COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64120163 RC46 .H87 1 899 A compend of t 't^^^vlW :m-^K ,?;%'aii;:-:, ;■ .;: -^ •■,':.•; v' ,..:'.!Tt--r;" '^^■^.."v/.^- '^1 r^!;:i-;u'':i-'!t''n';.::i RL^LL Columbia (IlniDertfitp intljfCttpofitogork College of $i)P£;icinn£( anb ^urgeong Hibrarp Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.arGhive.org/details/compendofpractic1903hugh HUGHES' COMPEND OF PRACTICE SIXTH PHYSICIANS' EDITION. BASED O N RECENT MEDICAL LITERA TU RE Gould's Medical Dictionaries BY GEORGE M. GOULD, A.M., M.D. Editor " American Medicine " ; President, 1893-94, American Academy of Medicine The Illustrated Dictionary of Medicine, Biology, and Allied Sciences Including the Pronunciation, Accentuation, Derivation, and Definition of the Terms Used in Medicine and those Sciences Collateral to it: Biology (Zoology and Botany), Chemistry, Dentistry, Pharmacology, Microscopy, etc. With many I'seful Tables and numerous Fine Illustrations. Large, Square Octavo. 1633 pages. Fifth Edition, now ready. FaU Sheep or Half Dark-Green Leather, $10.00 ; -with Thumb Index, $11.00 / Half Russia, Thumb Index, $12.00, net The Student's Medical Dictionary. Illustrated ELEVENTH EDITION. NOW READY Including all the Words and Phrases generally used in Medicine, with their Proper Pro- nunciation and Definition, Based on Recent Medital Literature. With Tables of the Bacilli, Micrococci, Leukomains, Ptomains, etc., of the Arteries, Muscles, Nerves, Ganglia, and Plexuses ; Mineral Springs of the U. S., etc., and a very complete table of Eponyniic Terms and Tests. Small 8vo. 840 pages. Illustrated. Half Morocco, $2.50; Thumb Index, $3.00, net The Pocket Pronouncing Medical Lexicon Fourth Edition, Revised and Enlarged. Now Ready 30,000 Words Pronounced and Defined Giving the Pronunciation and Definition of the Principal Words used in Medicine and the Collateral Sciences, including Very Complete Tables of Clinical Eponymic Terms, of the Arteries, Muscles, Nerves, Bacteria, Bacilli, Micrococci, Spirilla, and Thernio- nietric Scales, and a Dose-list of Drugs and their Preparations, in both the English and Metric Systems of Weights and Measures. Arranged in a most convenient form for reference and memorizing. New Edition. The System 0/ Pronunciation tn this book is very simple. Thin 64mo. 838 pages. Full Limp Leather, Gilt Edges, $1.00 f Thumb Index, $1.25, net These books may be ordered through any bookseller, or upon receipt of price the publishers will deliver free to the purchaser's address. Full descriptive circulars and sample pages sent free upon application. 145,000 COPIES OF GOULD'S DICTIONARIES HAVE BEEN SOLD ■Z^/i7,^'a^ /-j^'/V, COMPEND PRACTICE OF MEDICINE BY DAN'L E. HUGHES, M.D., CHIEF RESIDENT PHYSICIAN', PHILADELPHIA HOSPITAL; PHYSICIAN-IN-CHIEF, INSANE DEPARTMENT, PHILADELPHIA HOSPITAL; LATE DEMONSTRATOR OF CLINICAL MEDICINE IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA, ETC., ETC. SIXTH PHYSICIANS' EDITION. THOROUGHLY REVISED AND ENLARGED. INCLUDING A SECTION ON MENTAL DISEASES AND A VERY COM- PLETE SECTION ON SKIN DISEASES. PHILADELPHIA : P. BLAKISTON'S SON & CO., IOI2 WALNUT STREET. 1903 Copyright, 1899, by P. Klakiston's Son & Co. WM. F. FELL & CO., rLECTROTYPERS AND PRINTERS, I230-24 SANSOM STREET, PHILADELPHIA. en Q. TO HIS ESTEEMED FRIEND AND TEACHER, 3". ^. ®a Costa, /llb.2)., PROFESSOR OF THE PRACTICE OF MEDICINE IN THE JEFFERSON MEDICAL COLLEGE, THIS COMPEND IS RESPECTFULLY DEDICATED BY THE AUTHOR. PREFACE TO SIXTH EDITION. The continued demand for the Compend of Medicine has en- couraged the author to make its sixth edition the most complete of any similar book. It was never intended that the Compend should in any way replace the text-books upon the practice of medicine, but, on the contrary, it was written to be an aid to the medical student, at a time when practical demonstrations and ward classes were the exception in the college curriculum. The book has, however, somewhat outgrown the original plan, and having met with considerable favor from physicians, the author has en- deavored to make it more useful to the profession without changing the arrangement which has made it so popular with the student, always keeping in mind, however, that it is a compend and not a treatise on medicine. The addition of the section on Mental Diseases has been kindly received, and has justified the statement in the preface to the fifth edition that no medical student's education should be considered as completed without some knowledge of insanity, the increase of which is the alarm of the closing hours of the century. D. E. H. CONTENTS. PAGE INTRODUCTION 9 FEVERS, 15 General Treatment of Fevers, 16 Continued Fevers, 17 Periodical Fevers, 39 Eruptive Fevers, , 51 DISEASES OF THE MOUTH, 68 DISEASES OF THE STOMACH 76 DISEASES OF THE INTESTINAL CANAL, 99 INTESTINAL PARASITES, 134 DISEASES OF THE PERITONEUM, 140 DISEASES OF THE BILIARY PASSAGES 147 DISEASES OF THE LIVER 151 DISEASES OF THE KIDNEYS , 159 DISEASES OF THE BLOOD 195 ACUTE GENERAL DISEASES 209 DISEASES OF THE RESPIRATORY SYSTEM, 244 DISEASES OF THE NASAL PASSAGES, 263 DISEASES OF THE PHARYNX, 269 DISEASES OF THE LARYNX 274 DISEASES OF THE BRONCHIAL TUBES 290 DISEASES OF THE LUNGS 316 DISEASES OF THE PLEURA, 346 DISEASES OF THE CIRCULATORY SYSTEM, 352 DISEASES OF THE NERVOUS SYSTEM, 401 vii viii CONTENTS. PACK DISEASES OF THE CEREBRAL MEMBRANES 402 DISEASES OF THE CEREBRUM 409 DISEASES OF THE SPINAL CORD, 449 DISEASES OF THE NERVES 475 GENERAL OR NUTRITIONAL DISEASES 484 MENTAL DISEASES 504 DISEASES OF THE SKIN 53i INDEX 611 COMPEND PRACTICE OF MEDICINE. INTRODUCTION. The Principles of Medicine constitute what may be termed Medical Science. The Practice of Medicine is the exercise of medical art, and embraces all that pertains to the knowledge of, prevention, and cure of the diseases which the physician is called upon to treat. Disease may be defined as any departure from the normal stand- ard of structure or function of an organ or tissue or in both com- bined : Organic disease, when associated with an organic change in the affected part ; Functional disease , when the abnormal phenomena are independent of any discoverable structural lesion. It is question- able whether alterations of function can occur without alteration in structure. The study of disease, whether organic or functional in character, is termed Pathology. Pathology is the science that treats of disease in all its aspects, and explains the origin, causes, clinical history, and nature of the various morbid conditions which may disturb the economy. The study of individual diseases constitutes Special Pathology, 9 10 PRACTICE OF MEDICINE. while llie study of the morbid conditions common to a greater or less number of diseases constitutes General Pathology. Nomenclature, or the naming of diseases, is a subdivision of gen- eral pathology. The real value of nomenclature applied to disease is that the name chosen shall express the morbid condition involved, and, if possible, its location. If the morbid condition be an inflammation, the suffix itis is added to the anatomical name of the part affected ; thus, if the disease be an inflammation of the peritoneum, it is \.&xrc\td peritonitis. If the morbid condition be catarrhal, such as a transudation or flux, the liquid escaping upon a mucous surface, the suffix rha'a is used ; thus, a catarrhal inflammation of the intestinal tract is termed diarrhoea and enterorrhcea. If the morbid condition be a flow of blood or a hemorrhage from a mucous surface, the suffix rhagia is used ; thus, a hemorrhage from the small intestines is termed enterorrhagia. If the morbid condition be pain without inflammation, the suffix algia is used. The various forms of neuralgias are examples ; for instance, neuralgia of the stomach is termed gastralgia. If the morbid condition be in the blood, the suffix (pmia is used. Thus, Anceviia is impoverishment of the blood ; Urcetnia, the morbid accumulation of urea in the blood ; Septicemia, putrid infection of the blood ; Pycemia, purulent infection of the blood. If the morbid condition be in the urine, the ending uria is used. Albuminuria, when albumin in the urine ; Hcematuria, when blood in the urine ; Oxaluria, when oxalates occur in the urine. If the morbid condition be a dropsical affection, the prefix hydro is added to the part affected. A dropsical accumulation in the perito- neum is termed hydro peritoneum. If the morbid condition be that of air in an unnatural part, the prefix pneuvio to the name of the part is used, as in pneutno thorax. If the morbid condition be an inflammation of the membrane investing the part inflamed, the prefix peri is used. Thus, an inflam- mation of the investing membrane of the kidney is termed perine- phritis. Inflammation of the connective tissue surrounding an organ is designated by the prefix /ara. Thus, parametritis for inflammation of the connective tissue about the womb. A termination in oma signifies a tumor, as in sarcoma or carcinoma. INTRODUCTION. 11 The su^x pathy is used to designate a morbid condition of a part, without indicating its particular character, an example being the use of the term e7icephalopathy. Morbid Anatomy, or pathological anatomy, a subdivision of pathology, is the study of the changes in the tissues and fluids of the body after death, appreciable either to the naked eye or with the aid of the microscope. Bacteriology is that division of science concerned with the study of bacteria, an important and developing etiological factor in the field of medicine and surgery. Histology is the study of the minute anatomy of the tissues and fluids of the body with the microscope and clinical chemistry. Haematology, or the science of the blood, its nature, functions, and disorders. Pathogenesis is the study of the origin and development of pathological processes or disease. Lesions {Icedo, to hurt) are appreciable anatomical changes. Etiology is that subdivision of general pathology which treats of the causes of disease. The knowledge of the cause of any mor- bid action is of value in the prevention, management, and removal of disease. The Causes of disease may be divided into internal, external, ordinary, specific, primary, secondary , predisposing-, and exciting. Examples of internal or intrinsic causes are those having their origin in the mind, such as prolonged mental application, intense or long-continued emotional excitement, long-continued mental depres- sion, and the possession of and concentration upon a predominant idea. Other examples are the accumulation of certain products in the blood, such as urea, uric acid, or lactic acid, or the absorption of ptomaines from the gastric or intestinal tract. External or extrinsic causes are such as infectious miasms, viruses, poisons, wounds, and injuries. An ordinary cause is one to which all are more or less exposed, such as atmospheric changes. Specific or special causes are those producing a distinct and specific disease, such ' as the bacillus tuberculosis, causing Tuberculosis ; comma bacillus, Asiatic Cholera ; oscillaria malarice, Malaria ; Loffier bacillus, Diphtheria. A contagious disease is one whose causative agent is a specific 12 PRACTICE OF MEDICINE. poison that, introduced into the system of another, will give rise to the same disease. An infectious disease is also due to a special cause that under certain conditions is capable of unlimited increase or mul- tiplication. An infectious disease may or may not be contagious. An example of a primary cause is any external traumatic injury. A secondary cause is well seen in the secondary pericarditis result- ing from an accumulation of urea in the blood, the retention of the urea in the blood being due to a diseased kidney. A predisposition to disease is a special liability or susceptibility to its occurrence, and may be either inherited or acquired. Inherited ox constitutional predisposition to certain diseases is also termed Diathesis ; an example is the offspring of phthisical parents, who are said to be of 71 phthisical diathesis. Acquired predisposition is such as arises from — I. Habits: Strain upon the nervous system resulting in nervous diseases, or the changes resulting from alcoholic or other excesses. II. Age: Children are very liable to catarrhal disorders. Young adults, to fevers and perverted sexual disorders. Middle age, to heart, kidney, and digestive disorders, and cancer. Old age, to degeneration of the heart and vessels, III. Occupation: Miners, weavers, and cutlers, lung diseases; or painters and printers, to lead colic. IV. Sex : Women, emotional nervous diseases. Men, as more exposed, rheumatism and pneumonia. V. Race : Negro, phthisis and scrofula ; often exempt from mal- aria. Exciting causes are those giving rise to morbid conditions in indi- viduals already predisposed to certain diseases, but lacking the action which determines their occurrence, to wit : persons predisposed to acute rheumatism, on being exposed to certain atmospheric changes have an attack ; fear has produced chorea ; anger has caused jaundice ; worry has produced cardiac and mental diseases. The Clinical History of diseases includes all the symptoms and signs which may occur from the period of incubation until its final termination. Symptomatolog'y is the study of the signs and symptoms of disease or such alterations in the healthy functions giving evidence of INTRODUCTION. 13 the existence of a diseased condition or perverted function. Symp- toms may be either objective or subjective : Objective, when evident to the senses of the observer, as redness, swelling, high temperature, or disorders of locomotion ; Subjective, when felt or known only by the patient, such as pain, numbness, vertigo, or nausea. Physical signs are, strictly speaking, objective symptoms, requir- ing for their elucidation special methods, such as inspectiojt, mensura- tion, palpation, percussion, and auscultation. These methods are chiefly used in examinations of the chest and abdomen. Associated with the study of symptomatology should be considered the complications and sequelce of disease. Complications are certain conditions which may arise during the course of the original disease, but are not considered necessary accompaniments of the disease; thus hemorrhage from the lungs or haemoptysis is a complication of tuberculosis ; intestinal hemorrhage, a frequent complication of typhoid fever. SequelcB {sequor, I follow) are the morbid phenomena left as a result of a disease ; thus, valvular disease of the heart often results from an attack of acute articular rheumatism. The Period of Incubation is that interval between the en- trance of a poison ,into the system and the manifestation of its symptoms. The Prodromes are the earliest recognizable symptoms ; as the rigors or chills during the invasion of fever, and the various auras preceding an epileptic attack. An acute disease is one in which the invasion is sudden and rapid, and as a rule severe ; when the symptoms develop less rapidly and are less intense, the disease is said to be subacute ; when gradual or slow in development, duration, and intensity, the disease is said to be chronic. It must be borne in mind, however, that there may be disturbed action in every intermediate degree between these extremes. Pathognomonic is the term applied to such symptoms as belong to one particular disease, and are therefore characteristic of it, thus : the rusty sputum of pneumonia, or the eruption of variola. The Termination of a diseased action may occur in one of three ways, to wit : Cure, Secondary Processes, or in Death, Cure may occur by — Lysis, or slow return to health. Crisis, abrupt termination, usually 14 PRACTICE OF MEDICINE. with a critical discjiarge. Metastasis, or changing from one location to another. Secondary Processes are those in which the diseased action is sub- stituted by a new morbid process, to wit : rheumatism followed by endocarditis ; apoplexy by cerebral softening. By Death is meant a complete cessation of tissue change occurring by- Asthenia, or an ever-increasing debility, to wit: phthisis, cancer, Bright's disease. Ancemia, or insufficient quantity or quality of blood. Apncca, or non-aeration of blood, to wit : acute lung dis- eases, or croup. Coma, death beginning at the brain, to wit: urae- mia, narcotic poisoning, or cerebral hemorrhage. Diagnosis of disease, or the discrimination of diseases, implies a complete, exact, and comprehensive knowledge of the phenomena under consideration, as regards the origin, seat, extent, and nature of all its morbid condition. A direct diagnosis is made when the morbid condition is revealed by a combination of clinical phenomena, or some one or more pathog- nomonic symptoms. A differential diagnosis is the result when the diseases resembling each other are called to mind and eliminated from each other. A diagnosis by exclusion is by proving the absence of all diseases which might give rise to the symptoms observed, except one, the presence of which is not actually indicated by any positive symptoms. The X- (or Rontgen) Rays, now in its infancy in diagnosis, will in the near future revolutionize the study of diseases of internal organs and structures. Prognosis of disease is the ability or knowledge to foretell the most probable result of the condition present, and involves an amount of tact or knowledge only acquired by prolonged clinical experience. Treatment. The ultimate and most important object in the study of medicine, from a practical point of view, is to be able to cure, relieve, or prevent disease. This does not consist solely in the ad- ministration of drugs, but requires strict and faithful attention to diet, hygiene, and exercise. When the object is to prevent disease, such as small-pox by vacci- nation, it is called Prophylactic or Preventive treatment. When disease is to be broken up, although already begun, such as aborting the chill of malaria, it is called the Abortive treatment. FEVERS. 15 When the disease is allowed to run its natural course without attempting its removal, but being constantly on the alert for obstacles to its successful issue, such as the generally adopted plan of treating continued fevers, it is called Expectant treatment. When the disease is incurable, and removal of marked suffering is the object, it is called Palliative treatment. When marked weakness and prostration are to be overcome, it is called Restorative treatment. FEVERS. Fever is a condition in which the temperature of the human body is raised above .the normal limit, — 98.2° F., — and there are present the phenomena of quickened circulation, marked tissue change, and disordered secretions.^ ^'Wq primary cause of the fever phenomena is still a mooted ques- tion, and is either a disorder of the sympathetic nervous system giv- ing rise to disturbances of the vaso-motor filaments, or a derangement of the nervous centres located adjacent to the corpus striatum, which have been found, by experiment, to govern the processes of heat pro- duction, distribution, and dissipation, or a toxsemia, — viz. : ptomaines, uraemia, or other poisons, — or of a bacterial origin. Rise of temperature is the preeminent feature of all fevers, and can only be positively determined by the use of the clinical thermometer, TJie i&rmfeverishness is used when the temperature ranges from 99° to 100° F. ; slight fever if 100° or 101°; moderate, 102° or 103°; high if 104° or 105° ; and intense if it exceed the latter. The term hyper- pyrexia is used when the temperature shows a tendency to remain at 106° F. and above. Quickened circulation is the rule in fevers, the frequency usually maintaining a fair ratio with the increase of the temperature. A rise of one degree Fahrenheit is usually attended with an increase of eight to ten beats of the pulse per minute. Ifi PRACTICE OF MEDICINE. The following table gives a fair comparison between temperature and pulse : A temperature of 98° F. corresponds to a pulse of 60 " '« 100° F. " " " 80 <« " 101° F. " " " 90 i< << 102° F. •' " " icx> " " 103° F. " " " no «' •* 104° F. " " " 120 << " 105° F. " " " 130 " " 106° F. " " " 140 TAe tissue waste is marked in proportion to the severity and dura- tion of the febrile phenomena, being slight or nil in febricula, and excessive in typhoid fever. The disordered secretions are manifested by the deficiency in the salivary, gastric, intestinal, and nephritic secretions, the tongue being furred, the mouth clammy, and there occurring anorexia, thirst, con- stipation, and scanty, high-colored, acid urine. GENERAL TREATMENT OF FEVERS. 1. Reduce the temperature. The cold bath or cold pack will do this most decidedly, but entails much labor, and is not altogether free from danger, and so its use is advised only in proper cases. Cool sponging is of decided value. Quinines sulphas, in gr. xx (1.3 Gm.) doses, repeated, rarely fails. Antipyrin, gr. xx (r.3 Gm.), repeated, antifebrin, gr. x-xv (0.65-1.0 Gm.), repeated, and phenacetin, gr, v (0.32 Gm.), repeated once or twice, are also recommended, but their tendency to depression must be watched. 2. Lessen the circulation. If the pulse be full, strong, and rapid, use aconitum or verairuvi viride. If the circulation be weak, stimu- lants with digitalis, caffeina, and nitroglycerin are indicated. 3. Attend to the secretions. Remove the waste of the tissues by diuretics, diaphoretics, and, if particularly indicated, laxatives. It is better for every fever that the skin should be moist, than that it should be harsh and dry. It is better that the urine should be abundant, than that it should be scanty and thick with tissue waste. Watch the stools that you may judge whether the food, be it solid or liquid, is FEVERS. 17 properly digested. The free use of water is beneficial in promoting the various secretions. 4. Nourish the patient. " Don't starve a fever." Administer milk, beef-tea, animal broths, peptonized and other light nutritious food, in small quantities, but at frequent intervals, watching that tympanites does not develop. Alcohol is only indicated in long-continued fevers or those of asthenic type. Check or discontinue alcohol when its odor is notice- able on the breath, 5. Watch the nursing. Much of the success in the management of fever patients can be attributed to good, sensible nursing. Through it are secured the five important essentials of every sick-room ; to wit : cleanliness, cheerfulness, regularity, ventilation, and light. CONTINUED FEVERS. All continued fevers are characterized by a steady progress of the febrile movement, without either a too decided rise or fall in the tem- perature to modify the impression of a continuous action. SIMPLE CONTINUED FEVER. Synonyms. Irritative fever ; febricula ; ephemeral fever ; synocha. Definition. A continued fever, of short duration, mild in charac- ter, rarely fatal, but when death does occur, presenting no character- istic lesion. Causes. Fatigue, mental and physical ; exposure to the sun ; great heat or cold ; excesses in eating and drinking resulting in an attack of indigestion ; excitementand violent emotion. Most common in childhood. It is not a miasmatic fever, neither is it contagious. Symptoms. Onset sudden with an abrupt feeling of lassitude, followed by a decided chill or chilliftess, a sudden and rapid rise of temperattire , quick, tense pulse, headache, dry skin, great thirst, coated tongue, costive bowels, and scanty, high-colored urine. Cases due to errors in diet are accompanied by tiatisea and vomiting. Attacks occurring during childhood, due to excitement, fright, or the emotions, may be associated with convulsions. The temperature may within an 2 18 PRACTICE OF MEDICINE. hour or two reach 103° F., or more, when slight delirium may occur. The affection has no constant or characteristic eruption. Duration. From twenty-four hours to six or seven days. Termination. Usually within a few hours, to a day or two, the temperature rapidly falls to the norm, an instance of crisis ; or it may continue for several days, gradually falling to the norm {/ysis). Herpes about the lips and nostrils are often observed at the close of an attack. Coti7>alcscence is rapid. Diagnosis. Unless the fever can be attributed to some one of the causes mentioned, a doubt as to its character may exist for the first twenty-four hours, after which time it can hardly be mistaken for any other disease. The following is a familiar instance of this affection. A child, apparently in the best of healtli, at play, or, may be, at school, suddenly complains of nausea and may vomit, the skin becoming hot, dry, and flushed, or soon cov- ered with an erythematous rash ; the pulse is quick and tense, there is head- ache, pains in the limbs, and great fretfulness or nervousness. The axillary temperature may reach I02°-I04° F. The whole aspect is most alarming. A laxative is administered, the surface sponged with a tepid lotion, sleep follows, during which there may be free perspiration, and the following day the child is and continues perfectly well. Pl'Ognosis. Recovery, without sequelae, the rule. Treatment. Rest in bed. If evidences of gastro-intestinal dis- order be present, order a dozen or more powders containing hydrar- gyri chloridimite, gr. Y^ (o.oi Gm.); sodii bicarbon., gr. ij (0.13 Gm.), pulv. ipecac, gr. -^ (0.005 Gm.), one every two hours, and some hours after the last powder has been taken, an enema or a seidliiz powder. Much comfort follows spottging- the surface with tepid or cold water and the use of saline diaphoretics and diuretics. If the pulse be very quick, add small doses of aconilum. Cases not associated with digestive disorder have the fever and nervous symptoms relieved by acetanilidum, gr. ij-v (0.13-0.32 Gm.), accord- ing to age, every two or three hours. Liquid diet is the most palatable. Cases in which the nervous symptoms or insomnia are prominent should have a few doses of potassii broniidum during the day, or a bedtime dose of irional, gr. v-xx (0.32-1.3 Gm.). During convales- cence tonic doses of quinines sulphas or tinctura nucis vomicce. FEVERS. 19 INFLUENZA. Synonyms. La grippe ; grip ; contagious catarrh ; epidemic or catarrhal fever. Definition. An acute, specific, infectious fever, moderately con- tagious ; sporadic, epidemic, and pandemic ; associated with catarrhal inflammation of the respiratory tract, sometimes of the digestive, muscular pain, and always accompanied with disturbances of the nervous system and a debility out of all proportion to the intensity of the fever and the catarrhal processes and apt to be attended with serious complications and sequelae. The disease was almost unknown upon the appearance of the pandemic in the winter of 1889-90. Causes. A specific poison, the bacillus of Pfeiffer, which is unin- fluenced by soil, climate, season, or atmospheric changes. The mode of development of the remarkable outbreaks of influenza is not yet understood. One attack rather predisposes to another attack. Morbid Anatomy, There are no characteristic anatomical lesions. Any anatomical changes are those of the complications. Symptoms. The clinical history of this disease presents the greatest variations as regards intensity, from the most trifling indis- position in one, to an illness of the gravest kind, terminating in death, in another. The onset is, in the majority of cases, sudden, with a chill or chilli- ness followed hy fever, the temperature reaching 101° to 103°, a quick, compressible pulse, and severe shooting pains in the eyes and frontal sinuses and myalgic pains in the joints and muscles. The chill and fever are rapidly followed by chilliness along the spifie, pain in the throat, hoarseness, deafiess, coryza, sneezing, injected, watery eyes, and a dry, irritative, laryngeal coiigh, sometimes becoming bronchial. Rarely there is severe and obstinate cough, the result of a bronchial spasm, with little or no secretion. The tongue is furred, there is anorexia, epigastric distress, nausea, occasionally vojnititig, and often- times diarrhcea. In some instances the digestive symptoms are the most prominent, when dysentery may occur. Associated with either the respiratory or digestive form of attack may be marked disturb- ances of the cerebro-spinal functions, or these latter may be the most prominent symptoms present. The above symptoms are always associated with depression of 20 PRACTICE OF MEDICINE. spirits, and a debility altogetlier out of proportion to the intensity of the fever and the catarrhal phenomena. Delirium is rare, but marked hebetitde and cutaneous hyperasthesia are common. Duration. The fever declines in from four to seven days, when begins a protracted convalescence. Relapses frequently occur, and second, third, or even more numerous attacks in the same individual may be observed, the susceptibility of the system after an attack being remarkable. Complications. The most frequent are those associated with the respiratory organs. Severe bronchitis, associated in the feeble or aged with fever, typhoid delirium, and tendency to oedema of the lungs. Croupous and catarrhal pneumonia are frecjuent and fatal complications. Cerebro-spinal meningitis is also noted. Sequelae. A persistent headache; neuralgia; neuritis; insomnia; neurasthenia or a confusional insanity ; depression of spirits often obstinate and needing treatment ; mania ; enlargement of lymphatic glands. The great increase in pulmonary phthisis since the pan- demic of 1889-90 is more than a coincidence. Diagnosis. Isolated cases maybe mistaken for a " bad cold." But when epidemic, the siddden onset, marked general catarrh, and decided prostration should prevent error. At the onset of an epidemic Dengue will be remembered. Cerebro- spinal Fever has many symptoms in common with the nervous form of influenza. Prognosis. Recovery is the rule w hen it occurs in the healthy and vigorous ; according to Pepper less than one-half of one per cent, die. Crave when the very young, the very old, or those suffering from organic disease, such as Bright's disease, fatty heart, emphysema, or the tubercular diathesis, are attacked. Treatment. No specific. During the prevalence of the epi- demic influence exposure to cold should be avoided. Support the system and pursue a purely symptomatic method of medication. All measures, of whatever kind, which tend to depress the general nervous system, or the functional activity of the respiration, and particularly the heart, are to be avoided. Patients should be kept in bed until fever declines or longer. Keep the bowels soluble. If many individuals must come in contact with the patient, some isolation and disinfection of the nasal and bronchial secretions should be prac- tised. FEVERS. 21 The catarrh, pains, and cotigh are at least ameliorated by the following : U. Phenacetin. , gr. iij .2 Gm. Pulv. camphone, gr. j .065 Gm. Caffeina citrata, gr. j .065 Gm. Every two or three hours, aUemated with qimiina sulphas, gr. ij (0.13 Gm.). Excellent results follow the use of the following combination : U . Sodii benzoat., ^ij 8. Gm. Salol, 5 S3 2. Gm. Phenacetin., gr. xl 2.6 Gm. Strychninse sulph., g^- i .012 Gm. M. Ft. chart, vel capsul. No. xij. SiG. — One every three or four hours. Sodii benzoas, gr. x (0.65 Gm.) every four hours, is strongly recom- mended. During the last pandemic the disease was frequently aborted in those of vigorous health by a few ten- or fifteen-grain (0.65-1 Gm.) doses of antipyrin, although in those of feeble resisting power much harm resulted from the indiscriminate use of this drug. Dr. Roland G. Curtin warmly recommends salicinum as coming " as near to being a specific as we can get with the drugs now in our possession." QuinincE sulphas, in full doses at the very onset, often aborts the disease. I have seen excellent results in neuralgic cases from cinchonidincs salicylas, gr. v (0.32 Gm.), every four hours. The frequent inhalation of tinctura benzoin, comp., foss-j (2-4 Cc.) in aqucB but., Gj (475 Cc), relieves the naso-pharyngeal and bronchial catarrh. If the bronchial symptoms become troublesome, use — JJ . Ammonii chlorid. , gr. x .65 Gm. Tinct. hyoscyami, tr^xv I. Cc. Syr. ipecac, TT\^v .3 Cc. Spts. frumenti, f^ss 2. Cc. Aquae chloroformi, f^iss 6. Cc. M. Every three or four hours, diluted. The complication oi pneumonia requires prompt stimulating treat- ment. Dr. Pepper recommends strychnines sulphas in full doses as 22 PRACTICE OF MEDICINE. tlie most important remedy against this complication, and suggests the foliowintr combination as often valuable: Morjihina' suliih., gr. j .065 G QuiniiKf siilpli., . Slrjxliniiia' suljih., Acid, plios. dil., Glyceritii, . . . . Aqucc gr.xxxv 2.3 Gm. gr. ss .03 Gm. {z^ iij 12. Cc. fi V 20. Cc. q. s. ad f 3 iij 90. Cc. M. SiG — A teaspoonful four to six times daily, in water. Dr, Bartholow recommends the early use o{ pilocarpine , gr. ^ (o.oi Gm.), repeated until its mild physiological effects ensue, when it is sub- stituted by duboisine, gr. ^Jij-^oiJ (0.00022-0.00032 Gm.), twice a day, and for the depression ferri ioiiidum, one of the official pills every four hours, and inhaling one or two drops of pyridine every few hours. During convalescence administer st7ychnina sulphas, gr. -^^ (0.0013 Gm.) four times daily. Always have in mind that influenza is often the exciting cause of a phthisical development in those so predisposed. Insomnia is a symptom calling for prompt treatment. The anaemia and general weakness of convalescence calls ior ferrum. TYPHOID FEVER. Synonyms. Enteric fever ; gastric fever ; nervous fever ; entero- mesenteric fever ; abdominal typhus ; autumnal fever. Definition. An acute, infectious febrile affection, due to a. special poison ; characterized by insidious prodromes, epistaxis, dull headache followed by stupor and delirium, red tongue, becom- ing dry, brown, and cracked, abdominal tenderness, early diarrhoea and tympany, and a peculiar eruption upon the abdomen ; rapid prostration and slow convalescence ; a constant lesion of Peyer's p.itches.the mesenteric glands, and enlargement of the spleen. Causes. Predisposing and exciting. The chief predisposing causes are Age and Season. It is claimed by Pepper that a particular susceptibility exists in certain individuals and families to typhoid fever. The most frequent age is between fifteen and thirty years, and FEVERS, 23 cases are rarely seen in those of forty-five years and over. I have seen well-marked cases with typical symptoms at eighteen months, and at five years of age. The autumn months show the most cases, and particularly following a hot and dry summer. The exciting cause is a special typhoid germ, the typhoid bacillus or bacillus of Eberth, which is found in the lesions and blood. The poison usually results from the deco7npositio7i of the typhoid stools and the sputum, although it has been claimed that the disease may be generated under certain undetermined circumstances, de novo, from ordinary filth and decomposition ; this view has less advocates each year. The contagiousness of typhoid fever is again advanced. The atmosphere is never impregnated with the fever germ. The poison gains its entrance into the system by means of infected water, milk, ice, meat, or other food. The germ is easily destroyed by thorough disinfection of the stools and sputum with heat, mercuric bichloride, or acidum carbolicum, but extreme cold will not destroy the typhoid germ. Pathological Anatomy. The specific anatomical lesions of typhoid fever are invariably present, and are so characteristic that an examination of the body after death will in any case make known the nature of the disease, even had the symptoms been unknown. These lesions consist in changes in the Peyerian patches and solitary glands, which may be divided into well-defined stages, as follows : First. Stage of Infiltration, or Swelling from infiltration and ex- cessive proliferation of their cellular elements ; the surrounding mucous membrane is also infiltrated with cells. The Peyer's patches are thickened, hardened, and elevated above the mucous membrane. The number of patches and glands involved is from three or four up to nearly the entire number. The above changes have been noted as early as the second day. Second. Stage of Necrosis, Softening, or Sloughing of the solitary and agminate glands. Not all the patches necessarily slough ; in a certain number of them the morbid changes are arrested before soft- ening. This stage constitutes the anatomical changes of the second and third week. Third. Stage of Ulceration following and depending directly upon the softening and sloughing, the sloughs gradually separating, begin- ning at the periphery of the swollen gland and finally, at about the 24 PRACTICE OF MEDICINE. end of the third week, become detached, leaving ulcers of various sizes. Foiirtli. Stage of CicatrizLition, or in rare cases Perforation. The ulcer gradually diminishes in size, the surface becoming covered with a delicate layer of granulations, which is soon transformed into con- nective tissue and covered with epithelium, the resulting scar being slightly depressed. The gland-structure is never regenerated. The M.senteric glands become infiltrated, enlarged, and softened, but seldom ulcerate. In about one-third of the cases the large intes- tine is also involved. The Spleen also enlarges and softens, the increase being twice or three times its normal size, beginning in the middle of the first week, and reaching its height at the end of the second week. There are, besides, parenchymatous degenerations, or granular changes in all the active organs and tissues of the body. Symptoms. Stage of Prodromes. — The onset is insidious, with a feeling of general fnalaise, vertigo, headache, particularly occipital pain, disordered digestion, disturbed sleep, epistaxis, depression, and muscular weakness, followed by a chill ox chilliness, iht patient being unable to designate the day when the symptoms began. In rare instances the disease begins abruptly with a chill, followed by high fever; this is particularly the case in malarial districts. The exact duration of these premonitory symptoms is not known, and may be said to vary from a few days to two or three weeks. First Week, dates from the onset of the fever, when are present in- creasing temperature, frequent pulse, headache, listlessness, the eyes closed as if asleep, coated tongue, natisea, diarrhaa (there may be constipation), the abdomen moderately distended and, upon pressure in the rigJit iliac fossa, gurgling sounds and tenderness. Upon the seventh day a few reddish spots resembling flea bites appear upon the abdomen, chest, or back. Second Week. The foregoing symptoms are exaggerated ; fever is now continuous, with a frequent and compressible and dicrotic pulse, tympanitic, tender abdomen , gurgling in the right iliac fossa, nocturnal delirium, severe and constant headache, often stupor, a short cough with distinct bronchial rales on auscultation, irregular muscular con- tractions {subsultits tendinum), sordes upon the teeth and lips, tlie tongue losing its coating and becoming more or less dry, the diarrhoea continuing. During this stage deafness develops, often increasing FEVERS. 25 until profound, and continuing into convalescence. Disturbances of vision are frequent in pronounced cases. The spleen increased in size. Third Week. Fever changes from continuous to remittent; the evening exacerbations continue as high as the preceding week, the morning fall growing more decided each day, but all the other symp- toms remain about the same until near the end of the week, when a marked amelioration begins. * In a fair proportion of cases all the symptoms grow worse toward the end of the second or during the third week. The prostration is extreme, the stupor so marked that it is hardly possible to rouse the patient, the tongue dry, hard, cracked, and covered with a brown crust, sordes collect on the gums, teeth, and cracked lips, the pulse is rapid and feeble, the respirations shallow and quickened, retention of urine, which contains albumin. The stools are often voided invol- untarily, and bed-sores develop, this condition terminating in death, or passing thus into the fourth week. Fourth Week. The fever decidedly remits ; almost normal in the morning, the pulse becoming less frequent and more full, the tongue gradually becoming clean, the abdomen lessens in size, the diarrhoea ceases, the patient passing into a slow convalescence, greatly emaci- ated, which convalescence may continue for several weeks. Analysis of Symptoms. The temperature record of typhoid fever is charactejistic. The fever on the morning of the first day may be stated at 98.5° F., evening 100.5°; second morning 99.5°, evening 101.5°; third morning 100.5°, evening 102.5°; fourth morning 101.5°, evening 103.5°; fifth evening 104.5°. From that time until end of the second week the evening temperature ranges between 103° and 105°, the morning temperature being a degree or more lower. During the second or third week hyperpyrexia, or fever above 105° F., may develop and adds to the gravity of the attack. A high temperature during the third and fourth week is of grave import. Temperatures of io6°-io7° with recovery are reported, but they must be rare. Afebrile cases of typhoid fever are reported, all other symptoms with the prostration, but the step-like temperature, being present. Diarrhoea is the principal intestinal symptom ; if absent, the lesion may be slight. The stools are ai first dark, but early in the second week they become fluid, offensive, ochre-yellow in color, resembling "peasoup," and maybe streaked with blood They number from three \.o fifteen during the twenty-four hours. 26 PRACTICE OF MKDICINE. Constipation occurs more frequently than is supposed. I have seen one hundred cases with constipation within the past ten years. The urine has the ordinary febrile characters. Retention is very common. Ehrlich' describes a reaction which he believes is rarely met with save in typhoid fever. In examinations of the urine by Ehrlich's diazo-reaction in fifty cases of typhoid fever in the wards of the Philadelphia'Hospital, the reaction was found in thirty-eight, h has also been found in a number of other conditions, particularly those having gastro-intestinal symptoms. Eruption is almost constant. Consists of fromy?7/2 .oi6-.032Gm. M. Ft. pil. No. j. SiG. — One such pill every three or four hours. If urgemic convulsions occur, use the hot-air bath, cuppin<; over the kidneys, hypodermic injections oi pilocarpine nilras, the inhala- tion of chloroformum, or, may be, the rectal use of chloral hydrate with or \s\\\\o\x\. potassii brotnidum. Urasmic symptoms are often re- markably controlled by full doses of sodii bertzoas. The elimination of the poison producing the convulsions is assisted by the high bowel enema of the normal salt solution. For scarlatinal rheuviatistn the use oi ferritin alternately with the following : R. Ammonii salicyl., z^V] 8. Gm. Elix. simplicis, f.^ss 15. Cc. Syr. simplicis, f ?j 30. Cc. Tinct. card. CO. , fSss 15. Cc. M. SiG. — Teaspoonful, diluted, four times daily. For infiammation of the middle ear it is much better to puncture the drum membrane than to allow its ulceration ; insufflations of acidum boricitm and the internal use of ammonii chloridiim. For the various other sequclcB the treatment is the same as if they occurred primarily, ^///J tonics. The disease being contagious, every means should be taken to prevent its spread — to wit, isolation, cleanliness, disinfection, and fumigation. Small doses of quinina, in those exposed, is said to prevent or modify the severity of an attack, but no true prophylactic is known. MEASLES. Synonyms. Morbilli ; rubeola. Definition. An acute i, spreading from the navel over the abdomen, alter- nating with intervals of ease. The pain is tearing, cutting, pressifig, most frequently twisting, pinching, accompanied by peculiar bear- ing-down pains. The patient is restless, and seeks relief xw changing his position and in compressing the abdomen; his surface maybe cold and his features pinched. The pulse is small and hard. The abdomen is tense, whether puffed up or drawn inward. There are DISEASES OF THE INTESTINAL CANAL. 103 often nausea and vomiting, and desire for stool. There is usually constipation, but sometimes the bowels are regular or even too loose. Duration from a few minutes to several hours, relaxing at intervals. The attack ceases suddenly, with a feeling of the greatest relief, although some soreness remains for a few days." Lead colic is always preceded by symptoms of lead poisoning, to wit: slate-colored skin, dark gums showing a blue line, heavy breath, with sweetish metallic taste, obstinate constipation, impaired appetite, slow pulse, and contracted abdominal walls. Diagfnosis. Gastralgia differs from colic, in the pain being in the epigastric region and associated with disorders of digestion. In hepatic colic, or the passage of gallstones, the pain is in the hepatic region, attended with soreness over the gall bladder, and retching and vomiting, followed by jaundice and the presence of bile in the urine. In nephritic colic, the pain follows the course of one or both ureters, shooting to loins and thigh, with retraction of the testicle of the affected side, strangury, and bloody urine. In uterine colic, the pain is in the pelvis, and associated with men- strual disorders, in fact, a dysmenorrhoea. In ovarian colic or neuralgia, pain or pressure over the ovaries, with hysterical phenomena. Infla7nmatory disorders of the abdomen differ from colic by the presence of fever and tenderness on pressure. Prognosis. Most favorable. Death is the rarest termination possible. Treatment. Relief of pain is the first indication, and is best ac- complished by a hypodermic injection of morphiticR sulphas, gr. yi-yi (0.011-0.022 Gm.), which has the additional advantage of relaxing the spasm, thereby favoring the action of purgatives, which should soon follow. One of the best in colic, no matter from what cause, is massce hydrargyrum, gr. v-x (0.3-0.6 Gm.), or hydrargyri chloridum mite, gr. ^ (0.03 Gm.) every half hour until four or five grains are taken, followed by a mild saline cathartic. After the relief of the pain and free action of the bowels, the cause of the attack should be ascertained and corrected, to prevent future suffering. For lead colic, morphines sulphas for the pain ; oleum ricini or magnesii sulphas, 3j (4 Gm.) every hour, for the constipation, and 1Q4 PRACTICE OF MEDICINE. po/iissii iodidum, gr. v-x (0.3-0.6 Gm.) after meals, or syrupus acidi Iiydf iodic i,io]-^v (4-15 Cc.) after meals, diluted, to eliminate the metal from the system. Excellent results often follow a fiee or several small venesections in lead poisoning. Gratifying results in attacks of lead colic have been reported from tumblerful doses of oUnm oliva, repeated until some six ounces (180 Cc.) have been used. It is said to be curative in lead poisoning, in daily doses of two ounces, continued for some time. CONSTIPATION. Synonyms. Intestinal torpor; costiveness. Definition. A functional inactivity of the intestinal canal, either due to atony of the muscular coat, causing lessened peristalsis, or to a deficiency of intestinal and biliary secretion ; characterized by a change in the character, frequency, and quantity of the stools. Causes. Dyspepsia; character of the food; habits of the patient, as sedentary habits and neglecting calls of nature ; diseases of the stomach and liver; malaria; lead poisoning ; syphilis. Symptoms. In the normal condition the majority of persons have one stool each day, although it is not to be considered abnormal if more or less than that number occur. The bowels are moved every three ox four days, with great straining and distress, the/atv oktn flushed, the cerebral vessels full ; leaving an uneasy sensation in the rectum. Or in other cases the bowels may be relieved once a day, but the stool is small and hard, causing great distress, and tenesmus, or teaz- ing. Another group of cases \\2iMt frequent stools during the day, small and non-formed, due to retained hardened feces acting as an irritant upon the rectum. The change in the character of the stools is soon followed by symptoms of dyspepsia, headache, mental torpor, vertigo, palpitation on exertion, and in many cases with great distention of the abdomen. Prognosis. Death never results from functional constipation. Treatment. The successful treatment depends upon the removal of the cause and the hearty co-operation of the patient. First, the patient must have a regular hour each day for going to DISEASES OF THE INTESTINAL CANAL. 105 stool, and must remain a sufficietit time to permit a thorough evacua- tion of the bowels, assisting, until habit of daily stools is formed, by a warm water injection. Second, the diet must be carefully regulated, as concentrated foods increase the costive habit, so that those predisposed should eat bulky foods, much vegetables and fruits. Third, purgative mineral waters or cathartic medicines are to be used with catition, their reckless administration often causing more injury than benefit. Fourth, either of the following formulse, aided by the enforcement of the above rules, will give good results : R. Ext. nucis vomicse, ^- % .016 Gm. Ext. belladonnae alco., gr- X •°''^ ^™* Ext. aloes aqua., gr. ss .032 Gm. Pulv. rhei, gr. j .065 Gm. Olei cajuputi, rr\^ j .06 Cc. M. In pill, at bedtime ; and after a week, every second or third night. B . Resina podophyl., Ext. physostig., Ext. belladonnae alco. , Aloini, aa gr. X aa .016 Gm. Id pill, every night, or second or third night. R. Ext. cascarse sagradse fld., . . . TTI^xx 1.3 Cc. Glycerini, tT\^xx 1.3 Cc. Syr. sarsaparillae, Tt\,xx 1. 3 Cc. Hour after meals, or once a day, as indicated. All cathartics and purgatives are improved by the addition of a small amount of sulphur praecipitatum. One of the very best purgatives is an early morning dose of magnesii sulphas (Epsom salts). Another excellent tonic purgative is aldinum, gr. y%-)i (0.008-0.016 Gm.), after meals. Success often follows an enema o{ glycerinum,i'Z]-\v (4-15 Cc), or a suppository of glycerinum. Electricity to the abdomen is worth a trial ; one pole over abdomen, the other at anus, using either galvanism or faradism. Kneading the abdomen is frequently of benefit. 106 PRACTICE OF MEDICINE. DIARRHCEA. Synonyms. Enterorrhoea ; alvine flux ; purging. Definition. Frequent loose alvine evacuations, without tenes- mus; due to functional or organic derangement of the small intes tines, produced by causes acting either locally or constitutionally. Causes. Those acting locally, such as indigestion, indigestible food, impure food and water, irritating matters or secretions poured into the bowels, or entozoa, cause the flux by a direct irritation of the mucous surface. Attacks of diarrhoea due to constitutional derangement may be secondary to such diseases as tuberculosis, pycemia, albuminuria, typhoid fever, or disturbances of the functions of other organs, giving rise to vicarious fluxes. Atmospheric changes, as well as a sudden mental shock, will often produce an attack of diarrhoea in those predisposed. Forms. Acute and chronic. Symptoms. Acute diarrhoea presents itself in several varieties, the result of the particular cause. Feculetit diarrJiCEa. A few hours after meals the patient feels colicky pains and flatulency, with a desire for stool. There is often nausea, coated tongue, but seldom vomiting. The pain is generally relieved by the purging which ensues. The stools have 3. feculent character, are of brown fluid, containing faeces, often ofiensive, the color becoming lighter after four or five evacuations. Constitutional symptoms are wanting. This form is the result of overeating, eating too rapidly, or indi- gestion of different forms, or worms in the intestinal canal, and patients generally recover in a day or two. Lientcric diarrhoea. In this form there is, with the frequency of evacuations, a ivant of assimilation o{food, which passes through the intestines more or less unaltered. The stools are frequent, mucous or serous, more or less covered with bile, mixed w'xih. undigested food. In this form the patients emaciate rapidly, owing to the deficient assimilation, the digested portions of the food being hurried on by the increased peristalsis of the irritated bowel. It is usually subacute in its course. Bilious diarrhcea. The stools arc frequent, green or yellow, with DISEASES OF THE INTESTINAL CANAL. 107 scalding sensations at the anus and griping pains in the abdomen. Excessive biliary secretion is the irritating cause. Any of the above forms may pass into chronic diarrhoea by exciting permanent diseases of the intestines. Diarrhoea due to constitutional causes will be mentioned when speaking of those conditions. Chronic diarrhoea results from repeated attacks of the acute form, or is the result of some cachexia. The syiftiptoms, so far as the stools are concerned, are much the same as in the acute disease, except they are paler, whence it has been termed white flux ; in addition, dyspeptic symptoms, aphthous condition of the mouth and tongue, flatulency, colic, emaciation, and aficEniia. The appetite is at times capricious, again impaired. Exacerbations result from indiscretions in diet and from the sudden onset of damp weather. Prognosis. Favorable va feculent and bilious forms; unfavorable in lienteric and chronic forms when emaciation begins. Diarrhoea occurring as a symptom, the prognosis is controlled by the original disease. Treatment. Acute diarrhoea. If the tongue is heavily coated, the breath fetid, and the stools not excessive in number, it is well to clear the intestinal canal with a laxative such as oleum ricini or a saline. For children between one and two years of age : R. Pulv. ipecac, gr. ss .032 Gm. Pulv. rhei, gr. }i-]A, .016-.022 Gm. Sodii bicarb. , gr. ss-ij .032-. 13 Gm. M. Every four hours until the character of the stools changes. As a rule, however, the stools have become so frequent when ad- vice is sought that the time for laxatives has passed, and some one of the following combinations is indicated : R. Salol, gr. xx-xxx 1-3-2. Gm. Bismuth subnit., gj 4. Gm. Sacch. lac, 3J 4. Gm. M. Ft. chart. No. x. SiG. — One every two or three hours, reducing the dose for children Or— B . Bismuthi salicylat. , gr. xxx 2. Gm. Morphine sulph., gr. j .065 Gm. M. Ft. chart. No. vj. SiG. — One every three hours. 108 PRACTICE OF MEDICINE. Oi the following modification of " Squibb's diarrhoea mixture": R. Tinct. opii deodorat., fS'^ ^5- Cc. Tinct. camphonv, f .^ '^ ^5- Cc. Tinct. capsici, f^ij 8. Cc. Chloroform! punv, f ::; iss 6. Cc. Spts. vini gallici, f 5j 30. Cc. Villi pepsini, ad f^iij ad 90. Cc. M. SiG. — One teaspoonful, p. r. n. Or the following, which I have always found successful : R. Tinct. opii deodorat., fo'^ IS- Co. Spts. chloroformi, f .^ ij 8. Cc. Acid, sulphuric, dil., f^^j 30. Cc. Vini pei>sini, q. s. adf5iij ad 90. Cc. M. SiG. — One teaspoonful in water after each stool. For the bilious form : R. Hydrargyri chlor. mitis, .... gr. ^ .008 Gm. Sodii bicarb., gr. ij .13 Gm. Pulv. opii, gr- /4 -0x6 Gm. M. In powder, every two or three hours, until eight ix)wders are used, followed by large doses of bismuthum and pepsinmn. In all acute forms restricted and regiilated dieta.re imperative, ^;/r<» milk with liquor calcis being the most suitable. In adults, an opium suppository often checks a flux that is uninflu. enced by opium internally. In lienieric or dyspeptic diarrhoea a carefully regulated diet and either of the following combinations : R. Pepsini glycerit., f^j 30. Cc. Liq. potassii arsenit., Tr\,xx 1.3 Cc. Tinct. opii deodorat., fzij 8. Cc. Aq. chloroformi, ... q. s. ad f5iij ad 90. Cc. SiG. — One teaspoonful at meal-time. Or— R. Papoid, gr. XX 1. 3 Gm. Bismuth, subnit. , 3J 4. Gm. M. Ft. chart. No. x. SiG. — One at meal-time. Chronic diarrhoea. Bismuth, gr. xxx-xl (2-2.6 Gm.), in milk, every four hours; Hope's camphor mixture, fjj (30 Cc), every four DISEASES OF THE INTESTINAL CANAL. 109 hours; or cupri sulphas, gr. j\ (0.005 Gm.), ext. opii, gr. ^^ (0.005 Gm.), every four hours ; or argenti nitras, gr. yk, (o.oi Gm.), ext. opii, gr. \ (o.oii Gm.), every five hours; may all be used with more or less success ; when dry tongue and great flatulency use : R. 01. terebinthin^, fzj 4. Cc. 01. amygdal. express., ..... fgss 15- Cc. Tinct. opii, f^ij 8. Cc. Mucil. acacise, f ^iv 15. Cc. Aq. lauro-cerasi, fsss 15. Cc. M. SiG. — f^j every three or four hours, diluted. The diet should be nutritious in character, and moderate stimulants are indicated. Activity of the skin and kidneys should be encour- aged. All varieties of intestinal catarrh or diarrhoea are benefited by a few days' rest in bed and daily hot baths. CATARRHAL ENTERITIS. Synonyms. Intestinal catarrh ; acute diarrhoea ; inflammation of the bowels. Definition. A catarrhal inflammation of the mucous membrane of the small intestines ; characterized by fever, pain, tenderness, and looseness of the bowels. When the catarrh is limited to the duode- num it is termed duodenitis, and there is some jaundice. Pathological Anatomy. There first ensues hypercemia of the mucous membrane and intestinal glands, manifested by redness, swelling, and oedema; this is followed by increased secretion, and an overgrowth and desquamation of the epithelium, together with a copi- ous generation of young cells. As a result of the hypersemia, rupture of the capillaries and extravasation of blood often occur. The swollen glands show a strong tendency to ulcerate. This catarrhal process may involve the entire tube or be limited to portions of it. If the catarrhal changes extend to the ileum, the solitary and Peyerian glands show swellings that might be mistaken for the changes of typhoid fever. Causes. A specific virus seems probable in some cases. Per- haps a ptomaine poisoning. Improper and indigestible food ; summer no PRACTICK OF MKDICINE. temperature and exposure to cold and wet, while perspiring. Swal- lowing fish-bones, cherry-stones, unmasticated kernels of nuts, etc. Symptoms. Begins with latii^uor, followed by chilliness and fcvcr, the temperature ranging at 102°-I03°; this is followed hy pain, colicky and paroxysmal in character, situated above the umbilicus, localized tenderness, and loose evacuations. Nausea and vomiting often occur. The bowels are at first constipated, followed by per- sistent diarrhoea; the stools contain but little fecal matter, are yellow ox greenish-yellow in color, mixed with undigested food ; if the stools are numerous, they become whitish and watery, the so-called "rice- water" discharges. No blood in the stools. The appetite is im- paired, and this, with the want of assimilation and great waste, soon produce extreme weakness and emaciation, which is always more marked in children. I have frequently noted a peculiar abdominal eruption in severe cases of intestinal catarrh, occurring as isolated dark-red spots, larger than those of typhoid fever, lasting, each, twenty-four hours, disappearing on pressure and with the decline of fever. Duration. In mild cases, four or five days; severe cases con- tinue, more or less marked, for a week or two. Diagnosis. From colic, by the absence of tenderness and fever, and presence of constipation and its paroxysmal character. From typhoid fever, by the absence of prodromes, characteristic step-like temperature record, characteristic eruption, enlarged spleen, and peculiar character of the stools. For points of distinction from dysentery or peritonitis, see those affections. Prognosis. Favorable, if early and proper treatment is em- ployed. Treatment. Rest the bowels by a restricted diet, such as milk and lime-water, or weak mutton or chicken soups, with well-boiled rice added. Keep the patient quiet in bed, a difficult matter in the case of children. For adults, opium is the remedy, in doses to control the symptoms; mild doses do well with — R. Ext. opii, gr- X~/^ .016-.032 Gm. Camphone pulv., gr. iij .2 Gm. M. In pill, every three hours. DISEASES OF THE INTESTINAL CANAL. Ill Or— R. Tinct. opii deodorat., ..... TT\,x .6 Cc- Liq. potassii citrat., f^ij S. Cc. M, Every hour until opium effect. The strength and the frequency of administration of either of tliese formulas must be governed by the severity of the attack. Salol, gr. j-iij (0.065-0.2 Gm.), alone or combined with bismutki :alicylas, gr. x-xv {0.6-1 Gm.), every few hours, is often of value in intestinal catarrh, although my experience is more fivorable to opium. If vomiting is annoying, all other treatment must be discontinued until it has been controlled, the following being usually efficient : R . Hydrargyri chlor. mite, .... gr. ^ .008 Gm. Sodii bicarbon., gr- ij .13 Gm. Sacch. lac, gr. ij .13 Gm. M. Give every hour or two, dry, on tongue. For children : 5c . Tinct. opii deodorat. , Try' .06 Cc. Bismuth, subnit., gr- v .32 Cc. Mist, cretse, fgj 4. Cc. M. Every two hours, for a child of one year. If the disease shows the least tendency to linger, the flir/rt^ treatment should be substituted, one of the best formulae being " Hope's Cam- phor Mixture." The following, which I have used with much success in the insane wards of the Philadelphia Hospital, where, at times, we see a good deal of intestinal catarrh, and which I have named " Mis- tura enterica," is generally satisfactory: 5t. Spts. camphors, f^j 30. Cc. Acid, sulphurici dil., f^iss 45. Cc. Tinct. opii deodorat., f 5j 30. Cc. Tinct. capsici, f^ss 15, Cc Spts. chloroformi, f.^ss 15. Cc. Spts. vini gallici, . . q. s. adf^vj ad 180. Cc. M. SiG. — One to two teaspoonfuls, well diluted, every three or four hours. Locally. Poultices, warm fomentations, such as a turpentine stupe, or ung. belladonna or oleum camphoratce, are agreeable. 112 I'KACTICE OF MKUICINE. CROUPOUS ENTERITIS. Synonym. Membranous enteritis. Definition. A croupous inflammation of the mucous membrane of the small intestines; characterized by tenderness, paroxysmal pain, moderate fever, and the formation and discharge at stool of membranous shreds or casts. Causes. A disease of adult life. The female sex more liable than the male, and neuralgic, nervous, hysterical, or hypochondriacal subjects are more subject to it than are other types. A peculiar state of the nervous system seems necessary to its pro- duction. It is not a frequent disease. Pathological Anatomy. A subacute inflammation of the small intestine, during which the mucous membrane becomes covered with a whitish or grayish-white, firmly adherent, membranous deposit, cemented together by a coagulable exudation, and prolonged by rootlets from the under surface into the intestinal follicles. Symptoms. Begins hy feverishness, feeling of soreness and eiis- tetition of the abdomen; these are followed hy pains of a colicky character, severe and depressing, felt around the umbilicus, asso- ciated with tenderness, continuing for half an hour, an hour, or longer, and after a longer or shorter interval occurring again ; these pheno- mena continue for a day or two, when looseness of the bowels with distressing pain and tenesmus occur, the stools containing mucus, with or without blood, and shreds of membrane or cylindrical casts of the bowel. Great relief follows the discharge of shreds, although a feeling of rawness or soreness persists for a few days. Preceding the local manifestations of the disease are attacks of hysteria, hypochondriasis, neuralgia, nervousness, or excitability. The paroxysms recur at intervals of a week or two, or after several months ; as long an interval as three years between attacks is recorded. Diagnosis. Peritonitis may be suspected until the characteristic stools occur. Dysentery is excluded when the shreds and casts of membrane ap- pear. Prognosis. Favorable as to life, but one of the most difficult of diseases to eradicate. DISEASES OF THE INTESTINAL CANAL. 113 Treatment. The diet is an important factor, and preference should be given to coarse articles instead of to liquids. ¥ or the pain 2ind suffering, opiu7}i in some form is indicated, the most effective being a hypodermic injection of morphines sulphas. For cottstipation during a paroxysm, an emulsion of oleimi ricini with terebiftihina is of benefit. Constipation must always be avoided. To prevent a return of the paroxysm, either liquor poiassii arsenilis, n\^j-ij (0.06-0.12 Cc), before meals, or hydrargyri chloridtnn corro sivum, gr. -^^ (o.ooi Gm.), three times a day, with a course of oleum morrhucB, seems to answer in the majority of cases. Prof. Da Costa speaks highly oi pix liquida in some form, as an alterative to the mucous membrane. CHOLERA MORBUS. Synonyms. Sporadic cholera ; English cholera ; bilious cholera. Definition. An acute catarrhal inflammation of the mucous membrane of the stomach and intestines, of sudden onset ; charac- terized by violent abdominal pains, incessant vomiting and purging, cold surface, rapid, feeble pulse, spasmodic contractions of the muscles of the abdomen and extremities, and prostration. Causes. A disease of summer and early autumn, climatic influ- ence being an important factor. Its prevalence during certain seasons seems to indicate a specific cause. Irritants of all kinds, unripe fruits and vegetables, and fermentation of food. Probably a ptomaine poisoning. Pathological Anatomy. Cases in which death has occurred within a few hours present no pathological changes. Generally, however, the gastro-intestinal mucous membrane is congested and denuded of epithelium ; the solitary and Peyerian glands are swollen and prominent. The blood is thick, and dark in color ; the kidneys are enlarged and congested ; and in prolonged attacks there are appearances of granular changes in the muscular system. Symptoms. Onset sudden and violent, and, unfortunately, gen- erally after midnight, with chilliness, intense nausea, vomiting, and purging, accompanied with distressing burning or tearing abdominal pains or colic. The vomited matter at first consists of the ordinary 114 PRACT1C1-: OF MLUICINE. contents of the stomach, and the siooh of ordinary ficces, but soon the dischargees by vomit and stool are liquid, wintish, or o{ ts. green or yellowish tint; if the attack is severe or protracted, the discharges are of the " rice-water'' character. The patient is rapidly emaciated and reduced in strength, the body shrinks, the surface is cold and covered with a clammy sweat, and the pulse is small and feeble. Intense thirst is present, and when drink is given it is at once rejected. Aggravating the distress of the patient are severe cramps of the muscles, and especially those of the calves, and of the flexors of the thighs, forearms, fingers, and toes. Termination. Mild cases often terminate favorably without treat- ment, the patient able to be around in a day or two, although weak. Severe cases, the vomiting and purging cease after some hours, but the patient remains weak, with irritable stomach and bowels for a week or two. Crave cases, the true cholera type, recover from the prostration very gradually ; reaction coming on slowly and usually passing into a typhoid condition of some weeks' duration. Diagnosis. Asiatic cholera and cholera morbus are easily con- founded during an epidemic of the former, and there are no positive points of discrimination, unless the comma bacilli oi Koch are proven to be always in the true cholera stools. Irritant poisons, such as tartar emetic, elaterium, or other sub- stances, cause vomiting and purging, similar to cholera morbus, and are only discriminated from it by the clinical history and cause. Prognosis. In the majority of cases favorable. The mortality is about five per cent. Treatment. At once, regardless of the cause, a hypodermic in- jection o{ mo7phincB sulph., gr. ^-^3 (0.008-0.022 Gm.), and atropines sulph., gr. y^^ (0.00054 Gm.), to be repeated in half an hour if no improvement; for patients who object to the hypodermic method, opium in some form by the mouth or rectum, giving the preference to the liquid preparations, Camphora and opium combined often act well, or the " enteric mixluie" mentioned on page iii,and if much depression, small doses of brattdy or dry champagne. The intense thirst must not be gratified by the use of liquids, unless very hot, but smaXX pellets of ice by the stomach are grateful. DISEASES OF THE INTESTINAL CANAL. 115 If the vomiting and purging continue, make use of — U . Bismuth, subnit., gr- xx 1. 3 Gm. Acid, carbol., gr- /^ -OI Gm. Glycerini, TTLxx 1.3 Cc. AquK, fgiv 15. Cc. M. Every hour, in water. If the vomiting is so severe that no opportunity occurs for the medicament to come in contact with the gastric mucous membrane, an enema of chloral, gr. x-xv (0.6-1 Gm.), in some demulcent with iinctiira opii deodorati, tt\^x-xx (0.6-1.2 Cc), acts often like magic in quieting the distress of the tortured patient. The closer the case approaches the true cholera type, the more severe are the muscidar cramps, and their treatment demanded. Prof. Da Costa suggests — R. Chloral, .:;iv 15. Gm. Ung. petrolei, ^j 30. Gm. M, To be rubbed over the affected muscles. Dr. Bartholow suggests — R. Chloral, ^iij 12. Gm. Morphinae sulph. , gr. iv .26 Gm. Aquae, f|j 30. Cc. M. SiG. — Twenty minims, hypodeiTaically, repeated p. r. n. Locally, sinapis, in the form of poultices of the dry powder, should be applied to the abdomen, or terebinthina stupes, or the hot-water bag. The after treatment depends upon the symptoms, generally an acid mixture and a regulated diet, with tonic doses of quinince sulphas, are indicated. ENTERO-COLITIS. Synonyms. Inflammatory diarrhoea ; ulcerative entero-colitis. • Definition. A catarrhal inflammation of the lower portion of the small — ileum — and the upper portion of the large intestines, with a great tendency to ulceration of the intestinal glands if the catarrh becomes chronic ; characterized by moderate fever, nausea, vomiting, diarrhoea, swollen abdomen, pain, and emaciation. A common dis- ease of childhood. Causes. Improper and indigestible food ; summer temperature ; impure air ; uncleanliness ; exposure to cold and damp air. 116 PRACTICE OF MEDICINE. Most commonly a disease of childhood. Forms. .Acute and chronic. Pathological Anatomy. Acute variety ; hyperaemia, swelling, oedema, and softening of the mucous membrane of the lower portion of the small and the upper portion of the large intestines, with hyper- plasia of the intestinal follicles, their excretory follicles enlarged and tumid, readily distinguished as grayish or blackish points in the mid- dle of the glands ; the patches of Peyer are also enlarged, tumefied, and project above the level of the surrounding mucous membrane, the orifices of the follicles appearing as dark points; these patches often have an ulcerated appearance, but upon closer examination ulcers are not discovered. Chronic variety ; the thickening and infiltration have extended to the submucous and muscular coats, followed by induration of the tissues, so that the walls of the intestines are often abnormally rigid. Ulceration occurs, which extends through the entire thickness of the membrane. " These ulcers, when isolated, are from one to one and a half lines in diameter, oval or circular in shape, and either have sharp-cut edges, as though the piece of mucous membrane had been cut out with a punch, or the mucous membrane bounding them is undermined." The small ulcers often coalesce, so that large, irregu- lar ulcerated patches are formed, having for their base the submucous or muscular coats, and have a grayish-white color. The mesenteric glands are enlarged, but seldom, if ever, undergo ulceration. Symptoms. Acute form ; may develop slowly, with restlessness and fretfulness, or suddenly \\\\.\\ feverishtiess , toss of appetite, thirst, nausea, moderate voniitittg, and abdominal pain ; or diarrhooa may be the first indication of illness. Regardless of the character of the onset, the stools should present the characteristic appearance ; they are semi-fiuid, heterogeneous, ^riia (Councilman and Lafleur). This variety is often epidemic in the tropics. Croupous or diphtheritic dysentery is often epidemic ; frequently occurs as a terminal event in acute and chronic diseases. The causes are much those of the acute catarrhal form, acting upon a depressed system. The Ainasba co/i ma.y be seen in the stools. Dysentery is not contagious, but is infectious. Pathological Anatomy. Catarrhal dysentery ; congestion, swelling, and oedema of the mucous membrane and submucous tissue of the large bowel, with an over-production of mucus ; the fol- licles are enlarged, from retention of their contents, the result of the swelling ; the congested vessels often rupture ; the mucous mem- brane softens in patches, and is detached, forming ulcers. Recovery follows, if the destruction of tissue is small, smooth cicatrices, minus gland structure, marking the site. Amcebic or tropical dysentery, the lesions are also in the large intes- tines and sometimes in the lower portion of the ileum. Abscess of the liver is a frequent complication. "The lesions consist of ulceration, produced by preceding infiltra- tion, general or local, of the submucosa, the general infiltration being due to an oedematous condition, the local to multiplication of the fixed cells of the tissue. In the earliest stages these local infiltrations appear as hemispherical elevations above the general level of tlie mucosa. The mucous membrane over these soon become necrotic and is cast off, exposing the infiltrated submucous tissue as a grayish-yellow, gelatinous mass, which at first forms the floor of the ulcer, but is subsequently cast off as a slough." (Osier.) Croupous or diphtheritic dysentery begins with intense congestion, swelling, and oedema of the mucous and submucous tissue, with extravasations of blood and the whole mucous membrane covered with a firm, fibrinofts exudation ; the mucous membrane softens and sloughs, leaving large ulcers and gangrenous spots. If recovery DISEASES OF THE INTESTINAL CANAL. 123 occur, large cicatrices form, which narrow the calibre of the intestinal tube. The mesenteric glands enlarge, soften , and abscesses form in them ; the liver becomes the seat of small abscesses, from embolic obstruc- tion of the radicles of the portal vein ; the heart muscles are flabby and more or less fatty. Symptoms. Catarrhal fortn begins gradually, with diarrham, loss of appetite, nausea, and very slight ftver, vihich. continues for two or three days, when the true dysenteric symptoms develop, to wit, paiti on pressure along the transverse and descending colon, tormina or colicky pains about the umbilicus, burjiingpaiji in the rectum, with the sensation of thie presence of a foreign body and a constant desire to expel it, ox tenesmus ; the stools for the first day or two contain more or less faecal matter, but they soon change to a grayish, tough, trafisparent mticus, containing more or less blood and /z/j/ dnrmgiYiQ tonnina, nausea and vomiting may occur; the urine is scanty and high-colored ; the number of stools varies from five to twenty or more in the twenty-four hours. The duration is about 07ie iveek, the patient being much emaciated and enfeebled. Amcebicform begins gradually as the catarrhal form, or gradually as an increasing diarrhoea. Soon the stools become characteristic of the variety of the attack, he.\ng frequent, bloody, mucoid, but very fluid ; as the disease progresses, the stools h&covne yelloivish-gray3.nd. liquid, containing mucus, sometimes bloody. The number of stools varies from six to a dozen or more in a day. Actively moving amoeba are found in the stools, disappearing as the stools become formed. Fever may or may not be present, or may come and go. Abdominal pain and tenesmus are present in the majority of cases. The loss of flesh and strength is marked. Abscess of liver and lungs are frequent and grave complications. Duration from six to twelve weeks ; recovery tedious, owing to anae- mia and loss of flesh. In every endemic or epidemic of dysentery a number of amcebic cases will occur. During the past three years I have seen probably two hundred cases of dysentery, beginning as catarrhal, but in the midst of the endemic a number of amcebic cases occurred, the con- valescence long outlasting the catarrhal variety. The croupous or diphtheritic form sets in suddenly, the stools being IL'4 PRACTICE OF MEDICINE. more frequent, containing more blood Z-nd. pus, wxiYi patches of »it-m- brane, even casts of the bowel, together with more or \tss t^augrenous mucous membrane ; nausea, voviiting, and great prostration, cold skin, feeble pulse, and emaciation with anxious expression, the odor surrounding the patient h€\r\ f.l ss 15. Co. Tinct. opii deodorat., f^^j 30. Co. Spts. camphoras, f_^j 30. Cc. Tinct. capsici, f^ss 15. Cc. Spts. chloroformi, f^ss 15. Cc. Spts. vini gallici, ........ fgiss 45. Cc. SiG. — One teaspoonful every two or three hours, diluted. In more than one instance I have seen a severe attack of acute dysentery succumb to morphines sulphas, gr. X~/^ (0.016-0.032 Gm.), three or four times daily hypodermically, within three or four days. For the intense tormina and tenesmus no remedy is comparable with morphia by the hypodermic method. In strong young individuals the very best prescription possible is — U . Magnesii sulph , ^j 4. Gm. Acid, sulph. dil., n^x .6 Cc. Tinct. opii deodorat., rrLx .6 Cc. Aquse chloroformi, .... ad 5 ij ad 8. Cc. M. Every two or three hours, until faeces appear in the stools, when small doses of opium and quinines sulphas may be used. Bismuthi subnii., gr. xxx (2 Gm.), every two or three hours, 01 126 PRACTICE OF MEDICINE. bismuthi salicylas, gr. xx (1.3 Gm.), every two or three hours, are often successful. Ur. Loomis speaks strongly of ipecacuanha, gr. \i (0.016 Gin.), every half-hour, with sufficient opium to secure quietness. The large doses of ipecacuanha recommended I have had no experience with. Ringer recommends hydrargyri chloridiim corrosivuin, gr. yj^ (0.00065 Gm.), every hour or two, which " rarely fails to free the stools from blood and slime, although in some cases a diarrhoea of a different character may continue for a short time longer." In children the following combination is successful : B . Pulv. ipecacuanhre, S^- H -O'^ G™- Bismuth, subnit., gr. v-x .32-.65 Cim. Cretae praep. gr- iij -2 Gm. M. SiG. — Every two hours. Washing out the rectum with either tepid, hot, cold, or iced water, as suggested by Prof. Da Costa, adds greatly to the patient's comfort and to the decrease of the inflammatory process. Ice suppositories are soothing and relieve the tenesmus and rectal pain. A one or two per cent, solution of creolin (one-half pint) as an enema often rapidly lessens the number of stools and the tenesmus. Dr. H. C. Wood recommends iodoform suppositories. " In the cases of amoebic dysentery we have been using at the Johns Hopkins Hospital, with great benefit, warm injections of quinine in strength of i to 5000, i to 2500, and i to 1000. The amoebae are rapidly destroyed by it." (Osier.) I have met over five hundred cases of acute dysentery during the past six years, and have nearly always been successful with nitclein- Aulde, gr. j (0.065 Gm.), or Tr^j-v (006-0.3 Cc), every hour until the character of the stools change, when the interval of the dose is widened to two or three hours and bismuthum or the foregoing mistura enterica added. Locally, poultices, stupes, and the water bag do no good, but if they are agreeable to the patient they may be allowed, as they do no harm, CJu-onic dysentery. A carefully selected but nourishing diet, change of scene, and some of the following remedies : Bismuthum subnitrat., gr. XXX (2 Gm.), t. i. d. ; terebinthina, n\,x (0.6 Cc), every three or four DISEASES OF THE INTESTINAL CANAL. 127 hours; argenii nitras , gr. yi-yi (0.008-0.022 Gm.), three or four times daily ; or B . Cupri sulphas, gr. ^ (o.oi i Gm.) ; ext. opii, aq., gr. X~K (0.016-0.032 Gm,) ; ext. nucis vomicce, gr. 3^ (o.oii Gm.), in pill, four times daily. Chronic dysentery is sometimes protracted by a trifling patch of in- flammation or ulceration in the rectum or sigrnoid flexure, or a relaxed condition of the mucous membrane of the rectum, and of the hemor- rhoidal vessels. There occur two or three loose stools in the morn- ing, a mucous dysentery, and then a comparatively comfortable day. The stools are preceded by some colicky pain across the lower part of the abdomen and in the line of the large bowel. The general condition, other than the anaemia and weakness, of the patient is good. Drugs by the mouth are useless to control these cases ; the medication must be made directly to the diseased part. Injections of argenii nitras, gr. v to xx or xxx (0.32-1.3-2 Gm.), to the pint, are curative ; the silver may be combined with opium (R. Argent, nitrat., gr, j (0.065 Gm.) ; tinct, opii deodorat,, ttLxv (i Cc.) ; aquge amyli, f|iv(i2o Cc) ; M.), During the convalescence from all varieties of dysentery, tonics are indicated (R. Strychninae sulph., gr. yi (0-032 Gm.) ; acid hydro- chlorici dil., f3>j (8 Cc.) ; tinct. gentian comp,, q. s. ad f^iv (120 Cc.) ; M. S. — One teaspoonful before meals in water. A course of oleum niorrhiKs with syr. calcii lactophosphatis, should be used if much emaciation. TYPHLITIS. Synonyms. Inflammation of the csecum ; typhlitis stercoralis. Definition. A catarrhal inflammation of the mucous membrane of the csecum and ascending colon ; characterized by pain, tender- ness, constipation, and in certain cases a characteristic vomiting. Causes. I do not believe the term " typhlitis " is to be sup- planted by the term appendicitis ; I am convinced there are two conditions having some symptoms in common. In a majority of instances typhlitis is mechanical, due to the accumulation of fasces in the csecum. Pathological Anatomy. Similar to the catarrhal inflammation of dysentery. Symptoms. Pain and tenderness in the right iliac fossa and 128 PRACTICE OF MEDICINE. along the ascending colon, with some pominence of this region ; the bowels are distended with gas (jneteoriivt) and are usually consti- pated, or small liquid stools may occur from time to time, due to the accumulation of hardened Acces in the sacculated periphery of the caecum, leaving a central canal through which the liquid contents of the upper bowel can pass. In severe cases, "the local pain, tenderness, and swellin*^ are greater; there are impaction oi faces and no movements or flatus. There are decided fever, restiessjtess, and also nausea and vomiting. The vomited matters, at first the contents of the stomach, then of the duodenum, with bilious matter, and ultimately, if the impaction persists, of material having the odor of faeces. With these symp- toms occur great depression of the vital powers. Peritonitis is finally developed by contiguity of tissue or by rupture of the bowel." The temperature in even mild cases is one or two degrees above the normal and in a fair number an eruption is seen upon the abdomen, consisting of one or two dark red spots the size of a pin- head, which are of short life and disappear on pressure. Duration. The mild form lasts about one week. The severe form may terminate in subacute peritonitis, continuing about two weeks. Diagnosis. The mild fonn is distinguished from other intestinal affections by the localized pain, tenderness, and prominence, and the constipation. The severe form can only be distinguished from the other forms of intestinal obstruction by the history of the case and attack, and the results of treatment. Prognosis. Mild form favorable. Severe form grave, although not necessarily fatal. Treatment. The patient should be kept in bed, and placed on a strictly milk diet in very limited amounts. Two indications are to be met, which are seemingly opposed to each other : first, the removal of the accumulation of faeces, which in the majority of cases has caused and still maintains the inflammation ; second, to retard the inflammation resulting from the presence of the fecal mass. If the pain and suffering be intense, at once administer a hypo- dermic injection of morphines sulphas. DISEASES OF THE INTESTINAL CANAL. 129 The two indications above named are met by the use of the fol- lowing : R. Magnesii sulph., ^^xij 48. Gm. Acid, sulphuiici dil., . , . . f^ij 8. Cc. Tinct. opii deodorat., . . . . fgiv 15. Cc. Spts. chloroformi, f^ij 8. Cc. Aquse menth. pip. , . . q. s. ad (^ iij ad 90. Cc. M. SiG. — One teaspoonful every hour, dikited. If it be true that calomel has a specific action upon the lower por- tion of the small bowel, increasing the secretion from the glands located there, then the following should be useful : U . Hydrargyri chlor. mite, . . . gr. ij . 13 Gm. Sodii bicarb., gr. xx 1.3 Gm. Sacc. lac, gr. xxx 2. Gm. Ft. chart. No. x. SiG. — One every hour till twelve taken, followed by ^of Hunyadi Janos water or other saline purgatives. In severe cases, begin an opium influence at once, by hypodermic in- jections of morphince sulphas guarded with atropincB sulphas, con- tinued until all symptoms of inflammation have subsided, when attempts to remove the accumulated fsces may be made by irriga- tion of the bowel with warm soapsuds, and the cautious administra- tion of magtiesii sulphas in drachm doses, every two hours. Locally, hot, dry applications, or the ice bag. PERITYPHLITIS— APPENDICITIS. Synonyms. Perityphlitic abscess ; suppurative appendicitis ; pericaecal abscess ; iliac abscess. Definition. Perityphlitis ; an acute inflammation of the connec- tive tissue around the caecum (with localized peritonitis) leading to the formation of an abscess. . Appendicitis. An acute or subacute inflammation of the appendix vermiformis, involving the surrounding tissues (with a localized peritonitis), leading to perforation of the appendix and the develop- ment of an abscess. Causes. The frequency with which appendicitis is met with has 9 130 rUACTICK OF NfEDIClNIi. led to the belief that the condition is of germ origin, the exact nature of which not having been determined. The great majority of cases of perityphlitis are secondary to inflammation of or perforation of the vermiform appendix — appendicitis. Have seen two cases of true perityphlitis, the result of exposure to cold and wet. Appendicitis may result from the presence of a foreign body in its canal, consisting of inspissated ficcal masses, which, becoming incrusted with lime salts, are termed " faecal calculi," and becoming rounded in shape closely resemble a cherry-stone, for which they have been mistaken. Foreign bodies, particularly seeds of fruit, sometimes, but not so often as is believed by the laity, gain access to the appendix and produce inflammation leading to perforation. Torsion of the appendix is also among the infrequent causes. The disease is more common in males than females. Occurs most fre- quently between the ages of ten years and thirty years. Relapses are fairly frequent in cases not progressing to perforation. Some one has suggested the increased frequency of appendicitis since the reappearance of influenza. Symptoms. The symptoms of the two conditions are much alike; begins with 2, feeling oi weight, soreness, and rapidly develop- ing and severe pain in the lower right abdomen (McBurney's point), accompanied with nausea and vomiting. The pain is increased by lying on the left side ; the right leg is flexed, the abdomen becomes tense, proininent, and tender, with the progressive development of a hard swelling in the right iliac region. The temperature at the onset is from 90°-ioo°, and may or may not be preceded by a chill; the pulse 80, full and strong ; the tongue coated with red tips, the bowels costive. In addition to the persistent, localized pain, occurs severe colicky paroxysms, which may shoot into the hip and thigh. The expression of the patient is pinched and denotes suffering. The special tendency of the disease is toward suppuration, which is an- nounced hy irregular c/tills, fez'erishness, ihe temperature shooting suddenly to ioi°-io3°, '^'id sweats ; and a feeling of tension and throbbing. Its development is slow, and if associated with typhlitis the symptoms of that affection are added. Complications. Perforationof the appendix. Local or general peritonitis. Diagnosis. Differs from typhlitis by the absence of the colicky pains, dyspeptic symptoms, costive bowels, and tympanites preceding DISEASES OF THE INTESTINAL CANAL. 131 the development of a tumor; in perityphlitis the tumor is. present with the development of the symptoms. Psoas abscess is not associated with intestinal symptoms, and the discharge is free from a faecal odor. Renal and ovarian tumors should not be sources of error. The possibility of hernial tumors must not be overlooked. Treatment. If not associated with typhlitis, the treatment is to allay the inflammation in the first stage, by either ice, locally, or freely pai}iting with tinctura iodi ; if suppuration is evident, surgical meas- ures are the indication, medical treatment endangering life. PROCTITIS. Synonyms. Catarrh of the rectum ; dysentery ; rectitis. Definition. A catarrhal inflammation of the mucous membrane of the rectum and anus; characterized by pain, tenesmus, and fre- quent stools of hardened faeces, or of mucus, pus, and blood. Causes. Chief cause, constipation ; also sitting on damp ground or stone steps ; habitual use of enemata or purgatives ; diseases of the liver; hemorrhoids. Pathological Anatom.y. Similar to those occurring in catar- rhal dysentery. Symptoms. Uneasy sensation and burning in the recfuvi, with a constant desire for stool, or tenesmus, often so severe as to cause a prolapse of the mucous membra^ie. The stools may be either hard- ened fceces or scybala from the distended colon, which cause intense pain when they reach the rectum ; or the stools may be of mucus, inucopus, or bloody or blood-streaked. Generally there are present nausea, especially during the tenesmus, headache, feverishness, and malaise. In severe cases there is strangury, and, with the tenesmus, straining with urination. If the case be protracted and severe, inflammation of the connec- tive tissue around the rectum occurs, causing periproctitis, which usually terminates in various kinds of fistula. Complications. Periproctitis ; peritonitis ; hepatic abscesses. Diagnosis. In males, the disease cannot be confounded with any other affection, save, perhaps, hemorrhoids. In females, displace- ments of the uterus may somewhat simulate the symptoms of proctitis. 132 PRACTICE OF MEDICINE. Prognosis. Uncomplicated cases favorable. Either of the com- plications adds greatly to the gravity of the affection. Treatment. In cases due to constipation the chief indication is to empty the bowels, using an enema of warm water and soap or magnesii sulphas : IjS. . Magnesii siili)h., _^ ij 60. Gm. Glycerin!, . f.o^s 15. Cc. Aquxbul., fo'^ ^-°- ^^* ^^• Irrigaiioti of the bowel with warm water once or twice daily assists in the liquefaction of the hardened faeces. Either enemata or sup- positories oi glyceriniwt should answer in certain cases. Cases other than those due to constipation, emollient enemata and opiu7n, one of the best being — li . 01. olivje, f 3 ij 60. Cc. Tinct. opii deodorat., Tt\^xv i. Cc. The use of hot injections of an astringent character, such as hot, strong black coffee, from half pint to quart, as hot as will be tolerated by the rectum, as suggested by Dr. Pepper, is valuable in cases of irritable rectum with a disposition to looseness. In cases not bene- fited by the hot injections, relief may follow the use of injections of water, say two ounces, as cold as can be borne without chilling, administered at bedtime, having it retained. If symptoms oi periproctitis occur, use ice to the parts, and if sup- puration ensue, evacuation by a free opening and qiiinince sulphas. INTESTINAL OBSTRUCTION. Synonyms. Intestinal occlusion; strangulated hernia; invagi- nation ; intestinal stricture ; ileus. Definition. A sudden or gradual closure of the intestinal canal; characterized by pain, nausea, vomiting, constipation, and finally col- lapse. Causes. The numerous causes are arranged as follows : 1. Accumulations within the bowel of hardened faeces, or foreign bodies. 2. Strictures the result of cancer, ulceration, or cicatrices. 3. Pressure against the bowel, from peritoneal adhesions, tumors, and abnormal growths. DISEASES OF THE INTESTINAL CAXAL. 133 4. Strangulations, due to the numerous forms of hernia. 5. Invagination or intussusception, the most common. 6. Twisting, volvulus or rotation of the bowel. Pathological Anatomy. Invagination is the form calling for special description here. It is usually caused by the lower portion of the ileum slipping down into the caecum, as the finger of a glove might be invaginated, causing thus an actual mechanical obstruction ; this is produced by a spasm of the ileum, whereby its calibre is greatly diminished, thus permitting its descent into the lower bowel. Result- ing from this occlusion or compression, are congestion, inflammation, with secondary constitutional reaction and death, or more rarely the invaginated bowel sloughs off and is voided by stool, union taking place at its site and recovery following. Symptoms. The onset of the symptoms may be either sudden or gradual, and are as follows : Constipation, with more or less s&vexe colicky pains, notr^Yitytdhj either purgatives or injections ; feeling of weight and soreftess, with distention of the abdomen from retained gas, and nausea and vomit- . ing ; the symptoms all grow more pronounced, the pain becoming violent, tenderness in limited areas, the vo7niting\>&cov!\\Vi^ stercorace- ous, the abdomen hard and tense, the eyes sunkett, the pulse quick z.^^ feeble, the skin cold and covered with a clammy sweat. Absence of escaping flatus is a valuable diagnostic symptom. The above con- tinue more or less pronounced for a week or ten days, when collapse and death occur, or more rarely there is a gradual return to health. Cases occur rarely in which small, f^cal, muco-purulent stools con- taining more or less blood exist, instead of constipation. Diagnosis. One of the most difficult, and can only be solved by a careful study of the case along with the different causes producing the affection. The sight of the occlusion can rarely be determined positively, unless the X-ray be successful. Intestinal obstruction may be mistaken for intestinal colic, hernia, enteritis, peritonitis, hepatic or renal colic. Prognosis. Always grave, but guided by the cause. Impacted faces favorable. Invagination less favorable, but recoveries occur ; the longer the symptoms continue, the more favorable the outlook. Strangulations unfavorable, but many recoveries recorded. Strictures due to cancer, cicatrized ulcers, and the like, are the most unfavorable. Treatment. Stop all forms of purgatives as soon as the diagno- sis of obstruction is determined. 134 PRACTICE OF mp:dicine. opium is indicated in all forms with pain, and is best adniinistered in the form of morphina: sulphas, combined with small doses of attopina sulpluis, hypodermically. The author has seen the most brilliant results follow the plan of washing out the stomach as suggested by Kiissmaul, and with full doses of atropines sulphas hypodermically, for its action on intestinal peristalsis, and with electricity, one pole over abdomen, the other in rectum. Cases resulting from impacted fasces are rapidly cured by the above plan combined with irrigation of the lower bowels with tepid soap- suds or a high enema of glycerinum and magnesii sulphas If invagination, raising the buttocks and lowering the chest, and repeated injections of warmed oil, are recommended, or have the abdomen opened and the invagination reduced. Distention of the bowel by pumping air through long rectal tubes, or disengaging carbonic acid gas in the bowel, by first injecting a solu- tion o{ sodii bicarbonas, and follow this with a solution oi acidum tar- taricum, about one drachm (4 Gin.) of each, pressure being made against the anus to prevent escape ; but the danger of rupture of the bowtl must not be overlooked. Flatulent distention can be removed by the long aspirator needle. Laparotomy is no doubt the operation of the future, when our means of diagnosticating the location of the trouble is more exact. The nutrition of the patient is best attained by injections of either peptonized foods or defibrinated blood, or both. INTESTINAL PARASITES. TAPEWORMS. Varieties. Tania solium; Tcenia saginata; Bothriocephalus latus. Causes. The Tania solium, the " armed tapeworm," is the most common in this country. It is derived from the embryos contained '\Vi pork, known as the cysticercus cellulosus. INTESTINAL PARASITES. 135 The TcBfiia saginata, the "unarmed tapeworm," a not uncommon variety, is derived from the embryos contained in beef, known as cysticerciis bovis. The Bothriocephalus latiis, also an " unarmed tapeworm," the largest parasite infesting man, is supposed to be derived from an embryo found mfish. The embryo or ovum is introduced into the intestinal canal with the food and drink. The parasite reaches its final growth after its entrance into the intestines. Those handling fresh meats or eating uncooked animal food are most liable to be affected. Uncleanliness is also an important factor. " Description. The tcenia solium is from six to thirty feet in length, has a globular head, or scolex, a slender neck connecting its numerous fiat segments or Joints. The head, or scolex, measures about -^-Q of an inch, has a double circle of booklets, — whence the term "armed tapeworm," — and is provided with from two to four suckers. The segments or joints (strobila) are flat, and vary from one-eighth to one-half of an inch in length, and each contains both male and female sexual organs, the uterus being a long, numerously branched tube, in which the ova develop ; the ova measures about YTQo of an inch in diameter. An ordinary tapeworm contains some five million ova. The parasite is firmly embedded in the mucous membrane of the upper third of the small intestines by its booklets and suckers. The lower or terminal segments represent the adult and complete animal, and are termed the proglottides, which separate from the parasite and are discharged either alone or with the faeces. The tania saginata is from ten to forty feet in length, has a rounded or oval-shaped head, measures about ^ of an inch, and has four strong and prominent suckers, but tio booklets, — whence the term " unarmed tapeworm " ; the neck is short and thick and the segments are larger, stronger, and thicker than those of the taenia solium. The Bothriocephalus latus is the largest of the three Cestoda, the length ranging from fifteen to sixty feet, the head oval, measuring about -^^ of an inch, a short neck, the segments or joints being nearly three times as broad as they are long. Its color is a dull, bluish-gray. Zoologically considered, this variety is not a true tapeworm. 136 PRACTICE OF MEDICINE. Syruptoras. Not unfrequently a tcenia produces no symptoms whatever. Usually, however, there are colicky pains \.\ixo\xgho\xl the abdomen, inordinate appetite, disorders of digestion, emaciation, constipation, attacks of cardiac palpitation, faintncss, disorders of the special senses, und pruritus of the anus and nose. Any or all of these symp- toms may be present. A large meal will often remove the majority of the symptoms present. In a large number of cases the discovery of the sejpnents is the first intimation of the presence of the parasite. Treatment. A number of remedies — termed taeniafuges — are used more or less successfully for the expulsion of the tapeworm. The very best of these remedies is undoubtedly oleoresince aspidii, foss (2 Cc), repeated or in the following combination : R . Oleoresince aspidii f^ij 8. Cc. Chlorofornii f^ij 8. Cc. Olei tiglii, TTLiv .24 Cc. Glycerini, f ~ ij 60. Cc. M. SiG. — Take half at 8 A. M. ; the rest in an hour if needed (Dock). The other tsniafuges often successful are : e.xtractum granati rad. cort. fluidu7n, f^ss-ij (2-8 Cc), or a decoctum granati rad. cott. (sij — 60 Gm. — bark of root, aquae Oj — 480 Cc), wineglassful every hour until all is taken, as suggested by Prof. Bartholow ; or oieum pepo express., foj-iv (4-15 Cc), followed by oleum ricini. Creosotum has been successful in a number of cases. Several cures are reported ixom glyccrinum, f3ij-f5J (8-30 Cc), repeated p. r. n. A much pleasanter remedy is pelietierine, the active constituent of granatum, used in the form of the tannate, gr. .\-x.x (0.65-1.3 Cm.), or Tanrei's solution of pcllciierine. An important precaution in the management is close attention to the " preparatory treatment " rendered essential to remove the mucus in which the head {^co\&x) is embedded. It consists in the adminis- tration of a thorough purgative for one or two days, and a light diet, such as milk and broths, preceding the use of the taeniafuge. INTESTINAL PARASITES. 137 ROUND WORMS. Varieties. Ascaris himbricoides ; Oxyuris ver7nicularis. Causes. The ascaris lumbricoides is one of the most common of the parasites affecting the human family, and develops in the intes- tines, either after the entrance of the ova of the same, or from the so- called " intermediate parasites." Their entrance is effected by means of the food and drink. The oxyuris vermicularis develops in the large intestines, from either its peculiar ova or the so-called " intermediate parasite," these finding their way into the bowel with the food and drink, or by direct contact. Description. The ascaris lutnbricoides, or the round woriii, is of a brownish color, a cylindrical body, from ten to twenty inches in length, and from an eighth to a fourth of an inch in circumference ; the head terminates in three semilunar lips, each having about two hundred teeth. The ova are oval-shaped, are produced in immense numbers, some sixty million in a mature female, have wonderful vitality, resist- ing extreme heat or cold. The round w or 7n inhabits principally the small intestines, although it often migrates to other parts. They are found in numbers from one to several hundred. The oxyuris vermicularis, thread, or seat worm, resembles an ordi- nary piece of white thread, measuring from a sixth to a half inch in length, the head terminating in a mouth with three lips, the tail i&r- minating as a sharp point. The ova are oval, produced in large numbers, each female containing about ten thousand, and are sur- rounded by a stout envelope, which increases their vitality. The seat worm, as its name indicates, inhabits the large intestines, especially the rectum, although they frequently migrate to the sexual organs. They vary in number, sometimes the parts frequented being entirely covered. Symptoms. The ascaris li^nbricoides, or round worm, may be present in great numbers and yet produce no characteristic symptoms other than gastric and intestinal irritation, causing picking the nose, foul breath, colicky pains, nausea and vomiting, diarrhoea, and dis- turbed sleep, such as tossing from side to side of bed and grinding the teeth. Any or all of these symptoms may be present or absent ; a positive diagnosis is only possible upon the passage of the parasite. 138 PRACTICE 01-" MEDICINE. The oxyuris vermicularis, or seat worm, produces intense itihing about the anus, with a desire for stool, the passages often containing much mucus, the result of the irritation produced by their presence. Should they migrate to the sexual organs, intense itching of these parts results, which, unless speedily corrected, leads in children to masturbation. Treatment. The ascaris Itimbricoides are readily removed by the following " worm powder " : H • S.-intonini, gr. ^-j-ij .Ol6-.065-.i3 Cm. Ilydrargyri chlor. mills, .... gr. j^'-ij .022-. 13 Cm. M. Ft. chart. SiG. — At bedtime, followed by a dose of cleutn ruini before breakfast. For the oxyuris vermicularis the above santoninuvi powder, with the use oi enemata oi quassia, aluinen, sodii chloridum, or R. Acidi carbolic!, gr. v-x .3-6 Gm. Aquae, Oj 480. Cc. according to the age, the injection not to be retained ; or an enema of a weak solution of corrosive sublimate (i to 10,000). Always precede any of the medicated enemata by a large injection of water to unload and clear the rectum. Washing the anus and external genitals with a solution of acidum carbolicutn should also be employed. For the pruritus ani apply a little tinguentum hydrargyri or extractum ham- amelis fluidttm. TRICHINOSIS. Synonyms. Trichiniasis; Trichina;; Trichina spiralis; "flesh- worm disease." Definition. A typhoid condition, the result of the entrance of a parasite — the Trichina spiralis — into the intestinal canal, and their subsequent migration into the muscular structure; characterized by severe gastro-intestinal irritation, severe muscular soreness, and a low typhoid condition. Cause. The Trichince spiralis are introduced into the human body by eating the infected hog's flesh, either raw or but partly cooked. Description. The parasite is found in two forms, to wit: intes- tinal trichina, which is sexually mature, and muscle trie hina,v/\\\ch. is sexually immature. INTESTINAL PARASITES. 139 The intestinal trichina is a small, hair-like worm, the male meas- uring y\ of an inch, and the female }i of an inch in length ; the head is smaller than the rest of the body ; the tail of the male has a bi-lobed prominence, between the divisions of which the anal opening is placed, and from which a single spiculum can be protruded ; the female has a blunt, rounded tail, the reproductive outlet being situated toward the anterior part of the body ; the ova are very small, containing embryos being produced viviparously at the rate of at least one hundred each week after the entrance of the female into the intestinal canal. The muscle trichina develops its sexual apparatus after it has entered the intestinal -canal of the host. The viable embryos discharged from the female are in a state of motion, and at once migrate from the intestines to the muscular structure of the individual, and here set up inflammatory action, they becoming surrounded by a capsule or shell in which they are coiled. After a time, in the muscle, the trichina undergoes a further change ; lime salts being deposited in and about the capsule and in the para- site itself, when minute specks of lime are seen distributed throughout the muscular structure. The development of the parasite from the period of impregnation up to the time of sexual maturity is, under favorable conditions, less than three weeks. Within two days from the ingestion of the infected pork occurs the maturation of the muscle larvae ; in six days more the birth of embryos occur, and in about two weeks the migrating nrogeny have arrived at their habitat, the muscular structure. Symptoms. These depend upon the number of parasites in the infected food. According to Dr. Sutton, of Indiana, a piece of pork the size of a cubic inch contained eighty thousand trichinee. There are three stages described, to wit : the intestinal, the migration, and the encapsulation. Intestinal stage, a gastro-intestinal inflammation, v^\'(hnausea,vom- iting, and watery diarrhcea, the severity depending upon the number of the parasites ingested. Migration stage, a typhoid-like fever, rapid, feeble pulse, profuse sweats, intense thirst, dry tongue and lips, and red, swollen face, with soreness and tenderness of the muscular structure, increased by any muscular act. As a rule the mind is clear but decidedly apathetic. 140 PRACTICE OF MEOICINE. Encapsulation Stage. If the number of parasites ingested has been few, recovery may occur in this stage ; but if the number has been large, the gastro-enleritis, fever, and niuscuhir phenomena are severe, the patient is in a critical condition, between twenty and fifty per cent, succumbing. Diagnosis. Unless the physician has some intimation of the cause, cases are readily mistaken for either ordinary ileo-coliiis or t) i)hoid fever. Prognosis. Depends upon the number of trichinae in the pork eaten. Mortality between twenty and fifty per cent. Treatment. The preventive treatment consists in eating no pork that has not been so prepared as to kill any trichina; that might exist. If the parasites have been recently taken, within the first four or five d2iys,, emetics z.r\d. purgatives or the stomach washed out with intes- tinal irrigation to remove them from the stomach and intestinal canal are indicated. After thorough action from these, attempts may be made to destroy such of the parasites as have escaped the action of the emetic or purgative. For this purpose much is said in favor of glycerini, one part ; aquce, two parts ; so that one teaspoonful (4 Cc.) of glycerinum be administered every hour ; or a trial can be made of acidum carbolicum and tinctura iodi, as suggested by Prof. Bartholow. QuiniiKx sulphas gave the best results in the cases seen by Dr. Sutton. After migration has begun, the powers of life should be sustained by nourishing food, stimulants, and tonics, as "there are no drugs which have any influence upon the embryos in their migration through the muscles." (Osier.) DISEASES OF THE PERITONEUM. PERITONITIS. Synonym. Inflammation of the peritoneum. Definition. A fibrinous inflammation of the peritoneum, either acute or chronic, characterized by fever, intense pain, tenderness, tympanites, vomiting, and prostration. It may be limited to a DISEASES OF THE PERITONEUM. 141 part, local, or it may involve the entire membrane, general, peri- tonitis. Causes. Aaite variety : Intense cold ; protracted irritation by blisters ; blows upon tiie abdomen ; penetrating wounds of the abdo- men ; inflammation or perforation of the stomach, intestines, gall or urinary bladder, vermiform appendix, or the surrounding parts ; in- flammation of the pelvic viscera ; septicaemia or pysemia ; erysipelas ; hernia. Many surgeons doubt that peritonitis is ever an idiopathic disease, but that rarely it does so occur is probable. Chronic variety: Tuberculosis; nephritis; scrofula; cancer; sclerosis of the liver. Patholog'ical Anatomy. Acute form : hyperasmia of the serous membrane, the capillaries distended and occasional extravasations of blood from their rupture ; the normal secretion is arrested, and the shiny membrane becomes dull and opaque, from an exudation of pure fibrin, which is adhesive, gluing the parts together ; if the inflam- matory action is now arrested, it is termed adhesive peritonitis ; if, however, the action progress, an effusion of serous fluid is poured out into the peritoneal cavity, the amount varying from a few ounces to several gallons ; this is termed exudative peritonitis. If recovery result, the fluid is absorbed with much of the solid exudation, the unabsorbed portions forming adhesions between the membrane and the different abdominal organs, often causing great deformity and irregularity in their relations. Local circumscribed peritonitis is the same as general except that adhesions develop around the site of attack so rapidly that the inflam- matory action is encapsulated. Why this occurs in some cases and not in others is not known. Pus develops if the absorption is not prompt or if any cachexia be present. The chronic form follows the acute, or is associated with tubercu- losis, scrofula, Bright's disease, or sclerosis of the liver. The membrane is irregularly thickened and opaque, with strong adhesions to one or more coils of the intestine, the liver, or spleen ; the quantity of fluid present is small, purulent, or sero-purulent in character, and encysted by the agglutinated membrane. Symptoms. Acute form: the onset is sudden, with a ^/^z7/,y^z/^r, ioi-2)°, pulse 100-140, wiry and tense, severe pain, cutting or boring in character, and tenderness, becoming so great that the slightest 142 PRACTICE OF MEDICINE. touch aggravates it, the ihcubiius being on the back with flexed thighs; \\\c ixbdomcn is distendid and rt'jp'd, from constipalion, effu- sion, and meteorism ; the diaphragm is pushed up as far as the third or fourth rib in severe cases, causing compression of the lungs and displacement of the heart, liver, and spleen. There is ivipaircd appe- tite, intense thirst, and nausea and vomiting are almost constant, as is hiccough. The patient passes through the varioi's steps of the dis- ease rapidly, collapse soon occurring. It is a clinical fact that a sub- normal temperature is of frequent occurrence in acute peritonitis. Secondary form, from extension, begins with local and gradually increasing pain, the temperature increases, tense pulse, and vomiting. If from perforation, it is announced by severe pain and all the symptoms of shock. Purulent peritonitis, usually secondary (most commonly seen in those with chronic Bright's disease), is accompanied with hectic phenomena. These symptoms continue from six to eight days, when they begin to decline and a tedious convalescence ensues, or pain and tender- ness grow more marked, strength fails, surface cold, pulse rapid, and collapse, with hippocratic face, anxious expression, pinched features, sunken eyes, and drawn upper lip. Chronic fonn, usually of tubercular origin, though other causes are given, shows irregular chills, fever, and sweats, distended abdomen, constipation alternating with diarrhoea, diffused tenderness, with points of intenseness 2^nd hardness; co/icky pains during digestion, rapid emaciation, and failure of strength. Usually the lower portions of the abdomen give a dull note on percussion, from the presence of fluid, or scattered points of dullness, showing the presence of encysted fluid. Diagnosis. The question of diagnosis in peritonitis is of great importance, as it is so frequently, if not always, associated with the diseases and accidents of the abdomen. Acute gastritis differs from peritonitis in having a history of cor- rosive poisoning, severe pain, limited to the stomach, with early and severe vomiting; while the latter has fever, diffused abdominal pain and tenderness, with decided distention. Acute enteritis has localized pain and tenderness witli marked diarrhoea; constipation being the rule in peritonitis. Rheumatism of the abdominal muscles occurs with a rheumatic DISEASES OF THE PERITONEUM. 143 history, is subacute, lacks the great abdominal distention and suffer- ing expression of peritonitis, and, while tenderness exists, it is not aggravated by deeper pressure. Biliary colic, or the passage of a gall-stone, has, as a prominent symptom, excruciating pain, localized over the common bile duct, which is of a paroxysmal character and followed by slight passing jaundice. In renal colic the acute pain follows the course of the ureters, with retracted testicle and altered urinary secretion. Prognosis. Always uncertain, but if symptoms progress slowly, quite favorable, as fatal cases usually end during the first week. Cases from perforation unfavorable. Chronic peritotiiiis being generally of tuberculous origin, the prog- nosis is unfavorable, although partial and complete recovery results in the cases following the acute form of the disease. Treatment. The peritoneal membrane being of such vast extent, its general inflammation is one of the most formidable diseases the physician meets. Acute form : Idiopathic and robust cases, locally, leeches or wet cups, followed by cold or hot applications, as most agreeable, or covering the abdomen with a blister ; adynamic cases, dry cups, fol- lowed by warm applications medicated with tinctura opii. The profession is divided between two plans of treatment for peri- tonitis, one side favoring opiiun and the other party as strongly urg- ing saline purgatives and laparotomy. Prof. Da Costa says opium and quinines sulphas are the remedies indicated at the onset of the disease, to wit: at once hypodermic of morphines sulphas, gr. X~/i (0.016-0.022 Gm.), maintaining the effect by hourly doses of either morphincB sttlphas or opium, by the mouth. Prof. Clark ascertained the tolerance of opium in this disease by the tremendous amounts used in a case under his care ; the first day he gave 200 gr., the second day 472 gr., the third day 236 gr., fourth day 120 gr., fifih day 54 gr., sixth day 22 gr., and on the seventh day 8 gr. Prof. Clark found that, as a rule, however, morphines sulphas, gr. Yd-^i (0.011-0.016 Gm.), every two hours, would maintain the effects of the drug. The opiiim. should be guarded with sufficient doses of atropines sulphas. Quinines sulphas, gr. v (0.3 Gm.), every four hours until exudation, after which gr. ij (0.13 Gm.), four times a day, is of marked benefit. While the opium treatment places the patient a§well as the bowel§ 144 PRACTICE OF MKDICINE. "in splints" and relieves the pain, it is urged by the advocates of saline purgatives, however, that instead of locking up the bowels, the use of salines puts the bowels into active peristaltic action, whereby the peritoneal cavity is drained of the products of inflammation and the inflamed surfaces are relieved of all engorgement by a thorough depletion of the vessels in the intestinal walls, the pulse and temper- ature are improved, the pain is lessened as quickly as by opium, and the formation of adhesions and bands is prevented. Should the active symptoms continue under either plan of treat- ment, laparotomy is indicated, and indeed there is a growing opinion that cases of peritonitis should at once be handed over to the surgeon. The decline of the vital powers must be averted by regulated nutri- tion and/ree stimulation. Locally, an ointment of belladonna and hydrargyrum is of value. During convalescence, perfect quiet, nourishing diet, moderate stim- ulation, scattered flying blisters, and the following: R. Potassii iodidi, gr- v-x -S-^ Gm. Ferri pyrophos Rf- ij 13 tJm- Elix. simpl., f^ss 2. Cc. Aqua; destillatse, ad f 3 ij ad 8. Cc. Every six hours. should constitute the treatment, with tonic doses of quinines sulphas. Peritonitis from perforation, absolute quiet, hypodermic injections of morphincE sulphas, ice locally, and stimulants per mouth, rectum, or hypodermically, and laparotomy. For puerperal and other varieties of peritonitis following disease of ovaries, tubes, uterus, and laparotomy, the reader is referred to works on gynecology and surgery. Chronic peritonitis ; locally tinctura iodi, and internally opium, for pain ; potassii iodidum as an absorbent, with nourishing diet, oleum morrhucB and stimulants, and rest in bed. ASCITES. Synonyms. Dropsy of the abdomen ; peritoneal dropsy ; hydro- peritoneum. Definition. A collection of serous fluid in the abdomen, or more correctly in the peritoneal cavity ; characterized by a distended abdo' DISEASES OF THE PERITONEUM. 145 men, fluctuation, dullness on percussion, displacement of viscera, embarrassed respiration, ^/z^j the symptoms of its cause. Causes. Ascites may form part of a general dropsy, to wit : car- diac or nephritic. The most common factor in its production is a mechanical obstruction of the portal system from cirrhosis of the liver, pressure of tumors, diseases of the heart or lungs. Pathological Anatomy. The quantity of fluid in the perito- neal sac varies from a few ounces to many gallons. It is generally of a straw color, or at times greenish, and is transparent, having an alkaline reaction. When blood is present in any great quantity, it points to cancer as a cause. The peritoneum becomes cloudy, sod- den, and thickened, from long contact with the fluid. Symptoins. The onset is insidious, and considerable swelling of the abdo7neft occnrsh&fore. the disease attracts attention. Constipa- tion, from pressure of the fluid on the sigmoid flexure. Scajiiy urine, from pressure on the renal vessels. Embarrassed respiration and cardiac action, from displacement of the diaphragm upward. The umbilicus is forced outward. Physical signs : oxv palpation, a peculiar wave-like impulse is im- parted to the hand lying on the side of the abdomen, while gently tapping the opposite side. Percussion :■ patient erect, the fluid distends the lower abdominal region, with dullness over the site of the fluid and a tympanitic note above ; if the patient turns on his side, the fluid changes, and dullness over the fluid, tympanitic note over the intestines. Diagnosis. Ovarian tumors differ from ascites in the history, in that the enlargement is limited to the iliac fossa, instead of a uniform abdominal enlargement, not changing its position when the patient changes posture, and by the detection of a tumor by conjoined manipulation through vagina, or by rectal exploration. Pregnancy differs from ascites in the character of the enlargement, the history, absence of menses, increase of mammae, change in the neck of the uterus, absence of fluctuation, and the presence of the sounds of the foetal heart. Distention of the bladder hsiS been mistaken for ascites ; the points of distinction are, in the former, the history, presence of tenderness over the bladder, rounded outline of the percussion dullness, and the relief afforded by the catheter. Chro?iic peritonitis is differentiated by the history, pain, tenderness, 10 146 PRACTICK OF MKOICINE. more or less vomiting, thickened abdominal walls, and its generally being associated with tubercle or cancer. Chronic tympanites presents the enlarged abdomen, but lacks the history, the dullness, and the fluctuation, giving instead a tense abdo- men and a universal tympanitic note. Prognosis. Influenced by the causes producing it. Idiopathic ascites, which is most rare, terminates in health within a few weeks. If peritonea/, generally favorable. If from ori^anic disease, most unfavorable, for while the dropsy may be removed, it as rapidly returns. Treatment. The first indication is to treat the cause of the ascites and the second to remove the fluid. Three modes of removing the fluid present themselves : ^rj/, by hydragogue cathartics ; second, diuretics and diaphoretics, and third, tapping. The first and second modes may be combined, as follows: R. Pulv. jala])a; comp., 3J-'j 4.-8. Gm. In water, an hour before breakfast; And— R. Potassii acetat., gr. xxx 2. Gm. Spts. setlieris nitrosi T^V xv I. Cc. Infus. digitalis, . . . q. s. ad f 5 ij ad 8. Cc. M. Every six hours. Or instead use the following : B M. Hydrargyri chlor. mitis, . . . gr. iij Ext. opii, gr. ^V Ft. pil. .2 Gm .005 Gm. Sic. — One every three or four hours. If these fail, as they certainly will after a time, the embarrassed respiration and cardiac action will call for tapping, which may be done with the trocar or the aspirator. The tapping does not remove the cause, and the fluid often rapidly accumulates again. Before tapping always examine the bladder, using the catheter if there be any doubt. As all modes of treatment weaken the patient, the diet should be highly nutritious, and the system supported with strychnincB sulphas. DISEASES OF THE BILIARY PASSAGES. 147 DISEASES OF THE BILIARY PASSAGES. CATARRHAL JAUNDICE. Synonyms. Catarrh of the bile ducts ; icterus. Definition. An acute catarrhal inflammation of the mucous membrane of the bile ducts and of the duodenum ; characterized by gastro-intestinal derangement, yellowness of the skin and sclera, itching of the skin, feverishness, and mental depression. Causes. Excesses in eating and drinking; a debauch ; malaria; climatic, as cool nights succeeding warm days. Pathological Anatomy. The mucous membrane of one or more of the bile ducts, or of the duodenum, becomes hyperasmic, swollen, and thickened, from an effusion of serum into the submucous tissue ; the result of this condition is the closure of the biliary pas- sages, thereby impeding the outward flow of bile. The bile in the hepatic ducts being retained by the obstruction, the result is a stain- ing of the liver substance and an absorption of bile, and its appear- ance in the blood. Symptoms. Begins by epigastric distress, coated tongue, im- paired appetite, nausea, with perhaps vomiting, and looseness of the bowels and slight feverishness, the phenomena of a gastro-intestinal catarrh. In from three to five days the eyes becotne yellow and jat/n- dice gradually appears over the whole body ; the feverishness disap- pears, the skin becomes harsh, dry, and itchy, the bowels constipated, the stools whitish or clay-colored, accompanied with muchy?a/z«, and colicky pains ; the uritie heavy and dark, loaded with urates and con- taining biliary elements. A few drops of the urine placed on a whitish surface, and a drop or two of nitric acid made to flow against it, will exhibit the following "play of colors" : a greenish tint, from the conversion of bilirubin into biliverdin, quickly followed by bhie, violet, red, and yellow, or brown. When XhQ Jaundice is complete, the surface is cold, the heart" s action slow, the mind torpid and greatly depressed, and pain or tenderness on pressure over the hepatic region. 148 PRACTICE OF MEDICINE. Duration. In from three to five days after the jaundice appears the symptoms subside, save the torpid bowels, depression, and discol- ored skin, which slowly disappear, often requiring a week or two. Diagnosis. There are two varieties of jaundice, and in arriving at a diagnosis this must be remembered. There is hepatogenous, obstructive or catarrhal jaundice, and hematogenous, non-obstructive or blood-change jaundice. The numerous diseases of which jaundice is a symptom will be differentiated when treating of them. Prognosis. Catarrhal jaundice always favorable; if the attacks are of frequent occurrence, however, they are apt to lead to organic hepatic changes. If jaundice shows tendency to linger, it is probably result of organic condition. • Treatment. Rest in bed, with a carefully regulated diet, avoiding all starchy, fatty, or saccharine articles, milk being the most suitable, adding lime-water if the stomach be irritable. The jaundice being the result of an acute catarrh of the duodenum and the ductus choledochus communis, treatment is to be directed to this condition by such remedies as sodii phosphas, 3j (4 Gm.), well diluted, every four hours, or calomel and soda (R . Hydrargyri chloridi mitis, gr. % (0.016 Gm.); sodii bicarbonatis, gr. iij (0.2 Gm.) ; sacc. lac, gr. iij (0.2 Gm.) ; M. SiG. — Taken dry on tongue every two or three hours until one dozen are used, followed by Hunyadi Janos water), or the following : fit. Sodii bicarb., ^:^iv 15. Gm. Tinct. nucis vom., f .o iv 15- Cc. Tinct. capsici, f^j 4. Cc. Tinct. rhei, f,^ij 60. Cc. Inf. gent, comp., . . . q. s. ad f5vj ad 180. Cc. SiG. — Dessertspoonful every four or five hours, in water. For the dry, itchy skin diaphoresis is indicated. The warm or hot bath night and morning is valuable, adding potassii carbonas, 5J (30 Gm.) to each. A weak carbolic solution often relieves a troublesome itching, 2LndJ)otassii bromidi, gr. xxx (2 Gm.), overcomes the insomnia and restlessness of itching. If the urine continues scanty, diuretics shouXd be used, a simple and efficacious one being potassii bitartras lemonade at very frequent intervals. Spiritus cetheris nitrosi, tt\,x-xx (0.6-1.3 Cc), diluted, is always valuable for torpid kidneys. DISEASES OF THE BILIARY PASSAGES. 149 If under the above plans of medication the constipation continues, a pill of aloes and podophyllum may be useful. A special plan, which is said to be effective, is with " enemata of cold water. By means of an irrigating apparatus the large intestine is well distended with water once a day for several days. The first enema has a temperature of 60° F., and subsequent injections are a little warmer. The increased peristalsis of the bowels and the reflex contractions of the gall-bladder dislodges the mucus obstructing the gall ducts. When the bile flows into the intestine, digestion is resumed and the catarrhal inflammation subsides," Other remedies may be conjoined with the irrigation method. For convalescence : R. Strychninaa sulph. , gr- ss .03 Gm. Acid, nitrohydrochloric. dil., . . fjiv 15. Cc. Tinct. gentian, comp., f^iiss 75. Cc. SiG. — Teaspoonful after meals, well diluted. BILIARY CALCULI. Synonyms. Hepatic calculi ; gall-stones ; hepatic colic. Definition. Concretions originating in the gall-bladder, or biliary ducts, derived partly or entirely from the constituents of the bile. Their presence is generally unrecognized until one or more attempt to pass along the ducts, when an attack oi hepatic colic is produced. Causes. Gall-stones result from the precipitation of the crystal- lizable cholesterine, and its combination with inspissated mucus in the gall-bladder or ducts. A disease of middle life, and more frequent in the obese, and in women. Gall-stones are said to be common in carcinoma of the stomach or liver. Pathological Anatomy. Cholesterine is the chief constituent of biliary calculi. Commonly several stones exist, and rarely one ; as many as six hundred are recorded. They are generally found in the gall-bladder or cystic duct, rarely in the liver or hepatic duct. Symptoms. The presence of gall-stones or biliary calculi is made known only by their expulsion from the gall-bladder, whence is developed hepatic colic. 150 PRACTICK OF MEDICINE. Hepatic colic begins suddenly, at the moment a gall-stone passes from the gall-bladder into the cystic duct. The patient is seized with a piercing, agonizing pain in the region of the gall-bladder, and spreading over the abdomen, right chest and slioulder; tlie abdominal muscles are cramped Sirxdi tender ; there are nausea and 7>oiniiing, a. smM,/eedle pulse, cool skin, pale, distorted, anxious face, with, may be, fainting, spasmodic trembling, chills, or convulsions. The paroxysm continues from an hour or two to several days, with remissions, but entire relief is not afforded until the stone reaches the duodenum, when the pain suddenly ceases. Jaundice usually follows the paroxysm of pain. When the calculi reaches the intestines, the pain, nausea, and vomiting cease, the appe- tite returns, and the jaundice soon disappears. Should the calculi become impacted, ulcerative perforation and consequent /y purgatives and diuretics, but sooner or later tapping becomes necessary. AMYLOID LIVER. Synonyms. Waxy liver ; lardaceous liver ; scrofulous liver ; albuminous liver. Definition. A peculiar infiltration into, or a degeneration of, the structure of the liver, from the deposit of an albuminoid material which has been termed amyloid, from a superficial resemblance to starch granules. Causes. The chief cause is prolonged suppuration, especially of the bones ; coxalgia; syphilis; cancer. Pathological Anatomy. The liver is uniformly enlarged. It presents a pale, glistening, translucent appearance, and has a doughy consistency. On section, the surface is homogeneous, is ansemic and whitish. The deposit begins in the arterioles and capillaries, finally closing them. The reaction with iodine and sulphuric acid affords a certain test of the amyloid or albuminoid deposits. After further cleansing, brush over the parts a solution of iodine with iodide of potassium in water, when they will assume a mahogany color, and if diluted sulphuric acid be added, a violet or bluish tint is produced. A pretty reaction is to take a one per cent, solution of aniline violet, which strikes a red or pink color with the amyloid or albuminoid material, while the unaltered tissues are stained blue, thus showing a beautiful contrast. The amyloid change involves the spleen, kidney, intestines, and other organs. Symptoms. Nothing characteristic. Hepatic dullness increased, with prominence over the liver ; absence of pain ; splenic dullness increased ; emaciation and anEemia ; urine increased in amount, pale and containing some albumin, due to amyloid changes in the kidneys. Disorders of digestion, with diarrhoea, due to amyloid changes in the intestines. Jaundice is rare. Ascites seldom occurs. 158 PRACTICE OF MEDICINE. Prognosis. Unfavorable. The progress is rapid or slow, depend- ing upon the cause. Treatment. No specific. Prof. Da Costa recommends ammonii chloriditm,gx. x-xx (0.6-1.3 Gm.), three times daily, for several weeks, then change for the same length of time to syrupus ferri iodidum, beginning with n\^x (0.6 Cc), gradually increased to fSj (4 Cc.) after meals, then to the former again, and so on, for months. Life may be prolonged by the use of ferrum, syrupus calcii lactophosphas, and oleum morrhuce. HEPATIC CANCER. Synonym. Carcinoma of the liver. Definition. A peculiar morbid growth, progressively destroying the hepatic tissue ; characterized by disorders of digestion, anaemia, emaciation, jaundice, and ascites, and terminating in the death of the patient. Causes. Hereditary, when it is termed primary cancer; exten- sion from other organs, termed secondary cancer. It is a disease of advanced life, from forty to sixty years of age. Pathological Anatomy. The most common variety of cancer of the liver is a compound of the medullary and scirrhus. The cancer cells develop from the interlobular connective tissue, and as they grow the hepatic cells atrophy, the result of the pressure of the new growth. The branches of the hepatic artery enlarge and permeate the growth, while the branches of the portal vein are compressed and atrophied, thereby blocking up the portal circu- lation. The cancer may develop in nodules or masses, or maybe diffused ; the nodules vary in size, and those on the surface are rounded, with a central umbilication. The peritoneum is adherent, cloudy, and thickened. Symptoms. The development of hepatic cancer is preceded by a history of dyspepsia, flatulency, and constipation. Uneasiness, weight, and pain, increased by pressure, are noticed ; jaundice, ascites, occasionally intestinal heviorrhages, emaciation, feebleness, anccmia, cold, dty, harsh skin, pinched features, with dejected, worn expression. Fever never occurs unless there is some complicating DISEASES OF THE KIDNEYS. 159 condition. The hepatic dullness is increased, with pains on palpa- tion, and the liver is indurated, irregular, and nodulated. The duration is less than a year from the time the disease is recog- nized. Diagnosis. The points of differentiation are the age, cachexia, pain, and tenderness, enlarged liver with hard nodules, and rapid emaciation and progress of the disease. Prognosis. Always terminates in death. Treatment. Early symptomatic. Sooner or later opium must be used to relieve the terrible and persistent pain. DISEASES OF THE KIDNEYS. THE URINE. The normal quantity of urine voided varies from forty to fifty ounces (1200-1500 Cc.) in the twenty-four hours ; it is decreased by free perspiration and increased hy chilling of the skin. Within the twenty-four hours, the least urine is passed during the night or in the early morning, very much the greater portion being passed during the course of the day. The normal color is light amber, due to urobilin ; the color deepens if the quantity voided be decreased, and vice versa. In nearly all normal urine a cloud of mucus forms after standing a short time. The normal reaction is slightly acid, due to the acid sodic phos- phate, uric and hippuric acids. After meals it may be neutral or even alkaline. The normal specific gravity varies from 1.015 to 1.02; it is low when an increasecJ quantity is passed, and high when the quantity is diminished. The normal odor of urine is a peculiar, well-known, aromatic one ; it is altered by certain foods, such as the violet stench after eating asparagus, and the garlicky odor after using garlic. IGO rRACTICK OK MTDICINE. The most important organic and inorganic solid constituents held in solution, are un-a (the index of nitrogenous excretion), from 308 to 617 gr. daily ; uric acid, from 6 to 12 gr. ; urates of sodium, ammo- nium, potassium, calcium, and magnesium, from 9 to 14 gr.; phos- phates of sodium, etc., from 12 to 45 gr., and chlorides of sodium, etc., from 154 to 237«gr. daily. I. Quantitative test for urea by hypobro- mite of sodium (Davy's method). II. Tests for urates and uric acid by nitric < acid. Fill a graduated glass tube one-third full oi mercury, and add one-half drachm of the 24 hours' urine; then fill the tube ever.l\ full with a saturated solution of hypobromite of sodium, and close it imtnediately with the thumb; invert the tube and place its open end beneath a sat. sol. of chloride of sodium ; the mercury flows out and is replaced by the solution of salt; nitrogen gas \s disengaged from the urea in the upper part of the tube. Each cubic inch of gas represents 0.645 gr. of urea in the half-drachm, from which the ^ amount passed in 24 hours may be calculated. Urine containing an excess of urates and uric acid, on cooling precipitates them (viz. : " brickdust deposits " in " pot dechambre "). i^a/ dissolves them to a certain extent. Nitric acid deprives the soluble neutral urates of their bases, and produces, at first, a faint, milky precipitate of amorphous acid urates ; adding more acid, the still less solu- ble red crystals of uric acid, resembling cay- enne pepper, are deposited. Put a small quantity of nitric acid in a test-tube, and pour the urine carefully down the sides of the tube upon it, and a zone of yellowish-red uric acid arfd altered coloring matter will form at their union ; and a dense, milky zone of acid urates above this, which, however, dissolve upon agitation. (See al- bumin test.) DISEASES OF THE KIDNEYS. 161 III. Ouantitativetest for uric acid by nitric ^ acid. IV. Test for the earthy and alkahne phosphates by the magnesium fluid. V. Test for the chlo- rides by nitrate of sil- ver. VI. Test for mucus by acetic acid and liq- ^ uor iodi comp. 11 To three ounces of the 24 hours' urine (after being shghtly acidulated, boiled, and filtered while hot) add one-te7ith as much jiitric acid ; place in a cool place for 24 hours, then collect the deposit of uric acid on a weighed filter, wash it thoroughly, and dry at 212° F. The increased weight represents ^ the uric acid in part excreted, approximately. Heat or liquor potasses increases the cloud- iness caused by earthy calcium and magne- sium phosphates. Acetic or nitric acid clears it by dissolving them. To two ounces of urine add one-third as much of the following solution ; R . Magnesii sulph., ammonii chloridi puri, liquor ammo- nise, each one part ; aquae destil,, eight parts ; if the precipitate has a milky, cloudy appear- ance, the quantity of phosphates is normal ; if creamy, the phosphates are in excess. To a convenient quantity of urine add a small quantity of nitric acid, to prevent the formation of the phosphates and other salts of silver ; filter this, if cloudy ; add to this 07ie drop of a solution of nitrate of silver (i part to 8) and the precipitate of white cheesy lumps of chlorides of silver denotes that the amount of chlorides is normal ; if, however, only a faint milkiness occurs, the chlorides y are diminished. Mucus alone is not visible, but causes cloudiness, from having entangled mucous or pus corpuscles, epithelium, granules of so- dium urate, crystals of oxalate of lime, and uric acid in various amounts. Add to the urine a little acetic acid, or, in ' addition, a few drops of liquor iodi comp., when threads and bands of mucift are made visible. The addition of nitric acid dissolves them. 162 PRACTICE OK MKDICINE. VII. Test for a/btt- min by heat and nitric < acid. Slightly acidulate the urine, if necessary, by addition of nitric or acetic acid, and boil ; this causes a white deposit of coagulated albiimm, which is not dissolved by nitric acid, unless the acid is in excess. Nitric acid causes a white deposit of coagulated albumin, which is dissolved if a large excess of acid be added. A delicate test is to put the nitric acid in the tube first, and then gradually pour the urine down the side of the tube upon it, when a white zone or ring of coagulated albumin appears. Pre- caution, see tests Nos. 3, 4, 11, and 13. VIII. Test for a/^«- mift by picric acid (saturated, watery so- lution). Pour a quantity of urine into a test-tube, and add the picric acid solution drop by drop and, as it passes through the urine, it is fol- lowed by an opaque white cloud if albumin be present. The test is very striking and beautiful. If cloudiness appears some time after, instead of at the time, it shows noth- ing. The test will not detect as small an amount of albumin as heat or nitric acid. IX. Nitric - magne- sian test for albumin. The fluid is prepared by mixing 1 part of pure nitric acid with 5 < parts of a saturated solution of the suK phate of magnesium, and filtering. X. Quantitative test for albumin. Approxi- mately. One drachm of the reagent is poured into a perfectly clean test-tube; the urine should be allowed to trickle slowly down upon the fluid; if albumin be present in an amount as small as one one-hundredth of one per cent., this test will show a compact, dense, white layer. This is one of the best and most reliable tests for albumin. Add a few drops of nitric acid to a pro- portion of the urine, and boil; set this away for 24 hours, and the proportionate depth of the resulting deposit is the comparative in- dication — viz. ; %-%, etc. DISEASES OF THE KIDNEYS. 163 For minute traces of albumin Millard's fluid may be used ; it is a delicate test and requires care. The fluid consists of glacial carbolic acid (ninety- five per cent.), 3ij (8 Cc.) ; pure acetic acid, 3vij (28 Cc); liquor potassse, 5'j, 3vj (84 Cc). XI. Test for blood ^ i%cr/ or «z7rzV acz"^ causes deposit of albu- by heat and nitric \ min, with the coloring matter changed to a acid. L dirty brown. ^ Heat the urine, then add caustic potash and heat anew. The phosphates are thus precipitated, taking with them the coloring matter of the blood, which imparts a dit'iy, yellowish-red color to the sediment, viewed by reflected light, and when seen by trans- mitted light, gives a splendid blood-red color. Neither the coloring matter of the blood, nor that of the bile, is precipitated with the phosphates, so that coloration of urine which shows this reaction cannot be ascribed to the presence of the latter pigments. When the quantity of blood in the urine is very large, it is of a dark or brownish-red, and, after standing, forms a coagulum of blood at the bottom of the vessel. Caution. Heat or nitric acid causes co- agfulation of the albumin. XII. Test for blood by heat and caustic potash (Heller's). XIII. Test for pus by liquor potass^. XIV. Test for bile by "fuming" or red nitric acid. Add to the urine, or preferably to its de- posit from standing, an equal volume of ■I liquor potasscE ; when well mixed, a viscid gelatinous fluid or mass is formed, which pours like the white of an e^Z' or jelly. Allow a specimen of urine and a few drops of red " fuming " «//rz"^ acid to gradually intermingle on a porcelain dish, and a "play of colors," green, blue, violet, red, ^v^A yellow or brown occurs, if biliary coloring matter be present. ]04 PRACTICE OF MEDICINE. XV. Test for bile pigment by pure hy- drochloric and pure nitric acids (Heller's). Pour into a test-tube about i.6-f5 of pure hydrochloric acid, and add to it, drop by drop, just sufficient urine Xo distinctly color it. The two are mixed. Then drop down the side of the test-tube pure nitric acid, which will " underlay " the mixture of hydro- chloric acid and urine. At the point of contact between the mixture and the color- less nitric acid a handsome " play of colors " appears. If the "underlying" nitric acid is now stirred with a glass rod, the set of colors which were superimposed upon one another will appear alongside of each other in the entire mixture, and should be studied by transmitted light. If the hydrochloric acid, on addition of the biliary urine, is colored reddish-yellow, the coloring matter is bilirubin; if it is col- ored ^r^^«, it is biliTerdin. XVI. Ttstiov sugar by liquor potassae and * heat (Moore's). Add to the urine half its volume of liquor potassce. (^Caution. This w/a^y give a white, flaky precipitate of the earthy phosphates, which should be removed by filtering.) Now boil ; this causes, at first, a yellow-brownish color, becoming darker if much sugar is present, due to glucic and finally to melassic acid. XVII. Test for sugar by subnitrate of bismuth, liquor potas- sai and heat. Add to the urine half its volume o{ liquor potassce, and then a little bismuth subnitrate, shake, and thoroughly boil ; the presence of sugar reduces the salt and black metallic bismjith is deposited, or, if but little sugar, a gray deposit occurs. Catition. Albumin must be absent. DISEASES OF THE KIDNEYS. 165 XVIII. Test for sugar by a solution of cupric sulphate, liquor < potassse, and heat (Trommer's). Add to the urine a few drops of a solution oi CKpric sulphate, and then its own volume oi liquor potasses. {Caution. On first addi- tion a light greenish precipitate occurs, which, on further addition of the reagent, if sugar or certain other organic matters are dissolved, giving a transparent blue liquid.) Now boil, and a yellowish precipitate of hydrated cupric stcboxide, occurring at once, denotes ihe. presence of sugar. Caution. Albumin must be absent. XIX. Quantitative test {ox sugar by Pavy s solution, to wit : R Cupric sulphate, 320 gr. Neutral potassic tartrate, . . 640 gr. Caustic potash, 1 280 gr. Distilled water, 20 f 5 . Keep corked. Take of Pavy s solution of cupric protox- ide, recently prepared (see margin), 200 minims or a multiple of this quantity, and boil in a porcelain dish ; while boiling, add minim by minim, from a measured portion of the 24 hours' urine, and it gives 2l yellow- ish precipitate of hydrated cupric suboxide, if sugar be present. Note carefully the gradual disappearance of the blue color, and when completed (best determined by looking through the margin of the fluid against the white porcelain dish), from the amount of urine used determine the amount of sugar passed daily. The quantity of urine containing one grain of sugar being just sufficient to reduce the 200 minims of the copper solution. XX. Quantitative test for sugar by fer- mentation and the specific gravity. Take two measured specimens from the 24 hours' urine, and to one add a little yeast. Place each specimen in a temperature of 75° to 80° F. ; in 24 hours fermentatioft hav- ing destroyed the sugar in the one contain- ing the yeast, the difference in the specific gravity of the two specimens expresses the number of grains in each ounce of the urine, approximately. 166 PRACTICE OF MEDICINE. XXI. Tests for In- doxyl-potassium sul- phate (Indican ?). Note.— If the urine con- tain albumin, it must be removed before applying these tests, otherwise the blue color often arising from the mixture of hydro- chloric acid and albumin after standing may prove misleading.— /"//''((y. XXII. Ehrlich's diazo-reaction test. I. McMunns Method : Equal parts of urine and hydrochloric acid, with a few drops of nitric acid, are boiled together, cooled, and agitated with chloroform. The fluid is col- ored violet, and shows an absorption band, before D, due to indigo blue, and another after D, due to indigo red. II. Taffe's Method : Mix lo Cc. of strong hydrochloric acid with an equal volume of urine in test-tube, and while shaking add, drop by drop, a perfectly fresh saturated solution of chloride of lime, or chlorine- water, until the deepest attainable blue color is reached. The mixture should next be agitated with chloroform, which readily takes up the indigo and holds it in solution. The quantity is estimated by depth of blue color. III. Pour 4 Cc. of hydrochloric acid into a small flask, and while stirring add from lo to 20 drops of urine. If the proportion of indigo be above normal, the resulting color will be rather light yellow ; if in excess, the acid will turn violet or blue, — the more in- tense will be the color in proportion to the quantity present. If no coloration appears after waiting a minute or two, there is no excess, no difference how deep a color may subsequently appear. I. Take 2 Gm. (30 gr.) of sulphanilic acid, 50 Cc. of hydrochloric acid, and 1000 Cc. of distilled water. II. Take solution sodium nitrite in water of the strength of 0.5 per cent. Place fifty parts of No. I and one part No. II in a test- tube and add equal amount of urine. The entire contents is rendered strongly alkaline by strong ammonia water. If the diazo-reaction occur, the mixture becomes carmine red ; now shake the tube, and if the red color is seen in ihtfoavi, the test is complete. Allow the tube to stand a day and a green precipitate forms. DISEASES OF THE KIDNEYS. 167 CONGESTION OF THE KIDNEYS. Synonyms. Renal hypersemia ; catarrhal nephritis. Definition. An increase in the amount of blood in the vessels of the kidneys ; when arterial, it is termed active congestion; when venoMS, passive co?tgestzon ; characterized by pain, frequent desire for urination, the amount of urine scanty, high-colored, occasionally containing albumin or blood. Causes. Active: from cold; irritating substances eliminated by the kidneys, as turpentine, copaiba, cantharides, carbolic acid, nitrate or chlorate of potash ; during the eruptive or continued fevers; in- juries over the kidneys. Passive : obstructive diseases of the heart or lungs, pressure of the pregnant uterus. Pathological Anatomy. The kidneys enlarge and increase in weight ; increased redness (the color being bluish li passive), with points of vascularity, corresponding to the Malpighian bodies, and occasionally minute ecchymoses. The abnormal hyperaemia causes a catarrhal state of the ducts of the pyramids, with shedding of their epithelium. If mechanical {passive) obstruction continues for some time, in- crease of the connective tissue with consequent induration and con- traction results, or a form of chronic Bright's disease. Symptoms. Active variety : pain over kidneys and following the course of the ureters into the testicles and penis, irritable bladder, almost constant and pressing desire for urination, the tiri7ie scanty, high-colored, and occasionally bloody, with fibrin, casts, and albumin ; there is, as a rule, no pain during the act of urination. The constitu- tional symptoms are headache, slight nausea, vomiting, and a general feeling of discomfort. If the condition persist, i7iflam7nation of the kidney results. Passive : the kidney changes are masked by the lung or heart trouble, until dropsy, scanty high-colored albumijious urine is ob- served. Prognosis. Active : if recognized and properly treated, favorable. Passive : controlled by the cause, and if prolonged, terminating in interstitial nephritis. Treatment. The most important indication is to ascertain and 168 PRACTICE OF MEDICINE. remove the cause. Rest of the body ; dry or wet cups over the loins; dilute the urine by increasing the quantity of bland fluids consumed; salitie purgLith'cs ; warm bath or other mild diaphoretics. lu/usutH digita/is is pre-eminently the remedy for congestion of the kidneys; if great irritability of the bladder, campliora, gr. ij-iv (0.13-0.26 Gm.) every four hours, combined with morphince sulp/ias, gr. -^\ (0.005-0.011 Gm.), or the hypodermic injection of morphina sul- phas, gr. -jV (0.005 Gm ). The treatment of the passive form resolves itself into the treatment of the cause, remembering that there is too much blood in the veins and too little in the arteries. There are three ways of restoring the circulation. By venesection, opening a large vein ; by increasing the power of the heart by the use of digitalis or strophanthus, preferably the first named ; and by dilatation of the capillaries with inhalations of aviyl nitrite or the internal use of spiritiis glonoini {miro-gXyctrxn I per cent, solution), TT\^j-iij (0.06-0.18 Cc.) every four hours. The bowels should be kept soluble by salines. ACUTE PARENCHYMATOUS NEPHRITIS. Synon3rms. Acute Bright's disease ; acute desquamative ne- phritis ; acute tubal nephritis ; acute croupous nephritis. Definition. An acute inflammation of the epithelium of the uriniferous tubules ; characterized by fever, scanty, high-colored, or smoky urine, dropsy, with more or less constant nervous phenomena, the result of acute urzemia. Causes. The young more liable than the aged ; cold and ex- posure ; scarlatina, diphtheria, and other infectious diseases; per- sistent use of irritants, as turpentine, canlharides, phosphorus, ginger, and others. Blows and injuries of the back have caused acute nephritis. Pregnancy is not an uncommon cause, resulting frequently in puerperal convulsions. Malarial poisoning. Patholo^cal Anatomy. The kidneys are generally swollen, engorged, more vascular, and of red color; in the second stage the organ remains large, irregularly red, especially the cortex ; the tubules are engorged and filled with epithelium, blood corpuscles, and fibrin. The capsule is easily detached, and is more opaque than normal. DISEASES OF THE KIDNEYS. 169 If a favorable termination, the swelling lessens, the vascnlarity diminishes, the tubules returning to their normal condition. Symptoms. In mild cases the slowly developing dropsy, with attcetnia, and dyspnasa, or simply shortness of breath, with weakness, are the only clinical phenomena present, the diagnosis being con- firmed by an examination of the urine. Usually, however, begins suddenly. Fever, with nausea and violent and persistent vomiting, duWpain over the kidneys, following the ureters ; frequent desire to urinate ; diarrhoea ; s^ift harsh and dry ; putse quick, tense, and full. Soon dropsy appears, the eyelids and face become puffy and swollen, followed by general oedema of the extremities, scrotum, and abdo- minal walls. If the attack follow scarlatina, there are from the onset much greater pallor and general debility. Uremic symptoms may develop any time during the attack. The urine is of high specific gravity, 1025 to 1030, scanty, smoky (like beef washings) in color, due to the presence of blood. Albumin is present in large quantities, and the microscope reveals casts of the uriniferous tubules, blood corpuscles, uric acid, urates, oxalate crys- tals, and epithelium. The total amount of urea eliminated during the twenty-four hours is lessened from one-fourth to one-half. The amount of phosphates and chlorides is also lessened. Duration from one to four weeks. Complications. Pericarditis, pleuritis, pneumonitis, peritonitis, and acute ttrtztnia, from retention and decomposition of urea in the blood. Diagnosis. The history, fever, scanty, smoky, albuminous urine, with dropsy beginning in the face, should prevent any error. Albu7ni7iuria may be confounded, on account of the presence of albumin in the urine, but lacks the clinical history, usually occurring in the course of some constitutional affection, as diphtheria, cholera, ) ellow fever, or erysipelas. Da Costa distinguishes between acute Bright's disease and acute nephritis by the last named " affecting only one kidney, by much greater pain and tenderness in the lumbar region, by the retraction of the testicle, and by the higher degree of febrile excitement. Then, tod, the deeply colored urine which is voided contains little or no albumin." Prognosis. Favorable. Majority of cases recover under prompt treatment. Rarely passes into chronic Bright's disease. Urcemic symptoms add to the gravity of the prognosis. no PRACTICE OF MEDICINE. Treatment. Absolute rest in bed until all symptoms have disap- peared. A strictly milk diet is the most suitable, but if there is much depression and weakness, may add animal broths and oysters. No tea, coffee, or stimulants. Water can be used ad libitum. Cream of tartar lemonade is a useful as well as pleasant drink. Locally, dry cups over the kidneys, followed by poultices — a digitalis poultice being of great value. A poultice oi jaborandi leaves and flaxseed, half and half, will increase the action of the kidneys. The bowels should be kept soluble with morning doses of salines or pulv. jalapa comp., 3j (4 Gm.), in water before breakfast, or elaterium, gr. ^ (o.oii Gm.), repeated p. r. n. Free action of the bowels assists in relieving the overtaxed kidneys, and conjoined with free diaphoresis seems almost indispensable in acute nephritis. Magnesii sulphas, in small and repeated doses, is a valuable cathartic in nephritis, as it acts upon the kidneys as well as the bowels. The most efficient diaphoretics are the hot-air bath or pack, or the wet sheet and blanket bath, stimulating the peripheral circulation, after free sweating has occurred, by rubbing with alcohol and water. For drugs, one of the very best is spiritus cetheris nitrosi, tt\^v-xxx (0.3-2 Cc), according to the age. Extractum pilocarpi fluidum, Tt\^v-xxx (0.3-2 Cc), according to the age, every three or four hours, is an excellent diaphoretic ; but as it is generally conceded that pilocarpus acts better when administered subcutaneously, employ pilocarpincB hydrochloras, gr. Y^ (o.oi i Gm.), repeated p. r. n., by the hypodermic method. Another valuable diaphoretic is vinum ipecacuanhce, Tt\j- iij (0.06-02 Cc), every half hour or so; combined with sweet spirits of nitre and neutral mixture it forms an excellent combination. Diuretics are of great value, indeed, often indispensable, in acute nephritis. Digitalis is the most reliable diuretic in this condition, and in the form of an infusion. The following formula of Millard's is suitable in the majority of cases : R. Tinct. digitalis, f .^ ss 15. Cc. Aceti .scili;^;, f .^ 'ss 45. Cc. Spts. a'tlieris nitrosi, fS'j ^- Cc. SiG. — Teaspoonful every two to four hours, in water. The following combination has given excellent results : li . Potassii acetat., ,^ iv 15. Gm. Inf. digital., f.^i'j 9°- Cc. Liq. potassii citratis, f^'U 9°- Cc. SiG. — Tablespoonful every two to four hours, in water. DISEASES OF THE KIDNEYS, 171 Other reliable diuretics are digitalinum (cryst.), gr. y^^ (0.00065 Gm.), caff'eincB citrata, gr. ij-iv (0.13-0.26 Gm.), or sparteince sulphas, gr- Vi-Y^ (0.02-0.03 Gm.). If urasmic symptoms develop, treat according to directions given in that section. As soon as the blood disappears from the urine, a course oift-rrum, in the shape of Baskam's Jtiixlure, until albumin disappears and health is restored. The following is the formula of Basham's mix- ture : R • Liq. ammon. acetat., f^^j iSo. Cc. Acid, acetic, f^iij I2. Cc. Tinct. ferri chlor., i'7,v 20. Cc. Alcoholis, f .1 ij 60. Cc. Syrup., ^S^^ 120. Cc. AquEe, f^iv 120. Cc. M. SiG. — Dose, f 3J-f^j, well diluted. The addition of one minim (0.065 Cc.) spiritus glonoini to each dose of Basham's mixture increases its nephritic action. Dr. James Tyson, than whom there is no greater authority in nephritic conditions, strongly urges the use of infusum digitalis in- stead of the tincture. He also recommends, as an admirable diuretic combination, Trousseau's diuretic wine, viz. : K. Junip. contus, ^x 40. Gm. Pulv. digitalis, ^ij 8. Gm. Pulv. scillae, ^j 4. Gm. Vin. xerici, Oj 473- Cc. Macerate for four days and add Potassii acetatis, ^iij 12. Gm. Express and filter. SiG. — Tablespoonful three times a day for an adult. CHRONIC PARENCHYMATOUS NEPHRITIS. Synonyms. Chronic Bright's disease ; chronic croupous ne- phritis ; chronic tubal nephritis ; chronic albuminuria ; large white kidney. Definition. A chronic inflammation of the cortical and tubular structure of the kidneys ; characterized by albuminous urine, dropsy, increasing anaemia, with attacks of acute uramia. 172 PRACTICE OF MEDICINE. Causes. Rarely follows the acute form, but in ever so many cases the etiology is unknown, and in the vast majority of cases it is primarily chronic or subacute; syphilis; chronic malaria; alcoholic excesses; chronic mercurialism ; lead poisoning ; opium habit ; pro- tracted suppuration; phthisis; hepatic disorders; pregnancy; some undetermined nervous condition. It is a disease of the young, rarely occurring after forty. Princi- pally occurring in males. Pathological Anatomy. A large white, or yellowish white, smooth kidney, often twice the normal size. The capsule is nowhere adherent to the organ. Upon section, considerable tumefaction of the cortical substance and the rarity of vascular striae are recognized. The medullary substance shows no appreciable alteration, its color being normal. The convoluted tubes are irregularly dilated and thickened, and filled with broken-down granulated epithelium and fibrinous casts. In pronounced cases there is fatty degeneration of the tubular epithelium. " The intertubular matrix is greatly thickened — a change due to hyperplasia of the connective-tissue elements, to the migration of the white corpuscles and their subsequent multiplication and fatty trans- formation, and to a quantity of fluid exudation, the product of the increased pressure in the veins." Symptoms. The onset is gradual and insidious, and the affec- tion is seldom recognized until the appearance of dropsy, which, beginning under the eyes and in the face, extends all over the body, causing dyspnoea from ascites or hydrothorax , although in many cases the dropsy may be a late symptom, the patient becoming /^/.f, debili- tated, and suffering from cardiac palpitation, increasing dyspnoea on exertion, and vomiting, all gradually developing without apparent cause ; also headache, vertigo, and defective vision. The urine is scanty, high-colored, albuminotis , and under the microscope showing hyaline and granular tube casts, granular epithelium, and if fatty de- generation ozcMx, fatty tube casts and oil globules. The increase above the normal amount of the urine, as the disease progresses, must not be forgotten when the specific gravity is low, 1.010-1.015, and the quan- tity of albumin is increased. The normal constituents of "the urine, and particularly urea, are diminished. Irritable bladder is a very constant symptom, beginning very early in course of the disease. In the hemorrhagic form the urine almost constantly contains blood. DISEASES OF THE KIDNEYS, 1Y3 Ancemia is pronounced, from the large waste of albumin. Gastro- intestinal disorders and various neuralgic pains are common occur- rences. Cardiac hypertrophy is of common occurrence. Bronchial catarrh^ with slight oedema of the larynx, causing husky voice, are frequent complications. Amaurosis, the result of neuro-retinitis, occurs in a greater or less degree in all pronounced cases. Urcemic symptoms occur and especially tiraviic asthma (renal asthma). Da Costa calls attention to a temporary loss of vision, soon returning and again recurring, in a well-marked case of this disease. Complications. Pneumonia, pleuritis, pericarditis, peritonitis, meningitis, and cardiac hypertrophy. Prognosis. Not unfavorable, unless the urine persistently con- tains a large number oi fatty tube casts and oil globules. Relapses are frequent, but many complete (?) recoveries are recorded. I have seen four apparent recoveries, one after twelve months* duration, another after two years' duration, and still another after five years' duration, no return showing itself after two years. The secondary contraction of the kidneys must always be kept in mind, the particular symptoms of which are increased flow of low specific gravity, urine with small amount of albumin, and hypertrophy of left ventricle, with accen- tuated aortic second sound. Treatment. It is to be borne in mind that the course of a case of chronic Bright's disease is not continuously downward ; periods of remission often follow the most aggravated symptoms, the patient and his friends being buoyed with the hope of an early recovery, when, suddenly, an attack of acute ursmia terminates life. A patient with chronic Bright's disease should, as far as possible, be relieved from all cares of business and spend a goodly portion of time in bed. The diet is of prime importance. It may consist of an absolute milk regimen, pure, or prepared as most palatable, or an exclusive lean meat diet, prepared by finely chopping, removing all fibrous and fatty portions, boiled quickly, salted to taste, and served hot — the so- called " Salisbury steaks." The use of half a pint of hot water, acidulated with lemon, before each meal is valuable. The use of diaphoretics and hydragogue cathartics are only indi- cated when the dropsy is marked, the skin harsh and dry, the urinary secretions scanty, and ursemic symptoms are threatening. Diuresis should be promoted, if the secretion of urine is scant, by 174 PRACTICE OF MKniCINK. digitalis, caffeines ciirata, or sparteina: sulphas, internally or hypo- dermic.iUy, or spiritus glonoini, and dry cups and poultices over the loins, and the use of the normal salt solution slowly injected into the bowels. The following is a good combination for scanty urine and costive bowels : JR. Tlydrargyri chlor. mitls, Pulv. scHIk, Pulv. digital., .14 gr. j aa .065 Gm. F pil. SiG. — Three times daily for a few days. An excellent plan to promote diuresis and diaphoresis in all forms of nephritis is by the use oi pilocarpus locally. I have used the fol- lowing ointment for several years with invariable success : R. Pilocarpine nitrat., gr. j-iij .065-.2 Gm. Ung. petrolei, 5J 30. Gm. M. SiG. — Apply piece size hickory-nut over dorso-lumbar region";, night and morning, covering surface with layer of cotton or gauze. Iron is preeminently the drug for this variety of Bright's disease, using the tinctura ferri chloridum. Large doses are not needed. Combined with spiritus aetheris nilrosi or in the form of Basham's mixture, makes an excellent combination for the ferrum ; one minim (0.06 Cc ) spiritus glonoini added to each dose of the ferrum com- bination is useful. The ancBviia is to be treated by oleum morrhuce, arsenicum, and ferruvt, an excellent formula for the latter being — K. Str)xhnince sulph., g"^- % .016 Gm. Tinct. ferri chloridi, f 3 ij 8. Cc. Acidi acetici purse, f^j 4- Cc. Curacore albae, f^j 30. Cc. Liq. ammonii acetat., . . adf5vj 180. Cc. M. SiG. — Tablespoonful every five hours, followed by a glass of cold water. To check the waste of albuviin, a difficult matter, the following remedies have been used with more or less success : ergota, quinince sulphas, acidian gallicum, sodii benzoas, tinctura cantharidis, or potassii iodiduin. For dropsy, purgatives, such ■&.% pulvis jalapcz co?npositus, tnagnesii sulphas, and alkaline mineral waters or the vapor baths, or pilocar- pines hydrochloras, gr. y^ (0.008 Gm.), repeated if not much cardiac depression, or combining pulvis ipecacuanhcB et opH, gr. iij (0.2 Gm.), DISEASES OF THE KIDNEYS. 175 with potassii nitras, gr. iij (0.3 Gm.), every two or three hours, or diuretin, gr. xx (1.3 Gm.), after meals; what is most valuable is the hot-air bath ox pack. If there be great distention of the serous cavities, interfering with the respiration, the aspirator should be used. Puncture of the skin may be necessary at times, and it is well accomplished with an ordinary cambric needle. Cases due to syphilis, if the loss of renal structure is slight, are cured by a course of hydrargyri corrosivum chloridum and potassii iodidian, with oleum morrhucB. INTERSTITIAL NEPHRITIS. Synonyms. Chronic Bright's disease ; sclerosis of the kidneys; contracted kidney ; small red kidney ; gouty kidney. Definition. An inflammation of the intervening connective tissue of the kidney, chronic in its progress, resulting in an induration or hardening, with contraction of the organ ; characterized by the fre- quent voiding of large amounts of pale, albuminous urine, of low specific gravity, disorders of the gastro-intestinal canal and nervous system, and a strong tendency to cardiac hypertrophy and changes in the vessel. Cases of interstitial nephritis are not uncommon in which albumin is never detected in the urine. Causes. A disease of middle life, from forty to sixty years. Gout a common cause ; lead cachexia ; syphilis ; alcoholism ; opium habit; following chronic cystitis and chronic gonorrhoea; long-con- tinued worry, anxiety, or grief; alterations in the renal ganglionic centres (Da Costa and Longstreth). Hereditary influence (Tyson), secondary to chronic cardiac disease. Hepatic disorders, as the functions of the liver and kidneys are closely related. A functional disorder of the liver, if not checked, leads to organic kidney disease. " Renal degeneration is a consequence of the long-continued elimination of products of faulty digestion through the kidneys." Uric acid is a nephritic irritant. " There is a tendency to overgrowth in the interstitial tissue of the kidney, as of other organs, in old age. Hence the term senile atrophy of the kidney. It is not safe, therefore, to call every instance of atro- phied kidney met in the post-mortem room a case of interstitial nephritis." (Tyson.) Pathological Anatomy. The kidneys are increased in size. 176 PRACTICE OF MEDICINE. The capsule is thickened, opaque, and adherent. The surface of the kidney is granular, with cysts of various sizes, of transparent color, scattered irregularly over the surface. On section the tissue of the kidney is tough and resistant. The cot/ical portion is thin, from atrophy, being only a line or two in thickness. The connective tissue is greatly thickened, compressing the tubules into mere threads, the glomeruli ht'xng grouped together in bunches, owing to the wasting of the intermediate tubes. The color varies from a darkish brown to a yellowish gray, according to the amount of blood in the organ. The left side of the heart is hypertrophied, and there is also hyper- trophy of the muscular fibre of the arterioles throughout the body ; if the case is protracted, the hypertrophied tissues undergo fatty degeneration. Cardiac degeneration with arterio-capillary sclerosis or fibrosis is associated with advanced nephritis. In many cases there occur fatty degeneration of the retinal tissues, or sclerosis of the nerve-fibre layer, changes which are termed retinitis albicminurica. The "ganglionic centres " undergo fatty degeneration and atrophy (Da Costa and Longstreth). Apoplexy is a frequent termination of interstitial nephritis, the rup- ture of a cerebral vessel suggesting it to be a disease of degeneration. Symptoms. Onset insidious, and often marked alterations in the kidneys, heart, and vessels have occurred before the disease is recognized. There are no characteristic early symptoms in the majority of cases, the disease being apparently latent until some special outbreak causes a more thorough examination of the patient, when interstitial nephritis is detected. Any of the following symptoms may first attract attention : Frequent tnicturition; increased amount of urine, fifty to ninety ounces, acid, and oi 3l pale color; low specific gravity, 1005-1015 ; containing a small amount of albianin, which may be absent for days ; occasional epithelial cells and hyaline diwd pale granular casts. No dropsy, but a little puffiness and cedema of the conjunctivcB — the Bright's eye. Disorders of vision. Forcible cardiac action with high arterial tension, due to left cardiac hypertrophy, which is an almost constant condition. Attacks of vertigo ; headache ; /wAa/zV^w^ in the head, neck, and other parts of the body, and, as the disease progresses, cardiac distress, dyspnoea, and palpitation occur. A reduplication of the first cardiac sound is common ; the second aortic sound is DISEASES OF THE KIDNEYS. 177 accentuated and the pulse is hard and resisting, indicating high tension and thickening. "Sclerosis is distinguished from tension by- obliterating the blood current by pressure and feeling the artery beyond. The sclerosed vessel continues tangible, that of high pressure disappears." (Tyson.) Disordered vision; attacks of epistaxis and disordered stomach. Progressive anaemia is a frequent symptom, with a sense oi greal weakness. Any of the following symptoms, the result of urcemia, may occur : Persistent dyspepsia, occasional vom- iting, regardless of food ; headache, vertigo, and stupor, ox drowsifiess ; violent itchijig of the skin ; tremors, convulsio7is, epileptic seizures, or apoplectic attacks. The body weight declines, the skin is dry and scurfy, the strength fails, and shortness of breath on exertion is present. Albumin may be absent from the urine throughout the entire course of interstitial nephritis, and casts be only occasionally detected after many trials, and yet the disease progresses to a fatal termination. Towards the termination of the disease the urine diminishes in quantity, specific gravity increases, and the casts increase in number and variety, dark granular and blood casts often being observed. The termination is usually by convulsions, coma, and death. Complications. Bronchitis ; pneumonitis ; pleuritis ; pericar- ditis ; cardiac hypertrophy. Pericarditis is always fatal. Diagnosis. Interstitial nephritis is most likely to be confounded with parenchymatous nephritis. The following table from Millard presents the most important point of difference between the two : In Chronic Croupous Nephritis, In Chronic Interstitial Ne- phritis, The urine is always albuminous. Urine not constantly albuminous. Urine usually scanty. Urine usually abundant. Dropsy and cedema almost always Dropsy seldom or never present ; occur. sometimes slight oedema. Hypertrophy of the heart seldom Some hypertrophy of heart, with exists. increased arterial tension, almost al- ways present. Specific gravity of lu^ine usually Urine generally of a light color higher than the normal. Urine darker and low specific gravity, and with less of a soapy appearance than in chronic interstidal nephritis. 12 178 PRACTICE OF MEDICINE. In Chronic Croupous Nkphritis, In Chronic Interstitiai. Nb. piiritis, Uncmic symptoms are met with in their most pronounced form, and in severe cases usually occur. Epistaxisand cerebral hemorrhages frequent. Occurs most frequently after forty. Unemic symptoms less frequent than in chronic interstitial nephritis. Epislaxis and cerebral hemorrhages rare. Occurs most frequently before the age of forty. Blood corpuscles and connective- tissue shreds more frequently found in chronic croupous nephritis. Casts more numerous and in greater variety than in chronic interstitial nephritis; waxy, granular, fatty, and hyaline casts occurring. Epithelia from the kindey and pus corpuscles more numerous than in interstitial nephritis. Urates and phosphates predomi- nate ; oxalates rare. Albuminous retinitis rare. Gangrenous erysipelas and phleg- monous swellings more common ; also dyspepsia and anoemia. Visceral complications, as pneu- monia, pleuritis, pericarditis, and bronchitis, not uncommon. Diarrhoea sometimes. Cirrhosis of liver rare. Atheroma of arteries rare. Absent in chronic interstitial ne- phritis. Development more gradual, the health of patient often less impaired, and duration longer than in chronic croupous nephritis. Casts rare, the hyaline variety be- ing most frequently met with. Kidney epithelia and pus corpus- cles scanty, and occasionally absent. Oxalate of lime almost always oc- curs. Albuminous retinitis common. Visceral complications rare. Cirrhosis the most frequent hepatic lesion. Atheroma common. Prognosis. Pursues a very chronic course ; cases recorded under observation eleven years. If the case is seen in its incipiency, a cure is possible, but as a rule we say the prognosis is unfavoiiible. DISEASES OF THE KIDNEYS. 179 Treatment. To prolong life is the great indication, as the dis- eased kidneys cannot be restored. Regulated diet is of first importance. The eliminating function of the kidney being lessened, the diet must be one as free from urea as possible. Milk should be the chief and for long periods the only nitrogenous food used ; plain, skimmed, and diluted with Vichy, ApoUinaris, and Seltzer waters. Eggs, soft-boiled or poached in milk. Occasionally chicken broth. The remainder of the diet should come from the vegetable list. Avoid alcoholic stimulants. A daily warm or hot bath is valuable, but under no consideration should cold or sea bathing be allowed. Warm clothing, and protect- ing the body from cold and damp is most important. Rest of mind and body as far as circumstances will permit. The bowels should be kept regular and soluble with salines or cas- cara sagrada, which is said to be a valuable eliminator of urea ; until the urine becomes scanty diuretics are not indicated. Ferrum should only be used for the ansmia. For the nephritic, cardiac, and vessel changes there is no one remedy comparable with niiroglycerinum, or spiritus glonoini, in doses of nvj (0.06 Cc), which equals gr. ^nu (0.00065 Gm.), repeated three to six times a day. An excellent combination in the early stages of interstitial nephritis is : R . Hydrargyri chloridi corrosiv., . . gr. j .065 Gm. Aurii et sodii chloridi, gr. j .065 Gm. Ferrireduct., gr. xxx 2. Gm. Spts. glonoini, Tr\^xxx 2. Cc. Ft pil. no. xxx. SiG. — One after meals. Potassii iodidum has been recommended to prevent or hinder the connective-tissue growth. If syphilis can be traced as the causative factor, it should be given a trial. For the urcEuiic symptoms the reader is referred to that subject. For the gastric symptoms the following is an excellent formula : U . Pepsin, puras, gr. xxxij 2. Gm. Acidi hydrochloric, dil., . . . . f .^ ss 15. Cc. Glycerin!, f5j 30. Cc. AquL^ chloroformi, .... ad f^iij 90. Cc. M. SiG. — One teaspoonful at meal-time, well diluted. 180 PRACTICE OF MEDICINE. AMYLOID KIDNEY. Synonyms. Chronic Bright's disease ; waxy kidney ; lardaceous kidney. Definition. A peculiar infiltration into, or a degeneration of, the structure of the kidney, from the deposit of an albuminoid material, having a superficial resemblance to molten wax or boiled starch. Simi- lar changes occur in the liver, spleen, intestines, and other organs. Causes. The chief cause is prolonged suppuration, especially of tha bones ; coxalgia ; syphilis ; cancer ; phthisis. Pathological Anatomy. The kidney is uniformly enlarged. It presents a pale, glistening, translucent appearance, and has a doughy consistency. On section, the surface is homogeneous, anaemic, and whitish. The deposit occurs along the renal vessels and in the vascular tufts of the glomeruli, progressing until all parts of the organ are infiltrated. When the organ is thus infiltrated, the proper structure undergoes an atrophic degeneration, the result of pressure. The reaction with iodine and sulphuric acid afifords a certain test of the amyloid d^Q^osxt. Brush over a section of the affected kidney a solution of iodine with iodide of potassium in water, when a mahogany color will be produced, and if diluted sulphuric acid is now added, a violet or bluish tint results. A very pretty reaction is to take a one per cent, solution of anilin violet, which strikes a red or pink color with the amyloid material, while the unaltered tissues are stained blue, making a beautiful contrast. Similar changes occur in other organs of the body. With the amy- loid change may be associated either parenchymatous or interstitial nephritis. Symptoms. Associated with wasting are cedema of the lower extremities and ascites, with an increased flow of uritie, pale, watery, and of low specific gravity, containing albumin and hyaline casts, which are transparent. If the amyloid change be associated with other forms of renal change, the urine will show the characteristics of such condition. A profuse, watery, and persistent diarr/icea caused by the amyloid changes in the intestinal canal. Diagnosis. Differs ixova. parenchymatous nephritis in its clinical history, and the fact of its always being associated with a suppurating disease. From interstitial nephritis, in its history, character of the urine, DISEASES OF THE KIDNEYS. 181 absence of ursemia, cardiac hypertrophy, changes in the vessels, and the fact of its association with suppurating diseases and similar changes in other organs. Prognosis. Controlled by the suppurating disease with which it is associated ; the termination, when the amyloid change is fully de- veloped, is unfavorable, death occurring within a few months, or, under favorable conditions, not for one or more years. Treatment. Sustaining and symptomatic in character. Gener- ous diet and the persistent use oi ferriiodidunt, alternating with am- monii chloridum and oleum morrhuce. If caused by syphilis, a thorough course oi potassii iodidum,ferri iodidum, and hydrargyri corrosivian chloridicm, with oleum morrhuce. If of syphilitic origin, the plan of Keyes (Dr. E. L.) is to be com- mended : " A case treated from the first should receive mercury continuously in small doses, gr. -^ to gr. ^^ (0.0015-0.002 Gm.), for a period not less than two and a half years, or, in any event, until at least six months have passed after the entire disappearance of the clearly syphilitic symptoms." PYELITIS. Synonyms. Suppurative nephritis ; pyelo-nephritis. Definition. An acute catarrhal inflammation of the pelvis of the kidney ; the X.&cva. pyelo-nephritis is used when suppurative inflamma- tion is superadded to the catarrhal inflammation. The disease is characterized by lumbar pains, irritability of the bladder, the urine neutral or alkaline in reaction and milky in appearance; \{ pyelo- nephritis occur, symptoms of hectic fever and exhaustion are added, the urine containing pus. Causes. Cold or exposure ; cystitis ; obstruction of the ureters by renal calculi ; pressure from a tumor ; prolonged use of bromides and other irritative drugs ; rheumatism ; sequelae of infectious diseases. Pathological Anatomy. The inflammation is catarrhal ; it is characterized by injection of the mucous membrane of the pelvis of the kidney, with slight extravasations of blood ; relaxation and soft- ening, shedding of the epithelium, and the subsequent discharge of mucus and pus. If the morbid condition has existed for some time, the kidneys, one or both, are in a process of suppuration ; they are 182 PRACTICE OF MEDICINE. enlarged, deeply congested, except where suppuration is proceeding, when they are of a yellowish-white color — pyclo-tiephritis. I'us is constantly forming, and if there be no obstruction, flows away with the urine ; should there be an impediment to its escape, pus accumu- lates in the pelvis of the kidney, causing its distention, giving rise to the condition known 7i% pyclo-nephrosis. The pressure caused by the obstruction finally leads to destruction of the entire organ, a mere sac, or renal cyst, remaining. Symptoms. If caused by cystitis, symptoms of this condition occur first; if from renal calculi, its characteristic symptoms precede those of pyelitis. Begins by chilliness, feverishness, lumbar pains following the course of the wxtX^xs, frequent micturition, the urine viilky in appear- ance when voided, acid or neutral in reaction, and depositing a copious sediment, whitish or yellowish-white in color, containing only a small amount of albumin, no more than is due to the/«5. Cases of pyelitis due to renal calculi frequently s,\\qv/ hemorrhages ; the urine bloody after some extra exertion. \i pyelo-ntphriiis ioWow, symptoms of pyemia supervene, to wit: fever, typhoid in character, low, muttering delirium, subsultus iendi- num, stupor, decline in strength, and loss of flesh, with perhaps a tumor in the lumbar region. If both kidneys are affected, urcemic symptoms are frequent. Diagnosis. From cystitis, by history, lumbar pains, and acidity or purulent urine, the urine in cystitis being always alkaline. A microscopical examination of the urine will aid the diagnosis very much. Perinephritis, a disease of the loose tissue, around about the kid- neys, terminating in abscess, causing lumbar pain, increased by motion or pressure, hectic fever, sense of fluctuation over kidneys, the urine remaining normal. Prognosis. Simple cases, where no obstruction to flow of pus, recover \\\ a week or ten days. If obstruction of the ureter, the prog- nosis is grave. Suppurative cases unfavorable. Treatment. Rest in bed. Milk diet. Free use of water to dilute the urine, and free diaphoresis. Qui7ii7ia sulphas to keep down temperature, prevent formation of pus, and maintain the powers of hfe. To change the character of the secretion. Prof. Da Costa strongly DISEASES OF THE KIDNEYS. 183 recommends //;r liquida ; other remedies are oleum sMitali, copaiba, eucalypiol, ierebinihina, and cubeba. I have seen excellent results from a prolonged course of the Buffalo Lithia Springs water or the Rockbridge Alum Springs water of Virginia. For renal hemorrhage, ahanen, gr. xx (1.3 Gm.), repeated p. r. n., is successful. \{ abscess results, aspiratioti, quinincE sulphas, and siiimdanis. Ex- tirpation of the diseased kidney has been followed with fair health. ACUTE UREMIA. Synonyms. Urasmic poisoning ; ureemic intoxication ; ursmic coma; uraemic convulsions. Definition. A group of nervous phenomena, which occasionally develop during the course of acute or chronic Bright's disease, and other maladies, the result of the retention or accumulation in the blood of an excrementitious material, supposed to be urea, the flow of urine being either normal, lessened, or increased. Causes. Suppression of urine, from acute or chronic Bright's disease, probably more frequent in chronic parenchymatous nephritis ; cystic, tubercular, or cancerous kidney ; the puerperal state; opera- tions on the uterus bladder, urethra, or rectum. Symptoms. Ursemic intoxication is the result of the failure of the kidneys to perform their normal function of eliminating some one or all of the poisonous elements of the urine. The toxaemia may develop suddenly, by a convulsive seizure fol- lowed by coma, or slowly and gradually. Usually the attack is pre- ceded by a decrease in the urinary secretion and slight or marked oedema in various parts of the body ; although it must be borne in mind that in rare instances, during, or immediately prior to, the ap- pearance of the urEemic phenomena, the normal urinary flow has been largely exceeded. The acute outbreak may manifest itself in a variety of ways. Gastro-intestinal variety : The patient suddenly experiences attacks oi vertigo, pallor of face, nausea and vomiting, y!\ih. fever, the tempera- ture varying between 100° and io'^°, pulse tense and rapid, respiration hurried, and the urine scanty with low specific gravity ; unless symp- toms are promptly relieved, convulsions may occur, followed by coma 184 PRACTICE OF MEDICINE. nnd death, or drowsiness supervenes, followed by coma, which is really nothing but a profound sleep. Rarely an acute maniacal outbreak follows the gastro-intestinal symptoms. Convulsive variety. Without any appreciable prodromes, epilepti- form convulsions, with or without loss of consciousness. The convul- sions may consist of a single paroxysm, or a succession of fits may fol- low one another at intervals of a few minutes or several hours, the patient in a condition of more or less profound insensibility during the intervals. The fits closely simulate true epilepsy. In this variety the temperature is high, from 103° to 106° or more, the pulse rapid, with or without tension, the respirations quickened. Coma followed by death is a very common ending of this variety of uraemia, or after a profound sleep of hours the patient gradually recovers his usual health. Alcoholic excesses are responsible for many of these attacks. Cerebral variety, or urcemic cotna. Develops gradually, with an increasing drowsiness, associated with headache and irritability of temper (mild mania). Nausea, vomiting, and rise of temperature, often reaching 105°, rarely 107°, with rapid, full pulse, or\\\& patient may fall suddenly into a condition of profound coma, the symptoms closely resembling an apoplectic stroke, excepting the high tempera- ture. Uraemic coma is always accompanied with rise of temperature and stertor. " The stertor is peculiar ; it is not the ' snoring ' of apo- plexy, but a sharp, hissing sound produced by the rush of expired air against the teeth or hard palate." (Loomis.) The respirations are accelerated, the pulse rapid but minus tension. This variety may suddenly terminate fatally with a convulsion, or a deepening coma with prostration and cold, wet skin, with oedema of the lungs, or, rarely, gradual recovery. Diagnosis. Uiaemic conditions closely resemble a number of conditions in which convulsions and coma are prominent symptoms. Much valuable assistance is obtained by a knowledge of the condition of the kidneys. Always obtain a specimen of urine at once and sub- ject to an albumin test at least. Another valuable aid is the temperature record. I believe acute outbreaks of uraemia are always associated with arise of temperature. The temperature is the result of the irritation of the heat-centres and not due to an increased arterial pressure. Cerebral apoplexy may be mistaken for uraemic coma, or the re- DISEASES OF THE KIDNEYS. 185 verse. The chief points of distinction are that in the latter the attack is usually in patients suffering from dropsy, and that the coma is not sudden in its appearance, but is generally preceded by other nervous phenomena, such as headache, vertigo, dimness of vision, obstinate vomiting, and convulsions. Again, the U7-(Emic stertor is a sharp, hissing sound, while that of apoplexy is " snoring." Apoplexy is fol- lowed by paralysis; uremic coma is not. An epileptic seizure is preceded by a sharp cry and extreme pallor of the face, the countenance being dusky in uraemic convulsions. Prognosis. An attack of acute uraemia is always a very grave condition. The prognosis depends upon the amount of retained poison, the length of time it has been retained, and the condition of the organs of elimination. Treatment. Promptness and thoroughness is the essential point in the treatment of a uraemic outbreak. For the gastro-intestinal variety, put patient to bed and administer the magnesium sulphate enema given below, and order ^k'Ccl^x caffeince citrata, gr. iij (0.2 Gm.), every three hours, or the spartein and pilo- carpine mixture mentioned below. As soon as the secretions have been started, give one of the following powders every two hours until a dozen or more are used, followed by Hunyadi Janos water: ^. Hydrargyri chlor. mitis, . . . . gr. X~/^ .016-.032 Gm. Sodii bicarb , gr- ij -130 Gm. Pulv. ipecacuanhas, gi"- 3^ .o\\ Gm. M. Ft. chart. No. j. For the convulsive or cerebral variety, the indications are : first, to arrest the nervous phenomena ; secondly, to promote elimination. Prof. Loomis has succeeded in meeting both of these conditions by hypodermic m]&c\.\orYsoi morphince sulphas, gr. y(,-%-%. (o.oi 1-0.016- 0.032 Gm), repeated, if required, every two hours. He says : " The most uniform effect of morphine so administered is, first, to arrest mus- cular spasms; second, to establish profuse diaphoresis ; third, to facili- tate the action of cathartics and diuretics, especially the action of digitalis." Following the injection of morphina, diaphoresis should be pro- moted by means of the hot-air bath, or the hot wet pack, or the hypo- dermic use of pilocarpijtcB hydf-ochloras, gr. X2~/^~X (0.005-0.01 1- 0.016 Gm.), provided no counter-indication to its use exists, or using at the same time frequent doses of caffeines citrata, gr. iij (0.2 Gm.). 18f) PRACTICE OP MEDICINE. The foUowinj^ combination has given excellent results in a number of cases when the patient was able to swallow : R. Spartein;e sulpliat., gT- '^ .26501x1. PilocarpiiKV hydrochlor., .... Rr. j .065 Gm. Infus. digital., f5ij 60. Cc. M. SiG. — Teaspoonful every half hour, hour, or two hours until effect. Spiritusglonoini added to the above combination is valuable. If patient is unable to use the medicine by stomach, the same drugs can be used by the hypodermic method, using digitalinae cryst. : li. Digitalinre cryst., S^- ih .001 Gm. Pilocarpinre hydrochlor., . . . • g^- % •016 Gm. Sparteine sulph., gr- K .032 Gm. AqucE deslil., Tt\,xv I. Cc. M. SiG. — As dose p. r. n. Or— U . PilocarpincE nitrat. gr. ij .13 Gm. Unguent, petrolei, f.^j 30. Gm. M. SiG. — Apply (rubbed) bis die over kidneys. I have never observed the alarming symptoms of depression men- tioned by some observers from the careful use of pilocarpus. The production of free diaphoresis alone must not mislead, for unless the sweat contains urea or its products it is only depressing, and the clinical fact is that in uraemia the eliminating function of the skin as well as of the kidney is in abeyance. The convulsions are rapidly controlled by inhalations of chloroform (although the after symptoms are badly influenced by the drug), or the internal or rectal administration of full doses oi chloral, or by a free venesection. Indeed, venesection is too much neglected in condi- tions of coma and uraemic convulsions. It not infrequently happens that upon opening a vessel the blood does not flow, or but a few drops slowly flow from the wound. If this obtains it is almost immediately changed by a hypodermic injection oi amyl nitrite, n\,v (0.3 Cc.) with spiritiis ammonicE aromatictis, TT\,xv (l Cc). Diuresis is promoted by infusiim digitalis, dry or wet cupping, poultices over the loins, and hot compresses of infusum digitalis over abdomen, pilocarpus rubbed over the kidneys, or caffcina: citrata, or spartei7tcB sulphas, or spiritus glonoini. The injection of the nor- mal salt solution, 3j : Oj (4 Gm. : 473 Cc), into the bowel every DISEASES OF THE KIDNEYS. 187 hour or two, and by hypodermoclysisinto the loose connective tissue, promotes diaphoresis and diuresis. Excellent results have been ob- tained in uraemia with scanty urinary secretion and in other condi- tions with scanty urine with diureiin (a mixture of salicylate of soda and theobromin) in gr. xx-xxx (1.3-2 Gm.) in an ounce of water every two or four hours. Catharsis is best promoted by elateriujn, gr. xs-J (0.005-0.008 Gm.), or an Epsom salts enema : ■R . Magnesii sulph., ..= .... _^ij 60. Gm. Glycerini, ^j 30. Cc. Aquffibul., giv I20. Cc. M. As enema. The febrile reaction does not call for antipyretics. It is one of the nervous phenomena of ursemia, and is controlled by the means employed to eliminate the poison. If symptoms of collapse develop, with cold, clammy skin, feeble, rapid pulse, and superficial respirations, at once administer atropincz sulphas, gr. ^ (o.ooi Gm.), repeat p. r. n., 2.VidL strychnines suiph., S""- •5j~tV (0.002-0.004 Gm.), repeated p. r. n., with rf\\] (0.12 Cc.) spiritus glonoini, and bathe surface with hot water and alcohol. Of late, sodii benzoas, 3j-ij (4-8 Gm.) during the twenty-four hours, has been lauded as almost a specific in urasmic intoxication. Under the action of this remedy the paroxysms lessen in severity, the inter- vals grow longer, and the convulsions after a time cease entirely. Profound sleep is induced by it, and during this the cerebral functions are restored. When albuminuria exists, a marked diminution occurs in the quantity present, or the albumin disappears entirely. Milk, in as large quantities, diluted as can be borne, should be the diet. The attack broken, the treatment resolves itself into that of the nephritic affection causing it. RENAL CALCULI. Synonyms. Nephro-lithiasis ; gravel ; renal colic. Definition. Renal calculi are concretions formed by the precipi- tation of certain substances from the urine, around some body or sub- stance acting as a nucleus. 188 PRACTICE OF MEDICINE. Their presence may not be recognized until one or more attempts to pass along the ureters, when an attack of renal colic results; or, by irritation, /j(f////j is produced; or, more rarely, they are voided by the urine without exciting any symptoms. By oravfl is meant very small concretions (sand), which are often passed in the urine in large numbers. Causes. Occur at all ages ; frequent at forty to fifty years of age. Males are more liable than females. A special liability seems to exist in some families, but the precise etiology of calculi is not yet determined. Varieties, i. Un'c acid, as calculi and gravel, and especially associated with the gouty diathesis. 2. Urates, chiefly urate of ammonium ; nearly always in childhood, 3. Oxalate of lime ox mulberry calculus ; characterized by hardness, roughness, and very dark color. 4. Phosphatic calculi form as frequently in the bladder as in the kidney, and present a chalky or earthy appearance. 5. Alternating calculi, consisting of alternate layers of two or more primary deposits. Anatomical Characters. In structure, a urinary calculus usually consists of a central nucleus, surrounded by the body, and outside of all there may be a phosphatic crust. The nucleus may or may not be of the same material as the rest of the stone, sometimes being a foreign body, mucus, or blood. A section generally shows a stratified arrangement, or it may be partly or completely radiated. Symptoms. Many individuals have renal calculi and have no suspicion of their presence until an attack of renal colic occurs. The following signs indicate a renal stone : pain in back, princi- pally in either dorso-lumbar region with tenderness; renal hemor- rhage (haematuria), always a valuable symptom ; slight albuminuria, but no pus, with a few hyaline casts — these are long and narrow; urine of high specific gravity is an important clinical symptom ; in- flammation terminating in abscess, pyelitis ox pyelo-nephritis, cystitis, or renal colic. The symptoms of retial colic begin abruptly, by severe, agonizing, pain in the lumbar region following the ureters into the corresponding groin and thigh. Pain and retraction of the corresponding testicle ; also of glans penis. Face pale ?iX\d features pinched, the surface cold DISEASES OF THE KIDNEYS. 189 and damp. Irritability of the bladder, the urine passing in drops containing some blood. So severe is the pain at times that the patient may faint or pass into unconsciousness, or have a general convulsion. If both ureters are obstructed, urcE7nic syjnpioms occur. The paroxysm usually terminates suddenly after some minutes or hours, the stone escaping into the bladder. Diagnosis. Not always easy, but the following are symptoms of renal stone ; pain and tenderness in back, persistent haematuria, albuminuria, hyalin casts, and high specific gravity of urine, and attacks of renal colic. The Roentgen ray is the hope for correct diagnosis. Prognosis. Renal calculus is attended with many dangers. It may produce extensive disorganization of the kidneys, or its passage along the ureter may prove fatal. If the stone be very large, or if more than one, the prognosis is graver. Calculus is a disease very apt to recur. Renal sand {gravel) and small concretions may, after more or less delay, be voided with the urine. Treatment. An attack of renal colic is best relieved by a hypodermic injection of morphines sulphas and atropines sulphas, and a warm bath or a suppository of ext. opii, gr. j (0.065 Gm.), ext. belladon?icB alco., gr. ss (0.032 Gm.), repeated if needed. For attacks oi gravel, liquor potassii citratis, f^ss (15 Cc), every two hours, and, if much vesical irritability, adding tinctura opii camphorata f^ss-j (2-4 Cc). For renal hemorrhage. Prof. Bartholow reports success with R . Extracti ergotse fluidi, Tincture kramerise, aaf3ij 60. Cc. M. SiG. — One teaspoonful every two or more hours. I have always successfully controlled renal hemorrhages with twenty-grain (1.3 Gm.) doses of alumen, repeated p. r. n. For uric acid calculi, as a solvent, Buffalo Lithia Springs water or the Rockbridge Alum Springs water of Virginia, or potassii tartra- borates, "obtained by heating together four parts of cream of tartar, one part of boracic acid, and ten parts of water. A scruple may be given three or four times a day, in water, largely diluted." I have met with entire success in four cases of renal calculi by the prolonged use oi piperazine gr. v (0.32 Gm.), three times a day in several ounces of water, with a non-nitrogenized diet. Potter sug- 100 PRACTICE OF MEDICINE. gests the following in the uric acid diathesis with a tendency to for- mation of renal calculi : K. Magnesii carbonat., 3J 4- Gm. Acid, citrici ^\] 8. Gm. Sodii borat., q ij 8. Gm. Ar|ure bullientis, 3^''j 240. Cc. M. SiG. — Tablespoonful three times daily, diluted. For phosphatic calculi, as a solvent, ammonii benzoas, well diluted and long continued is highly commended. CYSTITIS. Synonym. Catarrh of the bladder. Definition. An inflammation of the mucous membrane lining the urinary bladder, acute or chronic in its course, and of either a catarrhal, croupous, or diphtheritic character ; characterized by rigors, moderate fever, hypogastric pain, frequent but scanty micturition, and severe vesical tenesmus, the urine containing pus (pyuria). Causes. Acute variety : long retention of urine; foreign bodies in the bladder; pyelitis; urethritis; blows over the pubes; myelitisi and secondary to fevers or diphtheria. Chronic variety: following the acute variety ; retention the result of enlarged prostate or a urethral stricture ; calculi ; gout ; chronic Bright's disease. Pathological Anatomy. \n acute catarrhal cystitis Xh^rt first ensues hyperemia of the mucous membrane of the entire or a por- tion of the bladder, manifested by redness, swelling, and oedema; followed by an increased secretion of the small glands at the base of the bladder, and an increased growth and consequent desquamation of the vesical epithelium, together with a copious generation of young cells ; if the hyperemia be decided, rupture of the capillaries and extravasation of blood occur. If the inflammation be intense, suppuration of the submucous con- nective tissue may result, and ulceration of the mucous membrane permit the submucous abscesses to empty into the bladder. If the inflammation be of a croupous or diphtheritic character, the morbid anatomy does not differ from the same variety of inflamma- tions in other mucous membranes. DISEASES OF THE KIDNEYS. 191. In chronic cystitis "the mucous membrane is thick, blue-gray in color, and very tough. Muco-pus and viscid mucus are formed in large quantities upon its surface. The muscular wall of the bladder may sometimes be half an inch thick, and the fasciculi give a ribbed appearance to the internal surface, called the ' columnar bladder.' The hypertrophy of chronic cystitis may be eccentric or concentric. In some cases diverticuli are formed, in whose walls are dilated and tortuous veins. In nearly all cases bacteria are found in abundance." (Loomis.) Symptoms. Acute cystitis : The onset is usually abrupt, by rigors, slight y^T/^r, loss of appetite, sleeplessness, a feeling of depression, frequent micturition, though the urine is only voided drop by drop, and its passage followed by distressing vesical tenesmus, the result of spasm of the bladder ; pain over the pubis and in the iliac regions, of a dull character, at times becoming sharp and agonizing. Burn- ing along the urethra adds to the distress of the patient. The urine is cloudy, of an alkaline reaction, and at times is fetid, the microscope showing epitheliu7n, pus, and red blood corpttscles and various forms of bacteria. Chronic cystitis : The onset is gradual and insidious, and is excited by some obstacle to the evacuation of the urine, such as stricture, the presence of a stone in the bladder, or enlargement of the prostate gland. There are present dull pain, frequent h\it scanty micturition. The urine is alkaliite, containing large amounts of muco-pus or pus ; on standing it deposits a thick, glairy, viscid sediment, in which, under the microscope, triple phosphates and large pus corpuscles, extremely regular both in contents and in shape, may be detected. Although the quantity of urine voided by the patient is small, yet if immediately after micturition the catheter is used, several ounces oi fetid, cloudy, alkaline urine may be removed. Patients with chronic cystitis usually present decided constitutional debility and mental depression. Severe local pain, emaciation, and occasional bloody urine indicate ulceration of the vesical mucous membrane. Diagnosis. Pyelitis has lumbar pains following the course of the ureters, frequent micturition without the severe vesical tenesmus ; the urine, although cloudy, has an acid or neutral reaction. Prognosis. The acute variety is, as a rule, good, being controlled by the cause. 192 PRACTICK OF MEDICINE. The chronic variety continues for years, and after hypertrophy of the bladder is incurable. Treatment. Rest in bed is invaluable. The diet must be restricted, all highly-seasoned articles being particularly interdicted ; milk is the most suitable article. Warm applications over the pubic region are of benefit, and leech- ing and cupping over the bladder are of service. The urine should be well diluted by large drauglits of pure water, and particularly the alkaline mineral waters, to wit : Farmville liihia, Buffalo lithia, Rockbridge alum, or Vichy waters. The following formulae are of decided benefit : » R . Acidi benzoici, Sodii borat., aa jij aa 8. Gm. Infusi Imchu, vel Infusi uva; ursi, f5^'j "So. Cc. M. SiG. — Tablespoonful every two hours, well diluted. Or— R. Tinct. hy ■scyami fi5vj 24. Cc. Tinct. opii camph., fS^'j 24. Cc. Potassii broniidi, Sodii bicarb., aa ►^viij aa lo. 5 Gm. Liq. potassii citrat., ... q. s. fjviij q. s. 240. Cc. M. SiG. — Tablespoonful every two or three hours, in water. A valuable prescription is — R. Ext. picbi fld. f^^j 30. Cc. Potassii nitrat., zj 4. Gm. Elix. simplicis, f 5 i'j 9°- Cc. M. SiG. — One teaspoonful every two hours, well diluted. Or— R. Liq. potassse (B. Ph.) {-i^X] 8. Cc. 01. santal. flav., f i:; ij 8. Cc. Aq. cinnamom., adf^viij 240. Cc. M. Sic. — Tablespoonful three times daily, diluted. (Saundby.) For alkaline urine from any cause, amtnottii beiizoas, gr. xx (1.3 Gm.) in water, or liquor potassii citratis, seems like a specific. For the pain and tenesmus relief is afforded by a suppository of extracium opii and exiractum belladonna ,xt.\>^-3X^^ as needed. Hot compresses over bladder and hot enemata often relieve the pain of cystitis. DISEASES OF THE KIDNEYS. 193 The vesical tenestnus is often benefited by extractum catinabis indica fliddum, Tr\,xv-xxx (1-2 Cc), every three or four hours. Chronic cystHis. The bladder should be completely emptied with the catheter several times in the twenty-four hours. The use of eucalyptol, gtt. x-xv (0.6-1 Cc), every four hours, well diluted, or a good preparation of tar, or extractum grindelice fluidum, Ti^xx-fjj (1.3-4 Cc), three or four times daily, or oleum santali, gtt. v-x (0.3-0.6 Cc), in emulsion or capsule after meals, are valuable remedies. Acidu?n boricuni, gr. v-xv (0.3-1 Gm.), internally, has removed pus from the urine in chronic cystitis. Washing out the bladder with the following mixture is of decided benefit : R . Sodiiborat., 5j 30. Gm. Glycerin!, f,^ij 60. Cc. Aquae, f Jij 60. Cc. SiG. — One to two tablespoonfuls added to warm water and injected into the bladder once or twice daily. The diet should be nutritious and without spices of any kind. The free use of the alkaline mineral waters is of value. MOVABLE KIDNEY. Synonyms. Floating kidney ; wandering kidney ; nephroptosis. Definition. A condition of the kidney, either congenital or acquired, in which the tissues around about the organ are so lax and the renal vessels so elongated as to permit the kidney to be moved in certain directions, causing a movable tumor in the abdomen. Causes. The kidney is normally held in position by the layer of peritoneum which is attached to the anterior surface of its adipose capsule. In movable kidney the adipose tissue, in which the normal kidney is imbedded, partly or wholly disappears. The renal vessels are in many cases abnormally long. Relaxation of the abdominal walls from pregnancy or other causes. The use of tight corsets or girdles about the waist ; violence ; increased weight of the organ from disease ; the pressure of tumors growing in the neighborhood of the kidney ; the traction of herniee. The condition may be congenital or acquired, more frequently the latter. It is far more frequent in women than in men. 13 194 PRACTICE OF MF.DICINE. Symptoms. Floating kidney may, and often does, exist without any noticeable symptoms, the condition being unknown until acci- dentally discovered by the physician while making a physical exami- nation of the abdomen. As a rule, however, patients experience a heavy, dragging pain in the abdomen, aggravated when walking or standing. There are also present gastro-intestinal symptoms, more or less constant, with melancholia, aggravated by the mental anxiety the presence of a iionor'xn the abdomen causes the patient, in spite of the assurances of the physician that it is not a cancer. ^ At times, from some unknown or unrecognized cause, the movable kidney swells and becomes very sensitive to the touch, and migrates a considerable distance from its normal position. Such an occurrence aggravates all the former symptoms mentioned. The condition has been ascribed to a twisting of the ureter and consequent retention of the urine in the pelvis of the kidney, or to localized peritonitis, or to a partial strangulation of the kidney from compression or twisting of its blood-vessels. Hysterical (?) symptoms are frequently observed in women suffering from wandering kidney. Diagnosis. The possibility of dislocation of the kidney is to be recollected in determining the nature of obscure tumors within the abdomen. The late Prof. Austin Flint based the recognition of this variety of abdominal tumor on the following diagnostic points: "It is situated in the hypochondriac region. It has the size and shape of the normal kidney, and this may be determinable by palpation, which is most advantageously employed by placing one hand over the lumbar region and the other in front on the abdominal walls, and then making counter-pressure from one hand to the other. It is generally movable, and in some cases the organ can be restored to its proper situation." Other tumors are to be excluded by the absence of their diagnostic characters. Prognosis. It is a rare occurrence to have a fatal termination from movable kidney per se. Treatment. Symptomatic. It is said that some of the incon- venience and sometimes suffering attending movable kidney may be lessened by means of an abdominal bandage, belt, or supporter. If attacks of pain and swelling occur, the patient should be placed DISEASES OF THE BLOOD. 195 in bed, have hot applications over the abdomen, and the use of opiates and attempts at replacing the organ. Extirpation of a movable kidney has been successfully performed a number of times. Nephrorrhaphy, an operation for fixation of the kidney by means of sutures, has been devised. DISEASES OF THE BLOOD. ANEMIA. Synonym. Spansemia. Definition. A deficiency of red corpuscles in the blood, or of its more important constituents, such as albumin and haemoglobin, or a reduction in the amount of blood as a whole ; characterized by pallor and general weakness. Oligamia is a general lessened amount of the blood. Ischcemia is a localized anaemia. Causes. Predisposing: Sex; females, pregnancy and meno- pause ; heredity ; pronounced anaemia without apparent cause is strongly suspicious of concealed tuberculosis. ExcHi7ig : Deficient food, air, or sunshine ; excessive work ; mental worry ; mental shock ; prolonged and frequent nocturnal emissions ; excessive nursing; chronic intestinal catarrh; Bright's disease; malaria; syphilis; cancer. Pathological Anatomy. Post-mortem, the tissues are thin, shrunken, and bloodless. If the anaemia has been of long duration, patches of fatty change are seen in the various organs. The blood has a brighter color, the result of diminution in the number of red corpuscles and the quantity of the haemoglobin ; it is thinner than normal, and coagulates slowly and imperfectly, from diminution of the fibrino-plastic constituent. In health the blood of an adult contains about five million red cor- puscles to the cubic millimeter (the female adult about half a million less). The white cells, in health, average about ten thousand to the cubic millimeter. 196 PRACTICE OF MEDICINE. Symptoms. Pallor, gums, tongue, ear, and conjunctivae pale. AfuSiitlar wi-aktie-ss, inability for exertion. Deficient appetite and impaired digestion, attacks of vomiting the result of anaemia of the medulla oblongata. Quickened respiration, irritable temper, vertigo in the erect position, attacks of swooning, /lysteria, and rarely epilepsy. Irritable heart, with soft systolic basic murmurs. Nocturnal emissions in male and deficient menses in female. Marasmus in children. More or less general a'dema of the eyelids and ankles. Long con- tinued, symptoms of fatty changes in various orgjyis or gastrjc ulcer result. Diagnosis. The symptoms of anaemia are so characteristic that an error is impossible; the cause of it, however, may be hidden. Prognosis. Favorable if treated early. If protracted, results in more or less general symptoms of fatty degenerations or ulcer of the stomach. Treatment. Remove the cause. Easily assimilated, blood-pro- ducing diet. Fresh air, sunlight, and exercise short of fatigue, The anaemic patient should spend several hours in bed during the day- time. Purgatives, with stomachic tonics, to promote digestion. For the anaemia proper, ferrum in some form is the most valuable remedy, always remembering that it is not assimilated if the intestines and liver be torpid. Ferri carbonatis, gr. ij-v (0.13-0.32 Gm.), is an excellent form of iron too little employed. The following alterative tonic, known as Smith's (Dr. A. H.) " four chlorides," is frequently of value : R. Hydrargyri chloridi corrosivi, . . gr. j-ij .065-. 13 Gm. Liq. arsenici chloridi, f^j 4. Cc. Tinct. ferri chloridi, Acid! hydrochlorici dil., . . .aaf^iv aa 15. Cc. Syrupi, f^'^ 'S- Cc. AqucE, adf^vj 180. Cc. M. SiG. — One dessertspoonful in a wineglassful of water after each meal. Cases of anaemia with weak stomach can take the following " iron lemonade " with ease : R. Tinct. ferri chloridi, f^ij 8. Cc. Acid, phosphor, dil., fgij 8. Cc. Syr. limonis, f.^ss 15. Cc. Aquce, f 5 ij 60. Cc. M. SiG. — One teaspoonful, well diluted. DISEASES OF THE BLOOD. 197 CHLOROSIS. Synonyms. Essential ansemia ; green sickness. Definition. A pronounced anaemia met with chiefly in young girls about the age of puberty, characterized by diminution in the percent- age of hsemoglobin. Causes. The true cause unknown. A disease for the most part of puberty. Most frequently seen in the ill-fed, overworked town girls, who are deprived of sunshine and fresh air. Heredity is sup- posed to play a part in its causation. Hammond maintains " that it is an affection of the nervous system, the blood changes being secondary." Pathological Anatomy. Death from chlorosis is such a rare occurrence that little data is known. The number of red corpuscles is nearly normal, but there is marked decrease in the haemoglobin, sometimes as low as twenty per cent, of the normal, or even less. Virchow pointed out the hypoplasia of the arterial system, many arteries being congenitally small. The body is usually well nour- ished and the subcutaneous fat well distributed. There is pallor of the organs and muscular system. The spleen, lymphatics, and the marrow of the bones are not affected. Symptoms. The condition is associated with disorders of men- struation. The young girl experiences a change of disposition, becom- ing morose and despondent, rarely hysterical ox melancholiac. "As respects the actual condition of the sexual organs, there are two forms of derangement which happen in chlorosis : there are the amenorrhceic form and the menorrhagic form." After an attack of menorrhagia or after the failure of the flow to appear, the changes occur. The complexion changes, blondes be- coming pallid, waxy, and puffy without cedema ; brunettes becoming muddy and grayish in color, with bluish-black rings under the eyes. Weariness and fatigue upon the least exertion ; the heart irritable, with shortness of breath, pulse full but soft, and at times pulsations in the peripheral veins. The appetite is vitiated, the digestion imper- fect; and attacks of gastralgia are frequent. A not infrequent complication is gastric ulcer. Phthisis develops in those having the slightest predisposition. Examination of the blood shows a relative decrease in quality and 198 PRACTICE OF MKDICINE. quantity of the haemoglobin, resulting in the blood being paler than normal. The red corpuscles are also lighter in color and show less tendency to form rouleaux ; their character also changes, not all being of uniform size, some normal, others small (microcytes), others unusually large (macrocytes), others irregularly shaped (poikilocytes). The number may be normal, 5,000,000 to the cubic millimeter, or the number is occasionally increased, but it is usually lessened, there being as few as 3,000,000 or 2,000,000. ^ The white corpuscles are usually normal in nuniber, but in some instances their number is increased (leucocytosis). Rarely granular bodies are found in the blood which are generally regarded as the products of the degeneration of the white blood corpuscles. Diagnosis. The disease is usually recognized at once by the color of the patient, whence its common name, green sickness. The circulatory symptoms and slight oedema may be mistaken for cardiac or nephritic diseases. Prognosis. The liability to complications and also to relapses, and the lack of knowledge of the true cause, make the prognosis always uncertain. Treatment. Three indications to be met in the treatment of chlorosis : plenty of food, fresh air, and ferrum. The form of iron is immaterial. The tinctura fcrri chloridi'xs the preparation usually prescribed. J. W. England, Ph.G., has proposed the following formula for an iron pill that has been successfully used at the Philadelphia Hospital: R. Massre ferri c.nrb. , gr. xlviij 3. Gm. Potassii sulph., gr. xxxiv 2. Gm. Potassii carb. , gr. v^ .33 Gm. Pulv. aUliere, gr. iss .02 Gm. Pulv. acacix, q. s. q. s. M. Ft. pil. No. xvj, and inclose in gelatin capsules. The following is Blaud's formula, so highly lauded by Nie- meyer : li. Pulv. ferri sulph., Potasbii carbonat. purse, . . aafjss aa 15. Gm. Tragacantlije, q. s. M. Ft. pil. No. xcvj. SiG. — One to three or four pills three times daily. DISEASES OF THE BLOOD. 199 In some instances y>rr«;;z alone does not seem to answer; in such cases the addition of arsenicum is valuable ; a good combination is — K- Ferri arseniatis, gr. y^-g^ .005-. oil Gm. Ext. nucis vomicse, gr. \--\ .011-.016 Gm. M. Ft. pil. No. j. SiG. — After meals. Or— R . Liq. arsenici chloridi, fj'j 8. Cc. Tinct. ferri chloridi, . . . ■ . . f^^vij 28. Cc. Glycerini, f^j 30. Cc. Elix. aurantii, . . . . q. s. adf^iij 90. Cc. M. SiG. — One teaspoonful after meals, in water. PROGRESSIVE PERNICIOUS ANEMIA. S37Tionyins. Idiopathic anaemia ; ansematosis ; essential anaemia ; anaemia of fatty heart. Definition. A pernicious, progressive form of anaemia, of un- known cause, usually resisting all treatment, and toward its termina- tion associated with fever. Causes. The underlying cause of idiopathic anaemia is not known. Among the exciting causes may be mentioned pregnancy, syphilis, and great worry. It is thought that it is probably the result of a toxin. Pathological Anatomy. The blood is scanty and pale, with diminished red corpuscles and haemoglobin, showing a very feeble tendency to coagulate. There is no increase in the white corpuscles. The marrow in adult bones becomes foetal, red, and adenoid, and contains microcytes; several other changes have occurred second- arily in the marrow. Secondary to the anaemia, the heart, larger arteries, and certain capillary tracts exhibit circumscribed or diffused fatty degeneration. The liver, spleen, kidneys, and stomach are decidedly anemic, causing fatty changes in those organs. The skin may contain petechiae of a purplish or brownish tint, and internal hemorrhages are not infrequent ; retinal hemorrhage is rarely wanting. There is not much emaciation, though the pallor is pronounced. 200 PRACTICE OF MEDICINE. Symptoms. It begins insidiously with increasing languor and pallor, tiie muscular weakness compelling the patient to take his bed. Cardiac palpitation, clyspncea, attacks of syncope, cedevta, and swell- ing about the ankles, petechial spots scattered irregularly over the surface; tenderness over the sternum and other superficial bones is a frequent symptom. The appetite is wanting, and nausea and vopniting occur, associated with marked dyspepsia and persistent diarrhoea. As the disease progresses a remittent form oi fever develops, the temperature fre- quently showing io2°-io4° F. Disorders of vision are the result of the retinal hemorrhage. The cardiac sounds are feeble, and associated with soft basic or anaemic murmurs. The blood shows under the microscope the changes described in chlorosis, save the red corpuscles may be reduced to as few as 500,- 000, or even less, to the cubic millimetre. " In addition, the following points of great diagnostic importance are to be noted. " First, the individual red corpuscles are richer than normal in haemoglobin. " Second, many red corpuscles are larger than normal (megalo- cytes). " Third, the red corpuscles are deformed, some being ovoid, others irregular in shape from projections and constrictions on their surfaces (poikilocytes). " Fourth, there are present microcytes or red blood-cells, which are smaller than normal. " Fifth, nucleated red blood-cells (normoblasts). " Sixth, quite constantly, there are other large cells like the megalo- cytes, named megaloblasts, which have a pale staining nucleus." (Hare.) Diagnosis. Progressive pernicious anaemia is distinguished from simple anaemia and chlorosis by the greater severity of the former. From leucocythemia by the normal-sized spleen and liver, and the absence of (leucocytosis) increase in the white corpuscles. Prognosis. Unfavorable as a rule, although recoveries occur, but relapses frequent. Treatment. The employment of arsenicum, either alone or com- bined with ferrum, has considerably changed the prognosis of per- DISEASES OF THE BLOOD. 201 nicious anaemia. The arsenicum must be pushed to the extreme point of toleration and continued for a long time. Rest in bed and a liberal nutritious diet are also essential. LEUCOCYTHEMIA. Synonyms. Leucaemia ; white cell blood ; white blood ; anaemia splenica. Definition. A condition in which there is an enormous increase in the number of white blood corpuscles, with enlargement of the lymphatic glands, spleen, and often of the bone marrow — viz. : splenic, ly??tphaiic, or myelogenic, and is characterized by symptoms oi pronounced anaemia. Causes. The real cause and nature of the affection is unknown. Pathological Anatomy. The spleen is increased in size, den- sity, and firmness ; the lymphatic glands all over the body also enlarge, but are soft to the touch, often fluctuating ; the marrow of the bones changes from its normal rose color to that of a greenish-yellow ; the liver also enlarges enormously. The blood is paler than normal, its specific gravity reduced from 1.055 to 1.040 or lower, andthe«/-^z/eczyic£-erm, the Klehs-hoeffiQrha.c'illus. The bacillus in its growth produces a potent toxic substance, — a toxalbumin, — the absorption of which produces the disease, and not the organism itself. The diphtheria bacillus is associated with other pathogenic bacteria, the most active of which is the streptococcus pyogenes. It is pre- eminently a disease of childhood. It is apt to recur in those who have once been affected. All conditions of bad hygiene increase its virulence and diffusion, although the chief cause of its spread is contagion. Nasal, pharyngeal, and laryngeal catarrh are the kind of soil promoting the growth of the bacillus and its toxin. The poison exists in the exudation and secretions of the fauces and saliva, and floats in the atmosphere at a considerable distance from the patient. The virus adheres to the clothing, the bedding, the fur- niture, and the room which the patient occupied. The period of incubation is from three to five days. Pathological Anatomy. The diphtheritic inflammation differs from either the croupous or catarrhal form, in that the exudation is not only upon, but also within, the substance of the mucous mem-. brane. At first there is redness, which may begin in any part of the throat, associated with swelling and an increased secretion of viscus mucus. The redness spreads over the entire mucous surface, when the exuda- tion makes its appearance, at first giving the affected mucous mem- brane a glazed appearance, which is very characteristic. The deposit may commence from one or several points, such as one tonsil, the soft palate, or the back of the fauces, which, however, speedily extend and coalesce, forming extensive patches, or cover uniformly the entire surface. The patches are of variable thickness, which is increased by suc- cessive layers being formed underneath. The color is usually gray, white, or slightly yellow, but may be brownish or blackish, the consistence ranging from " cream to wash leather." On removing the membrane, which is accomplished with more or less difficulty, a raw bleeding surface is exposed, and at times an ulcer, which is speedily covered with a fresh deposit. If the exudation separate itself, it is either not renewed at all or only in thinner films. The exudation or membrane, examined by the microscope, is 1212 PRACTICE OF MEDICINE. composed of fibrin, pus corpuscles, epithelial granular cells, and the Klebs-Loeffler bacillus and other pathogenic bacteria. If the larynx, trachea, or nasal mucous membranes participate in the disease, the crottpous and not the diphtheritic form of inflamma- tion occurs. The lyjiiphatic glands of the neck, whose vessels originate in the faucial tissues, are enlarged and inflamed, and contain large numbers of bacteria, probably originating as the result of decomposition. The muscular tissue of the heart becomes soft, is easily torn, and its fibrillae are far advanced in granular degeneration. Ulcerative endocarditis has been frequently observed. The kidneys undergo a granular degeneration in severe attacks. The blood undergoes altera* tion, being bl ick and fluid. Symptoms, Following the law oi contagious diseases, the symp- toms vary in intensity in different cases, the prominent symptoms being often disproportionate to the gravity of the attack. The invasion may be fnild, with rigors succeeded by moderate fever, headache, languor, loss of appetite, stiffness of the neck, tender- 7iess about the angles of the jaw, or slight soreness of the throat. In other cases the invasiofi is more abrupt and severe, with chilli- ness followed by gxtAi febrile reaction, 103° to 105° ¥.,pain in the ear, aching of the limbs, loss of strength, painful deglutition, and swelling of the neck, compelling the patient to take to bed from the onset. The appetite is poor, the tongue slightly coated, sometimes more or less exudation appearing upon it, the bowels either regular or slightly relaxed. The pulse, at first full and strong, soon becomes either rapid or slow, but compressible. The urine is scanty, high- colored, and contains albianin. The local symptoms in the majority of cases are associated with the throat. The patient often complains of a frequent and persistent desire to hawk, in order to clear the throat. On inspection, the fauces are seen red and swollen and more or less covered with a film of diphtheritic exudation, giving a glazed appearance, soon followed by the dirty-white membrane ; sometimes the tonsils and uvula are greatly swollen and spotted with exudation. In severe cases, more or less ulceration or sloughing may be observed. Not infrequently fragments of exudation, the false membrane, are expectorated, with particles of the ulcerated tissues, having an offensive odor, which is transmitted to the breath. The lymphatic glands of the neck are ACUTE GENERAL DISEASES. 213 enlarged and tender, and in severe cases the tissues of the neck are greatly tumefied. Extension to the nasal cavities causes a sanious and offensive discharge from the nose, with attacks of epistaxis. Extension to the larytix is indicated by hoarseness or cotnplete loss of voice, croupy cough, and obstructive dyspnoea, which often becomes urgent, the breathing being noisy and stridulous, and subject to par- oxysmal exacerbations. If the inflammation extend to the bronchi, the breathing becomes still more embarrassed. Duration. Ranges from two to fourteen days, an average being about nine days, although complications and sequelae may prolong its course. Relapses are not uncommon. Sequelae. Those who recover from a severe attack remain often for weeks with a pale and cachectic appearance, due to the profound blood alteration. Paralysis is a common sequela, following the mild as often as the severe attacks. Usually not occurring until the patient seems fully convalescent. /%ary;z^^(2/ paralysis is most common, causing difficulty or inability of deglutition, fluids regurgitating through the nose. Cardiac paralysis, bradycardia, is not infrequent, the pulsations descending to 60, 50, 40, and, in a case seen by the author, to 20 per minute. Heart failure and fatal syncope may occur at any time during the disease. Diphtheritic paralysis may affect the motor muscles of the eye, causing strabistnus ; the muscles of one side, hemiplegia ; of the legs, paraplegia ; and of the bladder, leading to retention of urine or difficulty in voiding it. Multiple neuritis, with the attending loss of power, is a rare sequela. Sensation and the reflexes are diminished in the paralyzed parts. Diagnosis. The diagnosis is now made certain by making a culture from the deposit, and if the bacillus is present, the charac- teristic colonies can be seen in the course of twenty -four hours, under the microscope. Yxom follicular ulceration of the tonsils, which is frequently termed diphtheria, by the slight or absent systemic symptoms, the ulcerated condition being limited to the tonsils, but often one, and the absence of glandular enlargement, and following palsies. 214 PRACTICE OF MEDICINE. From pharyngitis, by the absence of exudation and loss of faucial tissue and constitutional symptoms. From scarlatina, by the presence of the eruption and the absence of membrane in the fauces. The association of scarlatina and diph- theria must not be forgotten. From membranous croup, by the difference in the constitutional symptoms; croup appears sporadically and is not contagious, diph- theria being highly contagious and frequently occurs in epidemics; in diphtheria of the larynx the depression is clearly that of blood- poisoning, while in croup the depression is in proportion to the mechanical obstruction of the respiration by the membranous exuda- tion. The pathology of croup is simple and easy of investigation; diphtheria is obscure in its etiology and progress. The temperature record of croup is a high one until carbonic acid poisoning is immi- nent from the mechanical obstruction to respiration, while in diph- theria the tendency to a decline in the temperature after the fourth day is nearly characteristic, regardless of the amount of laryngeal obstruction. In croup the pharynx contains no membrane, and is but slightly, if at all, inflamed, and associated trouble in the nose is of the rarest occurrence, the very reverse obtaining in diphtheria. In croup the laryngeal symptoms are from the onset, while in laryngeal diphtheria the pharyngeal symptoms almost always precede. In croup glandular involvement is a clinical novelty, as are subsequent palsies, while glandular involvement and various palsies are the rule in diphtheria. Albuminuria is the rule in diphtheria, seldom occur- ring in croup. Prognosis. Always grave, but more so in children than in adults. Its gravity, in the majority of cases, is proportionate to the local symptoms. The average mortality is about ten per cent. Favorable indications are, moderate fever, strength slightly im- paired, a good constitution, and moderate exudation. Unfavorable indications are, high fever, great depression, spreading exudation, great swelling of the cervical glands, large amounts of albumin, extension to larynx and nasal mucous membranes, hemor- rhages from the fauces and nose, and an epidemic character. Treatment. The introduction of the antitoxin serum has changed the proj:,^nosis of this formidable malady. The injections are made where the skin is loose and at points that will not interfere with the comfort of the patient. The dose must be estimated in antitoxic ACUTE GENERAL DISEASES. 215 units, and not by the unit of the serum. The dose is from looo to 3000 units, according to the severity of the attack. If the dose is sufficient, evidences of improvement are seen within a few hours. With the serum-therapy must be associated the constitutional treat- ment, as it is a disease of great debility, and the blood being more or less altered, it follows that sustaining measures should be resorted to in all cases. The diet should be of the most nutritious character, from the onset, using such articles as milk, eggs, broths, and oysters, at intervals of every two or three hours. If deglutition be too painful, resort must be had to nutritious enemata, the following being a suitable formula : R. Milk, fgj 30. Cc. Spts. frumenti, ^3'^ ^S- ^^• Egg, One M. SiG. — Little salt added, beaten up and warmed. Stimulants should be used boldly from the onset, guiding the dose by the effect ; usually a child of two years requires from thirty \.o sixty minims (2-4 Cc.) of spirittis vini gallici or spiritus frumenti every two or three hours ; an adult from two to four drachms (8-1 5 Cc.) every three hours. It is a mistake to wait for signs of debility before using alcohol in diphtheria. Strychnince sulphas, in frequent doses, should be used from the onset. Of drugs, two are warmly advocated ; ferrum and hydrargyrum. Of the great value of tinctura ferri chloridi there is no question, but for hydrargyri chloridum corrosivum it has hardly realized the expectations of the profession, except in laryngeal cases. A com- bination of ferrum and potassii chloras, in full doses, frequently repeated, has seemed, when begun early in the attack, to modify the course of the malady, and they have the additional advantage of acting locally upon the throat as they are swallowed. A good formula is — B- Tinct. ferri chlor., TtLv-x .3-6 Cc. Potassii chlor., gr. iij-v -2-. 3 Gm. Glycerini, f.^ss 2. Cc. Syr. zingib., ad fgj-ij ad 4.-8. Cc. M. SiG. — In water every three hours, for a child of two or three years. Ferrum and hydrargyri chloridum corrosivum, repeated every second or third hour, may be combined as follows : 216 rRACTICE OF MEDICINE. K- Ilydrargyri chloridi corrosiv., . gr. ^'^ .0015 Gm. Tinct. fcrri chloridi, n\,v-x .3-.6 Cc. Giycerini, Tt\^x .6 Cc. Aqiue, (^'} 4. Cc. M. SiG. — Every hour or tsvo, well diluted. The efficacy of the above is greatly enhanced by the addition to each dose of iinctura belladonncF, tt\, j-v (0.06-0.3 Cc). QuinincE sulphas, gr. xvj-xxiv (1-1.56 Gm.) per day for a young adult, and gr. v-x (0.3-0.6 Gm.) for a child, should be used through- out the disease ; if irritability of the stomach prevent its administra- tion by the mouth, it can be used as a suppository, or locally in the form of the oleate. Sustain the heart with either digiialis, glonoin, ca(feifia: citrata, or strychnines sulphas, or a combination of these drugs. Calomel \n small doses, combined with sodii bicarbotias every hour until it is beneficial, and especially in cases showing a tendency to spread toward the larynx. Indeed, a tolerance to calomel seems to exist in diphtheria of the larynx. Watch the urine carefully throughout the disease ; diminution in the amount with much albumin is of bad omen. The bowels must be regular. Isolation of the patient and disinfection of the clothing and utensils is of importance. All clothing should be soaked twenty-four hours and boiled in a two per cent, solution of carbolic acid. Inhalations of steam and hot water, and allowing the patient to suck pellets of ice, give relief. Sponges dipped in hot water and applied to the angles of the jaw are beneficial. The chief danger of communication of the poison is the air exhaled from the fauces and from the surface. Dr. J. Lewis Smith recom- mends the following plan to counteract the danger. Add four ounces of the following solution to one quart of water and allow them to simmer constantly, near the patient, in a broad surfaced tin or zinc wash-basin : R. Olei eucalypt., acidi carbolici, aa f5J (30 Cc.) ; spirit, terebinthinae, f J viij (240 Cc). M. The vapor is strong, penetrating, and prophylactic, but not unpleasant. In hot weather, or when a fire is not convenient, saturate cloths a foot square with the same solution and place them on paper on the bed of the patient. Locally. Two indications to be met, one to prevent or limit the local development of the bacilli, and the other to combat the effects ACUTE GENERAL DISEASES. 217 of the toxic material which the bacilli produce. The first question asked is, Can we dissolve the membrane ? " In laboratory, yes ; in throat, no." (Da Costa.) Cleanliness of the fauces is of the utmost importance, and if a non- irritatittg disinfectant be added, its value is enhanced. Prof. Bar- tholow " has seen excellent results from the frequent application of r- solution oi acidnni lactictan, strong enough to taste sour, by means of a mop." Excellent results are obtained from spraying the throat with a fifty per cent, solution of hydrogen peroxide. Swabbing the throat with the following is valuable : K. Acidi carbolici, TTLxx I.3 Cc. Tinct. ferri chlor. , ^Tt^'^ 1 5- ^^^ Glycerini, f_^j 30. Cc. Aq. destil, fgj 30. Cc. M. SiG. — Locally, every three hours. Applications of corrosive sublimate to the throat are often valuable. Dr. Ernest Laplace has demonstrated that corrosive sublimate in solution, slightly acidulated with tartaric acid, has its germicide prop- erty increased, as in the following 1-500 solution (R. Hydrargyri chlor. corrosiv., gr. 3.85; acid tartaric, gr. 19.25. M.) The following, used as a gargle, or applied by a mop, is useful : R. Potass, chlorat., ^5 iv 15. Gm. Acid, carbol., gr. ij-iv .13— .26 Gm. Tinct. myrrh., f^j 30. Cc. Inf. cinchonse, f ^ ij 60. Cc. M. It is a mistake to struggle with children over their refusal to use a gargle or allow the use of the spray, as they do not know how to gargle and they are afraid of the spray. Much better to add plenty of glycerin to their medicine, and use no liquid for some time after swal- lowing. For laryngeal diphtheria the same general treatment, especially the merctirial , with inhalations of lime by slaking freshly-burned lime in a vessel and directing the vapor to the child by a newspaper, or some similar contrivance, or using three parts of liquor calcis and one part oi glyceriniwi in an atomizer, every half hour or hour, or liquor trypsin, as a spray. If these means fail, resort must be had to trache- otomy, or intubatio7i of the larynx, which have succeeded in many 218 PRACTICE OF MEDICINE, desperate cases. It is safer to insert a tube at the onset in all cases of laryngeal diphtheria. For nasal diphtheria, the same general treatment, and syringing the nose every two or three hours with a weak solution oi potassii chloras, or aciduin carbolicum, or hydrogen peroxide, or the follow- ing : li . Sodii sulpbit. 3 iij 12. Gm. Glycerin!, f % ij 8. Cc. Aquce, f 5 'v ^20. Cc. For the paralysis, strychnines sulphas and femon internally, 01 strychnines sulphas hypodermically, with the galvanic or faradic current locally. GLANDERS. Synonyms. Farcy ; malleus humidus. Definition. An infectious disease of the horse, communicable to man and some domestic animals, but not to cattle; characterized by nodular growths in the nose — glanders, and under the skin — farcy. Cause. Due to a specific bacillus — bacillus Mallei. The organ- ism resembles the tubercle-bacillus, though somewhat shorter and thicker. Communicated by the discharge from an infected animal to an abraded skin or mucous surface. Contagious. Incubation from three to five days. Pathological Anatomy. Nodules, consisting of aggregations of round cells of lymphoid or polymorphonuclear type, which have a strong tendency to suppurative or necrotic softening. The floor and edges of the ulcers (softened nodules) are irregular and yellow- ish, discharging more or less purulent matter. The nodules develop particularly in the nares and the skin, and, rarely in the lungs. The lymphatic glands of the neck and elsewhere enlarge and may sup- purate. Symptoms. There is an acute and a chronic form of glanders. Acute glanders. Redness and swelling oi the nasal mucous mem- brane with burning and dryness, followed by the development of the tiodules,\\\\\z\\ rapidly breakdown and discharge a fetid hemorrhagic or muco-pus. There is headache, painful deglutition, cough, fever, prostration, rapidly developing typhoid symptoms, and death. ACUTE GENERAL DISEASES. 219 Acute farcy or glanders of the skin is a nodular swelliftg w'lih. subse- quent ulcers and discharge of a fetid hemorrhagic pus on the skin. Papules, becoming pustules, followed by ulceration, occur in the neighborhood of the nodules. The lymphatic glands and vessels are involved, but not the nose. Prostration and typhoid symptoms rapidly develop. In the chro7iic variety the development, course, and symptoms are all more backward and of less severity. Diagnosis. The certainty of diagnosis is made possible by mak- ing cultures. Prognosis. Acute variety fatal. Chronic variety, if early diag- nosed, many may recover. Treatment. Palliative and surgical means for the lesions. It is possible the serum-therapy may soon be able to control, cure, or modify this fatal disease. ACUTE ARTICULAR RHEUMATISM. Synonyms. Rheumatic fever; inflammatory rheumatism. Definition. A constitutional disease, characterized by fever, in- flammation in and around the joints, occurring in succession, and a great tendency to inflammation of either the endocardium or peri- cardium. Causes. The predisposing causes are inherited tendency, scarla- tina, and the puerperal state. The exciting causes are exposure to cold and chilling of the body in those predisposed. Rheumatism rarely occurs before seven or after fifty years. The liability to the disease is increased by having had an attack. It is claimed that a specific bacteria has been found in the swollen joints, which may prove to be the etiological factor in the production of the painful affection. Pathological Anatomy. The blood contains an excess of lactic acid. The Joints bear the brunt of the attack ; the synovial mem- brane is reddened, the vascularity of the synovial fringes is increased ; so with the synovial fluid, which is thinner, of a reddish color, con- taining some gelatinous coagula of fibrin, and, under the microscope, nucleated cells, ordinary pus cells being rarely seen. The swelling visible from the affected part depends mostly on inflammatory oedema of the connective tissue around the joint. 220 rUACTICE OK MKDICINE. The pain is probably due, in all cases, to stretching of and press- ure on the elements of the tissues by the dilated capillaries and the inflammatory oedema. For the changes which ensue when theendo- and pericardium are attacked, the reader is referred to the sections on those diseases. Symptoms. Begins suddenly, generally at night, with a chill ox chilliness, />a/« and stiffness in the joints, loss of appetite, at times nausea and vomiting, followed hy fever, the temperature soon reach- ing 102° to 104° F., in rare cases 108° to 1 10° {the hyperpyrexia), the pulse seldom exceeding g^, great thirst, profuse acid sweats, scanty, high-colored, acid urine, at times showing traces of albumin ; the bowels constipated. The fever continues throughout the attack, show- ing marked remissions. Delirium is absent, except the hyperpyrexia occur. 6"/!?^^ is prevented by Xhe pain and the profuse perspirations. The strength is moderately well preserved. The s^in is often covered with an eruption of viiliaria rubra, red papules, and miliaria alba, the result of irritation at the orifices of the sweat glands, from the excessive perspiration. The local phenomena Vive pain, tenderness, increased heat, swelling; and redness of one or more joints; if but one joint, it is termed tnonoarthritis ; if more than ont, polyarthritis. Paiti is aggravated hy motion 2inA pressure. Swellifig is most apparent in those joints not covered with muscle, as the knee, wrist, elbow, ankle, and the hands and feet, and is proportionate to the acuteness of the attack. The inflammation may abruptly cease at one or more joints, and as suddenly attack others. The disease is extremely irregular as regards the number of joints affected, although the local manifestations are controlled by an important pathological law, the law of parallelism. Correspond- ing joints are often affected together, and when not, the different affected joints are either on one side of the body, or those on both bides which are analogous, as the knee, elbow, wrist, ankle, hip, and shoulder, are attacked together. Complications. Pericarditis, endocarditis, myocarditis, cerebral endarteritis, bronchitis, pneumonitis, and pleuritis. Duration. The duration of acute rheumatism is governed entirely by the presence or absence of complications. Uncomplicated cases recover in from thirteen to twenty one days, although they may be prolonged to five or six weeks. Relapses are frequent. ACUTE GENERAL DISEASES. 221 Diagnosis. A typical case cannot be mistaken for any other disease, but cases running a subacute course may be mistaken for acute rheumatoid arthritis, gonorrhoeal rheumatism, or pyaemia. Acute rheumatoid arthritis attacks one joint at a time and becomes permanent, has slight, if any fever, no sweats or cardiac lesions. Gonorrhoeal rheumatism is associated with a gleety discharge, or follows the sudden cessation of an acute or subacute gonorrhoeal discharge, attacks either the ankle or wrist only, is slowly influenced by treatment, and lacks the febrile phenomena. PycE7nia is usually manifested at a single joint at the time, and is followed by suppuration and all the symptoms of hectic fever. Prognosis. Recovery is the rule in uncomplicated cases, the mortality being about three per cent. When death occurs, it usually depends upon hyperpyrexia, cardiac complication, or cerebral end- arteritis. Treatment. Owing to our imperfect knowledge of the exact nature of this most painful disease, its treatment still remains either empirical or is directed toward certain prominent symptoms or com- plications. Garrod claims that "colored water" is about as potent as anything else, for it is, he says, a "self-limited disease," some- times running a long and sometimes a short course. Rest in bed, whether the pain forces it or not, is important. Warmth is as imperative, for which purpose the patient should be kept in blankets — no sheets — and wear woolen garments. The diet should be easily digested food, milk being the most suitable. Strong and vigorous patients do well with acidum salicylictan or the salicylates in large and frequently repeated doses. R. Acidi salicylici, Iss 15. Gm. Liq. ammonii acetat., f^i^ \20. Cc. Spts. Eetheris nitrosi, f 5j 30. Cc. Syr. simplicis, f^j 30. Cc. M, SiG. — Tablespoonful every three hours, well diluted. Or— R. Sodii salicylat., ^^j 30. Gm. Tinct. cinchonse comp. , .... fSiij 90. Cc. Aq. menth. pip., f § 'U 9°- Co. M. SiG. — Dessertspoonful every three or four hours till relief, when widen the interval. 222 PRACTICE OF MEDICINE, Or— R. Potassii acetat ^j 30. Gm. Acid, salicylici, s ss 15- Gm. Syr. limonis, f.^'j ^- ^^• A(\. meiith. pip., '^o^'"J ^4°- ^^- ^' SiG. — Tabiespoonful every three hours, diluted. If benefit follows, the evidence is quickly afforded in the relief of pain and the decline of the temperature and swelling. If, therefore, after three or four days' use of the salicylates or acidum salicylicum, as above recommended, signs of improvement are wanting, the treat- ment had better be changed for the alkaline treatment, which consists in the administration of an ounce and a half of the alkaline carbon- ates, either alone or with a vegetable acid, each twenty-four hours, until the urine becomes neutral or alkaline, when the quantity i= reduced to an amount sufficient to maintain alkaline urine. The following are good formulae for the alkaline treatment: R. Potassii bicarbonatis, ^ij 8. Gm. Acid, tartarici, gr. xxx 2. Gm. Dissolve in a glass of water and drink effervescing every three hours. Or— R . Potass, bicarb. 3 ij 8. Gm. Succi limonis, f^iv 15. Cc. Aqure chloroform! fo^^ ^5- Cc. M. SiG. — In water, every three hours. After the more acute symptoms are relieved change whichever plan of medication has been used for iinchira ferri chloridi, tt)^xx (1.3 Cc), every three or four hours, well diluted, or for full doses of Basham's mixture. Pale, feeble, and anaemic patients, or attacks following scarlatina are most favorably influenced by — R. Strychnin?e sulph., gr- ?V .001 Gm. Tinct. ferri chlor., TT\^xv-xxx I. -2. Cc. Liquor, ammonii acetat., . . . . f 'ss 15. Cc. M. SiG. — Every four hours, in a glass of water. Dr. S. Solis-Cohen has reported good results from the following combination in anaemic and run-down cases, to which he has given the name of " mistura ferro-salicylata " : ACUTE GENERAL DISEASES. 223 R. Sodii salicylatis, . , ziv 15. Gm. Glycerini, f^j 30. Cc. Acidi citrici, gr- x .6 Gm. 01. gaultherise, f^ss 2. Cc. Mucil. acacise, f^ss 15. Cc. Misce tt adde while stirring, Tinct. ferri chlorid., ^5'^ ^S- Cc. M. Liq. ammonii citrat. (B. P.), ad f^iv ad 120. Cc. SiG. — One to two teaspoonfuls every two, three, or four hours, diluted. Prof. Da Costa reports a lessened proportion of cardiac compli- cations with ammonii broinidtan, gr. xv-xx (1-1.3 Gm.), every four hours. I much prefer ajjtfnonii salicylas, gr. x-xv (06-1 Gm.), in simple syrup, well diluted, every four to six hours. Subacute attacks and lingering cases are favorably influenced by cinchonidi7tcE salicylas, gr. v (0.3 Gm.), every four hours, or — 5k . Lithii salicylatis, gr. xv-xx I.-I.3 Gm. Syr. zingiberis, f^j 4. Cc. Aq. lauro-cerasi, f^j 4. Cc. M. Every four hours. Or— R. Potassii iodidi, J^iv 5.3 Gm. Sodii salicylatis, ^iv 15. Gm. Elix. cinchonas, f.^iss 45. Cc. Infus. gentianae, f.S^^^ 45- ^^• Aquse destil., fjj 30. Cc. M. SiG. — Dessertspoonful every three or four hours, diluted. Good results are reported from the use of salol, gr. v-x (0.3-0.6 Gm.), every four hours, from ammonii hydrochloras, gr. xv-xx (1-1.3 Gm.), every four hours, and from salipyrin in solution, every four hours ; R. Salipyrin, ^iij 1 2. Gm. Glycerini, f^i'j 12. Cc. Syr. aurantii, f .^ vj 24. Cc. Aquae destil., ad f^vj ad 180. Cc. M. SiG. — Tablespoonful, well diluted. Whichever plan, acidum sahcylicum, salicylates, alkahne, or fer- rum, is adopted, guinittcs sulphas, gr. xv (i Gm.), per day, should also be used. Pain and restlessness should be controlled by opium in some form, in full doses, or atropines sulphas, gr. -g^j (0.0008 Gm.), hypodermic- ally. 224 PRACTICE OF MEDICINE. For the hyptrpyrexiix, quinhta: sulphas, gr. xxx-lx (2-4 Cim.), repeated p. r. n., with the cold bath or wet pack. Locally, the affected joints should be wrapped in cotton-wool or flannel, saturated with a solution of tinctura opii, one part, and liq. plumb, subaceiat. dil., two parts, or olei gaiilthericr , foj (4 Cc), with lin. saponis comp., f5iij (90 Cc), or — Ht. Sodii bicarboiiatis, _^ i j 60. Gm. Tinct. opii, f.^ss 15. Cc. Aqucebul., Oij 960. Cc. M. Dr. Bartholow finds the application of blisters an effective method. He says : " I have small blisters, the size of a silver dollar, placed around the joint, leaving an interval between for succeeding applications. It is by no means so painfiil and disagreeable as it appears at first sight. The blisters remarkably relieve the pain, bring about a more alkaline condition of the blood, and render the urine less acid, or bring it to neutral, or even to alkaline." If the disease shows a tendency to linger in one or more joints, such joints should be immediately placed in the hot-air apparatus. MUSCULAR RHEUMATISM. Synonyms. According to location: cephalodynia; lumbago; torticollis ; pleurodynia. Definition. An affection of the voluntary muscles, inflammatory in character, either actite or chronic ; characterized by pain, tender- ness, and stiffness of the affected muscles. It is never complicated with cardiac disease. Causes. A disease of adult life. One attack predisposes to an- other. Almost always due to cold or damp, or direct draught of cold air. Gout increases the tendency to attacks. Pathological Anatomy. The true nature of muscular rheu- matism is not yet determined. Virchow suggests a " hypersemia of, and scanty serous exudation between, the muscular stria:, and in chronic cases inflammatory proliferation of the connective tissue." Symptoms. The first attack is generally acute. Onset rather sudden, with pain in the affected muscles, with slight tenderttess,2indi considerable stiffness and difficulty of movement, by which also the pain is increased. ACUTE GENERAL DISEASES. 225 The suffering may be severe and constant, or only on motion. Spasm of the affected muscles may occur. Objective symptoms are wanting, except it is evident that the patient keeps the affected muscles as quiet as possible. Fever is absent. The pain may pre- vent sleep. Duration, acute form, about one week. Chronic variety returns fre- quently, and finally becomes constant and aggravated when the weather is damp. Varieties. It may affect any or all of the voluntary muscles, but its most frequent and important varieties are : 1. Cephalodynia. Situated in the occipito-frontal muscles. Dis- tinguished from neuralgia of the trifacial, or occipital nerve, by pain on both sides of the head, excited or aggravated by the movements of the muscle and by absence of disseminated points of tenderness. The muscles of the eye may be affected, and movements of that organ excite pain. If the temporal and masseter muscles are attacked, mastication excites pain. 2. Torticollis. Wry neck, or stiff neck. Situated in the sterno- mastoid muscles. Generally limited to one side of the neck, toward which side the head is twisted, great pain being excited on attempting to turn to the opposite side. Rheumatism of the muscles of the back of the neck, cervicodynia, may be mistaken for occipital neuralgia. 3. Pleurodynia. Situated in the thoracic muscles, and may be mistaken for pleuritis, or intercostal neuralgia, from which it is differ- entiated by the absence of the diagnostic features of each. Pain is excited by forced breathing, coughing, and sneezing. 4. Lwnbodynia or lumbago. Situated in the mass of muscles and fascise, which occupy the lumbar region. Most common variety. Usually affects both sides. It may set in rapidly, and become very severe. Motion of any kind aggravates the pain, often becoming very sharp or stabbing in character. It is sometimes complicated with acute sciatica, when the suffering is agonizing. Diagnosis. The different varieties may be mistaken for any of the following ailments, to wit : trifacial, occipital, or intercostal neu- ralgia, pains of progressive muscular atrophy, neuritis, syphilis, metallic poisons, or painful affections of the loins, arising from calculi or gravel in the kidney. A careful examination of the history is usually sufScient to arrive at a correct diagnosis. 15 22f) PRACTICE OF MEDICINE. Prognosis. Difficult to eradicate, and in chronic cases to amelio- rate, but is not dangerous to life. Death never results. Treatment. Rest is the first indication. This is accomplished \x\ pleurodynia by firmly strapping the affected side with broad strips of plaster, extending from mid-spine to mid-sternum. The A'a// application to the aflfected muscles of //^/poultices, made oiXwo-^w^s pilocarptis leaves and ov\t-\}[\\xdL. flaxseed meal, changing them every two hours, is the most rapidly successful treatment in acute cases. Internally, ajtiipyritt, gr. x-xx (0.6-1.3 Gm.), repeated in several hours, or ammonii hydrochloras, ^x,yM-\y. (1-1.3 Gm.), every three hours, or sodii salicylas, gr. xv-xx (1-1.3 Gm.), every two or three hours, are each of value. Prof. Bartholow declares that Hthii bromidum is almost a specific in muscular rheumatism. For \}ci& pain and consequent sleeplessness, use — B . Pulv. ipecac, et opii, gr. x .6 Gm. Potass, nitrat., gr. v-x .3-.6Gm. M. SiG. — In powder, morning and night. Or, hypodermically, at the seat of pain, tnorphina sulphas, gr. %- ^ (0.008-0.016 Gm.), and atropines su/p/ias, gr. ^^^j (0.0008 Gm.), p. r. n. In attacks where the disease is limited to a few muscles, the follow- ing liniment is valuable : R. 01. gaultherlffi, jiss 6. Cc. Spirit, vini rectif., ...■••. f^ij 60. Cc. M. SiG. — Thoroughly rub into affected part. In all forms, but more particularly in lumbago, a few dry cups over the seat of the pain give immediate relief. Wonderful results have followed the use of the hot-air apparatus in acute and subacute lumbago. Chronic cases : Rest, flannel worn next to the skin, stimulating and anodyne liniments, mild galvanism, dry heat, as ironing over the affected part with a common flat-iron, a piece of paper or towel being placed next to the skin. InXernviWy , potassil iodidum, ammonii hydroc Moras, sulphur, guai- acton or arsenicum variously combined. ACUTE GENERAL DISEASES. 227 RHEUMATOID ARTHRITIS. Synonyms. Arthritis deformans ; rheumatic gout (?). Definition. A destructive disease of the joints, accompanied with but slight fever, without suppuration ; progressive in character, causing nearly symmetrical enlargement and deformity of various articulations. Causes. The neuro-trophic theory, as advocated by Mitchell (J. K.) and supported by Charcot, is accepted as the predisposing cause." Among the exciting causes are bad hygiene, exposure, injury, prolonged lactation, frequent pregnancies, menopause, grief, tuber- cular diathesis, and following attacks of articular rheumatism. More common in women than men. A disease of middle life. Pathological Anatomy. It is not rheumatism, as the blood contains no lactic acid. It is not gout, as uric acid is not found in the blood nor urate of sodium in the joints. At first rheumatoid arthritis is attended with hypersemia of the affected synovial membrane and increase of the synovial fluid. Soon the capsular ligament becomes irregularly thickened, the synovial fluid decreasing. If the process continue, the internal ligament is destroyed, thus allowing dislocation to occur. The interarticular fibro-cartilages ulcerate and disappear, as do the cartilages covering the ends of the bone, the ends of the bones becoming smooth and eburnated, and often greatly enlarged. Symptoms. Either acute or chronic, the latter more frequent. Acute form involves several joints at the same time, and is attended with slight pyrexia. Chronic form slowly involves one joint, which seemingly soon recovers, and is attacked again, and may never recover, but grows progressively worse. The. Joint slowly enlarges, is painful, movement exciting neuralgic pains along the limb. Soon the articulations become rigid or slightly movable after prolonged attempts, are more or less distorted and flexed, with nodules (Heberden's nodosities) on the sides or ends of the distant phalanges. Redness and tenderness are wanting. The muscles of the affected limb waste, giving the joint a greatly hyper- trophied appearance. Crepitation is distinct after ulceration has destroyed the cartilage. '2l28 PRACTICE OF MEDICINE. The hands are first involved, the disease spreading symmetrically from articulation to articulation, until in severe cases every joint is deformed. Diagrnosis. Chronic articular rhcKmaiistn is often confounded with rheum;itoid arthritis; but the former lacks the marked structural changes and the progressive involvement of joint after joint. Gout differs from rheumatoid arthritis by the presence of deposits of urate of sodium in the joints, the ears, tips of fingers, and the bursse over the olecranon process of the elbow, the presence of uric acid in the blood, and the decided history of acute paroxysms. Gonorrhccal r/ieutnatisvi, so-called, has symptoms akin to rheu- matoid arthritis, but the history of urethral suppuration clears up the diagnosis. Paralysis agitans, when pronounced, might be confounded with rheumatoid arthritis if the examination were limited to the joints; but the whole history, such as the tremor, the gait, etc., should pre- vent error. F^rognosis. If early treatment be instituted, the disease may be held in abeyance for several years. After pronounced structural changes have begun, the malady is incurable, although it may remain stationary for a long time. Treatment. If treatment be instituted before serious structural lesions have occurred, the author has seen benefit in many cases by the following plan : Oleian viorrhuce carefully and thoroughly rubbed into the affected joints three times a day, with the internal use oi lithii citras effervescentes, 3j (4 Gm.), three times a day, and the following tonic mixture : R. MasscE ferri carbonat. gr. v .3 Gm. Liquor, potass, arsenit., .... Tt\^v .3 Cc. Vini xerici, {t^'] 4. Cc. Aquffi distill., fjj 4. Cc. After meals, well diluted. I have had some success from painting the joints when painful with the following combination, using at the same time guaiacol carbonat., gr. v-x (0.3-0.6 Gm.), three times daily: R . Guaiacol, i part Tinct. iodi, 6 parts. M. Sig. — Paint over joints twice daily. ACUTE GENERAL DISEASES. 229 Complete recoveries are reported from the long-continued adminis- tration of small doses of liquor potassii arsenitis. Attention to diet and hygiene are most important and valuable. When structural changes have destroyed portions of the joint, pallia- tive treatment is the chief indication. GOUT. Synon3rms. Podagra, gout in the foot ; chiragra, the hand ; gonagra, the knee. Definition. A constitutional disease, usually inherited ; charac- terized by the sudden occurrence of a paroxysm of severe pain and swelling in one of the smaller joints, — the great toe usually, — with the presence of uric acid in the blood, and the deposit of the urate of sodium in the structure of the joint. Causes. Predisposing : inherited, male more than female — women after menopause. Exciting; malt liquor and wine drinking; large consumption of animal food ; lead poisoning ; winter season. When an inherited tendency, may begin early in life ; when an acquired tendency, after thirty-five years. The pathological cause consists in the presence of an excess of uric acid in the blood in the form of urate of sodiu??i. Pathological Anatomy. Gout is characterized by the deposit o{ urate of sodiutn from the blood into the structure of joints and tissues that are not very vascular. The deposit is associated with signs of inflammation — to wit : hyperaemia, redness of the surface, with swelling and effusion in and around the affected joint. The surfaces of the joint are incrusted with chalk-like masses, consisting of urates, which become greater with each attack, finally causing great deformity. The deposit usually begins in the metatarso-phalangeal joint of the great toe, but other and many joints are soon affected. The deposits may also be found in the knuckles, eyelids, and car- tilages of the ear. " Crystals of urate of soda are deposited in the tubules and intra- tubular tissues " of the kidneys — " gouty kidney " — and may be seen by the naked eye, the kidneys becoming small, granular, and fibrous. 230 PRACTICE OF MEDICINE. Hypertrophy of the left ventricle and of the arteries, ending in atheromatous changes, are results of gout. Symptoms, ylcute gout is rare in the United States. It occurs in paroxysms; one year's interval between the first and second attack ; six months usually between the second and third, after which it may occur at any time. Prodromes usually precede the paroxysm for several days, to wit, acid dyspepsia, constipation, headache, and lassitude. The paroxyvn'\)t^\x\s suddenly, between midnight and 2 A. M., with acute pain in the ball of the great toe, which becomes red, hot, sivolU-n, and so sensitive that the slightest touch cannot be borne. The veins are filled, the foot, ankle, and leg swollen, and the limb the seat of sudden spasmodic contractions, which increase the suffer- ing ; slight relief is afforded by elevating the limb. Associated with the local symptoms are cJiill, fever, quickened pulse, thirst, coated tongue, constipation, and scanty, acid, high-colored urine, which de- posits, on cooling, a heavy ^r^V/v/z/^i/ sediment. Towards daylight the symptoms ameliorate, to return again at sun- down, the severity gradually lessening, until the fourth or fifth day, when convalescence is established, the patient, as a rule, feeling better than before the attack. Chronic Gout. Either the result of acute attacks or with a greater number of joints being attacked. The paroxysms occur at any time, but develop slowly, with less pronounced local and general symptoms. Deposits are noticed, the joints becoming hard, knobby, and often distorted. The deposits or chalk stones (urate of sodium) occur about the joints, tendons, and bursjE, and helix of the ear. Diagnosis. An error cannot occur if the history of the case can be obtained, to wit : hereditary tendency, age, sex (females rare, until menopause), mode of living, character of symptoms, and presence of the characteristic deposits. Prognosis. Acute gout rarely fatal ; is prone to return, but much depending upon the mode of living. Chronic gout decidedly shortens life. The most serious signs are those indicating advanced renal disease, with non-elimination of uric acid. Gout influences unfavorably the prognosis from acute diseases or injuries. Treatment. For the acute paroxysms, at once, vinutn colchici ACUTE GENERAL DISEASES. 231 radicis, gtt. xv-xx-xxx (1-1.3-2 Cc), every two hours, ivell diluted, either alone or in combination with a. potassitcni salt, or sodiisalicylas, gr. XX (1.3 Gm.), every two to four hours, well diluted, until relief or ringing in the ears occurs. While the acute symptoms of gout are not so rapidly relieved by sodii salicylas as are those of acute rheu- matism, still it is an invaluable remedy and is rapidly succeeding colchicum. After the decrease of the acute symptoms, lessen the dose, but continue the remedy for some time. Dr. Bartholow recommends the following pill : • B:. Colchicinse, g^- Tff • -0013 Gm. Ext colocynth. comp., gr- ss .032 Gm. Quininse sulph., gr. iij .2 Gm. M. Every two or three hours. For the pam, hypodermic injection of morphince sulphas, and wrapping the intlamed joint in cotton-wool saturated with liq. pliwib. subacetat. dil. and tinciura opii. The use of morphia in acute gout must be with caution, as many subjects have more or less contracted kidneys. The diet must be restricted to milk and non-acid fruits, raw or cooked. The drinking of several ounces of water, hot or natural, every three hours, is most useful. For subacute or lingering cases, and in chronic gout, potassii iodi- dwn is valuable. JJ . Potassii iodidi, ^ij 8. Gm. Vini colchici radicis, f^i'' ^5- Cc. Aquae destil., f^iiss 75. Cc. M. SiG. — Teaspoonful, well diluted, after meals and at bedtime. Y ox chronic gout, regulated diet, free action on the secretions, and lithii citras efferuescentes, Z] (4 Gm.), three or four times a day, well diluted with water ; and perhaps a course of quinina, ferrum, and arsenicum. To prevent paroxysm, keep secretions acting by the free use of pure water or a good alkaline water, such as Buffalo lithia or Farm- ville lithia water, or Saratoga Vichy. The diet is of the greatest importance, and should consist chiefly of vegetables and fruit, excepting tomatoes and strawberries, lemons and oranges ; fresh meat must be discontinued for a time ; oysters, fish, and soups may be used sparingly. Alcoholic and malt liquors 232 PRACTICE OF MEDICINE. are contraindicated, as are tea and coffee ; inilk should replace all the above. No eggs or dishes containing eggs ; no pastry, hot bread, or cakes; no sweetmeats, spices, or condiments. Systematic exercise, especially walking, is of great advantage. Cold bathing with caution, while the vapor or Turkish baths are of benefit. Changing from a cold to a warm climate in winter, and the use of flannel underclothing, are strongly recommended. DIABETES MELLITUS. Synonyms. Glycosuria ; melituria. Definition. A chronic affection characterized by the constant presence of grape sugar in the urine, an excessive urinary discharge, and the progressive loss of flesh and strength. Causes. Most common in males. More frequent in the Hebrew than the Christian. Rare in negroes. Occurs at all ages, but most frequently between twenty-five and fifty years. It is often hereditary. Disorders of the nervous, hepatic, and renal systems. Excessive use of farinaceous food and malt liquors. Sexual excesses. The tx^ct pathology of diabetes mellitus differs in different cases, and in the present state of knowledge no exclusive view can be adopted. Still, there are reasons for believing that, in a large pro- portion of cases, the nervous system is primarily at fault, though the character of the lesions may differ. Pavy believes diabetes mellitus originates in the nervous system, and probably as a vaso-motor paralysis. Disease or extirpation of the pancreas is followed by diabetes, and it is claimed the pancreas secretes a glycolytic ferment. Patholo^cal Anatomy. None peculiar to diabetes is yet recognized. Hyperaemia and hypertrophy of the liver and kidneys are gener- ally present, the result of increased functional activity. Various organic changes are found in the pancreas. The changes in the lungs peculiar to phthisis are often found in very chronic cases. The changes in the nervous system are not fully determined. Symptoms. Clinically, cases differ greatly in their course and severity ; one class presenting slight symptoms and a chronic course; another class having marked local and constitutional symptoms and ACUTE GENERAL DISEASES. 233 running an acute course. The symptoms of a typical case may be arranged under the following heads : Urinary Orgajis and Urine. Micturition more frequent and the tirine increased \n. quantity. Pain over the region of the kidneys. The quantity of urine may amount to 4, 8, 12, 20, or 30 pints in twenty-four hours. It is usually pale, clear, and watery, having a sweetish taste and odor, the specific gravity ranging from 1.025 to I 050. It ferments rapidly if kept in a warm place. It yields grape sugar to the usual tests, the amount present varying from an ounce to two poujids in the twenty-four hours. The urea and uric acid are increased. Albumin may be present. The increased passage of a large quantity of saccharine urine causes a constant itching, burning, and uneasy sensation at the prepuce, along the urethra, and at the neck of the bladder; in females, itching and eczema of the vulva are common ; in children, incontinence of urine is frequent. Digestive Organs. An almost constant symptom is thirst, with a dry and parched condition of the mouth. At times the appetite is excessive, again absent. The breath may have a sweetish odor, the tongue irritable, red, and often cracked. Dyspeptic symptoms are common, and occasionally vomiting. The bowels are constipated, the stools pale and dry. At times diarrhoea may occur. The patient complains of feeling very weak, languid, and of S07'e- ness and pain in the limbs ; there is more or less etnaciation, a harsh, dry skin, the countenance distressed and worn. The mind is often greatly altered ; depression of spirits, decline in firmness of character and moral tone, with irritability, are present. Sexual inclination and power are greatly diminished. Defects of vision are present. The blood and various secretions cotttain sugar. Complications. Pulmonary phthisis ; Bright's disease ; defects of vision from atrophy of the retina or the formation of a soft cataract ; boils and carbuncles, and chronic skin affections, such as psoriasis and eczema. Course. The clinical history varies in different cases. In the majority of instances the course is chronic, lasting for years, the symptoms beginning insidiously, and becoming progressively worse, with, at times, decided remissions. Occasionally the disease runs an acute course, death occurring within four or five weeks. 234 I'RACTICE OF MEDICINE. Termination. The majority of cases ultimately prove fatal, the symptoms markedly changing, the urine and sugar diminishing \x\ quantity, the occurrence of albuminuria, disgust for food and drink, and the development of hectic fever and colliquative diarrhoea. The fatal result usually arises (rom gradual ex/iauslion from blood- poisoning, leading to stumor, ending in complete coma, or occasionally io delirium or convulsions, or from complications. Rarely death occurs suddenly from urcemic convulsions or uraniic coma. Diagnosis. Diabetes mellitus only exists when grape sugar is permanently present in the urine. " It is not the quantity, but the persistence of sugar which constitutes diabetes." With grape sugar in the urine, associated with more or less in- crease in the urinary flow, it should be mistaken for no other affection. From Bright' s disease, by the absence of dropsy, and of tube casts in the urine, and the constant presence of sugar in the urine ; but the amount of albumin in the urine is never so great or constant in dia- betes mellitus as in Bright's disease. From diabetes insipidus, by the absence of sugar in the blood and urine, and the larger quantity of urine voided in polyuria. Simple glycosuria differs from diabetic glycosuria in that the amount of sugar in the urine is not constant, — at one time being pres- ent, at another absent, — the amount of urine voided is never in excess of health; simple glycosuria is a disease of the aged; diabetic glyco- suria usually appears under fifty years. Simple glycosuria often results from the inhalation of chloroform, the excessive use of chloral, and in the insane, also from excitement, or as one of the results of injuries to the head. Prognosis. Most unfavorable as regards a cure, it being fairly questionable if complete recovery has ever occurred in a typical case. Still, decided amelioration may take place in the symptoms, and the progress of the malady be greatly retarded. The younger the patient, the more rapid the fatal termination. Treatment. Impress upon patients the importance of a strictly regulated diet. Prohibit or restrict the consumption of such articles as contain sugar or starch, especially ordinary bread or flour, sugar, honey, potatoes, peas, beans, rice, arrowroot, cracked wheat, oat- meal, turnips, beets, corn, and carrot?, prunes, grapes, figs, bananas, pears, apples, and liquors of all kinds, whether distilled or fermented. ACUTE GENERAL DISEASES. 235 The main diet should be of animal food, including meat, poultry, game, and fish. A moderate amount of fluids should be allowed, and in a majority oi cases milk will prove beneficial, although, theoretically, contraindi- cated. Tea, coffee, and cocoa, without sugar, may be allowed in moder- ation, glycerin or saccharin being used as a substitute for the sugar. Regulated exercise is of importance. The patient should wear flannel, and have two or three warm baths every week, or an occa- sional Turkish bath. Therapeutical treatment. It is difficult to estimate correctly the action of any drug in this disease, for, as is well known, a proper modi- fication of the diet will alone produce the most marked improvement. Opium exercises an influence over the excretion of sugar, but the effect is not always maintained. Pavy strongly urges the use of codeina in doses of gr. ss-iij (0.032-0.2 Gm.), three times a day, gradually increased. The use of morphines hydrochloras, gr. j (0.065 Gm.), daily, or pulvis opii, gr. iij-v (0.2-0.3 Gm.), daily, is a favorite prescription. Prof. Da Costa suggests the use of ergota, which has decreased the urinary discharge and the quantity of sugar in a number of cases. Prof. Bartholow has met with an apparent cure by ammonii carbonas. Uranii nitras, gr. iij (0.2 Gm.), three times daily, will often markedly reduce the urine and sugar, and sodii salicylas, gr. xv (l Gm.), three times daily, will markedly control the formation of sugar. Liquor bromini arsenitis, TTLiij-v (0.2-0.3 Cc), three times a day, often gives good results. Dickinson remarks that " strychnina is, of all remedies, the most constantly useful." Potassii bromidum, 3j (4 Gm.) during the twenty-four hours, is strongly urged. The fol- lowing remedies are recommended by different observers — to wit: pepsi7ium, liquor potassii arsenitis, iodum, potassii iodidum, acidum lacticum, glycerinum, quinina, and tinctura cannabis indices. Cures are reported from pulvis j'ambul seeds, gr. v-x (0.3-0.6 Gm.), three times daily. Also methylene blue, gr. viij (0.52 Gm.), per diem. The evidence in favor of the majority of these drugs is far from satisfactory. For diabetic cotna, alkalies are particularly indicated. Sodium carbonas subcutaneously, or by intravenous injection, watching closely the effect on pulse and heart, as recommended by Stabel- man. The use of large quantities (quarts) of the normal salt solution by means of hypodermoclysis, and slowly thrown into the large bowel, is a most valuable aid to elimination. Use also inhalations of oxygen and diuretics and fluids to promote elimination of toxic products. 236 PRACTICE OF MEDICINE. Symptomatic treatment is mostly called for. For emaciation and zx\7K.m\'x, fcrrum and oleum morrhua; ; for sleeplessness and restless- ness, viorphina sulphas, potassii bromutum, chloral, or hyoscina hydrobromas. For boils and carbuncles, r(^?A7V57/'/^/^/V/«w. Duchenne suggests the following solution for the excessive thirst of diabetic patients : R . Potassii phosphat. two parts. Aquce seventy-five parts. SiG. — One teaspoonful twice or thrice daily, in wine or hop tea. The dyspepsia and lung symptoms must be managed on general principles. The constant _^a/z/<7«/V current \vx'=, been productive of good results. A change of scene and air is beneficial. Surgical operations should on no account be undertaken on diabetic patients. DIABETES INSIPIDUS. Synonyms. Polyuria; polydipsia. Definition. An affection characterized by the excessive secretion of a very large quantity of pale, watery urine, free from albumin and sugar. Causes. Occasionally hereditary, or diabetes mellitus may have existed in the parent; more common in children or young adults; men are more liable than women ; injuries and diseases of the ner- vous system ; hysteria ; exposure to cold ; drinking freely of cold water; fatigue; prolonged debility ; malaria; syphilis. The probable immediate cause of the excessive secretion of urine consists in dilatation of the renal vessels, the result of paralysis of their muscular coat, caused by derangement of innervation, as the condition can be induced experimentally by irritating a spot in the fourth ventricle, or by section of portions of the sympathetic nerve. Symptoms. The affection is characterized by ^^r^a/ ///;W/, with an increased flow of pale, watery, slightly acid urine, the amount varying from one to five or six gallons in the twenty-four hours. The specific gravity ranges from i 001-1.007. Sugar and albumin are absent. Urea and the other solids are increased. The appetite is voracious, the bowels are obstinately constipated, and the skin is dry and harsh. ACUTE GENERAL DISEASES. 237 The large flow of urine is usually preceded by various nervous phenomena, as nervousness, irritability , inability to concentrate the mind, vivid imagination, a failure of memory, and headache. Unless the affection is soon arrested, great loss of flesh and strength result. Diagnosis. It differs from diabetes mellitus by the absence of grape sugar in the urine. From paroxysmal diuresis, by the absence of the increased urine permanently. From interstitial nephritis, by the greater amount of urinary dis- charge and the absence of albumin, oedema, and casts, and the cardiac and vessel changes. Prognosis. Rather unfavorable as to a radical cure, unless caused by syphilis. Death rarely is due to the diabetes, but to some inter- current malady that the patient has been unable to withstand, on account of the weakness produced by the diabetes. Treatment. If due to syphilis, potassii iodiduin and hydrargyrum are of real benefit. Prof. Da Costa has had success with ergota in the form of the fluid extract or the aqueous extract. Pilocarpus has been used with success. Prof. Bartholow recommends galvanism in cases not cured by potassii iodidum, placing "one electrode to the neck below the occiput, the other to the hypochondriac region in turn." Valerian, potassii bromidum, and sodii salicylas have been used. The author has effected a cure in three cases, where other remedies had failed, by the use, internally, of — K. Strychninse sulphatis, gr. ^-^ .0015 Gm. Acid, hydrochlor. dil., TT^x .6 Cc. AquEe lauro-cerasi, f^ij 8. Cc. M. Well diluted. The obstinate constipation is best overcome \i^ pilules cathartic ce compositcE, one at bedtime. LITH^MIA. Synonyms. Lithiasis ; uric acid diathesis ; uricaemia; American gout. Definition. A condition to which the fluids of the body are satu- rated with nitrogenized waste, in the form of lithic or uric acid ; characterized by marked dyspepsia, various nervous phenomena, 238 IKACTICE OF MliDlCIM-:. muscular and arliiular pains, bronchial catarrh, all or any of these associated with scanty, high-colored, acid urine. Causes. High living, with little exercise; imperfect digestion of nitrogenized food; impaired elimination of uric acid. The direct or remote offspring of the gouty are most frequently the victims. Pathology. Not yet clearly determined. Tlie non-elimination of certain products which have a deleterious influence upon the nervous system. That uric acid does exist in the blood is now gen- erally accepted. Symptoms. Those of dyspepsia, associated with irregular bowels, scanty, high-colored, acid urine, sp. gr. i. 024-1. 028, contain- ing neither sugar nor albumin, but showing an increased proportion of urates or uric acid, or both, and oxalate crystals. Also depressed spirits, impaired memory, loss of interest in occupation, sleepless nights, attacks of vertigo, neuralgic pains in the head, and a constant dread of apoplexy or cerebral disease. Also pains in the joints, neuralgic in character, and in the dorso-lumbar region and right scapular region. If the condition be allowed to continue, the following organic changes may result — to wit : fatty heart ; fibroid kidney ; enlarged liver, or changes in the cerebral vessels. Diagnosis. From gout, by the absence of acute paroxysms and resulting changes in the joints. Prognosis. If properly recognized and treated, complete recov- ery will result, although it is a disorder of long duration. If not properly treated, develops some one of the organic diseases mentioned. Treatment. Regulated diet, using fresh meat once daily, poultry, game (plainly cooked), fresh fish, oysters, occasionally eggs, lettuce, spinach, celery, cold slaw, and tomatoes; avoid all kinds of starchy and saccharine foods, also all stimulants, tea and coffee, using milk, skimmed milk, or milk and cream. Act freely on all the secretions, particularly the liver and kidneys. Systematic exercise. Avoid tonics, bromides, chloral, and opium. Long course of alkaline waters, particularly the lithia waters. Intestinal antiseptics are valuable, such as salol, gr. j (0.065 Gm.) three times daily, or potassii permanganas, gr. j (0.065 Gm.) in coated pills after meals. Good results follow lithiicitras, gr. xx (1.3 Gm.), t. d., sodii phosphas, gr. xxx-lx (2-4 Gm ), ter die, or acidiim benzoicutn, gr. x (0.6 Gm.), t. d., all well diluted with water. One of the very best drugs is acidum nitricum dilutum. ACUTE GENERAL DISEASES. 239 vr^x (0.6 Cc.) in half a glass of water, four times a day, with the occa- sional use of pihdcB rhei composiia at bedtime. Considerable success has been obtained with piperazine , gr. x-xv (0.6-1 Gm.) in solution, after meals. Strontium has acted nicely in several cases. R . StroQtii bromidi purse, gr. xxx 2. Gm. Glycerini, TTLxxx 2. Cc. Infus. gentianae, fjiss 6. Cc. M. SiG. — Before meals, well diluted. CHOLERA. Synonyms. Epidemic cholera ; Asiatic cholera ; malignant cholera ; spasmodic cholera. Definition. An acute, specific, infectious disease, epidemic in the majority of, although endemic in other, localities ; characterized by the transudation of serum into the stomach and intestinal canal, and violent purging of a peculiar, rice-water-like fluid, the persistent vomit- ing of a similar material, severe muscular cramps, and a condition of prostration, followed by collapse and death, or of a reaction from the collapse and the development of the typhoid state {cholera typhoid'). Causes. A specific poison, the "comma bacillus" of Koch. Cholera is but feebly contagious, in the usual acceptation of that word, but it is unquestionably ififectious. The evidence seems conclusive that the cholera stools are the main, if not the only, channel of infection, and that the great cause of the propagation of cholera is the contamination, with the cholera stools, ■ of the water used for drinking purposes. Milk may also be the vehicle by which it spreads. It is claimed that the bacillus is inert in the intestinal canal unless the individual is in the " receptive state" — that is, a condition of intestinal catarrh, such as results from eating unripe fruit, beer and spirit drinking, and indigestible food. It is also determined that the bacilli are destroyed by acids, and that if the stomach be normal, cholera will not result. "With pure water, pure air, pure soil, and pure habits, cholera need not be feared." (Hart.) Little, if any, danger exists from being in the presence of the affected, although the emanations from the cholera excreta in the atmosphere may generate the disease if swallowed or inhaled. The dead bodies of cholera subjects apparently possess slight infective property, "the bacteria of composition" probably destroying the cholera germs. One attack does not afford protection against another. 240 PRACTICE OF MKIMCINE. The pc-riod of incubaiion is short, under .1 week, usually. Pathological Anatomy. This is, as yet, far from satisfactory. The morbid appearances in the majority of cases of death from chol- era may be thus summarized. The temperature generally rises after death, the body remaining warm for a considerable time. Rigor mortis rapidly ensues, the muscular contractions being often so pow- erful as to displace and distort the limbs. The skin is mottled and the body greatly shrunken. The blood is darker in color, thick, viscid, feebly coagulable, and slightly acid. The arteries are quite empty of blood ; the veins, on the other hand, are distended. The organs are, as a rule, pale and shrunken. The stomach and intestinal mucous membranes are congested, and present evidence of extravasation and ecchymoses, or are bleached and pale. The stomach and intestines usually contain a quantity of whey like material, having an alkaline reaction, as well as quantities of cast-off epithelium and the bacillus. It is thought by many that the stripping-off of the epithelium is a post-mortem phenomenon. The Peyer's solitary and Brunner's glands are usually enlarged and prominent, and occasionally evidences of ulceration are apparent in the solitary glands, and sections placed under the microscope show the "comma bacillus." The villi of the mucous membrane, as well as the epithelium of the small intestines, are stripped off, leaving the basement membrane, for the most part, exposed. The Ihter is more or less advanced in fatty degeneration, presenting a somewhat mot- tled, yellowish discoloration. The kidneys are congested, the epi- thelium of the tubules granular, and detached from the basement membrane, blocking up the tubes. Prof. Bartholow observed, in all of his autopsies, "considerable hyperaemia and dilatation of the ves- sels of the medulla oblongata. The constancy of this lesion would seem to indicate a relationship between congestion of the medulla and the cramps." Symptoms. In accordance with the law of epidemic infectious diseases, the onset, course, and character of the symptoms vary in different cases and at different periods in the same epidemic. The disease may either set in suddenly in a patient previously in good health, or it may follow an attack of rather severe and persistent diarrhoea, with pain, nausea, 7>omiti}ig, and depression. Such cases are termed Cholerijie, the stools of which are infectious. In a typical case there are three stages : Jirst, diarrhoea ; second, prostration ; third, collapse, or, in favorable cases, reaction. ACUTE GENERAL DISEASES. 241 First Stage. Begins with chilliness, excessive thirst, coated tongue, unpleasant taste in the mouth, slight abdominal pain, and three or four copious, watery, yet faecal stools during the day, and a decided feeling of weakness, the stools rapidly becoming whey-like, easily voided, but with force and only slight pain. Second Stage. The stools rapidly increase in number, are voided with a rushing force, and consist of many quarts of grayish, or whitish, rice-water-like fluid, accompanied with forcible vomiting, first of the contents of the stomach, mixed with more or less bilious matter, afterward of the peculiar rice-water-like material ; thirst becomes most intense, increasing or diminishing with the variations in the number of the vomiting and stools ; severe imiscular cramps soon follow, most severe in the calves, although occurring in all parts of the body. Third Stage. The stools, vomiting, and cramps continue. The appearance of the patient becomes frightful ; the eyes are sunken and surrounded by blackened rings, the nose pinched and pointed, the cheeks hollow, and the lips blue (facies cholerica) ; the surface cold and moistened with a sticky perspiration ; the skin of the hands and.fingers has the sodden appearance of the " washerwoman who has washed all day," and if picked up in folds, the fold but slowly disappears. The temperature rapidly falls, the pulse becomes small and compressible, barely perceptible at the wrist, and the heart-beats are scarcely recognizable. The voice is weak, husky, and sepulchral (vox cholerica), the tongue is like ice, the breath is cold and icy, the urine markedly diminished and albuminous. The fnind is clear, but most patients are apathetic and indifferent to their danger. This, the algid state of cholera, or cholera asphyxia, usually terminates in death in from three to twelve, twenty-four, or forty-eight hours, but reaction may be established. Stage of Reactioji. The temperature of the body rises, the pulse gradually becomes fuller and stronger, the countenance becomes brighter, the stools less frequent and more faecal, the vomiting de- creases, the thirst lessens ; the urine increases in amount, but con- tinues albuminous, the patient entering a slow convalescence, or typhoid symptoms develop, the so-called cholera typhoid, which pro- longs the recovery for several weeks. Convalescence is often prolonged and complicated by thedevelop- ment of severe bed-sores, boils, bronchitis, pneumonia or parotitis, 16 242 PRACTICE OF MEDICINE. Sequelae. Suppuration of the parotid gland ; painful tetanic con- traction of the flexor muscles of the limits; abscesses or ulcers of the limbs ; profuse sweats ; roseola, erythema, urticaria, and rarely vesicu- lar eruptions. Diagnosis. The epidemic character and rapid spreading and great mortality of the affection prevents its being mistaken for any other disease, although isolated cases are often confounded with cholerine or with cholera morbus, the points of distinction being few, unless the "comma bacillus" only be found in the stools of true cholera. Prognosis. Very unfavorable, the mortality ranging from twenty to eighty per cent. The last epidemic in this country was much milder than former ones. The prognosis is controlled by the general condition of the patient, the age, habits, and the development of the algid state; the prognosis being more favorable in those cases which develop gradually than in those in which it reaches its acme at a single bound; the very young or very old, those addicted to the various excesses and surrounded by unfavorable hygienic conditions, are more apt to perish than are others. Treatment. The success depends, to a great extent, upon its prompt and early treatment, for experience amply attests that the arrest of the disease in the diarrhoeal stage is comparatively easy, and in the stage of collapse its cure is altogether an exceptional occurrence; therefore, during the prevalence of cholera the mildest cases of diarrhoea ought to receive prompt treatment, for many cases have their beginning as a mild diarrhoea. It must not be overlooked that intelligent nursing and regimen are equally as important as medical treatment. The patient should be put to bed at once, and all food withheld for a time at least. Small pellets of ice may be allowed instead of water. " Of all the remedies proposed for the arrest of the diarrhoea, not one has done so much good as sulphuric acid. It is usual, and generally best, to combine some opium with it (R. Acid, sulphuric, aromat., f^v (20 Cc); tinct. opii deodorat., f5iij(i2 Cc). M. SiG. — Ten to twenty drops every hour or two in sufficient water)." (Bar- tholow.) Large doses of bisjnuth should be of value in this early stage, but opiwn is particularly indicated, preferably in the form of morphina: sulphas, hypodermically. During the epidemics of i892-'93, good re- ACUTE GENERAL DISEASES. 243 suits were reported from the internal use of hydrogen peroxide, f^ij (60 Cc), with aqua destillata, f^viij (237 Cc), in cupful doses every two hours. Salol and plumbi acetas are of value for the early- diarrhoea. Ziemssen says : '" Calomel has the first place of all drugs which have been recommended in the prodromal stage. Begin with two or three doses of gr. vij (0.45 Gm.), followed with small doses — gr. ^ (0.048 Gm.) — every two hours." It is now generally admitted that as the first symptoms of cholera are those of intestinal catarrh, direct medication ought to be of the greatest service. This is done by etiteroclysis or irrigation of the canal with large amounts, from one to three gallons twice daily, of hot soaped water, hot four per cent, solutions of hydrogen peroxide, or weak solutions of tannin, or hot one per cent, solutions of common salt. The enteroclysis is accomplished by means of a soft rubber tube, one metre in length and of suitable size, to be introduced into the rectum, in front of the promontory of the sacrum, into and up through the sigmoid flexure and into the descending colon. This tube, which is connected with a reservoir, should not be too small nor too large, in order to facilitate its introduction through the folds of the sigmoid portion of the lower bowel. In fact, the greatest difficulty to be encountered is to successfully pass the tube in front of the promontory of the sacrum, and enter it into the sigmoid flexure. The tube should be of proper firmness to prevent it from bending or buckling upon itself when the end (which in all cases should be rounded) comes in contact with the obstructing folds of the intestine. For the distressing vomiting, lavage of stomach with hydrogen peroxide, f^ij (60 Cc.) to two or three pints of hot water, or iced chain - pagne, cocaine, or acidum hydrocyatticum may sometimes give relief. Locally, either mustard applications to the abdomen or the constant use of rubber bags filled with boiling water. For the cramps, hot water in bottles, hot irons or bricks applied over painful parts, or an ointment of chloroform or chloral, chloro- form or ether inhalations, or the use of the following hypodermic solution, strongly recommended by Prof. Bartholow : R. Chloral, giij 12. Gm. Morphinas sulph. , gr- iv .26 Gm. Aquse lauro-cerasi, f|j 30, Cc, M. SiG. — Fifteen to thirty minims each injection. 244 PRACTICE OF MEDICINE. For the collapse, heat to the surface and the free use o{ stimulants, or spiriius frumenti, or spiritus vini gallici, hypoderniically, also the hot bath, also hypodennatoclysis and the intravenous injection of saline fluids and hypodermic injections of strychninae sulphas, gr. 2V (0.003 Gm.). Heat is of the greatest value in all stages of cholera, both externally as very hot baths (hot air or hot water), and hot rectal injections. If reaction occur, treat indications as they arise, and use tonics, such 2is/erru)n, quinina, and arsenicum. All the discharges from the patient should be thoroughly disinfected as soon as voided, and the stools and vomited material buried. DISEASES OF THE RESPIRATORY SYSTEM. PHYSICAL DIAGNOSIS. Physical Diagnosis is the art of discriminating disease by means of the eye, the ear, and the touch. The signs thus ascertained are connected with changes or altera- tions in the form, density, or condition of the structures within, and are known 2i% physical signs. " Physical signs are, then, the exponents of physical conditions, and of ?ioihing more." (Da Costa.) The methods employed in the physical exploration of the chest, are: I, Inspection; II, Palpation; III, Mensuration; IV. Percussion; V, Auscultation; M, Succxission. Percussion and auscultation, dealing with sounds, are of the great- est value clinically. For the purpose of physical exploration, the chest is mapped ofif into regions or divisions, as follows : ANTERIORLY. First. — Supra-clavicular, Lying above the upper edge of the clavicle, usually about an inch in extent. DISEASES OF THE RESPIRATORY SYSTEM, 245 Second. — Clavicular, Corresponding to the inner two-thirds of the clavicle. Third. — Infra-clavicular , From the clavicle to the lower border of the third rib. Fourth. — Mammary, Between the third and sixth ribs. Fifth. — Infra-mammary, Downward from the sixth rib, LATERALLY. First. — Axillary, That portion above the sixth rib. Second. — Infra-axillary, That portion below the sixth rib. POSTERIORLY. First, — Suprascapular, That portion above the scapula. Second. — Scapular, That portion covered by the scapula. Third. — Inter-scapular, That portion between the scapulae. Fourth. — Infra-scapular, That portion below the angle of the scapula. INSPECTION. Inspection signifies "the act of looking." Views of the chest should be taken from the sides and behind as well as from the front, for which purpose a good light should be obtained, and the patient be placed in as easy and comfortable a position as is possible. Inspection reveals the form, size, color, and movements of the chest, as well as the condition of the superficial pai-ts. In health the sides of the chest are for the most part symmetrical in form, size, color, and movements, both sides rising equally during the act of inspiration, and falling equally during the act of expira- tion. During the act of inspiration the intercostal spaces in the lower two-thirds of the chest become more hollow, as also do the supra-clavicular fossae. Inspij-ation is almost entirely the result of muscular action ; expira- tion, on the other hand, is chieily due to the elasticity of the lungs and chest walls, aided somewhat in forced respiration by muscular action. The movement of inspiration by inspection is of longer duration than that of expiration, and the pause between the acts but momentary. The respiratory tnovement is visible over the whole thorax, although 246 PRACTICF. OF MEDICINE. in males and in children it is most distinct at the lower portion (/«- ferior costal breathing), while in the female it is most distinct at the upper portion of the chest {superior costal breathing). PALPATION. By palpation is meant the application of the palmar surfaces of the hands and fingers to the chest, by means of which are appre- ciated impressions which are capable of being conveyed by the sense of touch. The objects of palpation are : First. — To give more accurate information of what is revealed by inspection. Second. — To locate spots of soreness, the density and condition of tumors, if any be present; the state of the chest walls, the frequency of the breathing, and the action of the heart. Third. — To determine the existence and character of the various kinds oi freviitus (vibrations). By fremitus is understood certain tactile impressions or vibrations conveyed to the surface of the chest, which are classed and produced as follows : First. — Vocal fremitus, produced by the act of speaking or crying. Second. — Tussive fremitus, produced by the act of coughing; of value especially when the voice is very weak. Third. — Bronchial fremitus, produced by the passage of air through mucus, blood, or pus, in the bronchial tubes, during the act of respiration. Fourth. — Frictio7i fremitus, produced by the rubbing together of the roughened surfaces of the pleura. When the normal chest vibrates lightly, it is termed the normal vocal freinitus. The vocal frejnitus is more distinct upon the right side toward the apex. If the lung be consolidated (denser), the vibration is greater and more easily distinguished, — the vocal fremitus is increased. In feeble persons, or when any cause interferes with the trans- mission of the vibrations, the vocal fremitus is ditninished or absent. DISEASES OF THE RESPIRATORY SYSTEM. 247 MENSURATION. Mensuration, or measurement of the chest, is of little practical importance, and hence seldom performed. The only measurement likely to be required is the circular or circumferential, in different parts of the chest, which is performed with either an ordinary gradu- ated tape measure or a double tape measure, made by uniting two tapes in such a manner that they start in opposite directions from the same point at the mid-spinal line. The tapes drawn around each side until they meet at the id-sternal line, on a line immediately above the nipple, or on the level of the sixth rib near its attachment to the cartilage, — the sixth costo-sternal joint, — the patient first being directed to effect a complete expiration, the number of inches noted, and then to take a deep inspiration, the increase in inches noted, the difference between the two giving a rough estimate of the capacity of the lungs. In right-handed persons the right side is usually one-half to three- fourths of an inch larger than the left; if larger than this, it is usually the result of some abnormal condition. In well-developed men the chest measures at the upper part about thirty-three to thirty-five inches during expiration, and is increased fully three inches upon inspiration. PERCUSSION. Percussion, or " The act of striking," to ascertain the composition of structures, affords signs and informationof great value in diagnosis. There are two methods employed, immediate and mediate. Immediate, or direct percussion, is performed by striking the thorax directly with the points of the fingers or the palmar surface of the hand. This method of percussion has been generally abandoned, as it does not enable the physician to distinguish, with sufficient correct- ness, between the various shades of difference in the pitch or quality of percussion sounds. Mediate, or indirect percussion, may be practised in three different ways, to wit : First. — ^With the finger of one hand interposed between the body percussed and the percussing finger. 248 PRACTICE OF MEDICINE. Second. — With the finger acting as a pleximeter and the percussion hammer. Third. — With the percussion hammer and the pleximeter. The first of these modes affords the most correct and ready infor- mation regarding the resistance of the parts percussed. The skillful use of the fingers is more difficult to acquire than that of the plexi- meter and hammer; but if the examiner has acquired sufficient skill in its performance, an absolutely accurate result may be obtained. " He who is skilled in digital percussion will be able to percuss equally well with the hammer, the inverse of which does not always hold good." In addition to being proficient in the technical 7nodus oper- andi, it is necessary to possess a sensitive ear, educated to distinguish between the various shades of the sounds. When the fingers are employed, it is a matter of choice whether one or more fingers are used as the pleximeter. Usually the last phalanx of the first or second fingers of the left hand are used, the other fingers being raised from the chest, so as not to interfere luith the sound vibrations ; they should be applied yf/v;//}/ and evetily to the surface, thus preventing the slipping of the soft parts, and also to determine the resistance of the chest walls when the blow is given. The rounded ends of the first and second fingers of the right hand are used as a hammer, striking the pleximeter fingers in such a manner that the nails shall not touch the skin of the underlying fingers. The force employed varies in different regions, but usually, for the chest, should be only of moderate degree. Forcible percussion is of use only when the sound of deep-seated organs is desired. The stroke should be made perpendicularly to the surface, and not slanting, as is too often done. The whole movement should proceed only from the wrist-Joint, and ought not to be too rapid or unequal, or of great force, the fingers being rapidly withdrawn, so as not to interfere with the vibrations. The objects of percussion are to elicit certain sounds, and the amount o{ resistance or elasticity of the organs percussed. The main sounds elicited by percussion are the dull, clear, and tytnpanitic. Familiarity with the intensify, character, and pitch of each of these sounds is essential. When percussing the healthy chest, the sound obtained is termed the normal pulmonary resonance. It is of variable intensity, depend- ing upon the force of the stroke employed and the amount of adipose DISEASES OF THE RESPIRATORY SYSTEM. 249 and muscular tissues covering the thorax, and the tension of the chest walls. There is no exact standard of the normal pulmonary or vesicular resonance, but if the two sides of the chest are compared, the normal standard of each person is obtained. The character is termed pulmonary or clear, as characteristic of the healthy chest wall. The pitch is always relatively low. The sounds elicited by percussing a healthy chest are not, however, alike over all its parts. Anteriorly, the portion of lung above the clavicle yields a sound which becomes somewhat tympanitic as the trachea is approached. Over the clavicle the sound is clear and pulmonary at the centre of the bone, but at the scapular extremity it is duller, and toward the sternum it becomes somewhat tympanitic. At the infra- clavicular region the resonance is clear and distinct, but little resistance being offered to the percussing finger, and the sound elicited may be taken as the type of the pulmonary resonance. In this region, however, a slight disparity exists between the two sides ; on the right side the sound is less clear, shorter, and of a higher pitch than on the left side. In the jnammary region of the right side the resonance of the lung is not so clear, the sound being modified by the size of the mamma and the upper border of the liver. On the left side the heart deadens the sound from the fourth to the sixth rib, and, in a transverse direc- tion, from the sternum to the left nipple. This dull sound in the left mammary region is lessened in extent during full inspiration, and in emphysema, when the lung more completely covers the heart. In the infra-maminary region on the right side the percussion note is dull, except during the act of complete inspiration, when the liver is displaced downward by the inflated lung. In the left infra-mam- viary region the sound consists of a mixture of the dull sound of the heart and spleen and of the clear sound of the lung, together with the tympanitic sound of the stomach. Over the upper part of the sternum — above the third rib — the sound is slightly tympanitic. Below the third rib, over the sternum, the sound is dull, due to the presence of the heart and liver. The position exercises some influence on the results of percussion. More accurate results are obtained when the patient is standing or sitting than when recumbent. While the front of the chest is per- 250 PRACTICE OF MF.niCINE. cussed, the arms should hang loosely by the sides; the hands may be clasped across the top of the head during tlie percussion of the axillary region ; during the examination of the back the head must be bent forward and the arms tightly crossed in front. On the />os h'rt'or surfa.ce of the chest the sound also varies accord- ing to the part percussed. Over the scapuIcB the sound is duller than between these bones or below their inferior angles. Over the infra-scapular region a clear sound is obtained as far as the lower border of the tenth rib on the right side, where the dullness of the liver begins. On the left side, below the angle of the scapula, the percussion sound is tympanitic if the intestines are distended, or it may be slightly dull if the spleen is enlarged. In the axillary region the sound is clear and distinct on each side. In the infra-axillary region of the right side the sound is duller, owing to the presence of the liver ; at the corresf>onding situation on the left side the sound is clear or iytnpanilic, from the distention of the stomach, and at the ninth or tenth rib of the left axillary region dullness and the sense of resistance mark the location of the spleen. The sounds obtained by percussion of the unhealthy or abnormal chest are as follows : First. — Hyper-resonance , or an increase of the normal pulmonary resonance, is due to the relative increase in the proportion of air to the solid tissues of the lung, provided the tension of the chest walls be not altered, occurring in emphysema of the lungs, atrophy of the lungs, or consolidation of the opposing lung. Second. — Dullness or an absence of resonance, due to the relative increase of solid tissues in proportion to the amount of air, as seen in the different stages of phthisis, in pneumonia, pleural effusion, and hydrothorax. The pitch is increased or heightened in proportion to the diminu- tion of the amount of the air and the increase of the solids. If there be entire want of resonance, the percussion note is said to be flat ; if there is a slight decrease in the resonance of the part, the note is said to be itnpaired. The sense of resistance is greater, the more marked the consolida- tion of the lungs and the greater the tension of the chest walls. Third. — Tympanitic, or \\\e. drum-like percussion note, is a non- DISEASES OF THE RESPIRATORY SYSTEM, 251 vesicular sound having the character elicited by percussing over the normal intestines ; wherever heard it indicates the presence of air in conditions similar to that of the intestines, to wit : inclosed in walls which are yielding, but neither tense nor very thick. When elicited over the chest it may be due to the transmitted sound of the distended stomach or colon. It is obtained over the chest in pneumothorax, in moderate pleural effusions above the level of the liquid, over the seat of cavities in the pulmonary tissue, and in cedema of the lungs. The tympanitic percussion note differs from the normal pulmonary resonance in being more ringing in character and of a higher pitch. The amphoric or metallic sound is in reality a concentrated tym- panitic sound of high pitch, and denotes a large cavity with firm, but yet elastic, walls. The cracked-pot or cracked-7netal sound is another variety of the tympanitic sound. The condition most frequently producing this sound is a cavity in the lung tissue, communicating with a bronchial tube. It requires for its development a strong, quick blow of the percussing finger, with the patient's mouth open. RESPIRATORY PERCUSSION. The percussion sound will vary greatly with the respiratory move- nients. If a full inspiration be taken and percussion performed, then a full expiration taken and percussion performed, and then the chest percussed during the normal respiration, slight changes in the char- acter and pitch of the note are obtained, which otherwise would escape detection. Prof. Da Costa has designated this method, respi- ratory percussion. AUSCULTATORY PERCUSSION. This method consists in listening, with a stethoscope applied to the thorax, to the sounds elicited by percussion. " It is a serviceable means of determining with accuracy the boundaries of various organs, as those of the lungs or heart, or of the liver or spleen, and yields particularly exact results when carried out with the double stethoscope." 252 PRACTICE OF MEDICINE. AUSCULTATION. Auscultation, or listening to the sounds produced within the chest during the act of respiration, coughing, or speaking, furnishes the most reliable means of studying the condition of the lungs and heart, and is, therefore, the most valuable method of discriminating between the various conditions which may affect the lungs and heart. Auscultation is either iuimediate or vu-diafe. It is immediate when the ear is applied directly to the chest, which may be either denuded or thinly covered. It is jnediate when the sounds are conducted to the ear by means of a tubular instrument, termed a stethoscope. For ordinary purposes, immediate or direct auscultation is suffi- cient, but when it is desirable to analyze circumscribed sounds, as in diseases of the heart, or where the patient objects to this method, on the score of delicacy, or the auscultator objects, on account of the uncleanliness of the person examined, the stethoscope is to be pre- ferred. Moreover, there are certain parts of the chest which can only be explored satisfactorily by the aid of a stethoscope, which instrument has the additional advantage of intensifying the sound. In auscultation, the following rules, formulated by Prof. Da Costa, should be observed : " I. Place yourself and your patient in a position which is the least constrained and permits of the most accurate application of the ear or stethoscope to the surface. Above all, avoid stooping, or having the head too low. " 2. Let the chest be bare, or, what is better, covered only with a towel or thin shirt. " 3. If a stethoscope be employed, apply closely to the surface, but abstain from pressing with it. This may be obviated by steadying the instrument, immediately above its expanded extremity, between the thumb and the index finger. "4. Examine repeatedly the different portions of the chest, and compare them with one another while the patient is breathing quietly. Making him cough or draw a full breath is, at times, of service: especially the former, when he does not know how to breathe." DISEASES OF THE RESPIRATORY SYSTEM. 253 SOUNDS IN HEALTH. If the ear be applied over the larynx or trachea of a healthy per- son, a sound is heard with both the act of inspiration and expiration. Its intensify is variable, its pitch high, and its quality tubular (to wit: a current of air passing through a tube — the larynx or trachea). The duration of the sound during inspiration being somewhat longer than during expiration. A short pause follows the act of expiration. This sound is termed the normal laryngeal respiration, and is identical in character, duration, and pitch with an important morbid sound, termed bronchial respiration. The sound heard by placing the ear over the lung tissue is differ- ent ; it is produced in the very finest bronchial tubes and air cells by their expansion and contraction, and is termed the 7iormal vesicular murmur. The inspiratory portion of the sound is of variable intensity, its pitch is low, its quality soft and breezy, designated vesicular ; its duratioft is during the entire act of inspiration. The expiratory portion of the sound is not always perceptible ; it is oi feeble intensity, very low pitch, its character soft and blowing, and its duration much less than the act of inspiration. It is to be remembered, however, that the vesicular murmur will be ibund to vary in the different regions on the same side, and in corre- sponding regions on the two sides of the chest. These variations within the range of health are especially important, and should be memorized. Infra-clavicular Region. — The vesicular murmur in this region on either side is much more distinct than over any other part of the chest. On the left side the inspiratory sound is of greater intensity, of lower pitch, and more distinctly vesicular in quality than that heard upon the right side. On the right side the expiratory sound is nearly or quite the same in length as the inspiratory sound, and is higher in pitch and more, tubtilar in quality than the expiratory sound upon the left side. Supra-scapular Region. — Owing to the small number of air vesicles and the large number of bronchial tubes, and their nearness to the surface, the respiratory murmur has an intense, high-pitched, tubular and expiratory quality. 254 PRACTICE OF MEDICINE. Scapuhir Re-gioti. — Compared with the infra-clavicular region, the respiratory murmur heard over the scapulae on either side is more feeble, and the vesicular quality less marked. Interscapular Rrgion. — The murmur in this region differs from the normal laryngeal breathing only in intensity and duration. Infra-scapular Region. — The murmur in this region very closely resembles that heard in the left infra-clavicular region. Mammary and Infra-mamtnary Regions. — The murmur in these regions differs from that heard in the infra-clavicular region, in being of less intensity. Axillary and Infra-axillary Regions. — The respiratory sound in the axillary regions is as intense as in any portion of the chest. In the infra-axillary regions the intensity is less and the pitch lower, VOICE IK HEALTH. If the ear be applied over the larynx or trachea of a healthy per- son, and he be directed to count " twenty-one, twenty-two, twenty- three," in a uniform tone and with moderate force, there is perceived a strong resonance, with a sensation of concussion or shock, and a sense of vibration, thrill, or fremitus, the voice seeming to be concen- trated and near the ear. Often the articulated words are distinctly transmitted (laryngophony). The sounds thus heard are termed the normal laryngeal resonance. If the ear or stethoscope be applied over the third rib anteriorly, on either side of the chest of a healthy person, and he be directed to count "twenty-one, twenty-two, twenty-three," in a uniform tone, with moderate force, a confused distant hum is perceived of variable intensity, accompanied with more or less vibration, thrill, or fremitus, most distinct in adults, but notably weaker in women than in men. This sound is termed the normal vocal resonance. If the ear or stethoscope be applied over the third rib anteriorly, of a healthy person, and he be directed to whisper, in a uniform man- ner, the words " twenty-one, twenty-two, twenty-three," there is heard a sound corresponding closely in character to the sound of expiration over the same region during the act of forced respiration ; or, in other words, a feeble, low-pitched, blowing sound. This sound is termed the normal bronchial whisper, and is produced by the movement of the air in the bronchial tubes during the act of respiration. DISEASES OF THE RESPIRATORY SYSTEM. 255 SOUNDS IN DISEASE. The vesicular murmur may undergo, in disease, changes in its hi- tensiiy, its j-hythin, and in its character. The intensity of the respiratory murmur may be : I . Exaggerated or increased. 1. Diminished ox feeble. 3. Absefit or suppressed. Exaggerated respiration differs from the normal vesicular respiration only in an increase in the intensity of the respiratory sounds. When general over one lung, it will usually indicate deficient action of other parts. In this manner an effusion compressing the lung, one-sided deposits, obstruction of the bronchial tubes by secre- tion, or inflammation of the lung structure, 'necessitate a supple- mentary respiration in a healthy portion of the same lung or the lung upon the opposite side. From its resemblance to the loud, strong, quick respiration of young children, it has been l^xxv^zdi puerile res- piration. Exaggerated respiration is, therefore, to be regarded as indirect evidence of disease in some portion of the pulmonary tissue. Diminished respiration, called also senile respiration, as being characteristic of old age, is characterized by diminished intensity and duration of the sound. In the large majority of instances the inspi- ration suffers the greatest, the expiratory sound not diminishing in the same proportion. In asthma, emphysema, diseasesof the larynx and bronchial tubes, pleuritic pain, rheumatism or paralysis of the chest walls, or in thickening of the pleural membrane, we observe super- ficial or diminished respiration. When one side of the chest is par- tially filled with fluid, we may hear a deep-seated but feeble breath sound. Absent or suppressed respiration occurs whenever the action of the lung is suspended ; this may be from external pressure, as when the lung is compressed by the presence of fluid or air in the pleural cavity, or when complete obstruction of the bronchial tubes prevents the air from either entering or escaping from the lungs. The rhythm of the respiratory murmur may be ; I. Interrupted or jerky, 1. The interval between inspiration and expiratiott prolonged. 3. Expiration prolonged. 250 PRACTICE OF MKUICINE. In health the inspiratory and expiratory sounds are even and con- tinuous, with a short interval between each act ; this may be altered in disease, and both sounds, especially the inspiratory, have an inter- rupted or jerky character, termed " cog-wheel respiration." This jerky breathing' is noted in some spasmodic affections of the air tubes, in hysteria, the earliest stages of pleurisy, pleurodynia, and the early stages of pulmonary phthisis. It is most frequently associated with phthisis, due probably to the adhering to the walls of the finer bronchial tubes of tough mucus, which obstructs the free entrance and exit of the air; it is usually most notable under the clavicles. The interval between inspiration and expiration may be prolonged, instead of these two sounds closely succeeding each other. When this occurs the inspiratory sound may be shortened, or the expiratory sound may be delayed in its commencement. If the inspiratory sound is shortened, it is the result of consolidation of the lungs; if the expiratory sound is delayed, it is the result of lessened elasticity of the lung structure, and is most commonly asso- ciated with emphysema. Prolonged expiration denotes that the air is obstructed in its exit from the lungs. It may be the result of diminished elasticity, the result of emphysema, or from the deposit of tubercles, which impair the contractile power of the lungs. If the former, it is asso- ciated with clearness on percussion; if the latter, however, with impaired resonance on percussion. When prolonged expiration is detected at the apex of the lung, and is associated with impairment of the normal pulmonary resonance, it is for the most part the result of a tubercular deposit. The quality of the respiratory murmur may be : 1. Harsh, termed vesiculo-brotichial respiration. 2. Bronchial. 3. Cavernous. 4. Amphoric. Harsh respiration, or, as it is termed by Prof. Da Costa, vesiculo- (Jrtf«t//w/ respiration, is that variety in which both the inspiratory and expiratory sounds have lost their natural softness. It generally indi- cates more or less consolidation of lung tissue. In normal vesicular respiration the sounds produced by the air expanding the air cells and finer bronchial tubes obscures the sound produced by the passage of DISEASES OF THE RESPIRATORY SYSTEM. 257 air through the larger bronchial tubes, the healthy lung being an imperfect conductor of sound, so that as soon as any portion of the lung becomes consolidated the vesicular element of the respiratory sound is diminished, the bronchial element becoming prominent. Harsh respiration is, then, a union of the vesicular and bronchial sounds, being a vesicular sound mixed with some of the qualities of a bronchial sound, the expiration being prolonged and tubular in character. It is present when the bronchial mucous membrane is swollen, as in the earlier stages of bronchitis, also in the earlier stages of phthisis and pneumonia. Bronchial respiration is characterized by an entire absence of all the vesicular quality. Inspiration is of high pitch and tubular in character; expiration still higher in pitch, of greater intensity, ^r<7- longed and tubular in quality ; the two sounds being separated by a brief interval. The bronchial respiration encountered in disease closely resembles that heard in health over the larynx or trachea. Whenever bronchial respiration is present where, in health, the normal vesicular murmur should be heard, it indicates consolidation of the lung structure. Cavernous respiration is a variety of the bronchial respiration, at least so far as the quality of the sound is concerned. It is essen- tially a blowing sound, yet not always heard during both the acts of inspiration and expiration, being often only perceptible in the one, and in the other mixed with gurgling sounds. Its pitch is lower than that of ordinary bronchial respiration, and its character \?> hollow. For its production there must be a cavity of considerable size in the lung substance, not filled with fluid, near the surface of the chest walls, communicating with a bronchial tube. It is met with most commonly in the last stages of pulmonary consumption, although hollow spaces of any kind, from abscess or dilatation of the bronchial tubes, occasion it. Amphoric respiration is a blowing respiration, having a musi- cal or metallic quality.- It is a variety of bronchial respiration pro- duced in a large cavity with firm walls, permitting the reflection of the sound. An imitation of this sound, though only an imperfect one, is produced by blowing over the mouth of an empty bottle. The amphoric character is present with both the acts of inspiration and expiration. Amphoric or metallic respiration is indicative of a large cavity, not 17 258 PRACTICE OF MEDICINE. common in phthisis, but much oftener heard at the upper part of a lung compressed by fluid and air, as in pneumo-hydrothorax. RALES. Rales, or, as they are termed, adventitious sounds, because they have no analogue in the healthy state, cannot be considered as modi- fications of the normal respiration. Grouped according to the anatomical situation in which they are produced, we have : 1 . Laryngeal and tracheal rales. 2. Bronchial rales. 3. Vesicular rales. 4. Cavernous rales. 5. Pleural rales. Rales may be divided into two groups, according to their character, to wit: dry and moist, and may be audible either during the act of inspiration or expiration, or during both. Dry rales, for the most part, are produced by the vibration of thick fluids which the air cannot break up, and which, therefore, temporarily lessens the calibre of the bronchial tubes. When this narrowing exists in the smaller bronchial tubes the resulting sound is high-pitched or the rale is said to be sibilant or whistling; when the narrowing exists in the larger bronchial tubes, the rale \s low-pitched, more musical in character, or sonorous. Dry rales are particularly prone to be dislodged by coughing, and when they are uninfluenced by the acts of breathing and coughing, they do not depend upon the presence of secretions, but upon the narrowing of the air tubes from the pressure of tumors, or from a thickened fold of mucous membrane, or from a spasmodic contrac- tion of the air tubes. Moist rales are those produced by the air passing through thin fluids, such as mucus, blood, serum, or pus, during the respiratory movements. When the fluid exists in the smaller bronchial tubes, the rales are termed small bubbling, mucous, or subcrepitant. When the fluid is in the large bronchial tubes, the lales are said to be large bubbling or mucous. Moist rales are not persistent, but vary in intensity, and shift their DISEASES OF THE RESPIRATORY SYSTEM. 259 position as the air drives the hquid which occasions them before it, or during violent attacks of coughing, or after copious expectoration. Laryngeal and tracheal rales are those produced within the larynx and trachea, and may be either moist or dry. The moist or bubbling sounds, produced when mucus or other liquids accumulate in this part of the air tubes, frequently occur in the moribund state, and are then known as the " death rattles." When not due to this condition they denote either insensibility to the presence of liquid, as in stupor or coma, or inability to remove liquid by the act of ex- pectoration, as in croup or inflammation of these parts in the very feeble. The dry rales produced within the larynx or trachea are generally caused by spasm of the glottis — to wit: laryngismus stridulus, whoop- ing cough or croup, or from the presence of a foreign body in the part. Bronchial rales, resulting from the passage of air through the thin liquid, occasion bubbling sounds. When the liquid is present in the large-sized bronchial tubes, the rales are said to be large bubbling, or large mucous rales, occurring in acute or chronic bronchitis. When the liquid is in the smaller bronchial tubes, the resulting rale is called small bubbling, small mucous, or subcrepitant, also occurring in acute or chronic bronchitis. Bronchial rales, due to the narrowing of the tube by its spasmodic contraction, or to the presence of tough, tenacious mucus, which is put into vibration by the passage of the air through the bronchial tubes, are termed dry bronchial rales. Frequently they are suggestive of cer- tain familiar sounds, such as snoring, cooing, humming, or wheezing, or they are often musical tones. When produced in the smaller bronchial tubes, they are termed sibilant, or high-pitched rales ; when produced in the larger bronchial tubes, they are termed sonorotis or low-pitched rales. They principally occur in the dry stage of bronchitis, or during an asthmatic paroxysm. The vesicular rale, or, as it is more commonly termed, the crepitant rale, is produced within the air vesicles or at the terminal portion of the smaller bronchial tubes. It is to be distinguished from very fine bubbling sounds, or the sub- crepitant rale. " // is a'very fine sound, or rather series of very fine uniform sounds, occurring in puffs and limited to inspiration." 260 PRACTICE OF MEDICINE. (Da Costa.) It resembles the noise occasioned by throwing salt on the fire, or alternately pressing and separating the tliumb and finger, moistened with a solution of gum arable, and held near the ear, or rubbing together a lock of dry hair near the ear. The crepitant rale is produced by the movement of fluid in the air cells or in the finest extremities of the bronchial tubes, or by the forcing open, during the act of inspiration, of the air cells aggluti- nated by exuded lymph. These sounds may be defined as being very fine, dry, crackling sounds, heard at the end of inspiration. They are usually present in the first stage of pneumonia, but when limited to the apices are significant of the incipient stage of phthisis. Cavernous rales, or, as they are commonly termed, gurgling rales, are produced in a pulmonary cavity of considerable size, containing a large amount of liquid communicating freely with a bronchial tube. The sound is occasioned by the agitation of the liquid within the cavity, and may be compared to the sound pro- duced by the boiling of liquid in a flask or large test-tube. The sound is sometimes high pitched or musical, whence it has been termed "amphoric gurgling," but it is generally low in pitch. The rale is heard almost exclusively during the act of inspiration, and its diag- nostic importance relates to the advanced stage of phthisis. Pleural rales may be either dry or moist. Dry pleural rales, or, as they are more commonly \.^xvnt^, friction sounds, are occasioned when the surfaces of the pleura are covered with a glutinous substance preventing the unobstructed movements of the pleural surfaces upon each other during the respiratory acts, for in health these movements occasion no sound whatever. The sounds are generally interrupted or irregular, occurring during the act of inspiration or expiration, or during both acts. The character of the sound is variable, being termed rubbing, grazing, rasping, grating, or creaking, according to the intensity of the respiratory acts and the amount of exudation. They are distinguished by the apparent nearness of the sound to the ear, and are usually intensified by firm pressure of the stetho- scope upon the chest. When the chest is fixed, especially at the lower two-thirds, and the ear applied over the seat of the sound, it will be found to have disappeared. The sound is diagnostic of the first stage of pleurisy or the pre-adhesive stage of tuberculosis of the pleura. DISEASES OF THE RESPIRATORY SYSTEM. 261 Moist friction sounds are produced in the same manner as those just mentioned, the exudation being softened in character. This sound is frequently confounded with moist bronchial rales, and its discrimination is often only positive by a careful study of the symp- toms and concomitant signs present. Metallic tinkling is a sign of pneumo-hydrothorax with per- foration of the lung, and when found, is usually diagnostic of this affection, although it occurs rarely in cases of phthisis with a large cavity, the physical conditions for its production being similar to those in pneumo-hydrothorax — to wit : a space of considerable size contain- ing air and liquid, the space communicating with the bronchial tubes. It consists of a series of tinkliftg sounds, of high pitch, silvery or metallic in tone, and is very well imitated by dropping a small marble into a metallic vase. It occurs irregularly, not being present with every act of breathing, and may be produced by forced, when not heard during tranquil, breathing. Were it not for the location and the absence of concomitant signs, it might be confounded with tinkling sounds sometimes produced within the stomach and transverse colon ; these latter sounds must be kept in mind in ausculting the lower chest area. THE VOICE IN DISEASE. The normal vocal resonance, as heard over the third rib of the chest anteriorly on each side, may have its intensity — 1. Diminished or absetii. 2. Iticr eased or exaggerated. Or its resonance may be of the character of — 3. Bronchophony. 4. Pectoriloquy. 5. yEgophony. 6. Amphoric voice. The vocal resonance may be diminished or feeble in bronchitis with free secretion, pleurisy with effusion, or in complete consolidation of the lung structure and the bronchial tubes. The vocal resonance is absent in pneumothorax and in pleurisy with effusion. Exaggerated vocal resonance differs from the normal vocal 262 PRACTICE OF MEDICINE. resonance in a slight increase of its density. It denotes a slight degree of solidification of lung tissue, and is chiefly of value in the diagnosis of tubercle. Bronchophony, or the voice concentrated near the ear, raised in pitch and in intensity, denotes complete consolidation of the pul- monary tissue in those parts in which the sound is abnormally present. Pectoriloquy is complete transmission of the voice to the ear, the articulated words being distinctly recognized. It has a close resemblance to the resonance heard over the larynx in health. Its presence indicates either a pulmonary cavity or more complete con- solidation — in other words, an exaggerated bronchophony. /^gnphony is a modification of bronchophony, consisting in tremulousness of the voice, its character nasal or bleating, somewhat suggestive of the cry of a goat. When heard it may be considered a sign of pleurisy with slight efTusion, or of pleuro-pneumonia. Anaphoric voice, or "the echo," as it is sometimes called, is a musical sound, of a somewhat hollow, metallic character, like that produced by blowing into an empty bottle. It is sometimes produced in large cavities within the lung, but is especially incident to pneumo- thorax. Increased bronchial -whisper is a sound in which the whis- pered words are abnormally intense, and higher in pitch than the normal bronchial whisper. It has the same significance as exagger- ated vocal resonance. SUCCUSSION. The Buccussion or splashing sound is pathognomonic of one affection — namely, pneumo-hydrothorax. It is obtained by jerking the body of a patient with a quick, some- what forcible movement, the ear being very near or in contact with the chest. The sound is like that produced when a small keg, partially filled with liquid, is shaken. The only liability to error is in confounding this splashing sound with that sometimes produced within the stomach ; but attention to concomitant signs and the symptoms will always protect against this error. DISEASES OF THE NASAL PASSAGES. 263 ASSOCIATION OF THE PHYSICAL SIGNS (DA COSTA). " As many of the signs elicited by the various methods of physical diagnosis depend on the same physical conditions, they may be studied in groups. The following will be usually found to be asso- ciated: Auscultation Percussion. OF Respiration. Auscultation OF Voice. Vocal Fremitus. Clear, .... Vesicular Normal vocal Unimpaired. murmur or its modifi- resonance. cation. ■ Bronchial, or harsh Bronchophony. Increased. Dull, .... respiration. Absent respi- . ration. Absent voice. Diminished or absent. Tympanitic, . Cavernous or feeble, ac- cording to cause. Uncertain ; cavernous or diminished. Uncertain ; mostly di- minished. Amphoric or metallic. Amphoric or metallic. Amphoric or metallic. Mostly di- minished. Cracked metal sound. Cavernous respiration. Cavernous respiration. Uncertain. Physical Conditions. Lung tissue healthy or nearly so ; at any rate, no increased density from deposits, etc. Solidification of pulmon- ary structure. Effusion into pleural sac. Increased quantity of air within the chest, due to a cavity or to overdis- tention of the air cells. Large cavity with elastic walls. Generally a cavity com- municating with a bron- chial tube. DISEASES OF THE NASAL PASSAGES. ACUTE NASAL CATARRH. Synonyms. Acute rhinitis; acute coryza; "cold in the head." Definition. An acute catarrhal inflammation of the mucous membrane (pituitary or Schneiderian membrane) lining the nose and the cavities communicating with it ; characterized by feverishness, feeling of fullness and discomfort in the head, and attended with dis- charges of fluid, watery, mucous, or muco-purulent in character. Pathological Anatomy. Hyperemia of the mucous mem- brane, attended with redness, swelling, and deficient secretion. This tumefaction is partly increased by an csdematous infiltration, causing a quantity of colorless, salty, and very thin liquid to flow from the 264 PRACTICE OF MEDICINE, nose. The secretion soon assumes the character of thick, tenacious mucus or muco-pus, due to the desquamation of the epithelium of the nasal mucous membrane, and a copious generation of young cells, the hyperasmia and the swelling of the membrane diminishing. The respiratory portions of the nasal fossae are more markedly affected than are the olfactory. Rarely, and then in new-born infants and those affected with the eruptive fevers, the exudation in the nasal passages is of a fibrinous nature, somewhat similar to that observed in diphtheria. Causes. Atmospherical changes are the most frequent and in- fluential. Exposure of the neck to a draught of cold air, or of the feet and ankles to cold and dampness, or changing from a warm to a cold atmosphere suddenly, are among the most usual causes. Irri- tating gases and vapors, dust, certain powders, as ipecac and tobacco. The scrofulous taint and the rheumatic diathesis seem to render the mucous membrane susceptible to frequent attacks. Acute coryza is usually present in the initial stage of measles and influenza; nearly always present in facial erysipelas. Epidemic influence occasionally prevails on an extensive scale. The poison of syphilis or the use of the iodide of potassium not in- frequently act as exciting causes. At times the catarrh seems to spread by contagion. Symptoms. "A cold in the head" is usually preceded by a feeling of /(Z^^/Vz/rt'i? or weariness and more or less frontal /wat/ac/ie ; then occur irregular chilly sensatio7is in the back, followed by more or less feverishness and an uncomfortable feeling of dryness in the nares, with a strong inclination to siiceze. This is soon followed by an abundant luatery and saline discharge, which is continually dripping from the nostrils, or occasions an attack of sneezing followed by blowing the nose, which relieves the congested and swollen mem- brane for a few moments. The relief is temporary, however, the fullness of the head and difficult obstructed nasal respiration rapidly returning. The anterior nares are red and injianied, and the eyes red and suffused with tears, through partial or entire closure of the tear ducts. The discharge soon assumes a purulent character. The voice has a peculiar tone, rather nasal and muffled in character. Within a few days the swelling subsides and secretion lessens, health being restored in about ten days from 'he beginning of the attack. DISEASES OF THE NASAL PASSAGES. 205 When the attack has almost terminated, hard crusts may form within the nostrils, either on the septum or turbinated bones, which are with difficulty expelled by blowing the nose. Complications. Irritation and swelling of the upper lip, from repeated blowing of the nose and the constant contact of the irri- tating discharge. Extension of the catarrh to the ethmoid or sphenoid cavities or fro7ital sinus, causing increased and severe frontal headache; or to the antrum of Highmore, causing tenderness over one or both cheeks. Extension to the Eustachian tube and middle ear, causing impaired hearing ; or i\\& pharytix or larynx, causing cough. Duration. In mild cases about one week ; severe cases continue, more or less marked, for two weeks. Prognosis. Favorable if early and proper treatment be insti- tuted; if neglected, the catarrh tends to become chronic. In very young infants, if the catarrh is not rapidly relieved, loss of flesh and strength occur, from inability to nurse. Treatment. Attacks the result of atmospherical causes may be aborted by the early administration of qiiinincE sulphas, gr. x-xv (0.6-1 Gm.), with morphinis, or even small Jlying-blistcrs, to the larynx. Inhalations of oxygen have seemed useful in several cases, as has the internal use of hydrogen dioxiditm. Niemeyer advises, in cases showing carbonic acid poisoning from obstruction of respiration due to accumulation of membrane, the pouring from a moderate height of a few gallons of cold water over the head, nape, and back of the child ; the shock produced always causes it to revive for a while, and to cough vigorously, thus expecto- rating large quantities of the membrane, but this procedure will become obsolete in proportion as intubation is practised. Ifthe exudation still continues, regardless of the means employed, the propriety of tracheotomy must be determined. LARYNGISMUS STRIDULUS. Synonyms. Spasm of the glottis ; pseudo-croup ; Millar's asthma ; thymic asthma : " Kopp's asthma" ; tetany. Definition. A spasm of the muscles of the larynx innervated by the inferior or recurrent laryngeal nerves ; characterized by a sudden development of dyspnoea and the appearance of deficient oxygena- tion of the blood. MacKenzie describes it as " a form of convulsion occurring in ill-nourished infants, characterized by spasmodic action of the abduc- tors of the vocal cords, and in severe cases by spasm of the diaphragm and intercostal muscles." Causes. Most common in children, the result of teething, laryn- gitis, indigestion, scrofula, or other cachexiae. Attacks in adults are not uncommon. It is often hereditary. Pathological Anatomy. Death the result of spasm of the glottis is such a very rare occurrence that the changes in the larynx are not determined. The mechanism consists in an irritation of the superior laryngeal nerve, — the afferent nerve, — whose function is to supply the mucous lining of the larynx with sensibility, whence is reflected through the inferior laryngeal nerve — the efferent nerve — the motor influence resulting in the spasm of the laryngeal muscles. DISEASES OF THE LARYNX. 287 Symptoms. The spasm of the laryngeal muscles is of sudden onset, and usually after nightfall. The child may have been in perfect health, to all appearances, on retiring, or it may have shown symptoms of catarrh of the upper air passages, or been suffering from gastro-intestinal or dental irritation. The child awakes suddenly, coughing in a metallic, resonant tone — the crotipy cough — and with great dyspncea, with loud, crowhig, stridulous inspirations, the result of narrowing of the larynx from spasm, with wheezy, stridulous expirations. The entrance of air is so greatly obstructed that all the accessory muscles of respiration are called into use ; the lips and finger nails become blue, the surface cold, the countenance anxious, and the inferior portion of the chest is drawn in, instead of being expanded, during inspiration. General convulsions occur at times, during a par- oxysm, also strabismus, and involuntary discharge of the faeces and the urine. The paroxysm continues from half an hour to an hour or more, to return after a few hours' sleep or during the following night ; the cough, during the day, having the croupy character. Diagnosis. The non-febrile and distinctly intermittent nature of the affection differentiates it from croup, and its own distinctive char- acters from all other diseases. The view is gaining that it is a variety of tetany. Prognosis. Favorable. Death from suffocation during the par- oxysm may occur in very young children, but it is certainly a very- rare termination. Treatment. For Xht. paroxys7n, the inhalation of a few drops of chloroformum is the most prompt method, care being exercised, as complete anaesthesia is unnecessary. Success is reported from the prompt inhalation oi amylnitris, also from niiro-glycerinum, in small but frequently repeated doses. The following combination is a prompt antispasmodic : U. Potassii bromidi, gij 8. Gm. Chloral, gr. xxxij 2. Gm. Syr. aurantii cort. , f _^ j 30. Cc. Aquce menth., f 2J 30. Cc. SiG. — One teaspoonful every half hour. After the paroxysm has been suspended by the above combination, the tendency to a recurrence of the attacks is prevented by the steady 2S8 PRACTICE OF MEI>ICINE. and continued use oi potassii bromiduvi, in moderate doses. Emetics are often useful in suspending an attack, especially if it be due to indigestion. Mackenzie advises the use of musk during the attack if the child can swallow ; and if not, then as soon as the child can take it, and continued at intervals for a day or two. His formula is as follows: li . Moschi, gr. iss .10 Gm. Saccli. alb., g""- 'j -IJ ^n\. Pulv. acacise, g""- 'j •^'3 Gm. Syr. aurantii flor., Aquam, aa ad f^j aa 4. Cc. SiG. — A dose. The high price of musk, however, prohibits its general use. Locally, the hot, alternating with the cold pack, should be constantly applied to the throat. The air of the room should be moistened by the vapor of hot water constantly disengaged in it. After the attack has passed off, the general condition of the child requires attention ; for this purpose it is well to administer a dose of hydrargyri chloridiim mite, to be followed by a dose of oleum ricini or inagnesii carbonas. The diet must be regulated, all farinaceous articles being absolutely forbidden. TUBERCULOUS LARYNGITIS. Synonyms. Laryngeal phthisis ; throat consumption. Definition. An inflammation, tending to ulceration, of the tissues of the larynx, of tuberculous origin ; characterized by pain on deglu- tition, cough, weakness of voice, and progressive emaciation, asso- ciated with hectic fever. Causes. An infection of the larynx with the bacillus tuberculosis, either from the inspired air or by the sputum. A depressed state of the system is essential for the action of the bacilli. Pathological Anatomy. It is well to remember that all chronic inflammations of the larynx associated with pulmonary tuberculosis are not tubercular. Begins with redness of the mucous membrane, showing scattered tubercles. The tubercles show a strong tendency to cluster, then DISEASES OF THE LARYNX. 289 soften, leaving shallow, irregular ulcers. The ulcers are covered with a grayish exudate. The mucous tissue round about the ulcers is thickened. The ulcers may, and generally do, erode the true vocal cords, often entirely destroying them. The ulcers slowly extend in all directions, destroying the tissues attacked. The epiglottis may be entirely destroyed. Symptoms. Usually develops secondary to pulmonary symp- toms ; rarely it may occur as a primary disease, to be followed with tuberculosis of the lungs. The first symptom is a change in the voice — huskiness ; this, associated with symptoms of ill health, is always a warning to the physician. The husky voice may proceed until it is but a painful whisper. Cough of an irritating, painful character associated with slight expectoration. Painful and difficult degbdiiion (dysphagia) is a very constant and distressing symptom. There is the remitting fever so characteristic of tuberculosis, with night sweats, loss of appetite, loss of flesh, and insomnia. Laryngoscopic examination reveals the characteristic broad, shal- low, irregular, grayish ulcers, with the thickened surrounding mucous membrane. The vocal cords show infiltration and thickening or ulceration. Diagnosis. To discriminate from non-tubercular laryngitis, ex- amine the sputum, and if the specific bacilli are found, the diagnosis is conclusive. Prognosis. Unfavorable. Treatm,ent. Remember that tubercular laryngitis is not always preceded by pulmonary phthisis, but in a fair proportion of cases is a primary disease. Much can be done to make the patient comfort- able. The application of twenty, forty, or even sixty per centum solution of acidutn lacticum is a very successful remedy. Cocaince hydrochloras applied directly to the ulcers gives relief to the pain and dysphagia. Local applications of hydrogen dioxidum, argenti nitras, and menthol are of value. Curetting the ulcers and applying iodo- formum in emulsion or with tnorphincB sulphas has been practised with benefit. The general condition must be treated, the diet liquid and of a most nourishing character. 19 290 PRACTICE OK MliUlClNK. DISEASES OF THE BRONCHIAL TUBES. ACUTE BRONCHITIS. Synonyms. Bronchial catarrh ; acute bronchial catarrh ; "cold on the clicst." Definition. An acute catarrhal inflammation of the bronchial tubes of the larger, middle, and third size ; characterized by fever, substernal pain, a feeling of thoracic constriction, oppression in breathing, and at first scanty, followed by more or less profuse, expectoration. Causes. Most frequent in childhood, especially during the period of dentition, when there exists a strong tendency to catarrh of the mucous membranes in general and of the bronchi in particular. In old age the predisposition again returns. Inhalations of irritants such as dust, smoke, and air too hot or too cold. More common in cli- mates characterized by considerable moisture of the atmosphere, combined with a low temperature, and especially where there are sudden and marked variations. A specific germ ? Pathological Anatomy. Hypcraviia of the mucous mem- brane of the bronchial tubes, manifested by a diffused redness, swell- ing, oedema, and diminished secretion, followed by an increased secretion and overgrowth and desquamation of the epithelial cells, together with a copious generation of young cells, the expectoration then becoming of a yellowish color (mucopurulent). As a result of the hyperaemia, rupture of the capillaries of the mucous membrane frequently occurs, when the slight expectoration of the first stage is streaked with blood. In cases of bronchitis following the exanthemata, or in scrofulous patients, the bronchial glands participate in the inflammation, becoming hyperaemic, swollen, and filled with secretion, and not mfrequently the glandular elements undergo a hyperplasia, and finally the " cheesy " degeneration. Symptoms. The itivasion is usually characterized by the occur- rence of either nasal or laryngeal catarrh, or both, the patient feeling DISEASES OF THE BRONCHIAL TUBES. 291 chilly, followed by flushes of heat; the limbs, joints, and even the body, are affected with pain of an aching, contused character, and with a sense of fatigue and want of energy ; there may be a furred tongue, anorexia, and constipation. In nervous, irritable persons, and in children, there may be slight delirium, and often in very young children, especially during the period of dentition, convulsions may usher in an attack. After a day or two of these initiatory symptoms, those characteristic of bronchial catarrh develop. Pain is experienced beneath the sternum, especially toward its upper . part, of a raw, bursting, or tearing character, aggravated by a deep inspiration or by coughing ; the pain also radiates toward the sides, following the course of the primary bronchial tubes. Tenderness over the sternum is often experienced. Muscular pain and tender- ness of rheumatic character are often associated with attacks of bron- chitis. Cough from the onset, at first in paroxysms of a hard, dry character, changing as the disease progresses, and becoming looser, followed \yY free expectoration. The expectoratio7i at first is small in quantity, almost transparent, frothy, and having a salty taste, often streaked with blood. As the disease progresses it becomes more abundant, of a yellowish or a greenish-yellow color, and of a tenacious con- sistency. There are present slight fever, hot, dry skin, frequent /zi^/^i?, loss of appetite, moderate thirst, and constipation. A feeling of languor and weariness, and often considerable de- pression, quite out of proportion to the febrile state, are not in- frequent. Percussion. Normal, except in those rare cases in which the bronchial glands are involved, when irregular spots of dullness can be developed. Auscultation. First Stage : The bronchial membrane being swollen and dry, the respiratory murmur is harsh or vesiculo-bronchial in character, associated with diffused sonorous and sibilatit rales. Second Stage : The secretion from the bronchial mucous membrane being increased, the respiratory murmur is less harsh in character, but is associated with large and small moist or bubbling rales. Diagnosis. The points of resemblance and difference between acute bronchitis and other diseases of the chest will be pointed out 2'J2 PRACTICE OF MEDICINE. when those affections are described. The association of bronchitis with other diseases must not be forgotten. Prognosis. Acute bronchitis of the larger tubes usually termi- nates in complete resolution within two weeks. In children and in the aged the course is more protracted, and the symptoms more severe, but recovery is the rule. Very aged and feeble persons may succumb, but it is rare. Treatment. Depends upon the stage when seen. During the invasion, quinina: sulphas, gr. x (0.6 Gm.), combined with tnorphina sulph., gr. Y^ (o.oi I Gm.), will usually prevent or abort an attack of acute bronchitis. In the first stage, in adults, when the mucous membrane is swollen and dry, either of the following prescriptions will give prompt relief: li. Antimonil et potassii tart., . . . jjr. ij .13 Gm. Liquor, ammonii acetatis, . . . fSiv 120. Cc. Spts. Klheris nitrosi, f^^j 30. Cc. (Tinct. aconiti, if indicated), . -f^ss 2. Cc. Syr. simplicis, adf^vj ad 180. Cc. M. SiG. — Two teaspoonfuls every two or three hours. Or— R. Vini ipecacuanhre, fzj Liq. potassii citrat., f5''j Liq. ammonii acetat., fo''J 9°- ^*-- ^^' SiG. — Tablespoonful every two or three hours. If the cough of the dry stage be severe, or if the looseness of the bowels follow the use of either of the above combinations, tinctura opii caviphorata may be added with advantage, or codeina, but use opium, with caution, in the dry stage. Tinctura Jiyoscyami, n^v-xv 0.3-1 Cc.) is much better. For young children the above, in proportionately reduced doses, or the following ; U. Pulv. ipecac, et opii, gr- v .3 Gm. Pulv. scilla;, gr- x .6 Gm. Hydrargyri clilor. mitis, . . . . gr. ij .13 Gm. Sacch. lact., gr. x .6 Gm. M. Ft. chart. No. x. SiG. — One every two hours. 4- Cc. 90. Cc. 90. Cc. DISEASES OF THE BRONCHIAL TUBES. 293 The following is an excellent mixture for children : U- Potassii citrat. , ^ij 8. Gm. Syr. ipecac, fgij 8. Cc. Syr. scillce, i^j 4. Cc. Syr. limonis, f^'j 8- ^^• Tinct. opii camphorat., fgij 8. Cc. Elix. simplicis, ad f ^ iij ad 90. Cc. M. SiG. — Teaspoonful every couple hours. Locally : Hot mustard foot bath, and sinapis or terebinthina stupes over the chest, or, if much substernal pain and sthenic, a few dry or even wet cups, the patient being confined to an apartment in which the air is moistened by the vapor of hot water. Second Stage : The secretion of the bronchial mucous membrane being copious, stimulating expectorants are indicated, such as ammonii chloridum, scilla, aintnonii carbonas, or potassii carbonas. A reliable combination is : R, Ammonii chloridi, ^ij 8. Gm. Scillse aceti, . f 3 iij 12. Cc. Syr. ipecac, . f^ij 8- Cc. Misturae glycyrrhizse comp., . ad f^iij ad 90. Cc. SiG. — Dessertspoonful every three hours. Attacks showing a tendency to linger are greatly benefited by the following : B . Terebeni, f 3 ij 8. Cc. Creosoti, rr\^xxiv 1.5 Cc. Mucil. acacise, q. s. q. s. Aquae chloroform!, .... adf^iij ad 90. Cc. M. SiG. — One teaspoonful every four hours, diluted. During the attack, attention must be given to the secretions and to the diet of the patient. During convalescence a course of strychninae sulphas or tinctura nucis vomicae is valuable. CAPILLARY BRONCHITIS. Synonyms. Broncho-pneumonia (?) ; " suffocative catarrh." Definition. An acute catarrhal inflammation of the mucous membrane of the ier7ni}tal bronchial tubes, or bronchioles ; charac- terized by fever, impeded and increased respiration, impeded circula- 294 PRACTICE OF MEDICINE. tion, slight cough and scanty expectoration, and symptoms of non- aeration of the blood. Causes. Most common in childhood, following exposure to cold or sudden changes of temperature ; occurs also in the aged, and also complicates measles, whooping cough, or any of the debilitating dis- eases. Tliere may be a special germ. Pathological Anatomy. Ihperamia, redness and swelling of the lining membrane of the bronchioles, with the exudation of a tough, tenacious secretion. In those cases in which the air cells are not involved the air passes, during the act of inspiration, through the secretion blocking the smaller tubes, but is prevented from escaping during the act of expiration, the secretion in the smaller tubes acting as a valve ; the result is distention of numerous vesicles, producing a circumscribed or diffused functional emphysema. If the secretion produces com- plete closure of any of the smaller tubes, the air previously drawn into the vesicles will be absorbed, causing pulmonary collapse (atelectasis). If the inflammation extends to the alveoli of the lungs, it produces the condition known as broncho-pneiimonia, a frequent complication in children and feeble elderly people ; it is most commonly lobular in character, whence the term " /obii/ar pneumonia."" Symptoms. Usually preceded by more or less ordinary bron- chitis, followed by rise of temperature, 102-103° F., increased pulse, difficult z.T\di increased respiration, numbering forty, fifty, or sixty in the minute, with paroxysms in which the dyspnoea is markedly aggra- vated, when cyanosis rapidly develops ; the tongue is coated, bowels costive, appetite impaired, and there is restlessness and headache. The circulation through the lungs is impeded by the dyspnoea, the />«/y^ becomes feeble and flickering, and there results general con- gestion of the venous system, the countenance becomes livid, the lips atid nails blue, the surface cold, and often covered with a clammy perspiration, the mind dull, and in children stupor and convulsions rapidly supervene, the result of the non-aeration of the blood. The cough is slight, but of a suppressed character, the expectoration scanty, the patient usually swallowing the sputum. When cyanosis occurs, the cough may almost entirely cease ; expectoration also ceases, death soon following from apncea and depression. Percussion. Normal, except over those portions of the lungs (a DISEASES OF THE BRONCHIAL TUBES. 295 bilateral disease) which are in a condition of collapse, when dullness rapidly develops and may as rapidly disappear, changing to other portions of the lungs — shifting dullness. Auscultation. First stage, a feeble, but high-pitched, respira- tory murmur, becomes less distinct and harsh as the disease progresses. The rales in the first stage are fine whistling, sibilant, changing in the second stage to fine bubbling or subcrepitant rales. The respira- tory murmur is absent over the dull area. Diagnosis. There is one point characteristic of capillary bron- chitis — it is a general or bilateral disease. Capillary bronchitis is often mistaken for true catarrhal pneumonia, the points of distinction between which will be pointed out when discussing the latter affection. Prognosis. In children, on account of their inability to expec- torate, which tends to rapid collapse of the lungs, and in the aged, the prognosis is most grave. In the strong and vigorous, recovery follows prompt and energetic treatment. Treatment. From the very onset of the attack the treatment must be supporting, with the addition of such measures as seem to possess a controlling influence over the catarrhal process. The patient must be confined to bed, well covered, and the tem- perature of the room varying between 75° and 80°, the air moistened with steam, or adding one or two teaspoonfuls of tinctura benzoin to the hot water. In the first stage dry cups, mild smapis applications, or terebinthina stupes should be applied to the chest, after which it should be covered with an oil-silk jacket or a cotton jacket. The diet must be of the most nutritious character, the great aim being to sustain the powers of life until the catarrhal process has passed through the different stages ; hence milk, eggs, chicken, mut- ton and beef broths, with the free use oi stimulants, commenced early and in amounts large enough to overcome the signs of depression which are present early in the attack. Unless the fever be high, 102° F., and continues, it need not be treated, but if it continues at that point or higher, a few doses of acetanilidum, gr. ij-iv (o. 13-0.26 Gm.), in brandy or whiskey, may be used. If the urine be scanty, use spiritus astheris nitrosi. If suffocation be imminent, the cautious use oi emetics may be indi- cated ; the most suitable are ipecacuanha and hydrargyri subsulphas flavus, or the hypodermic use of apomorphina, gr. -^^ (0.003 Gm.). Do not repeat emesis often enough to produce exhaustion. 296 PRACTICE OF MEDICINE. For the catarrhal process two remedies are of inestimable value: one, potassii iodidum or amviotiii todiduni, gr. j-ij (0.065-0.13 Gm.) for a child every hour or two, and gr. v-x (0.3-0.6 Gm.) for an adult, its action being to liquefy or thin the tenacious secretion and modify the inflammatory action ; the other is ainmonii carbonas, gr. j-ij (0.065-0.13 Gm.) for a child every hour or two, and gr. v-x (0.3-0.6 Gm.) for an adult. The two combined, but for the taste, make a valuable prescription : R. Potassii iodidi, gT' 'j .13^111. Ammoiiii carbonat. gr. iij .2 Gm. Syr. glycyrrh., fo^s 2. Cc. Syr. tola, fSss 2. Cc. SiG. — Every two or three hours. Excellent results have been obtained in the children's wards of the Philadelphia Hospital from the systematic inhalation of oxygen. Prof. H. C. Wood, in desperate cases of suffocative catarrh, advises the alternate use of the hot and cold douche conjointly with stimu- lating: remedies. FIBRINOUS BRONCHITIS. Synonyms. Membranous bronchitis; plastic bronchitis; diph- theritic bronchitis; croupous bronchitis. Definition. An acute inflammation of the mucous membrane of the larger and middle-sized bronchial tubes, attended with an exuda- tion, forming a membraniform layer, which is closely adherent to the mucous surface ; characterized by febrile reaction, cough, difficult breathing, scanty expectoration, followed by the expulsion of the false membrane in the form of patches or casts. Causes. Unknown; associated with membranous laryngitis from extension downward; asthma; emphysema; phthisis; frequently result of exposure to cold or damp, in those of feeble health or in tuberculous (?) constitutions. Pathological Anatomy. Hypercemia of the mucous mem- brane of the bronchial tubes, associated with sivc/Iing nx\<\ oedema, during which the surface is covered with a whitish or grayish-white, firmly adherent, membranous deposit, cemented together by a coagu- lable exudation, and prolonged by rootlets from its under surface into DISEASES OF THE BRONCHIAL TUBES. 297 the bronchial folHcles, which sooner or later is loosened and detached by suppurative process, and is expectorated after a violent fit of coughing or vomiting. When expectorated, Xhe false membrane, as it has been termed, has either the form of patches or is thrown off en- tire from the bronchial tube, and may be found to consist of casts representing more or less of the bronchial subdivisions, and present- ing an appearance not unlike " boiled macaroni." On 7nicroscopical examination, the detached membrane presents fibrillas which characterize fibrin or lymph in other situations ; and if placed in a solution of acetic acid, it becomes greatly swollen, while ordinary mucus contracts and becomes more dense if added to the same solution. Symptoms. There are no symptoms or signs by means of which this variety of bronchitis can be distinguished from ordinary catarrhal bronchitis, prior to the expectoration of the false m,embrane. Expectoration is preceded and accompanied by violent paroxysms of coughing, and after more or less of the membrane has been raised, a muco-purulent expectoration, streaked with blood, may be present for several days. Duration. The inflammation may be either acute, subactde, or chronic, expectoration of patches or strips of the membrane being repeated at intervals of days, weeks, months, or even years. Prognosis. In adults, favorable, if not associated with other grave affections, such as phthisis, pneumonia, emphysema. In young children it may cause obstruction to the respiration, and not infrequently proves fatal. Treatment. As the character of the inflammation can seldom be determined until the membrane or portions of it have been expec- torated, the treatment is at first the same as in attacks of ordinary acute bronchitis. As soon, however, as the character of the inflammation can be de- termined, active emesis is the most effective means of removing the obstruction caused by the false membrane, the best agents of this class being eith^ hydrargyri subsulphas flavus, apomorphina, ipecac- uanha, or zinci sulphas, to be repeated as indicated. Inhalations of solutions of ammonii chloridum, pix liquida, euca- lyptol, or simply the vapor of water, and especially of lime-water, are highly serviceable. To prevent the formation of membrane, Prof. Bartholow strongly 298 PRACTICE OF MEDICINE. urges the use of ammonii iodidutn and ammonii carbonas combined, in small doses, every hour or two. In a case treated by the author after this method, excellent results followed. Potassii iodidum is also useful. In cases showing a tendency to become chronic, good results will follow the application of flying blisters to the chest and the internal administration oi arscniciim and some preparation oi pix liquida. CHRONIC BRONCHITIS. Synonyms. Chronic bronchial catarrh ; winter cough; second- ary bronchitis. Definition. A chronic inflammation of the mucous membrane of the larger and middle-sized bronchial tubes ; characterized by cough and more or less profuse expectoration, plus, in many cases, the symptoms of etnphysema of the lungs, which is a frequent complica- tion. Chronic bronchitis may be €\\\\tx primary or secondary. Causes. Primary, exposure to wet or cold, or the repeated inha- lation of dust, vapors, or other irritants. Secondary, gout, rheuma- tism, syphilis ; cardiac, renal, or pulmonary diseases, or alcoholism. Varieties. I. Mucous catarrh, associated with moderate expec- toration. II. 5r<7«r//<7rr^a?a, profuse expectoration. \\\. Diy catarrh, scanty expectoration. IV. Fetid bronchitis. V. Bronchiectasis, or dilatation of the bronchi. Pathological Anatomy. The mucous membrane of the bron- chial tube is discolored, being of a more or less dull red, often of a deeply venous hue, mingled with a grayish or brownish color. These changes may be either in patches or extensively diffused. The ves- sels of the mucous membrane are dilated. The mucous membrane is thickened, resulting in reduction in the calibre of the tube and a roughening of its internal surface. The submucous tissue becomes infiltrated, contracted, and indurated. * The elastic and muscular coats of the tubes become hypertrophied, lose their elasticity, and the cartilages become the seat of calcareous deposits. As the result of the loss of elasticity and muscular tone of the tubes they become irregularly dilated — " bronchial dilatation." The dilata- DISEASES OF THE BRONCHIAL TUBES. 299 tions may be uniform in character, resembling somewhat the fingers of a glove, or they may be sacculated or globular, forming actual cavities in the bronchial structure. In the mucous variety the secretion consists of young cells and mucous corpuscles, having a yellowish color ; in the dry variety, the "catarrhe sec" of Laennec, or "dry bronchial irritation," the secre- tion is scanty, tough, semi-transparent, and occurs in globular masses ; in bronchorrhaea, which is usually associated with bronchial dilatation, the secretion is abundant, greenish-yellow in color, and frequently fetid. The majority of cases of chronic bronchitis are associated with chronic gastric catarrh. Symptoms. The most characteristic symptoms of chronic bron- chitis are the cough and expectoration. The cough occurs at all hours, but is more severe at night and early in the morning. The cough is not always present. It disappears almost altogether for a time, and then reappears, continuing thus for years. Coated tongue, disagree- able taste, loss of appetite, impaired digestion, with eructations of gases, are present in many cases, due to the chronic gastric catarrh. Unless associated with other diseases, the general health suffers but little, if at all, constitutional symptoms being present only during acute exacerbations. Mucous catarrh, or, from its occurring most commonly during the winter months, "winter cough," is characterized by paroxysms of cough, more or less violent, followed by the expectoration of a yellow- ish mucus. Dry catarrh is characterized by a harsh cough, a feeling of soreness or rawness under the sternum, and the expectoration of small globu- lar jnasses ; this variety occurs with emphysema, gout, rheumatism, and asthma. Bronchorrhcaa, which is associated with bronchial dilatation, and most common in the elderly, is characterized by paroxysms of severe coughing, followed by the copious expectoration of greenish-yellow, often fetid, mucus ; the amount expectorated often amounts to four or five pints in the twenty-four hours. Fetid bronchitis, often associated with bronchial dilatation, has an excessively fetid odor of the breath and expectoration. The decom- position of the secretion may cause gangrene of the bronchial mucous membrane, and even of the lung structure. 300 PRACTICE OF MEDICINE. Percussion. Unless complicated with other affections, normal ; if bronchial dilatation occur, there are diffused spots of the tympanitic or amphoric percussion sound, the physical condition being a circum- scribed cavity containing air and communicating with a bronchial tube. Auscultation. Harsh or vesiciilo-bronchial respiration, asso- ciated with more or less profuse, sonorous, sibilant, and large and small bubbling rales ; in bronchial dilatation, in addition to the harsh respiration, is found broncho-cavernous breathing, with large and small gurgling rales. If emphysema complicate chronic bronchitis, the physical signs are somewhat modified, and will be pointed out when discussing that affection. Diag'nosis. Always examine the urine in case of cough, and particularly in chronic bronchitis, as this disease is one of the most frequent complications of Bright's disease. Incipient phthisis is often confounded with chronic bronchitis. The diagnosis is not always easy. The physical signs of chronic bron- chitis are more or less diffused through both lungs, and not, as a rule, associated with failure of the general health ; while in phthisis, from the onset, there is failing health, with a concentration of the physical signs to the apices. The discovery of the bacillus determines the diagnosis. Prognosis. If unassociated with disease of the lungs, heart, or kidneys, chronic bronchitis is never dangerous to life, although the symptoms are present, more or less, contmually, and aggravated upon the least exposure. Rarely is a complete cure recorded. If associated with phthisis, emphysema, diseases of the heart or of the kidneys, the prognosis is governed by these affections. In turn, it is to be remembered that chronic bronchial catarrh may lead to emphysema of the lungs, asthma, or to cardiac dilatation. Treatment. Cases of chronic bronchitis, of whatever variety, should observe the following general rules: i. Attention to the gen- eral health. 2. The clothing; wearing flannel the year round, or, what is better, silk underclothing, avoiding the opposite extreme of excessive clothing. The medical treatmentis guided by the cause, character, and severity of the disease. If secondary to other affections, in the majority of cases remedies DISEASES OF THE BRONCHIAL TUBES. 301 directed to the bronchial mucous membrane are contra-indicated. If the result of the rheumatic or gouty diathesis, in addition to the remedies directed to the disease itself, should be combined change to a warm climate, if possible, and a more or less protracted course o^ fiotassii iodidu7n, or lithii citras, or a residence at one of the alka- line sprijtgs. If associated with alcoholism or chronic gastric catarrh, the follow- ing is a valuable combination : R. Ammonii chloridi, J^iij 12. Gm. Tinct. nucis vomicse, f^ij 8. Cc. Infus. gentianse comp., . q. s. adf^iv ad I20. Cc. M. SiG. — Dessertspoonful in water before meals. For mucous catarrh with acute exacerbations : R. Ammonii chloridi, ^\] 8. Gm. Glycerin!, f^iss 45. Cc. Codeinge sulph., gr. j .065 Gm. Vini picis liq., f.^i'j 9°- Cc. Syr. prun. virg., f^iss 45. Cc. M. SiG. — Tablespoonful every three or four hours. Dry catarrh is greatly benefited by — R. Potassii iodidi, gr. v-x .3-.6 Gm. Elix. cinchonse, Ti\^xx 1. 3 Cc. Vini picis liq., adf^ss ad 15. Cc. M. Three times a day. For an acute exacerbation of dry or tenacious chronic bronchitis : R. Ammonii chloridi, giv 15. Gm. Tinct. hyoscyam., f^i"^ ^S- Co. Syr. scillse comp., f.^iv iS- Cc. Aq. chloroformi, f^ij 60. Cc. M. SiG. — One teaspoonful every three hours, diluted. An excellent expectorant combination in all forms and at any stage of bronchial catarrh is : R. Ammonii carbonat. , gr. xvj I. Gm. Ext. scillse fld., f.^ss 2. Cc. Ext. senegas fld., f^ss 2. Cc. Tinct. opii camphorat., .... f.^iij 12. Cc. Syr. tola, f^iss 45- Cc. M. SiG. — Teaspoonful every few hours, diluted. 302 rRACTICC OF MKOICINE. For brotic/iorr/iaa, copaiba, n\^v-x (0.3-0.6 Cc), every three hours, or sp/s. terebintliince, Ti\,v (0.3 Cc), every four hours, or acidum car- bolicitm, gr. ss (0.032 Gm.), four times a day, are excellent drujjs, or — R . Tereheni, f J5 ij 8. Cc, Creosoii, " Acacire, Aq. cliloroformi, Syr. prun. virg. , ITLxxx 2. Cc. q s. q. s. f.^j 30- Cc. ad f.^iij ad 90. Cc. M. SiG. — Teaspoonful every three or four hours, diluted. And at the same time using ol. tnorrhuce and arsenicum, or, if these means fail, inhalations of alumen, acidum gallicum, or acidum tan- nicutn. If the expectoration be fetid, " ffetid bronchitis," Prof. Da Costa recommends the internal use of acidum carbo/icum, n\,j (0.06 Cc), every third hour, vifith inhalations of acidum carbolicum, gr. v (0.32 Gm.), aqttcB, f5J (30 Cc), two or three times a day. Good results may also be obtained from the terebene and creosote mixture given above. If, after prolonged treatment, cure or great amelioration does not occur, then a change of climate is called for. Usually a warm climate is the most suitable, but sometimes a dry, bracing climate does better. Locally, irritation with tinctura iodi, or flying blisters, repeated once or twice weekly, is of advantage. ASTHMA. Synonyms. Bronchial asthma ; spasmodic asthma. Definition. A paroxysmal, spasmodic contraction of the mus- cular layer surrounding the smaller bronchial tubes, and perhaps associated with a tonic spasm of the diaphragm and more or less bronchial catarrh ; characterized by spasmodic attacks of distressing expiratory dyspnoea, continuing several hours, days, or weeks. Cause. A true neurosis of the respiratory apparatus. The result of peripheral or local disturbances in the nervous system. Chiefly hereditary. A family history of asthma, chorea, or epilepsy. It is sometimes of reflex origin, starting from diseases of the nasal mucous membrane, explaining the attacks due to the inhalation of DISEASES OF THE BRONCHIAL TUBES. 303 various substances, as ipecac, turpentine, or irritating dusts. Climate. Some attacks may be due to a peculiar and characteristic disease of the bronchial mucous membrane — an "asthmatic bronchiolitis." Bronchitis; "peri-bronchitis"; emphysema; chronic cardiac disease; chronic gastric catarrh ; malarial toxaemia. Asthma is more common in men than in women, and may occur at any age. Pathological Anatomy. Unless a " peri-bronchitis," nothing purely distinctive. The changes of emphysema are common. Symptoms. The onset of 3. first attack of asthma is abrupt and sudden, the succeeding attacks being preceded hy prodrotfies, which the individual rapidly learns to appreciate — to wit : coryza, bronchial irritation, thoracic cons trie tioti, marked dyspepsia, or the scanty pas- sage of pale, limpid urine, the " hysterical urine." The paroxysm begins, in the majority of instances, in the earty morning hours or during the afternoon, with a feeling of anguish and constriction in the chest and an intejise desire for air. The breathing is accompanied with loud wheezing, the face is flushed, at times even cyanosed and bathed in perspiration, the eyes staring, the eyeballs protrude, and the muscles of the neck become prominent as they aid in the effort for air. The dyspncea soon becomes so severe that the inspiration is but a gasp, the lips are pallid, cyanosis deepens, and the patient feels as if death were impending. Owing to the tonic contraction of the smaller bronchi, the air drawn into the alveoli escapes imperfectly, resulting in the expiratory dyspnoea, the emphy- sematous chest, and the lowered position of the diaphragm. After some minutes or hours the respiration becomes easier, the air in the lungs changes, the cyanosis disappears, and gradually the paroxysm ceases, the patient feeling exhausted and the chest fatigued. During the paroxysm there is a short, dry cough, becoming looser as the attack subsides. The sputum of asthma is unique. Early in the paroxysm it is raised with difficulty, and is in the form of rounded gelatinous masses ("pedes" of Laennec). If these pellets be care- fully examined, they will be found to consist of moulds of the smaller bronchi, and, under the microscope, show Leyden's crystals and Curschmann's spirals. After a day or two the sputum becomes muco purulent, and the spirals and crystals are absent. The duration of an attack varies from one to many hours, or even days. Instead of single paroxysms, slight remissions may occur at 304 PKACTICE OF MKDICINE. intervals of one, two, or three hours, to be followed by exacerbations lasting from four to six hours, continuing for a week or two, prevent- ing the patient lying down or taking food. Percussion. During the paroxysm, hyper resonance over both lungs, termed vcsiculo-iympanitic, the "band-box tone" of Bam- berger, due to the retained air in the alveoli. Auscultation. First stage feeble or absent vesicular murmur, with prolonged expiration associated with loud wJieezing, whistling, sibilant and sonorous rales ; as the paroxysm subsides, the vesicular breathing becomes more apparent and is associated with moist rales. Prognosis. In itself asthma is not fatal to life ; but if the parox- ysms are frequently repeated, there results either emphysema, cardiac dilatation with subsequent dropsy, or even cerebral hemorrhage. Attacks of asthma frequently occur as a complication in emphy- sema, chronic bronchitis, valvular diseases of the heart, and Bright's disease. Treatment. There are two indications to meet: the relief of the paroxysm, and to prevent its recurrence. To relieve the paroxysm, no medication is so effective as the hypo- dermic injection of viorphince sulphas, gr. y(,-% (0.011-0.016 Gm.), combined with atropines sulphas, gr. ^J^ (0.00065 Gm.). Chloral, gr. x (0.6 Gm.), repeated, where no heart complication exists, is often effective. Drinking strong, hot, black coffee is often serviceable. Caffeine citrata during or at the onset of a paroxysm, in doses of gr. iij-v (0.2-0.3 Gm.), hypodermically, or in a cachet or in solution, re- peated until bronchial spasm is relieved, is a valuable drug. Page strongly recommends sodii nitras : li. Pulv. sodii nitritis, gr. xxiv 1.6 Gm. Aquae, f3J 30. Cc. M. SiG. — Teaspoonful at once ; repeat in half an hour, once or twice if necessary. The following combination by hypodermic injection is often most successful in relieving an attack of asthma, and particularly if compli- cated with cardiac or nephritic disease, continuing the combination after relief, in pill form or solution at ordinary intervals for several days: R. Spirit, glonoini, TTLij .12 Cc. Strychnine sulph., S""- 3V -OO^S Gm. Morphince sulph., g''- ^V •°°3 *^™" ^' SiG. — Dose. DISEASES OF THE BRONCHIAL TUBES, 305 Chloroformii7n, cether, or amyl nitris inhalations have been recom- mended, and also the naiiseant expectorants, lobelia, ipecac, and scilla. Ext. grindelicE fld., TTLxx (1.3 Cc), repeated every two or three hours is sometimes useful. Dr. Pepper speaks highly of the following for the paroxysm : B . Ammonii bromidi, ' 5 'J 9 'J i°- Gm. Ammonii chloridi, 3 iss 6. Gm. Tinct. lobeliae, f^iij ^2. Cc. Spts. Eetheris comp., f^^j 30. Cc. Syr. acacia, q.s. f^iv ad 120. Cc. M. SiG. — Dessertspoonful in water every hour or two, diluted. After the use of many drugs I have finally come to depend upon potassii iodidum, gr.v-x (0.3-0.6 Gm.), every three hours, either alone or combined with tinctura belladonncz, n\,v (0.3 Cc), or nitro- glycerin, gr. ^o~t^ (0.00032-0.00065 Gm.), to remove the catarrhal condition remaining after a paroxysm and to prevent a return. Another remedy that at times is successful is sympus acidi hydrio- dici, f3ss-f5 (2-4 Cc), every three or four hours, well diluted. Inhalations of the fumes of belladonna, stramoniutn, nitre-paper, chloroform, ethyl brofttidum, or the use of various pastilles or cigar- ettes, are of immense benefit in many cases, A twenty per cent, solu- tion of menthol as an inhalation has been successful in some instances. Inhalations of oxygen have given excellent results in a number of cases. If an attack is impending, it may often be aborted by drinking freely of strong, black coffee, or by full doses of the bromides. To prevejit the recurrence of the paroxysms, the general health must be cared for, and any suspected causes corrected. In all cases a thorough examination of the nasal mucous membrane should be made and any diseased condition found removed. If chronic bron- chitis be present, it should be persistently treated. Two remedies long continued frequently give good results : potassii iodidum in doses ranging from five to fifteen grains (0.3-1 Gm.), and arsefiicum in small doses. Additional aids are systematic exercise short of fatigue, bathing, regulated diet, and, when possible, a change of climate. 20 306 PRACTICE OF MEDICINE. HAY ASTHMA. Synonyms. Hay fever ; autumnal catarrh ; rose fever ; rose cold. Definition. An acute, specific, catarrhal inflammation of the upper air passages, extending to the bronchial tubes, associated with spasmodic contraction of their muscular layer, occurring at a par- ticular season of the year, characterized by coryza, croupy or wheezy cough, and difficult respiration. Causes. A predisposition, often hereditary, of the nervous system seems to be a strong etiological factor. Persons in whom the predisposition exists have attacks excited by the inhalation of the pollen of grasses, rye, corn, wheat, or roses. Pathological Anatomy. Hypertrophy of the inferior and middle turbinated bones; a peculiar hyperesthesia of the mucous membrane covering the inferior and middle turbinated bones, the middle meatus, the floor of the nose, and that part of the septum below the limit of the olfactory membrane are frequently associated with the disease. Symptoms. Begins by irritation of the eyes, severe coryza, with sneezijig ; a clear, watery, nasal discharge, and congested Eustachian tubes, rapidly extending to the larynx and bronchial tubes, when occurs a hoarse, croupy, and wheezing cough, and difficulty of breath- ing. The dyspnoea occurs in paroxysms, which are often as severe as those occurring during a regular asthmatic attack. There is mild depression of the nervous system in nearly all attacks. The paroxysms remit after a few days, returning again for several days or weeks, and again remitting, the bronchial catarrh persisting for a month or more. The constitutional symptoms are mild, unless complications occur. Complications. The affection may extend to the finer bronchial tubes (capillary bronchitis); congestion or oedema of the lungs and pneumonia are not infrequent. Duration. Unless a change of climate is resorted to, paroxysms of hay fever continue more or less severe for six, eight, or ten weeks of the year, each year the paroxysms growing more severe. Prognosis. The affection never proves fatal in itself, but one or more of the following sequelae may result, to wit : asthma, DISEASES OF THE BRONCHIAL TUBES. 307 chronic bronchitis, or loss of the special sense of hearing or of smelling. Treatment. No specific, unless the hypertrophy of the turbin- ated bones be a constant condition, when their removal by the galvano-cautery would remove the liability to attacks. An attack of hay asthma is often prevented by a change of climate during the season of the year when the attacks are most common, to wit: the early autumn. Any of the following locations may be selected — White Mountains, Catskills, Adirondacks, Rocky Moun- tains, or a sea voyage. Dr. W. C. HoUopeter reports wonderful success in over two hun- dred patients with the following plan of treatment : "For the last ten years I have used the ordinary Dobell's solution. This I thoroughly use in both nostrils, first by means of a hand-ball atomizer, after which, with a curved aluminum applicator, I very carefully swab the whole naso-pharynx. I scrub most carefully every portion of the mucous membrane, being sure to reach between the turbinated bones and all around and over every slight prominence. I then as carefully dry the membrane with clean cotton, and use freely blandine comp. (a mild solution of menthol in albolene), loosely plugging the nose for a few minutes to retain the oily application. Great stress is laid upon the thoroughness of the application and the correction of any ills the patient may have." Attacks are sometimes aborted and always relieved by the applica- tion to the nares of tablets of cocaincB hydrochloras, gr. ^ (o.oi i Gm.), or a four or six per .centum solution, every few hours. On several occasions pulvis ipecacuanhce et opii, gr. v (0.3 Gm.), ter die, has aborted a suspected attack, as has the following pill : B . Atropinse sulph., gr- i -012 Gm. Morphinse sulph., gr. \ .016 Gm. Strychninse sulph., gr. |- .008 Cm. Quininee muriat., gr. x .65 Gm. Sodii arseniat., g^- i -Oll Gm. M. Ft. pil. No. XXX. SiG — One every hour until dryness, then two or three hours apart. Success has followed the use of qui^tince sulphas, gr. v (0.3 Gm.), three times a day, beginning one month before the expected paroxysm. Bartholow " has seen several cases benefited greatly " by a solution of guinina applied to the nares, as suggested by Helmholtz, "but to achieve success the application must be thorough and timely." 3U8 PRACTICE OF MEDICINE. The following applied ihoroui^lily to the nostrils has a high re])ule ; li. Menthol, ^j 4. Gm. Ccrat. siinpl., s ij 60. Gm. 01. amyL,'(l. diilcis, f.^'ss 45. Cc. Zincioxidi punv, gj 4. Gm. Acid, carbolici, gss 2. Gm. SiG. — Apply every two hours. A long course of arsenicum in minute doses sometimes removes the susceptibility to the disease. WHOOPING COUGH. Synonyras. Hooping cough ; pertussis. Definition. A convulsive, paroxysmal cough, consisting of a number of forcible expirations, followed by a series of deep, loud, sonorous inspirations (the whoop), repeated several times during each paroxysm, and associated with catarrh of the bronchial tubes. Causes. Chiefly a disease of childhood, and fully one-half of the cases are during the first two years of life, one attack generally removing the susceptibility ; contagious; due to an unknown micro- organism. Pathology. The changes, if any, occurring in the nervous sys- tem are unknown. It is said that " irritation of the internal branch of the superior laryngeal nerve produces relaxation of the diaphragm, spasm of the glottis, and a convulsive expiration, the series of phe- nomena present in a paroxysm of asthma." HypercBtnia of the mucouS membrane of the nares, pharynx, larynx, and bronchial tubes, with diminished secretion, followed by an in- creased secretion of a transparent mucus, afterward becoming puru- lent, the mucous membrane pale and anaemic. Symptoms. Divided into three stages, to wit : catarrhal, spas- modic, and tenninal. Catarrhal stage originates in an ordinary naso-laryngo-bronchial catarrh, with a loose cough. Duration, one or two weeks. Spasmodic Stage : The cough becomes paroxysmal, consisting of a succession oi short, rapid, expiratory efforts, the face becoming red, the eyes swollen and protruding, the body bending forward, and when these expiratory efforts have exhausted the breath, they are followed DISEASES OF THE BRONCHIAL TUBES. 309 by a deep, loud, crowtftg inspiration — the ivhoop : each paroxysm being composed of three such spells, the last one followed by the expectoration of a small amount of tough, viscid mucus. The attacks of cough may be so severe as to cause vomiting, and if the vomiting occur shortly after food has been taken, the nutrition of the patient will suffer. Profuse epistaxis is not infrequent. Dura- tion, about four weeks. Terminal Stage : The paroxysms recur at longer intervals, are of shorter duration and less intensity, the catarrhal symptoms being more marked, the expectoration freer. Duration, one or two weeks, often followed by the " cough of habit." Coraplications. Congestion of the lungs, capillary bronchitis, pneumonia, and emphysema, or, rarely, convulsions, hydrocephalus, or apoplexy. Diag'nosis. During the catarrhal stage whooping cough cannot be distinguished from a common cold, but on the advent of the char- acteristic whoop, the diagnosis is determined. Prognosis. Depends upon the age and strength of the patient, the severity of the paroxysms, and the presence or absence of com- plications. Ordinary cases, favorable. Moderately severe attacks during infancy are followed by cerebral symptoms, while attacks occurring in adults are followed by chest symptoms. Treatment. No specific. A self-limited disease. Remedies will not cure the disease, but often lessen the duration of or modify the severity of the symptoms. Always watch the heart's action. Prof. Da Costa prefers quinincB sulphas in full doses, or chloral \n good-sized doses, often advantageously combined with the bromides, and the use of a spray oi sodii bromidum, gr. xx (1.3 Gm.), and aquse, f^j (30 Cc), to which may be added extractum belladonncB fluidiim, TTLij (0.12 Cc). A remedy of great utility is ammonii bromidum.. Excellent results have followed the use of antipyrin gr. ^-v (o.oii- 0.3 Gm.), or acetanilidtim, gr. j-iij (0.065-0.2 Gm.), every four hours, according to the age, ox phenacetin, gr. j-ij (0.065-0.13 Gm.), four times daily. Either of these drugs seems to act better if given with an expectorant. L. Emmett Holt recommends atitipyrin, gr. j (0.065 Gm.), every three hours for child six months old. Terpini hydras, gr. j-ij-v (0.065-0.13-0.3 Gm.), is sometimes valuable. Belladonna may be added to any of the remedies named with advantage, or the tincture may be used alone in doses of Tr\,v-x (0.3-0.6 Cc.) three 310 PRACTICE OF MEDICINE. times daily until flushing of the surface, and a dose continued that maintains the flushing. Starr recommends the following for a child of one year: li . Ext. belladonna:, gr. j .065 Gm. Aluminis, 3 ss 2. Gm. Syr. zingiberis, Syr. acacii^, Aquce, ^^o) *^ 3°- ^^' ^^• SiG. — A teaspoonful four times in tlie twenty-four hours. Inhalations of creosote are very valuable, dropped upon cotton in a respirator, or vaporized over an alcoholic lamp, or cloths dipped in solutions may be hung in the room. Eucalypiol'x's, also a valuable remedy for inhalation. The diet of the patient must be regulated, the clothing to be warm but not too heavy, and the patient kept in the open air as long as possible. EMPHYSEMA. Synonym. Vesicular emphysema. Definition. Dilatation of or increase in the size and capacity of the air vesicles, characterized by enlargement or distention of the lungs, difficulty of breathing, especially on exertion, and associated sooner or later with dilatation of the heart. Causes. The predisposing cause of emphysema is a hereditary nutritive derangement of the lung structure, often associated with a rigid enlargement of the thorax. The exciting cause is the result either of a too forcible and long continued inspiration, — the theory of inspiration, — or the excessive mechanical distention of the vesicular walls by forced expiration — tlie theory of expiration. But for either of these theories to be operative the lung structure must be congenitally weak, for if violent respiratory efforts alone were the essential factor, the disease would be much more frequent. What is known as vicarious emphysema is a distention of the air cells of the healthy portion of the lung, some other part being the seat of consolidation. Interlobular emphysema is the presence of air in the spaces between the lobules of the lungs underneath the pulmonary pleura. DISEASES OF THE BRONCHIAL TUBES. 311 Path.olog'ical Anatomy. The situation of vesicular emphy- sema is, in the majority of cases, the superior portions of the chest, and is more marked on the left side than on the right. An emphysematous lung feels remarkably soft to the touch, and upon cutting a dull, creaking sound is barely perceptible. It is of a pale- red color ; the vesicular walls are thinner and slighter ; the vesicles are greatly enlarged, sometimes to the size of a pea or bean, and have an irregular shape, and traversing most of these large sacs (dilated vesicles) a few delicate bands, the remains of the lacerated inter- alveolar septa, are visible. With the destruction of the septa many of the capillaries are destroyed, leaving the emphysematous tissue remarkably bloodless and dry. In consequence of the destruction of so many of the capillaries the obstruction to the pulmonary circulation becomes so great that the pulmonary artery and right cavities of the heart are greatly dis- tended ; finally the muscular tissue of the heart undergoes granular, followed by fatty, degeneration. The distention of the veins results in a general venous stasis, to wit : nutmeg liver, congested kidneys, and gastro-intestinal catarrh. Symptoms. The disease is often not suspected until it is well developed. The chief symptoms of vesicular emphysema are diffi- culty of breathi7tg {diysY>T^c&2i) , greatly aggravated on exertion ; more or less cough, the result of an attending brotichiiis, and the various symptoms resulting from dilatation of the hearty particularly cyanosis without marked distress. The discomfort of the patient is often in- creased by paroxysms of asthma. Inspection. The shoulders are rounded, the intercostal spaces widened, the vertical diameter elongated, with circumscribed promi- nences between the clavicles and nipples, often increased by the act of coughing — the peculiar "barrel-shaped" chest, characteristic of this disease. The character of the respiratory movements is marked, there being but slight movement observed on forcible respiration, the chest hav- ing the constant appearance of a full inspiration. Palpation. The vocal fremitus is diminished, and the cardiac impulse depressed and nearer to the sternum. Percussion. The resonance is increased (hyper-resonant) over all the emphysematous portions, and, if the whole lung be involved, extends to the seventh or eighth rib anteriorly and to the twelfth rib 312 PRACTICE OF MEDICINE. posteriorly. The hepatic dullness may not begin until the inferior margin of the ribs is reached ; the cardiac dullness is lessened, on account of the emphysematous lung nearly covering the heart. Auscultation. The vesicular murmur is lucakctied, and in pro- nounced cases ahnost absent. If bronchitis be present, the inspira- tory sound may be rough or sibilant in character, but its duration is always shortened. Expiration is always prolonged, and if bronchitis be present, may be associated with more or less pronounced moist or bubbling rales. The first sound of the heart is lessened in intensity and duration, the second sound being sharply accentuated. Diagnosis. Bronchitis is distinguished from emphysema by the absence of dyspnoea, hyper-resonance of the chest, changes in its shape, size, and movements, and the disturbance of the circulation. Spasmodic asthma, by the paroxysmal character of the affection, emphysema being a permanent malady, with attacks of asthma. Cardiac diseases due to other causes than emphysema do not have the characteristic physical signs of that affection. Prognosis. Vesicular emphysema is essentially a chronic disease. In itself it rarely proves fatal, but if aggravated from any cause, or if associated with frequent or prolonged asthmatic paroxysms, the car- diac changes are hastened, general dropsy supervenes, death occur- ring from exhaustion, or, more commonly, as the result of intercurrent attacks of pneumonia. Treatment. It being impossible to restore the altered lung struc- ture, the indications for treatment are to relieve the symptoms and to endeavor to prevent its further progress. For the relief of the asthmatic paroxysms, morphines sulphas com- bined with atropines sulphas may be used hypodermically, or ext. quebracho fld., f^ss-j (2-4 Cc.) every hour until relief; caffeina citrata, gr. ij-v (0.13-0.3 Gm.), repeated, or a combination of nitro- glycerinum, strych?iincE sttlphas, and fnorphince sulphas, or large doses oi potassiiun iodidum, frequently repeated, or inhalations of oxygen. For attacks of bronchial catarrh use : li . Ammonii chloridi, 3 ij 8. Gm. Tinct. hyoscyami, f.5'v 15. Cc. Glycerini, f sj 30. Cc. Syr. prun. virg., ad f.^iv ad 120. Cc. SiG. — Half-tablespoonful every few hours, well diluted. DISEASES OF THE BRONCHIAL TUBES. 313 To prevent the progress of the affection, remove the bronchial catarrh, relieve the difficulty of breathing, and strengthen the cardiac action, no one combination seems comparable with the following: R. Potassii iodidi, gr- v -3 Gm. Strychninse sulph. , ^- zi. .002 Gm. Liq. potassii arsenit., .... Tr\^v .3 Cc. Aq. lauro-cerasi, f 3J 4. Cc. SiG. — Four times a day, well diluted. But of all means hitherto proposed for the relief of emphysema, nothing has approached the inhalation of compressed air, by means of the apparatus of Waldenberg. For attacks oi cyanosis a free venesection often saves life, combined with and followed by full doses of spiritus gionoifii. The dropsy arising from failure of the heart to compensate for the circulatory derangement in the lungs may be relieved for a time by the use of digitalis and strychnincB sulphas, or caffeines citrata, the last two being cardiac and respiratory tonics and stimulants, and the last mentioned also a diuretic. HEMOPTYSIS. Synonyms. Bronchial hemorrhage; broncho-pulmonary hemor- rhage ; bronchorrhagia. Definition. The expectoration of pure or unmixed blood, usually of a bright red color, following the act of coughing. Causes. In the majority of cases, the result of ttibercular deposi- tion in the walls of the minute bronchial arteries ; excessive car.diac action ; bronchial congestion ; excessive bodily exertion, straining, lifting, or running; a symptom of hcemophilia ("bleeder's disease "). Pathological Anatomy. Hsemoptysis rarely causes death in itself, so that few opportunities for observing post-mortem appear- ances are obtained, and when they do occur, the location of the hemorrhage is seldom found. The air passages are more or less filled with clotted blood ; the mucous membrane is swollen, and of a dark-red color ; rarely, pale and bloodless. The air cells contain blood clots, or are distended with air, the bronchi being filled with clots, preventing its escape. 27 314 PRACTICE OF MKDiriNE. Unless the clots are rapidly removed by expectoration or absorption, a secondary inflammation develops around about them. Symptoms. "Spitting of blood " occurs suddenly; rarely, it is preceded by epistaxis, cardiac palpitation, and some difficulty of breathing. It begins with a sensation of warmth under the sternum, tiikiirt^ in the throat, 2t. sweetish taste in the mouth, an attempt to remove which by the act of coughing is followed by a warm, saltish, brit^hl red, frothy liquid gushing from the mouth and nose. The quantity of blood raised varies from an ounce to a pint. The appearance of the blood depresses the individual, he becoming pale, tremulous, often fainting. The attack may subside within half an hour to several hours, re- turning for several days, in the meantime the expectoration being either bloody or streaked with blood. A slight febrile reaction, with chest pains, supervenes upon the hemorrhage, the result of the inflammation at the site of the bleeding, which soon subsides, except where blood clots develop a secondary pneumonia, which may undergo the cheesy metamorphosis. Auscultation. Coarse, bubbling rales are heard in circumscribed portions of the chest. Diagnosis. From epistaxis, or hemorrhage from the posterior nares, it is distinguished by the absence of air bubbles and an inspec- tion of the fauces and the nasal cavities. Hcematemesis, or hemorrhage from the stomach, differs from haemoptysis in the blood being vomited instead of expectorated, of a dark color, clotted, mixed with the acid contents of the stomach, fol- lowed with black, tar-like stools, and the absence of rales in the chest. Exceptions to the above occur when the blood from the lungs is first swallowed and afterward raised by vomiting, or when the hemor- rhage in the stomach is caused by the erosion of a large artery, the result of ulcer of the stomach ; in these cases, however, the raising of blood is preceded by epigastric pain and the blood is not frothy. Prognosis. Hiemoptysis in itself rarely terminates fatally, al- though causing much depression ; the patient rapidly recovers, unless secondary pneumonia results. In nine cases out often it is the diag- nostic sign of phthisis. Treatment. Perfect rest in bed, the head and shoulder elevated, DISEASES OF THE BRONCHIAL TUBES. 315 and perfect quiet, the diet to be bland, the drinks cool, the patient slowly swallowing small particles of ice. An ice bagovtr the chest, if it does not cause chilliness, is sometimes valuable. Common salt, slowly dissolved in the mouth, is a popular remedy, and, if of no real benefit, serves to occupy the attention of the patient and friends until medical advice is obtained. The hypodermic injection of atropines sulphas, gr. -^^ (o.ooi Gm.), will usually at once control a hemorrhage. It may be repeated pro re nata. The one per cent, solution of nitro-glycerinum (spiritus glonoini), in half to minim doses every half hour till relief, often promptly stops a hemorrhage. The hypodermic injection of ergotiti, gr. x-xxx (0.6-2 Gm.), or the internal administration of extractuni ergotce Jluidian, 3ss-j (2-4 Cc), are recommended, but I consider them injurious. R. Acidi gallici, gr. xv i. Gm. Acidi sulphurici dil., rt\^x .6 Cc. Aquae cionamomi, fji''' ''5- Cc. SiG. — Repeated every fifteen or twenty minutes. Or tinctura matico, fjj (4 Cc), or extractum hqmamelis fld., TTLxx-f^j (1.3-4 Cc), alunten, gr. xx (1.3 Gm.), acidum gallicimi, gr. v-x (0.3-0.6 Gm.), or oleum terebinthincE , TTLv-xv (0.3-1 Cc), frequently repeated. If the hemorrhage causes great nervous excitement or depression, morphitia, either hypodermically or internally, to quiet the patient, is indicated. Inhalations, by means of the steam atomizer, of either MonseFs solution or tinctura ferri chloridum, are recommended when the above means fail. Prof. Da Costa recommends, for frequent small hemorrhages, con- tinuing day after day, cupri sulphas [gr. -^^ (0.005 Cm.)], ext. opii [gr. tV (0.005 Gm.)],p. r. n. 316 PRACTICE OF MEDICINE. DISEASES OF THE LUNGS. CONGESTION OF THE LUNGS. Synonyms. Pulmonary engorgement ; hypostatic congestion. Definition. An increase in, or abnormal fullness of, the capil- laries of the air cells ; active congestion when the result of an accel- erated circulation ; passive congestion when caused by an impeded outflow from the capillaries. Causes. Active. Increased cardiac action ; over-exertion ; alco- holic excesses ; mental excitement ; inhalation of cold or hot air. Passive. Obstruction to the return circulation. Dilated heart; val- vular diseases; low fevers (hypostatic congestion); Bright's disease. Pathology. The congested or engorged lung has a bloated, dark-red appearance ; its vessels are distended to the uttermost, the tissues succulent and relaxed, blood flowing freely over the cut surface ; a bloody, frothy liquid is present in the bronchi, and the alveolar walls are so much swollen that the condensed lung shows scarcely any indication of its cellular structure, resembling the tissue of the spleen {splenificatioti). Symptoms. Active. Rapidly developing thoracic distress and difficulty of breathing, flushed face / strong, full pulse; throbbing caro- tids, cardiac palpitation, and congested eyes, with a short, dry cough, followed by scanty, frothy expectoration, slightly streaked with blood. Passive. Developed slowly, with difficulty of breathing, blueness of the surface, almost continuous hacking cough, followed by scanty, blood-streaked expectoration. Percussion. The resonance of the lungs slightly diminished, the quality of the sound being somewhat tympanitic. Auscultation. The vesicular murmur is diminished and accom- panied by sub-crepitant rales. Duration. Active. Usually from three to five days, terminating either by resolution, hemorrhage, or, rarely, pneumonia. The onset may be so severe and overwhelming that death rapidly supervenes. Passive. Developed slowly, and subject to great variations, de- pending upon the cause. DISEASES OF THE LUNGS. 317 Diagnosis. Active congestion of the lungs cannot be distin- guished from the stage of engorgement of a true pneumonia. Prognosis. An acute congestion of the lungs may prove fatal within a few hours, but under prompt treatment it generally terminates favorably. The passive form is controlled entirely by the cause. Treatment. Active. In the strong and vigorous wet cups to the chest, or, if the symptoms are pronounced, a ^'&x\&x2\ venesection, and ice bags over chest and heart. Internally , tinctura aconiti, t^j-ij (0.06-0.12 Cc), every half hour or hour, as indicated, with free catharsis with saline purgatives. Passive. Dry or wet cups over the chest, hydragogue cathartics, and the internal administration of digitalis and strychfiince sulphas ; if much depression of the vital powers, stimulants, such as spiritus frumenti and spiritus ammonicB aromaticus, are indicated. CEDEMA OF THE LUNGS. Synonym. Pulmonary cedema. Definition. An exudation of serum into the pulmonary interstitial tissue and the alveoli of the lungs ; characterized by dyspnoea, cough, and a frothy, blood-streaked expectoration. Causes. Pulmonary oedema is the result of stasis, occurring when the outflow of venous blood in the lung meets an obstacle that cannot be overcome by the right ventricle, as in cardiac diseases, in which the left ventricle fails. Bright's disease; alcoholic excesses, causing cardiac depression. Sequelae to other lung inflammations. Patholog'ical Anatomy. The lung tissue is swollen, and does not collapse when the chest is open. The elasticity of the tissue has disappeared, and it pits upon pressure. If following acute congestion of the lungs, the color is red ; if a symptom of a general dropsy, its color is pale. On cutting into the oedematous spots, an enormous quantity of albuminous fluid, sometimes clear, at other times of a red color, mixed more or less with blood, flows over the cut surface. The liquid is filled with bubbles, is frothy, from being copiously mixed with air, provid- ing the air cells have not been entirely filled with serum, thereby excluding the air. 318 PRACTICE OF MF.DICINK. Symptoms. The pre-eminent symptom is dyspna'a, the breath- ing being hurric-d, labored, and ratiling, all the accessory muscles of respiration being called into action. The setise of oppression and anxiety is extreme. There is also a constant, harassin<^, short cough, and the expectoration is a blood streaked, frothy mucus. The action of the heart may be tremulous or feeble. The face is at first flushed, but as the left ventricle fails, or if the effusion into the air cells be sufficient to prevent the entrance of air, symptoms o( cyanosis rapidly supervene, the pu/sehecom\ngfeeb/e, the surface cold, the breathing shaltozu and hurried, the cough suppressed, stupor replacing the rest- lessness, soon deepening \nio cotiia. Percussion. If no other lung disease, the percussion note is but slightly, if at all, impaired. Auscultation. The vesicular murmur is lost by the diffused sub- crepitant z.x\di bubbling rales. Diagnosis. Acute pncuvtonia in the earlier stages is the only condition likely to be confounded with oedema of the lungs, but as the two diseases progress, the picture of pulmonaiy oedema is so characteristic that it cannot be mistaken. Prognosis. Grave, and particularly if occurring in pneumonia, cardiac, or Bright's disease. In the majority of instances it is a terminal symptom coming on in all forms of acute and chronic diseases. Treatment. As a rule, remedies are useless. The indication is to hold up the left heart, and this is best done by hypodermic injec- tions of atropines sulphas, gr. j^^j (o.ooi Gm.), repeated, which often has an almost magical effect ; or strychnines sulphas, gr. -^^ (0.0035 Gm.), repeated every half hour; caffeines cilrata, gr. iij-v (0.2- 0.3 Gm.), sparteines sulphas, gr. j-ij (0.065-0.13 Gm.), every hour or two ; or digitalinum , gr. -^^—^^ (0.001-0.002 Gm.), repeated every hour or two. One or more of these drugs may be advantageously com- bined. Occasionally relief follows a free venesection or the appli- cation of wet cups. Alcoholic stimulants are often invaluable, as is spiritus aminonicB aromaticus, frequently repeated. The above means may be aided by counter-irritation to the chest, or ice-poultices, hot mustard foot-baths, 2.ci\v& saline purgatives, diu- retics, and inhalations of oxygen. DISEASES OF THE LUNGS. 319 CROUPOUS PNEUMONIA. Synonyms. Lobar pneumonia ; pneumonitis ; fibrinous pneu- monia ; pleuro-pneumonia ; lung fever ; winter fever. Definition. An acute, infectious, croupous inflammation, involv- ing the vesicular structure of the lungs rendering the alveoli imper- vious to air ; characterized by a severe chill, headache, fever, thoracic pain, dyspnoea, cough, rusty sputum, and great prostration. Causes. Croupous pneumonia is an infective disease caused by the diplococcus pneumonicE of Fraenkel, " which has its seat of elec- tion in, and produces its chief effects on, the lung." The micro- organism is found in the sputum and in the lungs in the majority of cases. " Occasionally other micro-organisms seem to occasion typi- cal fibrinous pneumonia. Among these are the pneumococcus of Friedlander, streptococci, staphylococci, the bacillus of typhoid fever, the bacillus of influenza, and the bacillus coli communis. In some cases in which bacteria other than the diplococcus are supposed to be the cause there is doubtless mixed infection, but it must be accepted at the present time that a number of micro-organisms are capable of causing the disease." (Stengel.) All ages liable. Males more frequently affected than females. One attack predisposes to another. Debilitating causes render individuals more susceptible. Alcoholism is among the most frequent predispos- ing factors. It is most frequent in winter, at times occurring epidemi- cally, the result of atmospheric conditions ; exposure to draughts and cold. Gout, rheumatism, diabetes, and Bright's disease. Pathological Anatomy. The most frequent seat of croupous pneumonia is the lower right lobe ; the next most frequent seat is the lower /^/ lobe ; the next, the upper right lobe, although in children and the aged this lobe is affected equally as often as the right lower lobe. The changes are: \. Hyperemia (engorgement); II. Exudation (red hepatization); III. Resolution (gray hepatization); or it may undergo purulent transformation or the development of abscesses (yellow hepatization). I. Stage of hyper cemia : Congestion, or engorgement, consists in the vessels of the alveoli being distended, encroaching upon the cavity of the air vesicle ; the lung has a reddish-brown color, is heavier, 320 PRACTICE OF MKmCINE. sinking somewhat lower in water than a normal lung, and having a slight exudation upon the vesicular surface. The same changes are seen in the adjacent bronchioles. II. S/ci^e of exudation : Consists in the exudation of a viscid, fibrin- ous fluid, mixed with white and red corpuscles and blood, which rapidly coagulate, firmly enclosing the corpuscles and completely filling the alveoli. When the exudation and coagulation are com- pleted, the lung is red, sinks at once when placed in water, and its elasticity is destroyed. When cut into, the color, density, and granu- lar appearance so closely resemble the cut surface of a section of the liver that Laennec termed the conditoin red Jtepatization. A thin section shows under the microscope, as a rule, the lancet- shaped diplococcus of Fraenkel, as well as staphylococci and strepto- cocci. III. Resolutionox gray hepatization follows in the majority of cases, the coagulated albuminous exudation undergoing liquefaction and absorption, the cellular element undergoing a fatty degeneration, the greater part absorbed, the remainder expelled during acts of expec- toration, the alveoli returning to their normal condition, both as to capacity, function, and elasticity. If resolution be retarded and portions of the coagulated exudation undergo pundent transformaiioti, changing from a yellowish to a greenish-yellow color (yellow hepatization), pus cells are rapidly formed, the part becoming a granular, fatty mass. The portions of the lung not undergoing this purulent transformation retain the red- dish color with intermixed yellowish patches. The purulent con- tents may be ejected in part, the remainder undergoing fatty degen- eration and finally absorption. Abscess of the lung may result from the lung structure becoming involved in the purulent disintegration. Abscesses may be solitary or in great numbers, which by disintegration of intervening structure form one or more large abscesses; these abscesses either terminate fatally or open into the pleural cavity, causing e7)ipyema and exhaus- tion, or open into the bronchi and are expectorated, or an interstitial pneiDHoiiia is developed and the abscess encapsulated in a firm cica- tricial tissue. Gangrene of the lungs may result from blocking up of the bron- chial or pulmonary arteries by coagula during any stage of the dis- ease. DISEASES OF THE LUNGS. 321 The uninflamed portions of the lungs are hypersemic and their functional activity is increased. Death sometimes results from a general cedema of the unaffected lung, such cases being often erroneously termed " double pneumonia." If inflammation of the pleura be associated with a pneumonia, the so-called pleuro-pneutnonia, the changes in the pulmonary pleura are characteristic. " An uneven, thin, downy-looking layer of plastic exudation covers its surface. This plastic layer may conceal the liver-brown color of the pneumonic lung. As the third stage is reached, the opposing surfaces of the pleura may become agglutinated. The pleuritic changes follow very closely those which occur within the lung. The cells in the pleuritic exudation are mainly pus. The pleuritic membrane is opaque, congested, and ecchymotic. It may become so thick as to give a dull note on percussion, after resolution is reached." Duration of Stages : stage of congestion, from one to three days ; stage of exudation, from three to seven days; stage of resolution, from one to three weeks. In severe cases or in the very young, the aged, or the depressed, the stage of red hepatization may be fully developed within forty-eight hours. Endocarditis, either simple or malignant, is a common association. Pericarditis is frequent. The spleen is usually enlarged and soft. Syraptoms. Begins with a severe and usually protracted chill (in children often convulsions, adults vomiting), followed by a rapid rise of temperature , io3°-io4° F. ; a strong, full, but rapid pulse, soon showing evidence of embarrassed cardiac action from obstructed pulmonary circulation, either a dull or sharp pain near the nipple, aggravated by pressure, breathing, or coughing ; shortness of breath, the inspiration short and superficial, the expiration accompanied by a moan or grunt, the number of respirations increasing to 40, 50, or more a minute, causing interrupted speech ; the ratio between pulse and respiration maybe i to 2 or more ; cough, first short, ringing, and harsh, followed by a scanty, frothy mucus, soon becoming semi- transparent, viscid, and tenacious, about the second day changing to the familiar rusty sputum, becoming more copious and of a yellow color as the disease advances ; rarely cases occur with bloody or blood-streaked sputum during the continuance of the fever. There are present headache, sleeplessness, rarely delirium (early delirium is 21 322 PRACTICE OF MKDICINE. a grave sign), save in drunkards; epista.xis, flushed counlenance, and especially over the malar bones is a weildelined mahogany blush; gastric disturbances and scanty, high-colored urine, with diminiihed chlorides, and often albuminuria. From the very onset of the disease the prostration is of the most pronounced character. The symptoms continue more or less marked until either the fifth, seventh, ninth, or eleventh day, when 7i crisis occurs, and within twenty-four hours convalescence is established, recovery rapidly fol- lowing. Typhoid pneumonia is a term applied to those cases which are accompanied by signs of extreme prostration, delirium, tref/ior, very high temperature, and profuse s.r\d. prolonged exudation. They may also terminate by a crisis. Bilious pneumonia occurs in cases accompanied by congestion of the liver or bile ducts ; the result of venous stasis from pulmonary obstruction or from an accompanying acute catarrhal Jaundice. In malarial districts pneumonia and malaria are often associated, when jaundice more or less pronounced occurs. Such cases are termed malarial or intermittent pneumonia. Alcoholic, or pneumonia of the intemperate, has one very charac- teristic symptom, to wit : early delirium. In pneumonia generally the mind is clear, even when all the conditions are unfavorable. Pneumonia of the intemperate may begin with symptoms closely resembling an attack of delirium tremens, cough, expectoration, and pain being very slight, or even absent. \{ purulent infiltration follow the stage of red hepatization, instead of the crisis, symptoms of exhaustion occur, with profuse purulent ex- pectoration, high temperature, severe sweats, the tongue brown and dry, sordes collecting on the teeth, low delirium, feeble pulse, rapid, rattling breathing, the recovery slow, and convalescence tedious. Pneumonia in the aged or the insane may be latent, coming on without chill or pain and with only a slight fever ; the cough and ex- pectoration are slight, physical signs ill-defined and changeable, and the constitutional symptoms out of all proportion to the amount of lung involved. Apyretic pneumonia are attacks minus fever, the result of exhaus- tion and the depressing effect of the infecting agent on the nervous system. DISEASES OF THE LUNGS. 323 Aspiration pneumonia is due to the aspiration of fluids of any kind, the disease being really of mechanical origin. Traumatic pneumonia is the variety resulting from severe contu- sions of the chest, the trauma predisposing to the disease by mechan- ical injury of the lung, the diplococcus finding suitable nidus at the site of injury. Inspection. First stage, deficient movement of the affected side, due to pain. Second stage, the healthy side rises normally, the affected side lag- ging behind. If both lower lobes are impervious to air, the diaphragm cannot descend and the epigastrium does not project during inspira- tion, the breathing being conducted by the upper part of the chest (superior costal respiration). Palpation. First stage, the vocal fremitus more distinct than normal. Second stage, the vocal fremitus is markedly exaggerated except in those rare instances of occlusion of the bronchi by secretion. The cardiac impulse is felt in the normal position. Percussion. First stage, the percussion note is slightly impaired, indeed, at times having a hollow or tympanitic quality. Second stage, dullness over the affected parts, with an increased sense of resistance. Auscultation. First stage, over affected part, feeble vesicular murmur, associated with the true vesicular or crepitant (crackling) rale, most distinct during inspiration. Second stage, harsh, high-pitched, bronchial respiration, at times resembling a to-and-fro metallic sound, except in those rare instances in which the bronchi are more or less filled with secretion. Bronchophony, or distinctly transmitted voice, at \.\me.s pectoriloquy, or distinct transmission of articulated sounds, is present. Third stage, breathing changing from bronchial to vesiculo-bron- chial, the crepitant {qx&'^\\.2X\o redux) rale returning, and if resolution proceed, the breath sounds are associated with large and small moist and bubbling rales. " The morbid phenomena, physical signs, and symptoms of the malady correspond usually in this matter." (Da Costa.) 324 PRACTICE OF MEDICINE. I. SlaKi; of ciiKorgenicnl Crepitant rftle ; slight per- Cough; bc);inirni);l lK-i;iiming exu- cussion dullness. and rapidly developed dation. fever heat. I II. Stage of solidification Percussion dullness ; bron- Rusty-colored sputum; of lung tissue (red cliial respiration ; bron- dyspnoea ; cough ; high hepatization). chophony. fever with marked even- ing exacerbations and morning remissions. III. Stage of softening The same physical signs as Chills; prostration, etc.; (gray hepatization). in the second stage, un- purulent or brownish less large abscesses have sputum ; generally high formed. temperature. Terminations. Asthenic cases recover within two weeks. When purulent infiltration supervenes, the disease pursues a tedious course of several weeks' duration, with a low exhaustive fever. If death occur during the first or second stages, it is usually the result of -aiConatcral cedema of the uninflamed lung, or cardiac failure and impaired nerve force. If abscesses occur, there are exhausting sweats, frequent cough, with a large amount of yellowish-gray, at times blood-streaked, expectoration. Gangrene of the lungs is a rare termination ; it is associated with symptoms of collapse, the expectoration of a blackish, foetid charac- ter, with the physical signs of a pulmonary cavity. Diag"nosis. CEdctna of the lungs may be confounded with the first stage of pneumonia, but the subsequent history, its presence on both sides, and the waterish expectoration and absence of chill and pain and the physical signs of pneumonia soon determine the diagnosis. Pleurisy is oftener confounded with pneumonia than any other dis- ease, the points of distinction between which will be pointed out when discussing that aft"ection. Complications. Acute pleuritis is a frequent complication of croupous pneumonia, occurring as often as from ten to twenty-five per cent, of cases. The more acute localized pain, the greater em- barrassment of respiration, and the usual physical signs of effusion are the evidences of z. pleuro pneumonia. Endocarditis is a common complication, showing irregular but protracted temperature record, with chills and sweats and great embarrassment of the respiration. DISEASES OF THE LUNGS. 325 Capillary bronchitis is a rare but dangerous complication. Peri- carditis, rheumatism, and £'Out a.re rare complications. Prognosis. Depends upon the extent of the inflammation, the dangerous features of croupous pneumonia being cardiac failure, the result of an endo- or myocarditis or of embarrassed respiratory circu- lation, and the rapid tissue waste, associated with extreme fever (105°), resultirg in impaired nerve force. Double pneumonia has a very grave prognosis, but it is not nearly so frequent as was at one time supposed. The coexistence of pleuritis adds to the gravity of the prognosis, although not so fatal as generally supposed. Pneumonia of drunkards almost invariably terminates fatally. Typhoid pneu- monia, pneumonia of the aged and in the insane, and the so-called bilious pneumonia, purulent infiltration, abscesses of the lungs, and gangrene, all give a grave prognosis. Treatment. If pneumonia be regarded as a constitutional malady with a local lesion, then the consolidated lung no more calls for treat- ment than does the intestinal ulcer of typhoid fever, but the general condition of the patient is to govern in the management and not the local changes in the thorax. A simple pneumonia attacking persons previously in good health requires no more active treatment than any of the so-called self-limited diseases^ provided only that the extent of the disease be moderate, and there be no complication. The much-discussed question of venesection is now a settled prob- lem in the affection ; if we bleed, it is " not because of pneumonia, but in spite of pneumonia.''' Called to a case in the first stage or early in the second stage, who has been vigorous and otherwise healthy, with a high temperature, 105° or more, with frequent pulse, one hundred and twenty beats or more, or a slow, full pulse showing cardiac oppression, flushed surface, and marked dyspnoea, a copious bleed- ing is indicated, and the same may be said when symptoms of collat- eral oedema threaten ; this is bleeding for symptoms and not for the disease per se. There is no remedy which can exert a favorable influence upon the pneumonic process. Many cases recover without, and many cases in spite of, treatment. When treatment is instituted, be guided by the fact that you are not to treat pneumonia, but a patient with a pneu- monia. At the onset, if venesection is not indicated, relief of the pain may 326 PRACTICE OF MEDICINE. follow the use of dry or wet cups. If the tongue be coated and the gastro-intestinal canal deranged, a calomel purge is indicated. K. llydrargyri chloridi mitis, . . . gr. ij .13 Gm. Sodii bicarb. , gr- iv .26 dm. I'ulv. ipecac, . • gr. j .065 Gm. M. Ft. chart. No. iv. Sio. — One every two hours, followed in two hours after last powder by mild saline. Action on the skin and kidneys by refrigerant mixtures or small doses of Dover's powder is valuable. The administration of the arterial sedatives, aconitum and veratrum viride, are recommended by Drs. Da Costa and H. C. Wood. In pneumonia of children the use of small, frequently repeated doses oi tinctura aconiii\x\. the early stage is most useful. Poultices are of slight value, but the use of home-made mustard plasters, weakened with flour, is useful in all stages. If the heart be weak from the onset, either of the following are valuable: digitalis, caffeines ciiraia, niiro glyceriiiuiii, spartein, or strychnina. Indeed, it seems a good practice to administer strychnina in full doses from the onset. Quinines sulphas, gr. ij-v (0.13-0.3 Gm.) every three or four hours, is always valuable. Second Stage. It is at this period of a severe attack of acute pneu- monia that two prominent indications for treatment arise — heart insufficiency and high temperature. To sustain the heart is one of the most important indications, for experience shows that cardiac failure is responsible for a large num- ber of deaths in this affection. Strychnines sulphas, gr. ^2~^s (° 002- 0.003 Gm.), repeated every few hours by mouth or by the hypodermic method, or caffeines ciirata, gr. ij-v (0.13-0.3 Gm.) every four hours, or tinctura strophanthus, Tt\^v-x (o 3-0.6 Cc.) every three hours, are valuable cardiac tonics in pneumonia. The availability of digitalis and nitro-glycerinum depends upon a careful study of the pulse. If the tension is low, the result of relaxation of peripheral blood vessels, — vaso-motor paralysis, — digitalis in full doses is indicated ; but if the tension is high, with embarrassed right heart, nitro-glycerinum every hour or two, with spiritus ammonii aromaticus, is the indication. Alcoholic stimulatits judiciously employed are most efficient means for preventing or overcoming the cardiac failure. The amount can DISEASES OF THE LUNGS. 327 only be determined by a careful study of each case, as a few ounces in the twenty-four hours may answer in one, while another may require eight or ten ounces. It is well to begin with small doses, increasing or decreasing as its effects are good or bad. The indi- cator of the heart's cottdition is the pulse. In the aged, the feeble, or in those accustomed to the use of alcohol, stimulation is indicated from the onset. Other indications would be a frequent, feeble, irregular, or intermitting pulse ; a dicrotic pulse ; delirium, muscular tremor, and subsultus ; immediately following crisis, and the period of collapse. To reduce the temperature is at times an important indication. If the fever is under 103° F., cool sponging with alcohol and water, or water alone, is sufficient. If the temperature is above 104° F., anti- febrin, gr. v (0.3 Gm.), may be used every three hours until a reduc- tion occurs. Strychnitice sulphas, or caffeines citrata, may be added to each dose. Phenacetin or acetanilidutft are also valuable, and considered less depressing, but it is to be remembered that a temper- ature under 104° is as normal to pneumonia as the dyspnoea or the rusty sputum, and so use antipyretic drugs with caution. The use of the cold pack or of cold baths for reducing the temper- ature in acute pneumonia has not given the success expected. Dr. Mays strongly advocates the use of ice bags to the chest in pneumonia. He says: "Very often it is found that the application of the ice to an affected spot is immediately followed by a marked lowering of the temperature and improvement in the physical signs in the part." I am able, from an experience of five years, to endorse this statement. For dysp7ioea and pain, a hypodermic injection of morphince sul- phas, repeated p. r. n. The dyspnoea is often relieved by inhalations of oxygen, but do not expect too much from oxygen as there is some additional factor besides the mechanical one of consolidation of the lung producing the dyspnoea, for the consolidation is just as marked immediately after the crisis, while the dyspnoea is wonderfully relieved. The diet must be of the most nutritious but easily digestible char- acter, and given at periods of every three hours, watching that the food is assimilated. A distended stomach and abdomen is danger- ous. Strong black coffee throughout the disease is valuable. Third Stage. The treatment is a continuation of that of the second stage, with the addition of the following valuable combination : 328 PRACTICE OF MEDICINE. IJ . Ammonii chloridi, gr. v-x .3-.6 Gni. Strychnin;v siilph., gr. ^'f -003 ^™- Aqua: chloroformi f^j 4. Cc. Syr. prun. virg., f 3 'U '-• ^c. M. SiG. — Every three hours, diluted. Many cases are favorably influenced by an expectorant from the onset of the disease. Convalescence. Nutritious diet, quinines sulphas in tonic doses, ferriim, together with a good blood-making wine or a good prepara- tion of malt. If the consolidation shows a disposition to linger, blisters may be used. The various symptoms other than those particularly mentioned are to be met, as they arise, by their proper remedies. For typhoid pneumonia, purulent infiltration, abscess of the lungs, or pneumonia in drunkards, the weak, or the aged, qninina: sulphas, ferrum, nutritiotts diet and bold stimulation, and the free use of annnonii carbonas or spiritus ammonia; aromaticus, caffeines citrata, and strychnines sulphas, — these last two being respiratory and car- diac tonics, — are the indications. Sleeplessness is an annoying symptom frequently requiring treat- ment. Balfour, of Edinburgh, advocates chloral. With strychnines sulphas it is safe and satisfactory. The same can be said for trional with strychnines sulphas. The so-called antiseptic treatment of acute pneumonia is still under trial, and no definite opinion can be expressed concerning it. CATARRHAL PNEUMONIA. Synonyms. Broncho-pneumonia; lobular pneumonia; capillary bronchitis (?). Definition. An acute catarrhal inflammation of the bronchioles and alveoli of the lungs, characterized by fever, cough, dyspnoea, copious expectoration, and great depression. Causes. From an extension of a bronchial catarrh downward; following the eruptive fevers, especially measles ; complicating whoop- ing cough. Persons of the rickety or scrofulous diathesis, in whom there is a greater irritability of the epithelial elements, are particularly predisposed to this form of pneumonia on slight exposure ; emphy- DISEASES OF THE LUNGS. 329 sema; diseases of the heart ; most frequently seen in childhood and old age. The inspiration of particles of food and mucus in the last stages of low diseases — the aspiration or deglutiiioii pneumonia — is of the catarrhal variety. Bacteriological investigations seem to indicate that broncho-pneu- monia is due to more than one germ, although the diplococcus pneumoniae is the most frequent etiological factor. Pathological Anatomy. Hypercemia of the mucous membrane of the bronchi, extending to the connective tissue of the bronchioles and accompanying arterioles and to the alveoli, with swelling and succtdence oi Xh^fs^ tissues, accompanied by an abnormal secreiioii and an immense production of young cells from the proliferation of the bronchial and alveolar epithelium, admixed with a yellowish, creamy, mucoid material, which blocks up the bronchioles and air cells. The affected parts first have a reddish-gray, soon changing to a yellowish-gray, color, due to the rapid metamorphosis of the newly developed cells. If the fatty change be completed, absorption takes place and the consolidation is removed ; if it remain incomplete, the cells atrophy, the little mass becoming caseous, and the disease passes into a chronic state. The bronchial tubes also participate in the disease ; the walls be- come thickened, from a hyperplasia of the connective tissue {^peri- bronchitis), and their calibre is often dilated. Symptonis. Catarrhal pneumonia begins as a catarrhal bron- chitis. It may be either acute, subacute, or chronic in its course. Acute variety : Its onset is announced by a gradual rise of tem- perature to io2°-io3° F., the febrile phenomena assuming a typical remittent character, with rapid, laborious, and shallow breathitig, as shown by the widely dilated nares and violent action of all the acces- sory muscles, while the insufficient distention of the lungs is shown by the great recession of the lower part of the chest walls and sinking in of the intercostal spaces. The inspiration is short and imperfect, the expiration noisy and prolonged; the pulse x's, frequent, 100-120 or more, and somewhat compressible ; the cough, which, during the bronchitis, was loose, now becomes short, hacking, dry, and painful, soon followed by more or less copious wuco-purulent expectoration ; the appetite is impaired, bowels somewhat loose, urine scanty, high- colored, and the surface frequently covered with a more or less profuse perspiration. 330 PRACTICE OF MEDICINE. The subacute and chronic varieties have the same general symp- toms, but the duration is longer and the exhaustion greater. The progress of catarrhal pneumonia is sonielimes, although not often, a very acute one. The disease may prove fatal in a few days, especially if it attack feeble children ; in such the countenance be- comes pale and livid, the lips bluish, the eyes dull, and a restlessness giving place to apathy, and a continually augmented somnolence. Resolution, when it occurs, is by lysis, several weeks elapsing before complete recovery. Percussion. Dullness, scattered in patches, over both lungs, the intervening healthy lung often giving a more or less hollow or tympanitic note. Auscultation. Vesiculo-bronchial breathing, changing to moist bronchial breathing, associated with small bubbling (sub-crepitant) rales. As the disease progresses toward resolution, the rales become larger (large bubbling) and more numerous. If pneumonic phthisis result, physical signs indicative of that condition are soon evident. Sequelae. Attacks of catarrhal pneumonia complicated with atelectasis, or collapse of the lobules, when recovery occurs, are fol- lowed by emphysema of the lungs. If the catarrhal products which fill the alveoli and bronchioles and intervening connective tissue do not rapidly undergo complete fatty metamorphosis and consequent absorption, pneumonic phthisis re- sults. Diagnosis. Ordinary bronchial catarrh differs from catarrhal pneumonia by the absence of dyspnoea, fever, and dullness on per- cussion, and the presence of the large bubbling rales, and also by the subsequent history of the two affections. Croicpoiis pneumonia is a unilateral disease ; catarrhal pneumonia is bilateral and diffused over both lungs — the former a self-limited disease, the latter having no fixed duration. Acute tuberculosis at its onset is characterized by the presence of a capillary bronchitis, a differentiation being possible only by a study of the clinical history and course of the two maladies and the presence or absence of the tubercular bacilli. CEdema of the lungs is a bilateral disease associated with a short, dry cough, and dyspnoea, but lacks the previous catarrhal history and high temperature of catarrhal pneumonia. Prognosis. Fully one-half of the cases of true catarrhal pneu- DISEASES OF THE LUNGS. 331 monia terminate fatally. The prognosis must be guarded in scrofu- lous or rachitic subjects, or those enfeebled by other diseases, for, unless prompt resolution can be effected, it will terminate fatally early, or develop pneumonic phthisis. Have seen cases continuing up and down for eight and ten months, and finally make a good recovery. Treatment. Confinement to bed is paramount, although the position of the patient is to be frequently changed. The diet must be of the most nutritious character, administered at frequent intervals : milk, eggs, chicken, beef, mutton and oyster broths are the most suitable articles. The steady use of brandy or w-^zj-/^^/ throughout the attack is of importance, regulating the amount by the age of the patient and the severity of the attack. Locally a weak mustard plaster followed with a cotton-batting jacket is valuable. Poultices are of little use. The febrile symptoms and early cough are often modified by the following mixture : R. Potassii citratis, ^vj 24. Gm. Spts. setheris nitrosi, f^iv 15- ^'^• Tinct. opii camphorat., f^i^^ ^S- Cc. Liquor, potassii citratis, ... ad f 5 vj ad 180. Cc. M. SiG. — Dessertspoonful every three hours. Early in an attack, in children with high temperature, tinctura aconiti, in small, frequently repeated doses is valuable. If the fever persists, a combination of phenacetin or antifebrin with camphor or digitalis is useful. The ice bags or poultices are as strongly urged for broncho- pneumonia as for croupous pneumonia, and in sthenic cases should be given a trial. For the catarrhal process, the air of the apartment should be main- tained at an even temperature and moistened by disengaging the vapor of water in it. The following combination is of great utility in nearly all cases, regulating the dose in accordance with the age of the patient : R . Ammonii carbonat Ammonii iodidi, Mucil. acacise, . Syr. glycyrrh. , . Syr. prun. virg., SiG. — Every three hours . gr. V .3 Gm. . gr. v-x -S-.S Gm. . q. s. q. s. . f53 4- Cc. ad f^iv ad 15. Cc. A much pleasanter way of administering the ammonia salts is in 332 PRACTICE OF MKDICINE. capsules, each containing about two and one-lialf grains of each salt with an aromatic oil. lerpinum hydras acts remarkably well in many lingering cases. The spiritus ammonii aromaticus in either chloroform or cherry-laurel water makes an excellent mild, stimu- lating expectorant. For convalescence, nutritious food, ferri iodidiim, quini/ur sulphas, and ohuin fnorrhiice. Locally : repeated application of mustard poultices or turpentine stupes, followed by cotton jacket. If the inflammatory processes tend to become chronic, scattering blisters should be used. PULMONARY TUBERCULOSIS. Synonyms. Phthisis pulmonalis ; phthisis; consumption; pneu- monic phthisis; tubercular phthisis. Definition. An infective disease, caused by the bacillus tubercu- losis, the lesions of which are characterized by nodular bodies called tubercles or diffused infiltrations of tuberculous tissue, which undergo caseation or sclerosis, and may finally ulcerate, or, in some situations, calcify. (Osier.) Clinical Varieties. I. Acute miliary tuberculosis; II. Pneu- monic phthisis ; 111. Tubercular phthisis ; IV. Fibroid phthisis. Cause. It is now generally accepted that all varieties of pulmon- ary consumption are due to the active presence of the bacillus tuber- culosis, discovered by Koch in 1880. The lung tissue must be in a receptive state, as the bacilli may be present in the respiratory tract without the development of the disease. Any condition that lowers the tone of the general system renders the tissues susceptible to the changes produced by the tubercle bacilli. These will be enumerated in speaking of the clinical varieties of the disease. ACUTE MILIARY TUBERCULOSIS. Synonyms. Acute phthisis; galloping consumption. Definition. An acute infective febrile affection, due to the rapid eruption in various parts of the body, but especially in the lungs, of miliary tubercles ; characterized by high fever, rapid pulse, hurried DISEASES OF THE LUNGS. 333 respiration, pains in the chest, cough, profuse expectoration, and rapid prostration. Causes. In the majority of cases it is the result of an auto-infec- . tion, arising from either an active or latent tuberculous focus. Cases develop in which no cause can be assigned. Often follows measles, whooping-cough, variola, and influenza. Most frequent between puberty and middle life. " That the gray granulation is deposited throughout the body under the influence of certain conditions of irritation, it is necessary that a peculiar vulnerability of the constitution exist — in other words, that it be of the scrofulous type." Clinical Forms. Getieral or typhoid, pulmonary and cerebral. The cerebral will be described in the section on nervous diseases. Pathological Anatomy. Pulmonary form. " The gray granu- lation or miliary tubercle consists of a fine reticulation of fibres, with a mass of epithelioid cells and granules, and often having a giant cell for its centre." The deposit is generally over both lungs and the bronchial tubes, and is followed by hypersemia, increase of secretion, having a viscid and adhesive character, and the destruction of all the tissue with which it comes in contact. Deposits also take place in the brain, pleurae, intestines, peritoneum, and kidneys. G-eneral or Typhoid. — Symptoins. Gradual progressive weak- ness, with loss of appetite ; dry, clean tongue ; costive bowels, flushed cheeks ; fever, irregular in type, and rapid, feeble pulse. Rarely the temperature reaches 103° F., to 104° F., associated with a mild delirium. The respirations are increased with slight or no cough, and little or no expectoration. Often the symptoms of a dififused bron- chial catarrh of the smaller tubes are present. As the symptoms continue the prostration increases, cyanosis develops, the patient growing stupid, gradually deepening into coma and death. Diagnosis. The symptoms of acute phthisis point to an acute general infection, and the disease is apt to be mistaken for typhoid fever. The points of difference are the absence of the typical typhoid, or step-like, temperature record, the characteristic eruption, and the diarrhoea. The differential diagnosis can be more readily determined by the Widal test and the diazo reaction in the urine. Prognosis. Recovery is the rarest termination. 334 PRACTICE OF MEDICINE. Treatment. Expectant and symptomatic. Pulmonary Form. Symptoms. The onset is usually sudden, with a chill or cJiilliness, followed by fever, io2°-io4° F., riipui, dicrotic pulse, 120-140, coui^/t, with scanty, glairy sputum, vicnased respiration, 30-50 per rnxnuie., pain in the chest, hot skin, dry tongue, deranged digestion, and great prostration, the severity of the symp- toms rapidly increasing, with evidences of cyanosis, the sputum becoming more abundant and often rusty in color, with more or less frequent attacks of hamoptysis, soon followed by headache, vertigo, sleeplessness, often delirium, coma, and death. If deposits have occurred in the meninges or the intestines symp- toms of these affections are superadded. Percussion. The percussion resonance is normal until consider- able deposits have occurred, when it is either slightly impaired or even slightly tympanitic. With the development of cavities ihe am- phoric percussion note is present. Auscultation. Often little change in the vesicular murmur, but diffused rales of bronchial catarrh, or vesiculo-bronchial breathing, associated with large and •s,xn7i\\,mo\'~Xox bubbling rales, soon followed by bronchial aiTid brcncho-cavemoics breathing, with large and small, moist and circumscribed ^i^/^r^/m^ rales. Duration. Acute phthisis usually terminates fatally in from four to twelve weeks. Rarely of several months' duration. Diagnosis. Commonly mistaken for typhoid fever with lung complications, an error that is readily made unless a close study of the history, symptoms, physical signs, and sputum be made. The Widal test may assist in determining the diagnosis. Treatment. There are no means of retarding the progress of this malady. Loomis says : " Morphia in small doses — 2V of a grain (0.003 Gm.) hypodermically every six or eight hours — has, in my hands, been more satisfactory in staying the progress of the disease, prolonging life, and keeping the patient comfortable than any other plan." Dr. McCall Anderson claims that subcutaneous injections of atropinae sulphas check the exhausting sweats, and that quininae sulphas, digitalis, and opium reduce the temperature, and if they fail, ice-cloths to the abdomen will accomplish the desired result. The various symptoms should be met as they occur, the patient at the same time being supplied with large quantities oi stimulants, and full doses of strychninae sulphas and arsenicum. DISEASES OF THE LUNGS. 335 PNEUMONIC PHTHISIS. Synonyms. Chronic catarrhal pneumonia ; catarrhal phthisis ; caseous pneumonia ; caseous phthisis. Definition. A form of pulmonary consumption characterized by the destruction of the pulmonary tissue resulting from the action of the bacillus tuberculosis, causing the caseation or cheesy degeneration of inflammatory products in the lungs, and the subsequent softening and destruction of the caseous matter, with greater or less destruction of the pulmonary tissue ; characterized by hectic fever, cough, shortness of breath, purulent expectoration, and more or less rapid prostration. Causes. The predisposing factor in the etiology of pneumonic phthisis is a strumous or scrofulous diathesis, or a condition of lowered health, the result of various unfavorable hygienic influences. The exciting causes are : the irritation produced by the presence of the bacillus tuberculosis and a catarrhal pneumonia in any portion of the lung, but especially at the apex ; inflammation occurring about a blood clot; inhalation of irritant particles occurring in such occu- pations as weaving, grinding, mining, milling, cigar-making, and the like. Many cases of pneumonic phthisis can be traced to an attack of influenza a year or so before in individuals having the peculiar diathesis. Pathological Anatomy. When a pneumonia terminates in resolution, the inflammatory products are absorbed by first undergoing 2. fatty i7ietamorphosis. If the fatty metamorphosis be incomplete, the cells are atrophied and undergo the caseous degeneration, which con- sists in the absorption of the watery parts, the fatty degeneration of the cellular elements, and the granular disintegration of the fibrinous material, so that ultimately a soft, solid mass is produced, yellowish in color, having the appearance of cheese. The destructive changes are thus described by Niemeyer: " Cells, the products of inflammation, accumulated in the alveoli and minute bronchi, crowd upon each other, becoming densely packed, and thus by their mutual pressure they bring about their own decay, as well as that of the lung textures, by interfering with their nutrition, the alveolar walls being also themselves damaged by the inflammatory process." The position of the catarrhal pneumonia resulting in the above 336 PRACTICE OF MEDICINE. changes is usually at the apex or under the lower inner scapular re- gion, but it may occur at any portion of tiie lungs, or a whole lung becomes infiltrated, and undergoes the cheesy degeneration (phthisis tlorida). As in croupous pneumonia, so in pneumonic phthisis is there in- volvement of the overlying pleura of tubercular character in the latter disease. Rarely rupture of lung and pleural structure occur, causing tubercular pneumohydrothorax. Symptoms. Pneumonic phthisis occurs in three forms — the chronic, the subacute, and the acute. Chronic form. The origin is rather insidious, the individual being susceptible to "colds," or " catarrhs," on the slightest exposure; gradually a persistent cough, with the expectoration of vucco-pus, is established, each severe cold being accompanied with chill, fever, pain in the chest, and either slight hemorrhages or blood-streaked sputa. Finally, the catarrhal symptoms become persistent, with morning chills, tv&nmg fevers, and rather profuse night-sweats, dis- tressing cough, profuse muco-purulent sputa, containing the bacilli, great weakness and exhaustion, loss of appetite and feeble digestion, the symptoms growing persistently worse, death occurring from exhaustion after one or two years' duration. Subacute variety. History of an acute attack of pneumonia of one or two weeks' duration, followed by a decided improvement, but not complete recovery. After a lapse of some weeks or months symp- toms of pulmonary softeninghtgm, destroying the lung structure and forming cavities, accompanied by chills, fever, night-sweats, emaci- ation, cough, muco-purulent 2iX\d.blood-streahed expectoration contain- ing the bacilli, the patient dying from exhaustion within a year. Acute variety, the. so-caiUed phthisis ^orida, runs a rapid course, beginning either as a croupous or catarrhal pneumonia, involving the whole of one or part of both lungs, associated with rapid loss of flesh and strength, high but variable temperature, I03''-I05'' F., with remissions, profuse night-sweats, shortness of breath, severe cough, profuse, purulent, and blood-streaked sputa containing the bacilli, loss of appetite, and feeble digestion, the patient succumbing in a few weeks or months from exhaustion. A decided remission in the local and general symptoms of the acute variety may occur, the disease afterward pursuing a more chronic course. DISEASES OF THE LUNGS. 337 Inspection. Shows deficient respiratory movements of the dis- eased portion of the lungs. Palpation. Increased vocal fremitus over the consolidated lung tissue and cavities. Percussion. The percussion note varies from a slight impair- ment of the normal note at either ape5c to dullness, and when cavities are formed, associated with scattered points of the tympanitic or hollow note. If the cavities communicate with a bronchial tube, the cracked-pot or cracked-metal sound is elicited. If the cavities are filled with pus, the percussion note is dull. If the pus be expelled, the tympanitic or cracked-pot sound returns. Auscultation. The vesicular murmur is unimpaired in those parts free from disease; it isy^^(5/iscribed pericarditis ; if it involve the whole of both surfaces, it is i^rsnt.^ general ox diffused pericarditis. The inflammation may be primary or secondary. Causes. Primary pericarditis resulting directly from cold and exposure or injuries is rare. Secondary pericarditis follows, or is associated with, rheumatism, influenza, scarlatina, variola, puerperal fever, tuberculosis, septicaemia, Bright's disease, gout, scurvy, and diabetes. It is frequently associated with pneumonia and pleuro-pneumonia, particularly in alcoholics. Pathological Anatomy. The same as of serous membranes in other situations. The morbid changes may be seen as (i) acute plastic or dry pericarditis (frequently tubercular) ; (2) pericarditis with effusion, sero-fibrinous, hemorrhagic, or purulent. Hyperczmia of the membrane, most marked on the visceral layer, followed by the exudation of lymph scattered in irregular patches, giving it a rough and shaggy appearance {dry pericarditis), followed by the effusion of a sero-fibrinous fluid, with flocculi floating in it, and at times mixed with blood. Rarely, the fluid is purulent. The fluid and lymph undergo absorption with resulting adhesions identical with those described under pleurisy. Symptoms. Acute pericarditis may be well marked and still present none of the characteristic subjective symptoms. It usually begins with rigors, fever of the remittent type, frequently nausea and vomiting, prcecordial distress dLTidtendLtmess, acute shooimg pains, in- creased by breathing and coughing ; dry, suppressed cough ; increased cardiac action, and sometimes violent palpitation. An attack of peri- carditis secondary to an existing disease presents no marked symp- toms other than those mentioned to indicate its onset. Attacks of nausea and vomiting occurring during the course of rheumatism, pneumonia, pleurisy, and nephritis should call attention to the heart. Duration of this early stage, from a few hours to a day or two. 360 PRACTICE OF MEDICINE. Effusion stage : The symptoms of this stage are in keeping with the amount and rapidity of the effusion : pracordial oppression, tendency io syncope ; dyspnaa, sometimes amounting to orthopncEa ; dysphagia, Aiccoug/t, Ti:iusea. and To/ni/ing ; feeble, irregular /«/.v^/ sometimes either melancholia, delirium, or acute maniacal excitement. Absorption is generally rapid, the heart remaining " irritable " for a long time after. If instead of absorption the fluid accumulates and life is not destroyed, the pericardial sac becomes dilated, chronic pericarditis resulting. Inspection. Early stage, excited cardiac action is evidenced by the impulse. Effusion stage, feeble, undulatory, or absent impulse ; its position displaced upward, or, rarely, downward ; bulging of the praecordium and protruding abdomen if effusion be large. Palpation. Early stage, excited or tumultuous impulse ; peri- Q.zxd^\-a\ friction fremitus rare. Effusion stage, feeble or absent impulse, and if present, its position is changed. Percussion. Early stage, normal. Effusion stage, cardiac dullness, enlarged vertically and laterally, and, if considerable fluid, of a triangular shape, with the base of the triangle on a line with the sixth or seventh rib, extending from the right of the sternum to the left of the left nipple, narrowing as it pro- ceeds upward to the second rib, or above, which represents the apex of the triangle. The shape of the dullness is sometimes altered by changing the position of the patient. Auscultation. jE'^r/j/j/ajcr,?, excited cardiac action, and usually Sifriction sound {e\oca.rd'ia.l murmur) synchronous with cardiac sounds and uninfluenced by respiration, but often increased by pressure with the stethoscope. Elusion stage, cardiac sounds feeble and deep-seated at the cardiac apex, becoming louder and distinct toward the cardiac base. The friction sound is sometimes heard at the cardiac base. If adsorption occur, the above signs gradually give place to the normal, the friction sound returning, of a churning, or clicking, or grating character, gradually disappearing. Diagnosis. Endocarditis is often confounded with pericarditis, the points of distinction between which will be pointed out when dis- cussing that affection. DISEASES OF THE CIRCULATORY SYSTEM. 361 Cardiac hypertrophy or dilatation is sometimes confounded with pericardial effusion ; the differences between which will be pointed out when discussing those affections. Hydropericardiufn may be mistaken for pericardial effusion ; see that affection. Prognosis. Controlled by the severity of the inflammation, causes, and coexisting affections. There is no doubt but that peri- carditis with slight effusion is frequently overlooked. If slight effusion, favorable. Death has quickly occurred when a large quantity of fluid has been rapidly effused, the patient being really drowned in his own fluid. Adherent pericardium is a frequent sequela. Treatment. Perfect rest in bed with absolute mental quiet. Death has followed neglect of this precaution, and particularly during the stage of effusion. The important indications for treatment are to limit the inflamma- tory action and quiet the heart in the first stage, and to promote absorption and prevent cardiac failure in the second stage. Local applications in the early stage are most valuable ; for vigor- ous patients, the application o'i leeches ox wet cvps\o the praecordium, followed by the application of ice poultices or iced compresses ; in the feeble, dry cups in the praecordium, followed by poultices. For the gastro-intestinal symptoms calomel is indicated, and it may have a beneficial effect on the inflammatory action : R . Hydrargyri chloridi mitis, . . gr. ^ .022 Gm. Sodii bicarbonat., gr- ij -IS Gm. Sacchar. lactis, gf- ij -13 Gm. Dry on tongue every two hours until free action. The late Dr. Pepper said the " following combination is often very acceptable " : R . Pulv. digitalis, Mass. hydrargyri, . . . , aa gr. x aa .6 Gm. Pulv. opii, gr. V .3 Gm. Quininss sulph., gr. xxx 2. Gm. Ft. mass et div. in pil. No. xx. SiG. — One pill three or four times daily. In young, vigorous patients, early in the disease control the excited cardiac action by small doses o'i aconitum or verairutn viride ; in the 362 PRACTICE OF MEDICINE. adult, aged, or feeble using digitalis ; in all cases quinina: sulpltas or hydrochloras is indicated. Avoid all cardiac sedatives in secondary cases save those following rheumatism. If pain is severe during the pre-effusion stage, fulvis opii et ipe- cacuanha or morphince sulphas may be cautiously used. Effusion stage : As the effusion progresses, the free administration of alkalies — to wit : ainvionii carbonas, gr. v (0.3 Gm.) every two hours, with liquor ammonii acetatis, or potassii acetatis, or potassii carbonatis, with quinincr sulphas or hydrochloras, nutritious liquid diet and stimu' lants, being cautious with the use of cardiac sedatives or tonics. If the pericarditis is secondary, the general treatment of such con- dition must be continued. If the effusion has a tendency to linger, blisters to the praecordium Tindi potassii iodidian should be used, and if the symptoms of oppres- sion are marked or the effusion linger, paracentesis is indicated. Dr. Roberts, in his monograph, gives an account of sixty cases of para- centesis with twenty-four recoveries. He advises that the tapping be done in the fossa between the ensiform and costal cartilages on the left side, or in the fifth left interspace near the junction of the sixth rib with its cartilage. Dr. Tyson recommends the use of a blister as soon as the diag- nosis is determined. He says : " There is no other disease in which I am so satisfied of the efficiency of a blister; it helps to prevent effusion and also to promote the absorption of effusion." The diet must be nutritious and easy of digestion throughout the disease. If evidence of cardiac failure, use strychnines sulphas, gr. ^ (0.0025 Gm.), hypodermically. three or four times daily. CHRONIC PERICARDITIS. Synonym. Adhesive pericarditis. Definition. A chronic inflammation of the pericardium, with either distention of the sac by fluid or adhesions of the pericardium (adherent pericardium) ; characterized by impaired cardiac action and disturbances of the circulation. Causes. Almost always the result of an acute attack. The line of demarcation between the acute and chronic forms is not sharp. Pathological Anatomy. If the effusion be absorbed, the peri- cardial surfaces are agglutinated by several layers of lymph, which DISEASES OF THE CIRCULATORY SYSTEM. 363 increase the thickness of the membranes half an inch or more, and the outer surface of the pericardium becomes adherent to the chest walls. If the fluid is not absorbed, it may progressively accumulate, dis- tending the sac in all directions, displacing the diaphragm and inter- fering with the functions of the surrounding viscera, or a low grade of inflammation supervenes, the fluid becoming purulent (empyema of the pericardium), the disease terminating fatally after a variable period. As much as eight to ten pints of fluid have accumulated in the sac. Symptoms. Prcecordial pain and distress ; \xx&gv\-3.x , feeble car- diac action ; dyspncea, aggravated by movement, and disturbed circu- lation. An agglutinated pericardium seriously increases the danger from an attack of any pulmonary inflammation. Inspection. If the effusion be present, bulging of the praecor- dium and displacement of the impulse. If adhesions are formed between the pericardial surfaces as well as with the chest walls, inspection reveals depression of the prcecordium, narrowing of the spaces, increased extent but displaced impulse, un- influenced by deep inspiration, and recession of the intercostal spaces {systolic dimpling) and epigastrium with every systole of the heart, the result of the adhesions. Palpation. If effusion, displaced, feeble, or absent impulse ; if adhesions, displaced and tumultuous impulse ; occasionally a peri- cardial fremitus is distinguished. Percussion. If effusion, the dullness has more or less the char- acter described for acute pericarditis. If adhesions, the cardiac dullness is but slightly modified. Auscultation. If effusion, cardiac sounds feeble and deep-seated at the apex, louder and more distinct at the cardiac base. If adhesions, cardiac sounds are heard with equal distinctness in their several positions, associated with a rough friction sound (exo- cardial murmur). Treatment. If effusion, blisters to the praecordium, with potassii iodidutn to hasten absorption, the patient being supported by nutritious diet, quinines sulphas, ferrum and stimulants, and perfect quiet. If these means fail to remove the fluid, or if the fluid be purulent, para- centesis should be performed at once. 364 PRACTICE OF MKDICINE. If adhesions of the pericardium have resulted, the application of blisters to the priccordiuin, with the administration o{ potassii iodidum, alternating \\\\.\\ferru}n and quinina hydrochloras, are indicated, with nutritious diet, stimulants, and perfect quiet. HYDRO-PERICARDIUM. Synonym. Pericardial dropsy. Definition. The accumulation of water in the pericardial sac, minus inllammation ; characterized by praecordial distress, disturbed cardiac action, dyspnoea, and dysphagia. Causes. Usually a part of a general dropsy ; Bright's disease; sudden pneumothorax ; pressure of an aneurism or other mediastinal tumor ; disease or thrombosis of the cardiac veins. Pathological Anatomy. The fluid may range in quantity from an ounce to one or two pints, and is of a clear, yellowish or straw- colored serum, at times turbid or bloody, and of an alkaline reaction. If the amount of fluid be large, the sac is dilated, its walls thinned by the pressure, and has a sodden appearance. Symptoms. Dropsy of the pericardium is so generally associated with hydrothorax or dropsy of the pleurae that the symptoms are but an aggregation of those attending upon that condition — to wit : dis- tio'bed cardiac action, dyspncea, dysphagia, dry cough, and feeble cir- culation. The physical signs are exactly those of the stage of effusion of pericarditis, minus a friction sound. Diagnosis. Pericarditis with effusion and hydro-pericardium present nearly the same signs and symptoms, a differentiation being possible only by a history of the case and the symptoms of the attack. Prognosis. Controlled entirely by the cause. Treatment. Depends upon the cause of the attack. If the amount of fluid in the pericardial sac be gTea.t, paracentesis will give relief. ACUTE ENDOCARDITIS. Synonyms. Valvulitis; exudative endocarditis. Definition. An acute fibrinous inflammation of the serous mem- brane lining the cavity of the heart and particularly its valves, in DISEASES OF THE CIRCULATORY SYSTEM. 365 severe cases the chordae tendineas being involved, resulting in changes in the valves or orifices of the heart, or both ; characterized by cough, dyspnoea, disturbed cardiac action, nausea, vomiting, and more or less marked febrile reaction. Acute endocarditis occurs in two distinct forms : plastic or simple exudative endocarditis ; ulcerous or diphtheritic endocarditis. Causes. Usually secondary to acute articular rheumatism (par- ticularly in young people), pleuritis, pneumonia, pericarditis, Bright's disease, scarlatina, influenza, and diphtheria. Rarely attacks of endocarditis are due to a gonorrhoea. The association of acute endo- carditis and chorea is frequent. While as yet no specific micro-organism has been discovered, the view is gaining, however, that it is a microbic affection. Pathological Anatomy. Inflammation of the endocardium is usually limited to the left side of the heart after birth, during foetal life the reverse being the case. The inflammation is limited or espe- cially marked at the valvular portions of the endocardium, owing probably to the presence of fibrous tissue beneath the membrane in these situations, and to the strain which falls upon the valves during the performance of their functions. Hyperamia from congestion of the vessels beneath the membrane, whh considerable swelling of the valvelets, the result of an exudation of lymph and serum beneath and on the free surface of the membrane covering the valves and chordce tendinece, resulting in the roughening of the surfaces and the agglutination of the mitral valves to each other, and of the aortic segments to the walls of the aorta, or the pro- liferation of the endocardial connective tissue, forming the nuclei of the so-called warty excrescences or vegetations, their size being increased by the deposition of fibrin from the blood on its passage through the orifices. These vegetations may be detached by friction, giving rise to ejnboli, which may be washed by the blood current to the left side of the brain, or into the kidneys and the spleen. In the ulcerative variety a process of softening takes place in the fibrinous deposits, leading to ulcerations and perforations. Symptoms. The affection is usually masked by the course of another disease until disturbances of the circulation direct attention to the heart. The onset is often by increase of temperature, prcecordial distress. 366 PRACTICE OF MEDICINE. short cough, slight dyspnaa, more or less persistent vomiting ; increased cardiac action, often rapid and tumultuous, with throbbing- carotids and noises in the ear. As the inflammation progresses, the cardiac action and pulse decline in frequency, with more or less congestion of the hinj^s and venous stasis. Auscultation. Shows a change in the character of the sounds or the development of murmurs at the various orifices, the character and points of distinction between which will be pointed out when discussing valvular diseases of the heart. Duration. Between one and three weeks. Diagnosis. Unless it is a rule of practice to always auscult the heart, many cases will pass unobserved or undetected. Piricarditis is distinguished from endocarditis by the character of the physical signs. In pericarditis the murmur or friction sound is heard with either cardiac sound, is near to the ear, and influenced by pressure of the stethoscope, besides being associated with more or less alteration in the size and shape of the cardiac dullness, and is not transmitted, while in endocarditis the murmur takes the place of or is associated with the cardiac sounds, and is transmitted to points beyond the preecordia, with the absence of change in size and form or increased dullness on percussion. If embolism occur, a new set of symptoms develop ; embolism of the kidneys causes sudden, deep-seated lumbar pain, with albumi- nuria and even ha^maturia ; embolism of the brain, sudden palsies and sudden disturbance of consciousness; of the spleen, sharp pain and tenderness in the splenic region ; of the skin, petechial or purpuric spots. Prognosis. Acute endocarditis is not very dangerous to life, hence a favorable prognosis may be given ; regarding the ultimate results of valvular lesions, however, the prognosis is grave. Treatment. Absolute rest in bed. At the onset leeches or wet cups to the pra^cordium, followed by ice, or, what may be preferable to the patient, poultices. The excited circulation should be controlled hy aconitu}n,z'eratrum viride, or digitalis, each of these drugs having their particular indi- cation. The free administration of such alkalies as arnmonii carbonas, poiassii acetas or carbonas, until the urine is decidedly aikalme, may prevent permanent changes in the valves or orifices. DISEASES OF THE CIRCULATORY SYSTEM. 367 If alkalies fail and the inflammation shows a tendency to linger, good results are often obtained by a slight hydrargyrum impression. If signs of oppressed circulation appear, the hands becoming blue, the face and extremities cedematous, with congestion of the lungs, the free use oi ammonii carbojias, spiritus a7nmonti aromaticus, nitro- glycerinum, digitalis, strophatithiis, hypodermic injections oi strych- nincB sulphas, and stimulants are indicated. No drug equals atropinat sulphas in oedema of the lungs, no matter what the cause. The free use of amfnonit carbonas will often prevent or break up heart clots. After the acute symptoms have subsided, more or less absorption of the exuded lymph has followed the free use oi potassii iodidum. During the entire course of the affection the diet should be of the most nutritious but digestible character. MALIGNANT ENDOCARDITIS. Synonyms. Ulcerative endocarditis ; septic, mycotic, and diph- theritic endocarditis. Definition. An acute septic inflammation of the lining mem- brane of the heart, with a strong tendency to ulceration ; characterized by depression of the vital forces with more or less cardiac distress. Causes. The specific micro-organism has not yet been deter- mined. Frequently complicates pneumonia. Associated with ery- sipelas and septiceemia. Rarely associated with acute rheumatism. Cases have been reported associated with or following influenza. Gonorrhoea is a rare cause. Pathological Anatomy. The changes are those of acute en- docarditis up to the development of the thickening of the endocar- dium lining the valves, and the development of the vegetations. Instead of the poison spending its force and the chronic condition obtaining, a process of softening, ulceration, development of abscesses and perforation of leaflets follows, resulting in loss of structure, gen- eral septic infection, and the development of emboli, which lead to infarctions, with their results in either brain, kidney, spleen, eye, or skin. Symptoms. Vary greatly, but always associated with constitu- tional signs of sepsis — a typhoid state, such as headache, restlessness, varying delirium with coated, dry tongue, sordes on teeth and lips, 368 PRACTICE OK MEDICINE. nausea, vomiting, loose or disordered stools, enlarged spleen, albumin in urine, and an irre^lar temperature record, varying from ioo° to 104° F. or higher, associated with rii^ors and profuse sweating. The cardiac action is rapid, irregular, and weak — a compressible pulse. In the notes of twelve cases observed in the Philadelphia Hospital are the following symptoms : attacks o{ prolonged dyspna\i with par- oxysms of intensity, or a slightly quickened respiration with parox- ysms of dyspncua occurring every few days in patients with hectic temperature record. In four cases the paroxysms occurred three limes daily, with respirations under twenty-five between the parox- ysms, for three weeks preceding death. Usually the respirations are so oppressed that the recumbent position is impossible for long periods. Another frequent symptom is marked cyanosis, either transient or lasting for days before the end. A frequent symptom of ulcerative endocarditis is a peculiar yb^Afj, indicative of a sense of impending danger, great anxiety, or terror. If embolism occur, there are superadded symptoms varying with the organ affected. If the brain, rapidly developing palsies with disorder of consciousness ; if the kidneys, deep-seated lumbar pains with hzematuria or disordered urinary flow ; if the spleen, pain and tenderness of the splenic region with increase of temperature record. Auscultatiotl. The booming, muscular, first sound is superseded by a feeble, irregular cardiac pulsation. Generally, a murmur may be detected. Diag'nosis. One of the most difficult in medicine. Remember- ing the diseases with which malignant endocarditis may occur, and particularly pneumonia or sepsis, and the dyspncea, the cyanosis, the facies, and the temperature record, it may be possible to detect the disease much more frequently than formerly. Prognosis. Unfavorable. Recovery the rarest termination. Treatment. Entirely symptomatic. Nutritious diet, quinines sulphas, fcrrum, alcohol, sttychnincB sulphas, strophanthus, caffeina citratra, and digitalis. For the cyanosis, large, frequently repeated doses of nitro-glycerinum. Local application seems only to distress the patient, unless it be an emplastrum belladonna. DISEASES OF THE CIRCULATORY SYSTEM. 369 CHRONIC ENDOCARDITIS. Synonyms. Sclerotic endocarditis; interstitial endocarditis; chronic valvular disease. Definition. Alterations in the cardiac valves or orifices, render- ing the former incapable of properly closing the orifices, or causing the narrowed orifice to interrupt the blood current in its normal move- ment. The lesions are of two kinds : obstructive and regurgitant. An obstructive lesion, termed also stenosis, is a narrowing of the orifice, thereby obstructing the onward passage of the blood. A regurgitant lesion, termed also ittsufficiency, is such alteration in the valves as permits a portion of the blood to flow backward instead of onward, the true direction of the blood current. Varieties. I. Mitral regurgitation. II. Aortic regurgitation. III. Tricuspid regurgitation. IV. Pulmonary regurgitation. V. Mitral obstruction. VI. Aortic obstruction. VII. Tricuspid obstruction. VIII. Pulmonic obstruction. Causes. The great majority of cases are the result of an attack of acute endocarditis following rheumatism, chorea, or the infectious diseases. A chronic endocarditis from the onset may be caused by alcoholism, syphilis, gout, or excessive muscular labor. Chronic Bright's diseases are also exciting causes. • Professor Da Costa has clearly established the development of aortic disease in early life by overwork and strain of the heart. In the elderly, chronic endocarditis is the result of atheromatous or fibroid changes. MITRAL REGURGITATION. This form of valvular disease is also termed mitral insufficiency, and is the most frequent variety of valvular heart disease. Pathological Anatomy. The most common conditions ob- served are more or less contraction and narrowing of the tongues of the valves, with irregular thickening and rigidity ; atheroma or calci- fication of the segments ; laceration of one or more segments ; adhe- sion of one or more segments to the inner surface of the ventricle ; thickened and stiffened or rupture of the chordcs tendinece, and also contraction and hardening of the musculi papillares. As a result of the regurgitation or leakage of the blood back into 24 370 PRACTICE OF MEDICINE. the left auricle, there is a dilatation of the auricle, foUowecl by slight cardiac hypertrophy. Ventricular hypertrophy occurs after a time from the increased number of the cardiac contraction?. Symptoms. Insufficiency of the mitral valves soon leads to car- diac hypertrophy, to compensate for the diminished amount of blood sent onward by the ventricular systole. This condition causes quickened and strong pulse with some shortness of breath on severe exertion. When the " compensation ruptures," there occurs pracor- dial distress, cough, dyspnoea ; feeble, soft, rapid, irregular pulse; finally, from weakened cardiac action, may result pulmonary conges- tion, with cedematous limbs and general cyanosis, the abdominal cavity filled, liver congested, urine scanty and albuminous, the patient dying " drowned in his own fluid." Inspection. Cardiac impulse (apex-beat) displaced to the left and downward. In children and youths, bulging of the prcecordia and increased cardiac impulse. Palpation. Displaced cardiac impulse, early stage being forcible and diffused ; as compensation fails, impulse feeble or absent. Percussion. Transverse and vertical cardie dullness increased. Auscultation. Systolic blowing or churning murmur, audible in the mitral area, propagated to the apex, left axilla, and under the angle of the scapula, either occurring with or taking the place of the first sottnd of the^ heart, the second sound being markedly accen- tuated. Prognosis. So long as the compensating hypertrophy can be maintained, the prognosis is not unfavorable; when dilatation super- venes, however, the patient soon perishes, either from congestion of the lungs or dropsy and exhaustion. AORTIC REGURGITATION, Termed also aortic insufficiency, occurs next in frequency to mitral insufficiency. Pathological Anatomy. The valves or segments adhere to the walls of the aorta, or a segment is lacerated or may be perforated, or, more commonly, the segments are shrunken, deformed, and rigid, permitting the regurgitation of the blood. These deficiencies in the valves are usually associated with more or less dilatation of the orifices. The inability of the aortic valves to completely close the aortic DISEASES OF THE CIRCULATORY SYSTEM. 371 orifice at the proper moment allows the blood that should go onward to flow back into the left ventricle, and the normal flow of blood from the left auricle continuing, causes overfilling of the ventricle, which results in a dilatation of its cavity, and the extra effort of the ventricle to empty itself results in hypertrophy of the walls. In no other con- dition does the dilatation and hypertrophy of the cardiac walls reach such a degree. The older writers named this enormous enlargement of the heart " cor bovinum." Symptoras. There are no characteristic symptoms so long as the insufficiency is compensated by just enough hypertrophy of the ventricular walls, but as the muscular growth increases, the symptoms are those of marked cardiac hypertrophy — to wit : forcible cardiac action, headache, tinnitus aurium, congestion of the face and eyes, with pulsating vessels, even small ones pulsating that before were not visible to the eye ; pulsations of the retinal vessels can be recognized with the ophthalmoscope ; the receding pulse, which is particularly characteristic — forcible impulse but rapidly declining, called " water- hammer " pulse and also the " Corrigan pulse." As soon as there is the slightest failure in the compensation, the cardiac action becomes excessive and distressing with palpitation, causing anxiety and fear upon the part of the patient. When "compensation ruptures," dyspnoea, increased on exertion, cough, cyanosis, hepatic enlargement, congestion of the kidneys, with scanty, albuminous urine, ascites, and dropsy develop either gradually or rapidly, calling for prompt medication. If mitral insufficiency is now superadded, general venous stasis and death rapidly occur. Praecordial pain is usually present in aortic disease. It may be a sensation of constriction in the cardiac region, or sharp, shooting pains extending to the arms — anginoidal attacks. Inspection. Forcible cardiac impulse. Palpation. Strong, full cardiac impulse. Percussion. Cardiac dullness increasing transversely and verti- cally. Auscultation. First sound, forcible ; second sound, replaced or associated with a churning, rushing, or blowing murmur of low pitch, distinct at the second right costal cartilage, but most distinct at the junction of the sternum and the fourth left costal cartilage, trans- mitted downward toward and below the apex. Prognosis. The one valvular disease most likely to occasion 372 PRACTICE OF MEDICINE. sudden death ; still, so long as the compensating hypertrophy remains intact, compatible with quite an active life. TRICUSPID REGURGITATION. Pathological Anatomy. This form of valvular insufficiency is either associated with right-sided cardiac dilatation from pulmonary obstruction, or is the result of mitral disease. The tricuspid orifice is dilated in the majority of cases ; occasion- ally the segments of the valves are contracted or adherent to the ventricle. Symptoms. Venous stasis with its various consequences, and especially pulsation of the jugulars, synchronous with the cardiac movement, and, finally, general venous pulsation, especially of the liver, pulmonary congestion, engorgement of the kidneys, and dropsy. These symptoms are superadded to those of the affections with which tricuspid insufficiency is always associated. Inspection. Diffused, wavy, cardiac impulse ; jugular pulsation synchronous with the cardiac movement, uninfluenced by respiration, also more or less prominent hepatic pulsation. Palpation. The cardiac impulse extended, but feeble. Percussion. Dullness on percussion, extending to the right and below the sternum. Auscultation. The first sound is accompanied by a blowing murmur most intense at the junction of the fourth and fifth ribs with the sternum, distinct over the xiphoid appendix, becoming feeble or lost in the left axillary region ; often associated, however, with a mitral systolic murmur. PULMONIC REGURGITATION. Pathological Anatomy. Insufficiency of the pulmonary valves is of rare occurrence, but when present, the changes correspond more or less with those described for aortic regurgitation. Symptoms. Those of dilatation of the right side of the heart and consequent pulmonary congestion — to wit : dyspnoea, deficient aeration of the blood and cyanosis, distention of the superficial ves- sels, palpitation of the heart, precordial distress, sudden suffocative attacks, and dropsy. Percussion. The cardiac dullness extending to the right of the sternum. DISEASES OF THE CIRCULATORY SYSTEM. 3/3 Auscultation. A loud, blowing murmur associated with the second sound of the heart, most distinct at the junction of the third left costal cartilage and the sternum. Prognosis. Death results, sooner or later, from dropsy and exhaustion. MITRAL OBSTRUCTION. Mitral obstruction or stenosis is not so frequent as regurgitation, and is very often associated with the latter. Pathological Anatomy. Mitral stenosis is caused by deposits around the orifice, the result of endocarditis, or else the segments of the valves are "glued together by their margins," leaving but a funnel-shaped opening, the so-called " buttonhole " mitral valve. Vegetations on the valves lead to more or less obstruction to the blood-current. Symptoms. Hypertrophy of the left auricle results from obstruc- tion at the mitral orifice, followed in time by dilatation, the symptoms of stenosis being unobservable until the " compensation ruptures," or until dilatation becomes excessive, when occur irregular, small, zxv^ feeble puhe, dyspnosa, cotigh, bronchorrhoea the result of bronchial congestion ; dilatation of the right side of the heart, soon leading to general venous stasis, dropsy, and death. Inspection. Normal until auricular hypertrophy, when an undu- latory impulse is observed over the left auricle. Palpation. When cardiac dilatation occurs, a diffused, feeble, and irregular cardiac impulse is felt near the xiphoid appendix. Auscultation. First sound normal in character, but often irreg- ular in rhythm. The second sound normal. A blowing, sometimes rasping, sound is heard, immediately after the second sound of the lieart ceases, and immediately before the first sound begins — a pre- systolic murjnur, heard most distinctly in the mitral area, lessening in intensity toward the cardiac base. The cardiac sounds are all more or less enfeebled if cardiac dilatation occur. Prognosis. The prognosis is controlled by the duration of the hypertrophy. Under favorable circumstances, mitral stenosis is compatible with a long and rather active life. AORTIC OBSTRUCTION. Pathological Anatomy. Stenosis of the aortic orifice is caused by the projection of the valves inward, and their becoming rigid 374 PRACTICE OF MEDICINE. and thickened, or atheromatous or calcareous, so that they cannot be pressed back by the blood, but remain constantly in the current of the circulation. Occasionally the valves are covered with fibrinous masses, the opening into the artery being thus more or less com- pletely closed, or the segments may be adherent by their lateral surfaces, leaving a central opening, which may be so contracted as to permit the passage of only the smallest probe. Aortic stenosis is nearly always a disease of advanced life, and is associated with the arterial changes of age. Aortic disease is not neaily so often of rheumatic origin as mitral diseases. Symptoms. Hypertrophy of the left ventricle rapidly super- venes upon aortic stenosis, and so long as the cardiac hypertrophy is just sufficient for compensation, there will be no subjective symptoms, many cases of stenosis being discovered when the individual is ex- amined for insurance or other reasons. T\\t pulse is s?iiail, slow, and hard. When, however, the compensatory hypertrophy begins to fail, the supply of blood to the brain is insufficient in many cases, and pallor, with attacks of 7>ertigo, syncope, or slight epileptiform seizures occur; finally, as dilatation of the left ventricle and incompetence of the mitral valve result, there occur pulmonary congestion, dyspnoea, and general venous stasis, the pulse soft and feeble. Palpation. Lowered cardiac impulse, strong in the early stage, feeble when dilatation occurs. Percussion. The cardiac dullness is increased vertically, the transverse dullness being but slightly increased. Auscultation. The first sound of the heart is replaced or asso- ciated with a harsh, rasping sound, whistling at times, having its greatest intensity at the junction of the second right costal cartilage with the sternum, transmitted along the vessels ; the murmur may sometimes be heard a short distance from the patient. Usually, aortic stenosis is associated with more or less aortic regur- gitation, whence a double miirviur occurs, having its greatest intensity at the base of the heart, the so-called to and fro, or see-saw murmur. Prognosis. So long as compensation is maintained the condi- tion of the patient is comfortable, if a quiet life be followed. When the compensation is ruptured, the usual symptoms of dilatation, venous stasis, and dropsy soon ensue. DISEASES OF THE CIRCULATORY SYSTEM. 375 TRICUSPID OBSTRUCTION. This condition is one of the rarest affections of the heart, and if it ever does occur with or following an attack of endocarditis, the anatomical changes are similar to those of mitral obstruction. This condition soon leads to auricular dilatation ; venous stasis rapidly supervenes, associated with venous pulsations similar to those de- scribed when speaking of tricuspid regurgitation. PULMONIC OBSTRUCTION. Pathological Anatomy. Always a congenital malady, the changes consisting in " constriction of the pulmonary artery, un- closed foramen ovale, unclosed ductus Botalli, stricture at the ductus Botalli, with hypertrophy of the right cavity and frequent association with tuberculosis of the lungs." Hypertrophy of the right ventricle may ensue, the walls becoming almost as thick as those upon the left side. Those in whom these congenital defects in the cardiac structure occur are otherwise weak, develop slowly, have flabby tissues, soft bones, and seem poorly nourished. Symptoms. The hypertrophy which often ensues may keep life apparently comfortable for some time, but sooner or later " compen- sation ruptures," when cough, dyspnoea, cyanosis, and death occur. Prognosis. The duration of these congenital affections is short, usually from a few days to a few months ; although several well- authenticated cases record a much longer duration. DIAGNOSIS OF VALVULAR DISEASES. In making a differential diagnosis between the various forms of valvular disease of the heart, strict attention must be paid to the points of greatest intensity at which the several murmurs are heard. A rmirmur occurring with or taking the place of the yirsi sound of the heart — the ventricular systole — heard most distinctly at the apex, transmitted to the left axilla, and to the inferior angle of the scapula, signifies mitral regurgitation — a mitral systolic niuntiur. A murmur occurring with or taking the place of ihejirst sound of the heart, with its point of greatest intensity at the xiphoid appendix, signifies regurgitation at the tricuspid orifice — a tricuspid systolic murmur. 376 PRACTICE OF MEDICINE. A murmur heard with the Jirsi sound of the heart, high-pitched, rasping or grating in character, with its point of intensity greatest at the second right costal cartilage, signifies obstruction at the aortic orifice — an aortic systolic murmur. A murmur heard with \.\v^ first sound of the heart, soft in character, with its point of intensity most distinct at the junction of the third left costal cartilage with the sternum, signifies obstruction at the pul- monic orifice — a pulmonic systolic murmur. A murmur occurring immediately after the second sound of the heart, and immediately before the beginning of the first sound of the heart, signifies obstruction at the mitral orifice — a presystolic tnitrat tnurmur. A murmur heard with or taking the place of the second sound oi the heart, most distinct at the second costal cartilage, to the right of the sternum, and well transmitted toward the apex or below, signifies insufficiency or regurgitation at the aortic orifice — an aortic regurgi- tant or diastolic murmur. Although eight distinct valvular murmurs have been described as occurring in the heart, those on the right side are of rare occurrence, and hence of little clinical importance. If a fnurmur be heard with Xhe, first sound of the heart, it is almost certainly aortic obstructive or mitral regurgitant ; and if heard with the second sound, it is probably aortic regurgitant. A presystolic mitral murmur is also of comparatively rare occurrence, the force with which the blood passes from the left auricle into the left ventricle being, under ordinary circumstances, insufficient to excite sonorous vibrations. Functional or anamic murmurs may be confounded with the va- rious forms of valvular disease of the heart. The chief points of dis- tinction between them are, that an anaemic murmur, which is always heard at the base of the heart, is always systolic in time, not trans- mitted away from the heart, and is soft in character, low in pitch, and of variable intensity, now being heard, now entirely absent. Treatment. There is no special plan of treatment for each form of valvular disease. Prof. J. M. Da Costa says : " I hold that the precise valve affected is not, with our present resources, the keynote to the treatment of valvular heart disease. We are to take as indications: I. The state of the heart-muscle and of the cavities. 2. The rhythm of the heart action. 3. The condition of the arteries and veins and DISEASES OF THE CIRCULATORY SYSTEM. 377 of the capillary system. 4. The probable length of existence of the malady and its likely cause. 5. The general health. 6. The second- ary results of the cardiac affection." A good rule in practice is that if the apex-beat is not displaced, the cardiac dullness is not increased to the right of the sternum, and dysp- noea is absent, medication is not indicated and even may be injurious. The important point to bear in mind in the treatment of valvular disease of the heart is that it is associated either with cardiac hyper- trophy or dilatation, and the treatment, if any at all be required, is directed toward this secondary condition. If compensation be com- plete, attention to the condition of the bowels, kidneys, and digestion, with some general directions as to exercise, are all that is required. If the hypertrophy become excessive, it is best controlled by either acoftittini, veratrinn viride, or spiritus glonoini. If dilatation have occurred, the heart's action weak and feeble, the circulation impeded, and venous stasis has followed, digitalis, caffeines citrata, strophanihus, or sparteines sulphas, with more or less active purgation, is indicated. If fatty degeneration of the heart result, the indications are for car- diac rest, strychnines sulphas, stimulants, strophanthus, or spiritus glonoini, and attention to the excretions. If the cardiac rhythm is disturbed, add belladonna or lithii bromi- dum to whatever other plan of treatment is being used. If the capillary circulation is weak, strophanthus and nitro-glycer- z««7?z(glonoinum) act better than digitalis, which latter has the power of contracting the arterioles. Any of the secondary results of the valvular affection are to be treated according to the particular indications. CARDIAC HYPERTROPHY. Definition. An overgrowth or increase in the muscular tissue which forms the walls of the heart ; characterized by forcible impulse, over-fullness of the arteries, diminished blood in the veins, and accel- erated circulation. Causes. Obstruction to the outflow of blood, resulting from valvular disease of the heart ; emphysema ; Bright's disease ; arterio- fibrosis ; functional over-action ; excessive use of tobacco, tea, coffee, or excessive muscular action. 378 PRACTICE OF MEDICINE. Varieties. I. Simple hypertrophy, or a simple increase in the thickness of the cardiac wails ; II. Eccentric hypertrophy ,'\v\zxt2i%^ in the cardiac walls and dilatation of the cavities, causing a dilated hypertrophy ; III. Concentric hypertrophy, increase in the cardiac walls with decrease of the cavities, a very rare form. Patholog^ical Anatomy. Hypertrophy of the heart is usually limited to the left side, the ventricles more commonly than the auri- cles, the latter dilating. The shape of the heart is altered by hypertrophy ; if the right ven- tricle, the heart is widened transversely and the apex blunted ; if the left ventricle, the heart is elongated and, as a rule, the cavity is dilated ; if both ventricles are hypertrophied, the heart has a globular shape. From increase in weight the heart may sink lower during the recumbent position, thereby lessening the area of cardiac dullness, but during the sitting or upright posture it sinks lower in the chest and to the left, causing more or less prominence of the abdomen. The increase in the size of the organ is a true increase or hyper- trophy of the muscular tissue, and not a hyperplasia. The tissue is firmer and the color brighter and fresher than when the size of the organ is normal. The cor bo^nnum of the old writers is an enormous hypertrophy of the heart with dilatation of its cavities. Symptoms. Depend upon the amount of hypertrophy. The most common are increased and forcible cardiac actioti, the arteries becoming fuller, the veins less full, and the circulation accelerated ; pul- sating carotids and aorta, headache, often vertigo, frequent epistaxis, congestion of the face and eyes, tinnitus auriuin, dyspncea on exertion, dry cough, restless nights, with more or less jerking of the limbs ; oc- casional praecordial pains shooting toward the left axilla; full, firm, bounding pulse, and pulsations in the superficial arteries. A sphygmographic tracing shows the line of ascent vertical and abrupt, but the apex is rounded, and the line of descent is oblique, unless there is more or less insufficiency of the valves. Inspection. Often fullness or prominence of the praecordium, with distinct impulse. Palpation. The impulse is felt one or two intercostal spaces lower down and to the left, and is stronger and more or less diffused — the heaving impulse. Percussion. The area of cardiac dullness is increased vertically DISEASES OF THE CIRCULATORY SYSTEM. 379 and transversely upon the left side of the sternum, unless the right ventricle is also hypertrophied, when the cardiac dullness is increased to the right of the sternum. Auscultation. If simple hypertrophy without any coexisting changes in the valves or orifices, the first sound has a loud and some- what metallic quality, the second sound being strongly accentuated. Sequelae. Cerebral hemorrhage; miliary cerebral aneurisms; dilatation of the heart ; fatty changes in the cardiac tissue. Diagnosis. Hypertrophy of the heart can scarcely be mistaken for any other disease if a careful study of the physical signs be made. Prognosis. When the result of valvular disease, the hyper- trophy is said to be compensatory. If the result of Bright's disease, emphysema of the lung, or if occurring late in life, or associated with atheromatous degeneration of the vessels, the prognosis is unfavorable. When the result of functional over-action in the strong and robust, a further enlargement can often be prevented by active and persistent treatment. Treatment. The indications are, if the hypertrophy be exces- sive, to lessen the force and number of the cardiac pulsations and to remove the cause whenever possible. The former indications are best met by the persistent use of tinctura acofiiti'vsx small doses, Tt\,j-ij (0.06-0.12 Cc), three times a day, or //;zr- tura veratri viridis, Tt\,j-ij (0.06-0.12 Cc), three times a day, and at the same time keeping the bowels, kidneys, and the skin acting freely. A certain amount of hypertrophy is beneficial in chronic valvular disease, and drugs should not be administered simply because a car- diac murmur is discovered on auscultation. The habits of the patient are to be corrected, all laborious or active exercise to be restricted, the patient to be in the recumbent posture several hours during the day if possible, the diet being restricted, avoiding all forms of stimulants, such as liquors, tobacco, tea, and coffee. Cases of cardiac hypertrophy associated with Bright's disease are often relieved by digitalis, the cardiac distress being secondary to the kidney disease, for which the digitalis is used. There is no doubt that in rare instances cardiac pain follows the use of digitalis, which is probably due to the firm and powerful car- diac contractions produced by digitalis ; such cases do better with caffeines citrata or strophanthus. 380 PRACTICE OF MEDICINE. Cases of cardiac hypertrophy associated with anaemia should, in addition to digitalis and rest, be placed upon a course oi/t-rrum. DILATATION OF THE HEART. Definition. An increase in the size of one or more of the cavities of the heart, characterized by feebleness of the circulation, terminat- ing in venous stasis, cyanosis, oedema, and exhaustion. Causes. Over-exertion in those of feel^le resisting powers, as youths or soldiers, as first pointed out by Prof. Da Costa; chronic valvular disease; emphysema; chronic bronchitis; gout; Bright's disease ; alcoholism ; syphilis. Varieties. I. Simple dilatation, the cavities being enlarged, the walls normal. II. Active dilatation, corresponding to eccentric hypertrophy ; the cavities being enlarged and the walls increased in thickness, the so-called " dilated hypertrophy." III. Passive dilata- tion, the cavities being enlarged and the walls thinned or stretched. Pathological Anatomy. The right side of the heart is far more frequently involved than the left side. The shape of the organ is altered, depending on the part affected. The weight of the organ is, as a rule, increased, as hypertrophy almost always accompanies or precedes dilatation. The muscular tissue is generally pale, mottled, and softened, and under the microscope presents evidences of degeneration. The orifices also participate, and especially the auriculo-ventricul.ir orifice, result- ing in the valves becoming incompetent to close the orifices, and this latter efifect is added to by the removal of the basis of the papillary muscles a greater distance from the orifice, in consequence of the extension of the wall. When the auricles dilate, the large venous trunks opening into them unprotected by valves commonly participate in the dilatation, and may become greatly enlarged. The passive congestion of the organs that follows the feeble circu- lation produces changes in their structure. Symptoms. Those associated with enfeebled circulation — to wit : Feeble pulse, veins distended, arteries emptied ; headache, aggravated by the upright position ; attacks oi syncope, cough, with any of the fol- lowing phenomena of venous congestion; of the lungs, dyspnoea; Wvtr, Jaundice ; stomach, dyspepsia; intestines, constipation; kid- neys, scanty, often albuminous, urine ; brain, dullness of the mind DISEASES OF THE CIRCULATORY SYSTEM. 381 and vertigo, often relieved by a copious epistaxis ; and, finally, dropsy, beginning in the lowerextremities, the patient dying from exhaustion. Great relief often temporarily follows any of the above symptoms under treatment ; sooner or later, however, the venous stasis produces the final symptoms noted. Inspection. Veins of the surface distended and enlarged ; in- distinct cardiac impulse, often diffused and wavy ; if associated with tricuspid insufficiency, there is pulsation of the jugular. Palpation. Feeble and irregular fluttering, but heaving impulse. Percussion. Cardiac dullness extended transversely, and espe- cially increased on the right side. Auscultation. If no valvular lesion accompany the dilatation, the cardiac sounds are weaker than normal, the first sounds having a sharper quality than normal ; if accompanied by valvular lesions, cardiac murmurs are present. Diagnosis. Hypertrophy of the heart shows increased cardiac dullness, and is a disease of powerful cardiac action, while dilatation is an affection of feeble action associated with dropsy. Pericardial effusion has many points of resemblance to cardiac dilatation, but it begins suddenly, associated with some acute malady, and while the heart sounds are indistinct or feeble at the apex, they both have their normal qualities at the cardiac base, while dilatation of the heart has a chronic history, results in general venous stasis, the cardiac sounds being of the same intensity over the entire prsecordium. Prognosis. Unfavorable, death resulting from gradual exhaus- tion, or suddenly by cardiac paralysis if there be some undue excite- ment. With careful living life may be prolonged for years. Treatment. Dilatation of the heart is incurable. In all cases there are two important indications : The first to maintain the general nutrition of the patient, and the second to control or prevent all irregular or violent cardiac action. The first is accomplished by a generous diet, moderate exercise, with bitters to increase the appetite QXiA. ferrtim to improve the blood, and, in a majority of cases, the more or less free use of a good red wine. The second indication is met by the observance of strict rules in regard to exercise and such heart tonics as digitalis in powder, tinc- ture, or infusion, or a combination like the following : R. Tincturce nucis vomicae, . . . . f^ss 15. Cc. Tincture digitalis, f^ss 15. Cc. M. SiG. — Fifteen to twenty drops after meals, in water. 3!S2 PRACTICE OF MEDICINE. Drs. Hare and Coplin have demonstrated by careful research that the prolonged use of digitalis actually increased the development of the normal heart muscle. StrychnincE sulphas, gr. ^^ (0.0025 Gm.), three times daily, is a valuable cardiac tonic ; the same may be said of caffeina: citrala, gr. j-iij (0.06-0.2 Gm.), three or four times daily. Sparteina sulpJuis is a powerful cardiac tonic, particularly of service in the dilating heart of Bright's disease. The tinctura strophanthus, alone or in combina- tion with digitalis, is valuable. Extractum convallaiiae fluidum is not always reliable. Morphince sulphas in small doses, particularly when compensation is failing and the dropsy becomes great and is associated with marked cyanosis, hypodermically, as suggested by Prof. Bartholow, " often acts like magic in restoring the circulation." The following pill is often of great advantage : BL. Ferri reduct. , gr. j-ij .065-. i3Gm. Quininas suljih., g""- j~'j .065-.13 Gm. I'ulv. digitalis, gr. j .065 Gm. Moqihinae sulph. , g*"- 2*1 0025 Gm. M. SiG. — Three times a day. An excellent combination is the following: R. Tinct. digitalis, f z iss 6. Cc. Tinct. cacti grandiflor f^j 30. Cc. Caffeine citrata X) 4. C>m. Tinct. card. comp. ad f _^ iv ad 120. Cc. M. SiG. — Teaspoonful, diluted, three or four times daily. The bowels, skin, and kidneys should be kept in action, using, if needed, purgatives, diaphoretics, and diuretics. The following combi- nation, suggested by Dr. J. M. Anders, is satisfactory in many in- stances : B . Caffeinae citrata, 3 j 4. Gm. Strychnine sulph., g""- K .022 Gm. Sparteinru .sulph., gr- ij •'^1 Gm. M. Ft. capsula; No. xij. SiG. — One every three or four hours. Or the following excellent diuretic pill: R. Pulv. scilla: gr. xxx 2. Gm. Pulv. digitalis, gr. xxx 2. Gm. Cafl'eina- citrata, gr. xxx 2. Gm. Hydrarg. chlor. mitis, gr. v .3 Gm. M. Ft. piiuU« No. xxx. SiG. — One three or four times daily. DISEASES OF THE CIRCULATORY SYSTEM. 383 If pulmonary congestion develop, dry cups, digitalis, caffeiyui, atro- pina, and stimulants. For cardiac asthma, dry cups, morpMncz sulphas, hypodermically, or spiritus cetheris compositus (Hoffman's Anodyne). For hepatic congestion, blue mass or podophyllin. For dropsy, dry cups over the kidney, digitalis with potassii acetas, with scoparius diXid juniperus , 2indi pulv.jalapce comp., 3j-ij (4-8 Gm.), in water, before breakfast. If the dropsy is uninfluenced by the above means, success will follow the use of hydrargyri chloridi mitis, gr. iij (0.2 Gm.), guarded with pulves opii, gr. ^^^ (0.005 Gm.), three or four times a day. The treatment of cardiac dilatation and cardiac failure by baths and systematic exercise has excited much interest and discussion re- cently, with the result of its indorsement in proper cases. Exercise is employed in one of three plans or, rarely, a combination of these plans : (i) passive exercise and massage (Swedish or Ling plan) ; (2) movements with limited resistance (Schott plan, but really a modifi- cation of the Swedish); (3) method of climbing (Oertel). The baths to be those of the Nauheim (saline) natural waters. A number of American and English clinicians report good results with artificial Nauheim baths. This system of cardiac treatment is associated with regulated diet and the use of some cardiac tonics, and business rest. ACUTE MYOCARDITIS. Synonyms. Carditis ; abscess of the heart. Definition. An inflammation of the muscular tissue of the heart, by extension from an inflamed pericardium or endocardium, or sec- ondary to pyaemia ; characterized by pain, feeble circulation, symp- toms of blood-poisoning and collapse. Causes. The result of endocarditis or pericarditis ; pyaemia ; typhoid fever; emboli of the coronary arteries. Pathological Anatomy. Discoloration and softening of the cardiac substance and the infiltration of a sero-sanguineous fluid, fibrinous exudation and pus, leading to the formation of abscesses in the muscular structure of the heart. The disease leads to the formation of either a cardiac aneurism or 384 PRACTICE OF MEDICINE. to rupture of the walls of the heart. If recovery occur, cicatrices or depressed scars may mark the site of a former abscess. Symptoms. The clinical evidences of inflammation of the car- diac muscles are very obscure. If, during the course of one of the maladies mentioned, there are developed pracordial pain, irregular and feeble cardiac acfion, cardiac dyspna'a, pyrexia of a low type, with symptoms of blood-poisoning and a tendency to collapse, or the symptoms of the so-called typhoid state, myocarditis may be suspected. Diagnosis. The existence of myocarditis can scarcely ever be anything but a presumption, the signs being all negative rather than positive. If during the course of rheumatism, pyaemia, puerperal fever, typhoid fever, pericarditis, or endocarditis, symptoms of cardiac failure appear suddenly, associated with signs of blood-poisoning and collapse, inflammation of the cardiac muscle may be suspected. Prognosis. The course of acute myocarditis is very rapid, death being the usual termination in from three to five days. Chronic myocarditis pursues a very latent course. Treatment. Largely symptomatic. Perfect rest of mind, gen- erous diet, free stimulation, and the administration of quinina sul- phas, ferrum, and spiritus cetheris nitrosi — a nitrite. CHRONIC MYOCARDITIS. Synonyms. Fibroid heart; chronic interstitial myocarditis; fibrous myocarditis ; chronic carditis ; cardio-sclerosis. Definition. A slowly developing hyperplasia of the interstitial connective tissue of the heart, leading to induration of its substance; characterized by shortness of breath on slight exertion, attacks of tachycardia, prsecordial pain, disordered circulation, and vertigo. It is proper to state that many cases present no symptoms whatever. Causes. The most frequent cause is sclerosis of the coronary arteries, leading to imperfect blood supply to the cardiac muscles. Among other frequent causes are diseases of the kidneys, alcohol- ism, excessive use of tobacco, syphilis, secondary to pericarditis, en- docarditis, and acute myocarditis. There is, undoubtedly, often an inherited predisposition to fibroid changes in the vessels, in which cases the causes named would act as exciting causes. DISEASES OF THE CIRCULATORY SYSTEM. 385 It is a disease of the aged, save in those instances resulting from hereditary predisposition or from excesses. The old saying, " A man is as old as his arteries," is applicable to this disease. Pathological Anatomy. The heart is enlarged and dilated. The morbid changes may be diffused, or limited to the walls of the left ventricle, the papillary muscles, and the septum. There is always more or less atheromatous deposit or changes in the aorta. All cases show atheroma in one, more, or all of the coronary arteries. Com- plete closure of one coronary artery, if produced suddenly, is usually fatal. On section, the cardiac wall cuts with a distinct resistance. The changes in the heart wall are an " overgrowth of the interfibrillar con- nective tissue, with development of fibrous tissue. These changes may be uniformly distributed through the substance of the heart when some intoxication, as by alcohol, or some general disturbance of the cardiac nutrition, has led to the myocardial disease ; or they may be seen in circumscribed areas when embolic or thrombotic occlusion of branches of the coronary arteries has occasioned anaemic infarction and subsequent sclerosis. In either case the microscope reveals masses of wavy fibrous tissue between the muscular bundles, and often slow degeneration or atrophy of the fibres themselves " (Pepper). The terminal branches of the coronary arteries are narrowed and sclerotic to the point of obliteration, particularly in cases resulting from syphilis. "Aneurism of the heart is commonly due to localized cardio- sclerosis. The inelastic fibrous tissue gradually gives way before the intracardial pressure, and saccular dilatation results " (Pepper). Atheromatous changes are often found in other than the coronary vessels, particularly the aorta. Various degenerative changes occur in other organs, the result of disturbed circulatory action. Symptoms. The great majority of patients having chronic myo- carditis present no symptoms until an extra cardiac effort is called for. An early symptom is breathlessness on slight exertion, with either cardiac palpitation or 2l feeble, irregular pulse. Vertigo is frequent and distressing, increased by indigestion and costive bowels. An- ginal attacks (cardiac pain) or a sensation of constriction or pressure over the prascordium are frequent, often following some exertion or an 35 386 PRACTICE OF MEDICINE. attack of indigestion. The pulse-rate is often decreased in frequency in cases which present no other symptom. A frequent symptom is syncope, coming without warning or after sudden exertion, the result of sudden failure of thecerebral circulation. Among other periodical symptoms are cardiac asthma, pseudo- apoplectic attacks, and hepatic, gastric and nephritic disorders. As the fibroid changes progress, there develop progressive weak- ness, dyspnoea, insomnia, disordered digestion, and cerebral weak- ness, often showing itself as mania, delusional attacks, or dementia. Percussion. Increased praecordial dullness is usually present, due to the dilated hypertrophy. Auscultation. The first sound of the heart is valvular in char- acter, the booming or muscular quality having disappeared. Mur- murs are very frequent, the result of valvular disease. A very characteristic condition is the irregularity in rhythm and in force, one contraction being fairly forcible, another weak or feeble, and so on. Diagnosis. A proper appreciation of chronic myocarditis is one of the most important questions in clinical medicine. The term '' Heart Failure'' is the opprobrium of the profession, and yet chronic myocarditis is one of the great causes of cardiac failure during the prevalence of some over-exertion or in acute pneumonia, typhoid fever, and other like diseases. The points of value in arriving at a diagnosis are : a careful study of the first sound of the heart at the apex ; the character of murmurs if present, the condition of the arteries, the dyspnoea, the feeble, irregular pulse in patients past fifty years, and the occurrence of anginal attacks after exertion or mental worry. Prognosis. This is controlled by the habits of the patient. The disease is incurable, but life may be fairly comfortable for many years if care be exercised. Treatment. No remedy can remove the fibroid change. The indications are to promote the patient's nutrition, hold in check the progress of the fibrosis, and meet or prevent the symptoms as they arise. Constipation is often a troublesome symptom, and calls for such drugs as aloes or cascarcs sagrada. For the general zond\\\on, fcrriim , arsettiaim, and the hypophos- phiies. For the breathlessness, spiritus glonoini (nitroglycerin, one per cent.), or spiritus cetheris nitrosi, or spiritus ammonics aromaticus. DISEASES OF THE CIRCULATORY SYSTEM. 387 For cardiac palpitation, potassii bromidum, lithii broniidtmt, or spiritus ammonicB aromatictis. For cardiac weahtess, strychnince sulphas, gr. -^-^ (0.0025 Gm.), three or four times a day, and if the pulse is frequent, tinctura digitalis, Tt\,x-xx (0.6-1.2 Cc), three times daily, or caffeines citrata, gr. iij (0.2 Gm.), after meals ; maintaining the recumbent position and re- moving all unfavorable associate symptoms, as constipation, scanty urine, and dyspepsia with flatulence. For the angijtal attacks, hypodermic injections of niorphince sul- phas, gr. yk-)i (0.008-0.016 Gm.), or chlorodyne, ttlx-xx (0.6-1.2 Cc), repeated as needed. Yorihe syncopal attacks, ihQ'pz.tXenX. should, be placed in bed and stimulants administered, often used by the hypodermic method, with mustard over the praecordium, and Ti^j-ij (0.06-0.12 Cc.) spiritus glo7toini every couple of hours. An excellent combination for breathlessness, vertigo, and chest pains is : R. Lithii bromidi, ^vss 22. Gm. Spirit! glonoini, fl^xv] I. Cc. Liq. potassii citratis, . . q. s. ad f§viij ad 240. Cc. M. SiG. — Tablespoonful four times daily, diluted. The patient must lead a quiet life, refrain from mental worry, phy- sical over-exertion, and eschew tobacco and malt liquors. The diet must be plain and simple, with but little tea or coffee. In the elderly, a small amount of good whisky once or twice a day is valuable. FATTY HEART. Synonyms. Fatty degeneration of the heart ; chronic myo- carditis. Definition. A change in the muscular fibres of the heart, in which the transverse strise are replaced by granules and globules of fat; characterized by feeble cardiac action, venous stasis, and dyspnoea. Causes. Impaired nutrition in the elderly ; prolonged anaemia ; chronic gout ; alcoholism ; phosphorus poisoning ; cancer ; tubercu- losis and scrofula; diseases of the coronary arteries. Pathological Anatomy. The distinction must be made be- 388 PRACTICE OF MEniClNE. tween a deposit of fatly tissue upon or around the heart, and the degeneration of its muscular tissue. The fatty metamorphosis may affect the whole organ, or the entire ventricular walls, or be limited to portions of them. If the degenera- tion be marked, the color is yellowish, the tissues soft and easily torn, and to the touch have a greasy feeling, oil being yielded on pressure. The microscopic changes are characteristic. The striae of the muscle are easily rendered indistinct by fat and oil globules, grad- ually becoming more and more obscured, and finally disappearing altogether, the fibres being replaced by fat granules. Symptoms. Those of weak heart, anaemia of organs, and venous stasis — to wit : feeble, irregular, but slow cardiac action ; com- pressible pulse, prcEcordial distress, often aggravated by attacks of angina pectoris ; dyspnoea, aggravated on exertion, with anaemia of the various organs from the feeble propulsive power; if of brain, vertigo, swooning, or pseudo-epileptic attacks, especially marked on suddenly rising from a recumbent position ; if of lungs, dry, hacking cough ; if of gastro-intestinal tract, dyspepsia and constipation ; if of kidneys, scanty urine, at times albuminous, and finally dropsy, begin- ning in the lower extremities. A formidable symptom, causing much inconvenience as well as alarm to the patient, is what he will term his constant " sighing," the Cheyne-Stokes breathing — "A pause in the breathing, a complete suspension of the respiratory acts for a period of time (during which breathing might occur several times in the normal manner), then the resumption of respiration very feebly and slowly, and a gradual and progressive increase in the number and depth of respirations until the maximum is reached, and then again a gradual and progressive diminution in the same order, in the number and depth of the res- pirations, until another pause occurs " — the " oscillating respiration." Concomitant symptoms are atheromatous changes in the vessels, and the arcus senilis. Palpation. Weak cardiac impulse. Percussion. Not markedly changed unless preceded by enlarge- ment of the heart. Auscultation. First sound feeble, toneless, almost inaudible, the second sound being normal, unless changes in the valves are present. Diagnosis. Feeble cardiac sounds, with slow pulse, attacks of DISEASES OF THE CIRCULATORY SYSTEM. 389 cardiac asthma or Cheyne-Stokes breathing, with evidences of arcus senilis, make the diagnosis very certain. The question of fibroid heart must always be considered. Prognosis. Incurable, the affections pursuing a more or less chronic course. Life may be prolonged at times by treatment, but death finally results from exhaustion, or suddenly from cardiac paralysis or rupture of the heart. Treatment. Incurable, there being no plan of treatment that can restore the degenerated muscular fibre. Generous diet, very moderate exercise, stimulants, oleum titorrhucE, and the " triple elixir " — elixir ferri, quinines, et strychjiince, or the hypophosphites. All the excreting organs must be kept active, so as to relieve the crippled heart as much as possible. To sustain the cardiac action, strychnince sulphas, gr. -j^-^ (0.002- 0.0015 Gm.), three or four times daily, is most valuable. Other drugs are caffeince citrata, spartei?tcB sulphas, or tinctura nucis vomiccB. Digitalis is contra-indicated in advanced cases. For syncopal attacks, nitro-glycerimim {spiritus glonoini), spiritus (Etheris nitrosi, spiritus amtnonicB aromaticus, or hypodermic injec- tions of CEtheris, camphora, or spiritus frumetiti. The recumbent position for hours each day is a valuable means of resting a crippled heart. PALPITATION OF THE HEART. Synonym. Irritable heart. Definition. A functional disturbance of the heart; characterized by increasing frequency of its movements and more or less irregu- larity of the rhythm, with a strong tendency toward hypertrophy. Causes. Over-exertion, " the heart-strain " of Da Costa ; dyspep- sia ; uterine diseases ; excesses in tea, coffee, tobacco, alcohol, or venery ; moral and emotional causes, grief, anxiety, and fear. Symptoms. Usually palpitation of the heart has a sudden onset after some one of the causes mentioned, with prcecordial oppression or pain ; rapid, tumultuous beating, the impulse being visible through the patient's clothing ; dyspitcea, atixiety, and a sense of choking or fullness in the throat, the recumbent position being impossible; vertigo, faintness, flashes of light, the pulse full and strong or feeble, the face 390 PRACTICE OF MEDICINE. flushi-d or pale, the patient having a feeling of anxiety with a sense oi impending danger and a fear of sudden death. These attacks are paroxysmal, lasting from a few moments to several hours, or a day, the patient often voiding a large quantity of limpid urine after the paroxysm has subsided, when there is a strong tendency to sleep. Diagnosis. Irritability of the heart is differentiated from the various forms of cardiac disease by the absence of all the physical signs mentioned as occurring in those conditions. Prognosis. If early and properly treated, favorable. Treatment. The first point in the treatment of irritability of the heart is to remove the cause ; the next, to prevent the recurrence of the attacks of palpitation. The majority of cases do well after a few doses of either spiritus atheris r<7;«/s. On attempt- ing to walk, it is accomplished with difficulty, from an incomplete loss of power. If the upper part of the cord be affected, dyspnaa and palpitation occur. There often occur painful priapism and frequent nocturnal emis- sions. The above symptoms may be followed by a more or less pro- nounced temporary depression, the sensation diminished, and the lower limbs benumbed and heavy, the movements weak. The electro-contractility is preserved, and in many cases even in- creased or exaggerated. Duration. From a few hours to several days; if longer, myelitis may result. Diagnosis. AncBmia causes more or less spinal irritability and tenderness ; but the history, pallor, and general weakness, unasso- ciated with defects of motility or sensibility, will prevent error. Spinal meningeal hetnorrhage is more sudden in its onset, its vio- lence, and its range of symptoms. Myelitis and spinal meningitis have symptoms in common with spinal congestion, which will be pointed out when discussing those conditions. Prognosis. Favorable, recovery occurring in three or four days. If the symptoms show a tendency to linger, myelitis, more or less pronounced, will ensue. Treatment. Rest, but avoid lying on the back; cups or leeches along the spine, followed either by the iced or the hot douche, or hot sponges, with active purgation, to diminish the blood pressure. If the result of suddenly arrested Y>tr%^\r2i\.\on , pilocarpus and a hot- air bath. If following suddenly arrested menses, aconitum. If associated with an active chcu\a.i\oT\,potassiidromidufn,or extracttttn gelsemiifluidiim, r(\y (0.3 Cc), every four hours, or extractum ergotce fluidum, foss-j (2-4 Cc), repeated p. r. n. ; and in all cases active purgation. For the passive form, treating the cause, ergota, digitalis, tonics, and purgatives. DISEASES OF THE SPINAL CORD. 451 PACHYMENINGITIS SPINALIS. Synonyms. Pachymeningitis spinalis interna ; hypertrophic pachymeningitis ; pseudo-membranous pachymeningitis. Definition. An inflammation of the inner surface of the spinal dura mater ; characterized by violent pains in the head, neck, shoul- ders, and arms, followed by contractures and paralyses of the upper extremities. Causes. Exposure to cold and damp ; alcoholism ; syphilis ; gout ; injuries. Pathological Anatomy. Hypertrophic pachymeningitis is characterized by an exudation upon the inner surface of the dura mater, which gradually solidifies into a layer of compact connective tissue, this presses upon the spinal cord and nerves, producing a myelitis and atrophic neuritis, resulting in muscular atrophy. The most frequent seat of this form of the affection is the cervical region, as first demonstrated by Charcot, whence the term cervical hypertrophic pachymeningitis. In the pseudo-membranous form a membranous ex^udation also occurs, in which large numbers of blood-vessels develop and rupture, the hemorrhagic extravasation forming a cyst — hasmatoma — which causes pressure on the cord and nerves. Symptoms. The onset is slow and gradual, with irregular chills arvd. feverishness , violent pains, and stiffness in the head, neck, shoul- ders, and arms, continuous, but subject to exacerbations, and associ- ated with a. painful constriction of the upper thorax. Numbness and prickling occur in the arms, more marked in one than the other. Rarely nausea and vomiting occur. These symptoms may continue off and on for several months, the muscles of the painful parts atrophying, followed by spasmodic contraction, particularly of the hands and wrists, followed later by paralysis. The paralytic stage develops gradually, with weakness in the arms, associated with contractures and rigidity. The pain continues with anaesthesia, hypersesthesia, and trophic changes. Later, paraplegia with rigidity, exaggerated reflexes, and spinal epilepsy develop. The development of tuberculosis and nephritis during the progress of chronic cerebral and spinal diseases, which are the immediate cause of death, is a clinical observation. 452 PRACTICE OF MEDICINE. The tlectro-contractility is lost. Prognosis. If early recognized and promptly treated, the hyper- trophic form may be improved. Generally, however, the prognosis is unfavorable. Treatment. Rest ; nutritious diet ; oleum viorrhua, and the hypophosphites ; large doses oi poiassii iodidum, and repeated but systematic counter-irritation. Symptomatic remedies for the pain and spasms are indicated. SPINAL MENINGITIS. Synonym. Leptomeningitis spinalis. Definition. Inflammation of the arachnoid and pia mater mem- branes of the spinal cord, either acute, subacute, or chronic ; charac- terized by pain in the back, rigidity of the muscles, disorders of motility and sensibility. It may be acute or chronic. Causes. The disease is rare and is always due to an infection from tubercle, syphilis, typhoid fever, or septicaemia, or the result of a traumatism. Pathological Anatomy. Acute. Hyperasmia of the mem- branes, with swelling of the tissues, the result of serous infiltration, followed by purulent and fibrinous exudations. The roots of the spinal nerves are covered with exudation, and are swollen and soft. The cord proper is more or less congested and oedematous. Chronic. Adhesion of the membranes, with more or less accu- mulation of fluid, resulting in atrophic degeneration of the cord from pressure. If the disease is secondary to tubercle, these granulations are seen distributed over the pia, arachnoid, and inner surface of the dura. Symptoms. There are two stages: the first, the stage of irrita- tion ; the second, the stage of paralysis of motion and sensation, with atrophy. Although an inflammatory affection, yet its onset is usually subacute, the febrile reaction being moderate, with intense boring pain in the back, aggravated by motion, rigidity of the spine, and a sense oi constriction around the body, — " the girdle." Spasmodic con- tractions of the muscles enervated by the nerves originating at the seat of the lesion, with inability to straighten the limbs. If the lower part of the spinal membranes is the seat, there occur retention of DISEASES OF THE SPINAL CORD. 453 urine and constipation ; if upper part, dysphagia, dyspncea, a.rvdfeeb/e heart. The muscular contractions are excited or increased by motion, but uninfluenced by pressure. Reflex 77ioveinents are not abolished. The rigidity and spasmodic contraction of the muscles are followed hy paralysis , more or less complete, death following from paralysis of the muscles of respiration. If the inflammation extend to the medulla, the above symptoms are associated with disorders of speech, voiniting, and delirium. Electro-contractility lessened or absent, both as to motility and sensibility in the affected parts. Chronic form succeeds to the acute or originates spontaneously, and presents the same form and order of symptoms — excitation or irritation, and depression or paralysis. Diagnosis. The points of importance are : deep, boring pain in the back, aggravated by motion but not by pressure, with spasmodic contraction of the muscles, followed by paralysis. Myelitis slight, or absence of pain, with earlier and more complete paralysis. Tetanus may be confounded with spinal meningitis. The points of distinction are : in the former occur early trismus with rhythmical spasms excited by irritation of the skin, whereas irritation of the skin does not in spinal meningitis produce muscular contractions, but movement of the limbs does do so ; progressively increasing, and not associated with fever ; usually a clear history of an injury. Prognosis. Generally unfavorable. Death is either sudden, from paralysis of respiration and of the heart, or gradually, the result of exhaustion. Critical discharges, such as profuse perspiration, urinary flow, or epistaxis occur, and are followed by rapid recovery. Cases recover- ing may have more or less pronounced partial or complete paralysis. Treatment. Rest in bed, upon the side or face. Cups or leeches along the spine, followed by ice, the hot douche^ hot sponges, or mustard. Active purgation. If the result of syphilis, full doses of potassii iodidum, gr. x-xl (0.6-2.6 Gm.), combined wiih hydrargyri chloriditm corrosivtmt, gr- -sVtV (0.0025-0.005 Gm.). For the paralytic stage, guinincB sulphas, gr. iij (0.2 Gm.), with extractuin belladonnce alcoholic, gr. }( (0.016 Gm.), three times a day, is sometimes useful. 454 PRACTICE OF MEDICINE. For paralysis, the j^^ahmtiic current to the spine and nerve trunks, and \.\\e faraiiic current to the affected muscles, with the deep injec- tion of strychnina and the use of massage. ACUTE MYELITIS. Synonyms. Acute or general diffuse myelitis ; transverse mye- litis ; softening of the cord. Definition. An inflammation affecting the substance of the spinal cord, which may be limited to the gray or white matter, and involve the whole or isolated portions of the cord.' When the gray matter alone is inflamed, it is termed central myelitis ; when the white matter and the meninges, it is termed cortical myelitis ; it may be ascending, descending, or transverse in its extension. The dis- ease is characterized by more or less sudden and complete loss of motion and sensation. Causes. Following spinal meningitis; exposure to cold and damp or wet weather ; injuries to the vertebra; ; prolonged func- tional activity of the cord; typhus fever; rheumatism; syphilis ; puerperal fever, or, during the course of the exanthemata, arsenical, lead, or mercurial poisoning. Pathological Anatomy. Intense hyperaemia of the substance of the cord, with extravasations, giving the tissues a reddish-brown or chocolate tint, and also serous transudations, resulting in soften- ing of the structure of the cord, the color changing to yellow and white, the nerve elements undergoing fatty degeneration, presenting the appearance and consistency of cream. The membranes also undergo more or less change. Symptoms. The severity of the symptoms depend upon the extent and location of the inflammation. The onset is usually sudden, with a chill, fever, 103° F., frequent pulse, with alterations in sensibility and motility — to wit : pain in the back, aggravated by touch and by heat and cold, with sensations of formication (" pins and needles"), the limb feeling as if asleep, or else complete ancesthesia, associated with severe neuralgic pains. The distinction between ancssthesia, insensibility to touch, and analgesia, insensibility to pain, must be clearly determined. A sensation o{ constriction around the body and limbs, as if encircled by a tight cord, " the girdle pains," is a characteristic symptom, fol- DISEASES OF THE SPINAL CORD. 455 lowed by rapidly developing paraplegia, complete in a few hours, with involuntary discharges. The reflex fiaictions are. usually abol- ished, as seen by attempting to cause movement of the limbs by tick- ling the feet or by striking the patella tendon ; rarely are they dimin- ished, very rarely exaggerated. The temperature of the affected limbs is lowered three or four degrees. Sloughs and bed-sores and muscular atrophy result if the anterior cornua — the trophic centres — are affected. The symptoms of loss of motion ajid sensibility, with rectal and vesical paralysis, are associated with more or less pronounced vomit- ing, hepatic disorders, irregularity of the heart, dyspnoea, dysphagia, apnoea, and painful priapisms. The urine is markedly alkaline in reaction, finally developing cystitis. Among the late manifestations are shooting" pains and spasmodic twitchings or contractions of one or all of the muscles of the paralyzed parts. The electro-contractility is abolished in the paralyzed parts. Diagnosis. Acicte spinal meningitis is distinguished from acute myelitis by severe pains, increased by pressure, with muscular con- tractions increased by motion, followed by paralysis much less pro- found than the paraplegia of myelitis ; in spinal meningitis there exists cutaneous and muscular hypersesthesia, which are absent in myelitis. Congestion of the spinal cordis characterized by the mild character and short duration of all the symptoms. Hemorrhage in the spinal canal is abrupt with irritative symp- toms, slight paralysis, preserved reflexes, and electro-contractility. The principal diagnostic points of acute myelitis are the " girdle " around the limbs or body, rapid and complete paraplegia, loss of sensation, lowered temperature in the affected parts, early and per- sistent sloughing (bed-sores), and alkaline urine or cystitis. Hysterical paraplegia shows no trophic changes, no altered reflexes, slight atrophy, irregular anaesthesia, contractures with impaired sensa- tion of the contracted limb, and the presence of the stigmata of hysteria. LithcEinic parcesthesia, tingling and numbness of fingers and toes, might lead to error if the cerebral symptoms of lithaemia are overlooked. The diagnosis of the location of the lesio7i is made by a study of the height of the ansesthesia, the skin reflexes, and the distribution and extent of the paralysis, which are shown in the following table from Dana, based on that originally devised by Starr and modified by Mills and Dana. 456 PRACTICE OF MEDICINE. LOCALIZATION OF THE FUNCTIONS OF THE SEGMENTS OF THE SPINAL CORD. Segment. Muscles. Reflex and Centres. Sensation. First cervi- Rectus laterales. cal. Rectus capitis. Aiiticus and posticus. Sterno liyoid. Sterno-thyroid. fjecond and Sterno-mastoid. Hypochondi turn (?). Back of head to vertex third cervi- Trapezius. Sudden inspiration and neck. (Occipi- cal. Scaleni and neck. produced by sudden talis major, occipi- Omo hyoid. pressure beneath the lower border of ribs. talis minor, auricu- Diaphragm. laris magnus, super- ficialis colli, and su- praclavicular.) Fourth cer- Diaphragm. Pupillary (fourth cer- Neck. vical. Deltoid. vical to second dor- Shoulder, anterior sur- Biceps. sal). Dilatation of face. Coraco-brachialis. the pupil produced Outer arm. (Supracla- Supinator longus. by irritation of neck. vicular, circumflex. Rhomboid. external musculo-cu- Supra- and infra-spi- taneous, cutaneous.) natus. Fifth cervi- Deltoid. Scapular (fifth cervi- Back of shoulder and cal. Biceps. cal to first dorsal). arm. Coraco-brachialis. Irritation of skin Outer side of arm and Brachialis anticus. over the scapula forearm to the wrist. Supinator longus. produces contrac- (Supraclavicular, cir- Supinator brevis. tion of scapular cumflex, external cu- Deep muscles of shoul- muscles. taneous, internal cu- der-blade. Supinator longus. taneous, posterior Rhomboid. Tapping the tendon spinal branches.) Teres minor. of the supinator lon- Pectoralis (clavicular gus produces flexion part). of forearm. Serratus magnus. Sixth cervi- Deltoid. Triceps (fifth to sixth Outer side and front cal. Biceps. cervical). Tapping of forearm. Brachialis anticus. elbow tendon pro- Back of hand, radial Subscapular. duces extension of distribution. Pectoralis (clavicular forearm. (Chiefly external part). Posterior turist (sixth cutaneous, internal Serratus magnus. to eighth cervical). cutaneous, radial.) Triceps. Tapping tendons Pronators. causes extension of Rhomboid. hand. Latissimusdorsi. Seventh cer- Triceps (long head). Anterior wrist (sev- Radial distribution in vical. Extensors of wrist enth to eighth cer- the hand. and fingers. vical). Tapping Median distribution in Pronators of wrist. anterior tendons the palm, thumb, in- Flexors of wrist. causes flexion of dex, and one-half Subscapular. wrist. middle finger. Pectoralis (costal part). Palmar (seventh cer- (External cutane- Serratus magnus. vical to first dorsal). ous, internal cuta- Latissimus dorsi. Stroking palm neous, radial, me- Teres major. causes closure of dian, posterior spinal fingers. branches.) Eighth cervi- cal. Triceps (long head). Flexors of wrist and Ulnar area of hand, back and palm, inner fingers. border of forearm. Intrinsic hand mus- (Internal cutaneous, cles. ulnar.) DISEASES OF THE SPINAL CORD. 457 LOCALIZATION OF THE FUNCTIONS OF THE SEGMENTS OF THE SPINAL COKD.—Contimted. Segment. First dorsal. Second dor- sal. Second to twelfth dor- sal. First lumbar. Second lum- bar. Third bar. Fourth lum- bar. Fifth lumbar. First and second sa- cral. Third, fourth, and fifth sa- cral. Muscles. Extensors of thumb. Intrinsic hand mus- cles. Thenar and hypothe- nar muscles. Muscles of back and abdomen. Erectores spinae. None. Vastus internus. Sartorius ; adductors of thigh. Flexors of thigh. Extensors of knee. Abductors of thigh. Outward rotators. Flexors of knee. Flexors of ankle. Peronei. Extensors of toes. Calf muscles. Glutei. Peronei. Extensors of ankle. Small muscles of foot. Perineal. Muscles of bladder, rectum, and exter- nal genitals. Reflex and Centres. Epigastric (fourth to seventh dorsal). Tickling mammar\- region causes re- traction of the epi- gastrium. Abdominal{%e.\&\i\.\\ to eleventh dorsal). Stroking side of abdo- men causes retrac- tion of belly. Vasomotor centres. Second dorsal to second lumbar. Cremasteiic (first to third lumbar). Stroking inner thigh causes retraction of scrotum. Patellar. Striking patellar tendon causes extension of leg. Gluteal (fourth to fifth lumbar). Stroking buttock causes dimp- ling in fold of buttock. Achilles tendon. Over- extension causes rapid flexion of ankle, called ankle clonus. Plantar (fifth lumbar to second sacral). Tickling sole of foot causes flexion oftoes and retraction of leg. Genital centre. Vesical centre. Anal centre. Sensation. Chiefly inner side of forearm and arm to near the axilla. (Chiefly intern al cutaneous and nerve of Wrisberg or lesser internal cutaneous.) Inner side of arm near and in axilla. (la- tercosto-humeral.) Skin of chest and ab- domen, in bands run- ning around and downward, corre- sponding to spinal nerves. Upper gluteal region. (Ii]tercostals and dorsal posterior nerves.) Skin over groin and front of scrotum, (llio-hy pogastric, ilio-inguinal.) Outer side and upper front of thigh. Lum- barregion. (Genito- crural , external cuta- neous.) Front and outer side of thigh. Inner side of leg and foot. Inner side of thigh, leg, and foot. (Internal cutaneous, long sa- phenous, obturator.) Back of thigh and outer side of leg and ankle; sole; dorsum of foot. (External popliteal, external saphenous, musculo- cutaneous, plantar.) Back of buttock and thigh ; side of leg and ankle ; sole ; dorsum of foot. Circumanal region, anus, rectum, penis, urethra, vagina, perineum. (Small sciatic, pudic, inferior hem- orrhoidal, inferior pudendal.) 458 PRACTICE OF MEDICINE. Prognosis. Depends upon the location of the lesion and com- pleteness of the symptoms. If the paralysis is of the ascending variety, death occurs within a few days, from paralysis of the muscles of respiration. If the trophic centres are affected, there occur bed-sores, intense pyelo nephritis and cystitis and changes in the joints ; death from exhaustion in several weeks. Central myelitis, or inflammation of \}[\& gray matter, is rapid in its progress, death occurring in a week or two. The morbid process may be arrested and the general health restored, but some spinal symptoms will persist. Treatment. Absolute rest is essential to even secure a palliation of the symptoms. Locally, considerable relief follows the use of hot-water bags or sponges dipped in //t?/ water and applied along the spine every few hours. The remedies most strongly recommended are : digitalis, strychnince sulphas, ergota, belladonna, bromides, cimicifuga, and qitinince sulphas, although I have never observed a cure with any plan of med- ication after the disease was fairly established. Cases due to syphilis are benefited by large doses oi potassii iodidum. Gray reports having administered 700 grains daily before improvement began. INFANTILE SPINAL PARALYSIS. Synonyms. Myelitis of the anterior horns; poliomyelitis ante- rior acuta ; essential paralysis of children ; atrophic paralysis of chil- dren. Definition. A rapidly developed inflammation of the anterior horns of the gray matter of the cord, occurring suddenly in children, at times in adults, — acute spinal paralysis of adults, — characterized by mild fever, muscular tremors and twitchings, and paralysis of groups of muscles, followed by more or less atrophy. Causes. Essentially a disease of early life — the second month to the third or fourth year. The fact of its having occurred in adults must be borne in mind. Cold and damp ; dentition (?) ; injuries to the spine ; developed during convalescence from the acute exanthe- mata. DISEASES OF THE SPINAL CORD. 459 Pathological Anatomy. The early changes are : Medullary hyperaemia, vascular exudation and inflammatory softening, although the naked eye may not recognize any changes. Microscopical exam- ination reveals inflammatory softening of the anterior horns of the gray matter. Among other constant lesions are atrophic degenera- tion of the multipolar ganglion cells and of the anterior nerve roots. The changes noted as occurring in the cord are usually limited to the dorso-lumbar and cervical enlargements. As a direct result of the changes in the trophic centres and the nerve degeneration of the muscular fibres supplied, there ensue changes in the bones and joints, leading to great deformities. Symptoms. The onset of the aflection varies ; it may be acute, subacute, or chronic ; it is usually sudden, with an attack of mild fever of a remittent type, of a few days' duration, on recovery from which it is noticed that the child is paralyzed. Rarely, the paralysis may be preceded by convulsions. The paralysis may affect both arms and both legs, the legs alone, or only one of the four extremities ; it may, but very rarely, be a hemiplegia. As a rule, however, the leg suffers more frequently than the arm : in paralysis of the leg the muscles below the knee suffer more severely than those above. The bladder and rectum are not affected, or if so, only temporarily, nor can anaesthesia or numbness be detected. The temperature of the paralyzed limb is low and the appearance cyanosed. After a few days there is a slight improve- ment in the paralyzed parts, although the muscles show a rapid wasting, which is progressive until all muscular tissue is gone. The reflex movements are impaired or abolished. The electro-contractility by the faradic current is abolished in the paralyzed parts. With the galvanic or constant current the " reactions of degenera- tion " are developed. To fully understand the meaning of this term a knowledge of the normal electrical reactions is necessary. The normal formula for the production of muscular contraction in the physiological state are as follows, the strength of the current being barely capable of causing fair contractions : First. The most effective contractions are produced by the cathode {negative) pole on closing the circuit (C. C). Second. The second most effective are produced by the anode {pos- itive) pole on closing the circuit (A. C). 460 PRACTICE OF MEDICINE. Third. The next most effective is by the anode pole on opening the circuit (A.O.). Fourth. Cathode pole contractions on opening circuit are rarely seen in the physiological state (C. O.). The " reactions of degeneration " are shown by any reversal of the regular formula: — to wit : if the anodal closure (A. C.) shows stronger contractions than lathoda/ closure (C. C.) ; still greater degeneration is shown \{ anodal openingf^K. O.) contractions are stronger than either of the above ; and most complete degeneration is shown by the complete reversal of the normal formulae as shown by distinct ^aM^r/a/ opening (C. O.) contractions. Sequelae. Amongst the deformities resulting from the paralysis are the different forms of talipes. Talipes equinus, the result of paralysis of the antero-external mus- cular group of the leg. Equino-varus, the result of paralysis of the antero-external mus- cular group of the leg, together with the adductors of the foot. Talipes calcaneus, the result of paralysis of the muscles of the calf of the leg. Talipes cavus, — " pes cavus," — characterized by the hollowing of the sole of the foot, with prominence of the instep, the result of paralysis of the calf muscles with contraction of the long flexor of the toe or the long peroneus — the foot flexors. Diagnosis. The recognition of acute poliomyelitis is not always possible at the onset or during its early days, as localized paralyses are difficult of detection in children, but immobility of one leg or arm in children with febrile symptoms or following convulsions is always an indication of poliomyelitis. After the initial stage has passed, the presence of paralysis, wasting, presence of R. D. (reactions of degen- eration), loss of reflexes, and the absence of anaesthesia, render the diagnosis very easy. Hemiplegia from acute cerebral affections in children can be dis- tinguished from infantile paralysis by the disorders of intelligence and the special senses, and the perseverance of the normal electro- contractility. Paralysis of myelitis occurs in older persons, and is associated with disturbances of the genito-urinary organs and bed-sores. Pseudo-muscular hypertrophy, with paralysis, begins gradually, becoming progressively worse with increase in the size of the limbs. DISEASES OF THE SPINAL CORD. 461 Prognosis. More or less paralysis, with muscular wasting, always results, although there is no doubt that the extent can be greatly lessened by early recognition and treatment. Treatment. The diagnosis during the initial fever is impossible, so that its treatment is symptomatic. On the appearance of the paralysis, complete rest, hot spinal douche, mild galvanism, and internally, quitiina, belladonna, ergota, d.w.A. potassii iodidinn. With the improvement that follows the above measure, use inter- nally ti7icinra nucis vomicce, Tr\j-iij (0.06-0.2 Gm.), three times daily, or hypodermic injections of strychnine sulphas, gr. t\- ioq (0.004- 0.00065 Gm.), according to age, twice a week, d^ndi faradism to the paralyzed muscles. CHRONIC PROGRESSIVE BULBAR PARALYSIS. Synonyms. Glosso-labio-laryngeal paralysis ; bulbar paralysis. Definition. A chronic degenerative affection of certain nuclei of the medulla oblongata ; characterized by a slowly progressive bilateral paralysis of the tongue, lips, palate, pharynx, and larynx, with atrophy of the tongue and lips. Causes. Obscure. Rare before the fortieth year. Among many others may be named cold, rheumatism, gout, syphilis, and injuries about the neck. Pathological Anatomy. " Degenerative atrophy of the gray nuclei in the floor of the fourth ventricle ; with atrophy and gray dis- coloration of the nerve roots from the medulla, especially of the facial and hypoglossal nerves." " Atrophy and disappearance of the motor ganglion cells are always to be noted. It may be the sole lesion." " The nerves going to the muscles exhibit sclerosis of the neuri- lemma, and the degenerative atrophy is found in the nerve roots coming from the bulb." Symptoms. The disease begins insidiously. There is first noticed some difficulty in articulation, from want of precision in movements of the tongue; particularly in the use of the lingual con- sonants, /, n, r, and /, which increases until that organ is completely paralyzed. The /ara/j/jz^ gradually invades tht soft palate 7\.r\d. pharyn- geal muscles, causing difficulty in deglutition, of the orbicularis oris preventing closure of the lips, of the laryngeal muscles, interfering 462 PRACTICE OF MEDICINE. with arlicHlaiion. With the increasing loss of power in the tongue and lips is also a gradual atrophy of these nuisc les ; tlie atrophy usually antedates the paralysis. When the disease is fully devel- oped, the condition of the patient is most pitiable, indeed ; articulation is impaired or impossible, deglutition interfered with, the lips remain- ing apart allowing the saliva to dribble from the mouth and liquids to return through the nose with attempts at swallowing. As the malady progresses, the pneumogastric nucleus becomes involved, resulting in loss of voice, difficulty of respiration, and cardiac irregu- larity. The general health gradually suffers from insufficient nutri- tion and imperfect respiration, although the inimi is clear until the end. The " reactions of degeneration " are present. Besides the chronic bulbar paralysis, there are two acute forms with the same symptoms as the chronic cases, only they develop suddenly, one, the result of hemorrhage into the nieduHa, which at the onset has vertigo, vomiting, loss of power in the limbs, and slight sensory disturbances, all of which disappear, leaving the glosso- labio-laryngeal paralysis ; the second form comes suddenly, with fever, vomiting, and loss of power in the limbs, soon disappearing, leaving the characteristic bulbar symptoms; this variety is inflam- matory and closely allied to acute poliomyelitis. Diagnosis. It can hardly be confounded with any other malady. Prognosis. Unfavorable. The duration is from one to five years. Treatment. Entirely symptomatic. " Galvanism is the most promising remedy. Stabile applications, the electrodes on the mas- toid processes and in the opposite direction, galvanization of the sympathetic, and applications to the lips, tongue, and fauces, should be persistently used" (Bartholow). PROGRESSIVE MUSCULAR ATROPHY. Synonyms. Wasting palsy ; chronic spinal muscular atrophy; chronic jjoliomyelitis ; amyotrophic lateral sclerosis. Definition. A chronic progressive motor paralysis and atrophy of certain groups of muscles. The paralysis proportionate to the wasting or fibrillary atrophy. Causes, Most frequent in males between twenty-five and fifty DISEASES OF THE SPINAL CORD. 463 years of age, and in many instances is hereditary. A predis- position seems to exist in those who habitually use one set of muscles (muscular strain). Exposure to cold and damp; lead; syphilis ; injuries to the spinal column. Following such acute diseases as diphtheria, measles, acute rheumatism, typhoid and typhus fevers. Pathological Anatomy. Two theories as to the origin of the pathological changes are held : one that the initial lesion is in the cord (Charcot), the other in the muscular interstitial connective tissue (Friedreich). The morbid alterations are of two groups — spinal and muscular. The spinal changes consist in the atrophy and degeneration of the anterior columns, wasting and disappearance of the multipolar gan- glion cells of the anterior horns, with hyperplasia of the neuroglia; rarely, the hyperplasia extends to the lateral columns (amyotrophic lateral sclerosis) ; also wasting, atrophy, and degeneration of the anterior nerve roots. The muscular changes consist of a progressive wasting of the mus- cular tissue, with increase of the interstitial connective tissue. " The final result is that the muscle is converted into a mere fibrous bard with numerous fat-cells, the development of this latter material taking place outside of the muscular elements and in the newly-formed connective tissue " (Bartholow). Symptoras. The invasion is gradual, the disease having been in progress some weeks or months before the patient is aware of its existence. In the immense majority of cases the disease is permanently lim- ited to one or a few groups of muscles in the upper, or more rarely in the lower, extremities. The only muscles not yet known to be at- tacked are those of mastication and those that move the eyeball (Roberts). Fibrillary contraction is an early symptom, continuing more or less marked so long as any muscular fibres remain. It consists of wave-like 7novements of the muscles, excited automatically, by draughts of air or percussion. Coincident with the wasting is loss of power, disorders of sensation, coolness and pallor of the surface. 'The natural roundness and contour of the body and limbs are changed, the bones standing out in unaccustomed distinctness, giving the individual the appearance of a skeleton clothed in skin. 464 PRACTICE OF MEDICINE. Four types of the disease are recognized : i, the hand-type; 2, the juvenile type ; 3, the infantile facial type ; 4, the peroneal type. The hand-type : uiasting begins in the hand, and particularly in the short muscles of the thumb and the ball of the little finger — the thenar and hypoihenar eminences. The complete atrophy of the thumb muscles produces such a change in the shape of the hand as to give it the name of the ape-hand. Soon, and may be at the same time, wasting of the dorsal interosseous is observed, with consequent loss of power in these muscles, producing the deformity known as claw-hand. Soon the deltoid and other arm muscles are involved in the wasting and contraction. The juvenile type (Erb) : a rare form, affecting the muscles of the shoulder and upper arm, and less commonly the muscles of the lower extremities. This form follows after a time in the hand-type, but Erb described cases occurring primarily in these parts. Rarely, wasting in the suprascapular muscles, with fibrillary contractions, is seen alone. The infantile facial type: involves the muscles of expression, changing entirely the appearance of the individual and giving the eyeballs a prominence from atrophy of the surrounding muscles, not unlike exophthalmos. After a time, the muscles of the shoulder and arm are involved, except the supraspinalis, infraspinalis, and the flexors of the hand and fingers. The peroneal type : wasting first appears in the muscles of the legs, extending to the feet, producing single or double club-foot. After a time, the muscles of the hands and arms are involved, with the conse- quent deformities. Vasomotor changes are observed in this type. Rarely, all the types are more or less blended in the same indi- vidual. Usually, the electro-contractility is preserved so long as muscular fibres remain. Diagnosis. When wasting palsy is fully developed, its diagnosis is a simple matter. In its early stages a doubt may exist, but atten- tion to the history, symptoms, and progress will determine the ques- tion. Syringomyelia often begins with muscular atrophy as a marked symptom, and may be confounded with wasting palsy, the chief points of distinction between which are : the loss of power of perceiving heat, or, often, to distinguish between heat and cold, and the appearance of trophic changes, such as a dusky or purplish hue of the hands, DISEASES OF THE SPINAL CORD. 465 with a uniform tliickness resembling myxoedema, the development of blebs and ulcers, and changes in the nails. Arthropathies are some- times met with. Prognosis. A^ery unfavorable, although the danger to life is often very remote. The disease may be arrested and remain stationary for years. Treatment. Internal medication seems to have no effect on the malady, although if mineral poisoning be suspected, ^ofasszt zodidi/m should be employed, and if syphilis be suspected, a course oi potassii iodiduin and hydrargyru7n should be administered. Arsenuiun, strychnine sulphas, and oleum morrhuce, with a generous diet, are amongst the remedies indicated. If the disease is the result of overworking any set of muscles, these must be allowed a rest. " The most effective remedy in wasting palsy is, undoubtedly, ^a/- vanisjn. Numerous observations attest its value when applied locally to the affected muscles " (Roberts). I have seen improvement from Xhefaradic current to the affected muscles, the strength being simply sufficient to produce contractions. Massage is a valuable adjuvant to the electrical treatment, as are hot sponging and rubbing along the spine. Prof. Bartholow " has apparently effected great improvement in a case, confined as yet to the left upper extremity, by the injection of glycerin solution into the wasting muscles." SPINAL SCLEROSIS. Synonym. Duchenne's disease. Definition. A myelitis ; an increase in the connective tissue of the spinal cord, with atrophy of the nerve structure proper. Varieties. I. Lateral sclerosis. II. Posterior sclerosis, or loco- motor ataxia. 111. Ataxic paraplegia. IV. Cerebro-spijial sclerosis. Causes. Generally a hereditary neuropathic diathesis ; syphilis; alcoholism ; mineral poisons ; shock or injuries to the cord ; exposure to cold and wet ; mostly occurring between the ages of thirty-five and fifty-five ; males more liable than females. It is said that railroad enginemen and firemen, as well as conductors and other trainmen, suffer from this and other spinal diseases by reason of the continual 30 466 PRACTICE OF MEDICINE. concussion of railway travel. The freedom from the disease in the negro has been noted by Mitchell. Pathological Anatomy. The chan/o- along the course of the nerve, preferably with the Paquelin cautery or a poker at white heat, with full doses oi potassii iodidum, are usually successful. Sodii salicylas, phenacetin, and antifebrin are often valuable, but for severe pain no drug is to be compared with morphincB sulphas by the hypodermic method. From the onset quinines sulphas, gr. ij-v (0.13-0.3 Gm.) every four hours, is most valuable, and if the attack be due to exposure to cold or damp, combine sodii salicylas, gr. ij-v (0.13-0.3 Gm.), in capsule. As the more acute symptoms subside, the use of galvanism or a feeble, slowly interrupted faradic current restores the disordered function of nerve and muscle. If anaemia be present, make use oiferrutn, with malt and the hypo- phosphites. MULTIPLE NEURITIS. Synonyms. Polyneuritis; peripheral neuritis; disseminated neuritis; degenerative neuritis; pseudo-tabes; alcoholic paralysis; beri-beri (Brazil and India) ; kakke (Japan). Definition. A parenchymatous inflammation of a number of symmetrical peripheral nerves, simultaneously or in rapid succes- sion ; characterized by pain, numbness, loss of power, or ataxia, with muscular atrophy. Mental symptoms are often associated. DISEASES OF THE NERVES. 477 Causes. Alcoholism; syphilis; malaria; lead, arsenic, or silver ; following diphtheria, typhoid fever, and rheumatism. Beriberi and kakke are epidemic varieties of multiple neuritis, the result of a special poison. The probability is that the various causes named develop in the blood a poison, having a particular susceptibility or " selective action " for nerve-fibres. Pathological Anatomy. The affection is generally bilateral and symmetrical. An important characteristic is its peripheral dis- tribution, the inflammation being most intense at the extremities of the nerves, lessening progressively toward the centre, usually termi- nating before the nerve roots are reached. The inflammatory process affects the nerve-fibres primarily and the sheath and connective-tissue secondarily — a parenchymatous inflammation. The affected muscles are paler and smaller than normal, the fibres reduced in size and undergoing granular changes. Symptoms. All plans yet suggested for classifying the varieties of multiple neuritis are imperfect. The onset may be sudden, even overwhelming, causing rapid death, but is usually subacute or chronic in its course, the symptoms being wide-spread in proportion to the acuteness, intensity, and cause of the malady. The symptoms may be described under three forms — a motor, a sensory, and an ataxic fortn. The motor form shows motor weakness, chiefly involving the flexors of the ankles, the extensors of the toes, and the extensors of the wrist and fingers in the forearms. Inflammation of the anterior tibial or peroneal nerve in the leg, and the radial branch of the musculo-spiral in the arm, resulting in the double "foot-drop" and "wrist-drop" so characteristic of this disease. Any nerves of the body may be affected, the symptoms varying with the particular nerves. The sensory form shows pains, tenderness, tingling, and numbness with loss of cutaneous sensibility. At times the hypersesthesia of the extremities is so marked, and especially that of the soles of the feet and the muscles, that the slightest touch cannot be tolerated. The ataxic form shows inco-ordination with or without sensory disturbances, but with loss of the muscular sense. The forms may all be associated, in greater or less extent, in any one case. 478 PRACTICE OF MEDICINE. Muscular atrophy begins early and progresses with the disease. The knee-jerk is feeble or absent. The electro-contractility is feeble or lost. In alcoholic cases, there may be delirium, mania, and delusions, associated with tremors. Foot-drop is a typical symptom in alcoholic neuritis. Trophic changes may occur in the nails, hair, and skin. The characteristic glossy condition of the skin, with some oedema, is due to involvement of the vaso-motor nerves. Rarely the vagus, optic, and laryngeal nerves are involved. The disease may be ushered in with fever, ioi° F.-i03° F. ; rapid, feeble pulse ; headache, nausea, vomiting, with delirium or con- fusion. The alcoholic variety affects chiefly all the limbs, beginning in the flexors of the feet ; the malarial, the legs ; diphtheria, the pharyngeal and motors of the eye; rheumatic, the face; and lead, the arms. Beri-beri, or endemic neuritis, is an infectious form of multiple neuritis due undoubtedly to micro-organisms. It is claimed that some defect in diet is a predisposing cause of this variety. The symptoms and development are much the same as seen in other varieties with the addition of ccdema and a tendency to effusions into the serous cavities and a cardiac involvement. In severe cases the pain is in- tense and the wasting rapid. Diagnosis, In no disease is an early diagnosis so important from a therapeutical standpoint. Early treatment may prevent months of suffering and idleness. Since the symptoms of this wide-spread affection have been prop- erly separated from diseases of the spinal cord, with which they were formerly always associated, the diagnosis is very readily deter- mined. Loss of power is an early symptom, usually beginning in the feet and extending upward so that multiple neuritis may be mistaken for Landry's paralysis. Ross considers these affections identical, but usually Landry's paralysis is a cord disease. Prognosis. As a rule, favorable if early and proper treatment be instituted. Treatment. Rest is of the greatest importance ; the more thor- oughly this is carried out, the better will be the results. Removal of the cause is an important indication. Warmth to the DISEASES OF THE NERVES. 479 affected parts by flannel next to the skin, hot baths, and keeping the parts wrapped in cotton-wool. There is no specific drug for polyneuritis. For alcoholic cases use strychnines nitras ; for malarial cases, quiniticB sulphas ; for diphthe- ritic cases, tinctura ferri chloridi and strychnincB stdphas ; for rheu- matic cases, sodii salicylas, salol, or phetiacetm ; for syphilitic cases, hydrargyrum or potassii iodidutn ; for lead or other mineral poison cases, the iodides ; and in all varieties, tonics with a generous nutri- tious diet. Paift should be relieved with either ayttifebrin, or mo7'phiticE sulphas, by the hypodermic method. As convalescence begins, moderate exercise and mild galvanism. Arsenicuin is considered the best constructive tonic for the convalescence of multiple neuritis. NEURALGIA. Definition. A disease of the nervous system, manifesting itself by sudden pain of a sharp and darting character, mostly unilateral, following the course of the sensory nerves. Varieties. \. Neuralgia of the fifth nerve; II. Cervico-occipital neuralgia ; 111. Cervico-brachial neuralgia ; IV. Dorso-intercostal neuralgia; V. Ltunbo-abdojninal neuralgia; VI. Sciatica; VII. Erythromelalgia (Mitchell). Causes. Hereditary. Ansemia ; malaria ; syphilis ; metallic poi- sons ; anxiety ; mental exertion ; exposure to cold and damp ; in- juries of a nerve trunk. Pathological Anatomy. The old axiom of neuralgia being " the cry of the nerves for pure blood'' is perhaps only part of the truth. The changes in the nerve trunks or centres have not as yet been fully determined. A fair number of cases present the changes of neuritis. NEURALGIA OF THE FIFTH NERVE. Synonyms. Tic-douloureux ;_ Fothergill's disease. Symptoms. Paroxysmal paiji, of a sharp, darting, stabbing character, most common at points along the course of the supra- and infra-orbital branches of the fifth nerve of the left side, attended with increased lacrymation. When of any duration, nutritive changes are observed in the nervous distribution, such as cedetna along the course of the nQxwe, gray eyebrows, and convulsive twitches of the muscles, 480 PRACTICE OF MEDICINE. termed " tic-doitlonreux," tetiderness at the infra- and supraorbital foramina, as well as along the course of the nerve distribution. CERVICO-OCCIPITAL NEURALGIA. Symptoms. Paroxysmal pain, of a sharp and lancinating, or deep, heavy, tensive character, along the course of the occipital nerve upon one or both sides, extending from the vertex, and on the neck as far down as the clavicle, and upward and forward to the cheek. May be associated with hypercEsihesia of the skin, and with cramps \n the cervical muscles, and with attacks of herpes. A sensation of cracki7ig at the nape of the neck is an annoying symptom in many cases. CERVICO-BRACHIAL NEURALGIA. Symptoms. Paroxysmal paifi of a severe, boririg, burning, or tensive character, with setisations of numbness and weakness of the arm, hand, shoulder, scapula, and mamma, with tenderness along the cervical plexus. CEdema of the arm and other parts along the dis- tribution of the cervical plexus occur if the neuralgia be of long dura- tion, the result of nutritive changes, the limb at times becoming pale, the skin glossy, dry, and harsh. DORSO-INTERCOSTAL NEURALGIA. Symptoms. Paroxysmal pain of a sharp, and lancinating char- acter, along the fifth and sixth intercostal spaces, often associated with the development of herpes, the so-called herpes zoster, or " shingles." Tenderness at the points where the nerves emerge from the inter- vertebral foramina at the sides of the chest and at points in front. LUMBO-ABDOMINAL NEURALGIA. Symptoms. Paroxysmal pain of a sharp and lancinating, at times heavy and dull, character, following the course of the ilio-hypo- gastric nerve, ilio-inguinal and external spermatic nerve, supplying the integument of the hip, the inner side of the thigh, the scrotum and labium. SCIATICA. Definition. A neuritis. Pain following the course of the sciatic nerve. The sacral plexus is made up of the fourth and fifth lumbar and the first two pairs of sacral nerves. DISEASBS OF THE NERVES. 481 Symptoms. Sciatica usually follows an attack of lumbago, the pain becoming fixed in the sciatic nerve ; at times it is a true neuritis. The pain is sharp, tearing, shooting, or lancinating in character, increased upon motion, shooting along the course of the nerve into the hip, inner side of the thigh, calf of the leg, ankle, and heel, at one or all of these points, in paroxysms lasting from a few hours to twenty-four hours or longer. The tactile sensation in the foot and motility in the limbs are impaired, and if of long duration, wasting of the limb occurs. ERYTHROMELALGIA. Synonyms. " Red neuralgia." Symptoms. This form of neuralgia was first described by Dr. S. Weir Mitchell. The/^.?/ principally, are affected by intense redness and burnijig pain. For a considerable period before the condition is typically developed there are aching pains in the feet, particularly when used. The feet, in Dr. Mitchell's own words, " get redder and redder, the veins stand out in a few minutes as if a ligature had been tied about the limb, and the arteries throb violently for a time, until at length the extremities become of a dark purplish tint." As a rule, the redness only occurs when the feet hang down, and when at rest they may be pale and perspire freely. Blisters and ulcers follow slight contusions of the feet. Diagnosis. Erythromelalgia has been confounded with Ray- naud's disease. The presence of pain, bright redness, throbbing, and increased temperature of the part are all the opposite of Raynaud's disease. PROGNOSIS OF NEURALGIAS. If promptly and properly treated, unless the result of pressure of an exostosis, aneurism, or other tumor, favorable, save for erythro- melalgia. TREATMENT. Rest; easily assimilated but nutritious diet; removal of the cause, if possible. If ^.n^rmc, ferricm and arsenicum. If rheumatic, alka- lies and sodii salicylas. If syphilitic or the result of metallic poisons, potassii iodidu7n. If malarial, quinincB sulphas, or hydrochloras. For an attack, tnorphince sulphas and atropines sulphas, hypoder- mically, afford the most prompt and ready relief. Success usually follows the use of the well-known " Gross (Prof. S. D.) neuralgic pill " : ai 482 PRACTICE OF MEDICINE. . Quinina.* sulphat., gr. ij .13 Gm Morphinne sulphat gr. ^'^ .003 Gm Strychninre sulphat., • • • • gr- 7V .002 Gm Acidi arseniosi, g""- uV .003 Gm Extract! aconiti, gr. ^ .032 Gm Ft. pil. No j. SiG. — One every one, two, or three hours. Few attacks of trigeminal neuralgia will resist the following powerful prescription : R . Aconitinse (Duquesnel), . . . gr. ^'5 .006 Gm. Glycerini, Alcoholis, ^'T-foJ ^^ 4- Cc. Aqucc menth. pip., .... adf^^ij ad 60. Cc. SiG. — Teaspoonful, repeated from four to eight times daily, carefully watching. For the pains of intercostal neuralgia, the following is recom- mended : R. Chloral, 3J 4- Gm. Pulv. camphorre, 3J 4. Gm. Menthol, 3J 4. Gm. Mix and rub together. SiG. — Paint over painful parts with brush, p. r. n. Facial neuralgia is often wonderfully benefited by the internal administration of extractum gelscmii Jluidum, n\,iij-v (0.2-0.3 Cc), every three or four hours until its physiological effects are produced; cannabis indica or belladonna may be combined with the gelsemium. Excellent results often follow the administration of Moussette" s pills (aconitine and quinine). For sciatica, antipyrin, gr. xx (1.3 Gm.), repeated two or three times daily, has given relief, as hssplienacetiti and a7itifebrin. The deep injec- tion of chloroformtan is recommended by Bartholow. Nitroglycer- inum has been strongly recommended for sciatica, beginning with one drop of a one per centum solution three or four times a day and gradu- ally increasing the dose until four or five drops several times daily are taken. Dr. Mitchell is a strong advocate of the application of a flannel bandage for the entire leg, changed daily, and a splint reach- ing from the axilla to the heel, held loosely to the limb, and tonics. Rarely, he uses cocaiitCB hydrochloras gr. \ (0.016 Gm.) hypodermically over a painful spot. A spray of chloride of methyl along the course DISEASES OF THE NERVES, 483 of the nerve for a few moments, watching the skin, will relieve the distressing pain. Rarely, full doses of potassii iodidum with a blister along the course of the nerve gives relief. For erythromelalgia all drug treatment has failed to cure. Rest and elevation of the limb gives rehef. Dr, Mitchell recommends either nerve stretching, and in aggravated cases nerve excision. All forms of neuralgia are more or less benefited with — ^. Quininse sulph., gr- iij -2 Gm. Ferri reduct, gr. j .065 Gm. Acid, arseniosi, g^- 2V -^^S ^™* Aconitise, gr. yi^ .00054 Gm, In pill, every four or five hours. FACIAL PARALYSIS. Synonjmi, Bell's palsy. Definition. An acute paralysis of the seventh cranial, — the facial nerve, the great motor nerve of the muscles of the face, — the nerve of expression. Causes, Exposure to a current of cold air against the side of the face — over the pes anserinus — is the most frequent cause. Also due to injury or disease of the middle ear. Syphilis, Symptoms. The facial nerve supplies the muscles of the face, the muscles of the external ear, also the stylo-hyoid, posterior belly of the digastric, the platysma, one muscle of the middle ear, the stape- dius, and one palate muscle, the levator palati ; by means of the chorda tympani branch it controls the secretion of the parotid and submaxillary glands, and, possibly, the sense of taste. It also furnishes motor power to the azygos uvulae, the tensor tympani, and the tensor palati muscles. The onset is usually sudden, with tingling of the lips and tongue, and upon looking into the mirror the patient is surprised by the per- fectly blank, motionless side of his face ; the corner of the mouth is depressed, the eyelids open, the face drawn toward the well side, and the patient is unable to expectorate, whistle, or swallow. Any of the muscles innervated by the nerve may participate in the paresis. The electro-contractility is feeble or lost. The reflexes are abolished. 484 PRACTICE OF MEDICINE. Diagnosis. Paralysis of the muscles of the face occurs in hemi- plegia ; the points of ditTerentiation are the presence of cerebral symptoms and the normal reflex excitability. Facial palsy with otorrhcea, ' imperfect hearing, obliquity of the uvula, and loss of taste determine its origin within the aqua;ductus Fallopii. It is due to peripheral neuritis if the taste be normal and the uvula straight. If other nerves are also involved, the origin is central. Prognosis. Favorable. Treatment. If the result of cold and damp, diaphoresis with pilocarpus, or diuresis with potatsii acetas, vel iodidum, and blisters in front of the ear, and the use of galvanism to the affected muscles. GENERAL OR NUTRITIONAL DISEASES. CHOREA. Synonyms. St. Vitus' dance; insanity of the muscles. Definition. A functional (?) disorder of the nervous system; characterized by irregular spasmodic fibrillary movements of groups of muscles, with muscular weakness, more or less approaching paral- ysis of the affected parts. Causes. Essentially a disease of childhood ; hereditary ; reflex, from dentition, worms, masturbation, or fright; probably the result of rheumatism in many cases. Pathological Anatomy. As yet there has been no constant anatomical lesion discovered, the theory of emboli having, however, many advocates. Symptoms. The onset is usually gradual, the child seemingly grimacing or jerking the arm or hand, as if in imitation, followed soon by decided irregular jactitations of the muscles of the face (histrionic spasm), of the eyelids (blepharospasm), eyeballs (nystagmus), and the shoulder, arm, and hand, finally extending to the lower extremi- GENERAL OR NUTRITIONAL DISEASES. 485 ties, interfering with motility; in severe cases, inability of self-feeding or of holding anything in the hands. The speech is often unintelli- gible, the tongue constantly moving in an irregular manner. The heart's action is tumultuous and irregular, associated often with a soft, blowing, systolic murmur, most distinct at the base. The muscles are usually quiet during sleep, although this is not always the case. The mind is somewhat blunted, the temper irritable, the memory impaired. If the irregular muscular movements are con- fined to one side of the body, it is termed hemi-chorea. Diagnosis. Chorea was confounded with epilepsy until the points of distinction were pointed out by Sydenham. Huntington's or chronic chorea is distinctly hereditary, and, instead of being fibrillary contraction of muscles, involves whole groups of muscles, so that the patient seems to be posturing and grimacing, with a dancing movement, with many queer contortions of the face and head. Generally, all the muscles of the body are involved. It may have associated the fibrillary muscular contractions of St. Vitus' dance. ^ Paralysis agitans has general muscular tremor, beginning in one limb, gradually progressing, uninfluencea by treatment; a disease of the elderly. Post-hemipiegic chorea is the choreic movement of a paralyzed limb. Prognosis. The vast majority of cases recover, but relapses are very frequent. Treatment. Remove the cause, if possible. Easily assimilated diet. Many cases improve rapidly by confinement to bed in a dark- ened room. If the muscular movements interfere with sleep, mor- phiftcs sulphas or chloral Sixe indicated. Regulate the secretiorls. Arsenicum is the most reliable remedy yet introduced for the treat- ment of chorea. It should be pushed to its first physiological effects, then gradually reducing the dose until all symptoms disappear. The form of the remedy best adapted for administration in this disease is liquor potassii arsenitis, Ti\,v (0.3 Cc). increased to in^x (0.6 Cc), or even n^xv (i Cc), three times a day. Exiractu7n cimicifugczfluidum, lTLxx-f3j (1.3-4 Cc), t. d., is serviceable, especially in cases following a rheumatic attack. Cases resisting the arsenicum treatment may rapidly improve under hyoscyaniinincs hydrobro7nas, gr. -j^-i^^ (0.00032- 0.00065 Gm.), three times daily. A patient of mine, aged sixteen 486 PRACTICE OF MEDICINE. years, who resisted all the remedies mentioned, was promptly cured by antipyrin, gr. x (0.6 Gm.), four times daily. This same lad had a former attack arrested by viorphince sulphas, gr. % (0.016 Gm.), four limes daily, but this latter remedy failed in the attack controlled by the antipyrin. If anaemia be present, combine or alternate arsenkum w'\th /errum. Wood recommends quinina sulphas. EPILEPSY. Definition. A chronic disease, of which the characteristic symp- toms are a sudden loss of consciousness, attended with more or less general convulsions. Causes. True epilepsy almost always first arises during the growth and development of the brain. Heredity. Rarely, worry, anxiety, depression, or fright. Pressure from a tumor at the periphery, or thickening of the membranes of the brain causing pressure; syphilis ; uterine diseases. Pathological Anatomy. There are no constant anatomical lesions, as yet, associated with essential epilepsy. In " Jacksonian," "cortical," or " partial epilepsy," however, the "motor cortex" is irritated by disease and there occur tonic and clonic spasms of the same character as in general epilepsy, confined to a single arm, or an arm and half the face together, or may be the entire half of the body. These epileptiform attacks furnish precise data as to' the locality of the lesion ; spasms affecting the distribution of the facial nerve point to the lower third of the central convolution ; of the arm, the middle third of the central convolution; of the lower extremity, the upper third of the central convolution. Varieties. I. Epilepsia gravior, le grand mal ; II. Epilepsia mitior, le petit mal. Symptoms. Le grand mal \s preceded by a more or less pro- nounced and curious sensation, the so-called aura epileptica. The attack proper is sudden, the subject suddenly falling, with a peculiar cry, loss of consciousness, and pallor of the face, the body assuming a position of tetanic rigidity, succeeded after a few mo- ments by more or less pronounced clonic convulsions followed by cotna of several hours' duration. The subject awakens with a con- fused or sheepish expression, with no knowledge of what has GENERAL OR NUTRITIONAL DISEASES. 487 occurred, unless he has injured himself during the attack, either by the fall, or, what is very common, has bitten his tongue during the convulsions. Le petit inal is manifested either by attacks of vertigo, the con- sciousness being preserved, or by 2. passing absent-mindedness, either form being associated with slight convulsive phenomena followed by slight coma or mental confusion of short duration. The mental functions are not, as a rule, injured by attacks of epi- lepsy, unless they recur very frequently. Indeed, when at wide intervals, the subject seems relieved by them, " the sudden, excessive, and rapid discharge of gray matter of some part of the brain on the muscles," the so-called " electrical storm," having cleared the cere- bral atmosphere. The great majority of epileptics suffer from chronic gastric catarrh, and have at the same time an inordinate appetite (boulimia) ; indeed, an attack of gluttony may immediately precede a fit. Epileptics are very liable to the development of tuberculosis and of nephritis. Diagnosis, Uremic convulsions closely resemble an epileptic attack ; but the dropsy or general oedema and albuminous urine, and increased temperature of the former should guard against error. Feigned epilepsy often misleads the most practical expert. Jacksonian epilepsy begins as a spasm of a limb or some portion of a limb, and is confined there or may gradually extend until even a general convulsion occurs. Prognosis. The vast majority of cases will not recover under treatment, but have the frequency and severity of the attacks greatly ameliorated, but sooner or later returning with their former severity. Cases the result of the various reflex causes usually recover when the cause is removed. Treatment. To avert an impending attack, inhalations of amyl nitris, Ti\,iij-v (0.2-0.3 Cc), a few whiffs of chlorofortnum, or the hypo- dermic injection oi morphincB sulphas. To prevent the return of attacks, remove the causeif possible, and attention to the secretions and the internal administration oi potassii bromidum, in doses sufficient to abolish the faucial reflex and produce the symptoms of bromism, have great power in diminishing the severity and frequency of the attacks ; better results are sometimes obtained by the combination of the various bromides. Cases in which 488 PRACTICE OF MEDICINE. the bromides are not serviceable are sometimes benefited by ar^e/ni niiras, belladonna, or cannabis indica, but such cases are rare. Weak and an;vmic subjects usually do better with strychnina in full doses than with potassii bromidum. If a history of syphilis can be obtained, the combination oi potassii iodidum zxi^ potassii bromidum, will effect a cure. Whichever of the above remedies is beneficial in any particular case, the permanency of the relief can only be maintained by the con- tinuation of the drug for at least two years after the last attack. Gowers highly recommends the following in cases complicated with cardiac dilatation : R. Potassii bromidi, gr- xx Ii3 Gm. Tinct. digitalis, tt\^x .6 Cc. SiG. — Tiiree times a day, well diluted. The following is the combination used in the insane wards of the Philadelphia Hospital : R. Sodii bromidi, Potassii bromidi, aa ^iv aa l6. Gm. Liq. potassii arsenitis, f^iss . 6. Cc. Aqux mentha; pip., f.^iij QO- Cc. Inf. gentian, comp., . q. s. ad f.^viij ad 240. Cc. SiG. — Tablespoonful, diluted, three times daily. Brown-Sequard's mixture for epilepsy is as follows : R. Potassii iodidi 8 parts. Potassii bromidi, 8 " Ammonii Ijromidi, 4 " Potassii bicarlj., 5 " Inf. columbo, 360 " SiG. — One teaspoonful before meals, and three dessertspoonfuls on going to bed. The following is an effective combination for the " mixed bro- mides" : R. Sodii bromidi, Jj 30. Gm. Potassii bromidi, ^ vss 22. Gm. Ammonii bromidi, .^'^'i'j 10.6 Gm. Potassii bicarb., ;^ ij 8. Gm. Inf. columbo, f ,^ x 300. Cc. Aq. chloroformi, . . q. s. ad Oj ad 480. Cc. M. SiG. — Tablespoonful equals gr. xxx (2 Gm.). GENERAL OR NUTRITIONAL DISEASES. 489 Status epileptictis is always a dangerous condition, and efforts to prevent it should be made by active medication the moment a series or group of fits occur. The following combinations sometimes are wonderfully successful in aborting the status : U . Chloral, gr. xxx 2. Gm. Tinct. cannab. indicse, .... TTLxv I. Cc. Infus. digitalis, fgj 30. Cc. M. SiG. — By high enema, repeated if indicated in two or three hours. Dr. Spratling, Craig Epileptic Colony, recommends: R. Tinct. opii deodorat., .... TTLv .3 Cc. Potassii bromidi, gr. xxx 2. Gm. Chloral, g*"- '^x 1-3 Gm. Liq morph. (U. S.), ■n\^iss .09 Cc. Aquse, f^ss 15. Cc. M. SiG. — By mouth, or, if cannot swallow, by enema. A hypodermic injection of morphince sulphas, gr. ^ (0.02 Gm.), and atropincE sulphas, gr. -^-^ (0.00 1 Gm.), has sometimes broken up a series of epileptic spasms. The diet of the epileptic must be carefully regulated — meats, tea, and coffee excluded, or used in ve^y moderate amounts. Forbid tobacco and alcohol. Much enthusiasm is reported in the important results following tre- phining in cases of Jacksonian epilepsy. It is to be hoped success will follow this operation, but the subject is still sub judice. " The surgical treatment of epilepsy has been extensively employed, but it is distinctly disappointing, for, while almost any operation may benefit a patient for a time, there is no operation which will certainly cure " (J. Chalmers Da Costa). HYSTERIA. Definition. A nutritional disorder of the nervous system, of the nature of which it is impossible to speak definitely ; characterized by disturbances of the will, reason, imagination, and the emotions, as well as motor and sensory disturbances. Causes. A morbid condition confined principally to women. Young girls, old maids, widows, and childless married women are the most frequent subjects of the disorder. The paroxysms frequently 400 PRACTICE OF MEDICINE. develop during the menstrual epoch. The menopause is another frequent period for its manifestation. A peculiar condition of the nervous system, either inherited or acquired, is responsible for the phenomena of hysteria, the peculiar manifestations being excited by disturbances of either the sexual, digestive, circulatory, or nervous systems. Hypochondriasis, a peculiar mental condition, characterized by inordinate attention on the part of the patient to some real or sup- posed bodily ailment or sensation. A continual introspection, as seen in males, is a condition much like the hysteria of the female. Pathogeny. Structural alterations having thus far not been de- tected in cases of hysteria, it is classed as a functional disturbance of the nervous system. It should, however, be borne in mind that hysterical manifestations frequently develop during the prevalence of organic diseases. Symptoms. These will be considered under the headings of the hysterical paroxysm, and the hysterical state . The Hysterical Paroxysm or fit occurs nearly always in the pres- ence of others, and develops gradually with sighing, meaningless laughter, causeless moaning, nonsensical talking, and gesticulations, or a condition oi fidgets followed with a sensation oi choking, dyspnoea, and a ball in the throat — i\\e globus hystericus. These and similar symptoms precede the fit, during which the unconsciousness is only apparent, the patient being aware of what is transpiring about her. During the paroxysm the patients may struggle violently, throwing themselves about, their thumbs turned in and their hands clenched. Again, spasmodic movements occur, varying from slight twitching in the limbs to powerful general convulsive movements, and to almost tetanic spasms. The paroxysm ends by sighing, laughing, crying, and yawning, and a sensation of exhaustion. During the attack it will be noted that the surface and face are normal, showing absence of respiratory embarrassment, the breathing varying from very quiet to spluttering and gurgling sounds, the pupils not dilated, the pulse normal, the temperature normal, and absence of foaming at the mouth and wounding of the tongue. The Hysterical State is shown by disturbances of the mental and sensory -tnotor inviC\\ox\s respectively. It may be a permanent condi- tion or occur at intervals with <;reater or less severity. GENERAL OR NUTRITIONAL DISEASES. 491 Mental disturbances. The patients are emotional, erratic, excitable, impatient, and self-important, showing marked defects of will and mental power. Sensory disturbances. This is either a condition of exaggerated sensibility or hyperaesthesia, as shown by the marked effects from the slightest irritation and the cutaneous tenderness along the spine, or a condition of anaesthesia, as shown by the apparent absence or recogni- tion of pain after severe irritation, or a perverted sensibility, as shown by the feeling of tingling, numbness, and formication. Sensibility to heat or cold are often absent. There is great perversion of the special senses in many of the cases. Charcot, referring to the ovarian hyperaesthesia of hysteria, says : " It is indicated by pain in the lower part of the abdomen, usually felt on one side, especially the left, but sometimes on both, and occu- pying the extreme limits of the hypogastric region. It may be extremely acute, the patient not tolerating the slightest touch ; but in other cases pressure is necessary to bring it out. The ovary may be felt to be tumefied and enlarged. When the condition is unilateral, it may be accompanied with hemianassthesia, paresis, or contracture on the same side as the ovarialgia ; if it is bilateral, these phenomena also become bilateral. Pressure upon the ovary brings out certain sensations which constitute the aura 7iyste7-ica,\>\x\. firm and systematic compression has frequently a decisive effect upon the hysterical con- vulsive attack, the intensity of which it can diminish, and even the cessation of which it may sometimes determine, though it has no effect upon the permanent symptoms of hysteria." Motor disturbances. These phenomena embrace every variety of motor disturbance, from exaggerated excitable movements to defect- ive or complete loss of power. With the paralysis that may occur, neither nutrition nor sensation is constantly impaired. Hysterical paralysis is liable to frequent and sudden changes, the loss of power often disappearing suddenly. Hysterical contractures often are most extensive and persistent. Under some emotion or unknown cause a group or groups of muscles contract abruptly or by degrees, the spasms involving flexors or extensors or both with changes in reflexes, and lasting for days or years. Aphonia, from paralysis of the laryn- geal muscles, is a frequent form of paresis. Some hysterical patients refuse to even make an attempt at speech (mutism). "A curious enlargement of the abdomen is observed sometimes, 492 PRACTICE OF MEDICINE. constituting the so-called phixntom itttnor. This region presents a symmetrical prominence in front, often of large size, with a constric- tion below the margin of the thorax and above the pubes. The enlargement is quite smooth and uniform, soft, very mobile as a whole from side to side, resonant, but variable on percussion, and not pain- ful. Vaginal examination gives negative results, and under chloro- form the prominence immediately subsides, returning again as the patient regains consciousness. Among the numerous other symptoms that may develop in a hys- terical patient are disturbances of digestion, circulation, respiration, and disorders of micturition and menstruation. Among other phenomena that belong to the Hysterical State are to be mentioned Hystero-epilcpsy, a condition of hysteria to which is superadded the convulsion, epileptic in form. Catalepsy, a condition in which the will seems to be cut off from certain muscles, and in whatever position the affected member is placed, it will so remain for an indefinite time. There may or may not be unconsciousness and loss of sensation. Trance, the individual lying as if dead, circulation and respiration having almost ceased. Ecstasy, a condition in which the individual pretends to see visions, and acts in a most ridiculous manner. Diagnosis. The hysterical state is so general in its manifesta- tions that it is to be borne in mind in diagnosing all ailments occurring in women. The diagnosis is attended with great difficulty, however, and requires the display of all the skill of the clinician to prevent error. Prognosis. Death from either a hysterical fit or the hysterical state is the rarest of events, if it ever occur. The ultimate recovery of a hysterical patient is of frequent occurrence. Marriage has cured many cases, although it can hardly be advised by the physician. Treatment. For the hysterical fit little need be done, as a rule, unless the paroxysm is violent or prolonged, in which case ammonii valerianas, Hoffman s anodyne, or spiritus am))ionicE aromatictts, may be administered. Charcot recommends the making of firm pressure over the ovarian region to check hysterical fits that are of a severe character. The management of a confirmed case of hysteria will tax the skill of the most astute physician. It is in connection with hysteria that the peculiar phenomena supposed to arise from applying different metals to the surface of the body have been noticed. GENERAL OR NUTRITIONAL DISEASES. 493 Moral and hygienic measures are of the first importance in the management of hysterical patients. The treatment by isolation of hysterical patients is strongly urged by many specialists. Dr. S. Weir Mitchell has devised a plan for bedfast hysterical patients, of massage, faradization, and forced feeding, which has been successful in a number of cases. There is no fixed therapeutical treatment for hysteria, the various symptoms calling for interference as they arise. It is well, however, to avoid the use of stimulants, opiates, chloral, and other nervous sedatives. NEURASTHENIA. Synonyms. Spinal irritation ; nervous prostration ; nervous ex- haustion. Definition. A debility of the nervous system, causing an inability or lessened desire to perform or attend to the various duties or occu- pations of the individual. Prof. Bartholow describes it as consisting " essentially in an exag- gerated susceptibility to bodily impressions and false reasoning thereon." Causes. Heredity. It may result from various chronic diseases ; mental worry or emotion ; overwork, as " whenever the expenditure of nerve-force is greater than the daily income, physical bankruptcy sooner or later results " (Jackson). Neurotic temperament ; sexual excesses; alcohol; tobacco. Symptoms. Nervous debility may affect any organ of the body. It is a condition of nerve-tire or exhaustion, and hence the nervous energy necessary for functional activity of any particular organ may be wanting, a fair example being seen in cases of nervous dyspepsia. One of the earliest manifestations of nervous exhaustion is an irri- tability or weakness of the mental faculties, as shown by inability to concentrate the thoughts, and efforts to do so causing headache, ver- tigo, restlessness, fear, a feeling of weariness and depression, together with the army of symptoms attendant on nervousness. There may be ocular disturbances, cardiac palpitation, coldness of the hands and feet, chilliness followed by flashes of heat, followed in turn by slight sweating. Patients are troubled with insomnia, or fatiguing sleep, accompanied with unpleasant dreams. 494 rRACTicR OF medicine. In the male there are genito urinary disorders, with pains in the back, giving the dread of impotence. In females, painful menstrua- tion, ovarian irritation, and irritable uterus. The "neurasthenic stigmata" are : Feeling of pressure on head; disturbance of sleep; pain in back; muscular weakness; dyspepsia; sexr..\l disturbances and mental disturbances. Diagnosis. It is of importance to determine between a true ner- vous exhaustion and nervous debility the result of organic disease. A study of the history of the case, together with the symptoms, should prevent error. Neurasthenic symptoms in puberty are strongly indicative of mental instability, and great care must be exercised to prevent actual insanity from developing. Prognosis. Usually some mental weakness remains after re- covery from an attack of neurasthenia. Treatment. The physician should remember that neurasthenia is not a disease per se, but that the victim is a sick individual needing the best environment, rest, and good food. Attention to the secretions, diet, and surroundings. Rest and diversion of the mind are essential to success. Travel, short of fatigue, pleasant companionship, and relief from responsibility. Bathing, massage, and galvanism are im- portant aids in the management. Among the internal remedies that are of value may be mentioned, arseniciim, sfrychntna, ferrum, zinci valerianas, phosphorus, ex- tractum cocce fluidum, vitiutn cocce, and syrupus hypophosphitis covipositits. QuinincE sulphas, in small doses, gr. i-ij (0.065-0.13 Gm.), daily, for weeks, seems to lessen the excitability of the nervous system. The following is an excellent neurasthenic tonic : li . Acid, phosphoric, dil., f^;!] 8. Co. Ext. cocffi fid., f^^j 24. Co. • Tinct. nucis vomicae, f .^ 'j 8. Co. Syr. zingiberis, f .^ '■''S 45- Cc. Aquar menthce pip., . ... ad f.^vj ad 180. Co. M. SiG. — Tablespoonful after meals, in water. GENERAL OR NUTRITIONAL DISEASES. 495 EXOPHTHALMIC GOITRE. Synonyms. Graves' disease ; Basedow's disease. Definition. A disease of the nervous system ; characterized by protrusion of the eyeballs, enlargement of the thyroid gland, dilata- tion of the arteries, and palpitation of the heart. Causes. An undemonstrable condition of the nervous system, either inherited or acquired, is the predisposing cause of Graves' disease. Among the exciting causes are anaemia, shock, fright, chagrin, worry, and reverses of fortune. It is more frequent in women than in men. Pathological Anatomy. " Some structural alterations have been found, in a majority of cases, in the sympathetic ganglia, and especially in the inferior ganglia." (Bartholow.) The veins and arteries of the thyroid gland are dilated, the result of a vasomotor paralysis. The enlargement of the gland is the result of the dilated vessels, and a serous infiltration of its tissues, followed, if long con- tinued, by hypertrophy. A considerable increase of fat behind the eyeballs has been observed. In the majority of cases more or less ansemia exists. Symptoms. The development of the quarternary of symptoms may occur suddenly, the result of some great shock to the nervous system, but in the majority of instances the symptoms develop slowly and insidiously, with cardiac palpitation, with paroxysms of more marked acceleration, or tachycardia, the pulse-rate varying from goto 1 20, 150, and rarely as high as 200 beats per minute ; zooxi pulsations of the vessels of the neck and thyroid gland may be felt and seen. The enlargement of the thyroid gland — the goitre — appears gradually after the development of the circulatory disturbances, although rarely it may be the first symptom observed. The goitre is elastic, rather soft, and has a thrill similar to an aneurism. The degree of enlarge- ment varies in different cases, and in none ever attains a very great size. Following the development of the goitre occurs the protrusion of the eyeball, — the exophthalmos, — which may be confined to one eye, but usually occurs in both. Prominence of the eyeball may be the first symptom observed, but usually it does not develop until after the appearance of the goitre. The degree of protrusion varies from a slight staring expression to a point so great that the eyelids cannot 496 PKACTICE OF MEDICINE, cover the balls. Associated with the protrusion of the eyeballs is incoordination in the movements of the eyelids and the eyeball, the sign of Graefe, so that when the eyes are quickly cast down, the eye- lids do not follow them, the sclerotic being visible below the upper lid. Vision is unimpaired. Conjunctivitis may arise, the result of the im- perfect protection of the protruding ball by the eyelids. Associated with the pathognomonic symptoms are nervousness, irritability of temper, headache, insomnia, vertigo, fits of despondency, aphonia, and cough the result of pressure of the goitre, disorders of digestion, increase of temperature, anaemia, and loss of flesh. Diagnosis. The fully developed disease presents no difficulties in diagnosis, but during its incipiency, before the characteristic symp- toms have appeared, the disease may be confounded with such condi- tions as cardiac disease, neurasthenia, lithaemia, malaria, or incipient phthisis. Prognosis. Recovery occurs in a fair number, but is slow and tedious. The disorders of the circulation lead to dilated heart in many cases, and ultimately death occurs from this cause. Relapses are frequent. Treatment, One of the first injunctions to be placed on a case of exophthalmic goitre is rest, both physical and mental, as well as freedom from worry or emotional excitement; little progress will be made if this point be neglected. The general nervousness, restless- ness, and insomnia will often call for special treatment, when use may be made of chloral, potassii brotnidiim, siilphonal, or trional. It is better, however, not to use this class of drugs in a routine manner, but for the special indications only. The chief indication next to rest is the condition of the circulation. To control this, two remedies are of inestimable value ; they are digitalis and strophanthus. The results I have seen from tinctura strophanthus, Ti^v (0.3 Cc), from three to six times daily, have been most satisfactory. Dr. Bartholow " has had good effects from quinina, belladonna, and ergotin in combination." I have had complete and quite rapid recovery in three pronounced cases from dried extract of thyroid gland in three grain doses (0.2 Gm.) twice and thrice daily. Always begin the use of the preparations of thyroid gland with very small doses, gradually increasing as required. Argenii Jiitras, gr. y% (o oo8 Gm.), after meals, is often a valuable remedy, alternating with strophanthus or digitalis. GENERAL OR NUTRITIONAL DISEASES. 497 The associated anaemia is to be treated hy ferrum, arsenicum, and an easily digestible and nutritious diet. Galvanism to the cervical sympathetic and pneumogastric is an important adjuvant to the medicinal treatment. Surgical treatment has been strongly urged for the cure of exoph- thalmic goitre. DaCosta (J. Chalmers), after reviewing the literature of such operations, concludes : " Treat most cases medically and by rest; if medical treatment fails, consider the advisability of surgical treatment. Surgical treatment is not certainly curative, and is dan- gerous." TETANY. Synonyms. Tetanilla ; intermittent tetanus. Definition. A succession of tonic, usually bilateral, painful mus- cular spasms, occurring at irregular intervals, without loss of con- sciousness. Causes. Unknown. Probably a special germ. It has been observed in those having a family history of nervous disorders. Pathology. The disease is very rare in America, and no lesion has as yet been determined. Symptoms. Tetany is the occurrence of intermittent spasms in the muscles of the arms, hands, legs, or feet, or, rarely, the face and larynx (laryngismus stridulus), associated with/az« or "cramp." The hands are thrown into a position such as they assume in writ- ing, or such as is taken by the hand of a midwife ; or the hand may be tightly closed, or one or more fingers may be cramped. The elbows and shoulders may be, at times, affected. In the feet the toes are drawn down and the instep upward, like in equinus. The knees may be cramped or the legs extended. Any muscles may be involved. Trousseau pointed out that in those suffering from tetany, pressure upon the affected extremities at certain points will excite the spasms. The duration of the spasm varies from a few moments to several hours, the intervals being from an hour to a day or more. A certain periodicity is noticed as to the hour of the day or night. The electro-contractility is increased, as are also the reflexes. Erb first described the peculiar galvanic exaltation found in this disease. The consciousness is always preserved, although the patients are very nervous. 32 498 PRACTICE OF MKDICINE. Diagnosis. Tetanus and tetany may be confounded, and yet trismus is rare in the latter, and always present in the former. Prognosis. Favorable. Treatment. Attention to the secretions and excretions, and the use of potassii bromiiium, gr. xx-xl (1.3-2.6 Gm.), well diluted, three times daily. Gowers recommends digitalis for nocturnal tetany — those painful cramps in the calves in the early morning hours. Urethan, gr. x (0.6 Gm.), every three or four hours, is highly spoken of. Gray says : " Cold to the extremities and ice to the spine have an excellent effect." TETANUS. Synonyms. Lockjaw; trismus; cephalic tetanus. Definition. An acute or subacute infectious disease, characterized by muscular rigidity, with paroxysms of tonic convulsions, the mind remaining clear. Idiopathic tetanus when no open wound is discoverable. Traumatic tetanus when an open wound is present. Tetanus neonatorum when it attacks infants. Lockjaw or trismus when the jaw alone is involved. Cephalic tetanus when the throat and face are affected. Causes. The result of a specific bacillus, which usually gains access to the system through an abrasion. Pathological Anatomy. In the post-mortem examinations which have been made, no uniform morbid appearance was dis- covered on microscopical examination. The brain, cord, lungs, and muscles are markedly congested, and show minute hemorrhages, such as are met with in all cases of death from convulsions, and which occur chiefly during the process of death. In four post-mortem examinations of cases dying from tetanus at the Philadelphia Hospital, marked chronic nephritis was observed. Probably the future may show some connection between nephritis and tetanus, by which the specific poison is not eliminated as it might be were the kidneys normal. Symptoms. The onset is rather sudden, with stiffness 0/ (he Jaw, neck, and tongue, and some difficulty in swallowing, which increases GENERAL OR NUTRITIONAL DISEASES. 499 in extent, the stiffness passing down the spinal muscles to the legs, which are held in a firm spasm. Gradually tofiic spasjns develop, which, involving the jaw muscles, cause " lockjaw " ; the face muscles, " risus sardonicus " ; neck and trunk muscles, "opisthotonos" ; thesetonicconvulsions are associated with intense pain, and the patient suffers the greatest distress, particu- larly if the chest muscles are involved. Usually the febrile reaction is slight, but in many cases 102° F.to 104° F. is reached, and in some instances, as death approaches, 108° F. to 110° F, may occur, rising still higher after death. The mind remains clear till carbonic acid poisoning occurs. Usually a wound, not severe, can be found, the symptoms developing some two weeks after its occurrence. The tonic spasms are developed by any sources of irritation, a draught of air, shaking of the bed or floor, suddenly opening the door of the room, the presence of a visitor, or attempts at speaking or movement. Diagnosis. The symptoms are so characteristic, with the addi- tion of a history of a wound, that an error seems hardly probable. Tetany. The spasms chiefly affect the extremities, the muscles being free in the interval and trismus a late or very rare condition. Strychnine poisoning often closely resembles tetanus, but there is no beginning trismus and more rapid development of the symptoms. No history. Hydrophobia does not have trismus, but respiratory spasm, excited by attempts at swallowing, with increasing mental symptoms. Prognosis. Unfavorable. The great majority die. Treatment. Rest and quiet in a dark room. Chloral, potassii bromidum, chloralamid, morphincz sulphas, a,nd paraldehyde are each useful in cases, to hold in check or lessen the severity of the spasm for a time. Inhalations oi chlorofortnu7n will control the spasms, and recoveries have been attributed to its use. Physostigtna and anii- pyrin are recommended to remove the spasms. Success has been reported in a number of cases from full doses, very early in the attack, of the tetanus serum. Success is reported from acidum carbolicum, gr. iij (0.2 Gm.) a day, rapidly increasing until gr. vj-viij (o 4-0.5 Gm.) per day is reached, by the hypodermic method, a tolerance to the drug being noted in tetanus. Baccelli's method of using acidum carbolicum consists in the administration, hypodermically, of a two per cent, solution of the 500 PRACTICE OF MEDICINE. acid at two or three hours' intervals. Other methods are to be con- tinued in addition to the acid. The nutrition must be maintained ; often, on account of the stiff- ness of the masseters, rectal alimentation must be resorted to. OCCUPATION NEUROSES. Synonyms. Professional neuroses ; artisans' cramp. Varieties. Writers' cramp ; piano-players' cramp ; telegraphists' cramp; violin-players' cramp; dancers' cramp. Definition. A group of affections of the nervous system, charac- terized by the occurrence of spasm (cramp) and pain in groups of muscles, in consequence of overuse or frequently-repeated muscular acts. Cause. Undetermined. It has been noticed that many persons suffering from occupation neuroses have a family history of nervous affections. Sjrmptonis. The symptoms of any of the varieties named gener- ally develop gradually and slowly, by a (eehng of sfi^ness in the used member, the part feels fatigued and heavy, until it is impossible to use it, from the occurrence of spasmodic contractions. Pain on using the affected muscles, often associated with tremor, and in many cases with an ZlCXm^X paralysis. Associated with the loss of power to follow the usual occupation is nervousness, mental worry, and often depression. There is often the sensation of prickling and numbness in the crippled member. The electro-contractility is preserved until the atrophy of non-use develops. Diagnosis. Calling to mind the history of the case and its re- sults, in being limited to one member, the nature of the condition is evident. Prognosis. Often unfavorable. Some recoveries are reported. Treatment. Rest of the part and mental quiet, with tonics and other means to improve the general nutrition. Faradism in weak doses once or twice weekly seems useful. The following combina- tion was of value in one case of writers' cramp and in a most aggravated case of ballet-dancers' cramp, each affecting the left limb: GENERAL OR NUTRITIONAL DISEASES. 501 R . Zinci phosphidi, . gr. ij .13 Gm. Ext. nucis vomicae, gr. x .6 Gm. Fern albimiinat. , gr. xxx 2. Gm. Ft. pil. No. xxx. SiG. — One after meals. PARALYSIS AGITANS. S3nion3rms. Shaking palsy ; Parkinson's disease. Deflnition. A nervous disease of unknown pathology, charac- terized by tremors, progressive loss of power in the affected muscles, moderate rigidity, with alterations in the gait, and at times mental changes. Cause. Age seems to be an etiological factor, most cases devel- oping after fifty years. Most frequent in women. Pathological Anatomy. No characteristic lesion yet deter- mined. It being a disease of past middle life, there is probably an interstitial hyperplasia of some layer of the cortex, from alterations in the intima of the vessels. Symptoms. The onset is gradual, the tremor beginning in one of the extremities, oftenest the hand and forearm. At first it can be controlled by the will, for a time at least, and is suspended by voluntary movement. The disease gradually extends until an entire side or the upper or lower limbs are involved. The face and head rarely present tremors, but are not exempt. A peculiar rigidity of the affected muscles is characteristic of the advanced stage. "At this stage of the disease the hands are apt to assume the so-called bread- crumbling position, /. rogenitalis). Causes. Herpes facialis ; during the course of febrile and nerv- ous disorders ; associated with digestive disorders and colds. Herpes progenitalis ; the origin is local, from uncleanliness or friction. Pathology. Hebra defines the various forms of herpes as " a series of acute cutaneous diseases of cyclical course, marked by an exudation which collects in drops under the epidermis and elevates it, forming vesicles which are never solitary, but always appear in groups." Symptoms. The appearance of the vesicles is usually preceded by a feeling of heat in the region, together with slight tumefaction or swelling. Rarely the herpetic attack is attended with malaise and pyrexia. The eruption usually appears in the form of a small cluster of pin- head to split-pea sized vesicles, containing a clear fluid, becoming cloudy, afterward puriform, and drying in small, yellowish or brownish crusts; they are few in number, and may coalesce. They disappear without leaving a scar. Herpes facialis ; occur upon any portion of the face, but most fre- quently about the lips — herpes labialis. The alae of the nose, auricles, and the mucous membranes of the mouth and tongue are frequent locations, in the latter appearing as excoriated patches from rupture of the vesicles. Herpes progenitalis ; in the male the chief site is the prepuce {herpes prcEpiitialis'). In the female they are comparatively rare ; but when occurring, it is upon the labiae majora and minora and the skin about the vulva. DISEASES OF THE SKIN. 561 This variety is preceded by burning, itching, or neuralgic pains, accompanied by redness, congestion, and more or less oedema. The lesion about the genitalia is likely to be mistaken for one form or other of venereal disease. Herpes gestationis ; a rare affection of the skin occurring during pregnancy, consisting of erythema, papules, vesicles, and bullae, at- tended with intense burning and itching. It may appear at any time of pregnancy up to the seventh month, and continues until some time after delivery. Treatment. Herpes facialis seldom calls for treatment, although in marked cases oi herpes labialis protection with liquor guttapercha or collodium fiexile promotes desiccation. Herpes proge7iitalis ; cleanliness is of the first importance. Coat- ing the eruption with the medicaments mentioned above, or washing with a saturated solution of acidum boricutn, and afterward dusting with hydrargyri chloridum jnite, are useful. In recurring cases of herpes of the vulva, arsenicum is a specific (Jonathan Hutchinson). The parts may be rendered less sensitive in frequently recurring cases by astringent lotions, as acidum tannicutn or zinci sulphas. Circumcision, when required, may be practised. HERPES ZOSTER. Synonyms. Zono ; shingles ; a girdle ; intercostal neuralgia. Definition. An acute, inflammatory disease ; characterized by the development of groups of firm and distended vesicles situated upon inflamed bases corresponding to a definite nerve trunk, and accompanied by more or less severe neuralgic pains. Causes. The eruption and consequent neuralgic pains are the immediate result of an inflammation of the ganglia or of the nerve trunks and branches, — a neuritis, — probably of the trophic fibers of the affected part ; but the cause producing this condition is obscure. Among the many that have been suggested are : cold, injuries to nerves, anaemia, malaria, and the medicinal use of arsenicum. Pathology. An inflammation of either the ganglia, the nerve trunk, or branches — probably the trophic system — causing the devel- opment of vesicles in the lower strata of the rete with " the infiltra- tion of serum and inflammatory cells " of the papillae and corimn, 36 5f)2 PRACTICE OF MEDICINE. Symptoms. Begins with neuralgic pains, either of a burning or lightning-like character, with slight febrile phenomena, followed by the appearance of papulo-vesicles along the tract of pain ; these soon become vesicles situated on bright-red, highly inflamed bases. The vesicles are about the size of pin-heads, or, perhaps, a little larger; usually discrete, although they frequently coalesce, forming irregular patches, coming in groups until the third to the fifth or even tenth day, when they gradually desiccate, and at the end of the second week nothing remains but a slight scar, which may disappear or become permanent. When the eruption is at its height, it is perfect in its anatomical formation, each vesicle being well shaped and seated on a bright-red, inflamed patch of skin, and distended with a translucent, yellowish fluid. The eruption is almost invariably confined to one side (unilateral) of the body, although in rare instances it is seen upon both (bilateral) sides. It is usually found upon well-known nerve tracts. According to the region affected it is termed zoster capitis, zoster frontalis, zoster faciei, zoster ophthalmicus, zoster a:inam, of an intermittent character, aggravated by pressure, is the chief symptom. Corns are often weather sensitive, being unusually painful before, during, or after the occurrence of storms, and should, therefore, not be confounded with gouty or rheumatic deposits below the skin. Treatment. If freedom from these annoying formations be de- sired, the use of a properly fitting foot-covering must be practised. The pressure which results in the severe pain is limited by the use of the ringed protective plasters in common use. To remove the corn, soaking with hot water, or a poultice kept in contact over night, will soften the part and permit of its ready removal with the knife. For so// corns, the application of argenti nitras, in solid stick form, is highly spoken of, to be used after the growth has been sufficiently softened. The following application will usually remove the " corn " : R. Acidi salicylic!, 3 iss 6. Gm. Ext. cannab. indicce, gr- x 0.6 Gm. Collodii, fij 30. Cc. M. SiG — Painted over corn at night and scraped off in the morning. VERRUCA. Synonym. Wart. Definition. A wart consists of a circumscribed hypertrophy of the papillary layer, with more or less epidermal accumulation, char- acterized by the appearance of a hard or soft, rounded, flat, or acumi- nated formation, of variable size. Varieties. The following varieties have chiefly a descriptive value : verruca vulgaris ; verruca plana ; verruca Jiliformis ; verruca digit ata ; verruca acuminata. Cause. Obscure. The various assigned causes are probably in- capable of producing the affection. Pathology. While the anatomy of warts differs somewhat accord- ing to their variety, in all forms there exists as a basis of their forma- tion a connective-tissue growth from which the papillary hypertrophy takes place. The interior of the growth is supplied by one or more vascular loops, from which their vitality is obtained. DISEASES OF THE SKIN. 589 Rymptnms. The various forms are so different as to require a separate description. Verruca vulgaris, or the ordinary wart commonly seen on the hands, consists of a small, circumscribed, elevated growth, having a broad base seated securely upon the skin. Their consistency is either soft or firm, the surface smooth or rough, the color that of the surrounding skin, or yellowish, brownish, or even blackish. They may develop upon any region of the body, but are most commonly seen upon the hands and fingers. Verrtica plana differs from the vulgaris in being flat and broad in form, and but slightly raised above the level of the surrounding skin. Their most common location is either on the back or forehead. Verruca filiformis assumes the shape of a minute, thin, conical, or thread-like formation, about an eighth of an inch in length. The most frequent location is the face, eyelids, and neck. Verruca digitata consists of a slightly elevated, broad formation, about the size of a split pea, and marked by a number of digitations coming from its border, giving an appearance, in marked cases, resembling a crab. Their most frequent site is upon the scalp. Verruca acttmiftaia, known also as the pointed wart, the moist wart, the pointed condyloma, cauliflower excrescence, and venereal wart, consists of one or more groups of irregularly shaped elevations, often so closely packed together as to form a more or less solid mass of vegetations (verrucae vegetantes). Their color depends somewhat upon the degree of vascularity. Varying from a pinkish, bright red to a purple color. They occur, for the most part, about the genitalia of either sex. Upon the penis, they usually spring from the glans and the inner surface of the prepuce. From the inner surface of the labia and from the vagina in the female. They are also seen about the anus, mouth, axillae, umbilicus, and toes. They may be either moist or dry, according to their location. About the genitalia, a yellowish, puriform secretion usually covers their surface, due to friction and maceration, which, owing to the heat of the parts, rapidly decomposes, producing a highly offensive, penetrating, and disgusting odor. Their size varies from that of a pea to that of an almond, an egg, or even the fist. Their development is rapid, attaining considerable size in a few weeks. Prognosis. Favorable. Treatment. For the smaller warts, excision by means of the 590 rUACTICE OF >tED»tTNE. knife or scissors affords the most satisfactory results. If the growth be large, and likely to be attended with considerable hemorrhage, as in cases of condyloma about the genitalia, the galvano-caustic wire or the Paquelin cautery are to be preferred. Transfixing the growth in several directions with long needles dipped in a fifty per centum solution of aciditvi chromicuiii has been recommended. The topical application of caustics, such as aciduin aceiicum, acidum nilricutn, argenti iiitras, ox fcti-i perchloridimi is often satisfactory. I have been successful in some cases by painting the growth with tinctura thuja occidentalis until their size was considerably reduced and then snipping them off with the scissors. The following formula for warts and corns is usually successful : R . Acidi salicylici, 3 ss 2. Gm. Ext. cannab. indicK, p;r. v-x 0.3-0.6 CIm. Collodii, fo^^~J '5~30- ^^- M- SiG. — Apply once or twice daily. An excellent formula is — li . Acidi salicylici, Acidi borici, aa gr. xv aa I. Gm. Hydrargyri chlor. mitis, . . . . gr. x 0.6 Gm. M. SiG. — Sprinkle over twice daily. ICHTHYOSIS. Synonyms. Ichthyosis vera ; fish-skin disease. Definition. Ichthyosis is a congenital, chronic deformity or hypertrophic disease of the skin, characterized by dryness, harshness, or general scaliness of the skin, or in the outgrowth of larger masses of a corneous consistency. Varieties. Ichthyosis simplex ; ichthyosis hystrix. Cause. Often hereditary, but not in all cases. It is to be re- garded as an affection which is born with the individual, although it does not usually manifest itself until after the first or second year of life. Pathology. " The diseased or, better, deformed skin is found microscopically to be hypertrophied in various degrees, according to the development of the malady ; the proliferation of its elements occurring in the connective tissue, papillae, stratum corneum, and DISEASES OF THE SKIN, 591 blood-vessels. In well-marked cases of ichthyosis hystrix the elongated papillae are surrounded by dense cones of the horny layer of the epidermis, more or less concentrically disposed, with sclerosis of the connective tissue and a relatively unchanged rete. In this last particular the dense plaque of ichthyosis differs in texture from the wart" (Hyde). Symptoms. Ichthyosis displays wide variation in its symp- toms. In one individual it amounts to slight inconvenience, while in another it may manifest itself in so pronounced a manner as to be the source of great discomfort and deformity. The two varieties named represent merely accentuated types of the disorder, rare in its fullest development, and, in its slightest, much more common than is generally believed. A simple dryness and harshness of the skin, with only slight fur- furaceous exfoliation, is termed xeroderma. Ichthyosis simplex is the more common variety, consisting of a harsh, dry condition of the whole surface, accompanied by the pro- duction of variously sized and shaped reticulated scales, either small, thin, and furfuraceous, like bran, or large and thick, resembling fish- scales. Upon the extremities the scales usually form diamond-shaped or polygonal plates, separated from one another by furrows or lines which extend down to the normal skin. In color the scales are either whitish, grayish, or yellowish, and often have a silvery or glistening appearance. Rarely the color is olive-green or blackish (ichthyosis nigricans'). The amount of scaling depends upon the age of the patient and the duration and severity of the disease. Ichthyosis hystrix. With or without the development of the above variety, in this, the hypertrophy of the skin may occur in circum- scribed patches or large areas, consisting of irregularly shaped ver- rucous, corneous, corrugated, wrinkled, or rugous masses, usually darker in color than those of the simple variety. They may occur upon the arms, as solid, warty patches, or upon the back, in the form of elongated, linear patches. Thej'' may constitute roughened, corru- gated, papillary growths, or uneven, horny, blunt, or pointed, spinous, warty formations. In the latter case the elevations may reach several lines or more, and stand out from the skin like quills upon the back of a porcupine — hence the name hystrix. The amount and extent of the hypertrophy varies ; the older the patient, the more highly devel- oped it will usually be. 502 PRACTICE OF MEDICINE. Course. Lhthyosis simplex may involve the entire surface uni- formly or appear more marked on the extremities, from the hips to the ankles and the arms and forearms. The affection is always worse in winter than in summer, the increased activity of the sweat glands at this season producing the most beneficial results. The course of the affection is essentially chronic, continuing throughout life, now better, now worse. Slight itching usually occurs. Diagnosis. The characteristics of the affection are so peculiar that an error in diagnosis is hardly possible. It is to be distinguished from the inflammatory affections of the skin which terminate in des- quamation by the absence of any history of inflammation. Prognosis. While much can be done to alleviate the affection, the prognosis is unfavorable as regards permanent relief. Treatment. Local measures are alone of value for ichthyosis. The maceration of the accumulated masses of epithelial hypertrophy is accomplished by water-baths, either simple or medicated. The relief thus afforded the patient, while temporary, is comforting. Duhring says : " It may be stated, then, that, as a rule, the more fre- quently the ichthyotic patient bathes, and the longer he is able to remain in the water, the less will the deformity show itself." Vapor and alkaline baths are also serviceable. Another valuable agent is sapo mollis in conjunction with baths, or alone, as a discutient. ' For severe cases, " a sufficient quantity is to be rubbed into the skin twice daily for four or six days, during which period the patient is to refrain from bathing. A bath is first to be taken four or five days after the last rubbing, when, in fact, the epidermis has begun to peel off; after- ward inunction with a simple ointment is to be applied, in order to prevent fissuring of the new skin. The following is a useful formula : R. Adepsbenzoat., 3J 30. Gm. Glycerini, Tr\^xl 2.6 Cc. Ung. petrolci, 555 15. Gm. M. SiG. — Apply daily, after washing or bathing. Or— R. Potassii iodidi, gr- xx 1.3 Gm. Olei bubuli, f,|ss 15. Cc. Adeps 5 ss 15. Gm. Glycerini, f 3 ij 8. Cc. M. SiG. — Apply after bathing. (Milton.) DISEASES OF THE SKIN. 593 PARASITIC DISEASES OF THE SKIN. TINEA FAVOSA. Synonyms. Favus ; porrigo favosa ; honeycombed ringworm ; crusted ringworm. Definition. A contagious affection of the skin, due to a vegetable parasite — Achorion Schonleinii ; characterized by the development of either discrete or confluent, small, circular, cup-shaped, pale-yellow, friable crusts, usually perforated by hairs. Cause. The presence and growth of a vegetable parasite known as the Achorion Schonleinii is the cause of tinea favosa. It is com- moner in children than in adults, attacking the former in the first place either de novo or through direct contagion, and is from them communicated to adults. It is a disease confined almost exclusively to the lower classes. Pathology. Tinea favosa may have its seat either in the hair- follicles and hair, or upon the surface of the skin or the nails ; the former, however, are the structures most frequently involved. It is purely a local affection, due solely to the presence and growth of the vegetable parasite discovered by Schonlein, of Berlin, in 1839, and named after him — Achorion Schonleinii. The crusts are made up almost entirely of fungus, which is seen, upon section, with the naked eye, to be composed of a porous mass and to possess a pale- yellow or whitish color. Under the microscope it is seen to consist of both mycelium and spores in great quantity and in all stages of development. Symptoms. When the affection attacks the hairs and follicles it is termed tiiiea favosa pilaris ; when the epidermis, tinea favosa epi- dermis ; and when the nails, tinea favosa unguitim. Rarely all the structures may be attacked at one and the same time ; its usual seat, however, is the scalp. The disease begins by the development of one or of several /z«- head sized, pale-yellow crusts, seated about the hair- follicles. In about a fortnight these crusts have increased in size and are umbili- cated, termed \hQ favus cups, are circumscribed, circular in form, and very slightly elevated above the level of the skin. In their normal condition they are of a pale-yellow or sulphur- 38 504 PRACTICK OK MKDICINE. w yellow color, but after a time, from dust and other matters, they become brownish or greenish yellow in color. The number of crusts vary from very few to immense numbers. The usual size is about that of a split pea. In iitica favosa pilaris et r(?//7/j the affection is often accompanied by pediculi, while swelling of the glands of the neck and small abscesses upon the scalp are not uncommon. The hairs become lustreless, opaque, brittle, and at times split longitudi- nally, and from atrophy of the follicles and sebaceous glands perma- nent baldness may result. In tinea favosa unguium the nails become thickened, yellow, opaque, and brittle. The disease has a peculiar odor, resembling that of mice, or of musty, stale straw. Diagnosis. In a recent case of characteristic favus cups, the pale-yellow color, the odor, and the history of contagion should ren- der the diagnosis easy. If of long standing, however, and the favi destroyed by scratching, some doubt may exist; but if a small frag- ment of a crubt be placed upon a glass slide with a drop of liquor poiassa, covered with a thin glass, and placed under a microscope with a power of from two hundred and fifty to five hundred diameters, the features of the Achorion Schonleinii will determine the diagnosis. Prognosis. Tinea favosa of the epidermis readily responds to treatment. Tinea favosa pilaris is more obstinate, and if of long duration, may result in baldness. Treatment. The general health, in the majority of instances, requires tonics. Oleum morrhua, and syrupus ferri iodidum, are invaluable to scrofulous patients. Cleanliness is essential to success- ful management. For tinea favosa pilaris et capitis two remedies are essential — parasiticides and depilation. The hair should be cut off as short as possible, the crusts removed by the use of oil, or soap and hot water, or poultices, again well oiled, and the hairs removed by means of broad-bladed forceps, a few hairs being removed at a time and only a small surface cleared at each sitting, when the following lotion is to be thoroughly applied : R. Hydrarg. chlorid. corrosiv. , . . . gr. v-x 0.3-0.6 Gm. Ammonii chlorid., ^^ ss 2. Gm. MisturK amygdalae amar., . . . .f^iv 120. Cc. M. SiG. — Apply thoroughly. (Bulkley.) DISEASES OF THE SKIN. 595 Dr. Shoemaker condemns epilation as injurious to the " hair-folli- cles and painful to the patient, and should be discarded as a relic of medical barbarism of the last century." He recommends" the appli- cation oi oleum ergoice, for twenty-four hours, to soften the crusts ; then apply a twenty-five to a fifty per centum solution of boroglyceridum, sponged thoroughly over the affected surface covered with the oil ; in a few hours the crusts will peel off and the surface can be cleansed, when the following powerful antiparasitics should be applied " : R. Ung. hydrargyrioleat., . . . . ,^ss 15. Gm. Adeps, ^ss 15. Gm. SiG. — Apply a small portion to each cup daily for two or three days. Then alternate with the following : R . Cupri oleat. , ^:^ ss 2. Gm. Adej)s, ^j 30. Gm. SiG. — Small portion to the affected spots. "These applications should be made every day or two, and con- tinued for three or four weeks. If, after a cessation of treatment for a week or two, the hair does not assume its natural aspect and new favus crusts develop, the treatment should be begun afresh." TINEA CIRCINATA. Synonyms. Tinea trichophytina corporis ; herpes circinatus ; ringworm of the body. Definition. A contagious, parasitic affection of the skin, due to the trichophyton fungus ; characterized by the development of one or more circular or irregularly shaped, variously sized, inflammatory, slightly vesicular or squamous patches, occurring upon the general surface of the body. Causes. Ringworm of the body is caused by the presence of a vegetable parasite discovered by Bazin, in 1854, termed the tricho- phyton, the same growth or fungus that produces tinea tonsurans and tinea sycosis. The affection is highly contagious, and is frequently communicated from one member of a family to another, although it has been determined that a certain unknown condition of the skin is requisite for its development. In children it is most frequently seen among the weakly and the poorly nourished. In adults it is usually associated with a decline in the general health. 596 PRACTICE OF MEDICINE. Pathology. The fungus is seated between the strata of the epi- dermis, more particularly in the superior layers of the rete. The presence of this foreign body produces the subsequent phenomena — a superficial dermatitis, erythema, exudation, minute vesiculation and papulation, and, in the severe grades, tubercles and pustules. The desquamative symptoms are exfoliative — nature's efforts for relief. Symptoms. Tinea circinata varies greatly in the degree of its development, from the trivial complaint so often seen in children, to the chronic, extensive, and obstinate disease sometimes seen about the thighs in adults {tittea circinata cruris). The disease usually begins as a small, reddish, scaly, rounded or irregularly shaped spot of papules, which in a very few days assumes a circular form (ringworm). It continues to increase in size, the papules often changing to vesicles. A characteristic of the eruption is its healing in the centre as it spreads on the periphery. Occasion- ally the circles or rings coalesce, forming serpiginous lesions. The usual size of a fully developed ringworm is about that of a silver quarter of a dollar. Chronic tinea circinata does not present the characteristic annular form, but " are usually in the form of single or multiple, disseminated, small, reddish, slightly scaly, ill defined spots, on a level with or but slightly raised above the surrounding skin. Not infrequently they are the size of a small or large finger-nail, and are irregularly shaped, and, as a rule, without line of demarcation." The "eczema marginatum" of Hebra is to be looked upon as a severe form of tinea circinata. Tinea circinata cruris, or ringworm of the thighs, a variety of the "eczema marginatum" of Hebra, is usually complicated with true eczema, and is a very obstinate, chronic form of the affection ; it is accompanied by severe itching. Tinea trichophytina unguium is a rare variety. The nails become opaque, whitish, thickened, and soft and brittle, especially along their free border. The microscope is essential for a diagnosis. Its course is chronic, and it is difficult to cure. Course. As commonly seen, ringworm is very amenable to treat- ment. Occasionally, however, it exhibits great obstinacy, showing itself repeatedly in the same region in the form of relapses, or mani- festing itself from time to time in new localities. Diagnosis. Tinea circinata may be mistaken for squamous or DISEASES OF THE SKIN. 597 Other varieties of eczema, but the circular and often annular form, the well-defined margin, the slight desquamation, and the course and history of ringworm should prevent error. Chronic ringworm is more difficult, however. Seborrhoea and psoriasis often assume a somewhat circular form, and then have a resemblance to ringworm, but a study of the clini- cal history should render the diagnosis easy. All doubtful points in diagnosis should be determined by the micro- scope. The examination can readily be made in the following man- ner : " A few of the scales may be scraped, with a blunt knife-blade, from the suspected patch and placed upon a glass slide containing a drop of liquor potassae, over which is laid a thin glass cover. The cover should be pressed down and the epidermic mass flattened out. Permitting the specimen to remain for a few minutes, it may be viewed with a power of from 250 to 500 diameters. The fungus will, in most cases, be detected here and there, having at first a faint outline, but becoming more distinct as the specimen stands." Prognosis. Favorable, as a rule, although the affection is rebel- lious to treatment in some instances, and prone to relapses. Treatment, Local treatment is usually all that is required for the cure of tinea circinata. In the majority of instances the following plan will be successful. Washing the patch with soft soap and water and the application of one of the following ointments : R. Cupri acetat. gr. x 0.6 Gm. Ung. aquae rosse, ^j 30. Gm. M. SiG. — Keep in contact with the patch. Or— R. Hydrargyri ammoniat. , . . . . gr. xx-xxx 1. 3-2. Gm. Ung. petrolei, . ^j 30. Gm. M. SiG. — Keep in contact with the patch. Or— R. Hydrargyri chloridi cor., ... gr. j 0.065 Gm. Tinct. benzoin, comp., .... f^j 30. Cc. M. SiG. — Apply over eruption. Or— R . Sulphuris, 5 j 4. Gm. Acid, borici, gj 4. Gm. Vaselini, g j 30. Gm. M. SiG. — Apply after scrubbing patch with green soap. 598 PRACTICE OF MEDICINE. In obstinate tinea circinata cruris a saturated solution of acidum boricton, applied for a few days, and afterward cover the parts with the acid in powder, or unguentum hydrargyri ammoniatum. TINEA TONSURANS. Synonyms. Tinea trichophytina capitis ; herpes tonsurans ; ring- worm of the scalp. Definition. A contagious, parasitic affection of the scalp, due to i\\t. trie hophyto)i fungus ; characterized by the development of circum- scribed, vesicular or squamous, more or less bald patches, showing the hair to be diseased and usually broken off close to the scalp. Cause. The resultof the presence and growth of the same fungus giving rise to tinea circinata — trichophyton. It is an affection of child- hood, seldom being seen after puberty. It is highly contagious, and may be communicated from a case of ringworm of the body. Pathology. The parasite, originally named " trichophyton tonsu- rans,'' invades the hair, hair-follicles, and epidermis of the scalp, the hair, however, suffering the most severely, becoming in a short time filled with the growth to such an extent, usually, as to cause its disin- tegration and destruction. The hair-follicle, also, becomes distended and prominently raised. The hair-shaft is fractured just above the level of the scalp, and usually presents a jagged, bristly, stubble-like extremity. The epidermis of the scalp may either present the changes of minute vesicles and desquamation, or, in severe cases, oedema and inflammatory symptoms, with fluid exudation {tinea ker ion'). Symptoms. Ringworm of the scalp usually begins in the form of small circumscribed patches, which soon become the seat of small vesicles or pustules, which terminate in desquamation, or of furfur- aceous scales. The patches spread rapidly, soon reaching the size of a silver quarter to that of a silver dollar. They are circular in form, circumscribed, of a reddish, grayish, or greenish-yellow color, covered with fine or coarse scales, with the hairs broken off close to the scalp. The epidermis of the scalp is more or less raised, and the follicles are prominent, giving the characteristic appearance of the disease — the goose-skin or pluckedfowl appearance. As a result of the loss of hair, baldness, more or less complete, but temporary, exists. Itching, slight or severe, is a constant symptom. DISEASES OF THE SKIN. 599 Ringworm of the face or body {tinea cbcinata) may complicate tinea tonsurans. Chronic ringworm of the scalp is the same condition in a more chronic form, having existed for six months to a year or two. Tmea kerion is a severe variety of tinea tonsurans, " characterized by oedema, inflammation, and the exudation of a viscid, glutinous, yellowish secretion from the opening of the hair-follicles. When fully developed the patches are yellowish, reddish, or purple in color, and are more or less raised, oedematous, and boggy. They are uneven and honeycomb-like (hence the name kerion), and studded with yellowish, suppurative points, or, later, with small cavities or foramina, the openings of the distended hair-follicles deprived of their hairs, which discharge a mucoid, gummy, honey-like fluid." The patches are tender, painful, and at times the seat of itching. The course of the affection is chronic. Diagnosis. The diagnosis is usually unattended with difficulty, if the characteristic circumscribed vesicular or scaly patches with stubby hair be present. Squamous eczema somewhat resembles tinea tonsurans, but the hairs are normal in eczema and firmly imbedded in the follicles, while they are almost always stumpy in ringworm, and in those cases in which they are not broken off, if pulled, they easily fall out. Ring- worm is contagious, eczema is not. Alopecia areata presents a white, shiny, ivory-like, bald patch, de- void of scales, eruption, or hair. Ringworm has the vesicular or scaly patch, with broken-ofif hairs. In any case of doubt the microscope will readily determine the diagnosis, if " one or two of the short, stumpy hairs should be placed upon a slide with a drop of liquor potassce and permitted to stand a few minutes, when under a power of two hundred and fifty diameters the fungus, as well as the lesions of the hair, will be visible." Prognosis. Favorable, although obstinate in chronic cases. Re- lapses are of frequent occurrence. Treatment. Local measures are usually satisfactory. Mild cases should be treated by cutting the hair as close as possible and thor- oughly scrubbing the patches with sapo viridis and water, or the ap- plication twice daily of a twenty-five to a fifty per centum solution of boroglyceridum, or a six per centum solution of oleatum hydrargyri, or either of the following : 600 PRACTICE OK MKDICINE. li . Sodii borat., ^] 4. Gm. Aceti destil. f 5 ij 60. Cc. M, SiG. — Apply tboroughly several times daily. Or— R . Acidi horici, gr- xv i. Gm. Sulphur, llor. , Rr. xv i. Gm. Vaselini, 3 'ss 45. Gm. M Sir.. — Apply morning and night. Or— K. Cupri oleat., z^s 2. Gm. Ung. petrolei, 3 i j 60. Gm. M, SiG. — Apply after using boric solution. Or use may be made of Morris' thymol solution, to wit : Be- Thymol gss 2. Gm. Chloroformi, f^^^ij 8. Cc. 01. olivx', f 3 vj 24. Cc. M. A preparation very popular in London, known as Coster's paste, is used by painting the patches with a brush and allowing it to remain on until the crust is cast off, in the course of five or six days, when it may be reapplied. A few applications often suffice. Its formula is — R . lodi, ,. 5 ij 8. Gm. Olei picis, f^j 30. Cc. M. The iodine and oil of tar should be gradually and slowly mixed. An excellent application in rebellious cases is — R . PotasscE (caustic), gr. ix 0.6 Gm. Acid, carbolici, gr. xxiv 1.5 Gm. Adeps lana; hydrosus, .... ,^ss 15. Gm. 01. theolsromce, fSss 15. Cc. M. SiG. — A small amount rubbed into head night and morning. If the scalp is not shaved, the application is retained better. The following is an excellent application for the scalp in tinea ton- surans and other scalp diseases : R. Ung. acid, borici, ^ij 60. Gm. Ung. eucalyptol, ^ij 60. Gm. 01. caryophylli, f^ss 2. Cc. Glycerini, . q. s. q. s. M. Ft. unguentum. Cases which resist these means are to be treated by removing the DISEASES OF THE SKIN. 601 loose hairs about the edges of the patches and the broken-off hairs over the surface by means of small, broad-bladed, short forceps, a few hairs only being seized at a time, a portion of the diseased hairs to be removed each day until the surface has been cleared. After each depilation one of the above formulae to be applied. TINEA SYCOSIS. Synonyms. Tinea trichophytina barbae ; sycosis parasitica ; barbers' itch ; ringworm of the beard. Definition. A contagious, parasitic affection of the hair, hair- follicles, and subcutaneous tissues of the hairy portion of the face and neck in the adult male, due to the trichophyton fungus ; character- ized by the development of tubercles and pustules. Causes. Tinea sycosis is the result of the presence and growth of the same vegetable parasite that causes tinea circinata and tinea ton- surans — trichophyton — which invades the hair-follicle and hair. It is highly contagious, and is said to be acquired, in most cases, at the hands of the barber (?). It is not a very common affection. Like the other vegetable growths, it seems to require some peculiar, un- known condition of the skin for its development. It may develop from a case of tinea circinata or develop simultaneously with it. Pathology. The parasite finds its way into the hair-follicles and attacks the root and shaft of the hair, causing inflammation, followed by more or less follicular suppuration and general infiltration of the surrounding tissues. The irritation caused by the presence of the fungus results in inflammation of the subcutaneous connective tissue and the well-known tubercular formations peculiar to the affection. They are firm, comparatively painless, and manifest but little dispo- sition to undergo change, remaining during the presence of the fungus and finally gradually disappearing without leaving a scar. Under the microscope the parasite is plainly discernible. Symptoms. Barbers' itch begins as an attack of tinea circinata — as one or more reddish, scaly patches. Soon the redness and des- quamation become more decided, attended with swelling and indura- tion. The hairs will also be dry, brittle, inclined to break, and many of them are already loose. The process rapidly increases, the skin becomes distinctly nodular and lumpy, and points of pustulation de- 51 602 PRACTICE OF MEDICINE. velop about the openings of the hair-follicles. The subcutaneous con- nective tissue is also involved, giving rise to thick, firm masses of in- duration. The surface has a dark-red or purplish color, and is studded with variously sized tubercles and pustules. In some instances the num- ber of tubercles are in excess, while in others the pustules are more numerous, numbers of them discharging, and are succeeded by thick crusts, which are often so abundant as to simulate pustular eczema. The hairs are always diseased, and break off either in the follicles or just above the level of the surface. Those not breaking drop out, leaving the region partly or wholly devoid of hair. The most frequent location attacked is the chin, neck, and sub- maxillary region. One or, what is more common, both sides of the face are involved. I/L/iing, burning, pain, and swelling always accompany the affec- tion, varying in intensity from moderate to very severe. The course of the affection is usually chronic. Relapses are fre- quent, unless most thoroughly eradicated. Diagnosis. Sycosis non-parasiiica occasions difficulty of diag- nosis at times. The points of difference, however, are usually so marked that error should not occur. Sycosis non-parasitica is a chronic, inflammatory, non-coniagious affection of the hair-follicles, characterized by the development of papules and pustules which are perforated with hairs, the hairs them- selves being unaffected. The upper lip, cheeks, and chin are the parts mostly involved. If of long duration, some inflammatory thickening results. In tinea sycosis, or sycosis parasitica, the skin and subcutaneous connective tissue are extensively involved, as manifested by the in- duration and formation of the characteristic tubercles. The upper lip is rarely invaded ; the hairs are diseased, broken off, or loose, and under the microscope reveal the parasite. Pustular eczema resembles tinea sycosis, with extensive pustulation and crusting; but in the former the hairs are not involved, nor aie the characteristic tubercles present. Treatment. Local measures are sufficient for the cure of tinea sycosis. In the majority of instances the following procedure will effect a cure in three or four weeks. If crusts are present, — and almost always some are, — they are to be thoroughly saturated with inunctions DISEASES OF THE SKIN. 603 of almond or olive oil, and removed by washing with soft soap and water. The part is then cleanly shaved, the first operation being more painful than subsequent ones. After shaving, the affected sur- face is bathed for ten minutes in water as hot as can be borne. All pustules are then opened with a fine needle, and the parts sponged freely for several minutes with a solution of sodii hypo- sulphitis, Z] (4 Gm.) ; aquce, f^j (30 Cc.) ; after which the parts are again thoroughly washed with hot water, carefully dried, and smeared with an unguetitum sulphuris , containing 3j-ij (4-8 Gm.) to the ounce. This procedure is preferably performed at night. The following morning the ointment is washed off with soap and water, the face bathed with the sodium solution, and dusted with any inert powder. This plan continued faithfully every night, omitting the shaving when the beard has not grown much, will usually be followed with success. Cases resisting the above means should, in addition, have the hairs depilated, the shaving performed every two or three days, thus allowing time for the hairs to grow sufficiently to depilate, the operation seldom being as painful as one would suppose. Shaving and depilation upon alternate days should be faithfully practised until the new hairs are healthy. In addition to the parasiticides mentioned, any of those recom- mended for the other vegetable parasitic diseases may be used. TINEA VERSICOLOR. Synonyms. Pityriasis versicolor ; liver-spots. Definition. A contagious, parasitic affection of the skin, due to the microsporon furfur ; characterized by the occurrence of variously sized, irregularly shaped, dry, slightly furfuraceous, yellowish spots upon the chest or other portions of the body. Cause. Pityriasis versicolor is the result of the presence upon the surface of the skin of a vegetable fungus termed microsporon furfur. It is a mildly contagious affection seen after puberty. It is said to occur most frequently in those suffering from wasting diseases, partic- ularly phthisis pulmonalis. It is not connected with any affection of the liver, as supposed by the laity. Pathology. The fungus permeates the horny layer of the epidermis, never the hairs or nails, and gives rise to the irregular- 604 PRACTICE OF MKDICINE. shaped and sized macula;, of a yellowish or brownish color. As a rule, it gives rise to neither hyperaeniia nor inflammatory symptoms. Symptoms. Tinea versicolor occurs in the form of irregular, roundish, circumscribed, or reticulated macula:. The spots vary in size from that of a small silver coin to that of the hand. By coa- lescing they often cover a greater portion of the chest, their most usual site. Upon close inspection the surface of the macule is seen to be covered with furfuraceous scales, and, if the scales be not visible, scraping with the finger-nail will demonstrate their presence. In color the spots vary from a delicate buff or fawn shade to a yellowish, deep brown, and, rarely, even blackish hue. At times mild itching accompanies the eruption. Diagnosis. The character of the eruption is so distinct that errors in diagnosis can hardly occur. If any doubt exist, a few of the scales upon a glass slide, with a drop of liquor poiassce, and covered with a thin glass cover and placed under a microscope with a power of from two hundred and fifty to five hundred diameters will readily determine the presence of the fungus. Prognosis, Favorable. Treatment. Mild galvanism over the discolorations is valuable. The parts should be cleansed with soap and water and either of the following lotions applied : R. Sodii sulphitis, ^iij 12. Gm. Glycerin!, f_5ij 8. Cc. Aqune, ad f^iv ad I20. Cc. M. SiG. — Apply frequently. Or— K. Hydrargyri chlorid. corrosiv., . gr. iv o. 26Gm. Alcoholis, f^vj 24. Cc. Aramonii chlorid., _:^ss 2. Gm. Aquae rosse, ad fjvj ad 180. Cc. M. SiG. — Apply frequently. (Tilbury Fox.) SCABIES. Synonym. The itch. Definition. A contagious, animal parasitic disease of the skin, due to the acarus, or sarcopies scabiei ; characterized by the formation of cuniculi (burrows), papules, vesicles, and pustules; followed by excoriations, crusts, and general cutaneous inflammation, and accom- panied by itching. DISEASES OF THE SKIN. 605 Cause, Contagion. The only cause is the presence of the ani- mal parasite, the acarus, or sarcoptes scabiei. The affection occurs at all ages and in every walk of life. Pathology. Scabies is an inflammation of the skin with the development of papules, vesicles, pustules, excoriations, and subse- quent crusting, the result of the ravages of the animal parasite, together with the irritation produced by the scratching of the patient. The parasite acarus, or sarcoptes scabiei, is a minute creature, barely visible to the naked eye as a yellowish-white, rounded body. The female is the most commonly met with ; the males are said to take no part in causing the affection, and so are rarely seen. They are said to die in about a week after copidation with the female. The female finds her way by boring through the horny layer into the mucous layer of the epidermis, and, being impregnated, begins at once laying her eggs and at the same time making her burrow. A variable number of eggs are deposited, usually about a dozen, after which she perishes in the skin. The ova hatch out in six or ten days. Symptoms. Scabies is an artificial dermatitis or eczema, accord- ing to the amount of irritation produced by the presence of the parasite and the traumatism resulting from the severe scratching of the patient. Immediately upon the arrival of the itch mite upon the skin it begins its work of burrowing, and very soon a burrow, or cuniculus, is formed, in which the eggs are deposited, and which also becomes the habitat of the. female during the remainder of her life. The ova are hatched in about one week after their deposit, and at once begin to care for themselves and to burrow, resulting in the formation of as many additional cuniculi as there are active female mites. It is the presence of these burrowing parasites that constitutes the irritation resulting in the inflammation of the skin, characterized by the formation of minute papules, vesicles, z-nd pustules, with more or less inflammatory indura- tion. Add to these the excoriations, scratch marks, fissures, torn vesicles, and pustules with yellow and bloody crusts, caused by the scratching, and a picture of the fully developed disease is seen. The burrow, or cimiculus, as it is termed, is formed by the mite entering and making its way beneath the horny layer of the epidermis, which is raised, very much as a mole undermines the ground. It occurs as a slight linear elevation of the epidermis, varying from a 606 PRACTICE OF MEDICINE. half a line to four or five lines in length, and having an irregular or tortuous course. Its color is whitish or yellowish, speckled here and there with dark dots. At either end the cuniculus terminates as darkish points, the more prominent of which represent the parasite. The papules are the first inflammatory lesion, are numerous and of small size, and may be the e.\tent of the disease. The vesicles are the next stage, varying in size and number, having an inflamed base, sometimes presenting cuniculi upon their summits. The pustules represent the completion of the inflammatory action, their size and number varying with ^he severity of the irritation. The intense itching, which is worse at night, results in excoriations, torn papules, vesicles, and pustules, followed by crustings, which after a time disguise the characteristic lesions. The regions of the body attacked are the hands, especially the sides of the fingers and the folds where they join the hands. After a time the wrists, penis, and mammae, and around about and upon the nipples, are invaded. Persons predisposed to eczema have this affection developed, in addition to the simple dermatitis, by the ravages of the itch mite. Diagnosis. A case of scabies seen before irritated by scratching presents no difficulty in diagnosis. The presence of the burrows always suffices for the diagnosis, but these are not always discover- able. The location of the eruption always points strongly to scabies. A history of contagion is of value. All doubt can be set at rest by the aid of the microscope. Prognosis. Always favorable, relapses only occurring when the treatment has been imperfectly carried out or when the individual has recontracted the disease. Treatment. Local measures are alone required in the treatment of scabies. The strength of the parasiticides must be controlled by the severity of the inflammatory symptoms present. If eczema com- plicate scabies, it is to be treated as an ordinary attack after the death of the itch mites. Scabies always succumbs to the following plan : The patient is to be thoroughly washed with soft soap and water, followed by a warm bath, after which cover eruption with tinctura benzoini, which imme- diately modifies the itching, or one of the following ointments is to be thoroughly rubbed into every portion of the body, especial attention being devoted to the hands, fingers, and other parts usually the seat of the disease : DISEASES OF THE SKIN. 60f R . Styracis liquidis, f 3 ij 8. Cc. Ung. sulphuris, 3 ij-iv 8.-16. Gm. Ung. petrolei, ad ^'} ad 30. Gm. M. SiG. — Apply after washing. (Bulkley.) Or— R. Sulphuris sublimat., 3J 4. Gm. Balsam Peruviani, g^s 2. Gm. Adeps, §j 30. Gm. M. SiG. — For children. (Duhring.) Or— R. Creolini, . gr. x 0.6 Cc. Ung. petrolei, ^ij 60. Gm. M. SiG. — Apply thoroughly. PEDICULOSIS. Synonyms. Phthiriasis ; morbus pedicularis ; lousiness. Definition. A contagious, animal parasitic disease of the head, body, or pubes, due to the presence of pediculi and characterized by the wounds inflicted by the parasite, together with excoriations and scratch marks. "Varieties. Pediculosis capitis ; pediculosis corporis ; pediculosis pubis. Cause. The cause is the presence of the parasite, the result of contagion, direct or indirect. The view of " a spontaneous genera- tion " of pediculi is not accepted by the great majority of observers. Pathology. The lesion produced by the presence of the pediculi is a minute hemorrhage, caused by the parasite inserting its sucking apparatus, or, as it is termed, its haustellum, into a follicle, and obtain- ing blood by a process of sucking, and not by biting, as is generally supposed. The presence of the parasite in any great numbers brings about a peculiar irritable state of the skin, which gives rise to an irre- sistible desire to scratch, as a consequence of which the surface is markedly excoriated and lacerated. Symptoms. The symptoms which arise from the presence of the parasite in different localities are somewhat different, and call for separate consideration. Pediculosis capitis. This variety is caused by the presence of the pediculus capitis, or head louse. The ova, or nits, are readily recog- 608 PRACTICE OF MEDICINE. nized at a distance. Their favorite seat is the occipital region, either upon the surface of the scalp or upon the hair. Their presence gives rise to considerable irritation, itching, and consequent scratching, re- sulting in the wounding of the scalp, with oozing of a serous or puru- lent fluid mixed with blood, which soon mats the hair and forms into crusts. In those predisposed to eczema the presence of the parasite will give rise to that condition. The general health is usually unaffected by the presence of the pediculi. Pediculosis corporis. This variety of the pediculosis is caused by the presence of the pediculus corporis, or body louse, or more properly termed the pediculus vestimenti, or clothes louse. Its color, when devoid of blood, is dirty-white or grayish, with a dark line around the margin of its abdomen. Its habitat is the clothing covering the general surface, remaining upon the skin only long enough to obtain sustenance. The ova are usually deposited in the seams of the cloth- ing, the lice being hatched within the week. Occasionally a few of the pediculi may be observed crawling about the surface, or in the act of drawing blood. As they move over the surface they give rise to an intensely disagreeable itching sensation, to relieve which the patient scratches, which in turn gives rise to the characteristic lesions of the affection. The lesions are numerous. The scratch marks are scattered here and there, either long and streaked, in other places short and jagged, the excoriations and blood-crusts varying in size from a pin-head to a split pea or even larger, with irregular-shaped pustules. In addition to the lesions resulting from the scratching are seen the primary lesions, consisting of minute, reddish puncta with slight areolae, the points at which the parasite has drawn blood. In cases of long stand- ing a brownish pigmentation of the whole skin may result from the long-continued irritation and scratching. The favorite site of the lesions are the back, especially about the scapular region, the chest, abdomen, hips, and thighs. Pediculosis is seen most commonly among the poorer classes, and especially the middle-aged and elderly. Pediculosis pubis. This variety of pediculosis is caused by the pres- ence of the pediculus pubis, or crab louse. Although having its seat of predilection about the pubes, it may also infest the axillae, sternal region in the male, beard, eyebrows, and even eyelashes. DISEASES OF THE SKIN. 609 They may be found crawling about the hairs, but more commonly hugging the surface closely. They infest adults chiefly, and occasion symptoms similar to those described in connection with other species. They are usually contracted through sexual intercourse, although occasionally they are present in cases in which they have not been communicated in this way, and where no explanation as to the mode of contagion can be suggested. The itching varies from slight to severe. Diagnosis. When violent itching exists in any case, without marked eruption, the possibility of the presence of pediculi should always be entertained, and if carefully sought after, are found. Prognosis. Favorable, if the treatment be thoroughly carried out. Treatment. Local measures alone are all that is necessary for the removal of the various forms of pediculosis. Pediculosis capitis. The most effective application to this variety is to thoroughly soak the head two or three times a day with ordinary petroletnn or kerosene oil, and keep it wrapped in a cloth for twenty- four hours. At the end of this time the head should be thoroughly washed with soft soap and hot water, dried, and saturated with the official unguentuin hydrargyri afmnoniatum. If required, this entire procedure may be repeated, but usually any pediculi escaping the petroleum are destroyed by the unguentum. Pediculosis corporis. In this variety the habitat of the parasite being the clothing, they must be boiled or baked at a temperature sufficiently high to destroy their life. After this the clothing should be changed every day or two, carefully inspected, and if pediculi are seen, they must again be baked or boiled. It is folly to expect satis- factory results unless these directions are faithfully adhered to. For the irritation, itching, and excoriations, mild alkaline baths or lotions of acidum carbolicum are sufficient. Pediculosis pubis. The parts should be washed twice daily with soft soap and water, after which the thorough application of tinctura cocculus indicus, full strength or diluted, or a lotion of hydrargyri chloridujn corrosivum or unguentutn hydrargyri ammoniatuin or unguentum hydrargyri (blue ointment), will be -effectual. 39 INDEX. Abdominal dropsy, 141 typhus, 22 Abscess, cerebral, 424 iliac, 129 of the heart, 383 of the liver, 153 peritypblitic, 129 Acne, 574 artificialis, 575 disseminata, 574 indurata, 574 papulosa, 574 punctata, 534, 574 pustulosa, 574 rosacea, 576 sebacea, 531 tubercula, 574 vulgaris, 574 Acute articular rheumatism, 219 Bright's disease, 168 diarrhoea, 109 gastric catarrh, 76 general diseases, 209 hepatitis, 153 meningitis, 404 nasal catarrh, 263 toxic gastritis, 78 ursemia, 183 yellow atrophy, 154 Addison's disease, 203, 584 Agraphia, 429 amnesic, 429 Ague, 39 brow, 39 cake, 39 dumb, 39 Albumin, tests for, 161 nitric-magnesian test, 161 611 Albuminuria, 169 chronic, 1 71 Alcoholism, 436 acute, 436 chronic, 443 Amygdalitis, 272 Amyloid kidney, 180 Ansematosis, 199 Anemia, 195 Blaud's pill for, 198 cerebral, 414 England's pill for, 198 essential, 197 lymphatic, 202 of fatty heart, 199 progressive pernicious, 199 splenica, 201 Anatomy, morbid, II Aneurism of the abdominal aorta, 4 "xa of the arch of aorta, 399 of the thoracic aorta, 399 Angina catarrhalis, 269 pectoris, 393 Anidrosis, 540 Anthrax, 571 Aorta, aneurism of the, 398 Aphasia, 429 Aphonia, 429 Aphtha, 69 confluens, 69 discrete, 69 Aphthous stomatitis, 69 Apnoea, 14 Apoplexy, 415 capsular, 417 cortical, 417 crus-cerebri, 417 ingravescent, 416 612 INDEX. Apoplexy, serous, 446 Ajipendicitis, 129 Argyria, 5S4 Arrhythmia, 393 Arteries, Cohnheim's terminal, 42I Arteriocapillary fibrosis, 396 Arterio-sclerosis, 396 Arthritis deformans, 227 Artisans' cramp, 500 Ascaris lumbncoides, 137 Ascites, 144 Asthenia, 14 Asthma, 302 bronchial, 302 hay, 306 Kopp's, 286 Millar's, 286 spasmodic, 302 thymic, 286 Ataxia, locomotor, 467 Ataxic paraplegia, 470 Atheroma, 396 iodides in, 398 Atonic dyspepsia, 96 Atrophic paralysis of children, 458 Atrophy, chronic spinal muscular, 462 progressive muscular, 462 Atropia for hemorrhage, 315 Auscultation, 252 Da Costa's rules for, 252 Autumnal catarrh, 306 fever, 22 Bacillus, comma, 239 malaria, 39 of Eberth, 23 of PfeilTer, 19 tuberculosis, 332 Bacteria of decomposition, 239 Bacteriology, 11 Barbers itch, 601 Basedow's disease, 495 Basham's iron mixture, 171 Bell's palsy. 483 Belt, hydropathic, 152 Beriberi, 476 Bile, test for, 147 pigment, test for, I47 Biliary calculi, 149 Bilious cholera, 113 fever, 42, 71 Bilious malignant fever, 48 remittent fever, 42 Biliousness, 151 Black-heads, 534 Bladder, catarrh of, 1 90 Blaud's pill, 198 Bleeders' disease, 204 Blepharospasm, 484 Blood, diseases of, 195 test for, 163 white cell, 20I Bloody flux, 121 Boil, 569 Bothriocephalus latus, 134 Bowels, inflammation of, I09 Brachycardia, 392 Bradycardia, 392 Brain, congestion of, 4 12 Brand's method, 30 Break-bone fever, 67 Bright's disease, acute, 168 chronic, 171, 175, 180 Bromidrosis, 537 pedum, 537 Bronchial catarrh, 290 dilatation, 299 hemorrhage, 313 Bronchiectasis, 298 Bronchitis, acute, 290 capillary, 293, 328 chronic, 298 croupous, 296 diphtheritic, 296 fetid, 298 fibrinous, 296 membranous, 296 peri-, 303 plastic, 296 secondary, 298 senile, 298 Broncho-pneumonia, 293, 328 Bronchorrhagia, 313 Bronchorrhoea, 298 Bronzed-skin disease, 203 Brow ague, 41 Cy^CUM, inflammation of, 127 Calculi, alternating, 188 biliary, 149 cutaneous, 535 hepatic, 149 613 Calculi, oxalate of lime, 1 88 phosphatic, 1 88 renal, 187 uric acid, 188 Callositas, 586 Cancer, gastric, 87 hepatic, 158 Cancrum oris, 75 Carbolic acid in tetanus, 499 Cart'uncle, 571 Carbunculus, 57 1 Carcinoma, gastric, 87 of the liver, 158 Cardiac dilatation, 380 fatty degeneration, 387 hypertrophy, 377 paralysis, 213 valvular diseases, 369 Cardialgia, 94 Carditis, 383 chronic, 384 Catalepsy, 492 Catarrh, acute bronchial, 290 gastric, 76 nasal, 263 autumnal, 306 chronic bronchial, 298 gastric, 81 nasal, 267 contagious, 19 dry, 298 intestinal, 109 mucous, 298 of the bile-ducts, 147 of the bladder, 1 90 of the mouth, 68 of the rectum, 13I suffocative, 293 Catarrhal enteritis, 109 jaundice, 147 laryngitis, 274 nephritis, 167 pneumonia, 328 stomatitis, 68 tonsillitis, 269 " Catarrh sec " of Laennec, 299 Cephalic tetanus, 498 Cephalodynia, 224 Cerebral abscess, 424 ansemia, 414 congestion, 412 Cerebral embolism, 421 fever, 464 hemorrhage, 415 hyperemia, 412 softening, 416 thrombosis, 421 tumors, 426 Cerebro-spinal fever, 35 neuroses, 484 sclerosis, 471 Cervico-brachial neuralgia, 480 Cervico-occipital neuralgia, 480 Cheyne-Stokes breathing, 388 Chicken-pox, 63 Child-crowing, 279 Chills and fever, 39 Chiragra, 229 Chloasma, 583 uterinum, 584 Chlorides, test for, 161 Chlorosis, 197 Cholera, 239 Asiatic, 239 bilious, 113 English, 113 epidemic, 239 infantum, 119 malignant. 239 morbus, 113 spasmodic, 239 sporadic, 1 13 typhoid, 239 Cholerine, 240 Chorea, 484 Huntington's, 485 post-hemiplegic, 485 Chromidrosis, 537 Chronic dyspepsia, 81 entero-colitis, 116 gastric catarrh, 81 gastritis, 81 nasal catarrh, 267 valvular disease, 369 Circular insanity, 514 Clavus, 587 Clinical history, 12 Cohnheim's terminal arteries, 421 Cold in the head, 263 Colic, hepatic, 149 intestinal, 102 lead, 103 614 INDEX. Colic, ovarian, 103 renal, 1S7 stomachic, 04 uterine, I03 Colitis, 121 ulcerative, 121 Coma, 14 urainic, 183 Comedo, 534 Comedones, 534 Congestion, cerel)ral, 412 of the kidneys, 167 of the liver, 151 of the lungs, 316 spinal, 449 Congestive fever, 44 Constipation, 104 Consumption, pulmonary, 332 galloping, 332 throat, 288 Contagious fever, ^;^ catarrh, 19 Convulsions, un\mic, 183 Cor bovinum, 371 Corns. 587 Corrigan's disease, 340 hammer, 442 sign, 89 Coryza, acute, 263 chronic, 267 Costiveness, 104 Cough, whooping, 308 winter, 298 Cow-pox, 63 Crisis, 13 Croup, catarrhal, 279 false, 279 membranous, 281 pseudo-, 286 spasmodic, 279 true, 281 Croupous bronchitis, 296 enteritis, 112 laryngitis, 281 pneumonia, 319 stomatitis, 69 Cyst, renal, 182 sebaceous, 536 Cysticercus bovis, 135 cellulosus, 134 Cystitis, 190 Cystitis, acute, 190 chronic, 190 Dandruff, 531 Dandy fever, 67 Death, 14 Delirium tremens, 438 Delusional insanity, 516 Dementia, 527 acute, 528 alcoholic, 529 apo|ilectica, 529 choreica, 529 ciironic 529 epileptic, 513,529 organic, 529 parnlytica, 529 paretic, 521 partial, 530 primary, 530 secondary, 530 senilis, 530 syphilitica, 530 toxica, 530 Dengue, 67 Diabetes insipidus, 236 meliitus, 232 Diagnosis, 14 by exclusion, I4 differential, I4 direct, 14 physical, 244 Diarrhcea, 106 acute, 106, 109 bilious, 106 choleriform, 1 19 chronic, 106 feculent, 106 inflammatory, II5 lienteric, 106 mixture, Squibb's, 108 Diathesis, 12 Dilatation, bronchial, 299 cardiac, 380 gastric, 90 Diphtheria, 210 bronchial, 296 laryngeal, 213, 281 nasal, 213 Diphtheritic paralysis, 213 stomatitis, 70 INDEX. 615 Dipsomania, 439 Discharges, chopped spinach, n6 rice water, no, 1 14 Disease, 9 acute, 13 Addison's, 203, 584 Basedow's, 495 bleeders', 204 Bright's, 168, 171, 175, 180 causes of, II chronic, 13 Corrigan's, 340 defined, 9 Duchenne's, 465 fish-skin, 590 flesh-worm, 138 Fothergill's, 479 functional, 9 Graves', 495 Hodgkin's, 202 Meniere's, 43 1 organic, 9 Parkinson's, 501 predisposition to, 12 subacute, 13 termination of, 1 3 Diseases, acute, general, 209 general or nutritional, 484 mental, 504 of the biliary passages, I47 of the blood, 1 95 of the bronchial tubes, 290 of the cerebral membranes, 402 of the cerebrum, 409 of the circulatory system, 352 of the intestinal canal, 99 of the kidneys, 159 of the larynx, 274 of the liver, 151 of the lungs, 316 of the mouth, 68 of the nasal passages, 263 of the nerves, 475 of the nervous system, 401 of the peritoneum, 140 of the pharynx, 269 of the pleura, 346 of the respiratory system, 244 of the skin, 531 of the spinal cord, 449 of the stomach, 76 Disorders of secretion, 531 Dizziness, 431 Dobell's solution, 54 Dropsy, cutaneous, 52 of the abdomen, 141 of the pleura, 350 pericardial, 364 peritoneal, 141 pleural, 350 Duchenne's disease, 465 Duodenitis, 109 Dysentery, acute, 121 chronic, 124 croupous, 121 epidemic, 122 nuclein in, 126 sporadic, 122 washing rectum in, 126 Dyspepsia, 96 acid, 97 atonic, 96 chronic, 81 drunkards', 8 1 flatulent, 97 hot water in, 78 intestinal, 99 irritative, 97 nervous, 97 Ecstasy, 492 Ecthyma, 568 Eczema, 542 acute, 543 ani, 555 aurium, 554 barbae, 553 capitis, 551 chronic, 545 erythematosum, 543 faciei, 552 fissum, 545 genitalium, 554 impetiginosum, 544 intertrigo, 555 labiorum, 552 madidans, 544 mammarum, 556 palmarum, 55^ palpebrarum, 553 papillomatosum, 545 papulosum, 543 r.io Eczema plantaruni, 556 pustulosum, 544 rimosum, 545 rubrum, 544, 549 sclerosum, 545 squamosum, 545 unguium, 557 verrucosum, 545 vesiculosum, 544 Elixir, triple, 389 Embolism, cerebral, 421 Emphysema, 310 Empyema, 347 Encephalitis, acute, 424 suppurative, 424 Endarteritis chronica deformans, 396 Endocarditis, acute, 364 chronic, 369 diphtheritic, 365 malignant, 367 mycotic, 367 septic, 367 ulcerative, 367 Enteralgia, 102 Enteric fever, 22 Enteritis, catarrhal, 109 croupous, 112 membranous, 112 Entero-colitis, 115 Entero-mesenteric fever, 22 Enteroptosis, 92 Enterorrhcea, I06 Ephemeral fever, 17 Epidemic catarrhal fever, 19 cerebru-spinal fever, 35 roseola, 58 Epilepsy, 486 Jacksonian, 4S6 Epileptic dementia, 513 imbecility, 513 insanity, 513 Erysipelas, 64 ambulans, 65 of the brain, 65 phlegmonous, 65 Erysipelatous dermatitis, 64 Erythema intertrigo, 541 simplex, 540 Erythematous stomatitis, 68 Erythromelalgia, 48 1 Essential anaemia, 199 Etiology, II Eucalyptol in cystitis, 193 Exophthalmic goitre, 495 Exudative endocarditis, 364 Facial paralysis, 483 Farcy, 218 I'atty heart, 387 Favus, 593 Febricula, 1 7 Fever, 15 abdominal typhus, 22 autumnal, 22 bilious, 42, 76 remittent, 42 typhoid, 38 breakbone, 67 catarrhal, 19 cause of, 15 cerebral, 404 cerebrospinal, 35 congestive, 44 contagious, ^^ continued, simple, 1 7 dandy, 67 enteric, 22 entero-mesenteric, 22 ephemeral, 17 epidemic cerebro-spinal, 35 gastric, 22, 76 hay, 306 intermittent, 39 irritative, 1 7 jail, 33 lung, 319 malarial, 39 malignant intermittent, 44 remittent, 44 marsh, 42 Mediterranean, 48 nervous, 22 neuralgic, 67 periodical, 39 pernicious, 4I relapsing, 38 remittent, 42 rheumatic, 219 rose, 306 sailors', 48 scarlet, 5 1 ship, 33 617 Fever, simple continued, 17 spirillum, 38 spotted, 2:i swamp, 39 thermic, 443 typhoid, 22 typho-malarial, 42 typhus, 33 winter, 319 yellow, 48 Fevers, 1 5 continued, 17 eruptive, 51 general treatment of, 1 6 periodical, 39 pernicious malarial, 44 primary cause of, 15 Fibrosis, arterio-capillary, 396 Fish-skin disease, 590 Floating kidney, 193 Folie circulaire, 514 Fothergill's disease, 479 Freckles, 583 Furunculosis, 569 Furunculus, 569 Gall-stones, 149 Gastralgia, 94 Gastric cancer, 87 carcinoma, 87 dilatation, 90 fever, 21, 76 hemorrhage, 93 neuralgia, 94 ulcer, 84 vertigo, 431 Gastritis, acute toxic, 78 chronic, 81 subacute, 76 toxic, 78 Gastrodynia, 94 Gastroptosis, 92 Gastrorrhagia, 93 General paralysis, 521 German measles, 58 Glanders, 218 Glenard's disease, 92 Glossitis, 73 Glottis, oedema of, 277 spasm of, 286 Glycosuria, 232 Glycosuria, simple, 234 Gonagra, 229 Gout, 229 rheumatic, 227 Gravel, 187 Graves' disease, 495 Green sickness, 197 Gripes, 102 Grutum, 535 H^MATEMESIS, 93 Hsematology, 11 Haematoma of the dura mater, 403 Hsematuria, 188 Haemophilia, 204 Haemoptysis, 313 Hay asthma, 306 fever, 306 Headache, 434 Heart, anaemia of fatty, 199 dilatation of, 380 fatty degeneration of, 387 hypertrophy of, 377 irritable, 389 neuralgia of, 393 palpitation of, 389 rapid, 390 valvular diseases of, 369 Heartburn, 96 Heat exhaustion, 444 stroke, 443 Hemicrania, 434 Hemiplegia, 417 Hemorrhage, bronchial, 313 cerebral, 415 gastric, 93 meningeal, 418 pons, 417 renal, 188 ventricular, 417 Hemorrhagic diathesis, 204 HemoiThoea petechialis, 206 Hepatic calculi, 149 cancer, 158 colic, 149 Hepatitis, acute, 153 general parenchymatous, 154 interstitial, 155 parenchymatous, 153 suppurative, 153 Hernia, strangulated, 132 618 INDEX. Herpes, 560 circinatus, 595 facialis, 560 gestationis, 561 pnvputialis, 560 progenitalis, 560 tonsurans, 598 zoster, 561 Histology, II Hives, 557 Hodgkin's disease, 202 Hooi)ing coui^h, 30S Hydrocephalus, acquired, 446 acute, 407, 446 chronic, 447 congenital, 447 Hydropericardium, 364 Hydropneumothorax, 350 Hydrosis, 537 Hydrothorax, 350 Hyperemia, cerebral, 412 renal, 167 spinal, 449 Hypera-mias of the skin, 540 Hyperidrosis, 537 local, 537 unilateral, 537 Hypertrophies of the skin, 583 Hypertrophy, cardiac, 377 Hypotonia, 469 Hysteria, 489 Hystero-epilepsy, 492 Ichthyosis, 590 Icterus, 147 hemorrhagic, 154 Impetigo, 567 Incubation, period of, 13 Indigestion, 96 acute, 76 intestinal, 99 Inebriety, 436 Inflammation of the skin, 542 Influenza, 19 Insanity, 507 alternating, 515 chronic delusional, 520 circular, 514 delusional, 516 epileptic, 513 Kahlbaum's, 515 Insolation, 443 Inspection, 245 Intercostal neuralgia, 561 Intermittent fever, 39 tetanus, 497 Interstitial nephritis, 175 Intestinal colic, 102 dyspepsia, 99 indigestion, 99 obstruction, 132 parasites, I34 stricture, 132 torpor, 104 Intestines, diseases of, 97 Introduction, 9 Invagination, 133 Ipecacuanha in dysentery, 126 Iron lemonade, I96 Irritative fever, 17 Ischamia, 195 Itch, 604 barber's, 601 Jail fever, 53 Jaundice, catarrhal, I47 malignant, 154 Kahlbaum's insanity, 515 Kakk6, 476 Katatonia, 515 Kidneys, amyloid, 180 congestion of, 167 contracted, 175 diseases of, 159 floating, 193 gouty, 175 lardaceous, 1 80 movable, 193 sclerosis of, 175 small red, 175 wandering, 193 waxy, 180 white, large, 171 La Grippe, 19 Laryngeal phthisis, 288 laryngismus stridulus, 286 Laryngitis, acute catarrhal, 274 croupous, 281 oedematous, 277 spasmodic, 279 INDEX. 619 Laryngitis, tuberculous, 288 Larynx, diseases of the, 274 Law of parallelism, 220 Lentigo, 583 Leptomeningitis, acute, 404 spinalis, 452 Lesions, II Leucaemia, 201 Leucocythemia, 201 Lichen simplex, 543 tropicus, 563 LithiEmia, 237 Lithiasis, 237 Liver, abscess of, 153 albuminous, 157 amyloid, 157 atrophy of, 156 carcinoma of, 158 cirrhosis of, 155 congestion, 151 diseases of, 151 gin drinkers', 1 55 hob-nailed, 155 hypertrophic sclerosis of, 1 56 lardaceous, 157 nutmeg, 156 sclerosis of, 155 scrofulous, 157 spots, 583, 603 torpid, 151 waxy, 157 yellow atrophy of, 154 Lock-jaw, 498 Locomotor ataxia, 467 Lousiness, 607 Lumbago, 224 Lumbo-abdominal neuralgia, 480 Lumbodynia, 224 Lungs, cirrhosis of, 340 congestion of, 316 consumption of, 338 gangrene of, 320 oedema of, 317 Lymphadenoma, 202 Lysis, 13 Malaria oscillaria, 11 Malignant endocarditis, 367 intermittent fever, 44 jaundice, 154 remittent fever, 44 Mai, le grand, 486 Mai, le petit, 487 Malarial fever, 39 Mania, 507 acute, 508 delirious, 508 amenorrhoeal, 509 asthenic, 509 chronic, 510 dancing, 509 delusional, 509, 516 erotic, 509 epileptica, 509 hallucinatory, 509 homicidal, 509 post-epileptic, 513 pre-epileptic, 513 puerperal, 510 reasoning, 520 recurring, 510 senile, 510 transitory, 510 Mania-a-potu,438, 509 Marsh fever, 42 Measles, 56 black, 57 false, 58 French, 58 German, 58 Mediterranean fever, 48 Megrim, 434 Melansemia, 42 Melancholia, 504 agitata, 505 attonita, 506 chronic, 506 delusional, 516 hallucinatory, 505 hypochondriacal, 505 senile, 506 Melasma supra-renalis, 203 Melituria, 232 Membranous enteritis, 112 Meniere's disease, 432 Meningitis, 403 acute, 404 basilar, 407 cerebrospinal, epidemic, 35 spinal, 452 tubercular, 407 Mensuration, 247 620 INDEX. Metastasis, 14 Migraine, 434 Miliaria, 563 alba, 563 rubra, 563 Milium, 535 Mitral regurgitation, 369 Mixture, Hashani's iron, 171 Hrown-Sequard's, for epilepsy, 4S8 Da Costa's muscular cramp, "4 enterica, 11 1 ferro salicylata, 223 Pepper's asthma, 304 Philadelphia Hospital epileptic, 488 Smith's tonic, I96 Squibb's diarrhoea, 108 Monomania, 520 Morbid anatomy, II Morbilli, 56 Morphina in acute urccmia, 185 in cardiac dilatation, 382 Morphiomania, 510 Mouth, catarrh of, 68 diseases of, 68 white, 72 Movable kidney, 193 Mucus, test for, 161 Muguet, 72 Mumps, 209 Murmurs, aortic, 358 endocardial, 356 exocardial, 356 mitral, 357 pericardial, 356 pulmonic, 358 tricuspid, 358 Muscular rheumatism, 224 Myelitis, acute, 454 Myocarditis, acute, 383 chronic, 384 Myxcedema, 502 Nasal acute catarrh, 263 chronic catarrh, 267 passages, diseases of, 263 Nephritis, acute desquamative, 168 parenchymatous, 168 catarrhal, 167 Nephritis, chronic parenchymatous, 171 interstitial, 175 peri-, 182 pyelo-, 181 suppiuative, 181 tubal, 168 Nephrolithiasis, 187 Nephroptosis, 92 Nephrosis, pyelo , 182 Nervous dyspepsia, 97 exhaustion, 493 fever, 22 prostration, 493 Nettle-rash, 557 Neuralgia, 479 cervico-brachial, 480 cervico-occipital, 480 dorso-intercostal, 480 intercostal, 561 lumbo-abdominal, 480 of stomach, 94 of the fifth nerve, 479 of the heart, 393 red, 481 sciatic, 480 Neuralgic fever, 67 Neurasthenia, 493 Neuritis, multiple, 476 simple, 475 Neuroses, occupation, 500 Noma, 75 Nomenclature, 10 Nuclein in dysentery, 126 Nymphomania, 509 Nystagmus, 484 Obstruction, aortic, 373 intestinal, 132 mitral, 373 pulmonic, 375 pyloric, 87 tricuspid, 375 Occlusion of ceiebral vessels, 42I Occupation neun ses, 500 CEdema of glottis, 277 of lungs, 317 OTdium albicai s, 72 Oinomania, 437 Oxyuris vermicularis, 137 Ozsena, 267 \ INDEX. 621 PAr.riYMENINGITIS, 4O3 "hypertrophic, 451 pseudo-membranoxis, 45' spin^^lis, 451 Pains, the girdle, 454 Palpation, 246 Palsy, Bell's, 483 shaking, 502 wasting, 462 Paragraphia, 429 Paralysis, 418 agitans, 50I alcoholic, 176 bilateral, 418 bulbar, 461 cardiac, 213 chronic progressive bulbar, 461 crossed, 418 diphtheritic, 213 essential, of children, 458 facial, 483 general, 521 glosso-labio-laryngeal, 416 infantile spinal, 458 of the insane, general, 521 of the tongue, 430 pharyngeal, 21 3 shaking, 501 spastic spinal, 466 unilateral, 418 wasting, 462 Paralytic dementia, 521 Paranoia, 520 Paraphasia, 424 Paraplegia, ataxic, 470 Parasites, intestinal, I34 Parasitic diseases of the skin, 593 Paresis, general, 521 Parkinson's disease, 501 Parotiditis, 209 metastatic, 209 Partial cerebral anaemia, 421 Pathogenesis, II Pathognomonic, 1 3 Pathology, 9 Pediculosis, 607 capitis, 607 corporis, 608 pubis, 608 Peliosis rheumatica, 206 Pemphigoid purpura, 207 Pemphigus, 565 Peptic ulcer, 84 Percussion, 247 auscultatory, 25 1 respiratory, 251 Perforating ulcer, 84 Pericarditis, acute, 359 chronic, 362 dry, 359 Pericardium, adherent, 328 hydro-, 329 Peri-nephritis, 182 Periodical fevers, 39 Peripheral neuritis, 475 Peri-proctitis, 131 Peritoneal dropsy, 141 Peritonitis, 140 Peri-typhlitis, 129 Pertussis, 308 Pharyngeal paralysis, 213 Pharyngitis, acute catarrhal, 269 erysipelatous, 270 exanthematous, 270 •« fibrinous, 270 gangrenous, 270 phlegmonous, 270, 272 Phosphates, tests for, 161 Phosphoridrosis, 537 Phthiriasis, 607 Phthisis, 332 acute, 332 * caseous, 335 catarrhal, 335 chronic, 338 fibroid, 346 florida, 336 incipient, 338 laryngeal, 288 pneumonic, 332, 335 pulmonalis, 332 tubercular, 332, 338 Physical diagnosis, 244 signs, 12 association of, 263 Pill, Blaud's, 198 Da Costa's, for hemorrhage, 315 England's, 198 Gross's neuralgic, 482 Moussette's, 482 Niemeyer's, 344 Pilocarpus fur spreading erysipelas, 66 622 INDEX. Pilocarpus for mumps, 210 Pityriasis, 531 versicolor, 603 Pleurisy, 346 Pleurilis, 346 clironic, 347 Pleurodynia, 225 Pleuropneumonia, 319 alcoholic, 322 apyretic, 322 aspiration, 323 Pneumonia, bilious, 322 caseous, 335 catarrhal, 328 chronic catarrhal, 329, 335 interstitial, 340 croupous, 319 lobar, 319 lobular, 328 traumatic, 323 typhoid, 322 Pneumonitis, 319 Pneumothorax, 350 Podagra, 229 Poliomyelitis anterior acuta, 458 chronic, 462 Polydipsia, 236 Polyurin, 236 Posterior spinal sclerosis, 467 Predisposition, 12 acquired, 12 inherited, 12 Prickly heat, 563 Primary delusional insanity, 516 Proctitis, 131 peri-, 131 Prodromes, 13 Professional neuroses, 500 Prognosis, 14 Progressive muscular atrophy, 462 jiernicious anaemia, 199 Pseudo-tabes, 476 Psoriasis, 579 circinata, 580 diffusa. 580 guttata, 580 gyrata, 580 nummularis, 580 of the mouth, 74 of the tongue, 74 palmaris, 580 Psoriasis, plantaris, 580 punctata, 580 unguium, 580 Psychalgia, 504 Pulmonary engorgement, 316 wdema, 317 tuberculosis, 332 Pulse, Corrigan, 371 irregularity of, 393 receding, 371 Purging, 106 Purpura, 206 ha^morrhagica, 206 simplex, 206 urticans, 206 Pus, test for, 163 Pyelitis, l8l Pyelonephritis, I Si Pyelo-nephrosis, 182 Pyloric obstruction, 90 stenosis, 90 Pyrosis, 96 QuiNiNA in trichinosis, 140 in typhoid fever, 26 Quinsy, 272 malignant, 210 Rales, 258 Reactions of degeneration, 459 Rectitis, 131 Rectum, catarrh of, 131 washing out the, 126 Regurgitation, aortic, 370 mitral, 369 pulmonic, 372 tricuspid, 372 Relapsing fever, 38 Remittent fever, 42 Renal calculi, 187 colic, 187 cyst, 182 Respiration, Cheyne-Stokes', 388 oscillating, 388 Respiratory system, diseases of, 244 Rheumatic fever, 219 gout, 227 Rheumatism, acute articular, 219 gonorrhceal, 221 hyperpyrexia of, 220 INDEX. 623 Rheumatism, inflammatory, 219 muscular, 224 Rheumatoid arthritis, 227 Rhinitis, acute, 263 chronic, 267 Rhinophyma, 577 Ringworm, honeycombed, 593 of the beard, 601 of the body, 595 of the scalp, 598 Rontgen or X rays, 14 Rosacea, acne, 576 Rose, the, 64 Rotheln, 58 Round-worms, 137 Rubella, 58 Rubeola, 56 Sailors' fever, 48 Salisbury steaks, 83 Sand, renal, 188 Scabies, 604 Scall, 542 Scarlatina, 51 Scarlet fever, 51 Schonlein s disease, 207 Sciatica, 480 Sclerosis, amyotrophic lateral, 462 antero lateral, 470 cerebrospinal, 471 disseminated, 471 hepatic hypertrophic, 156 of the liver, 155 posterior spinal, 467 primary lateral, 466 spinal, 465, 471 Scorbutu-, 205 Scurvy, 205 Sebaceous cyst, 536 Seborrhcea, 531 capitis, 532 faciei, 532 oleosa, 532 sicca, 532 Secondary processes, 13 Secretions, disorders of, 53I Shaking palsy, 501 Shingles, 561 Ship fever, 33 Sick headache, 434 Sickness, green, 197 Sign, Corrigan's, 89 Signs, 13 physical, association of, 263 Silver nitrate in phlegmonous erysip- elas, 67 in purpura h^emorrhagica, 208 Skin, hypersemias of, 540 inflammations of, 542 Smallpox, 59 Smith's, Dr. A. H., tonic, 196 Sore throat, acute, 274 Sounds, in disease, chest, 255 in health, chest, 253 normal cardiac, 353 Spanaemia, 195 Spasm, histrionic, 484 of the glottis, 286 Spasmodic croup, 279 tabes dorsalis, 466 Spastic spinal paralysis, 466 Spinal hyperemia, 449 irritation, 493 meningitis, 452 sclerosis, 465 Spinalis pachymeningitis, 45 1 Spotted fever, 33 Sprue, 72 St. Anthony's fire, 64 St. Vitus's dance, 484 Stomach, cancer of, 87 diseases of, 76 neuralgia of, 94 spasm of, 94 Stomatitis, aphthous, 69 catarrhal, 68 croupous, 69 diphtheritic, 70 erythematous, 68 follicular, 69 gangrenous, 75 parasitic, 70 simple, 68 ulcerative 70 vesicular, 69 Stonepock, 574 Stricture, intestinal, 132 Strychnina in phthisis, 342 Succussion, 262 Sudamen, 539 Sudamina, 539 Sugar, test for, 164, 165 624 INDEX. Summer complaint, 1 19 Sunstroke, 443 Swamp fever, 39 Sycosis paralitica, 601 Symptoms, 12 Syncope, 419 Synociia, 17 Syringomyelia, 474 Tabes dorsalis, 467 Tachycardia, 390 Taenia saginata, 134 solium, 134 Tapeworm, armed, 134 unarmed, 135 Temulentia, 436 Test for albumin, 161 for bile, 163 for bile pigment, 164 for blood, 163 for chlorides, 161 for Ehrlichs diazo-reaction, 166 for indican, 166 for mucus, 16 1 for phosphates, 161 for pus, 163 for sugar, 164, 165 for urates, 160 for urea, 160 Tetanilla, 497 Tetanus, 498 Tetany, 286, 497 Tetter, 542 Thermic fever, 443 Throat, acute sore, 274 consumption, 288 putrid sore, 210 Thrombosis, cerebral, 421 Thrush, 72 Tic-douloureux, 479 Tinea circinata, 595 favo-a, 593 furfuracea, 531 kerion, 599 sycosis, 601 tonsurans, 598 versicolor, 603 Tinkling, meiallic, 261 Tone, bandbox, of Bamberger, 304 Tongue, strawberr}', 52 Tonsillitis, acute, 272 Tonsillitis, catarrhal, 269 Tormina, 102 Torticollis, 225 Toxic gailritis, 78 Trance, 492 Treatment, 14 abortive, I4 expectant, 15 palliative, 15 preventive, 14 restorative, 15 Tremens, delirium, 438 Trichince, 138 spiralis, 138 Trichinosis, 138 Trismus, 498 Trousseau's diuretic wine, I7i Tubbing in typhoid fever, 30 Tubercular meningitis, 407 Tuberculosis, 338 acute miliary, 332 Tuberculous laryngitis, 288 Tumor, phantom, 492 sebaceous, 536 Tumors, abdominal, 89 intra-cranial, 426 Turpentine in purpura, 208 Tympanites, chronic, I46 Typhlitis, 127 Typho-malarial fever, 42 Typhoid fever, 22 Typhus fever, 33 Ulcer, duodenal, 86 gastric, 84 perforating, 84 Ulcerative colitis, 121 stomatitis, 70 Ulcerosa gingivitis, 70 Uraemia, acute, 183 moqihina in, 185 Uncmic coma, 183 convulsions, 183 intoxication, 183 Urates, test for, 160 Urea, test for, 160 Uric acid diathesis, 237 test for, 160, l6l Uridrosis, 537 Urine, 159 hysterical, 303 625 Urine, normal color, 159 constituents, 159 quantity, 159 reaction, 159 Urticaria, 557 Vaccination, 63 Vaccinia, 63 Valvular diseases of the heart, 369 diagnosis of, 375 Valvulitis, 364 Varicella, 63 Variola, 59 Verruca, 588 Verriicktheit, 520 Vertigo, 431 auditory, 431 aural, 431 gastric, 431 nervous, 431 senile, 431 stomachic, 82, 431 Vesicular emphysema, 310 Voice in disease, 261 in health, 254 Vomit, black, 49 coffee-ground, 49 Waddle, the, 467 Warburg's tincture, 46 Wart, 588 venereal, 589 Wasting palsy, 462 Water blisters, 565 cancer, 75 Wen, 536 Wlieals, 55S White blood, 201 cell blood, 201 mouth, 72 Whooping-cough, 308 Widal reaction, 27 Wilson's, Erasmus, tonic, 533 Winter cough, 319 Worms, round, 137 seat, 137 tape-, 134 Xeroderma, 591 Yellow fever, 48 Jack, 48 Zona, 561 MEDICAL BOOKS Note Subject Index, Page 6 "f There have been sold more than 145>000 copies of Gould's Dictionaries See Pages 12 and 13 P. Blakiston's Son & Company PUBLISHERS OF MEDICAL AND SCIENTIFIC BOOKS 1012 WALNUT STREET, PHILADELPHIA Montgomery's Gynecology A PRACTICAL TEXT-BOOK A modern comprehensive Text-Book. By Edward E. Montgomery, M.n., Professor of Gynecology in Jefferson Medical College, I'liiladelphia; Gynecologist to the Jefferson and St. Joseph's Hospitals, etc. 527 Illustrations, many of which are from original sources. 800 pages. Octavo. Cloth, $5.00; Leather, <;6.oo %* This is a systematic modern treatise on Diseases of Women. The auttior"s aim has been to produce a lx)ok that will be thorough and practical in every particular. The illustrations, nearly all of which are from original sources, have for the most part been drawn by special artists who, for a number of months, devoted their sole attention to this work. 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'.'V*'? everything else emanating from this distinguished author this little book is replete with practical information from beginning to end. — The Chicago Medical Recorder. ■ " The author approaches his subject from a practical point of vi_ew and the little work will prove a good friend to the student "— I he American Journal of the Medical Sciencet. 3 NEW THIRD EDI TION— NOV READY MORRIS' Anatomy Rewritten— Revised— Improved WITH MANY NEW ILLUSTRATIONS Out of I02 of the leading medical schools 60 recommend " Morris." It contains many features of special advantage to students. It is modern, up-to-date in every respect. It has been carefully revised, the articles on Osteology and Nervous System having been rewritten. Each copy con- tains the colored illustrations and a Thumb Index. Octavo. With 846 Illustrations, of which 267 are printed in colors. 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(Lond.), formerly Professor of the Principles and Practice of Medicine, Cooper Medical Col- lege, San Francisco ; Major and Brigade Surgeon, U. S. Vol. Ninth Edition, Revised and Enlarged. 8vo. Witk Thumb Index in each copy. Cloth, $5.00 ; Leather, $6.00 *^* This is the most complete and trustworthy book for the use of students and physicians. Students who pur- chase it will find it to contain a vast deal of. information not in the usual text-books arranged in the most practical man- ner for facilitating study and reference. It cannot be sur- passed as a physician's working book. WHITE AND WILCOX. Materia Medica, Pharmacy, Pharmacology, and Thera- peutics. Fifth Edition* A Handbook for Students. By W. Hale White, m.d., F.R.C.P., etc.. Physician to, and Lecturer on Materia Medica and Therapeutics at, Guy's Hospital, etc. Fifth American Edition, Revised by Reynold W. Wilcox, M. A. , M.D. , ll.d. , Professor of Clinical Medicine and Thera- peutics at the New York Post-Graduate Medical School and Hospital ; Visiting Physician, St. Mark's Hospital ; Assist- ant Visiting Physician, Bellevue Hospital. i2mo. Cloth, ^3.00 ; Leather, ^3.50 SUBJECT INDEX. Gould's Medical Dictionaries, - Pages 12, 13 Alorris' Anatomy, New Edition, - - Page 4 Compends for Students, - - - - Page 27 BUBJECT. PAGE Alimentary Canal (see Sur- gery) 24 Anatomy 7 Anesthetics 18, 19 Autopsies (see Pathology) 20 Bacteriology 8 Bandaging (see Surgery) . . 24 Blood, I'^xamination of... 8 Brain 8 Chemistry. Physics .... 9 Children, Diseases of 11 Climatology 19 Clinical Charts 25 Compends 27 Consumption (.see Lungs) . 16 Cyclopedia of Medicine. . . 13 Denti.stry 11 Diabetes (see Urin. Organs) 25 Diagnosis 11 Diagrams (see Anatomy) . 8 Dictionaries, Cyclopedias. 12 Diet and Food 13 Disinfection 16 Dissectors 7 Ear 14 Electricity 14 Embryology 7 Emergencies 24 Eye 14 Fevers 15 Food 13 Formularies 21 Gynecology 15 Hay Fever 25 Heart 15 Histology 15 Hydrotherapy 19 Hygiene 16 Hypnotism 8 Insanity 8 Intestines 23 Latin, Medical (see Phar- macy) 21 Life Insurance 19 Lungs 16 Massage 17 Materia Medica 17 Mechanotherapy 17 Medical -Turisprudence. .. . 18 SUBJECT. PAOB Mental Therapeutics 8 Microscopy 18 Milk 8. 10 Miscellaneous 18 Nervous Diseases 19 No.se 25 Nursing 20 Obstetrics 20 Ophthalmology 14 Organotherapy 18 Osteology (see Anatomy) . 7 Pathology 20 Pharmacy 21 Physical Diagnosis 11 Phy.sical Training 17 Physiology 22 Pneumotherapy 19 Poisons (see Toxicology) . . 18 Practice of Medicine 22 Prescription Books (Phar- macy) 21 Refraction (see Eye) 14 Rest 19 Sanitary Science 16 Serum-Therapy 17 Skin 23 Spectacles (see Eye) ..... 14 Spine (see Nervous Dis- eases) 19 Stomach 23 Students' Compends..... 27 Surgery and Surgical Dis- eases 24 Technological Books 9 Temperature Charts 25 Therapeutics 17 Throat 25 Toxicology 18 Tumors (see Surgery) .... 24 U. S. Pharmacopoeia 22 Urinary Organs 25 Urine 25 Venereal Diseases 26 Veterinary Medicine. ..... 26 Visiting Lists, Physicians'. (Send for Special Circu- lar.) Water Analysis 16 Women, Diseases of 15 Self-Examination tor Medical Students. 3500 Questions on Medical Subjects, with References to Standard Works in which the correct replies will be found. Together with Questions from State Examining Boards. 3d Ed. Paper Osver, 10 cts. SUBJECT CATALOGUE OF MEDICAL BOOKS. 7 SPECIAL NOTE. — The prices given in this catalogue are net; no discount can be allowed retail purchasers under any con- sideration. This rule has been established in order that everyone will be treated alike, a general reduction in former prices ha\'ing been made to meet previous retail discounts. Upon receipt of the advertised price any book will be forwarded by mail or express, aU charges prepaid. ANATOMY. EMBRYOLOGY. MORRIS. Text-Book of Anatomy. Third Revised and Enlarged Edition. 846 Illustrations, 267 of which are printed in colors. Thumb Index in Each Copy. Cloth, S6.00; Leather, $7.00 "The ever-growing popularity of the book with teichers and students is an index of its value." — Medical Record, New York. BROOMELL. Anatomy and Histology of the Human Mouth and Teeth. 2d Edition, Enlarged. 337 Illus. Cloth, $4.50 CAMPBELL. Dissection Outlines. Based on Morris' Anatomy. 2d Edition. .50 DEAVER. Surgical Anatomy. A Treatise on Anatomy in its Application to Medicine and Surgery. With 499 very hand- some full-page Illustrations Engraved from Original Drawings made by special Artists from dissections prepared for the pur- pose. Three vols. By Subscription only. Half Morocco or Sheep, $24.00 ; Half Russia, $27.00 GORDINIER. Anatomy of the Central Nervous System. With 271 Illustrations, many of which are original. Cloth, $6.00 HEATH. Practical Anatomy. 9th Edition. 321 Illus. $4.25 HOLDEN. Anatomy. A Manual of Dissections. Revised by A. 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Human Anatomy, Systematic and Topograph- ical. 816 Illustrations. Cloth, $5.00; Leather, $6.00 McMURRICH. Embryology, The Development of the Human Body. 276 Illustrations. $3.00 8 SUBJECT CATALOGUE. MARSHALL. Pbysiolog:ical Diagrams. Eleven Life-Sixe Colored Diagrams (each seven feet by three feet seven inches). Designed for Demonstration before the Class. In Sheets, Unmounted, $40.00; Backed with Muslin and Mounted on Rollers, $60.00; Ditto, Spring Rollers, in hand- some Walnut Wall .Map Case, $100.00; Single Plates — Sheets, S5.00; Mounted, $7..50. Explanatory Key, .60. Purchaser must pay freight charges. MINOT. Laboratory Text-Book of Embryology. 218 Illustra- tions. Just Ready. $4.50 POTTER. Compend of Anatomy, Including Visceral Anatomy. 6th Edition. 16 Plates and 117 other Illustrations. .80; Interleaved, $1.00 WILSON. Anatomy. 11th Edition. 429 Illus., 26 Plates. $5.00 BACTERIOLOGY. CONN. Agricultural Bacteriology. Including the Study of Bacteria as relating to Agriculture, Soil, Dairy and Food Products, Sewage, Domestic Animals, etc. Illustrated. $2.50 CONN. Bacteria in Milk and Its Products. Designed for Students of Dairying, Boards of Health, Bacteriologists, etc. lUustrated. $1.25 EMERY. Bacteriological Diagnosis. 2 Colored Plates and 32 other Illustrations. $1.50 HEWLETT. Manual of Bacteriology. 75 Illustrations. Second Edition, Revised and Enlarged. $4.00 SMITH. Laboratory Exercises in Bacteriology. A Handbook for Students. Illustrated. $1.50 WILLIAMS. Bacteriology. A Manual for Students. 90 Illus- trations. 2d Edition, Revised. $1.50 BLOOD, Examination of. DA COSTA. Clinical Hematology. A Practical Guide to the Examination of the Blood, with Reference to Diagnosis. Six Colored Plates and 48 other Illus. Cloth, $5.00 ; Sheep, $6.00 BRAIN AND INSANITY (see also Nervous Diseases.) BLACKBURN. A Manual of Autopsies. 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With a Digest of Laws Relating to Care of Insane. Illustrated. Cloth, S2.7.5 ; Sheep, S3.25 TUKE. Dictionary of Psychological Medicine. Giving the Definition, Etymology, and Symptoms of the Terms used in Medical Psychology, with the Symptom?, Pathology, and Treatment of the Recognized Forms of Jlental Disorders. Two volumes. SIO.OO WOOD, H. C. Brain and Overwork. .40 CHEMISTRY AND TECHNOLOGY. Special Catalogue of Chemical Books sent free upon application. ALLEN. Commercial Organic Analysis. A Treatise on the Modes of Assaying the Various Organic Chemicals and Prod- ucts Employed in the Arts, Manufactures, Medicine, etc., with Concise Methods for the Detection of Impurities, Adul- terations, etc. 8vo. Vol. I. Alcohols, Neutral Alcoholic Derivatives, etc., Ethers, Vegetable Acids, Starch, Sugars, etc. 3d Edition. S4.50 Vol. II, Part I. Fixed Oils and Fats, Glycerol, Explosives, etc. 3d Edition. S3.50 Vol. II, Part II. Hydrocarbons, Mineral Oils, Lubricants, Benzenes, Naphthalenes and Derivatives, Creosote, Phenols, etc. 3d Edition. S3. 50 Vol. II, Part III. Terpenes, Essential Oils, Resins, Camphors, etc. 3d Edition. Preparing. Vol. Ill, Part I. Tannins, Dyes, and Coloring Matters. 3d Edition, Enlarged and Rewritten. Illustrated. S4.50 Vol. Ill, Part II. The Amines, Hydrazines and Derivatives, Pyridine Bases. The Antipyretics, etc. Vegetable Alka- loids, Tea, Coffee, Cocoa, etc. 8vo. 2d Edition. S4.50 Vol. Ill, Part III. Vegetable Alkaloids, Non-Basic Vegetable Bitter Principles. Animal Bases, Animal Acids, Cyanogen Compounds, etc. 2d Edition, 8vo. S4.50 Vol. IV. The Proteids and Albuminous Principles. 2d Edition. ' S4.50 BAILEY AND CADY. Qualitative Chemical Analysis. SI. 25 HARTLEY. Medical and Pharmaceutical Chemistry. A Text- Book for Medical, Dental, and Pharmaceutical Students. With Illustrations, Glossary, and Complete Index. 5th Ed. S3. 00 BARTLEY. Clinical Chemistry. The Examination of Feces, Saliva, Gastric Juice, Milk, and Urine. Sl.OO BLOXAM. Chemistry, Inorganic and Organic. With Experi- ments. 9th Ed., Revised. 281 Engravings. Preparing. BUNGE. Physiologic and Pathologic Chemistry. From the Fourth German Enlarged Edition. S3. 00 CALDWELL. Elements of Qualitative and Quantitative Chem- ical Analysis. 3d Edition, Revised. Sl.OO CAMERON. Oils and Varnishes. With Illustrations. S2.25 10 SUBJECT CATALOGUE. CAMERON. Soap and Candles. 54 Ulustrntiona. $2.00 CLOWES AND COLEMAN. Quantitative Analysis. 5th Edi- tion. 1-22 lllustnitions. S.^J.-W COBLENTZ. Volumetric Analysis. Illustrated. $1.25 CONGDON. Laboratory Instructions in Chemistry. With Numerous Tables and 50 Illustrations. $1.00 GARDNER. The Brewer, Distiller, and Wine Manufacturer. Illustrated. $1.50 GRAY. Physics. Volume I. Dynamics and Properties of Matter. :W0 Illustrations. $4.50 GROVES AND THORP. Chemical Technology. The Applica- tion of Chemistry to the Arts and Manufactures. Vol. I. 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A Systematic Handbook for the Quantitative Estimation of Chemical Substances by Measure, Applied to Liquids, Solids, and Gases. 8th Edition, Revised. 112 Illustrations. $5.00 SYMONDS. Manual of Chemistry. 2d Edition. $2.00 TRAUBE. Physico-Chemical Methods. 97 Illustrations. $1.50 MEDICAL BOOKS. 11 THRESH. Water and Water Supplies. 3d Edition. $2.00 ULZER AND FRAENKEL. Chemical Technical Analysis. Translated by Fleck. Illustrated. $1.25 WOODY. Essentials of Chemistry and Urinalysis. 4th Edition. Illustrated. $1.50 *** Special Catalogue of Books on Chemistry free upon application. CHILDREN. HATFIELD. Compend of Diseases of Children. With a Colored Plate. 3d Ed. Just Ready. .80; Interleaved, $1.00 IRELAND. The Mental Affections of Children. Idiocy, Im- becility, Insanity, etc. 2d Edition. $4.00 POWER. Surgical Diseases of Children and their Treatment by Modem Methods. Illustrated. $2.50 STARR. The Digestive Organs in Childhood. The Diseases of the Digestive Organs in Infancy and Childhood. 3d Edition, Rewritten and Enlarged. Illustrated. $3.00 STARR. Hygiene of the Nursery. Including the General Regi- men and Feeding of Infants, and Children, and the Domestic Management of the Ordinary Emergencies of Early Life, Massage, etc. 6th Edition. 25 Illustrations. $1.00 SMITH. Wasting Diseases of Children. 6th Edition. $2.00 TAYLOR AND WELLS. The Diseases of Children. 2d Edition, Revised and Enlarged. Illustrated. 8vo. $4.50 "It is well worthy the careful study of both student and prac- titioner, and can not fail to prove of great value to both. We do not hesitate to recommend it." — Boston Medical and Surgical Journal. DIAGNOSIS. BROWN. Medical Diagnosis. A Manual of Clinical Methods. 4th Edition. 112 Illustrations. Cloth, $2.25 DA COSTA. Clinical Hematology. A Practical Guide to Exam- ination of Blood, with Reference to Diagnosis. 6 Colored Plates, 48 other Illustrations. Cloth, $5.00 ; Sheep, $6.00 DOUGLAS. Surgical Diseases of Abdomen, with Reference to Diagnosis. 20 Full-Page Plates. Just Ready. Cloth, $7.00 ; Sheep, $8.00 EMERY. Bacteriological Diagnosis. 2 Colored Plates and 32 other Illustrations. $1.50 MEMMINGER. Diagnosis by the Urine. 2d Ed. 24 Illus. $1.00 PERSHING. Diagnosis of Nervous and Mental Diseases. Illustrated. $1.25 STEELL. Physical Signs of Pulmonary Disease. $1.25 TYSON. Handbook of Physical Diagnosis. For Students and Physicians. By the Professor of Clinical Medicine in the Uni- versity of Pennsylvania. Illus. 4th Ed., Improved and En- larged. With 2 Colored and 55 other Illustrations. $1.50 DENTISTRY. Special Catalogue of Dental Books sent free upon application. BARRETT. Dental Surgery for General Practitioners and Students of Medicine and Dentistry. Extraction of Teeth, ete. 3d Edition. Illustrated. $1.00 12 SUBJECT CATALOGUE. BROOMELL. Anatomy and Histology of the Human Mouth and Teeth. Second Edition, Revised and Enlarged. 337 handsome Illustrations. Cloth, §4.50 ; Leather, $.5.50 FILLEBROWN. Operative Dentistry. Illustrated. $2.25 GORGAS. Dental Medicine. A Manual of Materia Medica and Therapeutics. 7th Edition. Cloth, 84.00; Sheep,$5.00 GORGAS. Questions and Answers for the Dental Student. Embracing all the subjects in the Curriculum of the Dental Student. Octavo. S6.00 HARRIS. Principles and Practice of Dentistry. Including Anatomy, Physiology, Pathology, Therapeutics, Dental Sur- gery, and Mechanism. 13th Edition. Revised by F. J. S. GoRGAS, M.D., D.D.a. 1250 Illus. Cloth, S6.00 ; Leather, S7.00 HARRIS. Dictionary of Dentistry. Including Definitions of Such Words and Phrases of the Collateral Sciences as Pertain to the Ajt and Practice of Dentistry. 6th Edition, Revised and Enlarged by Ferdinand J. S. Gorgas, m.d., d.d.s. « Cloth, S5.00 ; Leather, S6.00 RICHARDSON. Mechanical Dentistry. 7th Edition. Thor- oughly Revised and Enlarged by Dr. Geo. W. Warren. 691 Illustrations. Cloth, S5.00; Leather, S6.00 SMITH. Dental Metallurgy. 2d Edition. Illustrated. $2.00 TAFT. Index of Dental Periodical Literature. S2.00 TOMES. Dental Anatomy. 263 Illustrations. 5th Ed. $4.00 TOMES. Dental Surgery. 4th Edition. 289 lUus. $4.00 WARREN. Compend of Dental Pathology and Dental Medicine. With a Chapter on Emergencies. 3d Edition. Illustrated. .80; Interleaved, Sl.OO WARREN. Dental Prosthesis and Metallurgy. 129 Illus. $1.25 WHITE. The Mouth and Teeth. Illustrated. .40 DICTIONARIES. CYCLOPEDIAS. GOULD. The Illustrated Dictionary of Medicine, Biology, and Allied Sciences. Being an Exhaustive Lexicon of Medicine and those Sciences Collateral to it: Biology (Zoology and Botany), Chemistry, Dentistrj', Pharmacology, Microscopy, etc., with many useful Tables and numerous fine Illustrations. 1633 pages. Fifth Edition. Sheep or Half Morocco. $10.00; with Thumb Index, $11.00 Half Russia, Thumb Index, $12.00 GOULD. The Medical Student's Dictionary, nth Edition. Il- lustrated. Including those Words and Phrases generally used in Medicine, with their Proper Pronunciation and Definition, Based on Recent Medical Literatm-e. With Table of Epo- nymic Terms and Tests and Tables of the BacUli, Micrococci, Mineral Springs, etc., of the Arteries, Muscles, Nerves, Ganglia, Plexiises, etc. Eleventh Edition. Enlarged and illustrated with a large number of Engravings. 840 pages. Half Morocco, $2.50 ; with Thumb Index, $3.00 MEDICAL BOOKS. 13 GOULD. The Pocket Pronouncing Medical Lexicon. 4th Edi- tion. (30,000 Medical Words Pronounced and Defined.) Con- taining all the Words, their Definition and Pronunciation, that the Medical, Dental, or Pharmaceutical Student Gener- ally Comes in Contact with; also Elaborate Tables of Epo- nymic Terms, Arteries, Muscles, Nerves, BacUli, etc., etc., a Dose List in both English and Metric Systems, etc., Arranged in a Most Convenient Form for Reference and Memorizing. Fourth Edition, Revised and Enlarged. 838 pages. Full Limp Leather, Gilt Edges, SI. 00; Thumb Index, $1.25 145,000 Copies of Gould's Dictionaries have been sold. GOULD AND PYLE. Cyclopedia of Practical Medicine and Surgery. Seventy-two Special Contributors. Illustrated. One Voltime. A Concise Reference Handbook of Medicine, Sur- gery, Obstetrics, Materia Medica, Therapeutics, and the Vari- ous Specialties, with Particular Reference to Diagnosis and Treatment. Compiled under the Editorial Supervision of George M. Goitld, m.d., Author of "An Illustrated Dictionary of Medicine," etc.; and Waiter L. Pn,E, m.d., Assistant Surgeon Wills Eye Hospital; formerly Editor "International Medical Magazine," etc., and Seventy-two Special Contribu- tors. With many Illustrations. Large Square 8vo, to corre- spond with Gould's "Illiistrated Dictionary." Full Sheep or Half Mor., SIO.OO; -svith Thumb Index, SI 1.00 Half Russia, Thumb Index, S12.00 net. GOULD APTD PYLE. Pocket Cyclopedia of Medicine and Sur- gery. Based upon above book and uniform in size with "Gould's Pocket Dictionary." Full Limp Leather, GUt Edges, $1.00 W^ith Thumb Index, SI. 25 HARRIS. Dictionary of Dentistry. Includiog Definitions of Such Words and Phrases of the Collateral Sciences as Pertain to the Art and Practice of Dentistry. 6th Edition, Revised and Enlarged by Ferdinand J. S. Gorgas, m.d., d.d.s. Cloth, $5.00 ; Leather, $6.00 LONGLEY. Pocket Medical Dictionary. Cloth, .75 MAXWELL. Terminologia Medica Polyglotta. By Dr. Theo- dore Maxwell, Assisted by Others. $3.00 The object of this work is to assist the medical men of any nationality in reading medical literature written in a language not their own. Each term is usually given in seven languages, viz. : English, French, German, Italian, Spanish, Russian, and Latin. TREVES AND LANG. Geiman-EngUsh Medical Dictionary. Half Calf, $3.25 DIET AND FOOD. ALLEN. Proteids and Albuminous Principles. An analytical Study of Food Products. 2d Edition. $4.50 BURNETT. Foods and Dietaries. A Manual of Clinical Diet- etics, with Diet Lists for Various Diseases, etc. 2d Ed. $1.50 DAVIS. Dietotherapy. Food in Health and Disease. With Tables of Dietaries, Relative Value of Foods, etc. See Cohen, Physiologic Therapeviics, page 17. GREENISH. Microscopical Examination of Foods and Drugs. Illustrated.. In Press. HAIG. Diet and Food. Considered in Relation to Strength and Power of Endurance. 4th Edition. $1.00 LEFFMANN. Select Methods in Food Analysis. lUus. $2.50 14 SUBJECT CATALOGUE. EAR (see also Throat and Nose). BURNETT. Hearing and How to Keep It. lllu.strated. .40 HOVELL. Diseases of the Ear and Naso-Pharynx. Including Anatomy and I'hy.'iioloKy of tlie Organ, toRcther with the Treat iiiciit of the Affections of the Nose and Pliarynx which ('oniliice to Aural IJisease. 128 lUu-strations. 2d Ed. $5.50 PRITCHARD. Diseases of the Ear. 4th Edition, Enlarged. Many Illustration.s and I'oriTiuhc. In Preta. ELECTRICITY. BIGELOW. 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The Microscopic Examination of the Eye. Illus- trated. $1.25 HARLAN. Eyesight, and How to Care for It. Illus. .40 HARTRIDGE. On the Ophthalmoscope. 4th Edition. With 4 Colored Plates and 68 Wood-cuts. $1.60 HARTRIDGE. Refraction. 104 Illustrations and Test Types. 11th Edition, Enlarged. $1.50 HANSELL AND SWEET. Treatise on Diseases of the Eye. With many Illus. drawn by special artists, etc. In Press. HANSELL AND REBER. Muscular Anomalies of the Eye. lUustrated. $1.50 HANSELL AND BELL. Clinical Ophthahnology. Colored Plate of Normal Fundus and 120 Illustrations. $1.50 JENNINGS. Manual of Ophthalmoscopy. 95 Illu-strations and 1 Colored Plate. $1.50 MORTON. Refraction of the Eye. Its Diagnosis and the Cor- rection of its Errors. 6th Editi^. $1.00 OHLEMANN. Ocular Therapeutics. Authorized Translation, and Edited by Dr. Charles A. Oliver. $1.75 PARSONS. Elementary Ophthalmic Optics. With Diagram- matic Illustrations. $2.00 MEDICAL BOOKS. 15 PHILLIPS. Spectacles and Eyeglasses. 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