. 176. LugoVs Solution. R . — Iodine, six drachms ; Iodide of Potassium, a troyounce and a half; Distilled Water, a pint; dissolve. Dose, five or six drops, twice daily, in water. In scrofulous affections. 111. Glycerole of Zinc. R. — Oxide of Zinc, half a drachm; Bower's or Price's Glycerin, four fluidounces; mix. Apply externally, as an emollient. Shake before using it. 178. Cold Cream with Zinc. R. — Acetate of Zinc, two grains, dissolved in one fluidrachm of Rose Water; mix with one ounce of Ointment of Eose Water (Cold Cream). Apply externally, for erythema. 179. Lead Ointment. R. — Carbonate of Lead, four grains ; Glycerin, a fluidrachm ; Simple Cerate, one ounce ; mix. For chronic erythema, etc. F0RMULJ3. 621 180. Ghjccrole of Lead. 31. — Carbonate of Lead, oue draclun; Glycerin, fotir fluidounces; mix. As a local application for ophthalmia {to the outside of the lids with a hair pencil), inflamed hemorrhoids, erysipelas, periostitis, etc, 181. Ointment of Oxide of Zinc. R. — Oxide of Zinc, two dracLins; Lard, one ounce, mix. Apply locally, for eruptions on the face, etc. 182. Cohhicum and Ipecacuanha. R. — Wine of Colcliiciim Root, and Wine of Ipecac, each, two flui- drachms ; mix. Take twenty drops, in water, thrice daily. In pustular diseases of the sl:in. 183. Ointment of 8idphn,ret of Potassium. R . — Sulphide of Potassium, and Carbonate of Sodium, each, two drachms; Lard, two ounces ; mix. For tinea capitis, etc. 184. Sulphite of Sodium and Glycerin. R. — Sulphite of Sodium, two ounces; Glycerin, four fluidounces; Water, enough to make a pint ; mix. Use as lotion, in chronic diseases of the skin. 185. Stimulating Embrocation. R . — Aromatic Spirit of Ammonia, Spirit of Rosemary, and Glycerin, each a fluidounce ; Tincture of Cantharides, three fluidrachms* Rose Water, enough to make eight fluidounces; mis. For the scalp, in premature baldness. 186. Cantharides and Castor Oil Pomade. R. —Balsam of Tolu, two drachms; Oil of Rosemary, twenty minims; Tincture of Cantharides, two fluidrachms; Castor Oil, four fluidrachms; Lard, an ounce and a half; mix. For premature baldness. 187. Ointment of White Precipitate. R. — Ammoniated Mercuiy, one scruple; Glycerin, a fluidrachm ; Oil of Bitter Almonds, three drops; Lard, or Simple Ointment, an ounce; mix. For acne rosacea, etc. 188. Iodide of Sulphur Ointment. R. — Iodide of Sulphur, one scruple; Lard, one ounce: mix. For army itch, etc. 189. Asti'ingent Powder. R. — Powder of Krameria, half an ounce; Prepared Chalk, two drachms ; Dry Starch, an ounce and two drachms ; mix. To be dusted on the skin in eczema, lichen agrius, etc. 622 FORMULA. 190. Juniper Tar Soap. R. — Oil of Juniper (Huile de Cade), Soft Soap, and Alcohol, each a fluidounce; mix. , Apply as local alterative, in obstinate skin diseases. 191. Anti-Pruriginous Lotion. R. — Oil of Juniper, and Alcohol, each a fluidounce; Water, six fiuidounces; mix. For itching of the skin in prurigo senilis, etc. 192. Acid Lotion. R. — Hydrochloric Acid, twenty drops; Water, four fiuidounces; dissolve. For obstinate itching. 193. Lotion of Blue Vitriol. B:. — Sulphate of Copper, six grains; Elderflower Water, two fluid- ounces; dissolve. Use as lotion for chronic erythema, etc. 194. Lotion of Corrosive Sublimate. g.. — Bichloride of Mercury, four grains; Alcohol, and Distilled Water, each a fluidounce ; dissolve. Infavus, etc., as parasiticide. 195. Astringent and Sedative Lotion. R . — Oreasote, eight drops ; Tincture of Krameria, two fluidrachms ; Hydrocyanic Acid, eight drops; Distilled Water, four fiuidounces: mix. In irritative and obstinate skin diseases. 196. Sedative Lotion. R. — Cyanide of Potassium, fifteen grains; Water, eight ounces; dissolve. Apply externally. It should be kept in a dark place. For lichen or prurigo. 197. Sidphuro-alkaline Ointment. R. — Two drachms of Sulphur; one drachm of Carbonate of Potas- sium ; one ounce of Lard ; mix. For itch. 198. Iodide of Potassium and Glycerin. R . — Iodide of Potassium, half an ounce ; Glycerin, two fiuidounces ; mix. Use as lotion. For scabies, army itch, etc. 199. Iodide of Potassium and Iodide of Sulphur. R . — Iodide of Potassium, half an ounce ; Iodide of Sulphur, a drachm ; Glycerin and Rose Water, each two fiuidounces ; Oil of Bit- ter Almonds, three drops; mix. For itch, etc. 200. Ointr)%ent of Carbonate of Potassium. R . — Carbonate of Potassium, one drachm ; Glycerin, one fluidrachm ; Lard, an ounce ; mix. For eczema, herpes, etc. FORMUI.iE. 623 201. Aloes Pills. R. — Powder of Aloes, one to two scruples: Oil of Cloves, four drops; mix, aiul divide into twenty pills. Take one twice or thrice daily. jFbr amenon-hnea. 202. Aloes and Iron. R. — Aloes, twenty grains; Quevenne's Metallic Iron (per hydrogen), half a draclnn; Oil of Cloves, three drops; mix, and divide into twenty pills. Take one thrice daily. I'or amenorrhcea. 203. Cav7phor, Lavender, Paregoric, and Ginger. R. — Spirits of Camphor, one fluidrachm ; Paregoric, two flui- drachms; Tinctiire of Ginger, half a fluidrachm; Compound Spirit of Lavender, half a fluidounce ; Water, enough to make two fluid- ounces; mix. Take a dessertspoonful every hour or two. In dysmenorrhcea. 204. Alum Lotion. R , — Alum, two drachms ; Water, eight fluidounces ; dissolve. Inject into the vagina, once or twice daily. For leucorrhcea. 205. Glycerole of Tannin. R. — Tannic Acid, one ounce; Glycerin, four fluidounces; mix, and dissolve by a gentle heat. Inject daily. For ozoena, gonorrhcea, or leucorrhcea. 20G. Santonin. R. — Santonin, half a drachm; divide into twelve pills. Take one twice daily. An excellent vermifuge. 207. Senna and Pink-Boot Infusion. R. — Leaves of Senna, and Eoot of Spigelia, each half an ounce; Boiling Water, a pint and a quarter; infuse, covered, for two hours. Take a wineglassful morning and night. A good vermifuge. 208. Fluid Extract of Senna and Spigelia. R. — Fluid Extract of Senna and Spigelia, a dessertspoonful ; take it in the morning, on an empty stomach. For worms. 209. Suppository of Santonin. R. — Santonin, twelve grains; Cacao Butter, a sufficient quantity to make four suppositories; mix, and divide. Introduce one into the bowel at bedtime. For seat-worm^, a very efficient remedy. 210. Corrosive Sublimate Lotion. R. — Corrosive Chloride of Mercury, a scruple; Water, four fluid- ounces ; dissolve. Use as a wash. To destroy lice. 624 FOEMUL^. 211. Coccidus Indicus. R. — Seeds of Oocculus Indicus, eighty grains; Prepared Lard, an ounce. Bruise the seeds well in a mortar, and mix with the lard. To destroy lice. 212. Carholic Acid and Glycerin. R. — Oarbolic Acid, one or two drachms; Glycerin, afluidounce; "Water, enough to make eight fluidounces ; mis. Use as a lotion. To destroy lice, or relieve pruritus. 213. Carbolic Acid Gargle. R. — Oarbolic Acid, twenty minims; Acetic Acid, half a drachm; Honey, two drachms; Tincture of Myrrh, two drachms; Water, enough to make six fluidounces. Mix together the acids first, and then, gradually, the honey and water. In diphtheria. 214. Carholated Glycerin. R. — One fluidounce of Oarbolic Acid (melted) ; nine fluidounces of Bower's or Price's Glycerin. Mix over a water-bath at 120° Fahr., stirring until incorporated. Use as injection, in ozosna, etc., diluted with ten or twenty times its bulk of water. 215. Hebra'^s Petroleum Unguent. R . — Petroleum and Alcohol, each one ounce ; Balsam of Peru, one drachm ; Oil of Eosemary and Oil of Lavender, each fifteen minims. To be applied externally. JFor itch. MISCELLANEOUS PRESCRIPTIONS. 216. Syrup of Iron, Quinine, and Strychnia. R. — Ferri Sulphatis, 5^; Sodii Phosphatis, 5'^]~SJi Quinige Sul- phatis, gr. cxcij ; Acidi Sulphurici Diluti, quantum suflicit; Aquae Ammonige, quantum sufiicit ; Strychnine, gr. vj ; Acidi Phosphorici Diluti, fgxiv ; Sacchari Albi, gxiv. Dissolve the sulphate of iron in one ounce of boiling water, and the phosphate of sodium in two ounces of boiling water. Mix the solutions, and wash the precipitated phos- phate of iron until the washings are tasteless. With suflicient diluted sulphuric acid, dissolve the sulphate of quinia in two ounces of water. Precipitate the quinia with ammonia water, and carefully wash it. Dissolve the phosphate of iron and the quinia thus obtained, and also the strychnia, in the diluted phosphoric acid. Then add the sugar, dissolve the whole, and mix, without heat. Dose, a tablespoonful thrice daily, in anmmia, chlorosis, leueocy- thcemia, etc. This is a favorite prescription with Dr. Aitken. 217. Chlorodyne. R. — Chloroformi fgss; ^theris Sulphurici, ^xc; Olei Menthse Piperitas, gtt. viij ; Resinge Oann-abis Indicas, gr. vj ; Oapsici, gr. ij. Mix, shake occasionally, and allow it to stand for a few days. Also Morphise Muriatis, gr. xvj ; dissolve by the aid of heat in f5ij of Water ; to which, when cold, add of Scheele's Hydrocyanic Acid, FORMULA. 625 trrjxv; Perchloric Acid, f^j; of Simple Syrup (or treacle), fgij. Add this gradually to the first mixture, and add enough water to make four fluidounces in all. Dose, thirty minims. A potverful narcotic, xvhose 'pretensions, however, have been exag- gerated. Dr. Edward Smith has given the following as the recipe for chloro- dyne : — R. — Chloroformi, f^iv; Morph. Muriat., gr. sx; yEther. Rectificat., f5ij ; 01. Menth. Pip., tr^viij ; Acid. ITydrocyan. Dilut., f5iv; Tinct. Capsici, f^yy, Mist. Acacifis, f gj . TheriaciB^ ad, fgv. 218. Dr. IIammond''s Alterative for Syphilis. R. — Potassii lodidi, 3j ; Hydrargyri Bichloridi, gr. vj ; Aquae, fo^ij ; misce. Take a tablespoonful thrice daily. In syphilitic rvpia, etc. 219. Ginchonated Syrup of Iron. R. — Ferri Phosphatis, 5J; Aquaj, fojss; solve. Cinchonia3 Sulphatis, 3j; Acidi Sulphuric! Diluti, gtt. xx. Aquo3, foJss; solve. Misce, et adde Syrupi Aurantii quantum sufEcit ut fiat mistura, fgiv. Dose, a dessertspoonful, as a tonic. 220. Antidote for Arsenic. R. — Liquoris Ferri Tersulphatis (U. S. P.), et Aqute Ammonias, aafgiv; Aquse, Oj ; misce. Pour this mixture into a small muslin bag, strain and wash it ; then mix the precipitate Avith half a pint of water. Give a tablespoonful every five minutes. 221. Compound Bhvharh Pills (U. S. P.). R. — Pulveris Radicis Rhei, gr. xxiv; Aloes, gr. xviij ; Myrrhte, gr. xij ; Olei Menthte Piperita, "Kij ; Aquee, q. s. ; misce bene, et divide in pil. no. xij. A good, active cathartic. 222. Compound Cathartic Pills (TJ. S. P.). R . — Extracti Colocynthidis Compositi, gr. xvj ; Extracti Jalapaa (pulv.), et Hydrargyri Chloridi Mitis, aa gr. xij; Gambogiffl, gr. ijss; Aqupe, q. s. ; misce, et divide in pil. no. xij. A decidedly active cholagogue cathartic. 1 Molasses. 53 2P 626 FORMULA. 223. Effervescing Solution of Citrate of Magnesium (IJ. S. P.). R. — Magnesii Carbonatis, 5v; Acidi Citrici, S'^ijss; Syrupi Limonis (vel Syrupi Acidi Oitrici), fgij; Aquae q. s. Dissolve the citric acid in four fluidounces of water, and add four drachms of the carbonate of magnesium, previously rubbed with three fluidounces of water. When the reaction has ceased, filter into a strong glass bottle holding twelve fluidounces ; into which the syrup has been introduced. Eub the remaining carbonate of magnesium with two fluidounces of water, pour into the bottle, cork quickly, and secure the cork with twine. Dose, from half a tumblerful to a whole bottle. The least disagreeable of all cathartic medicines. 224. Hope'' s Mixture. R . — AquEe Oamphorse, fgiv ; Acidi Mtrosi, ■njjxsx ; Tincturas Opii, TT^xx ; misce. Dose, a tablespoonful, every two or three hours. In, diarrhoea and asthenic dysentery. 225. Quinine and Chloride of Iron. R . — Quiniae Sulphatis, 9j ; Tincturse Ferri Ohloridi, f5ijss. Fiat solutio. Dose, fifteen drops, in solution. In diphtheria, asthenic erysipelas, etc. 226. Quinine for Children. R. — Quini* Sulphatis, 5ss; Pulveris Gummi Acacige, 5ss; Syrupi Zingiberis, f^iv; misce. Dose, a teaspoonful (one grain of quinine) or less, as requir^id, in intermittent, etc. 227. Effervescing Fever Powders. R. — -Acidi Oitrici, 5^; divide in partes xij. Virap each of these in a white 2)aper. R. — Potassii Bicarbonatis, 3vjss ; divide in partes xij. Wrap each of these in blue paper. For use, dissolve the acid powder in four tablespoonfuls of cold water in a tumbler, and add, with stirring, the other powder. One dose every two or three hours will be suitable in inflammatory or remittent fever, etc. 228. Liquid Substitute for Dover'' s Powders. R. — Vini IpecacuanhEe, ^xvy, Tincturfe Opii, ""Kxiij; Spirittis JEtheris Nitrici, f 5j ; misce. To be taken with water, at bedtime. For influenza, etc. 229. Soda Powders. R. — Sodii Bicarbonatis, gr. xxiij. R . — Acidi Tartarici, gr. xx. Dissolve each in four tablespoonfuls of water, separately ; then pour the solutions together, and drink while effervescing. Gring(H- syrup may be added if desirable. FORMUL-E. 627 230. Scudamore''s Gout Mixture, Modified. R. — Magnesii Sulphatis, gj; MagnesifB Optimre, 5ij; Vini Colchici Hadicis, £5.1 ; Aqn{T3 Menthas Piperitas, fgx. Misce. Dose, a tablespoonful every iiour until it operates, 231. Black Wash. R. — Plydrargyri Cliloridi Mitis, 5j ; Liquoris Calcis, fgiv; misce. Apply on lint. Apojjular lotion for chancre. 232. Yellow Wash. R. — Hydrargyri Chloridi Corrosivi, gr. xvj ; Liquoris Calcis, fgviij; misce. For Chancre. Apply on lint. 233. Volatile Liniment. R. — Aqu£B AraInoni^B et Olei Olivse, aa fgss. Misce. To bathe an inflamed throat, etc. 234. Iodine Ointment. R. — lodinii, 9j ; Potassi lodidi, gr. iv; Aqua3, ^tj^vj ; Adipis, 5J- Misce. For tumors, chronic inflammation of joints, etc. 235. Tar Ointment. R. — Picis Liquidse, et Sevi (vel Adipis), aa gij. Mix with the aid of heat, and strain through muslin. For tinea capitis, etc. 236. Glycerin Ointment. R . — Cetacei, gss ; Cerse Albse, 5j ; Ol^i Amygdalae Dulcis, f gij ; GlycerinfB, fgj. Melt the wax and spermaceti with the oil of almonds at a moderate heat ; put these into a mortar, add the glycerin, and triturate until cold. For chapped hands, etc. 237. Calomel and Carcphor Ointment. R. — Hydrargyri Chloridi Mitis, gr. viij ; Camphorse, 9j ; Glycerinse, f 5j ; Cetacei, gss; Adijiis, gjss. Misce. For lichen or herpes of the face, etc. 238. Sulphur Ointment. R. — Sulphuris, gj; Adipis, gij; misce. For itch, etc. 239. Lozenges for Hoarseness. R . — Pulveris Cubehoa, gss ; Aminonii Chloridi, gj ; Olei Eucalypti, f5.i ; Pulveris Glycyrrhizae, Sacchari Albi, et Gummi Acacise, aa 5iy j Syrupi Tolutani, q. s. Rub the powders thoroughly together, then add the oil, lastly the syrup. Divide the mass into lozenges of ten grains each. 240. Liquorice and Opium Lozenges (U. S. P.). R. — Opii Pulveris, gss; Glycyrrhizje, Gummi Acacise, et Sacchari AJbi, aa gx; Olei Anisi, f3j. Rub the powders thoroughly together, 628 FORMULA. then add the oil of anise, and lastly add enough water to form a mass. Divide into lozenges, each of ten grains. Like " Wistar's Cough Lozenges," these are very soothing to cough, when taken at night. 241. Shubarl), Magnesia, and Charcoal. R. — Pulveris Rhei Radicis, Magnesiaa Optimss, et Oarbonis Animalis Purificati, aa 5j ; Pulveris Zingiberis, 5ss ; misce. Divide into three parts, and take one each morning, on rising. For "biliousness," etc. 242. Iodide of Lead Ointment B ■ — Plumbi lodidi, 3j ; Adipis, gj ; misce. For scrofulous and other tumors, 243. Liniment of Iodide of Potassium. R . — Potassii lodidi, 5j ! Grlycerinse, f gj ; Tincturse Saponis Cam- phoratse, f giij ; Olei Limonis, gtt. iv ; misce. For swollen joints, etc. 244. Phosphate of Manganese. R . — Manganesii Phosphatis, 5j ; Acidi Phosphoric! Diluti, ttjJxxv ; Ferri Phosphatis, 5jss; Syrup Cinnamomi, fgj; Aquae, igvij; misce. Take a teaspoonful or two, thrice daily. For anaemia, hysteria, etc. 245. Stevens^ Saline Draught. B . — Sodii Ohloridi, Qiv ; Potassii Ohloratis, gr. xxviij ; Sodii Oar- bonatis, 5ij ; Aquge, f gyj ; dissolve. Take two or three tablespoon- fuls every half hour, as the "saline treatment" of cholera. 246. PadcUffe''s Phosphorus Pills. Take of Phosphorus, six grains; Suet, six hundred grains. Melt the Suet in a stoppered bottle capable of holding twice the quantity indicated. Put in the Phosphorus, and, when liquid, agitate the mixture until it becomes solid. Roll into three-grain pills, and cover with gelatin. Each pill will contain one thirty-third of a grain of phosphorus. 247. Trousseau'' s Syrup of Lime. Saturate Simple Syrup with unslaked Lime. Or mix two ounces of Lime and eight ounces of Sugar in a mortar, and pour over them a jiint of boiling Water. Take half a teaspoonful two or three times daily, in milk. For rheumatism. 248. To make a Sponge -Tent. Cut a small, elongated, conical piece of sponge, dip it in water, and bind it tightly, with fine strong twine or cord, around a central wire; then dry it, remove the cord, coat it with a mixture of equal parts of wax, lard, and glycerin, and fasten a piece of tape four inches long to the larger end.^ ' Or, before wettiDg the sponge, pass the tape through it, from end to end ; so that both ends of the tape may be used to withdraw the tent. FORMULA. 629 For uterine dilataHon, etc. Great care is necessary in its use. The dried stem of tlic sea-tangle (laiiiinaria digitata) is preferred for the same purpose by some practitioners; and strips of slippery elin bark by others. 249. Carbolized Sponge -Tent. Prepare a piece of clean sponge as above, and, before wrapping it, saturate it with a mixture of twelve grains of crystallized carbolic acid in an ounce of gum mucilage. Use as above. 250. Bichardson''s Stjiptic Colloid. Dissolve, in Absolute Aclohol, as much pure Tannin as it will take lip with several days' digestion. Then add enough washed Ether to make the thick tinctui-e quite fluid. Satui-ate this with Xyloidin or Gun-cotton. Lastly, add a few drops of Tincture of Benzoin. To be applied externally, for open cancer, hemorrhage, gangrene. 251. Styptic Colloid^ modified. Dissolve one di-achm of pure Tannin in as little Absolute Alcohol as will take it up, and then add. it to one fluidounce of Collodion. Use externally. In open cancer, hemorrhage, gangrene, etc. 252. Phosphorized Oil. Add two parts of Phosphorus to one hundred parts of Oil of Almonds; warm gently by a water-bath for twenty minutes in a bottle almost closed from the air; then cool and pour off. Dose, a portion equal to one-hundredth to one-fiftieth of a grain of Phosphorus. I7i locomotor, ataxy, neurasthenia, etc. 253. Phosphorus Pills. Take of Phosphorus, 2 grains ; Rice-flour, 200 grains ; White Soap, 250 grains ; Oil of Anise, and Glycerin, each 50 drops. Mix carefully, and divide into 100 pills. A powerful tonic, in nervous exhaustion. 254. Sir H. Thompson'' s Emollient Injection for the Bladder. Dissolve one ounce of Borax and two fiuidounces of Glycerin in two ounces of Water. Of this, for use, add. two or three teaspoonfuls to four fluidounces of warm Water. Inject into the bladder through a catheter ; in cystitis, or irritable bladder. 255. Brown- Siquard^s Prescription for Epilepsy. Take of Iodide of Potassium, one drachm; Bromide of Potassium, one ounce; Bromide of Annnonium, two drachms and a half; Bicar- bonate of Potassium, two scruples; Tincture of Colurabo, one fluid- ounce ; Water, five fluidounces ; dissolve. Dose, a teaspoonful, with a little water, before each meal, and three teaspoonfuls at bedtime. 256. Carbolic Acid. Mix eight grains of Crystallized. Carbolic Acid with two fluid- ounces, each, of Cinnamon Water and Mucilage of Gum Arabic. Dose, a tahlespoonful every three or four hours. 53* 630 FORMULA. 257. Hydrate of Chloral. Dissolve half an ounce of Hydrate of Chloral and twenty drops of Essence of Peppermint in four fluidounces of pure Glycerin. Dose, a dessertspoonful (two teaspoonfuls) with a tablespoonful of water. 258. Syrup of Lacto-Phospliate of Calcium. Take of Phosphate of Calcium, sixteen grains; Lactic Acid, thirty- three grains; Simple Syrup, a iluidounce. Mix. Dose, one or two teaspoonfuls, thrice daily. In rickets, etc. 259. Anti-pruriginous Lotion. Mix together two drachms of Borax, twenty grains of Hydrochlorate of Morphia, half a drachm of Hydrocyanic Acid, one fluidounce of Glycerin, and eight fluidounces of Rose Water (or Distilled Water). Use as a wash in pruritus vagince, etc. 260. Carbolic Liniment. Take of Carbolic Acid, one fluidounce ; Liniment of Camphor (satu- rated solution of Camphor in Olive Oil), three fluidounces. Mix well together. Apply with camel's-hair pencil. For neuralgia, inflamed corns, bunions, etc. 261. Lead, Carbolic Acid, and Glycerin. Take of Carbolic Acid, half a fluidounce ; Solution of Subacetate of Lead (Goulard's Extract), one fluidrachm; Glycerin, enough to make a four ounce mixture. Apply with a large camel's-hair pencil. For inflamed corns, bunions, etc. 262. Salicylic Acid. Take of Salicylic Acid, one drachm; Citrate of Ammonia, one drachm; Glycerin, two fluidrachms; Brandy, six fluidrachms. Dis- tilled Water, five fluidounces. Dissolve. Dose, one or two table- spoonfuls. For acute inflammatory rheumatism. 263. Liquor Fids Alko2inus, Take of Tar, two fluidrachms; Caustic Potassa, one drachm ; Water, five drachms. Mix together, and use diluted. For chronic eczema, etc. 264. Acid Syrup of Iron. Take of Tincture of Chloride of Iron, three fluidrachms; Dilute Phosphoric Acid, half a fluidoimce; Syrup of Lemons, three fluid- ounces. Mix. Dose, a dessertspoonful. An agreeable tonic, for ancemia, etc. 265. Meigs'' Aromatic Syrup of Galls. Take of Pialverized Galls, half an ounce; Pulverized Cinnamon, two drachms; Pulverized Ginger, half a drachm; Best Brandy, half a pint. Mix, and leave the mixture to stand in a warm place for two hours. Then burn ofi" the brandy, holding lumps of sugar in the flame. FORMULAE. 631 Strain tliroiij^li filtering i)ai)er. Dose, 15 to 40 drops every three hours. For infantile diarrhcea. 2GG. Squihb''s Cholera Mixture. Take of Laudanum, Tincture of Capsicum, and Spirits of Caniplior, each a Huidraclim; Ciiloroform, tliree tluidraclnns; Alcoliol, enough to make a tluidounce. Mix. Dose, 20 to 40 minims. 2G7. ChurchilVs Hypophosphites. Dr. F. Cimrohill recommends a formula, which he calls "Liquor Ferri Ilypophospliitis Compositus," and of which the following is the percentage composition: Ferrous hypo])hosphite .... 2.T7 Calcium hypophosphite .... 3.5 Sodium hypophosphite .... 3.5 Magnesium hypophosphite . . . 1.99 Hvpophosphorous acid .... 1.66 Water 86.58 100.00 One fluidrachm is equal to 6.7 grains of the mixed salts. In phthisis, etc, 268. Basham^s Mixture. Take of Liquor of Acetate of Ammonium, six fluidounces ; Acetic Acid, three drachms; Tincture of Chloride of L-on, iive drachms; Alcohol, two fluidounces; Syrup and Water, each four fluidounces. Mix. Dose, a teaspoonful three or four times a day. In ancemic dropsy, etc. 269, Four Chlorides (A. H. Smith). Take of Corrosive Sublimate, one or two grains ; Solution of Chloride of Arsenic, a fluidounee; Tincture of Chloride of Iron, and Dilute Hydi'ochloric Acid, each four fluidrachms; Simple Syrup, three fluid- ounces; Water, enough to make in all six fluidounces. Dose, a dessertspoonful, in water, after each meal. A poiver/ul alterative ; e. g., in chlorosis, ancemic syphilitic cases, etc. 270. Pills of Phosphorus, Iron, Quinine, and N'ux Vomica. Take of Phosphoras (for each pill) one hundredth of a grain ; PiU of Carbonate of Iron (Vallet's), two grains; Sulpliate of Quinine, one grain ; Extract of Nux Vomica, one quarter of a grain. To be taken thrice daily. A powerful nervine tonic. 271. Bla^id^s Pills of Iron. Take of Dried Sulphate of Iron, and Carbonate of Potassium, each two drachms; Simple Syrup, a sufficient quantit}^ to make a mass. Divide into 48 pills. One to be taken three or four times daily. 682 FORMULA. 272. Phosphorated Cod Liver Oil (Squibb). Take of Phosphorus, one grain ; Cod Liver Oil, ninety grains. Mix, with great care. Dose, one or two drops, in a tablespoonful of Cod- Liver Oil. 273. Phosphorus Mixture. Dissolve, with gentle heat, one grain of Phosphorus in five fluid- ounces of Absolute Alcohol. Mix together one fluidrachm of Essence of Peppermint, two fluidrachms of Alcohol, and a fluidounce and a half of Glycerin. Add this mixture to the Solution of Phosphorus in Alcohol, while it is warm. Dose, 20 to 30 minims. 274. Gregory'' s Powder. Mix together two ounces of Rhubarb with one ounce of Ginger and six ounces of Magnesia. Dose, about a teaspoonful ; as a stomachic laxative. 276, Compound Senna Powder (Blackwell). Take of Pulverized Senna, Washed Sulphur, and White Sugar, each half an ounce; Pulverized Fennel Seed, and Pulverized Liquorice, each two drachms. Mix. Dose, a teaspoonful. A moderate laxative. 276. Iodoform with God-Liver Oil. Take of Iodoform, four grains ; Cod Liver Oil, three ounces and a quarter (by weight) ; Aniseed Oil, twenty-five drops. Mix. Dose, from a teaspoonful to a tablespoonful. 277. Bitter Syrup of Iodide of Potassium. Take of Iodide of Potassium, one ounce; Tincture of Quassia, and Simple Syrup, each half a fluidounce. Dose, a quarter to a half a teaspoonful. 278. Iodide of Potassium with Digitalis. Take of Iodide of Potassium, half a drachm ; Tincture of DigitaHs, half a fluidounce; Syrup of Gum Arabic, four fluidounces. Mix. Dose, a dessertspoonful four times daily. In aneurism of aorta, etc. 279. Aloes with Nux Vomica. Take of Extract of Nux Vomica, five grains; Ipecacuanha, ten grains; Aloes and Assafcetida, each half a drachm. Mix, and divide into twenty piUs. One to be taken at night. For habitual constipation. 280. Colocynth and Nux Vomica. Take of Extract of Nux Vomica, ten grains; Pulverized Black Pepper, one scruple ; Compound Extract of Colocynth, two scruples. Mix, and divide into twenty pills. One to be taken at night. A tonic laxative, in obstinate constipation. 281. Quinine with Hydrochloric Acid (Fothergill). Take of Sulphate of Quinine, half a grain; Dilute Hydrochloric Acid, three drops ; Orange Syrup, twenty minims ; Water, enough to make two fluidrachms. Mix, for a single dose. In infantile remiite^it. FORMULAE. 6313 282. Quinine, Iron, and Chlorate of Potassium. Take of Siili)li!ite of (Quinine, lialf :i druclun ; Tincturu of Chloride of Iron, throe riuidrjichins; Clilorate of 'Potiisshiiu, four druchins; Simple Syriii), half a Huidouu'ce; Peppermint AVater, euougli to make in all two tinidouncos. I'ake a teaspoonj'al every three or four hours ; or half a teanpooiij'id every two hours. In malignant diphtheria. 283. Benzoale of Sodium (Letzerich). Take of Penzoate of Sodium, four scruples; Syrup of Orange, two and a half tiuidrachms; Peppermint Water and Distilled Water, each a tluidounce and a half. Mix. Dose, from a teaspoonf ul to a table- spoonful, according to age. In diphtheria, or scarlet fever. 284. Salicylic Acid with Acetate of Potassium. Take of Salicylic Acid, two drachms and two scruples; Acetate of Potassiiun, tivo drachms and one scruple; Glj^cerin, a tluidounce; Water, enough to make four iluidounces. Mis. Dose, a teaspoonful. In rheumatic fever. 285. Salicylic Acid with Bicarbonate of Potassium. Take of Salicylic Acid, three drachms; Bicarbonate of Potassium, six drachms; Water, two fluidounces. Mix. Dose, a teaspoonful • every three hours. In acute rheumatism. 286. Salicylic Acid with Citrate of Potassium. Take of Salicylic Acid, foui- drachms and four scruples; Citrate of Potassium, one ounce; Glycerin, four fluidounces; Alcohol, one fluid- ounce ; Cinnamon Water, enough to make eight ounces. Dose, a dessertspoonful. In acute rheumatism. 287. Salicylate of Sodium. Take of Salicylic Acid, three drachms ; Bicarbonate of Sodium, two drachms; Glycerin and Water, each two fluidounces. Mix. Dose, a tablespoonful every four hours. In acute rheumatism. 288. Salicylic Acid with Acetate of Ammonium. Take of Salicylic Acid, two drachms ; Solution of Acetate of Am- monium, and Water, each fom* fluidounces. Mix. Dose, a table- spoonful. In acute rheumatism. 289. Anti-emetic Mixture. Take of Dilute Hydrocyanic Acid, twenty drops; Compound Tinc- ture of Gentian, three tiuidrachms; Subnitrate of Bismuth, one drachm ; Aromatic Spirit of Ammonia, one fluidrachm ; Syrup of Ginger, a fluidounce; Water, two fluidounces. Mix. Take a dessert- spoonful at once. 634 FORMULA. 290. Soda Mint Mixture. Take of Bicarbonate of Sodium, one drachm ; Aromatic Spirit of Ammonia, two fluidrachms; Peppermint Water, four fluidounces. Mix. Take from a teaspoonful to a tablespoonful at once. 291. Carminative Mixture. Take of best Magnesia, one drachm ; Aromatic Spirit of Ammonia, forty minims ; Tincture of Assafoetida, a fluidrachm ; Essence of Pep- permint, fifteen di'ops; Syrup of Gum Arabic, a fluidounce; Water, enough to make four fluidounces. Dose, a teaspoonful to a table- spoonful. I'^or infants' colic, etc. 292. Bismuth, Pepsin, and Strychnia (Pepper), Take of Subnitrate of Bismuth, and of Pepsin, each a drachm and a half; Sulphate of Strychnia, one grain; Compound Tincture of Cardamom, enough to make in all four fluidounces. Mix. Take a teaspoonful thrice daily, in water. In atonic dyspepsia. 293. Nitromuriatic Acid loith Nux Vomica (Pepper). Take of Dilute Nitromui-iatic Acid, and Tincture of Nux Vomica, each half a fluidrachm ; Compound Tincture of Gentian, enough to make in all four fluidounces. Mix. Take a teaspoonful, in water, after each meal. In atonic dyspepsia. 294. Mercury with Iron (Otis). Take of Blue Pill two grains ; Dried Sulphate of Iron, one grain. One such pill to be taken twice or thrice daily. They should be omitted if signs of salivation appear. In ancemic cases of syphilis. 295. Iron and Nvx Vomica. Take of Tinctui-e of Chloride of Iron, and Tincture of Nux Vomica, each a fluidrachm; Water, a fluidounce. Dose, a tea- spoonful. 296. Compound Solution of Phosphoric Acid with Iron. Take of Phosphate of Iron, one-half grain ; Phosphate of Potas- sium, one-quarter of a grain ; Phosphate of Magnesium, half a grain ; Phosphate of Calcium, three grains; Syrupy Phosphoric Acid, six and a half minims ; Water, enough to make one fluidrachm : a single dose. To be taken thrice daily. For general debility, ancemia, etc. 297. Cantharides with Iron. Take of Tincture of Chloride of Iron, fifteen drops; Tincture of Cantharides, five drops. Mix. Take twice daily, in water. For sexual exhaustion and impotence. FORMULA. 635 208. Hua Vomica and Phosphorus. Tiike of Extract of Nux Vomica, a quarter of a grain; Phospliide of Zinc, one-sixth of a grain; Extract of Gentian, two grains. Mix, in a pill, to be taken twice daily. For impotence. 209. Iron ayul Digitalis with Phosphoric Acid.* Take of Tincture of Oliloride of Iron, a tiuidracbm and a half; Dilute Phosplioric Acid, two ttuidrachins; Tincture of Digitalis, one fluidraclun; Water, enough to make in all one tliiidounce. Mix tirst the Tincture of Chloride of Iron and Phosphoric Acid, and afterwards add the Tincture of Digitalis. Dose, half a teaspoonful to a tea- spoonful. In exophthalmic goitre, etc. 300. Quinine, Iron, and Nux Vomica. Take of Sulphate of Quinine, two scruples; Tincture of Chloride of Iron, four tluidrachms; Tincture of Nux Vomica, four fluidrachins; Hydrochloric Acid, half a tluidrachm; Simple Syrup, one fluidounce; Water, enough to make three fluidounces. Dose, a teaspoonful, thrice daily. In ancemia, neurasthenia, etc. 301. Iron with Chloride of Am^noniurn (T. G. Stewart). For each minim of Tincture of Chloride of Iron, add half a grain of Chloride of Ammonium. When iron does not agree with the digestive system. 302. Iron with Hydrochloric Acid (Fothergill). Take of Tincture of Chloride of Iron, five minims ; Dilute Hydro- chloric Acid, ten minims. Take, in water, three or four times daily. 303. Modified Dover''s Powder (Chisholm). Substitute the Bromide of Potassium, in equal quantity, for the Sulphate of Potassium, in the ordinary formula for Dover's Powder. 304. Chloral, Bromide of Potassium, and Opium. Take of Hydrate of Chloral, one drachm ; Bromide of Potassium, one drachm ; Laudanum, one fluidrachm ; Simple Syrup, half a fluid- ounce ; Cinnamon Water, enough to make two fluidounces. Mix. Dose, from a dessertspoonful to a tablespoonful, at night. For insomnia. 305. Valerian, Lupidin, and Lactucarium. Take of Tincture of Lupulin, a fluidounce ; Elixir of Valerianate of Ammonium, and Syrup of Lactucarium, each half a fluidounce. Mix. Dose, a teaspoonful or two, at bedtime. For insomnia, or nervous restlessness at night. * This makes an almost perfectly clear solution, which may be made entirely so by filtration. 636 FORMULA. 306. Bromide of Potassium and Hyoscyamus. Tale of Bromide of Potassium, half a drachm; Tincture of Hyos^ cyaraus, half a tluidrachm ; Camphor Water, a fluidounce. To be taken at bedtime. For chordee or spermatorrhoea. 307. Anaphrodisiac (Bartholow). Take of Tincture of Gelsemium, .one fluidrachm ; Tincture of Bel- ladonna, two fluidrachms. Mix. Dose, 15 drops, in water, thi-ice daily. 308. Chloral with Bromide of Potassium. Take of Hydrate of Chloral, five grains; Bromide of Potassium, twenty grains ; Peppermint Water and Simple Syrup, each two flui- drachms. Mix. Dose, from a teaspoonful to a tablespoonful. For nervous restlessness ; as night-terrors in children. 309. Nitre with Camphor and Ammonia. Take of Nitrate of Potassium, one drachm ; Sweet Spirit of Nitre, two fluidrachms; Camphor Water, a fluidounce and a half; Solution of Acetate of Ammonium, enough to make four fluidounces. Mix. Dose, a tablespoonful every three or four hours. A calmative diaphoretic. 310. Aconite with Nitre and Citrate of Potassium, Take of Tincture of Aconite Eoot, five minims; Sweet Spirit of Nitre, one fluidrachm; Citrate of Potassium, one drachm; Water., enough to make two fluidounces. Mix. Dose, a tablespoonful, every two, three, or four hours. A sedative diaphoretic. 311. Ipecacuanha with Nitre. Take of Nitrate of Potassium, one drachm ; Sweet Spirit of Nitre, two fluidrachms ; Wine of Ipecac, one fluidrachm ; Water, enough to make four fluidounces. Mix. Dose, a tablespoonful, every three hours. A good diaphoretic mixture. 312. A Sedative Diaphoretic. Tako of Wine of Antimony, five drops ; Tincture of Hyoscyamus, fifteen drops ; Solution of Acetate of Ammonium, half a fluidounce. Mix, and take every four or six hours. 313. Diuretic Pills. Take of Squills and Digitalis, each half a drachm ; Nitrate of Potas- sium, one drachm. Mix, and divide into thirty pills. Take one thrice daily. 314. Expectorant Mixture. Take of Chloride of Ammonium, two drachms ; Syrup of Senega and Syrup of Squills, each two fluidrachms ; Syrup of Wild Cherry Bark, a fluidounce ; Deodorized Tincture of Opium, half a fluidrachm ; Fluid Extract of Liquorice, two fluidrachms; Water, enough to make two fluidounces. Mix. Dose, one or two teaspoonfuls, every four hours. In chronic bronchitis. FORMULiE. (iol 315. A Calmative Expectorant. Tiike of riiloride of i\iiiiiioniiiin, two (Iracliin.s; nofrmann\s Ano- il.vne, six tiuidnu'lims; Synip. of Wild Cherry l^ark, a fliiidounce; ('iunplior Water, enough to iiiake two tiuidoiinces. Mix, Dose, a dessertspoonful. In chronic bronchitis, phthisin, etc. 316. Sedative Expectorant Mixture. Take of Acetate of Morphia, one grain; Tincture of Bloodroot (Sanguinaria), two fluidra<-Iims; Wine of Ipecacuanha, one fluidraclnn ; Fhiid Extract of Wild ('lierry Bark, lialf a tiuidounce; ttyrup of Senega, a tiuidounce and a half: Syrup of Gum Arabic, enough to make four tluidounces. Mix. Take from u dessertspoonful U) a table- spoonful every 8 or 4 liours. I'br bronchial cotir/h, etc. 317. Sedative Cough Mixture. Acetate of Morphia, six grains ; Cyanide of Potassium, one-fourth of a grain; Fluid Exti-act of Wild Cherry Bark, six tluidounces; Syrup of Tolu, two tluidounces. Mix. Take a teaspoonful at once. For irritative bronchial cough, etc. 318. Chloride of Amtnonium Mixture. Chloride of Ammonium (Muriate of xiniTnonia), two drachms ; Ex- tract of TJquorice, one drachm ; Vinegar of Opium, half a fluidrachm ; Syrup of Orange, two tluidounces; Distilled Water, four tluidounces. Mix. Take a tablespoonful thi-ee or four times daily. In chronic bronchitis. 319. For Troublesome Hooping- Cough, etc. Take of Hydrate of Chloral, a scrn[)le; Wine of Ipecacuanha, two fluidrachms; Orange Syrup, half a tiuidounce ; Mint Water, one fluid- ounce. Mix. Take a teaspoonful or two occasionally. 320. Lobelia and Hoffmann''s Anodyne. Take of Tincture of Lobelia, half a fluidrachm; Compound Spirit of Ether, two fluidrachms and a half; Camphor Water, five Hui- drachms. Dose, a teaspoonful. In asthma, etc. 321. Gallic and Sulphuric Acid Mixture (Pepper). Take of Gallic Acid, two drachms; Aromatic Sulphuric Acid (Elixir of Vitriol), one fluidrachm; Glycerin, a tiuidounce; Water, enough to make six fluidounces. Mix. Dose, a tablespoonful as required. For hremoptysis. 322. Spigelia, Senna, and Santonin (J. L. Smith). Take of Fluid Extract of Spigelia and Fluid Extract of Senna, each four fluidrachms; Santonin, eight grains. Mix. Dose, one or two teaspoonful s. Ati excellent vermifuge, 54 638 FORMULA. 323. Scammony and Cream of Tartar (G. Johnson). Take of Eesin of Scammony, five grains ; Bitai'trate of Potassium, twenty grains ; Ginger, eight grains. Mix. To be talsen at once. In urcemia. 324. Laxative Pills. Take of Resin of Podophyllum, two grains ; Extract of Hyoscy- amus, six grains ; Castile Soap, ten grains. Mix, and divide into 24 pills. Take one at night. 325. Laxative Pills. Take of Podophyllin, two grains; Exti-act of Nux Vomica, six grains; Aloes, twelve grains; Extract of Gentian, thirty-six grains. Mix, and divide into 24 pills. Take one at night. 326. For Diarrhoea. Take of Aromatic Sulphuric Acid (Elixir of Vitriol), two flui- drachms; Extract of Logwood, two drachms; Paregoric, half a fluid- ounce; Syrup of Ginger, enough to make six fluidounces. Mix. Take a tablespoonful at once. 327. Bismuth and Opium (J. L. Smith). Take of Deodorized Tincture of Opium, sixteen drops; Subnitrate of Bismuth, two drachms; Simple Syrup, half a fluidounce; Water, a tiuidounce and a half. Mix. Dose, a teaspoonful for a child one year old. In infantile summer diarrhoea. 328. Nitrate of Iron and Columho (J. L. Smith). Take of Solution of Nitrate of Iron, eighteen drops ; Tincture of Oolumbo, two fluidrachms; Simple Syrup, two fluidounces. Mix. Dose, a teaspoonful for an infant. In protracted infantile diarrhcea, etc. 329. For a Severe Cold in the Head. Take of Hydrochlorate of Morphia, one grain ; Subnitrate of Bis- muth, six drachms; Gum Arabic, in powder, two drachms. Mix. Use as snufE in the course of two or three days. 380. Benzoic Acid with Copaiba. Take of Benzoic Acid, four scruples; Sweet Spirit of Nitre, half a fluidounce ; Copaiba, four fluidrachms ; Sugar and Gum Arabic, each two drachms; Aniseed Oil, ten drops; Camphor Water, enough to make eight fluidounces. Take a tablespoonful thrice daily. In inflammation of the bladder, gonorrhoea, etc. 331. Carbolic Acid for Atomization. Take of Carbolic Acid, thirty-two grains; Glycerin, two fluid- ounces; Lime-water six fluidounces. Mix. To be sprayed into the throat. In diphtheria. FORMULA. 639 332. Carbolic Acid with Chlorate of Potassium (J. L. Smith). Take of Cjirbolic Acid, thirty-two tiraiiis; Chk)nite of Potassium, three t1iii(h-:ichms; (ilyoerin, , three thiidoiiuces; Water, five fluid- ounces. Mix. To he sprayed into the throat. In diphtheria. 333. SalirnUc Add for Alnmization (J. L. Smith). Take of Salicylic Acid, half a drachm; Glycerin, two fluidonnces; Lime-water, eifi;'ht tluidounces. Mix. To he sprayed into the throat. In diphtheria. 334. Gargle of Salicylic Acid (Letzerich). Dissolve fifteen fjrains of Sahcyhc Acid in thirty drops of Ahsolute Alcohol ; then dissolve this in eight fluidounces of Distilled Water. Use as gargle. In diphtheria. 335. Borax and Zinc Wash. Take of Borax, twelve grains; Sul])hate of Zinc, one grain; Cam- phor Water, a i^uidrachm; Distilled Water a fluidounce. To be applied to the eyelids. In ophthalmia of neiv-born infants. 330. Borax Solution. Take of Borax, three grains; Water, and Eose- water, each a fluid- ounce. Mix. To be applied to the cleansed conjunctiva. In ophthalmia neonatorum, early stage. 337. Atropia vnth Glycerin. Take of Sulphate of Atropia, one grain ; Glycerin, half a'fluidrachm; Water, two fluidrachms. Mix. To be dropped into the eye. Ii ophthalmia neonatorum, late stage. 338. Benzoin Gargle. Take of Componnd Tincture of Benzoin, two fluidrachms; Glycerin, half a fluidounce ; Water, enough to make four fluidounces. Mix. To be used as a gargle. In ulceration of the throat, fi'om syphilis or laryngeal phthisis. 339. Morphia Poivder (Lauder Brunton). Mix one grain of Sulphate of Morphia with twelve grains of Pul- verized Starch. Divide into six powders. One to be blown through a tube into the larynx. 1)1 laryngeal phthisis, or syphilitic sore throat. 340, Chlnrinated Soda with Borax. Take of Borax and Bicarbonate of Sodium, each two drachms ; Labarraque's Solution of Chlorinated Soda, a fluidrachm; Glycerin, a fluidounce ; Water, enough to make eight fluidounces. Mix. To be sprayed into tlie nostrils. In ozeena. 640 FORMULA. 341. Carholic Acid and Borax for Atomization. Take of Carbolic Acid, one grain ; Borax and Bicarbonate of Sodium, eacli two grains ; Glycerin, a fluidrachm ; Water, enough to make a fluidounce. Mix. To be sprayed into the nostrils. For chronic nasal catarrh. 342. Ap2:)licaUon for Chronic Nasal Catarrh (H. Allen). Take of French Gelatin, a drachm ; dissolve it in a small portion of "Water; then add to it, of Glycerin, ten drops; Pulverized Iodo- form, three drachms and a half; Carbolic Acid, five grains. Rub together into a smooth paste. To he applied to the nostril on a pledget of cotton. 343. Boracic Acid Wool (Woakes). Take of Cotton Wool, one drachm; Glycerin, ten minims; Boracic Acid, one drachm ; Alcohol, six fluidrachms. Mix, saturate the wool, and dry it. To be introduced into the nostrils. In chronic nasal catarrh, etc. 344. Ojjium Wool (Woakes). Take of Cotton Wool, one drachm ; Glycerin, ten minims ; Lauda- num, half a fluidounce. Mix, saturate the wool, and dry it. To be introduced into the nostrils. In painful nasal affections. 345, Perchloride of Iron Wool (Woakes). Take of Cotton Wool, one drachm ; Glycerin, ten minims ; Tincture of Chloride of Iron, one fluidounce. Mix the Glycerin with the Tincture, saturate the wool with the liquid, and dry it. To be intro- "luced into the nostrils. Z«i chronic nasal catarrh, ozcena, etc. 346. Zinc and Tar Ointment (Bulkley). Take of Tar Ointment, an ounce; Oxide of Zinc, two drachms; Cold Cream (Ointment of Kose-water), three ounces. Mix. For infantile eczema. 347. Ointment of Atropia with Opium and Iodoform. Take of Sulphate of Atropia, six grains; Opium, twelve grains; Iodoform, a drachm ; Vaseline, enough to make tlu-ee ounces. Mix. Apply externally. For painful piles, etc. 348. Iodoform and Tannic Acid (Sturgis). Take of Tannin and Iodoform, equal parts; triturate them well together. Apply the powder locally. For chancroidal ulcers. 349. Iodoform and Mercury Ointment. Take of Oleate of Mercury, half a fluidounce ; Iodoform, twenty- four grains ; Oleic Acid, a fluidounce. Mix. Apply externally. For swollen Joints, syphilitic eruptions, or parasitic affections of the skin. F O R M U L iE . 641 350. Chloroform with Vaseline. Mix top:etlicr equal parts of Cliloroforin, Etlicr, and Vaseline. An anodyne liniment, for contusions, sprains, chronic rJieuniatism, etc. 351. Lead Ointment (Ilebra). Mix together, with the aid of heat, three ounces and six scruples of Litharjre and fifteen ounces of Olive Oil; then add three fluidrachras of Oil of Lavender. A soothing unguent, in affections of the skin. 352. Ointment of Oleate of Zinc (Crocker), liul) tosjether an oimee of Oxide of Zinc and eip:ht ounces of Oleic Acid, and then leave the mixture to stand for two hours. Heat gently in a water-bath, and add, stirring, nine ounces of Vaseline. A soothing unyuent. 353. Liniment of Chloral and Cam^jhor. Pulverize an ounce of Gum Camphor, with aid of a few drops of rectified spirit. Mix this with an ounce of Hydrate of Chloral. When tliis mixture becomes liquid, add to it enough Glycerin to make six fluidounces. Apply locally. For neuralgia. 354. Croton Oil and Iodine. Take of Croton Oil, half a fiuidrachm; Ether, one fiuidrachm; Tincture of Iodine, two fluidrachms and a half. Mix. To be painted upon the skin with a camel's-hair pencil. A counterirritant, for chronic pleurisy, etc. 355. Liniment for Neuralgia. Take of Camphor, one ounce; Hydrate of Chloral, half an ounce; Chloroform, a'tiuidounce and a half; Soap Liniment, two and a half fluidounces. Apply externally. 356. Acid Lotion of Corrosive Sublimate. Take of Bichloride of Mercury, eight grains; Hydrochloric Acid, sixteen minims; Water, eight fluidounces. Mix. Apply as a wash. la lupiis. 357. Styrax and Sidplmr Ointment (Bulkley). Take of Styrax, one or two drachms ; Sulphur Ointment, three or four drachms; Simple Cerate, an ounce. Mix. Apply externally. For itch. 35R. Carhnlic and Hydrocyanic Acids, xoith Morphia. Take of Carholic Acid, twelve grains; Acetate of Morphia, eight grains; Dilute Hydrocyanic Acid, one fiuidrachm; Glycerin, a fluid- ounce ; Water, enough to make four fluidounces. Mix. To be applied locally. For troublesome pruritus. 359. Antipruriginous Ointment (Bulkley). Take of Tar Ointment, three drachms; Belladonna Ointment, two drachms; Tincture of Aconite Eoot, half a fluidraclim ; Oxide of 54* 2Q 642 FORMULiE. Zinc, a drachm; Ointment of Eose-water (Cold Cream), three drachms. Mix. Apply locally. 360. For Pruritus. Take of Camphor and Hydrate of Chloral, each a drachm ; Cold Cream (Unguent. Aquae Eos.), one ounce. Mix. To be applied locally (to a sound skin). 361. Antipediculous Wash (Bulkley). Eub well together one drachm of Caustic Potassa, two drachms of Carbolic Acid, and four fluidrachms of Water. For local application. To get rid of lice. 362. Sulphite of Sodium and Carbolic Acid (Morrison). Take of Carbohc Acid, half a drachm; Sulphite of Sodium, three drachms ; Water, six fluidounces. Mix. Apply externally. For poison-vine eruption. 363. Odorless Iodoform Ointment (Lindemann). Take of Iodoform, sixteen grains ; Balsam of Peru, thirty grains ; Vaseline, Lard, and Ointment of Glycerin, each two drachms. Mix. For external application. For scrofulous tumors, etc. 364. Zinc with Huile de Cade. Take of Empyreumatic Oil of Juniper (oleum cadini), of soft soap (sapo viridis), and of alcohol, each two ounces; Oil of Lavender, one fluidrachm. Mix. A stimulating ointment for alterative effect in shin diseases. 365. Vaseline and Lead-plaster (Piffard, Hebra). Take of Vaseline and Diachylon Plaster, equal parts. Dissolve and incorporate them together by aid of heat. Add a few drops of bei'- gamot (for odor). Apply externally. For eczema. 366. Corrosive Sublimate with Borax (Bulkley). Take of Bichloride of Mercury, eight grains ; Pulverized Borax, two drachms; Dilute Acetic Acid, two drachms; Alcohol, two fluid- ounces; Water, enough to make four fluidounces. Mix. Apply locally with hair pencil. For chloasma, or brownish discoloration of the face in spots or patches. 367, Iodoform Paste (Bronson). Take of Iodoform, one drachm ; Mucilage of Gum Arabic and Gly- cerin, each ten drops ; Oil of Peppermint or Oil of Cloves, one drop. Mix. For local application. For piles, etc. 368. Iodoform and Oxide of Zinc with Benzoated Vaseline. Take of Benzoated Vaseline (one ounce of Gum Benzoin to five ounces of Vasehne), one ounce ; White Wax, two drachms and a half ; EXPLOSIVK IMiARMACAL COMPOUNDS. 643 Oxide of Zinc, one ilriicliin and one scruple; Iodoform, two drachms. Apjjly externally. For irritated ulcers or severe irritation of the skin. 369, Ointment for Contusions. Mix one part of Iodoform with thirty parts of Lard or Vaseline. Apply locally with gentle friction. (A minim of Tincture of jMusk to au ounce will deodorize the ointment.) 370. Chloral and Camphorated Oil. Mix together one ounce of Hydrate of Chloral with four fluidounces of ■ Camphorated Oil (Olive Oil saturated with Gum Camphor). Hub in over affected muscles in trichinosis. 371, Carbolic Acid and Glycerin (Bill, Bergonzini). Mix together two parts of Carbolic Acid and one part of Bower's or Price's Glycerin. To be placed for five minutes in contact with the skin, as anaisthetic, before opening an abscess. 872. Lotion for Freckles. Take of Sulphocarbolate of Zinc, two drachms; Glycerin, three fluidounces; Alcohol, half a tluidounce; Rose Water (or Water), enough to make eight tiuidounces. Apply locally. 373. For Sore NipiDles. Take of Compound Tincture of Benzoin, a sufficient quantity. Apply it to the nipple with a camel's^hair pencil after each time of suckling. 374. For Sore Mpples. Take of Iodoform, one drachm; Glycerin, a fluidounce. Mix. Apply with a camel's-hair pencil. 375. Sup2')Ository of Ergot (Barker). Take of Aqueous Extract of Ergot, two scruples; Cacao Butter, one drachm. Mix, and divide into twelve suppositories. Introduce one into the rectum, twice or thrice daily. For menorrhagia or excessive leucorrhoea. 376. Antispasmodic Suppository. Take of Opium, eight grains; Camphor, half a drachm; Extract of Belladonna, three grains; Cacao Butter, enough to make six sup- positories. One to be used at night. In painful piles, i?}flammation of the bladder, etc. 377. Injection Brou. Take of Sulphate of Zinc, eight grains; Acetate of Lead, fifteen grains ; Tincture of Catechu, one drachm ; Laudanum and Water, each three fluidounces. Mix, and use for urethral injection in gonor- rhoea. EXPLOSIVE PHARMACAL COMPOUNDS. The following combinations of medicinal substances may ignite or explode, if agitated or warmed, as by can-ying about the person : 644 METEICAL PRESCRIBING. Iodine with soap liniment or camphor liniment ; chloride '^r iodide of ammonium with phosphorus, arsenic, oil of turpentine, olive or cod-liver oil ; concentrated solution of permanganate or of bichromate of potassium in alcohol ; nitromuriatic acid with alcoholic " essences " or alcoholic extracts; tannin with dry clilorate of potassium or hydro- chlorate of morphia; hypophosphite of calcium with chlorate of potassium and lactate of iron ; clilorate of potassium with catechu ; golden sulphuret of antimony with chlorate of sodium; tincture of perchloride of iron with chlorate of potassium and glycerin ; nitrate of silver with essence of bitter almonds ; oxide of silver in pills. METRICAL PRESCRIBING. Probably a generation may pass before it will become common to write prescriptions according to the metrical or decimal system. But that system has so much in its favor, and is so largely employed already in scientific works, especially upon the continent of Europe, that it is likely, in the end, to prevail. Every student will do well, therefore, to familiarize himself with it. For the immediate purposes of the practitioner, a few particulars only require to be kept in mind.^ Accurately stated, a gramme is equal to 15.45234874 grains, Apothe- caries' weight. A Kilogi'amme (1000 grammes) equals 2.679227 Troy pounds. A ciibic centimetre is equal to 16.231169 minims. A litre equals 1.056717 wine quarts. When the transition from our present system to the metrical has been fully effected, there will, of course, be no more difficulty than now, in regard to the most mimite precision with it in prescriptions. But, while becoming acquainted gradually with the new method, it may for a time be, with advantage, chiefly resorted to for combina- tions of medicines in which a small difference of amounts will not be important. This being understood, approocimative equivalency can be made available and convenient, as follows:^ A gram (adopting, as preferable, the English spelling) is ahout equal to 15 grains. A kilogram is about equal to 2|- Troy pounds (2J Avoirdupois pounds). A citbie centimeter is about equal to 15 minims. A liter is about a quart measure. It will be convenient also to remember that a meter is rather less 1\ yard (39.87079 inches) ; a yard is somewhat more than 9 decimeters; a decimeter is not quite 4 inches ; a centimeter is nearly f of an inch ; and a millimeter is somewhat less than -^ of an inch. From these approximations we may proceed to accept 4 grams as equal to a drachm, and 4 cubic centimeters as equivalent to ^fiiddrarJim. Instead of cubic centimeter, we may call it (A. B. Tajlor) Jiuigi^am. Then we have a simple statement : 15 grains, 1 gram. 4 grams, 1 drachm. 15 minims, 1 fluigrara. 4 fluigrams, 1 fluidrachm. 1 See Oldberg's " The Metric System in Medicine," Philada., 1881. METRICAL PRESCRIBING. 645 "Whence these rules follow : To convert (/ri/iiin into grams, or minimn into linigrams, divide ly 15. To convert grtinis into (/rains, or fluigrams into minims, multiply ly 15. To convert grams into drachms^ or fluigrams into Jluidrackms, divide To convert drachms into grams, oy Jluidrachms into fluigrams, mul- tiplji by 4. With a similar approximation (8 drachms being equal to one ounce) wo nuiy say : To convert ounces into grams, or fluidounces into fluigrams, multijjly by 30. To convert grams into drachms, or fluigrams mto fluidounces, divide ly 30. To prevent mistakes, it will be well to use capital letters for the metrical abbreviations in prescriptions : Gm for gram, fGm for flui- gram. It is actually unnecessary to employ any other terms in met- rical prescribing ; as all other differences may be expressed by decimal notation. Thus a grain (^ of a gram) is (approximately) .06 Gram; & minim (^ of a tiuiGram) .06 fluiGram. Half a Gram will be writ- ten .50 Gm ; half a fluiGram. .50 fGm ; etc. Tliere may be a convenience, however, sometimes, in speaking or writing of a deciGram {-^ Gram) and centiGram (^^ GramK It is important also to remember that a deciGram (dGm) is equal to 1^ grain; and /y of a fluiGram (dfGm) equals IJ minim. Roughly, a teaspoonful niay be counted as 5 fGm; a wineglassful, 75 fGm ; a fluidounce, 30 fGm ; four fluidounces, 125 fGm ; eight fluidounces, 250 fGm. It becomes, with the acceptance of these approximate equivalencies, a matter of simple calculation, to translate a prescription in grains and drachms, or minims and tiuidrachms, etc., into one of Grams or fluiGrams and their decimal subdivisions. It will, however, with most practitioners, be difficult to write metrical prescriptions with ease and confidence, until they have grown familiar with metrical doses. For an extended table of these, the reader may be referred to Dr. Oldberg's work' upon this subject. The enumeration on the next page of doses of some leading medicines may suffice for our present purpose. It will be observed that (with the exception of a few new remedies) the drugs named are such as are likely to be often used. Their metrical doses can thus, with practice, be rendered familiar. More- over, except tartar emetic, extract of belladonna, sulphate of morphia, extract of nux vomica, pilocarpin and nitrate of silver, their doses are not usually less than a grain or a minim. Therefore, the approxi- mative character of such doses, already referred to, will not necessarily cause inconvenience. This will especially be the case, so long as the prescriber observes the important practical rule, to give, oi aW 2}otcer- fnl medicines, when^/frsi administered to a patient, the smallest doses likelv to have sufficient cftect. 1 The Metric System iu Mediciae, p. 127. 64:6 TABLE OF DOSES. TABLE OP DOSES. Medicine. Acid, Nitro-muriatic, ^ther, Nitrous, Spirit of j3llther, Oomp. Spirit of, Aloes, Ammonium, Carbonate, Ammonium, Chloride, Antimony and Potassi- um Tartrate Assafoetida, Belladonna, Extract, Bismuth, Subnitrate, Camphor, Camphor, Spirit, Catechu, Tincture, Chloral, Hydrate, Chloroform, Colchicum Root, Wine, Creasote, Digitalis, Tincture, Ergot, Wine, Hyoscyamus, Extract, Iron, Chloride, Tincture, Jaborandi, Jaborandi, Fluid Extract Jalap, Eesin, Kino, Tincture, Lactucarium, Syrup, Lead, Acetate, Lobelia, Tincture, Morphia, Sulphate, Nux Vomica, Extract, Nux Vomica, Tincture, Oil, Cod-Liver, Opium, Opium, Tincture, Pilocarpin, Potassium, Arsenite, So- ' lution. Potassium, Chlorate, Potassium, Iodide, Quebracho, Ehubai'b, Squills, Syrup, Silver, Nitrate, Wild Cherry Bark, Syrup Apothecaries' Weights or Measures. According to Metric System. 2 to 5 minims .1 to .5 fGm J to 1 fluid rachm 1 to 5 fGm ^ to 2 tiuidrachms 2 to 10 fGm 2 to 15 grains .1 to 1 Gm 2 to 5 grains .1 to .5 Gm 5 to 20 grains .3 to 1.5 Gm ^to J grain .0015 to .015fGm 3 to 10 grains .2 to .75 Gm |- to f grain !oi5 to .05 Gm 5 to 15 grains .3 to 1 Gm 1 to 10 grains .05 to .75 Gm 5 to 30 minims .3 to 2 fGm •| to 1 fluidrachm 1 to 5 fGm 5 to 30 grains .3 to 2 Gm 5 to 60 minims .3 to 4 fGm 10 to 20 minims .75 to 1.6 fGm 1 to 2 minims .1 to .2 fGm 10 to 20 minims .76 to 1.5 fGm ^ to 1 fluidrachm 2 to 4 fGm 1 to 4 grains .1 to .4 Gm 10 to 30 minims .75 to 2 fGm 5 to 60 grains .3 to 4 Gm J to |- fluidrachm 1 to 2 fGm 2 to 5 grains .1 to .3 Gm J to 1 fluidrachm 1 to 5 fGm 1 to 3 fluidrachms 5 to 12 fGm J to 3 grains .03 to .2 Gm l5 to 80 minims .75 to 2 fGm ito i grain .008 to .015 Gm 1^ to 1 grain .015 to .06 Gm 10 to 30 minims .75 to 2 fGm 1 to 4 fluidrachms 4 to 16 fGm i to 1 grain .008 to .05 Gm 5 to 20 minims .3 to 1.5 fGm J to f grain .008 to .05 Gm 2 to 10 minims .1 to .75 fGra 5 to 20 grains .3 to 1.5 Gm 5 to 30 grains .3 to 2 Gm- 10 to 45 grains .75 to 3 Gm 2 to 30 grains .1 to 2 Gm ^ to 1 fluidrachm 2 to 5 fGm J to 1 grain .015 to .05 Gm 1 to 2 fluidrachms 5 to 10 fGm '^ Approximately coxD.^&rBdi\ preferring, when practicable, for metrical doses, numbers divisible by 10 or 5. These doses are for adults. METRICAL PRESCRIPTIONS. 647 EXAMPLES OF METRICAL PKESCRIPTIONS. R. — Potass. Chlorat., 5 Gm. A(nue, (]. s. ut ft. 100 Gm. M. Dose, frt)ni a teaspoont'ul to a tablespoonful. R. — Vin. Ipecac, 5 fGra. Tiiict. Opii, 5 fGin. Sp. Ath. Nitr., 50 fGra. Syrup Sini])., q. s. ut ft. 100 fGra. M. Dose, a teaspoonful witli water. R.— Tinct. Aconit. Rad., 50 fGra. Sp. Ath. Nitr., 50 fGra. Liq. Potass. Oitrat., q. s. utft. 100 fGra. M. Dose, a tablesi^oonful. R.— Acid. SalicyL, 2 Gra. Aninion. Carb., 3 Gm. Cliloral. Hydr., 3 Gra. Syr. Simp., 50 Gra. Aqufe, q. s. ut ft. 100 Gm. M. Dose, a dessertspoonful. R.— Potass. lodid., 10 Gm. Syr. Ferri lodid., 20 fGra. Tinct. CalumbiB, q. s. ut ft. 100 Gm. M. Dose, a teaspoonful with water. R.— Potass. Bromid. 10 Gra. Tinct. Amnion. Valerianat, 20 fGm. Tinct. Lupulin, 30 fGra. Tinct. Digital., 30 fGra. Acjufe, q. s. ut ft. 100 fGm. M. Dose, a dessertspoonful. R .—Syr. Scill. et Syr. Ipecac, et Tinct. Opii Camph. et Glycerin, aa, ' 25 fGm. M. Dose, a teaspoonful. Brown Mixture. R.— Ext. Glych-rhiz., Sacch. et Acac. aa, Tinct. Opii Camph., Vin. Antiinon., Sp. Ath. Nitr., Aquas, q. s. ut ft. M. Dose, a dessertspoonful to a tablespoonful R. — Pulv. Jalapiie, Potass. Bitart., M. Dose, a teaspoonful. 3 Gra. 3 Gra. 12 fGra. 6 fGm. 3 fGm. 100 fGm. [iful. 20 Gm. 80 Gm. 648 ALIMENTS. R.— Pulv. Opii et Pulv. Ipecac, et Pulv. Gum Oamph. aa, 5 Gm. M. et div. in pil. no. 100. One to be taken at a time. R.— Pulv. Opii, 2 Gm. Acid. Tannic, 15 Gm. M. et div. in pil. no. 100. One to be taken at once. For Chancre (Bouchardat). R.— FerriPercHorid., 12 Gm. Acid. Citric, 4 Gm. Aq. Destillat., 24 Gm. M. Use as wash. For Epistaxis. R.— Ergotin, 2 Gm. Glycerin, 30 fGm. M. Inject 20 drops at once, liypodermically. ALIMENTARY PREPARATIONS. Toast Water. Cut a slice of stale bread half an inch thick, and toast it brown, without scorching. Pour over it a pint of boiling water ; cover closely till it cools ; then pour off and strain it. Bice Water. Take of rice, two ounces; water, two quarts. Boil it for an hour and a half, then add sugar and nutmeg to taste. Some prefer salt. An excellent drink in diarrhoea, dysentery, etc. Barley Water. Wash two ounces of pearl barley with cold water; put the barley in a pint and a half of fresh cold water, bring it to the boiling-point, and boil for twenty minutes in a covered vessel. Strain, sweeten to taste, and flavor with lemon juice and a little lemon peel. • (In some cases, the lemon had better be omitted. ) Boiled Flour. Tie up a quart of flour in a pudding bag, tightly ; put it into a pot of boiling water, and leave it there, boiling, for several hours (all day, or all night, will not be too long). Then take out the flour ball, and di-y it near the fire. Pee! off and throw away the thin outer poi-tion, and grate down the mass, with a nutmeg-grater, into a powder. One or two teaspoonfuls of this may be rubbed into a paste with a small portion of milk, then stirred into a pint of milk, which is to be scalded, i. e., just brought to the boiling-point, without being boiled. Useful in infantile cliarrhma, etc. To Keep Ice for the Sick. Cut a piece of clean flannel about eight inches square. Put this ALIMENTS, 649 over the top of a glass tumbler, pressing the flannel down to half or more of the depth of the tumbler. Then bind tiie Hannel fast to the tumbler with a tape or cord. When the ice has been i)ut into tliis ice-cup, lay upon it another piece of tlanuel, three or four inches square. It will keep thus for hours. Oatmeal Gruel. Boil a pint of water in a saucepan; when boiling, mix with it two tablespoonfuls of oatmeal (previously rubbed smooth with a little cold water), half a pint of milk, and a little salt. Let it then simmer for half an hour ; strain it through a hair-sieve, sweeten, and add a little uutmeg. A few raisins may be added before the boiling. Vegetable Soup. Put two potatoes, one tomato, and a piece of bread, into a quart of water ; boil it down to a pint. Then throw in a little chopped celery or parsley, and salt. Cover, and remove from the fire. Bread and Butter Broth. Spread a shce of well-baked bread with good fresh butter; sprinkle it moderately with salt and black pepper. Pour a pint of boiling water over it, cover, and let it stand a few minutes before use. Lime-water and Milk. Take of clear saturated lime-water and fresh milk, each a wine- glassful ; mix. Let a tablespoonful or less be taken at once. This will sometimes remain upon an irritable stomach which will retain nothing else. Chicken Broth. Clean half a chicken and remove the skin; pour on it a quart of cold water, and salt to taste ; add a tablespoonful of rice, and boil slowly for two or three hours; skim well, and add a little parsley. Panada. Cut two slices of stale bread, without crust; toast them brown, cut them up into squares of about two inches, lay them in a bowl and sprinkle with salt and a little nutmeg. Pour on a pint of boiling water, and stand to cool. Arrowroot. Mix a tablespoonful, or a tablespoonful and a half, with a little cold w^ater, till it makes a paste. Boil a pint of water, stir in the arrowroot, and boil it a few minutes. Sweeten with white sugar. Brandy, whisky, or wine may be added if necessary ; and half or all milk may be used instead of water. A little lemon- or orange-peel added before boiling will improve the flavor. Tapioca. Cover two tablespoonfuls of tapioca with a teacupful or more of cold water, and soak for two or three hours, or over night. Put it then into a pint of boiling water, and boil it until it is clear and of the desired consistence. Sugar, nutmeg, or wine, etc., may be added as required 55 650 ALIMENTS. Sago Jelly. Mix well together four tablespoonfuls of sago, tlie juice and rind of one lemon, and a quart of water. Sweeten to taste, let it stand half an hour, and boil it, stirring constantly, until clear. Then add a wineglassful of wine ; currant wine will do. Beef-tea. Chop a pound of lean beef into very small pieces, pour over it a pint or less of cold water, cover, and let it stand two hours by the side of the fire. Then put it on the fire and boil it for half an hour. Remove the scum, skim off all the oil drops, and salt to taste. Pour it off, but do not filter or strain it, unless through a coarse sieve. Oood 'beef-tea should have a rich Itroicn afpearance when stirred. Frozen Beef-tea. Place a convenient portion of beef-tea, in a bottle or other vessel, in an ice-cream freezer ; and freeze it as cream would be frozen in making ice-cream. This will be useful in protracted cholera infantum, etc. Farina Gruel. Mix two tablespoonfuls of farina with a quart of water, and let this boil until it becomes thick. Add a pint of milk and a little salt, and then boil for a quarter of an hour longer. Sweeten according to taste. Indian Meal Gruel. Stir a tablespoonful of Indian meal till it becomes smooth in half a teacupful of cold water. Then mix it well with a teacupful of boil- ing water, and boil it until it is sufficiently thickened. Salt or sweeten to taste. Bice Milk. Boil a tablespoonful of rice for an hour and a half in a pint of fresh milk, then rub it through a fine sieve. Add a full teaspoonful of sifted white sugar, and boil again for two or three minutes. Essence of Beef. Cut up a pound of lean beef into small pieces, put it into a pint bottle, without water, cork it loosely, and immerse the bottle to its neck in cold water in a stewpan. Bring the water to a boil, and let it boil for two hours. Then pour off (do not filter) the essence. Extract of Baw Beef. Out up good lean beef fiery fine, and put it with cold water (half a pint to a pound) in a bottle. Soak it for twelve hours, shaking it half a dozen times or more during that time. Then strain it off with pressure through a cloth ; or, better, pour it through a coarse sieve. Mutton or chicken may be treated in the same way. Oatmeal with Beef-tea. Mix a tablespoonful of oatmeal quite smoothly with two tablespoon- fuls of cold water. Add this to a pint of strong beef-tea, and heat to the boiling-point, stirring all the time. Boil for five minutes. Then remove from the fire, skim, and serve for use. ALIMENTS. 651 Roast Oysters. Place a dozen fresh oysters, in the shell (the shells should he spon- taneously closed if good), iL{)on a moderately strong? tire, and allow them to remain there until the shells hegin to open a little. Then remove them, open them at once, and serve them, with a little hhick pep[)er, and salt if they need it. This is the method of cooking oystei's most favorable to their digestibility. Liehvfs Broth. Chop half a pound of beef, mix it well with one drachm of table salt, four dro])S (ton would be better) of muriatic acid, and eighteen ounces <;f distilled water. Macerate for an hour, and strain tlirough a tine hair sieve. Dose, a teacupful. This contains the soluble con- stituents of the meat ; but not all its nutritive elements. Liehig''s Food for Infants. Mix together half an ounce of wheat flour, the same of malt flour, seven and a quarter grains of bicarbonate of potassium, and an ounce of water. Add tive ounces of fresh milk, and put the whole upon a gentle fire. When it begins to thicken, take it from the fire, stir it for fiv^e minutes, heat and stir again until it becomes quite fluid ; finally boil it for a short time. Filter through a sieve to separate the bran; it is then ready for use. It will keep for twenty-fom- hours. Its effect is slightly aperient. Camplin''s Bran Loaf for Diabetes. Take two or three quarts of wheat bran, boil it in two snccessive waters for ten minutes, each time straining it through a sieve, then wash it well with cold water (on the sieve), until the water runs off perfectly clear; squeeze the bran in a cloth as dry as you can, then spread it thinly on a dish, and place it in a slow oven. If put in at night let it remain until the morning, when, if perfectly dry and crisp, it will be fit for grinding. The bran thus prepared must be ground in a fine raiU, and sifted through a wire sieve of sufficient fineness to require the use of a brush to pass it through ; that which does not pass at first ought to be ground and sifted again, until the whole is soft and fine. Take of this bran-powder three Troy ounces ; three fresh eggs ; an ounce and a half of butter, and rather less than half a pint of milk. Mix the eggs with part of the milk, and warm the butter with the other portion; then stir the whole well together, adding a little nut- meg and ginger, or other spice. Just before putting into the oven, stir in, first, tliirty-five grains of bicarbonate of sodium, and then three drachms of dilute hydrochloric acid. Bake the loaf in a basin (well buttered) for an liour or rather more. Meigs^ Gelatin Food for Bifants. Soak for a short time in cold water a scruple (a jjiece two inches square) of prepared gelatin; then boil it in a half pint of water ten or fifteen minutes, until it dissolves. Stir into this (previously made into a paste with a little cold water), at the end of the boiling, a tea- spoonful of arrowroot ; also, from three to eight fluidounces (accord- 652 ALIMENTS. ing to the age of the child) of milk ; and, lastly, from half a fluid- ounce to two fluidounces of cream, and a moderate amount of loaf sugar. Egg Broth. Boil (after it has stood, mixed, half an hour) two ounces of pearl sago in half a pint of water, until it is smooth and thick. Beat the yolks of four fresh eggs with half a pint of cream ; then mix with the sago, and stir the whole well with a quart of boiling beef-tea, just poured off. A tablespoonf ul of whisky or, half a glass of Sherry wine may be added if required. Wine Whey. Boil half a pint of milk, and, while boiling, add a glass of Madeira or Sherry wine. Separate the curd, by straining through muslin or a sieve. Sweeten the whey to taste, and grate upon it a little nut- meg. Egg and Wine or Brandy. Beat up a raw fresh egg, and stir with it two tablespoonf uls of wine, or one of brandy. Sweeten or not, according to taste. Caudle. Beat up a raw egg with a wineglassful of Sherry, and add to it half a pint of hot gruel. Flavor with lemon-peel, nutmeg, and sugar. Milk Punch. Into a tumblerful of milk put one or two tablespoonfuls of brandy, whisky, or Jamaica rum. Sweeten, and grate nutmeg on top. Ferruginous Chocolate. Mix sixteen ounces of chocolate with half an ounce of carbonate of iron. Divide the mass into cakes of one ounce ejich. One may be dissolved in half a pint of hot milk, to be taken night and morning. Koumiss of Cow''s Milk. To a quart of cow's milk, add a teaspoonful of sifted white sugar, and a teaspoonful of brewer's yeast. Leave it to stand for some hours until fermented; then serve for use, or else put away in strong bottles, well corked. DISINFECTANTS. 658 DISINFECTANTS. The best preventives of infection are ventilation and cleanliness. No agencies can be made to take tbe place of these. Tbe following are the most available temporary aids in purification of insalubrious places : For disinfection of privies : sulphate of iron^ a pound dissolved in a gallon of water; or the same amount of chloride of lime may be thoroughly mixed in water. Common tar will deodorize a i)rivy (cxce[)t a slight odor of its own) very promptly. JJurnet's Li(juid consists of solution of chloride of zinc, twenty-five gi-ains in each Huidrachm of water. Of this a pint may be put into a gallon of water for use. For water-closets, bed-pans, etc., Labarraque's solution of chlo- rinated soda may be employed — a liuidounce to a quart of water ; or perviaiu/anate of potassium,''- ten gi'ains to a quart of water; or carbolic acid, twenty grains to the pint or quart. Chal tar possesses the virtues of carbolic acid in a dilute form. Fluid carbolic acid may be used diluted with 50 to 100 parts of water; or the impure acid, a fluidounce to a gallon of water. Common petroleum is not a bad dis- infectant. Tar is a very good one. Drinking-water niay be disinfected by the addition (after filtra- tion) of enough permanganate of potassium to render it just percep- tWAy pink in a strong hght. Boiling will render impure water much safer to drink. Articles of clothing", contaminated by discbarges, etc., from patients, if very bad, should be hurned. Otherwise, they should be boiled thoroughly ; or, at least, plunged into boiling water. Solution of permanganate of potassium (an ounce to three gallons of water) is sometimes used. Woollens and all clothing which cannot be washed, as well as bedding, should be exposed for several hours to a dry heat of from 2000 to 250° Fahrenheit. Occupied rooms and houses may be disinfected (besides ventila- tion) by diffusing in spray through the air Ledoyen's liquid (solution) of nitrate of lead, made by dissolving one pound of litharge in seven ounces of nitric acid and two gallons of water. Or, by placing in shallow vessels the solid chloride of lime (bleaching salt). Or, sprink- ling a solution of carbolic acid, 1 part to 100 of water. Fresh white- washing is beneficial to the air of a cellar. Charcoal and qtiicMime are absorbent (especially the former) of gases, and thus aid in purify- ing the air. They may be combined, as in what is called "calx pow- der." But the best way to disinfect an unhealthy or suspected house or room is, to burn in it, with closed doors and windows (all occupants of course being first removed) sitljihur ; to the amount of a pound and a half for every thousand cubic feet of space. Hospital wards may be disinfected (besides ventilation and cleans- ing) by Ledoyen's liquid, chloride of lime, bromine left exposed to the air in shallow vessels, or iodine, heated moderately. Emptying the I The crude permanganate is much cheaper than the crystallized, and will answer. 55* 654 DISINFECTANTS. wards, however, and fumigating them for several hours with burning sulphur, will be much more effectual. Heaps of filth, solid or semi-liquid, may be covered with charcoal, two or three inches deep, or with dry earth. Drains, ditch.es, and sewers may be disinfected with sulphate of iron, coal tar, chloride of lime, etc. A pound of good chloride of lime will suffice for a thousand gallons of running sewage. CMoralum and Salicylic acid are good antiseptics and disinfectants. On the subject of ozone as a disinfectant, the reader is referred to works on chemistry and hygiene. INDEX OF FORMULA. Agile. See Intermittent Fever. Alimentary preparation, page 648. Amenorrhoea, F. 201. 202, 271, 275, 279, 297. Anscraia, F. 23, 30. 33, 56. 71, 267, 2G9, 270, 271, 295. 296, 300, 301. 302. Angina Pectoris, F. 47, 48, 49, 278, 299, 300, 301, 304, 308. 320. Arsenical Poisoning, F. 220. (See p. 482.) Asthma, F. 18, 19, 20, 98, 153, 278, 314, 315, 316, 317, 320. Baldness, premature, F. 185, 186. Benzoate of Sodium, F. 283. Biliousness, F. 221, 222, 241, 290, 301. Boracic Acid, F. 343. Brain, congestion or inflammation of, F. 151. 221, 222, 311, 313, 323. Bronchitis, F. 1. 4, 13, 14, 15, 16. 17, 20, 239, 240, 314, 315, .316, 317, 318, 319, 320. Bunions, F. 260, 261. Carbolic Add, F. 256, 260, 261, 331, 332, 341, 342, 361, 371. Chloral Hydrate, F. 257, 304, 308, 319, 353, 360, 370. Chlorosis, F. 213, 267, 269, 271, 276, 296, 300, 301. Cholera, F. 91, 92, 245, 266. p. 410, note. Cholera Infantum, F. 107, 108, 109, 110, 265, 327, 328. Cholera Morbus, F. 99. 289. (See Vomiting.) Chorea, F. 22, 23, 32, 33, 34, 306. Colic. F. 74, 78, 79, 86, 87, 89, 90, 91, 93, 94, 96, 100. Constipation, F. 75, 76, 77, 82, 83, 84, 85, 95, 141, 221, 262, 275, 279. 280, 324, 325. Consumption. See Phthisis. Cough, F. 13, 14, 15, 16, 17, 19, 20. 35, 36, 240, 311. 314, 315, 316, 317, 318, 319, 320. Croup, F. 5, 24, 25, 26, 331, 333. Delirium Tremens, F. 144, 145, 304, 305, 308. Diarrhoea, F. 101, 102, 103, 104, 105, 106, 110, 265, 326, 327, 328. Dietetic formula, page 648. Diphtheria, F. 54, 55, 56, 1.56, 157, 158, 213, 225, 282. 283, 331, 332, 3.33, 334. Dropsy, F. 8, 10, 11, 12, 38, 39, 40, 268, 277, 313, 323. Dysentery, F. 97, 111, 112, 113, 114, 115, 116, 117. DvJ-menorrhoea, F. 124, 125, 203 303, 304, 305, 306, 376. Dyspepsia, F. 34. 71, 72, 73, 74, 75, 76 274. 275, 290, 292, 293, 295, 296. Earache, F. 133. Epilepsy, F. 254. Erysipelas, F. 5, 180, 184. Fever, F. 7, 149, 150, 165, 166, 227, 310, 311, 312. Gangrene of Lung, F. 2, 3, 152. Gastritis, chronic, F. 62, 63, 64. Glanders, F. 1.52. Gonorrhcea, F. 171, 172, 173, 174, 175, 205, 330 377 Gout! F. 37. 45, 47, 48, 49, 230. Gravel, F. 122, 123, 124, 125, 126. Haematemesis, F. 80. 81. Haemoptysis. See Spitting Blood. Hemorrhages, F. 146, 147. .321. (See p. 326.) Hoarseness, F. 5, 13, 14, 239. Hooping-cough, F. 19, 20, 98, 153, 154, 155, 305, 306. 315, 320. Hypertrophy of the Heart, F. 41, 42, 44. Hysteria, F. 22. 23, 134, 142, 143, 267, 270, 271, 272, 300, 301, 305. Influenza, F. 2, 13, 14, 15, 225, 309, 310, 311, 312. Insomnia, F. 22. 143, 144, 145, 256, 303, 304, 305, 306, 308. Intermittent Fever, F. 2, 159, 160, 161, 162, 226, 270. Iodoform, F. 276, 342, 348, 349, 363, 367, 368, 374. Jaundice, F. 21, 221, 222, 293, 294, 301, 324. Laryngitis, F. 1, 4. 5, 310. 311, 312. Leucocythajmia, F. 213, 269, 270, 271, 276, 302. Leucorrhoea, F. 204, 205, 328, 376. Lice, F. 210, 211, 212, 361. Neuralgia, F. 27, 28, 29, 162, 216, 217, 219, 271, 272. 276, 298, 304, 305, 306, 308, 350, a53, 355. Neurasthenia, 270, 271, 272, 273, 295, 296, 298, 300, 301, 302. Ophthalmia. F. 88, 128, 129, 130, 131, 335, 336, 337. Ozcena, F. 205, 329, 340, 341,342, 343, 344. 655 656 INDEX OF FORMULA. Palpitation, F. 66, 72, 90, 216, 292, 305. Paralysis, F. 34, 137, 138, 139. Pericarditis, Endocarditis, F. 4, 6, 7, 8, 9, 10, 310, 311, 312. Periostitis, F. 88, 180, 349, 351, 352, 363, 365. Peritonitis, F. 6, 7, 8, 9, 111, 113. Pernicious Fever, F, 163, 164. Phosphorus, F. 246, 252, 272. 273, 298. Phthisis, F. 30. 31, 32, 33, 35, 36, 140, 267, 276, 314, 315, 317, 318. Piles, F. 88, 118, 119, 120, 121, 124, 125, 347, 367, 376. Pleurisy, F. 1, 4, 6, 7, 8, 9, 10, 11, 278. 310, 311 312 313. Pleurodynia,' F. 27, 28, 29, 138, 139, 277, 303, 350, 353. 354. Pneumonia, F. 1, 2, 3, 4, 6, 7, 8, 310, 311, 312, 316. Poisons, page 482. Pyaemia, F. 2, 3, 132. Remittent Fever, F. 2, 7. 226, 310. Rheumatism, F. 37, 45, 46, 61, 79, 138, 139, 167, 168, 230, 243, 262. (See Salicylic Acid.) Salicylic Acid, F. 262, 284, 285, 286, 287, 288, 333, 334. Scarlet Fever, F. 7, 26, 149, 150, 151, 224, 255. 309, 310, 311, 312, 313. Scrofula, F. 30, 31, 32, 33, 176, 276. Sick Headache, F. 66, 74, 290, 292. Skin, Diseases of, F. 148, 177, 178, 179, 180, 181, 182, 183, 184, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 236, 237, 238, S46, 349, 351, 352, 356, 357, 358, 359, 360, 361, 363, 364, 365, 366, 367, 369, 372. Sore Mouth, F. 50, 61, 52, 53, 54, 57, 58, 59. Sore Nipple, F. 373, 374. Sore Throat, F. 5, 52, 54. 59, 332, 339. Spermatorrhoea, F. 22, 30, 33, 162, 807. Spitting of Blood, F. 80, 81, 146, 147, 321. (See p. 327.) Sprains, F. 138, 139, 350, 369. Syphilis, F. 61, 169, 170, 215, 231, 232, 269, 276, 294, 337, 348, 349. Tetanus, F. 257. (See p. 313.) Tonsillitis, F. 5, 60, 228, 310, 311, 312. Tumors, F. 234, 242, 363. Typhlitis, F. 87, 351, 352. Tvphoid Fever, F. 2, 7, 147, 150, 165, 309. Typhus Fever, 2, 7, 150, 165, 309. Ulcer of Stomach, F. 62, 63, 64, 80, SI. Vomiting, F. 63, 64, 65, 66, 67, 68, 69, 70, 289, 290, 291, 292. Worms, F. 206, 207, 208, 209, 322. (For Metrical Presckiptions, see pa^e 647.) GENERAL INDEX. ABDOMINAL diseases, physical diag- nosis of, 115. Abdominal dropsy. 406. traction, 28(), .'iuo. Abscess of the brain, 342. liver, 303. lung, 206. retro-pharyngeal, 262. Acarns foUiculoriim. 549, 585. Acetate of animoniimi, F.' 7. lead and opium pills, F. 114. lead pills, F. 41. morpnia for hypodermic use, 185. potassium, F. 8. Acetonsemia, 31. Acidity of perspiration, 93. urine. 179. Aclnesia, 95. Aconite 147; F. 310, 360. embrocation, F. 27. Acrodynia, 433. Acute phthisis, 231. softening of stomach, 203. yellow atrophy of liver, 307. Addison's disease, 533. Ad6nie of Trousseau, 525. j?r;gophony, 107. Aflections of alimentary system, 257. brain and nervous system, 335. heart and aorta, 239. kidneys and bladder, 315. liver. 301. respiratory system, 194. skin, .036. spleen, 314. Agoraphobia, 63. Ague. 433. cake, 314. Air, impure, promotive of phthisis, 232. Alarm, at night, in children, 378. Albuminuria, 83, 317. Alcohol injection in neuralgia, 394. in treatment of debility, 158. in urine, 79. Alimertary preparations, 648. Alimentation, hvpodermic, 187. rectal, 265, 267. Alison. 22. Alkalies in gout and rheumatism, 166. Alkalinitv of urine, 80. Aloes, F. 279. and iron, F. 202. pills, F. 201. rhubarb and belladonna, F. 85. Alopecia, 547. Alphos, 543. Alterative treatment, 109. Alum, brandy, and water, F. 59. eye-water, F. 129. lotion, F. 204. Amaurosis, 340. Amblyopia, 96. Amenorrhcea, 562. Ametropia, 593. Ammona^mia, 315. Ammonia mixture, F. 3. rliubarb and paregoric, F. 109. soda and morphia, F. 67. Ammoniated urine, 81, 315. Ammonio-ferric alum, F. 80. Amphoric sounds, 102, 109. Amyl nitrite, 27, 183, 250. Amyloid kidnev, 331. liver, 311. Analeptic treatment, 157. Analysis of urine, 76. Anaemia, 31, 518. progressive perniciou.s, ,519. Anaesthesia, 95, 284, 556. for diagnosis, 219, 284. Ansesthetics, 179. Anaphrodisiac mixture, F. 307. Anasarca, 405. Aneurism of aorta, 253. abdominal, 255. miliary of Charcot, 319. thoracic, 253. Angeioleueitis. 530. Angina pectoris, 250. Animism, 16. Ankle-clonus, 358, 368. Anodyne remedies, 163. Anorexia, 68. Anoxamia, 31. Anthelmintics, 578 ct seq. Anthrax, 532. Anthroijophobia, 63. Antidotal treatment, 164. Antidote for arsenic, F. 220. Anti-emetics, 265. Antilitliics, 165. Antimony as a remedy, 146. Antiphlogistic treatment. 141. Antipruriginous lotion, F. 191. Antipsorics, 165. Antipyretic treatment, 152. Antiscorbutics, 166. ' Antiseptic remedies, 107. Antisyphilitic treatment, 166. Anus, fissure of, 300. prolapsus of, 301. Aorta, aneurism of, 253. Aortic stenosis, 256. Aphasia, 384. Aphonia, 218. 1 F., Formula; p. 601 ct scq. 2R 657 658 GENERAL INDEX, Aphthse, 258. Apnoea, death by, 66. Apoplectic syncope, 248. Apoplexy, 348. Apomorphia, 186, 222, 375. Apparatus for examination of urine, 91. Appetite in disease, 68. Arachnitis, 335. spinal, 353. Arcus senilis, 96. Aretseus, 14, 18. Argyll-Robertson pupil, 369. Army itch, 558. Aromatics, etc., for colic, F. 89. Arrowroot, 649. Arsenic in anaemia, 518. Arsenical poisoning, 586. Arterio-capillary fibrosis, 321. Arthritis, 502. Artificial respiration, 590. Asarum for ascarides, 580. Ascarides, 580. Ascites, 406. Asclepiades, 15. Asphyxia, 590. Aspirator, pneumatic, 133. Assafoetida and expectorants, F. 153. mixture, F. 98. pills, F. 143. Asthenia, death by, 66. Asthenopia, 594. Asthma, 210. A.stigmatism, 593, 596, 599. Astringent and sedative lotion, F. 195. powder, F. 189. Ataxiee, 193. Ataxie locomotrice progressive, 368. Atelectasis pulmonum, 207. Atheroma, 349. Athetosis, 370. Atomization, 181. Atrophy, 45. of liver, acute yellow, 307. Atropia, F. 336, 347. for night-sweats, 236. solution for the eye, F. 131. Auscultation, 103. Autopsic inspection, 134. Aveling, apparatus for transfusion, 188. BABINGTON, the first laryngoscope, 119. Bacillus malariee, 436. Bacon, 15. Balancive remedies, 139. Baldness, 547. Barbadoes leg, 548. Barthez, 16. Basedow's disease, 250. Basham's mixture, F. 268. Battey's operation, 569. Beef essence. 650. raw, extract, 650. tea, 650. Belladonna, F. 359, 360, 377. mixture, F. 154. ointment, F. 120. suppositories, F. 125. Bell's disease, 399. Benzoate of sodium, 169, 235, 499, F. 283. Benzoic acid, F. 126. and soda, F. 123. for albuminuria, 322. Bergson's steam-inhaler, 181. Beriberi, ,522. in Japan, 522. Bernard, experiments of, 140. on liver-sugar, 327. Bibron's antidote, 589. Bichat, 16. Bigelow, 18, 23. Bile, agents increasing, in dogs, 302. in urine, tests for, 78. Bilharzia, 579. Bilious dysentery, 296. fever, 439. Billing on support and depletion, 156. Bismuth, pepsin, and strychnia, F. 292. Bites of serpents, 589. Bitters in debility, 157. Bladder, inflammation of, 333. Bland's pills, F. 271. Bleeding from the nose, 401. Blood, desiccated, 162. in disease, 70. Blood-corpuscles, counting, 71,, in urine, 83. Bloodletting, 142. authorities upon, 143. Blood-root, F. 316. Blood, spitting of, 402. vomiting of, 403. Blowing respiration, 104. 108. Blue mass and ipecac, F. 111. ipecac, and camphor, F. 112. Blue vitriol lotion, F. 193. Boerhaave, 16. Boracic acid, 344, 347, F. 335, 343. Borax, myrrh, etc., F. 52. Borelli, 16, 18. Bothriocephalus, 578. Bottger's test for sugar, 86. Bouchardat's bread for diabetics, 82S, Bougies, medicated, 512. Bowels, hemorrhage from, 404. inflammation of, 273. obstruction of, 284. Brain, abscess of, 342. ejections of, 335. exhaustion, 340. inflammation of, 335. softening of, 342. Bran loaf, Camplin's, 651. Bread and butter broth, 649. Breakbone fever, 432. Breath in fever, 26. temperature of, 74. Bright's disease, 317. Bromide of ammonium, 374. F. 134. of potassium, 163, F. 22, 254, 304, 306, 308. of sodium, 163. Bromine in epilepsy, 374. for rhus poisoning, 561. Bromo-camphor, 163. Bronchial dilatation, 214. sounds, 105, 107, 108. Bronchiectasis, 214. Bronchitis, 208. Bronchocele, 534. Bronchophony, 106, 107, Broussais, 17. Brown, 17. Brown-Sgquard, 17. Bucnemia tropica, 548. Buhl, resorption theory of tubercle, 40, Bulbo-nuclear sclerosis, 358. Bulging of the chest, 100, 253. Bulimia, 68. Bullse, .541. Burns and scalds, 562. GENEliAL INDEX. 659 CACHEXIA, 32. Cujiipiit oil, lf)7, 282. Calabur bciui in chorea, 383. in k'tunus, oSO. Calculu.s, '.tl. :i2l. California, clinuite of. 238. Ciilnuitivu rL'uicilie^, 1G3. Calomel powders, F. 09. and eamphor ointment, F. 237. and nitre, P. 25. ipecae. and nitre, F. 0. and opium pills, F. 80. opium, and tartar emetic, F. 9. quinine, camplior, and opium, F. 164. soda, and ginger, F. 107. Camman's double -stethoscope, 103. Camp fever, 4tJl. Camphor mixture, F. 103. ipecac, and opium, F. 113. lavender, paregoric, and ginger, F. 203. Camplin'.s bran loaf, 651. Cancer, 57. of kidney, 330. of liver, 312. of stomach, 267. Cancrum oris, 259. Cantharides and castor oil pomade, F. 18G. and iron, F. 2i)7. Capillary circulation in disease, 70. Capsicum pilLs, F. 163. Cap.sule of Glisson, inflammation of, 303. Carbolic acid as antizymotic, 168. doses of, note, 418, F. 2.55, 260, 261. formulae containing, F. 331, 332, 341, 358. 362, 363, 372. and glycerin, F. 212. inhalation of, 183. Carbonate of ammonium in urine, 81. of potassium and nitre, F. 37. ointment, F. 200. Carbuncle, 532. Cardamom and potassa mixture, F. 66. Cardiac exhaustion, 253. Cardialgia, 268, 271. Carey, Matthew, yellow fever of 1793, 453. Caries of the spine, 516. Carminative mixture, F. 78. anodvne, F. 90. for infants, F. 94. Carotid, ligature of, for neuralgia, 395. Castor oil and laudanum, F. 97. and spiced syrup of rhubarb, F. 96. Catalepsy, 375. Catalysis in di.sease, 29. Catarrh, chronic nasal, 215. epidemic, 432. summer, 213. Catarrhal croup, 221. Catechu and paregoric, F. 105. Cautery, actvial, 149. Cavernous respiration, 106. Cellular pathology, 19, 48. Celsus, 15. Cephalalgia, 97, 395. Cerate of carbonate of lead, F. 88. Cerebellar absce.ss. 312. Cerebral and spinal sclerosis, 355, Cerebritis, 3:j5. Cerebro-spinal fever, 457. meningitis. 457. Cerium oxalate. 210. Chalk mixture, F. 102. Chancroid, 507. Chapman, N., pathology of, 17. on phthisis, 228. Ohaulnioogra oil, 545. (;heloi(i, 553. (Ihemiater, 16. Chemical analysis of urine, 76, 91. Cliiun turiieiitine, 268. Chicken broth, 649. pox, 414. Chigoe. 585. Chilblain, 561. Child-bed fever, 476. Children, consumption in, 238. Chills and fever. V.i^i. Chloasma, 547, 560. Chloral, depression from, 163. formulae containing, F. 304, 308, 319, 332, 353, 355, 361, 371. • hydrate of, 163, F. 256. in urine, 87. Chlorate of potassium, F. 54, 156, 282. with iron, F. 157. Chloride of sodium in urine, 91. of iron, F. 57. Chlorides in prescription. F. 269. Chlorinated soda and glycerin, F. 57. Chlorodyne, F. 217. Chloroform, inhalation of, 179. and camphor, F. 100. Hottmann's anodyne, etc., F. 49. liniment, F. 28. mixture, F. 91. paregoric, Nos. 1 and 2, F. 92, 93. Chlorosis. 521. Choked disk, 123, 337. Cholaemia, 30. Cholecystotomy, 314. CholeiTi, 478. infantum, 291. morbus, 287. winter, 288. Cholestera^mia, 30. Cholesterin, 92, 281. Choluria, 79. Chorea, 382. Choreic spasm, 62. Chronic diarrhoea. 291. ga.stritis, 264. inflammation, 54. nasal catarrh, 215. pleurisy, 203. Chrysophanic acid, 543. Cider mixture, F. 40. Cinchonated syrup of iron, F. 219. Cinchonia in intermittent, 437. Cinchonization, 165. Circulation, symptoms affecting, 69. Circulatory organs, affections of, 239. Cirrhosis of liver, 309. of lung, 200. Citrate of iron, F. 23. magnesium solution, F. 223. Classification of diseases, 192. of remedies, 139. Clavus, 548. Clergyman's sore throat, 219. Climates for the consumptive, 237. Clitoridectomy, 375. Clonic spasm, 62. Club-foot, 371. Coarse crepitant rale, 109. Coca, 164. Cocculus Indicus, F. 211. in epilepsy, 375. Cod-liver pil, 157, F. 30, 104. 660 GENERAL INDEX, Cod-liver oil in phthisis, 233. and glycerin, F. 31. iron and quinine. F. 32. Colchicum in gout, 1G6. and alkalies, F. 46. and ipecacuanha, F. 182. and magnesia, F. 45. Cold applications, 141. baths in fever, 152, 471. cream with zinc, F. 178. Colic, 277. prevention of, 283. remedies for, 283. Collapse of lungs, 207. Collodion styptic, F. 250, 251. Colloid degeneration of liver, .311. Collyrium of nitrate of silver, F. 130. Color bli^idness, 600. of the skin in di.sease, 74. Colorado for asthmatics, 213. Coloring matters in urine, 77. Colotomy, 286. Coma, 97'. death by, 66. Compound cathartic pills, F. 222. rhubarb pills, F. 221. spirits of juniper, F. 11. Conclusions, general, in therapeutics,191. (Condylomata, 548. Congestion of kidneys, 315. of the liver, 301. Congestive fever, 445. Conjunctivitis. 343. Constipation, 272. Constructive antidotes, 165. Con.sumption, 227. Contro-stimulant treatment, 146. Convulsions, 379. Copaiba, F. 330. mixture, F. 17, 174. Cophosis, 347. Copper, protection against cholera, 490. Cord, spinal, iniiammation of, 353. softening of, 353. Corneitis, 344. Corns, 548. Corrigan's pulse, 70. Corrosive sublimate lotion, F. 194, 210. Coto, 290. Cough, 73. Countenance, expression of, in disease, 97. Counter-irritation, 149. Coup de soleil, 376. Cow-pox, 411. Coxalgia, 517. Oackle, 107. Cramp of stomach, 282. Cream of tartar and dandelion, F. 39. Creasote pills, F. 81. and glycerin, F. 58, 158. soda and morphia, F. 68. Crepitant rale, 107. Cretinism, 534. Croton oil, F. 127. chloral hydrate, 137. Croup, 220. Croupal catarrh, 221. Crusta lactea, 539. Cruveilhier's palsy, 366. Cubebs mixture, F. 175. Cullen, 18, 192. Cunisset's test for bile, 78. 4 Cupping, 145. Curara in hydrophobia, 388. Currie, cold affusion in fever, 152. Cutaneous affections, 536. Cyanide of potassium, F. 317. Cyanosis, 70. Cylindrot83nium, 485. Cystine, 82. Cystitis, 833. Cysts of liver, 313. of kidneys, 317. DAMIANA, F. 276. Dance, St. Vitus's, 382. Da Vinci, 13. Deafness, 347. Death in heart disease, 249. modes of, 66. Decubitus in disease, 93. Degeneration, 55. fatty, of the heart, 248. treatment of, 171. De Lebo, 18. Delirium, 97. tremens, 395. Dementia, 308. paralytic, 367. Demme, cranium-holder, 134. Demodex folliculorum, 549, 585. Dengue, 432. Depression, 156. of the chest locally, 100. Diabetes insipidus, 325. mellitus, 326. Diabetic sugar, tests for, 84. Diagnosis, physical, 98. Diaphoretics in fever, 157. Diarrhoea, 289. Diatheses, 192, 497. Dicrotous pulse, 70. Diet, In disease, 146. Dietetic formulse, 648. Dieulafoy's aspirator, 133. Digestibility of foods, 272. Digestive organs, affections of, 257. system, symptoms connected with,67. Digitalis, F. 42, 43. in heart-disease, 247. squills, etc., F. 38. with iron, F. 299. Dilatation, bronchial, 214. of the heart, 246. of OS uteri, 446. of Stomach, 264. Dimensions of the chest, 99. Diphtheria, 424. Diphtheritic paralysis, 364. Diplopia, 96. Dipsomania, 397. Disease, definition of, 25. Diseases, classification of, 192. Disinfectants, 653. Disinfection after autopsies, 137. Displacement of organs from effusion, etc., 109. Dissecting wounds, 530. Distomata, 579. Diuresis, 75. Diuretic pills, F. 313. Dochmius duodenalis, 580. Dogmatic medicine, 14. Donovan's solution, F. 170. Doses for inhalation, 183. in hypodermic meditation, 185. metrical, 646. Dracunculus, 584. Drainage in pleuritic effusion, 205. GENERAL INDEX. 661 Dropsies, 405. Dropsy of the head, SIO. Drowning, o'JO. Dry craclvle, 107. Dry sounds on auscultation, 104. ' Drysdale's t;ranular cell, -107. Duehenne's di.sease, 3(i7. Dumbness, feigncil, 2V\ Dysentery, 2!M. scorbutic, 506. Dysmenorrhcea, 5C4. Dyspepsia, 2(>8. Dysphagia, 68. Dysphonia. 219. Dyspntea, 73. Dysuria, 33i. EARACHE, ai6. Ear, inflammation of, tUO. Ears, sounds in, 96. Echinococcus, 577. Echo, metallic, 109. Eclampsia nutans, 379. Eclecticism, 15. Economic remedies, 139. Ecthyma, 512. Eczema, 538. Effervescence in urine, 81. Effervescing draught, F.65. fever powders, F. 227. Electricity as a remedy, 171. Electropuncture, 17-1. 256. Elephantiasis Arabum, 548. Grrecorum, 553. Elimiuative remedies, 139. Emaciation. 74. Embolism, 528. multiple, 243, 528. .Smmetropia, 593. Emphysema of lung, 207. Empirical medicine, 14, 20-23. Emprosthotonos, 386. Empyema, 203. vocal resonance in, 108, 201. Encephalitis, 335. Endocarditis, 242. ulcerative, 243. Enema of castor oil, etc., F. 141. laudanum and starch, F. 115. sulphate of zinc and laudanum, F. 116. Enteric fever, 464. Enteritis, 273. Entozoa, 576. Enuresis, 335. Ephelis, 547. Epidemic and sporadic inflammations contrasted, 151, Epilepsy, 372. Epistaxis, 401. Epi.synthetism, 14. Epizoa, 585. Equinia, 431. Ergophobia, 63, Ergot, as an antiphlogistic, 147. hypodermically, 187. in suppository," F. 276. Eruptions, medicinal, 536. Ervsipelas, 474. Erythema, 536. Erythromelalgia, 55. Ether spray to spine in chorea, 383. in tetanus, 386. Eucalyptus globulus, in ague, 43S. Exanthemata, 536. 56 Excito-secretory action, 62. Exclusivism, 175. Exhaustion, 157. of the hc'urt, 253. Ex-oi)htlialmic goitre, 2.50. E.xpansion of the chest, 99. Expectant medicine, 23. Expectoration, 74. Exi)iratory murmur, 105. Explo.sive pharmacal compounds, 643. E.xpression of tlie face in disease, 97. Extra-cardiac soiiffles, 115. Exudation, 50. Eyes, changes of in disease, 95. inflammation of, 343. Eyesight, e.xamiuatiou and correction. 592. FACIAL palsy, 360. Facies Hippocratica, 97. Famine fever, 455. Faradization, 171. Fatty degeneration of the heart, 248. embolism, 528 liver, 310. urine, 91. Favus, 558. Fawn-colored deposits in urine, 81. Febrifuge treatment, 151. Feeble respiration, 108. Feigned dumbness, 219. Felon, 531. Ferguson's .speculum, lis. Fermentation test for sugar, 86. Ferrier, 63, 361. Fever, cerebro-spinal, 457. cot, Kibbee's, 141. flood, of Japan, 475. intermittent, 433. malarial, 433. pathology of, 26. pernicious, 445. puerperal, 476. relapsing, 455. remittent, 439. scarlet, 415. treatment of, 151. typhoid, 464. typho-malarial, 448. typhus, 61. yellow, 449. Filaria medinensis, 584. newly discovered, 585. producing elephantiasis, 548. sanguinis hominis, 584. Fissure of anus, 300. Fleas, 585. Flood fever, of Japan, 475. Fluctuation, 115. Fluid extract of hyoscyamus, F. 155. Fluorescence in human blood, 165. Fluoric acid in goitre. 534. Follicular pharyngitis, 219, 261. stomatitis, 258. Food, digestibility of different kinds, 272. for the sick, 648. Forbes, Sir John, 18, 23. Formulee, 601. Foulis, ovarian cells, 407. Friction-sounds, loS. sounds of the heart, 115. Friederickshall water, 522. Frostbite, 561. Fungoid neoplasm, 551. 662 GENERAL INDEX. GALEF, 15. Galvanism as a remedy, 171. Gall-bladder, aff'ectious of, 314. puncture of, 314. Gallic acid, F. 146, 321. Galloping consumption, 231. Gall-stones, 92, 278, 280. impaction of, 278. Galls, aromatic syrup of, F. 321. Ganglia in Bright's disease, 321, Ganglio-therapy, 140. Gangrsena oris, 259. Gangrene of lung, 206. Gastric remittent, 264. Gastritis, 263. subacute, of children, 264. Gastrodynia, 271. Gastro-hepatic catarrh, 263. Gastrotomy, 286. General paralysis of insane, 367. pathology, 25. therapeutics, 138. vital condition, 98. Gentian and rhubarb pills, F. 73. and rhubarb, tincture, F. 72. rhubarb and blue mass, F. 74. Gheel, 400. Giant cells, 42. Gin liver, 309. Glanders, 431. Glaucoma, 124. Glioma, 343. Glisson's capsule, inflammation of, in cirrhosis, 309. Glosso-labio-laryngeal paralysis, 358. Glucose, tests for, 284. Glyceramyl, F. 148. Glycerin ointment, F. 236. and rose-water, F. 50. Glycerole of lead, F. 180. of zinc, F. 177. Glycosuria, 326. Gmelin's test for bile, 78. Goitre, 534. exophthalmic, 250. Gonorrhoea, 512. Gonorrhoeal ophthalmia, 344. rheumatism, 502. Gout, 502. treatment of, 166, 504. Gouty colic, 282. Gravel, 324. Graves's disease, 250. Gregorinoid haemoptysis, 402. Gregory's powder, F. 274. Grindelia robusta, 210, 212. Growths, morbid, 56. Guaiacum, F. 167. Guinea-worm, 584. Gums, signs of disease concerning, 67. lancing, 380. Gurgling, 109. Gurjun oil, 545. HEMACYTOMETER, 71. H^matemesis, 402, 403. Hematuria, 404. HEemophilia, 400. Hsemoptysis, 402. HsemorrhagisB, 554. Hsemorrhoids, 297. Harsh respiration, 108. Haschisch in hydrophobia, 388. Hay fever, 213. refuges from, 214. Headache, 97, 395. sick, 263, 396. Heart-clots, signs of, 249. Heart, dilatation of, 246. diseases of, 239. enlargement of, 247. exhaustion of, 253. fatty degeneration of 248. physicaA diagnosis of, 110. starvation, 253. Heatstroke, 376, Heller's test for bile, 78. Hemicrania, 392. Hemiopia, 96, Hemiplegia, 361. Hemo-ansesthesia, 390. Hemorrhage, 400. from bowels, 404. from kidneys, 404. from lungs, 402. uterine, 405. Hemorrhoids, 297. Hepatitis, 303, Hepatization, 195. Herpes, 540. Hiccough, 74. Hip-disease, 517. Hippocrates, 13, 14, 23. Hoang-nan, 545. Hob-nailed liver, 309. Hodgkin's disease, 525. Hoft'mann, 16. anodyne, ammonia, and soda, F. 47. anodyne, squills, and morphia, F. 36. Homoeopathy, 18. Hooping-cough, 422. Hope's mixture, F, 224. Hopije-Seyler, test for bile, 78. Hosack, 18. Hot-air bath, 175. Hot water in menorrhagia, 565. Humid crackling, 107. Humorali.sm, 18. Hunter. John, 16. Hunyadi Janos water. 270, 522. Hyaline casts, 183. degeneration, 55. Hybrid between scarlatina and measles, 420. Hydatids of kidney, 332. of liver, 313. of lung, 207. Hydrocephalus, 340. Hydrocyanic acid, F. 20. Hydronephrosis, 329. Hydropathy, 175. Hydrophobia, 887. Hydro-pneumothorax, 109, 201. Hygienic management of consumptioUj 232. HyperEEmsesthesia, 55. treatment of, 149. Hypersesthesia, 61. Hypermetropia, 593, 596, 597. Hypertrophise, 547. Hypertrophy, 44. of the heart, 247, Hypodermic medication, 183. Hypophosphites, F. 267. Hyposulphite of sodium, 168. Hysteria, 390. Hysterical paralysis, 363. Hystero-epilepsy. 391. Hysterotomy, 466. GENERAL INDEX. 668 TATROMEOIIANISM, 16. JL Ice, medicated, 418. Ice-cap, Ml, ;i;!H. Ichorhiuiairt, i>'.>.6. Ielitl>yo.sis, 448. Icterus, 305. Ileus, '>»i. Impetigo, 542. IiicoiUiueuee of urine, 335. liKluclive medicine, 24. 'jifantile paralysis, 371. remittent, ilM. Infants' colic, 280. Inllanmiation, 47. of bladder. 333. bowels. 273. brain, 335. bronchi, 208. ear. Mil endocardium, 242. eye, 343. kidney, 316. larynx, 217. liver, 303. lungs, 194. lymphatics, 530. mouth, 257. pericardium, 239. peritoneum, 275. pharynx, 2G1. pleura, 201. spinal marrow, 353. stomach. 263. tonsil, 260. trachea, 220. veins, 526, 528. remedies for, 141. Influenza, 432. Ingluvin, 271. In-growing nail, 531. Inhalation, 179. in phthisis. 237. Inhibitory action, 364. Injection for gonorrhoea, F. 171 , 172, 377. Brou. F. 377. of lung cavities, 237. Inoculation, introduction of, 411. of tubercle, 35. Insane, general paralysis of, 367. Insanity, 31)8. Insolatio, 376. Insomnia, 377. Inspection, 98. of the body after death, 131. Insufflator. 18(i. Intercostal neuralgia, 227. rheumatism, 226. Intermittent fever. 433. Intestinal hemorrhage, 404. obstruction. 284. Intussusception, 284. Inunction, 178. Iodide of iron, F. 33. of lead ointment, F. 242. of mercury. F. 169. of potassium, F. 61, 277, 278. of potassium and glycerin, F. 198. of potassium and iodide of sulphur, F. 199. of sulphur ointment, F. 188. Iodine, as counterirritant, 149. ointment, F. 234. Iodoform, 218, 267. 351. 426; F. 276, 342, :«7, 3 18, 349. .364. 368. 375. Ipecacuanlia and alum, F. 24. Iritis, 344. Iron, F. 294, 295. 296, 297, 299, 300, 301, 302, 328, *15. in antemia, 157. quinine and strychnia, syrup, F. 216. Irregularity of pulse, 70. Irritable uterus, 566 Irritation, 46. spinal, 354. Ischajmia, 32. Ischuria, 334. Itch, 557. TABORANDI, 204. J Jacksonian epilepsy, 372. Jail fever, 461. Jalap and squills, F. 151. Japan, beri-beri in, 522. cholera in, 484, 487. flood fever of, 475. Jaundice, 305. Juniper, infusion, F. 12. tar soap, F. 190. KAKKE, of Japan, 522. Keloid, 553. Keratitis, 344. Kerion, 449. Kibbee's fever cot, 141. Kidney, affections of, 315. cancer of, 330. congestion of, 315. hydatids of, 332. tubercle of, 331 . Kinesipathy, 177. Knowsley Thornton's ice-cap, 141, 338. Koumiss in phthisis, 234, 652. Kyestein, 91. LABIO-GLOSSO-PHARYNGEAL paral- ysis, 358. Lactic acid in croup, 223. Lacto-phosphate of calcium, F. 257. Laennec, 18. Language, theory concerning, founded on aphasia, 384. Laparotomy, 286. Lardaceous" liver, 311. Laryngitis, 217. Laryngismus stridulus, 219. Laryngoscope, 119. Lateral spinal sclerosis, 357. Lauder Bronton. pathology of angina pectoris, 250. Laurus nobilis, in ague, 438. Lead and morphia mixttire, F. 104. colic, 279. ointment, F. 179, 351. palsv, 365. water for the eyelids, F. 128. LeclanclnS cell, 172. Leeches, 145. Lepra, .543. Leprosy of the Bible, 545. report of College of Physicians, 545 Leucocythsemia, 524 Leucorrhoea. 566. Leuksemia, 524. Lice, 482. Lichen, 537. Liebig, 18. Liebig's broth. 650. food for infants, 6.50. Lime, syrup of, Trou.sseau's, F. 247. use of in croup, 225. 664 GENERAL INDEX. Lime-water and milk, F. 64. Lipsemia, 31. Liquid Dover's powder, F. 288. Liquorice aud opium lozenges, F. 2-10. Liquor picis alkalinus, F. 263. Lithia, in gout, ■117. Lithiasis, 324. Liver, abscess of, 303. acute yellow atrophy of, 307. afl'ections of, 301. aspiration of, 304. cancer of, 312. cirrhosis of, 309. fatty, 310. hydatids of, 313. pigmentary degeneration of, 308. syphilitic, 312. tubercle of, 313. waxy, 311. Lobelia, F. 320. and ipecacuanha, F. 18. Localization of brain lesions, 63, 361. Lock-jaw, 384. Locomotor ataxy, 368. Logwood, F. 326. Lotion for the ear, F. 132. Louis, 18, 24. Lozenges for hoarseness, F. 2.39. Lugol's solution. F. 186. Lumbricoid worms, 580. Lungs, diseases of, 194. Lupulin. F. 305. Lupus, 552. Lymph corpuscles, 50. inflammatory, 51. MACULiE, 547. Magnesia and ammonia mixture, F. 99. Maize, stigma, 334, F. 276. Malarial fever, 433. continued fever, 440. Maltine, 235. Manganese, phosphate of, F. 244. Mania, 398. a potu, 395. from bromides, in epilepsy, 307. MarSchal's test for bile, 78. Marriage of consumptives improper, 233. Massage, 177. Maumeni^'s test for sugar, 86. Maxims, therapeutic, 191. Measles, 419. German, 420. Mediate percussion. 101. Medicinal eruptions, 536. Medico-legal examinations, 137. Melancholia, 398. Melansemia, 32. Melasma supra-renal is, 533. Membranous croup, 221 . dysmenorrhoea, 564. Menilre's disease, 347. Meningitis. 335. cerebro-spinal, 457. spinal, 353. Menorrhagia, 565. Menstruation and its deviations, 93, 562. Mensuration. 99. Meutagra, 559. Mercurial palsy, 365. sore mouth, 260. Mercury in inflammation, 147. with chalk and cinnamon, F. 108, with iron, F. 294. Metallic tinkling, 109. Metamorphosis of tissue, retardation, 160. Methodism, 14. Methomania, 397. Methyl-aniline test, 55, 311. Metrical prescribing, 644. Miasmatic typhoid fever, 448. Microbes of typhoid fever, 467. Microphone, 103. Microscopic examination of urine, 82, 91. Miliary aneurisms, 349. Milk crust, 539. in disease, 162. -sugar in urine, 326. transfusion, 189. Millon's test for albumen, 83. Mitchell, J. K., fungous theory of fe- vers, 436. Moist sounds, 105, 107. Moles, 547. Moleschott, 18. Molluseum, 551. Monomania, 398. Moore's te.st for glucose, 86. Morbilli, 419. Morbus Addisonii, 533. Morell, 19. Morgagni, case of reflex paralysis, 364. Morphia with valerian, F. 144. Mosquitoes carriers of filariee, 584. Mouth, inflammation of, 257. Movement-cure, 177. Mucous disease, 530. rale, 107. Mucus in urine, 82. Muguet, 258. Mulberry calculus,. 92. 324. Multiple embolism, 243, 528. sclerosis, 359. Mumps, 422. Muriate of ammonium, F. 16. Muriatic acid and honey, F. 55. Murmur, vesicular, 105. Murmurs of the heart, 112. Musca: volitantes, 96. Muscular debility in disease, 94. Musk mixture, F. 19. Mustard bathing, 176. Myalgia, 227, 354, 501. Mycosis, 514. endocardii, 243. Myelitis, 353. Myocarditis, 242. Myopia, 593, 596, 598 Myxoedema, 523. ]VT.5:VUS, 547. l^ Nail, ingrowing, 531. Nasal, catarrh, chronic, 215. Naturalism, 17. Nausea, 68. Nearsightedness, 593, 596. 598. Nephritis, 316. Nerve-stretching, 370. 375, 395. Nervous system, affections of, 335, pathology of, 60. Nettle-rash, 537. Neural.gia, 392. cutis, 555. Neurasthenia. 63. Neurataxia, 390. NeuropathologJ^ 60. Neuroses, 193, 555. Neurotic theory of gout, 503. Neurotomy, 395. GENE It A L INDEX, 605 Neutral mixture, F. 149. Night terrors, 378. Nitrate of iron. F. 3'28. of potassium, F. 4. in inflammation, 147. pills, F. G2. silver in chronic inflammations, 150. solution, F. 20. urea, 8^1, 8ii. Nitre, F. 309, 310, 311, ,313. Nitric acid, F. 166. Nitrite of amyl, 27, 250, 374. 381, 387. Niti'oglycerin. 374. Nitro-miiriatic acid, F. 21, 293. etc., F. 105. Nosology, 192. Nummular sputa. 74, 228. Nurses' sore-mouth, 260. Nutmeg liver. 309. Nux vomica. F. 279, 293, 295, 298, 300. colocynth, and soap, F. 84. iron, and quinine, F. 71. tincture, F. 3-1. OBSTRUCTION of bowels, 284. Occipital pressure a cause of trismus nascentium, 385. Odontalgia, 395. CEdema of the glottis, 217. CEsoiihagus. stricture of, 262. Oidium albicans. 2.")8. Oil, for biliary calculus, 282. of cajuput, F. 79. turpentine mixture, F. 147. Oinomania, 3'J7. Ointment of galls and opium, F. 118. Oleate of mercury, 276. of zinc, F. 3-52. Olive oil and laudanum, F. 133. Onychia, .'i31. Ony.xis, 531. Oopliorectomv. 569. Ophthalmia, 343. Ophthalmoscope, 121, 337. Opisthotonos. 3,hlilis, 271. TyplxiiJ iL'ver, 404. jmt'Uiminia, I'Jl). suite in reiuittont fever, 440. Typlio-niularial lever, 44S. Tvplius lever, 4C1. Typical ranges of temperature, 131. DLCER of stomach, 266. of womb, r)()8. Ulcerated sore throat. 262. Ulcerative uudociivdilis, 243. Umbilical iuthimmation a cause of tris- mus neonatorum, 385. Ursemia, 315. Urates, 81, 88. Urea, excess of, 89. Uric acid, 82, 91. Urinary calculi, 91. Urine, symptoms connected with, 75. incontinence of. 335. retention of, 334. Urostcalith, 91. Urticaria, 537. Uterine hemorrhage, 404, 505. tumors, 569. iilcers, 508. VACCINATION, 411. Valerian, F. 305. Valves of the heart. 111. Valvular disease of the heart, 244. Van Helmont, 16. Varicella, 414. Variola, 409. Varioloid, 411. Va-seline, F. 350, 364, 866. Veins, infiammatiou of, 526, 528. pulsation of. 70. Venesection, 142. Venous circulation in disease, 70. Veratria ointment, F. 29. Veratrum viride, F. 44. Verruca, 548. Vertigo, 98. Ve.sicul£e, 538. Vesicular murmur, 105. Vesiculo-cavernous respiration. 106. Vibration of the walls of the chest, changes in, 100. Vibriones. 83. Vicarious hemorrhage, 404. Vigilance, morbid, 377. Virchow, 20. Vital condition, 98. Vitalism, 17. Vitality, depressed, its effect upon secre- tions, 91. Vitiligo, M7. Vitreous degeneration, 42. Vivi-section, ()1. Vocal resonance, 105, 107. Voice, loss of, 219. Volatile liniment, F. 233. Voltaic electricity, 171. Vomiting of blood, 402, 403. as a symptom, 68. remedies for, 265. WAKEFULNES.*^, 377. Walshe's pleximeter, 101. Warner's cordial and laudanum, F. 48. Warts, .548. Wasting palsy. 366. Water a remedy in fever, 151. Waxy liver, 311. Weight of organs of the body, 136. Westphal's symptom, 368. Whisper, modified, in auscultation, 107. White precipitate ointment, F. 187. spot of heart in soldiers, 242. Whitlow, 531. Whooping-cough, 345. Wild cherry and lactucarium, F. 35. bark, F. 316. 317. Wine of ipecacuanha, F. 5. Winter cholera, 288. fever, 199. Womb, hemorrhage from, 405, 565. Women, diseases of, diagnosis, 117. treatment, 562. Wood. H. C, theory of fever, 27. Woodward's student's microscope, 91. Woorara in hydrophobia, 388. Worms, 576. Wristdrop, 365. Writer's cramp. 361. Wiinderlich's pleximeter, 101. Wyman's apparatus for paracentesis, 205 XERODERMA, 544. Xylol in small-pox, 411. YELI.OW atrophy of liver, acute, 307. Yellow fever, 449. localities of, 450. Woodward's report on, 451. ■wash, F. 232. ZINC, F. 335, 340, 3.52, 300, 365, 369, 373. Zymoses, 192, 409. Zymosis, 29. Zymotic diseases. 409. treatment of, 167, THE END. 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